Original Research

M. Kaur, PT, PhD, Department of

Physical Therapy, MGH Institute of Creative Yoga Intervention Improves
Health Professions, Charlestown,
Massachusetts.
A. Bhat, PT, PhD, Department of
Motor and Imitation Skills of Children
Physical Therapy, Biomechanics and
Movement Sciences Program,
With Autism Spectrum Disorder
University of Delaware, 540 S College
Avenue, Newark, DE 19713 (USA);
Maninderjit Kaur, Anjana Bhat
and Department of Psychological and
Brain Sciences, Behavioral
Background. There is growing evidence for motor impairments in children with

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Neuroscience program, University of
Delaware. Address all correspondence
autism spectrum disorder (ASD), including poor gross and fine motor performance, poor
to Dr Bhat at: [email protected]. balance, and incoordination. However, there is limited evidence on the effects of motor
interventions for this population.
[Kaur M, Bhat A. Creative yoga
intervention improves motor and
imitation skills of children with autism
Objective. In the present study, the effects of a physical therapist intervention using
spectrum disorder. Phys Ther.
creative yoga on the motor and imitation skills of children with ASD were evaluated.
2019;99:1520–1534.]
Design. This study had a pretest-posttest control group design.
© 2019 American Physical Therapy
Association.
Methods. Twenty-four children with ASD aged between 5 and 13 years received 8 weeks
Accepted: April 12, 2019
of a physical therapist-delivered yoga or academic intervention. Children were tested
Submitted: August 23, 2018
before and after the intervention using a standardized motor measure, the Bruininks-
Oseretsky Test of Motor Performance–2nd Edition (BOT-2). The imitation skills of children
using familiar training-specific actions (ie, poses for the yoga group and building actions
for the academic group) were also assessed.

Results. After the intervention, children in the yoga group improved gross motor
performance on the BOT-2 and displayed fewer imitation/praxis errors when copying
training-specific yoga poses. In contrast, children in the academic group improved their
fine motor performance on the BOT-2 and performed fewer imitation errors while
completing the training-specific building actions.

Limitations. The study limitations include small sample size and lack of long-term
follow-up.

Conclusions. Overall, creative interventions, such as yoga, are promising tools for
enhancing the motor and imitation skills of children with ASD.

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article at:
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1520 Physical Therapy Volume 99 Number 11 November 2019

 Yoga in Autism

A
utism spectrum disorder (ASD) is a neurological balance, and coordination, clear opportunities for
disorder characterized by impairments in social reinforcement and feedback, and, finally, opportunities for
communication skills and the presence of restricted trial and error learning and free exploration.29,30 Further,
and repetitive behaviors.1 Apart from the diagnostic clinical researchers are calling for pediatric physical
impairments, there is growing evidence for motor therapist interventions to not be limited to the motor
impairments in children with ASD such as poor balance system alone and instead be more holistic with
and postural control, unsteady gait, and incoordination, as multisystem goals, as well as cascading effects on other
well as poor handwriting and manual dexterity skills.2–7 In developing systems (eg, social communication, behavioral,
fact, the motor performance of children with ASD is at the cognitive).31,32 However, there is limited preliminary
level of children with typical development (TD) who are evidence for efficacy of yoga in children with ASD,33 with

