Brigham & Women’s Hospital Harvard Medical School

Yoga as an Intervention for Mental Healthwithin the High School Curriculumwithin the High School Curriculum

February 23, 2011y ,

Prevention Research CenterSpring 2011 seminar seriesSpring 2011 seminar series

Penn State University

Sat Bir S. Khalsa, Ph.D.

Assistant Professor of MedicineBrigham and Women’s Hospital, Harvard Medical School

Director of Research, Kundalini Research InstituteR h Di K i l C f Y d H l hResearch Director, Kripalu Center for Yoga and Health

YogaYoga

Physical Posturesand Exercisesand Exercises

static posturesisometricstretching of trunk and limbs

id i t f li bwide variety of limb and trunk movementsmovements

Physical Posturesand Exercises

BreathingExercises

long, slow and deepabdominalpatterned and pacedsegmentedsegmentedalternate nostril

MeditationMeditationrelaxed focused attention on breathing, words, sensespassive exclusion of ruminating thoughtspassive exclusion of ruminating thoughts

Philosophy / PsychologyPhilosophy / Psychology

yoga as mysticismyoga as mysticismcontemplative practice for personal growth

i f itiexperience of a unitivestate of consciousness as the ultimate goalgpsychology of detachment and expanded identity

Benefits of Yoga PracticeBenefits of Yoga Practice

Arousal reduction, physical/mental well-being

Mind/body awareness, resilience, self-regulation

Psychological / philosophical transformation

Reasons for PracticeReasons for Practicein a Beginners Program

From: Yoga in the real world: Motivations and patterns of use Quilty MT Saper RFrom: Yoga in the real world: Motivations and patterns of use, Quilty MT, Saper R, Goldstein R, Khalsa SBS, Abstract, NARCCIM 2009.

Prevalenceof Yoga Practice

Popularity of Yoga Practice

Yoga Practice in the United States

I do oga in m s iteI do yoga in my suite.Doctor’s orders.It’s a good conversationIt s a good conversationstarter at breakfast.Almost as good as theAlmost as good as thecomplimentary waffles.

M dit tiDeep Breathing

YogaMeditation

From: Complementary and Alternative Medicine Use Among Adults and Children: United St t 2007 B PM Bl B N hi R CDC N ti l H lth St ti ti R tStates, 2007, Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12, 2008.

Yoga Use in the Last 12 MonthsYoga Use in the Last 12 Months

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ent o

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0Adults < 18 yr old

From: Complementary & Alternative Medicine Use Among Adults & Children: United States, 2007, Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12, 2008.

How Do We Reach All of Society?

Two systems are in place in society that penetrate to all levels of the population

The healthcare systemThe healthcare system

The education system

Both systems require validation of techniques and procedures before implementationand procedures before implementation

Yoga ResearchYoga Research

Brosse, 1936

From: Documents recueillis aux Indes sur les “Yoguis” par l’enregistrement simultane du

l d l i ti t dpouls, de la respiration et de l’electrocardiogramme[Data gathered in India on a Yogi with simultaneous registration ofwith simultaneous registration of the pulse, respiration, and electrocardiogram]Laubry C, Brosse TL P M di l 44 1601La Presse Medicale 44:1601-1604, 1936.

Das and Gastaut 1955Das and Gastaut, 1955

From: Variations de l’activite electrique du cerveau, du coeur et de muscles squelettiques au cours de la meditation et de l’extase yogique [Variations in the electrical activity of the brain heart and skeletal muscles during yogic meditation and trance] Das N Gastaut Hbrain, heart, and skeletal muscles during yogic meditation and trance], Das N, Gastaut H, Electoencephalography and Clinical Neurophysiology, Suppl. 6:211-219, 1955.

Anand et alAnand et al., 1961

From: Some aspects ofFrom: Some aspects of electroencephalographic studies in yogis, Anand BK, Chhina GS, Singh B, Electroencephalography and Clinical Neurophysiology, 13:452-456, 1961.

Bagchi and Wenger 1957Bagchi and Wenger, 1957

“…physiologically p y g yYogic meditation represents deep relaxation of the autonomic nervous system without drowsiness or sleep …”

From: Electro-physiological correlates of some Yogi exercises, Bagchi BK, Wenger MA, Electroencephalography and Clinical Neurophysiology, 7 (Suppl):132-149, 1957.

