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What is Tapping? How does it work? Who should use it?

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What is Tapping? How does it work? Who should use it?

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How Can I Use Tapping in My Life?

Millions of people are settling for lives filled with poor health and emotional baggage.

Not knowing how to achieve the joyful and satisfying lives they desire, they're stuck accepting a lifestyle of emotional trauma, chronic physical pain, compulsions and addictions, or perhaps just an empty feeling inside, leading, as Henry David Thoreau famously said, lives of quiet desperation.

Does this sound familiar to you? Is there something holding you back from enjoying your life?

If you're like many people, you may feel trapped, caught in this cycle. You're tired of feeling sad, depressed, anxious, discontent, and unwell. You'd like to grow, flourish, and thrive, putting the past in the past. You want to be your best, living a life that is filled with peacefulness, joy, and fulfillment, from day to day and moment to moment.

Tapping can be used on a daily basis to reduce the stress and anxiety that is interfering with your happiness and well-being. You can use Tapping to help you fall asleep at night, to help you overcome your paralyzing fear of driving, and everything in between.

Many people also use Tapping in combination with protocols from their doctor or therapist, so make sure to let any of your health professionals know what additional steps you're taking to support your wellbeing.

If you're wondering, "Can I use Tapping for <insert your topic here>?" take a look at the long list of topics we currently have in our Tapping Solution App!

Introduction to the Tapping Points

Eyebrow Point (EB)
Where the eyebrows begin, closest to the bridge of the nose.

Side of Eye (SE)
On the bone directly along the outside of either eye.

Under Eye (UE)
On the bone directly under either eye.

Under Nose (UN)
The area directly beneath the nose and above the upper lip.

Chin Point (CP)
This is the area just below your bottom lip and above the chin, right in the crease.

Collarbone Point (CB)
Starting from where your collar bones meet in the center, go down an inch and out an inch on either side.

Under Arm (UA)
On your side, about four inches beneath the armpit.

Top of Head (TH)
Directly on the crown of your head.

Basic Tapping Sequence for Anxiety

As discussed, Tapping can be used to help a variety of challenges - so try it on everything! Here's the method for how to use it. In this example, we'll focus on general anxiety.

You can also follow along to our Releasing Anxiety Tapping meditation. After 260,000 plays of this Tapping meditation, the average reported reduction of anxiety was 41% in 9 minutes.

The basics of the Tapping process are simple

Always begin Tapping on the karate chop point while you repeat the setup statement to yourself. This allows you to be honest with how you feel and sets you up for the Tapping process (more on the setup statement below).

Begin Tapping while focusing on how you feel or on the problem. By doing this you send a calming signal to your brain, allowing you to think of the problem without feeling stress in your body.

When you feel better, you can move to more empowering thoughts. The same way you need to weed a garden before you plant seeds, you have to release the intensity of what you're feeling before more empowering thoughts can take root.

Lets break down the steps:

Identify the problem on which you want to focus. It can be general anxiety, or it can be a specific situation or issue which causes you to feel anxious.

Consider the problem or situation. How do you feel about it right now? Rate the intensity level of your anxiety on a scale of 0 to 10, with zero being the lowest level of anxiety and ten being the highest.

Compose a setup statement. Your setup statement should acknowledge the problem you want to deal with, then follow it with a phrase of acceptance. This helps nuteralize judgements you have around how you feel and allow you to be more honest with your Tapping.

Setup statement examples:

"Even though I feel this anxiety, I accept how I feel"
"Even though I'm anxious about my interview, I accept myself and how I feel."
"Even though I'm feeling this anxiety about my financial situation,
I honor my feelings and give my body permission to relax. "

Get ready to begin Tapping!

With four fingers on one hand, begin tapping the Karate Chop point on your other hand. The Karate Chop point is on the outer edge of the hand, on the opposite side from the thumb.

Repeat the setup statement three times aloud, while simultaneously tapping the Karate Chop point. Now take a deep breath.

Now, tap about 5 to 7 times each on the remaining eight points in the sequence described below. As you tap on each point, repeat a simple reminder phrase, such as "my anxiety" or "my interview" or "my financial situation" to help you mentally focus on your issue.

Eyebrow Point (EB)
Where the eyebrows begin, closest to the bridge of the nose.

Side of Eye (SE)
On the bone directly along the outside of either eye.

Under Eye (UE)
On the bone directly under either eye.

Under Nose (UN)
The area directly beneath the nose and above the upper lip.

Chin Point (CP)
This is the area just below your bottom lip and above the chin, right in the crease.

Collarbone Point (CB)
Starting from where your collar bones meet in the center, go down an inch and out an inch on either side.

Under Arm (UA)
On your side, about four inches beneath the armpit.

Top of Head (TH)
Directly on the crown of your head.

And take another deep breath!

Now that you've completed the sequence, focus on your problem again. How intense is the anxiety now, in comparison to a few minutes ago? Give it a rating on the same 0 to 10 scale. Did you notice a shift?

If your anxiety level is still higher than 2 or 3, you can do another round of tapping. Keep tapping through the sequence until the anxiety is gone. You can change your setup statement slightly to take into account your efforts to fix the problem or your desire for continued progress.

Examples:
"Even though I have some remaining anxiety, I accept how I feel and choose to relax."
"Even though I'm still a little worried about this interview, I deeply and completely accept myself." And so on.

Now that you've focused on dispelling your immediate anxiety, you can work on instilling some positive feelings in its place. This approach is different from traditional "positive thinking." You're not being dishonest with yourself. You're not trying to obscure the stress and anxiety inside yourself with a veneer of insincere affirmations. Rather, you've confronted and dealt with the anxiety and its corresponding negative emotions, offering deep and complete acceptance to both your feelings and yourself.

The same way you need to weed a garden before you plant seeds, you have to release the intensity of what you're feeling before more empowering thoughts can take root. That's what makes Tapping so much more effective than the "positive thinking" techniques that many of you have already tried.

Here are some example phrases to guide you:
"I have faith in my ability to change."
"I am joyful about these positive changes."
"I am accomplishing so much."
"I enjoy the calm and peace that I have."
"I love the person that I am."
"I am becoming a more relaxed and joyful person."

You can use these positive phrases with the same sequence of Tapping points described above.

Here are some tips to help you achieve the correct technique.

You should use a firm but gentle pressure, the same as if you were drumming on the top of your desk or testing a melon for ripeness.

You can use all four fingers, or just the first two (the index and middle fingers). Four fingers are generally used on wider areas, while just two can be used on sensitive areas, such as around the eyes.

You can tap one side of the body or both at the same time. The meridian points are symmetrical on either side of the body.

Congratulations! You've completed your first Tapping sequence.

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Tapping 101 - Learn the Basics of the Tapping Technique

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What is Tapping? Get started right here! Learn the history, science, EFT Tapping points, how Tapping works, and how to use Tapping for anxiety.

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How to Tap with Jessica Ortner: Emotional Freedom Technique Informational Video

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Research on Tapping to Reduce Test Anxiety

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Research on Tapping to Reduce Test Anxiety

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Lay Summary of EFT Research with Children and Youth

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Research on ETF and Cortisol Levels in the Body

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Research on ETF and Cortisol Levels in the Body

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Scientific Research

EFT SIGNIFICANTLY LOWERS CORTISOL

A study published in the Journal of Nervous and Mental Disease, the oldest peer-reviewed psychology journal in the United States, found that Emotional Freedom Techniques (EFT) lowered the major stress hormone cortisol significantly more than other interventions tested.

In a randomized controlled trial 83 subjects were randomly assigned to a single hour-long session of EFT, talk therapy, or rest. Their cortisol levels were measured via a saliva test before and after the session. Cortisol was measured because it is known as the "stress hormone" of the body. As stress goes up, cortisol levels go up.

Originally designed to help us survive life in the wild, the "fight or flight" response was essential when our ancient ancestors were faced with sudden, brief danger like, let's say, a tiger.

However useful in short bursts, releasing cortisol too frequently, as we seem to be doing in response to the ongoing or "chronic" stress of modern life, may have serious, even scary, impacts on our physical, mental and emotional health.

In fact, living in this kind of biological "survival mode" may be making us more vulnerable to everything from cancer to heart disease, and more.

Results

The normal rate of cortisol decline is 14% over the length of an hour. The 1st group (Tapping) demonstrated a 24% decrease in cortisol levels, while the 2nd and 3rd groups showed only the standard cortisol reduction that happens with time passing. The 10% improvement in the 1st group (Tapping) is statistically significant. The EFT group also exhibited lower levels of psychological symptoms, including anxiety, depression, and other, as measured by the Symptom Assessment-45 (SA-45), a standard psychological assessment tool.

THE REALITY

Pyschotherapy alone relieves stress, but over a long period of time. The immediate benefits of psychotherapy don't register in your body, where excessive amounts of the "stress hormone" cortisol still run rampant, putting your health at risk.

STUDY FINDINGS

Tapping balances activity between the sympathetic and parasympathetic regions of your brain, producing "a neutral emotional state," the gold standard of health and wellness. It's also the state of well-being people have sought to achieve for millennia through meditation, prayer, yoga, and other mindfulness practices.

Dr. Feinstein, a clinical psychologist who uses EFT in his own practice, adds that EFT is an "unusually precise, rapid, and direct for shifting the neurological underpinnings of a range of psychological problems."

In fact, he adds, "the number of therapists using EFT has been rapidly increasing over the past decade, and now peer-reviewed research is showing that their instincts have been right. Surprisingly rapid outcomes with a variety of disorders are being documented."

RESEARCH ON EFT & SCHOOLS:

MORE RESEARCH ON EFT:

"The Science and Research Behind Tapping" - David Feinstein Ph.D.

"Acupoint Stimulation is Treating Psychological Disorders: Evidence of Efficiency" - David Feinstein Ph.D.

"Clinical EFT as an Evidence-Based Practice for the Treatment of Psychological and Physiological Conditions" - Dawson Church

Trauma Relief

"Based on my clinical experience and my reading of the research literature, EFT is the treatment of choice for rapid intervention in traumatic situations like Newtown that trigger overwhelming emotions in individuals and groups. Its use can prevent the future development of full-blown PTSD..."

-Eric Leskowitz, MD from the Department of Psychiatry at Harvard Medical School

Below are a number of excerpts from a paper written by David Feinstein, Ph.D.
Download and read the full paper.
"(Energy Psychology) brings about, with unusual speed and precision, therapeutic shifts in affective, cognitive, and behavioral patterns that underlie a range of psychological concerns related to disasters."

"Energy psychology has been applied in the wake of natural and human-made disasters in the Congo, Guatemala, Indonesia, Kenya, Kosovo, Kuwait, Mexico, Moldavia, Nairobi, Rwanda, South Africa, Tanzania, Thailand, and the U.S. At least three international humanitarian relief organizations have adapted energy psychology as a treatment in their post-disaster missions."

FOUR TIERS OF ENERGY PSYCHOLOGY INTERVENTIONS INCLUDE:

1) Immediate relief/stabilization
2) Extinguishing conditioned responses
3) Overcoming complex psychological problems, and
4) Promoting optimal functioning

"The first tier is most pertinent in psychological first aid immediately following a disaster, with the subsequent tiers progressively being introduced over time with complex stress reactions and chronic disorders."

"Energy psychology, as most commonly practiced in clinical and post-disaster situations, is an exposure-based treatment. The effectiveness of exposure therapies with PTSD and other anxiety disorders is well established. Exposure is, in fact, the single modality for which the evidence is sufficient to conclude, according to stringent scientific standards (National Institute of Medicine's Committee on Treatment of Posttraumatic Stress Disorder, 2007), that the method is an efficacious treatment for PTSD. Other treatments that have strong empirical support in treating PTSD, such as cognitive-processing therapy, stress inoculation training, and eye movement desensitization and reprocessing (EMDR ), also generally incorporate substantial exposure components (Keane, Foa, Friedman, Cohen, & Newman, 2007)."

TRAUMA RELIEF WORK DONE BY DR. JOHNSON

"Johnson kept a simple but ultimately provocative set of statistics during his visits to Kosovo and other areas of ethnic cleansing, warfare, and natural disasters. He tracked the number of people treated, the number of traumatic incidents identified, and the number of incidents where full relief was reported (i.e., hyperarousal to the traumatic memory was completely neutralized according to the person's subjective report). Table 1 shows his tally. Johnson, who holds diplomate status with the American Board of Professional Psychology, acknowledges that such figures raise even his own skepticism. While recognizing that 'well-controlled research is essential before results like these can be accepted,' he affirms that the figures accurately reflect his experiences and that he 'recorded them exactly according to what happened.' After interviewing Johnson, the author of this paper interviewed several therapists who worked on these teams, and their reports corroborate Johnson's.

"Johnson emphasizes that reducing the impact of traumatic memories with Energy Psychology, as reflected in the [below] numbers, is not the end of a person's healing journey. 'Often,' however, 'it is a new beginning,' providing people an opportunity to rebuild their lives without the oppressive emotional weight of their traumatization."

Also noted in this article, Lynn Garland, a social worker with the Veterans' Healthcare System in Boston, reports that she, along with numerous colleagues using [Energy Psychology] in the V.A. (Veteran's Administration), are having 'dramatic results in relieving both acute and chronic symptoms of combat-related trauma' (Feinstein, Eden, & Craig, 2005, p. 17)."

Read the full 24 page paper.

