As occupational therapists, we know that learning is impacted both positively and negatively through children's abilities, personal characteristics and/or internal beliefs, as well as through their social and physical environments. Supporting children inside the school environment and outside in the community environment for continued engagement in learning is a personal pursuit of mine in my OT practice.

In Carolyn Baum's Centennial Vision address given at the 2006 Annual Conference & Expo of the American Occupational Therapy Association, she stated, "helping children and youth achieve the capacity to be successful in school, be engaged with families and communities, and transition into adult roles, including employment" is a future and important opportunity for OTs.

In support of Dr. Baum's Centennial Vision, I have developed a unique yoga program-Yoga with a Twist®--that incorporates the promotion of health and wellness in the school and community for children and youth.

Yoga as an Intervention
It is important that children participate in healthy habits that support their ability to learn and engage in their occupations as a student, family member and friend. This can happen if the child engages in good eating habits, has plenty of sleep, has emotional support, and increases participation in physical activities (Scott). Yoga is a natural way to exercise with children; it helps them to relax, focus, develop body awareness, develop motor planning skills and strengthen the body/mind/spirit connection. Studies show that yoga is an effective intervention and a self-help skill for children with Attention Deficit Hyperactivity Disorder (ADHD) or autism, and the general health and well-being of all children and adults (Jensen & Kenny; Kenny; Reif; Zentall, S. S.).

Using yoga as an intervention is still going strong in the OT community.  It is a great form of exercise and the benefits are wonderful at any age. Yoga is a social activity that is a great form of exercise that positively impacts physical and emotional health. A structured yoga class is a wonderfully rich sensory experience and can help open the lines of commutation, ultimately helping children learn functional coping strategies for dealing with stressful life situations.

The very basic definition of yoga means union. The goal of Yoga with a Twist® is to provide the students with a form of exercise to help strengthen their body, mind and spirit. For the physical body, yoga provides a way to help children build balance and coordination, balance the functions of their internal organs and glands, help align the spine and promote good posture and foster confidence that links the physical body to their inner strength3 (Anderson & Frick; Buckley-Reen). For the mind, yoga provides a path for clear, direct communication, fosters imagination, enhances memory, promotes creative problem solving and self-discipline, provides positive thinking, and helps calm the mind while increasing one's ability to focus and concentrate3 (Khalsa & Khalsa). For the spirit, yoga fosters each child's own unique qualities, special aim in life, compassion and capacity for love and understanding through inner peace.

Yoga with A Twist® is similar to traditional yoga but has a special "twist" to address self-help, mobility, play, fine motor development, gross motor development, learning (auditory memory, visual memory, sequencing/order, critical thinking, problem solving, and reading) and socialization.

In the School Setting
The program is currently being utilized in a school environment. The yoga group starts off by having the children move their desks if needed. Most classrooms are not very big so moving furniture is necessary to have enough room. Moving the desks provides a much-needed "heavy work" experience before starting yoga. The students are then instructed to get their towels and set them up. Next they are asked to remove their shoes and socks and to place them where I tell them to, such as under, next to or in front of their desks, which helps them work on positional concepts and follow auditory directions. The children then sit with their legs crossed and wait until everyone is ready to begin.

Every yoga group begins with four of my special stretches:

1. The "What is in your sandwich?" stretch is where the children sit with long legs and hold their hands up over their head waiting to close the sandwich by touching their toes. Each child gets a chance to express their favorite healthy food; fostering healthy eating habits, which is an important Instrumental Activities of Daily Living (IADL).  The benefits of a forward bend stretch like this can calm the brain, help relieve stress, and stretches the spine, shoulders and hamstrings (Sumar).

2. The "What is behind you?" stretch is where the children stay seated with legs crossed and twist and rotate their head and trunks to look behind them and name someone or something they see. The benefits of a seated twist pose like this are strengthening and stretching the spine and shoulders and creating a feeling of being organized7.

3. The "Apple picking stretch" is where the children have their legs crossed and they reach up laterally, trying to "pick the apples" on the very top of a tree. I have them reach over their head to try and get those hard to reach apples. I will have them pretend to bite the apples after picking them or have them name their favorite apple. At different times of the year, I will have them pick different fruits from the tree, such as oranges or peaches. The benefits of a lateral stretch pose are opening the side ribs and allow full expansion of the lungs to help improve breathing (Massery).

