JACM

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 26, Number 8, 2020, pp. 701–707
ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2020.0126

An Evaluation of Yoga and Meditation

to Improve Attention, Hyperactivity,
and Stress in High-School Students
Kirti Saxena, MD,1 Christopher D. Verrico, PhD,1 Johanna Saxena, BS, BA,1
Sherin Kurian, MD,1 Stefanie Alexander, MD, PhD,2 Ramandeep Singh Kahlon, MD,1
Ruchir P. Arvind, MD,3 Adam Goldberg, MD,3 Nicholas DeVito, BA,1 Mirza Baig, BS,1
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Anastasia Grieb, BS,1 Jafar Bakhshaie, MD, PhD,1 Alessio Simonetti, MD, PhD,1,4
Eric A. Storch, PhD,1 Laurel Williams, DO,1 and Lex Gillan, BS5

Abstract
Objective: Problems with attention and stress are common in children and predict academic difficulties and
other behavioral and emotional problems. Mind–body interventions such as yoga and meditation improve
attention and reduce stress. In this study, we examined the impact of Hatha yoga on attention and stress in ninth
graders.
Design: A total of 174 ninth graders from a Texas high school were enrolled in the study. Teachers assigned
students to a yoga group (YG) or control group (CG) based on their class schedule. The YG participated in 25-min
Hatha yoga classes twice weekly over 12 weeks (n = 123). The CG included 51 students. Student self-reports on
measures of inattention and hyperactivity (the strengths and weaknesses of ADHD [attention-deficit/hyperactivity
disorder] symptoms and normal behavior rating scale for ADHD) and stress (perceived stress scale) were obtained
at baseline and at 12 weeks.
Results: There were no significant differences in baseline levels of inattention ( p = 0.86), hyperactivity
( p = 0.25), and perceived stress ( p = 0.28) between the YG and CG. Regarding inattention scores, there was a
significant interaction of group and time (b = -1.09, standard error [SE] = 0.30, p < 0.001). Pairwise t-tests
showed a significant reduction in inattention for the YG (d = 0.27) but a significant increase in inattention for the
CG. Regarding hyperactivity, there was no significant interaction of group and time (b = -0.43, SE = 0.26,
p = 0.1). Pairwise t-tests demonstrated a significant reduction in hyperactivity for the YG (d = 0.22), but not the
CG. The interaction of group and time was not significant in predicting the slope of change in perceived distress
(b = -0.93, SE = 1.19, p = 0.43). Pairwise t-tests did not show a significant reduction in perceived distress for
either group.
Conclusion: These findings suggest that Hatha yoga may improve attention and hyperactivity in high school
students.

Keywords: yoga, high school students, attention, hyperactivity, stress

1
Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.
2
Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.
3
Department of Psychiatry, University of Texas Health—McGovern Medical School, Houston, TX, USA.
4
Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy.
5
Institute for Spirituality and Health, Houston, TX, USA

701
 702 SAXENA ET AL.

