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SYSTEMATIC REVIEW

The effectiveness of mindful parenting programs in promoting parents’ and children's wellbeing

a systematic review

Townshend, Kishani; Jordan, Zoe; Stephenson, Matthew; Tsey, Komla

Author Information
JBI Database of Systematic Reviews and Implementation Reports: March 2016 - Volume 14 - Issue 3 - p 139-180
doi: 10.11124/JBISRIR-2016-2314
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Abstract

Background

Mindfulness-based interventions are increasingly being used to address the rising prevalence of child and youth mental health disorders. The primary mental health disorders during childhood tend to be internalizing (anxiety, depression) and externalizing (aggression, oppositional defiance) disorders.1 Approximately 25% of Australian and international youth, who present with these disorders, continue to be impacted by the poor outcomes of unemployment, underemployment and social isolation into adulthood.2–4 Internalizing disorders refer to disorders associated with depression, anxiety and somatic symptoms.5 Externalizing disorders are characterized by impulsive, disruptive conduct and substance use symptoms.5 The annual cost of mental health disorders to the Australian community is approximately $20 billion per annum.6 Raising parents’ awareness about the early detection of mental illness could be one cost-effective strategy to address the delayed diagnosis of mental health disorders. Mindful parenting has been defined as the ability to pay attention to your child and your parenting in a particular way, which is intentionally, non-judgmentally while being in the here and now.7,8 This review aims to investigate the effectiveness of mindful parenting programs in alleviating symptoms associated with internalizing and externalizing disorders.

The Western concept of mindfulness is qualitatively different from its apparent Eastern roots. The definition of “mindfulness” as a psychological construct appears to have changed over the centuries, as it traversed across cultures. Although the modern Western definition of mindfulness is stated to be of Buddhist origin, Wallace9 notices there is no basis for this claim. The traditional Buddhist definitions of mindfulness as retention, recollection or memory is a common thread that pervades Theravadan, Zen and Indo-Tibetan Buddhism, all of which trace this meaning back to Buddha's own recordings in Pali and Sanskrit.9 It refers to the memory of the moment with consideration for the ethics or values underpinning the eight-fold path. The English term “mindfulness” is a translation of the Pali, Sanskrit and Japanese terms, “sati”, “smRti” and “nen”.10–12 “Sati” means “memory” in English.10 In contrast to this unified cluster of Buddhist definitions, modern clinical psychology defines mindfulness as a non-judgmental present-centered awareness in which whatever arises to attention is acceptable as it is.9 Such attention requires no remembrance, recollection, recognition or naming, and it is free from ideas, ideals and prejudices.9 The essence of the modern mindfulness appears to be nothing more than bare attention.

Attention appears to be the key active ingredient within modern mindfulness interventions that is attributed to promoting positive change. However, the modern definitions of mindfulness vary according to different authors and their views on which aspects of attention is responsible for stimulating change. For instance, Kabat-Zinn13(p.145) defines mindfulness as “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment.” According to Kabat-Zinn,13 it is the ability to focus on the moment, without judgment and running on automatic pilot that facilitates change. Langer's14(p.40) definition of mindfulness emphasizes “attention to variability” as an important contributor to promoting change. Attention to variability is the ability to be aware of moment-to-moment changes in one's emotions, thoughts and surroundings.8 Regardless of the aspects of attention that promotes change, there appears to be a consensus that mindfulness improves wellbeing. A comprehensive meta-analysis found that mindfulness-based therapy is an effective treatment for a variety of psychological disorders, especially for reducing anxiety, depression and stress.13 The key active ingredient of mindfulness is thought to be the improved self-observation that promotes better coping skills.15,16 Mindfulness interventions have often been referred to as the third wave of cognitive behavioral therapies. The traditional cognitive behavioral therapy (CBT), tends to focus on creating psychological change, whereas mindfulness interventions tend to focus on being aware of negative emotions and one's ability to process them.17,18 Hence, it appears that paying attention without judging or challenging one's negative thinking can improve one's ability to regulate emotions, focus attention and react with greater flexibility to events.

The integration of mindfulness with parenting started to appear in the Western literature around 1997, when Myla and John Kabat-Zinn7 coined the term “mindful parenting” in their book, Everyday blessings: the inner work of mindful parenting. Kabat-Zinn developed a manual for a mindful parenting program. However, over the past 18 years, primary studies on mindful parenting programs using other manuals have steadily increased. The theoretical rationale that underpins other mindful parenting programs tends to be drawn from two broad approaches of mindfulness that have been integrated into psychotherapy, namely, mindfulness based and mindfulness oriented. Mindfulness-based psychotherapy includes mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT) and mindfulness-based cognitive behavior therapy (MBCBT).17 Mindfulness-oriented models include acceptance commitment therapy (ACT) and dialectical behavior therapy (DBT).15,19 Although there are different versions of mindful parenting programs, the content of these programs is similar as the central focus is on integrating mindfulness with parenting.

A core similarity among the various mindful parenting programs is the emphasis on being responsive to a child's emotions. Other similarities include intentionality, emotional awareness, emotional regulation, attention regulation and non-judgmental acceptance. Mindful parenting is a meta-concept that is a higher level of awareness parents have about their internal states, how they think and feel about their thoughts.20 It goes beyond the simple expression of emotion to being aware of and reacting to parenting emotions.21 Interestingly, both Gottman et al.21,22 and Kabat-Zinn7 started writing about similar concepts of parenting emotions in 1997. It involves both intrapersonal and interpersonal processes of parenting. The intrapersonal processes assist parents change the relationship with their internal states, namely thoughts, feelings, attributions, attitudes and values.20 The interpersonal processes enable empathic responding, perspective taking, emotional awareness and interpersonal closeness.20 Although various theorists propose different models of mindful parenting, a fundamental similarity between the mindful parenting programs is the integration of mindfulness with parenting.

