Impact of mindfulness-based interventions on anxiety and depression among adolescents with a neurological disorder: A systematic narrative review

The review is guided by the following research question: What evidence exists regarding the impact of MBIs on anxiety or depression among adolescents with a ND?

a. The term ‘ND’ is defined in this review as a dysfunction in the brain or nervous system, potentially resulting in physical and psychological symptoms.^[2]

b. The term ‘mindfulness’ is defined in this review as a “moment-to-moment, non-judgmental awareness, cultivated by paying attention in a specific way, that is, in the present moment, and as non-reactively, as non-judgmentally, and as open heartedly as possible” (p. 1481).^[6] Mindfulness and MBI are used interchangeably in this review. Examples of MBIs explored in this review include yoga, mindfulness martial arts, and meditation.

c. The term ‘adolescent’ refers to a person in the unique phase of life between childhood and adulthood.^[7] While the World Health Organization defines adolescents as individuals between the ages of 10 and 19, this review specifically defines adolescents as those between the ages of 10 and 17. This distinction is made because many adult-based MBI studies involving participants with NDs often use 18 years of age as the lower age limit for inclusion criteria.

This systematic narrative review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement.^[8] Relevant studies were discovered through searching the Cumulated Index to Nursing and Allied Health Literature (CINAHL) database and PubMed (MEDLINE) database. Studies published in English within the past 10 years (2013–2023) were included, given that the search was conducted in December 2023. The following search terms were applied within CINAHL: i) ‘mindfulness-based stress reduction’ OR ‘mindfulness’ OR ‘mbsr’ OR ‘mindfulness intervention’ AND ii) ‘adolescent’ OR ‘teenager’ OR ‘young adults’ OR ‘teen’ OR ‘youth’ AND iii) ‘NDs’ OR ‘neurological disease’ OR ‘disability. An advanced search was conducted in PubMed (MEDLINE) and included the following search terms: ‘mindfulness’ AND ‘adolescent’ AND ‘ND’ (see Appendix 1 for full search strings). The initial screening and retrieval of articles was conducted by one reviewer; however, when the primary reviewer was undecided about the inclusion of an article, a second reviewer assisted in the decision. Figure 1 illustrates the screening process using a PRISMA flow diagram.^[8]

Figure 1.

PRISMA flow diagram

The inclusion criteria consisted of qualitative, quantitative, and mixed methods studies, as well as reviews and meta-analyses. The studies must have examined adolescents (aged 10-17) with an ND, though they were not excluded if they also included children or adult participants with NDs. The studies must have evaluated or qualitatively described depression or anxiety, and incorporated a mindfulness-based aspect. Expert opinions, clinical discussion papers, and theoretical papers were excluded from this review. Additionally, studies involving adolescents with a disorder deemed mainly psychiatric in origin, such as schizophrenia or borderline personality disorder, were excluded from this study.

During the search process, it became evident that a dearth of literature existed addressing this topic within the population of interest. Consequently, the inclusion of relevant systematic reviews and meta-analyses within this systematic narrative review was necessary to comprehensively capture the available evidence and was consistent with the established inclusion criteria.

In December 2023, a total of 214 articles were retrieved from database searches, and one article was obtained through reviewing reference lists. After importing the articles into Covidence and removing duplicates, 208 unique articles remained. The titles and abstracts were initially screened for relevance and eligibility, resulting in the elimination of 117 articles. This left 91 articles for the full-text examination. The final screening led to the removal of 81 articles, leaving 10 eligible articles for inclusion in the review.

The results of this review were analyzed and developed by two reviewers through communication via telephone and Zoom at several time points. Because of the broad inclusion of NDs, both reviewers agreed to thematically synthesize the articles based on the type of MBI employed, whether physical or behavioral in nature. When disagreements occurred, a third reviewer assisted in resolving decisions. Although the literature search spanned over 10 years (2013-2023), eight of the ten reviewed articles included in this review were published within the last five years (between 2018-2023). A majority of the articles (n = 8) employed a quantitative design, while two articles employed a qualitative design and case study respectively.^{[9, 10]} Of the eight quantitative studies; two were systematic reviews and meta-analyses,^{[11, 12]} two were randomized controlled trials (RCTs),^{[13, 14]} three were quasi-experimental in design,^[15,16,17] and one was mixed-methods.^[18] An overview of each study can be viewed in Appendix 2.

