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Running head: MINDFULNESS AND MATH ANXIETY 1 The Effect of Mindfulness Practice on Math Anxiety Sean M. Shiverick University of Wisconsin-Platteville Author Note. This is a final report for 2012 SAIF Research project entitled: ‘A Brief Mindfulness Intervention to Reduce Stress in College Students and Improve Academic Performance.’ The Institutional Review Board (IRB) protocol for the longitudinal is included separately. This research was presented at the 2013 meeting of the Association for Psychological Science (APS) in Washington, DC. Address correspondence to: Sean M. Shiverick, Department of Psychology, University of Wisconsin-Platteville, Platteville, WI 53818. [email protected] / 608.341.1693

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Page 1: The Effect of Mindfulness Practice on Math Anxiety AND MATH ANXIETY 3 The Effect of Mindfulness Practice on Math Anxiety The transition to college can be stressful and many students

Running head: MINDFULNESS AND MATH ANXIETY 1

The Effect of Mindfulness Practice on Math Anxiety

Sean M. Shiverick

University of Wisconsin-Platteville

Author Note. This is a final report for 2012 SAIF Research project entitled: ‘A Brief Mindfulness

Intervention to Reduce Stress in College Students and Improve Academic Performance.’

The Institutional Review Board (IRB) protocol for the longitudinal is included separately. This

research was presented at the 2013 meeting of the Association for Psychological Science (APS)

in Washington, DC.

Address correspondence to: Sean M. Shiverick, Department of Psychology, University of

Wisconsin-Platteville, Platteville, WI 53818. [email protected] / 608.341.1693

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Abstract

Mindfulness meditation is a non-judgmental awareness of experiences in the present moment

(Kabat-Zinn, 2012). This research examined the effect of mindfulness practice on math anxiety.

The experimenter met weekly with N=7 undergraduates and led them in guided meditations on

breathing, body sensations, thoughts and emotions; students were encouraged to practice

mindfulness daily for 15 minutes. Participants completed a questionnaire at baseline and after 4

weeks. The results showed positive correlations between emotion-regulation, mindfulness

presence, acceptance, and psychological well-being. Emotion-regulation was negatively related

to math anxiety. Cognitive reappraisal was a significant predictor of mindfulness acceptance, and

mindful acceptance significantly predicted well-being. There was a significant decrease on one

measure of math anxiety (A-MARS) and marginally significant for another measure (MARS)

following four weeks of mindfulness practice. There were also positive increases in emotion

regulation, mindful presence, acceptance, and well-being, and a reduction in negative affect.

Relations between mindfulness, math anxiety, and academic achievement are discussed.

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The Effect of Mindfulness Practice on Math Anxiety

The transition to college can be stressful and many students experience anxiety that can

impair their academic performance. By helping students to learn more effective strategies of

emotion regulation, psychologists and educators can help them to manage their anxiety and

improve classroom performance. Researchers have examined methods for reducing math anxiety

(Ramirez & Beilock, 2011). Although past work has shown that meditation can reduce stress and

enhance attention (Greeson, 2009; Grossman, Niemann, Schmidt, & Walach, 2004; Tang, et al.,

2007), few studies have examined whether mindfulness meditation may help reduce anxiety

related to math. The present study investigated changes in math anxiety, emotion regulation, and

psychological well-being following four weeks of mindfulness practice. The relations between

mindfulness, math anxiety, and academic achievement are discussed.

Emotion Regulation

Emotion regulation involves a set of processes by which people manage emotionally

charged states, including specific emotions, mood, and stress. Reviews of the literature on

emotion regulation have shown that attention regulation, cognitive reappraisal, and bodily

manifestations are central processes for managing negative emotions (see Koole, 2010).

Cognitive strategies, such as directing attention away from negative information to positive

information, or reinterpreting situational and contextual aspects of stimuli, help inhibit the

experience of unwanted emotions and decrease activation of emotion areas in the brain. In

addition, bodily strategies, such as controlled breathing and progressive muscle relaxation, are

also effective for regulating stress and negative emotions.

