Scoping Review of Yoga in Schools: Mental Health and Cognitive Outcomes in Both Neurotypical and Neurodiverse Youth Populations

1 Physical Activity for Health Research Centre (PAHRC), Institute for Sport, Physical Education and Health Sciences, Moray House School of Education and Sport, University of Edinburgh, Edinburgh EH8 8AQ, UK; ku.ca.de@trah.hmain (N.H.); ku.ca.de@nevin.aslia (A.N.)

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Samantha Fawkner

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Ailsa Niven

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Josie N. Booth

2 Institute for Education, Community and Society, Moray House School of Education and Sport, University of Edinburgh, Edinburgh EH8 8AQ, UK; ku.ca.de@htoob.eisoj

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2 Institute for Education, Community and Society, Moray House School of Education and Sport, University of Edinburgh, Edinburgh EH8 8AQ, UK; ku.ca.de@htoob.eisoj

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

Associated Data

GUID: 5A431252-94CA-4D34-8CAF-DF0A6A850B2C

Details of reviewed articles can be found in Table 3 and Table 4 . The search terms and strategy can be found in the Supplementary Materials along with the PRISMA Scoping Review checklist.

Abstract

Yoga is used widely as a therapeutic tool for physical and mental well-being. The mind-body activity could be an inclusive and cost-effective intervention used within schools to help tackle the mental health crisis in youth populations. To date, research has focused on mainly neurotypical youth populations. However, greater acknowledgement of the impact for neurodiverse youth populations is warranted. Therefore, the aim of this scoping review is to understand what is known about the relationships between yoga in schools and mental health and cognition in neurotypical and neurodiverse youth populations. Methods: This review followed O’Malley and Arskey’s methodological framework. A comprehensive database search using fundamental keywords and index terms was conducted. Screening was carried out in Covidence TM software. Results: Substantial evidence to support the use of school-based yoga programmes for the improvement of anxiety, self-concept, resilience, depression, self-esteem, subjective and psychological well-being, executive function, inhibition, working memory, attention and academic performance in neurotypical populations was found. Evidence to support school-based yoga programmes in neurodiverse populations with improvements in self-concept, subjective well-being, executive function, academic performance and attention was also found. Conclusions: The findings support the provision of yoga in schools to improve mental health and cognition whilst also creating clear pathways for future research and school-based yoga intervention development.

Keywords: yoga, schools, physical activity, mental health, cognition

1. Introduction

In UK youth populations (YP) (Throughout this article, the term ‘youth population’ is used to describe school-aged (4–18 years) children and young people.), 1 in 8 present with at least one mental health difficulty (e.g., anxiety, depression) with rising prevalence rates from 9.7% in 1999 to 11.2% in 2017 [1]. However, the experienced trauma associated with pandemics can cause short-term and long-term effects on YP’s mental health [2]. Therefore, it is likely that these percentages have increased following the restrictions imposed worldwide following the emergence of COVID-19. A recent systematic review [3] describing mental health in YP during the first year of the COVID-19 pandemic found that most studies included in the review observed a general trend of worsening mental health and increases in depressive and anxiety symptoms in participants.

A population that is at higher risk for mental health comorbidities is neurodiverse youth [4] due to high levels of social, emotional and education associated impairments and lifelong persistence [5]. Neurodiverse youth are those who require Additional Support for Learning (ASL) needs that are different from those of the same age to ensure they benefit from education, whether during early learning, school or preparation for life after school [6]. Amongst YP requiring ASL, it is estimated that around 2–5% of school-aged youth in the UK have Attention Deficit Hyperactivity Disorder (ADHD) [7], and around 1 in 57 are on the Autistic spectrum [8].

Many treatments and therapies for mental health are either expensive, ineffective or not readily available to all [9]. Additionally, medication often presents with adverse side effects [10]. A potential low-risk complementary therapy for mental health in YP is physical activity (PA) [11,12]. To experience the multiple physical and mental health benefits of PA, the WHO recommend that YP participate in an average of at least 60 min of moderate to vigorous PA daily [13]. PA is associated with positive outcomes on cognitive function and academic attainment and is beneficial for a range of neurological and mental health difficulties in YP [11,12,13]. One potential PA intervention for YP is yoga.

