Complementary, Holistic, and Integrative Medicine: Meditation Practices for
Pediatric Health
Erica M.S. Sibinga and Kathi J. Kemper
Pediatrics in Review 2010;31;e91
DOI: 10.1542/pir.31-12-e91
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Article
complementary medicine
Complementary, Holistic, and Integrative
Medicine: Meditation Practices for Pediatric Health
Erica M.S. Sibinga, MD,*
Kathi J. Kemper, MD,
†
MPH
Author Disclosure
Dr Sibinga has
disclosed no financial
relationships relevant
to this article. Dr
Kemper has disclosed
that she is supported,
in part, by the
Kohlberg Foundation.
Case Presentations
Case #1
Maria is a 14-year-old Hispanic girl who has developed chronic headaches and appears to be
mildly depressed. She has become irritable and gotten into two fights at school this year. Her
aunt, who is raising her, does not want to start her on medication. The aunt has a friend who
works as a nurse and recently started a mindfulness-based stress reduction program. Maria’s
aunt wants to know if she could try a similar program. What is the evidence that practicing
mindfulness meditation can help someone like Maria?
Case #2
Antwan is a 12-year-old African American boy in an urban sixth-grade class who has mild
hypertension. His teacher is interested in having her students learn some stress management
skills to help them focus better in the classroom. She does not want anything inconsistent with her
religion, but she has heard that even simple meditation can be helpful. What is the evidence
that training in focused attention or concentration-type of meditation can help students like
Antwan?
The views expressed
Case #3
in this article are
those of the author
and do not
necessarily represent
the views of the
Maggie is a 17-year-old girl who has anorexia nervosa and really wants to keep exercising. Her
family physician advised her not to exercise vigorously to avoid further weight loss. Her mother
wants to know if yoga can help decrease Maggie’s anxiety safely. Is yoga safe and effective for
teens who have eating disorders?
Kohlberg Foundation.
Introduction
This commentary does
The word “meditation” has the same Indo-European root, “med” (to measure), as the
word “medicine”; in Latin, meditation referred to physical or intellectual exercise. Just as
various physical activities build different athletic capacities, various types of meditation
build different mental and emotional capacities. The National Institutes of Health National Center for Complementary and Alternative Medicine (NCCAM) defines meditation
as a set of techniques or practices intended to enhance focus or attention. They are
characterized by NCCAM as mind-body therapies along with practices such as hypnosis,
guided imagery, and biofeedback. When such practices are used in the context of a
religious or spiritual practice, they also may be intended to promote a sense of oneness with
the Divine; higher states of consciousness; or greater compassion, loving-kindness, peace,
creativity, or forgiveness. Meditative techniques have been used by cultures throughout
the world since antiquity to promote health and well-being.
Meditative techniques are widely practiced for health purposes, most often to promote
overall health and to relieve stress, anxiety, insomnia, depression, and chronic pain or
fatigue. In a 2007 national survey of 23,393 adults in the United States, 9.4% (representing
more than 20 million people) reported using meditation for health purposes in the past
12 months, an increase from 7.6% reported in a similar survey conducted in 2002. (1)(2)
Subsequent surveys found that about 5.1% of adults used yoga, while about 1% used tai chi,
qi gong, or both for health reasons. (3)(4) In a 2007 pediatric survey, approximately 1%
(representing 725,000 children and adolescents) used meditation for health purposes. (2)
Because the surveys did not specifically list all of the various types of meditative practices,
these estimates are likely to be conservative.
Few families spontaneously report CAM therapy use to their physicians. To provide
comprehensive care, physicians need to ask about all the therapies that patients use. We
contain a discussion
of an unapproved/
investigative use of a
commercial product/
device.
*Assistant Professor, Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md.
†
Caryl J. Guth Chair for Holistic and Integrative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.
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complementary medicine
meditation
review scientific studies about the most commonly used
meditation practices in this article to help pediatricians
counsel patients using evidence-based information.
Types of Meditation Practice
Just as the broad category of sports includes sports played
with a ball (eg, basketball, baseball, football), a racquet
(eg, tennis, squash), skates (eg, figure skating, hockey),
running (eg, track, cross-country), jumping (eg, hurdles,
high jump, broad jump), weight lifting, and swimming
(eg, freestyle, backstroke, butterfly stroke), meditation
includes many different practices. Different practices may
appeal to different individuals and have different mental
and physical effects.
