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Final Thesis Proposal
Using Mental Skills Training to Reduce Anxiety and Stress Among Adolescents: A New
Approach to Strengthening Youth Mental Wellness
Alecsander B. Wortman
National University
PSY 615
June 25, 2022
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Acknowledgements
I would like to express my greatest appreciation to Dr. Bart Lerner for his intangible
support and guidance throughout the development of this thesis project. I could not have refined
my work to its current form without the valuable feedback and expertise that he provided.
Likewise, special thanks should be extended to my classmates as well for their honesty,
openness, and insight throughout peer revisions.
Furthermore, this endeavor would not have been possible without the combined efforts
by my team of colleagues at Intellectual Athlete (Sean Tuohey, Katherine Zhukova, and Nadine
Correa). Their collective support and hard work created opportunities for the program’s
successful inauguration, evaluation, and continuation.
Lastly, I would be remiss in not mentioning my family, especially my parents, for their
love and support throughout my academic journey. Their belief in me has kept my spirits and
motivation high during difficult times, to which I am truly blessed and grateful.
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Using Mental Skills Training to Reduce Anxiety and Stress Among Adolescents: A New
Approach to Strengthening Youth Mental Wellness
In December of 2021, U.S Surgeon General Dr. Vivek Murthy issued a national advisory
highlighting the urgent need to address the existing youth mental health crisis throughout the
country. Prior to the COVID-19 pandemic, “mental health challenges were the leading cause of
disability and poor life outcomes in young people, with up to 1 in 5 children ages 3 to 17 in the
U.S. having a mental, emotional, developmental, or behavioral disorder” (OSG, 2021, p. 8).
Since the COVID-19 pandemic, the surgeon general reported that the prevalence of these issues
had exponentially increased and a coalition of the nation’s leading experts in pediatric health
declared a national emergency in child and adolescent mental health. Among the many issues
encompassed by child and adolescent mental health, anxiety and stress-related disorders have
been found to be the most widespread and, “predict a range of psychiatric disorders later in life,
including other anxiety disorders, substance use disorders, and depression” (Wehry et al., 2015,
p. 51). Within the national advisory, Dr. Murthy stated that the future wellbeing of our country
requires acting now to support and invest in the next generation. In response to this national
emergency, the demand for youth mental health services has surged. McGorry et al. (2022)
emphasized, for instance:
The high degree of unmet mental health needs in young people worldwide demands that
youth mental health care be elevated to an absolute top priority in health care. Global
reform and adequate investment in youth mental health will not only substantially
improve the health and lives of young people, but will pay for itself and promote mental
wealth for all of society. (p. 73)
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Part of the reform for increased mental health care service requires ease of accessibility.
The traditional commencement and continuation of mental health programming involves the
client(s) seeking the practitioner(s). Relying on the child and one’s family to independently find
access is not a feasible option for successfully meeting the demand for mental health support.
Considering this dilemma, mental health services must be actively introduced and implemented
in settings where children are already present. Beames et al. (2020) suggested that, “improving
young peoples’ access to care is important in prevention and early intervention efforts and… one
way to overcome barriers to help-seeking and treatment access is to provide mental healthcare in
schools” (p. 128). The problem with providing youth mental health service is that there is a
lasting stigma surrounding it.
From the parent/guardian perspective, many are not fond of their child being labeled or
diagnosed as mentally ill which has long been the common belief for those who receive mental
health support. From the child/student perspective, many are reluctant to engage in mental health
support because of the beliefs and attitudes from their peers regarding mental health that lead to
stereotyping developed from stigma. Research from Kranke et al. (2010) as cited in Bowers et al.
(2012) discovered that family perception and school environment were two major barriers to
young people accessing mental health services. If there was a negative perception towards
mental health in the family, the authors found that young people expressed more shame related to
receiving help. In terms of school, they discovered that young people were most concerned with
the behaviors and opinions of their peers and teachers. If the opinions were perceived as
stigmatizing, young people became more secretive and felt more shame about receiving help. It
is clear that the false conceptualization of mental health support service needs to be addressed.
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Implementing non-clinical, preventative care services that feature the instruction of programs
such as mental skills training may combat the stigma of receiving “help.”
Many skills from sport and performance psychology literature such as breathing,
mindfulness, imagery, self-talk, and more have been found to improve the psychological
wellbeing of individuals outside of sport and performance contexts. For example, one interesting
sport psychology skills training program featured the instruction of imagery, self-talk, and
self-confidence skills to a group of adolescent orphans and found a significant improvement in
their mental wellbeing, social acceptance, behavioral conduct, and overall life satisfaction, thus
highlighting the applicability of mental skills training to non-sport contexts and the mental health
of children (Hanrahan, 2005). Additionally, physical exercise has been thoroughly documented
as a highly beneficial strategy for improving mental health as it reduces anxiety and depression
as well as improves self-esteem and cognitive functioning (Callaghan, 2004).
Intervention programs that feature a synergy of mental skills training from sport and
performance psychology along with exercise/physical activity could then, in theory, address the
current youth mental health crisis while avoiding the stigma of receiving mental health support.
With respect to the aforementioned considerations, I propose that because the prevalence of
stress and anxiety among youth populations is dangerously high and adolescents are reluctant to
engage in clinical therapy, parents and schools should explore non-clinical, preventative mental
fitness services to help children learn skills for reducing negative symptoms associated with
anxiety and stress. Intellectual Athlete (IA), a company in which I am an executive partner, is
developing programs with that goal in mind. One such IA program that I have proudly designed
involves the combined benefits of physical activity and mental skills training within
school-based curricula for the purpose of improving student psychological fitness. The objectives
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of this thesis paper were to (a) present a review of relevant literature, (b) propose the
implementation of Intellectual Athlete’s mental skills training program within the scope of
school-based mental health service, and (c) discuss future implications of the program.
Literature Review
Youth Mental Health Concerns
Young people are in an important developmental stage of their lives where their
experiences and psychological changes significantly impact who they will become. Every aspect
of our lives begin with a strong foundation of mental health. It influences how we perceive
ourselves among the world, how we solve problems, overcome challenges, and build
relationships. For the purpose of this paper, mental health also impacts how we cope with stress
and perform in school and subsequently, throughout life. It is our humane responsibility to take
action and assure that the youth population and our future leaders have access to resources that
strengthen and support their mental wellbeing.
