for Childre n Continuing Nursing Education Laura Santangelo White Series

There is an increasing interest in the use of yoga for children to calm the mind and increase health and well being. Despite scant but increasing evidence supporting the efficacy of yoga in children, special yoga pro- grams within schools are being developed for children and adolescents. This increasing popularity of the potential benefits of yoga may encourage parents to consider yoga for their children and request referrals or clarification of the purported effects. A description of the philosophical basis of yoga, the basic compo- nents of a yoga practice, safety concerns, and how to locate and evaluate a yoga program for children will be addressed.

rom a school principal man- Encouraging anecdotal re p o r t s ness, happiness, and well-being dating yoga for high school describe yoga calming childre n , (Feuerstein, 2003). Wholeness, in this seniors (Rimer, 2007) to a reducing obesity, reducing discipline context, appears to mean the integra- principal of an elementary p roblems, decreasing anger and panic tion of body, mind, and spirit, and con- Fschool providing yoga to calm stu- attacks, and enhancing imagination, nection between the self and a divine dents and handle stress (Eagan, concentration, and academic per- Being that leads to self realization or 2007), yoga is in the news. Schools f o rmance (Flisek, 2001). Health pro b- o n e ’s true identity – the authentic self. a re increasingly using this ancient lems, such as headaches, stom- Yoga helps individuals focus attention. t h e r a p y, including breathing and pos- achaches, constipation, back pain, Humans are viewed as conscious- t u res, to help students manage stre s s and colds or sinus problems, are n e s s - e n e rgy (cit-shakti), and the and influence well being and behavior. re p o rted ly improved with a yoga prac- physical body surrounds this underly- The increased awareness of the tice (Luby, 1998), as well as a ing existence. Yoga as a traditional potential benefits of yoga for childre n d e c rea sed need for medication for practice was thought to lead to self- has resulted in school programs that c h i l d ren with attention deficit disord e r t r a n s f o rmation through transcendence a d d ress stress and anxiety by tre a t i n g (Flisek, 2001). There is scant but of the ego (Feuerstein, 2003). The the body and mind. Emphasis on indi- g rowing empiric support for positive mind and breath are intimately con- vidual abilities rather than competition health effects of yoga (Galantino, nected so that influencing the one will makes yoga appropriate for all chil- G a l b a v y, & Quinn, 2008; Jensen & a ffect the other. Yoga consists of spe- d ren, including those with physical K e n n y, 2004; Kuttner et al., 2006; cific postures coordinated with bre a t h - limitations and lack of involvement in Manjunath & Telles, 2001). ing, meditation, and concentration to o rganized sports. Obesity and a lack Despite the paucity of re s e a rch, the focus and calm the mind (Feuerstein, of exercise are recognized as factors i n c r easing attention to yoga may 2003). in the health and well being of chil- encourage parents to explore yoga for The first mention of yoga was doc- d ren, and are acknowledged as public their children and request re f e rrals or umented in ancient Hindu scripture health concerns (Budd & Hayman, clarification of the purported eff e c t s . 5,000 years ago and influenced by 2006). Yoga provides a non-thre a t e n- Some children may practice yoga Buddhist philosophy. The traditional ing and gentle method to incre a s e within physical education classes, and purpose of yoga was to help transform physical fitness and enhance health p a ren ts may express concern re g a rd- or transcend the self. The early Hindu and well being. ing the perceived religious affiliation of s c r i p t u res are re p o r ted to have been yoga. What exactly is yoga and should written in 2000 BCE. These early writ- c h i l d ren practice it? A description of ings of the Vedic peoples who inhabit- the philosophical basis of yoga, the ed present-day India were re s p o n s i b l e Laura Santangelo White, MS, RN, is a basic components of a yoga practice, for the oldest extant literature, the Doctoral Student, Connell School of safety concerns, and how to locate Vedas (Feuerstein, 2003). The early Nursing, Boston College, Chestnut Hill, MA. and evaluate a yoga program for chil- Hindu scriptures included “philosophi- Statement of Disclosure: The author d ren will address these questions. cal texts to epic stories” (Bre u i l l y, re p o r ted no actual or potential conflict of O’Brien, & Palmer, 1997). i n t e rest in relation to this continuing nursing The early Vedic writings included education art i c l e . Philosophical Foundations four collections of scripture. The old- Of Yoga est and most popular is the Rig Ve d a , The root of the word yoga is “to which is a collection of hymns Objectives and the yoke” or “to harness” (Feuerstein, ( B r euilly et al., 1997). These early CNE posttest can be 2003, p. 4). The goal of yoga was texts concentrated on the pantheon of found on pages 296-297. originally to provide a guide for whole- gods and divine belief and ritual. The

PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 277 Upanishads presented a more ab- t h rou gh postures (ãsanas), mindful c u r rent health interests, such as fit- stract philosophy, which reflected a b reathing (prãnãyãma), and medita- ness, stress management, and the decline in the emphasis on rituals and tion (Dhyana), eventually experienc- recognition of psychosomatization, as p resented more of a personal, intern a l ing the union of the self with the well as the re p o r ted decline of institu- religious practice. The concept of re i n- objects of meditation (Samadhi) tionalized religion (DeMichelis, 2004). c a r nation was presented as an impor- (Gates, 2002). Moral teachings within Within a secularized West, yoga began tant part of life described as a perpet- yoga include the guidance of the to be associated with emerging alter- ual cycle of birth, suffering, death, and yamas, niyamas, the four aims of life, native medicine and personal inner re b i r th. Individuals sought a way to and the five moral afflictions. private religious practice. By the escape this cycle. The further evolu- The Yamas include the practice of 1970s, yoga was related to healing tion of Hindu scriptures moved fro m five moral restraints: non-violence and personal growth (DeMichelis, the abstract to the concept of devotion (ahimsa), truthfulness (satya), non- 2004). The practice of yoga in the to a personal God (Breuilly et al., stealing (asteya), moderation (brah- West is described as reductionistic and 1997). m a c a r ya), and non-hoarding (apari- may only concentrate on the ãsanas The most famous Hindu writing is graha). The Niyamas include five to the neglect of prãnãyãma, mental the Bhagavad-Gita, a part of the o b s e r vances: purity (sauca), content- discipline, or spiritual development w o r l d ’s oldest poem, M a h a b h a r a t a. ment (santosa), austerity or zeal (Feuerstein, 2003). The Bhagavad-Gita describes a moral (tapas), self-study (svadhyaya), and The individual yoga practice conflict resulting in the realization that the devotion to a higher power depends on the needs and abilities of the love between God and humanity is (isvara-pranidhana). the yoga student and the qualifica- of utmost importance in life (Bre u i l l y The four aims of life include the tions of the yoga teacher. When prac- et al., 1997). o b s e r vation of a spiritual discipline ticing yoga at fitness gyms, the The yoga was originally associated ( d h a r ma), the creation of a balanced emphasis is likely to concentrate on with the early rituals of Hindu spiritual- life (artha), the enjoyment of the pro- its physical benefits. Yoga studios with ity (Feuerstein, 2003). The posture s duction from one’s work (kama), and teachers who may see yoga as a way (ãsanas) are meant to increase flexi- the freedom from the cycle of suff e r- of life rather than an exercise may bility and strength, and improve bodi- ing (moksa). The five moral aff l i c t i o n s include the higher practices of yoga ly functions, such as the endocrine within yoga are spiritual ignorance beyond postures and breathing and system, gastrointestinal and immune (avidya), pride (asmita), desire m e d i t a t i o n . functioning, sleep, eye-hand coord i- (raga), aversion (dvesa), and fear of nation, and balance. The practice of death (abhinivesa) (Gates, 2002). In the ãsanas may also lead to psycho- general, classical yoga follows the Styles of Yoga logical findings of increasing somatic Yoga Su˜tras of Patanjali (Feuerstein. T h e re are 40 re p o r ted styles of a w a ren ess, attention, memory, learn- 2003). However, the major compo- Hindu yoga, which reflect diff e re n t ing, and mood (Feuerstein, 2003). nent of We s t e rn yoga practice is the a p p roaches and techniques of train- Prãnãyãma is the coordination of relationship between the ãsanas (pos- ing. For example, one style may focus b reathing and postures (ãsanas) to t u r es) and prãnãyãma (mindful on meditation (Dhyãma-yoga) and c o n t rol the concentration of the mind. b reathing). another focus on repetitive sounds The breath plays a very important ro l e (Mantra-yoga) (Feuerstein, 2003). in yoga and is considered energ y Modern Western Yoga is a major branch of yoga p resent in all animate beings. The M o d e r n yoga refers to certain types developed in 1000 CE that focuses on early yoga practitioners, yogi (male) of yoga that evolved primarily fro m physical aspects and breath contro l or yogini (female), noticed that if the interaction of We s t e r n individuals and cleansing. Hatha yoga was the someone was upset, the breath was i n t e r ested in yoga over the last 250 style that entered the West by practi- rapid and shallow. At times of re l a x- years (DeMichelis, 2004). Prior to tioners in the 1920s. After underg o i n g ation and calm, the breath was slow 1849, yoga was not considered an many adaptations for the needs of and even. Because the breath and the option of practice, but rather, an intere s t- We s t e r n students, Hatha yoga is the mind are intricately related, it was i n g E a s t e rn phenomenon (DeMichelis, most widely practiced style of yoga in believed that deliberately contro l l i n g 2004). In 1893, Swami Vi v e k a n a n d a the West (Feuerstein, 2003). Practi- and slowing the breath would slow and attended the Chicago Parliament of tioners tend to be primarily intere s t e d calm the mind (Feuerstein, 2003). Religions and presented and in health and fitness and less intere s t- E v e n t u a l l y, yoga was codified by yoga to the West. The Swami is cre d - ed in self-transform a t i o n . Patanjali into Yoga Su˜tras in appro x i- ited for “reshaping” the yoga tradition The goals of Hatha yoga are health, mately 200 CE. (DeMichelis, 2004, p. 3). In 1966, v i t a l i t y, and longevity of life. The life B.K.S. Iyengar presented yoga within f o r ce (prana) travels through channels Classical Yoga the framework of We s t e r n anatomy in the body called nadi and can be The philosophical system of classi- and physiology and self-help. The c o n t rolled by the breath to lead to self cal yoga was written as the Yo g a ãsanas were related to We s t e r n ill- c o n t rol of the mind (Feuerstein, S˜utras by Patanjali. Yoga is pre s e n t e d nesses and conditions, and addre s s e d 2003). There are many types of yoga as an eight-limb path of guidance to specific body parts. within the hatha