document/management/Development and validation of Yoga Module for Anger Management in adolescents conv.txt

Complementary Therapies in Medicine 61 (2021) 102772

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Complementary Therapies in Medicine

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Development and validation of Yoga Module for Anger Management in adolescents

Alaka Mani TLa,*, Omkar SNb,1, Manoj K. Sharmac, Astha Chouksed, Nagendra HRe,2

a Yoga and Counselling Professional, Life Skills Trainer, Life-Style Couch, Adolescent Health Couch, India b Dept of Aerospace Eng., Indian Institute of Science, Bangalore, India
c Dept of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, India d Yoga Professional, India
e Founder and Chancellor of a World Renowned Yoga University, India



A  R  T  I  C  L  E   I  N  F  O

Keywords: Yoga Module
Anger management Adolescent
School

A  B  S  T  R  A  C  T

Background: Development of anger management programs and in particular, yoga module for anger management has  not  been  well  researched.  Being  a  complex  emotion,  anger  poses  serious  challenges  in  developing  a comprehensive anger management program. While various theories of anger are dealt in modern psychology, several anger management techniques are set forth in Indian traditional texts. Yoga, which is considered as a holistic and integrated approach is explored in this study to develop and validate a school-based yoga program for anger management in adolescence.
Materials and methods: Integrated Approach to Yoga Therapy (IAYT) principles and literary review formed the basis  for  deriving  the  concepts  of  anger  management.  The  methodology  includes  construction  of  the  yoga module, validation of the module by 22 experts followed by a pilot non-randomised control study (n-50) to assess feasibility and initial effectiveness. Content Validity Ratio (CVR) and paired t-test were employed to analyse the experts’ rating and pilot-study data respectively.
Results: Emergence of IAYT based yoga program for anger management. Based on CVR ratio, 16 out of 18 yogic techniques qualified for the final module. The pilot study revealed viability of the module and its recognition as an anger management program. Significant reduction of anger scores in yoga group substantiates initial effec-tiveness of the module.
Conclusion: The developed and validated yoga module for anger management is recognised as a well-accepted and effective yoga program for anger management in adolescents.




1.  Introduction

Anger and its manifestations among adolescents have drawn global
concern.  Anger  is  a  difficult  construct  to  understand,  assess  and  to conceive coping strategies.1,2  Furthermore, anger issues and conduct disorders among adolescents and youth are on rise in India.3
Anger  is  marked  by  a  profound  chemical  and  electrical  activity
simultaneously occurring at the hypothalamic-pituitary-adrenal (HPA) axis.4 Arousal of anger is marked by release of noradrenaline (nor-epi-
nephrine)  hormone  that  results  in  a  sudden  surge  of  energy  and increased   sympathetic   activity.   Anger   arousal   is   counteracted   by

activation  of  parasympathetic  activity  with  release  of  acetylcholine neurotransmitter.5
Considering the adverse effects and the long-term consequences of anger, researchers and clinicians have prescribed a variety of interven-tion programs for anger management. Cognitive-behavioural and skills-
based approaches are widely studied and empirically validated treat-ments for anger in adolescents.2,6 Recent years have witnessed the use of
mindfulness, yoga, and other healing techniques to manage emotional dyscontrol or affective states.7–9  School-based yoga programs that has
gathered special interest among researchers, promote healthy behav-iours at societal level by focusing on prevention of negative patterns



*  Corresponding author.
E-mail addresses: [email protected] (A.M. TL), [email protected] (O. SN), [email protected] (M.K. Sharma), [email protected] (A. Choukse), [email protected] (N. HR).
1   www.yogaomkar.com. 2   www.svyasa.org.

https://doi.org/10.1016/j.ctim.2021.102772
Received 3 September 2020; Received in revised form 20 August 2021; Accepted 25 August 2021 Available online 8 September 2021
0965-2299/©    2021    The    Authors.	Published    by    Elsevier    Ltd.	This    is    an    open    access    article    under    the    CC    BY-NC-ND    license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.M. TL et al.

during adolescent transition.10–14
Yoga is an umbrella term used for any physical, psychological and spiritual activity that originated from ancient texts to enhance quality of life. Yoga is broadly classified as Bhakti Yoga (Yoga of devotion), Jnana
Yoga (Yoga of knowledge), Raja Yoga (Yoga of mental mastery) and Karma Yoga (Yoga of action).15  Among these, Raja Yoga or Patanjali
Yoga is more popular and researched. This form of yoga comprises of 8 limbs called Yama (social conducts), Niyama (individual adherences), Asana (postures), Pranayama (breathing techniques), Pratyahara (con-trol of senses), Dharana (focusing), Dhyana (meditation) and Samadhi (contemplation). Adherence to first two limbs (Yama and Niyama) is essential to tread the path of yogic way of life. Yama comprises of five essential social conducts called ahimsa (non-violence), satya (truthful-ness), asteya (non-stealing), brahmacharya (living in moderation) and aparigraha (non-possessiveness). Niyama also comprises of five essential qualities such as shoucha (purity), santosha (contentment), tapas (aus-terity), swadhyaya (self-awareness) and Iswara pranidhana (let go of ego). Both Yama and Niyama play a vital role in establishing self-control of emotions and judicial use of intellect.
The tenets of yoga emphasise on establishing harmony between the physical body, breath and mind.16,17 In yogic parlance, human existence
is  an  amalgamation  of  five  sheaths  described  as  the  physical  body, breath, emotions, intellect, and blissfulness. This theory of human ex-istence is called pancha-kosha model and is explained in detail in the ancient text called Taittiriya Upanishad. The Brahmananda Valli and Brugu  Valli  sections  of  this  text,  also  define  human  existence  as  a composition  of  5  koshas  (sheaths)  called  Annamaya  kosha  (gross sheath),    Pranamaya    kosha    (energy    sheath),    Manomaya    kosha
(emotional sheath), Vijnanamaya kosha (intellectual sheath) & Anan-damaya kosha (bliss sheath).18
Holistic and integrated approach is to consider suitable yogic prac-tices from different forms of yoga to establish health and wellbeing at all the five sheaths. This approach is also well correlated with the definition of health declared by World Health Organisation (WHO). According to WHO, health is the state of complete wellbeing at physical, psycholog-ical, social and spiritual domains and not merely the absence of disease and infirmity.
Considering the vastness of the Yogic science, experts have derived a comprehensive approach called Integrated Approach to Yoga Therapy (IAYT) or Integrated Yoga Module (IYM). Anchored in the concept of pancha-kosha, IYM is a prescription of yogic techniques derived from all major forms of yoga, to address specific health conditions. A study based
on qualitative evidence, decoded IAYT module to prescribe a framework of yogic practices for different koshas as detailed below.19,20

