>> GOOD MORNING, EVERYONE. I'M JOCIE BRIGGS, DIRECTOR FOR NATIONAL CENTER FOR COMPLIMENTARY MEDICINE. IT'S MY PLEASURE TO INTRODUCE OUR GUEST SPEAKER FOR THE DAY, DR. ERICA SMIT SIBINGA. DR. SIBINGA GOT HER UNDERGRADUATE FROM WESLEY AND M.D. FROM UNIVERSITY OF PENNSYLVANIA AND RESIDENCY AND FELLOWSHIP AT JOHNS HOPKINS. SHE'S A PEDIATRICIAN. LATER DID A MASTER PUBLIC HEALTH AT JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH. HER CURRENT POSITION IS AS AN ASSISTANT PROFESSOR IN THE DIVISION OF GENERAL PEDIATRICS AND ADOLESCENT MEDICINE. SHE'S ALSO ON THE FACULTY OF THE JOHNS HOPKINS SCHOOL OF MEDICINE CENTER FOR MIND BODY RESEARCH AND THE CLINICAL DIRECTOR OF THE CENTER FOR ADDICTION AND PREGNANCY AT JOHNS HOPKINS BAY VIEW. SHE HAS LOTS OF BOTH RESEARCH AND PRACTICAL EXPERIENCE IN THE THINGS THAT WE COLLECTIVELY WORRY ABOUT. HER ONGOING RESEARCH, A FAIR AMOUNT WHICH IS SUPPORTED BY NCCAM INCLUDES STUDIES LOOKING AT STRATEGIES TO REDUCE STRESS AND HIV INFECTED YOUTH THROUGH MINDFULNESS TRAINING. MINDFULNESS BASED STRESS REDUCTION AS A TRAT JI TO SUPPORT CHILDREN AND YOUTH WITH DEPRESSION. STRATEGIES FOR PREVENTING DEPRESSION AND DISCONNECTED AFRICAN AMERICAN ADOLESCENCE IN YOUNG AND ADULTS AND GENERAL MEDICATION PROGRAM FOR STRESS AND WELL BEING. THESE ARE KINDS OF INTERVENTIONS THAT ARE NOT WIDELY PRACTICED IN OUR INNER CITIES, AS EVERYONE KNOWS. YET THE NEEDS AND STRESSES AND HEALTH IMPACT OF THAT STRESS IS SOMETHING CERTAINLY ALL OF US HERE AT THE NIH ARE AWARE OF. SO WE'RE REALLY PROUD OF THE INTERESTING WORK DR. SMIT SIBINGA IS DOING AND GLAD TO HAVE AN OPPORTUNITY FOR YOU ALL TO HEAR ABOUT IT. DR. SIBINGA.pq– >> THANKS VERY MUCH, DR. BRIGGS. IT'S A PLEASURE TO BE HERE THIS MORNING AND TO SEE EVERYBODY HERE. SO I THOUGHT I WOULD TALK ABOUT AS DR. BRIGGS SUGGESTED MINDFULNESS FOR URBAN YOUTH BUT TRY TO TAKE A MOMENT AND SAY WHAT DO WE KNOW AND BY IMPLICATION WHAT DON'T WE KNOW AS WELL. MY WORK REALLY BEGINS FROM ITS HEART WITH BALTIMORE YOUTH. I'M A GENERAL PEDIATRICIAN, TRAINED AS AN ALIPAS. I HAVE INTEREST IN INTEGRATION OF COMPLIMENTARY THERAPIES. YET AS AN ALLO PATH I'M AWARE OF MY LACK OF COMFORT IN THE PRESCRIPTION OF SOME MORE THAN OTHERS BUT CERTAINLY IN GENERAL AND I THINK THAT'S THE HEART OF MY INTEREST IS TO FIGURE OUT WHAT WE CAN USE, WHAT WE MIGHT USE TO MAKE THINGS BETTER FOR THESE, MY PATIENTS. MY PATIENTS ARE BALTIMORE YOUTH. AND THEY EAR JUST AMAZING CHILDREN, AS MANY CHILDREN ARE, YOU SEE PROMISE AND POTENTIAL AND BEAUTY AND CREATIVITY. AS THE YEARS GO ON AND THEY'RE GROWING UP IN BALTIMORE WHERE THERE'S LOTS OF PROFOUND PERSISTENT STRESSES, YOU CAN SEE THAT GO OUT A LITTLE BIT. IT'S A TRAGIC FEELING. SO SOUNDS TRITE BUT IT REALLY IS MOTIVATING. SO BALTIMORE CITY IS AN EXAMPLE OF A CITY LIKE MANY OTHER AMERICAN CITIES. AND THE EXPERIENCES THAT THE YOUTH IN THESE CITIES HAVE IS PRETTY PROFOUND. HIGH LEVELS OF INNER CITY AND -- 2.5 TO FOUR TIME IT IS NATIONAL CRIME RATE, HIGH SEXUALLY TRANSMITTED INFECTION RATE INCLUDING HIV, THE HIV INCIDENCE IS 1.7 TO 3 TIMES THE SURROUNDING AREAS. THEY'RE INCREASING RATES OF HIV TRANSMISSION IN THE YOUNGER AGES AND BY HETEROSEXUAL EXPOSURES MAKING IT MUCH MORE DIFFICULT TO IDENTIFY HIV TRANSMISSION ONLY BY EXPOSURE AND SEXUAL PREFERENCES, NOT THAT THAT'S -- HADN'T BEEN PART OF IT BEFORE IT'S AN INCREASING RATE SO THINGS WE THINK OF AS TYPICAL EXPOSURES NOW IN THE CITY WILL ALSO PUT YOU AT RISK FOR HIV INFECTION. THERE ARE HIGH RATES OF SUBSTANCE ABUSE ANDTY 10TH GRADE 45% OF YOUTH ARE CURRENTLY USING ALCOHOL, THESE ARE A LITTLE BIT OLD STATISTICS BUT FROM UNIVERSITY OF MARYLAND, 27% ARE USING DRUGS OTHER THAN ALCOHOL OR TOBACCO. 25% IS MARIJUANA SO IT'S PERVASIVE MARIJUANA USE. THERE ARE LIMITED ECONOMIC ACTIVITIES, OPPORTUNITIES. PARTICULARLY IN TERMS OF VARIETY. SO THERE IS A ROBUST ILLEGAL ECONOMIC TRADE IN THE URBAN AREAS BUT WE LIKE TO SEE MORE VARIETY FOR OUR YOUTH TO THINK ABOUT OPPORTUNITIES THAT WILL LAND THEM SOMEWHERE OTHER THAN IN JAIL. ALTHOUGH THE BALL MORE CITY SCHOOLS HAVE BEEN WORKING INCREDIBLY HARD AND ACTUALLY HAVE GREAT IMPROVEMENTS OVER RECENT YEARS, THERE'S STILL ONLY A 70% GRADUATION RATE THAT, MEAN AS 30% NON-GARAGE WAYS RATE AND THAT -- NON-GRADUATION RATE AND THAT DOES NOT INCLUDE DROP-OUT RATES. SO MY OVERALL GOAL IS TO IDENTIFY A COMPLIMENTARY THERAPY WHICH MAY REDUCE URBAN YOUTH STRESS AND AMELIORATE THE NEGATIVE EFFECTS OF STRESS. BECAUSE THERE'S SO MANY OF THESE THINGS THAT WE HAVE LIMITED ABILITY TO AFFECT. THAT BROUGHT ME TO THE MINDFULNESS SPACE STRESS REDUCTION PROGRAM DEVELOPED BY