Mental health promotion for young people - the case for yoga in schools

Abstract

Background

Mental wellbeing among young people is deteriorating. Poor mental wellbeing can be related to unmanaged stress. Adverse Childhood Experiences are widespread and result in young people having stressful lives. Stress has many manifestations, and coping with it can lead to risky health-related behaviours.

Main body

A safe, scientifically-supported, efficient and effective set of stress-reduction skills is provided by the practice of yoga. At present, yoga is available privately, not publicly. After appropriately designed and evaluated interventions, the public provision of yoga could be integrated within the school curriculum, thereby reducing the high prevalence of prescription medication and offering a preventative strategy to promote positive mental health among young people.

Short conclusion

We suggest that the long-term benefits of an investment in a curriculum-embedded school-based yoga programme would do much to reduce stress both now for future generations.

Background

Mental wellbeing among young people is deteriorating. It is widely accepted that perceived stress, when not managed, may be a cause of mental ill-health such as anxiety and depression which can continue into adulthood [1]. This is a major public health concern. Given that costly mental health treatments are often not accessed, or are ineffective, addressing our young people’s mental health by way of a more preventative approach to reducing stress is of the utmost importance to the health of our populations.

Long consigned to the backwaters, mental health has recently attained greater prominence [2–4]. Mental wellbeing is stated as a fundamental component of the World Health Organisation's definition of health, and in a recent WHO report it is predicted that the estimated cumulative global impact of mental disorders in terms of lost economic output will amount to US$16.3 billion between 2011 and 2030 [5]. Perceived stress can also lead to poor health-related choices such as smoking, drinking and unhealthy eating; and chronic stress can lead to disease as a result of compromised immune and cardiovascular systems [6]. For example, across the UK, 850,000 young people aged 5–16 have mental health problems; three children in every classroom have a diagnosable mental health disorder [7]. The recent international World Health Organisation report Health Behaviours in School-aged Children compared the health of children in 42 European and North American countries and concluded that Scotland had a significantly greater proportion of 15-year-old girls who reported to be stressed [8]. This finding highlights a serious problem for Scottish adolescents’ mental health, and it is this population – Scottish adolescents – who will be specifically addressed in this paper.

There are many causes of stress facing young people. Adverse Childhood Experiences (ACEs) are widespread in Scotland. An exploratory analysis of the Growing Up in Scotland study found that as many as two-thirds of children have experienced more than one ACE, and three or more ACEs have been experienced by 10% [9]. In England and Wales, by adulthood, 50% of all adults have experienced more than one ACE, with 8% in England and 14% in Wales reporting 4+ ACEs [10–11]. As exposure to ACEs increases, so do the prevalence and risk of depressed mood and suicide attempts, as well as other indicators of poorer mental and physical outcomes [12]. Puberty is a period that heralds great psychological and biological changes which can cause stress. Young people are also dealing with a range of pressures: those arising from family life; having to succeed academically; to be popular; and to have a fit or slim body [13]). Additionally, from the moment they wake up until the moment they fall asleep, the majority of young people are bombarded with advertising imagery and messages, to which they may be particularly susceptible as they strive to construct their identities. A principal outcome of this advertising is to create feelings of inadequacy and dissatisfaction, which in turn provoke further desires to buy the products that promise to provide a renewed feeling of adequacy and satisfaction. But, satisfaction is always temporary. Herein lies a paradox in our consumer culture: our constant consumption may create or reinforce those very anxieties and stresses which it purports to assuage [14]. All considered, it is little wonder that young people are experiencing such high levels of perceived stress. These stress levels not only impact on their mental health, but also hamper their school experience and performance [15].

Evidence suggests that stress impairs learning [16]. The purpose of the argument here is to open up a discursive space for a further consideration of the relationship between schooling and mental health. How can schools foster mental wellbeing amongst their pupils, thereby reducing perceived stress? Should a more formal place in the school curriculum be assigned to teaching specific stress-reduction skills - in particular yoga – which may enable pupils to reduce their stress levels and better learn and flourish?

The argument begins with a consideration of perceived stress and its physiological correlates. It goes on to explore briefly how individuals cope with perceived stress, often with methods which are deleterious to their health. Thereafter, it is suggested that the practice of yoga has the potential to minimise stress, an outcome which is now strongly supported by scientific research. In support of this assertion, the paper examines the evidence in the literature of research into the benefits of yoga in society and school contexts, in the UK, the US and India. The argument here will show that yoga could and should be integrated into the school curriculum. If implemented, there is strong evidence from published research that it would constitute an important preventative public health measure for Scotland’s young people.

