Evaluation of Yoga for Preventing Adolescent Substance Use Risk Factors in a Middle School Setting: A Preliminary Group-Randomized Controlled Trial

“Questionnaires were administered by study staff during physical education class time using mini-laptop computers equipped with REDCap survey software (Harris et al. 2009).”

“The 10-item Perceived Stress Scale (PSS; Cohen et al. 1983) is a widely used and validated measure of the degree to which situations in one’s life are appraised as stressful.”

“Emotional self-regulation refers to ‘‘the process by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions’’ (Gross 1998, p. 275).”

“Behavioral skills training has generally achieved modest effects in preventing health risk behaviors among youth (Durlak et al. 2011), and prevention programs solely providing educational information about the dangers of substance use rarely change adolescent substance use behaviors (Skiba et al.…”

“Indeed, a nationally representative survey in the US found that 2.1 % of children under 18 practice yoga and 4.8 % of child/adolescent complementary and alternative medicine users were specifically targeting anxiety and stress (Barnes et al. 2008).”

“In addition, negative internalizing processes such as low mood and high stress have been linked to substance use in adolescents (Chan et al. 2008; King et al. 2004) and adults (Grant et al. 2004).”

“Table 3 Summary statistics for ANCOVAs comparing end-program (Time 2) scores between the yoga and control conditions on emotional selfregulation, substance use willingness, perceived stress, mood, and impulsivity Scale(s) Construct Main effect of condition F statistic p Partial eta squared (gp 2) KWSCS; CAMS-AC; CSMS-…”

“Thus it is possible that North American cultural preconceptions regarding the gender-appropriateness of yoga may influence the effects that yoga has on students, particularly during developmental periods such as middle school when gender differences are accentuated (Hill and Lynch 1983).”

“These findings are consistent with prior research suggesting that females tend to report higher levels of internalizing disorders than males (Zahn-Waxler et al. 2008), whereas males tend to report higher levels of impulsivity than females (Cross et al. 2011).”

“variety of health-related outcomes (Ross and Thomas 2010), as well as research showing that yoga may increase exercise adherence in adults (Bryan et al.”

“These findings are consistent with prior research suggesting that females tend to report higher levels of internalizing disorders than males (Zahn-Waxler et al. 2008), whereas males tend to report higher levels of impulsivity than females (Cross et al. 2011).”

“Similarly, recent meta-analyses suggest that mindfulness practices may have beneficial effects on adolescent mental health (Kallapiran et al. 2015) and psychological symptoms (Zoogman et al. 2015).”

“Research on yoga for adults has grown in recent years (Jeter et al. 2015; McCall 2014), with studies suggesting that yoga may have beneficial effects on psychological and physiological outcomes such as stress (Sharma 2014), mood (Cramer et al. 2013), and cardiovascular disease (Cramer et al. 2014).”

“In addition, negative internalizing processes such as low mood and high stress have been linked to substance use in adolescents (Chan et al. 2008; King et al. 2004) and adults (Grant et al. 2004).”

“The Brunel University Mood Scale (BRUMS) was designed to assess mood in adolescents (Terry et al. 1999; Terry and Lane 2002).”

“Table 3 Summary statistics for ANCOVAs comparing end-program (Time 2) scores between the yoga and control conditions on emotional selfregulation, substance use willingness, perceived stress, mood, and impulsivity Scale(s) Construct Main effect of condition F statistic p Partial eta squared (gp 2) KWSCS; CAMS-AC; CSMS-…”

“More recently, the BRUMS has been successfully used in a large sample of American adolescents (Gould et al. 2005).”

“Adolescent substance use has been linked to a variety of detrimental long-term outcomes such as increased risk of sexually transmitted infections, vehicular fatalities, juvenile delinquency, and DSM-IV substance use disorder diagnoses (Moss et al. 2014; Whitesell et al. 2013).”

“Given that the majority of studies of school-based yoga and mindfulness do not include long-term follow-up evaluations (Greenberg and Harris 2012), it is possible that prior research may have failed to capture these effects.”

“The 7-item Anger Coping subscale of the Wills Coping Inventory measures the tendency to respond with anger in everyday situations, and was rated on a 5-point scale ranging from 1 (‘‘never’’) to 5 (‘‘usually’’) (Wills 1986).”

