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Mindfulness-based school interventions: A systematic review of outcome

evidence quality by study design

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Mindfulness
https://doi.org/10.1007/s12671-022-01885-9

REVIEW

Mindfulness‑Based School Interventions: a Systematic Review

of Outcome Evidence Quality by Study Design
Mary L. Phan1 · Tyler L. Renshaw1 · Julie Caramanico2 · Jeffrey M. Greeson3 · Elizabeth MacKenzie4 ·
Zabryna Atkinson‑Diaz2 · Natalie Doppelt2 · Hungtzu Tai5 · David S. Mandell2 · Heather J. Nuske2

Accepted: 28 March 2022

© The Author(s) 2022

Abstract
Objectives The purpose of this systematic review was to assess the current literature on mindfulness-based school interven-
tions (MBSIs) by evaluating evidence across specific outcomes for youth.
Methods We evaluated 77 studies with a total sample of 12,358 students across five continents, assessing the quality of each
study through a robust coding system for evidence-based guidelines. Coders rated each study numerically per study design
as 1 +  + (RCT with a very low risk of bias) to 4 (expert opinion) and across studies for the corresponding evidence letter
grade, from highest quality (“A Grade”) to lowest quality (“D Grade”) evidence.
Results The highest quality evidence (“A Grade”) across outcomes indicated that MBSIs increased prosocial behavior,
resilience, executive function, attention, and mindfulness, and decreased anxiety, attention problems/ADHD behaviors, and
conduct behaviors. The highest quality evidence for well-being was split, with some studies showing increased well-being and
some showing no improvements. The highest quality evidence suggests MBSIs have a null effect on depression symptoms.
Conclusions This review demonstrates the promise of incorporating mindfulness interventions in school settings for improv-
ing certain youth outcomes. We urge researchers interested in MBSIs to study their effectiveness using more rigorous designs
(e.g., RCTs with active control groups, multi-method outcome assessment, and follow-up evaluation), to minimize bias
and promote higher quality—not just increased quantity—evidence that can be relied upon to guide school-based practice.

Keyword Mindfulness · School-based interventions · Youth · Systematic review · Evidence-based practice · School mental
health

Many preschool, elementary, and high school students expe- (Leigh & Clark, 2018; Maughan et al., 2013; Murphy et al.,
rience problems related to anger, anxiety, depression, and 2015) and have lasting effects on their well-being (Steger
low self-esteem (Barnes et al., 2003; Fisher, 2006; Langer & Kashdan, 2009). Schools can play a pivotal role in pro-
et al., 2015; Mendelson et al., 2010; Rempel, 2012) that moting students’ mental health and their social, emotional,
negatively influence their academic and social development and behavioral development (Barnes et al., 2003; Fisher,
2006; Mendelson et al., 2010). To address these challenges,
* Mary L. Phan many schools have adopted mindfulness-based interventions
[email protected] (MBIs). Studies conducted over the past 15 years have exam-
ined the impact of MBIs on mental health, educational per-
1
Department of Psychology, Utah State University, Logan, formance, and related outcomes in children and adolescents
UT 84322, USA
(Kallapiran et al., 2015; Meiklejohn et al., 2012).
2
Penn Center for Mental Health, University of Pennsylvania Mindfulness is the process by which we “pay attention
Perelman School of Medicine, Philadelphia, PA, USA
in a particular way: on purpose, in the present moment
3
Department of Psychology, Rowan University, Glassboro, NJ, and nonjudgmentally” (Baer, 2003; Roeser, 2014). Origi-
USA
nally adapted for adults, practicing mindfulness typically
4
Graduate School of Education, University of Pennsylvania includes meditation exercises and bringing mindful aware-
Perelman School of Medicine, Philadelphia, PA, USA
ness to daily activities, such as eating and walking. These
5
Child Life and Health, Centre for Clinical Brain Sciences, practices are intended to foster purposeful focused attention,
University of Edinburgh, Edinburgh, UK

13
Vol.:(0123456789)
 Mindfulness

coupled with a nonjudgmental attitude toward moment-to- mindfulness exercises, including awareness of breath, mind-
moment experience (Kabat‐Zinn, 2003). Mindfulness-based ful body scans, and awareness of thoughts, feelings, and sen-
interventions target many aspects of well-being, resiliency, sations. MBSIs are often delivered in the context of whole
and mental health by cultivating a present-centered aware- class instruction (general population of students) or targeted
ness and acceptance (Fjorback et al., 2011; Gawrysiak intervention (at-risk or clinical populations; Kuyken et al.,
et al., 2018; Greeson, 2009; Khoury et al., 2013; Roeser, 2013; Napoli et al., 2005; Raes et al., 2014). In addition,
2014). In particular, emotion regulation has been the focus MBSIs are offered in a variety of formats (i.e., delivered
of much MBI research (Guendelman et al., 2017; Wisner, by the research team or teacher, as multi-session programs
2014). Individuals who have difficulty with emotion regu- or brief single-session workshops, with a variety of activi-
lation have problems processing, experiencing, expressing, ties and exercises included), which previous reviews have
and managing emotions effectively (Chambers et al., 2009). shown to impact the effectiveness of MBSIs (Bender et al.,
Furthermore, the nonjudgmental awareness in mindfulness 2018; Carsley et al., 2018; Schonert-Reichl & Roeser, 2016;
may facilitate a healthy engagement with emotions, allow- Semple et al., 2017).
ing individuals to experience and express their emotions Mindfulness practices targeting school-aged popula-
without under-engagement (e.g., experiential avoidance and tions include developmentally appropriate adaptations for
thought suppression) or over-engagement (e.g., worry and children and adolescents (Bostic et al., 2015; Carsley et al.,
rumination; Hayes & Feldman, 2004; Ivanovski & Malhi, 2018). For example, time for practices is shorter; they incor-
2007). Specifically, research indicates that MBI with adults porate multiple sensory modalities into activities, and rely
can increase awareness of moment-to-moment experience on simplified metaphors to communicate difficult concepts;
and promote reflection, empathy, and caring for others (Höl- and there is more time for explaining key concepts (Burke,
zel et al., 2011). Mindfulness training with adults can also 2010; Felver et al., 2013). Most MBSIs tested in schools are
improve stress regulation, resilience, anxiety, and depression designed to increase resilience to stress and decrease depres-
(Forkmann et al., 2014; Hofmann et al., 2010; Irving et al., sion and anxiety symptoms (Wisner, 2014). Early studies
2009; Klatt et al., 2015; Li & Bressington, 2019; Marcus showed promising results in decreasing anxiety, fatigue,
et al., 2003; Morton et al., 2020; Tang et al., 2007). depressive symptoms, stress-related issues, and disorders for
Despite extensive empirical support for mindfulness prac- various conditions (Bei et al., 2013; Fjorback et al., 2011;
tice with adults, the question of whether MBI also benefits Grossman et al., 2004; Piet & Hougaard, 2011; Piet et al.,
youth remain less clear, as far fewer studies examine mind- 2012). Furthermore, mindfulness training for youth has been
fulness practice with school-aged children and adolescents shown to be efficacious for some neurocognitive, psycho-
(Caldwell et al., 2019; Greenberg & Harris, 2012; Zoog- social, and psychobiological outcomes while also showing
man et al., 2015). Mindfulness practices have gained recent that MBIs are feasible and acceptable for youth in schools
worldwide popularity as a school-based intervention (Burke, (Black, 2015). Although there have been studies examining
2010; Greenberg & Harris, 2012; Zenner et al., 2014). These outcomes of MBIs, there are limited reviews focused solely
mindfulness-based school interventions (MBSIs) target a on school-based interventions. Additionally, it is important
host of outcomes, including increasing awareness, empa- to examine which outcomes show promising results together
thy, compassion, gratitude, perspective-taking, psychologi- with outcomes that are not improved through MBSIs. Previ-
cal flexibility, present centeredness, and self-regulation such ous reviews and meta-analyses examined the quantity and
as regulating behaviors, cognitions, and emotions (Bernay strength of the evidence but did not weigh this by the quality
et al., 2016; Eva & Thayer, 2017; Hill & Updegraff, 2012; of the evidence according to research design. Thus, the pre-
Moses & Barlow, 2006; Sapthiang et al., 2019; Schonert- sent study addresses this gap in the literature by providing a
Reichl et al., 2015). MBIs with youth have shown reduc- systematic review that examines MBSIs on youth outcomes
tions in behavioral problems, affective disturbances, stress, by quality of study design using evidence-based guidelines,
and suicidal ideation as well as improvements in ability to which is key to advancing the field of MBSIs. Prior to turn-
manage anger, well-being, and sense of belonging (Carsley ing to the present study, we first consider what is known
et al., 2018; Coholic et al., 2019; Felver et al., 2016; Mur- from previous reviews of MBI with youth and in schools.
ray et al., 2018). Empirical studies have also demonstrated Several meta-analytic and systematic reviews include
improvements in attention skills, social skills, sleep qual- MBIs delivered across multiple settings, including schools.
ity, and reductions in somatic and externalizing symptoms Previous reviews found that youth who practiced mindful-
(Beauchemin et al., 2008; Biegel et al., 2009; Bootzin et al., ness have positive outcomes for cognitive performance,
2005; Britton et al., 2010; Napoli et al., 2005; Zylowska resilience to stress, mindfulness, executive functioning,
et al., 2008). attention, depression, anxiety, and negative behaviors (Chi
The practices incorporated in MBSIs include psychoedu- et al., 2018; Dunning et al., 2019; Zenner et al., 2014). Fol-
cation about emotions and mindfulness, as well as specific lowing is a summary of ten published meta-analytic and