style (see Table 1). actions, thoughts, and morality The dissemination of yoga to the The most common types are a) (Feuerstein, 2003). The Yoga S˜u t r a s West modified facets of the practice to I y e n g a r, b) Ashtanga, c) Bikram, d) defined important yoga concepts c o n f o r m to the needs and sensibilities Integral, e) Kripalu, f) Viniyoga, g) t h rou gh the compilation of 195 apho- of We s t e r n students (Feuerstein, Sivananda, h) Ananda, i) Kundalini, j) risms or maxims (S˜utras) (Feuerstein, 2003). The modern practice of yoga is Hidden Language, and k) Somatic 2003). The practice of yoga pro v i d e d v e r y diff e ren t from the classical Hindu yoga. The underlying concept of guidance on moral restraints (yamas) practice that was grounded in spiritual calming the mind through posture s and moral observances (niyamas) development. re f l e c t s and breath are similar, but the envi-

278 PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 Yoga for Children

Ta ble 1. Meyers, Sternlieb, & Zeltzer, 2004), Styles of Hatha Yo g a i m p roves hypertension (Gupta et al., 2002; Sivasankaran et al., 2006), and Hatha Yoga Style C h a r a c t e r i s t i c s reduces coro n a r y art e r y disease (Gupta et al., 2002), stress (Brown & I ye n g a r Uses props, such as bl o ck s, stra p s, bags, and cushions, to G e r b a rg, 2005; Granath, Ingvarsson, connect the body and mind chiefly through careful ãsanas. von Thiele, & Lundberg, 2006; Ashtanga (powe r ) The focus is on strength and flexibility tra i n i n g . M ay be fo u n d Michalsen et al., 2005), depre s s i o n in gyms and health clubs. (Butler et al., 2008; Michalsen et al, 2005; Wo o l e r y et al., 2004), and pain B i k ra m Includes vigorous postures in a standard sequence in a (daSilva, Lorenzi-Filho, & Lage, room heated to 100 to 110 degrees F. The practitioner mu s t 2007). be physically fit. A review of 24 articles of yoga for I n t e gra l Po s t u r e s, breathing techniques, relaxation, and meditation c h i l d r en revealed a large variety of with an emphasis on the function of the practice rather than outcomes and measures, lack of explicit fo rms and techniques. adverse re p o r ting, small sample sizes, and low power (Galantino et al., K ri p a l u Includes three stages created for We s t e rn students.The first 2008). The paucity of high quality stage includes body and breath awa r e n e s s. The second studies of yoga in children limits the stage focuses on holding the postures for a longer time.T h e usefulness and generalizability of the third stage is referred to a meditation in motion because it findings. However, evidence suggests i nvo l ves a deeply relaxed mind leading to spontaneous that yoga is associated with impro v e d u n s t ructured move m e n t s. c a rdiovascular status, physical func- tioning, and behavior (Galantino et al., V i n i yo g a Sequence of postures focused on the individual’s phy s i c a l 2 0 0 8 ) . and mental capacity with an emphasis on the coordination Yoga may improve attention and of breath and postures. emotional control. Jensen and Kenny S i va n a n d a S e ries of 12 postures that include mantra chanting, relax- (2004) studied 19 boys with attention ation, and breathing exe r c i s e s. deficit hyperactivity disorder (ADHD). Despite low power, varied attendance, Ananda Gentle move m e n t s, meditation, affirm a t i o n s, and special- and lack of determination of quality i zed energetic breathing exercises called kri ya to conscious- and duration of home practice, there ly direct the life force (prana) to all parts of the body. was a re p o rted reduction of mood swings, temper outbursts, and cry i n g Ku n d a l i n i Po s t u r e s, breath control, chanting, and meditation are used fits on the Conners Global Emotional to awa ken the innate energy, considered coiled like a ser- Liability Index for the 11 boys in the pent within the lower abdomen. i n t e r vention group compared to the 8 boys in the control group. This is con- Hidden language E m p h a s i zes physical well being and self-understanding sistent with a paper by Nardo and though the study of the symbolism in the postures. Reynolds (2002) (as cited in Peck, S o m a t i c - i n t e gra t e d S l ow postures with visualization and conscious breathing Kehle, Bray, & Theodore, 2005) p re- with relaxation between postures joined with principles of sented at the annual meeting of the p s y c h o p hysiology to connect body and mind. National Association of School Psychologists described by Peck et al. (2005), who re p o r ted that yoga pro- S o u rc e : Adapted from Feuerstein, 2003. motes self-control, attention, concen- tration, self-eff i c a c y, body aware n e s s , and stress reduction. ronment, emphasis on breathing or condition. is practiced in Yoga may play a role in the man- p o s t u res, and methods differ by style an excessively hot room. Ashtanga agement of chronic illness. In a study (Feuerstein, 2003). yoga focuses on strength training and o f 25 participants ranging in age fro m rapid movements. 