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Mindfulness ISSN 1868-8527Volume 4Number 2 Mindfulness (2013) 4:179-189DOI 10.1007/s12671-013-0197-7

The Use of Mindfulness with People withIntellectual Disabilities: a SystematicReview and Narrative Analysis

Melanie J. Chapman, Dougal J. Hare, SueCaton, Dene Donalds, Erica McInnis &Duncan Mitchell

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ORIGINAL PAPER

The Use of Mindfulness with People with IntellectualDisabilities: a Systematic Review and Narrative Analysis

Melanie J. Chapman & Dougal J. Hare & Sue Caton &

Dene Donalds & Erica McInnis & Duncan Mitchell

Published online: 24 February 2013# Springer Science+Business Media New York 2013

Abstract This paper presents a systematic review of the evi-dence on the effectiveness of mindfulness for people withintellectual disabilities. Primary studies published in theEnglish language between 1980 and 2012were identified fromelectronic databases, experts and citation tracking. Elevenrelevant studies evaluating mindfulness training and practicewere identified: seven studies with people with intellectualdisabilities, two studies with staff members or teams and twostudies with parents. The studies found improvements in ag-gression and sexual arousal for people with intellectual dis-abilities after mindfulness training. Training staff led tobenefits for people with intellectual disabilities, decreased useof physical restraint for aggressive behaviour and increased jobsatisfaction. Training parents led to improved parental satisfac-tion and well-being and improved parent–child interactions.The reported positive findings suggest that service providers,people with intellectual disabilities and their families may want

to consider mindfulness approaches. However, the findingshave to be interpreted with caution due to methodologicalweaknesses identified in the studies. Further high-quality in-dependent research is needed before the reported improve-ments can be more confidently attributed to mindfulness.

Keywords Mindfulness . Systematic review . Intellectualdisabilities . Learning disabilities . Narrative analysis .

Developmental disabilities

Introduction

Mindfulness involves focussing attention purposefully in anon-judgmental, non-reactive way on the present moment andwhat is happening in an individual’s mind, body and the worldaround them (Kabat-Zinn 1990). Mindfulness approaches dif-fer from existing therapy programmes as they aim to helppeople to focus on the present moment, to accept difficult tochange symptoms or situations and to enable different ways ofviewing and responding to situations (Fjorback et al. 2011).There is evidence of the effectiveness of mindfulness for man-aging various physical and psychological health problems in-cluding stress, anxiety, depression, pain and disordered eating(Baer 2003; Chiesa and Serretti 2010; Fjorback et al. 2011).

Mindfulness is a core strategy within treatment packagessuch as mindfulness-based stress reduction (Kabat-Zinn1990) and mindfulness-based cognitive therapy (Segal etal. 2002). The former is a structured group programmeconsisting of eight weekly 2–2.5-h sessions with daily homeassignments and a day retreat between weeks 6 and 7(Kabat-Zinn 1990). Mindfulness is cultivated through for-mal practices such as the body scan, mindful movement andsitting meditation, which are integrated into everyday life asa coping resource to improve physical and psychologicalwell-being (Fjorback et al. 2011). Mindfulness-based cog-nitive therapy is an adaptation of mindfulness-based stressreduction which focusses more on thoughts and consists of

M. J. Chapman (*)Manchester Learning Disability Partnership,Central Manchester University Hospitals NHS Foundation Trust,Westwood Street, Moss Side,Manchester M14 4PH, UKe-mail: melanie.chapman@manchester.gov.uk

D. J. HareThe University of Manchester, Manchester M13 9PL, UK

S. CatonManchester Metropolitan University, Manchester M13 0JA, UK

D. DonaldsPathways Associates Community Interest Company,Accrington BB5 1NA, UK

E. McInnisCentral Manchester University Hospitals NHS Foundation Trust,Manchester M16 7AD, UK

D. MitchellManchester Metropolitan University and Manchester LearningDisability Partnership, Manchester M13 0JA, UK

Mindfulness (2013) 4:179–189DOI 10.1007/s12671-013-0197-7

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eight weekly 2-h sessions which incorporate elements ofcognitive therapy to facilitate a ‘detached or decentred viewof one’s thoughts’ (Fjorback et al. 2011, p. 103).

Mindfulness-based programmes for a range of healthconditions have been provided in the USA since the 1980sand are increasingly common in the UK. However, mind-fulness has not been widely used with people with intellec-tual disabilities, despite the increased prevalence of mentalhealth problems and vulnerability to chronic health condi-tions (e.g. epilepsy and diabetes) (Emerson et al. 2011).People with intellectual disabilities have poor access tohealthcare services (Alborz et al. 2005), including mentalhealth services, and anecdotal evidence indicates that this isalso true for psychological therapies, including mindfulness.