“Research on yoga for adults has grown in recent years (Jeter et al. 2015; McCall 2014), with studies suggesting that yoga may have beneficial effects on psychological and physiological outcomes such as stress (Sharma 2014), mood (Cramer et al. 2013), and cardiovascular disease (Cramer et al. 2014).”

“The 3-item measure for Sadness Rumination was adapted from the CSMS and assesses adolescents’ emotional capabilities in dealing with sadness (Zeman et al. 2001).”

“Indeed, a recent increase in research on this topic has led to a number of systematic literature reviews summarizing the effects of mind–body practices on substance use (Carim-Todd et al. 2013; Chiesa and Serretti 2014; Katz and Toner 2013; Khanna and Greeson 2013; Zgierska et al. 2009).”

“Indeed, a recent increase in research on this topic has led to a number of systematic literature reviews summarizing the effects of mind–body practices on substance use (Carim-Todd et al. 2013; Chiesa and Serretti 2014; Katz and Toner 2013; Khanna and Greeson 2013; Zgierska et al. 2009).”

“These findings are consistent with prior research suggesting that the cumulative prevalence of psychiatric disorders increases throughout childhood and adolescence (Copeland et al. 2011) as well as willingness to experiment with drugs and alcohol (Johnston et al. 2006).”

“Emotional self-regulation was assessed using seven selfreport scales based on validated adolescent measures of self-regulation that have been shown to be sensitive to change over time (Wills et al. 2006, 2010).”

“Research on yoga for adults has grown in recent years (Jeter et al. 2015; McCall 2014), with studies suggesting that yoga may have beneficial effects on psychological and physiological outcomes such as stress (Sharma 2014), mood (Cramer et al. 2013), and cardiovascular disease (Cramer et al. 2014).”

“…corrections to reduce Type I error) based on the relatively small sample size and exploratory nature of the current study (Fishbein et al. 2015; Sproull 2002; Warner 2008), as prior research has shown that these approaches can increase the likelihood of Type II error in studies with small…”

“Similarly, recent meta-analyses suggest that mindfulness practices may have beneficial effects on adolescent mental health (Kallapiran et al. 2015) and psychological symptoms (Zoogman et al.”

“Indeed, prior research has found that future time perspective has preventive effects whereas present time perspective has harmful effects on adolescent substance use (Wills et al. 2001).”

“Adolescent substance use has been linked to a variety of detrimental long-term outcomes such as increased risk of sexually transmitted infections, vehicular fatalities, juvenile delinquency, and DSM-IV substance use disorder diagnoses (Moss et al. 2014; Whitesell et al. 2013).”

“For example, in two preliminary randomized controlled trials of school-based yoga, Noggle et al. (2012) and Khalsa et al. (2012) found that participants in the control groups reported deteriorations in psychosocial well-being, whereas participants in the yoga groups maintained their baseline levels.”

“…use (Southam-Gerow 2013), however preliminary research has found that emotional dysregulation increases adolescents’ vulnerability to substance use whereas emotional selfcontrol is related to resisting temptations for substance use (Kassel et al. 2000; Simons et al. 2004; Wills et al. 2006).”

“These systematic reviews and theoretical papers propose multiple overlapping mechanisms to explain how mind–body practices may prevent or reduce substance use, including: (1) Reduction of stress (and/or tension) and its overt behavioral and underlying neuroendocrine components (Khanna and Greeson 2013); (2) Improvemen…”

“…beneficial effects on the physical and psychological well-being of children and adolescents, particularly with regard to improvements in mood and reductions in stress, anxiety, and negative emotional states (Birdee et al. 2009; Galantino et al. 2008; Hagen and Nayar 2014; Kaley-Isley et al. 2010).”

“Group randomization is relatively more vulnerable to threats to internal validity such as history and maturation (Eldridge et al. 2008).”

“For example, in two preliminary randomized controlled trials of school-based yoga, Noggle et al. (2012) and Khalsa et al. (2012) found that participants in the control groups reported deteriorations in psychosocial well-being, whereas participants in the yoga groups maintained their baseline levels.”

“These seven scales were grouped into measures of emotional self-control (three scales) and emotional dysregulation (four scales) based on prior literature suggesting that these measures can be reliably grouped into these constructs (Wills and Ainette 2010; Wills et al. 2007; Wills and Dishion 2004).”

“2009), taking advantage of the widespread, long-term nature of schooling during formative development (Greenberg 2010).”