13
Mindfulness

systematic reviews that examined the use of MBIs for youth small to moderate positive effects, it is noteworthy that some
(Bender et al., 2018; Black, 2015; Carsley et al., 2018; Kalla- reviews yielded null effects for some outcomes. For exam-
piran et al., 2015; Klingbeil, Fischer, et al., 2017; Klingbeil, ple, Maynard et al. (2017) found no effect for behavioral and
Renshaw, et al., 2017; Maynard et al., 2017; Semple et al., academic outcomes; similarly, Zenner et al. (2014) found no
2017; Zenner et al., 2014; Zoogman et al., 2015). First, it effect for emotional problems. Therefore, further examina-
is important to note the types of primary studies that were tion is needed on the consistency of positive outcomes from
included. One meta-analysis included single-case designs MBSIs. That said, it is also important to note that none of
(Klingbeil, Fischer, et al., 2017), three included any group the previous reviews indicated harmful or iatrogenic effects.
designs (Carsley et al., 2018; Klingbeil, Renshaw, et al., Finally, previous reviews have not focused on grading
2017; Zoogman et al., 2015), and one included only ran- the quality of evidence but instead produced the average
domized controlled trials (RCTs; Kallapiran et al., 2015). effect sizes. Given that several reviews collapsed all the stud-
Five systematic reviews included randomized control trials, ies together, the evidential quality is mixed, which makes
nonrandomized control trials, case studies, cohort studies, it challenging to know how strong the quality of evidence
and quasi-experimental designs (Bender et al., 2018; Black, is that supports the outcomes (Bender et al., 2018; Black,
2015; Maynard et al., 2017; Semple et al., 2017; Zenner 2015; Carsley et al., 2018; Klingbeil, Fischer, et al., 2017;
et al., 2014). The findings from these several reviews across Klingbeil, Renshaw, et al., 2017; Maynard et al., 2017; Sem-
study design types found that MBIs with youth improve ple et al., 2017; Zenner et al., 2014; Zoogman et al., 2015).
cognitive and socio-emotional competencies, executive Likewise, one review that only examined RCTs produced
functions, depressive symptoms, anxiety symptoms, rumi- much higher quality evidence (Kallapiran et al., 2015). Since
nation, internalizing problems, externalizing problems, these reviews either collapsed all studies together or looked
prosocial skills, stress, physical health, well-being, per- at RCT only, none of the reviews systematically considered
ceptions of peer relations, mood, quality of life, academic the quality of evidence both across study designs and within
achievement, disruptive behavior, and negative and positive RCTs.
emotions (Bender et al., 2018; Black, 2015; Carsley et al., To address the growing interest in MBSIs and to inform
2018; Kallapiran et al., 2015; Klingbeil, Fischer, et al., 2017; those choosing programs, we systematically reviewed pub-
Klingbeil, Renshaw, et al., 2017; Maynard et al., 2017; Sem- lished studies of MBSIs for youth in schools (cf. Felver
ple et al., 2017; Zenner et al., 2014; Zoogman et al., 2015). et al., 2016; Zenner et al., 2014). Unlike prior systematic
Compared to MBIs in other settings, MBSIs have effects reviews and meta-analyses, our review sought to examine
that are in the cognitive domain as well as in psychologi- the quality of outcome evidence by research design, as well
cal measures of stress, coping, and resilience (Zenner et al., as the quantity of evidence across studies. Specifically, the
2014). Furthermore, MBSIs appear to be more effective for first objective was to determine the quality of the evidence
decreases in negative mental traits (e.g., affective distur- across diverse outcomes including well-being, self-compas-
bances, anxiety) as opposed to increases in positive mental sion, social functioning, mental health, self-regulation and
traits (e.g., positive affect, prosocial functioning; McKeering emotionality, mindful awareness, attentional focus, psycho-
& Hwang, 2019). However, further research comparing the logical and physiological stress, problem behaviors, aca-
relative strength of MBSIs for improving different mental demic performance, and acceptability. The second objective
traits is needed, particularly research weighting evidence of was to investigate the quantity of the evidence across stud-
these outcomes by study design. ies. Finally, the quality and quantity combined was exam-
These reviews indicate the need for future studies to ined across studies to determine which outcomes are most
examine the effects of MBI with youth and in schools on robustly associated with MBSIs. We anticipate that findings
symptoms of psychopathology, to include more active con- from our systematic review would contribute to the literature
trols as the comparison group to allow future meta-analyses by providing evidence-based recommendations to clinicians,
to compare the effects of the intervention, and to examine educators, and school-based researchers on which specific
potential moderators that potentially influence program outcomes can be reliably targeted with MBSIs.
effectiveness (e.g., length of program), as well as to inves-
tigate the additional benefit of incorporating mindfulness
practices with other evidence-based practices. Methods
Considering the findings from the previous meta-analyses
and systematic reviews, there seems to be a clear pattern of We identified studies through a systematic search of pub-
evidence suggesting that MBIs are, on the whole, safe and lished articles of MBSIs with youth from the first available
effective for use with youth (generally) as well as in schools date until July 2021. The electronic databases searched
(specifically) for improving a host of valued outcomes. were PsycINFO, EBSCOHost, MEDLINE, and CINAHL
Although most of the outcomes in most reviews showed using terms related to MBSIs: (school-based mindfulness