1) Annamaya Kosha – Asanas (Yogic Postures), Loosening Exercises, Kriyas (cleansing techniques) and Yogic Diet predominantly work on Annamaya Kosha. A stable and comfortable asana engages musculo-skeletal system in a systematic way. Asanas also provide stimulation and  deep  relaxation  to  internal  organs  by  thoroughly  massaging them. Sage Patanjali states that the mind becomes tranquilled and expanded in a natural effortless way by practicing Asanas. He further claims that the dualities of the mind cease to exist by practicing Asanas. Loosening exercises strengthens the muscles, reduces joint stiffness and increases physical stamina. Kriyas have many hidden benefits in addition to purifying the body. Balanced diet helps to maintain internal harmony in the body and mind.
2) Pranamaya Kosha – Breathing exercises increases bodily awareness, corrects breathing pattern, clears the lungs and increases lung ca-pacity.  Pranayamas  help  to  slow  down  breath  rate  and  restore autonomic balance thereby calming the mind. It promotes free flow of  energy  in  the  body  thereby  makes  the  mind  ready  for  higher practices.
3) Manomaya  Kosha  –  Meditations,  Devotional  Sessions  and  Bhakti Yoga   engage   the   mind   to   promote   emotional   regulation   and emotional culture.


Complementary Therapies in Medicine 61 (2021) 102772

4) Vijnanamaya Kosha – Lectures, Counselling, Satsang (company of good people) and Jnana Yoga (in-depth study of a subject) sharpens the intellect. All these provide right knowledge and eradicate igno-rance. Helps to understand realities of life.
5) Anandamaya Kosha - Karma Yoga (selfless service) leads to a state of blissful silence with awareness, perfect poise, and freedom of choice where the mind is not troubled by stressful thoughts and fears.

Anchored in this theory, an attempt is made to develop an integrated and holistic yoga module for anger management by deriving the concept of anger management from the traditional texts as detailed below.
According to ancient texts, anger is an innate emotion and has its origin in manomaya kosha. It is experienced throughout the body and causes disruption in all dimensions of existence (koshas). Anger triggers sympathetic arousal causing various physiological changes in the body (annamaya kosha). It alters the breathing pattern (pranamaya kosha) and leads to momentary memory loss (manomaya kosha). Further it destroys the power of discrimination (vijnanamaya kosha) and distances one from being at bliss (anandamaya kosha).
Among  the  several  traditional  texts,  Patanjali  Yoga  Sutras  (PYS), Yoga  Vasista,  Bhagavad-Gita  (BG)  and  Upanishads  have  illustrated many anger management techniques. Yama –Niyama concepts of PYS provide a strong base to overcome anger. Yoga Vasista offers evidences for mind–body inter-connectedness in defining, diagnosing and treating illnesses of all kinds. BG explains the origin of anger, its consequences, and management techniques spread across in various verses. To mention a  few,  Yoga  Vasista  talks  about  sublimation  of  thoughts  (mana  pra-shamana),  PYS  suggests  distraction  (pratipaksha  bhavana),  physical activity (asanas), regulating the breath (pranayama) etc. BG promotes developing virtues such as ahimsa, forgiveness, and patience as a rem-edy for anger.
Although it is seen that yoga is effective in schools for nurturing mental   health,   available   studies   suffer   from   several   limitations regarding  study  design,  methodology,  standardization  yoga  module,
sample size, absence of control group, etc. Review studies on yoga in schools calls for standardisation of yoga module.12,21
Considering the dearth in studies pertaining to yoga modules for anger management, this study aims at developing an integrated and holistic yoga program for anger management suitable to school envi-ronment. Holistic and integrative approach is established by considering the yogic practices suited to all layers of existence and also considering major forms of yoga such as Raja Yoga, Bhakti Yoga and Jnana Yoga.