“1, including improvements in self-regulation (Bergen-Cico et al. 2015; Daly et al. 2015; Razza et al. 2015), mood (Felver et al.”

“These findings are consistent with some studies of school-based yoga that have found very few (Telles et al. 2013; White 2012) or no (Haden et al.”

“However, it is important to note that existing research on yoga for children and adults tends to suffer from a number of methodological limitations, such as small sample sizes and a relatively low frequency of randomized controlled trials (Birdee et al. 2009; Jeter et al. 2015).”

“…the substance use categories from the Youth Risk Behavior Survey (YRBS-MS; CDC 2014) were used to determine participants’ willingness to experiment with substances such as cigarettes (3 questions), alcohol (3 questions), marijuana (3 questions), and other drugs (4 questions) (Gibbons et al. 1998).”

“These findings are consistent with some studies of school-based yoga that have found very few (Telles et al. 2013; White 2012) or no (Haden et al.”

“2015; McCall 2014), with studies suggesting that yoga may have beneficial effects on psychological and physiological outcomes such as stress (Sharma 2014), mood (Cramer et al.”

“…beneficial effects on the physical and psychological well-being of children and adolescents, particularly with regard to improvements in mood and reductions in stress, anxiety, and negative emotional states (Birdee et al. 2009; Galantino et al. 2008; Hagen and Nayar 2014; Kaley-Isley et al. 2010).”

“Indeed, Khalsa and Butzer (2016) found that only 57 % of the studies in their review utilized randomized controlled designs and most had small sample sizes.”

“Indeed, a recent increase in research on this topic has led to a number of systematic literature reviews summarizing the effects of mind–body practices on substance use (Carim-Todd et al. 2013; Chiesa and Serretti 2014; Katz and Toner 2013; Khanna and Greeson 2013; Zgierska et al. 2009).”

“For example, Sussman et al. (2001) and Idrisov et al. (2013) found that a teen smoking cessation program that involved components of yoga had beneficial effects on quit rates, future smoking expectation, and motivation to quit.”

“…as a strategy to enhance student health, well-being, and performance (Butzer et al. 2015), with systematic analyses (Ferreira-Vorkapic et al. 2015; Serwacki and Cook-Cottone 2012) and narrative reviews (Butzer et al. 2016; Khalsa and Butzer 2016) revealing preliminary evidence for the benefits of…”

“Following the recommendations of Locascio and Atri (2011) for analyzing data with a continuous dependent variable, a between-subjects predictor variable, and a continuous covariate, a series of analyses of covariance (ANCOVAs) with condition (yoga; control) as the between-subjects factor and…”

“Similarly, in a qualitative study of a school-based yoga intervention, Conboy et al. (2013) found that students often reported health behavior changes resulting from the intervention, despite the fact that the intervention did not provide specific recommendations regarding health behavior.”

“Existing studies of school-based yoga and mindfulness for substance use in non-clinical samples have generally found limited results, with most findings emerging as trends (Fishbein et al. 2015; Parker et al. 2014).”

“…taught in school settings as a strategy to enhance student health, well-being, and performance (Butzer et al. 2015), with systematic analyses (Ferreira-Vorkapic et al. 2015; Serwacki and Cook-Cottone 2012) and narrative reviews (Butzer et al. 2016; Khalsa and Butzer 2016) revealing…”

“Few studies have examined the effects of emotional self-regulation on substance use (Southam-Gerow 2013), however preliminary research has found that emotional dysregulation increases adolescents’ vulnerability to substance use whereas emotional selfcontrol is related to resisting temptations for substance use (Kassel…”

“1, including improvements in self-regulation (Bergen-Cico et al. 2015; Daly et al. 2015; Razza et al. 2015), mood (Felver et al. 2015; Noggle et al. 2012), and anxiety (Frank et al. 2014; Parker et al. 2014).”

“Indeed, school-based yoga interventions have been found to alleviate a number of known substance use risk factors including emotional dysregulation (Daly et al. 2015), anxiety (Parker et al. 2014), and mood impairment (Felver et al. 2015).”

“Indeed, a recent increase in research on this topic has led to a number of systematic literature reviews summarizing the effects of mind–body practices on substance use (Carim-Todd et al. 2013; Chiesa and Serretti 2014; Katz and Toner 2013; Khanna and Greeson 2013; Zgierska et al. 2009).”