Emotional awareness, emotional regulation, intentionality, attention regulation and non-judgmental acceptance appear to be central tenants of these mindful parenting programs. Two mindful parenting programs are the Mindfulness-based Strengthening Families Program (MSFP) and Tuning Into Kids (TIK). Mindfulness-based Strengthening Families Program has been used to prevent alcoholism and substance abuse among adolescents.23 The TIK program uses Gotman's emotion coaching technique to reduce parental stress among parents of preschoolers from the general community and preschoolers diagnosed with autism. Although emotion coaching24 is not specifically claimed to be a mindful parenting technique, it upholds the central tenants of mindful parenting. The five steps of emotion coaching24 are:

  • becoming aware of a child's emotion, particularly when it is at a lower intensity
  • viewing a child's emotion as an opportunity for intimacy and teaching
  • communicating and understanding and acceptance of the emotion
  • helping the child to use words to describe how they feel
  • if necessary, assisting them with problem solving (while setting limits).

Reperceiving is thought to be a key change process that facilitates mindfulness. It refers to the fundamental ability to reduce automatic response patterns and the ability to distance themselves from negative affect.25 These programs provide new insights into how to be responsive to children's needs.

The Interpersonal Mindfulness in Parenting (IM-P) scale measures five dimensions of mindful parenting.26 These five dimensions of mindful parenting are:

  • listening with full attention involves training parents to listen to their children with focused attention
  • non-judgmental acceptance of self and child emphasizes training parents to become aware of judgments and adopt a non-judgmental acceptance of traits, behaviors of self and their youth
  • emotional awareness of self and child involves building parent's capacity to become aware of emotions within themselves and their youth
  • self-regulation in the parenting relationship requires becoming less reactive and calmly selecting behaviors in accordance with parenting values
  • compassion for self and child involves helping parents develop a genuine empathic concern for their child and themselves as parents.

The development of this psychometric assessment is a substantial contribution to this field as it helps researchers to investigate which dimensions of mindful parenting are most effective in facilitating positive change. At present, there is no evidence that mindfulness has an impact on the child's brain development. However, there is a wealth of evidence demonstrating how neglect impairs the hippocampus and brain development in children.

Mindful parenting has the potential to offer service providers with additional resources, namely parents, in the early detection of mental health disorders. Unlike vaccination campaigns for physical health conditions such as polio, parents are often not involved in the prevention or early detection of a child's mental health disorders. One of the most significant mediators in promoting wellbeing within infant and youth mental health services are programs that focus on parenting and the quality of the parent-child relationship.27 A wealth of evidence now demonstrates the effectiveness of parenting programs in addressing children's emotional and behavioral problems. Some of these programs include the Incredible Years, Stepping Stone Triple P, Signposts for Building Better Behavior, Research Units in Pediatric Psychopharmacology Parent Training, Sign and Grow Music Therapy, Mindfulness Training, Parent-Child Interaction Therapy, the Autism Spectrum Conditions – Enhancing Nurture and Development program, Parent Training for Smaller Groups and Shorter Schedules, video modeling and feedback parent training and parent management training.28 However, there is also a significant group of parents in which the standard parent training is not effective in addressing parental anger or capacity for self-regulation.29 Furthermore, various authors have advocated for the development of additional components to parent programs to consolidate treatment gains as the effects do not appear to be long-lasting. Mindful parenting programs offer a range of techniques to break automatic patterns, also referred to as “automaticity” of negative emotions, thoughts and behavior that traditional behavioral parent training alone does not impact.30 The focus seems to be on interpersonal rather than intra-psychic, wherein parents are encouraged to “slow down”, enhance their emotional states and respond with more compassion to their children. Hence, reviewing the evidence on mindful parenting programs can contribute to the broader debate on the role and effectiveness of these programs in the timely diagnosis of mental health conditions.

Parental mental health plays a significant role in promoting their children's mental health. Evidence shows that 23% of Australian children live with a parent that has a mental illness.27 These children are identified as a vulnerable, high-risk population because of predisposed mental health concerns and the stressors associated with living with parents diagnosed with a mental health disorder.27 The stressors may include the social, emotional, environmental and financial stressors. The etiology of mental health disorders appears to be bidirectional, wherein parents and children influence each other's thinking and behavior.31 Parental mental illness, poor quality parenting, substance abuse and disrupted family life are all involved in the development of childhood conduct disorders.32 Poor parenting has been found to be one of the most important precursors to early onset of conduct disorders.33 Inadequate parenting is characterized by ineffective parenting skills such as punitive and inconsistent discipline, low levels of parental supervision and low levels of involvement.34 In addition, children's behavioral difficulties contribute to the development of parental mental illness. The cyclical nature associated with the development of mental illness means that any form of early intervention needs to address parental mental health and parenting skills.

Studies evaluating mindful parenting programs generally tend to be group-based programs and a few studies focus on programs delivered through the one-to-one format. Group programs are qualitatively different from the individual sessions as the group dynamics play a key role in the therapeutic process. Results also show that parents in the individual therapy session appear to have better outcomes. The majority of the studies evaluating group-based mindful parenting programs tend to be descriptive case series.35–37 The settings tend to be mostly home based with parents attending one to two-and-a-half hours per week for six to 12 weeks. There are also a few randomized controlled trials (RCTs)38,39 using small sample sizes. These studies are mainly conducted in America, Australia or Europe. Although all the participants are parents, the target group of parents tends to vary from pregnant mothers, parents of children presenting with autism, parents of children diagnosed with conduct disorders and parents of children from the age 10 to 14, to parents on a methadone program with preschoolers. Both experimental and descriptive studies indicate that mindful parenting programs can improve the parent-child relationship, parenting skills and the child's wellbeing with regard to social and emotional competence.40 The results from these primary studies indicate some consistency of positive effects.

