Rachel Schempp

Northland Community and Technical College

Occupational Therapy Assistant Program
Critically Appraised Topics Assignment
Focus Question:
Should yoga be implemented in school based occupational therapy sessions to help increase
attention and limit negative behaviors in the classroom?
Clinical Scenario:
Steiner et al. explains that approximately 12-13% of school aged children suffer from at
least moderate emotional behavioral disorders (EBD). Smith et al. stated that increasingly, school
aged children present challenging emotional and behavioral problems and may be resistant to
traditional special education approaches. EBD can contribute to poor grades, poor personal
relationships, failure to compete in high school, unemployment, incarceration, substance abuse,
and suicide (Steiner et al., 2012).
Along with EBDs, there are many students in the school systems that are suffering from
attention deficit/ hyperactive disorder (ADHD). ADHD affects approximately 3-7% of school
aged children (Kofler, Rapport, & Alderson, 2008). Children with ADHD have significant
deficiencies in attention in the classroom. In a study completed by Kofler, et al, 2008,
approximately 75% of students with ADHD were able to focus in the classroom compared to
88% of typically developing students. Sessions of inattentiveness lasted for 1 minute and 40
seconds in children with ADHD, and just 20 seconds of typically developing children.
This focus question was developed to determine if or how school based OT professionals
could use yoga to help with children than have behaviors or attention deficits in the classroom.
Yoga is a relaxation technique that includes different postures and deep breathing exercises. Yoga
has been proven to improved eye-hand coordination, attention, concentration, and relaxation
(Kauts & Sharma, 2009).
Summary of Key Findings:
Level I:
- Evaluation of the Mental Health Benets of Yoga in a Secondary School: A Preliminary
Randomized Controlled Trial. -- S. Khalsa, L. Hickey-Schultz, D. Cohen, N. Steiner, S.
Cope. (2012)
The goal of this study was to evaluate potential mental health benets of yoga for
adolescents in secondary school. The study consisted of 120 students that were either in 11th or
12th grade. Of the 120 students selected 74 received an average of 40 minute 20.5 yoga sessions
throughout 11 weeks. The yoga intervention that was completed was a modified version of Yoga
Ed that includes simple yoga postures, breathing exercises, and visualization. In the area of
fatigue, there was a signicant difference that was observed over time. The yoga group showed a

strong decrease in the level of fatigue at the end of the semester. In the area of resilience or
persevering, the yoga group did not show a significant change, however the control group,
showed a significant decrease of resilience at the end of the semester. The study also found that
there was a significant positive effect on the students anxiety and life satisfaction rating. Many
of the students in the yoga group commented that they felt that yoga helped them relax and also
gave them energy for the rest of the day. Students also commented that they felt an improvement
in their posture, and they also felt they slept better at night.
Level II:
-Effect of Yoga on Academic Performance in Relation to Stress. --A. Kauts and N. Sharma.
(2009)
The main focus of this study was to determine whether yoga has an effect on academic
performance in mathematics, science, and social studies in relation to stress levels. The study
was completed on 800 9th grade students with a 50/50 ratio of males to females. The students
completed the Bisht Battery of Stress Scale (BBSS), which consist of 13 scales of stress. The two
scales of stress that were chosen were the scale of academic stress and scale of achievement
stress. After the BBSS was administered the students received an academic test that focused on
math, science, and social studies. This test, with a 0.01 level of confidence, proved that students
with a high amount of stress perform at a lower academic level than those with low stress. After
the academic test was given, a group of 301 students were selected for the main study. The
intervention of this experiment was 1 hour of yoga in the morning daily for 7 weeks. The results
of the study concluded that the group that received yoga did better on the posttest than those who
did not receive yoga.
- Effects of Yoga on Inner-city Childrens Well-being: A Pilot Study. D. Berger, E.
Johnson, R. Stein. (2009)
The goal of this study was to examine the effects of yoga on inner-city children. This
study consisted of 72 4th or 5th grade students that were in an after school program. The students
were divided into after school programs; one of the programs included yoga interventions that
totaled 1 hour a week for 12 weeks, and the other program received no yoga interventions. The
group that received yoga completed the Bent on Yoga education program, which is a program
that includes a written curriculum that is up to New York and national standards, the sessions
include physical postures, breathing, meditation, and relaxation. At the end of the 12 weeks, a
survey was given to the students that asked how yoga directly and indirectly effected them. The
survey indicated that 50-80% of the students reported improvement in directly affected areas
such as balance, flexibility, attention, like of ones self, body sensation, behavior in class,
strength, ability to calm self, and sleep. Responses to the questions on indirectly targeted
behaviors, including getting along with others, eating healthy foods, doing homework, test
performance, dealing with aches and pains, and stress and worry was that participants felt the
same or worse. The study concluded that participation in a short-term yoga may have positive
effects on ones well-being.