“ulation, mood, and stress may not be the mechanisms by which yoga exerts its effects on substance use, an idea that is supported by an existing study of yoga for adolescent substance use that failed to find effects on these outcomes (Fishbein et al. 2015).”

“1, including improvements in self-regulation (Bergen-Cico et al. 2015; Daly et al. 2015; Razza et al. 2015), mood (Felver et al. 2015; Noggle et al. 2012), and anxiety (Frank et al. 2014; Parker et al. 2014).”

“Indeed, school-based yoga interventions have been found to alleviate a number of known substance use risk factors including emotional dysregulation (Daly et al. 2015), anxiety (Parker et al. 2014), and mood impairment (Felver et al. 2015).”

“…sample size and exploratory nature of the current study (Fishbein et al. 2015; Sproull 2002; Warner 2008), as prior research has shown that these approaches can increase the likelihood of Type II error in studies with small sample sizes and/or small effect sizes (Smith et al. 2002; Strahan 1982).”

“2015), reduced risk of alcohol and drug use in women with posttraumatic stress disorder (Reddy et al. 2014), improved global functioning and well-being in substance-dependent inpatients (Sureka et al.”

“…enhance student health, well-being, and performance (Butzer et al. 2015), with systematic analyses (Ferreira-Vorkapic et al. 2015; Serwacki and Cook-Cottone 2012) and narrative reviews (Butzer et al. 2016; Khalsa and Butzer 2016) revealing preliminary evidence for the benefits of yoga in schools.”

“…skills training has generally achieved modest effects in preventing health risk behaviors among youth (Durlak et al. 2011), and prevention programs solely providing educational information about the dangers of substance use rarely change adolescent substance use behaviors (Skiba et al. 2004).”

“Accordingly, a number of substance abuse treatment programs have incorporated yoga or meditation as contributing therapies, and there is some research demonstrating efficacy of such treatments for adults (Carim-Todd et al. 2013; Hallgren et al. 2014).”

“These findings are consistent with some studies of school-based yoga that have found very few (Telles et al. 2013; White 2012) or no (Haden et al. 2014; Hagins et al. 2013) group differences in potential risk factors for substance use.”

“Other studies of yoga and meditation have also reported mixed findings in which quantitative outcomes do not show significant change, whereas participants report improvements when they are interviewed qualitatively (Sibinga et al. 2014).”

“Emotional self-regulation was assessed using seven selfreport scales based on validated adolescent measures of self-regulation that have been shown to be sensitive to change over time (Wills et al. 2006, 2010).”

“2014), and improved mood and quality of life in women undergoing heroin detoxification (Zhuang et al. 2013).”

“Indeed, Black et al. (2012a) found that higher levels of trait mindfulness were inversely associated with adolescent smoking via the positive influence of mindfulness on negative affect and perceived stress, while Black et al. (2012b) found that adolescents with high intentions to smoke were more…”

“Several theoretical review papers have hypothesized that mind–body practices such as yoga and meditation/mindfulness may be beneficial for preventing and treating substance abuse and addictive behavior (e.g., Calajoe 1987; Dakwar and Levin 2009; Kissen and Kissen-Kohn 2009; Lohman 1999).”

“A combination of these neurobiological changes with social-contextual risk factors such as low parental monitoring and/or deviant peer environments, as well as psychological risk factors such as high anxiety or mood impairment may result in increased substance use during adolescence (Schulenberg et al. 2014).”

“Previous research suggests that support from teachers and administrative staff is essential to the success of school-based yoga (Mendelson et al. 2013; Miller et al. 2014), thus the relatively low levels of physical education teacher buy-in may have influenced the present results.”

“These seven scales were grouped into measures of emotional self-control (three scales) and emotional dysregulation (four scales) based on prior literature suggesting that these measures can be reliably grouped into these constructs (Wills and Ainette 2010; Wills et al. 2007; Wills and Dishion 2004).”

“In addition, a number of studies have evaluated the specific effects of yoga interventions on addictive behavior, substance use risk factors, and substance abuse itself and have found positive results for adults, such as improvements in quality of life in opioid-dependent users (Dhawan et al. 2015), reduced risk of al…”

“In addition, as described below and in LoRusso et al. (2015), students in the present study reported mixed evaluations of the yoga intervention, and on average, participants indicated that they preferred regular physical education to yoga.”

“…yoga more often outside of school than students in the control group, a finding that is consistent with qualitative research suggesting that students often report using skills and techniques from school-based yoga in a variety of areas of their lives (LoRusso et al. 2015; Wang and Hagins 2016).”

