Stacha C. Leslie, MEd, BCBA, Breanna Roberts, MA, BCBA, and Thomas Zane, PhD, BCBA-D
Department of Applied Behavioral Science, University of Kansas

Is there science behind thatDeficits in social communication and restricted, repetitive patterns of behavior are the two diagnostic criteria of autism spectrum disorder that can range in severity – requiring minimal to substantial support (American Psychological Association, 2022). In addition to these deficits, research suggests that approximately 40% of children and 50% of adults with autism may experience anxiety (van Steensel, 2011). Taken together, these deficits may inhibit an individual’s ability to safely respond to and cope with challenging situations such as changes in routine, non-preferred events and activities, and overstimulation. For example, some individuals may respond to aversive situations like unplanned changes in routines by engaging in challenging behaviors (e.g., self-injury, physical aggression; Gerow et al., 2023; Rispoli et al., 2014). Several therapeutic interventions have been evaluated to address these challenges, such as the use of synchronous reinforcement (Diaz de Villegas et al., 2020; Leslie et al., 2023) and graduated exposure with differential reinforcement (Carter et al., 2019) to increase tolerance to aversive situations, and the use of functional communication training (FCT) to appropriately request a break from an aversive situation (Tiger et al., 2008; Zangrillo et al., 2016). However, given the clinical oversight and training needed to evaluate the efficacy of these therapeutic interventions, parents and caregivers have sought alternative interventions that are less effortful to implement. Purportedly, one intervention used to enhance an individual’s awareness of their environment and increase more independent responses and coping strategies during challenging situations is Mindfulness.

What is Mindfulness?

Mindfulness originates in Hindu and Buddhist practices developed as a first step towards an individual reaching “enlightenment,” or, full internal awareness (Xiao et al., 2017). It has since been adopted by western Positive Psychologists, firstly Dr. Jon Kabat Zinn, and delivered through programs such as the Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy program (Selva, 2023). Mindfulness, also referred to as “quieting the mind” (Patel, 2017), involves “non-judgmental and non-reactive attention to experiences occurring in the present moment, including bodily sensations, cognitions, emotions, and urges” (Cachia et al., 2016). In other words, Mindfulness aims to bring individuals to the “present” by helping them to objectively identify what is occurring within their environment. In doing so, individuals are more likely to disrupt negative and unhelpful thought patterns and less likely to engage in ‘mindless” behaviors (e.g., anxious thoughts that may lead to stress; Mindfulness and Autism: Its Amazing Impact on Families! 2022). Mindfulness is often described as a relaxation technique used to decrease stress, anxiety, and depression. To create mindfulness as a daily practice, proponents of mindfulness suggest techniques such as daily meditation, breathwork, body scans, and “calming” activities like coloring and drawing. Although practiced by Positive Psychologists, mindfulness techniques can be facilitated by anyone who has completed Mindfulness Trainer Certificate programs (e.g., MBSR certification at Brown University), or anyone who has benefitted from mindfulness techniques. Of note, the Mindfulness approach focused upon in this study should not be equated with Acceptance and Commitment Therapy (ACT) – a different intervention altogether which includes a broader treatment package that may include mindfulness strategies (e.g., Hoffmann et al, 2016).

How is Mindfulness and Relaxation Implemented with Individuals with Autism?

For individuals with autism, mindfulness techniques are often used to address potential side effects of social communication and executive functioning deficits. For some individuals with autism, deficits in social communication can lead to increased anxiety and difficulties with self-regulation (Merrill, 2016). Thus, some proponents of the mindfulness approach hypothesize that the demand of most social environments may be higher than an individual’s coping abilities (Ridderinkhof et al., 2018). Given this, mindfulness has been used to address the stressors of social demands and assist individuals with autism in being more present for their experiences, rather than being overwhelmed by them. In doing so, individuals with autism are more likely to accept their environment, rather than respond negatively (i.e., engaging in emotional responses or challenging behavior; Patel, 2017). Mindfulness has also been used to improve executive functioning by encouraging the individual to pause and become more aware of their environment. This awareness may help to control shifts in attention, reflect on experiences, and control automatic impulses (Ridderinkhof et al., 2018).

