The Use of Mindfulness with People with
Intellectual Disabilities: a Systematic
Review and Narrative Analysis
Melanie J. Chapman, Dougal J. Hare, Sue
Caton, Dene Donalds, Erica McInnis &
Duncan Mitchell
Mindfulness
ISSN 1868-8527
Volume 4
Number 2
Mindfulness (2013) 4:179-189
DOI 10.1007/s12671-013-0197-7
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Author's personal copy
Mindfulness (2013) 4:179–189
DOI 10.1007/s12671-013-0197-7
ORIGINAL PAPER
The Use of Mindfulness with People with Intellectual
Disabilities: a Systematic Review and Narrative Analysis
Melanie J. Chapman & Dougal J. Hare & Sue Caton &
Dene Donalds & Erica McInnis & Duncan Mitchell
Published online: 24 February 2013
# Springer Science+Business Media New York 2013
Abstract This paper presents a systematic review of the evidence on the effectiveness of mindfulness for people with
intellectual disabilities. Primary studies published in the
English language between 1980 and 2012 were identified from
electronic databases, experts and citation tracking. Eleven
relevant studies evaluating mindfulness training and practice
were identified: seven studies with people with intellectual
disabilities, two studies with staff members or teams and two
studies with parents. The studies found improvements in aggression and sexual arousal for people with intellectual disabilities after mindfulness training. Training staff led to
benefits for people with intellectual disabilities, decreased use
of physical restraint for aggressive behaviour and increased job
satisfaction. Training parents led to improved parental satisfaction and well-being and improved parent–child interactions.
The reported positive findings suggest that service providers,
people with intellectual disabilities and their families may want
M. J. Chapman (*)
Manchester Learning Disability Partnership,
Central Manchester University Hospitals NHS Foundation Trust,
Westwood Street, Moss Side,
Manchester M14 4PH, UK
e-mail: [email protected]
D. J. Hare
The University of Manchester, Manchester M13 9PL, UK
S. Caton
Manchester Metropolitan University, Manchester M13 0JA, UK
D. Donalds
Pathways Associates Community Interest Company,
Accrington BB5 1NA, UK
E. McInnis
Central Manchester University Hospitals NHS Foundation Trust,
Manchester M16 7AD, UK
D. Mitchell
Manchester Metropolitan University and Manchester Learning
Disability Partnership, Manchester M13 0JA, UK
to consider mindfulness approaches. However, the findings
have to be interpreted with caution due to methodological
weaknesses identified in the studies. Further high-quality independent research is needed before the reported improvements can be more confidently attributed to mindfulness.
Keywords Mindfulness . Systematic review . Intellectual
disabilities . Learning disabilities . Narrative analysis .
Developmental disabilities
Introduction
Mindfulness involves focussing attention purposefully in a
non-judgmental, non-reactive way on the present moment and
what is happening in an individual’s mind, body and the world
around them (Kabat-Zinn 1990). Mindfulness approaches differ from existing therapy programmes as they aim to help
people to focus on the present moment, to accept difficult to
change symptoms or situations and to enable different ways of
viewing and responding to situations (Fjorback et al. 2011).
There is evidence of the effectiveness of mindfulness for managing various physical and psychological health problems including stress, anxiety, depression, pain and disordered eating
(Baer 2003; Chiesa and Serretti 2010; Fjorback et al. 2011).
Mindfulness is a core strategy within treatment packages
such as mindfulness-based stress reduction (Kabat-Zinn
1990) and mindfulness-based cognitive therapy (Segal et
al. 2002). The former is a structured group programme
consisting of eight weekly 2–2.5-h sessions with daily home
assignments and a day retreat between weeks 6 and 7
(Kabat-Zinn 1990). Mindfulness is cultivated through formal practices such as the body scan, mindful movement and
sitting meditation, which are integrated into everyday life as
a coping resource to improve physical and psychological
well-being (Fjorback et al. 2011). Mindfulness-based cognitive therapy is an adaptation of mindfulness-based stress
reduction which focusses more on thoughts and consists of
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180
eight weekly 2-h sessions which incorporate elements of
cognitive therapy to facilitate a ‘detached or decentred view
of one’s thoughts’ (Fjorback et al. 2011, p. 103).
Mindfulness-based programmes for a range of health
conditions have been provided in the USA since the 1980s
and are increasingly common in the UK. However, mindfulness has not been widely used with people with intellectual disabilities, despite the increased prevalence of mental
health problems and vulnerability to chronic health conditions (e.g. epilepsy and diabetes) (Emerson et al. 2011).
People with intellectual disabilities have poor access to
healthcare services (Alborz et al. 2005), including mental
health services, and anecdotal evidence indicates that this is
also true for psychological therapies, including mindfulness.