Systematic and meta-analytic reviews of the use ofmindfulness-based interventions (e.g. Baer 2003; Chiesaand Serretti 2010; Fjorback et al. 2011) have identified over60 studies published since 1976 looking at the impact ofmindfulness on physical health conditions such as multiplesclerosis, cancer, chronic obstructive lung disease, chronicpain, rheumatoid arthritis, fibromyalgia, psoriasis and HIV,and mental health problems such as recurrent depression,anxiety and mood disorders, with some studies also examin-ing the use of mindfulness with healthy participants. Whilstthere are methodological limitations to many of these studies,there is some evidence supporting the use of mindfulness-based interventions to improve psychological functioning andalleviate various mental health and physical health conditions.

Existing systematic reviews have generally excludedstudies on the use of mindfulness with people with intellec-tual disabilities. Two recent systematic reviews have exam-ined the use of mindfulness with people with developmentaland intellectual disabilities (Hwang and Kearney 2013a) andwith caregivers (Hwang and Kearney 2013b). However,these reviews included people with educational learningdisabilities and autistic spectrum conditions and interventionswhich involve additional non-mindfulness components (forexample, lifestyle interventions).

This paper reports on a systematic review conducted toinform a study evaluating the use of mindfulness sessionswith people with intellectual disabilities (Chapman andMitchell 2013). The review objective was to assess theeffectiveness of mindfulness training and practice in relationto people with intellectual disabilities. The review includesstudies of mindfulness interventions provided to both peoplewith intellectual disabilities and paid and informal carers.

Method

The systematic review followed the process set out by theCentre for Reviews and Dissemination (2009). The follow-ing databases were searched in October 2012: EMBASE,

MEDLINE, AMED, CINAHL and PSYCHINFO using thefollowing search strategy: (learning AND disab*) OR(mental* AND retard*) OR (intellectual* AND disab*) OR(developmental* AND disab*) ANDmindfulness. A messagewas also posted on the Jiscmail list Mindfulness and IDD todetermine whether professionals or academics interested inthe field were aware of additional publications. In addition,citation tracking and checking of reference lists from journalarticles identified by the search were carried out.

Papers were included if they described a study evaluatingan intervention described as being based on mindfulnessprinciples with people with intellectual disabilities, theirfamily members or staff and which were published in anEnglish language journal from 1980–5th October 2012.Papers were excluded if they involved people with autisticspectrum conditions, attention deficit hyperactivity disorder,conduct disorder or educational disabilities (e.g. dyslexia)but not intellectual disabilities, or people who had braininjuries acquired during adulthood. Studies that describedinterventions of which mindfulness formed a component(e.g. dialectical behaviour therapy, acceptance and commit-ment therapy) and interventions that included health promo-tion or behavioural training were also excluded, as it wouldnot be possible to distinguish whether it was mindfulness oranother aspect of the intervention which was having animpact. A study examining the impact of mindfulness trainingfor staff working with people with intellectual disabilities wasexcluded as it focussed on the impact on interactions with theirnon-disabled children, not their children with intellectual dis-abilities (Singh et al. 2010). Figure 1 gives details of theselection process.

Quality Assessment, Critical Appraisal and Data Extraction

Each study that met the inclusion criteria was allocated totwo members of the review team for independent qualityassessment and critical appraisal. The Evaluative Methodfor Determining Evidence Based Practice (EBP) was usedto assess the quality of the studies (Reichow et al. 2008).This method provides two rubrics for evaluating researchreports, one for group research and one for single subjectresearch. Each rubric evaluates primary quality indicators(e.g. participant characteristics and independent and depen-dent variables) on a trichotomous ordinal scale (high quality,acceptable quality and unacceptable quality) and secondaryquality indicators (e.g. inter-observer agreement and socialvalidity) on a dichotomous scale (evidence or no evidence).The ratings from the rubrics are combined to provide astrength of research rating (strong, adequate or weak).Originally developed for use in autism research, the rubricsare easily adaptable to research with people with intellectualdisabilities and are recommended as the most rigorous meth-od for the quality appraisal of single-subject experimental

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designs (Wendt andMiller 2012). An advantage of themethodis that comparable ratings are created for single subject andgroup research.

Detailed critical appraisal of the studies was conductedusing tools produced by CASP at the Public Health ResourceUnit (2007). These tools assist reviewers to consider the ap-propriateness of study design, risk of bias, choice of outcomemeasures, recruitment, sample findings, follow-up and gener-alisability in a structured way. Information was extracted fromthe included papers on study aims, design, intervention, sam-ple, setting, length of follow-up, outcomes and key findings.

Analysis

As the studies identified were not randomised controlledtrials, a meta-analysis was not possible. Therefore, a narra-tive analysis was carried out describing and comparing themain findings from the included studies and discussing theirmethodological strengths and weaknesses (Centre forReviews and Dissemination 2009).