Math Anxiety

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Many students experience anxiety related to math. Math anxiety is a negative emotional

response that reduces online working memory and impairs mathematical performance (Ashcraft

& Moore, 2009). A neuroimaging study of highly math anxious second- and third-graders found

increased activation in areas of the brain associated with fear and reduced activation of areas

associated with mathematical reasoning (Young, Wu, & Menon, 2013). In addition, intrusive

thoughts, preoccupation with performance, or worries about evaluation can trigger math anxiety.

Furthermore, individuals with high math anxiety (HMA) can experience fear and apprehension

even in anticipation of a math task (Lyons & Beilock, 2012). Research has examined cognitive

approaches to reducing negative emotions due to math anxiety such as expressive writing

(Ramirez & Beilock, 2011) and reappraisal or reframing techniques (Jamieson, et al., cited in

Maloney & Beilock, 2012). Yet, no research has addressed the question of whether meditation

can help students to regulate math anxiety.

Mindfulness Meditation

Mindfulness is an intentional, non-judgmental awareness of sensations and experiences in

the present moment (Kabat-Zinn, 1990). Meditation involves both cognitive and bodily strategies

of emotion regulation (Feldman, et al., 2007; Greeson, 2009). Although meditation and

mindfulness are often regarded as cognitive strategies of emotion regulation (Feldman, et al.,

2007), they include bodily activities such as breathing and relaxation. Meditation research has

shown mindfulness practices that enhance attention, awareness, and acceptance are associated

with decreased stress, anxiety, and depression (Brown, & Ryan, 2003; Greeson, 2009; Goldbin &

Gross, 2010) and increased psychological well-being and health (Holzel, Lazar, Gard, Schuman-

Olivier, Vago, & Ott, 2011). In addition, individuals with higher levels of trait mindfulness

report less stress, anxiety, depression, better self-regulation, and more positive emotion.

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Furthermore, research suggests that emotion regulation may be improved through directed

mindfulness practices (Cahn & Polich, 2006, Holzel, et al., 2012).

Mindfulness based stress reduction (MBSR) is an established program developed by Jon

Kabat-Zinn (1990) that involves an 8-week training program of meditation and yoga. MBSR has

been used with clinical samples (Grossman, et al., 2004), undergraduates (Rozenzweig, Reibel,

Greeson, Brainerd, & Homat, 2003), and community samples (Harnet, et al., 2010). MBSR

training may be difficult for many students to complete due to the length of the training. It is also

difficult to find comparable behavioral controls in experimental research (MacCoon, et al.,

2012). However, the effectiveness of shorter mindfulness interventions has been demonstrated.

For example, Tang, et al. (2007) reported beneficial effects on attention and stress reduction in

students after 5 days (20 minutes per day) of integrated mind-body meditation. In addition,

Harnett, et al. (2010) found that a brief group-based mindfulness therapy program (3 sessions of

2 hours) effectively reduced psychological distress and increasing short-term life satisfaction.

There are contradictory findings about the effectiveness of very brief mindfulness

exercises on stress and anxiety. In an unpublished thesis, Niss and Arch (2013) reported a

decrease in test anxiety after a 9-minute mindfulness exercise administered before math exams in

a sample of high school students. In other research, Shiverick and Eckhoff (May, 2013) tested the

effect of a 10-minute mindfulness exercise on anxiety related to math in college students. State

anxiety was measured before and after a mindfulness (breathing, body-scan) exercise or a neutral

control. Overall, ten-minutes of mindfulness did not significantly reduce state anxiety either in

anticipation of math or after working on math problems. However, change in state anxiety varied

according to individual math anxiety and trait mindfulness. Students with high math anxiety

(HMA) showed a greater reduction in state anxiety than students with low math anxiety

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(LMA)(see Figure 1). Trait mindfulness may also moderate the effect of math anxiety. These

findings suggest mindfulness practice may especially benefit individuals high in anxiety.

