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Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineArticle ID 345835

Review ArticleAre There Benefits from Teaching Yoga at Schools? A SystematicReview of Randomized Control Trials of Yoga-BasedInterventions

C. Ferreira-Vorkapic,1,2,3 J. M. Feitoza,2 M. Marchioro,1 J. Simões,1 E. Kozasa,4,5 and S.Telles6

1Department of Physiology, Laboratory of Neurophysiology, Federal University of Sergipe (UFS), Avenida Marechal Rondon, s/n,Jardim Rosa Elze, São Cristóvão, 49100-000 Aracaju, SE, Brazil2Department of Psychology, FASE\UNESA, Aracaju, SE, Brazil3Trika Research Center, Loei, Thailand4Hospital Israelita Albert Einstein, São Paulo, Brazil5Department of Psychobiology, Federal University of São Paulo, São Paulo, Brazil6Indian Council of Medical Research Center for Advanced Research in Yoga and Patanjali Research Foundation, Bengaluru, India

Correspondence should be addressed to C. Ferreira-Vorkapic; [email protected]

Received 1 March 2015; Revised 21 June 2015; Accepted 25 June 2015

Academic Editor: Vernon A. Barnes

Copyright © C. Ferreira-Vorkapic et al.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction. Yoga is a holistic system of varied mind-body practices that can be used to improve mental and physical health andit has been utilized in a variety of contexts and situations. Educators and schools are looking to include yoga as a cost-effective,evidence-based component of urgently neededwellness programs for their students.Objectives.Theprimary goal of this studywas tosystematically examine the available literature for yoga interventions exclusively in school settings, exploring the evidence of yoga-based interventions on academic, cognitive, and psychosocial benefits. Methods. An extensive search was conducted for studiespublished between 1980 and October 31, 2014 (PubMed, PsycInfo, Embase, ISI, and the Cochrane Library). Effect size analysis,through standardized mean difference and Hedges’g, allowed for the comparison between experimental conditions. Results andConclusions. Nine randomized control trials met criteria for inclusion in this review. Effect size was found for mood indicators,tension and anxiety in the POMS scale, self-esteem, and memory when the yoga groups were compared to control. Future researchrequires greater standardization and suitability of yoga interventions for children.

1. Introduction

Yoga is an ancient mind-body practice which originated inIndia more than 2.000 years ago and is described system-atically early on (Patanjali’s Yoga Sutras, circa 900 B.C.).Although, according to traditional scriptures, its ultimategoal is to achieve a unified state of consciousness and self-realization, yoga may be used to improve overall health andwell-being [1]. Yoga involves different techniques such asphysical postures (asanas), controlled breathing (pranaya-mas), deep relaxation (yoganidra), and meditation [1]. Thesetechniques seem to have specific influences on one’s psycho-logical state [2, 3] and the research on the psychophysiological

benefits of yoga and meditation on adults has demonstratedimprovements in emotional self-regulation with consequentreductions in depression, stress, anxiety levels [2–11] andposttraumatic disorder [12] as well as improvements in mood[13], quality of life, and well-being [14–16]. However, in spiteof the positive effects of yoga on mental health, this practiceis not just limited to therapeutic use and has been utilized in avariety of situations and contexts, including educational andschool settings, where teaching students about wellness andhealth accompanies the primary aim of academic instruction[17].

According to United Nations [18], children and adoles-cents around the world spend an average of 10 to 15 years

2 Evidence-Based Complementary and Alternative Medicine

at school. As a result, schools hold the potential to teachabout healthy habits from an early age and promote children’shealth and well-being. For children who have to deal withstressors, anxiety, traumas, abuse, learning disabilities, andeven bullying, the discipline developed by practicing con-templative techniques could be the difference between failureand success, both in their professional and personal life.[19]. Furthermore, according to Noggle et al. [20], the age ofonset of most mental health disorders in adults occurs duringchildhood and adolescence, with around 7.5% of adolescentsmeeting DSM-IV-TR criteria for one or more mental healthconditions.

The solution for dealingwith stressors, anxiety, and learn-ing disabilities certainly depends on many factors; however,evidence suggests that some of these problems may be easedby mind-body practices, which have been shown to redirectattention, improve concentration, increase self-control, andprovide people with reliable and healthy coping mechanisms[19]. Yet, the efficacy of such practices among children isunclear and evidence is insufficient. A review conductedby Galantino et al. [21] found that there was evidence forthe benefit of yoga in the pediatric population in physicalrehabilitation, but a recent meta-analysis concluded that thedata on the clinical applications of yoga among the childrenare uncertain [22]. Authors state that while most studies weresuggestive of benefits, results were based on low quality trials.

Studies utilizing yoga in school settings have been shownto benefit children and adolescents [17]. According to Khalsaet al. [23], a yoga program might help children recover theirself-esteem and confidence, restore their mental health, pro-mote positive attitudes, improve concentration, and reducestress and anxiety. Unfortunately, traditional curricula focusprimarily on intellectual development, and schools have pro-gressively been losing the capacity to adopt health-focusedprograms. The ability to cope with stress and anxiety (due topsychosocial demands) and to maintain physical and mentalhealth is priceless in any spheres of an individual’s life,including education. Students must be healthy in order tolearn, and academic accomplishment has been shown to berelated to health status. Consequently, there is urgent needto develop and investigate cost-effective and evidence-basedwellness programs that can be delivered in school settings.

Therefore, the primary goal of this study was to systemat-ically examine the available literature on yoga interventionsexclusively in school settings. The objective of this reportwas to reviewmethodological quality among selected studies,exploring the evidence of yoga-based interventions regardingacademic, cognitive, and psychosocial benefits, and to con-tribute to the study of low-cost, health-focused alternativeprograms for children and adolescents in school settings.

2. Methods

2.1. Searching. Studies were identified by searching PubMed,PsycInfo, Embase, ISI, and the Cochrane Library. A widesearch was conducted for studies published between 1980 andOctober 31, 2014, using the following terms or key words:

yoga, school, education, and children alone and in combina-tion with additional terms such as program, intervention, andyoga-based. A manual evaluation of reference lists of relevantstudies and reviews was also conducted. All articles relatedto the subject yoga at schools were selected for additionalexamination.

2.2. Selection. Peer-reviewed, published manuscripts wereconsidered. Studieswere selected if (1) they included a yoga oryoga-based intervention, (2) the intervention was restrictedto school settings (integrated into the school schedule or afterclass), (3) they included children and adolescents (ages 5–18),(4) they included an evaluation of anxiety, depression, stress,or other psychological measures such as mood indicators,self-esteem, confidence, and quality of life at both preinter-vention and postintervention, (5) they included the assess-ment of academic or cognitive performance as a consequenceof the yoga intervention (pre- and postintervention), (6)the research designs were pilot studies, quasi-experimentaldesigns, or randomized designs and included control groupswith no interventions or an active control (comparativeintervention), and (7) they were written in English. Exclusioncriteria comprised (1) studies that utilized only meditationor relaxation techniques without the physical componentssuch as postures (asana) or controlled breathing (pranayama)(MBSR based programs usually have yoga as part of thepractice but only MBSR studies in which yoga is highlightedor is the main component of the program were included inthis review whose intention is to cover primarily yoga), (2)yoga-based programs for children with learning disabilitiesor any diagnosed mental disorder, and (3) dissertations andconference presentations.

Authors screened abstracts to identify articles that meetinclusion criteria. Potential articles were then evaluatedfor inclusion. To conduct the study, all data was collectedand evaluated in terms of selection criteria, procedure,participants, intervention, methodology, assessment tools,and outcomes. Follow-up and results were also assessed. Toevaluate or discuss non-RCTs was not part of the review’sscope. Other reviews have mentioned non-RCTs, includingmethodology and possible bias [17]. The review has beenprepared using preferred reporting criteria for systematicreview guidelines (PRISMA) [24].

The quality and reliability of the randomized controltrials (RCTs) were evaluated according to the evidence levelsrecommended by the Oxford Center for Evidence-BasedMedicine [25]. Table 1 shows the classification of scientificevidence in systematic literature reviews. Four authors con-ducted the literature searching (C. Ferreira-Vorkapic, M.Marchioro, and S. Telles) and study selection (C. Ferreira-Vorkapic, M. Marchioro, and E. Kozasa).

After the first appraisal, another examiner (J. Simões)evaluated the selected RCTs and kappa coefficient was cal-culated in order to estimate reliability of data collectionmethods. The observed kappa score of 𝑟 = 0.9 suggests greatconsistency of agreement between investigators.