Systematic and meta-analytic reviews of the use of
mindfulness-based interventions (e.g. Baer 2003; Chiesa
and Serretti 2010; Fjorback et al. 2011) have identified over
60 studies published since 1976 looking at the impact of
mindfulness on physical health conditions such as multiple
sclerosis, cancer, chronic obstructive lung disease, chronic
pain, rheumatoid arthritis, fibromyalgia, psoriasis and HIV,
and mental health problems such as recurrent depression,
anxiety and mood disorders, with some studies also examining the use of mindfulness with healthy participants. Whilst
there are methodological limitations to many of these studies,
there is some evidence supporting the use of mindfulnessbased interventions to improve psychological functioning and
alleviate various mental health and physical health conditions.
Existing systematic reviews have generally excluded
studies on the use of mindfulness with people with intellectual disabilities. Two recent systematic reviews have examined the use of mindfulness with people with developmental
and intellectual disabilities (Hwang and Kearney 2013a) and
with caregivers (Hwang and Kearney 2013b). However,
these reviews included people with educational learning
disabilities and autistic spectrum conditions and interventions
which involve additional non-mindfulness components (for
example, lifestyle interventions).
This paper reports on a systematic review conducted to
inform a study evaluating the use of mindfulness sessions
with people with intellectual disabilities (Chapman and
Mitchell 2013). The review objective was to assess the
effectiveness of mindfulness training and practice in relation
to people with intellectual disabilities. The review includes
studies of mindfulness interventions provided to both people
with intellectual disabilities and paid and informal carers.
Method
The systematic review followed the process set out by the
Centre for Reviews and Dissemination (2009). The following databases were searched in October 2012: EMBASE,
Mindfulness (2013) 4:179–189
MEDLINE, AMED, CINAHL and PSYCHINFO using the
following search strategy: (learning AND disab*) OR
(mental* AND retard*) OR (intellectual* AND disab*) OR
(developmental* AND disab*) AND mindfulness. A message
was also posted on the Jiscmail list Mindfulness and IDD to
determine whether professionals or academics interested in
the field were aware of additional publications. In addition,
citation tracking and checking of reference lists from journal
articles identified by the search were carried out.
Papers were included if they described a study evaluating
an intervention described as being based on mindfulness
principles with people with intellectual disabilities, their
family members or staff and which were published in an
English language journal from 1980–5th October 2012.
Papers were excluded if they involved people with autistic
spectrum conditions, attention deficit hyperactivity disorder,
conduct disorder or educational disabilities (e.g. dyslexia)
but not intellectual disabilities, or people who had brain
injuries acquired during adulthood. Studies that described
interventions of which mindfulness formed a component
(e.g. dialectical behaviour therapy, acceptance and commitment therapy) and interventions that included health promotion or behavioural training were also excluded, as it would
not be possible to distinguish whether it was mindfulness or
another aspect of the intervention which was having an
impact. A study examining the impact of mindfulness training
for staff working with people with intellectual disabilities was
excluded as it focussed on the impact on interactions with their
non-disabled children, not their children with intellectual disabilities (Singh et al. 2010). Figure 1 gives details of the
selection process.
Quality Assessment, Critical Appraisal and Data Extraction
Each study that met the inclusion criteria was allocated to
two members of the review team for independent quality
assessment and critical appraisal. The Evaluative Method
for Determining Evidence Based Practice (EBP) was used
to assess the quality of the studies (Reichow et al. 2008).
This method provides two rubrics for evaluating research
reports, one for group research and one for single subject
research. Each rubric evaluates primary quality indicators
(e.g. participant characteristics and independent and dependent variables) on a trichotomous ordinal scale (high quality,
acceptable quality and unacceptable quality) and secondary
quality indicators (e.g. inter-observer agreement and social
validity) on a dichotomous scale (evidence or no evidence).
The ratings from the rubrics are combined to provide a
strength of research rating (strong, adequate or weak).
Originally developed for use in autism research, the rubrics
are easily adaptable to research with people with intellectual
disabilities and are recommended as the most rigorous method for the quality appraisal of single-subject experimental
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Mindfulness (2013) 4:179–189
Fig. 1 Quality of reporting of
meta-analyses (QUORUM)
flow diagram
181
Publications identified for review (n=606):
- Database search (n=588)
- Internet searching (n=4)
- Professional networks (n=3)
- Content alerts/WELD Blog and JISCMAIL alerts (n=2)
- Reference tracking (n=9)
Publications excluded after sifting titles
and abstracts (n=549)
Publications retrieved that were potentially
relevant for data extraction (n=57)
Articles excluded after detailed relevance
checks (n=46)
- Not an intervention study (i.e.
discussion piece, book chapter, Editorial,
review, training manual, measure
development) (N=15)
- Intervention incorporates components
other than mindfulness (N=14)
- Not intellectual disabilities (e.g.
dyslexia, ADHD, ADD, high functioning
ASD, chronic health needs, focus on
sibling without ID) (N=10)
- Doctoral dissertation or conference
abstract (N=7)
Publications included in review (n=11)
designs (Wendt and Miller 2012). An advantage of the method
is that comparable ratings are created for single subject and
group research.