The present research investigated change in math anxiety, emotion regulation, and well-

being in college students with high math anxiety after four weeks of mindfulness practice. The

project was conducted in three phases. During the first phase, the researchers obtained

mindfulness training. The second phase consisted of a longitudinal study in which the principle

investigator (PI) met weekly with participants for 6 weeks, leading students in guided

meditation, providing in-class exercises, and home practice assignments. Phase two was

conducted in the Fall 2012 and Spring 2013 semesters. Due to low sample sizes (n1=5, n2=3),

participants were combined into a single sample. The third phase involves using technological

applications to support and facilitate individual mindfulness practice (mindfulness applications).

Method

Participants

Eight undergraduate students (MAGE=18.9, SD=1.08, range: 18 to 23; 5 Females) from a

Midwestern university were recruited to participate in the study. Participants were predominantly

White (80% White, 10% Latino, 10% East Indian). One participant did not attend the weekly

meetings and was dropped from the study. Students received no compensation for participation.

Materials

The materials included Mindfulness for Beginners (Kabat-Zinn, 2012), Full Catastrophe

Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (Kabat-Zinn,

1990), Guided Mindfulness Meditation–4 Practice CDs (Kabat-Zinn, 2002), and Insight

Meditation: A step by step course on how to meditate (Salzberg & Goldstein, 2001). Two 8GB

iPod touch devices and an iPad were purchased from the Apple store. Electronic applications for

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mindfulness practice (‘Mindfulness App’; www.mindapps.se) were downloaded from the iTunes

store onto these devices.

A questionnaire included demographic information (age, gender, year in school), math

history (number of math courses, highest math course), personal history (counseling or

medication for anxiety), Perceived Stress Scale (PSS, Cohen, Kamarck, & Mermelstein, 1983),

Abbreviated Mathematics Anxiety Rating Scale (A-MARS; Alexander & Martray, 1989; Suinn

& Winston, 2003), Math Anxiety Scale Revised (MAS-R, Bai, Wang, Pei, & Frey, 2009), Brief

Symptom Inventory (Derogatis & Melisaratos, 1983), Emotion Regulation Questionnaire (ERQ;

Gross & John, 2003), Short Version of the Freiburg Mindfulness Inventory (FMI; Walach, et al.,

2006), Mindfulness Attention and Awareness Scale (MAAS; Brown & Ryan, 2003), short form

of Positive and Negative Affect Scales (PANAS; Watson, Clark, & Tellegen, 1988), and Rapid

Assessment of Well-Being–Short Depression and Happiness Scale (SDHS; Joseph, Linley,

Harwood, Lewis, & McCollom, 2004).

Procedure

The PI completed the Mindfulness Program at UW-Health Center in Madison. A research

assistant obtained mindfulness training from a certified instructor in Rochester, MN. A

consultant on the study, Dr. Marc Wruble, is a clinical psychologist who uses mindfulness in

therapy in his private practice. The iPod and Mindfulness App are used by the PI and consulting

colleague to facilitate mindfulness practice. The iPad was used to research online mindfulness

resources, for literature searches, and to investigate formats for delivering mindfulness exercises

to students. The PI recruited students with high math anxiety from introductory courses in

Psychology and Math by flier and campus email. Participants were informed that the study

involved a time commitment of meeting for one hour weekly over the course of 6 weeks.

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On the first meeting, the experimenter explained the study, obtained consent, and had

participants complete the questionnaire. Each week the PI introduced a new mindfulness exercise

(eating, breathing, body-scan, thoughts and emotions) and led students in guided meditations,

that included in-class exercises, with assigned readings and home practice. Students were

encouraged to practice formal or informal mindfulness exercises daily for 15 minutes.

Participants were provided with a copy of ‘Mindfulness for Beginners’ (Kabat-Zinn, 2012) that

included an audio CD with several guided meditations. The book and audio CD were provided to

support individual practice. Participants completed the questionnaire again after 4 weeks. The

last session involved reflection on mindfulness experiences and ways to continue practice.

Results

Pairwise correlations were calculated for the main variables and stepwise multiple

regression was used to identify predictors of mindfulness and well-being. Related samples t-tests

were conducted to test change in outcomes before and after the intervention.