While a preliminary search conducted in April 2014 found no completed systematic reviews or review protocols in the major bibliographical databases, a later search found a similar review protocol,41 which was written in 2012 and published in September 2014. The databases that were searched in April 2014 included the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, EMBASE, PsycINFO and PROSPERO, the international database of prospectively registered systematic reviews in health and social care. The similar protocol states the systematic review was planned to be completed by the end of January 2013. However, no completed systematic review has been published on the topic by the authors to date. This protocol was not found on PROSPERO. Similarities between the studies are that both protocols are evaluating the effectiveness of mindful parenting interventions on children's outcomes. Although the title of Macvean et al.'s41 protocol states the review is focusing on the psychosocial outcomes for children, the protocol specifies it will also be evaluating parental psychosocial outcomes such as depression, anxiety, stress, family functioning and adverse effects.

The main differences between the two protocols are that the primary outcomes of Macvean et al.'s41 protocol are psychosocial outcomes for the children. In contrast, the primary outcomes of this systematic review are both parents’ and children's outcomes related to internalizing and externalizing disorders. Another difference between the protocols is that Macvean et al.'s41 study excludes discrete studies wherein parents present with clinical diagnosis such as mental illness or substance dependency. The current review included studies wherein parents had a clinical diagnosis. Another major difference between the studies is that although the Macvean et al.'s41 protocol excludes perinatal studies wherein children's outcomes had not been measured, this review includes perinatal studies that have and have not measured children's outcomes. The Macvean et al.'s41 protocol focuses on brief, group-based interventions typically less than 20 sessions. The inclusion criteria for this review is slightly different as it focuses on group-based mindful parenting programs with a minimum duration of one to two hours per week for six to eight weeks, delivered in a group format, by a facilitator with appropriate training. The secondary outcomes for the current study were emotional regulation, quality of the parent-child relationship, mindfulness and resilience. The secondary outcomes for the Macvean et al.'s41 protocol were parental psychosocial outcomes. So although there are similarities between the two protocols, there are many differences in the inclusion criteria. Both the systematic reviews can complement each other and contribute to collecting the best available evidence on mindful parenting programs and may be used collaboratively to work with parents, children and service providers to promote the timely diagnosis of children's mental health disorders.

Several systematic reviews have been completed on group-based parenting programs. However, there appears to be no completed reviews on mindful parenting programs. A recent systematic review on the effectiveness of mindfulness practices on parents and professionals caring for children with developmental delays found that mindful practices improved care providers’ experiences and supported them, providing a better standard of care to the recipients.42 The proliferation of mindfulness-based interventions targeting children and families tend to have conceptual and methodological limitations. First, there appears to be no consistent model of mindful parenting. Second, the studies vary in content, dose and theoretical underpinnings. A recent review found no significant relationship between class hours for a MBSR program and the effect sizes for psychological distress. In fact, there was no evidence to show that reduced hours were less effective than standard hours in reducing psychological distress.43 Finally, the limited use of psychometrically sound measures of mindfulness, as it relates to parents and children, leads to difficulties in articulating and measuring the active agent responsible for positive change.

This systematic review aims to select studies with similar theoretical rationale content, dose and validated scales to investigate whether mindful parenting programs are effective in promoting wellbeing. The definitions of both wellbeing and mindfulness are just as controversial as its measurement. This study draws upon the Western definition of mindfulness as the ability to be attentive to the present.7,13 More specifically, mindfulness was defined as the non-judgmental attentional process of being present in the moment without running on automatic pilot. It focuses on the clarity of thinking and flexibility of thinking. Wellbeing was defined according to the definition provided by Dodge et al.,44 that is wellbeing as the state of equilibrium or balance that can be affected by life events or challenges. Given the scarcity of studies with validated wellbeing measures, this review also measured wellbeing in terms of the reduction in the intensity of symptoms associated with internalizing and externalizing disorders. This review can add to the broader debate on whether mindful parenting programs could be added to the repertoire of tools used in the prevention and early intervention of mental illness. This systematic review was conducted in accordance with the protocol45 registered on PROSPERO (http://www.crd.york.ac.uk/PROSPERO) with the registration number CRD42014015164.

Objectives

The primary objective of this review was to systematically evaluate the effectiveness of mindful parenting programs in promoting children's, adolescents’ and parents’ wellbeing, particularly in relation to the intensity of symptoms associated with internalizing (depression, anxiety, stress) and externalizing (conduct) disorders. The secondary objective was to evaluate how the effectiveness of mindful parenting programs in improving emotional regulation, quality of the parent-child relationship, resilience and mindfulness of the children, adolescents and parents. The comparator was the control or waitlist conditions. The populations of interest in this study were children aged between 0 and 18 years and their parents who have completed a mindful parenting program.

Inclusion criteria

Types of participants

This review considered studies that included children aged 0–18 years old, whose parents have completed a mindful parenting program. The participants were the children or adolescents and their parents. Most countries across the world consider a child to be an adult when they become 18 years old. This study considered an individual younger than 18 years old as a child. The inclusion criteria encompassed children with or without a mental health diagnosis and those from culturally diverse, adopted or fostered backgrounds.