Introduction et al.22 found improvements in sustained attention in 66 uni-

versity students who also practiced an IYM. Thus far, self-

T he concept of a ‘‘complete education’’ is gaining

popularity within schools worldwide. With focus on so-
cial, emotional, and physical wellbeing together with academic
reported outcomes on inattention and hyperactivity in high
school students participating in a school-based yoga inter-
vention have not been studied.
achievement, children and adolescents can acquire lifelong In addition, the presence of life stressors are a consistent
tools and skills to improve attention capacity and manage predictive factor for the emergence of mental health con-
stress. Mind–body interventions, which utilize physical pos- ditions.23,24 Given that many adults report the onset of their
tures, breathing exercises, relaxation techniques, and medita- own mental health problems during childhood and adoles-
tion practices, produce overall improvements in wellbeing.1–4 cence, addressing these problems at a young age is partic-
For thousands of years, yoga has been taught and prac- ularly important.1,25
ticed throughout the world in various forms with the ulti- Positive findings have emerged suggesting that yoga may
mate goal being the union of mind, body, and spirit.5 The reduce stress. West et al.26 found significant reductions in
practice of yoga aims to develop and maintain good physical perceived stress scores of 18 college students who practiced
and mental health.6–9 The six branches of yoga include Raja, Hatha yoga compared with students who had participated in
Bhakti, Jnana, Karma, Mantra, and Hatha yoga. Hatha yoga physical exercise. Among 14- to 15-year-old students in
encompasses the practices of physical postures, breathing India, those students with lower stress scores and practiced
exercises, and meditation.5 Its goal was to develop strength yoga performed significantly better in academics.27
and flexibility of the body, a calm and clear mind, and However, the current body of literature around school-
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overall good health.10–12 In the West, Hatha yoga is the most based yoga is fewer than 20 years old, and is oftentimes
popular practice.13 inconclusive due to varying methodologies of studies. There
Given the accessibility of yoga (i.e., can be offered without is no consensus on dose of yoga intervention across age
equipment) and its cost-effective nature (i.e., group format), groups, fidelity of implementing the intervention, and the
schools are an ideal environment to incorporate this practice. measurement of long-term outcomes. Even the highest
Children spend most of their day at school, so yoga practice can quality studies yield both positive and negative results.17
be incorporated into the curriculum.3,14 There are over 36 yoga- The aim of this study was to determine the impact of a
based programs utilized in more than 940 schools across the Hatha yoga and meditation intervention on self-reported
United States. Across programs, the length (i.e., number of measures of inattention, hyperactivity, and stress in ninth
weeks), number of sessions, session duration, and formality (i.e., graders. We hypothesized that in comparison with students
school-based vs. self-motivated) vary.1,15 However, the common in the control arm, those receiving yoga for 25 min twice a
theme across programs include physical posturing, breathing week for 12 weeks would report improved inattention and
exercises, relaxation techniques, and mindfulness practices. hyperactivity and decreased stress.
Khalsa and Butzer1 reviewed 47 yoga studies conducted in
elementary, middle, and high schools primarily in India and Methods
the United States. Comparison across studies was not possible
as yoga interventions differed in length, number of sessions, Study participants
session duration, and curricula across schools—from formal The local school district and the Institutional Review Board
curricula to instructors creating their own. Furthermore, the (IRB) at Baylor College of Medicine approved this study. The
methodological quality was low to moderate; there were often teachers assigned ninth graders to two groups, yoga group
small sample sizes and a lack of control group. Yet, the (YG) or control group (CG), and selected those students in the
implemented yoga classes have yielded both positive and second-period health science class to participate in the YG.
negative outcomes. The yoga classes took place in the morning during the students’
Serwacki and Cook-Cottone16 reviewed 12 quantitative health science class, a required course for all ninth graders. The
school-based yoga studies and encountered similar method- students enrolled in a health science class at a different time of
ological limitations. Yet, the school-based programs deemed day constituted the CG.
beneficial for the students. Ferreira-Vorkapic et al.17 reported Every student received a parental consent and a child as-
the usefulness of school-based yoga to be uncertain because sent form that informed the minimal risks and that partici-
of few randomized controlled trials, methodological con- pation is voluntary. Each student read and signed the assent
cerns, small sample sizes, lack of control groups, varying form demonstrating their own understanding of and willing-
yoga interventions taught, and varying duration of yoga ness to participate in the study. Parents of each student read
sessions. They found that positive and negative outcomes and signed the consent form to approve their child’s partici-
often cancelled each other out. pation in the study. Only those students with signed consent
Some studies suggest that yoga may improve inattention, and assent forms were enrolled. In total, 184 students pro-
and early intervention techniques that diminish attention- vided consent for the study. Demographics of our sample are
deficit/hyperactivity disorder (ADHD) symptoms are im- given in Table 1. Of that group, 174 ninth-grade students
portant for favorable outcomes18; an 8-year longitudinal completed the baseline and post measurements, with 123
study19 revealed that lower school retention rates, failure to students in the YG and 51 students in the CG.
graduate secondary school, and lower level academic perfor-
mance were accurately predicted by inattention and hyperac-
Hatha yoga intervention
tivity symptoms. Sethi et al.20 found that 60 low-income high
school girls who participated in an integrated yoga module The yoga classes consisted of 25-min sessions of Hatha
(IYM) for 5 days21 had improved attention. Similarly, Sheela yoga and meditation, twice per week for 12 weeks. Each
 YOGA BENEFITS IN HIGH SCHOOL 703