13
 Mindfulness

interventions subt.exact ((“mindfulness” OR “mindfulness- teachers or children and/or implementation outcomes; (4)
based interventions” AND “students” OR “preschool stu- review paper on school-based mindfulness interventions;
dents” OR “elementary school students” OR “high school and (5) grade levels from kindergarten to 12th grade. Exclu-
students” OR “adolescent” OR “schools” OR “adolescent sion criteria included the following: (1) studies focusing
development” OR “curriculum” OR “teachers” OR “edu- only on yoga, creativity, or other approaches not specific
cational programs” OR “middle school students” OR “ele- to mindfulness; (2) parent-based training on mindfulness;
mentary school teachers” OR “public school education”) (3) clinic-based mindfulness interventions; (4) student age
NOT (“middle aged” OR “yoga” OR “college students” group ≥ 22 years (as students with disabilities in the USA
OR “young adult” OR “occupational stress” OR “parents” can stay at school until they are 21 years old). Raters reached
OR “chronic pain” OR “drug abuse” OR “neoplasms” OR high inter-rater reliability (k = 0.98) in determining article
“parenting” OR “substance-related disorders” OR “relapse eligibility. When raters disagreed, they discussed eligibility
prevention” OR “no terms assigned” OR “psychotherapy” to reach a consensus.
OR “test construction” OR “health care services” OR “medi-
cal students” OR “mobile phones” OR “adult” OR “preg- Extracted Data from Studies
nancy”)) NOT su.exact (“Thirties (30–39 yrs)” OR “Middle
Age (40–64 yrs)” OR “Aged (65 yrs & older)” OR “Very The following information was extracted from each study:
Old (85 yrs & older)”) NOT po.exact (“Outpatient” OR (1) country, (2) sample characteristics (sample size, mean
“Inpatient” OR “Animal”) AND PEER(yes) AND la.exact age [or age range if mean was not provided], percentage of
(“English”) NOT rtype.exact (“Comment/Reply” OR “Edi- males and females, ethnicity, socioeconomic status, whether
torial” OR “Erratum/Correction” OR “Review-Book” OR children were of a special needs population), (3) information
“Letter”)). We found 352 articles through this initial search on the school level (preschool, elementary, middle, or high
prior to eligibility coding (see Fig. 1 for the study selection school), classroom setting (general education, special edu-
process). In defining MBSIs, we selected only intervention cation, or alternative school; private or public), (4) type of
studies that applied mindfulness meditation including dia- intervention, (5) research design (quantitative, qualitative, or
lectical behavior therapy (Linehan, 1993) and acceptance mixed), (6) evaluation design (e.g., RCT, pre-post), (7) the
and commitment therapy (Strosahl & Wilson, 1999) as inter- mediator (i.e., person who conducted the intervention), (8)
vention frameworks since they both focus on acceptance and the findings on outcomes (outcome measures), (9) outcome
mindfulness. measure type (self-report, teacher-report, etc.), (10) control
group, and (11) whether teacher training was provided. We
Eligibility Ratings believe it is important to consider the research and evalua-
tion design of studies given the impact of methodological
Two coders assessed the eligibility of each journal article for variations on the results. Furthermore, it is also essential
inclusion based on the following criteria: (1) peer-reviewed to examine whether teacher training was provided since
journal article; (2) mindfulness-based school interven- research shows that there are significant effects at follow-up
tion, program, or strategies; (3) mindfulness outcome on

Fig. 1  Article screening, inclu-

sion, and design
Records identified through Records excluded (n=275)
database searching and screened
245 studies not based in schools,
(n=352)
15 studies with participants ≥ 22 years old,
13 studies not using mindfulness, and
2 studies not peer-reviewed
Studies included in review (n=77)
36 RCTs,
13 Pre-Post Design w/ Non-
Randomized Control,
21 Pre-Post Design w/ No Control
Group
5 Case Series,
1 Case Study, and
1 A-B-A Design

13
Mindfulness

when teachers are trained to deliver the program (Carsley of evidence for each article on a scale outlined by Har-
et al., 2018). bour and Miller (2001), ranging from 1 +  + (RCTs with a
very low risk of bias), 1 + (RCTs with a low risk of bias),
Evidence Ratings 1 − (RCTs with a high risk of bias), 2 +  + (high-quality
case–control or cohort studies with a very low risk of con-
We used a robust system for grading recommendations in founds, bias, or chance, and a high probability that the
evidence-based guidelines (Harbour & Miller, 2001) to relationship is causal), 2 + (well-conducted case–control
weigh evidence per study design in a two-step process. or cohort studies with a low risk of confounds, bias, or
Using PRISMA 2020 as a guideline for our systematic chance and a moderate probability that the relationship
review, we used the Harbour and Miller (2001) ratings to is causal), 2 − (case–control or cohort studies with a high
examine the level of evidence since PRISMA 2020 recom- risk of confounds, bias, or chance and a significant risk
mends assessing certainty in the body of evidence of an that the relationship is not causal), 3 (non-analytic stud-
outcome (item #15 in the PRISMA checklist) and to pre- ies, e.g., case reports, case series) to 4 (expert opinion).
sent assessments of certainty in the body of evidence for We further specified criteria relating to risk of bias; for
each outcome assessed (item #22 in the PRISMA check- example, studies rated as 1 +  + were RCTs that include
list). We are not using the Harbour and Miller guidelines at least three of the following criteria: competence/fidel-
in replacement of the PRISMA 2020 guidelines, but rather ity measurement, daily program implementer meetings,
to grade evidence per study design in order to adhere to high participant attendance rate of 90% or higher, experi-
items #15 and #22 in the checklist. As such, we graded enced program implementer, large sample size, 8 week or
evidence based on the methodological rigor of studies to longer sessions, conducted follow-ups post-intervention.
draw conclusions about the state of the science of MBSIs, See Table 1 for the full grading system of recommenda-
and to make informed recommendations to advance the tions in evidence-based guidelines. Using the breakdown
field. First, for all eligible articles, two authors indepen- mentioned above, ratings of studies included in this review
dently assigned a numerical rating regarding the level ranged from 1 +  + , 1 + , 1 − , 2 +  + , 2 + , 2 − , 3 to 4, with

Table 1  Grading system for recommendations in evidence-based guidelines based on Harbour and Miller (2001)