2.  Material and methods

The purpose of the study is to develop a yoga module  for anger management for secondary school children. The scope of the study in-cludes a) construction of the module based on IAYT principle and lit-erary review, b) validation of the module by experts, and c) through the pilot study, assessing the feasibility of the module and also check its initial effectiveness. It is a school-based yoga program designed to be taught in secondary schools. This study was approved by Institutional Ethics Committee of S-VYASA Yoga University. Clinical trial registry was not done as it was not mandatory at the time of study and the scope of the work was more theoretical.
The study relies on scriptural evidences for deriving various anger management  techniques  and  contemporary  yoga  books  for  selecting relevant  yogic  practices  for  anger  management.  Strict  adherence  to modern scientific module development procedures and processes was ensured during construction and validation of the module.
The  study  methodology  comprises  of  three  processes.  They  are construction of a yoga module, validation of the module by experts, and a pilot study administering the module in a non-randomised control trial.
Initially a framework of 18 yogic techniques was prepared providing justification for each technique. Evidences for justification of the yogic


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A.M. TL et al.

techniques were drawn from the contemporary books on yoga.22–30  In general, yogic techniques that activate parasympathetic activities and promote balance of sympathetic and parasympathetic activities were chosen. These include asanas that promote concentration, attention, and balance; pranayamas that promote calmness and tranquillity; medita-tion that promotes emotional mastery. Under the premise of Jnana yoga, a few aspects of Yama, Niyama, Pratyahara and also physiology and psychology of anger are discussed.
This framework was prepared in a tabular form providing columns for validation using Likert scale of 0–4 with 0 being necessary, 1 a little useful, 2 moderately useful, 3 essential 4 extremely essential. Provision were made to provide overall comments, suggestions and also to review the module in terms of it’s

a) relevance - whether the technique significantly works for anger b) specificity - whether the technique is precise for anger;
c) sensitivity - whether the technique is sensitive enough to be prac-ticed by children (both girls and boys) in school setting; and
d) evidence - whether the justification provided is adequate for its use.

The  framework  was sent  to 26  experts (6  yoga  practitioners and therapists, 4 yoga professors, 4 yoga research scholars, 10 psychologists, and 2 adolescent counselling experts). A detailed note on the purpose of this study was also sent along with the framework in printed form for local experts and in electronic form for outstation and overseas experts. Experts were requested to respond immediately but not later than 30 days. Most of the experts were Ph.D. holders with more than 10–15 years of experience and are veterans in their field.
Content  rationality  of  the  module  was  calculated  using  Lawshe’s Content Validity Ratio (CVR), which is a method for measuring the level of agreement of an item among experts in the panel. The more the ex-
perts agree on an item, the greater the level of content validity for that item.31
A yoga module was constructed using techniques that were qualified in  expert  validation.  It  was  broadly  classified  into  1)  Opening  and closing prayers 2) Postures and breathing techniques 3) Meditations 4) Knowledge points, and 5) Home practice.
The developed module was administered in a non-randomised con-trol study (pilot study) carried out in a secondary school. The school had two sections (divisions/ classrooms/groups) of 8th grade students i.e. Section A and Section B with around 30 children in each section. Among them, 28 children in Section A and 22 children in Section B consented for the  study  and  met  inclusion  and  exclusion  criterion.  Using  lottery method, one section was considered as the yoga group and the other section as the waitlist control group. Randomisation at the children level could not be done as it was disturbing the school’s internal set-up. Yoga sessions were conducted during the academic hours in the slots (free periods) allotted by the school. Control group students attended regular classes. Yoga sessions were conducted for four months with two sessions of 30 min each per week.
Anger  assessment  was  done  using  a  validated  Adolescent  Anger Assessment  Scale.  This  23-item  self-reporting  scale  assesses  anger  at behavioural, verbal, and mental domains in adolescents and enjoys high reliability scores with Alpha coefficient (α-0.804) and test-retest reli-ability (r-0.835). Anger scales tend to have limitations of culture spec-
ificity and sensitivity as the words used to describe anger have variety of meanings in different cultures.32,33 This is the first of its kind anger scale developed in India34  and is found to be in par with the popular and
widely  used  STAXI-2A  anger  assessment  Scale  which  is  of  western origin.


Complementary Therapies in Medicine 61 (2021) 102772

psychologists)   partially   filled   the   forms   excluding   the   asana   and breathing part as they stated that they don’t have expertise in these aspects. Remaining eight experts did not provide their rating item-wise but  responded  saying  that  everything  is  OK  and  it  is  an  excellent attempt. For the purpose of calculation, only technique-wise provided responses were considered.
Out of 18 practices in the framework, 12 practices were validated by 8  experts  and  6  practices  were  validated  by  14  experts.  As  per  the Lawshe’s CVR ratio, the minimum value (qualifying value) for 8 experts is 0.75, and for 14 experts is 0.51. CVR was calculated for all the prac-tices which are presented in Table 1 below.
Seven techniques have scored CVR 1.0 indicating total agreement. 11 techniques with CVR ³ 0.75 reviewed by 8 experts, and 5 techniques with CVR ³ 0.51 reviewed by 14 experts, qualified for inclusion in the module. Techniques (with asterisk mark in Table 1) namely krida yoga (CVR = 0.50)  and  screening  of  movies  (CVR = 0.14)  were  excluded. Experts have expressed their apprehension about screening of movies and conducting krida yoga in the class room in the 30-minutes slot.
Even though experts who gave an overall OK comment and did not provide item-wise rating were excluded, it is worth mentioning that they have validated all the techniques in total agreement. In general, these responses were excellent.
The pre and post data of pilot study is anlysed using paired t-test to examine the effectiveness of the yoga module. For the purpose of sta-tistical testing, α level was set at 5 %. Normality test was not carried out as it was a pilot work and randomisation at children level was not done. Results are tabulated in Table 2 below.
Results indicate significant reduction of anger  scores in the yoga group. An increase, though not significant is observed in control group. Table 2 also reveal a big difference in baseline data which renders the results non conclusive. However, p value 0.000 of yoga group moder-ately substantiates the initial effectiveness.
Subjective feedback from the students during practice was excellent. The module was well accepted and children found it very convenient and comfortable to practice. Oral feedback from the teachers was that


