It is "probably not warranted" for UK schools to adopt universal mindfulness training in the attempt to address the ongoing crisis in adolescent mental health, the latest research has concluded.
The disappointing conclusion stems from a cluster of five studies that represent the culmination of 8 years of research for the My Resilience in Adolescence (MYRIAD) trial, published today in a special issue of Evidence Based Mental Health.
The project,sponsored by Wellcome, was prompted by previous research suggesting that mindfulness training can help both teachers' and students' mental health. However design flaws and too few participants undermined the findings of most of these studies, even though many schools were experimenting with it, said the MYRIAD trial researchers.
They, therefore, set out to explore how school-based mindfulness training compared with standard psychological wellbeing education in terms of its impact on teens, teachers, and the 'school climate'.
Adolescence Sets the Trajectory for People's Lives
Mental health problems often start during the teen years, a period of heightened vulnerability amid increasing academic, social, and emotional demands, the researchers noted. Recent years have seen a huge rise in the number of children and adolescents with significant mental health problems, which now affect as many as 1 in 5, possibly as many as 1 in 4 young people, said Professor Willem Kuyken of the Department of Psychiatry at the University of Oxford, one of the lead researchers, during a briefing at the Science Media Centre (SMC).
"But it’s actually much bigger and more important than that. Adolescence is an absolutely crucial time of development: both the psychology and the brain go through important and fundamental changes in adolescence that set the trajectory for people’s lives: 75% of mental health problems in adulthood will have first arisen at some point in adolescence."
The researchers wanted to target that "developmental window, before mental health problems first arise". Developing young people's resilience has consequences downstream, Prof Kuyken said.
Over 100 investigators were involved in the project, led by the Universities of Oxford and Cambridge, which included 28,000 children aged 11-14 taught by 650 teachers in 100 secondary schools – giving about 20 million data points. A range of different studies was performed.
Epidemiological Analysis
A survey of mental health and wellbeing in 26,885 11-14 year olds in 85 schools across the UK revealed that:
- As many as 1 in 3 children reported significant depressive symptoms and social-emotional-behavioural problems
- In terms of wellbeing, about 55% were doing well, but 29% were either languishing or had mental health problems
- Schools had a small but significant impact on young people’s mental health and wellbeing, with the main aspect being the 'climate' of the school: the degree to which it embodies a culture of respect, of teachers being approachable, and of effective leadership
Mindfulness Studies
Two cluster randomised controlled trials of the effects of a mindfulness intervention on mental health in schools were undertaken. In one of the largest investigations to date, involving 8376 children, whole schools were randomised to the mindfulness intervention (43 schools; 362 teachers) or to normal social-emotional learning (SEL) (41 schools; 310 teachers).
As currently taught in secondary schools, SEL aims to develop the self-awareness, self-control, and interpersonal skills that young teens need for school, work, and personal life.
The version of mindfulness training offered in UK schools typically involves teachers learning mindfulness - attentional control, combined with emotional and social regulation, as well as training in how to teach it to their students.
After the initial 8 week course, the mindfulness programme enhanced teachers' mental health and reduced burnout – something that Prof Kuyken said could be important in improving teacher retention - as well as improving some dimensions of the school climate. But after a year, these effects had all but disappeared.
The researchers concluded that despite the study – unlike others in the past – being well-conducted and adequately powered, results showed that: "The school-based mindfulness training, delivered by schoolteachers, in this developmental 11-14 window, did not do better than what schools were already doing in terms of teenagers’ mental health or wellbeing."
In another study, 460 11-16 year olds who had previously been randomly assigned to either mindfulness training (235) or to a matched study skills curriculum (225) were monitored in the midst of the pandemic to see whether mindfulness training had enabled them to stave off worsening mental health. There was no evidence that it had been any more protective than study skills training. Sub-analyses suggested that school mindfulness training might be best suited for older children and those who are well, but was not suitable for younger children and those with existing or emerging mental health symptoms.
Systematic Review and Meta-analysis
Finally, the team conducted a meta-analysis in context of the wider literature. A pooled data analysis of the results of 66 randomised controlled trials published up to January 2022, involving 20,168 participants, indicated that mindfulness based programmes led to small but significant improvements in mindfulness skills, attention, self-control, antisocial behaviour, depression and anxiety/stress, compared with other approaches. However these programmes didn’t improve wellbeing, nor, again, was there any evidence of sustained benefits a year later, prompting the researchers to conclude: "The enthusiasm for [mindfulness based programmes] in youth has arguably run ahead of the evidence. While [they] show promising results for some outcomes, in general, the evidence is of low quality and inconclusive."
In a linked perspective published in the same issue, Professor Pim Cuijpers from the Department of Clinical, Neuro, and Developmental Psychology at Vrije University in Amsterdam, said that despite decades of research, it still wasn’t clear if mindfulness training in schools really did boost psychological resilience and stave off mental ill health.
"The fully powered, high quality MYRIAD trial was a courageous attempt to come up with the right answer. It showed that universal prevention is probably not effective. Although no definite conclusion about this can yet be drawn, because there may be alternative explanations for the null findings, we seriously have to consider that it simply does not work. We may have to consider other options."