Level III:
-Sahaja Yoga Meditation as a Family Treatment Programme for Children with Attention
Decit-Hyperactivity Disorder.-- L. Harrison, R. Manocha, K. Rubia. (2004)
This study looked at the effects of Sahaja Yoga Meditation on children with ADHD.
Sahaja Yoga Meditation is a simple meditation method that can easily be taught to children. The
parents and participants completed a pre and post-test, which consisted of parent ratings of
childrens ADHD symptoms, self-esteem and the quality of childparent relationships. Thoughts
of the program were collected from parent questionnaires and child interviews. The participants
completed a 6 week program of two clinic sessions a week and regular at-home meditation. After
the 6 week program, the results indicated that the participants showed a 35% improvement in
their symptoms of hyperactivity, low focusing ability and, anxiety. Of the 26 children that
completed the pre and post-tests 20 of the children were on medication, a comparison between
the 20 participants that were on medication and the 6 that were not showed that there was no
significant influence on the decrease of symptoms due to the medication. Eleven of the parents
that had children on medication stated that they were able to reduce their childrens dosage. The
children that had a lowered dosage of medicine stated that they felt great. Children also stated
that they had fewer headaches, less moments of panic, better amount of concentration, got into
less trouble, and were able to ask their teacher for help. Overall, the study concluded that Sahaja
Yoga Meditation has a large effect on children diagnosed with ADHD.
-Yoga as an Intervention for Children with Attention Problems. H. Peck, T. Kehle, M. Bray,
L. Theodore. (2005)
Ten elementary school students between the ages of 6-10 that had attention problems
volunteered to participate in the study. The students completed Yoga Fitness for Kids, which is
a 30 minute yoga video that comes in 2 different levels, 2 times a week for 3 weeks. The levels
are divided between 2 different age groups 3-6 and 7-12. During the video, students were
reminded to take slow deep breaths throughout the poses. The effect sizes reported in the study
were interpreted in concert with Cohen's guidelines. That means that a small effect should be .20
or greater, a moderate effect should be .50 or greater and a large effect should be .80 or greater.
After the 3 weeks were up the results showed that the effect was 1.51-2.72 indicating a larger
effect. At the follow up the effect decreased to .77-1.95 indicating a moderate effect. The
findings in this article show similar results to prior studies that were performed by others.
-Yoga in an Urban School for children with Emotional and Behavioral Disorders: A
Feasibility Study N. Steiner, T. Sidhu, P. Pop, E. Frenette, E. Perrin. (2013)
Forty-one children with behavioral and emotional disorders that were in the 4th and 5th
grade and enrolled in an urban school participated in the study. Every student, teacher, and parent
received a pre-test before the yoga intervention and a post-test after the intervention. The
intervention lasted one hour twice a week for 3 1/2 months. After the 3 1/2 months ended and the
post-tests were completed, it was concluded that 64% of teachers, 89% of students, and 72% of

