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ABSTRACTYoga is being used by a growing

number of youth and adults as ameans of improving overall healthand fitness. There is also aprogressive trend toward use of yogaas a mind-body complementary andalternative medicine intervention toimprove specific physical and mentalhealth conditions. To provideclinicians with therapeutically usefulinformation about yoga, the evidenceevaluating yoga as an effectiveintervention for children andadolescents with health problems isreviewed and summarized. A briefoverview of yoga and yoga therapy ispresented along with yoga resourcesand practical strategies for clinicalpractitioners to use with theirpatients. The majority of availablestudies with children andadolescents suggest benefits to usingyoga as a therapeutic interventionand show very few adverse effects.These results must be interpreted aspreliminary findings because many ofthe studies have methodologicallimitations that prevent strongconclusions from being drawn. Yogaappears promising as acomplementary therapy for childrenand adolescents. Further informationabout how to apply it most

YOGA AS A COMPLEMENTARY THERAPYFOR CHILDREN AND ADOLESCENTS:A Guide for Cliniciansby LISA C. KALEY-ISLEY, PhD, RYT-500; JOHN PETERSON, MD; COLLEEN FISCHER, PhD; and EMILY PETERSON, CYTDr. Kaley-Isley is from the University of Colorado School of Medicine, Division of Psychiatry, Denver, Colorado; Dr. Peterson is Director, Child andAdolescent Psychiatric Services, Denver Health Medical Center and Associate Professor, Department of Psychiatry, University of Colorado School ofMedicine, Denver, Colorado; Dr. Fischer is from Denver Health Medical Center and the University of Colorado School of Medicine, Division ofPsychiatry, Denver, Colorado; and Ms. Peterson is from Beloit College, Beloit, Wisconsin.

Psychiatry (Edgemont) 2010;7(8):20–32

FUNDING: There was no funding for the development and writing of this article.

FINANCIAL DISCLOSURES: The authors report no relevant conflitcs of interest relevant to thecontent of this article.

ADDRESS CORRESPONDENCE TO: Lisa C. Kaley-Isley, PhD, RYT-500, University of ColoradoSchool of Medicine, Division of Psychiatry, 9 Glenluce Road, London, UK SE3 7SD; E-mail:lckaley_isley@me.com

KEY WORDS: adolescent, child, complementary and alternative medicine, pediatric, reviewarticle, yoga

[ R E V I E W ]

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effectively and more coordinatedresearch efforts are needed.

CASE STUDYJeremy was a 12-year-old boy with

a history of being diagnosed withmild asthma, attention deficithyperactivity disorder (ADHD), andrecent onset obesity. Jeremy wasaccompanied to a psychiatricevaluation by his mother and his 14-year-old sister, Janice. The motherreported that Janice was “alwaysstressed out” and “worried aboutgaining weight.” The motherexplained that she was interested ingetting help for her children but shewished to avoid medication. She andher children heard that yoga couldbe helpful but they did not knowmuch about it and wanted to learnmore.

INTRODUCTION The practice of yoga for fitness

and wellness in gyms, communitycenters, and yoga studios isbroadening into yoga therapy beingprovided in schools, hospitals, andcommunity treatment centers. Infact, the leading yoga magazine,Yoga Journal, recently claimed that“yoga as medicine represents thenext great wave.”1 According to a2008 survey, an estimated 6.9percent (15.8 million) people in theUnited States practice yoga.1

Additionally, another 4.1 percent(9.4 million) of those who are notcurrently practicing yoga said theywould definitely try yoga during thenext year.1 While many cliniciansremain unfamiliar with the practiceof yoga, the same 2008 surveyindicated that 6.1 percent (14million) of Americans said a doctoror therapist had recommended yogato them.

Other surveys assessing thefamiliarity and acceptance ofcomplementary and alternativemedicine (CAM) practices by thegeneral public and medicalpractitioners report similar use andacceptance patterns for yoga. In a2000 survey of 39 CAM practices, 95percent of 589 respondents hadheard of or tried yoga, and 93

percent had heard of or triedmeditation.2 Yoga was ranked fifthout of 39 therapies surveyed interms of its perceived effectiveness.In a study looking specifically at theacceptability of CAM practices in apediatric hospital outpatient painclinic setting, both the children’s andparents’ ratings placed yoga as thethird most likely helpful CAMapproach.3 When conventionaltreatments were included in theratings, yoga was rated fourth forboth groups, with medications rated“more likely” to help, and surgery“less likely” to help than yoga.

Likewise, the 2002 and 2007United States National HealthInterview Surveys (NHIS), whichincluded specific questions on CAMuse by adults and children,document a growing trend of yogapractice by adults and children, inparticular by children whoseparents use CAM.4 Four of the 10most frequently used CAMinterventions by children are yogapractices. In addition, 3 of the 4CAM practices showing the mostgrowth in use by adults between the2002 and 2007 NHIS surveys wereyoga practices.4

TABLE 1. Timeline for the development of yoga

3000–1500 BCE1

Vedic texts (“to know”) collection of hymns and ritualscelebrating harmony with the forces of nature provide earliestwritten evidence of yoga including breath, philosophy, andspirituality

1500 BCE1

Upanishads (“sitting down near” [a teacher]) answers theexistential questions of birth, death, meaning and purpose oflife, “yoga” encountered by name

700 BCE2

Bhagavad Gita text on brahmavidya (supreme science) of yogadefines 3 paths of yoga: jnana (path of wisdom), bhakti, (pathof devotion), and karma (path of service/action)

400 BCE3 Patanjali writes the Yoga Sutras; Ashtanga (eight-limb) and Raja(royal) yoga defined

600 CE–1500 CE4 Hatha Yoga Pradipika written

1900–present Hatha yoga introduced in the West and becomes mainstream asexercise and a popular lifestyle choice

1989 International Association of Yoga Therapists (IAYT) established

1991 Office of Alternative Medicine (OAM) established in the NationalInstitutes of Health (NIH)

1998 OAM upgraded to NIH National Center for Complementary andAlternative Medicine (NCCAM)

1999Yoga Alliance (YA) formed from merger between Unity in Yoga(formed 1982) and Ad Hoc Yoga Alliance (formed 1997). Setsnational training standards for yoga teachers.