Table 1
Yogic Techniques with CVR as per Lawshe formula.
Yogic techniques	ne	N	N/	ne	CVR 2	-N/2
Techniques reviewed by 8 experts
1	Dynamic practice of asanas in sequence -	7	8	4	3	0.75 Shashankasana, Bhujangasana,
Adhomukha swanasana
2	Triyak Tadasana	7	8	4	3	0.75 3	Ostrich Pose	7	8	4	3	0.75 4	Vrikshasana, veerabhadrasana-3,	7	8	4	3	0.75
Natarajasana
5	Paschimottanasana	7	8	4	3	0.75 6	Suryanamaskara	8	8	4	4	1.0 7	Conscious Breathing	8	8	4	4	1.0 8	Abdominal breathing	8	8	4	4	1.0 9	Alternate Nostril Breathing	7	8	4	3	0.75 10	Brahmari	7	8	4	3	0.75 11	Yogic Concepts (Ahimsa, Brahmacharya,	8	8	4	4	1.0
Santosha, Swadhyaya, Iswara Pranidhana, Pratyahara)
12	Krida Yoga	6	8	4	2	0.5* Techniques reviewed by 14 experts
13	Meditation	12	14	7	5	0.71 14	Physiology & Psychology of Anger	14	14	7	7	1.0 15	Screening of Movies	7	14	7	0	0.14
*



16 2.1.  Analysis and results	17
18

Food and Anger Stories on Anger
Home work

14        14        7            7               1.0 14        14        7            7               1.0
13	14	7	6	0.88



The framework that was sent to experts for their rating is placed as Appendix A. Out of twenty-six, four experts did not respond. Eight ex-perts  provided  their  ratings  for  all  the  items.  Six  experts  (mostly


ne = number of experts indicating ‘essential and extremely essential’ (3 or 4 in 0–4 Likert scale), N = Total number of experts, CVR = Content validity ratio.
*   Excluded in final module.


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Table 2
Results of intervention study.


Complementary Therapies in Medicine 61 (2021) 102772

3.  Discussion



Category	Groups	pre-mean	post-mean	p-value
Yoga Group (n = 28)              51.50                 45.07                   .000 Control Group (n = 22)         46.82                 47.23                   .585
School (n = 50)

children were active, energetic and attentive in the class after the yoga sessions. As a part of homework, children were asked to practice 12 surya namaskaras every day at home which led the students’ family members also to start practicing yoga.
The  conclusive  result  of  the  study  is  the  emergence  of  the  Yoga module after expert validation and pilot study. The framework of the module is detailed below in Table 3.

Table 3
Summarised Integrated Yoga Module for Anger Management.
Sl	Technique	Description No
Opening Prayer, sitting	Bhagavad-Gita Chapter 2 verse 62 and 63. position, (2 min)	The verses are "dhyayato vishayaanpumsaha
sangasteshoopajaayate| sangaat sanjaayate kaamaha kaamaat krodhobhijaayate|| krodhaadbhavati sammohah sammohaat smritivibhramaha| smritibhramshaad
1	Prayer should be chanted	buddinaasho buddhinaashaat pranashyati||”, followed by explaining the	Meaning: Looking at something, an interest meaning.	develops, which leads to attachment then the
desire to have it. From the desire, anger arises. Anger leads to mesmerisation which leads to loss of memory which leads to loss of decision making ability. With that, one ruins. Surya namaskar 6–12 rounds + any 2 prescribed asanas practice in each session (Shashankasana, Bhujangasana, Adhomukha swanasana, Ostrich Pose Vrikshasana,
Asanas, standing position,
(10 min)
2	veerabhadrasana-3, Natarajasana, Triyak Tadasana, Paschimottanasana); each asana should be done twice. Repetition of asanas in subsequent sessions one after the other depending on their learning
Any one of the prescribed breathing Breathing practice, sitting	technique each session (Conscious Breathing, position, (5 min)	Abdominal breathing, Alternate Nostril
3
Breathing, Brahmari)
Any one of the prescribed four guided short Meditation, sitting position	meditations in each session Meditations
4
(8 min)	include Awareness, Sublimation, Distraction to opposite emotion, Developing Virtues Any one concept is driven in each session either through story or lecture. Concepts include Ahimsa (non-violence), Brahmacharya (moderation), Santosha (contentment), Swadhyaya (Self-awareness), Iswara Pranidhana (dropping of ego), Mindful eating, Pratyahara (controlling the senses). Story telling on anger and its management. Basic physiology and psychology of anger.
Jana Yoga (knowledge
5	points), sitting position,
(3 min)
Bhagavad-Gita, Chapter 3, verse 37 - "Kaama esha krodha esha rajoguna samudhbhavaha| mahaashano mahaapaapmaa viddhyenamiha
Closing Prayer, sitting
position (2 min)
6	vairinam ||" Meaning: Desire and Anger are same. It arises from the Rajasic nature. Anger is most sinful and heinous character. It is said to be biggest enemy of man.
Children are asked to practice minimum 12 rounds of Surya Namaskara everyday morning. Children can be asked to maintain a log book of the following: 1) wake up time &
7	Home Practice	going to bed time; 2) No. of times got angry, brief about the situation, with whom; 3) Screen time (TV watching time); 4) foods eaten details; 5) No. of Surya Namaskara
done on that day