Detailed critical appraisal of the studies was conducted
using tools produced by CASP at the Public Health Resource
Unit (2007). These tools assist reviewers to consider the appropriateness of study design, risk of bias, choice of outcome
measures, recruitment, sample findings, follow-up and generalisability in a structured way. Information was extracted from
the included papers on study aims, design, intervention, sample, setting, length of follow-up, outcomes and key findings.
Review Findings
Eleven relevant studies were identified. Seven studies evaluated mindfulness training and practice for people with
intellectual disabilities (Table 1). Two studies evaluated
mindfulness training and practice for staff members or teams
working with people with intellectual disabilities (Table 2).
Two studies evaluated mindfulness training and practice for
parents of people with intellectual disabilities (Table 3).
Mindfulness Training for People with Intellectual
Disabilities
Analysis
As the studies identified were not randomised controlled
trials, a meta-analysis was not possible. Therefore, a narrative analysis was carried out describing and comparing the
main findings from the included studies and discussing their
methodological strengths and weaknesses (Centre for
Reviews and Dissemination 2009).
Singh and colleagues carried out six of the seven studies
focussing on the provision of mindfulness training directly
to people with intellectual disabilities (Singh et al. 2003,
2007a, 2008b, 2011a, c). In these studies, mindfulness procedures were taught to help people with intellectual disabilities deal with behavioural issues such as anger, aggression
and inappropriate sexual arousal.
To explore the possibility of teaching
a mindfulness-based technique, Soles
of the Feet, to self-regulate aggression
To evaluate the impact of teaching a
mindfulness technique (Soles of the Feet)
to adults with moderate intellectual disabilities
Singh et al.
(2003)
To explore the impact of communitybased therapists providing mindfulness
training (Soles of the Feet) to people
with intellectual disabilities
To investigate impact of mindfulness
group sessions on the aggressive
behaviour of women with intellectual
disabilities in a forensic medium secure
psychiatric unit
To evaluate the impact of mindfulness
practice (Soles of the Feet) when taught
by a peer with intellectual disabilities
To examine whether meditation procedures
(Soles of the Feet and mindful observation
of thoughts) could change sexual offenders’
inappropriate sexual arousal
Adkins et al.
(2010)
Chilvers et al.
(2011)
Singh et al.
(2011b)
Singh et al.
(2011c)
To evaluate the effectiveness of a
mindfulness-based procedure (Soles
of the Feet) for physical aggression
Singh et al.
(2008b)
Singh et al.
(2007a)
Aims
Study
Weak
Weak
Weak
Weak
Weak
Weak
Weak
Rigour
3 men with mild intellectual disabilities
from a forensic mental health facility
for people with intellectual disabilities
who had been sentenced for aggravated
Sexual assault on a minor or incest
and rape of children
Aged 23–34. 1 African-American,
1 Caucasian, 1 White Hispanic
3 adult males with mild intellectual disabilities
who lived in the community in supported
living and had anger and aggression
issues at work. Aged 26–32
3 Caucasian people with mild intellectual
disabilities, living in a group home or
with their parents, who were at risk of
losing their job, living placement,
preferred staff or funding
Aged 22–42. 2 male, 1 female
15 women with mild to moderate intellectual
disabilities in a forensic medium secure
psychiatric unit
Aged 18–47
27-year-old male with mild intellectual
disabilities who was an inpatient in a
psychiatric hospital
Three Caucasian adults with moderate
intellectual disabilities at risk of losing
their community placements in group
homes because of aggressive behaviour
Aged 27–43. One female, two males
6 male offenders with mild intellectual
disabilities from a forensic mental health
facility for people with intellectual disabilities.
