Mind full or mindful: a report on mindfulness and psychological health in healthy adolescents

Abstract

Mindfulness is defined as a non-judgemental awareness and accepting of present-moment experience. With intentional attendance to one's ongoing stream of thoughts, sensations and emotions as they arise, it allows the individual to react with less impulsivity and flexibility. However, empirical findings of mindfulness to date have largely been confined to outcome studies using clinical populations. This cross-sectional study examined the relationships between mindfulness, self-esteem, resiliency and mental health symptoms (anxiety, stress, depression and cognitive inflexibility) in a sample of 106 healthy adolescents. Participants completed a set of questionnaires. First, we found moderate effect size for anxiety, depression and self-esteem and large effect size for cognitive inflexibility. These results, when compared with clinical samples, demonstrated similar trends found in a healthy adolescent sample. Second, predictive value of mindfulness was examined and we found significant contribution of mindfulness to mental and psychological health.

Keywords:

• Mindfulness
• non-clinical
• adolescents
• mental health
• self-esteem
• resiliency

Introduction

Mindfulness has been associated with psychological well-being. The fundamentals of mindfulness are present-moment awareness and non-judgemental acceptance of experience. With mindful intentional attendance to one's ongoing thoughts, emotions and sensations, it is regarded as a potential antidote against psychological distress (worry, anxiety, rumination, etc.) and its maladaptive tendencies to avoid, suppress or over-engage with one's distressing emotions and thoughts (Hayes & Fieldman, 2004; Kabat-Zinn, 1990).

Existing empirical studies have largely studied mindfulness and its effects on mental health outcomes (for a review, see Baer, 2003), but little is known of how mindfulness correlates with positive mental health indicators in healthy adolescents. A chief gap in the existing literature centres on how mindfulness relates to emotional well-being in children and adolescents.

In this report, we first provide an overview of the study constructs. We then examine the relationship of mindfulness and its interactions with resiliency, self-esteem, cognitive inflexibility as well as negative mental health in healthy adolescents, without confounds such as cognitive and affective symptoms of psychopathology. Next, we investigate concurrently the unique value of mindfulness in relation to multiple facets of both positive and negative psychological health, after controlling for age.

Resiliency

Resilience is a complex construct that involves interaction between adversity and an individual's internal and external protective factors and competencies that allow one to overcome adversity (Luthar & Zigler, 1991; Rutter, 1987). The literature has portrayed a resilient individual as one who has a healthy sense of self, is self-efficacious and is able to find equanimity and meaningfulness in life (Earles, 1987; Haase, 1997; Wagnild & Young, 1993).

Resiliency may be apparent to varying degrees across psychopathologies and also understood as a core explanatory process in psychological adaptation in general. Although resilience has been the focus of much discussion and research over the past decades, the operational definition has varied considerably over time. It has been known as hardiness, optimism, self-esteem, social skill, achievement, or the absence of pathology in the face of adversity. Developmental psychopathologists have studied resilience in the face of adversity extensively. This body of work has generally defined resilience as the ability to weather adversity or to bounce back from a negative experience (Prince-Embury, 2006).

Like mindfulness construct, there is much controversy in the literature as to whether resilience is a characteristic (i.e. personal quality), a process or an outcome (Ahern, Ark, & Byers, 2008). Others characterised resilience as a phenomenon incorporating both outcomes and process (Leipold & Greve, 2009). Despite the vast range of definition, there is some agreement in the literature that to determine whether someone is displaying resilience two elements must be present: adversity (e.g. threat to internal resources) and successful adaptation or competence (Luthar, Cicchetti, & Becker, 2000; Masten, 2001). Adversity is evaluated according to negative life circumstances and adaptation is defined as successful performance on age-developmental tasks. A more recent definition of resilience outlined a new ecologically focused definition:

In the context of exposure to significant adversity, whether psychological, environmental, or both, resilience is both the capacity of individuals to navigate their way to health-sustaining resources, including opportunities to experience feelings of well-being, and a condition of the individual family, community and culture to provide these health resources and experiences in culturally meaningful ways. (Unger, 2008, p. 225)

Psychological inflexibility

Psychological inflexibility is considered an emotional vulnerability for many forms of psychopathology and has drawn increased attention from researchers (Chawla & Ostafin, 2007; Hayes, Luoma, Bond, Masuda, & Lilis, 2006; Kashdan & Rottenberg, 2010).

