1

Introduction

Survival rates from spontaneous cardiac arrest and conduction disorders in pediatric patients have increased substantially over the last several years largely due to advancements in disease recognition, earlier medical interventions, and implantation of pacemakers and implanted cardiac defibrillators (ICDs) [ ]. Further research in this area has included the evaluation of psychosocial factors related to the effects of living with a cardiac implanted electronic device (CIED) [ ]. Previous research surrounding CIEDs and quality of life has primarily focused on the adult population, though more recent research specific to the adolescent population reports an increase in psychosocial stress and decreased quality of life in patients with CIEDs compared to patients without [ ]. Specifically, adolescents with CIEDs have increased anxiety, depression, and psychosocial complexities given the physical appearance of their implanted device, reliance on a “machine,” and stress surrounding potential therapies by the device [ ].

Mindfulness based stress reduction (MBSR) is a psychoeducational training program in mindfulness and its applications to daily life. More specifically, mindfulness practices focus on awareness of one’s thoughts, feelings, and physical sensations in the present moment, without harmful judgment, with the goal of integrating this awareness and acceptance into everyday life as a continuous practice [ ]. Mindfulness based interventions (MBI) have long been studied and found to be effective in reducing psychosocial stress and anxiety in the adult population, with more recent research focusing on adolescents [ , ]. Both general and disease specific populations have integrated MBIs into their treatment plans with positive outcomes [ ]. Previous research suggests that adolescent patients with ICDs or chronic medical illness respond well to mindfulness based interventions (MBI), decreasing psychosocial stress, anxiety, and/or depression [ ].

In this study, we developed a pilot mindfulness based stress reduction-teen (MBSR-T) program for adolescent patients with an implanted pacemaker or ICD cared for by our Pediatric Electrophysiology Team.

2

Methods

Following approval from the Washington University School of Medicine Institutional Review Board, patients who met study inclusion criteria were identified and contacted via telephone to gauge interest in participating in the program. The phase 1 in-person sessions were held in a centrally located out-of-hospital facility due to patients reporting hospital associated anxiety, while the phase 2 virtual sessions were held via Zoom (Zoom Communications Inc., San Jose, CA) with Canva (Canva Inc., Austin, TX) presentations.

Inclusion criteria for Phase 1, an 8-week in-person MBSR-T program, included patients who 1) were between the ages of 14–21, 2) currently had a CIED in place, 3) lived within 60 miles of SLCH, and 4) had their device implanted for >1 month.

Inclusion criteria for Phase 2, a virtual 8-week MBSR-T program, included patients: 1) between the ages of 14 and 21, 2) live >30 miles from SLCH, and 3) CIED implanted >1 month prior to program start. Patients were excluded from either phase if they 1) were non-English speaking, 2) were current wards of the state, 3) were outside the ages of 14–21, 4) had current substance abuse, 5) had cognitive impairment, and/or 6) were currently suicidal.

Recruitment consisted of identifying patients who met inclusion criteria then arranging them by mileage from the hospital. As our institution covers a wide geographical base, we presumed that those living within 30 miles of the hospital were more likely to participate in the in-person group, whereas those that lived outside of that radius were primarily considered for the virtual group. We called 33 patients for the in-person group, 10 agreed to participate, 9 completed consents and attended sessions, 1 participant dropped out during the study. We called 19 patients for the virtual group, 5 agreed to participate, 4 completed consents and attended sessions; there were no dropouts.

The age range for inclusion was determined by our patient population (birth to 21 years) and age of adolescence, as defined in recent research to be 10–24 years of age based on biologic growth and major social role transitions [ ].

In both programs, after consent and assent were obtained, patients filled out pre-intervention surveys (Florida Patient Acceptance Survey (FPAS) [ , ]. The Hospital Anxiety and Depression Scale (HADS) [ , ] and Pediatric Quality of Life Short Form (PedsQL 4.0 SF)) [ ].

The coursework closely modeled the MBSR-T curriculum from the Stressed Teens Curriculum written by Gina Biegel (a licensed marriage and family therapist) and taught by MBSR-T trained personnel [ ] (See Table 1 ). Participants utilized the Stressed Teens Workbook [ ] during each session. The first three sessions primarily focused on identifying stressors and current coping skills while defining and exploring mindfulness. Subsequent sessions focused on developing positive coping strategies for stress through mindfulness. Each session ended with an instructor led mindful practice and group discussion. All sessions occurred on weekdays during after-school hours, were conducted in real-time, and lasted one hour under the instruction of LR or NM (both certified MBSR-T facilitators) with assistance from clinical psychology. At the completion of both 8-week programs, participants completed post-intervention surveys (FPAS and PedsQL 4.0 SF) with the addition of a post-program qualitative survey. While home practice was recommended, assessment of home practice workbook completion was not performed.

3

Results

Twelve participants (5 female, 6 male, 1 nonbinary; mean age = of 16 ± 2 years) completed the study, with 8 in the in-person cohort and 4 in the virtual cohort. Participants had an average device implant duration of 9.8 years, with 10 pacemakers and 2 implantable cardioverter defibrillators (ICDs) for diagnoses including complete heart block ( n = 5), sinus node dysfunction ( n = 3), cardioinhibitory syncope ( n = 2), long QT syndrome ( n = 1), and hypertrophic cardiomyopathy (n = 1) (See Table 2 ).

Table 2

Description: demographic data by gender, age, device type and diagnosis.

Demographic	In Person ( n = 8)	Virtual ( n = 4)
Gender
Female	4(50 %)	1(25 %)
Male	4(50 %)	2(50 %)
Non-Binary		1(25 %)
Age (in years)	16.2 ± 2.0	17.5 ± 1.3
Device Type
Pacemaker	7	3
Defibrillator	1	1
Indication for Device
Complete Heart Block	3	2
Sinus Node Dysfunction	2	1
Cardioinhibitory Syncope	2
Long QT Syndrome	1
Hypertrophic Cardiomyopathy		1
Age at Implants (in years)	6.5 ± 5.5	6.8 ± 6.0
Time in Device (in years)	9.5 ± 5.8	11.25 ± 3.4
Presence of Structural Heart Disease	4	2
Receiving Psychological Services	2	3

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