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Original Article
Effects of Yoga on Attention, Impulsivity, and Hyperactivity in
Preschool-Aged Children with Attention-Deficit Hyperactivity
Disorder Symptoms
Samantha C. L. Cohen, MD,*†Danielle J. Harvey, PhD,‡Rebecca H. Shields, MSc,§†
Grant S. Shields, MA,\Roxanne N. Rashedi, MA,¶Daniel J. Tancredi, PhD,*
Kathleen Angkustsiri, MD,*†Robin L. Hansen, MD,*†Julie B. Schweitzer, PhD**†
ABSTRACT: Objective: Behavioral therapies are first-line for preschoolers with attention-deficit hyperactivity
disorder (ADHD). Studies support yoga for school-aged children with ADHD; this study evaluated yoga in
preschoolers on parent- and teacher-rated attention/challenging behaviors, attentional control (Kinder Test
of Attentional Performance [KiTAP]), and heart rate variability (HRV). Methods: This randomized waitlist-
controlled trial tested a 6-week yoga intervention in preschoolers with ‡4 ADHD symptoms on the ADHD
Rating Scale-IV Preschool Version. Group 1 (n 512) practiced yoga first; Group 2 (n 511) practiced yoga
second. We collected data at 4 time points: baseline, T1 (6 weeks), T2 (12 weeks), and follow-up (3 months
after T2). Results: At baseline, there were no significant differences between groups. At T1, Group 1 had faster
reaction times on the KiTAP go/no-go task (p50.01, 95% confidence interval [CI], 2371.1 to 259.1, d5
21.7), fewer distractibility errors of omission (p50.009, 95% CI, 214.2 to 22.3, d521.5), and more
commission errors (p50.02, 95% CI, 1.4–14.8, d51.3) than Group 2. Children in Group 1 with more severe
symptoms at baseline showed improvement at T1 versus control on parent-rated Strengths and Difficulties
Questionnaire hyperactivity-inattention (b522.1, p50.04, 95% CI, 24.0 to 20.1) and inattention on the
ADHD Rating Scale (b524.4, p50.02, 95% CI, 27.9 to 20.9). HRV measures did not differ between groups.
Conclusion: Yoga was associated with modest improvements on an objective measure of attention (KiTAP)
and selective improvements on parent ratings.
(J Dev Behav Pediatr 39:200–209, 2018) Index terms: ADHD, yoga, preschool.
Attention-deficit hyperactivity disorder (ADHD) is
a common and impairing neurodevelopmental disorder,
occurring in up to 7% of children and adolescents.
1
Core symptoms include inattention, hyperactivity, and
impulsivity. ADHD is also associated with impaired
self-regulation and decision making, leading to negative
educational outcomes.
1
ADHD symptoms often emerge
in preschool-aged children and can be associated with
similar behavioral, social, and cognitive impairments as
seen in older children with ADHD.
1
These ADHD
symptoms persist beyond preschool for 70% to 80% of
children.
1
ADHD symptoms are associated with poor
outcomes across the life span: academic and/or occu-
pational difficulties, trouble maintaining friendships and
other relationships, criminality, and substance use.
1
In
preschool-aged children, the American Academy of Pe-
diatrics recommends evidence-based behavioral therapy
as first-line treatment.
2
Common behavioral inter-
ventions include parent education, visual schedules, and
classroom accommodations.
Exercise and mindfulness practices (e.g., meditation)
may be beneficial for school-aged children with ADHD.
3,4
Aerobic exercise improves parent and/or teacher ratings
of childhood ADHD symptoms, executive function, sus-
tained attention, disruptive behaviors, and response in-
hibition.
3
Emerging evidence suggests that physical
exercise may be associated with more sustained
improvements in ADHD than medications and/or behav-
ioral interventions.
3
Physical exercise game instruction
has also been successful in decreasing ADHD severity in
preschoolers on parent and teacher rating scales.
5
An
additional benefit of implementing these games at home
included enhancement of parent-child relationships.
5
From the *Department of Pediatrics, University of California Davis, Sacramento,
CA; †MIND Institute, University of California Davis, Sacramento, CA;
‡Department of Public Health Sciences, University of California Davis, Davis,
CA; §Human Development Graduate Group, University of California Davis,
Davis, CA; \Department of Psychology, University of California Davis, Davis, CA;
¶School of Education, University of California Davis, Davis, CA; **Department of
Psychiatry, University of California Davis, Sacramento, CA.
Received June 2017; accepted December 2017.
Disclosure: The authors declare no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of this
article on the journal’s Web site (www.jdbp.org).
Address for reprints: Samantha C. L. Cohen, MD, Department of Pediatrics, Uni-
versity of California Davis, 2825 50th St, Sacramento, CA 95817; e-mail: lewissc@
gmail.com.
Copyright 2018 Wolters Kluwer Health, Inc. All rights reserved.