1Easwaran E. The Upanisads. Tomales, CA: Nilgiri Press; 1987.2Easwaran E. The Bhagavad Gita. Tomales, CA: Nilgiri Press; 1985.3Saraswati S. Four Chapters on Freedom. Bihar, India: Yoga Publications Trust; 1976. 4Muktibodhananda S. Hatha Yoga Pradipika: Light on Hatha Yoga. Bihar, India: YogaPublications Trust; 1985.

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The popularity of yoga hascreated a need for empirical studiesto evaluate the efficacy andlimitations of yoga as a method ofwellness, disease prevention, andtreatment intervention. There is alsoa need to provide clinicians withpractical information about yoga andthe current state of evidencesupporting its use with children andadolescents. The majority ofavailable yoga studies have beenconducted with adults, with recentepidemiological research indicatingthat many adults perceive yoga to bebeneficial for musculoskeletal

problems, mental health conditions,and overall health.5 However, studiesto evaluate the potential benefits ofyoga with children and adolescentsare limited. Two recent systematicreviews of yoga for the pediatricpopulation concluded that themajority of studies report benefitsfrom yoga, but the evidence is low inmethodological quality andquantity.5,6 While this conclusioncontinues to appear valid, it seemsinsufficient for clinicians who arequestioned by patients and familiesabout the practice and potentialbenefits of yoga.

The objectives of the presentarticle are as follows: 1) provideclinical practitioners with a brief andpractical overview of yoga and howit might be used as a complementarymind-body therapeutic tool in thepediatric population; 2) review thecurrent evidence suggestive ofbenefits to using yoga for theimprovement and maintenance ofoverall health and fitness as well asthe evidence for potentiallyimproving or augmenting thetreatment of specific healthproblems; and 3) provideinformation about the availabilityand evaluation of yoga resources forchildren and adolescents.

SOME BACKGROUNDINFORMATION ON YOGA

Yoga originated 4,000 or 5,000years ago in what is now India.7 Overtime, yoga developed as a science,philosophy, and psychology.8–10 Table1 provides a timeline for thedevelopment of yoga in ancienttimes and the present. The yogapractices that arose out of thesesystems of thought were designed tofacilitate development andintegration of the human body,mind, and breath to producestructural, physiological, andpsychological effects.7 The aims ofyoga are the development of thefollowing: 1) a strong and flexiblebody free of pain; 2) a balancedautonomic nervous system with allphysiological systems, e.g.,digestion, respiration, endocrine,functioning optimally; and 3) a calm,clear, and tranquil mind. Beyondthese specific outcomes, yogapractices are intended to facilitateself transformation at every level offunctioning, with the goal ofimproving the overall quality of life.

In the century since yoga wasintroduced into the West, there hasbeen a substantial proliferation inthe number of schools of yoga andyoga teachers. As of April 2010, YogaAlliance (YA), the professionalcredentialing body for yoga, lists1,007 schools approved by YA in theUnited States to train yoga teachers,and 25,026 registered yoga teachers

TABLE 2. Factors to consider in choosing a yoga class

DIFFERENTIAL CLASS FACTORS VARIATIONS

Temperature of the room • Heat of the room between 90 and 104 degrees F• Heat of the room between 75 to 80 degrees F

Fixed vs. variable sequences • Repetition of same poses in same order each class • Sequence of poses varies

Pace of movement in and out ofposes and between poses

• Poses may change with each inhale and exhale• Poses may be held for between 5 breaths to one

minute• Combination of repetition in and out of the pose,

then holding the pose for several breaths

Use of props to make poses moreaccessible and supported

• Block, strap• Blanket, bolster• Chair, wall

Use of augmenting yoga practices• Bandha (energy locks) • Kriya (purification) • Mudra (gesture, seal, or attitude)

Use of more regulated orvigorous breathing practices

• Nadhi shodhana (alternate nostril) • Kapalabhati (skull shining/bellow)• Krama (inhale and/or exhale in segments)• Bramuri (bumble bee)• Ratio - regulate individual components of inhale,

retain after inhale, exhale, suspend after exhale

Meditation

• Guided visualization• Focus on breath• Witnessing thoughts• Mantra japa (silent repetition of a meaningful sound

or phrase)

Spirituality• Kirtan (devotional chanting)• Mantra japa • Connection with the divine or a higher power

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(RYTs). The schools of yoga differon a number of dimensions thatinfluence the instructions given bythe teacher, the structure andcontent of the class, and theenvironmental conditions of theclass. Table 2 lists factors to takeinto consideration when choosing ayoga teacher and class. Table 3defines terms and practicescommonly used in yoga classes.

Traditionally, yoga was taught byoral transmission from teacher tostudent so that the practices couldbe individually tailored to theevolving needs of the student.Currently in the West, the principlemode of instruction is a group class.The advantages of group yogaclasses are similar to those for grouptherapy: one teacher can provideinstruction to more individuals atone time, the cost for a class is lessthan for private instruction, and thegroup members can provide supportin addition to that offered by theteacher. The disadvantages are alsosimilar to those of group therapy inthat less personalized attention andinstruction may be less beneficiallytargeted or even harmful to theneeds of the individual at any giventime. However, skilled yoga teachers,like skilled clinicians, can provideindividualized guidance even in agroup setting by offeringalternatives, modifications, andpersonalized adjustments toindividual class members.

One of the hallmarks of yoga isthat the practice has beencontinuously adapted to the cultureand the individual needs of thepractitioner. The growing number ofyoga schools in the West is evidencethat this tailoring to different needs,interests, and conditions persists.The processes of matching andindividualizing yoga to eachparticipant are quintessential toyoga, and are recommended for yogaclasses, but they are an even moresignal aspect of yoga therapy.