11 to 18 years (20 girls and 5 boys) The effects of yoga in childre n with irritable bowel syndrome practic- Yoga for Children remain unsupported due to small ing yoga daily for four weeks, subjects The yoga teacher brings his or her sample sizes, inconsistent interv e n t i o n re p o r ted less functional disability, philosophy and style to the class, and description, varying outcome meas- d e c reased emotion-focused avoid- should adapt the style to child devel- u res, and low power. Research with ance, and decreased anxiety com- opmental and physical needs. The adults is also limited by the lack of p a red with a wait list control gro u p focus in childhood is less on the per- c o n t r ol groups and explication of the (Kuttner et al., 2006). The mechanism fection of postures than the cultivation specific yoga intervention or duration. of action of yoga remains unclear. of compassion, non-judgment, con- H o w e v e r, findings in adults suggest Yoga may affect the functioning of nection between breath and posture s , that yoga improves symptoms of anx- the pre - f rontal cortex, including the and forging the foundations of a life- iety (Brown & Gerbarg, 2005; Gupta, ability to plan and execute complex long practice. However, certain styles Khera, Vempati, Sharma, & Bijlani, functions. After one month of 75 min- of yoga may not be appropriate for 2002), enhances relaxation (Smith, utes of daily yoga, breathing, intern a l c h i l d r en. For example, Bikram and Hancock, Blake-Mort i m e r, & Eckert , cleansing practices, meditation, devo- Ashtanga styles of yoga re q u i re the 2007; Waelde, Thompson, & tional songs, and relaxation, 10 to 13- practitioner to be in excellent physical G a l l a g h e r-Thompson, 2004; Wo o l e r y, y e a r-old girls decreased the time

PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 279 re q u i red to execute a mental test include quieting the mind, posture s may be used with younger childre n (Manjunath & Telles, 2001). The and breathing, relaxation, and a re a d- ( M e t z g e r, 2002, 2003). A warm - u p authors suggested that yoga in- justment time to bring the mind and period of gentle movements, including c reased blood flow to the frontal lobe, body back to normal activity. For chil- s t r etching, will pre p a re the body for which resulted in the rapid re a l i z a t i o n d ren, these phases may be described the postures. This period may also and correction of erro r s . as a warm-up, breathing, posture s , include songs or chants for all ages Yoga may also influence neuro- and relaxation (Schwartz, 2003). ( M e t z g e r, 2002, 2003). transmitter function. For example, a The class may begin by laying The postures (ãsanas) may be significant 27% increase in brain y- down, sitting cross-legged on the floor, classified as a) standing, b) seated, c) aminobutyric acid (GABA) levels that or sitting in a chair. Special objects balance, d) twists, e) supine, f) for- may affect mood was found in 8 expe- may be used to symbolize a special w a rd bends, g) backbends, and h) rienced adult yoga practitioners com- time for relaxation. This may be a inversions (Metzger, 2002, 2003). The p a red with 11 non-practicing contro l s . , pillow used exclusively for inversions include postures in which D e c rea sed GABA is associated with yoga and relaxation, special clothing, the legs are above the level of the d e p ression and anxiety (Streeter et al., blanket (DeMichealis, 2004), or h e a r t. For example, a shoulder stand 2 0 0 7 ) . s t u f fed animal (Metzger, 2002, 2003). involves balancing on the upper The postures and breathing may C h i l d ren are encouraged to shut their shoulders while the legs and back are i m p rove the strength and flexibility of eyes only if they feel comfort a b l e raised in the air. muscles while increasing circ u l a t i o n , doing so. Yoga is not competitive and The postures may be held to the uptake of oxygen, and functioning of should not hurt. Children, especially if count of 10, but the individual’s body h o r mones. The parasympathetic ner- used to competition and sports, need response needs to be the guide, and vous system may become more dom- to be reminded not to compare them- c h i l d r en need to be reminded that they inant and stabilize the autonomic selves to classmates. Explaining this should not force a position or be in n e r vous system to enhance re s i s t a n c e to children in the beginning is impor- pain. If a child is believed to be anx- to the effects of stress (Parshad, tant to encourage children to focus on ious due to stre s s - related symptoms, 2 0 0 4 ) . themselves without concern for being the pose may be held for one to two Some yoga programs for childre n laughed at or not keeping up with the minutes, if possible (Luby, 1998). have been met with resistance to a class. C h i l d ren less than 6 years of age can system viewed as Hinduism and a The mental quieting phase focuses be encouraged to hold postures for 20 method of spreading Eastern mysti- on leaving worries behind. For chil- seconds to one minute. Children older cism. To compensate for these con- d ren, this may be thinking of one thing than 6 years of age may hold posture s c e r ns, yoga teachers within schools that worries them and mentally imag- for one and a half minutes (Khalsa, change the terminology fro m ining the worry flying away or thro w- 1 9 9 8 ) . prãnãyãma to “bunny breathing” or ing it away. For younger children at a C h i l d ren may be instructed in the meditation to “time in.” Pro g r a m s m o re concrete operational level, the p o s t u res in relation to imitating plants, re p o r ted in the media, such as the w o r ry may be written, then torn up or objects, or animals (see Figures 1 and “Power Moves Kids Program for Public hung on a tree. The concept is to bring 2). Some programs for children pro- Schools,” include character- b u i l d i n g what is the most concerning issue for vide pictures of the object for the child components, such as quotes by the child into consciousness and dis- to imitate. Some animals used as a M a r tin Luther King, Jr. (CNN.com, c a rd it from his or her mind. guide are a pigeon, lion, mouse, 2007). How well children feel they do yoga mountain, or tree. For example, the one day may change the next session mountain pose emphasizes feeling and is not as important as doing the s t r ong and steady. The tree encour- Components of a Yoga best they can and to concentrate on ages balance. Younger children may Practice for Children b reathing. One technique is to focus need to look at the pictures and try to Common