The COVID-19 pandemic raised global awareness and concern regarding mental
wellness issues among youth populations; however, the ubiquity of these issues was alarming
even prior to the uncertainties of COVID-19. “The pandemic era’s unfathomable number of
deaths, pervasive sense of fear, economic instability, and forced physical distancing from loved
ones, friends, and communities have exacerbated the unprecedented stresses young people
already faced” (OSG, 2021, p. 4). As a result of lockdowns, social distancing, and remote
learning, the adolescent population experienced a noteworthy reduction of in-person interactions
that led to adverse outcomes related to anxiety. “Recent research covering 80,000 youth globally
found that depressive and anxiety symptoms doubled during the pandemic, with 25% of youth
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experiencing depressive symptoms and 20% experiencing anxiety symptoms” (Racine et al.,
2021, as cited in OSG, 2021, p. 9).
Mental health conditions that exist among young people can be shaped by a wide range
of factors that are classified as adverse childhood experiences (ACEs). According to the Surgeon
General’s Advisory (2021), ACEs are cause for concern because of their potential harm to both
physical and psychological health:
ACEs can undermine a child’s sense of safety, stability, bonding, and wellbeing.
Moreover, ACEs may lead to the development of toxic stress. Toxic stress can cause long
lasting changes, including disrupting brain development and increasing the risk for
mental health conditions and other health problems such as obesity, heart disease, and
diabetes, both during and beyond childhood as well as for future generations. (p. 6)
Furthermore, ACEs have been thoroughly documented as a causal factor for conditions such as
anxiety among youth populations. Zare et al. (2018) interviewed 31,060 children between the age
of 6 and 11 years old and found that, “economic hardship, poor parental mental/behavioral
health, exposure to violence, or racial/ethnic discrimination increased the risk of depression
and/or anxiety in 6- to 11-year-old children” (p. 267).
Within the chain events that lead to the development of mental health issues among youth
populations, the leading solution that would seemingly have the greatest effect in prevention
would be to eradicate ACEs from occurring in the first place. That would, of course, be a
difficult task because the majority of these experiences are unpredictable and unavoidable such
as exposure to community violence, living in under-resourced conditions, or encountering the
consequences of a widespread emergency such as COVID-19. A more realistic solution is to
provide young people with skills and techniques that build resilience and mental fitness so they
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are prepared to healthily combat the negative mental complications that arise from ACEs. In
order to protect children from ACE exposure, mental fitness programs can help young people
identify and utilize strategies that promote resilience and the strengthening of mental skills which
can alleviate the long-term effects of ACEs (Zare et al., 2018).
The question of finding a resolution to the ever-growing prevalence of mental health
issues among youth populations is now clear; how do we effectively prevent or reduce these
issues from developing in the first place so that they do not persist throughout one’s life?
McGorry et al. (2022) explained:
Mental ill-health in young people is a potent yet largely ignored risk factor for age-related
physical illnesses later in life and effective treatment of mental ill-health in youth will
help to reduce the total burden of disease in older people. Responding effectively to this
‘perfect storm’ will deliver enormous benefits not only to young people but to people
across the lifespan and the whole of society. (p. 61)
To understand why early intervention and preventative care programs have been widely
overlooked, we must first acknowledge that, “It is only relatively recently that adult mental
health care evolved from the alienist era of stand-alone psychiatric institutions to join the
mainstream of general health care” (McGorry et al., 2022, p. 63), let alone the mental health care
of children. Even when mental wellbeing and health is independently considered, the focus tends
to be on providing a cure for those who already have chronic disabling illnesses rather than
providing people from the start with skills for prevention.
There is a gap in mental health care where preliminary symptoms such as moderate
anxiety and stress should be alleviated through preventative mental wellness programs so that
young people do not allow their non-clinical symptoms to develop into clinical illness. “The high
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degree of unmet mental health needs in young people worldwide demands that youth mental
health care be elevated to an absolute top priority in health care” (McGorry et al., 2022, p. 73). If
preventative youth mental health care services become more prevalent, the following barrier is
getting parents and children to actively engage in the services. One solution is bringing the
service to the source. That is, school settings.
Problems with Current School-Based Interventions
The social, emotional, mental, and physical development of children is influenced by the
interacting natural contexts in which they live, work, and play. To this extent, it is believed that
schools present the greatest impact among these contexts by virtue of their long-term influence
on children’s cognitive and social development (Atkins et al., 2010). Despite this common belief,
school administrations have not reached an agreeable consensus regarding the optimal form of
delivery for mental health programs. Although school systems across the country have widely
incorporated mental health support services, “there is, as yet, scant evidence for the effectiveness
of current school-based service models, and reason to think that these services are providing little
advantage over clinic-based services” (Kutash et al., 2006, as cited in Atkins et al., 2010, p. 41).
One primary issue of school-based mental health service is that, (similar to current trends
of mental health support outside of school) these programs are only offered to students as a
resource for helping cure a pre-existing mental health disorder. The vast majority of students
would greatly benefit from preventative mental health care services within schools, but are not,
“legally entitled to school-based services because they struggle with mental health-related
problems that do not qualify as a diagnosable mental health disorder” (NASP, 2015, as cited in
Kern et al., 2017, p. 205). Consequently, those who do qualify for these mental health services
within schools are detached from the rest of the school community. Their interventions are
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delivered through the periphery of the school culture and do not engage teachers or other
students. Instead, the students who qualify for the interventions are pulled away from classes or
free periods such as recess to complete their mental health program. This is not an effective way
to present mental health interventions within a school atmosphere because it strengthens the
fallacy that these services are only for students with diagnosable mental health disorders and are
not suitable for students who are experiencing mental health-related problems such as stress and
anxiety.
Preventative and proactive mental fitness programs would be highly beneficial for
improving the overall mental wellbeing of young people and their performance in school and
life, yet we unfortunately see that, “schools often take a reactive rather than proactive and
systematic approach to mental health, with different approaches being adopted to suit immediate
student needs (Beames et al., 2020, p. 135). Despite these findings, school teachers and
counselors still believed, “prevention was just as important as treatment and that schools needed
to incorporate more preventative approaches” (Beames et al., 2020, p. 134). When mental health
services are not available school-wide and only offered to students as a treatment/cure for
existing mental health disorders, it imposes that mental health programs are only for individuals
who already have a diagnosable disorder. Additionally, the segregation of mental health services
from the school curriculum implies that the school culture does not value the fundamental
benefits of mental wellness. To this extent, Tomé et al. (2021) suggested:
School-based interventions yield the most successful outcomes when they are integrated
into daily practice and school culture, seek to engage all staff, reinforce skills outside of
the classroom such as hallways and playgrounds, support parental engagement, and
coordinate work with outside agencies, emphasizing the importance of adopting a whole
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school approach in order to improve the young people’s social and emotional skills
development. (p. 3)
Consequently, when mental health support programs are offered as a peripheral,
clinically-focused service exclusively for the students with diagnosable complications, it
reinforces one of the largest barriers to mental health reform within schools– stigma.