Levels of evidence
• 1 +  + RCTs with a very low risk of bias, competence/fidelity measured, program implementers meet regularly to prevent drift, facilitator/
teacher blind to study condition, participant attendance rate 90% or higher, program implementer has 3 + years of mindfulness training, large
sample size (> 100), 8-week or longer, 10 session course, follow-ups on studies that are 12 months or longer
• 1 + RCTs with a low risk of bias, facilitator/teacher blind to study condition, participant attendance rate 80% or higher, medium sample size
(40–100), 6–7 week or 8–9 session course
• 1 − RCTs with a high risk of bias, small sample size (< 40), self-reported data, facilitator/teacher not blind to study condition, competence/
fidelity not formally measured, single study site (less generalizable), high percentage of female vs. male (or vice versa), < 6 week or < 8 ses-
sion, implementation of program was shorter than intended
• 2 +  + High-quality case–control or cohort studies with a very low risk of confounds, bias, or chance and a high probability that the relation-
ship is causal, competence/fidelity measured, program implementers meet regularly to prevent drift, facilitator/teacher blind to study condition,
participant attendance rate 90% or higher, program implementer has 3 + years of mindfulness training, large sample size (> 100), 8-week or
longer, 10 session course, follow-ups on studies that are 12 months or longer, has a control group
• 2 + Well-conducted case–control or cohort studies with a low risk of confounds, bias, or chance and a moderate probability that the relation-
ship is causal, facilitator/teacher blind to study condition, participant attendance rate 80% or higher, medium sample size (40–100), 6–7 week
or 8–9 session course
• 2 − Case–control or cohort studies with a high risk of confounds, bias, or chance and a significant risk that the relationship is not causal, small
sample size (< 40), self-reported data, facilitator/teacher not blind to study condition, competence/fidelity not formally measured, single study
sight (less generalizable), missing data, high percentage of female vs. male (vice versa), < 6 week or < 8 session, lack of control group, imple-
mentation of program was shorter than intended
• 3 Non-analytic studies, e.g., case reports, case series
• 4 Expert opinion
Grades of recommendations
• A At least one RCT rated as 1 +  + and directly applicable to the target population, or a body of evidence consisting principally of studies rated
as 1 + directly applicable to the target population and demonstrating overall consistency of results
• B A body of evidence including studies rated as 2 +  + directly applicable to the target population and demonstrating overall consistency of
results, or extrapolated evidence from studies rated as 1 +  + or 1 +
• C A body of evidence including studies rated as 2 + directly applicable to the target population and demonstrating overall consistency of
results, or extrapolated evidence from studies rated as 2 +  +
• D Evidence level 3 or 4 or extrapolated evidence from studies rated as 2 +

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high inter-rater reliability (k = 0.91). Raters discussed the the study. Likewise, most studies did not include socioeco-
six discrepant articles that they initially rated differently nomic status (62%).
until they reached a consensus on the ratings. Regarding the person that mediated the treatment deliv-
Second, after determining the level of evidence for each ery, 3% did not report on the mediator, and of the studies
article, a lettered grading system was applied based on a that did report on the mediator, 40% were researchers, 28%
summary of the numbered ratings across studies: A (at least teachers, 19% trained instructors, 7% mix of researcher and
one RCT rated as 1 +  + and directly applicable to the target teacher/mindfulness instructor, 4% mindfulness instructors,
population, or a body of evidence consisting principally of and 3% counselors. In terms of teacher training on mindful-
studies rated as 1 + directly applicable to the target popula- ness interventions, only 31% reported teacher training. Fur-
tion and demonstrating overall consistency of results), B (a thermore, 50% reported using self-report as their outcome
body of evidence including studies rated as 2 +  + directly measure, 17% used both teacher report and self-report, 11%
applicable to the target population and demonstrating over- used a cognitive test with teacher or self-report, 8% used
all consistency of results), C (a body of evidence including only teacher report, 8% used two or more measures, and
studies rated as 2 + directly applicable to the target popula- 7% used other forms of outcome measure (i.e., computer
tion and demonstrating overall consistency of results), and tasks, cognitive tests, observation). See Online Resource 1
D (a body of evidence including studies rated as 3 or 4). See and Online Resource 2 for participant demographics, design,
Table 1 for the full grading system of recommendations in and methods for each of the 77 included studies.
evidence-based guidelines with further specificity per evi-
dence rating level. There was often variability in the num- Outcomes
bered study ratings across outcome measures. The ultimate
letter grade was determined by the inclusion of the number Outcomes from studies of MBSIs fit into the following
and number rating for high-quality studies (1 +  + or 1 +), as 11 categories determined by the main findings: (1) well-
described above. For example, for an outcome documented being, (2) self-compassion, (3) social functioning, (4) men-
in two studies rated 1 + and 3, the letter grade would be tal health, (5) self-regulation and emotionality, (6) mind-
Grade B as there was only one 1 + rated study (if there was ful awareness, (7) attentional focus, (8) psychological and
a 1 +  + rated study or a body of 1 + rated studies, the letter physiological stress, (9) problem behaviors, (10) academic
grade would be Grade A). performance, and (11) acceptability. For the purposes of this
study, we conceptualized well-being as subjective well-being
(i.e., feelings of contentment, life satisfaction) and mental
Results health as per clinical descriptors (i.e., depression, anxiety,
suicidality, trauma, eating disorders).
Study Characteristics
Summary of the Highest Quality Evidence Across Outcomes
We identified 77 eligible articles, which incorporated data
from 12,358 students across 5 continents (North America, In this systematic review of the quality of existing scientific
South America, Europe, Asia, and Australasia). The break- literature base of MBSIs (see the “Methods” section, “Evi-
down of articles by methods was as follows: 9 qualitative, 49 dence Ratings”), the strongest level of evidence (“A Grade”)
quantitative, and 19 mixed methods. For the control group across outcomes indicated that MBSIs increased prosocial
type, there were 28 active control groups, 21 passive con- behavior, resilience, executive function, attention, and mind-
trol groups, and 28 without a control group. There were 35 fulness, and decreased anxiety, attention problems/ADHD
elementary schools, 8 middle schools, 25 high schools, 1 behaviors, and conduct behaviors, with evidence for well-
preschool, 5 mixes of elementary and middle schools, and being being split, with some studies showing increased well-
3 mixes of middle and high schools. Given that all studies being and some showing no improvements. As described in
took place in a school setting, the data from this review are the “Methods” section, “A Grade” evidence comes from at
community-based instead of clinically based. least one RCT rated as 1 +  + and directly applicable to the
Forty-three percent of schools did not report on setting target population, or a body of evidence consisting princi-
(e.g., public, private), but across those that did, 22% were pally of studies rated as 1 + directly applicable to the target
private, 55% public, 5% alternative schools, 2% specialized population and demonstrating overall consistency of results.
school, and 16% a combination of schools. Fifty-two percent See Table 1 for a description of each level of evidence,
of children were female. Forty percent of studies did not Table 2 for the outcomes per study, Fig. 2 for the breakdown
include race/ethnicity, but those that did showed a diverse of studies for each outcome by quality, and Online Resource
sample of 44% while 16% had homogenous samples within 3 for the numbered list of included studies from Table 2.