JOHN SIM IN 1979, THE CORE ELEMENTS OF MBSR ARE DEFINED BY JOHN CABOS SIM AND THE META ANALYSIS BY PAUL GROSSMAN AS A STRUCTURED 8 TO 10 WEEK PROGRAM. GROUPS CONSISTING TYPICALLY OF 10 TO 40 PARTICIPANTS LASTING TWO HOURS PER SESSION. WITH CONTENT -- CONSISTING OF MINDFULNESS MEDITATION, THE MIND-BODY CONNECTION, THE PRACTICE OF A VARIETY OF MINDFULNESS TECHNIQUES. AND THE DISCUSSION FOCUSED ON BARRIERS TO EFFECTIVE PRACTICE. ONE THING THAT'S HELPFUL IN THE MBSR PROGRAM IS IT HAS A HOME, A CENTRALIZED TRAINING SITE WHERE INSTRUCTORS RECEIVE SYSTEMATIC TRAINING, SO THAT VASTLY IMPROVES THE ABILITY TO DO RESEARCH ON THE NBSR PROGRAM. THERE'S QUITE A BIT OF EVIDENCE OUT THERE IN THE LITERATURE FOR NBSRs EFFECT IN ADULTS OR PERHAPS THE POTENTIAL EFFECT. NBSR IS FOUND TO BE POTENTIALLY BENEFICIAL IN HETEROGENEOUS POPULATIONS OF ADULTS INCLUDING HEALTHCARE PROVIDERS, HEALTHY ADULTS, ADULTS WITH VARIOUS DIFFERENT CLINICAL PROBLEMS. IN GENERAL, THE PO POTENTIAL BENEFITS SEEM TO BE IMPROVED MENTAL HEALTH, IMPROVED MOOD STATES, IMPROVED QUALITY OF LIFE, IMPROVED JOB SATISFACTION DRAMATICALLY SHOWN IN NICK CROSNER'S WORK WITH CONDITIONS. IMPROVED PARAMETERS IN JOHN SIMILARS ANDRY -- SIMS AND RICHEY DAVIDSON LOOKING AT FLU VACCINE RESPONSE. BUT ALMOST ALL THE REVIEWS AN META ANALYSIS CONFIRM THIS POTENTIAL BUT CALL FOR INCREASED RIGOR IN OUR STUDY OF THESE INTERVENTIONS. MOST COMMONLY, THE CONCERN IS THAT THE CONTROL GROUP IS VERY OFTEN A WEIGHTLESS CONTROL OR INACTIVE CONTROL AND DOESN'T BALANCE POTENTIAL EFFECTS OF BENEFITS GAINED THROUGH COMING TOGETHER AS A PEER GROUP WITH A POSITIVE LEADER. IN TERMS OF NBSR FOR CHILDREN AND YOUTH, THERE'S GROWING LITERATURE, STARTED A DECADE AGO WITH CASE STUDY BY MARY ANN OTT OF CHILD, A TEENAGE AGER WHO HAD INCAPACITATING NAUSEA AND SHE GOT BENEFIT FROM ONE ON ONE KIND OF MINDFULNESS INSTRUCTION. THERE'S MULTI-MODAL STUDIES INCORPORATING INTERVENTIONS INCLUDING NBSR SO IT'S HARD TO TEASE THAT OUT. WE HAVE PUBLISHED AN UNCONTROLLED STUDY WITH URBAN YOUTH FINDING BENEFITS, REDUCED HOSTILITY AND CONFLICT ENGAGEMENT AND GINA BEAGLE L PUBLISHED A RANDOMIZED CONTROL TRIAL OF NBSR COMPARED WITH USUAL CARE IN OUTPATIENT PSYCHIATRIC PATIENTS. SHE FOUND REDUCE ANXIETY, DEPRESSION AND REDUCED PSYCHOLOGICAL ASSESSMENTS. PARTICIPANTS IN THIS STUDY LOST THEIR DIAGNOSES AFTER MBSR INTERVENTION. BUT AGAIN, THERE WAS NO CONTROL GROUP FORCE EXPECTATION AND THE KIND OF INTERACTION THAT MBSA BRINGS WITH IT. MBSR IS THE PROGRAM THAT I HAVE JUST DESCRIBED FOR YOU. BUT I JUST WANT TO TAKE A STEP BACK AND SAY WHAT IS MINDFULNESS? WHAT IS MBSR'S INTENDING TO ENHANCE AND DO PEOPLE WANT TO THROW OUT THOUGHTS? WHAT DO PEOPLE THINK OF WHEN THEY HEAR MINDFULNESS? AWARENESS OF THE PRESENT. GREAT. ANY OTHER THOUGHTS? DESCRIPTIONS? SORRY? NON-JUDGMENTAL. ANYTHING ELSE? HOW DO WE GET THERE? SO THIS IS A -- THIS IS OBVIOUSLY A PRIMED AUDIENCE. SO JOHN CABOT SIM HAS DESCRIBED MINDFULNESS AS A CONSCIOUS MOMENT TO MOMENT AWARENESS CULTIVATED BY SYSTEMATICALLY PAYING ATTENTION ON PURPOSE IN A PARTICULAR WAY. SYLVIA BORESTEIN, MINDFULNESS IS THE AWARE BALANCED ACCEPTANCE OF THE PRESENT EXPERIENCE. IT ISN'T MORE COMPLICATED THAN THAT. IT IS OPENING TO OR RECEIVING THE PRESENT MOMENT PLEA ZAHN OR UNPLEASANT, JUST AS IT IS WITHOUT CLINGING TO IT OR REJECTING IT. THAT IS A PRETTY GOOD EMBODIMENT OF WHAT YOU SAID ALREADY. MOST OF THE OTHER DEFINITIONS OF MINDFULNESS. JOHN CABOT ZIM HAS DESCRIBED MINDFULNESS QUALITIES NOT PRESCRIPTIVE BUT AS AN OBSERVATION OF WHAT PEOPLE WHO ARE PRACTICING MINDFULNESS OR HAVE MINDFULNESS OF PARTICULAR MOMENTS ARE EXUDING, IF YOU WILL, NON-JUDGING, PATIENCE, BEINGERS MIND, DO PEOPLE KNOW WHAT BEINGERS MIND IS? THAT'S A TOUGH ONE. ANYBODY HAVE AN IDEA? WE WON'T JUDGE YOU. IT'S OKAY. (OFF MIC) YEAH. YEAH. NICE. LITTLE LATIN IN THERE TOO. ANYBODY ELSE? SO -- CURIOUS. OPEN. YEAH. SORT OF ALL OF THOSE THINGS. I ACTUALLY THINK ABOUT THIS AS SOMETHING TO REMEMBER WHEN WE'RE SEEING PATIENTS. SO WE HAVE TO BALANCE OUR WISDOM, OUR PREVIOUS EXPERIENCES WITH ALLOWING THE PATIENT TO BE THEIR OWN EXPERIENCE. THEIR OWN INTERACTION TO HAVE THEIR OWN PATH OF WHATEVER IT IS, ILLNESS, WELLNESS, SO IT'S AN OPENNESS, A CURIOSITY. I THINK WE DONE WANT TO BE NAIVE, WE DON'T WANT TO NOT REMEMBER WHAT WE KNOW. BUT AT THE SAME TIME WE DON'T WANT TO BE SO CONSTRICTED DOWN BY WHAT WE KNOW THAT WE'RE NOT OPENING TO THIS MOMENT, THIS TIME THIS -- IT SORT OF TAKES INTO ACCOUNT THE DIMENSION OF TIME. SOMETHING CAN NEVER BE EXACTLY THE SAME AS IT WAS LAST TIME BECAUSE THE TIME IS DIFFERENT. BEINGERS