Mental health stigma refers to, “beliefs and attitudes about mental health and mental
illness that lead to the negative stereotyping of people and to prejudice against them and their
families” (Mental Health Commission of Canada, 2009, as cited in Bowers et al., 2012, p. 165).
Adolescent individuals have become increasingly conscious of how they are being perceived by
their peers. Many factors have contributed to this rise of adolescents becoming more concerned
with their self-image including (but not limited to) bullying, parenting style, and media
portrayals that create unrealistic expectations. When a mental health stigma exists within school
cultures, the students are far less likely to acknowledge the status of their own mental wellness
and subsequently seek help or support. Within the U.S Surgeon General’s Advisory (2021), Dr.
Murthy emphasized:
Without individual engagement, no amount of energy or resources can overcome the
biggest barrier to mental health care: the stigma associated with seeking help. For too
long, mental and emotional health has been considered, at best, the absence of disease,
and at worst, a shame to be hidden and ignored. (p. 40)
In order to refute the existing stigma, we need to normalize mental health care in schools,
making it part of the school culture and general curriculum. If mental fitness was acknowledged
and respected by students the same way physical fitness and appearance was respected by
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students, the effect of school-based mental health services would likely show exponential
improvement.
Another presenting issue of stigma and school-based mental health service is how
students and service providers comparatively perceive the barrier of stigma. It has been found
that many more students perceive stigma as a barrier to receiving help than the service providers
themselves (Bowers et al., 2012). The results from online surveys distributed to students from
various high schools and the mental health service providers within those schools showed that,
“there was a significantly greater proportion of young people (69.5%) who perceived stigma as a
significant barrier to accessing school-based mental health services than did school-based service
providers (51%)” (Bowers et al., 2012, p. 167). Additional results from this study showed that
stigma was, indeed, the most common barrier to young people accessing mental health services,
but peer pressure and ‘not knowing you have a problem’ was the second most common barrier
for students without a mental health concern (Bowers et al., 2012).
There is no doubt that the current model of school-based intervention needs to be
reevaluated. Aside from addressing youth mental health through the direct application of youth
mental health services, there are other approaches for improving the mental wellness of this
population. One such domain is physical activity and youth sport. However, similar to the
presented issues in current school-based interventions, traditional youth sports have their flaws
as well.
Problems with Traditional Youth Sport
The psychological and emotional benefits of physical activity and exercise have been
thoroughly documented and will be addressed in a later section of this literature review, but the
current models of delivery and participation among traditional youth sport have become
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progressively less beneficial for the mental wellbeing of children. For traditional youth sports
particularly, the popularity of these programs have created a shift from what was once a fun and
recreational endeavor to a big profit-centered business, “substantially intensifying the
environment within which the children play…often operating to the children's physical,
emotional and psychological detriment - driving some young athletes out of sport prematurely
and damaging the experiences of those who remain involved” (Duru, 2021, p. 2).
Many of the issues that are imposed on children participating in youth sports are derived
from the beliefs, behaviors, and intensity of their parents and coaches. “Many suggest that youth
often feel obligated to continue training and competing in order to fulfill parent or coach
expectations” (Fraser-Thomas et al., 2005, p. 29). Unfortunately, what parents believe is best for
their young athlete(s) often contradicts what is actually best:
Generally, parents desire what is best for their children. With respect to youth sports,
parents often do not know what that is and consequently make choices that harm, rather
than help, their children. Whether these choices stem from unrealistic expectations about
the likelihood of their children realizing financial benefits through sports, incorrect
assumptions about the inputs that produce an elite athlete, or other sources, they damage
children and youth sports. (Duru, 2021, p. 26)
A common misconception from parents is that the benefits and success in sport is measured by
winning and playing time rather than the social connectedness or physical and emotional gains.
Gould & Carson (2004) as cited in Theokas (2009) explained that, “youth sports are becoming
‘professionalized’, with year-round training, early specialization, ranking, and a focus on the
outcomes of success rather than on educational goals or life skills development” (p. 303). When
parents possess this mentality, their children often lose the natural joy of participating in sports
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and experience burnout. The athletes themselves are not the only factor among youth sports
experiencing “burnout.”
The increasing cost of youth sports have forced out many children due to their families
being unable to afford the participation fees and associated costs such as equipment and travel:
The inability to afford high-priced youth sports opportunities is not the only reason
children with limited means are decreasingly able to participate in sport. In addition, as
those with means have flocked to such opportunities, once ubiquitous public youth sports
programs have received less support and are increasingly being cut out of recreation
department budgets. (Duru, 2021, p. 17).
The open access and affordability of traditional youth sport, like many of its athletes, have
burned out. Despite the potential of traditional youth sports providing a significantly positive
impact on the mental wellbeing of youth populations, it has evolved into a platform with more
negative outcomes than positive. A final statement from Duru (2021) concluded that, “America's
youth sports system is broken. Over-involved and under-informed parents push their children
into expensive, yet damaging sports experiences in pursuit of illusive athletic glory…This
phenomenon physically and emotionally burdens young athletes” (p. 29).
These issues surrounding youth mental health concerns, school-based mental health
service, and traditional youth sport collectively bestow a need for change. That said, it creates an
opportunity for new approaches and interventions to be applied. Many facets of mental skills
training and performance psychology are effective in preventing the development of negative
symptoms such as stress and anxiety outside of their traditional sport and performance-based
contexts. The following sections provide evidence supporting the use of these skills to address
stress and anxiety.
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Positive Impact of Mindfulness on Stress and Anxiety
One of the most widely accepted and understood definitions of mindfulness comes from
the internationally recognized scientist, writer, and meditation teacher, Jon Kabat-Zinn. He
defined mindfulness as, “the awareness that arises through paying attention in a particular way:
on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, as cited in Keng et
al., 2011, p. 1042). Controlled research regarding mindfulness-based interventions and sport
performance have been thoroughly documented in recent literature highlighting the positive
influence of mindfulness practice on self-reported sport performance and other psychological
performance variables from athletes and coaches (Pineau et al., 2014). Many of these
interventions were implemented with performers with a history of experiencing pre-competition
anxiety and/or stress after competition when reflecting on poor performance. These negative
symptoms contribute to decreased self-esteem, emotional wellbeing, and mental health. In both
pre-performance and post-performance scenarios, the onset of stress and anxiety is due to
excessive worry and anticipation about future outcomes or dwelling on events that have already
occurred. In either case, the performer is not being mindful. That is, paying attention
purposefully, in the present moment, and nonjudgmentally.