For the effect size calculation, the means and standarddeviations (postintervention) from experimental and control

Evidence-Based Complementary and Alternative Medicine 3

Study extraction flow diagram

Records identified through database searching

Additional records identified

Total records

Studies excluded— special issues or

reviews

Studies excluded due to interventions or

outcomes

Full-text articles assessed for eligibility

Full-text articles excluded—uncontrolled and not

randomized or not randomized

Studies included in qualitative synthesis

Studies included in quantitative synthesis

(meta-analysis)

Studies excluded—dissertations

Studies excluded—

Full-text articles Full-text articles Full-text articlesexcluded—qualitative

study excluded—

insufficient data excluded—not

randomized trials

(n = 15) (n = 33)

(n = 26)

(n = 48)

(n = 8)

(n = 8)

(n = 9)

(n = 9)

(n = 3) (n = 3) (n = 3)

(n = 7) (n = 5)(n = 2)

Iden

tifica

tion

Scre

enin

gEl

igib

ility

Inclu

ded

through other sources∗

unpublished∗

Figure 1: Criteria for inclusion in the review. ∗Articles sent to the authors by other researchers.

Study or subgroup Mean SD Total Mean SD Total Weight

Noggle et al., 2012 35.42 6.27 36 40.72 9.51 15 9.9%Khalsa et al., 2012 5.2 70 1.69 5.8 34 22.1%Hagins et al., 2013 82.21 5.2 15 83.68 2.28 15 7.3%Telles et al., 2013 14.96 2.41 49 14.94 3.09 49 24.3%Verma et al., 2014 6.01 1.49 37 5.62 1.8 34 17.4%Sarokte and Rao, 2014 14.97 6.58 30 11.4 6.56 30 14.3%Haden et al., 2014 24.93 1.96 14 21.58 2.12 12 4.7%

Total (95% CI) 251 189 100.0%

Std. mean difference Std. mean differenceIV, fixed, 95% CI IV, fixed, 95% CI

0 1 2Favours yoga Favours control

Favours yoga Favours control

−0.97

Heterogeneity:𝜒2 = 28.40, df = 6 (P < 0.0001); I2 = 79%Test of overall effect: Z = 0.11 (P = 0.91)

−2 −1

0.01 [−0.39, 0.40]0.23 [−0.23, 0.70]0.54 [0.02, 1.05]1.59 [0.69, 2.50]

−0.71 [−1.33, −0.09]−0.49 [−0.90, −0.07]−0.36 [−1.08, 0.37]

−0.01 [−0.21, 0.18]

Figure 2: Plot of the general effect size in the selected studies.

groups were obtained directly from the studies. The com-parison between experimental conditions was carried outafter the analysis of the pooled effect size by the genericinverse variance method (random effect model) throughstandardized mean difference and Hedges’ g. Hedges’ g effect

is the difference between the two means (postinterventionfor the experimental and the control groups) divided by thepooled standard deviation. Ninety-five percent confidenceintervals were computed for all variables.



−3.55 15.1 67 1.27 19.4 34 69.0%38.4 16.9 36 51.2 20.1 15 31.0%

Total (95% CI) 103 49 100.0%

Yoga Control Std. mean differenceIV, fixed, 95% CI

Std. mean differenceIV, fixed, 95% CI

0 1 2−2 −1Favours yoga Favours control

Heterogeneity:𝜒2 = 1.21, df = 1 (P = 0.27); I2 = 17%Test of overall effect: Z = 2.37 (P = 0.02)

−0.29 [−0.70, 0.13]−0.71 [−1.32, −0.09]−0.42 [−0.76, −0.07]

Noggle et al., 2012Khalsa et al., 2012

Figure 3: Profile of Mood States (POMS) general score effect size.

Study or subgroupMean SD Total Mean SD Total

Weight

−0.48 3.8 67 −0.03 4.7 34 70.1%5.1 3.6 36 9.3 5.8 15 29.9%

Total (95% CI) 103 49 100.0%

Yoga Control Std. mean difference Std. mean differenceIV, fixed, 95% CI IV, fixed, 95% CI


Heterogeneity:𝜒2 = 4.79, df = 1 (P = 0.03); I2 = 79%Test of overall effect: Z = 2.04 (P = 0.04)

−0.11 [−0.52, 0.30]−0.95 [−1.58, −0.32]−0.036 [−0.71, −0.01]

Noggle et al., 2012Khalsa et al., 2012

Figure 4: Profile of Mood States (POMS): subitems tension and anxiety effect size.

Table 1: Classification of scientific evidence in systematic literaturereviews according to the evidence levels recommended by theOxford Center for Evidence-Based Medicine.

Level of evidence Grading criteria

1a Systematic reviews of RCTs includingmeta-analysis.

1b Individual RCT with narrow confidenceinterval.1c Case of series “all or nothing.”2a Systematic review of cohort studies.

2b Individual cohort study and low qualityRCT.2c Outcome research study.3a Systematic review of case control studies.3b Individual case control study.

4 Case series, poor quality cohort, and casecontrol studies.5 Expert’s opinion.Adapted from levels of evidence of the Oxford Center for Evidence-BasedMedicine [62].

Two studies [19, 26] were excluded from the effect sizeanalysis due to insufficient data (mean values not provided).

3. Results

3.1. Description of Studies. Of the 48 studies identified, 9randomized control trials met criteria for inclusion in thisreview, as illustrated by Figure 1 (PRISMA Guidelines StudyExtraction) [24]. Table 2 shows the PRISMA 2009 checklist.Selected randomized control trials (RCTs) are displayed inTable 3.

Generally, the RCTs had low AHRQ evidence scores,with most studies receiving a score of 2b due to the lack

of blindness and follow-up, reflecting the reduced quality ofreporting in these studies.

All results and conditions of the studies are summarizedin Table 3.

Due to the limited number of RCTs and the greatheterogeneity of the variables (ununiform constructs), theanalysis of the effect size of specific measures could only beperformed on studies that observed the same variables suchas mood, tension, anxiety [20, 23], self-esteem [23, 27], andmemory [28, 29] when comparing the yoga to control groups.

After an overall effect size calculation of each study(except for [19, 26]), the effect sizes obtained from similarmeasures were grouped together: mood, tension, anxiety,self-esteem, and memory. Figure 2 shows the forest plot ofthe general effect size in the selected studies.The general plotshows divided results with half of the studies favoring yogaand the other half favoring control. 𝑃 value for overall effectis not significant (𝑃 = 0.91), but this is probably due toheterogeneity of the variables.

Effect size from mood state indicators (POMS) wascalculated fromKhalsa et al., 2012 [23], andNoggle et al., 2012[20]. Results indicate that the yoga group showed significantlybetter scores in the postintervention condition (𝑃 = 0.02)(Figure 3). The same scale shows a second significant effectfor the subitems tension and anxiety also after the yogapractice (𝑃 = 0.04) (Figure 4).

A third comparison was carried out for the variable self-esteem [23, 27]. Results show greater self-esteem perceptionin the postintervention condition for the yoga group (𝑃 =0.04) (Figure 5).

Effect size for memory was also analyzed in [28] andVerma et al., 2014 [29]. Both studies utilized memory assess-ment tools, but Sarokte and Rao [28] used two differentinstruments. The results show increased memory perfor-mance for the yoga group (𝑃 < 0.00001) (Figure 6).


Table2:PR

ISMA2009

checklist.

Section/topic

#Ch

ecklist

item

Repo

rted

onpage

#Title

Title

1Are

ThereB

enefitsfro

mTeaching

Yoga

atScho

ols?ASyste

maticRe

view

ofRa

ndom

ized

Con

trolT

rialsof

Yoga-Based

Interventio

ns.

1Ab

stract

Structured

summary

2

Background

.Yogaisa

holistic

syste

mof

varie

dmind-bo

dypractic

esthatcanbe

used

toim

provem

entaland

physicalhealth.D

ueto

the

well-k

nownresto

rativ

eeffectso

fyogao

nmentalh

ealth

,ith

asbeen

utilizedin

avarietyof

contextsandsituatio

nsbeyond

thes

tand

ard

therapypractic

e.Ed

ucatorsa

ndscho

olsinparticular

areloo

king

toinclu

deyoga

asac

ost-e

ffective,evidence-based

compo

nent

ofurgently

needed

wellnessp

rogram

sfor

theirstudents.Objectives.Th

eprim

arygoalof

thisstu

dywas

tosyste

maticallyexam

inethe

availableliterature

fory

ogainterventions

exclu

sively

inscho

olsetting

s.Th

eobjectiv

eofthisreportw

asto

explorethe

evidence

ofyoga-based

interventio

nson

academ

ic,cognitiv

e,andpsycho

socialbenefits.Methods.Studies

wereidentified

bysearchingPu

bMed,PsycInfo,Em

base,ISI,and

the

CochraneL

ibrary.A

nextensives

earchwas

cond

uctedforstudies

publish

edbetween1980

andOctob

er31,2014,usingthefollowingterm

sor

keywords,yoga,school,edu

catio

n,andchild

ren,alon

eand

incombinatio

nwith

additio

naltermssuchas

program,intervention,and

yoga-based.R

esultsandCo

nclusio

ns.Forty-eight

studies

wereidentified

andnine

rand

omized

controltria

lsmetcriteria

forinclusio

nin

this

review

.Alth

ough

mosto

fthe

studies

werec

lassified

as2b,according

toAHRQ

evidence

levelcriteria,w

hich

means

lowqu

ality

rand

omized

controltria

ls,thisreview

suggestsbeneficialeffectso

fyoga-basedinterventio

nsatscho

olon

both

psycho

logicaland

cogn

itive

functio

ns.