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one-half their chronological age.5 Motor delays have been suggestions for improved imitation and social
reported as early as the first year of life in infants who participation and reduction in maladaptive and negative
later develop ASD, and the magnitude of these delays behaviors.34–37 Children with ASD between 8 and 14 years
appears to increase with development.8,9 Imitation of age improved imitation of yoga poses and breathing
impairments emerge later in children with ASD and are exercises as well as gross motor actions such as jogging
often considered part of a generalized praxis deficit.10–14 and running, and orofacial movements following
Children with ASD may show spatial errors (eg, incorrect 10 months of yoga training.34 Similarly, another study
positioning of the moving limb in space), reversal errors reported a decrease in maladaptive behaviors based on
(eg, waving with palm facing inward), and the Aberrant Behavior Checklist following 16 weeks of
body-part-for-tool errors (eg, scissoring motions involving classroom yoga in a group of children with ASD who were
movements of the index and middle fingers) while compared with a control group of children with ASD
performing actions on imitation, verbal command, and receiving usual morning routines.35
tool use.10–12 Both motor and imitation impairments could
have cascading effects on the social, communication, and Although the current yoga literature is limited in children
cognitive development of children with ASD.2,15–18 For with ASD, there is evidence from children with TD
example, children with poor motor skills may avoid suggesting the positive effects of yoga on the balance,
playing with their peers and hence lack opportunities to strength, flexibility, and motor speeds of children.38–42 For
build friendships with them.15,16 Similarly, poor example, an intensive 24-week school-based yoga
praxis/imitation skills could limit a child’s ability to learn intervention including poses and breathing exercises
new functional skills, such as dressing and feeding,19,20 or improved the strength of hand and respiratory muscles in
social skills, such as gestures or joint social children compared with the control group engaged in
engagement.17,18 Given the evidence for motor regular classroom routines.38 Similarly, a 6-week
impairments and their broader impact on social randomized controlled trial using yoga intervention
communication development, there is a clear need to suggested improvements in the static balance of children
devise interventions that could offer opportunities to with TD between 11 and 14 years of age compared with a
improve both motor skills and their use in developing no-intervention control group.39 Furthermore, research
social communication skills in children with ASD. studies comparing yoga with regular physical activity have
suggested better outcomes for children in the yoga group
Yoga is gaining popularity as a complementary and compared with the physical activity group.40,41 A 4-week
alternative therapy for multiple reasons. It is cost-effective yoga intervention (involving poses, breathing, relaxation)
given the minimal number of supplies required to improved the motor planning and execution of children
complete the various tasks. Yoga offers multisystem with TD during a problem-solving task compared with
experiences impacting several developing systems aerobic interventions (involving jogging, jumping, and
including motor (flexibility, strength, balance),21–23 stretching).41 This perhaps could be attributed to the
perceptual (joint proprioception, kinesthesia),24 positive effects of yoga on the motor (eg, motor speed,
cardiorespiratory (heart rate variability, respiratory muscle planning) and behavioral skills (eg, awareness, alertness)
strength),21–23 behavioral (attention, alertness),25 and social of children. Overall, yoga-based interventions could be a
communication skills of children (social interactions, promising tool for children with ASD given the evidence
speech, and affect).26–28 Additionally, yoga-based activities from yoga studies involving children with TD and the
are easy to learn and modifiable based on the age and initial studies conducted in children with ASD.
level of functioning of the child. Yoga as provided in this
study was made fun and creative through the use of The primary goal of the current study was to compare the
songs, stories, games, and props to better contextualize effectiveness of an 8-week physical therapist-delivered
the complex poses and breathing/gaze activities and yoga intervention or academic intervention in children
hereafter will be termed Creative Yoga. Creative Yoga as with ASD between 5 and 13 years of age. The academic
offered in this study embraced the principles of motor intervention included sedentary activities usually practiced
learning such as repetitive task-specific practice of within school settings (eg, reading, arts, and crafts).
complex movements/postures requiring physical strength, Because of the nature of the activities practiced within

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Yoga in Autism

each group, we hypothesized that the yoga group would study, 6 children were “well below average,” 12 children
improve their gross motor performance and the academic were “below average,” and the remaining 6 children were
group would improve their fine motor performance on a “average” performers. None of the children performed
standardized motor test. Additionally, we hypothesized “above average”; hence, all children had room for
that both groups would improve their imitation of familiar, improvement in gross/fine motor skill performance at the
training-specific actions following the intervention. point of study entry.

Methods Testing Measures

The study lasted 10 weeks, with a pretest session in the
Participants
first week, 8 weeks of intervention, and a posttest session

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Twenty-four children with ASD between 5 and 13 years of
in the last week of participation. We used 2 testing
age participated in the study, with 12 children each in the
measures, a standardized motor test administered during
yoga and academic groups (Tab. 1). We estimated our
the testing sessions and an imitation test administered
sample size based on our past intervention study involving
during the training sessions. An additional third measure
children with ASD who received similar multisystem,
was used at the end of the study for the parents to report
movement-based interventions.43–45 Participants were
on the social validity of the intervention. We used several
recruited by distributing fliers in the local schools and
strategies during the study to ensure comprehension and
through online postings on autism websites. The initial
established an adequate communication system with the
screening process included parents completing the Social
children. For example, we used pictures to illustrate the
Communication Questionnaire46 and/or providing a
steps within each motor activity, simple and brief
medical record confirming an ASD diagnosis for their
instructions, and provided 1 practice trial with manual
child. If the participating child did not show social
feedback, if needed. Depending on the variable, either a
communication delays on the Social Communication
single coder or 2 coders coded the entire dataset after
Questionnaire and the parents failed to provide a medical
establishing an interrater reliability of greater than 85%
record, they were excluded. We further confirmed the ASD
and an intrarater reliability of above 90% for a randomly
diagnosis using the Autism Diagnostic Observation
selected 25% of the video dataset. This approach is
Schedule, Second Edition (ADOS-2).47 All 24 children
consistent with our past intervention studies reporting
received the diagnosis using ADOS-2, with comparison
behavioral coding variables.43–45 Coders discussed the
scores ranging from 5 to 10 indicating moderate to high
coding definitions, coded videos independently, and later
severity of the disorder (Tab. 1). All participants had
computed the correlations between the summated scores
delays on the Social Communication Questionnaire and/or
they assigned for each condition/domain. After the initial
parents of participants provided a medical record
reliability was assessed, the coders met to establish
confirming their child’s diagnosis. Four children were
consensus on the codes they disagreed on to establish
excluded during the screening process because of
interrater agreement of > 85%. After establishing
significant behavioral problems (eg, aggression,
interrater reliability of > 85%, the coders coded the
nonparticipation, or inattention) and/or communication
dataset 1 more time to establish intrarater reliability of
impairments (eg, inability to follow simple commands
> 90% between the 2 iterations of coding the same set of
during imitative actions). All parents signed the consent
videos spaced by a period of more than 2 weeks.
form approved by the University of Delaware Review
Board before participating in the study. We matched the
children in the yoga and the academic group on various Bruininks-Oseretsky Test of Motor Proficiency–2nd
criteria including the group demographics (age, sex, and Edition (BOT-2). The BOT-251 was administered in the
socioeconomic status),48 autism severity (ADOS-2 pretest and posttest session to assess the generalized
comparison scores), and level of functioning (intelligence, changes in motor performance following the intervention.
adaptive functioning, and motor performance) (Tab. 1). The BOT-2 was selected over other measures of motor
Specifically, the Stanford-Binet Intelligence Scales, Fifth performance because it has high validity and reliability,
Edition,49 were used to assess level of intelligence; the and it allowed detailed evaluation of gross motor skills,
Vineland Adaptive Behavior Scales, Second Edition,50 were such as balance and coordination, and fine motor skills,
used to assess the level of adaptive functioning; and the such as precision and integration, following the
short form of the Bruininks-Oseretsky Test of Motor yoga/academic intervention. We used 2 gross motor and 2
Proficiency-2nd Edition (BOT-2)51 was used to assess the fine motor subtests of the BOT-2, including the bilateral
level of motor functioning (Tab. 1). On the basis of coordination (ability to synchronize upper and lower
standard scores on the short form of the BOT-2, children limbs), balance (postural control in standing and walking),
with scores below 30 were considered “well-below fine motor precision (precise hand and finger control)
average,” those with scores between 30 and 45 were (FMP), and fine motor integration (ability to integrate
considered “below average,” those with scores between 45 visual stimuli during motor control) (FMI) subtests. The
and 55 were considered “average,” and those with scores testers were doctoral students in the laboratory with a
above 55 were considered “above average.” In the current background in occupational therapy/physical therapy.