200 | www.jdbp.org Journal of Developmental & Behavioral Pediatrics
Copyright Ó201 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.8
Similar to benefits associated with exercise for ADHD,
there is preliminary evidence of mindfulness training
as a complementary form of therapy for ADHD. In
school-aged children with ADHD, mindfulness training
in conjunction with similar parent training resulted in
decreased parent ratings of ADHD behaviors,
increased mindful awareness in children, and decreased
parenting stress and overreactivity.
4
A review
of mindfulness-based interventions in typical pre-
schoolers described improved self-control through ob-
server ratings and executive functioning performance
after 10 hours of Integrated Body-Mind Training.
6
An-
other study in typical preschoolers found improvements
in teacher ratings of social competence and higher
grades in social-emotional development after 12 weeks
of mindfulness training.
7
Notably, baseline functioning
moderated treatment effects—children with initially
lower social competence and executive functioning
demonstrated larger gains in social competence than
controls.
7
Yoga is a form of movement meditation that incor-
porates physical postures/poses, breathing practices,
and meditation to hone self-regulation skills within the
body and mind.
8
Yoga thus combines physical exercise
and mindfulness. Previous studies evaluating the effects
of yoga demonstrated promising results for school-aged
children with ADHD, including improved parent and/or
teacher rating scales
9–12
and clinician-completed rating
scales.
13
Yoga improved attention through on-task at-
tention
10
and direct observations of “time on task.”
12
Parents who practiced yoga with their children reported
better management of their own stress and improved
parent-child relationships.
11
Promising evidence for the
use of yoga with typically developing preschoolers is
emerging. Significant gains in self-regulation, particularly
for children with low baseline levels of self-regulation,
were found through direct assessment in children who
received a yearlong daily school yoga intervention versus
controls.
14
Physiology may also be affected by yoga, such as vagal
tone, which seems to improve in adults who practice
yoga.
15
Heart rate variability (HRV), a measure of the
beat-to-beat changes in heart rate, reflects the activity of
the vagus nerve.
16
The degree of HRV is associated with
physiologic resiliency, self-regulatory capacity, and per-
formance on tasks of executive function.
16
Compared
with healthy controls, children with ADHD have higher
mean heart rates and, unmedicated, have significantly
lower HRV.
17
The primary aim of this study was to explore the
efficacy of practicing yoga for 6 weeks on behavioral
symptoms, attentional control, and HRV. The second-
aryaimwastoassessthemaintenanceofthein-
tervention effects over time. We hypothesized that
participation in yoga for 6 weeks would lead to
improvements in ADHD symptoms rated by parents
and teachers, scores on attention tasks, and increases
in HRV.
METHODS
Participants
Children 3 to 5 years of age with 4 or more attention-
deficit hyperactivity disorder (ADHD) symptoms rated by
teachers or parents on the ADHD Rating Scale-IV (ADHD
RS-IV) Preschool Version
18
were recruited from a local
urban, community-based preschool. We chose 4 or more
symptoms as our cutoff to catch children at high risk of
ADHD, but did not require a diagnosis of ADHD, as it is
often not diagnosed in preschoolers. Non–English-speak-
ing children or those with a medical condition precluding
them from safely participating in yoga were excluded.
Recruitment included posting flyers at the preschool and
meeting with teachers and parents to discuss the study.
This study was approved by the institutional review
board. Written informed consent was obtained from the
parents and teachers of the children enrolled.
Design
We conducted a mixed-methods randomized waitlist-
controlled trial of a 6-week home- and school-based
children’s yoga intervention. Behavioral symptoms were
evaluated using 2 parent and teacher rating scales: ADHD
RS-IV Preschool Version
18
and Strengths and Difficulties
Questionnaire
19
(SDQ). Attention was measured by
computer-based tasks using the Kinder Test of Atten-
tional Performance (KiTAP).
20
We used heart rate vari-
ability (HRV) as a physiologic index of self-regulation.
16
Qualitative data were also collected through ques-
tionnaires and focus groups and/or interviews with
parents, teachers, and the yoga instructors after each
6-week yoga intervention (not included here).
To maximize the frequency of yoga, the intervention
occurred at home and school. During the first 6 weeks,
students in Group 1 practiced school yoga in a separate
room from their classroom and completed home yoga
with parent encouragement using a yoga DVD featuring
the same protocol. Group 2 (waitlist control) continued
their regular classroom and home activities without ex-
posure to yoga. During the second 6 weeks, the groups
switched. Based on the teachers’feedback after the first
6-week intervention, school yoga for Group 2 was
moved into the classroom as part of their morning rou-
tine; home yoga practice was the same. Group 1 stopped
receiving school yoga (aside from 3 students in the
classroom where school yoga was taught for Group 2;
however, they were not included in the analysis for Time
2). See Figure, Supplemental Digital Content 1, http://
links.lww.com/JDBP/A171, for the study timeline.