Table 1. Demographics Perceived stress scale. The perceived stress scale (PSS)
is a widely used instrument for measuring the perception of
Yoga group Control group stress. This 10-item scale assesses the degree to which sit-
(N = 123), (N = 51), uations in one’s life are appraised as stressful. Items tap into
n (%) n (%) p
how unpredictable, uncontrollable, and overloaded respon-
Sex dents have found their lives within the past month. Scores
Female 74 (60.2) 38 (74.5) 0.07 on the PSS can range from 0 to 40: scores ranging from 0 to
Male 49 (39.8) 13 (24.5) 13 are considered low stress, 14 to 26 moderate stress, and
Age (mean years – SD) 14.73 – 0.41 14.84 – 0.47 0.79 27 to 40 high perceived stress.34 The PSS had sufficient
Race internal reliability with a Cronbach’s a of 0.68. A mean
Asian 37 (30) 13 (26) 0.48 composite of perceived stress was subsequently created. The
African American 22 (18) 14 (27) scale has high internal consistency and test–retest reliabili-
Caucasian 58 (47) 22 (43) ty.34 Studies with children have used the PSS, but it is yet to
Other 6 (5) 2 (4) be statistically validated in children.25,35–38
Ethnicity
Hispanic or Latino 43 (35) 18 (36) 0.90 Yoga and meditation questionnaire
Not Hispanic 80 (65) 32 (64)
or Latino We created an IRB-approved self-assessment question-
naire for the yoga and meditation practice (Table 2), which
SD, standard deviation. was distributed after the 12-week intervention. Our aim was
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to understand which component of the practice the students

most liked, so we divided the questionnaire into yoga and
meditation practice.
lesson consisted of 18 min of yoga poses and 7 min of
meditation. The classes were led by a yoga instructor (L.G.) Data analyses
with 46 years of experience who was assisted by five yoga
instructors. L.G. composed a 12-lesson curriculum intended Data analysis was conducted using SPSS version 24.
for daily yoga and meditation practice during and outside First, data were examined for normality and presence of
class, which was provided to the YG in a written format. All outliers. No outliers were detected, and none of the variables
the yoga instructors are nationally certified by L.G. and showed highly non-normal distributions.39 Next, sample
registered with the YogaALLIANCE at the Registered Yoga descriptive statistics and a series of t-tests and chi-square
Teacher level (200 h) and the National Association of Cer- tests were conducted to examine differences across the
tified Yoga Teacher 200 h level. treatment groups regarding demographic characteristics and
All yoga instructors followed the curriculum by L.G. baseline levels of each dependent variable. The powers of
However, the consistency in teachings was not objectively these tests considering the sample size were all >0.8.
measured. Therefore, intervention fidelity data are lacking, The primary statistical analyses included multilevel
which is a limitation to this study. modeling with the scores on the scales/subscales of inat-
tention, hyperactivity, and stress as the dependent variables,
and time (baseline—1 week before classes started—and
Outcome measures week 12) and group (YG vs. CG) as the two independent
One week before the beginning of the study and week 12 of variables. The models included two levels, where repeated
the study, each student completed self-report questionnaires. assessments across time (level 1; time) were nested within
participants (level 2; group). The baseline levels of per-
ceived stress were controlled for models with inattention
The strengths and weaknesses of ADHD symptoms and
and hyperactivity as dependent variables. The estimation of
normal behavior rating scales. The strengths and weak-
missing data in the models was based on restricted
nesses of ADHD symptoms and normal behavior (SWAN)
maximum-likelihood estimation. Satterthwaite approxima-
is an 18-item questionnaire, consisting of two 9-item
tion was used to calculate the degrees of freedom.40
subscales: an inattentive subscale (IA; items 1–9) and a
Post hoc moderation analyses were also conducted to
hyperactive/impulsive subscale (HI; items 10–18). The
examine the moderator role of baseline levels of perceived
scores range from 0 to 18 (Refs.28,29). A score of six or
greater on the IA indicates ADHD—inattentive type, the
HI indicates ADHD—hyperactive/impulsive type, and both Table 2. Yoga and Meditation Questionnaire
the IA and HI indicate ADHD—combined type. Self-assessment questionnaire for yoga meditation
The SWAN self-report was used in 2763 adolescents (13– and practice
17 years) in a study at the Ontario Science Centre in Tor-
onto, Canada,30 where self-report versions of the SWAN 1 Did yoga help you in any way? In a sentence,
included the same 18 items, but with reference to ‘‘your please tell us how yoga was helpful
child’’ instead of ‘‘me.’’ High internal consistency of the 2 How many times did you practice yoga at home?
SWAN has been reported,31,32 which was confirmed by this 3 Will you continue yoga?
study. The SWAN-self in adolescents has good sensitivity 4 Did meditation help you in any way? In a sentence,
and specificity for diagnosis, high internal consistency, and please tell us how meditation was helpful
5 How many times did you practice meditation at home?
good convergence with the Conners–Wells’ Adolescent 6 Will you continue meditation?
Self-Report Scales.33
 704 SAXENA ET AL.