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Table 1.
Demographics and Matching Criteria

Yoga Group Academic Group Pa

Matching
Characteristic No. of No. of
Criterion Mean SE Range Mean SE Range
Participants Participants
Demographic Age 7.77 0.5 5.5–11 7.8 0.7 5.11–12.5 .98
information
Sex 11 boys; 1 girl 11 boys; 1.00
1 girl

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Socio-economic 56.5 2.2 40–66 52.5 2.9 29–66 .3
status
Ethnicity 7 white; 9 white; <.01
5 Asian 1 Asian;
1 African
Ameri-
can; 1
Hispanic
Autism ADOS-2b 8.4 0.5 5–10 8.7 0.5 5–10 .7
severity
Level of Stanford-Binet IQc 84.3 5.5 58–115 82.9 8.0 47–119 .9
functioning (cognitive level)
VABS-IId (adaptive 81.2 4.4 57–102 75.9 5.3 39–100 .5
level)
Short form of 37.25 2.1 24–46 39.30 3.12 20–54 .6
BOT-2e
(motor level)
a
P determined by t test or χ 2 test.
b
ADOS-2 = Autism Diagnostic Observation Schedule, Second Edition.
c
Stanford-Binet Intelligence Scales, Fifth Edition, intelligence quotient (IQ) scores had a normative mean of 100 and an SD of 15.
d
Vineland Adaptive Behavior Scales, Second Edition (VABS-II), scores had a normative mean of 100 and an SD of 15.
e
Bruininks-Oseretsky Test of Motor Proficiency–2nd Edition (BOT-2) scores had a normative mean of 50 and an SD of 10.

They were blinded to group assignments and interacted pushing, and pulling using building materials such as
with children only during the testing sessions. We are Play-Doh (Hasbro, Pawtucket, RI, USA), LEGO (The LEGO
reporting on the raw scores of the BOT-2 subtests. One Group, Billund, Denmark), and ZOOB (Alex Brands,
child in the academic group was excluded from the BOT-2 Fairfield, CT, USA) (Fig. 1). For each action, errors ranged
analysis because of nonparticipation and inability to from 0 to 2, with higher scores indicating worse
complete the posttest session. performance. A score of 2 indicated the child was unable
to complete the action. A score of 1 indicated that the
child completed the action but required verbal (repeated
instruction), physical (manual hand-on-hand assistance),
Training-specific imitation test. We developed a test
or visual assistance (repeated demonstration of the action)
using a subset of actions usually practiced within the
from trainers. Finally, a score of 0 indicated that the child
training sessions to assess the imitation skills of children
completed the action independently without any
during the intervention. This test was administered by the
assistance from trainers. We reported on the total percent
trainer during the early, mid, and late training session.
of errors by summing the errors across all actions and
Specifically, for the yoga group, the test included sitting,
dividing by the total number of errors possible given the
standing, and lying poses involving upper and/or lower
number of steps involved (Fig. 1).
extremity (Fig. 1). The scoring for the test was based on
imitation error classifications commonly used in the ASD
literature11–13 and our past published studies.44 ,45 We coded Exit questionnaire. Parents completed an exit
the imitation errors performed by the child while questionnaire at the end of the study to describe their
executing the essential elements of a pose; for example, overall experience and acceptance of the intervention. The
for the dog pose, the child was evaluated for 3 elements: exit questionnaire served as a measure of social validity
hands and feet flat on the floor, knees and elbows and was used to assess whether the parents perceived the
straight, and hips bent at an acute angle. For the academic intervention to be socially meaningful for their child.52
group, the test included actions such as rolling, pinching, The exit questionnaire had 6 statements regarding the