“These findings are consistent with some studies of school-based yoga that have found very few (Telles et al. 2013; White 2012) or no (Haden et al. 2014; Hagins et al. 2013) group differences in potential risk factors for substance use.”

“Research on yoga for adults has grown in recent years (Jeter et al. 2015; McCall 2014), with studies suggesting that yoga may have beneficial effects on psychological and physiological outcomes such as stress (Sharma 2014), mood (Cramer et al. 2013), and cardiovascular disease (Cramer et al. 2014).”

“Taken together, these findings suggest that more work is needed in developing and testing substance use prevention programs for adolescents (Glassman et al. 2007), which has motivated researchers and practitioners to examine alternative approaches to substance use prevention.”

“Yoga is being increasingly taught in school settings as a strategy to enhance student health, well-being, and performance (Butzer et al. 2015), with systematic analyses (Ferreira-Vorkapic et al. 2015; Serwacki and Cook-Cottone 2012) and narrative reviews (Butzer et al. 2016; Khalsa and Butzer 2016)…”

“Several theoretical review papers have hypothesized that mind–body practices such as yoga and meditation/mindfulness may be beneficial for preventing and treating substance abuse and addictive behavior (e.g., Calajoe 1987; Dakwar and Levin 2009; Kissen and Kissen-Kohn 2009; Lohman 1999).”

“For example, Sussman et al. (2001) and Idrisov et al. (2013) found that a teen smoking cessation program that involved components of yoga had beneficial effects on quit rates, future smoking expectation, and motivation to quit.”

“In addition, a qualitative analysis of mindfulness for incarcerated adolescents suggests that mindfulness may be effective for treating adolescent substance use (Himelstein et al. 2014).”

“…as well as research showing that yoga may increase exercise adherence in adults (Bryan et al. 2012) and improve physical fitness in adolescents (Purohit et al. 2016), study staff and school administrators felt confident that the yoga intervention would provide the physical activity necessary…”

“…sample size and exploratory nature of the current study (Fishbein et al. 2015; Sproull 2002; Warner 2008), as prior research has shown that these approaches can increase the likelihood of Type II error in studies with small sample sizes and/or small effect sizes (Smith et al. 2002; Strahan 1982).”

“Several theoretical review papers have hypothesized that mind–body practices such as yoga and meditation/mindfulness may be beneficial for preventing and treating substance abuse and addictive behavior (e.g., Calajoe 1987; Dakwar and Levin 2009; Kissen and Kissen-Kohn 2009; Lohman 1999).”

“Previous research suggests that support from teachers and administrative staff is essential to the success of school-based yoga (Mendelson et al. 2013; Miller et al. 2014), thus the relatively low levels of physical education teacher buy-in may have influenced the present results.”

“These seven scales were grouped into measures of emotional self-control (three scales) and emotional dysregulation (four scales) based on prior literature suggesting that these measures can be reliably grouped into these constructs (Wills and Ainette 2010; Wills et al. 2007; Wills and Dishion 2004).”

“Indeed, middle adolescents (ages 14–17) display heightened reward-seeking in combination with low impulse control and immature selfregulatory capabilities which serve as risk factors for substance use, particularly when adolescents are in the presence of their peers (Steinberg 2015).”

“ment to existing substance use prevention programs by, for example, preparing students for behavioral skills acquisition by creating calmer classrooms and addressing implicit, associative, and emotional cues for behavior (Pentz 2014).”

“Researchers have distinguished between emotional self-control (a promotive, positive self-regulation) and emotional dysregulation (an impulsive, problematic selfregulation), and found them to be distinct constructs with different antecedents and substance use consequences (Wills et al. 2015, 2006).”

“existing research is preliminary, mindfulness and yoga exhibit the strongest evidence base when compared with other complementary and alternative medicine modalities for treating substance use disorders in adolescents (Wittenauer et al. 2015).”

“The Brunel University Mood Scale (BRUMS) was designed to assess mood in adolescents (Terry et al. 1999; Terry and Lane 2002).”

“One out of five studies assessing depression showed significant changes within and between groups on the depression subscale of the BRUMS outcome measure when comparing a yoga session to a regularly scheduled PE class (49).”