All had a history of physical aggression
against staff
Aged 23–36. 3 Caucasian, 1 African-American,
1 White Hispanic, 1 non-White Hispanic
Sample
Level of sexual arousal
Aggression
Incidents of aggression towards self
and others resulting which resulted
in interventions
Psychological well-being (stress,
obsessive–compulsive symptoms,
depression, state and trait anxiety)
Staff and peer injuries
Lost days of work
Cost of medical and rehabilitation
due to injury caused by participants
Behaviour (verbal and physical
aggression, disruptive behaviour)
Physical restraint
Medication
Physical aggression
Physical aggression
Incidents of physical and verbal
aggression
Outcomes measured
182
Interviews
Final measure at 35–40 weeks
mindful observation of
thoughts phase
Multiple baseline design
across participants
Interviews
2-year follow-up
Multiple baseline design
across participants
Repeated measures design
No follow-up
Multiple baseline across
individuals
4–8 weeks follow-up
Final measure at 27 months
of mindfulness training
Multiple baseline design
across participants
Single subject case study
with an AB design
12-month follow-up
Multiple baseline design
across participants
2-year follow-up
Study type
Table 1 Studies evaluating mindfulness training and practice for people with intellectual disabilities
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Mindfulness (2013) 4:179–189
183
Table 2 Studies evaluating mindfulness training and practice for staff working with people with intellectual disabilities
Study
Aims
Study type
Rigour
Sample
Outcomes measured
Singh et al.
(2004)
To investigate whether
mindfulness training for
paid caregivers would
increase levels of happiness
for adults with profound
multiple disabilities
Weak
To assess how training
staff members in mindfulness
affected their use of
physical restraints
6 female African-American
caregivers who worked in
4 group homes. 3 males
with profound intellectual
disabilities and complex
medical and physical
problems.
23 staff members working
in 4 group homes
for 20 people with
intellectual disabilities
Happiness
Singh et al.
(2009)
Alternating treatments
embedded within a
multiple baseline
across subjects design
Final measure taken
at end of 16 week
mindfulness practice phase
Multiple baseline design
across 2 staff shifts
Final measure taken
at end of 22 week
mindfulness
practice phase
Provision of Mindfulness Training The mindfulness training
in the studies incorporated various meditation procedures
provided over different timeframes in both institutional and
community settings by people from a range of backgrounds.
The most commonly taught meditation procedure was Soles
of the Feet (Adkins et al. 2010; Singh et al. 2003, 2007a,
2008b, 2011b, c). The Soles of the Feet meditation procedure teaches participants to divert their attention from an
emotionally arousing thought, event or situation to an emotionally neutral part of one’s body (the soles of the feet).
Once mastered, it becomes automatic to calm the mind by
focussing on the body rather than the thought or situation.
Weak
Number of potential and
actual incidents of
physical or verbal
aggression
Physical restraints
Staff verbal redirections
Medication
Staff and peer injuries
Other mindfulness techniques taught to people with intellectual disabilities included Mindful Observation of
Thoughts which involves a series of mindfulness procedures
(e.g. focussing on the breath, visualising and observing
thoughts as clouds passing through awareness) (Singh et
al. 2011a) and observation of breathing, noises and objects
(Chilvers et al. 2011). Whilst the length and manner of
training in mindfulness techniques varied across studies,
Soles of the Feet training usually involved intensive weekly
or daily sessions of supervised role-play and practice and
home practice assignments (Adkins et al. 2010; Singh et al.
2003, 2007a, 2008b, 2011a, c). Chilvers et al. (2011) held
Table 3 Studies evaluating mindfulness training and practice for parents of people with intellectual disabilities
Study
Aims
Study type
Singh et al.
(2007b)
To assess the effects of
mindfulness training for
parents of children with
intellectual disabilities
on the children’s behaviour
and interactions with
siblings, parental stress
and parental satisfaction
with parenting skills and
interactions with their
children
Multiple baseline design
Weak
across participants
(parent–child dyads)
Interviews with parents
Final measures taken
after a 52-week
mindfulness practice stage
Bazzano et al. To evaluate the feasibility of a Participatory research
(2010)
mindfulness-based stress
using a single group
reduction community-based
pre–post-design
program for parents/caregivers
of children with intellectual
disabilities
Rigour Sample
Weak
Four African-American
mother–child dyads. All
children attended a day
centre for children with
intellectual disabilities
Outcomes measured
Child’s aggression towards
mother or siblings
Child’s social interactions
with siblings
Mother’s satisfaction with
their own parenting skills
and their interactions
with their child
Mother’s use of mindfulness
in parenting
Parents’ experiences and
perceived outcomes of
mindfulness
37 parents of children with Mindfulness
intellectual disabilities
Self-compassion
Psychological well-being
General and parenting stress
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twice weekly 30-min mindfulness sessions over a 6-month
period using observation, description and participation exercises to focus on different mindfulness practices.
A range of people with different levels of mindfulness
skills and experience have provided mindfulness training. In
the majority of studies, mindfulness training was provided
by a single therapist experienced in the practice and teaching
of mindfulness (Singh et al. 2003, 2007a, 2008b). Training
has also been provided by ward or community-based therapists trained in mindfulness techniques (Adkins et al. 2010;
Chilvers et al. 2011) and by a person with intellectual disabilities trained in the Soles of the Feet technique (Singh et
al. 2011c).