Review Findings

Eleven relevant studies were identified. Seven studies eval-uated mindfulness training and practice for people withintellectual disabilities (Table 1). Two studies evaluatedmindfulness training and practice for staff members or teamsworking with people with intellectual disabilities (Table 2).Two studies evaluated mindfulness training and practice forparents of people with intellectual disabilities (Table 3).

Mindfulness Training for People with IntellectualDisabilities

Singh and colleagues carried out six of the seven studiesfocussing on the provision of mindfulness training directlyto people with intellectual disabilities (Singh et al. 2003,2007a, 2008b, 2011a, c). In these studies, mindfulness pro-cedures were taught to help people with intellectual disabil-ities deal with behavioural issues such as anger, aggressionand inappropriate sexual arousal.

Publications identified for review (n=606): - Database search (n=588)- Internet searching (n=4)- Professional networks (n=3)- Content alerts/WELD Blog and JISCMAIL alerts (n=2) - Reference tracking (n=9)

Publications retrieved that were potentially relevant for data extraction (n=57)

Publications excluded after sifting titles and abstracts (n=549)

Publications included in review (n=11)

Articles excluded after detailed relevance checks (n=46)- Not an intervention study (i.e. discussion piece, book chapter, Editorial, review, training manual, measure development) (N=15)- Intervention incorporates components other than mindfulness (N=14)- Not intellectual disabilities (e.g. dyslexia, ADHD, ADD, high functioning ASD, chronic health needs, focus on sibling without ID) (N=10)- Doctoral dissertation or conference abstract (N=7)

Fig. 1 Quality of reporting ofmeta-analyses (QUORUM)flow diagram

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Tab

le1

Studies

evaluatin

gmindfulness

training

andpracticeforpeop

lewith

intellectualdisabilities

Study

Aim

sStudy

type

Rigou

rSam

ple

Outcomes

measured

Singh

etal.

(200

3)To

explorethepo

ssibility

ofteaching

amindfulness-based

technique,Soles

oftheFeet,to

self-regulateaggression

Singlesubjectcase

stud

ywith

anABdesign

Weak

27-year-oldmalewith

mild

intellectual

disabilitieswho

was

aninpatient

ina

psychiatricho

spital

Incidentsof

physical

andverbal

aggression

12-m

onth

follo

w-up

Singh

etal.

(200

7a)

Toevaluate

theim

pact

ofteaching

amindfulness

technique(Soles

oftheFeet)

toadultswith

moderateintellectualdisabilities

Multip

lebaselin

edesign

across

participants

Weak

Three

Caucasian

adultswith

mod

erate

intellectualdisabilitiesat

risk

oflosing

theircommunity

placem

entsin

group

homes

becauseof

aggressive

behaviour

Physicalaggression

2-year

follo

w-up

Aged27–43

.One

female,twomales

Singh

etal.

(200

8b)

Toevaluate

theeffectivenessof

amindfulness-based

procedure(Soles

oftheFeet)forph

ysical

aggression

Multip

lebaselin

edesign

across

participants

Weak

6maleoffenderswith

mild

intellectual

disabilitiesfrom

aforensic

mentalhealth

facilityforpeople

with

intellectualdisabilities.

Allhadahistoryof

physical

aggression

againststaff

Physicalaggression

Aged23–36.3Caucasian,1African-A

merican,

1White

Hispanic,1no

n-White

Hispanic

Medication

Physicalrestraint

Final

measure

at27

mon

ths

ofmindfulness

training

Staffandpeer

injuries

Lostdays

ofwork

Costof

medical

andrehabilitation

dueto

injury

caused

byparticipants

Adk

inset

al.

(201

0)To

exploretheim

pact

ofcommunity

-basedtherapistsprovidingmindfulness

training

(Soles

oftheFeet)to

people

with

intellectualdisabilities

Multip

lebaselin

eacross

individu

als

Weak

3Caucasian

people

with

mild

intellectual

disabilities,liv

ingin

agrouphomeor

with

theirparents,who

wereat

risk

oflosing

theirjob,

livingplacem

ent,

preferredstaffor

funding

Behaviour

(verbalandph

ysical

aggression

,disruptiv

ebehaviou

r)4–8weeks

follo

w-up

Aged22–42

.2male,1female

Psychological

well-being(stress,

obsessive–compulsivesymptom

s,depression

,stateandtraitanxiety)

Chilverset

al.

(2011)

Toinvestigateim

pact

ofmindfulness

grou

psessions

ontheaggressive

behaviourof

wom

enwith

intellectual

disabilitiesin

aforensic

medium

secure

psychiatricun

it

Repeatedmeasuresdesign

Weak

15wom

enwith

mild

tomoderateintellectual

disabilitiesin

aforensic

medium

secure

psychiatricun

it

Incidentsof

aggression

towards

self

andothers

resulting

which

resulted

ininterventio

nsNofollo

w-up

Aged18–47

Singh

etal.