YOGA THERAPYYoga is recognized by the National

Institutes of Health (NIH) NationalCenter for Complementary and

TABLE 3. Commonly used Sanskrit terminology in yoga

SANSKRIT TERM APPLIED DEFINITION

Yoga To yoke together to unite

Jnana yoga Path of wisdom

Bhakti yoga Path of devotion

Kriya yoga Path of action

Raja yoga Royal path

Hatha yoga

Ha signifies prana (vital force, life energy) and Tha indicates mind ormental energy. Hatha encompasses the dialectical elements of heatingand cooling, active and passive, energizing and calming, which areindividually developed and then brought into balance.

Yoga Cikitsa Yoga therapy

Asana “Seat,” physical poses

Prana Life force energy

Pranayama Breathing practices: heating, cooling, cleansing, and balancing

Pratyahara Drawing the senses inward

Dharana Concentration

Dhyana Uninterrupted concentration

Samadhi Becoming united as one with the object of concentration

Kriya Cleansing and purification of physical organs or subtle energy channels

MudraGesture with a part of the body, e.g., the hand with thumb andforefingers touching, or the whole body, e.g., bowing, to stimulate anawareness or attitude

BandhaDirecting attention to an area of the body (throat, abdomen, orperineum) then through muscular action and subtle awarenessdeepening the awareness of energy in the area

Mantra japa Silent repetition of a meaningful sound or word(s)

Kirtan Chanting or singing mantras out loud

Yoga Nidra Yogic sleep; guided, progressive relaxation of body, mind, and emotionsto help achieve intentions

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Alternative Medicine (NCCAM) as aform of CAM in the category of“mind-body” medicine. NCCAMasserts that mind-body medicine“focuses on the interactions amongthe brain, mind, body, and behavior,and on the powerful ways in whichemotional, mental, social, spiritual,and behavioral factors can directlyaffect health.”11 Furthermore, “Mind-body medicine typically focuses onintervention strategies that arethought to promote health…Itregards as fundamental an approachthat respects and enhances eachperson’s capacity for self knowledgeand self care, and it emphasizestechniques that are grounded in thisapproach.”11 Consistent with theNCCAM definition, yoga therapy is

defined by the InternationalAssociation of Yoga Therapists(IAYT) as “the process ofempowering individuals to progresstoward improved health and well-being through the application of thephilosophy and practice of yoga.”12

Yoga practices can be designed tofoster developmental, preventative,therapeutic, and/or transformationalaims.7,13 In yoga therapy, theemphasis is on adapting thetechniques of yoga to address thespecific concerns of the individual orgroup.7 Table 4 lists developmentalfactors to consider when teachingyoga to children and adolescents.Table 5 provides guidance inmatching types of yoga to particulardiagnostic presentations.

METHODWe conducted a comprehensive

review of the literature, extractingcitations from the following sources:Ovid MEDLINE, PsycINFO, CochraneReviews, EMBASE, and ERICdatabases. Using controlled languagefor each of these databases, wesearched expanded terms for yogaand children, as well as the truncatedsynonyms of these concepts as textwords utilizing appropriate proximityoperators. We excluded bookchapters, dissertation abstracts,studies involving participantsyounger than school age, studies ofphysiological responses, anddevelopmental disabilities. Weincluded studies specificallyevaluating college students, but didnot include other adult studies orstudies that examined a mixedpopulation of children and adults.Studies included in the currentreview cite the use of yoga 1) in adevelopmental or preventative wayto foster or bolster healthierfunctioning in youth at risk forpsychiatric or medical disorders and2) in a therapeutic way with youthwho are diagnosed with psychiatricor medical disorders. For areas inwhich the pediatric literature wasscarce, the use of yoga in the adultliterature was referenced. In additionto a literature review,recommendations and resourceswere gathered and presented forclinical practitioners in their workwith children and adolescents.

DEVELOPMENTAL ANDPREVENTATIVE USES OF YOGA

Developmental uses of yoga aregeared toward nurturing inherentcapacities and facilitating mastery,e.g., strengthening the physical body,increasing energy and stamina,building coping capacity, andenhancing attention, concentration,and memory.13 Preventative yogaapproaches aim to protect andpreserve capacity that an individualhas already achieved. This mayinclude protecting structural stabilityor maintaining self esteem in the faceof challenges. Three studiesexamined the effects of yoga on self

TABLE 4. Developmental considerations in a yoga class with children and adolescents

AGE OF PARTICIPANTS DURATION

Preschool age (3–6 years)

• Total duration: 15–20 minutes• Focus awareness 2–3 minutes• Poses: 10 minutes• Breathing or singing 2–3 minutes• Guided visualization 2–3 minutes

School age (7–12 years)

• Total duration: 30–45 minutes• Focus awareness: 3–5 minutes• Poses: 15–25 minutes (can be

incorporated into a story or game)• Breathing or singing: 3–5 minutes• Guided visualization relaxation: 5 minutes

Adolescents (13–18 years)

• Total duration: 45–90 minutes• Focus awareness: 5–10 minutes• Poses: 30–50 minutes• Breathing: 5–10 minutes• Guided relaxation: 5–10 minutes

AGE OF PARTICIPANTS SPECIAL CONSIDERATIONS

Preschool and school age

• Use English nature names for poses• Use short and simple instructions• Demonstrate poses• Hold poses for a maximum of 3 breaths• Maintain an attitude of playful calm• Create a safe environment

Adolescents

• Be sensitive to body image• Use touching adjustments with care; give

opportunity to opt out of being touched• Be aware of clothing issues (tight jeans,

bare feet, revealing shirts or shorts)• Encourage nonjudgmentalness and

noncompetitiveness

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worth and self perception with thegoal of improving positive selfconcept. The findings must beconsidered preliminary as the studiesall have small sample sizes and theinterventions lack appropriatecontrols. Table 6 presents links tothe yoga programs evaluated in thestudies.14–16,18,21,25,40

An uncontrolled pilot studyexamined the effects of an after-school “Bent on Learning” programthat included yoga postures,breathing, relaxation, and meditationwith fourth and fifth grade inner-citychildren.14 The yoga intervention wasone hour per week for 12 weeks ingroups of approximately 20 students.The participants demonstratedimproved negative behavior scorespost-intervention compared to thenon-yoga group, although nosignificant differences were indicatedfor the other well being outcomes.