The most commonly included categories of meditation practice are: concentration, cultivating positive
emotions or spiritual qualities, mindfulness, movement,
and emptying (Table 1). Within each of these broad
categories are multiple varieties of practice. For example,
concentration meditation includes practices that focus
on the breath, a word (eg, transcendental meditation ) or
phrase (eg, repetitive prayers, such as the Catholic rosary,
the Muslim mishbaha, short scripture verses, poetry, or
affirmations), an image (eg, a candle, cross, or mandala),
a body part (eg, the heart, the “third eye” between the
eyebrows, or the “dan tien” in the lower mid-abdomen),
a sound (eg, chanting), a concept (eg, death or impermanence, inter-relatedness), or an emotion (eg, focusing
on gratitude or adoration). Closely related to this last
type of concentration meditation are practices designed
to cultivate emotional/spiritual states or qualities such as
the Buddhist metta and tonglen meditation (cultivating
compassion and loving-kindness) and forgiveness. (5)
Mindfulness practices involve the intention to notice,
without judgment, the thoughts, emotions, sensations,
and other experiences that arise in each moment. They
Table 1.
can include mindful awareness of the breath, eating,
listening, and moving. The most widely used training
program in mindfulness, Mindfulness-Based Stress Reduction (MBSR), defines mindfulness as “paying attention on purpose” or as “moment to moment, nonjudgmental awareness.” It includes three components:
intention (of increasing awareness of the present moment), attention (sustained focus on current experience),
and attitude (nonjudgmental acceptance).
Moving meditative practices include mindful yoga,
tai chi, and qi gong. Many cultures also include meditations based on repetitive movements such as circle
dancing, stamping, and whirling (Sufi dervishes). Emptying meditations include Christian practices such as
centering prayer. Among related meditative practices are
the Quaker practice of sitting in communal silence and
“waiting on the Light” or the “still, small voice within.”
Just as a basketball player also may run track, those who
primarily practice one type of meditation also may practice others. For example, Zen practices incorporate concentration, cultivating positive attitudes, mindfulness,
and movement.
Formal training and the intensity, duration, and frequency of practice vary for different types of meditation
and different people. Just as health guidelines recommend 30 to 60 minutes daily of physical exercise to
maintain physical health, recommendations for meditation practice typically range from just a few minutes for
young children to 10 minutes twice daily for school-age
children to 45 minutes daily for older adolescents and
adults engaged in mindfulness practice. Those who have
greater needs or higher aspirations may engage in longer
practices and seek formal training or guidance.
This review focuses on meditation practices for which
there are at least five published pediatric studies available
through PubMed or PsycInfo databases since 1972. Dis-
Types of Meditation Practice
Types of Meditation Practice
Examples
Concentration on a word, thought, sensation, or image
Transcendental meditation; relaxation response; breath-focused
meditation; mantra repetition; meditation on a prayer,
mandala, or other image
Mindfulness-based stress reduction, Vipassana
Yoga, tai chi, qi gong, Sufi dancing
Buddhist metta or tonglen practices (cultivating compassion
and loving-kindness), Institute of HeartMath training
(cultivating gratitude or compassion)
Centering prayer, waiting on the inner voice or inner light
Mindfulness
Movement-based meditation
Cultivating positive emotions (such as compassion,
forgiveness, gratitude, or loving-kindness)
Emptying
Note: Some practices include more than one type of meditation. For example, yoga practices may include meditation on the breath, a word phrase, or sensation
as well as movement and postures. All of these practices involve mental training that enhances the ability to focus or sustain attention.
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complementary medicine
sertations are not included unless they were subsequently
published in peer-reviewed publications.
Physiologic Effects in Adults
Just as different types of athletic participation tend to
build strength and stamina, regardless of the type of
sport, different meditation practices tend to have similar
mental and physical effects. Most nonmovement meditative practices lead to a hypometabolic state (decreased
heart rate, respiratory rate, skin resistance, and blood
pressure). Most practices are also associated with changes
in the autonomic nervous system (less sympathetic and
more parasympathetic activity), endocrine function (lower
cortisol concentrations), and neurotransmitters (changes
associated with decreased stress and greater psychophysiologic coherence). (6)(7)(8) Meditation practices geared
toward relaxation are associated with electroencephalographic (EEG) changes showing greater alpha and theta
coherence, with increased activity in the left prefrontal
cortex (an area often associated with greater happiness
and less anxiety) in adults. (9) Among experienced practitioners, meditation that intentionally generates compassion generates synchronized gamma activity. (10)(11)(12)
Meditation training also has been associated with enhanced immune function in response to stress and immunization. (8)(13)(14)(15) Few studies have evaluated
physiologic changes such as EEG and immune function
in children.
Neuroimaging studies have demonstrated significant
associations between long-term meditation (⬎ 10 years)
practice and enhanced blood flow and thicker cortical
areas (compared with age-matched controls) in those
parts of the brain associated with attention and emotional regulation, such as the prefrontal cortex and the
anterior cingulate cortex. (12)(16)(17)(18) Functional
magnetic resonance imaging studies show that meditation (compared with other mental tasks) results in regional brain activation in the dorsal lateral prefrontal
cortex and anterior cingulate cortex. (19)(20) Regional
cerebral blood flow studies show increased flow in the
right temporal lobe and posterior cingulate gyrus with
chanting meditation. (21) As with studies of many biomedical interventions, those who take the medicine
(practice more) show greater physiologic benefits than
those who do not. (22)(23)
Both concentrative and mindfulness meditation practices enhance the ability to focus and monitor attention.