Rating scales, KiTAP scores, and HRV were collected
from the children at 4 time points: baseline, Time 1
(Group 1 completed yoga), Time 2 (Group 2 completed
yoga), and follow-up (3 months after Time 2). See Fig-
ure 1, a participant flowchart from randomization through
follow-up, for details. During each intervention period,
the yoga teachers completed time on task ratings for each
student after school yoga classes. They also completed
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Yoga Fidelity Measures after each yoga class. While par-
ticipating in the intervention, parents completed daily
yoga logs through e-mail or hard copy to determine the
frequency of yoga practice for each child. After each 6-
week yoga intervention, parents and teachers completed
Perception and Satisfaction Questionnaires.
Intervention
School Yoga
Five months before starting the study, 2 yoga instruc-
tors completed an intensive 3-day training with Tiffany
Gullberg, owner and founder of If I Was a Bird Yoga.
Leading up to the study, yoga teachers and assistants
participated in monthly group practice sessions and more
frequent home practice using yoga videos created for the
study. During the study, 30-minute group yoga sessions
were held twice a week at the preschool, led by trained
children’s yoga instructors and 1 to 2 assistants, using
a manualized curriculum from If I Was a Bird Yoga(see
Table, Supplemental Digital Content 2, http://links.lww.
com/JDBP/A172, for the protocol). The sequence of
breathing exercises and poses was consistent over the 6-
week intervention. We created 3 themes (Ocean, Jungle,
and Space Yoga Adventures) to help keep the children
engaged; each theme was implemented for 2 weeks.
During school yoga for Group 1, the children practiced
away from the structure of their classroom. In this envi-
ronment, some children, especially those with significant
hyperactive/impulsive symptoms, became disruptive
(running, climbing, and hitting), which resulted in being
Figure 1. Participant flowchart of the study depicting both the number of children included in each group over the course of the study and the sample
sizes (n) available for the analysis of each outcome measure: parent (p) and teacher (t) rating scales, KiTAP subtests, and heart rate variability (HRV).
KiTAP, Kinder Test of Attentional Performance.
202 Effects of Yoga on ADHD Symptoms in Preschoolers Journal of Developmental & Behavioral Pediatrics
Copyright Ó201 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.8
sent back to the class to ensure the safety of the other
children. Based on the teachers’feedback, Group 2’s
school yoga exercises were taught within the classroom
setting along with typically developing peers, where
classroom teachers and aides assisted in managing
behaviors and enforcing rules.
Home Yoga
To maximize yoga practice, parents were given
a yoga DVD (also available online), featuring the same
30-minute yoga protocol themes. Home practice oc-
curred on days the children did not practice at school.
Children with persistent challenges participating in
school yoga classes were asked to practice yoga daily
at home, as some children complied better in more
intimate settings.
Measures
Parent and Teacher Rating Scales
The ADHD RS-IV Preschool Version includes 18 de-
velopmentally appropriate statements based on ADHD
symptoms defined in Diagnostic and Statistical
Manual of Mental Disorders (Fourth Edition) (Text
Revision) (DSM-IV-TR).
18
It includes Inattentive and
Hyperactive/Impulsive subscales and a total symptom
scale. The scale screened and monitored response to the
intervention.
The SDQ includes 25 developmentally appropriate
statements divided into 5 subscales: Emotional Symp-
toms, Conduct Problems, Hyperactivity/Inattention, Peer
Problems, and Prosocial Behaviors.
19
There is a total
difficulty score and a prosocial scale score.
KiTAP Test of Attentional Performance for
Children
The KiTAP
20
is a computer-administered child-friendly
test with the theme of an enchanted castle. Four tasks
(alertness, distractibility, flexibility, and go/no go) are
feasible to administer and reliable for a mental age of 31
years and are correlated with behavioral ratings of hy-
peractivity and attention.
21
We selected measures that
were based on the manual or were shown in previously
published research to be reliable and valid,
21
including
number of correct responses, total errors, omissions, and
reaction times to correct responses. At each administra-
tion, the children were taught how to do each task and
were given up to 3 practice tests. If more correct
responses or equal numbers of correct responses and
errors or omissions were achieved, the child completed
the actual test recorded by the computer. The test was
considered invalid if the child persistently needed re-
direction to participate. At baseline, many children in
both groups did not pass the practice tests or did not
finish the actual test, resulting in insufficient data in ei-
ther group to analyze at baseline. However, at sub-
sequent times, sufficient numbers of children in both
groups completed the full tests. Intermittent technical
problems with the go/no-go task prevented the program
from capturing data for some children: 4 at baseline, 7 at
Time 1, 3 at Time 2, and 5 at follow-up.
Heart Rate Variability
The emWave
Coherence System by HeartMath
measured HRV using a photoplethysmography optical
sensor placed on subjects’earlobes. We used emWave to
extract R to R intervals and Kubios
22
to analyze HRV
data. Automated artifact correction was set at a threshold
of 0.35 seconds. HRV indices of interest were the SD of
beat-to-beat intervals, root mean square of successive
differences, high-frequency (HF), and the low-frequency/
HF ratio. Because of a positive skew, HF HRV was log
transformed before analyses. HRV was measured while
the children listened to stories (resting condition) and
during the KiTAP (an inhibitory control/attention task).