components necessary on the breath and picture a colorf u l make their bodies look like the pose in when teaching yoga to children or balloon in their bodies with the open- the pictures while following the young adolescents include the envi- ing near the chest and the bottom at t e a c h e r ’s instructions (Luby, 1998). ronment and atmosphere, parts of a the stomach. As they breathe in During the postures, children need yoga session, and re c o m m e n d e d d e e p l y, they are instructed to feel the to be reminded to inhale and exhale length of the class. The enviro n m e n t air fill the balloon. When they bre a t h e the breath in relation to movement. may be a special location or “space” out slowly, they are to imagine the air Each posture should be followed by to help with relaxation and the con- moving back up the balloon to the one to two deep breaths. After pos- cept of removing oneself from the opening of the balloon at the chest t u res that are more strenuous or diff i- usual daily hassles. Shoes are usually ( L u b y, 1998). cult, a short relaxation period of removed before entering the ro o m Another example is to sit cro s s - a p p roximately 15 seconds on the floor ( M e t z g e r, 2002, 2003). If the class is legged on the floor with hands togeth- is recommended (Khalsa, 1998). in a usual classroom or gym, a night er at the center of the chest. After the During the movements, the child light may be used or the lights may be eyes are closed, the children are needs to breathe slowly and deeply t u r ned down with soft music playing. i n s t r ucted to feel as if they can see t h rough the nose. The breath should Candles or incense should be avoided f r om the center of their fore h e a d not be forced or held. The posture s to reduce the risk of fire or allergic re s - between their eyes. At the same time, may be in any ord e r, but there needs p i r a t o r y symptoms in susceptible chil- they are guided to feel a warm glow in to be a concentration on balance. For d ren. The class should be conducted their heart. Then they are guided to example, if the child bends forw a rd , with a feeling of compassion and non- b reathe in and out slowly and deeply the next posture should involve bend- judgment, and without competition t h rou gh the nose three times (Khalsa, ing backward. The postures should ( M e t z g e r, 2003). 1998). Special age-appropriate activ- not hurt, and children need to be The parts of each yoga class ities, such as songs, chants, or crafts reminded to feel their body during a

280 PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 Yoga for Children

Figure 1. Figure 2. 9 - Ye a r-Old Alyssa White in Bow Pose 9 - Ye a r-Old Alyssa White in Mouse or Child’s Po s e ( D h a nu r a s a n a ) ( G a r b h a s a n a )

p o s t u re and only go as far as the body Safety Guidelines for Yoga Disease Control and Prevention [CDC], feels comfortable. Practice and slow Practice 2 0 0 9 ) . concentrated eff o rt can lead to in- P r i m a r y safety issues surro u n d i n g Yoga mats are worth purc h a s i n g . c reasing flexibility (Schwartz, 2003). the practice of yoga involve the safety Mats range in price from $11 to over The relaxation or meditation period of the environment including practicing $100 depending on size, thickness, occurs after the completion of the on level ground, using a clean mat, material, and decorative features. A p o s t u res. This may include laying on moving slowly and carefully without 1/8-inch thick standard mat is ade- the floor supine with the eyes shut and pushing beyond capabilities, and con- quate ($11 to $16). A small pillow concentrating on breathing, a sound, traindications to postures or practice. may increase comfort when sitting on or the repetition of a phrase. A sound The yoga practice is best done on an the floor. Some teachers re c o m m e n d or phrase may be repeated to help empty stomach because some pos- a strap or foam block or thick blanket c h i l d r en increase their concentration t u res raise the stomach above the to help with postures if the person is on breathing. Children may be head, which may cause re g u rgitation of not flexible enough to reach toes or lift encouraged to visualize a picture and stomach contents. Before a yoga prac- legs, but this is not necessary hold it in their mind (Schwartz, 2003). tice, children should wait 2 to 4 hours ( M e t z g e r, 2002, 2003). To pre v e n t T h e re may also be a guided visualiza- after a large meal or 1 to 2 hours after i n j u ry, movements must be slow, with tion, such as imaging lying on a cloud a light meal (Schwartz, 2003). Yo g a concentration as postures are and floating through the sky. After the should be practiced on level gro u n d changed (Luby, 1998). A water bottle relaxation period, there is a slow with as little distractions as possible to may be kept near children to sip reawakening to normal activity by encourage focus and concentration. t h roughout the class. The ro o m s t retching or wiggling fingers and toes. To practice yoga, a mat is best to should be heated to a comfort a b l e If they are lying down, they will be p revent slipping. If yoga is being done t e m p e r a t u re and the postures should i n s t r ucted to roll over to one side on a carpet, this is less import a n t , not be strenuous enough to cause pro- b e f o re slowly arising (Metzger, 2002, although dust mites in carpets may be fuse sweating. 