TRAUMA RELIEF IN EL SHADAI, RWANDA

"Particularly poignant are reports that have been coming in from the Trauma Relief Committee of the Association for Thought Field Therapy Foundation about their work with the El Shadai orphanage in Rwanda. Many of the children had seen their parents die by machete during the ethnic cleansing twelve years earlier or were reliving the horrors of the massacre of 800,000 Rwandans. Daily flashbacks and nightmares were common, as were bedwetting, depression, withdrawal, isolation, difficulty concentrating, jumpiness, and aggression. Standardized pre- and post-treatment tests for PTSD (translated into Kinyarwandan) were administered to 50 of these children (27 boys and 23 girls), ages 13 through 18, and a children's PTSD assessment tool for parents and guardians was administered to their caregivers. Treatment, provided in April and May 2006, generally involved three TFT sessions of approximately 20 minutes each. The tests were structured after DSM IV criteria for PTSD. Average symptom scores, based on both the tests taken by the children and the caregivers' observations about the children, substantially exceeded the cutoffs for a diagnosis of PTSD. Scores after the three sessions were substantially lower than the cut-offs. Immediate reductions in flashbacks, nightmares, and other symptoms were common. Retesting a year later showed that the improvements held. Details of these findings are being prepared for publication (C. Sakai, personal communication, March 7, 2008)."

EFT TAPPING CAN HELP ALLEVIATE ALL TYPES OF STRESS

"Energy Psychology in Disaster Relief" - David Feinstein, Ph.D.

"Energy Psychology Treatment for Post traumatic Stress in Genocide Survivors in a Rwandan Orphanage: A Pilot Investigation" - Barbara Stone, Lori Leyden, & Bert Fellows

"Energy Psychology Treatment for Orphans Heads of Households in Rwanda: An Observational Study" - Barbara Stone, Lori Leyden, & Bert Fellows

EFT, also known as Tapping, can help alleviate all types of stress. This video will show you the results Tapping can achieve and some of the studies Tapping has undergone:

Visit thetappingsolution.com to get a Free Ebook on EFT (Emotional Freedom Techniques). This documentary on Tapping features energy and abundance experts such as Jack Canfield, Bob Proctor, Dr. Joseph Mercola, Carol Look, Joe Vitale, Cheryl Richardson and more.

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Science & Research - Tapping Solution Foundation

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Scientific Research EFT SIGNIFICANTLY LOWERS CORTISOL A study published in the Journal of Nervous and Mental Disease, the oldest peer-reviewed psychology journal in the United States, found that Emotional Freedom Techniques (EFT) lowered the major stress hormone cortisol significantly more than other interventions tested. In a randomized controlled trial 83 subjects were randomly assigned to ...

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Abstract

INTRODUCTION

A number of systematic reviews consider the evidence for Emotional Freedom Techniques (EFT) as an "evidence-based" practice. 1- 3 Studies are typically evaluated using criteria published by the American Psychological Association's (APA's) Division 12 Task Force on Empirically Validated Treatments, hereafter abridged as "APA standards." 4- 6 The APA standards amalgamate current scientific consensus to identify 7 "essential" criteria that must be present for a study to qualify: randomization, sample size sufficient to establish statistical significance, a clear definition of the treatment population, valid and reliable assessments, blind interview assignments, a treatment manual, and sufficient data to allow the study's statistical methods to be assessed for appropriateness. 1- 3 A minimum of 2 randomized controlled trials (RCTs) are required for a therapeutic method to be deemed "efficacious."

When proposing its own standards, the US Food and Drug Administration contemporaneously set a similar standard of 2 RCTs for drug trials. 7 A systematic review searching the scientific literature until April 2012 found 51 studies of EFT and allied methods collectively referred to as energy psychology. It found that "Criteria for evidence-based treatments proposed by Division 12 of the American Psychological Association were also applied and found to be met for a number of conditions, including PTSD." 1

A systematic review and meta-analysis of 7 studies of EFT for posttraumatic stress disorder (PTSD) was recently reported. 8 It used the Cohen difference, an appropriate effect size for the comparison between 2 means, in which 0.2 indicates a treatment effect, 0.5 indicates a moderate treatment effect, and 0.8 indicates a large treatment effect. The meta-analysis found a large treatment effect, with a d of 2.96 when EFT was compared with normal care. Compared with eye movement desensitization and reprocessing (EMDR) and cognitive behavior therapy (CBT), no significant treatment difference was found, indicating similarities in efficacy between the 3 treatments. Two other systematic reviews with meta-analyses, 1 for anxiety (14 RCTs) and 1 for depression (20 RCTs and within-subjects studies), found "large" treatment effect sizes of 1.23 and 1.31, respectively. 9, 10 Authors of all 3 meta-analyses used the APA standards as their quality-control criteria when selecting studies for inclusion. An online database of EFT research lists more than 100 clinical trials ( www.Research.EFTuniverse.com).

A psychophysiologic intervention, EFT draws from 2 established therapies: CBT and exposure therapy. It adds the novel component of somatic stimulation using acupuncture points ("acupoints"). Developed in the early 1990s, EFT is described in subsequent editions of a standardized manual. 11, 12 Clients are asked to assess the intensity of traumatic events before and after EFT using the Wolpe Subjective Units of Distress (SUD) measure, 13 an 11-point Likert scale ranging from 0 (no distress) to 10 (maximum distress). During a typical treatment session, clients recall a traumatic event and pair it with a statement of self-acceptance, such as "Even though I experienced [name of the event] I deeply and completely accept myself." They stimulate 7 acupuncture points with their fingertips (acupressure) by tapping on them or rubbing them while repeating the name of the event. If their SUD score is still high, they might describe the event in detail. An optional supplemental technique is called the 9 Gamut procedure and uses eye movements similar to those employed in EMDR. Often EFT is taught by therapists, physicians, nurses, and life coaches to patients as a method of self-care to use between treatment sessions. The method and typical applications are fully described elsewhere in the literature. 2, 3

To differentiate the acupressure component from the cognitive and exposure elements that EFT shares with other therapies, a meta-analysis examined six dismantling studies. 14 While retaining the cognitive and exposure parts of EFT, these six studies used control groups that either substituted an active treatment such as diaphragmatic breathing for acupressure or used pressure on sham acupoints. The meta-analysis found a large treatment difference between the groups that used authentic acupoints vs controls, indicating that acupressure is an active treatment ingredient in EFT's protocol and not merely an inert component.

Many studies conducted by independent research teams using a variety of different population samples, including veterans, adolescents, refugees, and disaster survivors, demonstrate the efficacy of acupressure stimulation as a treatment of PTSD. 15- 23 In a typical RCT of veterans who met clinical criteria for PTSD (N = 59) and were assessed against a control group receiving treatment as usual (TAU), 86% of participants no longer met the criteria for PTSD after 6 sessions of EFT (p < 0.0001). 15 The military version of the Posttraumatic Stress Disorder Checklist (PCL-M), 24 a valid and reliable 17-item tool on which a score of 50 indicates the likelihood of a PTSD diagnosis, was used to assess symptoms. Mean PCL-M scores were 61.4 before treatment and 34.6 on posttreatment test. A replication of this study by an independent research team demonstrated similar results. 18

A hospital in the United Kingdom's National Health Service conducted a study of a PTSD-positive outpatient population (N = 46) comparing EFT with EMDR and a waiting list with usual care. 17 They found both EFT and EMDR to remediate PTSD in a mean of 4 sessions (p < 0.001). An RCT of abused male adolescents (N = 16) used the Impact of Events Scale 25 to evaluate participant distress. Scores declined from 36 to 3 (p < 0.001) after a single EFT session. 16 Another RCT (N = 21) examined the impact of EFT on resiliency in veterans at risk of PTSD. 26 Six sessions produced a reduction in symptoms comparable to the results noted in a clinical population (p < 0.0001). Gains were maintained on follow-up in all 4 studies, whereas the wait-list participants did not improve. 16- 18, 26

A systematic review of the literature includes 12 studies in which EFT demonstrated efficacy for a range of psychological conditions, such as PTSD, depression, and anxiety when delivered in the form of group therapy. 2 A written protocol called Borrowing Benefits, describing how to use EFT in groups, has been tested in both RCTs and outcomes studies. 12 In an uncontrolled study with veterans and their spouses, 218 participants were evaluated for PTSD symptoms before and after a 7-day retreat in which they used Borrowing Benefits and other EFT techniques. 27 Of the veterans, 83% exhibited clinical symptom levels on pretest, as did 29% of their spouses. On follow-up, only 28% of veterans and 4% of spouses still met the clinical cutoff (p < 0.001). 27 The Borrowing Benefits technique is described in detail in the EFT manual. 12 In a group, the practitioner works with one individual while witnesses self-apply EFT to their own personal issues. Studies of Borrowing Benefits find it efficacious for a wide variety of psychological conditions. 2

Clinicians widely practice EFT and similar techniques. A recent survey critical of the method solicited responses from licensed psychotherapists using Listservs such as Acceptance and Commitment Therapy, the Society for a Science of Clinical Psychology, and the Association for Behavioral and Cognitive Therapies. 28 It found that 42% of therapists were using these modalities.

The Veterans Stress Project 29 is a charitable program of the National Institute for Integrative Healthcare that has served as a recruitment vehicle for several studies. Its Web site ( www.StressProject.org) serves as a clearinghouse, allowing veterans to locate practitioners. The Veterans Stress Project also hosts an interactive virtual EFT coaching software program called Battle Tap and archives numerous testimonials from veterans who have used Battle Tap, individual therapy, and group EFT therapy to support their recovery from PTSD. These and other private and public initiatives pair veterans seeking treatment with practitioners offering EFT and similar therapeutic methods.

The objective of the current research was to develop clinical best practice guidelines for the use of EFT to treat PTSD. Toward that end, we evaluated practitioner experience and the published literature to arrive at a consensus statement.

METHODS

We undertook a survey of practitioners using EFT to treat PTSD ( www.surveymonkey.com/s/GTZXD2B; SurveyMonkey, Palo Alto, CA). The goals of the survey were to develop a demographic profile of practitioners, to evaluate how EFT is used in professional settings, and to determine current practices for PTSD treatment. Drawing on the results, the evidence base, and case histories, we formulated clinical guidelines for the use of EFT in the treatment of veterans and military personnel, with the "stepped care" model used by the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom as our framework.

The invitation to complete the survey was extended in February 2014 by several US and United Kingdom organizations: the National Institute for Integrative Healthcare, the Association for Comprehensive Energy Psychology, and the Association for Meridian and Energy Therapies, as well as informal networks of practitioners. We received responses from 448 practitioners. The number of those responding to each question is indicated in to . Some survey questions allowed practitioners to select more than 1 option. For example, a practitioner could select both "nurse" and "retired" or for professional settings both "private practice" and "medical center"; thus; the number of responses to these questions exceeded 448.

One item asked practitioners to estimate how many sessions were required to treat complex PTSD (C-PTSD). Although C-PTSD does not appear as a diagnosis separate from PTSD in current diagnostic manuals, C-PTSD has been the subject of a great deal of debate in the clinical community. It is scheduled to appear in the upcoming edition of the World Health Organization's (WHO) International Statistical Classification of Diseases and Related Health Problems. 30 Usually, C-PTSD is defined as repetitive and prolonged trauma, such as that which can occur in a war zone, in cases of child abuse, or in domestic violence situations. It is regarded as more difficult to treat than single-incident PTSD.

RESULTS

summarizes the demographic characteristics of the 448 respondents. Most respondents were either licensed mental health professionals (37.7%) or alternative medicine practitioners (31.6%). More than 62% held a master's degree or higher, and 84.5% reported practicing in a private practice setting. The percentage of practitioners with 10 or fewer years of experience was 32.8%, 11 to 20 years was 26.8%, 21 to 30 years was 18.2%, 31 to 40 years was 15.9%, and 41 or more years in practice was 6.2%. Respondents had a mean age of 58 years, with a range of 22 to 85 years, and 72.4% were women.

profiles the course of treatment for PTSD-positive clients. The PTSD clients constituted more than 20% of the practice for 37.0% of practitioners and less than 10% for 39.9% of respondents. Nearly half the respondents (45.2%) reported having worked with more than 50 clients with PTSD, and 41.4% said they spend more than 5 hours per week treating PTSD. Estimates of the average number of sessions needed to successfully treat complex PTSD were in the 1 to 5 range for 25.7% of the practitioners and 6 to 10 sessions for an additional 37.3% of practitioners. These estimates of sessions required align with those in the published literature. 15- 23

summarizes responses regarding the perceived prevalence of PTSD, the use of diagnostic scales, and referrals. According to the US National Institutes of Health, the prevalence of PTSD in the general adult population is 3.5%, 31 but 91.7% of our survey respondents believed that this estimate is too low; only 7.6% assessed it as accurate. When asked to estimate the true prevalence, answers varied widely, but the most common answers were 6% to 10% (24.1%), 11% to 15% (19.7%), and 16% to 20% (18.2%).

Validated instruments to track client progress were used by 29.3% of respondents, which is consistent with other surveys of mental health professionals. 32 Of the 448 respondents, 153 reported which assessments they use. The PTSD Checklist (PCL) was the most common, used by 56.9%, followed by the Life Events Checklist (36.6%) and the PTSD Symptom Scale (30.7%).