There are several mindfulness exercises suggested to improve environmental awareness for individuals with autism across the lifespan, including mindful walks, mindful breathing and meditation, mindful bedtime, Soles of the Feet, and Glitter Jar (Patel, 2017; Salazar, 2021; Singh et al., 2003). Mindful walks, breathing, meditation, and bedtime routines are all exercises during which individuals are encouraged to attend to sensory stimulation around them like the wind blowing through their hair and different smells like flowers or trees (mindful walks), taking deep, concentrated breaths while placing their hands on their stomach (mindful breathing and meditation), and repeating scripts of gratitude and attending to how it makes their body feel (Salazar, 2021). The latter exercises, Soles of the Feet (Singh et al., 2003) and Glitter Jar, are typically implemented when an individual with autism is experiencing a stressful situation. Using the Soles of the Feet exercise, if an individual is engaging in aggression (e.g., kicking, hitting, yelling), they may be instructed to redirect their attention to the soles of their feet – a neutral part of the body that can assist with calming during a stressful situation. Using the Glitter Jar exercise, if an individual is having a stressful day or engaging in challenging behaviors, they may be directed towards a glitter jar (jar filled with water and glitter) and asked to swirl it around and watch the glitter settle – a visual representation of settling down after a chaotic experience.

The proponents of mindfulness argue that this set of procedures directly address some of the major deficits experienced by individuals with autism. Additionally, little to no training is needed to implement mindfulness exercises. That is, although a certification is available, it is not required to teach or practice the techniques. In fact, mindfulness techniques are often facilitated by classroom teachers, social workers, school psychologists, and licensed professional counselors with no formal training – suggesting a low-effort and low-cost intervention for individuals with autism. But is there science behind it?

Does Science Support Mindfulness?

Cachia et al. (2016) conducted a systematic review that highlighted six studies evaluating the use of mindfulness on reducing “symptoms” of autism that manifest as a result of core deficits (i.e., social communication and restricted, repetitive interests, American Psychological Association, 2022). These symptoms included anxiety, depression, stress, and aggressive behavior often experienced as stressors for both the individual with autism and their caregivers. Although this review highlighted the potential application of mindfulness with individuals with autism, overall findings suggested weak empirical support to establish mindfulness as an evidence-based practice and the need for more clarity with the respect to methodological arrangements. Two representative studies are described below.

Singh et al. (2011) evaluated the use of the “Soles of the Feet” procedure with three adolescent males with autism ages 14-17, who engaged in physical aggression. A multiple-baseline design across participants was used to evaluate the efficacy of a “mindfulness procedure” taught to participants by their parents. Procedures were implemented during daily 30-min training sessions across five consecutive days. During each session, participants were in a comfortable position (eyes closed, comfortable chair, with feet on the floor), and provided with instructions for how to participate in the Meditation on the Soles of the Feed procedure. This procedure included a 10-step script of reminders to remain calm throughout a potentially angering situation that was read by each participant’s mother in a “calm and soft voice.” For example, Step 3 stated “Breathe naturally, and do nothing,” while Step 4 stated “Cast your mind back to an incident that made you very angry. Stay with the anger.” After participants learned the procedures, they were encouraged to practice twice per day during particularly triggering situations (e.g., high stress) and prior to engaging in aggressive behavior (e.g., physical aggression). Parents were then asked to report the number of aggressive behaviors that occurred across several weeks (i.e., 3-10 weeks) and during follow-up (i.e., 6-36 months). Results from the study showed a decrease in aggressive episodes across all three participants from baseline (14-20 episodes per week) to follow-up (3-4 episodes within a 3-year period). Although results seem promising, there were several significant limitations worth noting. First, procedural integrity measures were not collected. Thus, the degree to which parents implemented procedures as designed is unknown. Second, the degree to which participants used the mindfulness procedures following instances of aggression and how they were used following instances of aggression (e.g., independent vs prompted by parents) is unknown. Third, reports of the dependent variable (i.e., instances of aggression) during training and follow-up were based on parent report. That is, no in-vivo observations of the aggressive episodes were conducted, thus the degree to which parents reported aggressive episodes accurately is also unknown. Finally, although not directly stated, it is possible participants were receiving intervention for aggression outside of the study; thus, we are unable to attribute the decrease in behavioral episodes to the “Soles of the Feet” procedure alone.