Outside of sport contexts, the same process of non-mindful thinking and subsequent
symptoms of stress and anxiety commonly occur for young people when they worry about future
events or dwell upon negative experiences that have already happened. As a result, “mindfulness
interventions have increasingly been incorporated in elementary and high school classrooms to
support students’ mental health and well-being” (Carsley et al., 2017, p. 693). The positive
outcomes of these mindfulness-based interventions within schools to address student stress and
anxiety have been evaluated and documented as well:
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Mindfulness-based interventions were associated with decreased anxiety, depression, and
stress in clinical and nonclinical youth samples (i.e., children and adolescents).
Educational settings are in a unique position to support students’ mental health as school
services (1) are extremely accessible, (2) can help decrease the stigma associated with
mental illness, and (3) can be cost-effective relative to clinical or hospital support.
(Kallapiran et al., 2015, as cited in Carsley et al., 2017, p. 694)
As previously discussed, the non-clinical approach to addressing the issues of youth mental
illness is effective because it is non-stigmatizing and easily accepted by parents and students
alike. There is a dual benefit that occurs between schools that offer mindfulness-based programs
and their students. The students, of course, improve their own mental fitness which positively
influences their performance and behavior within the school setting. As a result, the teachers and
school administrators are able to more easily teach and support children who are able to
emotionally and behaviorally regulate themselves in the absence (or decreased presence) of
stress and anxiety.
Interestingly, research has indicated that increased mindfulness practice not only has a
positive impact on self-report measures of mental health, but also influences positive differences
in brain activity contributing to psychological health by using functional neuroimaging methods.
Creswell et al. (2007), as cited in Keng et al. (2011) discovered:
Mindfulness was associated with reduced bilateral amygdala activation and greater
widespread prefrontal cortical activation during an affect labeling task. There was also a
strong inverse association between prefrontal cortex and right amygdala responses among
those who scored high on mindfulness, but not among those who scored low on
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mindfulness, which suggests that individuals who are mindful may be better able to
regulate emotional responses via prefrontal cortical inhibition of the amygdala. (p. 1043)
These findings provide neurological evidence supporting the effectiveness of mindfulness-based
interventions. Specifically, these results explained how right amygdala inhibition was a common
outcome of those who score high on mindfulness scales. Additionally, recent studies have shown
that right amygdala activity in children is a causal influence of stress and anxiety responses
(Warren et al., 2020) meaning that the collective efforts of these two studies suggest that
mindfulness practices could decrease activity in the right amygdala, thus alleviating anxiety and
stress responses of children.
Mindfulness-based strategies are one component of mental skills training in performance
psychology literature that have been empirically shown to alleviate stress and anxiety symptoms.
“Research suggests that mindfulness-based practices can have a positive impact on academic
performance, psychological wellbeing, self-esteem, and social skills in children. There is
evidence that mindfulness-based training in schools is feasible and acceptable to those who
participate” (Rempel, 2012, p. 216). One important skill that is associated with mindfulness
execution–and represents its own branch of performance enhancement–is the use of intentional
breathing.
Positive Impact of Breathing on Stress and Anxiety
Breathing and mindfulness go hand in hand where mindfulness involves tuning into the
present moment while bringing awareness to one’s current physiological state and functioning.
Indeed, “the primary element of mindfulness practice is a focus on the breath” (Napoli et al.,
2005, 101). Directing one’s awareness toward one’s breath is encouraged during the use of
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mindful practices because it facilitates the process of remaining in the present moment, but
breathing alone can provide its own unique benefits for addressing stress and anxiety:
Many of the detrimental effects of negative emotional states and sympathetic dominance
of the autonomic nervous system have been shown to be counteracted by different forms
of… breathing. Breathing techniques reduce stress, anxiety, depression, and other
negative emotional states…We propose that these breathing techniques could be used as
first-line and supplemental treatments for stress, anxiety, depression, and some emotional
disorders. (Jerath et al., 2015, p. 112)
As discussed, we are beginning to see that school-aged children are experiencing increased rates
of stress, anxiety, and other emotional states. Providing them with specific breathing techniques
will help them learn to address the onset of these states so that they do not progress to a point
where it is debilitating for their physical, psychological, social, or academic functioning.
“Breathing has been reported to regulate the autonomic nervous system, focus the mind
and increase self-awareness. Rhythmic breathing not only affects the autonomic nervous system,
but also focuses the mind and increases levels of self-awareness” (Davidson et al., 2003; Salmon,
et al., 1998, as cited in Napoli et al., 2005, p. 101). One popular form of breathing to address
heightened levels of stress and anxiety is diaphragmatic breathing. In a study designed to
evaluate the effectiveness on reducing anxiety from the use of diaphragmatic breathing, Chen et
al. (2016) delivered an 8-week diaphragmatic breathing training program to an experimental
group of participants and found that their anxiety inventory scores all improved providing
evidence that diaphragmatic breathing can reduce anxiety symptoms.
Performance anxiety is a specific phenomenon that occurs for athletes and performers
who experience debilitating stress and worry during times of pressure or in anticipation of a
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meaningful performance. The use of breathing techniques have been commonly prescribed as a
method for reducing these symptoms so they do not negatively impact the execution of skills
needed for a good performance. In a trial involving NCAA softball players, the use of breathing
techniques created successful results where they were able to reduce their heart rates and
alleviate stress during various anxiety events at their softball practices and games (Garza & Ford,
2009). Performance anxiety is not specific to sport domains and is experienced by any individual
who experiences pressure to perform. Students and children feel pressure to perform in many
different capacities. Whether it is anticipation of a test, making new friends, or giving a
presentation, children experience performance anxiety and can substantially benefit from
breathing.
Within schools, programs that instruct the use of deep-breathing techniques to address
anxiety have been implemented and evaluated. One study evaluated 81 students and their rates of
test-anxiety, a form of anxiety in which negative symptoms occur as a result of students feeling
threatened by academic testing. Over a 5-week period leading up to a major academic
examination, half the students were taught deep-breathing and relaxation exercises and the other
half were not. After the 5 weeks, “students completing relaxation training reported a significant
reduction in test anxiety scores, whereas students in the control group reported no significant
change in levels of anxiety” (Larson et al., 2011, pp. 20-21).