4. The "Rainbow breathing stretch" is where everyone breathes in while raising their arms up, making a rainbow, and then breathes out while bringing their arms down. During these last two stretches is where I start to focus more attention on breathing with movement. In most cases, children have a tendency to hold their breath when moving their body to the position they are trying to imitate. I use techniques from Mary Massery's, PT, DPT, work on If You Can't Breath You Can't Function, Integrating the Pulmonary, Neuromuscular and Musculoskeletal Systems in the Pediatric Population 10. I use external sensory influences like changing the volume of my voice to activate different muscle groups. For example, when I have the children raise their arms over their heads to make a "rainbow", I will say; "Arms up-breathe in" in a loud confident voice to stimulate more chest breathing, which uses fast-twitch muscle fibers. When I have the children bring their arms down I will say, "Arms down-breathe out" in a softer and quieter voice for lower chest and diaphragmatic breathing, which uses slow-twitch muscle fibers. During the "picking apples" stretch I will have the children look up when they are reaching, which helps facilitate movement because vision leads movements and respiring involves movement10. The pairing of inhalation and exhalation patterns helps teach breathing with movement, which helps increase flexibility, improve circulation and motor performance.

Adding Books
After completing the stretches, I read a book that sets the yoga sequence routine. The children can take turns reading the book or helping me read it by turning pages for me and showing their friends the pictures. The majority of the groups are based on simple books that follow a theme, such as animals, holidays, family, friends, seasons, etc. This helps to match yoga to the class curriculum or themes. The books have appropriate animals or characters to transform into yoga poses, supporting the child's occupation of reading and learning to focus.

After using the book for about one month or so, the children have developed a stronger recall for the sequence and how to perform the poses. This repetition and routine clearly provides the children with the necessary foundation needed to increase skill development3. This is further supported through whole-body movement and participation in hands-on activities that help to support learning and information retention, which is a primary educational need (Hartman, Miller, & Nelson).

The yoga poses and stretches are a natural way for children to exercise, which happens to be very therapeutic for developing trunk stability, flexibility, coordination, strengthening, balance, body awareness, motor planning, breathing, and respiration (Sabel & Gallagher). A structured yoga program like this can facilitate an open line of communication, ultimately helping children learn functional coping strategies for dealing with stressful life situations. Much literature supports yoga benefits as a form of exercise, but the evidence-based research evidence is limited when it comes to yoga as a therapeutic intervention. With its steady growth as a therapeutic intervention in both the adult and the pediatric population, hopefully more research interests will surface in support of yoga's benefits as a therapeutic intervention for diagnoses that interfere with a person living life to the fullest.

Relaxation & Meditation
Once the yoga poses are done, it is now time for the "bed" pose or the relaxation part of the class. Guided relaxation and visualization are used with the children at the end of the class, which happens to be a powerful tool in treating sensory modulation and sensory defensiveness6. Learning to relax is an import skill for children to learn. Children undergo a great amount of stress from school, family, peer pressure, and the media. Stress has many effects on the way children learn and interact with their surroundings. Stress also impacts their health, well-being and confidence. The children cover themselves with their blankets while they listen to me or someone else read one of Maureen Garth's collection of books, Starbright, Moonbeam, The Inner Garden, and Sunshine or listen to Indigo Dreams or Relax Kids' collection of relaxation CDs.

Traditionally, you lay on your back during yoga, but the children are instructed to lie in a comfortable position. This part of the class lasts about 5 to 10 minutes. The environment is adapted to make sure it is quiet and relaxing; lights are dimmed or turned off. This supports rest and sleep through the use of relaxation techniques that can be used in preparation for bed time or when life gets stressful. This also supports emotional regulation skills, allowing the children to express how they feel while they are actively engaged in the activity as well as interacting with friends/peers. Supporting how the children are feeling at that moment integrates with the yoga philosophy of being in the moment. Being able to work through frustration and anger and facilitate persistence and control is what this yoga group is all about. This is supported through utilizing relaxation techniques, positive re-enforcement, and emotional state.

When the relaxation part of the group is done, I ask the children to fold their towels, put them in their cubby or on the table, put their socks and shoes on, and push their desks back where they belong. This process is fostering healthy routines for good ADL habits.

Yoga Storybooks
After the yoga exercise, the children are more centered and better able to participate in the fine motor group activity that follows. The next activity is creating a yoga storybook, which links the stretches and poses to the fine motor group. The children get to participate in school-related tasks and activities such as cutting, gluing, tracing, imitating basic strokes, and coloring. In addition, hand skills are honed because the games require in-hand manipulation and bilateral coordination, tactile experiences, and constructional activities. The "book" the children make is a combination of pictures from coloring books; pictures drawn by me, other teachers, and the children themselves; mazes; sticker activities; made-up memory games based on the book using pictures; and so much more.

