Name: Breanna Dickson & Kristen Kincaid

Date: October 7, 2014

Focus Question: What is the effectiveness of yoga for reducing negative stress behaviors in children?

Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table: Level IIII articles, English only, full-length publications in peer-reviewed journals, child and adolescent populations only

Author/
Year
White
(2012)

Study
Objectives

Level/Design/
Subjects

Intervention and
Outcome Measures

Results

Study
Limitations

Implications for OT

To investigate
the efficacy of
an 8 week
mindfulness
stress-reduction
program through

Level I

Intervention:
Weekly one hour
class that met
immediately after
school; Mindful
Awareness for Girls

No significant
differences were
found between
the intervention
and control
group for

Sample selection
bias

The clinical and

community-based
practice of OT: Schoolbased therapists would
easily be able to
implement yoga
programs but should be

Randomized
control trial

Large number of
participants in

yoga with
school-age girls
to reduce
perceived stress,
enhance selfesteem, coping
abilities, and
self-regulation.

155 fourth and

fifth grade girls
randomized to
either an 8-week
mindfulness
through yoga
treatment group
or a wait list
control group

through Yoga
program was adapted
from the principles
from the MBSR
program developed
by Kabat-Zinn and
focused on the yoga
portion.

Outcomes:
- The Feel Bad Scale
- The Childrens
Coping Strategies
Inventory
-The Global SelfWorth subscale of
the SelfPerception Profile
for Children
-The Healthy SelfRegulation subscale
of the Mindful
Thinking & Action
Scale for

perceived stress,
coping
frequency, selfesteem, or selfregulation

sessions may
have affected the
receipt of the
intervention
because of
behavioral
disturbances,
lack of adequate
space, and
limited
individual
attention

cautioned by the
evidence that there were
no significant
improvements.

Program development:
A yoga intervention can
easily be incorporated as
an after-school program
but class sizes should be
small to increase
individual attention and
minimize distractions.

Societal Needs: N/A

Healthcare delivery and

policy: The evidence of
this article cannot be
applied since it proved
to be inconclusive.

Education and training

of OT students: Students
should be informed that
special training beyond

entry level certification

is required in order to
use yoga in treatments.

Adolescents

Refinement, revision,
and advancement of
factual knowledge or
theory: Mindfulness
meditation and yoga in
children and adolescents
remains unclear and
requires further
investigation.

Hagins,
Haden, &
Daly,
(2013)

To test the
hypothesis that a
yoga program
would provide a
significant
reduction in
stress reactivity
in 6th grade
students
compared to that
provided by a
standard
physical
education class.

Level I

Randomized
control trial

30 sixth grade
student
randomized to
15-week
treatment yoga
group or PE
control group

Intervention:
Yoga & physical
education (PE)
occurred for the
same duration (50
min each, 3 times a
week) at the same of
day

Yoga class consisted

of an opening ritual,
30-min asana
practice (each pose
held for 5 sec), brief

No statistically
significant
difference
between the
groups for stress
reactivity (BP or
HR)

Small sample
size

Outcome
measures taken
in a noncontrolled
environment

The clinical and

community-based
practice of OT:
There was no
meaningful difference
found between the two
groups in any of the
outcome measures.
Therefore the use of
yoga as opposed to
general PE is not
supported.

Program development:

seated meditation,
closing ritual of
guided relaxation in
Savasana

N/A

PE class used
common games such
as soccer &
volleyball, 75% of
total time spent in
physical activity,
25% being
physically inactive

Healthcare delivery and

policy: N/A

Societal Needs: N/A

Education and training

of OT students: Yoga
does not yield
meaningful stress
reduction in students
when compared to a
general PE class.

Outcomes: Heart
rate and blood
pressure

Thygeson,

To explore the

Level III

Intervention: The

Refinement, revision,
and advancement of
factual knowledge or
theory: Further studies
are needed to prove
efficacy of yoga
compared to other
physical activity
interventions.