Effectsizew

asfoun

dform

oodindicators,tensio

nandanxietyin

theP

OMSscale,self-esteem

,and

mem

ory.Fu

ture

research

requ

ires

greaterstand

ardizatio

nandmustd

ealw

iththep

roblem

ofapprop

riateness:w

hattypeo


nismostsuitablefor

child

renandatwhatfrequ

ency

anddu

ratio

nandob

served

varia

bles.

1

Intro

duction

Ratio

nale

3

Yoga

isah

olisticsyste

mof

varie

dmind-bo

dypractic

esthatcanbe

used

toim

provem

entaland

physicalhealth.D

ueto

thew

ell-kno

wn

resto

rativ

eeffectso

fyogao

nmentalh

ealth

,ith

asbeen

utilizedin

avarietyof

contextsandsituatio

nsbeyond

thes

tand

ardtherapypractic

e.Ed

ucatorsa

ndscho

olsinparticular

areloo

king

toinclu

deyoga

asac

ost-e

ffective,evidence-based

compo

nent

ofurgentlyneeded

wellness

programsfor

theirstudents.How

ever,there

isno

critically

appraisedevidence

such

assyste

maticreview

sonpo

tentialbenefitsof

yoga-based

interventio

nsin

scho

olsetting

s.

2

Objectiv

es4

Theo

bjectiv

eofthisreportw

asto

review

metho

dologicalqualityam

ongselected

studies,explorin

gthee

videnceo

fyoga-based

interventio

nsregardingacadem

ic,cognitiv

e,andpsycho

socialbenefits,andto

contrib

utetothes

tudy

oflow-cost,health-fo

cused

alternativep

rogram

sfor

child

renandadolescentsinscho

olsetting

s.2

Methods

Eligibility

criteria

5

Peer-reviewed,pub

lishedmanuscriptswerec

onsid

ered.Studies

weres

electedif(1)theyinclu

deday

ogao

ryoga-basedinterventio

n,(2)the

interventio

nwas

restric

tedto

scho

olsetting

s(integrated

into

thes

choo

lscheduleo

rafte

rclass),(3)theyinclu

dedchild

renandadolescents

(ages5

–18),(4)

they

inclu

dedan

evaluatio

nof

anxiety,depressio

n,stress,oro

ther

psycho

logicalm

easuressuchas

moo

dindicators,

self-esteem

,con

fidence,and

quality

oflifea

tbothpreinterventionandpo

stinterventio

n,(5)theyinclu

dedthea

ssessm

ento

facademicor

cogn

itive

perfo

rmance

asac

onsequ

ence

ofthey

ogaintervention(pre-a

ndpo

stinterventio

n),(6)

ther

esearchdesig

nswerep

ilotstudies,

quasi-e

xperim

entald

esigns,orrando

mized

desig

nsandinclu

dedcontrolgroup

swith

nointerventio

nsor

anactiv

econ

trol(comparativ

einterventio

n),and

(7)theywerew

rittenin

English

.Exclusio

ncriteria

comprise

d(1)studies

thatutilizedon

lymeditatio

nor

relaxatio

ntechniqu

eswith

outthe

physicalcompo

nentssuchas

postu

res(asana)

orcontrolledbreathing(pranayama)

(MBS

Rbasedprogramsu

sually

have

yoga

aspartof

thep

ractice,bu

tonlyMBS

Rstu

dies

inwhich

yoga

ishigh

lighted

oristhem

aincompo

nent

ofthep

rogram

were

inclu

dedin

thisreview

,who

seintentionisto

coverp

rimarily

yoga),(2)y

oga-basedprogramsfor

child

renwith

learning

disabilitieso

rany

diagno

sedmentald

isorder,and

(3)d

issertatio

nsandconference

presentatio

ns.

5


Table2:Con

tinued.

Section/topic

#Ch

ecklist

item

Repo

rted

onpage

#

Inform

ation

sources

6

Literature

searches

werec

ondu

cted

inPu

bMed,PsycInfo,Em

base,ISI,and

theC

ochraneL

ibrary

(1980–2014).A

nextensives

earchwas

cond

uctedforstudies

publish

edbetween1980

andOctob

er31,2014,usingthefollowingterm

sork

eywords,yoga,school,edu

catio

n,and

child

ren,alon

eand

incombinatio

nwith

additio

naltermssuchas

program,intervention,andyoga-based.O

ngoing

registe

redclinicaltria

lsweren

otsearched.Th

edetailsforthe

fullsearch

strategy

werelisted

inafl

owdiagram,assho

wnin

Figure

1.

5

Search

7Pu

bMed,E

MBA

SE,and

theC

ochraneC

entralRe

giste

rofC

ontro

lledTrials(C

ENTR

AL)

intheC

ochraneL

ibrary

5

Stud

yselection

8Fo

urauthorsc

ondu

cted

theliterature

searching(C

.Ferreira

-Vorkapic,M.M

archioro,and

S.Telles)andstu

dyselection(C

.Ferreira-Vorkapic,M.M

archioro,and

E.Ko

zasa).

5

Datac

ollection

process

9

Authors(C.

Ferreira-Vorkapic,M.M

archioro,S.Telles,andE.

Kozasa)screenedabstractstoidentifyarticlesthatm

eetinclusio

ncriteria

.Po

tentialarticlesw

erethenevaluatedforinclusio

n.To

cond

uctthe

study,alldatawas

collected

andevaluatedin

term

sofsele

ctioncriteria

,procedure,participants,

interventio

n,metho

dology,assessm

enttoo

ls,andou

tcom

es.Follow-upandresults

werea

lsoassessed.Th

ereview

hasb

eenprepared

usingpreferredrepo

rtingcriteria

forsystematicreview

guidelines

(PRISM

A).J.M.Feitoza

hasp

erform

edallthe

statistics(effectsize).For

thee

ffectsiz

ecalculatio

n,them

eans

andsta

ndarddeviations

(postin

terventio

n)fro

mexperim

entaland

control

grou

pswereo

btaineddirectlyfro

mthes

tudies.

5

Dataitems

10Yo

ga,schoo

l,education,

andchild

ren.

5

Risk

ofbias

inindividu

alstu

dies

11Afterthe

firstappraisal,anothere

xaminer

(J.Simões)evaluatedthes

electedRC

Tsandak

appa

coeffi

cientw

ascalculated

inordertoestim

ate

reliabilityof

datacollectionmetho

ds.Th

eobservedkapp

ascore

of𝑟=0.9suggestsgreatcon

sistencyof

agreem

entb

etweeninvestigators.

6

Effectsize

calculation

12

Thec

omparis

onbetweenexperim

entalcon

ditio

nswas

carriedou

tafte

rthe

analysisof

thep

ooledeffectsizeb

ytheg

enericinversev

ariance

metho

d(rando

meffectm

odel)throu

ghsta

ndardizedmeandifferencea

ndHedges’g.Ninety-fivep

ercent

confi

denceintervalswere

compu

tedfora

llvaria

bles.Twostu

dies

[19,26]

weree

xcludedfro

mthee

ffectsiz

eanalysis

duetoinsufficientd

ata(

meanvalues

not

provided).Th

eanalysis

ofthee

ffectsiz

eofspecific

measuresc

ould

onlybe

perfo

rmed

onstu

dies

thatob

served

thes

amev

ariables

such

asmoo

d,tensionandanxiety[20,23],self-esteem

[23,27],andmem

ory[28,29]w

hencomparin

gthey

ogatocontrolgroup

s.