Examination of the correlations showed that participants’ highest math course was

negatively related to perceived stress (PSS), r(5) = -90, p = .006. Emotion regulation (cognitive

reappraisal) were negatively related to history of counseling for anxiety, r(5) = -.85, p = .02, and

medication for anxiety, r(5) = -.85, p = .02. Cognitive reappraisal (CA) was positively correlated

with mindfulness presence, r(5) = .83, p = .02, mindfulness acceptance, r(5) = .83, p = .02, and

psychological well-being r(5) = .89, p = .008. Mindfulness presence was positively correlated

with mindfulness acceptance, r(5) = .80, p = .03, and well-being, r(5) = .93, p = .002 (Table 1).

A surprising finding is that the two measures of math anxiety (A-MASR, MAS-R) were not

correlated with each other, r(5) = .39, p = .38. In addition, the math anxiety scale (MAS-R) was

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positively correlated with emotion regulation, r(5) = .81, p = .03, and marginally correlated with

well-being, r(5) = .71, p = .08. No other correlations were significant.

Stepwise multiple regression revealed that emotion regulation (cognitive reappraisal) was

a significant predictor of mindful acceptance F(1, 5) = 18.19, p = .008, β = .89, R2 =.78; the

cognitive reappraisal dimension of emotion regulation accounted for 78% of the variance in

mindfulness acceptance. Mindfulness presence was excluded from the model. In addition,

mindful acceptance was a significant predictor of well-being F(1, 5) = 33.08, p = .01, β = .93, R2

=.87); the acceptance dimension of the Freiberg mindfulness inventory accounted for 87% of the

variance in psychological well-being. Mindfulness presence and emotion regulation were

excluded from the model.

Related-sample t-tests were used to test change (after-before) in the main dependent

variables (see Table 2). There was a significant decrease in math anxiety on one measure (A-

MARS), t(6) = -3.34, p = .01, and marginally significant decrease on the second measure of math

anxiety (MAS-R), t(6) = -2.02, p = .09. In addition, there was a significant reduction in negative

affect, t(6) = -2.76, p = .03. Finally, there were positive increases in emotion regulation (CA),

t(6) = 3.56, p = .01, mindfulness presence (FMI), t(6) = 3.78, p = .001, mindfulness acceptance

(FMI), t(6) = 3.71, p = .01, and psychological well-being, t(6) = -3.34, p = .07.

Discussion

The goal of this research was to determine whether mindfulness can help reduce anxiety

related to math and the results supported this hypothesis. The main finding is that math anxiety

decreased after four weeks of mindfulness practice. This effect was significant for one measure

of math anxiety (A-MARS); however, this decrease on the second measure (MAS-R) was only

marginally significant. It is possible that with a larger sample this effect would be significant for

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both measures of math anxiety. There were also positive increases in emotion regulation,

mindfulness presence, mindfulness acceptance, psychological well-being, and a decrease in

negative affect. These results are striking given the small size of the sample.

The second finding is that emotion regulation was closely linked to mindfulness.

Cognitive reappraisal was positively correlated with mindfulness presence, mindful acceptance,

and psychological well-being. Mindfulness acceptance was predicted by emotion regulation;

individuals with higher levels of cognitive reappraisal also reported higher levels of mindfulness

acceptance. Although mindfulness presence and acceptance were positively correlated with each

other, the mindful presence was not significantly related to well-being. It is possible that with a

larger sample some of these relationships would prove to be significant; however, in the present

sample, the regression analysis showed that well-being was predicted only by mindful

acceptance. Individuals with higher levels of acceptance reported higher levels of well-being.

These findings are consistent with previous research showing beneficial effects of

mindfulness practice (Tang, et al., 2007; Harnet et al.’s (2010). In Tang et al.’s study, students

completed 20 minutes of meditation for 5 days in a row; in Harnet et al.’s study, participants

completed mindfulness practice in three meetings lasting two hours in a group-based context. In

the present study, Participants were encouraged to practice mindfulness daily for 15 minutes;

however, examination of student logs and verbal reports revealed that few students sustained

practice on their own outside the weekly meetings. This suggests the beneficial effects of

mindfulness may be obtained after four, 20-minute guided meditations once a week over four

weeks. This research demonstrates that relatively brief mindfulness practice can result in

significant decreases in anxiety, negative affect, and gains in emotion regulation and well-being.