Practitioners rarely terminated work with a client and referred that client to another practitioner. For 91.8% of respondents, this occurred with 10% or fewer of clients. Continuing treatment in conjunction with another professional was more common.

summarizes the most used therapy techniques, both EFT and non-EFT. Regarding use of EFT, 43.6% indicated they use it 51% or more of the time during their therapy sessions, and 27.4% said they use EFT 21% to 50% of the time. The 3 most common non-EFT methods used are cognitive therapy (45.7% of practitioners surveyed), life coaching (39.8%), and EMDR (31%). In an open-ended question, the non-EFT techniques that respondents listed as most beneficial for treating PTSD were cognitive therapy (12.0%), EMDR (10.2%), and meditation (7.7%).

summarizes respondents' evaluations of PTSD therapy outcomes. Full rehabilitation in more than 60% of their clients was reported by 64.7% of respondents, with full rehabilitation in 90% of their clients being reported by 22.1% of respondents. Clinical trials of EFT in treating PTSD 15- 23 show higher success rates than those most frequently reported by the respondents. Most respondents (89.8%) reported that less than 10% of their clients make little or no progress with EFT. This is reflected in the low dropout rates typical of EFT treatment programs; in the 7 studies reported in the meta-analysis of EFT for PTSD, the mean dropout rate was under 10%. 8

We now present two typical case studies of veterans who presented for treatment at Veterans Affairs facilities and exhibited positive outcomes.

Case Study 1: Vietnam Combat Memories

More than four decades after returning from service in Vietnam, a male veteran presented for treatment. His issues included complex medical problems, multiple addictions, broken relationships, intolerable mental and emotional symptoms, nightmares, and homelessness. As one component of a multidisciplinary evidence-based treatment regimen at the Veterans Affairs Medical Center, he chose to learn and practice EFT as an adjunct to individual psychotherapy and group therapy.

During one appointment, he chose to use EFT on three persistent Vietnam combat memories that induced hyperarousal, reexperiencing, and avoidance. In the first, he was faced with an approaching enemy unit. In the second, his unit was attacked and most of his "battle buddies" were killed. In the third, he witnessed another adolescent warrior's life-threatening wounds and emotional suffering.

He provided an SUD score of 10 of 10 for the first 2 memories at the start of an hourlong appointment. After EFT, this fell to 0. He commented, "It's over. I'm home now. I'm safe." By the time he felt ready to apply EFT to the third memory, he reported distress already reduced to 3 and, after EFT, 0. He appeared animated and chose to retell the stories, sharing graphic details without any evidence or report of emotional distress. He demonstrated positive cognitive shifts, reframing his perception to reflect that his quick actions under fire did not reflect cowardice, as he had believed since the incident, but rather that he had quickly done exactly what he was trained to do; this saved his own life and the lives of others. He smiled and laughed and reported immense relief, energy, and joy. By the following appointment, he reported that he had not had a single nightmare about Vietnam that week, for the first time in more than 40 years.

He continues to experience sustained symptom relief. He now has spent three years in recovery from substance abuse, the longest period yet. Veterans Affairs clinicians are gradually weaning him off his psychotropic medications. He uses EFT independently between appointments for sustained smoking cessation, ongoing healthy weight loss, and stress management. He has found stable housing and renewed healthy relationships with his family. He wants clinicians and other veterans to know this: "I was in a fight for my life. Don't give up. Keep trying. EFT helped me to cope with life. It relaxes me and puts me in a place where I want to be: from the inside looking out, not the outside looking in. It's given me a positive perspective on life. I have my family back, my mind got clearer, and I have more confidence. It's lovely."

Case Study 2: Military Sexual Trauma

When he came for treatment, this veteran was experiencing intolerable emotional, mental, and physical symptoms. He had been numbing these by self-medicating with multiple illicit substances for more than 30 years. He was homeless, with broken relationships and medical problems. Although skeptical about EFT "because it gave me the impression of being silly," he decided to try it. He states, "After a few sessions, with practice, I began to notice how I was able to release the distress and fears caused by old and new painful emotions. ... One of its advantages [is] that I can and would utilize it at home, in school, or on the job as a form of relaxation."

Initially, he was reluctant to address his experience with military sexual trauma using any psychotherapeutic modality. He had already dropped out of other evidence-based modalities before trying EFT, stating that sessions were like "experiencing it all over again." During one appointment, he chose to use EFT on his military sexual trauma experience, stating that it was blocking him from moving forward in his life. During the next four EFT appointments, he achieved resolution of his distressful symptoms. The positive effect persisted for the following year as he was weaned from his psychotropic medications.

During an EFT session, a defining moment occurred when he was stuck at a persistent level of emotional distress, a 5 to 6 on the SUD scale. He used EFT on a particular aspect of his sexual trauma experience, "the look on their faces." (For a discussion of "Aspects," see The EFT Manual, p 100 12). Once his SUD score fell to 0, he stated: "It doesn't matter now. I don't have to live my life this way anymore. It's over. I know it happened, but I can think about it now without feeling those symptoms or wanting to go out and use [illegal substances]. I'm at peace now. I feel as if the weight of the world has been lifted off my shoulders." The clinician observed positive cognitive shifts, relaxed facial and body posture, and smiles in support of his comments.

This veteran has now achieved more than five years in recovery from substance abuse, his longest time ever. His PTSD symptoms are resolved. He is enjoying healthy relationships with family and friends. He is independent, living in his own apartment, attending classes with the goal of employment, and experiencing a positive quality of life. He continues to use acupuncture, meditation, and EFT. He wants clinicians and other veterans to know this: "These techniques have given me a new outlook on life and to see new possibilities in the hope of setting goals and to visualize stability in my life, free of tension. Most of all it has helped me to accept my faults, forgive myself and others, to make amends, and change my negative feelings and behaviors into positive ones, giving me a sense of peace, lots of joy, and much love and compassion for others."

Additional veteran case studies; letters from veterans, practitioners, and members of the US Congress; and transcripts from congressional testimony on EFT may be viewed at the Web site of the Veterans Stress Project ( www.StressProject.org). 29

DISCUSSION

On the basis of the studies outlined earlier, the results of the survey, and expert consensus, we propose the following treatment guidelines for using EFT for PTSD.

Proposed Treatment Guidelines

The NICE guidelines use a "stepped care" model that we believe is an appropriate framework for treating PTSD. 33 We also believe that the risk of PTSD should be mitigated using a proactive approach to develop resiliency. In the NICE model, the patient is offered the least intrusive potentially effective intervention first. If the patient does not benefit, or prefers not to continue, s/he is offered the next step. The NICE guidelines emphasize the importance of integrated care, because many mental health conditions share similar neural pathways. This position is reinforced by results of EFT studies, which show the symptoms of depression, anxiety, and other psychological conditions declining simultaneously after PTSD treatment. 2, 34 A study of 216 health care workers tracked whether participants used EFT after the intervention period and found that those who used EFT afterward experienced greater symptom reductions than those who did not. 35 At the Warrior Combat Stress Reset Program at Fort Hood, TX, EFT has been used for many years, along with EMDR and other complementary therapies. 36 Fort Hood clinicians typically use EMDR during sessions while teaching EFT to patients as a method of managing stress between sessions. Practitioners typically recommend that clients use EFT between sessions as well as during them, and after courses of treatment have ended to manage the stress of daily life. 2, 12 The following recommendations are based on NICE Guideline 26, titled "The Treatment of PTSD in Adults and Children in Primary and Secondary Care." 37

The NICE Step 1 guideline advocates identification, assessment, psychoeducation, active monitoring, and referral for further assessment and interventions. In Step 1, the PCL or PCL-M is used to assess PTSD symptom levels, and further treatment is based on the cutoff scores. Although several cutoff points for the PCL-M have been evaluated, a score of 35 or greater indicates PTSD risk probability in a military population and is appropriate for Step 1. 38 Veterans Affairs guidelines describe a 10- to 20-point reduction in PCL scores as representing clinically significant change. 39 Although reduction of symptoms below a score of 50 results in a client falling below the cutoff for a PTSD diagnosis, we recommend a treatment goal of below 35 because this reduces the risk of delayed-onset PTSD. If indications of complex PTSD are apparent, a multimodal approach encompassing more than 10 sessions might be considered. These scores should be updated as subsequent versions of the PCL are implemented and validated. For other assessments, accepted cutoff scores for clinical and at-risk symptom levels can be substituted for those of the PCL.

NICE Step 2 guidelines for PTSD recommend treatment using Trauma-Focused Cognitive Behavior Therapy (TFCBT) or EMDR. These recommendations did not include EFT because most of the earlier referenced studies had not been published at the time the guidelines were developed. To make EFT available to a PTSD-positive population, we recommend an update of the guidelines based on currently published research. We propose that EFT be added to the recommended treatments based on the following criteria:

Subclinical Scores (35-49) in Initial Assessment

Treatment as usual plus A) 5 individual EFT therapy sessions and B) 1 instructional session on using the Battle Tap interactive online coach plus C) 3 Borrowing Benefits group therapy sessions. If members of the client's family are willing and able to attend Borrowing Benefits sessions, they should be invited.

Assessment 2: After the primary treatment program is complete, if symptom levels are persistently more than 34, A) 3 more sessions plus B) 1 additional Battle Tap instructional session.

Follow-up Assessment: 3 months after the final therapy session, if symptom levels are persistently above 34, monitor the client and perform regular follow-up assessments.

Clinical Scores (> 49) in Initial Assessment

Treatment as usual plus A) 10 individual EFT therapy sessions plus B) 2 sessions on using Battle Tap plus C) 5 Borrowing Benefits group sessions. If members of the client's family are willing and able to attend Borrowing Benefits sessions, they should be invited.

Assessment 2: After the primary treatment program is complete, if symptom levels are persistently above 40, A) 3 more individual therapy sessions plus B) 1 additional Battle Tap session plus C) 5 additional Borrowing Benefits group sessions.

Follow-up Assessment: 3 months after final therapy session, if clinical symptoms persist, escalate intervention to Steps 3 and 4 of the NICE guidelines, which advocate appropriate medication and intensive individual psychotherapy.

RISK MITIGATION FOR ACTIVE-DUTY WARRIORS

Instead of waiting until PTSD is diagnosed, we recommend a proactive approach using psychoeducation and Borrowing Benefits to mitigate the risk of development of symptoms in active-duty warriors. This has two components: the first applicable to the predeployment phase and the second in the postdeployment phase.

Predeployment Component

Independent of PCL-M assessment, three days of group EFT training using Borrowing Benefits as stress inoculation therapy, including an introduction to Battle Tap.

Postdeployment Component

Independent of PCL-M assessment, seven days of group EFT therapy using Borrowing Benefits and Battle Tap. Individual psychotherapy sessions as requested by participants.

CONCLUSION

According to published reports, systematic reviews of the published evidence, a meta-analysis of seven RCTs, and practitioner consensus, most cases of PTSD are remediated in ten EFT sessions or less. As a safe, efficacious, and easily learned self-help method, EFT should be offered to clients as an initial treatment option immediately after diagnosis. Group therapy involving family members may reinforce treatment effects through social support, and access to Battle Tap provides veterans and warriors with access to EFT at times and places of their own choosing. A structured evidence-based practice protocol should be widely disseminated to clinicians and institutions bearing the burden of PTSD treatment. For those patients who do not respond, appropriate medication and intensive individual psychotherapy is recommended, especially in cases of complex PTSD.

Solely for Good

Not for the self, not for the fulfillment of any worldly desire or gain, but solely for the good of suffering humanity, I will treat my patients and excel all.

- Charaka, ~6th-2nd century BCE, principle contributor to Ayruveda, author of Charaka Samhita

Acknowledgment

Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

Footnotes
Disclosure Statement
Dr Church is a stockholder in Energy Psychology Group, an organization providing training services and publications to medical and mental health professionals; he also receives income from presentations and publications related to the therapeutic method discussed. Dr Feinstein is the CEO of Innersource and Volunteer Executive Director of Energy Medical Institute.

The author(s) have no other conflicts of interest to disclose.

References

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Emotional Freedom Techniques to Treat Posttraumatic Stress Disorder in Veterans: Review of the Evidence, Survey of Practitioners, and Proposed Clinical Guidelines

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A number of systematic reviews consider the evidence for Emotional Freedom Techniques (EFT) as an "evidence-based" practice. 1- 3 Studies are typically evaluated using criteria published by the American Psychological Association's (APA's) Division 12 Task Force on Empirically Validated Treatments, hereafter abridged as "APA standards."

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Getting Stared with Trauma-Informed Practices

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Edutopia video that introduces Trauma-Informed Practices in the school setting.

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Getting Started With Trauma-Informed Practices

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Quick Classroom Exercises to Make Learning Lively

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Quick Classroom Exercises to Make Learning Lively

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Quick Classroom Exercises to Make Learning Lively

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Physical Activity, Fitness, and Physical Education: Effect on Academic Learning

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Physical Activity, Fitness, and Physical Education: Effect on Academic Learning

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Evidence suggests that increasing physical activity and physical fitness may improve academic performance and that time in the school day dedicated to recess, physical education class, and physical activity in the classroom may also facilitate academic performance.

Available evidence suggests that mathematics and reading are the academic topics that are most influenced by physical activity. These topics depend on efficient and effective executive function, which has been linked to physical activity and physical fitness.

Executive function and brain health underlie academic performance. Basic cognitive functions related to attention and memory facilitate learning, and these functions are enhanced by physical activity and higher aerobic fitness.

Single sessions of and long-term participation in physical activity improve cognitive performance and brain health. Children who participate in vigorous- or moderate-intensity physical activity benefit the most.