The study documented development and validation of an integrative yoga module for anger management among healthy students in a school setting. Anchored in IAYT concept, the module was very well received by the students. Excellent CVR scores, pilot study results and feedback from the subjects confirm the validity and feasibility of the yoga module. The pilot study also records significant reduction of anger scores in the yoga group which provides reasonable evidences for initial effectiveness of the module.
The current study is considered as a maiden step to develop a holistic and  integrative  module  based  on  IAYT  for  anger  management.  The strength of the module is  that it comprises of specific techniques to address the issues of anger at physical, psychological, and social do-mains. Utmost care was taken while designing the module to aptly suit to the school environment.
The  novelty  of  this  study  is  in  developing  the  framework  by providing justification and seeking both subjective and objective vali-dation of experts. The framework developed was validated by multi-disciplinary  experts,  which  is  first  of  its  kind.  The  experts  included experienced  and  veteran  Yoga  Practitioners,  Yoga  Scientists,  Yoga Therapists, Psychologist, and Counselling Professionals. Sixteen out of 18 yogic techniques suggested in the framework received high scores of CVR in expert validation confirming high content validity of the module. Uniqueness of the study also lies in emphasising on Yama–Niyama concept  as  well  as  considering  physiology  and  psychology  of  anger under  the  premise  of  Jnana  Yoga  and  incorporating  it  in  a  planned manner. Novelty of the program also lies in driving the yogic concepts through stories and lectures immediately after asana and pranayama practice. An observation is that the dynamic practice of 10–15 min of Asanas helped children to counter their fatigue and burn a few calories. They seemed to be in a calm state of mind after practicing Asanas and Pranayamas. Children were more attentive and focused throughout the session. The concept driven through lectures and stories were very well understood by the students. It also helped them to internalise the con-
cepts better.
In the current study, the framework that was prepared for expert validation appeared to be having too many dimensions to evaluate. The fragmentation of sensitivity, relevance, significance, evidence etc. also did not receive good response. The response was almost same for all the features. This may be due to many of the experts resorting to providing an overall comment. This complexity could be considered as a limitation and future studies may consider simplifying the aspects for validation. Secondly, the significant reduction in the anger scores in the yoga group failed  to  provide  strong  evidences  for  effectiveness  of  the  module because  of  weak  methodology.  As  it  was  a  pilot  study,  sample  size calculation,  normality,  and  significance  tests  were  not  done  a  priori which could be considered as a limitation. Further, subject wise ran-domisation was not done and hence could not explain the baseline dif-
ference observed. However, testing of baseline difference is debated in a couple of studies.35,36
The developed module has been used in a separate study to assess anger among 187 children. The design of this non-randomised control study is similar to the pilot study of current research work. The study was conducted in two schools and each school had a yoga and control group. Yoga intervention was provided for 4 months with two sessions
per week. Yoga group had 114 (71+ 43) children and control group had 73 (38+ 35) children.37The study showed significant reduction of anger
scores in yoga group. In addition to confirming efficacy of the module, the	study	also	substantiates	module’s	standardisation	and generalisation.
Very few studies on developing and validating yoga modules are available. Common aspects followed in these studies are 1) reviewing yoga  texts  (Literary  review),  2)  validation  by  yoga  experts  and  3) administration of the module in a small sample size.
A study developing yoga module for depression reports validation of


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the module by 9 experts and pilot intervention study with 7 patients.38 Another yoga module developed for Parkinson disease carried out only
validation  by  20  experts.  Twenty  one  out  of  28  techniques  scored required CVR ratio in this study.39  A study developing an IAYT Yoga
module for obesity in adolescents developed the module based on lit-
erary review and was validated by 16 yoga experts. This module consists of 43 techniques.40 Another study developing yoga module for children
with visual impairment developed the module based on traditional texts,
followed by validation by 25 yoga experts and pilot administration with 9 children.41
The highlights of the current study are 1) detailed literary review of Indian traditional texts for deriving concepts of anger management, 2) yoga books referred for selection of yogic practices are placed as refer-ences 3) provided justification and evidences for each of the techniques chosen  in  the  module,  4)  inter-disciplinary  experts  were  chosen  for validation of the module, 5) field study was conducted with a reasonably good sample size, and 6) an attempt to combine the best of East (Indian traditional  concepts  of  anger  management)  with  the  best  of  West (modern scientific research processes and practices).
There are a couple of yoga studies that assessed anger along with
other parameters in adolescents. These studies have used yoga modules based on Kripalu Yoga,42 Yoga Ed program,11 and IAYT.43 Though they
have found effectiveness of yoga in reduction of anger scores, there is no mention of validation of the yoga module in any of these studies.
A few studies have reported benefits of specific yogic techniques. Studies on Suryanamaskara report multiple benefits such as activation of 80  %  of  the  musculoskeletal  system,  enhanced  executive  functions,
improved attention and concentration and also inducement of peace and calmness44,45 Brahmari pranayama helps in activating the higher limbic activities and harmonizing the hypothalamic functions.46  The medita-
tions are known to produce changes in the limbic lobes of brain and influence the expression of anger and also produce calmness.47
The waitlist control group in the pilot study did not perform any specific activity during the period of study which could also be consid-ered as a limitation. Secondly, a data sheet (dairy) was provided to all the children to fill. Children did not respond well for this and most of the