Two processes define the state of psychological inflexibility: cognitive fusion and experiential avoidance. Cognitive fusion represents the phenomenon by which individuals are influenced by the literal meaning of their thoughts, instead of viewing these experiences as transient internal states (Greco, Lambert, & Baer, 2008). It refers to the entanglement with the content of private events and a response to this content as if it was literally true (Hayes et al., 2006). The result of this entanglement with problematic thoughts and feelings is avoidance.

As such, cognitive fusion gives rise to experiential avoidance, or unwillingness to experience certain private events and attempts to avoid or alter behaviours. Experiential avoidance is the opposite of psychological acceptance (Hayes, Wilson, Gifford, Follette, & Stroshl, 1996). These processes result in a restriction in valued living. Conversely, psychological flexibility is the ability to be open, present-focused and awareness to change or persist in behaviour that serves ones values and goals (Hayes, Stroshl, & Wilson, 1999).

To date, little is known about the nature of psychological inflexibility and mindfulness in healthy adolescents. Adolescence is described as a transitional period in which individuals experience major physical, cognitive and socio-affective changes. Other life events (e.g. family structure changes, school changes, accidents, etc.) can also affect adolescents' well-being. In this study, the relationships of mindfulness in relation to mental health (stress, anxiety, depression and cognitive inflexibility), resiliency and self-esteem are investigated.

No studies to date have specifically examined the influence of demographic (age and gender) variables on mindfulness in the general adolescent population, and its unique value in relation to both positive (i.e. self-esteem and resiliency) and negative mental health symptoms (i.e. stress, anxiety, depression and cognitive inflexibility) in healthy adolescents. Therefore, the specific hypotheses are: mindfulness correlates positively with self-esteem and resiliency; and mindfulness correlates negatively with negative mental health symptoms.

Method

Participants and procedures

This was a cross-sectional design study with a total of 106 adolescents (between 13 and 18 years) recruited from the general population in schools, youth and sports clubs. Participants were told this was a study on mindfulness and psychological well-being that involved the completion of validated self-report instruments, and upon completion they received a monetary gift voucher for their participation.

Participants were excluded on the basis of: limited mental competency, or the inability to provide informed, written consent; and lack of parental written consent. Participants were instructed to complete all items.

Measures

The Depression Anxiety Stress Scale – short version (DASS-21; Lovibond & Lovibond, 1995) consists of three scales assessing symptoms of depression, anxiety and stress. Adolescents rate items on a three-point scale (i.e. 0 = did not apply to 3 = most of the time). DASS-21 has been shown to have high internal consistency (alpha = 0.80–0.91). Confirmatory factor analysis has shown distinct depression, anxiety and stress factors as well as a general distress factor (Henry & Crawford, 2005).

The Rosenberg Self-Esteem Scale (Rosenberg, 1965) is a 10-item self-report of adolescent's self-esteem. Responses are rated on a four-point scale (i.e. 1 = strongly agreed to 4 = strongly disagree) relating to overall feelings of self-worth or self-acceptance. It has high reliability; test–re-test correlations were in the range 0.82–0.88 and Cronbach's alpha values were in the range 0.77–0.88 (Blascovich & Tomaka, 1993; Rosenberg, 1986).

The Resiliency Scale for Children and Adolescents (RSCA; Prince-Embury, 2006) is a 64-item instrument consisting of three self-report scales: the Sense of Mastery Scale (which measures optimism, self-efficacy and adaptability), the Sense of Relatedness Scale (which measures trust, support, comfort and tolerance), and the Emotional Reactivity Scale (which measures sensitivity, recovery and impairment). Item responses are rated on a four-point scale (i.e. 0 = never to 4 = almost always). Internal consistencies of the RSCA global scales for adolescents were in the range 0.92–0.96 (Prince-Embury, 2006). It yields a total Resiliency score.

The Avoidance and Fusion Questionnaire for Youth (AFQ-Y8; Greco et al., 2008) is a uni-dimensional scale, specifically used in mindfulness and acceptance-based therapy research. Adolescents rate their responses to the eight items on a four-point scale (0 = not at all true to 4 = very true). High scores on the scale indicate greater psychological inflexibility. AFQ-Y8 scores correlated positively with measures of child internalising symptoms and externalising behaviours problems and negatively with quality of life. Adolescent's level of psychological inflexibility characterised by experiential avoidance (e.g. ‘I push away thoughts and feelings that I don't like’), cognitive fusion (e.g. ‘The bad things I think about my self must be true’) and behavioural ineffectiveness in the presence of unpleasant emotions (e.g. 'I do worse in school when I have thoughts that make me feel sad').