Given the importance of time on task to learning, students should be provided with frequent physical activity breaks that are developmentally appropriate.

Although presently understudied, physically active lessons offered in the classroom may increase time on task and attention to task in the classroom setting.

PHYSICAL FITNESS AND PHYSICAL ACTIVITY: RELATION TO ACADEMIC PERFORMANCE

State-mandated academic achievement testing has had the unintended consequence of reducing opportunities for children to be physically active during the school day and beyond. In addition to a general shifting of time in school away from physical education to allow for more time on academic subjects, some children are withheld from physical education classes or recess to participate in remedial or enriched learning experiences designed to increase academic performance ( Pellegrini and Bohn, 2005; see Chapter 5). Yet little evidence supports the notion that more time allocated to subject matter will translate into better test scores. Indeed, 11 of 14 correlational studies of physical activity during the school day demonstrate a positive relationship to academic performance ( Rasberry et al., 2011). Overall, a rapidly growing body of work suggests that time spent engaged in physical activity is related not only to a healthier body but also to a healthier mind ( Hillman et al., 2008).

Children respond faster and with greater accuracy to a variety of cognitive tasks after participating in a session of physical activity ( Tomporowski, 2003; Budde et al., 2008; Hillman et al., 2009; Pesce et al., 2009; Ellemberg and St-Louis-Deschênes, 2010). A single bout of moderate-intensity physical activity has been found to increase neural and behavioral concomitants associated with the allocation of attention to a specific cognitive task ( Hillman et al., 2009; Pontifex et al., 2012). And when children who participated in 30 minutes of aerobic physical activity were compared with children who watched television for the same amount of time, the former children cognitively outperformed the latter ( Ellemberg and St-Louis-Desêhenes, 2010). Visual task switching data among 69 overweight and inactive children did not show differences between cognitive performance after treadmill walking and sitting ( Tomporowski et al., 2008b).

When physical activity is used as a break from academic learning time, postengagement effects include better attention ( Grieco et al., 2009; Bartholomew and Jowers, 2011), increased on-task behaviors ( Mahar et al., 2006), and improved academic performance ( Donnelly and Lambourne, 2011). Comparisons between 1st-grade students housed in a classroom with stand-sit desks where the child could stand at his/her discretion and in classrooms containing traditional furniture showed that the former children were highly likely to stand, thus expending significantly more energy than those who were seated ( Benden et al., 2011). More important, teachers can offer physical activity breaks as part of a supplemental curriculum or simply as a way to reset student attention during a lesson ( Kibbe et al., 2011; see Chapter 6) and when provided with minimal training can efficaciously produce vigorous or moderate energy expenditure in students ( Stewart et al., 2004). Further, after-school physical activity programs have demonstrated the ability to improve cardiovascular endurance, and this increase in aerobic fitness has been shown to mediate improvements in academic performance ( Fredericks et al., 2006), as well as the allocation of neural resources underlying performance on a working memory task ( Kamijo et al., 2011).

Over the past three decades, several reviews and meta-analyses have described the relationship among physical fitness, physical activity, and cognition (broadly defined as all mental processes). The majority of these reviews have focused on the relationship between academic performance and physical fitness-a physiological trait commonly defined in terms of cardiorespiratory capacity (e.g., maximal oxygen consumption; see Chapter 3). More recently, reviews have attempted to describe the effects of an acute or single bout of physical activity, as a behavior, on academic performance. These reviews have focused on brain health in older adults ( Colcombe and Kramer, 2003), as well as the effects of acute physical activity on cognition in adults ( Tomporowski, 2003). Some have considered age as part of the analysis ( Etnier et al., 1997, 2006). Reviews focusing on research conducted in children ( Sibley and Etnier, 2003) have examined the relationship among physical activity, participation in sports, and academic performance ( Trudeau and Shephard, 2008, 2010; Singh et al., 2012); physical activity and mental and cognitive health ( Biddle and Asare, 2011); and physical activity, nutrition, and academic performance ( Burkhalter and Hillman, 2011). The findings of most of these reviews align with the conclusions presented in a meta-analytic review conducted by Fedewa and Ahn (2011). The studies reviewed by Fedewa and Ahn include experimental/quasi-experimental as well as cross-sectional and correlational designs, with the experimental designs yielding the highest effect sizes. The strongest relationships were found between aerobic fitness and achievement in mathematics, followed by IQ and reading performance. The range of cognitive performance measures, participant characteristics, and types of research design all mediated the relationship among physical activity, fitness, and academic performance. With regard to physical activity interventions, which were carried out both within and beyond the school day, those involving small groups of peers (around 10 youth of a similar age) were associated with the greatest gains in academic performance.

The number of peer-reviewed publications on this topic is growing exponentially. Further evidence of the growth of this line of inquiry is its increased global presence. Positive relationships among physical activity, physical fitness, and academic performance have been found among students from the Netherlands ( Singh et al., 2012) and Taiwan ( Chih and Chen, 2011). Broadly speaking, however, many of these studies show small to moderate effects and suffer from poor research designs ( Biddle and Asare, 2011; Singh et al., 2012).

Basch (2010) conducted a comprehensive review of how children's health and health disparities influence academic performance and learning. The author's report draws on empirical evidence suggesting that education reform will be ineffective unless children's health is made a priority. Basch concludes that schools may be the only place where health inequities can be addressed and that, if children's basic health needs are not met, they will struggle to learn regardless of the effectiveness of the instructional materials used. More recently, Efrat (2011) conducted a review of physical activity, fitness, and academic performance to examine the achievement gap. He discovered that only seven studies had included socioeconomic status as a variable, despite its known relationship to education ( Sirin, 2005).

Physical Fitness as a Learning Outcome of Physical Education and Its Relation to Academic Performance

Achieving and maintaining a healthy level of aerobic fitness, as defined using criterion-referenced standards from the National Health and Nutrition Examination Survey (NHANES; Welk et al., 2011), is a desired learning outcome of physical education programming. Regular participation in physical activity also is a national learning standard for physical education, a standard intended to facilitate the establishment of habitual and meaningful engagement in physical activity ( NASPE, 2004). Yet although physical fitness and participation in physical activity are established as learning outcomes in all 50 states, there is little evidence to suggest that children actually achieve and maintain these standards (see Chapter 2).

Statewide and national datasets containing data on youth physical fitness and academic performance have increased access to student-level data on this subject ( Grissom, 2005; Cottrell et al., 2007; Carlson et al., 2008; Chomitz et al., 2008; Wittberg et al., 2010; Van Dusen et al., 2011). Early research in South Australia focused on quantifying the benefits of physical activity and physical education during the school day; the benefits noted included increased physical fitness, decreased body fat, and reduced risk for cardiovascular disease ( Dwyer et al., 1979, 1983). Even today, Dwyer and colleagues are among the few scholars who regularly include in their research measures of physical activity intensity in the school environment, which is believed to be a key reason why they are able to report differentiated effects of different intensities. A longitudinal study in Trois-Rivières, Québec, Canada, tracked how the academic performance of children from grades 1 through 6 was related to student health, motor skills, and time spent in physical education. The researchers concluded that additional time dedicated to physical education did not inhibit academic performance ( Shephard et al., 1984; Shephard, 1986; Trudeau and Shephard, 2008).

Longitudinal follow-up investigating the long-term benefits of enhanced physical education experiences is encouraging but largely inconclusive. In a study examining the effects of daily physical education during elementary school on physical activity during adulthood, 720 men and women completed the Québec Health Survey ( Trudeau et al., 1999). Findings suggest that physical education was associated with physical activity in later life for females but not males ( Trudeau et al., 1999); most of the associations were significant but weak ( Trudeau et al., 2004). Adult body mass index (BMI) at age 34 was related to childhood BMI at ages 10-12 in females but not males ( Trudeau et al., 2001). Longitudinal studies such as those conducted in Sweden and Finland also suggest that physical education experiences may be related to adult engagement in physical activity ( Glenmark, 1994; Telama et al., 1997). From an academic performance perspective, longitudinal data on men who enlisted for military service imply that cardiovascular fitness at age 18 predicted cognitive performance in later life (Aberg et al., 2009), thereby supporting the idea of offering physical education and physical activity opportunities well into emerging adulthood through secondary and postsecondary education.

Castelli and colleagues (2007) investigated younger children (in 3rd and 5th grades) and the differential contributions of the various subcomponents of the Fitnessgram ®. Specifically, they examined the individual contributions of aerobic capacity, muscle strength, muscle flexibility, and body composition to performance in mathematics and reading on the Illinois Standardized Achievement Test among a sample of 259 children. Their findings corroborate those of the California Department of Education ( Grissom, 2005), indicating a general relationship between fitness and achievement test performance. When the individual components of the Fitnessgram were decomposed, the researchers determined that only aerobic capacity was related to test performance. Muscle strength and flexibility showed no relationship, while an inverse association of BMI with test performance was observed, such that higher BMI was associated with lower test performance. Although Baxter and colleagues (2011) confirmed the importance of attending school in relation to academic performance through the use of 4th-grade student recall, correlations with BMI were not significant.

State-mandated implementation of the coordinated school health model requires all schools in Texas to conduct annual fitness testing using the Fitnessgram among students in grades 3-12. In a special issue of Research Quarterly for Exercise and Sport (2010), multiple articles describe the current state of physical fitness among children in Texas; confirm the associations among school performance levels, academic achievement, and physical fitness ( Welk et al., 2010; Zhu et al., 2010); and demonstrate the ability of qualified physical education teachers to administer physical fitness tests ( Zhu et al., 2010). Also using data from Texas schools, Van Dusen and colleagues (2011) found that cardiovascular fitness had the strongest association with academic performance, particularly in mathematics over reading. Unlike previous research, which demonstrated a steady decline in fitness by developmental stage ( Duncan et al., 2007), this study found that cardiovascular fitness did decrease but not significantly ( Van Dusen et al., 2011). Aerobic fitness, then, may be important to academic performance, as there may be a dose-response relationship ( Van Dusen et al., 2011).

Using a large sample of students in grades 4-8, Chomitz and colleagues (2008) found that the likelihood of passing both mathematics and English achievement tests increased with the number of fitness tests passed during physical education class, and the odds of passing the mathematics achievement tests were inversely related to higher body weight. Similar to the findings of Castelli and colleagues (2007), socioeconomic status and demographic factors explained little of the relationship between aerobic fitness and academic performance; however, socioeconomic status may be an explanatory variable for students of low fitness ( London and Castrechini, 2011).

In sum, numerous cross-sectional and correlational studies demonstrate small-to-moderate positive or null associations between physical fitness ( Grissom, 2005; Cottrell et al., 2007; Edwards et al., 2009; Eveland-Sayers et al., 2009; Cooper et al., 2010; Welk et al., 2010; Wittberg et al., 2010; Zhu et al., 2010; Van Dusen et al., 2011), particularly aerobic fitness, and academic performance ( Castelli et al, 2007; Chomitz et al., 2008; Roberts et al., 2010; Welk et al., 2010; Chih and Chen, 2011; London and Castrechini, 2011; Van Dusen et al., 2011). Moreover, the findings may support a dose-response association, suggesting that the more components of physical fitness (e.g., cardiovascular endurance, strength, muscle endurance) considered acceptable for the specific age and gender that are present, the greater the likelihood of successful academic performance. From a public health and policy standpoint, the conclusions these findings support are limited by few causal inferences, a lack of data confirmation, and inadequate reliability because the data were often collected by nonresearchers or through self-report methods. It may also be noted that this research includes no known longitudinal studies and few randomized controlled trials (examples are included later in this chapter in the discussion of the developing brain).

Physical Activity, Physical Education, and Academic Performance

In contrast with the correlational data presented above for physical fitness, more information is needed on the direct effects of participation in physical activity programming and physical education classes on academic performance.

The regular engagement in physical activity achieved during physical education programming can also be related to academic performance, especially when the class is taught by a physical education teacher. The Sports, Play, and Active Recreation for Kids (SPARK) study examined the effects of a 2-year health-related physical education program on academic performance in children ( Sallis et al., 1999). In an experimental design, seven elementary schools were randomly assigned to one of three conditions: (1) a specialist condition in which certified physical education teachers delivered the SPARK curriculum, (2) a trained-teacher condition in which classroom teachers implemented the curriculum, and (3) a control condition in which classroom teachers implemented the local physical education curriculum. No significant differences by condition were found for mathematics testing; however, reading scores were significantly higher in the specialist condition relative to the control condition ( Sallis et al., 1999), while language scores were significantly lower in the specialist condition than in the other two conditions. The authors conclude that spending time in physical education with a specialist did not have a negative effect on academic performance. Shortcomings of this research include the amount of data loss from pre- to posttest, the use of results of 2nd-grade testing that exceeded the national average in performance as baseline data, and the use of norm-referenced rather than criterion-based testing.

In seminal research conducted by Gabbard and Barton (1979), six different conditions of physical activity (no activity; 20, 30, 40, and 50 minutes; and posttest no activity) were completed by 106 2nd graders during physical education. Each physical activity session was followed by 5 minutes of rest and the completion of 36 math problems. The authors found a potential threshold effect whereby only the 50-minute condition improved mathematical performance, with no differences by gender.

A longitudinal study of the kindergarten class of 1998-1999, using data from the Early Childhood Longitudinal Study, investigated the association between enrollment in physical education and academic achievement ( Carlson et al., 2008). Higher amounts of physical education were correlated with better academic performance in mathematics among females, but this finding did not hold true for males.