MIND I FIND IT A CHALLENGING ONE, NOT JUST TO LIVE BUT TO ACT KNOW LEDGE. TRUST, NON-STRIVING, THIS IS A TOUGH ONE, PARTICULARLY AT INSTITUTIONS LIKE THIS. AND AT JOHNS HOPKINS. HOW DO WE DO NON-STRIVING WHEN WE'RE ALL GOAL-ORIENTD? I ALSO FIND -- THIS IS A TOUGH ONE FOR URBAN YOUTH TO BALANCE BECAUSE A LOT OF WHAT THEY HEAR FROM MENTORING IS TO DEVELOP GOALS. SO IT'S THIS BALANCE OF KEEPING YOUR GOALS IN MIND BUT NOT ALLOWING THE STRIVING FOR THE GOALS TO SUPER SEED THE UNDERSTANDING AND APPRECIATION OF WHAT'S HAPPENING RIGHT NOW. YEAH. (OFF MIC) >> IT IS. THAT HAS A DUALITY. AS RESEARCHERS WE ARE TRAINED TO THINK ABOUT OUTCOMES, HOW TO MEASURE THEM, HOW TO GET TO THEM, YET THE REALLY AMAZING FINDINGS TEND TO BE ACKNOWLEDGEMENT OF SERENDIPITY. THAT WE DON'T NECESSARILY, WE HAVEN'T NECESSARILY PREDICTED WELL BUT IT'S -- ACCEPTANCE, ANOTHER CHALLENGING ONE. ACCEPTING THAT THINGS REALLY ARE AS THEY ARE. THIS CAN BE VERY HARD FOR OUR PATIENTS. AND LETTING GO. ANOTHER HARD ONE, I THINK OF THE LETTING GO PART AS THE WHAT SYLVIA BERNSTEEN DESCRIBES AS THE CLINGING TO IT OR REJECTING IT. SORT OF A BALANCED WAY OF LETTING THINGS COME AND GO. AND ACCEPTING THAT IN FACT, THAT'S THE WAY THINGS HAPPEN IN LIFE. THEY COME AND THEY GO. SO I UNDERSTAND THAT HERE AT THE NIH AND LOTS OF US ARE VERY INTERESTED IN MECHANISMS AND HOW THESE KINDS OF INTERVENTIONS ARE PRAK -- OR PRACTICES MIGHT WORK. SO I JUST PUT UP THERE AS ACCUMULATION OF DIFFERENT WAYS THAT I HAVE HEARD PEOPLE DESCRIBE POTENTIAL EFFECT OF MBSR OR MINDFULNESS PRACTICES. NEUROSCIENTISTS TALK ABOUT MULTIPLE PATHWAYS AND THE SYNCHRONY OF BRAIN WAVES. SHAWNA SHAPIRO DESCRIBED CONCEPT OF MINDFULNESS, ALLOWING ONE TO REPERCEIVE OR HAVE A SHIFT IN PERSPECTIVE OF THEIR LIVES. IT'S BEEN FOUND THAT MINDFULNESS DECREASES RUMINATION AND THAT RUMINATION MEDIATES MBSR'S AFFECT ON PSYCHOLOGICAL DISTRESS AND DEPRESSION. THERE'S SOME FMRI DATA THAT SHOW DECREASES IN ACTIVITY IN SELF-FOCUSED REGIONS OF THE BRAIN. DECREASED NEGATIVE AUTOMATIC RESPONSES IN PSYCHOLOGICAL TESTS JUST TAKE A MOMENT. SO WHAT I WOULD LIKE TO DO IS TELL YOU AB OUR WORK WITH MINDFULNESS FOR URBAN YOUTH. THE OBJECTIVES OF THIS WORK WERE TO ADAPT AND EVALUATE MBSR FOR HIV INFECTED AND AT-RISK URBAN YOUTH TO. IDENTIFY AND EXPLORE THE AFFECT OF NBSR IN THIS POPULATION. SO FIRST THE PROGRAM ADAPTATION. I WAS VERY FORTUNATE TO WORK WITH TRISH MCGARY, AN EXPERIENCED MBSR INSTRUCTOR AND SHE ALREADY HAD MORE THAN TEN YEARS EXPERIENCE TEACHING MBSR WITH ADULTS AND HAD ALREADY ADAPTED IT FOR GRADUATE STUDENTS. INTERESTINGLY SHE THOUGHT THAT ADAPTATION IS PERHAPS A LARGER JUMP THAN THE ONE FROM GRADUATE STUDENTS TO URBAN YOUTH THAT'S INTERESTING. WE DID QUITE A BIT OF WORK WITH THE WORK BOOK WE HANDED OUT. WE CLARIFIED AND CONQUERED THE LANGUAGE IN RECOGNITION OF SORT OF A LITTLE BIT LESS ABSTRACT THINKING AMONG OUR POPULATION THOUGH WE REALLY DIDN'T CHANGE ANY CONCEPTS AT ALL. WE JUST TRIED TO STRIP DOWN LYNNGO IF IT DIDN'T SEEM ESSENTIAL TO THE INSTRUCTION. WE STANDARDIZED THE MBSR FORMAT. IN -- JUST IN THE WORK BOOK, IT IS ALREADY STANDARDIZED IN JOHN ZIM'S 1990 BOOK, FULL CATASTROPHE LIVING AND INCORPORATED IMAGES MORE RELEVANT TO URBAN ADOLESCENTS. THE CORE CONTENT STRUCTURE AN TIMING STATE ESSENTIALLY THE SAME AS JOHN CABOT ZEM'S MBSR PROGRAM FOR ADULTS. SO AS AN EXAMPLE, THIS IS ONE OF THE PAGES TAKEN OUT OF THE WORK BOOK, THREE BREATHS BREAK, STOP AND PAUSE. WHEN YOU ARE STRESSING OR DIZZY OR ON AUTOMATIC PILOT, THAT'S A CONCEPT THAT HAD ALREADY BEEN UNPACKED AND DISCUSSED PRIOR TO THIS PAGE. JUST STOP, STOP EVERYTHING. PUT EVERYTHING DOWN A MINUTE. TURN OFF THE MUSIC OR THE TV OR LEAVE THE ROOM, CLOSE YOUR EYES, TAKE THREE MINDFUL BREATHS. JUST DROP IN TO THE BREATH THIS BREATH. NOTHING TO DO, NOWHERE TO GO IN THIS MOMENT. SAY TO YOURSELF N WITH THE P IN WITH THE IN BREATH AND OUT WITH THE OUT BREATH. SO THEY HAD ALREADY DONE SITTING OR BREATHING MEDICATION IN THE CLASS. THIS IS AN EXAMPLE OF HOW WE TRY TO CONQUERTIZE IT TO SHOW THEM THIS IS A WAY IT CAN BE USED AT ANY MOMENT AT ANY TIME. FOR HIV INFECTED URBAN YOUTH OUR PILOT RESULTS SHOWED IT WAS VERY ACCEPTABLE FOR THE YOUTH WHO SHOWED UP. THEY ENJOYED THE GROUP PARTICIPATION. AND IN SEMISTRUCTURED INTERVIEWS THEY PERCEIVED THE BENEFITS TO BE IMPROVED ATTITUDE. DECREASED REACTIVITY, IMPROVED BEHAVIOR, SO THEY DESCRIBE NOT GETTING INTO ARGUMENTS SO MUCH. IMPROVED SELF-CARE, THIS INCLUDED FOR A COUPLE OF PARTICIPANTS, IMPROVED MEDICATION AD HEREIN, IMPORTANT FOR THE HIV MEDICATION PIECE. THEY DESCRIBED REDUCED DAILY STRESS AND FOR