The Children's Acceptance and Mindfulness Measure (CAMM) (Greco, Smith, & Baer, 2011) comprises 10 items and assesses the adolescent's self-report on mindfulness awareness. Adolescents rate their responses on a four-point scale (i.e. 0 = never true to 4 = always true). The CAMM was developed and validated specifically for children and adolescents to measure characteristics of mindfulness. The CAMM items assess three facets of mindfulness in children and adolescents: observing involves the degree to which adolescents notice or attend to internal phenomena (thoughts, feelings, and bodily sensations); acting with awareness refers to present-moment awareness; and accepting without judgement entails non-judgemental awareness and openness to experiencing a full range of internal events.

Results

Overview

Exploratory analyses were conducted for data screening, examination of distribution and descriptive statistics. To ensure a healthy adolescent sample, participants with high scores (i.e. in the clinical range) on the DASS measures were excluded. Where there were substantial missing data these responses were also excluded. A total of 13 responses were deemed invalid. Ninety-three participants (49 female, 44 male; mean age = 15.02 years, standard deviation [SD] = 1.15) were included in data analyses. After removing outliers, an inspection of histograms, skewness and kurtosis showed that all variables were normally distributed, considering both symmetry and peakedness (see Table 1).

Table 1 Descriptive statistics.

						Skewness		Kurtosis
	n	Minimum	Maximum	Mean	SD		Standard error		Standard error
DASS stress	93	0	26	8.39	4.766	0.514	0.250	1.016	0.495
DASS anxiety	93	0	18	4.45	3.947	0.979	0.250	0.647	0.495
DASS depression	93	0	14	5.05	3.265	0.342	0.250	− 0.328	0.495
AFQ cognitive inflexibility	93	0	22	7.12	3.967	0.975	0.250	2.108	0.495
Rosenberg Self-Esteem	93	10	30	20.04	4.366	− 0.082	0.250	− 0.146	0.495
CAMM mindfulness	93	10	40	26.57	6.772	− 0.259	0.250	− 0.314	0.495
RSCA resiliency	93	28	65	46.87	6.794	− 0.025	0.250	0.763	0.495

Analyses were conducted to explore differences on the variables between the gender groups (males; females) and whether there is a significant gender difference in mindfulness. Independent-sample t-tests were utilised to compare the two groups (gender: males, females) and their scores for mindfulness, cognitive inflexibility, self-esteem, resiliency and DASS scores of stress, depression, anxiety.

The homogeneity of variance assumption of the independent t-test was examined by conducting the Levene's test. Results showed no violations for all proposed analyses. There were no significant differences between gender in terms of mindfulness, self-esteem, resiliency, cognitive inflexibility and depression ratings. There was a significant difference between males and females on stress and anxiety. Females scored significantly higher (mean = 9.40, SD = 4.80) on stress than males (mean = 7.30, SD = 4.53), t(91) = 2.18, p = 0.032. Males scored significantly higher (mean = 5.60, SD = 4.4) on anxiety compared with females (mean = 3.43, SD = 3.19), t(91) = 2.73, p = 0.008.

Total scores on the CAMM were computed by summing the responses to the 10 items, yielding a possible range of 0–40. Means and SDs are shown in Table 2. Mean differences for gender and mindfulness were not significant.

Table 2 Comparing gender scores on CAMM, AFQ-Y8, Rosenberg Self-Esteem Scale, Resiliency Scale and DASS-21.

	Males (n = 44)		Females (n = 49)
Variable	Mean	SD	Mean	SD	p value (two-tailed)
DASS stress	7.27	4.53	9.39	4.80	0.032**
DASS anxiety	5.59	4.41	3.43	3.19	0.008**
DASS depression	5.14	3.62	4.98	2.95	0.819
Cognitive inflexibility (AFQ-Y8)	7.50	4.66	6.78	3.25	0.382
Rosenberg Self-Esteem	20.68	4.59	19.47	4.12	0.183
Mindfulness (CAMM)	26.93	6.84	26.24	6.76	0.628
Resiliency	46.89	7.257	46.86	6.43	0.984

Relationships between the variables

To further examine the relationships between mindfulness (as measured by the CAMM) and the other study variables, analyses were conducted using Pearson product-moment correlation coefficients. Using a simultaneous method, further regression analyses were computed. The predictors or dependent variables were age, stress, anxiety, depression, cognitive inflexibility, self-esteem and resiliency scores, with total CAMM score being the independent variable. Means, SDs and correlation coefficients are displayed in Table 3. The correlations between age and CAMM total score were also not significant.