(2011c)

Toevaluate

theim

pact

ofmindfulness

practice(Soles

oftheFeet)whentaug

htby

apeer

with

intellectualdisabilities

Multip

lebaselin

edesign

across

participants

Weak

3adultmales

with

mild

intellectualdisabilities

who

lived

inthecommun

ityin

supported

livingandhadangerandaggression

issues

atwork.

Aged26–32

Agg

ression

Interviews

2-year

follo

w-up

Singh

etal.

(2011b

)To

exam

inewhether

meditatio

nprocedures

(Soles

oftheFeetandmindful

observation

ofthou

ghts)couldchange

sexual

offend

ers’

inapprop

riatesexu

alarou

sal

Multip

lebaselin

edesign

across

participants

Weak

3men

with

mild

intellectualdisabilities

from

aforensic

mentalhealth

facility

forpeople

with

intellectualdisabilities

who

hadbeen

sentencedforaggravated

Sexualassaulton

aminor

orincest

andrape

ofchild

ren

Levelof

sexu

alarou

sal

Aged23–34.1African-A

merican,

1Caucasian,1White

Hispanic

Interviews

Final

measure

at35–40

weeks

mindful

observationof

thou

ghtsph

ase

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Provision of Mindfulness Training The mindfulness trainingin the studies incorporated various meditation proceduresprovided over different timeframes in both institutional andcommunity settings by people from a range of backgrounds.The most commonly taught meditation procedure was Solesof the Feet (Adkins et al. 2010; Singh et al. 2003, 2007a,2008b, 2011b, c). The Soles of the Feet meditation proce-dure teaches participants to divert their attention from anemotionally arousing thought, event or situation to an emo-tionally neutral part of one’s body (the soles of the feet).Once mastered, it becomes automatic to calm the mind byfocussing on the body rather than the thought or situation.

Other mindfulness techniques taught to people with in-tellectual disabilities included Mindful Observation ofThoughts which involves a series of mindfulness procedures(e.g. focussing on the breath, visualising and observingthoughts as clouds passing through awareness) (Singh etal. 2011a) and observation of breathing, noises and objects(Chilvers et al. 2011). Whilst the length and manner oftraining in mindfulness techniques varied across studies,Soles of the Feet training usually involved intensive weeklyor daily sessions of supervised role-play and practice andhome practice assignments (Adkins et al. 2010; Singh et al.2003, 2007a, 2008b, 2011a, c). Chilvers et al. (2011) held

Table 2 Studies evaluating mindfulness training and practice for staff working with people with intellectual disabilities

Study Aims Study type Rigour Sample Outcomes measured

Singh et al.(2004)

To investigate whethermindfulness training forpaid caregivers wouldincrease levels of happinessfor adults with profoundmultiple disabilities

Alternating treatmentsembedded within amultiple baselineacross subjects design

Weak 6 female African-Americancaregivers who worked in4 group homes. 3 maleswith profound intellectualdisabilities and complexmedical and physicalproblems.

Happiness

Final measure takenat end of 16 weekmindfulness practice phase

Singh et al.(2009)

To assess how trainingstaff members in mindfulnessaffected their use ofphysical restraints

Multiple baseline designacross 2 staff shifts

Weak 23 staff members workingin 4 group homesfor 20 people withintellectual disabilities

Number of potential andactual incidents ofphysical or verbalaggression

Final measure takenat end of 22 weekmindfulnesspractice phase

Physical restraints

Staff verbal redirections

Medication

Staff and peer injuries

Table 3 Studies evaluating mindfulness training and practice for parents of people with intellectual disabilities

Study Aims Study type Rigour Sample Outcomes measured

Singh et al.(2007b)

To assess the effects ofmindfulness training forparents of children withintellectual disabilitieson the children’s behaviourand interactions withsiblings, parental stressand parental satisfactionwith parenting skills andinteractions with theirchildren

Multiple baseline designacross participants(parent–child dyads)

Weak Four African-Americanmother–child dyads. Allchildren attended a daycentre for children withintellectual disabilities

Child’s aggression towardsmother or siblings

Child’s social interactionswith siblingsInterviews with parents

Mother’s satisfaction withtheir own parenting skillsand their interactionswith their child

Final measures takenafter a 52-weekmindfulness practice stage

Mother’s use of mindfulnessin parenting

Parents’ experiences andperceived outcomes ofmindfulness

Bazzano et al.(2010)

To evaluate the feasibility of amindfulness-based stressreduction community-basedprogram for parents/caregiversof children with intellectualdisabilities

Participatory researchusing a single grouppre–post-design

Weak 37 parents of children withintellectual disabilities

Mindfulness

Self-compassion

Psychological well-being

General and parenting stress

Mindfulness (2013) 4:179–189 183

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twice weekly 30-min mindfulness sessions over a 6-monthperiod using observation, description and participation exer-cises to focus on different mindfulness practices.