Mindfulness and breathing can surely be introduced to children independently or
collaboratively to address mental fitness issues of stress and anxiety. The use of both skills
reinforce and strengthen the other. Building upon these techniques of performance psychology,
self-talk has also been shown to have a positive impact on self-confidence and the reduction of
stress and anxiety.
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Positive Impact of Self-Talk on Stress and Anxiety
Self-talk is a common process among young people. Even from a very young age,
children talk to themselves. Toddlers and preschoolers often do so out loud which has been
found to help them self-regulate their focus, especially when they work on challenging tasks
(Diaz & Berk, 2014, as cited in Thomaes et al., 2019). “As these children grow up, they
continue to talk to themselves, but they increasingly do so internally, in silence. We refer to
such mental speech as self-talk” (Thomaes et al., 2019, p. 2211). Self-talk can be defined as,
“cognitive products that reflect what people say to themselves, expressing thoughts and beliefs
about oneself, the world, and relationships with others” (Calvete & Cardeñoso, 2002, p. 473).
The theory of cognitive behavior therapy (CBT) suggests that our thoughts influence our feelings
which influence our behaviors. Starting from the source, negative thoughts or forms of self-talk
such as self-deprecating statements will impact how we feel and subsequently perform/behave.
“Children who habitually engage in positive self-talk experience higher levels of subjective
wellbeing. Conversely, those who habitually engage in more negative self-talk [that is,] self-talk
that emphasizes incompetence, failure, or personal harm experience elevated symptoms of
anxiety and depression” (Thomaes et al., 2019, p. 2212).
In sport contexts, “the use of self-talk plans to control and organize athletes’ thoughts,
has been promoted as a key component for successful sport performance, and is frequently
included as an integral part of psychological skill training” (Hatzigeorgiadis et al., 2009, p. 186).
Unlike the previous mental skills techniques, the use of self-talk has not been frequently
explored within school-based contexts for the purposes of improving mental health fitness and
remains widely exclusive to athletic and other performance-based realms. A recurring theme of
this paper is that life in general can be considered a performance. Many of the psychological
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complications that are experienced in sport such as anxiety, stress, and pressure to perform well
are experienced in daily life settings. Likewise, young people experience negative self-talk
(knowingly or unknowingly) that contributes to their issues of mental health and wellness. As
Thomaes et al. (2019) highlighted, children who habitually engage in negative forms of self-talk
experience higher rates of anxiety which has the potential to develop into more serious mental
health complications. Self-talk should be incorporated into mental health interventions because,
“overall…self-talk had a positive effect on task performance, increased self-confidence, [and]
reduced cognitive anxiety (Hatzigeorgiadis et al., 2009, p. 190). Unlike self-talk, an area that has
received plentiful attention for its applicability in addressing issues of mental health is physical
activity and exercise.
Positive Impact of Physical Activity and Exercise on Stress and Anxiety
Although it is not a direct component of mental skills training or mental health
interventions, physical activity has been proven to have numerous psychological and
physiological benefits. Therefore, it would be advantageous to include physical activity within a
proposed intervention for addressing the mental fitness of youth populations. As reported by
Bélair et al. (2018):
Physical activity such as participation in sports and exercise has benefits for physical
health…and has also been demonstrated as an effective supplement to treatment for
mental health problems. A sedentary lifestyle has been associated with poor mental
health [and] intervening early to reduce sedentary activities and increase physical activity
may reduce the odds of developing mental illness. (p. 1)
Many schools recognize the importance of physical education programs for the purpose of
promoting physical wellness and activity, however, “exercise is seldom recognized by
22
mainstream mental health services as an effective intervention in the care and treatment of
mental health problems” (Callaghan, 2004, p. 476). On that account, “interventions aimed at
making youth more physically active may be effective in reducing risk of mental illness” (Bélair
et al., 2018, p. 7).
As a preventative and reactive measure, physical activity and exercise can reduce stress
and state anxiety as well provide emotional benefits for all ages and genders (Bélair et al., 2018).
As a measure that is purely preventative, there is evidence suggesting that physical activity can
facilitate the development of perceived resilience, or “the ability to respond and adapt
successfully to acute or chronic adversity as a function of adaptive physiological/psychological
stress responses” (Hegberg & Tone, 2015, p. 1). The simple belief that one can persevere during
times of increased anxiety may prevent the further development of anxiety-related issues.
“Physical activity is positively associated with self-perceived dispositional resilience among
those with high trait anxiety. As such, for those at risk for mental health problems, physical
activity may facilitate resilience and reduce the likelihood of developing stress-related disorders”
(Hegberg & Tone, 2015, p. 6).
Despite the plethora of evidence supporting the psychological benefits, most mental
fitness programs do not include any form of exercise within their implementation. “Exercise
could be part of structured interventions and [participants] could be accompanied or partnered by
[mental fitness coaches] whilst doing exercise” (Callaghan, 2004, p. 482). Additionally,
including these exercise-focused interventions during the school day can have benefits that
extend beyond mental fitness and support academic achievement directly and indirectly. A report
by the CDC (2010) as cited in Chaddock et al. (2011) explained that, “children’s attention,
23
attitudes, behaviors, and academic performance were positively influenced by physical activity
opportunities during the school day” (p. 976).
Part of what gives physical activity an excellent opportunity to be integrated into mental
health interventions for youth populations is the acceptable and non-stigmatizing impression that
it presents. According to Pascoe et al. (2020):
Young people are often reluctant to seek help for mental health concerns; therefore,
interventions need to be youth-friendly, acceptable, feasible, non-stigmatising, and
matched to their specific needs. Physical activity/exercise is a non-stigmatising
intervention with few side effects and is viewed by young people as helpful in promoting
mental health and treating mental health problems. (p. 1)
Failure to seek and receive help due to stigma is a prominent barrier to youth populations who
would benefit greatly from mental health interventions. The current modality of mental health
delivery seems very serious and not appealing to younger individuals. It’s important that
practitioners and mental health professionals make their programs fun and inviting. When
interventions include opportunities for students to be active, they will be less reluctant to receive
care.