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Table 2  Results and evidence grades from MBSI studies

Category Results References Grade of
evidence

1) Well-being General well-being

↑ Well-being 35, 45, 64, 67, 68 A
= Well-being 10, 16, 22, 32, 33 A
↑ Feelings of contentment 13 D
↓ Life satisfaction 65 C
2) Self-compassion Self-compassion/intrapersonal
↑ Self-compassion 13 D
↑ Intrapersonal strengths 73 C
↑ Embracing life 45 D
↑ Self-acceptance 15 C
↑ School self-concept 58 B
↓ Inferiority complex 45 D
3) Social functioning Social relationships
↑ Interpersonal problems 28 D
↑ Interpersonal strengths 73 C
↑ Psychosocial functioning 73 C
↑ Relationships with others 71 D
↑ Prosocial behavior 60, 71 A
= Psychosocial adjustment 47 D
↑ Empathy 45, 58 B
= Empathy 53 C
↑ Connection with others 45 D
= Compassion 53 C
↑ Caring/respect for others 11 D
↑ Social competence 25 B
↑ Social skills 6 D
↓ Social problems 52 C
Social participation
↑ Collaboration 19 D
↑ Communication 19 D
↑ Participation in activities 11 D
Social bias
↓ Stereotype/prejudice towards 9 B
Israeli-Palestinian outgroup
4) Mental health Depression
↓ Depressive symptoms 8, 12, 20, 46, 48, 54 B
= Depressive symptoms 16, 18, 32, 33 A
↓ Rumination 62 C
Anxiety
↓ Anxiety symptoms 7, 8, 41, 48, 62, 63 B
↓ Generalized Anxiety Disorder 42 A
↓ State and trait anxiety 6 D
= Anxiety 16, 32, 33 C
↓ Worry 42 A
↓ Panic disorder 42 A
↓ Obsessive-compulsive Disorder 42 A
↓ Psychosomatic complaints 49 C
↓ Internalizing problems 14, 18, 27, 42 A
Suicidality

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 Mindfulness

Table 2  (continued)
Category Results References Grade of
evidence

↓ Suicidal thoughts 44 C
Trauma
↓ Posttraumatic symptoms 63 B
Eating disorder
↓ Dietary restraint 1 C
↓ Thin ideal internalization 1 C
↓ Eating disorder symptoms 1 C
↓ Psychosocial impairment 1 C
= Weight/shape concern 32, 33 C
↓ Weight/shape concern 1 C
5) Self-regulation and emotionality Self-regulation
↑ Self-regulation 23, 28, 44, 53, 66 B
↑ Emotion regulation 4, 15, 49, 58, 71 B
↑ Resilience 70 A
↑ Coping skills 63 B
↑ Distress tolerance 59 D
↑ Emotional awareness 49 C
↑ Emotional clarity 49 C
↑ Feelings of relaxation 15 C
↑ Relaxed in school 66 B
↑ Calmness 15 C
↑ Self-control 11, 75 D
↑ Effortful control 64 D
↑ Anger management skills 68 D
↑ Executive function 31, 34, 43, 52, 77 A
↑ Cognitive control 50, 58 B
↑ Cognitive inhibition 74 C
Emotionality
↑ Positive mood 45, 55 B
↓ Negative feelings 9, 21, 37 B
↓ Negative affect 15, 45, 69 C
= Negative affect 16 C
6) Mindful awareness Mindfulness
↑ Mindfulness 10, 21, 23, 37, 59 A
= Mindfulness 22, 33, 38 C
↑ Awareness of thoughts 76 B
↑ Awareness of feelings 76 B
↑ Awareness of emotions 76 B
↑ Awareness of bodily sensations 76 B
↑ Being present in life 76 B
↑ Sense of efficacy 59 D
↓ Mind-wandering 58 B
Positive outlook
↑ Optimism 23, 57 C
↑ Positive thinking 23 D
Perspective-taking 58 B
↑ Perspective-taking
7) Attentional focus Attention
↑ Attention 11, 22, 31, 37, 53, 66, 72 A

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Mindfulness

Table 2  (continued)
Category Results References Grade of
evidence

↑ Selective attention 51 C
↑ Attention awareness 23 D
↑ Concentration 55 B
↑ Controlled thoughts 75 D
↑ On-task behavior 36, 56 D
= Task-shifted facilitation 1 C
↓ Attention problems 14, 18, 48 A
↓ Distractibility 66 B
↓ Off-task behaviors 24, 56 D
↓ ADHD behaviors 51, 60 A
Impulsivity
↓ Impulsivity 26 B
8) Psychological and physiological stress Psychological stress
↓ Stress 5, 17, 29, 46, 49, 67, 68, 75 B
↑ Stress 28, 61 D
= Stress 16 C
Physiological stress
↑ Stress physiology—skin temperature/conductivity 40 B
↓ Stress physiology—cortisol 58 B
↓ Right amygdala activation to fearful stimulus 5 B
↓ Tiredness 15 C
↓ Aches/pains 15 C
↑ Sleep 7 D
↑ Functional connectivity 5 B
↑ Brain plasticity 5 B
9) Problem behaviors ↓ Aggression 26, 48, 52 B
↓ Disruptive behaviors 39 D
↓ Conduct behavior 2, 48, 60, 71 A
↓ Externalizing problems 14, 27 C
10) Academic performance General academic performance
↑ School specific efficacy 28 D
↑ Academic performance 6, 8, 25 B
↑ Creativity 19 D
↑ Critical thinking 19 D
↑ Meta-cognition 69 D
↑ Auditory-verbal memory 55 B
↑ Grade Point Average 3 B
↑ Data-driven information processing 74 C
↑ Academically engaged behavior 24 D
↑ Positive attitude towards academic subjects 37 B
↓ Test anxiety 51 B
↓ Cognitive errors 50 C
Math
↑ Math performance 58 B
↑ Math score 3 B
Reading
↑ Grades in reading 2 C
= Reading fluency 30 D
Science

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 Mindfulness

Table 2  (continued)
Category Results References Grade of
evidence

↑ Grades in science 2 C
Social studies
↑ Social studies score 3 B
11) Acceptability ↑ Satisfaction with program 61 D
↑ Understanding and willingness to use strategies 61 D
↑ Acceptance of mindfulness 7, 32, 68 C

Note: ↑ increase, ↓ decrease, = no change. See Online Resource 3 for numbered list of included studies