A range of people with different levels of mindfulnessskills and experience have provided mindfulness training. Inthe majority of studies, mindfulness training was providedby a single therapist experienced in the practice and teachingof mindfulness (Singh et al. 2003, 2007a, 2008b). Traininghas also been provided by ward or community-based thera-pists trained in mindfulness techniques (Adkins et al. 2010;Chilvers et al. 2011) and by a person with intellectual dis-abilities trained in the Soles of the Feet technique (Singh etal. 2011c).

In most studies, mindfulness training was provided toparticipants with intellectual disabilities individually, with onlyChilvers et al. (2011) using a group format. Mindfulnesstraining programmes have been provided in various settings,including institutional settings such as psychiatric hospitalsand forensic mental health facilities (Chilvers et al. 2011;Singh et al. 2003, 2008b, 2011b) and community settings withpeople living in group or family homes (Adkins, et al. 2010;Singh et al. 2007a, 2011c).

The Impact of Mindfulness Training All of the studies foundimprovements after the mindfulness training and practice.Singh et al. (2003) found major improvements in behaviourfor the man who was trained in Soles of the Feet with noaggressive behaviour reported during the 1 year follow-up.The mean number of incidents of physical aggression re-duced from 15.4 during baseline to 2.0 during training and 0during follow-up and those of verbal aggression reducedfrom 10.0 at baseline to 2.1 during training and 0 duringfollow-up. There were also increases in self-control (from 0during baseline to 4.5 during follow-up) and reduction anddiscontinuation of physical restraints (from 10.4 duringbaseline to 0) and medication (from 12.2 during baselineto 0). Staff injuries reduced from 9.2 during baseline to 0during follow-up, and resident injuries also reduced to 0from 8.6 at baseline. The number of activities in which theparticipant took part also increased from 3.6 socially inte-grated activities and 0 physically integrated activities atbaseline to more than 100 of each type of activity atfollow-up.

Singh et al. (2007a) found reductions in aggressive be-haviour during mindfulness training, with further reductionsduring follow-up after 2 years. Michael’s mean level of 5.0aggressive behaviours during baseline reduced to 0.1 atfollow-up, Rosemary’s reduced from 3.4 to 0.3 andRaymond’s reduced from 2.8 to 0. All three participantsmaintained their community placements.

Singh et al. (2008b) found that physical and verbal ag-gression decreased substantially. During baseline, the aver-age number of physically aggressive behaviour made each

month ranged between 1.0 and 2.6. Across the 27 months ofmindfulness training, the number of physically aggressivebehaviours declined to 0, and none of the six participantsmade a physically aggressive response for at least 6 monthsbefore training ceased. Mean levels of verbal aggressionreduced, although remaining higher than levels of physicalaggression. The measure of participants’ self-reported self-control increased, and no PRN (as needed) medication orphysical restraint was required. In addition, there was areduction in the number of staff days absent and the associ-ated wage and medical costs.

Adkins et al. (2010) found that target behaviours de-creased as mindfulness training proceeded and during mind-fulness practice were maintained at near-zero levels. Lowlevels were maintained during follow-up, although withsome variability, and most of the self-reported psychologicalwell-being scores improved. For example, mean incidents ofKevin’s verbal aggression reduced from 4.00 per weekduring baseline to 0.35 during mindfulness practice,Samy’s disruptive behaviour reduced from 13.50 duringbaseline to 5.58 during mindfulness practice, whilstMonica’s verbal aggression reduced from 24.00 to 5.33and her physical aggression reduced from 12.75 to 1.00.

Chilvers et al. (2011) found a decrease in the number ofincidents of aggression (including self-directed), with a con-comitant reduction in interventions such as use of the ob-servation lounge, physical intervention or seclusion. Over aperiod of 6 months, the mean number of observations re-duced from 5.07 to 1.53, mean number of physical inter-ventions reduced from 3.40 to 1.53 and mean number ofseclusions reduced from 1.20 to 0.53. The changes in obser-vations and physical interventions were statistically signifi-cant. There was a relatively sharp reduction when thesessions were introduced, followed by a more gradual in-crease and then further reduction.

The three participants who received mindfulness trainingfrom a peer (Singh et al. 2011c) initially had an average ofbetween 1.00 and 10.63 anger events and between 0.86 and1.13 aggressive acts per week. After mindfulness training,the frequency of anger and aggressive events decreased tozero over the mindfulness practice phase. Whilst the threeparticipants reported occasional incidents of anger duringthe 2-year follow-up, there was no reported aggression.

Singh et al. (2011b) found that mean weekly ratings ofself-reported sexual arousal for the three participants re-duced from 12 at baseline to 8.75, 10 and 10.75 during theself-control phase and then to 7.77, 7.38 and 6.92 at theSoles of the Feet phase. During the mindful observation ofthoughts phase, these ratings reduced further to 2.95, 3.03and 1.51, respectively.