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As described in the introduction, there is some question as to the effectiveness of very brief

mindfulness; repeated practice with mindfulness may be necessary to obtain beneficial results.

A limitation of this research is the small sample. Despite a healthy student response in

initial recruiting efforts, only few respondents reported high math anxiety. Students may be

reluctant to report math anxiety, perhaps minimizing the extent that anxiety impacts their math

performance. Anecdotally, students in my research methods courses do not readily admit to

experiencing math anxiety, but many display symptoms of anxiety based on their difficulty with

elementary statistics. Of the eligible respondents, some had conflicts with the scheduled meeting

time or and others could not commit to meeting weekly for 6 weeks. In future, active steps will

be taken to boost recruitment and retainment by offering incentives (e.g., gift cards) and using

online resources to facilitate practice by increasing accessibility of the materials.

A second limitation is that phase three of the study was only partly implemented. The PI

purchased two iPods and one iPad and downloaded the Mindfulness Apps I & II onto these

devices. After completing the initial Mindfulness training at UW-Health, the PI found the

Mindfulness apps helped support his mindfulness practice. The iPod increased accessibility of

the mindfulness exercises, making them available at any time or place, thus facilitating practice.

The iPad was used to conduct literature searches, prepare mindfulness exercises, and for

mindfulness practice. The Mindfulness apps were helpful resources for guided meditations; the

iPod and iPad were the hardware for content delivery. After learning how the iPod, iPad and

mindfulness apps work, I concluded it was impractical to provide iPods to participants to use

during the study for at least two reasons: (1) the user interface on the iPod (i.e., log-in) makes it

difficult to transfer between users, and (2) there was no way to ensure that students would return

the electronic devices after the study. An iPod was provided to my collaborator and consultant on

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the project, Dr. Marc Wruble, a clinical psychologist who uses mindfulness as therapy and

teaches a course on the Psychology of information and technology.

In the next phase of this research resources for mindfulness will be delivered directly to

participants via an existing electronic educational platform, iTunes U. Mindfulness exercises and

podcasts of guided meditations will be posted on iTunes U for students to download directly onto

any electronic device they choose (e.g., personal computer, smart phone, iPod, iPad, MP3

player). In this way, we can provide content to participants on the device of their choosing rather

than providing the devices to students. Researchers have explored the use of web-based

mindfulness training; in a pilot study, participants completed self-guided online training for 12

days (Gluck & Maercker, 2011). The key difference is that phase three of the present study will

include weekly meetings with researcher over the course of 6 weeks, using podcasts of

mindfulness exercises on iTunes U to facilitate participants’ mindfulness practice. Phase three of

the study will also seek to replicate previous findings with a larger sample.

The finding that mindfulness meditation can promote positive psychological outcomes

has been demonstrated in past work (Greeson, 2009). The direct benefit of this project to

students is that by practicing mindfulness over a period of weeks, they can learn to regulate

negative emotions, be less anxious, and improve their well-being, which may carry over into

other areas of their lives. This study also promoted mentorship and collaboration. In developing

this project, the PI trained an undergraduate student to design and implement research studies,

assist with an education intervention, and present findings at a conference. As described above,

the PI consulted with colleagues interested in mindfulness and technological applications. Dr.

Wruble and I are currently exploring ways to incorporate this technology into our teaching and

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practice. I am communicating with Dr. Yu-Ting Su in the Department of Counseling Psychology

about collaboration. Dr. Su teaches graduate courses in counseling and practices meditation.

In conclusion, the SAIF grant has allowed the principle investigator to expand his

research into a new area, obtain MBSR training from a nationally renowned program, learn about

emerging technologies, and engage in scholarly research that may lead to a publication. These

activities will all contribute to my professional development and progress toward tenure. This is

the first SAIF grant that I have received and the project generated a follow-up study that has also

been supported by SAIF award. One of the most satisfying things about this project has been to

continue to learn and grow as a teacher and give back to students something that has been a

personal interest of mine for several years. This has been an invaluable experience.