SOME, THEY DESCRIBE TRANSFORMATIONAL SHIFTS IN LIFE ORIENTATION. COUPLE OF YOUTH WHO DESCRIBED SEEING THEIR LIFE IN AN ENTIRELY DIFFERENT WAY AS IF THEY HAD A VIEW INTO THE FUTURE THEY HADN'T PREVIOUSLY. SO WE WERE ENCOURAGED BY THOSE RESULTS WITH HIV INFECTED YOUTH AND WE WANTED TO DO -- TO BROADEN -- SORRY. BECAUSE THESE RESULTS, ALTHOUGH WE INITIALLY THOUGHT THEY MIGHT BE MOST HELPFUL FOR YOUTH AROUND THE HIV SPECIFIC ISSUES, THEY SEEM TO BE FUNDAMENTALLY HELPFUL AROUND URBAN YOUTH ISSUES. THE STRESSES THAT THEY FELT IN THEIR DAILY LIVES THAT WERE NOT NECESSARILY RELATED TO THE HIV. MEDICATION ADHERENCE OF COURSE WAS SPECIFICALLY RELATED TO HIV. BUT AMONG THESE WE HEARD LOUD AND CLEAR THAT THEY FELT THESE TECHNIQUES HELPED WITH DEALING WITH DAY TO DAY LIFE LIVING IN THE CITY. SO WE EXPANDED THE WORK TO THE CLINIC SETTING IN GENERAL TO THE NOT NECESSARILY HIV INFECTED YOUTH BUT THE YOUTH OF THE WHOLE CLINIC. WE DID A MIXED METHOD UNCONTROL STUDY, PRE-POST. WE FOUND IN THIS GROUP OF 26 YOUTH THERE WERE REDUCTIONS IN HOSTILITY, GENERAL DISCOMFORT AND EMOTIONAL DISCOMFORT. WE ALSO DID QUALITATIVE INTERVIEWS WITH TEN OF THESE YOUTH AND THEY DESCRIBED IMPROVEMENTS IN INTERPERSONAL RELATIONSHIPS INCLUDING LESS CONFLICT. THEY DESCRIBED IMPROVEMENTS IN SCHOOL ACHIEVEMENT, OFTEN USING MEDITATION TECHNIQUES IN PREPARATION FOR EXAMS, THEY DESCRIBED IMPROVEMENTS IN PHYSICAL HEALTH, INCREASING PHYSICAL ACTIVITY AND IMPROVING CHOICES ABOUT WHAT THEY WERE EATING. AND THEY DESCRIBE REDUCED STRESS. SO ENCOURAGED BY THOSE RESULTS, BUT UNDERSTANDING THAT PARTICULARLY IN THIS POPULATION, VERY IMPORTANT TO CONTROL THE BENEFITS OF COMING TO THE GROUP, HAVING AN OPPORTUNITY TO TALK TOGETHER WITH PEERS, TO HAVE THE OPPORTUNITY TO SPEND TIME WITH A POSITIVE SUPPORTIVE INSTRUCTOR WAS VERY IMPORTANT. SO OUR NEXT STEP WAS TO LOOK AT MBSR COMPARED WITH AN ACTIVE CONTROL. WE ALSO FOUND IN BOTH STUDIES THAT ALTHOUGH MANY, MANY YOUTH EXPRESSED INTEREST IN THE STUDY, IT WAS QUITE -- THERE WERE QUITE A NUMBER OF BARRIERS THAT KEPT THEM FROM SAYING THEY'D BE PART OF THE STUDY TO ACTUALLY COMING IN FOR THE GROUPS. NOT ENTIRELY SURPRISING GIVEN THE POPULATION AN EVEN THOUGH OUR CLINIC RATE FOR KEEPING APPOINTMENTS BUT A CHALLENGE FOR SURE. WE ALSO NEEDED TO CONTROL FOR SELECTION BIAS OF THE STUDY BY HAVING AN ACTIVE CONTROL GROUP. SO THE JOHNS HOPKINS PEDIATRIC OUTPATIENTS WERE THE STUDY SAMPLE, 13 TO 21 YEARS OLD. WE DID QUANTITATIVE MEASUREMENT OF MEN A IT -- MENTAL HEALTH, QUALITY OF LIFE AND STRESS AND INTERVIEWS TO FIND OUT THE QUALITATIVE PIECE. ALL THESE STUDIES ARE IRB APPROVED. GOES WITHOUT SAYING. SO CHOOSING THE ACTIVE CONTROL GROUP FOR MINDFULNESS SPACE STRESS REDUCTION IS A BIT OF A CO-NUMBER DRUM. WHAT ARE YOU TRYING TO CONTROL FOR? IN OUR MINDS WE WANTED TO CONTROL FOR THE POSITIVE ADULT INSTRUCTOR, THE EFFECTS OF PEER GROUP PARTICIPATION, LEARNING NEW INFORMATION, SESSION FREQUENCY LENGTH, TIME OF DAY, GROUP SIZE, ATTENTION. WE CHOSE A HEALTH EDUCATION GROUP AS OUR CONTROL GROUP THINKING THIS WOULD BE AN APPROPRIATE THING NOT TOO TOO ACTIVE BUT AN OPPORTUNITY TO SHARE AN TEST THESE YOUTH EXPRESSED IN WELL BEING IN BEING HEALTHIER AND LEARNING SOME NEW INFORMATION. WE HAD WONDERFUL INSTRUCTORS WHO ARE ENTHUSIASTIC AND EXPERIENCED WITH THE AGE AND THE POPULATION. THIS DOES NOT INCLUDE INSTRUCTION IN MEDITATION. A LITTLE BIT OF CONVERSATION ABOUT STRESS BUT NOT REALLY SPECIFIC TECHNIQUES THAT ARE ALSO TAUGHT IN MBSR. SO AS YOU CAN SEE, THESE ARE THE RESULTS FROM ENROLLMENT AND ATTENDANCE, YOU CAN SEE WE HAD 113 YOUTH INTERESTED AND WILLING TO CONSENT. WE RANDOMIZED AT THAT POINT WE LEARNED FUTURE STUDIES IS NOT THE WAY TO GO. WE HAD QUITE A BIT OF DROP-OFF FROM CONSENT, RANDOMIZATION TO THE FIRST SESSION. SO WE HAD 43 YOUTH OR 33% OF THE TOTAL CONSENTED SAMPLE MADE IT TO ANY SESSION. SO THAT WAS A BIT DISAPPOINTING THAT WE HAD SUCH A LOW RATE OF ATTENDANCE BUT OF THOSE 43, 81% OR 35 OF THEM ATTENDED MAJORITY OF THE SESSIONS GREATER THAN 5 OF 9 SESSIONS. THEY WERE ALL AFRICAN AMERICAN, THOSE CONSIDERED COMPLETERS OR THOSE WHO ATTENDED GREATER THAN FIVE SESSIONS, AVERAGE AGE 15 YEARS OLD AND 80% WERE FEMALE. SO IN TERMS OF THE MBSR VERSUS THE HEALTHY TOPICS GROUP PARTICIPATION, WE DID NOT SEE ANY DIFFERENCES IN MENTAL HEALTH, QUALITY OF LIFE OR STRESS IN THE QUANTITATIVE MEASURES. HOWEVER, IN THE QUALITATIVE WORK, INDIVIDUAL INTERVIEWS, WE DID SEE SIGNIFICANT DIFFERENCES. WE FOUND THAT -- SORRY, THERE WERE 20 INTERVIEWS COMPLETED, EIGHT WITH WITH HEALTHY TOPICS GROUP, 12 IN THE MBSR GROUP. INTERVIEWS