The effectiveness of Mindful Parenting programs in promoting parents' and children's wellbeing: a systematic review protocol
Authors: Townshend Kishani , Jordan Zoe , Peters Micah DJ , Tsey Komla 
Published: December 2014

Review question/objective
The primary objective of this review is 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 is to evaluate how effective Mindful Parenting programs are in improving emotional regulation, quality of the parent-child relationship, resilience and mindfulness of the children, adolescents and parents. The comparator is the control or waitlist conditions. The population of interest in this study is children aged between 0 to 18 years and their parents who have completed a Mindful Parenting program.

Background
There is a growing consensus that a paradigm shift is needed to address the profound impact of mental illness, the delayed diagnosis and long waiting lists. Depression is the leading cause of disability with 350 million people affected across the world.1 The cost of mental health disorders to the Australian community is approximately $20 billion per annum which includes loss of productivity and labour force participation.2 The initial onset of anxiety, depression and conduct disorders tends to occur in childhood and adolescence.3 However they are not detected until later in life due to gaps in the efficacy and effectiveness of mental health services to young people.4 Mental illness has complex, multifaceted etiologies. The dominant view is that parenting and the quality of the parent-child relationship significantly influence early brain development and the development of mental health disorders.5 Mindful Parenting has been defined as the ability to pay attention to your child and your parenting in a particular way, that is intentionally, non-judgementally whilst being in the here and now.6 This study aims to investigate whether Mindful Parenting programs could be added to the repertoire of tools used in the prevention and early intervention of mental illness.
Epidemiological evidence shows that half of all lifetime mental health disorders commence by the age of 14 years, with anxiety and impulse control disorders having a median age of onset at 11 years for clinical diagnoses.3 The primary mental health disorders in childhood tend to be internalizing (anxiety, depression) and externalizing (aggression, oppositional defiance) disorders.7 Internalizing disorders represent disorders associated with depression, anxiety and somatic symptoms.8 Externalizing disorders refer to disorders characterized by impulsive, disruptive conduct and substance use symptoms.8 Approximately 25% of youth in Australian and international populations present with these disorders which continue to adolescence and adulthood.9-11 Furthermore there are higher rates of mental health conditions amongst Indigenous, migrant and African American children. Yet, due to the stigma associated with mental illness and gaps in services, these children are even less likely to receive a timely diagnosis or treatment.4, 12 Childhood mental health problems that are not effectively treated can result in significant health costs to society, protracted psychological distress, learning difficulties, school dropout, poor employment outcomes, social isolation, substance abuse, family violence and suicide.13

The term "Mindful Parenting" was coined by John and Myla Kabat-Zinn in 1997 in their book, Everyday Blessings: The inner work of mindful parenting.
14 It originates from the Eastern and Western concept of mindfulness. Mindfulness is defined as the ability to be attentive to the present.6, 14 It is an attention process that focuses on clarity of thinking, flexibility of thinking and being present in the moment rather than running on automatic pilot. Over the last three decades, studies have indicated that mindfulness-based interventions have positive outcomes in relation to mental health issues, weight loss, cancer, parenting stress and the parent-child relationship.15-17 Integrating mindfulness with parenting, "Mindful Parenting" is one of the newer applications of mindfulness in mental health contexts.17 Although mindfulness-based psychotherapies are becoming increasingly popular in promoting mental health, there is a scarcity of literature on whether Mindful Parenting programs can promote children's wellbeing. However the definition of wellbeing is just as controversial as its measurement.18 This paper will refer to the definition of wellbeing provided by Dodge, Daly, Huyton & Sanders18, that is, wellbeing as the state of equilibrium or balance that can be affected by life events or challenges. In the absence of studies with validated wellbeing measures, this review will measure wellbeing in terms of the reduction in the intensity of symptoms associated with internalizing and externalizing disorders.
The growing interest by clinicians and researchers in the field of mindfulness is fuelled by the promise of a new tool to alleviate the suffering associated with physical, psychological and psychosomatic disorders. Whilst mindfulness is an ancient concept, its application in modern healthcare, education, employment and prison systems is becoming increasingly popular. The key active ingredient of mindfulness is thought to be the improved self-observation that promotes better coping skills.19 Two broad approaches of mindfulness that have been integrated into psychotherapy include mindfulness-based and mindfulness-oriented.5 Mindfulness-based psychotherapy includes Mindfulness Based Stress Reduction (MBSR), Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Cognitive Behavior Therapy (MBCBT).5 Mindfulness-oriented models include Acceptance Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT).20, 21 A comprehensive meta-analysis found Mindfulness Based Therapy is an effective treatment for a variety of psychological disorders, especially for reducing anxiety, depression and stress.20

Although an initial search found no systematic reviews on Mindful Parenting, it found several systematic reviews on the burgeoning field of mindfulness. A recent systematic review of randomized controlled trials (RCTs) using MBSR and MBCT found that MBSR improves mental health and MBCT prevents depressive relapse with medium effect sizes.19 From the 21 studies included in this study, 11 studies found MBSR improved mental health compared to the waitlist control or treatment as usual (TAU) and was as efficacious in the active control group in three studies.19 Mindfulness Based Cognitive Therapy was found to reduce the risk of relapse in two studies and was found to be as efficacious as TAU on the active control group in two studies.19 The literature however does acknowledge the limitations with "mindfulness". One limitation is that the results are only generalizable to individuals who have an interest in mindfulness and the ability to participate in such programs.19 This is because mindfulness studies are not double-blinded as participants actively chose the program and know they are participating. So bias is inherent in self-selected samples. Publication bias may be another limitation as most studies report positive results.19 Regardless of these limitations, the studies tend to concur that attention is one of the mechanisms of change. Future research needs to clarify how attention is therapeutic.
Over the last 17 years since Myla and Jon Kabat-Zinn's first significant application of mindfulness in 1997, there have been several primary studies on Mindful Parenting. Whilst some of these are RCT22, 23 the majority of the study designs tend to be descriptive case series.24-27 The sample sizes are generally small. The settings tend to be mostly home-based with parents attending two to two-and-a-half hours per week for eight to twelve weeks. The studies are usually conducted in America, Australia or Europe. While all the participants are parents, the target group of parents tends to vary from pregnant mothers, parents with children presenting with autism, parents with children diagnosed with conduct disorders and parents of children from the age 10-14, to parents on a the methadone program with pre-schoolers. 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.17 Mindful Parenting programs have also been used to prevent the transmission of mental health disorders from parent to child.17 The results from these primary studies indicate some consistency of positive effects.
A preliminary search in the major bibliographical databases identified no completed systematic review or review protocol on the topic of interest for this proposal. The databases that were searched 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 (DARE), EMBASE, PsycINFO and PROSPERO, the international database of prospectively registered systematic reviews in health and social care. A systematic review evaluating the effectiveness of Mindful Parenting Programs on children's and parents' outcomes is the first step in establishing whether there is sufficient empirical support to justify the promotion of Mindful Parenting as a prevention intervention.