Mental Skills Training and Physical Activity for Stress and Anxiety: Limited Research
As described, there is abundant evidence that describes the current youth mental health
crisis, problems with school-based interventions designed to address these issues, and a failed
youth sport system that frequently does more harm than good. Fortunately, we have found that
mental skills training traditionally used with athletes and performers such as mindfulness,
breathing, and self-talk have been shown to provide excellent results when applied to youth
populations for the purpose of enhancing mental fitness and wellness. Lastly, the positive impact
24
of physical activity on youth mental health has been thoroughly documented as well.
Unfortunately, there are not any programs offered within schools (to the extent of my
understanding) that approach mental health interventions through a synergy of mental skills
training and physical activity. The program I proposed will serve to address issues of anxiety and
stress through this lens in order to provide a non-stigmatizing, fun, and effective approach to
preventing the development of youth mental health complications.
Methods
The inaugural implementation of the proposed school-based program was evaluated using
self-developed surveys for measuring its effectiveness in teaching breathing and mindfulness
skills only. Since the preliminary trials, the proposed school-based program has been further
adapted to include performance enhancement skills such as self-talk, imagery, and
concentration/focus cues in addition to breathing and mindfulness. The use of empirically
supported measurement tools have also been added to the evaluation component of the adapted
program in order to strengthen its validity. The methods and results of the preliminary trials
along with the proposed methods and hypothesized results of the newly adapted program for
future trials are discussed.
Preliminary Trials
The preliminary trials of the proposed school-based program were completed over the
span of 8 weeks within 3 different elementary schools (2 public, 1 private) in the San Diego area.
The programs were offered as 1-hour enrichment opportunities occurring once a week after
school and were implemented for the purpose of providing non-clinical, preventative mental
health care using a play-based framework centered around the use of breathing and mindfulness
techniques. The program was designed to teach the students when, why, and how to breathe in
25
response to the onset of stress, anxiety, anger, or other debilitating emotional responses. The
population of interest were K-8 students who were enrolled in the program by their parents.
Pre-Program Surveys
At the start of the first day in the program, the students filled out a 10-question Likert
scale survey that was designed to assess their pre-program tendencies pertaining to 3 domains of
resilience: (1) self-management, (2) emotional wellbeing, and (3) self-regulation (see Appendix
A). The questions on the Likert scale survey measuring self-management were conceptually
derived from resilience assessment tools such as the Connor-Davidson Resilience Scale from the
Resilience Research Centre of Canada. The questions measuring emotional wellbeing were
conceptually derived from the Columbia Depression Scale of the American Academy of Child
and Adolescent Psychiatry. The questions measuring self-regulation were internally developed
and intended to assess the use of breathing and mindfulness (or lack thereof). As shown in
Appendix A, emoticon (emoji) images were used instead of numbers for students to circle so that
the method of responding was more clearly understood by younger students. Shortened parent
versions of these surveys were also developed to evaluate the perceptions of parents regarding
their child’s pre-program tendencies for breathwork (see Appendix B). Like the students, these
surveys were delivered to and completed by the parents during the first week of the program.
Preliminary Session Design
Each session began with a brief warm up activity/game to get the students moving and
excited for the session. Shortly after, the instructor led an open discussion that allowed students
to share moments from their life at home, in school, or during sports where they had used a
breathing technique or mindfulness practice covered in a previous session. For the first week of
the program, the session began with an introduction to the difference between passive breathing
26
and intentional breathing techniques. After the opening discussion, a new breathing technique
(e.g. box breath) was taught to the class and practiced together. The students were taught how to
use the breathing technique, why the technique is useful, and when they should use it. After
practicing the breathing technique, the students engaged in various sports, games, and challenges
that promoted physical activity, increased pressure and stress, and provided opportunistic
moments for the students to use the learned breathing technique in order to self-regulate, focus,
and/or calm down to be successful. During these activities, the instructor facilitated the use of the
learned breathing technique by monitoring gameplay and reminding students to breathe when
they were visibly stressed or emotionally escalated. For the last 5 to 10 minutes of the session,
the group reconvened and found comfortable self-space to engage in a guided meditation led by
the instructor. Within the religiously-focused private school, the meditations were re-phrased as
“moments of mindfulness” to avoid the suggestion of spirituality.
Post-Program Surveys
At the end of the last session in the program, the students filled out the same 10-question
Likert scale survey that they completed at the beginning of the first session in the program. The
parents completed the same parent version of the survey that they filled out at the beginning of
the program as well. Qualitative responses from the students and parents were also recorded in
the form of narratives and written vignettes to receive rich data that explained personal
experiences.
Adapted Program for Future Implementation
Like the preliminary trials, the adapted program was designed as a school-based program
and intended to provide preventative, non-clinical mental health care using a play-based
27
framework centered around the use of breathing and mindfulness techniques with the addition of
other skills from performance psychology literature such as imagery, self-talk, and focus cues.
Adapted Pre-Program Surveys
The preliminary trials of the proposed program involved the evaluation of internally
developed surveys that were administered before and after the program implementation. This
pre-test, post-test, within-groups design of measurement is replicated within the adapted program
for future implementation, however, two empirically supported measurement tools have been
added to the evaluation design in order to receive data that is valid and reliable. The first of these
additional measurement tools was the Child and Adolescent Mindfulness Measure (CAMM),
presented in Appendix C.
“The CAMM is a 10-item, self-report measure of present-moment awareness, and
nonjudgmental, nonavoidant responses to thoughts and feelings in children and adolescents age
10 to 17” (Greco et al., 2011, as cited in Goodman et al., 2017, p. 1411). The items on the
CAMM scale were negatively worded and subsequently reversed-scored so that higher scores
reflected higher levels of mindfulness. “The convergent validity [of the CAMM] was supported,
with significant correlations between CAMM scores and measures of psychological
functioning/distress in the expected directions…Overall, the CAMM appears to be a reliable and
valid mindfulness measure for both boys and girls” (Kuby et al., 2015, p. 1448).
The second measurement tool to be added into the adapted program was the Screen for
Child Anxiety Related Emotional Disorders (SCARED), presented in Appendix D.
The SCARED consists of 41 items presented on a 3-point likert scale, which is designed
to assess social anxiety, as well as four other subtypes of anxiety: panic disorder, general
28
anxiety, separation anxiety, and school avoidance, along with a “total anxiety” score.