Complementary Therapies in Medicine 61 (2021) 102772

children in the control group did not return the data sheets.
Sample size calculation could not be done for considering the num-ber of experts. Number of expert in previous studies varied from 5 to 26 and had experts only from yoga field. The current study considered 26 experts in total from interdisciplinary fields like yoga, psychology, ed-ucation etc. Four of the experts did not respond and eight experts did not provide  item-wise  rating.  Hence,  only  responses  of  14  experts  were considered for calculation. Further, out of 18 practices in the frame-work, 12 practices were validated by 8 experts and 6 practices were validated by 14 experts. Future studies may consider streamlining this process in a more effective way.

4.  Conclusion

Holistic and integrative approach employed by considering Pancha Kosha concept and IAYT principle in developing yoga module for anger management provided adequate basis to achieve content validity.
Validation  from  multi-disciplinary  experts  greatly  supported  the integrative approach. The pilot study provided satisfactory evidence for standardisation of the module.
Yoga program for anger management is feasible in school environ-ment and the techniques were very well accepted by students.
The developed yoga module is recognized as a very useful program for anger management among adolescents.

Declaration of Competing Interest

The authors report no declarations of interest.

Acknowledgement

The current study is part of a project on anger in adolescents for which financial assistance is provided by Sri. Venkateswara Vedic Uni-versity, Tirupati. The authors acknowledge the support of the funding institution.



Appendix A.  Framework of yogic techniques – sent to experts for validation


Sl no




1



2

3


4


5


6


7

Yogic Technique


Dynamic practice of these asanas in sequence

Shashankasana, Bhujangasana, Adhomukha swanasana,


Triyak Tadasana

Ostrich Pose

Vrikshasana, veerabhadrasana-3, Natarajasana

Paschimottanasana


Suryanamaskara


Conscious Breathing

Details and Justification	1	2	3	4	5

1-relevance, 2-specificity, 3-sensitivity, 4-evidence, 5-overall comments

Provides gentle movement, flexion and extension to all major joints - head to toe
Enhanced blood flow throughout the body Induces cycle of relaxation and activation
Bhujangasana – has balancing effect on some hormones, keep the spine supple Shashankasana – regulates the functioning of adrenal glands and good for anger Strengthens the nerves and muscles of arms and legs.
(ref : book ‘Yoga Education for children’ by Bihar School of Yoga) Lateral bending and lateral balancing posture.
Simple movement in coronal plane as opposed to sagittal plane movements in the previous step (ref : book ‘Yoga Education for children’ by Bihar School of Yoga)
Develops balance, attention and concentration balancing postures
Enhance focusing, strengthen the lower extremities, Awareness of sensory input perception
Balancing enhances concentration / attention. (anger is associated with restlessness or lack of attention and concentration)
Good for strengthening lower extremities, Thymus gland activation Mind-body-breath coordination;
80 % of the musculoskeletal system gets activation, sub maximum pressure on joints (Ref: SNO paper)
Positive outlook; improved memory, concentration and attention; induces peace and calmness; promotes well-being; enhances depth of perception
(Ref: Book - Dynamic Suryanamaskar-Krzysztof Stec)
Awareness of breathing