6

Summary

measures

13

Theq

ualityandreliabilityof

ther

ando

mized

controltria

ls(RCT

s)weree

valuated

accordingto

thee

videncelevelsrecom

mendedby

the

OxfordCenterfor

Evidence-Based

Medicine(AHRQ

,2002).Th

eitemsincludedstu

dyqu

estio

n,stu

dypo

pulation,rand

omization,blinding

,interventio

ns,outcomes,statistic

alanalysis,

results,disc

ussio

n,andfund

ingsource.Th

equalityof

allthe

inclu

dedtrialswas

categoriz

edinto

levelsof

evidence

varyingfro

m1to5,accordingto

low,

uncle

ar,orh

ighris

kof

bias.Th

equalityandreliabilityof

ther

ando

mized

controltria

ls(RCT

s)weree

valuated

accordingto

thee

videncelevelsrecom

mendedby

theO

xfordCenterfor

Evidence-Based

Medicine.

Table1

show

sthe

classificatio

nof

scientifice

videnceinsyste

maticliteraturer

eviews

6


Table2:Con

tinued.

Section/topic

#Ch

ecklist

item

Repo

rted

onpage

#Results

Stud

yselection

14

Aflo

wchartd

epictedthes

earchprocessa

ndstu

dyselection(Figure1).Ofthe

48stu

dies

identifi

ed,9

rand

omized

controltria

lsmetcriteria

forinclusio

nin

thisreview

.Generally,

theR

CTsh

adlowAHRQ

evidence

scores,w

ithmoststudies

receivingas

core

of2b

duetothelackof

blindn

essa

ndfollo

w-up,reflectingther

egular

quality

ofrepo

rtingin

theses

tudies.A

llresults

andcond

ition

softhe

studies

ares

ummarized

inTable3

.

6

Stud

ycharacteris

tics

15

Them

etho

dologicalqualityof

mostincludedtrialswas

generally

redu

ced.Th

edetailsarea

ssho

wnin

Table3

.Ther

ando

mized

allocatio

nof

participantswas

mentio

nedin

alltria

ls.Blinding

inform

ation,

however,w

asinsufficientd

ueto

then

atureo

fthe

study

(inyoga

trials

practitionerb

linding

isim

possible).Interventio

nsinclu

dedyoga

oryoga-based

programsc

ondu

cted

exclu

sively

inscho

olsetting

sfor

child

renrang

ingfro

m7to

17years.Com

paris

ongrou

psinclu

dedph

ysicaleducation,

Ayurvedictreatment,andcontrol.Cognitiv

eand

psycho

logicalfun

ctions

werea

ssessedandthetotaltre

atmentd

urationrang

edfro

m8to

18weeks.

6

Risk

ofbias

with

instu

dies

16Th

enum

bero

ftria

lswas

toosm

alltocond

uctany

sufficientadd

ition

alanalysisof

publicationbias.

6

Effectsize

results

17

Afte

ranoveralleffectsiz

ecalculatio

nof

each

study

(exceptfor

Ramadossa

ndBo

se,2010[19],and

White,2012[26]),thee

ffectsiz

esob

tained

from

similarm

easuresw

ereg

roup

edtogether:m

ood,tension,

anxiety,self-esteem

,and

mem

ory.Figure

2show

sthe

forestplot

oftheg

eneraleffectsizeinthes

elected

studies.Th

egeneralplot

show

sdivided

results

with

halfof

thes

tudies

favorin

gyoga

andtheo

ther

half

favorin

gcontrol.𝑃valuefor

overalleffectisno

tsignificant(𝑝=0.91),bu

tthisisp

robablydu

etoheterogeneity

ofthev

ariables.

Effectsizefrom

moo

dsta

teindicators(POMS)

was

calculated

from

Khalsa

etal.,2012

[23],and

Nogglee

tal.,2012

[20].R

esultsindicatethat

they

ogag

roup

show

edsig

nificantly

bette

rscoresinthep

ostin

terventio

ncond

ition

(𝑝=0.02)(Figure

3).Th

esam

escaleshow

sasecond

significanteffectforthe

subitemstensio

nandanxietyalso

after

they

ogap

ractice(𝑝=0.04)(Figure

4).

Athird

comparis

onwas

carriedou

tfor

thev

ariables

elf-este

em[23,27].Re

sults

show

greaterself-este

emperceptio

nin

thep

ostin

terventio

ncond

ition

forthe

yoga

grou

p(𝑝=0.04)(Figure

5).

Effectsizefor

mem

oryw

asalso

analyzed

inSaroktea

ndRa

o2013,[28]and

Verm

aetal.,2014

[29].B

othstu

dies

utilizedmem

orya

ssessm

ent

tools,bu

tSarokteandRa

o2013,[28]u

sedtwodifferent

instr

uments.

Ther

esultsshow

increasedmem

oryperfo

rmance

forthe

yoga

grou

p(𝑝<0.00001)(Figure

6).

7

Synthesis

ofresults

18

Regardingthee

ffectso

fyogao

npsycho

logicalw

ell-being

,ofthe

sixstu

dies,three

ofthem

supp

ortthe

benefitso

fyogao

ryoga-based

programsfor

child

renin

scho

olsetting

s.Khalsa

etal.[23]o

bservedthatyoga

participantsshow

edsta

tistic

allysig

nificantd

ifferenceso

ver

timer

elativ

etocontrolson

measureso

fanger

controland

fatig

ue/in

ertia

.Nogglee

tal.[20]

also

observed

preventiv

ebenefitsin

psycho

socialwell-being

(anx

ietyandnegativ

eaffect)for

studentse

nrolledin

ayogap

rogram

.InRa

madossa

ndBo

se[19],onlythey

oga

grou

pdemon

stratedas

light

decrease

instresswhilemaintaining

self-control.In

contrast,

Haden

etal.,2014

[30]

andWhite[26]

observed

asig

nificantincreaseinperceivedstr

essinthey

ogag

roup

comparedto

thep

hysic

aleducationandcontrolgroup

s,respectiv

ely.H

owever,in

White[26],bothgrou

ps(yogaa

ndcontrol)repo

rted

significantly

greaterself-este

emandself-regulationover

time.Lastly,

Haginse

tal.[32]

foun

dthatyoga

didno

treduces

tressreactiv

itycomparedto

aphysic

aleducationcla

sswhenstu

dentsw

eres

ubmitted

tostressor

tasks.

Effectsizew

asfoun

dform

oodindicators,anx

ietyandtension(POMS),self-este

em,and

mem

ory.Th

eRCT

ofeach

articleisdescrib

edin

detailin

thetext.

7


Table2:Con

tinued.

Section/topic

#Ch

ecklist

item

Repo

rted

onpage

#Discussio

n

Summaryof

evidence

19

Alth

ough

mosto

fthe

studies

werec

lassified

as2b,according

toAHRQ

evidence

levelcriteria,w

hich

means

lowqu

ality

rand

omized

control

trials,

thisreview

show

sbeneficialeffectsof

yoga-based

interventio

nsatscho

olon

both

psycho

logicaland

cogn

itive

functio

ns(effectsiz

ewas

foun

dform

oodindicators,anx

ietyandtension,

self-esteem

andmem

ory),but

then

egativee

ffectso

fyogaw

erea

lsoob

served

insome

ofthes

tudies

andmight

beexplainedto

somee

xtentb

ythea

daptationprocessb

ychild

ren,

thea

bsence

ofattentionalcon

trol,andthe

inadequacy

ofyoga

practic

efor

child

ren.

Future

research

requ

iresg

reater

stand

ardizatio

nandmustd

ealw

iththep

roblem

ofapprop

riateness:w

hattypeo


nismostsuitablefor

child

renandatwhatfrequ

ency

anddu

ratio

nandob

served

varia

bles.

16

Limitatio

ns20

Not

onlyisthen

umbero

fRCT

slow

,but

also

thetria

lswereo

freduced

metho

dology

quality

andhadris

kof

bias

interm

sofd

esign,

repo

rting,andmetho

dology.Itisc

omprehensib

lethatitisdifficultto

perfo

rmdo

uble-blin

ding

studies

with

yoga,but

blinding

tothe

outcom

eassessorsanddataanalyzer

couldbe

feasibleandhasn

otbeen

repo

rted.O

nelim

itatio

nof

thisreview

isthatitwas

notp

ossib

leto

calculatethe

effectsizeo

fallvaria

bles

observed

inthes

elected

studies

duetotheirh

eterogeneity.