Table 3 Means, SDs and Pearson correlations of study variables in healthy adolescents.

	Mean	SD	Age	DASS stress	DASS anxiety	DASS depression	AFQ cognitive inflexibility	Rosenberg Self-Esteem	RSCA resiliency
Age	15.12	1.15	–	–	–	–	–	–	–
DASS stress	8.39	4.77	0.11	–	–	–	–	–	–
DASS anxiety	4.45	3.95	− 0.29**	0.25**	–	–	–	–	–
DASS depression	5.05	3.27	− 0.14	0.41**	0.44**	–	–	–	–
AFQ cognitive inflexibility	7.12	3.97	− 0.10	0.21*	0.45**	0.32**	–	–	–
Rosenberg Self-Esteem	20.04	4.37	− 0.12	− 0.20*	− 0.01	− 0.18*	− 0.16	–	–
CAMM	26.57	6.77	− 0.12	− 0.21*	− 0.39**	− 0.36**	− 0.66**	0.34**	0.23*
RSCA resiliency	46.87	6.79	− 0.09	− 0.18*	− 0.21*	− 0.05	− 0.05	0.45**	–

Note: n = 93; *p < 0.05. **p < 0.01 (one-tail).

Stress

There was a significant negative correlation between mindfulness and stress, r = − 21, n = 93, p = 0.002. Using the regression simultaneous method (see Table 4), a significant model emerged, (3, 89) = 2.94, p = 0.037. Mindfulness accounted for 4% of the variance in predicting stress (β = − 0.14, p = 0.050).

Table 4 Linear regression with mindfulness (CAMM) predicting mental health outcomes, adjusting for age and gender.

Outcome	R^2	F	β	sr^2	t	p
DASS stress	0.09*	2.94	− 0.20	0.04	− 1.98	0.050
DASS anxiety	0.53**	11.59	− 0.38	0.14	− 4.21	< 0.001
DASS depression	0.14**	4.73	− 0.35	0.12	− 3.47	0.001
AFQ cognitive inflexibility	0.44**	23.99	− 0.66	0.43	− 8.32	< 0.001
Rosenberg Self-Esteem	0.16**	5.57	0.36	0.13	3.67	< 0.001
RSCA resiliency	0.07*	2.15	0.25	0.06	2.39	0.019

Note: *p < 0.05; **p < 0.01; degrees of freedom = 3.92. β, standardised beta; sr², squared semi-partial correlation.

Anxiety

There was a significant negative correlation between mindfulness and anxiety, r = − 0.39, n = 93, p < 0.001. Further regression analyses demonstrated that a significant model emerged, F(3, 89) = 11.59, p < 0.001. Mindfulness accounted for 14% of the variance in predicting anxiety (β = − 0.38, p < 0.001).

Depression

There was a significant negative correlation between mindfulness and depression, r = − 0.21, n = 93, p < 0.05. Further regression analyses demonstrated that a significant model emerged, F(3, 89) = 4.73, p = 0.004. Mindfulness accounted for 12% of the variance in predicting depression (β = − 0.35, p = 0.001).

Cognitive inflexibility

There was a significant negative correlation between mindfulness and cognitive inflexibility, r = − 66, n = 93, p < 0.001. Using Cohen's (1988) interpretation this represents a large correlation, indicating a strong relationship between mindfulness and cognitive inflexibility. This is consistent with previous research findings, supporting a strong negative relationship between mindfulness and cognitive inflexibility, F(3, 89) = 23.99, p < 0.001. In terms of the model, mindfulness accounted for 43% of the unique variance in predicting cognitive inflexibility (β = − 0.66, p < 0.001).

Self-esteem

There was a significant positive correlation between mindfulness and self-esteem, r = 0.35, n = 93, p < 0.001. Further regression analyses using the Enter method demonstrated that a significant model emerged, F(3, 89) = 5.57, p = 0.002. Mindfulness accounted for 13% of the variance in predicting self-esteem (β = 0.36, p < 0.001).

Resiliency

There was also a significant positive correlation between mindfulness and resiliency, r = 0.23, n = 93, p = 0.013. Regression analyses demonstrated that mindfulness accounted for 6% of the variance in predicting resiliency (β = 0.25, p = 0.019).