A nonrandomized, controltreatment design evaluated a “SelfDiscovery Program,” whichintegrated elements of yoga,massage, and relaxation for childrenages 8 to 11 years with emotional,behavioral, or learning difficulties inthe United Kingdom.15 Theintervention was 45 minutes, once aweek, for 12 weeks. The yoga groupdemonstrated small, thoughsignificant, improvements in levels ofself confidence, social confidencewith teachers, communication withpeers, contributions in theclassroom, and level of totaldifficulties on the Strengths andDifficulties scale.

In another study, college studentsin a lecture-only health course werecompared to peers in health fitnesscourses where yoga was one of thefitness courses.16 The health fitnesscourse groups collectively evidencedsignificant differences on fiveindicators of emotional well being(e.g., Global Self Worth,Appearance), but the specific effectsof the yoga class were not separatelyevaluated.

CASE STUDY, CONTINUEDJeremy was interested in doing

yoga. He asked, “Could yoga help my

TABLE 5. Diagnostic considerations in a yoga class with children and adolescents

DIAGNOSES CONSIDERATIONS

Anxiety and attention deficit hyperactivitydisorder

• Use movement in poses to discharge anddirect energy; begin with energizing andend with calming poses.

• Use instructions to focus attention onpresent moment sensations.

• Teach belly breathing as anxiety/agitationmay increase with upper chest breathing.

• Teach guided relaxation asanxiety/hyperactivity may increase duringrelaxation.

• Progressively increase length of exhale.

Depression and obesity

• Begin with slow and easy movements;progressively increase activity level.

• Use instructions to focus attention onpresent moment sensations.

• Gently encourage deeper twists, newposes, and longer holds in poses toincrease capacity to go beyond self-perceived limits.

Eating disorders: anorexia nervosa andbulimia

• Be sensitive to competitiveness,especially in groups.

• Find balance between overly vigorousand too gentle poses to dischargeagitation and not weight loss.

• Cultivate awareness of positive bodilyattributes, e.g., strength and flexibility,and change in pre-post states.

• Use guided relaxation and progressivemuscle relaxation to cue how to relax.

• Consider use of positive mantras asaffirmations.

Pain and injury

• Differentiate pain from unfamiliarsensation; do not increase pain.

• Move gently in and out of poses withawareness of effects.

• Direct attention to area of pain andvisualize breathing into it to release pain;observe changing sensations.

• Use props to make poses more safelyaccessible (blocks, straps, bolsters,blankets).

Asthma

• Focus on breath in belly and lengtheningexhale; use windmills and feathers to seeeffect of exhale.

• Use frequent reminders to breathesmoothly and evenly and to increaseawareness of changes in breath, e.g., if itbecomes erratic or constricted.

Irritable bowel syndrome• Use prone backbends, gentle twisting

poses, and forward bends to increaseperistalsis and relaxation.

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ADHD?” Janice also wanted to findout whether yoga might help her feelless “stressed out.” The clinicianexplained that both children neededto be thoroughly evaluated beforeany specific treatmentrecommendations were made, thendiscussed some of the evidencesupporting the use of yoga forpediatric mental health problems.

THERAPEUTIC USES OF YOGAFOR MENTAL HEALTHDISORDERS

Therapeutic yoga is intended toalleviate suffering, supportrehabilitation, and improve quality oflife.13 With children, therapeuticinterventions are often facilitativerather than rehabilitative in thattheir capacities are still in theprocess of being developed. Thecurrent review shows yoga beingused in its facilitative capacity withchildren at risk for developingdisorders, and in academic andtreatment settings with childrenwith diagnosed disorders ofattention, anxiety, depression, andeating disorders.

Attention. Four publishedstudies17–21 have evaluated methodsof teaching yoga to children (ages8–13) diagnosed with ADHD, and afifth study assessed yoga taught tofirst through third graders with“attention concerns.” A randomized,controlled crossover treatmentdesign examined the effect of yogaas a complementary treatment for 19boys (ages 8–13) diagnosed withADHD.17 Most of the boys weretaking medication during the 20-week study. The weekly one-houryoga classes included postures,breathing practices, relaxationtraining, and a yoga gazingconcentration exercise (tradaka).Significant improvements pre- topost-test were found for five of theConners Parent Rating subscales forthe yoga group only: Oppositional,Global Index Restless/Impulsive,Global Index Emotional Lability,Global Index Total, and ADHDIndex. The control group (and notthe yoga group) that participated incooperative activities showed

TABLE 6. Yoga resources

NAME OF RESOURCE DESCRIPTION AND URL

CAM on PubMedA subset of the PubMed system developed by NCCAM and NLM focused onCAM http://nccam.nih.gov/research/camonpubmed/

NCCAM Time to TalkToolkit

An educational campaign to encourage patients and their healthcareproviders to openly discuss the use of CAMhttp://nccam.nih.gov/timetotalk/forphysicians.htm

Yoga Alliance

Yoga Alliance (YA) has established minimum curriculum standards andnumber of contact training hours for yoga teachers at the 200, 500, and1,000-hour levels. The YA website is a good resource for locating a yogateacher and knowing the questions to ask when choosing a yoga teacher.http://www.yogaalliance.org/teacher_search.cfm

International Associationof Yoga Therapists (IAYT)

Supports research and education in yoga and serves as a professionalorganization for yoga teachers and yoga therapists worldwide. Establishesyoga as a recognized and respected therapyhttp://www.iayt.org/

American ViniyogaInstitute, Gary Kraftsow

An approach to yoga that adapts the various means and methods of practiceto the unique condition, needs, and interests of the individual; practitionersgiven tools to individualize and actualize the process of self discovery andpersonal transformation.http://www.viniyoga.com/

Bent on Learning

Seeks to improve the physical fitness and cognitive, social, and emotionalskills of New York city public school students by providing regularinstruction in yoga and meditationhttp://www.bentonlearning.org/who_we_are/index.htm