2003). This may last under three min- a concern for children with asthma. Yoga should not be perf o r m e d utes for children between 3 and 6 Scented candles should be avoided when a child is sick, such as with a years of age, and longer in older chil- due to the potential exacerbation of cold, flu, headache, or vomiting. d ren (Luby, 1998). As children get asthma and fire. I n v e r ted postures (with the legs o l d e r, this period will increase, but this The yoga mats need to be cleaned extended above the heart or head) depends on the individual child. re g u l a r l y. To clean mats, follow the that put pre s s u re on the head, neck, or The frequency of practice is ideally m a n u f a c t u re r ’s directions. Some mats shoulders should be avoided. Specific four to six times a week to best enjoy can be machine-washed. In general, p o s t u res that increase pre s s u re or the cumulative benefits of yoga, but at mats can be washed with 2 cups of twisting motions should be avoided in least once a week is re c o m m e n d e d . water mixed with 4 drops of dish soap c e r tain circumstances. For example, The length of a yoga class depends on and wiped with a damp sponge, then c h i l d ren suffering from migraine the attention span and developmental rinsed, dried with a towel, and hung to headaches or from any condition that age of the students. A class for adults d r y (Raskin, 2009). Mats at yoga stu- is affected by extra pre s s u re to the may last from one to two hours. For dios and gyms with multiple users head or neck, such as hypertension or c h i l d r en less than 6 years of age, the should be washed with a disinfectant c a rdiac problems or menstrual period, class may be 15 minutes. A class for and discarded after 1 year. The label of should avoid shoulder stands. c h i l d r en between 7 and 9 years of age the disinfectant should be re g i s t e r e d C h i l d ren with back pain or pro b l e m s may be 25 minutes in length (Khalsa, with the U.S. Environmental Pro t e c t i o n should also avoid shoulder stands as 1998). Agency (EPA), and the label should well as the boat position (lying on the read that it is effective against stomach with arms behind the back Staphylococcus Aureus (Centers for holding up bent legs at the ankles)

PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 281 Ta ble 2. R e s o u rces to Find Yoga Pro g r a m s Web Site D e s c r i p t i o n w w w. yo g a a l l i a n c e. o r g P r ovides info rmation regarding certified programs and teachers. w w w. c o l o rm eyo g a . c o m P r ovides trainings and classes specializing in yoga for children. w w w. yo g a j o u rn a l . c o m P r ovides basic info rmation about yoga issues. w w w. yo g a f i n d e r. c o m Assists in locating yoga programs intern a t i o n a l l y. w w w. s p e c i a l yo g a . c o m P r ovides info rmation and trainings for children with special needs. w w w. yo g a s e e ke r. c o m Lists teachers and yoga schools. w w w. yo g a . c o m Finds classes and studios. w w w. c h i l d r e n s yo g a . c o m P r ovides trainings and classes specializing in yoga for children. w w w. yo g a k i d s. c o m P r ovides trainings and classes specializing in yoga for children. that strains the back. Problems such Ta ble 3. as asthma or bronchitis may be exac- Questions to Consider When Assessing a Yoga Pro g r a m erbated by special yoga bre a t h i n g techniques; there f o re, concentration Te a cher Characteristics may need to focus only on a simple What is the teacher’s ex p e rie nce with this age gr o u p ? a w a ren ess of the breath going in and out at a normal depth and fre q u e n c y. For how many years has the teacher practiced yo g a ? C h i l d ren with any hernia should avoid Where did the teacher train and what certification does he or she have ? f o r w a rd bending postures (Schwart z , 2 0 0 3 ) . What special needs training and ex p e rience has he or she had? C h i l d ren limited to wheelchairs are What should the child expect to learn ? able to participate in yoga by focusing on the breath and movements of the What are the benefits of the class? upper body and head. An experienced Po l i cy yoga teacher should be able to adapt the postures for children with special What is the policy for behavior and discipline? needs. If a child cannot do a standing What are the policies regarding fe e s, cancellations, and make-up s t retch, he or she may be able to classes? Is there liability insura n c e ? adapt it to lying down or sitting ( S c h w a r tz, 2003). Are guardians expected to stay ? For toddlers, are diapers allowe d ? Locating a Yoga Program Logistics and Routine For Children H ow many children are in the class? What is the age range of the students? To locate an appropriate yoga class H ow many teachers are in one class? Are there any assistants? for children, parents may ask physical education teachers, dance teachers, H ow long is the class? and sports coaches; talk to people What is the routine of the class? a l r eady practicing yoga; refer to books or yoga magazines (Schwart z , What does the child need for the class? 2003); and ask at mothers’ groups or Is a snack prov i d e d ? the local YMCA (Metzger, 2002, 2003). Yoga studios can be found in Is a bathroom on site and what supervision is ava i l a ble for bathroom use? local phone books and Intern e t re s o u rces, such as those listed in S o u rc e : M . M e t z g e r, personal communication, Ja nu a r y 23, 2009. Table 2. C e r tification may be inconsistent, and a minimum of a weekend or expectations from yoga. The pare n t activities, such as singing, chanting, week-long training in yoga for childre n needs to notify the teacher about any crafts, or make believe play, may be is suggested. Some reputable training health problems and concerns, and noted in classes for younger childre n . in yoga for children is also listed in assess the experience of the teacher The atmosphere should feel peaceful, Table 2. The teacher should practice with these issues. Additional questions s u p p o r tive, calm, warm, spacious, yoga regularly and have basic knowl- to consider are listed in Table 3. level, and uncluttered. Music is usual- edge of yoga, safety, benefits of yoga, P a r ents may observe the class ly playing. There should not be any and contraindications of postures (M. prior to registration to determine what candles burning. The teacher should M e t z g e r, personal communication, types of activities are perf o r med, the demonstrate the posture first and not J a n u a r y 22, 2009). t e a c h e r ’s manner, and the enviro n- focus on perfection (Metzger, 2002, Specific questions to ask the ment. The children should appear to 2003). teacher depend on the age and special be having fun and receive kind atten- The age range of the children in the needs of the child, and pare n t a l tion from the teacher. Age-appro p r i a t e class and the number of children per