Utilizing the Joanna Briggs Institute (JBI) level of evidence for effectiveness grade,^[19] we determined three of the articles had a level I grade,^{[11, 13, 14]} five had a level II grade,^{[12, 15,16,17,18]} one had a level III grade,^[9] and one had a level IV grade.^[10] Most of the studies reviewed utilized convenience sampling to recruit participants. In contrast, Stephens employed purposive sampling for the case presentation study.^[10] Among the systematic review/meta-analysis articles, one included a variety of studies with different designs,^[12] while the other focused solely on RCTs related to the author’s specific research topic.^[11] Each included article was critically analyzed and interpreted using a matrix table (see Appendix 2), which enabled the researchers to systematically examine study quality and methodological limitations. Identified limitations were discussed between two reviewers, and consensus was reached regarding final article inclusion.

The studies reviewed included a diverse range of participants with NDs due to the literature examining MBI’s among adolescents with NDs, particularly in relation to anxiety and depression. Most articles included in this review focused on adolescents with migraines or chronic tension headaches.^{[10, 15, 16]} One study examined adolescents with neurofibromatosis.^[17] Another study focused on children and adolescents with cerebral palsy,^[13] and a separate study examined adolescents and youth adults with autism spectrum disorder and intellectual disability.^[18] The remaining studies included adolescents with learning disorders and self-regulation challenges (e.g., anxiety, behavior problems)^[9] and adolescents and children with attention deficit hyperactivity disorder (ADHD).^[14] Of the ten articles included in this review, six incorporated parents and/or caregivers within the study design.^{[9, 10, 13, 14, 17, 18]}

An eight-week yoga intervention program involving children with cerebral palsy was associated with improvements in consistency and attentiveness reported by both parents and children; however, no significant changes were observed in post-intervention psychological measures, including depression and anxiety.^[13] A separate study implemented a multifaceted approach combining yoga, pharmacological, and nonpharmacological interventions to improve the quality of life for a 14-year-old girl with migraines and neurological comorbidities, leading to notable improvements in her psychological well-being, specifically anxiety.^[10] A third study evaluated a mindfulness martial arts program for youth with learning disabilities, finding significant enhancements in emotional and behavioral well-being. A parent of a participant detailed how his son wanted to participate in the MBI, verbalizing that he was feeling sad and anxious, but wanted to feel less sad and anxious.^[9]

Behavioral interventions have demonstrated promising results across various studies as well. One article found behavioral group sessions for adolescents with chronic migraine and high-frequency episodic headaches significantly reduced headache days, medication intake, disability, anxiety, depression, and catastrophizing.^[15] A second study discovered individualized therapy with mindfulness meditation significantly improved reactivity, dysphoria, irritability, anxiety, and depression for children with autism spectrum disorder.^[18]

Researchers from an additional study integrated an education component into their mindfulness-based behavioral group sessions, focusing on medication use and lifestyle modifications to manage chronic migraine and high-frequency episodic headaches through mindfulness meditation practices.^[16] This combined approach significantly reduced headache frequency, depression, catastrophizing, and headache-associated disability, although it did not significantly impact anxiety.

Martin and colleagues examined the effects of a mindfulness-based behavioral intervention, implementing a workshop program incorporating acceptance and commitment therapy for adolescents and young adults with neurofibromatosis type 1 and chronic pain.^[17] Participants received education about the psychological aspects of pain and were subsequently provided with mindfulness-based techniques to practice independently. A three-month follow-up revealed significant improvement in patient-reported pain; however, no significant changes were noted in functional ability, anxiety, depression, or quality of life as reported by the patients or their parents. The final mindfulness-based behavioral study compared mindfulness-oriented meditation with an emotion education program for children with ADHD. The findings revealed significant improvements in impulsivity, attentiveness, emotional lability, hyperactivity, social functioning, and perfectionism in the meditation group—outcomes not observed in the control group.^[14] However, anxiety and depression outcomes did not significantly improve.^[14]

Six of the reviewed studies included parents or caregivers.^{[9, 10, 13, 14, 17, 18]} While some studies reported improvements in caregiver stress and acceptance of their child’s condition, these changes were generally not statistically significant. These findings, however, were not thoroughly explored in this review as they did not align with its primary purpose.