Sahaja Yoga Meditation Focuses on awakening dormant energies to facilitate self-realizationhttp://www.sahajayoga.org/

Yoga Ed

“Yoga Fitness for Kids ages 3–6” and “Yoga Fitness for Kids ages 7–12” 30-minute VHS tapes, instructed by Kalish, published by Gaiam, 2001 and2002. Develops health/wellness programs, training, and products forteachers, parents, children, and health professionals that improve academicachievement, physical fitness, emotional intelligence, and stressmanagementhttp://www.yogaed.com/

Sivananda Yoga VedantaCenters

A nonprofit organization founded by Swami Vishnu-devananda to spread theteachings of Vedanta worldwidehttp://www.sivananda.org/

Ashtanga Yoga

A physically vigorous form of yoga that aims to build internal heat throughsynchronizing movement with breathing while doing a set sequence ofpostureshttp://yoga.about.com/od/ashtangayoga/a/ashtangs.htmhttp://www.kpjayi.org/

Yoga for the Special Child®

LLC

A comprehensive program of yoga techniques designed to enhance thenatural development of children with special needs; emphasizes gentle andtherapeutic yoga safe for babies and children with Down syndrome, cerebralpalsy, microcephaly, autism, and other developmental disabilities; also usedwith children diagnosed with attention deficit hyperactivity disorder andother learning disabilitieshttp://www.specialyoga.com/

YogaKids

A comprehensive program using yoga, Howard Gardner’s MultipleIntelligences Theory, curriculum integration techniques, and charactereducation techniqueshttp://yogakids.com/

Storytime Yoga

Integrates yoga and storytelling, poetry, Spanish, healthy eating, and peaceand character education to produce healthy, peaceful, and literate children,families, and communitieshttp://www.storytimeyoga.com/

CAM: complementary and alternative medicine

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improvements on the ConnersHyperactivity, Anxious/Shy, andSocial Problems subscales. Bothgroups showed improvements insome of the parent-rated scales(e.g., Perfectionism, DSM-IV Total),but no changes on the teacherreport. There was a positive doseresponse effect on a measure ofattention for subjects whoparticipated in more home-basedpractice and attended more sessions.

In a nonrandomized,quasicontrolled treatment study, asix-week Sahaja Yoga Meditationintervention was evaluated withchildren (ages 8–12 years)diagnosed with ADHD (most ofwhom were taking medication) andtheir parents.18 The three-weekintervention was a 90-minute guidedmeditation two times a week. Inbetween sessions, parents wereasked to lead their child inmeditation at home and to keep arecord of their practice. Pre- andpostintervention results indicated adecrease in ADHD symptoms on theConners Rating Scale, reduceddosage in stimulant medicationreported at six weeks, and anincrease in parent-child relationshipquality in the treatment group.

A nonrandomized, controlledtreatment design evaluated theeffects of an eight-week yogaprogram in a group of Iranianchildren (ages 9–12 years)diagnosed with ADHD.19 The 45-minute yoga class included 10minutes of breathing practices, 25minutes of beginner yoga poses, and10 minutes of relaxation, twice aweek for eight weeks. Resultsindicate a reduction in ADHDsymptoms on both attentional andhyperactivity subscales.

One study assessed the additivebenefits of yoga and massage asadjunctive treatments to standardoutpatient care for childrendiagnosed with ADHD.20 Allparticipants received standard care.One group also received yoga asexercise, and a second group alsoreceived massage. The yoga andmassage interventions were 20minutes, once a week, for six weeks.

Parents were present during thetraining sessions and they wereasked to provide massage or guidethe yoga practice at home with theirchild between sessions. No statisticalanalysis was reported for any of themeasures. Results were reported interms of patient satisfaction scoresand interview comments, whichwere positive for all groups. Negativecomments from yoga participantswere 1) children did not like doingthe poses at home with their parentsbut did enjoy class, and 2) parentswould have liked more instructionbefore being asked to teach theposes at home.

A yoga video was assessed as ameans of increasing time on-task ina study of elementary schoolchildren (first through third graders,n=3) with attentional concerns.21

The children practiced to a 30-minute “Yoga Fitness for Kids” VHStape twice a week for threeweeks.22,23 Using a multiple baseline,nonrandomized, controlledtreatment design and a follow-upphase, effect sizes of theintervention ranged from 1.5 to 2.7for the outcome of on-task behavior,a large effect size according toCohen’s 1992 guidelines; follow-uptreatment gains decreasedsomewhat (0.77 to 1.95), but fellwithin a moderate-to-large effectsize. The comparison group’s on-taskbehaviors did not improve.

Anxiety. Three child andadolescent studies24–26 were identifiedthat evaluated yoga as a treatmentintervention for anxiety. Anintervention that combined yogapostures, rolling pin massage, andprogressive muscle relaxationintervention was used with 40psychiatrically hospitalizedadolescents diagnosed withadjustment disorder anddepression.24 Using a within-subjectspretest/post-test design, thecombination intervention wasadministered once to assess itsimmediate effects. The yogaparticipants (and not the controls)reported decreased anxiety andincreased positive affect, and theywere observed to show less anxious

behavior and fidgeting. The subjectsdiagnosed with adjustment disorderand one-third of those diagnosedwith depression had reduced cortisollevels post intervention.

Using a nonrandomized,controlled treatment design, theeffectiveness of the “Training ofRelaxation with Elements of Yoga forChildren” program based onSivananda yoga was evaluated withparticipants aged 11 and 12 whoevidenced high levels of schoolexamination anxiety.25 Theparticipants showed significantreductions in aggression,helplessness in school, physicalcomplaints, and an increase instress-coping abilities and generalwell being, but no significantreduction in school exam anxiety orincrease in self efficacy.

The effects of Hatha yoga onperceived stress, affect, and salivarycortisol were examined using anonrandomized, controlled trialdesign in a sample of collegestudents.26 The Hatha yoga andAfrican dance course groups (butnot the biology lecture group) selfreported significant reductions innegative affect and perceived stress.The yoga participants showed adecrease in salivary cortisol incontrast to the African dance groupwho had an increase in cortisollevels. No significant effects werefound for positive affect in the yogagroup, but were found for theAfrican dance group. The authorsspeculate that the cortisoldifferences may have been due todifferences in the intensity of thetwo activities.