282 PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 Yoga for Children class may vary by the availability of CAM practices incorporating mind Fow l e r, S., & Newton, L. ( 2 0 0 6 ) . C o m p l e- classes. In areas where there are and body are consistent with nursing m e n t a ry and altern a t i ve thera p i e s : T h e many classes, single-age classes may t h e o r y and practice, which focus on nu r s e ’s role. J o u rnal of Neuroscience be off e red . Other locations with less wholeness and healing (Fowler & Nursing, 38(4), 261-264. G a l a n t i n o, M., Galbav y, R., & Quinn, L. i n t e rest or yoga classes may only off e r Newton, 2006). Yoga may be a pro m- ( 2 0 0 8 ) . T h e rapeutic effects of yoga fo r classes with mixed ages. According to ising nursing intervention to enhance c h i l d r e n : A systematic rev i ew of the liter- a pediatric yoga expert (M. Metzger), well being for children of many ages a t u r e. Pe d i a t ric Physical T h e ra py, 20( 1 ) , it is recommended that toddlers, as and capabilities. 6 6 - 8 0 . well as children younger than 5 years R e s e a rch is greatly needed to eval- G a t e s, R. ( 2 0 0 2 ) . Meditations from the mat. of age, have their own class. Childre n uate the purported health claims of N ew Yo r k : Anchor Books. between 5 and 11 years of age may be yoga in children and provide evidence G ranath, J., Ingvarsson, S., von T h i e l e, U., & taught together, but 10 to 11-year- o l d for the best styles and practices for Lundberg, U. ( 2 0 0 6 ) . Stress manage- c h i l d r en may not want to share a class c h i l d ren at specific ages and health m e n t : A ra n d o m i zed study of cognitive b e h av i o u ral thera py and yo g a . C o g n i t i ve with younger children. By 11 years of needs. For children, yoga should be a B e h av i o ral T h e ra py, 35(1), 3-10. age, children may also desire single fun way to learn how to relax their Gupta, N., Khera, S., Vempati, R., Sharm a , gender classes. The ideal number of minds and exercise their bodies. The R., & Bijlani, R. ( 2 0 0 2 ) . E f fects of yo g a c h i l d r en per class is 6 to 10. Over 10 practice of yoga may serve as a foun- based lifestyle intervention on state and c h i l d r en may necessitate a second dation for the nurturing of inner t rait anxiety. Indian Journal of Phy s i o l o g y teacher (M. Metzger, personal com- re s o u rce s and strengths to facilitate and Pharm a c o l o g y, 50(1), 41-47. munication, January 22, 2009). lifelong health and well being. Jensen, P., & Ke n ny, D. ( 2 0 0 4 ) . The effects of Once having attended classes and yoga on the attention and behavior of l e a r ned basic postures, children may b oys with attention-deficit/hy p e ra c t i v i t y R e fe r e n c e s disorder (ADHD). J o u rnal of Attention practice yoga at home with the same D i s o r d e r s, 7(4), 205-216. safety re q u i rem ents. An area in the B r e u i l l y, E., O’Brien, J., & Pa l m e r, M. ( 1 9 9 7 ) . Religions of the wo rl d . N ew Yo r k : Khalsa, S. K . ( 1 9 9 8 ) . Fly like a bu t t e r f l y. home may be designated as a special Po r tland, OR: R u d ra Press. place for calmness and yoga practice. I C O R E C. B r own, R., & Gerbarg, P. ( 2 0 0 5 ) . S u d a r s h a n Ku t t n e r, L., Chambers, C., Hardial, J., Isra e l , Despite practice at home, form a l K ri ya yogic breathing in the treatment of D., Jacobson, K., & Eva n s, K. ( 2 0 0 6 ) . A classes are recommended to periodi- s t r e s s, anxiety, and depression: Pa r t II – ra n d o m i zed trial of yoga for adolescents cally check proper postures and Clinical applications and guidelines. with irri t a ble bowel syndrome. Pa i n b reathing (Schwartz, 2003). J o u rnal of Altern a t i ve and Complementary Research & Management, 11(4), 217- M e d i c i n e, 11(4), 711-717. 2 2 3 . Budd, G., & Hayman, L. ( 2 0 0 6 ) . C h i l d h o o d L u by, T. ( 1 9 9 8 ) . C h i l d r e n ’s book of yo g a Nursing Implications o b e s i t y : D e t e r m i n a n t s, prevention, and games and exercises mimic plants and t r e a t m e n t . J o u r nal of Cardiova s c u l a r animals and objects. Santa Fe, NM: C h i l d ren use complementary and Nursing, 21(6), 437-441. Clear Light Publ i s h e r s. a l t e rna tive medicine (CAM), including B u t l e r, L., Wa e l d e, L. H a s t i n g s., T., Chen, X., Manjunath, N., & Te l l e s, S. ( 2 0 0 1 ) . I m p r ove d yoga. There f o re, nurses need to S y m o n s., B. Marshall, J., et al. ( 2 0 0 8 ) . p e r fo rma nce in the Tower of London e n s u r e child safety and assess Meditation with yoga, group thera py test fo l l owing yo g a . Indian Journal of p a ren tal knowledge re g a rding expec- with hy p n o s i s, and psychoeducation fo r P hysiology and Pharm a c o l o g y, 45( 3 ) , l o n g - t e r m depressed mood: A ra n d o m- 3 5 1 - 3 5 4 . tations and interactions. A recent sur- M e t z g e r, M. (2002, 2003). Color me yo g a vey of 281 families in general pedi- i z ed pilot tri a l . J o u rnal of Clinical P s y c h o l o g y, 64(7), 806-820. t raining manu a l . Wenham, MA: M a r s h a atrics and specialty care re p o r ted a T. M