16

Con

clusio

ns21

Thisreview

analyzed

nine

peer-reviewed

RCTstu

dies,inwhich

yoga

was

taug

htto

child

renin

aschoo

lsettin

g.Outcomem

easuresincluded

psycho

logicalw

ell-b

eing

andcogn

itive

functio

ns,suchas

attentionandmem

ory.Eff

ectsizew

asfoun

dform

oodindicators,anx

ietyand

tension(POMS),self-este

em,and

mem

ory.Whilesupp

ortiv

einmanystu

dies,the

utilityof

yoga

ineducationalsettin

gsisinconclusiv

edue

tothes

malln

umbero

frando

mized

controltria

lsin

theliterature.E

venthou

ghon

lyRC

Tswerer

eviewed,m

etho

dologicaland

statistic

alprob

lemsm

ight

have

contrib

uted

totheu

ncertainty:inadequ

ates

amples

izes,absence

ofcontrolgroup

s,varia

bilityin

thetypeo

fyoga

beingtaug

ht,lon

gdu

ratio

nof

yoga

sessions,inapp

ropriatepsycho

metric

toolsfor

child

ren,

andfailu

reto

measure

interveningvaria

bles

such

asmindfulnessandbo

dyaw

areness,which

areimpo

rtantp

artsof

yoga

practic

e.Th

isreview

suggestsvaluableeffectsof

yoga-based

interventio

nsatscho

olon

both

psycho

logicalstatusa

ndcogn

itive

functio

nin

somes

tudies

butfuturer

esearchrequ

iresg

reater

standardizationandmustd

ealw

iththep

roblem

ofapprop

riateness;w

hattypeo


nismostsuitablefor

child

ren,

specifically

interm

softhe

frequ

ency

anddu

ratio

n?

22

Fund

ing

Fund

ing

22Th

isresearch

was

fund

edby

theF

APITE

CAgencyun

derP

rocessno

.7838.UNI321.21944

.25062013.

22Ad

aptedfro

m[24].


Table3:Selected

rand

omized

controltria

ls(RCT

s).

Stud

ySample

Program

Interventio

nVa

riables

Evaluatio

ntools

Results

Evidence

level

Haginse

tal.,2013∗

[32]

Middle

scho

olstu

dents,ages

11to

12(𝑛=30)

VinyasaY

oga

15weeks

50minutes,three

times

aweek

Yoga

orph

ysical

education(c)

Bloo

dpressure

(BP),

heartrate(HR),and

behavioralstr

essor

tasks(mental

arith

meticand

Mirr

orTracing

Tasks).

Automated

bloo

dpressure

cuff,

MentalA

rithm

eticTask

(MAT

),andMirr

orTracing

Task

(MTT

).

Therew

eren

osig

nificant

differences

betweengrou

ps.

2b(not

doub

leblinded,no

follo

w-up)

Haden

etal.,

2014∗

[30]

Middle

scho

olstu

dents,ages

11to

12(𝑛=30)

Ashtanga

Yoga

12weeks

90minutes,three

times

aweek

Yoga

orph

ysical

education(c)

Emotional(affect

andself-perceptio

ns)

andbehavioral

varia

bles

(internalizingand

externalizing

prob

lemsa

ndaggressio

n).

PANAS,Ch

ildBe

havior

Checklist

(CBC

L),R

evise

dParent

Ratin

gScalefor

Reactiv

eand

Proactive

Aggression(R-PRA

),andthe

Self-Perceptio

nProfi

lefor

Child

ren(SPP

C).

Therew

eren

osig

nificantchanges

betweengrou

psin

self-repo

rted

positivea

ffect,globalself-w

orth,

aggressio

nindices,or

parent

repo

rts

oftheirc

hildren’s

externalizingand

internalizingprob

lems.How

ever,

negativ

eaffectincreasedfortho

sechild

renparticipatingin

yoga

when

comparedto

theP

Eprogram.

2b(in

sufficient

blinding

,no

follo

w-up)

Khalsa

etal.,2012

[23]

Highscho

olstu

dents,ages

12to

13(𝑛=136)

Yoga

Ed11weeks

30to

40minutes,two

tothreetim

esaw

eek

Yoga

orph

ysical

education(c)

Moo

d,anxiety,

perceivedstr

ess,

resilience,andother

mentalh

ealth

varia

bles.

TheS

elf-Reporto

fPersonality

(SRP

)versio

nof

theB

ehavior

AssessmentSurveyfor

Child

renVe

rsion2(BASC

-2),

POMS,theR

esilience

Scale

(RS),and

theP

erceived

Stress

Scale(PS

S).

Yoga

participantsshow

edstatisticallysig

nificantd

ifferences

over

timer

elativetocontrolson

measureso

fanger

controland

fatig

ue/in

ertia

.Mosto

utcome

measurese

xhibitedap

attern

ofworsening

inthec

ontro

lgroup

over

time,whereas

changesinthey

oga

grou

pover

timew

eree

ither

minim

alor

show

edslight

improvem

ents.

2b(not

doub

leblinded,no

follo

w-up)

Nogglee

tal.,2012

[20]

Highscho

olstu

dents,ages

16to

17(𝑛=51)

KripaluYo

ga10

weeks

30minutes,twoto

threetim

esaw

eek

Yoga

orph

ysical

education(c)

Psycho

logical

well-b

eing

,moo

dandnegativ

eaffect

(prim

arymeasures),

stress,resilience,

anger,and

acceptance

(secon

dary

measures).

Prim

aryou

tcom

es:P

rofileo

fMoo

dStates-Sho

rtFo

rmand

Positivea

ndNegativeA

ffect

Schedu

leforC

hildren.

Second

aryou

tcom

es:Stre

ssScalea

ndInventoryo

fPositive

Psycho

logicalA

ttitudes,

ResilienceS

cale,

StateT

rait

Anger

Expressio

nInventory-2,andCh

ildAc

ceptance

Mindfulness

Measure.

Moo

dim

proved

inyoga

and

worsenedin

controls.

Negative

affectw

orsenedin

controlsand

improved

inyoga.

2b(not

doub

leblinded,no

follo

w-up)


Table3:Con

tinued.

Stud

ySample

Program

Interventio

nVa

riables

Evaluatio

ntools

Results

Evidence

level

Ramadoss

andBo

se,

2010

[19]

Highscho

olstu

dents,ages

orgrades

not

inform

ed(𝑛=472)

Niro

gaTL

S18

weeks

15minutes,from

oneto

fivetim

esaw

eek

Yoga

once

aweek,yoga

twicea

week,

yoga

three

times

aweek,

yoga

five

times

aweek,

oraw

aitin

glistgroup

(c).

Stressand

self-control.

PerceivedStressScale(PS

S-10)

andTang

ney’s

Self-Con

trol

Scale(TS

CS-13).

Theinterventiongrou

pdemon

strated

aslight

decrease

instr

essa

ndmaintenance

inself-control.In

contrast,

thec

ontro

lgrou

p,which

received

nocla

sses,

demon

strated

nosig

nificantchange

instressandan

onsig

nificanttrend

towarddeterio

ratio

nof

self-control.

2b(not

doub

leblinded,no

follo

w-up)

White,

2012∗

[26]

Elem

entary

scho

olstu

dents,ages

9to

11(girls)

(𝑛=155)

TheM

indful

Awareness

forG

irlsthrou

ghYo

ga8weeks

60minutes,oncea

week(10-minute

homew

orkforthe

other

6days

ofthew

eek)

Yoga

orno

interventio

n(c).

Stress,cop

ing

strategies,

self-esteem

,and

mindfulness.

TheF

eelB

adScale,the

Scho

olagers’Cop

ingStrategies

Inventory,andtheH

ealth

ySelf-Re

gulationSubscaleof

theM

indful

Thinking

and

Actio

nScalefor

Adolescents.

Nosig

nificantd

ifferencesb

etween

grou

pswerefou

nd.

Overtim

e,theinterventiongrou

pwas

morelikely

than

thec

ontro

lgrou

pto

repo

rtstr

ess

2b(not

doub

leblinded,no

follo

w-up)

Saroktea

ndRa

o,2013

[28]

Middlea

ndhigh

scho

olstu

dents,ages

10to

16(𝑛=90)

Hatha

Yoga

3mon

ths

40minutes,every

day

asho

mew

ork

Medhya

Rasayana

(Ayurveda

treatment),

Yoga,orn

ointerventio

n(c)

Executivefun

ctions

andmentalstatus.

Short-term

mem

orytest,

pictures,serialeffectstest,

words,and

minim

entalstate

scale.

Group

Bshow

edhigh

lysig

nificant

andmosteffectivec

hanges

inshort-term

mem

orytestpictures

andseria

lrecalleffectstestu

sing

mem

oryscop

e.Group

Cshow

edhigh

lysig

nificantand

mosteffective

changesw

ithrespecttosubjectiv

eandob

jectivep

aram

etersinmini

mentalstatusscale.

2b(not

doub

leblinded,no

follo

w-up)

Tellese

tal.,

2013

[27]

Elem

entary

andmiddle

scho

olstu

dents,ages

8to

13(𝑛=98)

Hatha

Yoga

3mon

ths

45minutes,five

times

aweek

Yoga

orph

ysical

activ

ity(c)

Self-esteem

,attention,

and

physicalfitness.