Feedback from Participants People with intellectual dis-abilities who have received mindfulness training have

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reported that they valued learning to control their own feel-ings rather than being told to calm down by others andfound this reinforcing (Singh et al. 2011b). Participantsinitially found mindfulness procedures difficult to under-stand as they could not easily remember and visualise pastevents (Singh et al. 2007a) or did not understand instruc-tions such as ‘observe your thought’ (Singh et al. 2011b).Repeated practice, the use of role-plays and discriminativestimulus being added to the soles of their feet helped toovercome such difficulties (Singh et al. 2007a, 2011b).Participants varied in their ability to initiate mindfulnessmeditation without prompting (Adkins et al. 2010) andmay find it difficult to implement mindfulness procedureswithin their lives at first (Singh et al. 2011c). Participantsfound it more difficult to use Soles of the Feet for deviantsexual arousal than for the precursors of aggression due totheir emotional attachment to the strong pleasurable sexualthoughts (Singh et al. 2011b).

Mindfulness Training for Staff Working with Peoplewith Intellectual Disabilities

Table 2 summarises the two studies evaluating the impact ofmindfulness training and practice for people working withpeople with intellectual disabilities, both carried out bySingh and colleagues. The mindfulness training in bothstudies covered aspects of mindfulness including meditationmethods, knowing your mind, focussed attention, being inthe present moment, beginner’s mind, non-judgmental ac-ceptance, letting go, loving kindness, problem solving andusing mindfulness in daily interactions. The studies lookedat both the impact of mindfulness training on staff in relationto the interventions and approaches they utilised and worksatisfaction and the impact on people with intellectualdisabilities.

Singh et al. (2004) measured changes in happiness levelsfor three adults with profound intellectual disabilities livingin group homes when supported by staff trained in mindful-ness techniques compared with staff who had received thesame amount of training in behavioural methods training.Observed happiness increased to a much greater extentwhen supported by the staff member trained in mindfulness(an increase of 146 % when supported by the person trainedin mindfulness compared to 11 % for the untrained caregiverfor the first person, 322 % compared to 1 % for the secondperson and 437 % compared to 10 % for the third person).

In another study, Singh and colleagues provided mind-fulness training to 23 members of staff working in fourgroup homes for people with mild to profound intellectualdisabilities (Singh et al. 2009). The mean number of inci-dents reduced from 10.67 during baseline to 6.76 during thepractice phase for the morning shift and from 8.60 to 6.22for the afternoon shift. The use of physical restraints for

aggressive behaviour decreased to almost none by the end ofthe study. Verbal redirections by staff and PRN medicationalso reduced and staff and peer injuries were close to zerolevels during the latter stages of mindfulness practice.

Mindfulness Training for Parents of People with IntellectualDisabilities

Two studies conducted have evaluated the impact of pro-viding mindfulness training to parents of people with intel-lectual disabilities (Table 3). These have investigated thedirect impact of mindfulness training and practice onparents’ satisfaction and wellbeing and on parent–childinteractions and the indirect impact on people with intellec-tual disabilities and other family members.

In the study of Singh et al. (2007b), four mothers ofchildren with intellectual disabilities received 12 1:1 mind-fulness sessions following the parent training programmeoutlined in Singh et al. (2006a). All four children showed adecrease in aggressive behaviours during the training stagewith more systematic and substantial reductions during themindfulness practice stage. With dyad 1, the child’s meannumber of aggressive behaviours per week decreased by33 % from baseline (14.3) to training (9.6) with an 87 %decrease from training to practice (1.3). With dyad 2, themean number of aggressive behaviours reduced by 26 %from baseline (8.6) to training (6.3) and 94 % from trainingto practice (0.4). With dyad 3, the mean number of aggres-sive behaviours reduced by 30 % from baseline (13.9) totraining (9.7) and 91 % from training to practice (0.9). Withdyad 4, the mean number of aggressive behaviours reducedby 36 % from baseline (14.4) to training (9.2) and 88 %from training to practice (1.1). In addition, there wereimprovements in interactions between the child with intel-lectual disabilities and their siblings, and mothers’ self-ratings of parental satisfaction, parental stress and mother–child interaction improved.

Bazzano et al. (2010) provided a community-basedmindfulness-based stress reduction programme for paren-ts/caregivers of children with intellectual disabilities. Theprogramme consisted of two concurrent classes twice weeklyin English with Spanish translation over 8 weeks, consistingof meditation practice, supported discussion of the stressorsparents faced and yoga. Parents also received a 30-min CD fordaily practice. Attendance was good with 78 % attending sixor more classes. Parents reported statistically significant lessstress and statistically significant increases in mindfulness,self-compassion and well-being after the programme.

Parental feedback suggests that people need to bedisciplined in their meditation practices and exercises inorder to achieve consistent, enduring practice on a dailybasis. Mothers found mindfulness training different to pre-vious training programmes they had attended, leading to

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transformational change rather than providing them withspecific rules or techniques to use with their child (Singhet al. 2006a). They felt that the training had enabled them totake a more holistic view of their child within the context offamily, social and physical environments and to respond totheir child in a calm, positive manner that pre-empted mal-adaptive behaviour and encouraged positive social behaviour.