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Table 2.
Parent Responses on the 5-Point Likert Scale of the Exit Questionnairea

Yoga Group Academic Group

Statement Do Not Agree Strongly Do Not Agree Strongly
Agree (3) Agree (3)
(1 or 2) Agree (4 or 5) (1 or 2) Agree (4 or 5)
I found the intervention very 0/11 2/11 9/11 0/11 1/11 10/11
useful for my child
I am satisfied with the overall 0/11 2/11 9/11 0/11 0/11 11/11
intervention

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I feel the training activities were 1/11 5/11 5/11 0/11 1/11 10/11
easy for my child
I would recommend the 0/9 2/9 7/9 0/11 0/11 11/11
intervention to other parentsb
I would continue practicing the 1/9 1/9 7/9 0/11 1/11 10/11
activities after the studyb
I think the intervention benefited 0/11 5/11 6/11 0/11 4/11 7/11
the motor skills of my child
a
Data represent the number of parents with the indicated responses.
b
Two parents of children in the yoga group did not respond to this statement.

overall efficacy, satisfaction, and therapeutic effects of the the majority of the sessions (yoga group = 95.51% ±
intervention (Tab. 2). The questionnaire was based on a 0.41%; academic group = 91.38% ± 0.90%). All the parents
5-point Likert scale with responses ranging from 1 to 5, were provided with instructional DVDs and manuals to
with 1 being “do not agree” and 5 being “strongly agree” deliver 2 sessions at home each week. Additionally, the
with the statement. trainer provided additional information to the parents
regarding the home instructional DVD-based sessions and
provided all the necessary materials, such as mats and
Training Protocol props, to the yoga group, and art, craft, and building
The frequency-intensity-time-type principle for this study supplies to the academic group. All children completed at
was as follows: frequency = 4 sessions/wk with 2 expert least 50% of the total training sessions (yoga
and 2 parent sessions; intensity = 40 to 45 minutes for group = 71.59% ± 3.73%; academic group = 80.21% ±
expert and 20 to 25 minutes for parent sessions; time = 3 4.41%; P = .19), except 1 child in the yoga group who
or 4 times/wk for 8 weeks; and type = yoga or academic was, therefore, excluded from the final analysis. Eleven
activities. Expert sessions were delivered by a pediatric children in the yoga group were compared with the 12
physical therapist (also a doctoral student and first author) children in the academic group.
after receiving significant training from the last author and
consultants with Applied Behavioral Analysis or yoga Children practiced different activities within the yoga and
expertise. Furthermore, the expert sessions involved a academic groups (Tab. 3). Specifically, for the yoga group,
triadic context, that is, a child with ASD, a trainer, and a we created a holistic intervention that could address the
model (Suppl. Appendix 1, available at https://academic. motor impairments and diagnostic social communication
oup.com/ptj). The models were university undergraduates impairments of children with ASD. The training session
who acted as a buddy to the child, modeled positive included traditional yoga activities such as breathing,
behaviors such as ready responses, and also copied the imitative poses, partner poses, and relaxation as well as
activities of the trainer. All models received at least context-appropriate social activities to encourage
6 hours of training in the form of instructional manuals greeting/farewell songs, touch/contact games, and looking
and videos as well as discussions with both authors before games (Tab. 3; see Supplementary Materials). The yoga
participating in the intervention sessions. To ensure poses were grouped around meaningful themes such as
training fidelity, a coder assessed the trainers’ and the songs (eg, “Twinkle Twinkle Little Star”), stories (eg,
models’ adherence to the training protocol using a “Goldilocks and the Three Bears”), and games (eg, a
checklist including general characteristics such as the musical game). The lyrics for the songs and the stories
environmental set-up and specific characteristics such as were significantly modified to make it more generic and
repetition and completion of activities (Suppl. Appendix 2, appropriate across the age groups. A music graduate
available at https://academic.oup.com/ptj). All the trainers student voice recorded all the songs/stories for this study.
and models adhered to the standard training protocol for Additionally, we used various props during the breathing

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Figure 1.
Training-specific actions included in the imitation test for the yoga and academic groups (Play-Doh [Hasbro, Pawtucket, RI, USA];
LEGO/DUPLO [The LEGO Group, Billund, Denmark]; ZOOB [Alex Brands, Fairfield, CT, USA]).

exercises, such as straws and pinwheels, to make the reminders for behavioral regulation such as attention and
breathing activities clear and engaging for the children. task-related focus. We also implemented common ASD
The academic group engaged in several sedentary treatment approaches such as the use of visual picture
tabletop activities typically used within academic settings schedules to convey session structure and conditions,
such as reading, arts and crafts, and building supplies repetition and reinforcement when completing the
such as Play-Doh, LEGO, and ZOOB (Tab. 3). Children activities, manual/visual feedback as needed, and
would create art, craft, or build creations based on structured space and materials to facilitate skill learning in
different themes such as the solar system, farm animals, the children. The academic intervention group served as a
and fruits and vegetables. Yoga facilitated motor skills control for various social and therapeutic components
such as balance, strength, and praxis/planning as well as mentioned earlier except for the gross motor
social skills such as social contact, eye movements, and coordination/posture and relaxation components of
cooperative play. The academic/tabletop play also yoga.
promoted fine motor coordination/planning as well as
social skills such as social gaze and cooperative play. In
both groups, trainers encouraged communication skills Data Analysis
including verbal (commenting, responding, singing) and For the BOT-2, we conducted a repeated-measures
nonverbal gestural use (showing, pointing), and offered analysis of variance (ANOVA) with testing session (pretest,