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References

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Feldman, G., Hayes, A., Kumar, S., Greeson, J., & Laurenceau, J.-P. (2006). Mindfulness and

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Gluck, T. M., & Maercker, A. (2011). A randomized controlled pilot study of a web-based

mindfulness training. BMC Psychiatry, 11, 1-12.

Greeson, J. M. (2009). Mindfulness research update: 2008. Complementary Health Practice and

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Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress

reduction and health benefits: A meta-analysis. Journal of Psychomatic Research, 57,

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Harnett, P. H., Whittingham, K., Puhakka, E., Hodges, J., Spry, C., & Dob, R. (2010). The short-

term impact of a brief group-based mindfulness therapy program on depression and life

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Holzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., & Ott, U. (2011).

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conceptual and neural perspective. Perspectives on Psychological Science, 6, 537.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face

stress, pain, and illness. 15th Anniversary Edition. Bantam Dell: New York, NY.

Kabat-Zinn, J. (2012). Mindfulness for Beginners. Sounds True. Louisville, CO.

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Koole, S. L. (2010). The psychology of emotion regulation: An integrative review. In J. D.

Houwer & D. Hermans, Cognition and Emotion: Reviews of Current Research and

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Bonus, K.A., Stoney, C.M., Salomons, T.V., Davidson, R.J., Lutz, A. (2012). The

validation of an active control intervention for Mindfulness Based Stress Reduction

(MBSR). Behavior Research and Therapy, 50, 3-12.

Niss, L. K., & Arch, J. (2012). Brief mindfulness intervention on math test anxiety and exam

scores in a high school population. Unpublished thesis, University of Colorado.

Rozenzweig, S., Reibel, D. K., Greeson, J. M., Brainerd, G.C., & Homat, M. (2003).

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Shiverick, S. M., & Eckhof, O. K. (May, 2013). The effect of a brief mindfulness intervention on

and math anxiety on state anxiety. Poster presented at Meeting of the Association for

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Table 1

Correlations between measures of stress, anxiety, emotion regulation, mindfulness, and well-

being following four weeks of mindfulness practice

_____________________________________________________________________________

MASR Reappraisal Presence Acceptance Neg Affect Well-being

_____________________________________________________________________________

Math Anxiety (A-MARS1) -.39 .60 .26 .30 -.17 .48

Math Anxiety (MASR2) .81* .49 .65 .15 .71

Cog Reappraisal (ERQ3) .83* .89** -.11 .89**

FMI4 -Presence .80* -.40 .62

FMI-Acceptance -.08 .93**

Negative Affect5 .18

____________________________________________________________________________

Note. 1Abbreviated Math Anxiety Rating Scale, 2Math Anxiety Scale Revised , 3Cognitive

Reappraisal Scale of Emotion Regulation Questionnaire, 4Freiberg Mindfulness Inventory,

5Scale from Positive and Negative Affect Scale. *p < .05, *p < .001.

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Table 2

Mean Changes in Math Anxiety, Emotion Regulation, Mindfulness, Affect, and Well-Being After

4 weeks of Mindfulness Practice

_____________________________________________________________________________

Measures M Pre- M Post- ∆ SE t p

_____________________________________________________________________________

Math Anxiety (A-MARS1) 3.97 3.59 -0.39 0.11 -3.34 .01**

Math Anxiety (MASR2) 4.03 3.81 -0.22 0.11 -2.02 .09

Emotion Regulation (ERQ3) 3.98 4.97 1.00 0.28 3.56 .01**

FMI4 Presence 3.14 4.31 1.17 0.31 3.78 .001**

FMI Acceptance 3.06 4.11 1.06 0.29 3.71 .01**

Negative Affect 2.23 1.57 -0.66 0.24 -2.76 .03*

Well-Being 4.43 5.26 0.83 0.57 3.84 .001**

_____________________________________________________________________________

Note. 1Abbreviated Math Anxiety Rating Scale, 2Math Anxiety Scale Revised, 3Cognitive

Reappraisal Scale of Emotion Regulation Questionnaire, 4Freiberg Mindfulness Inventory,

5Scale from Positive and Negative Affect Scale. *p < .05, *p < .001.