(24) Psychophysiologic studies show improved attention
and reaction time, less autonomic reactivity under stress,
and fewer errors, even among adults who have had
very brief training in meditation. (15)(25)(26)(27)(28)
meditation
Meditation appears to affect subsystems of attention.
(29) Some studies also suggest increased creativity, intelligence, and learning ability. (30)(31)(32)(33) Experimental studies also show decreased pain sensitivity in
those who meditate, even after very brief training.
(34)(35)(36)
Research on the physiologic effects of meditation
practice among children is needed.
Clinical Effects in Adults
Despite methodologic variability, the hundreds of
meditation studies conducted in adults suggest significant benefits for both physical and mental health. (37)
Physical benefits have been reported for pain, fatigue,
hypertension, asthma, autoimmune disorders, epilepsy,
irritable bowel syndrome, and premenstrual and menopausal symptoms. (38)(39)(40)(41) Mental health benefits include improved moods and decreased stress,
anxiety, obsessive-compulsive thoughts, depression, aggressiveness, and substance abuse. (6)(20)(39)(41)(42)
(43)(44)(45)(46) Experience with focusing attention
and building the capacity to monitor attention as it
wanders and returns can help individuals more readily
recognize precursors to aggressive or addictive thoughts
and feelings, even among those who have intellectual
disabilities. (47)(48) Those who practice most consistently report the greatest physical and mental health
benefits. (49) It is not always clear whether the benefits
are greater in such individuals because of the effects of
the intervention per se or the general personality characteristics of those who adhere or whether adherence is
related to other beneficial changes in health behavior. In
rare cases, meditation has been associated with precipitation of psychosis or psychotic episodes among individuals who have pre-existing schizophrenia or significant
thought disorders, but no other serious adverse effects
have been reported. (38)
A number of products (such as CDs, DVDs, and
books) and training programs (both in person and
online) have been developed for adults and children,
targeting conditions such as attention-deficit disorder,
chronic pain, eating behaviors, sleep problems, anxiety,
and depression.
Clinical Effects in Pediatrics
This review divides the data from pediatric studies into
three practices: mindfulness, concentration (eg, relaxation response, transcendental meditation [TM], or similar
practices), and movement-based practices (yoga and tai
chi).
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complementary medicine
Table 2.
meditation
Mindfulness Meditation Practices for Health: Pediatric Studies
Investigator
Biegel, 2009
(50)
Bootzin, 2005
(51)
Flook, 2010
(52)
Condition/Study
Participants
14- to 18-year-olds
Outpatient psychiatric
facility
nⴝ102
Adolescents who have
substance abuse
nⴝ17
Second and third
graders
nⴝ64
Lee, 2008 (53)
9- to 12-year-old
students
nⴝ25
Napoli, 2005
First through third
(54)
graders
nⴝ194
Ott, 2002 (55) GI symptoms
nⴝ1
Saltzman, 2008 Fourth through sixth
(56)
graders and their
parents
nⴝ32
(MBSRⴝ24; WLCⴝ8)
Semple, 2005
Anxious 7- to 8-year(57)
old children
nⴝ5
Sibinga, 2008
HIV
(58)
nⴝ5
Qualitative
Singh, 2008
Mindfulness for teen
(59)
who has PraderWilli syndrome
Wall, 2005
(60)
Practice/Training
Study Design/Training Period Outcome/Comments
MBSR
Randomized, controlled trial
8 weeks with WLC
Stimulus control, bright 6 sessions; no control group
light therapy,
cognitive therapy,
MBSR, and sleep
education
Mindful awareness
30 minutes twice per
practices
weekⴛ8 weeks
Randomized control (silent
reading period)
MBCT-C
12 weekly 45-minute
sessions; no control
Attention Awareness
Program (AAP)
MBSR
MBSR
MBCT-C
Improved executive function
for students with lower
baseline (P<0.02) by
teacher and parent rating
Improved attention and
anger management by
parental report
12 45-minute sessions every Reduced test anxiety
2 weeks
Improved behavior,
Control group (no AAP)
attention
Case report of individual
Improved GI symptoms and
MBSR instruction
function
Nonrandom WLC
Improved attention (parents
and children)
Reduced emotional
reactivity
(parents>children)
6 weekly 45-minute
Feasible; may be beneficial
sessions; no control
for anxiety
MBSR
8 weeks; no control group
Mindful eating
Meditation
Significant weight loss with
Phased study:
addition of mindfulness
Baseline, exercise, exercise ⴙ
food awareness, exercise
ⴙ food awareness ⴙ
mindfulness; 12 months
of each phase
1 hr/wk for 5 weeks
Decreased reactivity and
increased well-being,
calmness, relaxation, selfawareness, and self-care
2.5 hr/wk for 8 weeks
Improved ADHD symptoms,
attention and cognitive