Below we summarize the results per outcome type, high- evidence quality (“C and D Grades”). The highest quality of
lighting “A Grade” and “B Grade” evidence, and noting any evidence documented (“A Grade”) was for improvements in
differences that were apparent between the overall summary prosocial behavior, followed by “B Grade” evidence show-
of results from pre- to post-treatment incorporating all stud- ing improvements in empathy and social competence, and
ies and when examining studies per research design (quan- reduced prejudice towards outgroups. No differences were
titative, qualitative, and mixed), evaluation design (RCT, apparent when examining results per research design, evalu-
pre-post, single case/series, etc.), or per control group type ation design, or control group type, except no pre-post or
(active, passive, none). For a full breakdown of outcomes passive design studies reported null improvements in social
by these study characteristics and individual study evidence functioning.
ratings, see Online Resource 4.
Mental Health
Well‑being
Nineteen of 77 eligible articles (25%) targeted mental health
Ten of the 77 eligible articles (13%) targeted well-being domain outcomes. Most studies reported reduced depression
domain outcomes. Results were mixed regarding well-being and anxiety symptoms (71% and 80%, respectively). How-
outcomes, with 50% of studies showing improved well- ever, higher quality evidence (“A Grade”) shows no decrease
being, and the rest showing no difference (42%) or lower in depression symptoms (compared to “B Grade” evidence
well-being (8%). The mixed results from studies specifically that does show a decrease in depression symptoms). By
studying well-being were both from “A Grade” evidence. contrast, studies showing no decrease in anxiety were of
No differences were apparent when examining results per lower quality evidence (“C Grade”) compared to evidence
research design, evaluation design, or control group type, showing a decrease in generalized anxiety disorder, worry,
except no pre-post design studies reported null improve- and panic disorder (“A Grade”), or anxiety symptoms (“B
ments in well-being. Grade”). The one study examining suicidality and the one
study examining trauma each found reduced symptoms.
Self‑compassion Only one of the three studies examining eating disorder
symptoms reported a reduction in symptoms. No differences
Five of the 77 eligible articles (6%) targeted self-compassion were apparent when examining results per research design,
domain outcomes. 100% of studies across research designs, evaluation design, or control group type, except no pre-post
evaluation designs, and control group types that examined design studies reported null improvements in mental health.
self-compassion showed greater improvement. There was no
“A Grade” evidence and the strongest evidence (“B Grade”) Self‑regulation and Emotionality
documented higher school self-concept.
Thirty-one of 77 eligible articles (40%) targeted self-reg-
Social Functioning ulation and emotionality domain outcomes. Most studies
(97%) in this category reported improved self-regulation and
Fifteen of 77 eligible articles (19%) targeted social function- emotionality across research designs, evaluation designs,
ing domain outcomes. Most studies (86%) that examined and control group types, except for one study of “C Grade”
social functioning found that MBSIs improved social rela- evidence that found no change in negative affect. No dif-
tionships and social participation as well as reduced social ferences were apparent when examining positive vs. null
bias, and those that found no improvements were of low improvement studies in terms of research design, evaluation

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Mindfulness

design, or control group type. For the self-regulation cat- followed by “B Grade” evidence showing improvements in
egory, the highest quality evidence (“A Grade”) docu- self- and emotion regulation, coping skills, and cognitive
mented improvements in resilience and executive function, control, as well as more frequent relaxed states at school.

Fig. 2  Breakdown of studies for each outcome by quality. Note: Acceptability outcomes were not included in the breakdown as few studies
examined this outcome

13
 Mindfulness

Fig. 2  (continued)

For the emotionality category, the highest quality studies perspective-taking and having a positive outlook, and most
(“B Grade”) documented higher positive moods and lower (73%) documented improvements in mindfulness; however,
negative feelings. evidence showing no improvements in mindfulness was of
a lower quality (“C Grade”). No differences were apparent
between positive and null improvement studies when exam-
Mindful Awareness ining results per research design, evaluation design, or con-
trol group type. The strongest evidence (“A Grade”) showed
Eleven of 77 eligible articles (14%) targeted mindful aware- improvements in mindfulness, followed by “B Grade” evi-
ness domain outcomes. All studies documented improved dence showing increased awareness of thoughts, feelings,

13
Mindfulness

emotions, and bodily sensations, being more present in life types, MBSIs improved academic performance. One study
as well as decreased mind-wandering. found null improvements in reading fluency, so this was
characterized as “D Grade” evidence. There was no “A
Grade” evidence for this domain. The strongest evidence
Attentional Focus (“B Grade”) documented specific improvements in academic
performance, auditory-verbal memory, GPA, math perfor-
Twenty of 77 eligible articles (26%) targeted attentional mance, math score, and social studies score, as well as an
focus domain outcomes. Most studies (95%) showed increase in positive attitudes towards academic subjects and
improvements in attention and reduced impulsivity across lower test anxiety.
research designs, evaluation designs, and control group
types, except one study finding no effects in task-shifted Acceptability
facilitation; however, evidence showing no improvements
was of a lower quality (“C Grade”). The highest quality evi- Only four of 77 eligible articles (5%) examined the accept-
dence (“A Grade”) found increased attention, and decreased ability of MBSIs, with all finding that they were highly
attention problems and ADHD behaviors, followed by “B acceptable; however; this evidence was of “C and D
Grade” evidence showing increased concentration, and Grades.” There was no “A or B Grade” evidence reported
decreased distractibility and impulsivity. for this domain.

Psychological and Physiological Stress Discussion

Fifteen of 77 eligible articles (19%) targeted psychological Our findings on the highest quality of evidence on MBSIs
and physiological stress domain outcomes. Overall, most (“A Grade”) are consistent with previous studies on adults
studies (73%) showed that MBSIs decreased psychologi- which have documented increased prosocial behavior, resil-
cal and physiological stress. Specifically for psychological ience, executive function, attention, and mindfulness, and
stress, eight studies showed a reduction in stress (“B Grade” decreased anxiety, attention problems/ADHD behaviors,
evidence), one study (7%) showed a null effect on stress (“C and conduct behaviors (e.g., Goldberg et al., 2021; Guen-
Grade” evidence), and two studies (13%) showed an increase delman et al., 2017; Hofmann et al., 2010; Hoge et al.,
in psychological stress (“D Grade” evidence). Specifically 2013; Kemeny et al., 2012; Ramasubramanian, 2017; Rog-
for physiological stress, four studies showed a reduction in ers, 2013). In addition, these results are in line with recent
stress (“B–D Grades” evidence) and one study showed an studies where MBIs have demonstrated therapeutic effects
increase in stress (“B Grade” evidence). There was no “A targeting these mental health outcomes with youth in both
Grade” evidence for this domain, and regarding research clinical and school settings (Borquist-Conlon et al., 2019;
designs, evaluation designs, and control group types, no Dunning et al., 2019; Renshaw et al., 2017).
studies with active control groups found null/negative effects Unlike in previous reviews, by examining the evidence
on psychological stress. grade per outcome measure, it is evident that there is a true
split in evidence on well-being outcomes, with some high-
Problem Behaviors quality evidence showing increased well-being and some
other high-quality evidence showing no improvements (both
Nine of 77 eligible articles (12%) targeted problem behavior “A Grade” evidence). When considering the studies rated as
domain outcomes. All studies reported a reduction in prob- 1 +  + (the highest evidence level), the positive effect study
lem behaviors across research designs, evaluation designs, included middle school students from private schools and the
and control group types, including reduced aggression, null effect study included elementary school students from
disruptive behaviors, conduct behavior, and externalizing public schools; therefore, the difference in outcomes may
problems. The highest quality evidence (“A Grade”) showed relate to resources or student age groups. Further research is
a decrease in conduct behavior, followed by “B Grade” evi- needed to elucidate this issue. Moreover, our re-examination
dence showing a decrease in aggression. of the evidence per evidence grades has highlighted that
MBSIs have a null effect on depression symptoms (as per
Academic Performance “A Grade” evidence).
Findings on well-being and depression are in contrast
Sixteen of 77 eligible articles (21%) targeted academic per- with prior reviews examining adults, where there are many
formance domain outcomes. In most studies (94%) across well-designed RCTs examining the efficacy of mindfulness
research designs, evaluation designs, and control group relative to control groups. These RCTs have shown that the