The results presented will focus on HRV measured dur-
ing the story.
Yoga Instructor Ratings
A 7-point Likert scale of time on task was rated by the
yoga instructor and/or assistant for each student after
school yoga classes (1 5never on task and 7 5always
on task). At the end of each school yoga class, they also
completed Yoga Fidelity Measures based on the yoga
study protocol (see Table, Supplemental Digital Content
2, http://links.lww.com/JDBP/A172, for the protocol) by
crossing out poses or breathing exercises not completed.
Satisfaction and Perception Questionnaires
At the end of each 6-week yoga intervention, parents
and teachers completed Satisfaction (teacher 7 items,
parent 9 items) and Perception (teacher 12 items, parent
14 items) questionnaires. Some questions used semantic
differential sliding scales between 0 and 100 (e.g., not im-
proved 50 and greatly improved 5100); other questions
were multiple choice.
Yoga Frequency
Parents completed daily yoga logs through e-mail or
hard copy to determine the frequency of yoga practice
for each child. The daily yoga log included 1 to 2
multiple-choice questions (Did your child practice yoga
today? If not, what were the barriers to practicing?).
Statistical Analysis
Assuming precorrelations/postcorrelations of 60%, our
target sample size was 30 subjects per group to estimate
treatment effects with margins of error of 0.41 SDs and to
provide 80% power (with 2-sided alpha 55%) to detect
between-group effects as small as 0.59 SDs. However, we
were only able to recruit 23 children (79% of the students
eligible for the study). We were not able to expand the
study to other preschools because of limitations in time
and financial resources. With this sample size, assuming an
alpha of 0.05 and a 2-sided test, the minimum detectable
difference with 82% power was 1.2 SDs. The primary as-
sessment of treatment effectswasestimatedbycomparing
treatment and control groups on mean outcomes at Time 1
using analysis of covariance with the baseline values used
as the covariate (when available). When the assumption of
parallel groups was violated, an interaction between group
and baseline values was included in the model. Secondary
analyses included a within-group contrast to estimate the
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treatment effect in Group 2 (T2–T1) and an evaluation of
treatment durability in Group 1 (follow-up—T1). If baseline
data were unavailable (i.e., in analyses of the KiTAP), a t
test was used to test differences between groups. Greek
letters (e.g., b) are used to represent unstandardized model
parameters. Feasibility and acceptability of the yoga in-
tervention based on the Perceptions and Satisfaction
Questionnaires were analyzed using Wilcoxon rank-sum
tests. Data are presented as mean 6SD unless otherwise
stated. Intention-to-treat analysis was implemented
throughout. All analyses were conducted using SAS soft-
ware version 9.4
23
or R version 3.2.2.
24
RESULTS
Demographics
A total of 23 students were recruited and randomized
to Group 1 (yoga first; n 512) or Group 2 (waitlist
Table 1. Demographic and Baseline Characteristics of the Children and
Their Parents by Group
Child Demographics
Group 1
(n 512)
Group 2
(n 511) p
Mean age in months 6SD 52 6746610 0.14
Male (raw count; %) 8; 67 7; 64 1.00¤
Non-Hispanic
(raw count; %)
9; 90 7; 78 0.72¤
Race (raw count; %) 1.00¤
White 5; 42 5; 46
African American 5; 42 4; 36
Asian 0; 0 1; 9
Mixed 1; 8 1; 9
Unknown 1; 8 0; 0
Years of preschool
experience
(raw count; %)
0.58¤
First year 6; 55 8; 73
Second year 2; 18 1; 9
Third year 1; 9 2; 18
Fourth year 2; 18 0; 0
ADHD diagnosis
(raw count)
1 1 1.00
ADHD medication
(raw count)
1 0 1.00
Child baseline
characteristics
SDQ—parent rating
(mean 6SD)^
Emotional problems 1.1 60.8 3.0 62.4 0.03
Conduct problems 2.9 61.8 3.5 62.0 0.48
Hyperactive inattentive 6.2 62.5 4.5 62.8 0.14
Peer problems 1.5 61.2 3.1 62.9 0.13
Prosocial 7.4 61.8 8.4 61.8 0.22
Total score 11.7 64.4 14.1 67.4 0.37
SDQ—teacher rating
(mean 6SD)
Emotional problems 0.6 60.9 1.9 62.0 0.07
Conduct problems 4.1 63.4 3.0 63.7 0.47
Hyperactive inattentive 7.0 63.0 6.2 63.2 0.53