In most studies, mindfulness training was provided to
participants with intellectual disabilities individually, with only
Chilvers et al. (2011) using a group format. Mindfulness
training programmes have been provided in various settings,
including institutional settings such as psychiatric hospitals
and forensic mental health facilities (Chilvers et al. 2011;
Singh et al. 2003, 2008b, 2011b) and community settings with
people living in group or family homes (Adkins, et al. 2010;
Singh et al. 2007a, 2011c).
The Impact of Mindfulness Training All of the studies found
improvements after the mindfulness training and practice.
Singh et al. (2003) found major improvements in behaviour
for the man who was trained in Soles of the Feet with no
aggressive behaviour reported during the 1 year follow-up.
The mean number of incidents of physical aggression reduced from 15.4 during baseline to 2.0 during training and 0
during follow-up and those of verbal aggression reduced
from 10.0 at baseline to 2.1 during training and 0 during
follow-up. There were also increases in self-control (from 0
during baseline to 4.5 during follow-up) and reduction and
discontinuation of physical restraints (from 10.4 during
baseline to 0) and medication (from 12.2 during baseline
to 0). Staff injuries reduced from 9.2 during baseline to 0
during follow-up, and resident injuries also reduced to 0
from 8.6 at baseline. The number of activities in which the
participant took part also increased from 3.6 socially integrated activities and 0 physically integrated activities at
baseline to more than 100 of each type of activity at
follow-up.
Singh et al. (2007a) found reductions in aggressive behaviour during mindfulness training, with further reductions
during follow-up after 2 years. Michael’s mean level of 5.0
aggressive behaviours during baseline reduced to 0.1 at
follow-up, Rosemary’s reduced from 3.4 to 0.3 and
Raymond’s reduced from 2.8 to 0. All three participants
maintained their community placements.
Singh et al. (2008b) found that physical and verbal aggression decreased substantially. During baseline, the average number of physically aggressive behaviour made each
Mindfulness (2013) 4:179–189
month ranged between 1.0 and 2.6. Across the 27 months of
mindfulness training, the number of physically aggressive
behaviours declined to 0, and none of the six participants
made a physically aggressive response for at least 6 months
before training ceased. Mean levels of verbal aggression
reduced, although remaining higher than levels of physical
aggression. The measure of participants’ self-reported selfcontrol increased, and no PRN (as needed) medication or
physical restraint was required. In addition, there was a
reduction in the number of staff days absent and the associated wage and medical costs.
Adkins et al. (2010) found that target behaviours decreased as mindfulness training proceeded and during mindfulness practice were maintained at near-zero levels. Low
levels were maintained during follow-up, although with
some variability, and most of the self-reported psychological
well-being scores improved. For example, mean incidents of
Kevin’s verbal aggression reduced from 4.00 per week
during baseline to 0.35 during mindfulness practice,
Samy’s disruptive behaviour reduced from 13.50 during
baseline to 5.58 during mindfulness practice, whilst
Monica’s verbal aggression reduced from 24.00 to 5.33
and her physical aggression reduced from 12.75 to 1.00.
Chilvers et al. (2011) found a decrease in the number of
incidents of aggression (including self-directed), with a concomitant reduction in interventions such as use of the observation lounge, physical intervention or seclusion. Over a
period of 6 months, the mean number of observations reduced from 5.07 to 1.53, mean number of physical interventions reduced from 3.40 to 1.53 and mean number of
seclusions reduced from 1.20 to 0.53. The changes in observations and physical interventions were statistically significant. There was a relatively sharp reduction when the
sessions were introduced, followed by a more gradual increase and then further reduction.
The three participants who received mindfulness training
from a peer (Singh et al. 2011c) initially had an average of
between 1.00 and 10.63 anger events and between 0.86 and
1.13 aggressive acts per week. After mindfulness training,
the frequency of anger and aggressive events decreased to
zero over the mindfulness practice phase. Whilst the three
participants reported occasional incidents of anger during
the 2-year follow-up, there was no reported aggression.
Singh et al. (2011b) found that mean weekly ratings of
self-reported sexual arousal for the three participants reduced from 12 at baseline to 8.75, 10 and 10.75 during the
self-control phase and then to 7.77, 7.38 and 6.92 at the
Soles of the Feet phase. During the mindful observation of
thoughts phase, these ratings reduced further to 2.95, 3.03
and 1.51, respectively.
Feedback from Participants People with intellectual disabilities who have received mindfulness training have
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Mindfulness (2013) 4:179–189
reported that they valued learning to control their own feelings rather than being told to calm down by others and
found this reinforcing (Singh et al. 2011b). Participants
initially found mindfulness procedures difficult to understand as they could not easily remember and visualise past
events (Singh et al. 2007a) or did not understand instructions such as ‘observe your thought’ (Singh et al. 2011b).