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Table 3.
Training Activities Practiced by Participants in the Yoga and Academic Groups

Yoga Group Academic Group

Hello: Child sings a song together with the trainer and the model Hello: Child greets the model and the trainer
Breathing: Child practices breathing exercises with or without props (eg, Reading: Child reads an age-appropriate book with the trainer and the model
nostril breathing, blowing pinwheels) while taking turns with them
Contact and looking: Child practices social touch (eg, joining hands or Building: Child builds various creations using building supplies such as
feet to form a shape). Child practices eye/head movements toward social Play-Doh,a LEGO,b and ZOOBc (eg, Lego car, Play-Doh snow man)
and nonsocial stimuli (eg, looking at bouncing ball).

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Poses/partner poses: Child practices poses on his or her own and Arts and crafts: Child makes various creations by coloring/painting/drawing as
together with the trainer and the model well as cutting and pasting
Relaxation: Child lies down and remains still, with prerecorded verbal Clean up: Child helps the trainer and the model clean up the working station
imagery playing in the background
Bye: Child bids farewell by singing a song together with the trainer and Bye: Child bids farewell to the trainer and the model
the model
a
Hasbro, Pawtucket, RI, USA.
b
The LEGO Group, Billund, Denmark.
c
Alex Brands, Fairfield, CT, USA.

posttest) and subtest type (bilateral coordination, balance, Role of the Funding Source
FMP, FMI) as the within-participants factors, and group The first author’s effort on this project was partially
(yoga group, academic group) as the between-participants supported by the University Graduate Fellowship from the
factor. For the training-specific imitation test, we Office of Graduate and Professional Development at the
conducted separate 1-way repeated-measures ANOVA for University of Delaware, and the last author’s effort on this
the yoga and the academic group with training session project and manuscript was supported by an Institutional
(early, mid, late) as the within-participants factor. For the Development Award (IDeA) from the National Institute of
exit questionnaire, we report a count for the number of General Medical Sciences of the National Institutes of
parents who responded with 1 or 2 (do not agree), Health (NIH) (grant no. U54-GM104941) (Principal
3 (agree), and 4 or 5 (strongly agree) for each of the investigator: S. Binder-Macleod). The funders played
statements. Finally, we determined the Pearson no role in the design, conduct, or reporting of this
correlations of several child-specific variables, such as age, study.
ADOS-2 comparison and total scores, and intelligence
quotient (IQ) levels, with the intervention effectiveness
and dosage. Specifically, for intervention effectiveness, we Results
conducted correlations for only those variables that Bruininks-Oseretsky Test of Motor
significantly improved after the intervention. For the yoga Proficiency–2nd Edition
group, we used the change in BOT-2 bilateral The repeated-measures ANOVA for BOT-2 revealed a
coordination as well as imitation scores from early to significant main effect of testing session (F 1,20 = 17.18;
mid/late sessions. For the academic group we used the P < .01; partial η2 = 0.46) and subtest type (F 3,60 = 57.84;
change in BOT-2 FMI, BOT-2 FMP, and imitation scores P < .01; partial η2 = 0.74), a 2-way subtest type × group
from early/mid to late session. For the intervention interaction (F 3,60 = 2.85; P = .05; partial η2 = 0.13), and
dosage, we correlated child-specific variables with the 3-way testing session × subtest type × group interaction
proportion of sessions completed by each child. To be (F 3,60 = 2.95; P = .04; partial η2 = 0.13). We further
clear, dosage was defined as follows: (number of sessions analyzed the 3-way interaction, testing session × subtest
completed/32) × 100, with 32 sessions provided in total, type × group using post hoc t tests. The post hoc tests
16 by physical therapists and 16 by parents. We checked indicated that the yoga group improved their performance
our data for parametric assumptions using the Mauchly for the gross motor subtest, bilateral coordination subtest
Test of Sphericity, and Greenhouse-Geisser corrections in the posttest compared with the pretest session
were applied in case of violations. The significance was (P < .006 after Bonferroni correction; d = 0.56 [medium
set at P ≤ .05, and further analysis was conducted using effect]) (Fig. 2A) with no changes for any of the other
post hoc dependent t tests with Bonferroni corrections subtests. The academic group showed statistical
applied for multiple comparisons. We are also reporting improvements in both the fine motor subtests (ie, FMI and
on the effect sizes using the Cohen d, with d ≥ 0.2 FMP) in the posttest compared with the pretest session
indicating a small effect, d ≥ 0.5 indicating a medium with no changes on the gross motor subtests (P = .03;
effect, and d ≥ 0.8 indicating a large effect. d = 0.30 and 0.32 [small effects]) (Fig. 2B).

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Figure 2.
Raw scores for the Bruininks-Oseretsky Test of Motor Proficiency–2nd Edition (BOT-2) subtests during the pretest and posttest sessions for
the yoga group (a) and the academic group (b). ∗ P = .006. † P = .03.