(Bowers et al., 2019, p. 561)
In the preliminary trials, the surveys had a student version and a parent version. The SCARED
measurement tool also has a child version and a parent version that both show consistent
reliability and validity:
The SCARED shows good internal consistency for both the parent and child versions and
both versions differentiate anxious from healthy children and children with anxiety
diagnoses from children with depression diagnoses or disruptive disorders. Moreover, the
instrument demonstrates good convergent validity with other self-report measures of
anxiety as well as clinician ratings. (Bowers et al., 2019, p. 562)
For the adapted program, the CAMM and SCARED tools along with the Likert scale survey
from the preliminary trials will be completed by the students and parents prior to the first session
because it requires too much time if they are completed during the first session of the program.
Although more time is being sacrificed by the students and parents to complete surveys, the
result will be data that is significantly more powerful.
Adapted Session Design
The foundational design of the adapted program is consistent with the design of the
preliminary trials with the addition of other mental skills techniques. Sessions begin with a brief
warm up followed by an open discussion that allows the students to share times where they have
used previously learned mental skills/techniques. After the opening discussion, the students are
taught a new skill from performance psychology literature such as breathing techniques, imagery,
effective self-talk, focus cues, and mindfulness practices. The instructor shows the students how
to use the skill, why the skill is useful, and when they should use it. After discussing relevant
29
scenarios where the skill is applicable and practicing the skill as a group, the students engage in
various sports and games that promote physical activity and provide opportunities for the
students to practice the learned skill. Lastly, all sessions end with an instructor-led, guided
meditation (or “moment of mindfulness”). The adapted program considers that breathing and
mindfulness can be accompanied by additional performance enhancement skills to provide
students with multiple strategies for addressing the onset of stress and anxiety.
Post-Program Surveys
At the end of the last session in the adapted program, the students complete the same
surveys from the beginning of the program (the CAMM scale, the SCARED scale, and the
internally developed Likert scale survey) so their answers can be evaluated and compared to the
pre-program survey scores. The parents also fill out the surveys at the end of the program to see
if their perspectives have changed as well. Lastly, qualitative responses from the students and
parents are also recorded in the form of narratives and written vignettes to receive rich data that
explains personal experiences.
Results
The results from the preliminary trials were consistent with the hypothesis that breathing
and mindfulness help children regulate their emotions and alleviate stress and anxiety. The
adapted program is expected to produce the same results, but to a higher degree due to the
addition of other mental skills techniques and with greater validity due to the use of empirically
supported tools such as the CAMM and SCARED scales. The results of the preliminary trials
along with the hypothesized results of the newly adapted program for future trials are discussed.
Results of the Preliminary Trials
30
Among the 3 schools (2 public, 1 private) that received the preliminary trial of the
proposed program, a total of 60 children and 26 parents completed pre-surveys. Of that number,
67 children and 20 parents completed post-surveys. Survey responses were evaluated as class
averages rather than evaluating change in specific student/parent responses in order to preserve
the privacy and anonymity of the parties involved.
In the first public school, there were significant changes among student responses to
self-regulation questions. Pre-program surveys showed that 68% of students agreed with the
statement, “When I feel angry during sports, I stop, breathe, and that makes me feel better.” That
number improved to 97% on post-program surveys (29% increase). Pre-program surveys showed
that 62% of students agreed with the statement, “When I feel angry at home, I stop, breathe, and
that makes me feel better.” That number improved to 94% on post-program surveys (32%
increase). Pre-program surveys showed that 75% of students agreed with the statement, “I can
stop my thoughts from racing and make better decisions when I stop to breathe.” That number
improved to 97% on post-program surveys (22% increase). Parents of students at this school
provided meaningful qualitative responses that support the effectiveness of the preliminary trial
program. One parent explained that their child, “has been thrilled to teach us the breathing
techniques he learned. We use the box breath or finger trace breath together when he is upset. I
have also seen him sitting alone doing the breaths to calm himself down. This was a very
valuable program, and we greatly appreciate your investment in our children’s mental health.”
In the second public school, there were, again, significant changes among student
responses to self-regulation questions. Pre-program surveys showed that 28% of students agreed
with the statement, “When I feel angry at home, I stop, breathe, and that makes me feel better.”
That number improved to 58% on post-program surveys (30% increase). Pre-program surveys
31
showed that 56% of students agreed with the statement, “I can stop my thoughts from racing and
make better decisions when I stop to breathe.” That number improved to 72% on post-program
surveys (16% increase). Within this school sample, the parent responses showed a 34% overall
increase in their children’s use of breathing techniques at home.
Within the private school preliminary trial of the proposed program, there were promising
results from the parent responses that suggested improvements in their perceptions of their
children across all 3 domains of resilience (self-regulation, self-management, and emotional
wellbeing). For self-regulation questions, pre-program survey responses from parents showed
that 33% of parents agreed with the statement, “when my child feels angry during sports, they
stop, breathe, and then feel better.” That number improved to 80% on post-program surveys
(47% increase). Pre-program survey responses from parents showed that 33% of parents agreed
with the statement, “my child knows how to breathe to stop thoughts from racing and make
better decisions.” That number improved to 100% on post-program surveys (67% increase). For
self-management questions, pre-program responses from parents showed that 40% of parents
agreed with the statement, “my child knows how to cheer themselves up when feeling down.”
That number improved to 80% on post-program surveys (40% increase). Pre-program responses
from parents showed that 67% of parents agreed with the statement, “my child believes they can
accomplish challenging tasks with sufficient effort and hard work.” That number improved to
100% on post-program surveys (33% increase). For emotional wellbeing, pre-program survey
responses from parents showed that 33% of parents disagreed with the statement, “my child gets
mad and loses their temper at home.” That number improved to 80% of parents disagreeing that
their child loses their temper at home on post-program surveys (47% increase). One parent from
a student in this private school trial shared that their child, “has been doing so much better.
32
Especially when playing sports, he takes time to do the breathing techniques he learned from
your program and his behavior at home has also improved.”
Hypothesized Results of the Adapted Program
The adapted program is expected to produce similar results to the preliminary trials, but
with greater validity due to the use of the CAMM and SCARED measurement tools. The
preliminary trials produced significant results that showed improvements from the students
across the domains of self-management, emotional wellbeing, and self-regulation. However,
these results were produced from internally developed surveys that were not used in any previous
studies to determine their reliability or validity. It is still noteworthy that the parents of the
students and the students themselves provided meaningful testimonials that suggested the
program was successful in teaching breathing and mindfulness.
In addition to the improved validity of prospective results, the adapted program is
expected to produce positive outcomes among multiple areas of mental wellbeing rather than just
self-management, emotional wellbeing, and self-regulation. The adapted program features other
mental skills techniques such as self-talk and imagery while still maintaining a primary focus on
breathing and mindfulness. The literature review has shown convincing support for the
effectiveness of these skills in addressing stress and anxiety among young people, so it is
hypothesized that the addition of these skills would improve the overall positive impact of the
program.