Take Home Messages
Prof Kuyken said that the take-home messages were:
- The age of the children appears key – older children appeared to benefit from the intervention but younger children didn’t
- Children with prior mental health challenges didn’t benefit from the intervention; indeed there was a suggestion they may have got worse
- Children’s views of the intervention were very mixed; many did not practice at all outside the classroom, and those children didn’t do as well
"Maybe what we need to do is design schools so that the whole school, the climate and the culture of the school, actually supports young people’s mental health and wellbeing," he said.
The authors concluded: "The overall evidence for the effectiveness of the approach, as delivered in its current format, is weak." They added "While there are some benefits for teachers, and the 'school climate' – the academic, community, safety, and structural features of a school – the effects are short-lived.
"Other options may now need to be considered to build psychological resilience in young people and ward off poor mental health later on."
Mental Health Worse After Pandemic Restrictions
The researchers stressed that the pandemic has considerably worsened the situation for this age group, as the impact of school closures and social restrictions hit children and young people particularly hard.
Co-Author Prof Tamsin Ford of the Department of Psychiatry at the University of Cambridge, who is also vice-chair Association for Child and Adolescent Mental Health, told the briefing that the epidemiological findings confirm "that mental health remains a huge challenge for young people". It has been deteriorating over a couple of decades, she said, and pandemic restrictions "have greatly amplified this situation". Those in their mid- to late-teens are particularly vulnerable, especially young women, and those living in deprived or highly urban areas.
There are more children who are struggling, despite the investments in school mental health teams: "Those investments are being swamped by the increased number of young people who need help.
"We’re running to keep still at the moment. We need to think of alternative ways to support young people’s mental health."
She added: "We have a consistent signal... in the UK... that among older teenagers and young women we seeing increasing levels of anxiety, depression and self-harm.
"We need to make sure that our schools are places that promote education and health rather than adding to young people’s stress and perhaps undermining their mental health."
Schools Contributing to Adolescent Stress
Also addressing the meeting, Sarah-Jayne Blakemore, professor of psychology and cognitive neuroscience at the University of Cambridge, said adolescence is "a sensitive period of brain development in which neuroplasticity is heightened". This means that "the brain is particularly susceptible to environmental input". This can confer vulnerability - if the input is stressful, that can lead to mental health problems - but can also lead to opportunity: adolescence offers a window of opportunity for interventions to increase resilience. However "there are vast individual differences in development".
"If you want to develop an intervention in schools aimed at improving resilience and wellbeing in young people", she said, "a one-size-fits-all program possibly just won’t work" – something she believes applies also in the context of general education in the UK.
Also, peers are really important: peer-led interventions in schools produce better results compared with similar interventions led by teachers. "We need to think about co-producing interventions with young people themselves – giving young people a voice... and empowering them to help each other."
The team also stressed that the problems of adolescents may be actually generated at school, particularly the stress of exams.
Prof Blakemore said: "The assessment system that we have in this country and the vast number of exams that young people have to do really needs to be radically re-thought... not just in terms of squeezing other skills out but also in terms of creating stress for young people."
Study co-lead Dr Tim Dalgleish, director of the Cambridge Centre for Affective Disorders at the University of Cambridge, concurred: "For policy-makers, it’s not just about coming up with a great intervention to teach young people to deal with their stress, you also have to think: where is the stress coming from? Are there policies that we could introduce that will reduce the stress?"
He added: "It’s not just about having skills to deal with stress once it’s arisen. You need to think earlier than that."
Commenting on the studies, Prof Stella Chan from the School of Psychology & Clinical Language Sciences at the University of Reading told the Science Media Centre: "Young people’s mental health is one of the most urgent health challenges we are facing across local and international communities. Large scale studies like this, with such scientific rigour, are critical in identifying what works and what doesn’t. While the key finding that mindfulness training does not improve young people’s mental health is disappointing, this study has made a significant contribution by highlighting the importance of the wider school culture and teachers’ wellbeing.
"It is important to note that the findings do not completely rule out the potential of mindfulness-based therapy for young people; as in any therapy, it works for some people but not all. The important questions are who can benefit from it, when and how. Finding ways to improve young people’s engagement in the practice and working with young people to re-design the programme are likely to be key. Overall, it is an impressive study.”
Dr Julieta Galante, NIHR Postdoctoral Fellow and Senior Research Associate, University of Cambridge, said: "This work shows the importance of large well-designed randomised trials to assess health interventions before any large-scale universal roll out. The mindfulness-based programme tested in this study had been thought to be effective based on a few small studies, and had already begun to be implemented in some schools. But we need to be very sure of benefit before rolling out any universal health intervention because the opportunity cost of implementing ineffective interventions can be high."
She added: "Large, well-designed trials also save taxpayers’ money in the long-term and avoid potential large-scale harm.
"The study also shows the importance of measuring follow-up outcomes, say after a year, rather than just measuring them right after the intervention ends – when more biases can be at play and fleeting benefit could be confused with long-term benefit."
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