Stroop

color-wo

rdtask

for

child

ren,

Battle’s

self-esteem

inventory,andtheteachers’

ratin

gof

thec

hildren’s

obedience,academ

icperfo

rmance,atte

ntion,

punctuality,and

behavior

with

friend

sand

teachers.

Teachers’ratingof

thec

hildren’s

behavior.

Socialself-esteem

:↑PA

grou

pStroop

:↑bo

thgrou

ps(higher

interfe

renceintheP

Agrou

p).

Total,general,andparental

self-esteem

improved

inthey

oga

grou

p.Bo

thgrou

psshow

edan

increase

inBM

Iand

numbero

fsit-ups.B

alance

worsenedin

the

physicalexercise

grou

p,whileplate

tapp

ingim

proved

inthey

ogag

roup

.

2b(not

doub

leblinded,no

follo

w-up)

Verm

aetal.,

2014

[29]

Middlea

ndhigh

scho

olstu

dents,ages

11to

15(𝑛=82)

Hatha

Yoga

12weeks

45minutes,five

times

aweek

Yoga

and

control

grou

psCognitiv

efun

ctions.

MentalA

bilityTestand

Batte

ryandMem

oryTest.

Sign

ificant

improvem

entw

asob

served

inmeasureso

fmental

abilityandmem

oryin

experim

ental

grou

p

2b(not

doub

leblinded,no

follo

w-up)

∗

Negativee

ffectso

nstr

essa

ndaffecto

rnosig

nificance

betweengrou

ps.



−0.01 5.2 70 0.6 6.6 30 47.3%Telles et al., 2014 33.51 6.46 49 36.98 4.82 49 52.7%Total (95% CI) 119 79 100.0%



Heterogeneity:𝜒 2= 2.73, (P = 0.10); I2 = 63%Test of overall effect: Z = 2.46 (P = 0.01)

−0.11 [−0.54, 0.32]−0.60 [−1.01, −0.20]−0.37 [−0.66, −0.07]

Khalsa et al., 2012

df = 1

Figure 5: Self-esteem effect size.


Sarokte and Rao, 2014 20.73 3.02 30 22.63 2.54 30 32.9%

Sarokte and Rao, 2014 12.13 3.09 30 17.07 2.79 30 25.5% 0.6000

5.57 2.39 37 6.83 2.73 37 41.7% 0.4600

Total (95% CI) 97 97 100.0%


0 1 2Favours yoga Favours control

−2 −1Heterogeneity: 𝜒2 = 9.96, (P < 0.007); I 2= 80%Test of overall effect: Z = 5.55 (P < 0.00001)

−0.67 [−1.19, −0.15]

−1.66 [−2.25, −1.06]

−0.49 [−0.95, −0.02]

−0.85 [−1.14, −0.55]Verma et al., 2014

df = 2

Figure 6: Memory effect size.

Since the number of selected RCTs is reduced and otherinteresting results were observed during the review process(that could not provide for an effect size calculation), suchas negative effects or different variables, the studies areindividually described in the following sections in order toprovide details, similarities, and differences between them.

3.2. Outcome Analysis

3.2.1. Yoga and Psychological Well-Being. Six RCT studiesobserved the effects of a yoga program on psychological well-being in school settings.

In [30], authors sought to determine the effects of yogaon children’s emotional and behavioral variables using acomparison group consisting of physical education (PE)classes. Thirty middle school children were randomized toparticipate in either a school-based ashtanga yoga programor PE class three times a week for 12 weeks. Yoga classes con-sisted of opening rituals (3–7min), asana practice (30min),seated meditation (2–5min), and guided relaxation (4min).

Emotional and behavioral functioning was measuredbefore and after intervention utilizing the following tools:Positive and Negative Affect Scales (PANAS), the ChildBehavior Checklist (CBCL), the Revised Parent Rating Scalefor Reactive and Proactive Aggression (R-PRA), and the Self-Perception Profile for Children (SPPC). Results show nosignificant changes between groups in self-reported posi-tive affect, global self-worth, aggression indices, or parents’reports of their children’s externalizing and internalizingproblems. However, negative affect increased for those chil-dren participating in yoga when compared to the PE pro-gram. Authors offer a few explanations for these findings: (1)the first contact with yoga may be demanding for children

at this age (sixth grade) and as a result may increase stresslevels in the short term; (2) the “dose” and type of yoga maynot have been satisfactory; (3) one of the outcomes of yogapractice may be greater self-awareness and mindfulness andthese variables were not assessed in the current study; and (4)the sample size was small.

Khalsa et al., 2012 [23], evaluated mental health bene-fits of yoga for adolescents in secondary school. Studentswere randomly assigned either to regular physical educationclasses (PE) or to 11 weeks of yoga practice based on the YogaEd program. Typical 30-minute Yoga Ed sessions included5-minute initial relaxation and breathing techniques, 5-minute warm-up, 15min of yoga poses, and 5-minute closingrelaxation. Each session also had a theme that was discussedby the instructor, such as yoga philosophy and method-ology, nonviolence, mind-body interactions and awareness,body systems, stress management, emotional intelligence,and similar topics. Psychological well-being was assessedusing the Self-Report of Personality (SRP) version of theBehavior Assessment Survey for Children Version 2 (BASC-2), the Profile of Mood States-Short Form (POMS-SF), theResilience Scale (RS), the Perceived Stress Scale (PSS), and theInventory of Positive Psychological Attitudes-32R (IPPA).

Outcome measures revealed that yoga participantsshowed statistically significant differences over time relativeto controls on measures of anger control and fatigue/inertia.Most outcome measures exhibited a pattern of worseningin the control group over time, whereas changes in theyoga group over time either were minimal or showed slightimprovements. Authors explain that while statisticallysignificant differences between groups were found for onlya few outcome measures, each of these favored the yogagroup. Onmost measures, findings suggested relatively smallpositive effects in the yoga group but marked declines in the


control group. A few study limitations such as inadequatepsychometric tools and short duration of the program mightbe responsible for the observed outcomes.

Noggle et al. [20] observed the effects of a yoga programonpsychologicalwell-being, psychological attitudes, and self-regulatory skills on 51 high school students.The overall scopeof this study was to evaluate the psychological benefits ofa yoga program conducted within the school curriculumfor adolescents and compare them to the regular physicaleducation classes (PE). This differed from Khalsa et al.,2012 [23], as Noggle et al. [20] focused on scales developedfor normative adolescent populations and based their inter-vention on a different yoga style (Kripalu Yoga). Studentsparticipated in both interventions two to three times a weekfor 30minutes. Yoga practice consisted of 5-minute centeringand breathing exercises, 5-minute warm-up, 15 minutes ofyoga postures/exercises, and 5-minute closing relaxation.The authors stated that the yoga intervention developedfor this study might become a standardized Kripalu-basedprogram for use in research within the school setting. After10 weeks of program, students attending physical educationclasses showed decreases in primary outcomes (Profile ofMood States-Short Form and Positive and Negative AffectSchedule for Children). Yoga students were maintained orimproved. Totalmooddisturbance improved in yoga studentsand worsened in controls as did Profile of Mood States-Short Form (POMS-SF) Tension-Anxiety subscale. Althoughpositive affect remained unchanged in both, negative affectsignificantly worsened in controls (PE), while it improved inyoga students. Secondary outcomes, such as the ResilienceScale, the State Trait Anger Expression Inventory-2, and theChild Acceptance Mindfulness Measure were not significant.While the study has specific limitations regarding the real-world applicability of an education setting (sample size,group-randomized trial, observer bias, and minor irregulari-ties), results suggest preventive benefits in psychosocial well-being from the Kripalu yoga program at school.

Ramadoss and Bose, 2010 [19], observed the effects of ayoga-based transformative life skills program (TLS) on stresslevels and self-control of 387 high school students. The con-trol group did not receive the TLS protocol, while among theintervention groups students received one, two, or five classesperweek. Each yoga session lasted 15minutes and included anorienting opening bell, focused breathing (pranayama), silentsittingmeditation, sun salutations, posture (asana), rhythmicbreathing, silent sitting, and a closing bell.Outcomemeasureswere stress and self-control, evaluated by the Perceived StressScale and Tangney’s Self-Control Scale. Results show thatthe intervention group demonstrated a slight decrease instress and maintenance in self-control. In contrast, in thecontrol group, there was no significant change in stress and anonsignificant trend toward deterioration of self-control.Thestudy indicates an improvement in stress, self-control, andself-awareness after 18 weeks of a yoga program, comparedto a control group. Although the study has specific strengthssuch as qualitative feedback from students and teachers,an appropriate sample, and a condensed and effective yogapractice (which might have been the reason for the positiveoutcomes), however, blinding protocol was not clear and

authors could have explored other psychological variables,such as anxiety anddepression, since the studywas conductedwith vulnerable teens.