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Figure 3.
Percentage of imitation errors during the early, mid, and late training sessions for the yoga group and the academic group. ∗ P ≤ .003.
† P = .03.

Training-specific Imitation Test novel and not often practiced whereas the academic
The 1-way repeated-measures ANOVA for the yoga and activities were similar to those practiced at school or
academic groups indicated a significant main effect of home. Furthermore, it is possible that parents in the
training (yoga group: F 2,20 = 10.32; P < .01; partial academic group perceived the training activities, such
η2 = 0.51; academic group: F 2,22 = 5.12; P = .03; partial as reading books and coloring/drawing, to have a
η2 = 0.32). The post hoc tests indicated that the yoga positive impact on the child’s school performance and,
group reduced the total percentage of imitation errors in hence, to be more useful for the child than the yoga
the mid and late training session compared with the early activities.
training session (P < .02 after Bonferroni correction;
d = 0.96 and 1.48 [large effects]) (Fig. 3). Similarly, the
academic group reduced the total percentage of imitation Correlations Between Intervention Dosage
errors in the late session compared with the early session and Effectiveness and Child-specific Factors
(P < .02 after Bonferroni correction; d = 0.83 [large Pearson correlations determined for each group indicated
effect]) and a statistical trend for reduced errors in the late that children’s IQ levels strongly correlated with the
compared with the mid training session (P = .03; d = 0.81) intervention outcome variables (the BOT-2 and the
(Fig. 3). imitation scores). For changes in BOT-2 scores, children’s
IQ levels positively correlated with improvements in the
BOT-2 FMI scores of the academic group (r = 0.71;
Exit Questionnaire P = .02), but not for the yoga group (r = −0.35; P = .29).
The exit questionnaire was completed by 11 parents in This meant that the children with higher IQ within the
each group, because 1 parent in the academic group did academic group showed more fine motor improvements
not fill out the questionnaire and 1 child in the yoga following the intervention than those with lower IQ. For
group was excluded from the final analysis because the changes in imitation scores, children’s IQ levels negatively
training intensity was < 50% (Tab. 2). Most of the parents correlated with training-related improvements in the
from both groups strongly agreed (score of 4 or 5) that imitation performance for the yoga group (r = −0.69;
the intervention was useful, that they would continue P = .02) but not for the academic group (r = −0.50;
practicing similar activities, and that they would P = .1). In short, in the yoga group, children with lower
recommend it to other parents. However, between the 2 IQ showed greater improvements in pose imitation
groups, there were relatively fewer parents in the yoga following training. None of the other child-specific factors
group who responded “strongly agree,” especially (ie, age, autism severity) correlated with the intervention
regarding the ease of training activities for their child. effectiveness variables or with the intervention
This could be because yoga-related activities were dosages.

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 Yoga in Autism

Discussion The academic group showed improvements in the fine

Generalized Effects on the Motor Skills motor subtests of BOT-2 (ie, FMP and FMI). The academic
of Children With ASD group practiced activities typically included within the
The yoga group demonstrated generalized improvements school settings of children with ASD, for example,
for a standardized measure, bilateral coordination subtest reading, building, and arts and crafts to promoting social
of BOT-2 administered before and after the intervention. interactions, engagement, and creativity. All these
The current evidence for yoga is limited in the ASD activities required isolated and controlled finger and hand
population,33 but the literature in children with TD movements as well as eye-hand coordination while
suggests a positive impact of yoga on several motor grasping (crayons, scissors, blocks) and manipulating the
domains such as strength, endurance, speed, flexibility, objects (rolling, folding, cutting, pressing). Therefore, it is