Study Quality

All of the studies were rated as weak using the EvaluativeMethod for EBP (Reichow et al. 2008). Several seriousmethodological weaknesses were identified in all of thestudies under review in areas appertaining to research de-sign, participants, sample size, treatment fidelity and out-come measurement. Most studies conducted by Singh andcolleagues used a multiple baseline design, which has severaladvantages (e.g. non-withdrawal of a potentially effectiveintervention, paralleling clinical practice and ease of conceptu-alisation and implementation) and can show a causal effectbetween an intervention and the outcome, especially at singlecase level (Cooper et al. 2007). However, given the smallnumber of participants, external validity is weak, limiting thegeneralisability of the findings (Silver Pacuilla et al. 2011).

A major methodological weakness of all the studies isthat they are uncontrolled with no comparison with othertreatments to determine whether observed improvements aredue to receiving some form of treatment or due to the impactof the therapist. Moreover, a single therapist provided mostof the mindfulness training, and it is possible that his inter-personal skills and style led to change rather than mindful-ness per se. Moreover, Singh and colleagues do not statewhich mindfulness approach they are following (mindful-ness-based stress reduction or mindfulness-based cognitivetherapy) and their training does not follow the typical time-frames and content of mindfulness-based stress reductionand mindfulness-based cognitive therapy programmes.There were no systematic or independent assessments ofthe quality of the interventions in the studies (i.e. treatmentcompliance) or of how closely interventions conformed tomindfulness principles (i.e. treatment fidelity).

In addition, the sample sizes within the studies are smallwith limited information about sampling criteria used, rais-ing questions about representativeness. Some people con-tacted the researchers and may be more motivated to changethan other people. All of the participants in the studieswhere mindfulness training was provided directly to peoplewith intellectual disabilities had mild or moderate intellec-tual disabilities, and it is difficult to generalise the findingsto people with more severe intellectual disabilities.

In relation to outcome measurement, most of the studiesof Singh et al. utilised more than one observer of thetargeted behaviours to ensure reliability of data and reported

that inter-observer reliability was generally high. However,reliability and validity data are not reported for many of themonitoring instruments and scales used in the studies todetermine how appropriate or accurate they are (for example,Bazzano et al. 2010).

Finally, there is a lack of procedural detail about how thequalitative data from informal interviews and anecdotalevidence was gathered, with no information about whetherinterview guides were used, whether interviews wererecorded and the method of analysis used. If the mindfulnesstrainer carried out interviews about the training, it is possiblethat participants would have responded more positively thanif an independent person had conducted the interviews.Therefore, whilst the majority of published studies suggestthat mindfulness-based training can have a positive impacton people with intellectual disabilities, their family membersand paid carers, such claims must be treated with extremecaution due to the serious methodological limitations of allof the extant studies.

Discussion

The studies identified by this systematic review indicate thatmindfulness training and practice leads to improvements inthe frequency of problem behaviours and psychologicalwell-being for people with intellectual disabilities. Theseimprovements have frequently been maintained over severalyears. The studies suggest that whilst benefits can beachieved by providing mindfulness training and practicedirectly to people with mild and moderate intellectual dis-abilities, people with intellectual disabilities also benefit iftheir staff and family receive mindfulness training.

Mindfulness training has been shown to be successfullyprovided in a range of community and institutional settingsand by experienced mindfulness practitioners, staff trainedin mindfulness techniques, family members and people withintellectual disabilities themselves. As the studies have in-cluded White, African-American and Hispanic populations,there is some evidence that mindfulness approaches areacceptable to people from diverse cultural backgrounds. Thefeedback from participants with intellectual disabilities dem-onstrates that mindfulness training must be accessible to themwith clear instructions, regular practice and use of concreteexamples, role play and stimuli to assist people with intellec-tual disabilities to understand and use mindfulness conceptsand techniques. The feedback from parents indicates that theytoo may need support and encouragement to persist withintegrating mindfulness practice within their lives.

The reported positive findings have implications for in-tellectual disability services considering mindfulnessapproaches with their clients and/or staff as an option forimproving the quality of life and well-being of people with

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intellectual disabilities, particularly if existing approachesare not effective. People with intellectual disabilities, theirfamilies and organisations may want to consider mindfulness.Mainstream health services also need to review whether themindfulness interventions which they provide are beingaccessed by people with intellectual disabilities and, if not,identify the reasons why and determine what action can betaken.