In another study, de Bruin and colleagues (2014) evaluated the use of “My Mind” mindfulness training with twenty-three adolescents and their parents. Parent-child dyads were used to evaluate the “reciprocal relationship between parenting stress and child behavioral problems.” For adolescents and parents, weekly 1.5 hour sessions were conducted across nine weeks. Each adolescent session consisted of engaging in breathing meditation, body scans, sensory awareness exercises, sound meditations, and yoga. Each parent session focused on understanding parental reactivity, paying unbiased attention to the child, becoming aware of boundaries, and accepting their child and their difficulties. Results were analyzed using a pre- and post-test of adolescent and parent reports. Parents reported positive changes in “social responsiveness” and feeling that their children were able to better communicate their thoughts and feelings – findings that may have been directly correlated with the training parents received to increase acceptance of their child. With respect to adolescent results, no change in autism core symptoms, worry, or mindful awareness was reported by either the adolescents or parents. As with the previous study, no objective measures were recorded, and procedural integrity data were not collected. Thus, it remains unclear if the “My Mind” strategies were implemented correctly and whether the strategies were learned by the individual well enough to be used in particularly stressful situations. Additionally, given the pre- and post-test design, the degree to which individuals engaged in behaviors relevant to outcomes throughout the training process is unknown.

Similar outcomes and limitations were found across additional studies (e.g., Hwang et al., 2015). That is, although some positive changes were reported by parents and caregivers, no objective empirical data were provided to support mindfulness as an effective procedure. Additionally, methodological arrangements were unclear leading to a lack of procedural integrity and experimental control to support results. Finally, although proponents of mindfulness suggest its efficacy across the lifespan, all studies reviewed by Cachia et al. (2016) included adolescents or adults with autism who require less supports (e.g., had advanced communicative repertoires, attending general education classrooms) that were taught various mindfulness procedures to implement as a replacement for engaging in less productive behaviors. Thus, the extent to which these procedures would be effective for children or individuals requiring more substantial support is unknown. Overall, the outcomes of these studies suggest methodological arrangements were perhaps feasible, but not effective or generalizable.

What Else Should We Consider?

The techniques of mindfulness in and of themselves are not necessarily harmful. In fact, having tools in your toolbelt to de-stress during a challenging situation is an appropriate and encouraged response. That is, if an individual typically engages in aggression during an aversive event (i.e., activities of daily living), our goal would be to teach this individual how to either tolerate the aversive event by accessing an alternative source of reinforcement (e.g., a glitter bottle) or to engage in a functional communicative response (FCR; Tiger et al., 2008) to request a break from this event all in the absence of challenging behavior. But one major component that we have to remember when teaching a new skill: timing is everything. Consider what we know about reinforcement. When a stimulus (typically a favorite snack, item, or type of attention) follows a behavior, it is possible that this behavior will occur more often. For example, when a child cleans up their toys, and their caregiver gives them their favorite snack soon afterward, it may be more likely that they will clean up their toys the next time. In the same way, however, if a child is engaging in aggression during a challenging situation and a caregiver redirects them to the “Soles of the Feet” exercise, this redirection may inadvertently serve as attention and access to a preferred activity – which may increase the chances that the child engages in aggression again to receive that same attention or access to the activity. Thus, mindfulness techniques may offer support for individuals with autism if they are taught as tools to help them de-stress, remain calm, and attend to their environment BEFORE the stressful situation begins. However, when these techniques are offered contingent upon or DURING stressful situations and ADDED to challenging behavior, we run the risk of teaching individuals to engage in challenging behaviors to access mindfulness techniques. Taken together, although teaching mindfulness techniques as potential coping strategies to address aversive situations sounds promising, caregivers and professionals must be vigilant about how such techniques are introduced and diligently analyze their data on how they impact challenging behavior.