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and coordination.21–23,38–42 In general, improved motor not surprising that the academic group improved on the
functioning following yoga has been attributed to FMI and FMP subtests of BOT-2. On the other hand, the
improved musculoskeletal health such as increased smaller effect sizes in the academic group could possibly
capillary formation in muscle tissue, alternate recruitment indicate smaller scope for improvement in this domain as
of motor neurons to avoid muscular fatigue, elongation of children were already receiving occupational
elastic connective and muscle tissue, and improved therapy/special education experiences that improved their
perception of performed movements.22,42 Specifically, fine motor performance within school settings. It is
improvements in joint proprioception, that is, the ability to estimated that children spend about 30% to 60% of their
sense joint position, could result in better coordination school time completing fine motor activites.53
between moving body segments. In another study, Nevertheless, therapies centered around arts (drawing,
4 weeks of yoga training enhanced the joint coloring), crafts (cutting, folding paper), and building
proprioception in a group of individuals who had visual (LEGO, Play-Doh) would be beneficial for children with
impairments and were between 10 and 19 years of age.24 ASD demonstrating fine motor impairments.53–55
Similarly, in our study, continuous practice of different
poses/postures in lying, sitting, and standing could have
improved the proprioceptive input from the joints and Training-specific Effects on the Imitation Skills
enhanced children’s awareness of their body movements. of Children With ASD
Although, the medium effect sizes observed for motor Both groups improved their imitation skills for
coordination are promising, it is possible that relatively training-specific actions, that is, poses for the yoga group
longer training durations could result in greater and building actions for the academic group. The
generalized changes in the motor improvements in the imitation skills of children following
functioning/musculoskeletal health of children. We would the intervention are not surprising because both the
like to add that our yoga sessions included a mix of interventions were primarily delivered within an imitation
traditional yoga elements such as poses and breathing as context. Social monitoring skills, that is, visually
well as nontraditional versus elements such as looking monitoring the actions of social partners, are extremely
and contact games. Therefore, it is difficult to tease apart important for strong imitation performance.17–19 Children
the effects of traditional vs nontraditional yoga elements with ASD often have reduced eye contact and monitoring
on the motor coordination of children. However, the of others’ actions,56 which impacts their ability to observe
selective improvement of children in the gross motor and copy actions of others. During both yoga and
subtest of BOT-2 could be a direct result of the poses and academic tabletop play, the children had to observe and
the partner poses practiced during the training sessions, copy the actions of the trainer and model. Hence, the
because these were the only activities requiring significant training activities may have improved the social
whole-body movements. monitoring and turn-taking abilities of children resulting
in improved imitation of the familiar and novel actions
Surprisingly, the yoga group did not show any following the training. Children’s motor coordination skills
improvements in the balance subtest, which could be are also closely related to their imitation
attributed to the differences in the training and the testing performance.2,11,17,19 In this study, children in both groups
activities. To be clear, the BOT-2 balance subtest uses a improved their motor coordination (gross or fine motor)
mix of static (eg, standing on 1 leg) and dynamic activities skills following the intervention on the BOT-2. We believe
(eg, walking heel-to-toe), whereas the majority of the yoga that their motor improvements could have translated to
training focused on the static balance of children (eg, improved imitation skills. There is limited evidence on the
holding a tree pose) for the majority of the training effects of yoga on imitation skills of children with ASD,
period. Moreover, the balance subtest involves children with only 1 study reporting better imitation of yoga poses,
holding a posture with and without visual input; however, breathing exercises, vocalizations, and orofacial
during the training period, children practiced holding the movements as well as increased eye contact with social
poses with the help of visual input. Thus, it is possible partners following an intensive 10- to 20-month yoga
that the changes in balance due to the yoga intervention intervention.34 Therefore, the current results are
did not generalize to a standardized measure of balance. encouraging in that creative movement interventions such

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Yoga in Autism

as yoga could improve the imitation skills of children with variability in terms of the number of parent sessions
ASD for familiar and unfamiliar actions. provided to each child. Furthermore, the training sessions
involved an adult model instead of a peer model; however,
Furthermore, the current treatment approaches for it was difficult to recruit age-matched peers in each
imitation, such as reciprocal imitation training and video instance because many children with ASD lacked
modeling, primarily target social imitation (eg, greeting) consistent friendships. We were unable to conduct
and object imitation (eg, brushing teeth) in children with long-term follow-ups after the completion of the study
ASD. Specifically, reciprocal imitation training is an adult- and hence are unable to comment on the long-term
or peer-delivered intervention in a naturalistic and socially maintenance of study effects or generalization to other
interactive environment to promote the spontaneous settings. Although we value the medium and large effects

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imitation of children with ASD.57,58 On the other hand, on imitation and motor performance seen in the yoga
video modeling includes watching the video clips of target group, we also advise clinicians and therapists to
behaviors along with opportunities to copy the televised cautiously interpret the study results because of the
behaviors.59,60 Although both approaches are successful in aforementioned limitations. In terms of future directions,
improving imitation skills of children with ASD, they do we suggest conducting larger randomized controlled trials
not focus on motor imitation or practice of motor skills. in children with wide-ranging autism-specific
Overall, our study adds to the current body of knowledge symptomology. Furthermore, we suggest using both
on movement-based interventions, along with its potential standardized and training-specific outcome measures,
to improve the fine/gross motor imitation skills of masked assessors, as well as short-term and long-term
children with ASD. follow-ups to evaluate the maintenance of training effects.
Finally, we recommend that future studies explore the
associations between factors such as age, autism severity,
Effects of Child-specific Factors on Intervention
and cognitive levels and the intervention dosage and
Effectiveness and Dosage effectiveness of yoga in children with ASD.
We found that IQ negatively correlated with change in
imitation scores in the yoga group, which suggested that
children with lower IQ and lower motor performance Recommendations for Clinicians and Researchers
(perhaps with more scope for improvement) also showed Given the rising evidence for motor impairments in
greater improvements in spite of a relatively short 8-week children with ASD and its strong association with social
intervention. On the other hand, for the academic group, communication and behavioral impairments,15 ,16 motor
IQ was positively correlated with changes in BOT-2 FMI interventions such as yoga could be beneficial for children
scores. Perhaps fine motor skills were at a higher level in with ASD. In this section, we have provided some
the case of children with higher IQ enough to produce recommendations for clinicians and researchers regarding
short-term improvements within an 8-week period. the use of yoga in children with ASD. First, in terms of
However, for children with lower IQ, greater fine motor intervention dosage, it is usually recommended to practice
practice was required to significantly impact performance. yoga 2 to 3 times per week for shorter periods
None of the other child-specific variables, such as age (20–30 minutes) in young preschoolers and longer periods
range and the degree of autism severity, correlated with (30–60 minutes) in school-age children.61 Second, a yoga
the dosage and the overall effectiveness of the session should include activities such as breathing
intervention. Overall, these results should be treated with exercises, attentional focus/gaze control along with
caution given the small sample size of our study. We chanting/singing, yoga poses done face to face in parallel
recommend that future studies continue to investigate the or with a partner, relaxation poses, as well as a period of
associations between the functioning of children with ASD reflection/thankfulness (see exemplar video content under
(IQ, severity) and intervention efficacy and dosage. Supplementary Materials).21–23,37,61