Child cohort had

Convenience

The clinical and

community-based

Hooke,
Clapsaddle,
Robbins, &
Moquist,
(2010)

feasibility of a
single yoga
session for
children and
adolescents
hospitalized
with cancer or
other blood
disorders and/or
their parents

To determine if
patients &
parents
experience a
significant
decrease in
anxiety after the
yoga session

Nonrandomized
before & after

16 children and
33 parents
participated in a
single yoga
session

yoga class was held

in the inpatient unit
playroom, and was
administered by a
registered yoga
teacher. The 45minute class was
modeled after a
standardized yoga
class consisting of an
opening seated
meditation, warmup, centering poses,
standing poses,
balance poses, cool
down/ spinal twists,
& final resting pose
with options for
modification
Outcomes:
-Spielberger State
Trait Anxiety
Inventory (STAI)
-Spielberger State
Trait Anxiety
Inventory for
Children (STAIC)

no significant
change in their
anxiety sense of
well-being

Adolescent
cohort
experienced a
significant
decrease in
anxiety with an
improved sense
of well-being

Parent cohort
had a significant
decrease in
anxiety and an
increased sense
of well-being

sample

Only 1 treatment
session

Intervention
included both
parents and
children in the
same room
instead of
offering separate
sessions.

practice of OT: Yoga

can be taught in a
separate room within a
hospital to
accommodate patients
who are unable to travel
but it is unclear how the
setting affects outcomes.

Program development:
A yoga intervention can
be used in an inpatient
setting to reduce stress
among adolescent
patients but caution
should be taken with
child patients. A greater
frequency of sessions
would also be favorable.

Societal Needs:
Hospitalized children
and their parents
experience a great
amount of stress which
could compound the
effects of illness and
prolong healing. Yoga is
feasible to do in an

inpatient setting and

should be offered to
child patients and
caregivers as a method
of stress reduction.

Healthcare delivery and

policy: A yoga
intervention is fairly
low-cost and risk-free,
but based on the number
of limitations in this
study and inconclusive
results for children;
policymakers should be
cautioned about the
effectiveness of this
intervention.

Education and training

of OT students: A
therapist should have
some advanced training
in the therapeutic use of
yoga before instructing
ill children.

Refinement, revision,
and advancement of
factual knowledge or
theory: More research
should be done to

evaluate the influence

of multiple yoga
sessions delivered
over the trajectory of
treatment in specific
populations of
pediatric oncology
and hematology
patients.
Khalsa,
HickeySchultz,
Cohen,
Steiner, &
Cope,
(2012)

To identify
which
psychological
constructs to
include in future
studies to
evaluate the
psychological
benefits of an incurriculum yoga
program in
secondary
school
adolescents.

Level I

Randomized
control trial

121 students in
7th, 11th, and 12th
grade at a
Massachusetts
rural secondary
school were
randomized to
either a yoga

Intervention: 4x/wk
for 11 weeks, typical
30-min yoga sessions
included: 5 min
initial relaxations, 5
min warm up, 15
min of yoga poses, 5
min of closing
relaxation taught by
certified instructors.
Each session had a
talking point that
was discussed by the
instructor including
mind-body

Yoga group had

an insignificant
increase in
resilience, while
the control had a
significant
decrease in
resilience

Significant
difference in
change between
the groups
BASC-2

BASC-2 is
designed for
identifying
psychopathology
in adolescents,
however the
participation
population was
largely
normative, the
outcome
measure may not
have been able
to identify subtle

The clinical and

community-based
practice of OT:
Due to the limitations of
the study, the results are
not clinically important
as no differences were
found when statistics
included adjustments for
the intention to treat or
for multiple
comparisons.

Program development:

treatment group
or PE control
group

interactions &
awareness, body
systems, stress
management,
discipline, decision
making, values &
principles,
commitment, and
acceptance.

PE was taught as
usual 3x/wk for 11
weeks

subscale anger
control: yoga
group decreased,
while the control
increased.

Fatigue/Inertia:
yoga showed
insignificant
decrease, while
control showed
significant
increase

Outcomes: -SelfHowever, when

Report of Personality adjustments for
(SRP)
multiple
comparisons
-Profile of Mood
were used with
States
the results listed
above the results
-Resilience Scale
were non(SC)
significant.
-Perceived Stress
Scale
-Inventory of

improvements

N/A

PE has similar
psychological
and physical
benefits as yoga,
therefore a
different design
may yield
stronger
improvements in
yoga

Societal Needs: N/A

Statistical
analysis did not
include
adjustments for
intention to treat
or for multiple
comparisons

Lack of blinding
of subjects

Healthcare delivery and

policy: The results of
the article cannot be
applied because of the
limitations of the study.