Physiology of Meditation

From: The physiology of meditation,Wallace RK & Benson H, Scientific American 226:85, 1972., ,

Perceived Stress Scale Stress Behavior Scale

e S

core

2 0

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core

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Pre-treatment Post-treatment1.4

Pre-treatment Post-treatment1.6

Urinary Noradrenaline

Stressin a Corporate Le

vel

300

350

pSetting

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age

200

250

From: Stress management: A randomized study of cognitive behavioural

Pre-treatment Post-treatment

therapy and yoga, Granath J, Ingvarsson S, von Thiele U, Lundberg U. Cognitive Behaviour Therapy, 35(1):3–10, 2006

Long-term Meditation & Cortical Thicknessg

From: Meditation experience is associated with increased cortical thickness, Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, McGarvey M, Quinn BT, Dusek JA, Benson H, Rauch SL, Moore CI, Fischl B, Neuroreport 16:1893-1897, 2005.

MBSR and Gray Matter DensityMBSR and Gray Matter Density

L Hippocampus

CPosterior CingulateTemporo-parietal

JunctionC b ll

…participation in MBSR is associated with changes in gray matter

Cerebellum

From: Mindfulness practice leads to increases in regional brain gray matter density,

concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing, and perspective taking.

g g y yHölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, Lazar SW, Psychiatry Research Imaging, 191:36-43, 2011.

Yoga Thalamic GABA Mood & AnxietyYoga, Thalamic GABA, Mood & Anxiety

From: Effects of yoga versus walking on mood, anxiety, and brain GABA levels: a randomized controlled MRS study, Streeter CC, Whitfield TH, Owen L, Rein T, Karri SK, Yakhkind A, Perlmutter R, Prescot A, Renshaw PF, Ciraulo DA, Jensen JE.Journal of Alternative and Complementary Medicine, 16:1145-52, 2010.

A Review of Yoga Therapy ResearchA Review of Yoga Therapy Research

http://www.ijpp.com/vol48 3/vol48 no3 spl invt art.pdfp jpp _ _ _ p _ _ p

Chronology of Yoga Therapy ResearchChronology of Yoga Therapy Research50

40

45

50

30

35

20

25

10

15

0

5

1963 1969 1974 1979 1984 1989 1994 1999 20041963-1968

1969-1973

1974-1978

1979-1983

1984-1988

1989-1993

1994-1998

1999-2003

2004-2008

Rationale for Yogain the Schools

Rationale for Yogagin the Schools

● Reach

Compulsory EducationCompulsory Education

Hygiene EducationHygiene EducationThe time when the preparation of teachers can be made by a study of psychology and methods ought to pass. When it does it will mean p y gy g pthat the health and welfare of a child will then be regarded as one of as much importance as arithmetic and geography, and then a knowledge of the elements of child hygiene will be regarded of as

From: The Hygiene of the School Child, LM Terman, 1914.

knowledge of the elements of child hygiene will be regarded of as fundamental importance in the training of every teacher.

… school health programs and the general academic curriculum, aim to help the child reach his maximum state of health and well-being, p gmotivating him to assume responsibilities for his own welfare as an adult.…basic objectives:…basic objectives:1. To help every child to attain his optimal state of physical, intellectual emotional and social well-being.

F P f d t l h lth d ti i N Y k St t bli h lFrom: Program of dental health education in New York State public schools, Gutman RE, Journal of School Health, 25: 229-232, 1955.

Dental Hygiene Education

The teaching of mouth hygiene.The instruction should be extended over several

years Health rules for the teeth could be pasted in theyears… Health rules for the teeth could be pasted in the back of all schoolbooks.

Special effort should be centered on making theSpecial effort should be centered on making the instruction carry over into action. Health instruction without health habits is vain. Children should be taught in the school how to rinse the mouth, to gargle and to brush the teeth. Actual drills for this purpose are to be commendedcommended.

From: The Teeth of School Children Chapter 9 pg 167-196 in The Hygiene of theFrom: The Teeth of School Children, Chapter 9, pg. 167 196, in The Hygiene of the School Child, LM Terman, 1914.