Table 3. Average Scores A two-tailed t-test revealed no significant group difference

in age ( p = 0.79) (Table 1). The t-test comparisons did not
Mean (–SD) show any significant differences regarding the baseline
Variable Baseline Week 12 levels of inattention ( p = 0.86), hyperactivity ( p = 0.25), and
perceived stress ( p = 0.28) between the yoga and control
Yoga groups. See Table 3 for average scores.
ADHD inattentiveness 2.11 (–2.001) 1.57 (–1.904)
ADHD hyperactive 1.80 (–1.949) 1.39 (–1.795)
PSS 17.76 (–7.775) 17.41 (–7.761) Inattention and hyperactivity
Control Regarding the change in the score of SWAN subscale of
ADHD inattentiveness 2.06 (–1.964) 2.67 (–2.197) inattention, after controlling for baseline levels of perceived
ADHD hyperactive 1.45 (–1.474) 1.51 (–1.837)
stress, there was a significant interaction of group and time
PSS 19.10 (–6.703) 19.92 (–7.256)
(b = -1.09, standard error [SE] = 0.30, p < 0.001). Pairwise
ADHD, attention-deficit/hyperactivity disorder; PSS, perceived t-tests showed a significant reduction in inattention for YG
stress scale; SD, standard deviation. (t = 3.239, p = 0.002; Cohen’s d = 0.27) and a significant in-
crease in inattention for the CG (t = -2.574, p = 0.013)
(Fig. 1). Post hoc analysis did not show a significant mod-
stress for the effect of group membership on the slope of erator effect for perceived stress in the relationship
change in inattention and hyperactivity. Furthermore, the (b = -0.02, SE = 0.04, p = 0.66). There was also no signifi-
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perceived helpfulness of yoga and meditation (a mean score cant moderator effect for the perceived helpfulness and
derived from separate reports on yoga and meditation per- home practice of intervention for the effect of time on in-
ceived helpfulness) and amount of yoga and meditation attention within the YG (b = 0.32, SE = 0.61, p = 0.59, and
practice at home (a mean score derived from separate reports b = 0.10, SE = 0.23, p = 0.65, respectively).
on yoga and meditation practiced at home) were examined as For predicting the change in the SWAN subscale of hy-
moderators of the relationships between the effect of time on peractivity, after controlling for baseline levels of perceived
inattention and hyperactivity, after controlling for baseline stress, there was no significant interaction of group and time
levels of perceived stress. Similar post hoc analyses were (b = -0.43, SE = 0.26, p = 0.1). Pairwise t-tests demonstrated
conducted for perceived stress as a dependent variable with a significant reduction in hyperactivity for the YG (t = 2.670,
no control variables. Cohen’s d41 was reported as estimates p = 0.009; Cohen’s d = 0.22), but not the CG (t = -0.323,
of effect size. p = 0.748) (Fig. 2). Post hoc moderator analysis did not
support the moderator role of perceived stress (b = 0.03,
SE = 0.04, p = 0.43). Neither perceived helpfulness nor home
Results
practice of intervention moderated the effect of time on
Chi-square tests revealed no significant group differences hyperactivity within the YG group (b = -0.14, SE = 0.56,
in gender ( p = 0.07), race, ( p = 0.48), or ethnicity ( p = 0.90). p = 0.79, and b = 0.22, SE = 0.21, p = 0.30, respectively).

FIG. 1. SWAN rating scale for ADHD—inattention. At baseline, the average scores for the YG (2.11 – 2.001) and the CG
(2.06 – 1.964) were comparable ( p = 0.86). At week 12, the average scores of the YG (1.57 – 1.904) and the CG
(2.67 – 2.197) were significantly different ( p < 0.001). Within the YG, the average scores significantly decreased (d = 0.27).
Within the CG, the average scores significantly increased ( p = 0.013). ADHD, attention-deficit/hyperactivity disorder; CG,
control group; SWAN, the strengths and weaknesses of ADHD symptoms and normal behavior; YG, yoga group.
 YOGA BENEFITS IN HIGH SCHOOL 705

FIG. 2. SWAN rating scale

for ADHD—hyperactivity.
At baseline, the average
scores for the YG
(1.80 – 1.949) and the CG
(1.45 – 1.474) were not sig-
nificantly different ( p = 0.25).
At week 12, the average
scores of the YG
(1.39 – 1.795) decreased from
baseline significantly
(d = 0.22) and the CG average
scores somewhat increased
(1.51 – 1.837). ADHD,
attention-deficit/hyperactivity
disorder; CG, control group;
SWAN, the strengths and
weaknesses of ADHD symp-
toms and normal behavior;
YG, yoga group.
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Perceived stress scale Discussion