Types of intervention(s)

A minor amendment was made to the inclusion criteria regarding the types of interventions specified in the protocol, as it was too restrictive and would have excluded the majority of the studies in the field. The intervention duration and facilitator qualifications were expanded to include mindful parenting programs with a minimum duration of one hour per week over a minimum of six weeks, delivered by a facilitator with appropriate training to maintain treatment fidelity. The duration of mindful parenting programs in included studies ranged from six to 12 weeks with parents attending a group workshop for one to one-and-a-half hours each week. The review selected studies with consistency in the variables such as program duration, timing, frequency, intensity and facilitator training to maintain treatment fidelity. It included parenting programs that drew upon MBSR, MCT, MCBT, DBT or ACT. The focus was on interventions that combined mindfulness and parenting.

Comparator

The mindful parenting programs were compared with the control group of standard care or usual care.

Types of outcomes

This review included studies that reported on outcomes for children, adolescents and parents that were measured with validated instruments. The primary outcomes were wellbeing in addition to the intensity of symptoms associated with internalizing disorders (depression, anxiety, stress) and externalizing disorders (conduct disorders) of the children, adolescents and parents. Secondary outcomes included emotional regulation, quality of the parent-child relationship, resilience and mindfulness of the children, adolescents and parents. These outcomes were measured on validated tools with known psychometric properties such as the Depression, Anxiety and Stress Scale46 and other relevant scales. Time points of measurements such as pre, post and follow-up were also relevant to the durability of the outcomes.

Types of studies

The primary study design of interest for this review was RCTs. In the absence of RCTs, other study designs such as quasi-experimental, observational and descriptive study designs were considered. As RCTs meeting the inclusion criteria and of sufficient methodological quality were identified, this review did not include other study designs.

Search strategy

A three-step search strategy was utilized to find published and unpublished studies written in English from 1997 to November 2014. The timeframe was selected because “mindful parenting” started to appear in literature from 1997, with Myla and Jon Kabat-Zinn's7 publication on the topic. Eight databases were searched for the keywords “mindful” and “parenting” from April to November 2014. The databases that were searched included PubMed, PsycINFO, EMBASE, Scopus, Psychology and Behavioral Sciences Collection, CINAHL, Cochrane Library and ProQuest Dissertations and Theses database. The initial search for keywords in the first eight databases was followed by an analysis of the text words contained in the title, abstract and index terms used to describe the articles. A second search using all identified keywords and index terms was then undertaken across all included databases. Third, the reference list of all identified reports and articles was searched for additional studies. As specified in the protocol, the search for gray literature focused on searching ProQuest Dissertations and Theses database, as there was an absence of high-quality published studies. Scopus also finds EMBASE and PubMed articles. The search deliberately searched these different databases with the acknowledgment that a high number of duplicates will be found. This was primarily to find additional material from the social sciences material.

A logic grid was developed for each of the eight databases to articulate the synonyms and indexing terms associated with the initial keywords of “mindful” and “parenting”. Keywords associated with “mindful” included mindfulness, MBSR, MBCT, MBCBT, DBT or ACT. Some keywords associated with “parenting” included parent, parent-child relationship, father, mother, parental, maternal, paternal, perinatal, prenatal and antenatal. Complete search strategies for each database, including all search terms, are provided in Appendix I. The search may appear simple, but repeated testing confirmed that the use of truncations yielded a more efficient and consistent search. Rather than listing individual possibilities for keywords, truncations allowed for all possible variations. For example mindful* allowed for all possible variations such as mindfulness, mindfulness-based, mindfully and all other variations, which was confirmed through repeated testing. A comprehensive search was conducted by utilizing a wide range of field codes that were used to conduct. For instance, text word [tw], mesh term [mh], [mp] and many more. The field code [tw] includes all words and numbers in the title, abstract, MeSH terms, MeSH subheadings, publication types, substance names, personal name as subject, corporate author, secondary source and other terms. Mindfulness was only listed as a PubMed mesh term in 2014. Nevertheless, various field codes, truncations and keywords were used to cast a wide search net. The field code [mh] captures mesh terms. The field code mp was used for exhaustive searching of multiple fields such as title, abstract, heading word, table of contents, key concepts, original title, tests and measures. Appendix I outlines all the various field codes used in the logic grids. All selected articles were reviewed to determine if they met the inclusion criteria.

Assessment of methodological quality

Articles selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendixes II and III). Any disagreements that arose between the reviewers were resolved through discussion or with a third reviewer. The primary reviewer allocated a final critical appraisal rating for each study after considering the assessments provided by the primary and secondary reviewers. A rating of 5/10 or above on the JBI Critical Appraisal Checklist (Appendix II) was considered to be the cut-off to be included into the review. Studies were considered to be of weak methodological quality if they scored 5/10 or 6/10, moderate methodological quality if they scored 7/10 and strong methodological quality if they scored 8/10 or above. This systematic review also assessed the methodological quality of the selected studies by analyzing the strengths and weaknesses. The rationale for presenting the strengths and weaknesses in a table format is to summarize the methodological quality of the selected studies.

Data extraction

The data extraction process entailed using the standardized data extraction form from JBI-MAStARI (Appendix III) to extract data from the selected studies. The first author extracted and analyzed the data from the studies that met the inclusion criteria and were of sufficient methodological quality. The extracted data included specific details about the interventions, populations and study methods in addition to the outcomes of significance to the review question and specific objectives. The authors of the selected articles were not contacted to obtain additional data, as this was not required for data synthesis. Data items were sought for the list of variables specified in the population, intervention, outcome and comparator (PICO). No assumptions or simplifications were made to the predefined variables. The principle summary measures that were extracted included means (M), standard deviations (SDs), standard errors (SEs), between group mean differences, effect sizes (Cohen's d, Cohen's f2) and statistics from general linear models together with respective P values.