Dental Hygiene Education

• Initial measures for a state-wide school program by the State Education Department in 1913 state lawState Education Department in 1913 state law

• Dental hygienists performing health instruction

• Shortly after an office of oral hygiene was established in the Division of Medical Inspection and Health Services

• Program has been state-wide since 1944

• 1955 personnel exceeding 450 dental hygiene teachersp g yg

From: Program of dental health education in New York State public schoolsFrom: Program of dental health education in New York State public schools, Gutman RE, Journal of School Health, 25: 229-232, 1955.

Rationale for Yogagin the Schools

● Reach

● Prevention

Genesis of AdultGenesis of AdultMental Health Problems

M j it f i l i i i d i t tMajority of seriously impairing and persistent conditions have child-adolescent onsets and hi h bidithigh comorbidity

Need for treatment of largely untreated child-g yadolescent disorders

From: The descriptive epidemiology of commonly occurring mental disorders in the United States. Kessler RC, Wang PS, Annual Review of Public Health, 29:115-29, 2008.g

Rationale for Yogagin the Schools

● Reach

● Prevention

● Need

Adolescent / School Challenges

Stress (developmental, family, social, academic, societal)

Behavior (apathy, violence, social skills, bullying, absenteeism)

Mental Health (depression anxiety substance abuse trauma)Mental Health (depression, anxiety, substance abuse, trauma)

Attention (ADD, ADHD)

Academics (grades, dropouts)

Physical Health (obesity, diabetes)

Adolescent / SchoolAdolescent / SchoolMental Health Challenges

7 5% adolescent prevalence for one or more7.5% adolescent prevalence for one or more DSM-IV disorders

The most consistent factors involve indicators of stress

Personal resources (e.g. mastery) enhance resilience to onset

From: One-year incidence of psychiatric disorders and associated risk factors among adolescents in the community Roberts RE Roberts CR Chan W Journal of Childadolescents in the community. Roberts RE, Roberts CR, Chan W., Journal of Child Psychology and Psychiatry. 50:405-15, 2009.

Adolescent / SchoolAdolescent / SchoolMental Health Challenges

Youth Risk Behavior Survey (YRBS)

36% (HS) attend home parties allowing teen alcohol use25% (HS) show evidence of binge drinking25% (HS) show evidence of binge drinking36% (MS) report having been bullied15% (HS) report having actually attempted suicide15% (HS) report having actually attempted suicide

Meditation inEducation

Meditation in Education

“…the faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character and will. No one is compos sui if he have it not. An education which should improve this faculty would be theeducation par excellence.”

From: William James, The Principles of Psychology, 1890.

Meditation in Education“The practice of meditation leads to mental p

concentration.The very essence of education is concentration ofThe very essence of education is concentration of

mind, not the collection of facts. If I had to do my education once again I would not study facts ateducation once again, I would not study facts at all. I would develop the power of concentration and detachment and then with a perfectand detachment, and then with a perfect instrument, collect facts at will.”

From: Swami Vivekananda, in Education, Compiled from the speeches and writings of Swami Vivekananda T Sthe speeches and writings of Swami Vivekananda, T.S. Avinashilingam,1943.

Mental Hygiene EducationMental Hygiene EducationSelf reliance does not grow out of habits of dependence, nor does steadfastness develop out of uninhibitednor does steadfastness develop out of uninhibited impulses. If we would free children from bondage to their whims, we must train them to concentrate, to attend.

Perhaps all of us have reserves of energy which we habitually fail to use and rich capabilities which we havehabitually fail to use and rich capabilities which we have failed to realize. The gates to these treasures are closed and sealed by the low opinion we entertain of ourselves,and sealed by the low opinion we entertain of ourselves, by the discouragement and self-distrust incident to failure, and by other inhibitions or repressions. As a means of tapping the hidden treasures of power…the loosening of the inhibitory stresses by suggestion, by hypnoidization…From: Preventive Mental Hygiene, Chapter 18, pg. 318-334, in The Hygiene of the School Child, LM Terman, 1914.