inhibition, anxiety,
depression
Middle-school students MBSR and tai chi
(11 to 13 years old)
nⴝ11
Zylowska, 2008 Adults (nⴝ24) and
(61)
adolescents (nⴝ8)
Reduced anxiety, depression,
somatic distress
Increased self-esteem and
sleep quality
Improved sleep, decreased
worry, and decreased
mental health distress
MBSR
Reduced reactivity
Improved self-care
ADHD⫽attention-deficit/hyperactivity disorder, GI⫽gastrointestinal, HIV⫽human immunodeficiency virus, MBCT-C⫽mindfulness-based cognitive
therapy for children, MBSR⫽mindfulness-based stress reduction, WLC⫽wait list control
Mindfulness (Table 2)
An emerging body of research suggests the potential
benefit of mindfulness instruction for children. Many of
the mindfulness studies use age-appropriate adaptations
of the MBSR developed for adults. (62) Case reports,
small studies, and multimodal studies suggest acceptabil-
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complementary medicine
ity and benefits related to symptom management, mental
health, and enhanced self-regulation. (55)(58)(59)(60)
(61)(63)(64)(65)(66)
A number of studies in school settings show improved
attention and behavior. (53)(54)(56)(67) For example, a
trial of 120 high school seniors using a school-based
mindfulness curriculum showed reductions in negative
affect, tiredness, and aches and pains and increases in
emotion regulation, feelings of calmness, relaxation, and
self-acceptance. (68) A randomized, controlled study of
mindfulness practices in 64 second- and third-graders
showed improvements in executive function among students who had poorer executive function at baseline, as
assessed by both parents and teachers using the Behavior
Rating Inventory of Executive Function. (52) In a pilot
study, urban youth who participated in MBSR reported
fewer fights (verbal and physical), improved relationships, increased reflection on internal processes, and better self-regulation. (69) Further, a randomized, controlled trial of MBSR compared with usual care for
adolescents in outpatient psychiatric treatment showed
significant reductions in anxiety and depression and improvements in global assessments. (50) These studies
suggest that mindfulness instruction may result in improved physical, cognitive, behavioral, and psychological
outcomes in children and youth, but more rigorous
research is needed to evaluate the specific role of mindfulness compared with other types of meditation training
or other interventions.
Concentration Meditation:
Transcendental Meditation and
the Relaxation Response (Table 3)
TM involves the use of a sound or mantra as a focus for
the practitioner’s attention and is practiced for 15 to
20 minutes twice per day while sitting comfortably with
closed eyes. Controlled studies of TM for pediatric populations primarily focus on the effect on cardiovascular
risk factors and school-related outcomes. Several studies
have shown that compared with a health education control in school settings, TM practiced 15 minutes twice
per day for 4 months resulted in significant decreases in
systolic and diastolic blood pressures as well as blood
pressure reactivity to a social stressor interview. (70)(72)
In addition, Barnes assessed problem behaviors in schoolage children and found that students who practiced TM
had reductions in absenteeism, school infractions, and
suspension for behavioral problems. (71) In a series of
three studies of high school students (n⫽372), TM
practiced twice daily for 15 to 20 minutes compared with
napping resulted in improvements in cognitive tasks (eg,
meditation
testing distractibility and creativity) and anxiety. (33)
Additional small studies have shown associations between TM and beneficial psychological, self-regulatory,
and academic outcomes. (64)(81) Looking at potential
causes for benefit from TM practice, a small controlled
study of healthy college students showed greater frontal
brain wave coherence and reduced sleepiness. (82) Studies of TM’s effect in youth on cardiovascular risk, cognition, affect, and behavior are promising, but larger, more
definitive comparative effectiveness research is needed.
A few pilot studies have evaluated Benson’s relaxation
response (RR), a form of brief focused attention on breath,
in children and youth. These small studies suggest that
the RR is feasible in pediatric populations and that it
may have benefits related to reducing headaches, reducing anxiety, and improving self-esteem and self-concept.
(73)(74)(75)(80) Larger trials with more rigorous designs are needed for better understanding of the effects of
the RR compared with other types of concentration and
mindfulness training in diverse pediatric populations.
Mindful Movement: Yoga and Tai Chi (Table 4)
Numerous types of yoga are offered in the United States.