Yoga is an ancient, mind-body practice that incorporates breathing regulation, physical postures, and meditation [14]. It is a low-cost, low-risk and inclusive mode of PA [9] that has been shown to have physical and mental health benefits in YP. There is review level evidence that supports the role of yoga in neurotypical YP in improving fitness and lean body mass [15,16] and promising effects on psychosocial well-being, stress [16,17], anxiety [18,19], resilience and self-regulation [15]. However, to date, reviews on yoga in YP have been focused on the physical and mental health effects in predominantly neurotypical YP. These reviews potentially have limited relevance for neurodiverse YP, with just one systematic review including neurotypical YP [19]. Serwacki and Cook-Cottone [19] noted effects supporting the provision of yoga in reducing stress in YP with autism as well as improvements in attention in those with severe educational problems. However, only 25% of their included study population were neurodiverse; therefore, it is difficult to confidently support the provision of yoga for youth who require ASL from these findings.

Schools provide an ideal location to deliver PA interventions with a broad reach to neurotypical and neurodiverse YP of all ages [20]. It is therefore critical to look specifically at school-based interventions to understand if yoga as part of the school day is feasible and effective. However, to the authors’ knowledge, only two reviews [17,19] have examined yoga interventions explicitly in the school setting. Whilst therapeutic benefits in psychosocial well-being (anxiety, stress and negative affect) [17] and positive effects on academic outcomes (IQ scoring and contribution in the classroom) [19] were reported, it is important to note these studies’ limitations. Both reviews are now over 7 and 10 years old, respectively, and as yoga is being utilised much more widely in the school environment [21], the research field has developed and needs updating. Furthermore, there is a clear under-representation of synthesised literature on neurodiverse YP and yoga in schools, who, ironically, may benefit most from yoga as part of their school day [22].

Therefore, the aim of this scoping review was to map the relationship between yoga in schools and mental health and cognitive outcomes in neurotypical and neurodiverse YP and identify any potential differences in outcomes between the two populations. Our proposed research question is broad to map out key concepts in the research area and to identify research priorities to support the provision of yoga in schools. The findings will enable stakeholders in education and yoga to make informed choices about utilising yoga within the school day.

Research Question: what is known about the relationships between yoga in schools and mental health and cognition in neurotypical and neurodiverse youth populations?

This scoping review has the following three objectives:

Scope out the different mental health and cognitive functioning outcomes for neurotypical youth populations receiving a yoga intervention as part of the school day;

Scope out the different mental health and cognitive functioning outcomes for neurodiverse youth populations receiving a yoga intervention as part of the school day;

To explore the differences in the outcomes for neurotypical and neurodiverse youth populations.

2. Materials and Methods

This study employed a systematic search of the literature in the form of a scoping review. Unlike systematic reviews, a scoping review allows for a broader approach to searching key concepts and types of sources within a research area [23]. When exploring a complex research area that has not been comprehensively reviewed before, the scoping review is useful to determine and present the existence and range of the evidence available in a systematic and meaningful way [23]. The methodological framework for this scoping review is based on the 5-Stage Process by O’Malley and Arksey [23], along with extra recommendations for each stage by Levac et al. [24] and followed the Preferred Reporting Items FOR Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews checklist [25] (Supplementary Materials). The framework discusses the need for the scoping review to be an iterative process, with the use of expert discussion throughout [23]. Terminology in the research area of neurodiversity area can be problematic, and there is a lack of consensus on modern definitions [26]; however, for the purposes of this research, we have used the definitions listed in Table 1 . The protocol [15] for this review is registered with The Open Science Framework.

Table 1

Terminology	Definition Used
Yoga in Schools	Yoga interventions either before, during or after school. Studies that utilise at least two of the four main components of yoga: physical postures [27] and movement, breathwork, relaxation techniques and meditation/mindfulness practices [15].
Neurotypical	Those who are developing like others of the same age and are not receiving additional or different support.
Neurodiverse	Those who require additional support that is different from that received by children of the same age to ensure they benefit from education, whether early learning, school or preparation for life after school [6].

Stage 1: Identify the research question

A broad research question was proposed following an initial literature search: What is known about the relationships between yoga in schools and mental health and cognition in neurotypical and neurodiverse youth populations?