WERE CONTINUED AT LEAST BEYOND THEME SATURATION, THE INTERVIEWER WAS PLEADING WITH ME BY THE END TO STOP SO FELT LIKE WE HAD GOOD SATURATION. SO WHAT WE FOUND WAS THAT THERE WAS QUITE COMPARABLE GROUP EXPERIENCE. ALL THE PARTICIPANTS FELT THEY HAD FUN, THEY LEARNED NEW THINGS, THEY MET NEW FRIENDS AND THEY WOULD RECOMMEND IT TO THEIR FRIENDS AND FAMILY, ALWAYS INTERESTING IN THE INTERVIEWS WHEN YOU ASK IF THEY WOULD RECOMMEND, THEY USUALLY CAN TELL YOU WHO THEY WOULD RECOMMEND THE GROUPS FOR. WHICH IS FUN. THEY DESCRIBED QUITE COMPARABLE AND SIGNIFICANT SERIOUS STRESSORS, DEATH, HEALTH PROBLEMS, DIVORCE, RELATIONSHIP, WORDED ABOUT COOL, WHETHER THEY WOULD FINISH THE WORK, GET GOOD ENOUGH GRADES, GRADUATE. AND THEY WERE WORRIED ABOUT RELATIONSHIPS IN THE HEALTHY TOPIC GROUP, THEY TALK ABOUT ANGRY PEOPLE IN THEIR LIVE AND RELATIONSHIPS AN FIGHTS WITH FRIENDS. WE SEE SOME DIFFERENCES IN THE YELLOW. IN RESPONSE TO STRESSORS. IN HEALTHY TOPICS GROUP THEY DIDN'T FEEL THEIR RESPONSE TO STRESSORS CHANGED AFTER THE CLASS. THEY DESCRIBED RESPONSE TO STRESSORS AS LISTENING TO MUSIC. SITTING ALONE, GOING TO THEIR ROOM. EATING SNACKS, WATCHING MOVIES. SO SOME SORT OF CLASSIC DISTRACTION AVOIDANCE TECHNIQUES. THOSE ARE GREAT. WE NEED TO USE THEM BUT WE DO BETTER WITH OPTIONS IN OUR ABILITY TO CHOOSE WHAT OUR RESPONSES TO STRESSORS ARE. WE DID SEE IN THE MBSR GROUP THEY FELT THE RESPONSE TO STRESS ORS CHANGED AFTER THE CLASS. THEY DESCRIBED THE THREE BREATH BREAK, THE EXAMPLE I GAVE BEFORE, TO HELP THEMSELVES CALM DOWN, THEY DESCRIBE FEWER FIGHTS AND WALKING AWHAT FROM -- AWAY FROM FIGHTS. THEY USE THE BODY SCAN, ANOTHER MBSR TECHNIQUE TO SLEEP BETTER. THEY FELT IT WAS A GOOD SLEEP AID, THEY WOULD SOMETIMES -- SOME WOULD DO IT ON THEIR OWN, SOME PUT THEIR CD IN. MANY DESCRIBE LIKE WALKING MEDITATION. THEY WOULD DO IT AS THEY WERE GOING FROM ONE PLACE TO ANOTHER. P PERCEIVED AFFECTS OF THE GROUP IN THE HEALTHY TOPICS GROUP IS THEY FELT THEY WERE MAKING BETTER EATING CHOICES, THEY EXERCISED AND HAD MORE PHYSICAL ACTIVITY AND THEY DESCRIBE THEY FELT LIKE THEY WERE MAKING BETTER CHOICES IN GENERAL. IN MBSR THEY'RE PERCEIVED EFFECTS WERE PARTICIPATING IN FEWER FIGHTS, VER BILL AND PHYSICAL. THEY THOUGHT THEY HAD IMPROVED RELATIONSHIPS. THEN AS WE WERE READING THE INTERVIEWS WE WERE STRUCK BY A SIGNIFICANT ARTICULATION OF THEIR OWN INTERNAL PROCESSES AN REFLECTIONS THAT DID NOT EXIST IN THE OTHER GROUPS INTERVIEWS. THEY DESCRIBEDDED HAVING MORE ABILITY TO DECIDE ABOUT THEIR OWN SELF-REGULATION. SO FROM THE MBSR GROUP, ONE OF THE PARTICIPANTS SAID MY SISTER DID SOMETHING TO ME. I FORGOT WHAT SHE DID. NO, SHE WAS GETTING ON MY NERVES, SHE WAS JUST DOING ANNOYING STUFF. AND I WAS ABOUT TO HIT HER. AND THEN I JUST WALKED AWAY. WHAT STOPPED YOU? I TOOK THREE BREATHS. THIS IS KIND OF A LONG ONE. BUT I THINK IT IS VERY ILLUSTRATIVE. AFTER I DO THREE BREATHS I'M AT PEACE. I'M COMFORTABLE WITH MYSELF AND MY SURROUNDINGS. ABOUT HOW OFTEN WOULD YOU SAY YOU PRACTICE IT? EVERY TIME I GET MAD. I GET MAD A LOT. LIKE EVERY DAY? EVERY TWO HOURS? >> EVERY DAY. LIKE ONCE OR TWICE EVERY DAY. HOW ARE YOU DEALING WITH THE ANGER THAT YOU ARE FEELING BEFORE YOU STARTED PRACTICING THIS? I JUST TOOK IT OUT ON OTHER PEOPLE FOR NO REASON. CAN YOU TALK MORE ABOUT THAT? >> IF I WAS JUST SITTING BY MYSELF AND EVERYONE CAN TELL WHEN I'M MAD BECAUSE IF I'M SITTING BY MYSELF AND SOMEBODY JUST CAME OVER TO ME OR THEY BUMP INTO ME ON ACCIDENT, I JUST GET MAD. AND I START YELLING FOR NO REASON. HAVE YOU STOPPED YELLING AT PEOPLE AS MUCH? YES. I DON'T YELL THAT MUCH ANY MORE. WHAT DO YOU THINK HAS CHANGED? I FOUND A WAY TO DEAL WITH IT WITHOUT TAKING IT OUT ON OTHER PEOPLE THAT DON'T HAVE ANYTHING TO DO WITH IT. DOES THAT FEEL GOOD? BAD? IT FEELS GOOD BECAUSE I'M NOT MAKING PEOPLE UPSET WITH ME. WHEN THEY DIDN'T DO ANYTHING WRONG. HAVE PEOPLE NOTICED THIS AT ALL? YES. >> WHIEK WHO? MY BEST FRIEND. SHE SAID I STARTED ACTING CALMER. I'M A NICER PERSON. I DON'T UNDERSTAND HOW. BUT THAT'S WHAT HE SAID. SO FROM THIS WORK WE STARTED THINKING MORE ABOUT SORT OF WRAP-AROUND PROCESSES OF WHAT MINDFULNESS MIGHT BE TAPPING INTO AND THAT IT IS SCENES FROM THE QUALITATIVE WORK IN PARTICULAR TO REFLECTION AND ABILITY TO ARTICULATE SELF-REGULATORY PROCESSES. SO FROM OURS AND OTHER WORK, WE KNOW THAT RUMINATION, WHICH IS A COPING PROCESS, SEEMS TO BE IMPROVED, THERE'S A SUGGESTION THAT EXECUTIVE FUNCTION AND ATTENTION REGULATION IS IMPROVED WITH MINDFULNESS. AND CERTAINLY EMOTION REGULATION. IS IMPROVED. SO WE SEE LESS ANGER REACTIVITY, LESS DIFFICULTIES