White [26] investigated the efficacy of eight-week mind-fulness training through yoga with 155 middle school girls(mean age of 9.9 years) on stress and coping abilities, self-esteem, and self-regulation. A randomized group designrandomly assigned two public schools to either the inter-vention or wait-list control group. The experimental groupmet one day per week, for one hour, and completed 10minutes of yoga homework six days a week. The MindfulAwareness for Girls through Yoga program, utilized in thisstudy, was adapted from Kabat-Zinn’s Mindfulness BasedStress Reduction (MBSR) [31] and focused on the yogaportion. The 10-minute practice comprised ringing tingshabells, breathing\sitting meditation, yoga warm-up, postures,and comments. Psychometric tools consisted of the FeelBad Scale, the Schoolagers’ Coping Strategies Inventory, theGlobal Self-Worth Subscale of the Self-Perception Profile forChildren, and the Healthy Self-Regulation Subscale of theMindful Thinking and Action Scale for Adolescents.

Authors reported no significant differences betweengroups. In addition, over time, the intervention group wasmore likely than the control group to report higher perceivedstress scores (although no increase in the frequency ofstressors was found) and greater frequency of coping withstress. As the authors state, as self-awareness progresseswith yoga practice, children may become aware of difficultemotions. This may lead to increased perceived stress at firstbut subsequently may result in better means to cope withsuch feelings. Both groups reported significantly greater self-esteem and self-regulation. According to the authors, thenegative outcomes regarding perceived stress might be dueto (1) use of inadequate psychometric tools, (2) the fact thatawareness of stress might have facilitated coping and that thisincreased awareness of stress might also have precipitatedmore stress, and (3) the fact that increase in stress mightbe transient and part of the process of becoming mindful.Study limitations include a homogeneous sample (only girls),the quality of intervention (due to a large sample size), and,especially, the fact that a greater part of the practice was doneas homework and children were unattended during most ofthe time.

Lastly, in a 15-week study, Hagins et al. [32] examined theeffects of yoga compared to a physical education class (PE)on physiological responses [based on the blood pressure (BP)and heart rate (HR)] to behavioral stressor tasks such asMen-tal Arithmetic Task (MAT) and Mirror Tracing Task (MTT)on 30middle school students. After initial screening, studentswere randomly assigned to either PE classes or yoga course.During 15 weeks, students participated in yoga program orPE classes. Both interventions occurred three times a weekand each session lasted approximately 50 minutes. The yogaclass consisted of an opening ritual (centering and consciousbreathing), asana practice (posture), seated meditation, andguided relaxation.

The authors stated that the two behavioral stressor tasks(Mental Arithmetic Task and Mirror Tracing Task) utilizedin this investigation had been previously used successfully in


studies of stress reactivity in children. The MAT consisted ofsimple arithmetic counts during a specific period of time. Inthe MTT, participants had to trace a star using only a mirrorversion of the star for guidance. Participants had to trace thestar asmany times as possible without any errors during threeminutes. Systolic and diastolic BP and HR were obtainedduring the tests through an automated blood pressure cuff.The procedures and measures in pre- and posttests were thesame. Pretesting occurred one to twoweeks before the start ofthe intervention and posttesting occurred one to two weeksafter the final class. After data analysis, authors concluded thatthe yoga program did not reduce stress reactivity comparedto a physical education class. Furthermore, statistical analysiscomparing the first stressors (MAT versusMTT) used duringthe pretest found that there were no significant differencesin BP or HR values relative to the type of stressor used.Besides, the difficulty in finding differences in BP orHR in theparticipantsmight be due to their good health, especially aftersuch a short time intervention. The authors concluded thatthe results do not support the idea that benefits from yoga arederived from a mechanism related to increased regulation ofthe autonomic nervous system. As in other studies, the resultsobserved here may be related to the way yoga practice wasapplied and a failure to directly address the issue of reactionto perceived stress.

3.2.2. Yoga and Cognitive Function. Three RCT studiesobserved the effects of a yoga program on different cognitivefunctions, such as attention, memory, and developmentalabilities, in school settings.

A three-month study by Sarokte and Rao [28] observedthe effects of a yoga program and Ayurvedic medicine (Med-hya Rasayana) on mental state and cognitive functions of 90students between the ages of 10 and 16. Medhya Rasayana(which means “a preparation which prevents mental andintellectual disorders” in Sanskrit) was administered everyday in the morning and evening and students in the yogagroup were asked to perform yogic practices regularly ina specific order. The practice included postures (asanas),breathing techniques, and meditation. The frequency orduration of each individual practice is not mentioned. In thecontrol group, no intervention or treatment was given. Thegroup treated withMedhya Rasayana showed significant andmost significant changes in the objective variables measured(short-term memory test pictures and serial recall effectstest).The yoga group showed significant changes with respectto subjective and objective parameters in mini mental statusscale. The first follow-up also shows a greater positive impactin the Ayurveda group when compared to the yoga group.The authors concluded that Medhya Rasayana brings fasterimprovements inmemory when compared to yoga. However,the yoga group was asked to perform yogic practices but itis not certain if these children were really practicing yogaat home, and if so, the duration and frequency are unclear.Although the administration of the Ayurvedic drug was alsonot controlled (Medhya Rasayana was given twice a day,possibly by the parents), it is much easier to have 12-year-old boys taking medicine than performing yogic practices,

which takes discipline, effort, and time. Yet, the study showsinteresting results, demonstrating that both interventionsmight be useful to improve cognitive functions.

Telles et al. [27] observed the effects of yoga or physicalexercise on physical fitness, cognitive performance, self-esteem, and teacher-rated behavior and performance in 98school children between the ages of 8 and 13. After initial ran-domization and group allocation, participants were assessedfor physical fitness (Eurofit physical fitness test), performancein the Stroop task (the Stroop color-word naming task), self-esteem, and analog scales (attention, punctuality, behaviorwith friends, and behavior with teachers) rated by the teach-ers. Both groups were assessed at the end of twelve weeks.Yoga practice involved pranayamas (yoga breathing tech-niques), sithilikarana vyayama (loosening exercises), asanas(postures), chanting, and yoga relaxation techniques andlasted three months with a frequency of five times a week (45minutes per day, during school hours). Physical exercise hadthe same time and frequency and consisted of jogging in placeas well as bending and spinal twists. In this study, authorsplaced an emphasis on the differences between yoga andphysical exercise, with this difference being the importanceof awareness, relaxation, and breathing regulation in yoga.

After testing for the differences between groups, socialself-esteem was the only variable with significant changes,increasing in the physical exercise group. pre and postvalues within each group also showed significant changes incognitive function. In the Stroop task, both groups showed anincrease in word scores, color scores, and color-word scores.The physical exercise group showed reduced interference rawscores and an increase in interference scores. In addition,both groups showed an improvement in obedience, academicperformance, attention, punctuality, behavior with friends,and behavior with teachers.

The authors suggest that the improved scores might bedue to better aerobic fitness (observed in both groups). Also,the increase in interference T scores in the physical exercisegroup suggests reduced flexibility and ability to respond tothe task demands after this intervention. Physical activity andyoga also separately improved emotional well-being in bothgroups, but the underlying mechanisms are not clear. Thestudy has limitations such as the fact that the yoga and thephysical exercise programs had to fit in the school schedule,which could have produced differences in outcomes. Therewas also no follow-up.

Finally, Verma et al., 2014 [29] observed significantimprovements in measures of mental ability and memory inan experimental yoga group of high school students, from11 to 15 years of age, randomly divided into a yoga and acontrol group (𝑛 = 82). All children were tested beforeand after the 12-week intervention (or control), using thetest battery of Cognition Function tests (CFTs), an Indianadaptation based on Guilford’s Structure of Intellect Model.Yoga sessions were conducted for 45min, five days a weekwithin the school setting. The practices included chanting,asanas (postures), and pranayamas (breathing techniques).Significant improvement was observed inmeasures ofmentalability and memory only in the experimental group, specifi-cally cognitive processes such as attention, perception, and


observation. The authors suggest that the observed results(on memory scores) indicate that yoga affected only primaryprocessing of visual inputs. Yoga intervention was wellaccepted, particularly due to its short duration,making it easyto be successfully incorporated into the school curriculum.

4. Discussion

This review systematically examined the literature on yoga inschool settings, exploring the evidence of yoga-based inter-ventions on different psychological variables and cognitivefunctions.