parents gave positive responses to the change of behaviors of the students. 63% of the teachers
that gave negative responses was because of scheduling and interference with class time. The
study also wanted to look at the feasibility of offering yoga based interventions in the school
setting. The study concluded that it was feasible to do any basic yoga interventions in the school
setting as many teachers were willing to let their student leave class to participate in the
interventions.
Level V:
- Yoga as a Complementary Therapy for Children and Adolescents: A Guide for Clinicians.
L. Kaley-Isley, J. Peterson, C. Fischer, E. Peterson. (2010)
This article is a review of literature in which its main objectives are to give an overview
of yoga and how it might be used as a complementary mind-body therapeutic tool in the pediatric
population. The article reviewed evidence of the benefits of yoga and provided information
about the availability of yoga resources for children and adolescents. In a group therapy setting
the instructor can provide yoga to multiple students at one time, the cost for class will be less,
and the students have extra support in addition to the support of the teacher. Although the one on
one time is lessened, the instructor can adapt the therapy session to each individuals needs. The
articles that this study gathered explain that yoga can help in the areas of ADHD, anxiety, eating
disorders, and medical conditions such as, asthma, irritable bowel syndrome, and diabetes
prevention. Yoga can help all of the previously stated conditions by decreasing anxiety and
depression, increase muscular and cardiopulmonary fitness, and also by relaxing the body and
mind.
-Yoga in the Schools: A Systematic Review of the Literature. - M. Serwacki, C. CookCottone. (2012)
This article is a review of literature in which the objective of the research was to examine
the evidence for delivering yoga-based interventions in schools. The reviewers in this article
examined 12 different articles that were separated into 2 different sections of development either
atypical development or typical development. The atypical developing section generally focuses
on the 2 diagnoses of autism and special needs. One of the studies the article reviewed looked at
the effects of the Self-Discovery Programme on children with special needs. The Self-Discovery
Programme integrates yoga, massage, and relaxation for children identified with special needs on
the basis of emotional, behavioral, or learning problems. The results of this study indicated that
after 12 weeks that consisted of 45 minutes of this intervention, the intervention group showed
improvements in self-confidence, social confidence, communication, and contributed more in
class. A study that was in the typical developing section, talked about the effects of yoga on the
psychosocial adjustment of children as their body changes and grows. Seventy-five 5th grade girls
participated in the intervention group attended 90 minute classes that included yoga, relaxation,
and information about the medias influences on young girls. Self-reports indicated that there
was a decrease in body dissatisfaction and dysfunctional eating behaviors and increases in
perceived self-concept.

Bottom Line for Occupational Therapy Practice:

Yoga has been proven to improve children's concentration, anxiety, heart rate, headaches,
general tension, behavioral disorders, and stress symptoms. With the improvement in all of these
areas, yoga can be a huge benefit in the school setting (Peck, Kehle, Bray, & Theodore 2005). In
one study it was found that because yoga relieves stress, it allows a student to perform better
academically (Kauts & Sharma 2009). In another study it was shown that yoga helped relax and
calm the childrens body and helped them concentrate in class (Steiner et al, 2013). Along with
the psychological benefits of yoga, it has also been documented that yoga has improved students
balance, flexibility, attention, body sensation, strength, posture and sleep. Due to many of the
direct effects of yoga, it was reported that children are also getting along with others, eating
healthier foods, doing homework, increasing their test performance, reporting greater life
satisfaction, and dealing with aches and pains better (Berger, Johnson, & Stein 2009; Khalsa,
Hickey-Schultz, Cohen, Steiner, & Cope 2012). It has also been found that yoga can help relieve
medical conditions such as, asthma, irritable bowel syndrome, and diabetes (Kaley-Isley,
Peterson, Fischer, & Peterson 2010).
In a study focusing on ADHD, it was found that yoga had a significant effect on the
childs symptoms of ADHD. The study done by Harrison, Manocha, & Rubia (2004), found that
the children had fewer headaches, less moments of panic, better amount of concentration, got
into less trouble, and were able to ask their teacher for help. The 11 of the 20 parents that had
children on medication were able to reduce their childrens dosage of medication. The children
that had a reduction of their medication said they felt great.
With all positive effects yoga has on children and adolescents it is evident that yoga
should be implemented in all different levels of education. The main problem with establishing a
yoga program in the school system is trying to find cooperation inside of the school. These
difficulties include getting teachers and principals to collaborate with yoga instructors, finding
yoga instructors, and finding time for children to be taken out of class (Steiner et al., 2013). This
is where occupational therapy (OT) should be a huge push. Occupational therapy practitioners
would be able to become certified yoga instructors and then they would be able to provide yoga
sessions within the context of school based occupational therapy as the main focus would be
increasing attention and behaviors. OT practitioners would be able to pull multiple students to do
a group yoga session, or they would be able to do one on one yoga therapy sessions. Although
becoming certified in yoga is the most reliable way to get the best results, OT practitioners can
teach basic yoga poses in their therapy sessions. OT practitioners can also educate the teachers,
principals, and superintendents about what the positive effects of yoga are and help teachers find
ways to have yoga sessions in the classroom or a yoga program throughout the entire school
system.
Review Process:

Inclusion Criteria: Yoga, Pediatric yoga, school aged children, male or female, ADHD,
articles published after 2004.
Exclusion Criteria: adults, article published before 2004
Search Strategy:
Categories
Patient/Client Population
Intervention
Comparison
Outcome

Key Search Terms

School aged children
Yoga
N/A
Better behaviors in the class room.

Databases and Sites Searched:

Databases:
All of EBSCOhost databases, ProQuest Nursing and Allied Health Source Journals, and Google
Scholar.
Quality Control/Peer Review Process:
First a question was formed by using AOTA.org emerging niches in the Rehabilitation
and Disability section. Peer reviewed journal articles were search for by using the NCTC
databases, EBSCOhost, ProQuest Nursing and Allied Health Source Journals, and Google
Scholar. The selected articles were not published before the year 2003. A total of 4 peer reviewed
journals were selected, and information that was relevant to the focus question was utilized to
answer the focus question. Once document was completed, another occupational therapy
assistant student peer reviewed it. When document was handed back, changes were made
according to the feedback that was provided. After changes were made, document was submitted
to instructor for further reviewing. After the instructor reviewed the CAT document, 4 more peer
reviewed articles were selected from the databases and relevant information was utilized to
answer the focus question. Once document was completed, another occupational therapy
assistant student peer reviewed it. When document was handed back, changes were made
according to the feedback that was provided. After changes were made, document was submitted
to instructor for another grade, and was handed back once more with further suggestions. After
changes were made according to the instructors suggestions, the document was submitted to
instructor for final grading.
Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of Evidence Study Design/Methodology of Selected
Number of Articles Selected
Articles
Level I
Systematic reviews, meta-analysis,
1
randomized controlled trials

Level II
Level III
Level IV
Level V
Qualitative

Two groups, nonrandomized studies (e.g.,

cohort, case-control)
One group, nonrandomized (e.g., before
and after, pretest, and posttest)
Descriptive studies that include analysis
of outcomes (single subject design, case
series)
Case reports and expert opinion, which
include narrative literature reviews and
consensus statements

2
3
0
2
0

Limitations of the Studies Appraised:

Level I:
- Evaluation of the Mental Health Benets of Yoga in a Secondary School: A Preliminary
Randomized Controlled Trial. -- S. Khalsa, L. Hickey-Schultz, D. Cohen, N. Steiner, S.
Cope. (2012)
There was only a few areas of benefits that showed a significant difference between the control
group and the treatment group. There was no blinding of the participants between the two
groups. There were a number of irregularities that include intervention lengths, frequency,
duration of sessions, and cancelled sessions
Level II:
-Effect of Yoga on Academic Performance in Relation to Stress. --A. Kauts and N. Sharma.
(2009)
This study was not conducted in the United States, so the results may be different in the US.
- Effects of Yoga on Inner-city Childrens Well-being: A Pilot Study. D. Berger, E.
Johnson, R. Stein. (2009)
There was a small sample size of 72. The yoga interventions were relatively short and had a low
intensity level.
Level III:
-Sahaja Yoga Meditation as a Family Treatment Programme for Children with Attention
Decit-Hyperactivity Disorder.-- L. Harrison, R. Manocha, K. Rubia. (2004)
There was a small sample size of 26. This study did not involve a control group. There was no
direct relationship with the school system. The findings could have been biased due to a high
drop-out rate. Results relied on questionnaires that were filled out by the participants parents,
and the parents might want to present their children in the best light.