“Gender has been the most studied potential moderator, with girls reporting greater benefits on self-regulation and mental health (Butzer et al., 2017; Johnson et al., 2016; Kang et al., 2018), while boys report greater benefits in physical health (Salmoirago-Blotcher et al.”

“A few studies that evaluated mindfulness-based programs have not shown significant impacts on clinical or behavioral outcomes when measured pre- and postintervention; however, in their evaluation of follow-up indicators months after intervention concluded, improvements in measured outcomes surfaced (Fjorback et al., 2…”

“…al., 2013; Horn et al., 2011; Mathews et al., 2007; Melnyk et al., 2013; Werch et al., 2011; Werch et al., 2005), followed by middle schools (n = 4: Butzer et al., 2017; Collingwood et al., 2000; Velicer et al., 2013; Werch et al., 2003) and other settings such as a substance counseling center, an…”

“Four studies only included female participants, the remainder were mixed with the majority an approximate equal split of male and female, with two studies having over 60% female participants [39, 51] and two studies having 31-33% female participants [52, 53].”

“or negative.(20,21) Another possible explanation is that the participants may have been better capable to handle their negative emotions through increased resilience, allowing them to surface.”

“the positive effects of school-based yoga programs on several aspects of mental health, such as concentration, attention, anxiety, stress, mood, resilience, emotional arousal, self-esteem, and coping frequency [38].”

“507 ing and alcohol abuse can result in substantial reduction and prevention of addiction in the near future [44].”

“Four experimental studies considered inhibition outcomes [58,65,78,97].”

“And consistent with other early-phase trials of meditation training with adolescents (Biegel et al., 2009; Butzer et al., 2016), no corrections were made for multiple comparisons.”

“did not observe significant changes in these outcomes [34, 35].”

“[41] Research has pointed out that yoga helps control addictive symptoms by promoting self‐regulation.[42,43] According to the World Health Organization (WHO), psychological health is one of the key components in defining health.”

“There is promising evidence from randomized controlled trials that mindfulness-based programs reduce symptoms of depression, anxiety, and stress in adolescents [48–50], and especially girls showing benefits in emotional regulation [51], anxiety [51], and positive affect [52].”

“Over several years, Kripalu Yoga programmes have demonstrably improved psychological and physical health indicators in many populations, including youth in schools (Butzer et al., 2017), police officers (Jeter et al.”

“14 18-28 Yoga is often used to increase relaxation, strength, and flexibility.”

“[29] Felver et al .”

“(Butzer et al., 2017; Elliot et al., 2004, 2006, 2008; Fishbein et al., 2016; Goldberg et al., 2000; Mathews et al., 2007; Melnyk et al., 2013) and two rated at 40% (Goldberg et al., 1996a; Wicki et al., 2018).”

“…yoga intervention studies, men are less likely to volunteer [18] and more likely to withdraw their participation than women [19], and in education settings, male students can be resistant to school-based yoga [20,21] and may feel peer pressure to distance themselves from yoga-based activities [22].”

“Yoga and meditation may enhance the states of flow and mindful awareness and reduce confusion in young adult musicians (Butzer et al., 2017).”

“These results are consistent with existing literature indicating that impulsivity and emotion regulation are crucial factors in the initiation and maintenance of substance misuse (Butzer et al., 2017; De Wit, 2009; Moeller & Dougherty, 2002).”

“Yoga is a comprehensive system of practices for physical and psychological health and well-being that consist of four techniques: physical postures/exercises to promote strength and flexibility, breathing exercises to enhance respiratory functioning, relaxation strategies that focus on reducing tension and stress, and…”

“The bene fi cial effects of yoga even extended to diminishing the willingness to smoke cigarettes in both genders, as well as improving emotional self-control in females in early adolescence (Butzer et al., 2017).”

“Butzer et al. (2016) stated that in the school-based yoga program they applied to students, the social emotional learning skills of the students who participated in the study improved more than the social emotional learning skills of the students who did not participate in the study.”

“…multifaceted aspects of school-based contemplative programs, often by capturing stories and narratives from study participants, school staff and intervention instructors (Butzer et al., 2017a; Cook-Cottone et al., 2018; Cook-Cottone et al., 2017; Cook-Cottone et al., 2020; Hyde & Johnson, 2019).”

“Like Butzer et al. (2017), Fishbein et al. (2016) analyzed data on more measures than can be reliably counted (e.g., 20 + ), and the authors discussed trends toward signi fi cance, a topic that we will also return to later.”