e t z g e r. high percentage of children using Centers for Disease Control and Preve n t i o n ( C D C ) . ( 2 0 0 9 ) . C A - M R S A : E nv i r o n m e n t a l Michalsen, A., Grossman, P., Acil, A., CAM therapies. The survey re p o r t e d management of Staph and MRSA in Langhorst, J., Lüdtke, R., Esch, T., et al. that 61.9% of children with epilepsy, c o m munity settings. R e t ri eved Ja nu a r y ( 2 0 0 5 ) . Rapid stress reduction and anx- 59% of children with cancer, 50.7% of 16, 2009, from http://www. c d c . g ov / n c i- iolysis among distressed women as a c h i l d r en with asthma, 47.4% of chil- d o d / d h q p / a r _ m r s a _ E nv i r o _ M a n a g e. h t consequence of a three-month inten- d ren with sickle sell disease, and 36% m l s i ve yoga progra m . Medical Science C N N . c o m . ( 2 0 0 7 ) . ‘Yoga lite’ stretches into pub - M o n i t o r, 11(12), CR555-CF561. of general pediatric patients used a Parshad, O. ( 2 0 0 4 ) . Role of yoga in stress CAM therapy (Post-White, Fitzgerald, lic schools. Message posted to http:// w w w . c n n . c o m / 2 0 0 7 / E D U C AT I O N / m a n a g e m e n t . West Indian Medical Hageness, & Sencer, 2009). Despite J o u rnal, 53(3), 191-194. this re p o r ted use, many patients do 0 1 / 2 9 / yo g a . i n . s c h o o l s. a p / i n d ex . h t m l d a S i l va, G., Lorenzi-Filho, G., & Lage, L. Pe ck, H., Ke h l e, T., Bray, M., & T h e o d o r e, L. not re p o r t their use of CAM to health ( 2 0 0 7 ) . E f fects of yoga and the addition ( 2 0 0 5 ) . Yoga as an intervention for chil- c a re providers (Shakeel, Little, Bru c e , of Tui Na in patients with fibromya l g i a . dren with attention probl e m s. S c h o o l & Ah-See, 2007). J o u rnal of Altern a t i ve and Complementary Psychology Rev i ew, 34(3), 415-424. Tindle, Davis, Phillips, and M e d i c i n e, 13(10), 1107-1013. Po s t - W h i t e, J., Fitzgerald, M., Hageness, S. , E i s e n b e rg (2005) re p o r ted that yoga D e M i c h e l i s, E. ( 2 0 0 4 ) . A history of modern & Sencer, S. ( 2 0 0 9 ) . C o m p l e m e n t a r y yo g a. N ew Yo r k : C o n t i nu u m . and altern a t i ve medicine use in children is one CAM therapy that has incre a s e d with cancer and general and specialty in use between 1997 and 2002. When Eagan, M. (2007, Ja nu a r y 30). D ow n wa r d dog is cat’s meow for at-risk kids. p e d i a t ri c s. J o u rnal of Pe d i a t ric Oncology asked which CAM therapies they Nursing, 26(1), 7-15. would be most willing to use, adoles- Boston Hera l d , p. 4 . Feuerstein, G. ( 2 0 0 3 ) . The deeper dimension Raskin, D. ( 2 0 0 9 ) . H ow to wash your yo g a cents with chronic pain re p o r ted a of yo g a. B o s t o n : S h a m b h a l a . m a t. R e t ri eved Ja nu a r y 15, 2009, from willingness to try yoga (Ts a o , Flisek, L. ( 2 0 0 1 ) . Teaching yoga to yo u n g h t t p : / / w w w. yo g a j o u rn a l . c o m / b a s i c s / 6 3 1 M e l d r um, Kim, Jacob, & Zeltzer, s c h o o l c h i l d r e n . Po s i t i ve Health, 70, 5 0 - R i m e r, S. (2007, October 29). A principal who 2007). 5 4 . c ra cks down on stress. N ew Yo rk T i m e s. Nurses need to be knowledgeable R e t ri eved from http://www. ny t i m e s. c o m / 2 0 0 7 / 1 0 / 2 9 / e d u c a t i o n / 2 9 s t r e s s. h t m l about evidence-based practices, pa- tient safety, and all methods of care that may enhance health and healing. continued on page 295

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S c h wa r t z . E . ( 2 0 0 3 ) . I love yo g a. P l a t t s bu r g h , N Y: Tu n d ra Books. S h a keel, M., Little, S., Bru c e, J., & Ah-See, K. ( 2 0 0 7 ) . Use of complementary and a l t e r n a t i ve medicine in pediatric oto- l a r yngology patients attending a tert i a ry hospital in the UK. I n t e r national Journ a l of Pe d i a t ric Otorhinolary n g o l o g y, 7 1(11), 1725-1730. S i va s a n k a ran , S., Po l l a r d - Q u i n t n e r, S. , S a c h d eva, R., Pugeda, J., Hoq, S. M., & Z a r ich, S.W. ( 2 0 0 6 ) . The effects of a six- week program of yoga and meditation of brachial art e r y reactivity: Do psy- chosocial interventions affect va s c u l a r tone? Clinical Cardiology, 29(9), 393- 3 9 8 . Smith, C., Hancock, H., Blake - M o r t i m e r, J., & E cke r t, K. ( 2 0 0 7 ) . A ra n d o m i zed com- p a ra t i ve trial of yoga and relaxation to re- duce stress and anxiety. C o m p l e m e n t a ry T h e ra p i e s, 15(2), 77-83. S t r e e t e r, C., Jensen, E., Pe rl mu t t e r, R., C a b ral, H., Tian, H., Te r h u n e, D., et al. ( 2 0 0 7 ) . Yoga sessions increase b rain GABA leve l s : A pilot study. T h e J o u rnal of Altern a t i ve and Complementary M e d i c i n e, 13(4), 419-426. T i n d l e, H., Dav i s , R., Phillips, R., & Eisenberg, D. ( 2 0 0 5 ) . Trends in use of c o m p l e m e n t a r y and altern a t i ve medi- cine by U. S. a d u l t s : 1 9 9 7 - 2 0 0 2 . A l t e r n a t i ve T h e ra p i e s, 11(1), 42-49. T s a o, J., Meldrum, M., Kim, S., Ja c o b, M., & Z e l t ze r, L. ( 2 0 0 7 ) . Treatment prefe r- ences for CAM in children with chronic p a i n . Evidence-Based Complementary and Altern a t i ve Medicine, 4(3), 367- 3 7 4 . Wa e l d e, L., Thompson, L., & Gallagher- Thompson, D. ( 2 0 0 4 ) . A pilot study of a yoga and meditation intervention fo r dementia caregiver stress. J o u rna l of Clinical Psychology, 60(6), 677-687. Wo o l e ry, A., Mye r s, H., Stern l i e b, B., & Z e l t ze r, L. ( 2 0 0 4 ) . Yoga intervention fo r young adults with elevated symptoms of d e p r e s s i o n . A l t e r n a t i ve T h e rapies in Health and Medicine, 10(2), 60-63.

A dditional Reading R o d g e r s, B., & Yen, W- J. ( 2 0 0 2 ) . R e - t h i n k i n g nursing science through the under- standing of Buddhism. Nursing Philosophy, 3(3), 213-221.

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