Education and training

of OT students: The
results of this study do
not concretely support
the use of yoga for
stress reduction with the
population.

Refinement, revision,
and advancement of
factual knowledge or
theory: The use of yoga
for stress reduction in
children remains
inconclusive and
requires further

Jensen, &
Kenny,
(2004)

To evaluate the
use of yoga
exercises as a
complementary
treatment to
pharmacological
therapy in
reducing the
behavioral and
attentional deficit
symptoms of
ADHD in boys

Level I

Randomized
control trial

19 boys were
randomized to
either a yoga
treatment group
or a cooperative
activities control

Positive
Psychological
Attitudes-32 R

There were no
statistically
significant
changes in other
measures

Number of
irregularities in
the study
execution due to
variable lengths
of intervention,
session
frequency,
duration of
sessions, late
acquisition of
some outcome
measures, and
canceled
sessions.

investigation.

Intervention:

Yoga group
showed significant
improvements on
five subscales of
the Conners
Parents Rating
Scales (CPRS):
Oppositional
behavior,
emotional lability,
restless/impulsive
and ADHD Index.

Small sample
size

The clinical and

community-based
practice of OT:
Although the yoga
group improved in the
areas of oppositional
behavior, emotional
lability, and restless/
impulsive, in terms of
stress reduction, the
cooperative activities
group had better results.

20 weekly 1-hour
traditional yoga
classes

Control group was

conducted for 1 hour,
1x/month, and at the
same location as yoga
sessions. Control
group focused on
cooperative games and

Co-intervention
(already
stabilized on
medication)

group

activities that involved

the skills of talking and
listening, turn-taking,
sharing equipment, and
talk time.

Outcomes:
-The Conners Teacher
Rating Scale- Revised:
Long (CTRS-R:L)
-Test of Variables of
Attention (TOVA)

Control group
showed significant
improvement on
three CPRS
subscales:
Hyperactivity,
Anxious/Shy, and
Social Problems.

Program development:
Since there was some
improvement, a yoga
program can be
combined with a
cooperative activities
group to treat stress in
boys with ADHD.

Both groups
improved
significantly on
CPRS
Perfectionism,
DSMIV
Hyperactive/Impu
lsive, and DSM
IV Total.

Societal Needs: N/A

Healthcare delivery and

policy: Yoga should not
be the primary
intervention for stress
reduction in boys with
ADHD.

Education and training

of OT students: N/A

Refinement, revision,
and advancement of
factual knowledge or
theory: N/A

Noggle,

To test feasibility

Level I

Intervention: A

Profile of Mood

Uneven groups

The clinical and

Steiner,
Minami, &
Khalsa,
(2012)

of yoga within a
high school
curriculum and
evaluate
preventive
efficacy for
psychosocial
well-being

Randomized
control trial

51 high school
students who
registered for PE
were clusterrandomized by
class 2:1 yoga: PE
as usual

Kripalu-based yoga
program of physical
postures, breathing
exercises, relaxation,
and meditation was
taught 2-3 times a
week for 10 weeks by
2 lead yoga instructors.

PE-as-usual class
period met for 30 to 40
minutes, 2-3 times a
week over the course
of the 10-week yoga
program

Outcomes:

States-Short Form
(POMS-SF)
Tension-Anxiety
subscale and total
mood disturbance
improved in yoga
students and
worsened in
controls.

Although positive
affect remained
unchanged in
both, negative
affect significantly
worsened in
controls while
improving in yoga
students.

-Yoga Evaluation
Questionnaire (YEQ)
-Profile of Mood
States-Short Form
(POMS-SF)
-Positive and Negative
Affect Schedule for
Children (PANAS-C)
-10-item Perceived

Other outcomes
were not
significant.

Small sample
size

community-based
practice of OT: Yoga
for the purpose of stress
reduction could serve as
a complementary
intervention, while the
child is also receiving
school-based or private
therapy services.