Repeated practice, the use of role-plays and discriminative
stimulus being added to the soles of their feet helped to
overcome such difficulties (Singh et al. 2007a, 2011b).
Participants varied in their ability to initiate mindfulness
meditation without prompting (Adkins et al. 2010) and
may find it difficult to implement mindfulness procedures
within their lives at first (Singh et al. 2011c). Participants
found it more difficult to use Soles of the Feet for deviant
sexual arousal than for the precursors of aggression due to
their emotional attachment to the strong pleasurable sexual
thoughts (Singh et al. 2011b).
Mindfulness Training for Staff Working with People
with Intellectual Disabilities
Table 2 summarises the two studies evaluating the impact of
mindfulness training and practice for people working with
people with intellectual disabilities, both carried out by
Singh and colleagues. The mindfulness training in both
studies covered aspects of mindfulness including meditation
methods, knowing your mind, focussed attention, being in
the present moment, beginner’s mind, non-judgmental acceptance, letting go, loving kindness, problem solving and
using mindfulness in daily interactions. The studies looked
at both the impact of mindfulness training on staff in relation
to the interventions and approaches they utilised and work
satisfaction and the impact on people with intellectual
disabilities.
Singh et al. (2004) measured changes in happiness levels
for three adults with profound intellectual disabilities living
in group homes when supported by staff trained in mindfulness techniques compared with staff who had received the
same amount of training in behavioural methods training.
Observed happiness increased to a much greater extent
when supported by the staff member trained in mindfulness
(an increase of 146 % when supported by the person trained
in mindfulness compared to 11 % for the untrained caregiver
for the first person, 322 % compared to 1 % for the second
person and 437 % compared to 10 % for the third person).
In another study, Singh and colleagues provided mindfulness training to 23 members of staff working in four
group homes for people with mild to profound intellectual
disabilities (Singh et al. 2009). The mean number of incidents reduced from 10.67 during baseline to 6.76 during the
practice phase for the morning shift and from 8.60 to 6.22
for the afternoon shift. The use of physical restraints for
185
aggressive behaviour decreased to almost none by the end of
the study. Verbal redirections by staff and PRN medication
also reduced and staff and peer injuries were close to zero
levels during the latter stages of mindfulness practice.
Mindfulness Training for Parents of People with Intellectual
Disabilities
Two studies conducted have evaluated the impact of providing mindfulness training to parents of people with intellectual disabilities (Table 3). These have investigated the
direct impact of mindfulness training and practice on
parents’ satisfaction and wellbeing and on parent–child
interactions and the indirect impact on people with intellectual disabilities and other family members.
In the study of Singh et al. (2007b), four mothers of
children with intellectual disabilities received 12 1:1 mindfulness sessions following the parent training programme
outlined in Singh et al. (2006a). All four children showed a
decrease in aggressive behaviours during the training stage
with more systematic and substantial reductions during the
mindfulness practice stage. With dyad 1, the child’s mean
number of aggressive behaviours per week decreased by
33 % from baseline (14.3) to training (9.6) with an 87 %
decrease from training to practice (1.3). With dyad 2, the
mean number of aggressive behaviours reduced by 26 %
from baseline (8.6) to training (6.3) and 94 % from training
to practice (0.4). With dyad 3, the mean number of aggressive behaviours reduced by 30 % from baseline (13.9) to
training (9.7) and 91 % from training to practice (0.9). With
dyad 4, the mean number of aggressive behaviours reduced
by 36 % from baseline (14.4) to training (9.2) and 88 %
from training to practice (1.1). In addition, there were
improvements in interactions between the child with intellectual disabilities and their siblings, and mothers’ selfratings of parental satisfaction, parental stress and mother–
child interaction improved.
Bazzano et al. (2010) provided a community-based
mindfulness-based stress reduction programme for parents/caregivers of children with intellectual disabilities. The
programme consisted of two concurrent classes twice weekly
in English with Spanish translation over 8 weeks, consisting
of meditation practice, supported discussion of the stressors
parents faced and yoga. Parents also received a 30-min CD for
daily practice. Attendance was good with 78 % attending six
or more classes. Parents reported statistically significant less
stress and statistically significant increases in mindfulness,
self-compassion and well-being after the programme.
Parental feedback suggests that people need to be
disciplined in their meditation practices and exercises in
order to achieve consistent, enduring practice on a daily
basis. Mothers found mindfulness training different to previous training programmes they had attended, leading to
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186
transformational change rather than providing them with
specific rules or techniques to use with their child (Singh
et al. 2006a). They felt that the training had enabled them to
take a more holistic view of their child within the context of
family, social and physical environments and to respond to
their child in a calm, positive manner that pre-empted maladaptive behaviour and encouraged positive social behaviour.