WITH EMOTION AND REDUCED ANXIETY. SO ONE OF THE CHAT LENGS IN MAKING MODELS ABOUT MINDFULNESS IN MY MIND IS THAT YOU WANT IT TO SORT OF P PERVADE THE MODEL, IT SAYS IF YOU WANT THE BACKGROUND TO BE A DIFFERENT COLOR BECAUSE IT EXISTS AS WHAT -- AS THE GROUND ON WHICH SOMETHING HAPPENS, THAT AFFECTS HOW PEOPLE REACT TO WHAT HAPPENS. I FIND THIS ONE OF THE CHALLENGES IN MAKING MINDFULNESS MODELS AND ONE OF THE FRUSTRATIONS IS THEIR LACK OF ABILITY TO CAPTURE THAT. NEVERTHELESS, MODELS HELP US THINK ABOUT IT, HELP US PLAN STUDIES, HELP FIGURE OUT WHAT WE LIKE TO MEASURE. SO THIS IS WHERE WE ARE AT THE MOMENT. ONE OF THE BIG PROBLEMS WITH WORK WE HAD DONE IN THE CLINICAL SETTING WAS AS I POINTED OUT, THE DROP-OFF FROM THOSE WHO ARE INTERESTED TO THOSE WHO CAME AND PARTICIPATED. WE HAD THE OPPORTUNITY TO DO A STUDY THAT WAS FUNDED THROUGH THE JOHNS HOPKINS CENTER FOR MIND/BODY VERGE, ANOTHER NCCAM FUNDED CENTER. AT A SMALL SCHOOL IN BALTIMORE. SO THE SCHOOL BASED STUDY ENGAGED THE 7TH AND 8TH GRADERS OF THIS MIDDLE SCHOOL. AN APPLICATION-BASED TUITION-FREE MIDDLE SCHOOL FOR BOYS WITH FINANCIAL NEED AND ACADEMIC POTENTIAL. 42 OF THE 44 STUDENTS IN THE 7 AND 78th GRADES WERE HE WILL I BELIEVE -- 8TH GRADES WERE ELIGIBLE AND 41 OF THOSE STUDENTS WERE WILLING TO PARTICIPATE IN THE STUDY. 95% AFRICAN AMERICAN, 12.5 YEARS ON AVERAGE, AND THEY WERE ALL BOYS. SO THIS SORT OF THE OTHER GROUP OF PARTICIPANTS THAT WE DID NOT GET IN THE CLINIC STUDY BECAUSE WHICH HAD 80% GIRLS WHICH IS A LITTLE BIT MORE REFLECTION OF MBSR WORK IN THE ADULT WORLD. TENDS TO BE MORE WOMEN. SO WE RAP DOCUMENTLY ASSIGNED THE BOYS TO MBSR OR THE HEALTH EDUCATION CONTROL GROUP. AS I SAID, IT WAS FUNDED BY THE CENTER FOR MIND/BODY RESEARCH. IT WAS THE PROGRAMS WERE ADAPT SOD THEY COULD INCLUDE -- BE INSERTED INTO THE SCHOOL'S CURRICULUM. THEY HAD -- WELL, WE MANIPULATED THE SCHOOL DAY A BIT BUT THEY HAD A CLASS THAT WAS CALLED SKILLS FOR LIFE SKILLS. AND THEY ALLOWED US TO DO OUR CONTROL GROUP BASICALLY AS THE SIT-IN FOR THAT. AND THEN MBSR IS THE ALTERNATIVE. IT WAS WONDERFUL TO WORK WITH THEM ON THIS. SO WE ADAPTED THE CURRICULUM TO BE 12 WEEKLY, 50 MINUTE CLASSES, WITHIN THE SCHOOL SCHEDULE. WE DID THIS IN THE FALL AND THE SPRING TO ACCOMMODATE THE PARTICIPANTS. WE USE THE SAME ACTIVE CONTROL GROUP OF HEALTH EDUCATION OR HEALTHY TOPICS AND CHECKED DATA AT BASELINE, POST GROUP AND THREE MONTHS FOLLOW-UP. WE LOOKED AT PSYCHOLOGICAL SYMPTOMS, COPING AN STRESS. WE ALSO LOOKED AT SLEEP ACTIGRAPHY AND DIARIES AND SALIVARY CORTISOL, MEASURED FOUR TIME AS DAY INCLUDING DURING THE SCHOOL DAY TO OPTIMIZE OUR ABILITY TO COLLECT SAMPLES. FOR TWO DAYS AT EACH OF THOSE DATA COLLECTION TIME POINTS. WE ALSO TRIED TEACHER REPORTED BEHAVIOR MEASURES AS WELL. AND ANALYSIS DONE WITH REGRESSION MODELING. WE FOUND SOME INTERESTING RESULTS. WE FOUND THAT BOYS IN THE MBSR GROUP DECREASED ANXIETY AT SIGNIFICANT LEVELS. THEY SHOWED REDUCE RUMINATION AND REDUCED NEGATIVE COPING, WE TOOK A COPING MEASURE WHICH LOOKED AT MULTIPLE TYPES OF COPING AND GROUPED INTO THE TYPICALLY ADAPTIVE OR POSITIVE COPINGYf’zx APPROACHES OR MAL ADAPTIVE OR NEGATIVE COPING APPROACHES? WE FOUND THE BOYS WHO HAD MBSR HAD LESS OF A NEGATIVE COPING TYPES. ADDITIONALLY JUST IN THE MBSR ARM, WE FOUND THAT INCREASED MINDFULNESS WAS ASSOCIATED WITH REDUCED ANGRY TEMPERMENT AND ANGER REACTIVITY. WE DID NOT SEE ANY DIFFERENCES IN SLEEP OR IN TEACHER-RATED BEHAVIOR. WE DID SEE SOMETHING INTERESTING IN THE CORTISOL DATA. IN THE CONTROL GROUP YOU CAN SEE IN THE FULL LINE THERE IS INCREASE FROM THE BEGINNING FROM THE PRE-MEASUREMENT TO THE POST MEASUREMENT AND WE THINK THIS MAYBE RELATED TO THE ACADEMIC TERM. WE SAW AN APPARENT ATTENUATION OF THAT IN MBSR GROUP. IT'S BORDERLINE SIGNIFICANCE. SO THIS IS SORT OF WHERE WE ARE. WE HAVE NEXT STEPS. WE'RE WORKING TOAX PAND THE MENTAL HEALTH PREVENTION EFFORTS, POTENTIALLY IN THE SCHOOLS OR IN THE COMMUNITY, THIS IS ALWAYS MATTER OF FINDING WHERE WAY OPENS AND IT'S A LITTLE BIT CHALLENGING. WE NEED TO COMPLETE THE NCCAM FUNDED R-21 STUDY ENTITLED MINDFULNESS INSTRUCTION TO REDUCE STRESS FOR HIV INFECTED YOUTH. OUR PRELIMINARY ANALYSIS WITH NOT ALL OF THE DATA IN YET SHOWS THAT THERE SEEMS TO BE AN ASSOCIATION BETWEEN MINDFULNESS AND SELF-REPORTED COPING. EMOTION REGULATION AND COGNITION PARTICULARLY RELATED TO ILLNESS ACCEPT ANSWER AND RECOGNITION OF -- ACCEPTANCE AND RECOGNITION OF ILLNESS BURDEN HIV SPECIFIC WE SEE HEALTH RELATED POTENTIAL HERE BEHAVIORS, PARTICULARLY MEDICATION ADHERENCE. SO MORE TO COME ON THAT. I WOULD LIKE TO THANK