There have been nine Cochranereviews involving the use of yoga,but only one of these reviewsspecifically focuses on children oryoung people. In this review, yogawas one of many exerciseinterventions used as a potentialprevention and treatment for anxietyand depression in youth 11 to 19years old.27 The authors reportedmethodological quality and quantitylimitations similar to the studiesevaluating yoga. Mindful of thiscaveat, the authors concluded,

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“there is a small effect in favor ofexercise in reducing depression andanxiety scores in the generalpopulation of children andadolescents,” and it made littledifference on the outcome whetherthe exercise was of high intensity,e.g., aerobics class, or low intensity,e.g., relaxation classes or yoga.

Eating disorders. Threestudies28–30 were identified thatevaluated the impact of yoga as acomplementary intervention forchildren and adolescents with eatingdisorders or weight and bodysatisfaction concerns. A pilot studyassessed the potential benefits of aneight-week, individualized yogatreatment added to standardoutpatient treatment for adolescentsdiagnosed with an eating disorder.28

The participants were 11 to 21 yearsold, primarily female (n=50 girls, 4boys), and diagnosed with anorexianervosa, bulimia nervosa, or eatingdisorder not otherwise specified. Allparticipants received outpatientcare, which included physicianand/or dietician appointments everyother week. The group that alsoreceived yoga demonstrated greaterdecreases in eating disordersymptoms as assessed by the EatingDisorder Examination (EDE)compared to the controls at fourweeks post-intervention, andreported significantly reduced foodpreoccupation immediately afteryoga sessions. Both groupsmaintained current body mass index(BMI) levels and evidenceddecreased anxiety and depressionover time.

A prevention study using anintegrated yoga, relaxation, andteaching intervention wasundertaken with normal fifth gradegirls to assess impact on self-perception related to body image.29

The participants showed significantdecreases in body dissatisfaction onbulimia subscales and an increase ona social self-concept scale. However,no support was found for theoutcomes of drive for thinness,eating disorderedattitudes/intentions, or perceivedstress.

In a study with college womenwho reported dissatisfaction withtheir bodies, no significant post-intervention differences were foundbetween the yoga and controlgroups, but the third study arm, acognitive dissonance intervention,reported lower scores on outcomesof disordered eating, bodydissatisfaction, alexithymia, andanxiety.30

CASE STUDY CONTINUEDAfter Jeremy underwent a

thorough psychiatric evaluation andphysical exam and information andbehavior ratings were obtained fromschool and home, the clinicianagreed with the diagnosis of ADHD.Treatment recommendations werereviewed and Jeremy and his motherconsidered all the options, includingyoga. Janice was recently diagnosedwith irritable bowel syndrome (IBS)and wondered if she would benefitfrom doing yoga. Jeremy’s motheralso wondered if yoga was helpfulfor other pediatric medicalproblems, such as Jeremy’s asthmaand overweight condition. Theclinician explained some of theevidence supporting the use of yogafor pediatric medical problems.

APPLICATION OF YOGA TOMEDICAL DISORDERS

The literature evaluating theeffectiveness of yoga as anintervention for specific medicaldisorders with adults is more robustthat the literature is with youth.Beneficial effects from yoga in adultpopulations have been reported forcardiovascular disease,31 diabetesmellitus,32–34 epilepsy,35 back pain,36

and asthma.29–32

In contrast, only 7 out of 63studies evaluating yoga and asthmaincluded child participants. Perhapsin response to recruitmentchallenges, a surprising number ofyoga studies include both childrenand adults in their subject pool.Eighty of the articles excluded fromthe pediatric yoga review by Birdeeet al5 were eliminated because theyincluded both child and adultparticipants. Three of the studies

showing yoga to be helpful forchildren and adolescents withasthma include studies combiningadults and youth as participants, soconsistent with our review exclusioncriteria these are not includedhere.33,34

Asthma. Given the emphasis ofyoga on regulating the breath, thepotential effect of yoga practices onasthma has been a primary target ofinvestigation. In addition to thechild-adult combined articles, twostudies37,38 have evaluated the impactof yoga as a treatment interventionfor asthma with children. Anintegrated yoga intervention thatincluded yoga postures, breathingtechniques, and cleansing rituals wasevaluated with hospitalized youth,mean age 15.8, with a history ofchildhood asthma, recurrentepisodes of asthma during theprevious year, and exercise-inducedbronchoconstriction.37 Theintervention was delivered twicedaily (90 minutes in the morning and60 minutes at night) for 40 days.Pulmonary functions, exercisecapacity, and exercise-inducedbronchoconstriction were allreported to improve post-intervention. Follow-up data for upto two years on some of the subjectsdocumented continued to showimprovements in asthma symptomsand decreased medication use. Ayoga exercise practice with 31school-aged Chinese childrendiagnosed with asthma found thatyoga exercise was a benefit toflexibility, muscular endurance, andcardiopulmonary fitness.38

Irritable bowel syndrome.Gastrointestinal disorders areclassed along with asthma asdisorders that may be exacerbatedor precipitated by stress and othermind-body interaction factors. Assuch, they may be particularlyamenable to a mind-bodyintervention. A 14-minute yoga videowas specifically designed to targetsymptoms of IBS.39 Twenty-fiveadolescents (aged 11–18 years)diagnosed with IBS took a one-hourinstructional class then were askedto practice daily with the video at

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home. The teens in the yogaintervention group reported lowerlevels of functional disability, lessuse of emotion-focused avoidance,and lower anxiety following theprogram than teens in the controlgroup. The yoga-group teens saidthey found practicing yoga to behelpful and indicated they wouldcontinue to use it to manage theirIBS.