Stress

What is meant by stress, and how does the body react to it? Aldwin suggests that stress refers to ‘the quality of experience, produced through a person-environment transaction that, through either over-arousal or under-arousal, results in psychological or physiological distress’ [17]. In The Body Keeps the Score, Van der Kolk describes the stress response. Ideally, when we face a stressor, whatever it may be, our stress hormone system provides a lightning-fast response to the threat and, once the danger is over, quickly returns us to equilibrium [18]. In this sense, our stress response is helpful – stress per se is not a problem. What can cause problems is when our autonomic nervous system gets ‘stuck’ in this stressed state – that is, our system is responding as though the threat were still present, continually secreting stress hormones, long after the threat has passed. The nervous system has more than one defence strategy: a mobilized ‘fight-flight’; or an immobilization ‘freeze’ shutdown [19]. For the fight-flight component, cortisol and adrenaline are pumping, the heart is racing, hands are sweating and there is a feeling of panic and agitation. All the energy in the body is directed to help the body either to fight a predator or to run away as fast as possible. Rarely are those responses actually appropriate for our present-day stressors. The brain can get 'stuck' in this state of hyper-arousal, and, when it does, it is known as chronic anxiety [20]. Although there is no actual threat, we still experience fear and its physical manifestation. If, however, we feel that the fight-flight response has not been effective, and that the perceived 'threat' remains, then we go into a freeze or dissociative state, or ‘the ultimate emergency system’ [18]. In the animal world it is equivalent to playing dead when cornered by a predator. When this system takes over in humans, it slows down the heart-rate, induces shallow breathing, and both we and others cease to matter. When we get stuck in this shutdown-level of dissociation, it is termed clinical depression [20]. Many people oscillate between these states of fight-flight-freeze to a greater or lesser degree. Crucially, during this time the digestive system and the immune system are suppressed, which can lead to a host of physical health problems [18, 19].

Often the way people cope with the discomfort of this stress is by seeking a temporary altered state by engaging in risky health-related behaviours in order to ‘dull the intolerable inner world’ [18]. These altered states may be accessed by teenagers drinking alcohol, by using illegal drugs, by overeating and by over-using technology. All of these behaviours may provide temporary solace through distraction, physical and/or mental pleasure; and possibly social connectedness and feelings of belonging. On the face of it, for those who engage in them, these risky health behaviours seem to be rational responses [21]. But there is a problem with these coping strategies: they all have – to a greater or lesser degree – further detrimental effects on physical and/or mental health, and on behaviour and learning.

Other solutions available for young people for coping with stress-induced mental health problems involve taking prescribed medications. Whilst helpful and necessary in some more severe cases, these treatments may leave the young person to face the immediate and long-term negative effects of medication [21], and they are often over-prescribed. Neither self-medicating through risky health behaviours, nor taking prescribed medication, reduces the stress symptoms by re-instating equilibrium to the system; rather they mask the uncomfortable fight-flight-freeze symptoms, such that, once the effect of the chosen stimulation has worn off, or the medication is stopped, the original symptoms may remain or are further exacerbated. Learning how to identify when we are in this fight-flight-freeze state, and learning how we can change our own physiology and inner equilibrium, not only reinstates a level of physical and mental comfort, but is also imperative in preventing a range of both physical and mental illness [18, 20]. If we put in place preventative programmes to deal with young people’s stress now, not only will they have better health and learning outcomes but it is likely to reduce government health expenditure in the future.

Coping with stress: the research-based benefits of yoga in society and schools

Many mind-body practices offer healthier and more sustainable alternatives for dealing with stress. One of the most popular and well-researched of these is yoga, a multi-component holistic system of practices that typically includes physical postures/exercises, deep-relaxation techniques and meditation/mindfulness practices. It may be useful here to distinguish yoga from mindfulness, which has attracted much recent interest [23]. Mindfulness focusses on cultivating non-judgemental awareness towards the present moment: bodily sensations, thoughts and the immediate environment. Mindfulness is 'the ability to pay attention to the present moment, on purpose' [24]. Yoga is also about present-moment awareness and is an inherently mindful practice, but crucially yoga practice goes beyond this. It involves various techniques to help improve the quality of those bodily sensations and thoughts. It poses the question: why would a person merely wish to be mindfully aware of the present moment - bodily sensations and thoughts - if it is uncomfortable or painful? Yoga techniques such as postures and breathing are simple and effective ways of improving the comfort and quality of our experience. If you are a teenager experiencing a bad mood, lethargy and a headache, it is unlikely you will be motivated to sit in mindful meditation. However, if you engage in a short practice of tailored yoga postures and yoga breathing this will improve such complaints. In sum, yoga delivers similar health benefits to mindfulness in terms of mood improvement and stress reduction [25, 26]; however, as yoga also involves breath regulation and postures it has wider-ranging and more pronounced physiological effects, including addressing chronic conditions such as cardiovascular disease, diabetes, obesity and respiratory conditions in a manner that mindfulness cannot.

A meta-analysis of yoga research suggests that ‘a growing body of evidence states that yoga benefits physical and mental health via down-regulation of the hypothalamic–pituitary–adrenal (HPA) axis and the sympathetic nervous system’ [27]. Research documenting the therapeutic benefits of yoga has grown steadily for the past three decades and now includes controlled clinical trials on a variety of mental health conditions such as depression and anxiety [25, 28]. In short, practising yoga reduces stress and the associated discomfort of stress-related symptoms, thereby negating the need to self-medicate with drinking, drug-taking, over-eating and technological distraction, or taking prescription medication.