13
 Mindfulness

intervention is effective in reducing depression and demon- (Lu et al., 2017; Thierry et al., 2016) although one review
strating improvements in well-being (Goldberg et al., 2021; found that MBSIs did not improve academic achievement
Hofmann & Gómez, 2017; Strauss et al., 2014). Previous (Maynard et al., 2017). Given the mixed results, the meth-
reviews have also shown that MBSIs positively affect well- odological differences in the quality of reviews compared
being and depression among youth (Chi et al., 2018; Erbe to studies should be considered before determining whether
& Lohrmann, 2015). Our findings also are inconsistent with MBSIs improve academic performance with children. It is
previous meta-analyses with adults (Khoury et al., 2015) noteworthy that gender differences in response to mindful-
and youth (Dunning et al., 2019; McKeering and Hwang, ness may also play an important role in youth academic per-
2019), which suggested that mindfulness practice improves formance. For example, a preliminary analysis indicated a
well-being. greater increase in both mindfulness and self-compassion
The next tier of evidence (B grade) supported the role of for females compared to males (Bluth et al., 2017). Like-
MBSIs in improving self-concept, social competence, self- wise, in terms of academics, girls tend to achieve higher
and emotion regulation, coping, executive function, cogni- grades than boys (Duckworth & Seligman, 2006; Duckworth
tive control, and mood, as well as reducing social bias and et al., 2015). Therefore, examining potential gender effects
attentional problems. Our review accords with previous stud- is especially important given the prevalence of gender dif-
ies (Joss et al., 2019; Nejati et al., 2015; Quaglia et al., 2019) ferences in affective disturbances and treatment outcomes
and a recent narrative review (Renshaw & Cook, 2017) of among youth (Kang et al., 2018). Future studies are needed
MBSIs, which strengthens the evidence that MBSIs improve to further explore these factors when looking at gender and
these outcomes for youth (Barnes et al., 2003; Flook et al., academic performance to refine and enhance existing pro-
2010; Mendelson et al., 2010). With improved self-concept grams and to inform future development of MBSIs.
and social competence, students can pay attention without Nonetheless, a smaller group of studies suggested posi-
judgment to what is happening with themselves and with tive changes (B grade) in physiology, neurophysiology, and
others (Schonert-Reichl et al., 2015). This can allow them brain plasticity. MBSIs have been shown to influence physi-
to become resilient and to confront the challenges they will ological changes in adults, although relatively fewer studies
face in classroom settings, such as exam stress, problems examine this connection compared to other behavioral and
concentrating, and dealing with difficult peers (Keye & mental health outcomes (Creswell et al., 2019). Given our
Pidgeon, 2013). As a result of mindful practice, students knowledge of brain plasticity in early development, future
may be better able to increase overall self-care by making research in this area with children is especially important
constructive changes in their personal and professional lives, (Black, 2015; Burke, 2010; Zoogman et al., 2015). Consid-
allowing for a healthier relationship with themselves and ering the potential neurophysiological processes of mind-
with others (Napoli & Bonifas, 2011). fulness, future studies should also explore the relationships
Strong (B grade) evidence also showed that MBSIs among length and quality of mindfulness practice, develop-
improved mindfulness, awareness of thoughts, feelings, mental stages of students, and their mental health outcomes
emotions, and bodily sensations, being more present in (Wielgosz et al., 2019). These factors may benefit MBIs
life, concentration, and attention, as well as reduced mind- in schools by improving memory and language skills (i.e.,
wandering, distractibility and impulsivity. Our findings on reading), which can increase academic success (Mundkur,
these outcomes are in line with increasing evidence on the 2005).
benefits of mindfulness for adults (Norris et al., 2018; Rahl Overall, there were no systematic differences between
et al., 2017; Shapero et al., 2018) and youth (Dunning et al., positive vs. null/negative effect studies in terms of research
2019; Renshaw, 2020). Although there is strong (B grade) design (quantitative, qualitative, and mixed), evaluation
evidence showing improved attention and reduced mind- design (RCT, pre-post, single case/series, etc.), and per con-
wandering, there is still insufficient evidence as to how much trol group type (active, passive, none), suggesting overall
mindfulness practice is needed to benefit students’ attention consistency in terms of these factors in the body of literature
regulation (Wimmer et al., 2020). Therefore, future studies to date on MBSIs. However, there were outcomes in need
should focus on the dosage—whether the length of interven- of higher quality evidence, including self-compassion, psy-
tion time, number of sessions, or total mindfulness practice chological and physiological stress, academic performance,
time—needed for students to achieve improved attention and acceptability.
regulation.
Strong (B grade) evidence also showed that MBSIs Limitations and Future Research
improved academic performance, specifically, report card
grades, auditory-verbal memory, GPA, math, and social There are several areas of notable strengths when consid-
studies performance. Several studies examining MBSIs have ering the literature on MBSIs used in schools. All studies
been shown to improve academic performance with children reported on group-based interventions conducted in typical