Peer problems 1.8 61.1 2.1 62.5 0.76
Prosocial 5.8 62.6 6.6 61.6 0.39
Total score 13.5 65.4 13.2 68.2 0.91
ADHD—parent rating
(mean 6SD)^
Inattention 8.4 64.7 9.2 64.8 0.70
Hyperactivity 13.3 65.3 10.7 65.7 0.28
Total score 21.7 69.1 19.9 610.3 0.66
ADHD—teacher rating
(mean 6SD)
Inattention 11.6 66.8 11.9 66.2 0.91
(Table continues)
Table 1. Continued
Child Demographics
Group 1
(n 512)
Group 2
(n 511) p
Hyperactivity 13.0 68.7 12.5 67.9 0.90
Total score 24.6 613.7 24.4 612.4 0.98
HRV (mean 6SD) (n 510) (n 59)
HF (ln) 7.9 60.8 7.5 61.3 0.44
RMSSD 101.1 624.6 90.8 629.0 0.41
SDNN 97.4 638.3 86.9 645.6 0.59
LF/HF ratio 1.9 61.7 1.5 61.2 0.63
Parent demographics
Parent age
(raw count; %)
1.00¤
18–24 yr 1; 8 1; 9
25–34 yr 5; 42 4; 36
35–44 yr 5; 42 6; 55
45–54 yr 1; 8 0; 0
Parent education
(raw count; %)
1.00¤
High school or less 3; 27 4; 36
Secondary education 8; 73 7; 64
SES (raw count; %) 1.00¤
Preschool
grant/voucher
6; 55 6; 55
Tuition paying 5; 46 5; 46
Caregivers in home
(raw count; %)
1.00¤
One 3; 33 3; 27
Two or more 6; 67 8; 73
Baseline KiTAP values are not included because there were not enough data to
analyze meaningfully. One individual in Group 1 was American Indian/African
American, and 1 individual in Group 2 was Asian/African American.^, missing for
1 participant in Group 2; ¤,Fisher’s exact test; ADHD, attention-deficit hyperactivity
disorder; HRV, heart rate variability; KiTAP, Kinder Test of Attentional Performance;
LF/HF, low frequency/high frequency; ln, natural logarithm; RMSSD, root mean
square of successive differences; SDNN, SD of beat-to-beat intervals; SDQ, Strengths
and Difficulties Questionnaire; SES, socioeconomic status.
204 Effects of Yoga on ADHD Symptoms in Preschoolers Journal of Developmental & Behavioral Pediatrics
Copyright Ó201 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.8
control, yoga second; n 511). There were no differences
between the groups based on their demographic data or
baseline scores on most outcome measures (Table 1). One
child in Group 2 had autism spectrum disorder.
Parent/Teacher Rating Scales
At baseline, there were no significant differences be-
tween the groups for parent-rated or teacher-rated scores
on the ADHD Rating Scale-IV (ADHD RS-IV) Preschool
Version. On the baseline Strengths and Difficulties
Questionnaire (SDQ) subscales, Group 2 had significantly
higher parent-rated emotional problems (95% confidence
interval [CI], 23.6 to 20.2). Significant time effects were
observed for the parent-rated SDQ total score (F 55.8,
p50.008), teacher-rated SDQ conduct scale (F 54.9,
p50.02), and teacher-rated inattention on the ADHD RS-
IV (F 54.8, p50.02), but not for the other outcomes
(F 50.2–2.9). Similarly, significant time by group inter-
actions were observed for the parent-rated SDQ
hyperactive-inattentive scale (F 55.2, p50.01), teacher-
rated SDQ conduct scale (F 56.2, p50.007), teacher-
rated SDQ prosocial scale (F 510.3, p,0.001), and
parent-rated inattention on the ADHD RS-IV (F 56.8, p5
0.004), but not for the other outcomes (F 50.3–2.5).
At Time 1, differences in mean rating scale scores
between the groups depended on baseline scores for
the parent-rated SDQ hyperactive-inattentive scale and
inattention on the ADHD RS-IV. Particularly, children
with parent-rated SDQ hyperactive-inattentive scale
scores of 8.5 at baseline in Group 1 had 2-point lower
ratings, on average, at Time 1 than similar children in
Group 2 (b522.1, SE 51.0, p50.04, 95% CI, 24.0
to 20.1). Similarly, children in Group 1 with baseline
ADHD inattention score ratings of 17 had 4-point
lower ratings at Time 1 than similar children in Group
2(b524.4, SE 51.7, p50.02, 95% CI, 27.9 to 0.9)
(Fig. 2). The total scores on both scales and the
other subscales did not differ between the groups at
Time 1.
Within Group 2, parent-rated SDQ total scores (b5
22.5, SE 50.7, p50.002, 95% CI, 24.0 to 1.0) de-
creased after the yoga intervention (Time 2–Time 1).
However, scores on the parent-rated ADHD RS-IV hy-
peractivity subscale increased after the yoga intervention
(b52.2, SE 50.9, p50.03, 95% CI, 0.3–4.1) in Group
2. There were no other differences observed in Group 2
after the intervention.