THE STUDY PARTICIPANTS, MANY COLLABORATORS, IN PARTICULAR, JONATHAN ALLEN, MENTOR, AND FUNDING, THOMAS WILSON SANITARIUM FOR THE CHILDREN OF BOOLT MORE CITY WHO HELPED WITH PILOT FUNDING. THE HAWN FOUNDATION, CENTER FOR MIND BODY RESEARCH AND NCCAM. I WANT TO THANK YOU AND I LEFT QUITE A BIT OF TIME FOR QUESTIONS. I HOPE WE'LL HAVE SOME DISCUSSION ABOUT THIS. [APPLAUSE] >> THANK YOU, DR. SMIT SIBINGA FOR YOUR LOVELY TALK AND FINE WORK. SO QUESTIONS, COMMENTS FROM THE AUDIENCE? (OFF MIC) >> IN THE PATIENT MORE BARRIERS TO THE -- TO THE YOWN MEN. I THINK IT'S A NUMBER -- YOUNG MEN. IT'S A NUMBER OF FACTORS. IN THAT AGE RANGE WE SEE MORE FEMALES THAN MALES SEEKING HEALTHCARE SO IT IS A BACKGROUND. I DON'T THINK IT'S QUITE THAT DRAMATIC DIFFERENTIAL BUT WE DEFINITELY SEE MORE YOUNG WOMEN COMING IN FOR CARE. I THINK THAT THERE'S A SOCIAL ACCEPTABILITY ASPECT THAT YOU SEE IN THE ADULT WORK AS WELL OR PERHAPS PROLIVETY FOR FEMALES TO THINK THAT THIS MIGHT BE A FUN THING TO DO OR AN INTERESTING THING TO DO. I THINK THAT THE YOUNG MEN MAY BE PULLED IN DIFFERENT DIRECTIONS THAN THE YOUNG WOMEN ARE. SO I'M NOT EXACTLY SURE. I THINK THERE'S A LOT TO BE LEARNED BY FINDING OUT WHAT HAPPENS TO THOSE OTHER -- TO THE PEOPLE WHO DO NOT PARTICIPATE IN THE CLINIC-BASED STUDY. WHAT IS THAT SELECTION BIAS AND WHO IS IT? WHO IS OUT THERE? YEAH. >> CAN I ASK YOU TO TALK A LITTLE BIT ABOUT THE SELECTION OF CONTROL GROUP? >> SURE. >> WE STRUGGLE WITH HERE A LOT. I LIKE YOUR COMMENT THAT WHEN YOU SELECT A CONTROL IT VERY MUCH IS INFLUENCED BY WHAT YOUR FUNDAMENTAL QUESTION IS AND WHICH ELEMENTS OF THE INTERVENTION YOU'RE TRYING TO DECIDE WHETHER THAT'S WHAT WORKS. >> RIGHT. >> IT CERTAINLY IS ALSO TRUE THAT THERE ARE A NUMBER OF VERY PRACTICAL QUESTIONS WHERE AN ACTIVE CONTROL MAY NOT ALWAYS GET THE BROADER QUESTION HOW HELPFUL. BUT TELL US YOUR THOUGHTS ABOUT CONTROL SELECTION. >> I THINK IT'S A VERY INTERESTING CONVERSATION. I THINK IT DEPENDS ON WHAT YOU'RE INTERESTED IN IDENTIFYING, SORT OF AT WHAT LEVEL YOU WANT TO EXPLORE THE AFFECT IS THE WAY I THINK ABOUT IT. PERHAPS THAT DEPENDS ON WHAT YOUR POPULATION IS THAT YOU'RE LOOKING AT. AND SO WE TRIED TO SELECT OUT WHAT WE THOUGHT WOULD BE THE MOST SALIENT ASPECTS OF THIS PROGRAM FOR OUR POPULATION. FOR URBAN YOUTH, TIME AND ATTENTION IS RELATIVELY STRAIGHT FORWARD TO TRY AND CONTROL FOR -- CONTROL AN MBSR INTERVENTION IN ANY POPULATION. FOR URBAN YOUTH WE THOUGHT THAT ONE OF THE IMPORTANT THINGS WOULD BE THE INSTRUCTOR. AND REALLY THE POSITIVITY OF THE INSTRUCTOR. IN OTHER POPULATIONS WHERE YOU MIGHT BE CONFIDENT THAT PEOPLE ARE HAVING THAT KIND OF POSITIVE INTERPERSONAL ENCOURAGEMENT AND INTERACTION, THAT KIND OF THING YOU MAY NOT FEEL THAT'S SO IMPORTANT. BUT WE HAD COMMENTS IN THE CONTROL GROUP ALONG THE LINES OF I WISH SCHOOL WERE LIKE THIS, I WISH I HAD TEACHERS, THE HEALTH EDUCATION TEACHERS. SO WE FELT THAT THAT -- THE INSTRUCTOR BEING A POSITIVE NOT MENTOR BUT POSITIVE ADULT PRESENCE WAS IMPORTANT. WE THOUGHT THE OPPORTUNITY TO HAVE THAT KIND OF PEER INTERACTION WAS IMPORTANT. I WANTED IT NOT TO BE TOO MUCH OF AN ACTIVE OTHER INTERVENTION. IDEALLY SPEAKING I WOULD LOVE TO HAVE HAD THREE ARMS BUT WE DIDN'T HAVE A SAMPLE SIZE FOR THAT. I THINK I WOULD EXPECT THIS THIS ACTIVE CONTROL GROUP DOES HAVE SOME POSITIVE EFFECTS BECAUSE OF ALL THE -- WHAT WE FOUND IN THE QUALITATIVE WORK AND BECAUSE WE EXPECT IT TO HAVE SOME BENEFIT ABOVE AND BEYOND NOTHING OR TREATMENT ADS USUAL IN THIS CASE. IDEALLY SPEAKING I WOULD LOVE THREE ARMS TO SEE WHAT THE NON-SPECIFIC EFFECTS OF THE PEER GROUP, THE TIME, THE INSTRUCTOR, THE NEW INFORMATION. AND EVEN THOUGH PRESUMABLY THE STUDENTS OR CLINIC PATIENTS HAD HEARD THE HEALTH INFORMATION BEFORE THEY PROBABLY HAD HEALTH CLASS, SCIENCE CLASS, I DON'T THINK IT'S ANYTHING PARTICULARLY NEW. IT'S STILL IN A SLIGHTLY DIFFERENT FORMAT AND THEY STILL RECEIVE IT LIKE IT'S NEW AND THEY HAVEN'T HAD AS MUCH OPPORTUNITY TO CONVERSE ABOUT IT AS WE GAVE THEM IN THIS GROUP. BUT I ALSO KNOW IN MBSR RESEARCH PEOPLE HAVE RUN INTO TROUBLE WITH DEVELOPING CONTROL GROUPS THAT ARE TOO ROBUST LIKELY CHI DAVIDSON'S EXERCISE GROUP. I THINK THAT'S A LITTLE TRICKY BECAUSE EXERCISE HAS SUCH PROFOUND POSITIVE EFFECT. SO THEN YOU'RE COMPARING MEDITATION INSTRUCTION TO EXERCISE. THAT HAS ITS OWN ISSUES. I DON'T KNOW WHETHER THAT REALLY ANSWERS YOUR QUESTION OR NOT. >> YOU'RE STRUGGLING AS WE ARE WITH THE QUESTION OF FORMULATING CONTROL GROUPS THAT ARE TRULY APPROPRIATE FOR THE MOST IMPORTANT QUESTION OF THE STUDY. THIS IS AN ON GO OAG LET'S MOVE OVER SO