With such a robust body of research showing the benefits of practices like yoga on the reduction of stress and the promotion of good mental health (among other benefits) it is little wonder that these practices are becoming increasingly popular. For example, the US National Center for Health Statistics state that, among adults, the reported use of yoga within the previous 12 months was 5.1 per cent in 2002, 6.1 per cent in 2007 and 9.5 per cent in 2012; and similarly so for children for the period 2007-12 [29]. That said, however, access to these practices is not equal, as is highlighted in the emerging socio-economic differences in yoga expenditure. A systematic review reported that both in the US and the UK yoga practitioners are generally white and of higher socioeconomic status [30]. Therefore, yoga classes are currently unaffordable for many; those without disposable income, including many young people, are not in a position to attend them. It is for this reason that in order for a larger proportion of the population to access the benefits of yoga, financial barriers must be removed.

The main proposition here is to recommend a publicly-funded yoga programme in schools. Teaching yoga in schools is the most effective and cost-effective way to provide a preventative resource for young people to access the mental health benefits of yoga. Yoga has already been recommended and used clinically for young people, particularly in the United States. Birdee et al.’s systematic review of the benefits of yoga in the paediatric population addressed many sorts of benefits, both mental and physical [31]. Yoga has demonstrated benefits for young people in the following areas: stress, anxiety and depression; cognitive function, memory and perception; flexibility; cardiopulmonary fitness; psychomotor and neuromuscular performance; and weight loss [32]. Whilst acknowledging these many benefits of yoga for young people, for the purposes of this paper the focus will be on mental health promotion and the reduction of perceived stress, anxiety and depression.

Other recent research on yoga in school settings suggests that yoga is a viable and potentially efficacious strategy for improving adolescent health [13, 33, 34]. In fact, yoga programmes in schools are already taking place. In the US - there have been no formal surveys taken in the UK - the most recent audit showed that there are 36 school-based yoga programmes [35]. These schools have recognised that educating the whole child - including their mental, emotional and physical health - in addition to teaching academic skills, is important. In essence, academic achievement is affected by, and is dependent upon, young peoples’ health, both physical and mental: by reducing young people’s stress levels, we can improve their learning. When the parasympathetic nervous system is activated, as it is in yoga, focus and concentration is increased and, as a result, yoga has been shown to improve academic performance and school grades [35, 36].

In England, a pioneer yoga-in-schools programme was commissioned in 2016 by the London Borough of Havering in order to address the mental health needs of both teachers and pupils. The programme, Mindfulness for Mental Health and Resilience, has already shown a significant positive change in the mental well-being of the participants [37]. Although this is called a ‘mindfulness’ programme, it in fact comprises mainly ‘moving mindfulness’ – that is, yoga – with its inclusion of yoga breathing and yoga postures along with mindfulness. Most importantly here is the programme’s novel approach of addressing both the teacher's and the pupils' mental health. Of particular note is the fact that the yoga practices taught are short – one to ten minutes – and are incorporated into the school day. Crucially, the programme does not require that yoga skills are taught instead of other physical education classes, but rather are taught across the curriculum, as and when the teachers deem it to be appropriate. To date, whilst there are some schools that provide yoga in the form of ad hoc after-school clubs, or as an option within physical education, the provision of yoga has been accessible mainly through private provision. But, given its benefits, the teaching of yoga may warrant a place in the school curriculum. A robust and well-researched programme of yoga interventions in schools could prove very beneficial, and may go a long way towards successfully addressing challenges faced by young people that impact negatively on their mental health. It is worth noting that in the ‘west’, yoga may be viewed as a feminine practice. Accordingly, if required, we would explore innovation on how to engage young males, perhaps by encouraging visits from local sportsmen who practise yoga.

Conclusion

It has been argued that unmanaged stress among young people may cause mental health problems now and in later life. The provision of preventative stress-reduction skills in schools is a priority for young people’s health. This paper also suggested that among the potential stressors these young people face may be the values promoted by consumer culture, particularly narcissistic individualism. Thus, an apparent paradox regarding yoga must be outlined and made clear. For those unfamiliar with it, yoga could be considered to be a practice that promotes that very individualism which has been shown to be a key stressor. After all, the locus of the practice is the individual. Crucially, however, an overall effect of a yoga practice is an awareness of the connection to everything that is not you, the individual [33]. It may result in the realisation that a positive mental state is not to be found in the values and practices promoted by consumerism but rather in the meaningful connection with others and the wider world. Indeed, Hagen and Nayar suggest that yoga can enable a greater social sensitivity – so much so that, by teaching yoga in schools, we may increase the likelihood of young people engaging in civic activities and shaping a more equal society [13].

Given the reported benefits of yoga-skills teaching in the US and elsewhere, further consideration of its broader adoption in the school curriculum is warranted, thereby paving the way for a robust and effective preventative approach to reducing stress and improving mental health among young people. As a first step, collaborative research is required which will develop an appropriate and effective yoga-skills programme that is suitable for the respective school population such that it would be easily embedded in the school curriculum. Programmes may take their cue from the current yoga-in-schools programme commissioned in 2016 in England by the London Borough of Havering (referred to earlier) in order to address the mental health needs of both teachers and pupils. We suggest that the long-term benefits of an investment along the lines proposed here would do much to reduce stress in the generations to come.