Program development:
Yoga should be used as
part of a larger program
of stress reduction in
school.

Societal Needs: The

authors mention a large
number of adolescents
report psychological
issues in high school.
Yoga can be offered as
an alternative or in
addition to PE class.

Healthcare delivery and

policy: N/A

Stress Scale (PSS)

-Inventory of Positive
Psychological
Attitudes-32R (IPPA)

Education and training

of OT students: N/A

-25-item Resilience
Scale (RS)

Refinement, revision,
and advancement of
factual knowledge or
theory: Larger, more
definitive trials should
be done to compare
yoga and PE.

-State-Trait Anger
Expression Inventory2 (STAXI-2)
-Child Acceptance and
Mindfulness Measure
(CAMM)

Ehud, An, &

Avshalom,
(2010)

To assess the
impact of yoga
intervention in a
group of Israeli
school children
residing in the
region affected
by the Second
Lebanon War

Level III
Nonrandomized
before & after
122 school children
aged 812 years in
two elementary
schools in Safed
and their teachers
participated in 13
yoga training
sessions

Intervention:
Trained yoga
teachers taught 13
after-school yoga
sessions over the
course of 4 months
Outcomes:
-Conners
Abbreviated
Symptom
Questionnaire
-WHO (Five) WellBeing Index
-Satisfaction

Teachers reported
many statistically
significant
improvements in
the childrens
concentration,
mood, and ability
to function under
pressure, although
the children
themselves were
unaware of any
change in their
behavior.

Lack of control
group
Inconsistency
between selfassessment &
external-observer
results

The clinical and

community-based
practice of OT: A yoga
program should have a
high frequency and
duration and remain
consistent.
Program development:
Although an afterschool yoga program is
feasible, before-school
or weekend programs
should be considered.
Societal Needs:

Children in war-torn
countries may require
complementary
interventions to
alleviate the stress from
the impact of war.

questionnaire

Healthcare delivery and

policy: N/A
Education and training
of OT students: N/A
Refinement, revision,
and advancement of
factual knowledge or
theory: There is a

potentially positive
role and effect of yoga
in the management of
children in post-stress
situations but further
research is needed.
Venkatarama
na,
Poomalil, &
Shobhasree,
(2008)

To investigate the
influence of Yoga
on academic
stress of high
school students

Level I
RCT

Intervention:
Yoga practice
(consisting of asanas
Students (n=139)
& breathing
enrolled in two
exercises) for one
schools: the United hour a day for a
Public School & Sri continuous period of
Prakash
90 days.
Vidyaniketan. The

The experimental
group showed a
significant
decrease (at the .
01 level) in
personal
inadequacy, fear
of failure,

A detailed outline
of the intervention
was not included
It is possible that
the results could
have been
accomplished with
any physical

The clinical and

community-based
practice of OT:
School and community
OTs can use consistent,
daily, 90 minute yoga
sessions as an effective
means to reduce stress
levels of high school

ages were 11-16

yrs. old.
Subjects were
randomly assigned
to either the test
group receiving
intervention or the
control group
receiving no
intervention.

Outcomes:
Student Academic
Stress Scale

interpersonal
difficulties,
teacher pupil
relationships &
inadequate study
facilities. .
Stress levels of
the experimental
group of subjects
decreased while
the stress levels
of the control
group increased
significantly (at
the .01 level).
The posttest
comparison
between the
groups indicated
highly significant
differences
between the
groups (.01 level)
in personal
inadequacy, fear
of failure &
inadequate study
facilities. At the .
05 level,
differences were
found in the

activity performed
for an hour, for 90
days.

students.