Data synthesis

The selected studies were initially assessed for methodological and conceptual similarities. As the age groups, outcome measures, presenting conditions and sample characteristics widely varied in the selected studies, a meta-analysis was rendered inappropriate because of the heterogeneity of the studies. Hence, a narrative summary was presented. To account for confounding factors that age, mental illness, cultural diversity and adoption may have on outcomes, the protocol planned to conduct sub-group analyses. The protocol aimed to conduct sub-group analyses according to Erikson's age brackets for psychosocial development, to address the large developmental differences between the ages of 0 and 18. Erikson's psychosocial developmental stages are infancy (0–18 months), early childhood (2–3 years), preschool (3–5 years), school age (6–11 years) and adolescence (12–18 years).47 Insufficient articles were found to conduct subgroup analysis according to Erikson's age groups, ethnic diversity (Indigenous, migrant or African American), adopted or fostered children and internalizing disorders. Sufficient studies were found to conduct subgroup analyses for externalizing disorders among children with autism and preschool children. The studies were analyzed according to three sub-groups: 1) mothers and 10–14-year olds from a community sample; 2) parents of children with autism, and 3) parents of preschool children. These categories are clinically more meaningful as they combine studies with similar characteristics of age, diagnoses, treatments and co-morbidities.

Methods used for handling data and combining results of studies included using consistent measures for measuring primary and secondary outcomes. As statistical pooling was not possible, the findings were presented in narrative form including tables and figures to aid in data presentation if appropriate. Means and standard deviations were analyzed for continuous scales items. All results were subjected to double data entry. Standard errors were converted to standard deviations when necessary. Between-group Cohen's ds were calculated from mean values post-intervention and at follow-up compared with the control group without any intervention. The commonly accepted criteria for effect sizes is small effect (d = 0.20), moderate effect (d = 0.50) and strong effect (d = 0.80).48 The P values were calculated for the calculated Cohen's ds by using independent t tests.

For Tables 1–3, the differences between the intervention and control groups were calculated by comparing post-program Cohen's ds and follow-up Cohen's ds for the two conditions. So these between-group differences do not take into account baseline differences. For that, Cohen's d would need to have been calculated on the average differences and their standard deviations between pre- and post-program. However, some studies did not report standard deviations of the differences, pre-program means or post-program means. For some studies and some outcome measures, the baseline differences were quite substantial, which would need to be taken into account. All between group differences were calculated by subtracting the control group Cohen's ds from the intervention group Cohen's ds. So the sign and size of the Cohen's d is a reflection of the between-group difference.

Table 1
Table 1:
Characteristics of included studies
Table 2
Table 2:
Summary of critical appraisal
Table 3
Table 3:
Strengths and weaknesses of included studies
Table 3
Table 3:
(Continued) Strengths and weaknesses of included studies

In addition, Cohen's f2 was presented as the effect measure for the study by Felver et al.49 as it includes an adjustment for differences in values at baseline. Cohen's f2of sizes 0.02, 0.15 and 0.35 are termed small, medium and large, respectively.48 Other statistics based on results from multivariable analysis were presented as appropriate. A difficulty in synthesizing results is that some studies compared the effect of the intervention at one point in time whereas other studies took into account their comparisons for the entire follow-up period. Those authors that took into account the entire follow-up period, calculated the slope of the outcome variable as it developed over time. This is also known as SLOPE or group-by-time interaction that analyzes the intervention effects over the entire time of follow-up period (pre-program, post-program and follow-up scores).

Results

Description of studies

A total of 1232 potentially relevant articles were retrieved from searching the eight databases. Endnote removed 601 duplicates. After duplicates were removed, 631 studies remained (Figure 1). As previously stated, the searching of EMBASE and Scopus, in particular, would have captured duplicates. However, these eight databases were deliberately searched to capture all relevant articles. Of those remaining, 595 articles were excluded after titles and abstract screening. From the 36 articles that advanced to the full article review, 29 did not meet the inclusion criteria (Appendix IV). Seven articles were assessed for methodological quality and subsequently included in this review. Mindful parenting research is still an emerging new field. All selected studies evaluated the impact of group-based mindful parenting programs on parents’ or children's outcomes.

Figure 1
Figure 1:
PRISMA50 flow diagram

Study characteristics

Table 4 describes the characteristics of studies included in this review. It highlights the variation of participant groups, programs, measurement times and the use of different outcome measures. The studies were conducted in Australia or the United States. All studies used a modified intention-to-treat analysis and did not blind their facilitators or assessors. Although the programs had different names, all the programs integrated mindfulness with parenting either by specifically drawing on Kabat-Zinn's MBSR (Studies 1, 2, 3 and 6)20,23,49,51 or Gotman's work on emotional awareness (Studies 4, 5 and 7).52–54 When the selected studies were categorized according to clinical characteristics, age groups and types of participants, three sub-groups emerged. These subgroups were 1) mothers and 10–14-year olds from a community sample, 2) parents of children with autism, and 3) parents of preschool children. Results for the predefined primary and secondary outcomes for these three subgroups are reported in Tables 1–3. A post-hoc decision was made to summarize findings on Attention Regulation and Maternal Emotional Regulation as it may be of clinical significance, in understanding both internalizing and externalizing disorders.