Diabetes. An uncontrolled pilotstudy examined both physical andpsychological outcomes of yogaintervention in a small sample ofpredominantly Hispanic children(ages 8–15 years) at risk for thedevelopment of type 2 diabetes.40

The yoga intervention was anAshtanga yoga class modified todecrease the physical intensity ofthe sequence so the children did notfatigue or harm themselves. Theclass was 75 minutes, three times aweek for 12 weeks. The participantsshowed positive outcomes of weightloss, improved self concept, andimproved anxiety symptoms.

CASE STUDY CONCLUDEDJanice and Jeremy practiced yoga

on a regular basis. Their mother waspleased with the health-promotingaspects of yoga and decided topractice it herself. Janice especiallyliked the breathing practices and theway she felt more relaxed afterclass. Jeremy lost some weight andwas proud of the many yoga poseshe could do.

DISCUSSIONYoga is intended to have an

optimizing effect, which is consistentwith the current research. One areaof focus in the child literature is theuse of yoga programs as a primaryprevention strategy and the schoolenvironment as a primary context toenhance children’s mental health.When using yoga to facilitatepositive self attitudes, two of thethree studies with school-agechildren reported significantimprovement in positive outcomesand reduction in negativebehaviors,15,40 but one study reportedonly reduction in problematic

behaviors.14 All three studies were of12 weeks duration and had similarcore yoga practice elements;however, they each used different,specific yoga interventions, and oneof the two with positive outcomesincluded massage.15 A secondpotentially distinguishing factor isthe degree of physical vigor in theyoga interventions. The study usingAsthanga yoga40 found reductions inanxiety but the one using Sivanandatechniques15 did not. The differentialbenefits cannot be clearly ascribedto the schools of yoga because ofother differing variables in thestudies, but it is noteworthy thatAshtanga is a more physicallyvigorous form of yoga thanSivananda. It may be that childrenwith anxiety benefit from morephysically active forms of yoga, atleast initially, in order to dischargephysical restlessness and shift theirattention from mentalpreoccupations.

The studies exploring thepotential for yoga to facilitatedevelopment of concentration andattention in a school setting withchildren with attention problemsdiffered in that two of them activelyincluded parents in delivery of theintervention.18,20 Three of the 4studies reported reductions inADHD symptoms;17–19 the fourth wasa parent-facilitated study where theparent led this aspect of the yogapractice.40 In contrast, the secondparent-facilitated treatment led toimprovement in the parent-childrelationship.18 One distinguishingfactor between the two parent-ledinterventions seemed to be theamount of coaching parents receivedbefore being asked to lead the childin the intervention, with morepreparation leading to greatersatisfaction.

The components in the yogainterventions used in three of theattention studies were otherwiserelatively similar, so we may begin toform some conclusions about thetype and dose of yoga needed to beeffective in this population. Theavailable evidence suggests a school-aged child diagnosed with ADHD

would most likely benefit from ayoga class 1) with same-aged peers,2) multiple components that includeuse of poses and focus on thebreath, 3) intentional cues toconcentrate attention, and 4) anending period of quiet or guidedrelaxation in a still position. Theclass time may span 45 to 90minutes. At least 6 to 8 weeks ofweekly sessions, or approximately 20hours of class time may be requiredto see beneficial effects, but theymay also manifest sooner. There islikely to be greater benefit if use ofthe skills is practiced at home andsupported by the classroomenvironment.

In addition to optimizingnormative development, yoga is alsobeing used as a remediation strategyfor children who demonstrateclinically significant mental healthconcerns. Three studies evaluatingyoga as a tool for reduction ofanxiety and stress and improvementin coping abilities and mood statesyielded mixed results.24–26 Onedemonstrated a decrease in anxietyand increase in positive affect,24 onefound no decrease in anxiety but anincrease in self efficacy,25 and thethird reported a decrease in negativeaffect and stress, but no increase inpositive affect.26 Two of the studiesused one-time cortisol sampling as abiomarker for stress and in bothcases cortisol levels decreasedfollowing yoga practice.24,26

Across the various studies, atrend emerged showing consistentreduction in problem behaviors andmixed results in terms of promotingpositive affect states. There was alsoone study showing a decrease inpositive self concept.40 Onehypothesis why yoga practice mayhave this differential effect is thatincreasing self awareness, especiallyof limitations, may have the effect oflowering self esteem and increasingexisting anxiety or depression, atleast in the short run. Tryingsomething new at which a person isnot skilled may also increase feelingsof inadequacy. It is noteworthy thatindividuals progressing through thestages of change from

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precontemplative to contemplativeand active often experience moredistress in the transitivecontemplative stage where there isawareness of the need to change,but the person has not yet developedthe means or the mastery to do so.The authors suggest that this findingwould reverse with a longer dose ofthe intervention. In order to addressthis question, it is recommended thatstudies use multiple data pointsrather than two data point pre-postmeasures to track the trajectory ofchange more closely. Also,implementation of studies withlonger intervention periods wouldhelp to clarify dose responsepatterns. Other factors to considerare the sensitivity of the measuresbeing used to detect shifts ininternalizing behaviors comparedwith externalizing behaviors, and thefact that a reduction in negativebehaviors may be more readilyobserved and valued by parent andteacher raters.

The studies targeting youth withdisordered eating habitsdemonstrated reductions in bodydissatisfaction, food pre-occupation,anxiety, and depression.28,29 The twostudies that measured thesereductions also found improved selfconcept. There was no weight loss inthe study populations with a low-weight eating disorder, but in apopulation at risk for type 2 diabetesthere was some weight loss, whichwas construed as a positive outcome.Weight regulation in children andadolescents is a topic of urgentconcern. Yoga may present a healthymode of exercise for youth who areobese or underweight, althoughstudies will need to continue toexplore this potential.