Ahamed and colleagues (2007) found in a cluster randomized trial that, after 16 months of a classroom-based physical activity intervention, there was no significant difference between the treatment and control groups in performance on the standardized Cognitive Abilities Test, Third Edition (CAT-3). Others have found, however, that coordinative exercise ( Budde et al., 2008) or bouts of vigorous physical activity during free time ( Coe et al., 2006) contribute to higher levels of academic performance. Specifically, Coe and colleagues examined the association of enrollment in physical education and self-reported vigorous- or moderate-intensity physical activity outside school with performance in core academic courses and on the Terra Nova Standardized Achievement Test among more than 200 6th-grade students. Their findings indicate that academic performance was unaffected by enrollment in physical education classes, which were found to average only 19 minutes of vigorous- or moderate-intensity physical activity. When time spent engaged in vigorous- or moderate-intensity physical activity outside of school was considered, however, a significant positive relation to academic performance emerged, with more time engaged in vigorous- or moderate-intensity physical activity being related to better grades but not test scores ( Coe et al., 2006).

Studies of participation in sports and academic achievement have found positive associations ( Mechanic and Hansell, 1987; Dexter, 1999; Crosnoe, 2002; Eitle and Eitle, 2002; Stephens and Schaben, 2002; Eitle, 2005; Miller et al., 2005; Fox et al., 2010; Ruiz et al., 2010); higher grade point averages (GPAs) in season than out of season ( Silliker and Quirk, 1997); a negative association between cheerleading and science performance ( Hanson and Kraus, 1998); and weak and negative associations between the amount of time spent participating in sports and performance in English-language class among 13-, 14-, and 16-year-old students ( Daley and Ryan, 2000). Other studies, however, have found no association between participation in sports and academic performance ( Fisher et al., 1996). The findings of these studies need to be interpreted with caution as many of their designs failed to account for the level of participation by individuals in the sport (e.g., amount of playing time, type and intensity of physical activity engagement by sport). Further, it is unclear whether policies required students to have higher GPAs to be eligible for participation. Offering sports opportunities is well justified regardless of the cognitive benefits, however, given that adolescents may be less likely to engage in risky behaviors when involved in sports or other extracurricular activities ( Page et al., 1998; Elder et al., 2000; Taliaferro et al., 2010), that participation in sports increases physical fitness, and that affiliation with sports enhances school connectedness.

Although a consensus on the relationship of physical activity to academic achievement has not been reached, the vast majority of available evidence suggests the relationship is either positive or neutral. The meta-analytic review by Fedewa and Ahn (2011) suggests that interventions entailing aerobic physical activity have the greatest impact on academic performance; however, all types of physical activity, except those involving flexibility alone, contribute to enhanced academic performance, as do interventions that use small groups (about 10 students) rather than individuals or large groups. Regardless of the strength of the findings, the literature indicates that time spent engaged in physical activity is beneficial to children because it has not been found to detract from academic performance, and in fact can improve overall health and function ( Sallis et al., 1999; Hillman et al., 2008; Tomporowski et al., 2008a; Trudeau and Shephard, 2008; Rasberry et al., 2011).

Single Bouts of Physical Activity

Beyond formal physical education, evidence suggests that multi-component approaches are a viable means of providing physical activity opportunities for children across the school curriculum (see also Chapter 6). Although health-related fitness lessons taught by certified physical education teachers result in greater student fitness gains relative to such lessons taught by other teachers ( Sallis et al., 1999), non-physical education teachers are capable of providing opportunities to be physically active within the classroom ( Kibbe et al., 2011). Single sessions or bouts of physical activity have independent merit, offering immediate benefits that can enhance the learning experience. Studies have found that single bouts of physical activity result in improved attention ( Hillman et al., 2003, 2009; Pontifex et al., 2012), better working memory ( Pontifex et al., 2009), and increased academic learning time and reduced off-task behaviors ( Mahar et al., 2006; Bartholomew and Jowers, 2011). Yet single bouts of physical activity have differential effects, as very vigorous exercise has been associated with cognitive fatigue and even cognitive decline in adults ( Tomporowski, 2003). As seen in Figure 4-1, high levels of effort, arousal, or activation can influence perception, decision making, response preparation, and actual response. For discussion of the underlying constructs and differential effects of single bouts of physical activity on cognitive performance, see Tomporowski (2003).

A randomized controlled trial entitled Physical Activity Across the Curriculum (PAAC) used cluster randomization among 24 schools to examine the effects of physically active classroom lessons on BMI and academic achievement ( Donnelly et al., 2009). The academically oriented physical activities were intended to be of vigorous or moderate intensity (3-6 metabolic equivalents [METs]) and to last approximately 10 minutes and were specifically designed to supplement content in mathematics, language arts, geography, history, spelling, science, and health. The study followed 665 boys and 677 girls for 3 years as they rose from 2nd or 3rd to 4th or 5th grades. Changes in academic achievement, fitness, and blood screening were considered secondary outcomes. During a 3-year period, students who engaged in physically active lessons, on average, improved their academic achievement by 6 percent, while the control groups exhibited a 1 percent decrease. In students who experienced at least 75 minutes of PAAC lessons per week, BMI remained stable (see Figure 4-3).

It is important to note that cognitive tasks completed before, during, and after physical activity show varying effects, but the effects were always positive compared with sedentary behavior. In a study carried out by Drollette and colleagues (2012), 36 preadolescent children completed two cognitive tasks-a flanker task to assess attention and inhibition and a spatial nback task to assess working memory-before, during, and after seated rest and treadmill walking conditions. The children sat or walked on different days for an average of 19 minutes. The results suggest that the physical activity enhanced cognitive performance for the attention task but not for the task requiring working memory. Accordingly, although more research is needed, the authors suggest that the acute effects of exercise may be selective to certain cognitive processes (i.e., attentional inhibition) while unrelated to others (e.g., working memory). Indeed, data collected using a task-switching paradigm (i.e., a task designed to assess multitasking and requiring the scheduling of attention to multiple aspects of the environment) among 69 overweight and inactive children did not show differences in cognitive performance following acute bouts of treadmill walking or sitting ( Tomporowski et al., 2008b). Thus, findings to date indicate a robust relationship of acute exercise to transient improvements in attention but appear inconsistent for other aspects of cognition.

Academic Learning Time and On- and Off-Task Behaviors

Excessive time on task, inattention to task, off-task behavior, and delinquency are important considerations in the learning environment given the importance of academic learning time to academic performance. These behaviors are observable and of concern to teachers as they detract from the learning environment. Systematic observation by trained observers may yield important insight regarding the effects of short physical activity breaks on these behaviors. Indeed, systematic observations of student behavior have been used as an alternative means of measuring academic performance ( Mahar et al., 2006; Grieco et al., 2009).

After the development of classroom-based physical activities, called Energizers, teachers were trained in how to implement such activities in their lessons at least twice per week ( Mahar et al., 2006). Measurements of baseline physical activity and on-task behaviors were collected in two 3rd-grade and two 4th-grade classes, using pedometers and direct observation. The intervention included 243 students, while 108 served as controls by not engaging in the activities. A subgroup of 62 3rd and 4th graders was observed for on-task behavior in the classroom following the physical activity. Children who participated in Energizers took more steps during the school day than those who did not; they also increased their on-task behaviors by more than 20 percent over baseline measures.

A systematic review of a similar in-class, academically oriented, physical activity plan-Take 10!-was conducted to identify the effects of its implementation after it had been in use for 10 years ( Kibbe et al., 2011). The findings suggest that children who experienced Take 10! in the classroom engaged in moderate to vigorous physical activity (6.16 to 6.42 METs) and had lower BMIs than those who did not. Further, children in the Take 10! classrooms had better fluid intelligence ( Reed et al., 2010) and higher academic achievement scores ( Donnelly et al., 2009).

Some have expressed concern that introducing physical activity into the classroom setting may be distracting to students. Yet in one study it was sedentary students who demonstrated a decrease in time on task, while active students returned to the same level of on-task behavior after an active learning task ( Grieco et al., 2009). Among the 97 3rd-grade students in this study, a small but nonsignificant increase in on-task behaviors was seen immediately following these active lessons. Additionally, these improvements were not mediated by BMI.

In sum, although presently understudied, physically active lessons may increase time on task and attention to task in the classroom setting. Given the complexity of the typical classroom, the strategy of including content-specific lessons that incorporate physical activity may be justified.

Recess

To examine the effects of engagement in physical activity during recess on classroom behavior, Barros and colleagues (2009) examined data from the Early Childhood Longitudinal Study on 10,000 8- to 9-year-old children. Teachers provided the number of minutes of recess as well as a ranking of classroom behavior (ranging from "misbehaves frequently" to "behaves exceptionally well"). Results indicate that children who had at least 15 minutes of recess were more likely to exhibit appropriate behavior in the classroom ( Barros et al., 2009). In another study, 43 4th-grade students were randomly assigned to 1 or no days of recess to examine the effects on classroom behavior ( Jarrett et al., 1998). The researchers concluded that on-task behavior was better among the children who had recess. A moderate effect size (= 0.51) was observed. In a series of studies examining kindergartners' attention to task following a 20-minute recess, increased time on task was observed during learning centers and story reading ( Pellegrini et al., 1995). Despite these positive findings centered on improved attention, it is important to note that few of these studies actually measured the intensity of the physical activity during recess.

From a slightly different perspective, survey data from 547 Virginia elementary school principals suggest that time dedicated to student participation in physical education, art, and music did not negatively influence academic performance ( Wilkins et al., 2003). Thus, the strategy of reducing time spent in physical education to increase academic performance may not have the desired effect. The evidence on in-school physical activity supports the provision of physical activity breaks during the school day as a way to increase fluid intelligence, time on task, and attention. However, it remains unclear what portion of these effects can be attributed to a break from academic time and what portion is a direct result of the specific demands/characteristics of the physical activity.

THE DEVELOPING bRAIN, PHYSICAL ACTIVITY, AND BRAIN HEALTH

The study of brain health has grown beyond simply measuring behavioral outcomes such as task performance and reaction time (e.g., cognitive processing speed). New technology has emerged that has allowed scientists to understand the impact of lifestyle factors on the brain from the body systems level down to the molecular level. A greater understanding of the cognitive components that subserve academic performance and may be amenable to intervention has thereby been gained. Research conducted in both laboratory and field settings has helped define this line of inquiry and identify some preliminary underlying mechanisms.

The Evidence Base on the Relationship of Physical Activity to Brain Health and Cognition in Older Adults

Despite the current focus on the relationship of physical activity to cognitive development, the evidence base is larger on the association of physical activity with brain health and cognition during aging. Much can be learned about how physical activity affects childhood cognition and scholastic achievement through this work. Despite earlier investigations into the relationship of physical activity to cognitive aging (see Etnier et al., 1997, for a review), the field was shaped by the findings of Kramer and colleagues (1999), who examined the effects of aerobic fitness training on older adults using a randomized controlled design. Specifically, 124 older adults aged 60 and 75 were randomly assigned to a 6-month intervention of either walking (i.e., aerobic training) or flexibility (i.e., nonaerobic) training. The walking group but not the flexibility group showed improved cognitive performance, measured as a shorter response time to the presented stimulus. Results from a series of tasks that tapped different aspects of cognitive control indicated that engagement in physical activity is a beneficial means of combating cognitive aging ( Kramer et al., 1999).

Cognitive control, or executive control, is involved in the selection, scheduling, and coordination of computational processes underlying perception, memory, and goal-directed action. These processes allow for the optimization of behavioral interactions within the environment through flexible modulation of the ability to control attention ( MacDonald et al., 2000; Botvinick et al., 2001). Core cognitive processes that make up cognitive control or executive control include inhibition, working memory, and cognitive flexibility ( Diamond, 2006), processes mediated by networks that involve the prefrontal cortex. Inhibition (or inhibitory control) refers to the ability to override a strong internal or external pull so as to act appropriately within the demands imposed by the environment ( Davidson et al., 2006). For example, one exerts inhibitory control when one stops speaking when the teacher begins lecturing. Working memory refers to the ability to represent information mentally, manipulate stored information, and act on the information ( Davidson et al., 2006). In solving a difficult mathematical problem, for example, one must often remember the remainder. Finally, cognitive flexibility refers to the ability to switch perspectives, focus attention, and adapt behavior quickly and flexibly for the purposes of goal-directed action ( Blair et al., 2005; Davidson et al., 2006; Diamond, 2006). For example, one must shift attention from the teacher who is teaching a lesson to one's notes to write down information for later study.

Based on their earlier findings on changes in cognitive control induced by aerobic training, Colcombe and Kramer (2003) conducted a meta-analysis to examine the relationship between aerobic training and cognition in older adults aged 55-80 using data from 18 randomized controlled exercise interventions. Their findings suggest that aerobic training is associated with general cognitive benefits that are selectively and disproportionately greater for tasks or task components requiring greater amounts of cognitive control. A second and more recent meta-analysis ( Smith et al., 2010) corroborates the findings of Colcombe and Kramer, indicating that aerobic exercise is related to attention, processing speed, memory, and cognitive control; however, it should be noted that smaller effect sizes were observed, likely a result of the studies included in the respective meta-analyses. In older adults, then, aerobic training selectively improves cognition.