Some, such as Ashtanga or Power yoga, focus primarily
on physical fitness; others, such as Integral, Kundalini,
and Sivananda yoga, aim toward spiritual enlightenment;
and still others, such as Kripalu and Viniyoga, focus on
healing. (88) Most yoga practices offer a combination of
physical postures, meditation, and breathing exercises.
Among adults, those who take up yoga are more likely
than non-yoga students to be Caucasian, female, and
college-educated; adults typically use yoga to help with
musculoskeletal or mental health challenges. (3)
Birdee and associates (83) conducted a systematic
review of 19 randomized, controlled trials and 15 nonrandomized, controlled trials of yoga for children and
adolescents up to 21 years of age published before
December, 2008. The primary conclusion was that more
rigorous research is needed to address problems with
randomization, withdrawal/dropouts, and details regarding the type and content of the yoga training provided (many included training in meditation, postures,
and breathing, and it is difficult to sort out the effects of
each component). However, the authors concluded that
yoga was safe, with no reported adverse effects in any of
the 34 trials reviewed. (83) Benefits that appeared to be
consistent across two or more studies included: greater
physical fitness and strength, better mood, lower stress
and anxiety, better attention and behavior, and better
verbal and spatial memory and visual perception. (83)
A few small studies also reported benefits for adolescents
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complementary medicine
meditation
Transcendental Meditation (TM) and Relaxation Response (RR)
Practices for Health: Pediatric Studies
Table 3.
Investigator
Condition/Study Participants
Practice
Design and Training Period
Outcome/Comments
Barnes, 2001
(70)
35 teens ages 15 to 18 years
with resting BPs at 85th
to 95th percentile for age
TM
Random assignment to health
education control or TM
practiced 15 minutes twice
daily for 2 months during
school and prescribed for
home
Barnes, 2003
(71)
45 African American teens
ages 15 to 18 years with
high normal SBP
TM
Random assignment to health
education control (nⴝ20)
or TM (nⴝ25) for 15
minutes daily for 4 months
Barnes, 2004
(66)
100 teens with high normal
SBP
TM
Barnes, 2004
(72)
BP in 73 12-year-old
children
Concentration on
breath
RCT
Ambulatory 24-hour BP
pretest, 2- and 4-month
posttests and 4-month
follow-up evaluation
RCT by classroom (health
education control) to
meditation practices 10
minutes at school and
home daily for 3 months
TM group had greater
decrease in SBP, HR, and
CO reactivity (P<0.03)
to simulated car driving
stressor and in SBP
reactivity (P<0.03) to
social stressor interview
Decreased absenteeism by
6.4 days versus increase
of 4.8 days in control
(P<0.05), decreased
school infractions
(P<0.03), and decreased
school suspension days
(P<0.04) for behavior
problems
Decreases in daytime SBP
and DBP (P<0.04 and
P<0.06) in TM versus
control across visits
Benson, 1994
(73)
37 high-school students
RR
Benson 2000
(74)
1,037 sixth through eighth
graders
RR (taught to
teachers and
students)
Day, 1982
(75)
62 students 10 to 12 years
old
RR
RCT RR 10 minutes daily for
6 weeks
Control: reading activity
Fentress, 1986
(76)
18 children 8 to 12 years old
RR
RCT: 4 weeks of baseline,
followed by 9 1-hour
treatment sessions over 11
weeks
nⴝ6 had EMG biofeedback,
RR training, and behavior
management
nⴝ6 had RR training and
behavior management
nⴝ6 wait list controls
RCT
Intervention 15 minutes
3 times/wk
In class RR per teachers
(no control group)
Resting SBP: 2.7 versus
1.1 mm Hg pre/post
change
Daytime ambulatory SBP:
2.0 versus 3.6 mm Hg
Daytime ambulatory DBP:
0.1 versus 4.3 mm Hg
Increased self-esteem with
RR (P<0.05)
Exposure to >2 semesters
with RR teachers: better
grade point average,
work habits, cooperation
Dose response (P<0.05)
RR group had lower
general anxiety scale
and test anxiety scale
(P<0.01), but effect did
not persist at 3 weeks
Headache diaries for 15week study and 4 weeks
1 year later
Both active treatment
groups had significant
reduction in headache
symptoms (P<0.05)
(continued)
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meditation
Transcendental Meditation (TM) and Relaxation Response (RR)
Practices for Health: Pediatric Studies—Continued
Table 3.