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Figure 1. Change in state anxiety (STA) according to math anxiety (MA) and trait mindfulness.

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University of Wisconsin-Platteville IRB HUMAN PARTICIPANTS RESEARCH REVIEW PROTOCOL: STANDARD FORM

This protocol is to be submitted to and approved in writing by the IRB prior to the initiation of any investigation involving human participants, data, or material. Approval is valid for one year unless otherwise noted. Indicate Requested Review Level: Expedited Full Board

See Section III, pages 9-11, of the IRB Manual for instructions to determine the appropriate review level. Be aware that the IRB may require a level of review different from your request.

Principal Investigator(s)

Name(s): Rank/Title(s):

Department/Program(s): Email:

Sponsor(s) (if PI is a student)

Name(s): Rank/Title(s):

Department/Program: Email:

Project Title: Start Date for Data Collection: End Date for Data Collection: Is federal or other extramural funding being sought? Yes No Name of potential supporting agency:

Assurance of Departmental/Program Review:

If a departmental/program HSR exists, the signature of the HSR Chair assures the IRB that the protocol has been approved and a copy is on file in the department. If no HSR exists, the signature of the Department Chair assures the IRB that s/he has been informed of the project and a copy is on file in the department.

Signature/Date: _____________________________________________________________ Indicate Title: HSR Chair Department Chair

Assurance to IRB: I/we have read the UW-Platteville IRB Manual of Policies and Procedures for Research Involving Human Participants and will comply with the informed consent requirement and conditions. Further, I/we will inform the IRB if significant changes are made in the proposed study. Signature of PI(s)/Date: _________________________________________________________________ Signature of Sponsor(s)/Date: ___________________________________________________________

Phone:

Phone:

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PART I: DESCRIPTION OF STUDY Note: For detailed instructions on completing Parts I and II, refer to pages 20-23 of the IRB Manual. A. RESEARCH QUESTION: (Include appropriate citations)

B. HYPOTHESIS (ES):

C. PARTICIPANT SELECTION:

1. Number of participants:

2. Human participant pool:

a. Relevant features of the participants you will be using:

b. Relevant affiliations of your participants:

3. If participants are from a legally restricted group:

a. Explain the necessity of using these particular groups:

2.

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b. Describe any special arrangements to protect their safety, rights and well-being:

D. PROCEDURES:

1. Recruitment procedures and material inducements for participation:

2. Location of study (data collection):

3. Personnel and relevant affiliations:

4. Information to be gathered and means for collecting and recording data (include citations, if applicable; attach all materials):

5. Step-by-step description of procedure(s):

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6. Proposed design and statistical analysis:

E. REFERENCES: (for above citations)

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PART II: HUMAN PARTICIPANT PROTECTION A. POTENTIAL RISKS YOU CAN ANTICIPATE FOR PARTICIPANTS:

1. Describe immediate risks, long-term risks, and rationale for the necessity of such risks, alternatives that were or will be considered, and why alternatives may not be feasible.

2. Describe any potential legal, financial, social, or personal effects on participants of unintentional data disclosure.

B. SAFEGUARDING PARTICIPANTS’ IDENTITY:

1. Where might you present or publish your findings? Will any formal papers or reports result from your project and with whom will they be shared?

2. What precautions will be taken to safeguard identifiable records of individuals and/or groups? How will confidentiality of data be protected?

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C. EXPECTED BENEFITS FOR PARTICIPANTS (IF ANY) AND/OR SOCIETY:

1. Clarify the potential for new knowledge resulting from this study as well as any benefits directly to the participants.

2. Summarize the content of your debriefing.

D. DECEPTION USED IN GATHERING DATA:

Justify the use of any deception in the project. If participants are provided with any untruthful or misleading information, provide a detailed written description of the debriefing.

E. INFORMED CONSENT:

Submit a copy of all materials used in the recruitment and selection of participants. Either submit a copy of the (signed or unsigned) consent form or, if you believe informed consent

should be waived for your project, write a justification for your recommendation based on the criteria detailed in Section VII, page 15, of the IRB Manual.