Study Quality
All of the studies were rated as weak using the Evaluative
Method for EBP (Reichow et al. 2008). Several serious
methodological weaknesses were identified in all of the
studies under review in areas appertaining to research design, participants, sample size, treatment fidelity and outcome measurement. Most studies conducted by Singh and
colleagues used a multiple baseline design, which has several
advantages (e.g. non-withdrawal of a potentially effective
intervention, paralleling clinical practice and ease of conceptualisation and implementation) and can show a causal effect
between an intervention and the outcome, especially at single
case level (Cooper et al. 2007). However, given the small
number of participants, external validity is weak, limiting the
generalisability of the findings (Silver Pacuilla et al. 2011).
A major methodological weakness of all the studies is
that they are uncontrolled with no comparison with other
treatments to determine whether observed improvements are
due to receiving some form of treatment or due to the impact
of the therapist. Moreover, a single therapist provided most
of the mindfulness training, and it is possible that his interpersonal skills and style led to change rather than mindfulness per se. Moreover, Singh and colleagues do not state
which mindfulness approach they are following (mindfulness-based stress reduction or mindfulness-based cognitive
therapy) and their training does not follow the typical timeframes and content of mindfulness-based stress reduction
and mindfulness-based cognitive therapy programmes.
There were no systematic or independent assessments of
the quality of the interventions in the studies (i.e. treatment
compliance) or of how closely interventions conformed to
mindfulness principles (i.e. treatment fidelity).
In addition, the sample sizes within the studies are small
with limited information about sampling criteria used, raising questions about representativeness. Some people contacted the researchers and may be more motivated to change
than other people. All of the participants in the studies
where mindfulness training was provided directly to people
with intellectual disabilities had mild or moderate intellectual disabilities, and it is difficult to generalise the findings
to people with more severe intellectual disabilities.
In relation to outcome measurement, most of the studies
of Singh et al. utilised more than one observer of the
targeted behaviours to ensure reliability of data and reported
Mindfulness (2013) 4:179–189
that inter-observer reliability was generally high. However,
reliability and validity data are not reported for many of the
monitoring instruments and scales used in the studies to
determine how appropriate or accurate they are (for example,
Bazzano et al. 2010).
Finally, there is a lack of procedural detail about how the
qualitative data from informal interviews and anecdotal
evidence was gathered, with no information about whether
interview guides were used, whether interviews were
recorded and the method of analysis used. If the mindfulness
trainer carried out interviews about the training, it is possible
that participants would have responded more positively than
if an independent person had conducted the interviews.
Therefore, whilst the majority of published studies suggest
that mindfulness-based training can have a positive impact
on people with intellectual disabilities, their family members
and paid carers, such claims must be treated with extreme
caution due to the serious methodological limitations of all
of the extant studies.
Discussion
The studies identified by this systematic review indicate that
mindfulness training and practice leads to improvements in
the frequency of problem behaviours and psychological
well-being for people with intellectual disabilities. These
improvements have frequently been maintained over several
years. The studies suggest that whilst benefits can be
achieved by providing mindfulness training and practice
directly to people with mild and moderate intellectual disabilities, people with intellectual disabilities also benefit if
their staff and family receive mindfulness training.
Mindfulness training has been shown to be successfully
provided in a range of community and institutional settings
and by experienced mindfulness practitioners, staff trained
in mindfulness techniques, family members and people with
intellectual disabilities themselves. As the studies have included White, African-American and Hispanic populations,
there is some evidence that mindfulness approaches are
acceptable to people from diverse cultural backgrounds. The
feedback from participants with intellectual disabilities demonstrates that mindfulness training must be accessible to them
with clear instructions, regular practice and use of concrete
examples, role play and stimuli to assist people with intellectual disabilities to understand and use mindfulness concepts
and techniques. The feedback from parents indicates that they
too may need support and encouragement to persist with
integrating mindfulness practice within their lives.
The reported positive findings have implications for intellectual disability services considering mindfulness
approaches with their clients and/or staff as an option for
improving the quality of life and well-being of people with
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Mindfulness (2013) 4:179–189
intellectual disabilities, particularly if existing approaches
are not effective. People with intellectual disabilities, their
families and organisations may want to consider mindfulness.
Mainstream health services also need to review whether the
mindfulness interventions which they provide are being
accessed by people with intellectual disabilities and, if not,
identify the reasons why and determine what action can be
taken.
However, the serious methodological limitations of the
published studies mean that the positive findings should be
treated with caution, and it is debateable whether the evidence
is strong enough to recommend the use of mindfulness. The
Evaluative Method for Evaluating and Determining EBP
provides criteria for determining whether a practice has
enough empirical support to be classified as an established
or promising EBP (Reichow et al. 2008). These criteria look at
the number of strength ratings, how many research teams have
conducted the studies, how many different locations have
conducted studies and the total sample size across studies.