Hillman and colleagues (2006) examined the relationship between physical activity and inhibition (one aspect of cognitive control) using a computer-based stimulus-response protocol in 241 individuals aged 15-71. Their results indicate that greater amounts of physical activity are related to decreased response speed across task conditions requiring variable amounts of inhibition, suggesting a generalized relationship between physical activity and response speed. In addition, the authors found physical activity to be related to better accuracy across conditions in older adults, while no such relationship was observed for younger adults. Of interest, this relationship was disproportionately larger for the condition requiring greater amounts of inhibition in the older adults, suggesting that physical activity has both a general and selective association with task performance ( Hillman et al., 2006).

Colcombe and colleagues (2003) investigated the relationship of aerobic fitness to gray and white matter tissue loss using magnetic resonance imaging (MRI) in 55 healthy older adults aged 55-79. They observed robust age-related decreases in tissue density in the frontal, temporal, and parietal regions using voxel-based morphometry, a technique used to assess brain volume. Reductions in the amount of tissue loss in these regions were observed as a function of fitness. Given that the brain structures most affected by aging also demonstrated the greatest fitness-related sparing, these initial findings provide a biological basis for fitness-related benefits to brain health during aging.

In a second study, Colcombe and colleagues (2006) examined the effects of aerobic fitness training on brain structure using a randomized controlled design with 59 sedentary healthy adults aged 60-79. The treatment group received a 6-month aerobic exercise (i.e., walking) intervention, while the control group received a stretching and toning intervention that did not include aerobic exercise. Results indicated that gray and white matter brain volume increased for those who received the aerobic fitness training intervention. No such results were observed for those assigned to the stretching and toning group. Specifically, those assigned to the aerobic training intervention demonstrated increased gray matter in the frontal lobes, including the dorsal anterior cingulate cortex, the supplementary motor area, the middle frontal gyrus, the dorsolateral region of the right inferior frontal gyrus, and the left superior temporal lobe. White matter volume changes also were evidenced following the aerobic fitness intervention, with increases in white matter tracts being observed within the anterior third of the corpus callosum. These brain regions are important for cognition, as they have been implicated in the cognitive control of attention and memory processes. These findings suggest that aerobic training not only spares age-related loss of brain structures but also may in fact enhance the structural health of specific brain regions.

In addition to the structural changes noted above, research has investigated the relationship between aerobic fitness and changes in brain function. That is, aerobic fitness training has also been observed to induce changes in patterns of functional activation. Functional MRI (fMRI) measures, which make it possible to image activity in the brain while an individual is performing a cognitive task, have revealed that aerobic training induces changes in patterns of functional activation. This approach involves inferring changes in neuronal activity from alteration in blood flow or metabolic activity in the brain. In a seminal paper, Colcombe and colleagues (2004) examined the relationship of aerobic fitness to brain function and cognition across two studies with older adults. In the first study, 41 older adult participants (mean age ~66) were divided into higher- and lower-fit groups based on their performance on a maximal exercise test. In the second study, 29 participants (aged 58-77) were recruited and randomly assigned to either a fitness training (i.e., walking) or control (i.e., stretching and toning) intervention. In both studies, participants were given a task requiring variable amounts of attention and inhibition. Results indicated that fitness (study 1) and fitness training (study 2) were related to greater activation in the middle frontal gyrus and superior parietal cortex; these regions of the brain are involved in attentional control and inhibitory functioning, processes entailed in the regulation of attention and action. These changes in neural activation were related to significant improvements in performance on the cognitive control task of attention and inhibition.

Child Development, Brain Structure, and Function

Effects of Regular Engagement in Physical Activity and Physical Fitness on Brain Structure

Recent advances in neuroimaging techniques have rapidly advanced understanding of the role physical activity and aerobic fitness may have in brain structure. In children a growing body of correlational research suggests differential brain structure related to aerobic fitness. Chaddock and colleagues (2010a, b) showed a relationship among aerobic fitness, brain volume, and aspects of cognition and memory. Specifically, Chaddock and colleagues (2010a) assigned 9- to 10-year-old preadolescent children to lower- and higher-fitness groups as a function of their scores on a maximal oxygen uptake (VO ₂max) test, which is considered the gold-standard measure of aerobic fitness. They observed larger bilateral hippocampal volume in higher-fit children using MRI, as well as better performance on a task of relational memory. It is important to note that relational memory has been shown to be mediated by the hippocampus ( Cohen and Eichenbaum, 1993; Cohen et al., 1999). Further, no differences emerged for a task condition requiring item memory, which is supported by structures outside the hippocampus, suggesting selectivity among the aspects of memory that benefit from higher amounts of fitness. Lastly, hippocampal volume was positively related to performance on the relational memory task but not the item memory task, and bilateral hippocampal volume was observed to mediate the relationship between fitness and relational memory ( Chaddock et al., 2010a). Such findings are consistent with behavioral measures of relational memory in children ( Chaddock et al., 2011) and neuroimaging findings in older adults ( Erickson et al., 2009, 2011) and support the robust nonhuman animal literature demonstrating the effects of exercise on cell proliferation ( Van Praag et al., 1999) and survival ( Neeper et al., 1995) in the hippocampus.

Effects of Regular Engagement in Physical Activity and Physical Fitness on Brain Function

Other imaging research has examined the neuroelectric system (i.e., ERPs) to investigate which cognitive processes occurring between stimulus engagement and response execution are influenced by fitness. Several studies ( Hillman et al., 2005, 2009; Pontifex et al., 2011) have examined the P3 component of the stimulus-locked ERP and demonstrated that higher-fit children have larger-amplitude and shorter-latency ERPs relative to their lower-fit peers. Classical theory suggests that P3 relates to neuronal activity associated with revision of the mental representation of the previous event within the stimulus environment ( Donchin, 1981). P3 amplitude reflects the allocation of attentional resources when working memory is updated ( Donchin and Coles, 1988) such that P3 is sensitive to the amount of attentional resources allocated to a stimulus ( Polich, 1997; Polich and Heine, 2007). P3 latency generally is considered to represent stimulus evaluation and classification speed ( Kutas et al., 1977; Duncan-Johnson, 1981) and thus may be considered a measure of stimulus detection and evaluation time ( Magliero et al., 1984; Ila and Polich, 1999). Therefore the above findings suggest that higher-fit children allocate greater attentional resources and have faster cognitive processing speed relative to lower-fit children ( Hillman et al., 2005, 2009), with additional research suggesting that higher-fit children also exhibit greater flexibility in the allocation of attentional resources, as indexed by greater modulation of P3 amplitude across tasks that vary in the amount of cognitive control required ( Pontifex et al., 2011). Given that higher-fit children also demonstrate better performance on cognitive control tasks, the P3 component appears to reflect the effectiveness of a subset of cognitive systems that support willed action ( Hillman et al., 2009; Pontifex et al., 2011).

Two ERP studies ( Hillman et al., 2009; Pontifex et al., 2011) have focused on aspects of cognition involved in action monitoring. That is, the error-related negativity (ERN) component was investigated in higher- and lower-fit children to determine whether differences in evaluation and regulation of cognitive control operations were influenced by fitness level. The ERN component is observed in response-locked ERP averages. It is often elicited by errors of commission during task performance and is believed to represent either the detection of errors during task performance ( Gehring et al., 1993; Holroyd and Coles, 2002) or more generally the detection of response conflict ( Botvinick et al., 2001; Yeung et al., 2004), which may be engendered by errors in response production. Several studies have reported that higher-fit children exhibit smaller ERN amplitude during rapid-response tasks (i.e., instructions emphasizing speed of responding; Hillman et al., 2009) and more flexibility in the allocation of these resources during tasks entailing variable cognitive control demands, as evidenced by changes in ERN amplitude for higher-fit children and no modulation of ERN in lower-fit children ( Pontifex et al., 2011). Collectively, this pattern of results suggests that children with lower levels of fitness allocate fewer attentional resources during stimulus engagement (P3 amplitude) and exhibit slower cognitive processing speed (P3 latency) but increased activation of neural resources involved in the monitoring of their actions (ERN amplitude). Alternatively, higher-fit children allocate greater resources to environmental stimuli and demonstrate less reliance on action monitoring (increasing resource allocation only to meet the demands of the task). Under more demanding task conditions, the strategy of lower-fit children appears to fail since they perform more poorly under conditions requiring the upregulation of cognitive control.

Finally, only one randomized controlled trial published to date has used ERPs to assess neurocognitive function in children. Kamijo and colleagues (2011) studied performance on a working memory task before and after a 9-month physical activity intervention compared with a wait-list control group. They observed better performance following the physical activity intervention during task conditions that required the upregulation of working memory relative to the task condition requiring lesser amounts of working memory. Further, increased activation of the contingent negative variation (CNV), an ERP component reflecting cognitive and motor preparation, was observed at posttest over frontal scalp sites in the physical activity intervention group. No differences in performance or brain activation were noted for the wait-list control group. These findings suggest an increase in cognitive preparation processes in support of a more effective working memory network resulting from prolonged participation in physical activity. For children in a school setting, regular participation in physical activity as part of an after-school program is particularly beneficial for tasks that require the use of working memory.

Adiposity and Risk for Metabolic Syndrome as It Relates to Cognitive Health

Recently published reports describe the relationship between adiposity and cognitive and brain health to advance understanding of the basic cognitive processes and neural substrates that may underlie the adiposity-achievement relationship. Bolstered by findings in adult populations (e.g., Debette et al., 2010; Raji et al., 2010; Carnell et al., 2011), researchers have begun to publish data on preadolescent populations indicating differences in brain function and cognitive performance related to adiposity (however, see Gunstad et al., 2008, for an instance in which adiposity was unrelated to cognitive outcomes). Specifically, Kamijo and colleagues (2012a) examined the relationship of weight status to cognitive control and academic achievement in 126 children aged 7-9. The children completed a battery of cognitive control tasks, and their body composition was assessed using dual X-ray absorptiometry (DXA). The authors found that higher BMI and greater amounts of fat mass (particularly in the midsection) were related to poorer performance on cognitive control tasks involving inhibition, as well as lower academic achievement. In follow-up studies, Kamijo and colleagues (2012b) investigated whether neural markers of the relationship between adiposity and cognition may be found through examination of ERP data. These studies compared healthy-weight and obese children and found a differential distribution of the P3 potential (i.e., less frontally distributed) and larger N2 amplitude, as well as smaller ERN magnitude, in obese children during task conditions that required greater amounts of inhibitory control ( Kamijo et al., 2012c). Taken together, the above results suggest that obesity is associated with less effective neural processes during stimulus capture and response execution. As a result, obese children perform tasks more slowly ( Kamijo et al., 2012a) and are less accurate ( Kamijo et al., 2012b, c) in response to tasks requiring variable amounts of cognitive control. Although these data are correlational, they provide a basis for further study using other neuroimaging tools (e.g., MRI, fMRI), as well as a rationale for the design and implementation of randomized controlled studies that would allow for causal interpretation of the relationship of adiposity to cognitive and brain health. The next decade should provide a great deal of information on this relationship.

LIMITATIONS

Despite the promising findings described in this chapter, it should be noted that the study of the relationship of childhood physical activity, aerobic fitness, and adiposity to cognitive and brain health and academic performance is in its early stages. Accordingly, most studies have used designs that afford correlation rather than causation. To date, in fact, only two randomized controlled trials ( Davis et al., 2011; Kamijo et al., 2011) on this relationship have been published. However, several others are currently ongoing, and it was necessary to provide evidence through correlational studies before investing the effort, time, and funding required for more demanding causal studies. Given that the evidence base in this area has grown exponentially in the past 10 years through correlational studies and that causal evidence has accumulated through adult and nonhuman animal studies, the next step will be to increase the amount of causal evidence available on school-age children.

Accomplishing this will require further consideration of demographic factors that may moderate the physical activity-cognition relationship. For instance, socioeconomic status has a unique relationship with physical activity ( Estabrooks et al., 2003) and cognitive control ( Mezzacappa, 2004). Although many studies have attempted to control for socioeconomic status (see Hillman et al., 2009; Kamijo et al., 2011, 2012a, b, c; Pontifex et al., 2011), further inquiry into its relationship with physical activity, adiposity, and cognition is warranted to determine whether it may serve as a potential mediator or moderator for the observed relationships. A second demographic factor that warrants further consideration is gender. Most authors have failed to describe gender differences when reporting on the physical activity-cognition literature. However, studies of adiposity and cognition have suggested that such a relationship may exist (see Datar and Sturm, 2006). Additionally, further consideration of age is warranted. Most studies have examined a relatively narrow age range, consisting of a few years. Such an approach often is necessary because of maturation and the need to develop comprehensive assessment tools that suit the various stages of development. However, this approach has yielded little understanding of how the physical activity-cognition relationship may change throughout the course of maturation.

Finally, although a number of studies have described the relationship of physical activity, fitness, and adiposity to standardized measures of academic performance, few attempts have been made to observe the relationship within the context of the educational environment. Standardized tests, although necessary to gauge knowledge, may not be the most sensitive measures for (the process of) learning. Future research will need to do a better job of translating promising laboratory findings to the real world to determine the value of this relationship in ecologically valid settings.