Discussion

The study of mindfulness has previously been limited to intervention and outcome studies using a clinical population. This study is among the first to describe mindfulness skills and its correlates with positive mental health variables in a healthy adolescent population, without mindfulness intervention, thus filling an important gap in the empirical literature on mindfulness. Three core findings emerged from the investigation.

First, in healthy adolescents no significant gender differences were found in mindfulness, as measured by the CAMM. In the development and validation of the CAMM (Greco et al., 2011) using a US sample of adolescents, the boys' mean score in their study was 23.27, compared with 26.93 in this study; and the girls' mean score was 22.43, compared with 26.24. This study supported the previous finding; that is, no significant effects were reported in mean differences for sex, age and mindfulness scores.

Second, investigations of mindfulness correlates showed significant relationships with positive mental health variables (self-esteem and resiliency). As predicted, mindfulness correlated positively with self-esteem and resiliency. These relationships range from small to moderate by Cohen's standards, in the expected positive direction (r = 0.34 and r = 0.23, respectively).

To the best of our knowledge, this is the first study to examine mindfulness and positive indicators of mental health (self-esteem and resiliency) in healthy adolescents. As such, no comparisons can be made at present. However, in the adult studies, many extant studies have examined positive indicators of mental health, such as satisfaction with life. In this regard, it is pleasing to find that results in this study are consistent with those reported in adult samples; that is, mindfulness is associated with higher pleasant affect, including satisfaction with life (Baer, Smith, Hopkins, Krietmeyer, & Toney, 2006; Brown & Ryan, 2003). Furthermore, the size of the observed incremental associations of mindfulness with self-esteem and resiliency after controlling for age accounted for 13% of the variance in predicting self-esteem and 6% for resiliency. These results provide novel, descriptive evidence of the association between higher levels of mindfulness and higher levels of resiliency and self-esteem.

Third, consistent with earlier hypothesis, the results indicated that mindfulness is negatively correlated to negative mental health symptoms (stress, anxiety, depression and cognitive inflexibility). As shown in Table 3, mindfulness scores were negatively correlated with stress, anxiety, depression and psychological inflexibility. These relationships were moderate to large by Cohen's (1992) standards, suggesting (as predicted) that mindfulness is negatively related to negative mental health symptoms. Results support previous findings found in university student, community adult and clinical samples (Brown & Ryan, 2003).

As far as we are aware this is the first study examining mindfulness and psychological inflexibility in a healthy adolescent context. A significant relationship was demonstrated between mindfulness and psychological inflexibility. Preliminary correlations showed that mindfulness predicted and accounted for a large variance in cognitive inflexibility. It is not surprising that mindfulness is negatively correlated with psychological inflexibility. As mindfulness consisting of components such as, acceptance, present-moment awareness, and being non-judgmental, is at odds with psychological inflexibility (processes which include experiential avoidance and cognitive fusion).

There are a number of interpretive caveats of this study. First, the current findings were based on a community sample of relatively homogeneous adolescents. It may be important for future work to examine the associations of mindfulness and mental health among clinical participants as well as ethnically and more developmentally diverse individuals.

Second, it is not possible to make definitive, causal statements concerning the relationships between the studied variables, due to the cross-sectional and correlational nature of the present research design. For example, the study oriented on mindfulness processes impacting on both positive and negative mental health, but the opposite relation is possible (e.g. self esteem or mental health impacting mindfulness processes). Therefore, the future direction in this line of inquiry would be to use prospective research methodologies and evaluate the consistency of the present findings over time. Another approach would be to experimentally manipulate, for example, stress in the laboratory and then test the effects of mindfulness processes on physiological and emotional outcomes (Arch & Craske, 2006).

Mindfulness processes are technically complex to measure and even more so in adolescents. The available instruments such as the CAMM and AFQ-Y8 being used are relatively recent developments. Nonetheless, both of these measures represent the most theoretically promising self-report measure of mindfulness skills and its related processes in adolescents presently. Future work could therefore benefit by replicating and extending this research using alternative measurement as they become available.

Additional information

Notes on contributors

Lucy B.G. Tan

Lucy B.G. Tan is a senior clinical psychologist at Queensland Children's Hospital and a researcher at The University of Queensland, Brisbane, Australia.

Graham Martin

Graham Martin is a professor and director of Child and Adolescent Psychiatry Program, The University of Queensland, and clinical director of Child and Youth Mental Health Services, Queensland Children's Hospital, Brisbane, Australia.