Investigator
Condition/Study Participants
Practice
Kindlon, 1983
(77)
35 undergraduate students
Linden, 1973
(78)
26 disadvantaged thirdgraders
Sitting meditation; RCT
concentration
Meditation for 30 minutes
on breath
daily
Control: rest for same period
of time
Meditation,
RCT
unspecified
Meditation versus guidance
(attention control) versus
regular class (no attention
control)
18 weeks
TM/RR
Meditation for 6 weeks
Control group: music
appreciation
RR
RCT
1.5-hour training (RR or
control), then 15 min/day
for 80 school days
Control: behavior charting
Mengel, 1979
(79)
27 10- to 15-year-old boys
who had learning
disabilities
Oldfield, 1986 21 disruptive fourth(80)
through sixth-graders
Design and Training Period
Rosaen, 2006
(81)
10 African American
seventh-graders who
practiced for 1 year
TM (qualitative
design)
20 minutes daily for 1 year
No control group
So, 2001 (33)
362 high-school students in
three studies
TM
15 to 20 minutes twice daily
for 6 or 12 months
Control groups included
napping, no interest
control, contemplation
control
Travis, 2009
(82)
50 healthy college students
(Full data on 38 students)
TM
Wait list control compared
with TM training for
10 weeks
Outcome/Comments
No significant differences
on test anxiety
Decreased test anxiety
(P<0.05)
More “field independent”
(P<0.05)
No effect on reading
achievement
No differences on reading
scores
RR scored higher on
behavior, intellectual,
and school status
ratings (Children’s Self
Concept Scale) and selfconcept (P<0.05)
Increasing “restful
alertness”
Improved self-control, selfreflection, and flexibility
in emotional response
Improved academic
performance
TM practice produced
significant improvements in measures of
creativity, anxiety, and
practical intelligence
compared with controls
(P<0.05)
Significant impact on Brain
Integration Scale,
sleepiness, habituation
rates
(P<0.007)
BP⫽blood pressure, DBP⫽diastolic blood pressure, EMG⫽electromyography, HR-heart rate, CO⫽cardiac output, RCT⫽randomized, controlled trial,
SBP⫽systolic blood pressure
A meta-analysis of other studies, including studies in adults and children, not cited within this table. (22)
who had irritable bowel syndrome, (89) asthma, (90)
and eating disorders. (91)
Since the Birdee article was published, a pilot study
has been presented that evaluated the impact of Ashtanga
yoga for obese children and adolescents in Florida. (84)
In this study, 20 predominantly Hispanic children ages
8 to 15 years were enrolled in a 12-week yoga program.
Among the 14 who completed the program, weight
decreased from an average of 61.2 kg to 59.2 kg
(P⫽0.01). In another pilot study, fourth- and fifthgraders were enrolled in either a yoga or other afterschool program for 12 weeks. (85) The researchers did
not detect significant improvements in the primary outcome of self-esteem, but they noted that yoga participants
had significantly better scores on negative behaviors and
improved balance compared with control children. In a
third study of 154 adolescents who had eating disorders and
were randomized to yoga or treatment as usual, those who
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complementary medicine
Table 4.
meditation
Yoga Practices for Health: Pediatric Studies
Investigator
Condition/Study
Participants
Practice
Training
Period
Controls
Outcome
Birdee, 2009
(83)
Multiple (review) Review of 34 pediatric yoga articles 19 RCTs and 15 non-RCTs May be useful for physical
through December 2008
fitness and
cardiorespiratory health
Need more rigorous trials
No adverse effects
reported
Benavides, 2009 20 obese 8- to Ashtanga yoga
12 weeks
No controls; pre/post
Weight loss average from
(84)
15-year-old
design
61.2 kg at baseline to
old children
59.2 kg (P<0.01)
1 hr/wk after school 12 weeks
Control: another afterHarter’s Global SelfBerger, 2009
39 yoga
school program
Worth and Physical
(85)
32 control
Appearance Subscales
fourth- and
improved negative
fifth-grade
behavior scores and
students in an
balance in yoga group
after-school
(P<0.05)
program
No significant difference
in self-worth
Carei, 2010
54 adolescents
Yoga
8 weeks
Treatment as usual
Eating Disorder
(86)
who had
Examination: improved
eating
eating disorder scores
disorders
and decreased food
preoccupation after
each session
No significant difference
between groups in
depression, anxiety, or
weight
Yoga, breathing, and 6 to 9 months No controls; pre/post
Qualitative, open-ended
Derezotes, 2000 9 male adoles(87)
cent sex
meditation
design
questions of both teens
offenders
and parents
0 relapses over course of
study
All felt it was helpful,
with better sleep, less
anger, more selfawareness of emotions,
greater clarity in
thinking, better control
of thoughts and
feelings
RCT⫽randomized, controlled trial
received yoga had greater decreases in eating disorder scores
and food preoccupation, and there was no adverse effect on
weight compared with treatment as usual. (86) Although
these data are promising, additional studies are needed that
include randomized control groups to reduce potential bias
and larger sample sizes to test the hypothesis that yoga
programs are more effective than other interventions for
weight loss or improved self-esteem in children and adolescents.