SUMMARY

From an authentic and practical to a mechanistic perspective, physically active and aerobically fit children consistently outperform their inactive and unfit peers academically on both a short- and a long-term basis. Time spent engaged in physical activity is related not only to a healthier body but also to enriched cognitive development and lifelong brain health. Collectively, the findings across the body of literature in this area suggest that increases in aerobic fitness, derived from physical activity, are related to improvements in the integrity of brain structure and function that underlie academic performance. The strongest relationships have been found between aerobic fitness and performance in mathematics, reading, and English. For children in a school setting, regular participation in physical activity is particularly beneficial with respect to tasks that require working memory and problem solving. These findings are corroborated by the results of both authentic correlational studies and experimental randomized controlled trials. Overall, the benefits of additional time dedicated to physical education and other physical activity opportunities before, during, and after school outweigh the benefits of exclusive utilization of school time for academic learning, as physical activity opportunities offered across the curriculum do not inhibit academic performance.

Both habitual and single bouts of physical activity contribute to enhanced academic performance. Findings indicate a robust relationship of acute exercise to increased attention, with evidence emerging for a relationship between participation in physical activity and disciplinary behaviors, time on task, and academic performance. Specifically, higher-fit children allocate greater resources to a given task and demonstrate less reliance on environmental cues or teacher prompting.

REFERENCES

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# data[].attributes.attachment_link.title
Physical Activity, Fitness, and Physical Education: Effects on Academic Performance

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Although academic performance stems from a complex interaction between intellect and contextual variables, health is a vital moderating factor in a child's ability to learn. The idea that healthy children learn better is empirically supported and well accepted (Basch, 2010), and multiple studies have confirmed that health benefits are associated with physical activity, including cardiovascular and muscular fitness, bone health, psychosocial outcomes, and cognitive and brain health (Strong et al., 2005; see Chapter 3).

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The   Association   Between  School-Based   Physical   Activity, Including   Physical   Education, and   Academic   Performance  

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The   Association   Between  School-Based   Physical   Activity, Including   Physical   Education, and   Academic   Performance  

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2010 U.S. Department of Health and Human Services Report

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Physical Activity and Academic Performance

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Chan-Zuckerberg Initiative

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Learning is a social process and the evidence supporting the importance of relationships, including mentorship, in connection to students' academic and social-emotional outcomes continues to build. Students also don't learn in a vacuum; physical conditions like hydration, sleep, and emotional state have direct impact on the learning centers of the brain and the ability to engage in the process of learning.

American education was established over a century ago, before the science of human development emerged as a field. Our whole child work is dedicated to accelerating the integration of what we know about the science of human development into education. Grounding education in human development means taking a whole child approach to learning that accounts for the many different ways in which young people grow. The graphic above details areas critical to learning and development, representing an expanded definition of student success and well-being

A. Academic

Skills and knowledge typically associated with K-12 education. This includes the four core content areas: mathematics, literacy, science, and social studies, as well as the subjects included in most requirements for a diploma, like art, health, and physical education.

B. Cognitive

Skills related to attention, perception and memory. These are the skills we draw upon to learn and retain knowledge like executive function, visual and auditory processing, reasoning, and short- and long-term memory.

C. Social-emotional

Skills and mindsets involved in the social process of learning and development. This domain includes social and emotional factors with links to well-being and academic success, like healthy adult attachment, stress management, self-regulation, and resilience.

D. Physical

Nutrition, fitness, and sleep, as well as vision, hearing, and dental health.

E. Mental

A state of well-being demonstrated by the ability to realize potential, cope with stress, work toward goals, and make meaningful social contributions and connections.

The mental health domain draws from the definition provided by the World Health Organization: a "state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community."

F. Identity

An individual's unique sense of purpose, including one's personal, collective, and cultural identities, as well as one's personal values.

# data[].attributes.attachment_link.description
Learning is a social process and the evidence supporting the importance of relationships, including mentorship, in connection to students' academic and social-emotional outcomes continues to build. Students also don't learn in a vacuum; physical conditions like hydration, sleep, and emotional state have direct impact on the learning centers of the brain and the ability to engage in the process of learning.

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How Making Time for Mindfulness Helps Students

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How Making Time for Mindfulness Helps Students

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Four times a week, instructors from Calmer Choice, a Massachusetts nonprofit specializing in mindfulness education, taught the group techniques and led them through practices, like focusing on a rock for a minute, then discussing when their mind wandered and refocused on the rock. Another group of sixth-graders took computer coding during that time instead. The students were randomly assigned between the groups.

At the end of the eight weeks, the mindfulness group reported being less stressed than they had been before the mindfulness education, and better able to practice self-control. About half of the students also volunteered for brain scans, and those revealed positive effects for the mindfulness group, too: their amygdalas - the part of the brain that controls emotion - responded less to pictures of fearful faces than they did prior to the mindfulness work, suggesting their brains were less sensitive to negative stimuli, or, in other words, that they were less prone to get stressed out and lose focus. The group who attended coding classes didn't see the same benefits.

The findings suggest that the mindfulness instruction helped boost students' attention skills, as well as develop coping mechanisms for stress. The authors maintain that this kind of evidence could be especially useful in efforts to support students suffering from trauma and other adversities that trigger stress in the body, hurting students' ability to succeed.

Bringing Mindfulness to Your School

The paper includes recommendations from educators and leaders of mindfulness-based education programs for implementing mindfulness in your own school:

Build consistency and school-wide buy-in. Make time for staff and students to learn about the theory and science behind mindfulness, so students know how to talk about mindfulness and understand its purpose. Creating consistent space for mindfulness practice - like guided meditations - and theory in the school day can positively affect the entire school culture, emphasizing acceptance, self-care, and empathy.

Provide teachers with dedicated time to engage in mindfulness practice themselves. In order to help students reap benefits, teachers also need time and support in adopting it. Research has also shown mindfulness to be helpful to teachers, improving their own emotional wellbeing, helping them understand student perspective, and freeing them up to be more effective in the classroom.

Allow students to make their own time for mindfulness. Encourage students' awareness of their own emotions by allowing and encouraging them to identify times when they can use and practice mindfulness. In order to adopt mindfulness as a tool for mental health and happiness, students have to have the space and time to practice it.

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How Making Time for Mindfulness Helps Students | KQED

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Four times a week, instructors from Calmer Choice, a Massachusetts nonprofit specializing in mindfulness education, taught the group techniques and led them through practices, like focusing on a rock for a minute, then discussing when their mind wandered and refocused on the rock. Another group of sixth-graders took computer coding during that time instead.

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Edutopia vi

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Himelstein was lucky that he got into trouble during middle school and was able to get back on track for high school. He was also lucky to be born into an affluent, white, two-parent home in Berkeley, California. His time in juvenile hall showed him what other kids his age were up against.

"A lot of the kids I work with it's a real uphill battle when they come into the system at [ages] 15 to 16 because they just have so many high school credits to catch up on that it becomes overwhelming," Himelstein said. "It's so easy for them to get in the mindset that 'school isn't for me' and turn that into a core belief."

When Himelstein explains mindfulness to young people he likes to use a metaphor coined by Larry Rosenberg the dog-mind versus the lion-mind. If a human waves a bone in front of a dog, the dog will track that bone and chase it when it's thrown. But wave a bone in front of a lion's face and that lion might eat the human behind the bone.

"The dog can't see beyond the bone. If I control the bone, I control the dog's reality," Himelstein said. But the lion sees a broader picture. He sees the human behind the bone. "That ability to see the larger picture gives the lion more autonomy, more choices."

Himelstein then directs students to think of the bone as anger or anxiety. Reacting with the mind of a lion allows a person to say, "I'm angry right now," and that little bit of metacognitive space between the person and the thought allows them to choose how to respond.

"It's much easier said than done, but that's what mindfulness is," Himelstein said. "It's noticing what's happening in the present moment with a non-reactive mind." When he's presenting to youths, he asks them: Who's the king of the jungle? The lion. And who doesn't want to be the king of their inner jungle?

Himelstein has found that teens gravitate to this metaphor because it makes the concept less abstract. They can see how mindfulness will be useful to them and how it could give them an edge. Additionally, the metaphor becomes a language thread Himelstein can return to over and over again. "Lion-mind" is a shorthand for that ability to choose a reaction.
TRAUMA SENSITIVE MINDFULNESS
"A trauma-informed lens is, 'this behavior may be a result of some sort of trauma.' Or even better, 'this may be a way for them to protect themselves,' " Himelstein said. There are some common issues he sees when trauma interacts with mindfulness.

Students don't take the activity seriously

Students are triggered by silence because it feels like a storm is brewing, so they don't want to be quiet

Students feel too many requests are made of them without the requisite trust being built up

Students exhibit avoidance behavior

Himelstein says building an authentic relationship is key to accessing the trust required to make mindfulness effective. For some kids, chaos is part of trauma so when adults are unpredictable they can't be trusted. That's why being a "predictable adult" is a good way to be authentic with kids.

Himelstein also offers these guidelines for teachers using mindfulness:

Don't force it

Don't focus on the logistics like sitting with eyes closed

Somatic awareness, like counting breaths, could be a good place to start. "There's different types of awareness. Sometimes we're really aware of what's going on in the mind and sometimes we're more aware of what's going on in the body," Himelstein said.

Think about the child's window of tolerance and whether he is already triggered or not. "It's good to strike when the iron is cold in a lot of these cases," Himelstein said.

Build relationships

When Himelstein works with teachers, he's conscientious of how different the classroom setting is from a therapeutic one. While teachers aren't trained therapists, students gravitate towards a trusted teacher and want to share with them. On top of that, teachers are keenly aware of their duty to cover required content.

"They do have the hardest job out of all the direct service folks because they have all this stuff the've got to get through," Himelstein said.

He likes to affirm with teachers right off-the-bat that the public school setting with 30-40 kids in a classroom is already not trauma-informed. It's a very difficult context in which to build relationships, and the architecture, policies and procedures that can make schools feel institutional only make it harder. That's why often Himelstein sees mindfulness first-and-foremost as a self-care technique for teachers. If teachers can successfully use their mindfulness practice to create metacognitive distance, they can take their ego out of interactions with kids.

"Classroom management skills that are based in trauma informed principles, which means learning how to redirect, learning how to confront people with a non-aggressive pose, not taking it personally, all of that overlaps to help form a relationship," Himelstein said.

If teachers can see the trauma-informed approach as a way to better build relationships, he thinks it may feel less daunting. Once those relationships are formed and students trust their teachers, it's more likely that mindfulness will be an effective tool for them.

Many teachers already see relationship building as a core part of their effectiveness, but one practice Himelstein recommends may be less intuitive in the rush to deliver information to students: active listening. "That's a super simple concept, but it goes a long way, especially in an educational setting because kids are used to not just being presented to, but talked down to," Himelstein said.
SELF CARE
Cultivating a trauma-informed classroom is much harder when educators themselves are burnt out. Building relationships, not reacting defensively to student behavior and taking time to listen to students can feel nearly impossible if the adult is barely making it through the day. Classrooms can be stressful places for teachers and even someone who has been practicing mindfulness for a long time may have difficulty calling upon that knowledge when triggered -- just like kids.

That's why a core part of a trauma-informed classroom is a healthy teacher. There are several categories of self-care, according to Himelstein:

1. Regular cultivation of relaxation response (3Rs): things like watching TV, going into nature, getting a massage.

2. Effortful training: These are things like more sustained meditation or exercise where the payoff comes over a longer time period.

3. Creativity: something that gives purpose and adds vibrancy to life. Writing, reading, painting or other passions are examples.

4. Advocacy: everything from learning to say "No" (set boundaries), to working at a higher level to impact policy or structural change.

Ultimately, Himelstein wants teachers to be aware of how students who have experienced trauma might be experiencing mindfulness in the classroom so they can respond in more empathetic ways. And, recognizing that sometimes teaching is traumatic and the practice may be more for the adults than the kids.

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Why Mindfulness And Trauma-Informed Teaching Don't Always Go Together | KQED

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Himelstein was lucky that he got into trouble during middle school and was able to get back on track for high school. He was also lucky to be born into an affluent, white, two-parent home in Berkeley, California. His time in juvenile hall showed him what other kids his age were up against.

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Boston Globe Article Jan.5, 2016

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READING - The only sound that could be heard in Maria Simon's first-grade classroom one December morning was the soothing hum from a vibrating Tibetan singing bowl. Her students had gathered on a brightly colored rug at the back of the classroom, sitting with their eyes shut, their legs crossed, and their arms extended outward palms up.

Each time a classmate struck the small bowl with a mallet - releasing a low sounding gong - the students breathed in. Then as the sound faded away, they breathed out. The exercise lasted about five minutes, and they started their math lesson.

"It helps give us a few minutes of peace and quiet so we can focus on our work," said one student, Grace Hayes.

This moment of "mindfulness" in Simon's classroom is part of a broader effort at Birch Meadow Elementary School and Reading's eight other schools to help put students at ease and get them more in tune with their emotions, and one another, so they can concentrate on learning.

Across Massachusetts, schools are devoting more time to address the social and emotional well-being of their students. Educators stress the movement is not simply "feel good" education. They say teaching students at every grade to manage their emotions can help them deal with a multitude of serious issues, including bullying, mental illness, substance abuse, or trauma.

An in-depth look at a wide range of issues that unfold every day in public schools.

Such problems, educators say, can present immense barriers to learning and, if left unaddressed, could exact heavy tolls like suicides, drug overdoses, or even school shootings.

Reading, a town of 25,000 north of Boston, has emerged as a state leader over the past few years in what is known as social-emotional learning. Like many communities, Reading grapples with students struggling with depression, anxiety, or alcohol use, among other issues.

But the town stands apart because it has devised an aggressive plan to reach out to students before signs of problems arise, and its initiatives go well beyond the school doors.