Table 4
Table 4:
Results for mothers and 10–14-year-old community sample

Methodological quality

Table 5 summarizes the critical appraisal ratings for the included studies. The ratings ranged from 5/10 (low) to 7/10 (moderate). So the strength of the evidence from these studies could be considered low to moderate. Although all studies did randomly allocate participants to treatment and control groups, none of the studies blinded their participants, facilitators or assessors. Randomization aims to address confounding bias. Many selected studies conducted tests to check if randomization was successful. It was unclear if the groups were comparable at entry for six of the seven included studies even after randomization in Table 5. The seventh study by Felver et al.49 stated that the groups were not comparable at entry. One reason for this may be because of the cluster randomization wherein certain preschools were allocated to the intervention group or the waitlist control group. For instance, the study by Havighurst et al.53 found more sole parents in the intervention group (n = 17) than the waitlist (n = 6) even after randomization. Implications of this are that other confounding factors may be responsible for the intervention effect. Havighurst et al.53 took these differences into account in their analysis by adjusting for the differences in marital status between the groups. Similarly, although Havighurst et al.52 randomly allocated children attending two behavior clinics to either the intervention or waitlist control groups, the sample characteristics show that the children whose parents were in the intervention group had significantly greater verbal ability at time 1 compared with the children in the waitlist control condition. Havighurst et al.52 accounted for these differences by co-varying verbal ability in their analyses. Strengths of these studies include outcomes being measured in a reliable and identical manner. The identical treatment of both the groups other than the named intervention is another strength of these selected studies.

Table 5
Table 5:
Results for parents/mothers of children with autism

Table 6 describes the methodological strengths and weaknesses of the studies included in this review. Limitations of the selected studies included small sample sizes, selection bias, information bias and confounding bias. The majority of the included studies had small sample sizes and no sample size calculations, which can lead to potentially low statistical power to detect the impact of the intervention. Selection bias was another limitation that resulted from participants being selected from a particular geographical area or loss to follow-up not being described. None of the selected studies blinded the participants. This may lead to information bias, because although some participant groups were not aware there were two groups (intervention and control), the outcome measures were self-assessed by the participants.

Table 6
Table 6:
Results for parents of preschool children

Findings of the review

Table 1 summarizes studies on parents and 10–14-year olds from a community sample. The mindful parenting program called MSFP appears to have significantly improved fathers’ and mothers’ emotional awareness of their youth. One study found fathers experienced significant increases in the emotional awareness of their youth (d = 0.28, P < 0.05) (small effect) directly after the intervention.23 At one-year follow-up, both the fathers (d = 0.51, P < 0.001) and mothers (d = 0.26, P < 0.05) reported significant improvement in their emotional awareness of their youth.23 The youth also agreed that their fathers had improved emotional awareness of them (d = 0.34, P < 0.05) (small effect). At one-year follow-up, the fathers reported a significant increase in their compassion/acceptance of their youth (d = 0.25, P < 0.05) (small effect) and compassion/acceptance for self (d = 0.37, P < 0.001) (small effect).23 Another study by Coatsworth et al.20 found MSFP increased mothers’ self-reported scores on the IM-P scale by a moderately significant effect (d = 0.76, P < 0.01). So this mindful parenting program appears to significantly improve parents’ emotional awareness of their children.

There is also tentative evidence to indicate that the Mindful Family Stress Reduction (MFSR) intervention appeared to improve children's attentional processes.49Table 1 shows that MFSR significantly decreased children's conflict monitoring with a medium effect size (f2 = −0.16, P < 0.01).49 There was also a significant improvement on orienting (f2 = −0.09, P = 0.01; small effect) and no significant impact on alerting (f2 = 0.10, not significant).49 This systematic review used the f2 reported by Felver et al.49 rather than calculating Cohen's d because f2 allowed adjustment for baseline values, which were quite different for the intervention and the control groups. The three domains underpinning attention regulation include conflict monitoring, orienting and alerting.49 Conflict monitoring is a process of regulating one's attention. It is the ability to focus on certain information while deliberately ignoring other information.

Results from Neece57 in Table 2 found that mindful parenting significantly reduces parental stress (moderate effect) at post-intervention (d = 0.70, P < 0.05) among parents with autistic children. Neece57 also found that the mindful parenting program called TIK significantly reduced one item namely attention-deficit/hyperactivity problems (strong effect) (d = 0.85, P < 0.05) in children at post-intervention.57 The Child Behavior Check List (CBCL) uses the Diagnostic Statistical Manual (DSM)-oriented scale to assess conduct disorders. The five items of the CBCL DSM-oriented scale for conduct disorders include affective problems, anxiety problems, pervasive developmental problems, attention-deficit/hyperactivity problems and oppositional defiant problems. Among the five items on the CBCL DSM scale, the mindful parenting program called TIK appears to have significantly reduced one item namely attention-deficit/hyperactivity problems.

Table 3 summarizes findings on parents of preschool children from the general community. Two studies53,54 reported conflicting results on how parents viewed their child's behavior at six months follow-up. TIK targets parents’ emotional awareness, regulation and communication with their child. Results from Maternal Emotional Scale Questionnaire were not reported as they were not identified in the predefined primary and secondary outcomes. Emotional regulation was a predefined secondary outcome. Table 3 describes the emotion regulation outcome as measured by the Difficulties in Emotional Regulation Scale that is a 36-item self-reported questionnaire measuring various aspects of emotional awareness and regulation.53 Parents in the intervention group reported moderately significant decreases in emotionally dismissive behaviors and beliefs (d = −0.79, P < 0.001), moderately significant increases in emotion coaching (d = 0.63, P < 0.001) and significant improvements in empathy (d = 0.93, P < 0.001) (strong effect) at six months follow-up.53 Similarly, a study by Wilson et al.54 found that parents reported moderately significant reductions in emotionally dismissing behaviors and beliefs (d = −0.66, P < 0.001). However, unlike the study by Havighurst et al.,53 Wilson et al.54 found no significant improvement in emotion coaching (d = 0.073, not significant). With regard to children's behavior, there were conflicting results. Wilson et al.54 found significant reductions in parents’ perceptions of their child's problem behavior (d = −0.48, P = 0.007) (small effect), but no significant improvements in parents’ perceptions of their child's behavior intensity (d = −0.32, not significant). In contrast, Havighurst et al.53 did find significant improvements in parents’ perceptions of their child's behavior intensity (d = −0.34, P = 0.027) but no significant reductions in parents’ perceptions of their child's problem behavior. So the main findings from the subgroup of parents with preschool children are that this mindful parenting program significantly reduces parents’ emotionally dismissive behavior. However, there were conflicting findings with regard to parents’ perceptions of their children's problem behavior and behavior intensity.