Tai Chi is an Asian meditative movement practice
that sometimes is taught in conjunction with mindfulness meditation training. (65) Qualitative research in
middle-school students suggests that regular tai chi
practice is associated with improved well-being, calmness, relaxation, improved sleep, less reactivity to
stress, greater self-care, and an improved sense of
interconnection with other people and with nature.
(60) In a study of 12 high school girls, weekly tai chi
e98 Pediatrics in Review Vol.31 No.12 December 2010
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complementary medicine
training was associated with improvements in mood
and quality of life. (92) We did not find any randomized, controlled comparative effectiveness trials of tai
chi in children or adolescents.
Trainers, Teachers, and
Therapists for Pediatric Meditation
Tables 5 and 6 provide resources for books, CDs, and
online training options. Some psychologists and other
mental health professionals have undergone specific pediatric training and certification to provide specific training (eg, MBSR or mindfulness-based cognitive behavioral therapy or dialectical behavior therapy). Similarly,
some yoga teachers have undergone specific pediatric
training and certification. Nevertheless, due to the absence of consistent national certification for pediatric
meditation
mind/body training, it is prudent for pediatricians to ask
for evidence of explicit training and experience before
recommending trainers. Even licensure and certification
do not ensure a perfect fit between a trainer and a patient,
so it is helpful to ask for recommendations among patients and colleagues and to meet local trainers. Ask how
many sessions are standard; the duration of training;
expectations for home practice; costs; how many pediatric patients or students they have taught in the past year;
and whether they work individually, in groups, or by
telephone or internet.
As with other clinicians, look for those who are welcoming, warm, empathetic, and show genuine interest in
people, not just their favorite techniques. The most
effective teachers and trainers offer steadfast acceptance
and positive regard and create an atmosphere of safety
Mindfulness and Concentration Meditation Resources for
Children and Adolescents
Table 5.
Books
●
●
●
●
●
●
●
●
●
●
●
Biegel GM. The Stress Reduction Workbook for Teens. New Harbinger Publications, 2009
Fontana D, Slack I. Teaching Meditation to Children: A Practical Guide to the Use and Benefits of Meditation. Watking
Publishing, 2007
Garth M. Starbright–Meditations for Children. HarperCollins, 1991
Garth M. Moonbeam: A Book of Meditations for Children. HarperCollins, 1993
Gordhamer S. Just Say Om!: Your Life’s Journey. Adams Media Corporation, 2001
MacLean KL. Moody Cow Meditates. Wisdom Publications, 2009
MacLean KL. Peaceful Piggy Meditation. Albert Whitman & Co, 2004
Rozman D. Meditating With Children—The Art of Concentration and Centering: A Workbook on New Educational
Methods Using Meditation. Planetary Publications, 1994
Lantieri L, Goleman D. Building Emotional Intelligence: Techniques to Cultivate Inner Strength in Children. Sounds True,
Inc., 2008
Vallely SW. Sensational Meditation for Children. Satya International, 2008
Weierbach J, Phillips-Hershey E. Mind Over Basketball: Coach Yourself to Handle Stress. Magination Press, American
Psychological Association, 2008
CDs
●
●
Salzman A. Still, Quiet Place: Mindfulness for Young Children. 2004
Biegel G. Stressed Teens: Mindfulness for Teens—Meditation Practices to Reduce Stress and Promote Well-Being. 2009
Online Training or Practice Guides
●
●
●
●
●
●
eMindful provides online interactive courses for a fee, including courses specifically for children and teens and others
focused on specific physical or mental health challenges: http://www.emindful.com/schedules/
Learning Meditation. Patsy Gray has developed this site that provides free audio files and printable scripts for children to
use to learn simple techniques: http://www.learningmeditation.com/children.htm
Meditation Society of Australia. This site has guided meditations for children that can be downloaded; a few
introductory scripts are free, but access to others requires an online subscription (about $8 for access): http://
children.meditation.org.au/. The site also has pages for adults: http://download.meditation.org.au/
Meditations for the Constantly Connected. This site offers audio files for a fee: http://www.sorengordhamer.com/
Homepage_1.html
Amy Saltzman offers free online guided meditations: http://www.Stillquietplace.com
Mindfulness in Education. http://www.mindfuled.org/innerkids/
Pediatrics in Review Vol.31 No.12 December 2010 e99
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complementary medicine
Table 6.
meditation
Resources on Yoga for Children and Adolescents
Books
●
●
●
●
●
●
●
Bersma D, Visscher M, Kooistra A. Yoga Games for Children: Fun and Fitness with Postures, Movements and Breath.