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8	Abdominal breathing



9	Alternate Nostril Breathing


10	Brahmari







11	Meditation







12	Physiology & Psychology of Anger



13	Screening of Movies






14	Yogic Concepts

Details and Justification	1	2	3	4	5

Helps to calm down.
Easy and simple way to practice – be in the present
Upper Chest breathing is observed with anger abdominal breathing is the natural breathing pattern
Requires less energy than chest or upper lunch breathing
Oxygen/Carbon dioxide exchange is greater during this type of breathing (Ref: Yoga Education for Children, Bihar School of Yoga; page 265, vol 1) Balances the sympathetic and parasympathetic tone ;
Flow of prana in Ida and Pingala nadis is equalized
Regulating breathing helps in calming down the mind. Mind stabilises when breath is steady (Ref: Hata Yoga Pradeepika 2-2)
Activates the higher limbic activities – anger is generated at lower limbic but coping is done at higher limbic region
Harmonises the hypothalamic functions by which entire mind-body complex gets benefits (Ref: book Power of Pranayama, Dr. Renu Mahtani)
Short guided-meditations comprised of three parts a) Preparation b) One of the four Anger Management Techniques and c) Conclusion.
Preparation process includes adopting a sitting meditative posture, bringing the mind-body-breath awareness by observing the posture and breathing. The concluding process includes observing silence, making a resolve. The middle part includes one of the four anger management techniques as detailed below:
Prajna (awareness) – Thinking and feeling of anger by evoking, intensifying and defusing the anger emotion. This helps children to become aware of their anger emotion, physiological and psychological changes that occur during anger.
Manaprashamana (sublimation) – Art of sublimation of anger thoughts. The process involves evoking anger emotion and then reducing the speed by slowing down the thought process.
Pratipaksha Bhavana (shifting of emotions) – It is a process of experiencing opposite emotions one after the other. This helps in swiftly shifting the mind to an opposite emotion.
Sadguna (developing positive virtue): Forgiveness is one of the positive virtues that turn away the anger emotion. This process involves calling or re-living an instance once with anger driven response and recalling it again with forgiveness driven response
Definition of anger
Stimulus and Response theory SNS and PSNS
What happens when you are angry Manifestations
Anger consequences Anger Management
Philosophers who emphasised Non-violence (Krishna, Gandhi, Vivekananda etc.) Health consequences of Anger
Ahimsa (Nonviolence)
Do not cause physical or mental suffering to anyone Do not hurt others for whatsoever reason
Do not blame anything and hate anybody
Be gentle in your speech - speak good and pleasant things Be polite in your behaviour
Be kind to everyone Brahmacharya (moderation)
Do not do anything in excess – watching TV, sleeping, playing, eating etc. Do not get addicted to electronic gadgets
Do not get into bad habits – smoking, alcohol, drugs etc. Judge what is good for you and do only that
Know your limits Live in moderation
Santosha (Contentment)
Be satisfied with what you have Love yourself
Enjoy doing things without focusing too much on the results Do not feel bad for what you don’t have
Don’t feel jealous
Do not get attracted towards crafty advertisements Swadhyaya (Self Awareness)
Know your strengths and weaknesses Be self-motivated
Have an inclination to understand the mind, consciousness, our existence and the whole creation Do not get fooled by false information / wrong knowledge
Do not learn anything that brings down your personality Iswara Pranidana (Giving up the Ego)
Develop humility
Treat everyone as equal Learn to surrender
Do good and forget it Do not argue
Don’t have rigid thoughts
Do not boast

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15	Food and Anger



16	Stories on Anger



17	Krida Yoga


18	Home Work

Details and Justification	1	2	3	4	5

Pratyahara (withdrawal of senses) Controlling the sensory inputs Focus on what you are doing
Do not get disturbed /distracted by other things (Ref : Book – SURYA by Dr. SN Omkar,)
Food types (rajasic, tamasic and satvic) What, when, how, how much, where to eat MINDFUL EATING
Stories on anger can be narrated to students to make them understand the concept of anger. Briefing and debriefing the moral of story is essential to reinforce the concept. 3 stories are listed below:
Story of a boy hitting the nail on a tree every time when he got angry. Moral : Anger comes and goes leaving a permanent scar
Story of smashed fingers: Enraged father punishing his son for making a scratch on the car. Moral: Anger has no limits. Anger leads to inappropriate and harmful actions. Anger leads to temporary memory loss. Story of Vivekananda as a student in Law College in UK. Interaction between him and Mr. Peters. Moral -Anger is not a solution to any problem. Keeping mind calm helps one to take better decisions.
A computer game on anger management will be developed and used if time permits.
Asana Practice : Daily practice of Surya Namaskara – minimum 12 rounds
Dairy writing – Children can be asked to maintain a log book of the following: 1) wake up time & going to
bed time; 2) No. of times got angry, brief about the situation, with whom; 3) Screen time (TV watching time); 4) foods eaten details; 5) Good thing of the day & Bad thing of the day and 6) No. of Surya
Namaskara done on that day





References

1  Kerr MA, Schneider BH. Anger expression in children and adolescents: a review of the empirical literature. Clin Psychol Rev. 2008;28:559–577.
2  Novaco RW. Chapter 35 - Anger. In: G. B. T.-S. C, ed. Fink cognition, emotion, and behavior. Academic Press; 2016:285–292. https://doi.org/10.1016/B978-0-12-800951-2.00035-2.
3  Sharma MK, Marimuthu P. Prevalence and psychosocial factors of aggression among youth. Indian J Psychol Med. 2014;36:48–53.
4  Garfinkel SN, et al. Anger in brain and body: the neural and physiological perturbation of decision-making by emotion. Soc Cogn Affect Neurosci. 2016;11: 150–158.
5  Hendricks L, Aslinia D. The effects of anger on the brain and body. Natl. Forum J. Couns. Addict. 2013;2:1–12.
6  Sukhodolsky DG, Kassinove H, Gorman BS. Cognitive-behavioral therapy for anger in children and adolescents: a meta-analysis. Aggress Violent Behav. 2004;9:247–269.
7  Narasimhan L, Nagarathna R, Nagendra H. Effect of integrated yogic practices on positive and negative emotions in healthy adults. Int J Yoga. 2011;4:13–19.
8  Amaranath B, Nagendra HR, Deshpande S. Effect of integrated Yoga module on positive and negative emotions in Home Guards in Bengaluru: a wait list randomized control trial. Int J Yoga. 2016;9:35–43.
9  Rodrigues J. Anger awareness and adolescent boys - a literature review. 2019.
10  Conboy LA, Noggle JJ, Frey JL, Kudesia RS, Khalsa SBS. Qualitative evaluation of a high school yoga program: Feasibility and perceived benefits. Explor. J. Sci. Heal. 2013;9:171–180.
11  Noggle JJ, Steiner NJ, Minami T, Khalsa SBS. Benefits of yoga for psychosocial well-being in a US high school curriculum. J Dev Behav Pediatr. 2012;33:193–201.
12  Hagen I, Nayar US. Yoga for children and young people’s mental health and well-being: Research review and reflections on the mental health potentials of yoga. Front Psychiatry. 2014;5:1–6.
13  Butzer B, Bury D, Telles S, Khalsa SBS. Implementing yoga within the school curriculum: a scientific rationale for improving social-emotional learning and positive student outcomes. J Child Serv. 2016;11:3–24.
14  Rangan R, Nagendra H, Bhat GR. Effect of yogic education system and modern education system on memory. Int J Yoga. 2009;2:55–61.
15  Vivekananda S. Raja Yoga. Kolkata: Advaita Ashrama; 1896. 16  Nagendra HR. Defining yoga. Int J Yoga. 2008;1:43–44.
17  Bhavanani A. Understanding the science of yoga. SENSE. 2011;1:334–344. 18  Sethumadhavan. Taittiriya Upanishad. Nagpur: Esamskriti.com; 2011.
19  Villacres MDC, Jagannathan A, Nagarathna R, Ramakrsihna J. Decoding the integrated approach to yoga therapy: qualitative evidence based conceptual framework. Int J Yoga. 2014;7:22–31.
20  Jagannathan A, Bishenchandra Y. Decoding the integrated approach to yoga therapy. Int J Yoga. 2014;7:166–167.
21  Butzer B, Ebert M, Telles S, Khalsa SBS. School-based Yoga programs in the United States: a survey. Adv Mind Body Med. 2015;29:18–26.
22  AYUSH. Yoga for children. Dept of AYUSH, Govt of Karnataka and National Rural Health Mission; 2011.
23  Nagaratna R, N. H. Integrated approach of yoga therapy for positive health. Swami Vivekananda Yoga Prakashana; 2008.