Program
development: The
article supports the
use of yoga to
decrease academic
stress. Based on these
findings, yoga should
be offered as a daily,
90 minute class option
to students during
school or as an after
school program.
Societal Needs:
According to author
of the study, academic
stress is cited as a
high-risk stimulator
for the onset of
behavior problems
and low success rates
among the educated
youth of their county.
Therefore, lowering
the academic stress of
the students should
increase the success
rates of the youth.
These successful
youths will likely
become successful

interpersonal
difficulties. No
significant
difference was
found in the area
of teacher pupil
relationship.

contributing members
of their society.
Healthcare delivery
and policy: Yoga is a
low cost medium to
reduce the stress of
students. Therefore,
these findings support
school policy
mandating that yoga
be offered to students.
Education and
training of OT
students: The study
supports yoga as an
effective intervention
for the management
of academic stress.
Refinement, revision,
and advancement of
factual knowledge or
theory: This study
supports the theory
that yoga can lower
academic stress in
youth.

Frank, Bose, The purpose of

&
the study is to

Level III

Intervention:
TLS- universal

(using unadjusted
means & std.

Lack of control
group, reliance on

The clinical and

community-based

Schrobenhau evaluate the

ser, (2014)
feasibility and
potential
effectiveness of
TLS (yoga
program) on
indicators of
emotional
distress, stress
symptomology,
prosocial
behavior, and
attitudes toward
violence in a
high-risk
sample of
students
educated in an
alternative
public high
school setting.

Nonrandomized
before & after
All students
(n=49) were
enrolled a single
alternative school
for at risk youth in
CA.
Students were
refereed by their
home school
because of faculty
concerns regarding
the presence of one
or more risk factors
9th grade (12.2%),
10th grade (22.4)
11th (57.1%) & 12th
(8.2%)
54.4 % female
33.3 black
33.3 Hispanic
4.2 native American
6.2 Asian
2.1 while
20.8 mixed

classroom-based
program for use with
adolescents in
middle/high school
settings
-lessons divided into 4
units (stress
management, body &
emotional awareness,
self-regulation &
building healthy
relationships
-each unit includes 12
lessons
-afterward, students
engage in the ActionBreathing Centering
Activities ( ABCs)
student engage in yoga
postures, focused
breathing, & centering
meditation
TLS lessons were
integrated into 1st
period homeroom
classes 3-4 days per
week during the 1st
semester of the school
year
-30 min each
-regular classroom
setting
-instructors were
certified yoga teachers
who had specialized

deviations) No
statistical sig
pre/post on
measures of
positive
affect/negative
affect
(after adj. p values
for multiple
comparisons) Stat.
Sig & meaningful
improvements
found on measures
of student anxiety,
depression, &
global symptom
index
Sig & substantive
improvements on
involuntary action,
rumination,
intrusive thoughts,
physical arousal,
emotional arousal
Sig reductions in
revenge
motivation &
reported hostility

students selfreport, small

sample of at-risk
youth, may not be
generalizable to
adolescent
population at large,
Unable to be
certain if the yoga
brought about the
changes or simply
the physical
activity

practice of OT:
The study supports
the inclusion of TLS
as an effective
measure to decrease
involuntary stress
actions in at-risk
students. Therefore,
at-risk youth may
benefit from the
inclusion of TLS in
alternative schools.
Program
development: The
program that has been
developed, TLS, is a
valid yoga based
program for students.
Societal Needs:
Adolescents ability to
modulate their
emotional responses
to stress in being
recognized as an
important skill for
ensuring mental
health, academic
success, and healthy
transition into
adulthood.
.
Healthcare delivery

training & certification

in TLS administration
-implementation was
monitored through
regular supervision of
yoga instructors,
review of checklists &
observation
-lessons implemented
with greater than 80%
fidelity
Outcome Measures:
Affect Valence Scale
Brief Symptom
Inventory-18
Responses to Stress
Questionnaire
Transgression-Related
Interpersonal
Motivation Scale

and policy:
Given the link
between the intensity
of involuntary stress
responses and later
onset and progression
of clinical anxiety &
depression, the
findings suggest that
yoga-based programs
in school will have a
positive impact on
youth mental health.
Therefore policy
should make the TLS
program available to
all students.
Education and
training of OT
students: The study
supports the use of
yoga to decrease
problematic
involuntary stress
responses like
rumination,
involuntary actions,
and intrusive
thoughts, physical &
emotional arousal. An
OT working with
students can utilize

yoga to help decrease

these behaviors.
Refinement, revision,
and advancement of
factual knowledge or
theory: This study
supports the theory
that yoga supports the
mental health of
students.