Hunter House, 2003
Calhoun Y, Calhoun MR. Create a Yoga Practice for Kids. Sunstone Press, 2006
Chryssicas MK. Breathe: Yoga for Teens. DK CHILDREN, 2007
Chryssicas MK. I Love Yoga (Yoga for Kids). DK CHILDREN, 2005
Gruber T, Kalish L, Fatus S. Yoga Pretzels (Yoga cards). Barefoot Books, 2005
Stewart M. Yoga for Children. Fireside, 1993
Wenig M. YogaKids: Educating the Whole Child Through Yoga. Stewart, Tabori and Chang, 2003
DVDs
●
●
●
●
●
A Child’s Way to Yoga. This DVD features an outdoor setting with a creative teacher working with preschool children.
Teen Yoga. Yoga teacher Kathleen Kastner leads Miss Teen USA 2005, Allie LaForce, through an energizing power yoga
program.
Yoga for Children With Special Needs. Taught by an occupational therapist, this DVD is for children and adolescents who
can stand, bend, and touch the floor and can imitate and follow directions.
YogaKids® DVDs. These three 40-minutes videos are designed for children from 3 to 6 years of age.
Yoga For Families: Connect With Your Kids. For ages 4 and up.
OnLine Training or Practice Sites (noncommercial sites)
●
●
●
●
Global Family Yoga guides parents and teachers through yoga training to teach children yoga at churches and other
nonprofit settings across the United States. E-courses are being developed. www.globalfamilyyoga.org
Yoga Calm is designed to train parents and teachers to teach children more than 60 activities integrating physical yoga
practices, mindfulness, and social and emotional self-regulatory skills. www.yogacalm.org
Yoga 4 Kids offers adult training and professional development to provide yoga therapy to infants, children, and teens,
particularly those who have special needs. www.yoga4kids.org
Yoga in Schools wants to make yoga available in all schools to improve body-mind awareness and the ability to nurture
well-being. http://yogainschools.org
Yoga Professional Training and Certification (to find teachers locally)
●
Yoga Alliance is a national education and support organization for yoga in the United States. Use http://
www.yogaalliance.org/teacher_search.cfm to find a local registered yoga teacher.
and trust, while fostering independence and acknowledging patients’ strengths and capacities.
Costs and Insurance
Aside from care provided by licensed psychologists or
counselors, meditation training is unlikely to be covered
under most insurance plans. Some flexible medical
spending programs cover the costs if the treating physician writes a letter indicating the condition being treated
and the rationale for training. Some trainers and teachers
of meditation and yoga take a percentage of patients with
limited means as part of their community service.
Reduced-price classes may be available from student/
trainee teachers. Students and trainees who offer these
services are generally idealistic, compassionate, diligent
individuals who receive ongoing supervision and feedback from experienced mentors and provide their services for very modest or reduced rate fees.
Cases Discussions
Scientific studies suggest that mindfulness meditation
training may be a good choice for Maria to help with her
headaches, mood, stress, and school behavior. Similarly, the
research on concentration meditation, particularly TM
and RR, generally supports its benefits for patients who
have hypertension and stress; it has been used successfully in
classroom settings for middle-school students like Antwan.
Yoga training has been used safely for adolescent girls like
Maggie who have eating disorders without risking additional weight loss. However, clinicians should consider the
many types of yoga and encourage patients to select a type
that focuses less on athleticism and more on mindfulness,
meditation, or breathing aspects of the practice. Clinicians
considering referring adolescents who have the recent onset
of behavior or psychiatric problems such as Maria and Maggie
should screen for thought disorders and other symptoms of
schizophrenia before recommending meditation training.
e100 Pediatrics in Review Vol.31 No.12 December 2010
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complementary medicine
Summary
meditation
11. Cahn BR, Polich J. Meditation states and traits: EEG, ERP,
Interest in, practice of, and research about a variety of
meditation forms for children and youth is growing.
Thus far, the evidence supports the feasibility and acceptability of numerous meditative practices, including
mindfulness practices, TM, RR, yoga, and tai chi. A number of well-controlled studies support the use of meditation for blood pressure reduction. In addition, research
suggests that meditative practices are associated with
improvements in attention, behavior, and psychological
functioning in children and youth. More rigorous comparative effectiveness research in larger, diverse pediatric
populations is needed to be confident that these results
are related specifically to the instruction and practice of
meditative practices and to tailor recommendations to
specific patients. Despite the desirability of additional
research, meditation is a very safe practice, with a variety
of approaches that can suit diverse unique needs, values,
and preferences. Clinicians should use similar approaches
and considerations in referring pediatric patients for
meditation training as for other complementary therapies
and therapists such as massage and acupuncture.
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Pediatrics in Review Vol.31 No.12 December 2010 e103
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Complementary, Holistic, and Integrative Medicine: Meditation Practices for
Pediatric Health
Erica M.S. Sibinga and Kathi J. Kemper
Pediatrics in Review 2010;31;e91
DOI: 10.1542/pir.31-12-e91
Updated Information &
Services
including high resolution figures, can be found at:
http://pedsinreview.aappublications.org/content/31/12/e91
References
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