In Group 1, improvements noted for children with
a baseline parent-rated SDQ hyperactive-inattentive
score of 8.5 at Time 1 continued at follow-up, with
scores of another 1.5 points lower, on average (b5
21.5, SE 50.4, p,0.001, 95% CI, 22.2 to 20.7).
Although no effects of the yoga intervention were ob-
served at Time 1 on the teacher-rated prosocial SDQ
subscale, scores were higher (better on this scale) in
Group 1 at follow-up than at Time 1 (b51.3, SE 50.4,
p50.003, 95% CI, 0.5–2.1). No other differences were
observed between follow-up and Time 1.
KiTAP Tasks of Attention
At Time 1, comparisons between Groups 1 and 2
showed that Group 1 had faster reaction times for
correct responses on the go/no-go subtest (t(12) 5
23.0, p50.01, 95% CI, 2371.1 to 259.1, d521.7).
The comparisons of the other subtests at Time 1 were
not significantly different between the groups: flexibil-
ity (t(20) 522.0, p50.06, 95% CI, 21123.1 to 12.8,
d520.9), alertness (t(21) 522.0, p50.06, 95% CI,
2509.1 to 13.9, d520.9), and distractibility (t(15) 5
22.0, p50.07, 95% CI, 2398.4 to 15.1, d521.0).
Group 1 also had fewer distractibility omission errors at
Time 1 (t(15) 523.0, p50.009, 95% CI, 214.2 to
22.3, d521.5), but also committed significantly more
commission errors on the distractibility subtest (t(15) 5
2.6, p50.02, 95% CI, 1.4–14.8, d51.3). Significant
differences on commission errors were not found on
other subtests (Fig. 3). No differences were found for
variability of reaction times on the alertness subtest or
Figure 2. Parent-reported behaviors on the inattention subscale of the (A) ADHD Rating Scale-IV Preschool Version and (B) Hyperactivity/Inattention
subscale of the Strengths and Difficulties Scales at baseline and Time 1. ADHD, attention-deficit hyperactivity disorder; SDQ, Strengths and Difficulties
Questionnaire.
Vol. 39, No. 3, April 2018 Copyright 2018 Wolters Kluwer Health, Inc. All rights reserved. 205
Copyright Ó201 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.8
errors on the flexibility subtest, p’s.0.58. Covarying
for age or ADHD severity did not affect the significance
of these results.
Changes in scores for Group 2 (Time 2–Time 1) were
not significantly different. However, controlling for age
at baseline led to some significant results. Specifically,
there were significant improvements in go/no-go re-
action times (b52113.7, SE 547.0, p50.04, 95% CI,
2223.9 to 23.5). Comparisons on the alertness subtest
were not significantly different for reaction times (b5
2148.4, SE 571.7, p50.07, 95% CI, 2311.4 to 14.5) or
variability of reaction times (b52215.7, SE 5102.9,
Figure 3. KiTAP performance at Time 1 (postintervention for Group 1) significantly or marginally differed on numerous tests. For symmetry, go/no-go
errors of omission were omitted from this figure; differences between groups on this task outcome were not significant, p50.894. †p,0.10, *p,
0.05, **p,0.01. ns, non-significant; KiTAP, Kinder Test of Attentional Performance.
206 Effects of Yoga on ADHD Symptoms in Preschoolers Journal of Developmental & Behavioral Pediatrics
Copyright Ó201 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.8
p50.06, 95% CI, 2442.0 to 10.6). Controlling for ADHD
severity at baseline did not reveal significant improve-
ments in go/no-go reaction time (b52109.5, SE 547.6,
p50.06, 95% CI, 2222.0 to 3.1), alertness reaction time
(b52139.9, SE 570.1, p50.08, 95% CI, 2297.5 to
17.7), or alertness variability in reaction times (b5
2225.6, SE 5104.9, p50.06, 95% CI, 2458.2 to 6.9).
We had insufficient data from Group 1 at follow-up to
make any comparisons with confidence.
Heart Rate Variability
At baseline, there were no significant differences in
heart rate variability (HRV) between Groups 1 and 2 (t’s
,0.84, p’s.0.41). At Time 1 (Fs ,1.84, p’s.0.19)
and follow-up (Fs ,0.59, p’s.0.43), none of the HRV
measures we assessed significantly differed between
groups, controlling for each respective measure at
baseline. Similarly, within Group 2 after the yoga in-
tervention (Time 2–Time 1), none of the HRV measures
we assessed significantly differed.
Yoga Instructor Ratings
Time on Task
The mean time-on-task ratings of Group 1 (3.9 61.8)
were similar to those of Group 2 (3.8 61.2), indicating
that on average, students were rated as being “occa-
sionally on task”during school yoga. Over the course of
the intervention, the mean time-on-task ratings remained
stable in both groups (b520.02, p50.6, 95% CI,
20.08 to 0.04). When considering ADHD symptoms,
defined as the average of parent and teacher ADHD RS-IV
ratings, children with higher symptoms on the total
score or the hyperactive/impulsive and inattention sub-
scales had lower time on task ratings initially (p,0.05).