13
Mindfulness

classrooms during normal school hours, suggesting the gen- address these problem behaviors in schools since it has been
eralizability of the results to school-based practice. Another positively associated with teacher burnout and self-efficacy
strength is that many studies in this review used compo- (Brouwers & Tomic, 2000; Burke et al., 1996). This leads
nents of MBSR, the mindfulness-based intervention with to poor student–teacher relationships, which could affect
the most empirical support for its effectiveness (Kabat‐Zinn, students’ learning and achievement (Herman et al., 2018).
2003; Klingbeil, Fischer, et al., 2017; Klingbeil, Renshaw, Although many studies examined the acceptability and feasi-
et al., 2017; Kriakous et al., 2020). Finally, several stud- bility of child adaptations to adult MBIs (Bluth et al., 2016;
ies included data on student educational, attentional, and Broderick & Metz, 2009; Hiltz & Swords, 2021; Luiselli
behavioral outcomes, such as student achievement, ability et al., 2017; Metz et al., 2013; Quach et al., 2017), future
to focus, and grades. However, additional studies and meta- work on MBSIs should consider scalability and other fac-
analyses are needed to explore the evidence of the effective- tors known to impact the implementation of other school-
ness of MBSIs on these educational outcomes, which may be based or youth-focused programs. This includes principal
relevant to educators and other school-based stakeholders. and district buy-in, individual attitudes towards the inter-
Nevertheless, the literature exploring the effects of vention, and organizational climate and culture, as well as
MBSIs with youth has several limitations. Many studies implementation climate and leadership (Locke et al., 2016).
included in this review relied on small samples, with studies To facilitate effective implementation and sustainment of
averaging around 35 participants. Future studies may ben- MBSIs, studies should use a mixed-methods approach to
efit from larger sample sizes to power statistical analyses assess both outcomes and acceptability, adopting methods
adequately and to aid in the generalizability of the findings. such as teacher reports on student outcomes, review ses-
There also are significant limitations in how outcomes were sions, observations of training sessions, and student ques-
measured. Most studies relied on questionnaire measures to tionnaires and interviews (Zenner et al., 2014).
assess for effects (particularly student self-report), which are Finally, despite compelling theory and emerging evi-
limited by possible response bias and retrospective memory dence from adult samples (Gu et al., 2015), no studies
biases. Although some studies included used multiple meth- examined the mechanisms or active ingredients of mind-
ods (e.g., subjective self-reports, behavioral observations, fulness to understand the key components of MBSIs for
and objective neurocognitive, and physiological testing), producing positive outcomes. These studies are essential
the majority relied on a single method. To address these to explore the various active ingredients in mindfulness-
limitations, we recommend future MBSI studies to collect based interventions such as social support, relaxation, and
data regarding the training quality of the instructors and the cognitive-behavioral elements. Examining the central con-
amount of meditation conducted during training, as well as struct of mindfulness itself is also important to determine
to use substantially larger and more diverse samples of stu- if the development of mindfulness is what leads to the
dents to examine both the immediate and long-term impact positive changes that have been observed (Shapiro et al.,
of mindfulness training post-treatment. 2006). This is important to advance knowledge on how to
A third limitation of studies included in this review was best develop, adapt, and implement MBSIs to optimize
the lack of reporting of participant characteristics. For exam- outcomes. Also, no studies examined the long-term impact
ple, 40% of studies in this review did not provide details of MBSIs after 1 year, which would be beneficial in learn-
about participant race and ethnicity, which is important ing about the lasting impact that MBSIs have on youth.
given the underrepresentation of racial and ethnic popula- Future studies should therefore examine both mediating
tions in rigorous trials of MBIs (Waldron et al., 2018). Very mechanisms and the long-term impact of school-based
few studies included students receiving education supports, mindfulness training post-treatment.
and only five studies specifically examined the impact of We should note several limitations of our review meth-
MBSIs on children with disabilities (see Online Resource odology as well. First, we did not include gray/unpublished
1 for more details). Given that most of these studies were literature, which may have resulted in missing some relevant
conducted through whole class instruction, it is possible that studies. Indeed, there may have been a publication bias in
existing mindfulness interventions are not well suited to the the literature included, in that published studies are system-
specific needs and reality of a classroom for children with atically different from results of unpublished studies due
disabilities. Attention to specific developmental child char- to either non-submission for publication or rejection at the
acteristics (e.g., cognitive ability, attention span) is therefore review stage. Second, we did not evaluate specific mindful-
required when adapting MBSIs. ness practices (e.g., sitting meditation, body scan, movement
Few studies, all of lower quality, investigated the impact meditations) and program delivery aspects (e.g., level of
of MBSIs on problem behaviors such as aggression, disrup- teacher training). Given that mindfulness training is highly
tive behaviors, conduct behavior, and externalizing prob- variable across studies, it is important for future research
lems. More studies of higher quality are needed to better to examine these factors to determine which intervention

13
 Mindfulness

best fits the needs of youth. We also did not examine pro- of incorporating mindfulness interventions to youth in a
gram fidelity, which is important to moderate the relation- school setting. Despite the benefits that MBSIs may have
ship between the intervention and its outcomes as well as with youth, this area of research is still maturing, with many
to prevent potentially false conclusions from being drawn studies incorporating pre-post design or otherwise less rig-
about the intervention’s effectiveness. Third, our review did orous evaluation methods. Therefore, we urge researchers
not analyze the age appropriateness and pedagogy used for interested in MBSIs to study their effectiveness using more
MBSIs so future studies may benefit from examining these rigorous designs (e.g., RCTs with active control groups,
factors. We would also like to acknowledge that comparing multi-method outcome assessment, and follow-up evalu-
public school versus private school as well as integrating ation), to minimize bias and promote higher quality—not
socioeconomic status into the analysis would have added to just increased quantity—evidence that can be relied upon to
higher quality studies. Given that our study did not incorpo- guide school-based practice.
rate this into our analysis, we recommend that future stud-
ies consider these factors when examining the quality of Acknowledgements This paper would not have been possible without
the exceptional support of the lead author’s friends and family.
MBSIs. Furthermore, our “Results” section focused mainly
on the outcomes of the MBSIs without reporting the differ- Author Contribution MP: conceptualized the research, reviewed the
ences in the effectiveness of MBSIs based on the other data literature, wrote the paper, submitted the manuscript. TR: collabo-
that was extracted from individual studies (e.g., research or rated in the writing and editing of the final manuscript. JC: reviewed
evaluation design, teacher training, educational level). Since the literature. JG: collaborated in the writing and editing of the final
manuscript. EM: conceptualized the research, reviewed the literature,
our review examined the quality of outcome evidence by designed measurement approach. ZAD: reviewed the literature. ND:
research design, as well as quantity and strength of evidence reviewed the literature. HT: reviewed the literature. DM: designed
across studies, examining the differences in the effectiveness measurement approach, designed analytic approach, and collaborated
of MBSIs based on the mentioned constructs is beyond the in the writing and editing of the final manuscript. HN: developed gen-
eral research design, conceptualized the research, designed measure-
scope of our study. The descriptive information we coded ment approach, designed analytic approach, conducted data analysis,
about the studies was intended to describe the characteristics wrote the “Results” section, and collaborated in the writing and editing
of the population studies we reviewed rather than examin- of the final manuscript. All authors approved the final version of the
ing moderator and mediator analyses. As such, we suggest manuscript for submission.
future studies to include moderator and mediator analyses
when looking at the overall effectiveness of MBSIs and sug- Declarations
gest considerations of these factors in further considerations
Conflict of Interest The authors declare no competing interests.
of outcome quality. Finally, there are limitations to using a
systematic review methodology, which could have resulted Open Access This article is licensed under a Creative Commons Attri-
in the variability of our findings. Various design factors such bution 4.0 International License, which permits use, sharing, adapta-
as the educational level of students, type of intervention, and tion, distribution and reproduction in any medium or format, as long
type of delivery may have impacted the lack of effectiveness as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
observed in this present review. We recommend future stud- were made. The images or other third party material in this article are
ies to conduct a meta-analysis using high-quality evidence, included in the article's Creative Commons licence, unless indicated
especially for the outcomes with mixed results. otherwise in a credit line to the material. If material is not included in
This study reviews the studies of MBSIs for youth using the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
a robust system for grading recommendations that consid- need to obtain permission directly from the copyright holder. To view a
ers the methodological rigor of studies to determine effec- copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
tiveness recommendations of MBSIs for producing certain
outcomes. Strong evidence (B grade) indicates that MBSIs
improve self-compassion, social relationships, mental
health, self-regulation and emotionality, mindful aware- References
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