Brigham & Women’s Hospital Harvard Medical School Yoga in Schools Research: A Review July 9, 2016 INSTILL Conference, London Sat Bir S. Khalsa, Ph.D. Assistant Professor of Medicine, Harvard Medical School Director of Research, Kundalini Research Institute Research Director, Kripalu Center for Yoga and Health Editor in Chief, International Journal of Yoga Therapy Research Associate, Benson Henry Institute for Mind Body Medicine

Yoga Use in the Last 12 Months 2012 From: Use of complementary health approaches among children aged 4-17 years in the United States: national health interview survey, , Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RL, National Health Statistics Report, 78:1-19, There was a statistically significant increase in the use of any yoga, tai chi, or qi gong between 2007 (2.5%) and 2012 (3.2%). Most of this increase can be attributed to the increased use of yoga (2.3% to 3.1%)

Yoga Practices Postures, Breathing, Relaxation, Meditation Fitness ↑Flexibility ↑Strength ↑Coordination/Balance ↑Respiratory Function ↑Self-Efficacy Global Human Functionality ↑Physical & Mental Health, ↑Physical, Mental, Emotional Performance, ↑Positive Behavior Change, ↑Social Responsibility, Values, Relationships, ↑Quality of Life, ↑Life Purpose & Meaning, ↑Spirituality Self-Regulation ↑Emotion Regulation ↑Stress Regulation ↑Resilience ↑Equanimity ↑Self-Efficacy Awareness ↑Attention ↑Mindfulness ↑Concentration ↑Cognition ↑Meta-cognition Spirituality ↑Transcendence ↑Unitive State ↑Flow ↑Transformation ↑Life Meaning/Purpose

23 chapters with theory, rationale, research & practice ~60 chapter contributors, ~30 yoga therapist contributors

Academic Pediatrics, 9: , 2009.

Pediatric Physical Therapy. 20:66-80, 2008

Demonstrated Benefits in Children Stress, anxiety, depression Self-concept Cognitive function, memory, perception Flexibility Cardiopulmonary fitness Psychomotor & neuromuscular performance Weight loss

From: Using Standards and High-Stakes Testing for Students, Exploiting Power with Critical Pedagogy, Series: Counterpoints - Volume 425, Gorlewski JA, Porfilio BJ, Gorlewski DA (eds.), Peter Lang Publ., NY, Chapter 7, 2012.

Survey of Formal Yoga Programs ~36 existing yoga in schools programs # of years in service 2 to 21 yrs, mean 9 yrs ~940 schools across the United States more than 5,400 trained instructors 42% of programs require 200-hr YA certification 75% offer programs from pre- to high school 8 full yoga sessions only, 3 in-class only, 25 both

From: Are There Benefits from Teaching Yoga at Schools? A Systematic Review of Randomized Control Trials of Yoga-Based Interventions, Ferreira-Vorkapic C Feitoza, Marchioro M, Simões J, Kozasa E, Telles S, Evidence-Based Complementary and Alternative Medicine, Article ID , Systematic Review of Yoga in Schools RCT’s

Published Yoga/School Studies

~ 50 studies of yoga in school settings Most done in elementary schools Many did not use control/comparison groups Many were after school programs Significant # of studies with negative results Numerous other methodological weaknesses Funding is the overriding challenge Published Yoga/School Studies

Quantitative Research Outcomes Stress coping Self-regulation Physical and emotional arousal Aggression, hostility, anger Mood, anxiety, depression Rumination, cognitive functioning Self-esteem Mental, social & physical well-being Behavior

Mental Health Outcomes

Academic Outcomes From: Yoga May Mitigate Decreases in High School Grades, Butzer B, van Over M, Noggle Taylor JJ, Khalsa SBS, Evidence-Based Complementary and Alternative Medicine Volume, Article ID , 2015.

Willingness to Smoke Cigarettes From: Evaluation of yoga for preventing adolescent substance use risk factors in a middle school setting: A preliminary group-randomized controlled trial, Butzer B, LoRusso A, Shin SH, Khalsa SBS, (in press) 2016.

Prevalence of Female Gender in U.S. Yoga Practice 1998: 68% (Saper et al, 2004) 2002: 76% (NHIS) 2008: 72% (Yoga Journal survey) 2012: 82% (Yoga Journal survey) 2016: 72% (Yoga Journal/Yoga Alliance survey) 2012: ~81% female age 4-17 (NHIS)

Yoga Use in the Last 12 Months From: Use of complementary health approaches among children aged 4-17 years in the United States: national health interview survey, , Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RL, National Health Statistics Report, 78:1-19, 2015.

Greater Consent for Females

Emotional Dysregulation

Substance Use Risk & Impulsivity: Time Perspective

Liking PE Classes p < p < 0.05 Very much So Not at all

Female Preference for Yoga “I don’t think I get anything out of gym class at all. There are all these senior guys playing basketball and I’m not going to play with them.” (Female, 9 th grade) “I had a lot of fun with [yoga] because I hate playing sports and I hate normal PE class.” (Female, 9 th grade)

“Some of my friends don’t take so kindly to [yoga] class. It’s just mellow and they like to be active.” (Male, 10 th grade) “It’s not that I don’t like yoga I would just rather be playing basketball or working out at the gym than doing yoga. Basketball is more active. Maybe I would try yoga again if it was not competing with sports.” (Male, 10 th grade) Male Preference for PE Class

Issues for Yoga Research ●Study duration and long-term followup ●Student, school, parent buy-in ●Sample size, research design, RCT ●Outcome measures (self-report: teacher/parent report; objective measures: health, psyhophysiology, performance, grades/behavior/attendance, performance) ●Intervention (instructor characteristics, duration, timing, venue, environment) ●Qualitative research

Positive experience with benefits Would continue if it were offered Better kinesthetic awareness/self-image Stress reduction/coping Managing negative emotions More optimism Increased social cohesion with family/peers Improved school environment Qualitative Research Outcomes

I also liked the breathing exercises cause… when I was feeling stressed it helped doing it at home. “I think [yoga] might have helped me when I was angry at someone. I just breathed through it and try to be not angry anymore” “I think [yoga] works. I think it helped me. Along with calming down it relaxed me and [I was] able to absorb more, rather than being all excited and not really having any room for learning.” Boston Latin School From: A Qualitative Examination of Yoga for Middle School Adolescents, LoRusso AM, Butzer, Windsor R, Riley F, Frame K, Khalsa SBS, Conboy L, (under review).

Kripalu | center for yoga & health

Acknowledgements Collaborators/Consultants Jessica Noggle, Ph.D. – Harvard Medical School Bethany Butzer, Ph.D. – Harvard Medical School Lisa Conboy, Ph.D. – Harvard Medical School Mindy Miraglia – Searcher LLC Ashleigh Parsons, Ed.M. – Harvard University Stephen Cope – Kripalu Center for Yoga and Health Lynn Schultz, Ph.D. – Harvard Medical School Naomi Steiner, M.D. – Tufts University Stephanie Shorter, Ph.D. – Yoga Yoga Natalie Trent, Ph.D. – Harvard Medical School Technical and Research Assistance Deborah Cohen Angela Wilson Iona Brigham Janna Delgado Mira Chernick Jane Rosen Caroline Boyce Torrey Baldwin

“I switched from yoga to visualization, for relaxation. I picture a world in which all students with discipline problems attend my class online, from their homes.”