So, What is the Gist?

Limited empirical research has been conducted on the impact of mindfulness and autism. That is, to date, less than ten studies have empirically evaluated the effectiveness of mindfulness training with individuals with autism. Of these ten studies, no objective empirical data were provided to support mindfulness as an effective procedure. Additionally, methodological arrangements were unclear, leading to a lack of procedural integrity and experimental control to support results. Further, no studies have evaluated the effects of mindfulness training for individuals with autism requiring more substantial support, such as those individuals with several communication disorders, high rates of challenging behaviors, and severe cognitive deficits. Thus, there is insufficient scientific evidence to support mindfulness as an effective treatment used to mitigate potentially severe deficits in individuals with autism (i.e., deficits in communication and the occurrence of challenging behavior). Further quality research studies are needed on the efficacy of mindfulness procedures and how they may best support individuals with autism and their families. Research must first examine if there is, in fact, a causal relationship between the implementation of mindfulness and a decrease in challenging behavior, as well as an increase in more socially adaptive behaviors (e.g., communicating thoughts and feelings). However, to determine this causal relationship, research must address the aforementioned limitations including following a valid research design that controls for threats to internal validity and establishing a measurement system that lends itself to accurate data collection and replicable methodology. Until then, we are unable to show that mindfulness procedures are causally related to specific and measurable improvements in defined autism symptomology. Therefore, caregivers and clinical professionals should not use or recommend the use of mindfulness as a scientific treatment for autism at this time.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Cachia, R. L., Anderson, A., & Moore, D. W. (2016). Mindfulness, stress and well-being in parents of children with autism spectrum disorder: A systematic review. Journal of Child and Family Studies, 25(1), 1–14. https://doi.org/10.1007/s10826-015-0193-8

Carter, L., Harper, J. M., & Luiselli, J. K. (2019). Dental desensitization for students with autism spectrum disorder through graduated exposure, reinforcement, and reinforcement-fading. Journal of Developmental and Physical Disabilities, 31, 161–170. https://doi.org/10.1007/s10882-018-9635-8

De Bruin, E. I., Blom, R., Smit, F. M., van Steensel, F. J., & Bögels, S. M. (2015). MYmind: Mindfulness training for youngsters with autism spectrum disorders and their parents. Autism: The International Journal of Research and Practice, 19(8), 906–914. https://doi.org/10.1177/1362361314553279

Diaz de Villegas, S. C., Dozier, C.L., Jess, R. L., & Foley, E. A. (2020). An evaluation of synchronous reinforcement for increasing on-task behavior in preschool children. Journal of Applied Behavior Analysis, 53(3), 1660-1673. https://doi.org/10.1002/jaba.696

Hoffmann, A. N., Contreras, B. P., Clay, C. J., & Twohig, M. P. (2016). Acceptance and Commitment Therapy for individuals with disabilities: A behavior analytic strategy for addressing private events in challenging behavior. Behavior Analysis in Practice, 9(1), 14–24. https://doi.org/10.1007/s40617-016-0105-4 

Hwang, Y. S., Kearney, P., Klieve, H., Lang, W., & Roberts, J. (2015). Cultivating mind: mindfulness interventions for children with autism spectrum disorder and problem behaviours, and their mothers. Journal of Child Family Studies, 24, 3093–3106. https://doi.org/10.1007/s10826-015-0114-x

Leslie, S. C., Dozier, C. L., Kamlowsky, M. E., McHugh, C. L., Diaz de Villegas, S. C., & Kanaman, K. C. (2023). Using synchronous reinforcement to increase mask wearing in young children: A replication and extension. Behavioral Interventions, 39(1), e1985. https://doi.org/10.1002/bin.1985