As all of the studies in this review were assessed as being of
weak research report strength, the current evidence cannot yet
be categorised as promising. Similarly, the evidence would be
judged as very low using international criteria for recommending evidence-based interventions developed by the Grades of
Recommendation, Assessment, Development, and Evaluation
(GRADE) Working Group (2004). In addition, most studies
have been carried out in the USA, and it is unclear how well
mindfulness will translate to other countries with different
cultures and services systems. Therefore, stronger evidence is needed before mindfulness could be confidently
recommended as routine practice with people with intellectual
disabilities.
Future studies need to be clear about the mindfulness
approach being evaluated. The mindfulness approaches
most commonly used with the general population are
mindfulness-based stress reduction and mindfulness-based
cognitive therapy. However, the mindfulness training programmes described in the reviewed studies include a myriad
of techniques, and it is not always clear how compatible
these are with more usual mindfulness approaches. Whilst
the programme delivered by Bazzano et al. (2010) was described as a mindfulness-based stress reduction programme,
Chilvers et al. (2011) do not specify which mindfulness approach their training was based upon, and the majority of
studies included in the review describe and evaluate an approach to mindfulness, the Soles of the Feet (and more recently Mindful Observation of Thoughts), developed by Singh and
colleagues. The use of more typical mindfulness-based stress
reduction and mindfulness-based cognitive therapy programmes with people with intellectual disabilities and carers
needs to be explored and evaluated.
A number of studies were excluded from this review as
they reported on interventions which included components
187
other than mindfulness. Some studies explored interventions
based on acceptance and commitment therapy or dialectical
behaviour therapy, which include mindfulness as a component (for example, Morrissey and Ingamells 2011; Noone
and Hastings 2010; Sakdalan et al. 2010). Three studies
were excluded which suggested that introducing a mindfulness component into health promotion interventions may
help to support and maintain lifestyle changes such as
weight loss and stopping smoking (Singh et al. 2008a,
2011a, d). Another study concluded that providing mindfulness training after behavioural training to staff working in
group homes considerably improved their ability to manage
the aggressive behaviour and improve learning of residents
with intellectual disabilities (Singh et al. 2006b). It is important that future studies are designed so that it is clear
whether it is mindfulness or other components of an intervention that are leading to change.
In addition to research evaluating the effectiveness of
mindfulness, further research is needed to develop a conceptual model that clarifies the mechanisms and processes leading
to any observed outcomes from mindfulness training and
practice. The perspectives of those who have received mindfulness training will be important in illuminating these processes. The studies included in this review show that people
with intellectual disabilities feel that mindfulness training and
practice has provided them with a method of controlling their
own feelings, rather than being dependent on their behaviours
being managed by other people. Family members report that
mindfulness training and practice provides them with new
coping mechanisms and leads to a form of transformational
change in the way in which they perceive and respond to their
family member with intellectual disabilities. This appears to
lead to improved parent–child interactions and as a consequence positive outcomes for the child with intellectual disabilities. The included studies did not gather information from
staff about their perceptions of mindfulness training and practice and potential reasons for the reported outcomes. It is
possible that if they too are experiencing a similar form of
transformational change in the way in which they view and
respond to the people they are working with, this may result in
improvements in staff–client interactions, which in turn improve outcomes for people with intellectual disabilities (for
example, improvements in behaviour, well-being and quality
of life).
Further research utilising controlled designs with both
larger sample sizes and random allocation to treatment or
comparison groups is therefore needed before reported
improvements can be more confidently attributed to mindfulness. Similarly, further research is needed to identify
which components of mindfulness lead to change and the
processes involved, whether mindfulness approaches are
more effective than other approaches or interventions and
to explore how factors such as facilitator characteristics,
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188
support, communication needs and cognitive abilities impact
on the success of mindfulness. Research into whether mindfulness is best taught on a 1:1 basis or in a group setting is also
required to inform clinical practice. Methodologically robust
qualitative research could also explore the experiences of
those receiving mindfulness training, to identify what they
feel the impact of mindfulness has been and to identify which
components of mindfulness participants find most useful.
Conclusion
In conclusion, there is some evidence that mindfulnessbased approaches may have the potential to improve the
psychological well-being of people with intellectual disabilities, but high-quality research conducted by independent
researchers is required before clear clinical recommendations can be made.
Acknowledgments This study was carried as part of an evaluation of
the Mindfully Valuing People Now project carried out by Pathways
Associates CIC and the North West Training and Development Team
with funding from Improving Access to Psychological Therapies.
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