Stage 2: Identify relevant studies

A preliminary literature search indicated that studies in this area vary in study design, mode of yoga used in the intervention and in the population targeted and outcomes measured. The following eligibility criteria were decided on after multiple discussions within the research team and with the experience from the initial literature review and upon analysing other systematic reviews on yoga in youth populations. The decision was made to include a variety of study designs and studies that included any type of yoga or yoga-inspired intervention and a mixture of outcome variables, where it was possible to disentangle the mental health and cognitive outcomes. Only peer-reviewed literature was included to increase the likelihood of including higher-quality information.

Inclusion criteria included: research from any geographical location, English language, school setting, both sexes, school-aged young people 4–18 years old, neurotypical and neurodiverse youth populations, all forms of yoga (e.g., hatha, ashtanga, yoga-inspired), and peer-reviewed sources of information. The review included primary research studies with pre-post outcomes measured, and qualitative research, evaluating mental health (MH) and/or cognitive functioning outcome variables (key definitions found in Table 2 below). These MH and cognitive outcomes were selected and constructed from Lubans et al. [28] “Conceptual model for the effects of physical activity on mental health outcomes in children and adolescents. ADHD, attention-deficit/hyperactivity disorder”. Studies that assessed MH and cognitive outcomes in addition to other outcomes such as physical health or prosocial behaviour were also included where it was possible to disentangle the findings.

Table 2

Mental Health and Cognitive Outcome Definitions.

Terminology	Definition Used
Mental Health Outcomes	Adapted from Biddle, Ciaccioni, Thomas and Vergeer [11] and Lubans et al. [28].
Anxiety	Activation of the automatic nervous system with distressing thoughts and/or feelings of tension, agitation, excessive worry or apprehension about certain events (such as environment, social, academic, occupational) [29].
Depression	Extended periods of low mood and loss of interest or pleasure in generally all activities [29].
Self-esteem	An individual’s evaluation of their own worth [30].
Self-concept	An individual’s awareness or beliefs regarding their qualities and limitations both globally and in specific subdomains (e.g., academic, physical, social) [31].
Psychological Well-being	Psychological well-being links with autonomy, environmental mastery, personal growth, positive relations with others, purpose in life and self-acceptance. This is often referred to as eudemonic well-being [29].
Subjective-Well-being	Subjective well-being is defined as a person’s cognitive and affective evaluations of their life. SWB is closely aligned with the construct of happiness [32].
Resilience	A personality characteristic that moderates the negative effects of stress and enables individuals to successfully cope with challenges and misfortune [33].
Cognitive Outcomes	Adapted from Diamond [34] and Welsch, Alliott, Kelly, Fawkner, Booth, Niven [35].
Executive Function	The cognitive processes that are used to carry out new or difficult tasks. These processes include inhibition, working memory, shifting and attention [34].
Inhibition	The control of attention, behaviour, thoughts and emotions by overriding internal tendencies or external distractions [34].
Working Memory	The of holding information in the mind and working with it mentally [36], e.g., thinking of a response while listening to a conversation.
Shifting	The flexibility to adjust to changed demands or priorities [34].
Attention	The ability to focus on information for several seconds (interrelated with working memory) [34].
Academic Performance	Academic performance broadly refers to the communicative (oral, reading, writing), mathematical, science, social science and thinking skills and competencies that enable a child to succeed in school and society. Because these forms of achievement are difficult to assess, most researchers have relied on a narrower definition that is largely limited to outcomes on standardised achievement tests [37].
IQ	Intelligence quotient [38] refers to mental age (MA) expressed as a ratio of chronological age (CA) multiplied by 100. For IQ to remain stable, MA must increase with CA over time [39].
Neurodevelopmental Impairments	The American Psychiatric Association [29] define neurodevelopmental disorders that present themselves at the onset of the developmental stage through personal, social, academic and occupational impairments.
ADHD	Attention-Deficit/Hyperactivity Disorder is defined by the American Psychiatric Association [29] as a consistent pattern of inattention, impulsivity and/or hyperactivity.
ASD	Autism Spectrum Disorder [38] is a complex developmental disorder that involves persistent challenges in social interaction, restricted and repetitive behaviours and speech and non-verbal communication [29]. The severity and effects of ASD differ between each individual.
Learning Difficulties	Identified as a particular type of “unexpected” low achievement and distinguished from types where low achievement is expected due to emotional disturbance, social or cultural disadvantage or inadequate instruction [40].