WE CAN BOTH SHARE THE MIKE. THIS IS AN AN -- SHARE THE MIC. THIS IS AN ONGOING DIALOGUE ABOUT THE SELECTION OF CONTROL GROUPS. ONE OTHER QUESTION. WHAT ARE YOUR OBSERVATIONS ABOUT THE STRENGTH OF INTERVENTION. WHO AMONG THESE KIDS? DO YOU HAVE ANY SENSE WHO STICKS WITH IT AND ANY SENSE OF WHAT PREDICTS THE CHILDREN WHO WILL PERSIST IN THESE PRACTICES AND FOR OTHERS THEY MAY FADE? >> SO FAR WE'RE LIMITED IN ABILITY TO ANSWER THAT QUESTION. I DIDN'T SHOW YOU THE THREE MONTH DATA FOR THE SCHOOL STUDY BECAUSE A PORTION OF THE SAMPLE GRADUATED, THE NUMBERS DROP OFF, THIS IS AN ONGOING PROBLEM IN THIS RESEARCH AS WELL. THE FOLLOW-UP IS LIMITED. I AM NOT SURE WE KNOW EITHER WHAT THE NATURAL HISTORY OF ADOPTION OF THE PRACTICES IS, OR IN SOME WAYS HOW THAT MIGHT BE DIFFERENCE FOR YOUNG PEOPLE THAN IT IS FOR ADULTS. BECAUSE I THINK IT'S POSSIBLE IF YOU INTERVENE A LITTLE BIT EARLIER IN SELF-REGULATORY PROCESSES THAT THERE MAY NOT NEED TO BE SUCH A DELIBERATE FOCUSED ROUTINE. MANY PEOPLE WILL ARGUE WITH ME ABOUT THIS IMPORTANCE OF DAILY RIGOROUS PRACTICE IS HELD DEAR BY MANY IN THIS FIELD. BUT I'M NOT -- I HAVE FELT IN THIS WORK THAT ANY UPTAKE OF PRACTICES THAT HELP WITH SELF- REGULATION WHETHER PRACTICED DAILY, WHETHER THEY'RE PRACTICED ON THE SLIDE BUT ALLOW PEOPLE TO WALK AWAY FROM FIGHTS, I DON'T KNOW THERE WE KNOW WHAT THE NATURAL HISTORY IS. IT'S A FASCINATING QUESTION AND WE HOPE TO BE ABLE TO LOOK AT IT MORE CAREFULLY. OTHER QUESTIONS FOR DR. SIBINGA? >> YOU HAD IN ONE OF THEM IS PRETTY MUCH ALL GIRLS AND IN THE SCHOOL SETTING ALL BOYS. CURIOUS AS TO WHETHER YOU THINK THAT'S BENEFICIAL TO SPLIT THEM IN TERMS OF HAVING LESS ISSUES AROUND ATTRACTIONS OR WHATEVER IT MAYBE IN THE CLASSROOM SETTING AND MBSR GROUPS? SECOND QUESTION FOR YOU, YOU HAVE GONE AS YOUNG AS 13. HAVE WE DONE PILOT WORK IN YOUNGER KIDS? >> WELL, SO THERE WERE A COUPLE OF KIDS YOUNGER. I'LL TAKE THE AGE ISSUE FIRST. THERE WERE A COUPLE -- THERE WAS SOME CHILDREN YOUNGER IN THIS SCHOOL STUDY. WE HAVE NOT DONE A LOT IN YOUNGER POPULATIONS, THERE ARE A NUMBER OF GROUPS AROUND THE COUNTRY THAT ARE WORKING QUITE A BIT WITH YOUNGER POPULATIONS, NOT EXACTLY MBSR BUT VARIOUS MINDFUL AWARENESS PRACTICES IN VARIOUS POCKETS AROUND THE COUNTRY. LINDA (INDISCERNIBLE) IN NEW YORK, A FEW DIFFERENT GROUPS THEY DON'T USE THE STRUCTURE OF MBSR WHICH I WAS PARTICULARLY INTERESTED IN USING AS SUGGESTED IN THE BEGINNING BECAUSE INSTRUCTOR TRAINING IS SUCH A CRUCIAL ASPECT. DELIVERY OF THESE CONCEPTS IS CRUCIAL IN PEOPLE LEARNING WHAT THE ISSUES REALLY ARE AND WHAT THE TECHNIQUES TRULY DRAW ON, I THINK. SO THAT IS NOT EXACTLY, I WOULD LOVE THAT TOO, I DO HAVE TO PICK AND CHOOSE OR NOTHING GETS DONE I THINK. SO FOR THE MOMENT THIS IS PATH THOUGH I'D BE HAPPY TO INCH DOWN A LITTLE BIT. NOT SURE WE FOUND THE YOUNGEST AGE THIS STRUCTURE CAN WORK WITH. IN TERMS OF GIRLS AND BOYS, I DON'T KNOW. I MEAN, THERE MAYBE BENEFIT. THERE'S CERTAINLY DATA TO SUGGEST THAT GIRL ONLY EDUCATION AND BOY ONLY EDUCATION HAS ITS BENEFITS. ONE INTERESTING ASPECT OF THE MIDDLE SCHOOL STUDY WAS THE INSTRUCTOR WAS A WOMAN. AFRICAN AMERICAN WOMAN AND THE ISSUE OF HOW ONE TREATS WOMEN AS A BOY OR A GROWING YOUNG MAN CAME OUT IN THE CLASS. SHE IS EXPERIENCEND, I'M VERY GRATEFUL TO HER, WILLING ENOUGH TO TACKLE M -- TACKLE HEAD ON AND USE AS AN OPPORTUNITY FOR DISCUSSION, MODELING AWARENESS, TALKING AB THIS IS HOW THAT KIND OF COMMENT MAKES ME FEEL. HOW WOULD YOU THINK ABOUT THAT. SO EVEN THOUGH THERE WEREN'T GIRLS THERE, GIRLS IN THE CLASS, IT CAME UP. HOW THAT WOULD PLAY OUT IF IT WERE A MIXED CLASSROOM, I'M NOT SURE. BUT I HOPE AN INSTRUCTOR USE IT AS AN OPPORTUNITY TO BRING THE CONVERSATION AROUND A BIT. I WOULD LOVE TO SAY I PLANNED IT THAT WAY BUT IT WAS MORE TAKING ADVANTAGE OF THE OPPORTUNITIES AS THEY -- AND THE COMPLIMENT, I LIKE THE COMPLIMENT BECAUSE WE DID HAVE PREDOMINANCE OF FEMALES IN THE CLINIC BASED STUDY, SEEMED A GREAT OPPORTUNITY TO LOOK AT THE BOYS AN PARTICULARLY CONCERNS OF CONFLICT AND VIOLENCE AND AGGRESSION. THEY DON'T STOP WITH BOYS ANY MORE BUT THEY ARE FUNDAMENTALLY AFFECT THEIR LIVES. VERY INSPIRING WORK. OTHER COMMENTS OR QUESTIONS FOR DR. SIBINGA? WE'RE VERY LUCKY TO HAVE DR. SMIT SIBINGA WITH US HERE FOR THE DAY. SHE'S GOING TO BE HAVING CONVERSATIONS OVER LUNCH WITH SOME OF OURKJ+ STAFF AND SHE'S GOING TO JOIN US FOR NCCAM'S AWARD EVENT THIS AFTERNOON. SO ALL OF YOU WHO STILL GOT THOUGHTS PERCOLATING, YOU'LL HAVE OPPORTUNITIES DURING THE DAY TO TALK WITH HER. THANK YOU AGAIN. IT WAS TERRIFIC. >> GREAT PLEASURE TO BE HERE. [APPLAUSE]