Forty-eight peer-reviewed, published studies in whichyoga was taught to school-aged children in a school settingwere identified. Inclusion criteria included only randomizedcontrol studies (i.e., the control group had no intervention oran active control) in which yoga (and not just meditation)was taught and the effects on psychological well-being orcognitive functions were analyzed. After wide qualitative andquantitative synthesis, nine studies were selected.

Regarding the effects of yoga on psychological well-being,of the six studies, three of them support the benefits of yoga oryoga-based programs for children in school settings. Khalsaet al. [23] observed that yoga participants showed statisticallysignificant differences over time relative to controls on mea-sures of anger control and fatigue/inertia. Noggle et al. [20]also observed preventive benefits in psychosocial well-being(anxiety and negative affect) for students enrolled in a yogaprogram. In Ramadoss and Bose [19], only the yoga groupdemonstrated a slight decrease in stress while maintainingself-control.

In contrast, Haden et al., 2014 [30] and White [26]observed a significant increase in perceived stress in theyoga group compared to the physical education and controlgroups, respectively. However, in White [26], both groups(yoga and control) reported significantly greater self-esteemand self-regulation over time. Lastly, Hagins et al. [32] foundthat yoga did not reduce stress reactivity, compared to aphysical education class, when students were submitted tostressor tasks.

The analysis of the effect size for psychological well-beingshowed that an effect size was found for mood state indi-cators (POMS), demonstrating that the yoga group showedsignificant better scores in the postintervention condition.The same scale showed a second significant effect for thesubitems tension and anxiety. The variable self-esteem alsoshowed effect size and better results in the postinterventioncondition for the yoga group.

The evidence for the benefits of yoga in adults, whetherhealthy or suffering from mental disorders, is significant[4, 16]. However, due to the reduced number of randomizedtrials in school settings and the conflicting findings, nodefinitive conclusions can be drawn from these studies withchildren but rather indications and suggestions based onsignificant and reliable but isolated results. The followingsubsections discuss some of the positive and negative results.

4.1. Initial Negative Effect and Insignificant Results. The nega-tive effects of yoga observed in some of the studies heremightbe explained to some extent by (1) the adaptation process, (2)attentional control, and (3) inadequacy of yoga practice forchildren.

4.1.1. Becoming Mindful. The practice of yoga requires effortand discipline. A child’s first contact with yoga is oftendemanding. When yoga is added to a child’s already existingacademic and extracurricular activities, the child may expe-rience higher levels of stress in the short term. According toHayes and Feldman [33], this temporary increase in stressmay also be part of the process of becoming mindful as indi-viduals begin to recognize the typical habits of the reactionto stress. In order to confirm if the initial increase in stress ispart of an adaptation process, the persistence of stress levelsshould be examined later on. Additionally, accomplishmentin yoga depends on acquired self-confidence. Benavidesand Caballero [34] have demonstrated that participants inyoga show increased self-worth but demonstrated that thisis dependent on one’s confidence. At first, initially, tryingsomething new at which a person is not skilled may increasefeelings of inadequacy. According to Kaley-Isley et al. [35],individuals progressing through the stages of change fromprecontemplative to contemplative and active often experi-encemore distress in the transitive contemplative stage wherethere is awareness of the need to change, but the person hasnot yet developed the means or the mastery to do so. Someauthors suggest that this finding would reverse with a longerdose of the intervention [35]. Kaley-Isley et al. [35] concludedthat although there are a few case reports of adverse eventsrelated to the use of yoga in adults [22], there is a need toconduct controlled studies in which systematic data could begathered regarding any adverse effects of yoga with adults,children, and adolescents.

4.1.2. Poor Attentional Control. Yoga techniques such asbreathing and meditation require attentional control, anexecutive function that is still not mature in children andadolescents. As the frontal lobes mature [36], children’scapacity to exercise attentional control increases [37], butthe ability remains much poorer in children than in adults[38]. Paradoxically, yoga has been found to improve attentionin adults and children [8, 39–42]. Therefore, yoga practiceshould be specifically adapted to children so they can reallybenefit from the positive effects observed in adults given theirbrain maturity.

4.1.3. Inadequacy of Practice and Methodology. The durationof yoga practice observed in some of the studies might not besuitable for children due to their inability to control attentionand reduced discipline. In studies where the yoga practice hasbeen found beneficial for the students [19, 20, 23], sessionswere short and condensed, lasting from 15 to 30 minutes.Additionally, many of these studies compared the effectsof yoga to exercise (physical education) and have observedvery similar results. A good methodological approach wouldconsider different intervention groups and a control group.


One of the outcomes of yoga practice may be greater self-awareness and mindfulness, a primary difference betweenyoga and standard physical education, and these variableswere not assessed in any of the studies. Actually, physicaleducation and yoga can be considered as complementary andit is therefore inappropriate to try and compare one as betterthan the other.

4.2. Yoga at Schools: Why It Might Work. Although thenumber of RCT studies observing the effects of yoga onpsychological and cognitive functions in school settings isvery limited, the results seempromising. Effect sizewas foundfor mood indicators, tension and anxiety in the POMS scale,self-esteem, and memory.

This review identified three RCT studies that observedthe effects of yoga-based interventions on different cognitivefunctions, such as attention, memory, and developmen-tal abilities. Overall, participation in a yoga program wasassociated with improvements in subjective and objectiveparameters in mini mental status scale [28], mental ability,and memory [29] while performing the Stroop task [27].

Lowered mood is associated with declines in cognitivefunction and, at least in adults, yoga has been reported toproduce improvements in mood [43, 44]. Additionally, thepractice of yoga emphasizes body awareness and involvesfocusing one’s attention. Indeed, it has been demonstratedthat yoga improves general attentional abilities in adults[8, 39–42]. Attentional focus is a key aspect of yoga. Itproduces similar effects as relaxation in that it tends topromote self-control, concentration, self-efficacy, and bodyawareness [45]. Studies with children suffering from ADHDhave demonstrated significant improvements pre- to posttestin different attention scales and tasks [39, 42]. Neuroimagestudies in adults demonstrate that the effect of meditation(one of yoga techniques) on gray matter was most significantin the putamen [46] and anterior cingulate cortex [47],structures involved in attention processing.

In addition, yoga practice has been shown to reduce anxi-ety based on reductions in psychological arousal [48] (thoughthis variable was not measured), and studies with adults haveverified that anxiety affects performance on tasks requiringattention [49]. Sarang and Telles [50] speculated that anxietyreduction was the likely basis for better performance in theirstudy.

Two of the studies reviewed here showed significantimprovements in memory tasks after a few weeks of yoga-based interventions [28, 29]. Memory improvement follow-ing the practice of breathing exercises (pranayama) [51, 52] orcontemplative techniques such as meditation [53–55], a piv-otal part of the yoga practice, has been widely demonstrated.Activation in the hippocampus, a subcortical structureknown to be critically involved in memory processes [56],has been reported during meditative states [57, 58]. A recentstudy contrasting structural MRI scans of novice meditatorsbefore and after eight weeks of ameditation training programconfirmed actual meditation-induced changes in regions ofthe left hippocampus [59]. Hippocampal differences existbetween meditators and nonmeditators or actual changes of

the hippocampus occur due to meditation, as revealed instructural imaging studies. Studies using positron emissiontomography or functional MRI (fMRI) indicated increasedbrain activation (compared to baseline) during meditationin left and right hippocampal and parahippocampal regions[57, 58, 60, 61]. Even though these are studies conductedin adults, improvements in attentional networks and higherhippocampal activation might also explain the effects of yogaon cognitive functions in children.

5. Conclusions

This review analyzed nine peer-reviewed RCT studies, inwhich yoga was taught to children in a school setting.Outcome measures included psychological well-being andcognitive functions, such as attention and memory. Whilesupportive in some studies and different variables, the utilityof yoga in educational settings is uncertain due to thesmall number of randomized control trials in the literature.Even though only RCTs were reviewed, methodological andstatistical problems might have contributed to the uncer-tainty: inadequate sample sizes, absence of control groups,variability in the type of yoga being taught, long durationof yoga sessions, inappropriate psychometric tools for chil-dren, and failure to measure intervening variables such asmindfulness and body awareness, which are important partsof yoga practice. This review suggests important effects ofyoga-based interventions at school on both psychologicalstatus and cognitive function in some studies, but futureresearch requires greater standardization and must deal withthe problem of appropriateness; what type of yoga-basedintervention ismost suitable for children, specifically in termsof the frequency and duration?

Conflict of Interests

None of the authors have any conflict of interests regardingthe publication of this paper.

Acknowledgments

This research was funded by the FAPITEC Agency underProcess no. 7838.UNI321.21944.25062013. The authors wouldlike to thank Andrew Jungkuntz for English revision.

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