The interaction of group and time was not significant in This 12-week study aimed to determine the effectiveness
predicting the slope of change in perceived stress (b = -0.93, of 24 Hatha yoga sessions in improving attention and hy-
SE = 1.19, p = 0.43). Pairwise t-tests did not show a signifi- peractivity, and decreasing stress in ninth graders. Studies
cant reduction in perceived stress for either YG (t = 0.223, have reported benefits in high school students who practiced
df = 118, p = 0.824) or CG (t = -0.604, df = 49, p = 0.549) yoga for 10–18 weeks one to five times per week. This study
(Fig. 3). Perceived helpfulness and home practice of inter- design is within these parameters: high school students, 12-
vention did not moderate the effect of time on change in week intervention conducted two to three times per week.42
perceived stress (b = -1.11, SE = 1.90, p = 0.56, and b = 0.70, Results from this study indicate reduced inattention and
SE = 0.73, p = 0.34, respectively). hyperactivity in those students who participated in the Hatha
yoga practice in comparison with the students in the CG.
In this study, the PSS assessed students’ stress levels
Yoga and meditation questionnaire
before and after the Hatha yoga practice and, no signifi-
Eighty-seven students completed this questionnaire. The cant differences were found over time or in comparison with
majority of students reported the practice of yoga (65.5% of the CG. The final yoga session and the rating scales were
students) and meditation (74.1% of students) to be helpful, administered about 2 weeks before the end of semester ex-
stating it ‘‘gave them a chance to relax, calm down, and aminations, which may have contributed toward no signifi-
relieve stress.’’ Further results of the survey are given in cant differences in the stress levels between the two groups.
Tables 4 and 5. Other studies yielded similar results. For example, Noggle

FIG. 3. Perceived stress.

At baseline, the average
scores for the YG
(17.76 – 7.775) and the CG
(19.10 – 6.703) were not sig-
nificantly different ( p = 0.28)
At week 12, the YG scores
somewhat decreased to
17.41 – 7.761 and the CG
somewhat increased to
19.92 – 7.256. There was no
significant difference found
within or between groups.
CG, control group; YG, yoga
group.
 706 SAXENA ET AL.

Table 4. Yoga and Meditation yoga exercises should be practiced daily, there was no ob-
Perceived Helpfulness jective way that assessed whether this practice occurred.
Fourth, objective ratings from teachers on student outcomes
Yoga was Yoga was were not assessed. Finally, our yoga class size was about 50
helpful NOT helpful TOTALS
students, whereas data from other studies suggest that
Meditation was helpful 49 16 65 smaller yoga classes (i.e., 10 or fewer students per class)
Meditation was 8 14 22 yield improvements.43
NOT helpful
TOTALS 57 30 87 Conclusions
Within these limitations, this study adds to the literature
et al.37 found no statistically significant differences in PSS because it shows feasibility of a Hatha yoga practice in a
scores between yoga (n = 36) and PE-as-usual (n = 15) school setting with positive outcomes for the students,
groups after 28 sessions over 10 weeks. Khalsa et al.25 also particularly in improving inattention and hyperactivity.
did not find significant reductions in PSS scores in high However, several important questions remain to be an-
school students (67 yoga and 33 controls) that participated swered. Indeed, for the best possible benefits, the optimal
in two to three yoga classes per week. dose for the yoga intervention and frequency and duration of
Potential reasons for different findings across studies are practice still need to be determined. Furthermore, use of
several. For instance, the frequency, amount, and duration of more objective outcomes including both symptomology and
functional outcomes is needed. In summary, school is an
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sessions across studies have differed. In addition, there is no

standardized curriculum currently outlining what dose and ideal place to teach the practice of yoga. It is a skill and tool
for how long yoga needs to be taught for results to be that can be incorporated into the daily routine of students to
deemed generalizable. improve academic performance and mitigate stress.

Clinical significance Acknowledgment

Results from the SWAN self-report were not in the The authors acknowledge the certified yoga instructors
clinically significant range as none of the mean scores were who taught the yoga curriculum to the students at the school.
above 6 (Table 3). Nonetheless, with the practice of Hatha
yoga, inattention and hyperactivity symptoms diminished. Author Disclosure Statement
In a clinical context, Hatha yoga, if practiced consistently, The authors declare that they have no conflicts of interest
might be a tool that could delay or potentially prevent onset to disclose.
of a clinical diagnosis of ADHD.
This study was not designed for clinical outcomes, but
Funding Information
can serve as a preliminary assessment of stress levels that
may warrant clinical intervention. All our students’ mean No funding was received for this article.
scores fell in the moderate stress range (Table 3). With the
practice of Hatha yoga, the PSS scores from the YG did References
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