24  Omkar S. Student Upliftment and Rejuvenation through YogA (SURYA). Bangalore: Yoga Mandir Trust; 2007.
25  RIMMI Teachers. Yoga Shastra TOME 1-4. Mumbai-13: YOG; 2012. 26  SVYASA. Yoga – the science of holistic living. 1988.
27  SVYASA. Krida Yoga. 2009.
28  Saraswati SN. Yoga education for children. Munge, Bihar, India: Yoga Publiscations Trust; 1985.
29  Saraswati SS. Yoga education for children. Munge, Bihar, India: Yoga Publiscations Trust; 1985.
30  Chanchani S. Yoga for children a complete illustrated guide to yoga. UBS Publishers, Distributors Pvt Ltd; 1995.
31  Lawshe CH. A quantitative approach to content validity. Pers Psychol. 2006;28: 563–575.
32  Barchard KA, Grob KE, Roe MJ. Is sadness blue? The problem of using figurative language for emotions on psychological tests. Behav Res Methods. 2017;49:443–456.
33  Matsumoto D, Yoo SH, Chung J. International handbook of anger. Int. Handb. Anger. 2010:125–137. https://doi.org/10.1007/978-0-387-89676-2.
34  Alaka Mani TL, Sharma MK, Omkar SN, Nagendra HR. Holistic assessment of anger in adolescents – development of a rating scale. J Ayurveda Integr Med. 2018;9:195–200.
35  de Boer MR, Waterlander WE, Kuijper LDJ, Steenhuis IHM, Twisk JWR. Testing for baseline differences in randomized controlled trials: an unhealthy research behavior that is hard to eradicate. Int J Behav Nutr Phys Act. 2015;12:1–8.
36  Roberts C, Torgerson DJ. Understanding controlled trials: baseline imbalance in randomised controlled trials. BMJ. 1999;319:185.
37  Alaka Mani, Sharma MK, Omkar SN, Marimuttu P, H. N. Yogic management of anger in high school children T.L. Int J Curr Res Acad Rev. 2016;4.
38  Naveen GH, et al. Development and feasibility of yoga therapy module for out-patients with depression in India. Indian J Psychiatry. 2013;55.
39  Kakde N, Metri KG, Varambally S, Nagaratna R, Nagendra HR. Development and validation of a yoga module for Parkinson disease. J Complement Integr Med. 2017;14.
40  Rathi SS, Raghuaram N, Tekur P, Joshi RR, Ramarao NH. Development and validation of integrated yoga module for obesity in adolescents. Int J Yoga. 2018;11: 231–238.
41  Mohanty S, Venkataramanujam S, Pradhan B, Hankey A. Development and validation of a yoga module for children with visual impairment: a feasibility study. Br J Vis Impair. 2018;37:64–73.
42  Khalsa SBS, Hickey-Schultz L, Cohen D, Steiner N, Cope S. Evaluation of the mental health benefits of yoga in a secondary school: a preliminary randomized controlled trial. J. Behav. Heal. Serv. Res. 2012;39:80–90.
43  Choukse A, Ram A, Nagendra HR. Effect of residential yoga camp on psychological fitness of adolescents: a cohort study. J Clin Diagn Res. 2018;12:VC07–VC11.
44  Bhutkar MV, Bhutkar PM, Taware GB, Surdi AD. How effective is sun salutation in improving muscle strength, general body endurance and body composition? Asian J Sports Med. 2011;2:259–266.
45  Omkar SN. An analysis of sun salutation. 2008:81–86. https://doi.org/10.1201/ 9781439828427.ch11.
46  Sahu KP, Kishore K. The effect of Bhramari Pranayama and Jyoti Dhyan effect on alpha EEG and Hemoglobin of college going students. Int J Phys Educ Sport Heal IJPESH. 2015;1:40–44.
47  Jindal V, Gupta S, Das R. Molecular mechanisms of meditation. Mol Neurobiol. 2013; 48:808–811.




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