Among the behavioral and physical mindfulness interventional studies, four of the eight specifically addressed feasibility.^{[15,16,17,18]} All four of these interventions were noted to be feasible in their respective populations. These studies provided evidence that their interventions were not only practical but also well-received by participants, suggesting that such approaches can be successfully integrated into real-world settings. In contrast, the remaining four studies did not include a discussion on the feasibility of their interventions, leaving the practicality and broader applicability of these approaches unaddressed.^{[9, 10, 13, 14]}

Wei and colleagues conducted a systematic review and meta-analysis on MBIs for patients with neurofibromatosis types 1 and 2 and schwannomatosis.^[12] They found that MBIs improved overall quality of life and demonstrated a positive correlation between relaxation response practice and quality of life indicators. One included study demonstrated significant improvements in depression and anxiety symptoms following an MBI. A similar article performed a review analysis for patients with autism spectrum disorder, revealing significant anxiety reduction in children whose parents received psychoeducation.^[11] However, the relationship between behavioral interventions and their effects on depression in children with autism spectrum disorder was unclear.

The limitations of this systematic narrative review relate to the limited number of databases included in the search. Although searching two databases is often deemed sufficient,^[30] higher-quality systematic reviews typically include searches across multiple databases. While many systematic reviews are conducted with only two databases, this approach introduces a risk of bias, as relevant studies may have been missed due to the restricted scope of the literature search. In an attempt to mitigate this risk, grey literature was thoroughly explored by reviewing the reference lists of included articles, as well as other articles with relevant context, in an effort to capture all pertinent studies for this review.

Furthermore, due to reviewer availability, only one individual screened for article inclusion, with a second reviewer providing input when the primary reviewer was conflicted. Two of the authors, however, analyzed the final ten articles individually and discussed together how best to organize the results section of the review (i.e., type of MBI implemented). The authors jointly wrote the results and discussion section of the review, strengthening the validity and reliability of the work by reducing interpretive bias.

Most studies in this review assessed psychological well-being indicators such as anxiety or depression as a secondary outcome and predominantly relied on single measurement tools. To strengthen the internal validity of future research, it is crucial to employ multiple measurement tools when evaluating variables^[31] and to assess the reliability of each instrument among the study population to ensure it adequately measures the variables (e.g., anxiety or depression) under examination. Additionally, future research should focus on adolescents with NDs who have pre-existing anxiety and depression diagnoses to assess the efficacy of MBIs in reducing these symptoms, thereby avoiding a potential ‘ceiling effect’ as observed in some studies. Including participants with diagnosed anxiety or depression or identifying these conditions through thorough screening during study inclusion will be key. Advanced care providers or practitioners must conduct comprehensive assessments to identify or diagnose mental health disorders^[32] in this population, likely requiring tailored assessments to address their challenges. Moreover, ensuring the delivery of the intervention is consistent from one person to the next is imperative to the fidelity of the intervention. A standard of delivery in conducting MBI studies among this population should be employed to confirm the findings are directly related to the intervention and not an inconsistent delivery of the intervention.

Furthermore, future studies may consider implementing MBI programs among adolescents and children with various NDs to evaluate the generalizability of such programs across varying ND populations. This will assist pediatric APRNs in providing effective case management services to adolescents with NDs and mental health disorders, ensuring they receive the best plan of care and services for their individual needs. Given the diversity of NDs, findings from this review should be interpreted with caution, as results from one condition may not be applicable to adolescents with other NDs. As future research in this area expands, a replication of this review may allow for thematic categorization of results by neurological condition, offering an alternative and more direct interpretation of the findings.

The unexpected findings related to caregiver involvement and outcomes in these studies highlight the need for future research to evaluate the impact of introducing new interventions on the care regimen of children with complex needs. This should include a particular focus on caregiver well-being and compliance rates over time, as the introduction of new interventions may contribute to caregiver burnout. Further studies are needed to investigate the potential correlation between the feasibility of interventions and their impact on caregiver well-being.