Poses could change week to week with gradual

Limitations and Future Directions progression from simple to complex whole-body
Our sample size was relatively small, with a wider age movements. The time spent within each activity could be
range of children and a mix of high- and low-functioning varied based on the child’s interest and attentional
children with ASD resulting in a relatively heterogeneous capacities. For example, a child with attention
study sample. However, we ensured homogeneity deficits/disruptive behaviors could benefit from breathing
between the 2 intervention groups by matching the and relaxation exercises whereas a child with motor
children on various demographic, cognitive, motor, and impairments will benefit more from individual and partner
adaptive behaviors. We also excluded children with severe poses. Third, the intervention should be socially
behavioral challenges and nonparticipation, which could embedded and inherently engaging for children. For
limit the generalizability of this intervention. Secondly, our example, in the current study, we used a triadic context
training duration (8 weeks of intervention) was relatively involving a trainer, a model, and a child to promote
shorter but intensive, with 4 sessions (2 expert and 2 natural communication such as turn-taking, spontaneous
parent) being delivered each week. There was some and responsive conversations, and gestural hand use.

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 Yoga in Autism

In addition, we used engaging themes involving stories, ASD. Ms Kofman is a registered yoga teacher who has been
songs, and musical games to make the sessions fun and trained in Yoga for the Special Child.
inherently motivating for children. Finally, the training
set-up should include appropriate props for better Funding
contextual understanding as well as appropriate
A. Bhat was supported by the Institutional Development Award
communication strategies to interact with children with
(IDeA) from the National Institute of General Medical Sciences of
ASD32,37 (eg, picture schedules to facilitate transitions the National Institutes of Health (NIH) (grant no. U54-GM104941)
between activities, predictable and familiar (Principal investigator: S. Binder-Macleod). M. Kaur was supported
environment/trainers across sessions, adequate breaks, by the University Graduate Fellowship from the Office of Graduate
use of prompts, and establishment of an appropriate and Professional Development, University of Delaware.

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communication system with the children).
Disclosure
Conclusion The authors completed the ICMJE Form for Disclosure of Potential
Conflicts of Interest and reported no conflicts of interest.
The current study explored the effects of a physical
This manuscript was written in partial fulfillment of M. Kaur’s
therapist-delivered yoga intervention on the motor and dissertation requirements for Doctor of Philosophy in Biomechanics
imitation skills of children with ASD between 5 and and Movement Sciences (“Creative Yoga Intervention for Children
13 years of age. Our findings show that an 8-week yoga with Autism Spectrum Disorder,” University of Delaware, 2016).
intervention leads to generalized and training-specific
improvements in gross motor and imitation skills of
children. To elaborate, generalized improvements refer to
Ethics Approval
improvements in the standardized BOT-2 as these This study was approved by the University of Delaware
activities were not practiced during the intervention and Institutional Review Board. All parents signed the consent form
were administered by a novel tester, who interacted with approved by the University of Delaware Review Board before
participating in the study.
the children only during the testing sessions.
Training-specific improvements refer to improvements in DOI: 10.1093/ptj/pzz115
the imitation skills for actions practiced throughout the
intervention with a familiar trainer. Furthermore, reports
from the exit questionnaire indicated that the parents
viewed both interventions as useful and beneficial for References
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Appendix 1.
Training setup indicating the triadic context during the yoga session (a) and the academic session 740 (b).

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Appendix 2.
Fidelity Checklist

Checklist Criterion Characteristic

General characteristics 1. Environmental setup: the trainer sets up the room, such as appropriate lighting and limited distractions within the child’s
vicinity
2. Incremental prompts: the trainer provides incremental prompts to the child if he or she is unable to perform the activity
(ie, visual, verbal, and physical hands-on-hands assistance)
3. Eye contact: the trainer encourages the child to maintain eye contact during social interactions
4. Social interactions: the trainer encourages the child to indulge in spontaneous and responsive verbalizations
5. Social praise: both the trainer and the model provide verbal and gestural praise to the child throughout the session
6. Picture board: the trainer uses the picture board to explain the training activities and transition between activities
7. Asking for help: the trainer and the model ask the child to help throughout the session (eg, “Can you help laying down the
mats?”)
Specific characteristics 1. Ready position: the trainer ensures that the child is ready for the activity (eg, cross-legged sitting for breathing in the yoga
group or tabletop sitting for reading in the comparison group)
2. Activity instructions: the trainer provides appropriate instructions before starting any activity (eg, “Today we are going to do
poses on a story theme.”)
3. Repetition: the trainer repeats each activity twice to ensure learning
4. Activity completion: the trainer ensures that the child completes the critical elements within each activity

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