However, the serious methodological limitations of thepublished studies mean that the positive findings should betreated with caution, and it is debateable whether the evidenceis strong enough to recommend the use of mindfulness. TheEvaluative Method for Evaluating and Determining EBPprovides criteria for determining whether a practice hasenough empirical support to be classified as an establishedor promising EBP (Reichow et al. 2008). These criteria look atthe number of strength ratings, howmany research teams haveconducted the studies, how many different locations haveconducted studies and the total sample size across studies.As all of the studies in this review were assessed as being ofweak research report strength, the current evidence cannot yetbe categorised as promising. Similarly, the evidence would bejudged as very low using international criteria for recommend-ing evidence-based interventions developed by the Grades ofRecommendation, Assessment, Development, and Evaluation(GRADE) Working Group (2004). In addition, most studieshave been carried out in the USA, and it is unclear how wellmindfulness will translate to other countries with differentcultures and services systems. Therefore, stronger evi-dence is needed before mindfulness could be confidentlyrecommended as routine practice with people with intellectualdisabilities.

Future studies need to be clear about the mindfulnessapproach being evaluated. The mindfulness approachesmost commonly used with the general population aremindfulness-based stress reduction and mindfulness-basedcognitive therapy. However, the mindfulness training pro-grammes described in the reviewed studies include a myriadof techniques, and it is not always clear how compatiblethese are with more usual mindfulness approaches. Whilstthe programme delivered by Bazzano et al. (2010) was de-scribed as a mindfulness-based stress reduction programme,Chilvers et al. (2011) do not specify which mindfulness ap-proach their training was based upon, and the majority ofstudies included in the review describe and evaluate an ap-proach to mindfulness, the Soles of the Feet (and more recent-lyMindful Observation of Thoughts), developed by Singh andcolleagues. The use of more typical mindfulness-based stressreduction and mindfulness-based cognitive therapy pro-grammes with people with intellectual disabilities and carersneeds to be explored and evaluated.

A number of studies were excluded from this review asthey reported on interventions which included components

other than mindfulness. Some studies explored interventionsbased on acceptance and commitment therapy or dialecticalbehaviour therapy, which include mindfulness as a compo-nent (for example, Morrissey and Ingamells 2011; Nooneand Hastings 2010; Sakdalan et al. 2010). Three studieswere excluded which suggested that introducing a mindful-ness component into health promotion interventions mayhelp to support and maintain lifestyle changes such asweight loss and stopping smoking (Singh et al. 2008a,2011a, d). Another study concluded that providing mindful-ness training after behavioural training to staff working ingroup homes considerably improved their ability to managethe aggressive behaviour and improve learning of residentswith intellectual disabilities (Singh et al. 2006b). It is im-portant that future studies are designed so that it is clearwhether it is mindfulness or other components of an inter-vention that are leading to change.

In addition to research evaluating the effectiveness ofmindfulness, further research is needed to develop a concep-tual model that clarifies the mechanisms and processes leadingto any observed outcomes from mindfulness training andpractice. The perspectives of those who have received mind-fulness training will be important in illuminating these pro-cesses. The studies included in this review show that peoplewith intellectual disabilities feel that mindfulness training andpractice has provided them with a method of controlling theirown feelings, rather than being dependent on their behavioursbeing managed by other people. Family members report thatmindfulness training and practice provides them with newcoping mechanisms and leads to a form of transformationalchange in the way in which they perceive and respond to theirfamily member with intellectual disabilities. This appears tolead to improved parent–child interactions and as a conse-quence positive outcomes for the child with intellectual dis-abilities. The included studies did not gather information fromstaff about their perceptions of mindfulness training and prac-tice and potential reasons for the reported outcomes. It ispossible that if they too are experiencing a similar form oftransformational change in the way in which they view andrespond to the people they are working with, this may result inimprovements in staff–client interactions, which in turn im-prove outcomes for people with intellectual disabilities (forexample, improvements in behaviour, well-being and qualityof life).

Further research utilising controlled designs with bothlarger sample sizes and random allocation to treatment orcomparison groups is therefore needed before reportedimprovements can be more confidently attributed to mind-fulness. Similarly, further research is needed to identifywhich components of mindfulness lead to change and theprocesses involved, whether mindfulness approaches aremore effective than other approaches or interventions andto explore how factors such as facilitator characteristics,

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support, communication needs and cognitive abilities impacton the success of mindfulness. Research into whether mind-fulness is best taught on a 1:1 basis or in a group setting is alsorequired to inform clinical practice. Methodologically robustqualitative research could also explore the experiences ofthose receiving mindfulness training, to identify what theyfeel the impact of mindfulness has been and to identify whichcomponents of mindfulness participants find most useful.

Conclusion

In conclusion, there is some evidence that mindfulness-based approaches may have the potential to improve thepsychological well-being of people with intellectual disabil-ities, but high-quality research conducted by independentresearchers is required before clear clinical recommenda-tions can be made.

Acknowledgments This study was carried as part of an evaluation ofthe Mindfully Valuing People Now project carried out by PathwaysAssociates CIC and the North West Training and Development Teamwith funding from Improving Access to Psychological Therapies.

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