From: Increases in positive psychological characteristics with a new relaxation-response curriculum in high school students, Benson H, Kornhaber A, Kornhaber C, LeChanu MN, et al., Journal of Research & Development in Education, 27:226-231, 1994.

From: Mindfulness training for elementary school students: The attention academy NapoliFrom: Mindfulness training for elementary school students: The attention academy, Napoli M, Krech PR, Holley LC, Journal of Applied School Psychology, Vol 21:99-125, 2005.

Yogai Ed tiin Education

Why Yoga?Why Yoga?

● Yoga may be more effective than meditation alone; the exercise, breathing and relaxation components of yoga

f ilit t ff ti dit ti timay facilitate a more effective meditation practice

● The exercise, breathing and relaxation components of g pyoga provide additional benefits

● Yoga may be more acceptable to adolescents● Yoga may be more acceptable to adolescents

● Yoga may be more acceptably integrated into schools

● Yoga has been shown to be effective in children

Why Yoga?Why Yoga?

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Yoga MeditationDeepBreathing

From: Complementary & Alternative Medicine Use Among Adults & Children: United States, 2007, Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12, 2008.

Kripalu Yoga for Performance AnxietyKripalu Yoga for Performance AnxietyMusic Performance Anxiety Inventory

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F Y R d P f A i t i Ad l t M i iFrom: Yoga Reduces Performance Anxiety in Adolescent Musicians, Khalsa SBS, Butzer B, Shorter SM, Reinhardt K., Cope S, under review.

Research on Yogai S h lin Schools

Dental Hygiene Research in the Schoolsto determine whether a short course of instruction in dental health…to determine whether a short course of instruction in dental health,

including brushing the teeth in the class room, produced any measurable effect on the cleanliness of the teeth of upper elementary grade children in the Baltimore Public Schoolselementary-grade children in the Baltimore Public Schools.

- 2 groups of children, 5th grade491 hild i 13 h l 283 i 8 h l- 491 children in 13 schools vs. 283 in 8 schools

- month-long course of instruction, 15-20’/day for 20 days- to motivate good general dental health practices/habits- principles of dental care, proper brushing- organized toot brushing drills in the class room- daily home use with daily record of usey y

From: Effect of oral cleanliness produced by dental health instruction and brushing the teeth in the class room, The 1953-1954 Baltimore Tooth Brushing Study, 25: 250-254, 1955.

Reduced breath rate and heart rate

Reduced aggression, helplessness, improved stress coping

Fewer negative behaviors in response to stress

Improved stress, rumination, intrusive thoughts, arousal

concentration, mood, ability to function under pressure

Improved self-esteem

Yoga Ed / Kripalu Yoga StudiesYoga Ed / Kripalu Yoga Studies

●12-week 1-hr Yoga Ed/Kripalu classes 2-3 times/week● RCT, yoga vs. physical education, N ~ 100● Qualitative interviews post-programQ p p g● Self-report pre-post mental health questionnaires

Qualitative StudyQualitative Study

Sample• 28 Students• 17 male, 11 female• 13 in 9th grade, 15 in 10th gradeg , g

Interview ThemesInterview Themes• Yoga research administration• Experience of yoga• Experience of yoga• Practical integration/ application of yoga in school

Qualitative DataQualitative Data

Improved stress, attitude and mood:

• stress management• focus and concentration• energy levels• overall optimism • academic and social performance• sleep

Quotes: Stress Attitude & Mood“Yoga helps us become more aware of our bodies…I notice

Quotes: Stress, Attitude & Moodg p

myself being more into my physical well-being…yoga is a break, rejuvenation, and when I return to class after yoga I am refreshed and have a new outlook on things.”

“If you had a lot of stuff on your mind or something you y y g ycould just use some of those exercises... I just felt calmer and stuff, if I was stressed out or angry for some reason, I’d use that at some point. I’d do their breathing exercises and they’d calm me down.”