Children with higher symptoms improved slightly over
time, although this improvement was not statistically
significant (see Figure, Supplemental Digital Content 3,
http://links.lww.com/JDBP/A173, for graphs). Children
with symptom scores of 1 SD below the mean (low
symptoms) declined in time on task over the course of
the intervention (total ADHD rating: b520.08, p50.
007, 95% CI, 20.15 to 20.02; hyperactive/impulsive:
b520.07, p50.006, 95% CI, 20.13 to 20.02; and
inattention: b520.08, p50.01, 95% CI, 20.14 to 20.
02). Children with average symptoms remained stable
over time.
Fidelity
Each part of the school yoga classes were completed
with rates of 63% to 100%. The poses missed most often
in both groups included bird-dog, chair, airplane, and
happy baby.
Satisfaction and Perception Questionnaires
Parent satisfaction and perception ratings were not
significantly different between the groups. Many parents
were satisfied with behavior changes they noticed
after yoga (Group 1: 80 623 and Group 2: 67 630) and
felt that learning yoga helped their children learn
self-calming skills (Group 1: 85 623 vs Group 2: 82 6
20). Overall parent satisfaction with the program was
promising (Group 1: 75 639 vs Group 2: 72 630), and
most would recommend the program to others (Group
1: 74 643 vs Group 2: 78 632). In both groups, most
parents did not perceive changes in their children’s ap-
petite, sleeping patterns, mood, and ability to handle
transitions. Most parents also did not perceive changes in
their stress level or parent-child relationships.
Teacher satisfaction and perception ratings were also
not significantly different between the groups: behav-
ioral improvements (Group 1: 28 631 vs Group 2: 59 6
25; p50.10), teacher-student relationships (Group 1: 61
616 vs Group 2: 64 623), and overall satisfaction with
yoga (Group 1: 50 622 vs Group 2: 78 622; p50.15).
After each intervention, teachers rated that they would
recommend the program to others at similar rates
(Group 1: 73 622 vs Group 2: 78 622).
Yoga Frequency
There were 42 possible days to practice yoga during
each intervention period. Overall, the children in both
groups practiced yoga approximately 50% of the possible
days (mean days of practice: Group 1: 25 614 and
Group 2: 20 68), which averaged 3 to 4 days of yoga per
week. None of the parents reported continuing to
practice home yoga after their intervention pe-
riod ended.
DISCUSSION
In our study, yoga led to modest improvements on
selective parent ratings of attention-deficit hyperactivity
disorder (ADHD) symptoms and an objective measure of
attention, but not our physiological measure (heart rate
variability [HRV]). Parent ratings of inattentive symptoms
on the ADHD Rating Scale-IV Preschool Version and
hyperactive-inattentive symptoms on the Strengths and
Difficulties Questionnaire (SDQ) were significantly im-
proved on average after yoga for children with high
baseline scores. These results raise questions regarding
which ADHD symptoms respond best to yoga. Published
theories about the underlying mechanisms of yoga draw
connections between yoga and increases in mind-body
awareness that lead to improvements in attention.
25
Thus, inattentive symptoms may selectively decrease af-
ter practicing yoga, as seen in our study of children with
higher baseline inattention symptoms. However, it is
important to note that teacher ratings of inattentive
symptoms did not significantly improve after practicing
yoga. This may be because teachers are trying to manage
a busy classroom and are less likely to notice inattentive
symptoms, as these symptoms are generally not disrup-
tive. This is likely the same reason that children with
predominantly inattentive symptoms are diagnosed with
ADHD at school age,
26
once inattention begins to affect
academic achievement. These results also suggest that
children with more significant symptoms at baseline and/
or children with inattentive symptoms show more
Vol. 39, No. 3, April 2018 Copyright 2018 Wolters Kluwer Health, Inc. All rights reserved. 207
Copyright Ó201 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.8
dramatic improvements after practicing yoga. These
findings are consistent with the study of yoga in typically
developing preschoolers, which found that children with
fewer self-regulation skills benefited most from yoga.
14
At
follow-up, parents did not report continued yoga prac-
tice; however, children in Group 1 with higher baseline
scores had continued improvements, on average, on
parent ratings of SDQ hyperactive-inattentive scores, in-
dicating that practicing yoga may have some lasting
benefits. This is consistent with the finding from the
Multimodal Treatment of Attention Deficit Hyperactivity
Disorder study regarding behavioral therapies.
27
They
found that when behavioral therapies for ADHD are dis-
continued, ADHD symptoms remain stable because of
the generalization of the practices learned, whereas
when ADHD medications are discontinued, symptoms
generally worsen but do not return to baseline.