Exclusion criteria: non-English-speaking language, opinion pieces, magazines or newspaper articles, dissertations or books, reviews, research articles that do not scientifically investigate measures of mental health or cognitive functioning and studies that include additional therapies used in combination with yoga interventions (e.g., yoga and Thai Chi) where it is not possible to disentangle.

Review Search Strategy

Step 1: An initial search

An initial search was conducted on Google Scholar to become familiar with the evidence base using the words yoga AND schools. The first 100 studies were reviewed, and 24 studies were identified as relevant with information extracted from the year, name of the study, reference, study design, methods, population, outcomes measured, and outcomes found. The initial search reviewed all outcome variables, including physical and mental health, cognitive outcomes, and prosocial behaviour; however, after discussions with the research team, it was deemed most relevant to focus on mental health and cognitive outcomes. The individual reference lists of the 24 studies were also examined to identify further relevant studies.

Step 2: Identify keywords and index terms

The initial literature search enabled the author to identify fundamental index terms and keywords for the main searches. To ensure inclusivity, “yoga” and “school*” were the main terms used in the database searches.

Secondary search terms (adolescen*, teen* mental health, depression, anxiety, self-esteem, self-concept, psychological stress, psychological well-being, subjective well-being, resilience, social-isolation, loneliness, cogniti*, executive function*, inhibition, shifting, academic attainment, academic achievement, IQ, and cognitive outcome*, well-being, cognitive function*) were combined with the Boolean operator OR and then combined with the yoga and school terms using AND to facilitate the recovery of relevant studies (The search strategies and terms can be found in Supplementary Materials). Searches were conducted on 13 April 2021 and updated on 7 April 2022.

Step 3: Searching electronic databases

The database search was designed to be as comprehensive as possible. After reviewing previous reviews in the field [16,19] and a consultation with an academic information specialist, a selection of databases (MEDLINE, PsycINFO, SPORTDiscus, CINAHL) were selected to reach saturation of searches with education, psychology and physical activity as the main areas of interest. The databases were searched for titles with “yoga” and “school*” and secondary search terms.

Step 4: Citation and reference lists

The reference and citation list of relevant studies were also searched to identify further relevant studies not picked up by the database searches. Authors of significant primary studies, scoping reviews and systematic reviews were contacted to locate any additional important sources of information that could not be retrieved through the online searches.

Stage 3: Study selection

Study selection required 2 steps;

All identified studies were uploaded to Covidence software, where duplicates were automatically removed on upload.

Titles and abstracts were screened by N.H. with 100% double screened between the members of the research team. The entire research team (N.H., S.F., A.N. and J.B.) double screened 30% of the full-text review as a quality assurance measure. This increased confidence for one author (N.H.) to continue the subsequent 70% full-text review. If a paper could not be retrieved during the study selection process, the author(s) were contacted to request a copy. However, if the paper was not recovered, the study was excluded.

Stage 4: Charting the data

Data were extracted, interpreted and synthesised as per best practice reported by Peters et al. [41]. A data extraction form was utilised to ensure all relevant data were extracted from each study. The data extraction form followed the headings: year of publication, reference, author(s), location, title, synopsis, study design, no. of participants, participant info (including gender, age, neurodiverse/neurotypical), type of yoga, components of yoga, intervention details, measurements used, outcomes measured in relation to RQ, effects found and implications.

N.H. carried out the extraction process whilst meeting with the research team at regular intervals to ensure the approach was consistent with answering the scoping review research question.

Stage 5: Collating, summarising and reporting the results

The findings are presented in two ways (1) table format, a table with study characteristics and (2) thematically, descriptive analysis presenting key themes and concepts relevant to the research question.

3. Results

3.1. Characteristics of All Studies

The study selection flowchart is presented in Figure 1 . A total of 695 references were identified for screening. Following the removal of duplicates, 561 studies were screened by title and abstract, and subsequently, 217 full-text papers were screened for eligibility. A total of 59 studies met the inclusion criteria and were included for data extraction. The 59 studies took place in the following locations: U.S (n = 32), India (n = 16), Germany (n = 2), UK (n = 2), New Zealand (n = 2), Israel (n = 1), Canada (n = 1), Columbia (n = 1), Sri Lanka (n = 1) and Tunisia (n = 1). Only 10% (n = 6) of studies were conducted before 2010, presenting a substantial and recent increase in the number of related studies. A total of 41% of studies (n = 24) were conducted in the last 5 years.