“Yoga definitely helped with sleeping…it would take me a long time to get to sleep. When I was doing yoga it was much easier to fall asleep and stay asleep…”

Qualitative Data

Continuing Yoga Practice:

Qualitative Data

Continuing Yoga Practice:

M t d t ld ti if ff d i h lMany students would continue yoga if offered in school

C b fit t d f ti tiCommon benefits noted for yoga continuation:• break from regular classroom routine

i d t ttit d d d• improved stress, attitude and mood• physical flexibility• performance and reduced injury in sports• social activities with peers

Quotes: Continuing Yoga PracticeQuotes: Continuing Yoga Practice

“It was nice to be out of a desk and blackboard environment and nice to come to yoga class to regain f f ti d d b d f h l ”focus from tiredness and boredom of school.”

“In the beginning I didn’t like [yoga], but over time, in the g g y gmiddle I started to notice results… I began to like it because it started to work…”

“Friends who are doing yoga with me are kinder…if they are mad or annoyed they breathe before talking…My y y g yrelationships with people are getting stronger.”

Rating of the InterventionDo you think the yoga was valuable enough

that you would recommend it to your friends?

Rating of the Intervention

that you would recommend it to your friends?ts

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From: Khalsa SBS, Noggle J, Cohen D, Steiner N, Cope S, in preparation.

Mental Health Outcomes YogaImprovementWorsening

Mental Health Outcomes - Yoga

Social Stress

ImprovementWorsening

Attitude to School

Anger

Resilience

Negative Affect

Anxiety

Anger ExpressionAnger Expression

Mental Health Outcomes ControlImprovementWorsening

Mental Health Outcomes - Control

Social Stress

pg

Attitude to School

Anger

Resilience

Negative Affect

Anxiety

Anger Expression

Mental Health OutcomesImprovementWorsening

Mental Health Outcomes

Social Stress

pg

Attitude to School

AAnger

Resilience

Negative Affect

A i tAnxiety

Anger Expression

Ongoing Study

● Waltham High School● 325 grade 9 students● Kripalu Yoga vs. Phys Ed ● 12 weeks of yoga across school year● Pre, Post, Mid-intervention questionnaires● Pre, Post, Mid intervention questionnaires ● Pre/post cognitive testing● Physical fitness metrics● Physical fitness metrics

Future StudiesFuture StudiesMental Health

Substance abuse, depression & suicidality, bullyingSelf-esteem, maturity, independence, values, positive psychology, spirituality

P fPerformanceAttention, memory, cognitive processingGrades and attendanceGrades and attendanceCreativitySports

Physical HealthRisk factors for diabetes, obesity, hypertensionImmune functionImmune functionFlexibility, injury prevention

Long-term Longitudinal ChangesLong term Longitudinal ChangesYoga throughout high school followed by adult followup

The Challenge of FundingThe Challenge of FundingReviewer Bias and Paradigm Shift Resistance

"It does not appear to be innovative since there is mention of an established Yoga Ed Program for adolescents that the interveners will be trained in. There evidently is an existing classroom based yoga program that has been tested.“y g y g p g"This process goes against most IRB requirements for research in children. …it is unclear how the process for study recruitment and participation will be handled if the IRB turns down the concept of "passive consent" which is not

ll itt d b IRB' f thi i l l ti "usually permitted by IRB's for this special population.""Requires testing within a controlled environment before it can be used safely within a school system."

“…yoga and other techniques serve a similar role as OTC medications do in getting relief from a cold. They temporarily relieve symptoms, but don’t address the underlying cause. Once the medication wears off, the symptoms (in this y g y p (case a dysfunctional amount of emotion) often return because the cause is still there…does not contribute something that would be a practical way to address this pressing gap in curricula, and if published, might only send some in a

l ti d d d d d l t d fi di b tt l ti ”relative dead end and delay progress toward finding a better solution.”– Reviewer, Journal of School Health

i lKripalu | center for yoga & health

A k l d tAcknowledgements

C ll b t /C lt tCollaborators/Consultants• Lisa Conboy, Ph.D. – Harvard Medical School

St h C K i l C t f Y d H lth• Stephen Cope – Kripalu Center for Yoga and Health• Jessica Noggle, Ph.D. – Harvard Medical School• Lynn Schultz, Ph.D. – Harvard Graduate School of Education• Naomi Steiner, M.D. – Tufts University

Instruction and Research AssistanceInstruction and Research Assistance• Torrey Baldwin• Iona BrighamIona Brigham• Deborah Cohen• Janna Delgado• Angela Wilson• Angela Wilson