The following written comment was submitted by the Health Policy Director, Dr. Amanda Berhaupt at The National Center for Health Research’ (NCHR) to the Agency of Health Research and Quality (AHRQ). AHRQ requested comments on the protocol for the Mindfulness-Based Interventions (MBI) for Mental Health and Wellbeing in Children and Adolescents: A Systematic Review by the Agency for Health Research and Quality (AHRQ).
AHRQ requested comments on sections of the proposed protocol for the systematic review. The statement has been modified to provide context for readers.
Background
NCHR applauds the AHRQ for its proposed protocol to systematically review the available evidence on Mindfulness-Based Interventions (MBI) to prevent and treat anxiety and depression, and improve physical expressions in children aged 3 to 17 years old. Our comments in response to the proposed protocol focus on the Methods and the Table specifying the Population, Interventions, Comparators, Outcomes, Timing, and Setting (PICOTS) Criteria for the systematic review.
The systematic review proposed by AHRQ is to explore the benefits and harms of MBI for children and adolescents and to guide evidence-based healthcare. Traditional approaches to prevent and treat anxiety and depression have focused on pharmacotherapy and behavioral interventions (e.g., counseling). This systematic review aims to examine the evidence for MBI, an alternative intervention, to educate and coach kids on mindfulness, meaning to focus and accept the present moment without judgment.
The systematic review will investigate the benefits and harms of MBI in three populations:
- General child and adolescent populations
- Children and adolescents diagnosed with anxiety and/or depression
- Children and adolescents at risk for elevated symptoms of anxiety and/or depression with a chronic condition
NCHR agrees that peer-reviewed articles be included in the systematic review on the impact of MBI on youth populations with a chronic condition (e.g., “cancer, diabetes, and epilepsy”) who are at risk for elevated symptoms of or being diagnosed with anxiety and/or depression. However, the Background and Objectives section of the proposed protocol includes three examples of a chronic condition and the scope of medical conditions is not clearly defined.
Table 1. Preliminary PICOTS Criteria – NCHR Comment on Population
Children diagnosed with Neurodevelopmental Conditions
Under Exclusion Criteria in Table 1, the protocol indicates that AHRQ will exclude studies that do not report findings by population if ≥ 20% of participants are “Diagnosed with advanced neurodevelopmental disorders (e.g., severe autism spectrum disorders [for example, level 3 on DSM-5], severe attention-deficit/hyperactivity disorder [e.g., based on DSM-5 definition], severe learning disorders [e.g., more than 2 standard deviations below the mean in one or more areas of cognitive processing related to the specific learning disorder]).” However, based on the inclusion criteria, we do not understand if this means that children with less severe neurodevelopmental conditions who were analyzed as a subgroup are to be included in the systematic review.
Under Inclusion Criteria in Table 1, the protocol states that AHRQ will study “Children and adolescents aged 3 to 18 years with a chronic condition who are at risk for elevated symptoms of or being diagnosed with anxiety and/or depression.” “Chronic physical conditions” are defined as “medical physical conditions (i.e., conditions that primarily affect the body’s systems and functions) that persist for one year or longer and require ongoing medical attention, limit activities of daily living, or both” (Table 1).
NCHR encourages AHRQ to clarify and further define “medical physical conditions,” and to include youth populations diagnosed with neurodevelopmental conditions (e.g., Autism Spectrum Disorder [ASD], Attention Deficit Hyperactivity Disorder [ADHD], and learning disorders), since those children also have an elevated risk for anxiety and depression, and greater social difficulties. We do not understand the proposed rationale for including children with cancer, epilepsy, and other somewhat rare conditions, but not children with neurodevelopmental conditions.
Evidence demonstrates that youth populations diagnosed with ASD and ADHD, who have an elevated risk for anxiety and depression, also experience social difficulties that are linked with a lower quality of life in adulthood. A recent systematic review of MBI (how defined) in adults with ASD concluded there was evidence that it alleviated “psychological distress, reduced behavioral problems, and enhanced cognitive and social skills.” Given those data on adults, we urge that children with neurodevelopmental conditions be included in the study, although we understand if AHRQ may want to separately evaluate those children in a subgroup analysis, in order to provide that information specifically for that group.
Bottom line: AHRQ should clarify if the protocol will include, at minimum, children diagnosed with mild or moderate neurodevelopmental conditions. If AHRQ will not include children with these conditions in their literature search, we ask for your justification for their exclusion and/or urge that they be included in a separate analysis.
Might data on adults be relevant to teenagers?
NCHR notes that it is possible the body of evidence is limited for MBI in children aged 3 to 17 years old. If an insufficient number of studies meet the inclusion criteria in youth, we request that AHRQ expand its literature search to include adults 18-30 years [or 18 and older] to examine the benefits and harms of MBI. Further, NCHR urges AHRQ to discuss the results of studies in adult populations separately to understand the relevance and implications of adult data for future study in children.
Table 1. Preliminary PICOTS criteria – NCHR Comment on Interventions
Under Interventions (KQ 1-3), the protocol states “A mindfulness instructor (e.g., therapist, teacher) must have some training in providing mindfulness. We do not specify the required minimum training.” While some evidence suggests that the benefits of MBI may require less professional training and take less time for both workers and clients to master, there is no justification for assuming that there is no difference between instructors with more or fewer professional qualifications. We agree with including them in the analyses and urge AHRQ to complete a subgroup analysis to determine if instructors with specific qualifications and experience are more or less effective.
There is clear evidence of a strong association between outcomes and effectiveness of instructors for other interventions, and this indicates that instruction may be enhanced with training, education, and experience. For example, The Teacher Training, Evaluation, and Compensation Evidence Review Protocol on the website of the Institute of Education Sciences states, “Research has shown that teacher effectiveness is the most important school-based factor that influences student outcomes, including student achievement.”
We recognize there may be relatively few studies to include in the systematic review and encourage AHRQ to require documentation of the training and/or education of mindfulness instructors in articles and to consider that variable in its analyses. We also urge the agency to require the two reviewers to contact the author if the training for the mindfulness instructor is not clearly stated in the methodology of a study, per Contacting Author. This is consistent with the protocol under Literature Search Strategies to Identify Relevant Studies to Answer the Key Questions, which states, “In the event that important information regarding methods or results appears to be omitted from the published results of a study, we will attempt to contact the authors to obtain additional information.”
NCHR applauds the efforts of AHRQ to systematically review the scientific evidence for MBI to prevent and treat anxiety and depression in children aged 3 to 17 years old and is anticipatory to learn the results for its impact.