I then make up a sheet that goes with the children's book that indicates their name and author of the book used in group, and the poses I made up to go with that story. I draw a little stick figure of the pose with a description of how to do it and attach it to the back of the child's "book" so each pose ties into the story line and is enhanced by the child's own pictures and creations, demonstrating their fine motor achievements.

This program supports motor and praxis skills through the child's ability to carry out motor activity; manipulate objects, sequence body movements and actions to perform yoga poses, being able to follow through on verbal commands, visual-spatial construction, and ocular-motor skills to participate and complete the program12.

Child- and family-centered care is the core values of my practice and is the heart of my yoga group. This yoga program is great for families to continue at home. The children will bring home their activity book they made so that the children can do yoga at home with their parents and siblings, which fosters and facilitates reading skills, gross motor skills, fun family time, and relaxation skills. The finished activity book provides the child with a tool to connect the context of school with that of his or her home life. It becomes a meaningful activity for the whole family that can continue throughout their life span for good health and overall well-being. Parents and children can make up their own poses for the animals as a way to foster exercise and movement into their family dynamic to stay active and healthy outside therapy (Cahill & Suarez-Balcazar). This meaningful occupation can grow and develop with the child while providing a valuable connection to others, which supports family and social participation, by encouraging interaction in the community by having the children go to the public library and find a book with animals in it and make up a yoga sequence with their family.

I am currently providing this yoga group, in whole and in parts, in the public school setting I currently work in for two self-contained classes and one integrated preschool class. I obtain permission from the director of special services and the children's parents before a child can become part of the yoga group. New children to the group, regardless of medical or physical ability, are given a simple questionnaire to find out the child's physical activity ability and health status to make sure there are no medical conditions that I would need to know about prior to starting my group. Most of the teachers recognize the benefits of my group and look forward to me coming in every week.

Melissa C. Fedosh OTR, RYT, is a registered yoga teacher and pediatric occupational therapis working in the Bedminster Township Schools, Bedminster, NJ. 

References
Scott, A. H., Wellness works: Community service health promotion groups led by occupational therapy students. American Journal of Occupational Therapy. 1999;53:566-574.

Jensen, P.S., & Kenny, D. T., The Effects of Yoga on the Attention and Behavior of Boys with Attention-Deficit / Hyperactivity Disorder (ADHD). Journal of Attention Disorders. 2004;7(4):205-216

Kenny, M. Integrated Movement Therapy: Yoga Based Therapy as a Viable and Effective Intervention for Autism Spectrum and Related Disorders. International Journal of Yoga Therapy. 2002;12:71-79.

Reif, S. How to Reach and Teach Children with ADD/ADHD Practical Techniques, Strategies, and Interventions (2nd ed.). San Francisco: Jossey-Bass, 2005.

Zentall, S. S. Theory- and Evidence-Based Strategies for Children with Attentional Problems. Psychology in the Schools 2005;42:821-836.

Anderson, S., & Frick, S. Developmental Therapeutic Yoga: Merging Concepts of Yoga and Sensory Integration for Individuals with Special Needs. April 21-23, 2005, Vital Links, Teaneck, NJ

Buckley-Reen, A. Yoga Therapy for the Child with Developmental Challenges. October 12-13, 2007, PG Chambers School, Cedar Knolls, NJ

Khalsa, S. K., & Khalsa, K. S. Heart and Soul Work with Children. July 14-15, 2006, Freehold Yoga Center, Marlboro, NJ

Sumar, S. Yoga for the Special Child. 1998, Special Yoga Publications, Evanston, IL

Massery, M. If You Can't Breathe, You Can't Function Integrating the Pulmonary, Neuromuscular and Musculoskeletal Systems in the Pediatric Population. March 23-25, 2006, PG Chambers School, Cedar Knolls, NJ

Hartman, B. A., Miller, B. K., & Nelson, D. L. The Effects of Hands-on Occupation Versus Demonstration on Children's Recall Memory. American Journal of Occupational Therapy 2000;54:477- 483

American Occupational Therapy Association. Occupational Therapy Practice Framework: Domain and Process (2nd ed.). American Journal of Occupational Therapy 2008;62:625-683

Sabel, R., & Gallagher, B. East & West, Mind and Body. October 14-15, 2006, Integrative Breathwork, East West Rehabilitation Institute, New York, NY