-Yoga as an Intervention for Children with Attention Problems. H. Peck, T. Kehle, M. Bray,
L. Theodore. (2005)
There was a small study group of 10 children. Students were occasionally engaged in different
activities related to their normal classroom routine when they were taken for the yoga session.
The investigator served dual roles as both implementer of the intervention and observer of the
participants, which introduces a potential bias.
-Yoga in an Urban School for Children with Emotional and Behavioral Disorders: A
Feasibility Study N. Steiner, T. Sidhu, P. Pop, E. Frenette, E. Perrin. (2012)
There was a low return rate of questionnaires (62%). During the 1st year of the study, the school
was quarantined for a week due to H1N1 right before the post-test was given.
Level V:
- Yoga as a Complementary Therapy for Children and Adolescents: A Guide for Clinicians.
L. Kaley-Isley, J. Peterson, C. Fischer, E. Peterson. (2010)
The review narrowed the range of pediatric yoga. The review was not exhaustive and did not
include quantitative analysis of data. Small number of studies on any one diagnosis made it
difficult to form practice recommendations that were evidence based.
-Yoga in the Schools: A Systematic Review of the Literature. - M. Serwacki, C. CookCottone. (2012)
There was a minimal number of 12 studies that were reviewed. The studies that were reviewed
had small sample sizes and had a lack of randomization which could lead to a bias in the studies.
Articles Selected for Appraisal:
Berger, D. L., M.D., Silver, E. J., PhD., & Stein, R. E. K., M.D. (2009). Effects of yoga on innercity childrens well-being: a pilot study. Alternative Therapies in Health and Medicine,
15(5), 36-42.
Harrison, L., Manocha, R., & Rubia, K. (2004). Sahaja yoga meditation as a family treatment
programme for children with attention deficit-hyperactivity disorder. Clinical Child
Psychology and Psychiatry, 9(4), 479-497.
Kaley-Isley, L., Peterson, J., Fischer, C., & Peterson, E. (2010). Yoga as a complementary
therapy for children and adolescents: a guide for clinicians. Psychiatry (1550-5952), 7(8),
20-32
Kauts, L. & Sharama, N. (2009). Effect of yoga on academic performance in relation to stress.
International Journal of Yoga, 2(1), 39-43. DOI: 10.4103/0973-6131.53860

Khalsa, S., Hickey-Schultz, L., Cohen, D., Steiner, N., & Cope, S. (2012). Evaluation of the
Mental Health Benefits of Yoga in a Secondary School: A Preliminary Randomized
Controlled Trial. Journal Of Behavioral Health Services & Research, 39(1), 80-90.
doi:10.1007/s11414-011-9249-8
Peck, H. L., Kehle, T. J., Bray, M. A., & Theodore, L. A. (2005). Yoga as an Intervention for
Children With Attention Problems. School Psychology Review, 34(3), 415-424
Serwacki, M. C. & Cook-Cottone, C. (2012). Yoga in the Schools: A Systematic Review of the
Literature. International Journal Of Yoga Therapy, 22101-110.
Steiner, N., Sidhu, T., Pop, P., Frenette, E., & Perrin, E. (2013). Yoga in an Urban School for
Children with Emotional and Behavioral Disorders: A Feasibility Study. Journal Of Child
& Family Studies, 22(6), 815-826. doi:10.1007/s10826-012-9636-7
Other Resources Found:
Kofler, M. J., Rapport, M. D., & Alderson, R. M. (2008). Quantifying ADHD classroom
inattentiveness, its moderators, and variability: a meta-analytic review. Journal Of Child
Psychology & Psychiatry, 49(1), 59-69. doi:10.1111/j.1469-7610.2007.01809.x