For children with medicalconditions, the studies revieweddemonstrated initial benefits fromthe mind-body interaction effects ofyoga. The studies with asthmashowed improvements in pulmonaryfunctions, exercise capacity, andexercise-inducedbronchoconstriction, which weresustained over two years follow upand led to decreased medication

use.37 The youth with IBS evidencedpsychological benefits in terms oflower levels of functional disability,less use of emotion-focusedavoidance, and reduced anxietylevels.39

The state of the yoga researchliterature clearly demonstrates thatthe utilization of yoga is outpacingthe Western scientific study of yoga.The current review of the pediatricliterature is consistent with previousreviews in finding promising resultsfrom studies with variablemethodological quality. Thelimitations of the studies include thefollowing: 1) few randomized,controlled trials (RCTs); 2) there arefew adequate descriptions of therandomization method in theexisting RCTs; 3) few studiesadequately characterize the type ofyoga intervention, the specificpostures used, and the intensity ofthe intervention; 4) small samplesizes and few studies adequatelyjustify the sample size; 5) fewstudies describe the qualifications ofthe yoga instructor; 6) the lack of anadequate description of the outcomeassessor’s blind status; and 7)adverse effects of yoga interventionsare not systematically described.5

The high utilization rates foryoga suggest it is an interventionthat children and adolescents arewilling to try and to sustain withsome degree of adherence. Theauthors who reviewed the yogaliterature as a treatment for anxietysuggested that yoga might beappealing because it isnonpharmacological, has few adverserisks if practiced as recommended,and may be an acceptable option toindividuals who reject psychologicaldiagnoses and treatments.41

Additional factors may include that,compared with most otherhealthcare options, yoga is relativelyaccessible and inexpensive. Yoga is aself-care practice, so it is a goodmatch for individuals who want totake a more active role in theirhealthcare. In general, yoga teachersadvocate a self-accepting,noncompetitive, and nonjudgmentalattitude that may be especially

appealing to youth with physicallimitations, body dissatisfaction, oremotional insecurities. The lessthreatening approach of yoga may bemore enticing than competitivesports as a means to increasechildren’s levels of physical activityand mental well-being. That yogamay help with children’s self-regulation abilities could be a keycomponent; children learn the skillsto regulate and calm their bodiesand emotions and to increase theirrepertoire of healthy coping skills.Furthermore, yoga may increase ayouth’s sense of mastery, particularlyfor those children who may not havefound mastery in the academic orsocial domains.

Along with the benefits, there arepotential risks involved in yogapractice. In the popular yogaliterature there are suggestions foravoiding “common yoga injuries”that include minor back and spinalproblems, neck injuries, shoulderand hamstring injuries, as well asankle, wrist, and knee injuries, butthere are no available data on thefrequency of these injuries.42

Although there are a few casereports of adverse events related tothe use of yoga in adults,5 there is aneed to conduct controlled studiesin which systematic data could begathered regarding any adverseeffects of yoga with adults, children,and adolescents. Only one of thestudies we reviewed reported anadverse event, in that case some oftheir yoga group participants scoredlower on the self-esteem measure atthe end of the study than atbaseline. Other potential risks arepresent in individuals with specificmedical conditions. Yoga poses thatare beneficial for some conditionsare contraindicated for others.Therefore, it is important thatchildren and adolescents takinggeneral yoga classes let the teacherknow if they have any illnesses,injuries, or chronic conditions. Poseswith the most risk tend to beinverted poses, which arecontraindicated for certain disordersmost often seen in adults (e.g., discdisease of the spine, extremely high

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or low blood pressure, glaucoma,retinal detachment, fragile oratherosclerotic arteries, a risk ofblood clots, ear problems, severeosteoporosis, or cervicalspondylitis).11 There are alsocautions for pregnant women, whichwould include pregnant teens,against practicing inversions or deeptwists, as well as the need fortrimester-specific guidance in theuse of supine, prone, and pelvicopening poses. Pregnant women areadvised to take prenatal yoga classesrather than general yoga classes ifthey are new to yoga, if they do notknow how to appropriately modifythe class content, and in order togain positive social support. There isa need to conduct controlled studiesthat gather systematic dataregarding any adverse effects ofyoga with adults, children, andadolescents.

Given that the initial research onthe use of yoga for children andadolescents is promising, moresystematic study is needed thatincludes the following:

1. More long-term and follow-upstudies

2. Larger sample sizes to enhancestatistical power

3. Randomization4. Use of appropriate control groups

are recommended.

The yoga literature would benefitfrom standardization of themeasures used to allow for accuratecomparison across studies. Moredirect study of the underlyingprocesses by which yoga is beneficialto children’s mental and physicalhealth concerns will also be animportant area for future research.Other potentially informativequestions for exploration include thefollowing: 1. Whether a specific style of yoga

might be most helpful for aspecific condition

2. If a specific dose-responserelationship exists for variousconditions and age groups

3. If certain yoga styles andapproaches might be optimal for

specific age groups4. Whether there are specific risks in

using yoga in the pediatricpopulation

5. Which conditions might place ayouth at greater risk for adverseevents from yoga participation

6. How the potential benefits of yogamight be modified by cultural andsocietal influences, since mostexisting studies of yoga have beenconducted in India where thepractice of yoga has a tradition ofgreater cultural acceptance

7. How the benefits of yoga might bemediated by specific factors, suchas exercise, meditation,philosophy, spirituality, andlifestyle.

There are limitations to thisreview as well. This review narrowedthe scope of the already limitedpediatric yoga literature to focus onthe effectiveness of yoga as acomplementary physical and mentalhealth intervention with school-agechildren and adolescents. Thereview was not exhaustive and didnot include quantitative analysis ofthe data (e.g., a meta-analysis).Studies evaluating physiologicalfunctioning, mental retardation,developmental disabilities, studies ofchildren younger than school age,and studies with mixed child andadult populations were excluded.Studies published only in India andin languages other than English werealso excluded. The small number ofstudies on any one diagnosticcategory made it difficult toformulate practice recommendationsthat are evidence based.

Many CAM interventions,including yoga, emerge from Easternsystems of medicine. As sciences,they have their own methods ofobservation and assessment, butthose strategies have not historicallyincluded randomized, controlledtrials and the other features forwhich Western reviewers look inrating the effectiveness of anintervention. Likewise, yogapractitioners train in small,independent training programs notaffiliated with universities. If yoga is

indeed to develop as a yoga therapyprofession in the Western healthcaresystem, partnerships and crosstraining are needed betweenresearchers and practitioners whoare knowledgeable in the elementsessential to both systems.

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