Discussion

This systematic review aimed to synthesize the small body of literature on mindful parenting. Given the methodological quality of the included studies, it is difficult to draw definitive conclusions about the effectiveness of mindful parenting programs. The tentative findings indicate that mindful parenting programs may reduce parental stress and reduce symptoms associated with attention deficit and hyperactivity in their preschoolers diagnosed with autism spectrum disorder. Chronic stress impairs wellbeing, health and the ability to learn.65 The mindful parenting program called MSFP appears to improve parents’ emotional awareness of children aged 10–14 years, particularly fathers’ emotional awareness of their adolescents. A practical implication of these findings is that MSFP could be used to encourage fathers to become more emotionally aware of their adolescents. Parents, particularly fathers, reported they were less emotionally dismissive and more aware of their adolescent's emotions. Furthermore, the mindful parenting program called TIK appears to reduce parents’ tendency to dismiss their preschool child's emotions. Most of the findings from the included studies demonstrated small-to-moderate effects according to different measures of significance (Cohen's d, f2 and F). Hence, the findings presented in this review can guide future hypotheses rather than declare definitive conclusions about intervention effects.

Methodological limitations

The interpretations of the findings need to be considered in light of key limitations. The three main limitations of this review include acknowledging the subjective decisions inherent in the critical appraisal tool, the methodological quality of the included studies and the lack of clarity on which aspects of mindfulness facilitate change. All systematic reviews are based on subjective decisions that are clearly stated at the outset to avoid only highlighting favorable outcomes. Some systematic review tools are better than others in reducing the subjectivity of the critical appraisal process. The JBI-MAStARI Critical Appraisal Checklist does not have a data dictionary that clearly articulated what types of statistical analysis were considered to be appropriate or what constituted strong, moderate or weak evidence. The primary reviewer made subjective decisions on defining how to rate what constituted strong, moderate and weak evidence. Other critical appraisal tools such as the Canadian Quality Assessment Tool for Quantitative Studies by the Effective Public Health Practice Project clearly defines how to rate the evidence and has a data dictionary.66 Although nine out of the 10 questions in the JBI-MAStARI Critical Appraisal Checklist are useful, the addition of a data dictionary to clarify appropriate statistical analysis could reduce the subjectivity associated with the tool. It is evident from an analysis of the study characteristics that the quality of the study designs tends to be weak. Mindful parenting research appears to be plagued by a range of methodological limitations such as inadequate research design, lack of statistical power to detect treatment effects in addition to lack of blinding in the implementation and assessment.

An additional major limitation with all of the included studies was the small sample sizes and limited power. Small sample sizes increase Type 1 error, compromises the ability to make meaningful conclusions and reduces external validity of treatment effects. Second, all the studies were conducted in developed countries with mainly middle-class Caucasian families. It is unclear if these findings can be generalized to diverse populations in developing countries. Future studies with larger sample sizes could reduce the potential threat of Type 1 error and increase the generalizability of the findings.

Another limitation with the selected studies is that none of the studies blinded their participants, assessors or facilitators during the implementation stage. Information bias may arise from not blinding the participants, facilitators or assessors. Failure to blind the participants can lead to information bias with participants over estimating treatment effects or under reporting symptoms. All the selected studies attempted to reduce selection bias and confounding bias by using computer-generated numbers to randomly allocate participants to the treatment and control conditions.

It was not possible to conduct a meta-analysis because of the heterogeneity of the studies and the failure of some studies to report summary statistics. Some of the included studies did not report standard deviations, pre-program means and post-program means. These studies did not follow American Psychological Association's (APA)67 publication manual for reporting summary statistics. The APA publication manual is the primary referencing guide for articles in the psychology, social and behavioral sciences. It outlines a format to report results so that readers can easily extract data for verification and easily understand the findings. The APA publication manual recommends the reporting of sample sizes, means, standard deviations and effect sizes. Some of the selected studies did not report all necessary summary statistics so a meta-analysis could not be conducted. The main aim of a RCT is to focus on comparing between-group differences to infer conclusions about causation. The field of mindful parenting would immensely benefit from future studies that report between-group means, standard deviations, pre-program means, post-program means, effect sizes and other findings according to APA guidelines.

Challenges of mindfulness

Some of the challenges of mindfulness research include the lack of clarity about which aspects of mindfulness are responsible for facilitating positive health benefits. Different scholars propose that different processes are responsible for promoting behavior change. Some of these processes include reperceiving, attention to variability, intentionality, breath awareness and non-judgmental awareness of the present.25 Focusing on one's breath or non-judgmental awareness does magically alleviate distress. Reperceiving is the fundamental ability to reduce automatic response patterns and intensity of strong emotions.25 It has been emphasized for further discussion in this article as different mindfulness theories acknowledge that reperceiving is a key change process that facilitates mindfulness and reduces distress.25 Overcoming highly conditioned responses and cognitive biases require insight and practice. This could be challenging for parents who lack insight or the motivation to practice the new techniques in emotional self-regulation. A commitment to maintaining a warm, affectionate relationship with a discipline not to react requires consistent daily effort.68 Mindfulness training alone may not be powerful enough to consistently reduce levels of distress.69 A physical component to mindfulness such as yoga, breath awareness and other techniques may strengthen behavior change. Another challenge of mindfulness is that different mindful parenting models are practiced from the purely psychological techniques to those that include breath awareness, yoga and video feedback. Despite the limitations of this systematic review, it highlights an intervention that could ameliorate significant mental health problems and family violence. As such, it holds the potential to be an innovative intervention that provides parents with an opportunity to exercise choice over responses rather than engaging in automatic, habitual reactions.