Breathing and mindfulness are taught in the first few weeks and receive the most
instructional emphasis throughout the adapted program because they both play justifiable roles in
the execution of the other mental skills such as self-talk and imagery. Simply directing your
attention to your breath and the present moment allows one to “tune out” the negative symptoms
33
that are being experienced and focus on the regulation strategy. In addition to the independent
benefits they provide, familiarity with breathing and mindfulness allows the learner(s) to practice
the foundations of other mental skills more easily.
The addition of self-talk to the adapted program enhances the students ability to
recognize how their own thoughts shape their perceived emotions, leading to subsequent
behaviors, actions, and performance. Something many individuals (especially young people) do
not understand is that we engage in self-talk frequently and subconsciously. Teaching the
students how to acknowledge the onset of negative self-talk in the first place allows them to
effectively use positive forms of self-talk such as countering or affirmations, which promotes
healthier inner dialogue and leads to improved behavior and performance.
The use of imagery in the adapted program serves to help students understand how to
prepare for tough situations that may occur and evaluate tough situations they have already
experienced. Situational adversity can take place in sports and in life. The use of imagery allows
one to recreate these experiences in their mind while forming vivid and controllable responses
that are ideal for the given situation. When this practice is done repeatedly, it primes neural
pathways so that the negative situations are able to be managed effectively when they occur in
real life. The addition of this skill to the proposed program will show students how to use
internal and external imagery in order to recap things they did well during past tough situations
and areas where they could improve the next time it occurs. Using imagery to prepare for future
stress and anxiety makes the difficult situations seem more manageable in the moment.
Discussion and Conclusions
There is currently a significant issue regarding youth mental health concerns and the
programs/interventions that have been designed to address them. Children are facing record-high
34
levels of stress, anxiety, irritability, and low self-esteem among many other negative symptoms
associated with poor mental health. Although it is widely recognized that these issues are
prevalent, the response has not been effective in reducing the problem at hand. Current
school-based interventions place a heavy focus on programs that help resolve diagnosed mental
health complications rather than programs that are preventative in nature and promote the use of
mental skills that can help all children improve their mental wellbeing regardless of their clinical
mental health status. A negative outcome from this approach is a strong stigma that suggests only
children with diagnosed issues should receive mental health support.
A well-known approach for promoting mental health and social connection is physical
activity and sports. Traditional youth sports have grown into a profit-centered business that has
unfortunately pushed out many children from affording participation and the focus of fun and
connection has been reduced. Winning and playing time have taken precedence over recreation
and inclusion which has led to damaging experiences for the children involved. The extreme
pressures and expectations imposed by coaches and parents progress into adverse outcomes that
intensify the stress and anxiety in children and take away from the natural joy, challenges, and
psychological benefits that sports inherently provide. The prominent youth mental health crisis,
poor school-based interventions, a misinformed stigma around receiving help, and a damaged
model of traditional sport all collectively require the need for reform.
Mental skills from performance psychology literature such as breathing, mindfulness, and
self-talk have been shown to improve the mental fitness of athletes/performers and do not hold
negative stigma. Mental skills training cannot replace clinical approaches to treating individuals
with diagnosed mental health disorders, however, it presents a phenomenal potential for
preventing the onset or development of common negative symptoms such as stress and anxiety
35
that are associated with mental health disorders. Mental skills training is non-stigmatizing and
the benefit can be immediately recognized when used during sports and games. Likewise,
challenging games and sports provide great benefits for improving the mental fitness of young
people when they are carried out in supportive and inclusive environments. There is very little
research that has explored the combination of physical activity and mental skills such as
breathing, mindfulness, and self-talk as a preventative approach for youth mental health despite
the reported benefits of these areas independently.
The proposed program has shown promise for its effectiveness as a school-based
intervention that prevents the development of mental health issues among young people. The
preliminary implementation showed that the use of breathing and mindfulness helped students
with alleviating their negative symptoms of stress, anxiety, and anger at school and at home. The
purpose of this program was to provide a new approach in addressing the youth mental health
crisis that is non-stigmatizing, fun, and beneficial for young people with and without diagnosed
mental health disorders.
Future Directions
The proposed program demonstrated encouraging evidence suggesting that mental
performance enhancement techniques from sport psychology literature are effective within youth
preventative mental health care contexts by alleviating negative symptoms associated with poor
mental health such as stress and anxiety. Future research should seek to provide further evidence
that supports the use of mental skills training, breathing, and mindfulness as a mental health
resource in schools. Although the results of the proposed program were promising, the power of
the study was weak due to a small sample size and geographical specificity. Future programs
should evaluate these constructs of sport psychology within the scope of preventative youth
36
mental health throughout a greater range of areas and schools in order to more accurately
represent the influence of these programs on the youth population as a whole.
Another suggestion for future research involves the use of biometric screening to
eliminate the potential for response errors in surveys. The current study analyzed pre-program
and post-program survey responses to evaluate the program’s effectiveness. Although each
question of the survey(s) were explained to the students and parents, the risk of confusion and
unintentional responses were still a possibility. Future studies should explore the use of biometric
screening tools such as heart rate monitors to record quantitative results that are indicative of live
regulatory responses occurring within the participants rather than relying on the accuracy of
survey responses.
Moreover, the perception of stigma should also be explored in future studies. The current
proposed program did not evaluate the student or parent perception of stigma that surrounds
receiving mental health support. Because stigma is among the most prominent barriers to service
access and delivery, this new approach for strengthening mental fitness and health should
evaluate its effectiveness in eliminating stigma as well.
Closing
Despite the limitations of this study and the need for further research, the results of the
current program proposal and literature review suggest that mental skills such as breathing,
mindfulness, and self-talk are highly beneficial for improving the mental fitness of young people.
When paired with exciting sports and activities that create pressure and opportunistic moments
for performance enhancement skill usage, this model could serve as effective means of
preventative care within schools as a stigma-free mental health intervention that teaches the
youth population how to healthily address debilitating stress and anxiety.
37
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Appendix A
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Appendix B
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Appendix C
CAMM: Scoring Instructions
First reverse all scores by changing 0 to 4, 1 to 3, 3 to 1, and 4 to 0 (2 stays unchanged). Then
sum all items. Higher scores correspond to higher levels of mindfulness.
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Appendix D
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