Merrill, A. (2016). Anxiety and autism spectrum disorders. Indiana Resource Center for Autism. https://www.iidc.indiana.edu/irca/articles/anxiety-and-autism-spectrum-disorders.html

Mindfulness and autism: Its amazing impact on families! ABA Centers of America. (2022, October 16). https://www.abacenters.com/mindfulness-and-autism/#:~:text=Mindfulness%20and%20autism%20lead%20to,of%20one’s%20influence%20over%20others.

Patel, K. (2017). Six simple mindfulness practices for kids with autism. Autism Resources and Community (ARC). https://blog.stageslearning.com/blog/six-simple-mindfulness-practices-for-kids-with-autism

Ridderinkhof, A., de Bruin, E.I., Blom, R., & Bogels, S. M. (2018). Mindfulness-Based Program for Children with Autism Spectrum Disorder and Their Parents: Direct and Long-Term Improvements. Mindfulness 9, 773–791 (2018). https://doi.org/10.1007/s12671-017-0815-x

Rispoli, M., Camargo, S., Machalicek, W., Lang, R., & Sigafoos, J. (2014). Functional communication training in the treatment of problem behavior maintained by access to rituals. Journal of Applied Behavior Analysis, 47(3), 580-593. https://doi.org/10.1002/jaba.130

Rivera, G., Avery, S. K., Gerow, S., & Exline, E. (2023). Functional communication training and a chained schedule of reinforcement to reduce escape-maintained challenging behavior related to a daily routine. Behavioral Interventions, 38(4), 1-11. https://doi.org/10.1002/bin.1972

Salazar, M. (2021, May 10). Mindfulness & autism – simple practices. Bright Autism. https://brightautism.org/blogs/news/mindfulness-autism-simple-practices

Selva, J. (2023). The history and origins of mindfulness. PositivePsychology.com. https://positivepsychology.com/history-of-mindfulness/

Singh, N. N., Wahler, R. G., Adkins, A. D., Myers, R. E., & The Mindfulness Research Group. (2003). Soles of the feet: A mindfulness-based self-control intervention for aggression by an individual with mild mental retardation and mental illness. Research in Developmental Disabilities, 24(3), 158–169. https://doi.org/10.1016/S0891-4222(03)00026-X.

Singh, Lancioni, G. E., Manikam, R., Winton, A. S. W., Singh, A. N. A., Singh, J., & Singh, A. D. A. (2011). A mindfulness-based strategy for self-management of aggressive behavior in adolescents with autism. Research in Autism Spectrum Disorders, 5(3), 1153–1158. https://doi.org/10.1016/j.rasd.2010.12.012

Tiger, J. H., Hanley, G. P., & Bruzek, J. (2008). Functional communication training: A review and practical guide. Behavior analysis in practice, 1(1), 16–23. https://doi.org/10.1007/BF03391716

van Steensel, F. J., Bögels, S. M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis. Clinical Child and Family Psychology Review, 14(3), 302–317. https://doi.org/10.1007/s10567-011-0097-0

Xiao Q., Yue, C., He, W., & Yu, J-y. (2017) The mindful self: A mindfulness-enlightened self-view. Frontiers in Psychology, 1752(8), 1-10. https://doi.org/10.3389/fpsyg.2017.01752

Zangrillo, A. N., Fisher, W. W., Greer, B. D., Owen, T. M., & DeSouza, A. A. (2016). Treatment of escape-maintained challenging behavior using chained schedules: An evaluation of the effects of thinning positive plus negative reinforcement during functional communication training. International Journal of Developmental Disabilities, 62(3), 147–156. https://doi.org/10.1080/20473869.2016.1176308

Citation for this article:

Leslie, S. C., Roberts, B., & Zane, T. (2024). Mindfulness: Is there science behind that? Science in Autism Treatment, 21(04).

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