Conclusions

This systematic review aimed to synthesize the current evidence on the effectiveness of mindful parenting programs. A comprehensive search of eight databases retrieved 1232 articles, from which seven studies met the inclusion criteria. At present, there is insufficient evidence to conclude that mindful parenting programs can improve children's and parents’ wellbeing. The findings indicate mindful parenting programs may reduce parental stress, increase parents’ emotional awareness of their children and reduce children's symptoms associated with externalizing disorders. However, these findings are tentative because of the major limitations with the selected studies, namely the small sample sizes, limited power and lack of methodological rigor. Future studies could make a substantial contribution to the field, if methodologically rigorous study designs with sufficient sample sizes tested the effectiveness of a mindful parenting program for internalizing and externalizing disorders.

Implications for practice

A systematic review of RCTs is considered to yield the highest level of evidence in evaluating the effectiveness of a health strategy (Table 7). However, according to JBI Grades of Evidence and Recommendations,64 the current evidence on mindful parenting programs would receive a Grade B or a “weak” recommendation (Appendix V). That is, the strength of the evidence is considered to be “weak” because of the methodological quality of the included studies. Applying the scale that rates the feasibility, appropriateness, meaningfulness and effectiveness64 of the results, the evidence appears to be “weak” because of the lack of rigorous studies measuring mental health outcomes (Table 8). So, futures studies need to utilize more rigorous research designs to clarify the effectiveness of mindful parenting programs.

Table 7
Table 7:
JBI levels of evidence for effectiveness64
Table 8
Table 8:
Application of JBI Grades of Evidence to the mindful parenting programs

Although there is no conclusive evidence for the recommendation of mindful parenting programs, these programs are growing in popularity among a variety of contexts and cultures. It appears to be having a positive, beneficial impact on raising the emotional awareness of both the parents and their children. The cognitive requirements of these programs would make them unlikely to be effective among parents with florid psychosis or severe trauma. The selected studies in this review did not report on side-effects. Hence, mindful parenting programs appear to be an appropriate psycho-education tool for parents in the general community who are interested in reducing their own stress levels and increasing their emotional awareness of their children.

Implications for research

Future mindful parenting research would benefit from designing more methodologically rigorous studies that blind the random allocation, implementation and assessment of both experimental conditions. Using a critical appraisal checklist could assist with designing a robust study. Conducting a power analysis could justify the recruitment of sufficient sample sizes to detect intervention effects. Effect size estimates provide important information about treatment effects particularly when small sample sizes reduce the power to detect statistically significant effects. Articulating clear hypotheses and implementing a consistent model of mindful parenting could assist with articulating and testing which aspects of attention/mindfulness promote change. Reporting results according to APA guidelines could enable meta-analysis of the future studies. The use of psychometrically validated tools to measure aspects of attention responsible for facilitating change is essential in understanding the rich tapestry of mindfulness. Investigations on mindful parenting should not just focus on the psychological measures of mindfulness but would also benefit from measuring biomarkers of stress, brain development and physical health. It is important for future studies to demonstrate the effectiveness of mindful parenting programs for both clinical and general samples from diverse backgrounds, for internalizing and externalizing disorders. Finally, future research that aims to clarify the mechanisms of mindfulness responsible for facilitating change has the potential to provide an innovative strategy to address the rising rates of youth mental health disorders and family violence.

Acknowledgements

Maureen Bell's assistance with database searching has been invaluable in conducting this systematic review. The authors are also grateful for the statistical support provided by Dr Petra Butner. Finally, they appreciate the critical appraisal of articles provided by the secondary reviewer, Andrew Gaffey.

Appendix I: search strategies

PubMed

Figure
Figure

10/11/14

Mindful = 3859

Parenting = 800,629

Mindful parenting = 175

PsycINFO

Figure
Figure

7/11/14

Mindful = 994

Parenting = 320,413

Mindful parenting = 57

EMBASE

Figure
Figure

3/11/14

Mindful = 5 225

Parenting = 961,933

Mindful parenting = 266

Scopus

Figure
Figure

3/11/14

Mindful = 8149

Parenting = 1,205,095

Mindful parenting = 337

CINAHL

Figure
Figure

3/11/14

Mindful = 1869

Parenting = 151,069

Mindful parenting = 95

Cochrane Trial Register

Figure
Figure

Cochrane 3/11/14

Mindful = 1016

Parenting = 38,736

Mindful parenting = 49

Trials = 27

Reviews = 24

Psychology and Behavioral Sciences

Figure
Figure

6/11/14

Mindful = 1259

Parenting = 59,102

Mindful parenting = 64

Theses and Dissertations

Figure
Figure

30/10/2014

Mindful = 2 122

Parenting = 177,059

Mindful parenting = 185

Appendix II: appraisal instruments

MAStARI appraisal instrument

Figure
Figure

Appendix III: data extraction instruments

MAStARI data extraction instrument

Figure
Figure
Figure
Figure

Appendix IV: full-text articles excluded

Figure
Figure
Figure
Figure

Appendix V: JBI grades of evidence and recommendations55

Figure
Figure

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                                            Keywords:

                                            Anxiety; conduct disorders; depression; emotional regulation and attention regulation; mindful parenting; mindfulness

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