"You treat every child as if they need a safe and supportive environment," said Sara Burd, Reading's district leader of social-emotional learning. "You never are going to know every student in a classroom who is experiencing trauma. They are not going to have a name tag that says, 'Yes, I have a trauma history.' "

Starting in preschool, instructors lead students in yoga. In elementary and middle schools, teachers gather students in circles to talk about issues on their minds and teach strategies for dealing with certain situations, such as bullying, and they use a common approach to discipline that emphasizes rewarding behavior instead of punishment.

At the town's high school, teachers embark on more deliberate conversations about students, making sure they know something about everyone and, if not, making a concerted effort to reach out to them.

Educators stress it is a challenging undertaking because it is not always clear which students are experiencing distress. Some may signal they are struggling by acting out in class or bursting into tears. But others can appear well-adjusted - putting on a smile - as turmoil swirls inside.

In one noteworthy endeavor, the town is training more than 350 educators, town librarians, clergy, crossing guards, bus drivers, and police to be "youth mental health first aid responders," instilling them with the skills to identify students who might be in trouble and the know-how to respond.

Reading officials acknowledge they have not found all the answers. While the school system has seen lower rates of alcohol and drug use among teenagers, it has experienced a slight increase in the percentage of students reporting depression over the last decade, according to a behavior survey of middle- and high-school students in 2015.

Superintendent John Doherty, in a state of the schools address in November, stressed the importance of remaining vigilant. He noted that 55 Reading Memorial High School students had been hospitalized for depression, anxiety, or suicidal tendencies last school year.

In an interview, Doherty said that in many cases the hospitalization rates reflect the enormous pressures many suburban students face to take the most rigorous classes and pile on extracurricular activities - often at the expense of sleep - to get into the best colleges.

"We are trying to do everything we can so students know they have adults they can talk to if they are in crisis," he said.

With Reading ranking almost at the bottom in the state for per-student spending, the town has relied on three federal grants, totaling about $2 million, to help support social and emotional programs in school and its communitywide effort to combat substance abuse among residents of all ages.

The growing emphasis on social-emotional learning represents a ground shift in Massachusetts.

For decades, schools had provided some lessons in those areas, especially in the early grades. But many tossed aside or substantially scaled back the lessons to devote more time to boosting standardized test scores in reading and math, in an effort to avoid state sanctions for poor performance.

Many educators saw it as a misguided trade-off: If students are not in a healthy state of mind, they will struggle academically and perform poorly on state tests; more alarmingly, it could set them up for a lifetime of failure.

"People are stepping back on that full focus on reading and math scores and are looking more holistically at all the skills that really matter,'' said Sara Bartolino Krachman, executive director of Transforming Education, an education nonprofit in Boston. "Social-emotional learning is not only crucial to academic success, but also career success and lifelong being."

A landmark study in 1998 often quoted by educators today - the Adverse Childhood Experiences Study - established a disturbing link between childhood trauma and increased risks for alcoholism, drug abuse, depression, suicide, severe obesity, and sexually transmitted diseases.

It suggested that participants who had four or more adverse childhood experiences - such as sexual or emotional abuse or living in a household where someone was mentally ill, suicidal, or abusing drugs - had a fourfold to twelvefold increase in the chance that they would experience risk behaviors as adults. The study, published in the American Journal of Preventative Medicine, involved 17,000 adults. Almost two-thirds of them had at least one adverse childhood experience.

Social-emotional learning received a boost last year in Massachusetts with the enactment of a gun-control law that called for creating "safe and supportive schools." The law encourages schools to integrate such initiatives as bullying prevention, trauma sensitivity, dropout prevention, and truancy reduction.

In Boston, Superintendent Tommy Chang added a Cabinet-level position this school year to ramp up an expansion of programs that address students' social and emotional well-being.

Over the last five years, Boston has been expanding its programs, raising more than $1 million to support the effort. But only about a third of the city's 125 schools offer robust programming in the area, and the school system has only 55 psychologists and 14 social workers to serve 56,000 students.

Many Boston schools taking part in the effort use some similar strategies as Reading, such as gathering students in circles, and have forged formal partnerships with Boston Children's Hospital and other medical centers to provide mental health services for students grappling with trauma. Some schools also have teachers fill out behavioral assessments on students to determine whether some need specialized interventions, such as working directly with a psychologist.

In Reading, an uptick four years ago in student hospitalizations for anxiety, depression, and other issues prompted much soul searching.

School officials moved the discussions out of their administrative offices and into the community, kicking off a dialogue by showing a film, " Race to Nowhere," which explores the lives of students who have been pushed to the brink by pressures to excel.

The community dialogue was a natural outgrowth of an effort the town began about a decade ago to address substance abuse in a public way after a series of fatal overdoses - many involving residents in their 20s or 30s - stunned this bedroom community. That effort led to such changes as requiring teenagers caught with alcohol anywhere in the town to go through an alcohol awareness program.

Conversations about substance abuse, and subsequently those about mental health, were nevertheless tough.

"We faced a lot of denial in the beginning," said Erica McNamara, director of the Reading Coalition Against Substance Abuse, which pushed the substance abuse changes and has been working with the school system on social-emotional learning. "A lot of people moved to Reading because it's a lovely little community. You don't necessarily want to know what happens behind closed doors."

School officials also undertook a review at that time that concluded the district lacked a comprehensive approach to fostering the social and emotional well-being of its students. In some cases, schools lacked programs. In other cases, schools left it up to teachers to craft their own lessons and approaches, creating uneven quality.

The findings prompted school officials to orchestrate an overhaul. They were also encouraged by research that showed the benefits of robust social-emotional learning programs on student performance.

For instance, a 2011 meta-analysis found that well-structured programs not only significantly improved students' social and emotional skills and behaviors, but students also enjoyed an 11 percentile point gain in achievement over students who did not participate in the programs. The study, published in the peer-reviewed journal Child Development, examined 213 social and emotional learning programs involving more than 270,000 students nationwide in kindergarten through 12th grade.

The overhaul appears to be paying off. In a report this fall, the Rennie Center, an education research and policy organization in Boston, highlighted Reading, along with Fall River and Gardner, as glowing examples for their work in student behavioral health, specifically because they made it a community effort rather than just a school initiative.

The Birch Meadow school in Reading, with about 400 students, uses a variety of strategies. A few years ago, the school instituted a common approach to discipline that rewards students at all grade levels for good behavior by stamping paw prints on their hands - giving them immediate gratification. If they get 20 stamps, which they call "yays," they get a brightly colored bracelet.

The school also uses a program called " Open Circle," which provides students with tips on weathering tough situations and allows them to frankly discuss common problems and break down stereotypes or misconceptions about their classmates.

One Tuesday afternoon last month, fourth-graders in Jolene Tewksbury's class arranged their blue desk chairs in a circle at the back of the classroom. The topic of conversation: the difference between playfully teasing and making fun of someone.

Students said the conversations were enlightening.

"It's nice to talk to people about similar things that have happened to you and learn new ways about what you could do differently the next time," said Kelsey Murphy.

Maria Simon, the first-grade teacher, said she is glad that school systems are realizing education is about more than the MCAS; it's about nurturing the whole child.

"The amount of academic work we do in a day is really overwhelming to many children and many teachers," Simon said. "My goal is for them to feel more comfortable in their learning environment and to use mindfulness the rest of their lives so they're more comfortable with themselves."

Mary Shanahan, a parent volunteer in Simon's classroom, said she is impressed with how Birch Meadow has made social-emotional learning part of the school's fabric, adding that the mindfulness activities have given her daughter, Abby, another way to self regulate her emotions at home.

"Sometimes she will say, 'Mommy, I'm going to take a moment' and she will close her eyes," Shanahan said. "It blew me away the first time she did it on her own."

James Vaznis can be reached at jvaznis@globe.com. Follow him on Twitter @globevaznis.

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In Mass. schools, a focus on well-being - The Boston Globe

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READING - The only sound that could be heard in Maria Simon's first-grade classroom one December morning was the soothing hum from a vibrating Tibetan singing bowl. Her students had gathered on a brightly colored rug at the back of the classroom, sitting with their eyes shut, their legs crossed, and their arms extended outward palms up.

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Schools in England Introduce a New Subject: Mindfulness

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Schools in England Introduce a New Subject: Mindfulness

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New York Times Article Feb. 4, 2019

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Schools in England Introduce a New Subject: Mindfulness (Published 2019)

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As mental health problems among children increase, the government will try having students practice mindfulness, relaxation and breathing exercises.

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Cultivating Mindfulness for Educators Using Resources From The New York Times

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Cultivating Mindfulness for Educators Using Resources From The New York Times

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Mindfulness for Educators

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Cultivating Mindfulness for Educators Using Resources From The New York Times

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Lesson Plan The Well section runs a regular column called " But what about when the photocopier is broken, your sixth-period class is bouncing off the walls, or you're teaching five sections in a row? We don't normally run "lesson plans" for teachers and school leaders, but we thought mindfulness for educators was a perfect topic for the start of a new school year.

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The Heart-Brain Connection: The Neuroscience of Social, Emotional, and Academic Learning

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The Heart-Brain Connection: The Neuroscience of Social, Emotional, and Academic Learning

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Neuroscientist Richard Davidson presents his research on how social and emotional learning can affect the brain. Dec. 10, 2007

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The Heart-Brain Connection: The Neuroscience of Social, Emotional, and Academic Learning

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Neuroscientist Richard Davidson presents his research on how social and emotional learning affects the brain.

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A website developed by the Dalai Lama Center for Peace and Education. Provides resources for families and educators.

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Heart-Mind Online is for all those who are searching for evidenced-informed resources that educate the hearts of children. The collection of resources builds capacity in individuals and communities to support the Heart-Mind well-being of children, and promotes their positive social and emotional development. This website was developed by the Dalai Lama Center for Peace and Education.

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Edutopia article

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Social & Emotional Learning (SEL)

Three social and emotional learning activities that are designed to address high school students' need for status and respect.

According to a 2018 survey, current and recent high school students don't believe their schools have done enough to help them develop socially and emotionally, and most graduates don't feel prepared for life after high school.

We're also learning that some social and emotional learning approaches simply aren't as effective with teens as they are with children. Why? It may be that teens need more opportunities to actively explore who they are and who they want to be in the world.

So how can we better address teens' developmental needs?

Researcher David Yeager and his colleagues argue that it's important to address teens' need for status ("How do others treat me?") and respect ("Am I granted the rights I expect to be granted as a student?"). If teens feel competent, autonomous, and valued in their community-if they have a sense of high status and respect, in other words-they're likely to be more motivated and engaged.

Here are three ways you can help teens develop greater self-awareness-and ultimately enhance their sense of status and respect among peers and adults.

Invite Students to Use Their Character Strengths

If teens crave respect, it's important to create a school climate where their strengths are recognized and valued.

Take time in class to have your students identify their personal strengths, such as hope, humility, honesty, kindness, and perseverance. You can begin by asking them to take a 10-minute online survey designed by positive psychology researchers.

After they learn about some of their key strengths, ask them to choose one strength to focus on every day for a week. Have them describe the strength in writing and propose several different ways they might use it each day, and challenge them to act on that strength throughout the week.

For example, if a student wants to capitalize on kindness as a strength, he might perform a random act of kindness for a peer, write a thank-you note to a teacher, or volunteer to care for abandoned animals at a local shelter over the weekend.

As an alternative to focusing on one strength all week, students might choose to focus on a different strength each day. Whichever option they choose, have them write about what they did, how it made them feel, and what they learned from the experience.

Research tells us that this activity can increase well-being and reduce symptoms of depression. It's easy for us to focus on our weaknesses and personal challenges, but when we spend time making the most of our positive qualities, we can build greater self-esteem and confidence.

Encourage Students to Imagine Their Best Selves

Another way to help students clarify who they are and how they want to be in the world is to invite them to envision their ideal future.

Ask your students to respond to the following questions in a 15-minute free-write: What is the best possible life you can imagine? Consider all the areas in your life that are important to you-relationships, school, career, hobbies and interests, etc. Be as creative and imaginative as you want, and don't worry about spelling and grammar.

Ask them to be as specific as possible, and tell them that it's easy to focus on current obstacles to reaching goals, so they should let go and simply dream about the future and exactly what it could look like.

Challenge Students to Explore Their Purpose

Respond to these questions: "Imagine you've been given a magic wand, and you can change anything you want in the world. What would you want to be different, and why? Is there anything you can do to help move the world closer to this ideal? If so, how?"

Discuss what this Viktor Frankl quote means: "Those who have a 'why' to live can bear with almost any 'how.'"

Create a tattoo design that symbolizes the things that matter most to you.

Once students have practiced using their character strengths and imagined their future selves, create opportunities for them to think about how they might contribute to something larger than themselves.

The Purpose Challenge Toolkit features research-based online activities that prompt students to imagine how they might leave their mark on the world-and make it a better place.

Apart from these prompts, it's crucial to connect students' sense of purpose to what they're learning. Are they studying social issues that matter to them? Are they learning as a means to an end-or to make a difference in the world?

Many of our students face significant obstacles in their lives due to factors beyond their control (like health challenges, poverty, and institutionalized racism). Prompting students to connect with their strengths, identify what matters most to them, and envision ways they might contribute to the world may ultimately help them to feel more respected and empowered.

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Three social and emotional learning activities that are designed to address high school students' need for status and respect.

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The Aspen Institute Practice Base for SEL

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The Aspen Institute Practice Base for SEL

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Recommendations for SEL implementation