27
Using the Kinder Test of Attentional Performance
(KiTAP), an objective measure of attention, we found that
children in Group 1 displayed improved attention with
significantly better reaction times on correct responses for
the go/no-go task and fewer omissions on the distracti-
bility task after the intervention than children in the
waitlist condition. Unexpectedly, at Time 1, Group 1
showed higher impulsivity after yoga, with significantly
more commission errors on the distractibility task. Thus,
although children evidenced improved sustained atten-
tion after the intervention, they also evidenced greater
impulsivity on this computerized measure. We were not
able to account for baseline scores on the KiTAP because
of insufficient data; however, we believe that these find-
ings are still notable and support our hypothesis that yoga
improves attention. The scores on the KiTAP tasks align
with the parent ratings, although they were not limited to
children with more severe ADHD symptoms.
When we controlled for age, Group 2 also evidenced
faster reaction times on correct responses for the go/no-
go task after yoga. Limited data were available to analyze
both groups at follow-up because of preschool gradua-
tion or changes in preschool.
None of the measures of HRV displayed significant
differences between groups at baseline, Time 1, or
within Group 2 at Time 2, which could be related to our
small sample size and short intervention period.
On average, both groups were rated as being “occa-
sionally on task”for school yoga sessions over the 6
weeks. The poses most often missed in both groups re-
quired significant balance and coordination. In future
studies, these poses could be excluded or taught gradu-
ally, allowing time to build the balance and coordination
required.
Based on the parent and teacher satisfaction ques-
tionnaires, both parents and teachers were satisfied with
the intervention. The change in the location of school
yoga introduced variation in instruction between groups,
although the yoga itself did not change. This variation
did not lead to significantly different ratings of satisfac-
tion, but teachers verbalized to us that the school yoga
worked better within the classroom, which may be
helpful for planning future research in the preschool
setting.
The findings of our study are similar to those of the
study by Jensen and Kenny
9
who performed a random-
ized control crossover study of the effects of yoga in
school-aged boys with ADHD and found improvements
on the parent rating scales but not teacher rating scales.
Harrison
11
also found improvements on parent ratings,
but did not include teacher ratings in their study, and
Haffner et al.
10
found improvements on parent ratings
but not on teacher ratings. Mehta et al.
28
found
improvements on both parent and teacher ratings. Cau-
ses proposed for the nonsignificant teacher rating scales
included the use of ADHD medications during the school
day and changes in the teachers who completed the
rating scales during the study
9
; however, most children
in our study were not taking ADHD medications.
Importantly, over the course of our study, there were
some changes in teachers who completed rating scales,
which may have contributed to not finding differences in
teacher ratings.
We had several limitations and challenges in this pilot
study, which included a smaller sample size than desired
based on power calculations, short intervention period,
missing data due to unreturned or incomplete rating
scales, inability of some children to complete the full tests
for some KiTAP tasks, refusal of some children to wear
the emWave
to measure HRV, change in the location of
school yoga between groups, and changes in teachers
rating the participants’behavior. Many mindfulness and
yoga interventions lack randomized assignment, statistical
power, active control groups, and holistic measurement
approaches.
29
The strength of our study is its randomized
design. Moreover, by including parent and teacher
reports of children’s behavior, clinical assessments, and
a physiological index of self-regulation, as well as quali-
tative data documenting the perceived changes and fea-
sibility of the yoga intervention, our study is 1 of the first
in the field to contribute to a holistic measurement
approach.
In conclusion, our study suggests that yoga practice
improves parent ratings of inattention and combined
symptoms for a subset of children with higher ADHD
symptoms at baseline, but not for the group overall, or
for teacher ratings. We also found that yoga improved
reaction times and decreased omission errors on some
tasks of attention, which are less subjective than parent/
teacher rating scales, and is a promising sign of the im-
pact of yoga on improved attention. We did not see
significant changes in HRV after yoga, although our study
was underpowered and of short duration. Importantly,
we learned that yoga was feasible and well liked by
parents and teachers. This study adds to the growing
body of literature, suggesting yoga as an intervention to
address attentional symptoms in ADHD, while also in-
cluding suggestions to guide future yoga studies in
this age group. Larger studies with an active control
208 Effects of Yoga on ADHD Symptoms in Preschoolers Journal of Developmental & Behavioral Pediatrics
Copyright Ó201 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.8
condition are needed to evaluate if subgroups with
higher baseline ratings or symptom subtypes respond
better to yoga. As more evidence supporting the use of
yoga for children with ADHD symptoms is gathered,
yoga may be considered an additional intervention to
improve attention.
ACKNOWLEDGMENTS
The authors thank the families, teachers, and staff from the Tri-
umph Center for Early Childhood Education who participated in this
study, as well as the time and dedication of the yoga instructors,
assistants, and volunteers who helped with this study. They are also
grateful for donations from the Brodovsky Family Foundation,
R. Robert and Suzanne W. Hansen Endowment Fund, and yoga mats
from Manduka
.
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