Slow-Breathing Curriculum for Stress Reduction in High School Students: Lessons Learned From a Feasibility Pilot

Abstract

Purpose: Nearly one in three US adolescents meet the criteria for anxiety, an issue that has worsened with the COVID-19 pandemic. We developed a video-based slow diaphragmatic breathing stress-reduction curriculum for high school students and evaluated its feasibility, tolerability, and preliminary effectiveness.

Methods: This cluster-randomized feasibility pilot compared 5-min slow diaphragmatic breathing for 5 weeks with treatment-as-usual control among four 12th-grade public high school classes. Students individually participated after school during COVID-19-related hybrid teaching, with slow diaphragmatic breathing three times/week and breath science education once/week. Feasibility was based on completion of breathing exercises, breath science education, and preliminary effectiveness assessments, and ease/tolerability was based on qualitative assessments. Preliminary effectiveness was measured with the State-Trait Anxiety Inventory (STAI) and a timed-exhale carbon dioxide tolerance test (CO₂TT) of physiological stress response. Descriptive statistics and repeated analysis of variance were performed to quantify and compare outcomes between time periods. Human subjects research approval was granted through Western IRB-Copernicus Group (WCG IRB) [ClinicalTrials.gov, Identifier: NCT05266833.].

Results: Forty-three students consented to participate. Breath practice compliance ranged from 29 to 83% across classes and weeks, and decreased on average over the 5 weeks. Compliance with the breath science videos ranged from 43 to 86%, and that with the weekly STAI-State and CO₂TT measures varied from 36 to 86%. Compliance with ease/tolerability assessments ranged from 0 to 60%. Preliminary effectiveness assessments' compliance varied across classes from 83 to 89% during baseline, and 29 to 72% at follow-up. The curriculum was rated as somewhat-to-definitely useful/beneficial, and definitely-to-very easy/tolerable. Students reported enjoying the diaphragmatic breathing, CO₂TT, and breath science education; some found the extended exhales challenging and the curriculum and assessments time-consuming. Preliminary effectiveness analyses indicated no significant changes in STAI or CO₂TT from baseline to followup or from before to after breathing exercises (p > 0.05 for all).

Conclusions: Implementation of this 5-week slow breathing curriculum was feasible and tolerable to this cohort. Compliance, tolerability, and effectiveness may be improved with in-class participation. Future research on simple and accessible slow-breathing exercises is warranted to address today's adolescent stress-management crisis.

Trial registration: ClinicalTrials.gov, Identifier: NCT05266833.

Keywords: adolescents; diaphragmatic breathing; feasibility pilot; high school; stress reduction.

Figure 1

Participant flow through study recruitment, procedures, data collection, and intervention. CO₂TT, carbon dioxide tolerance test; SDB, slow diaphragmatic breathing; STAI, State-Trait Anxiety Inventory. *For the control class, CO₂TT was done each week once before and once after STAI-State; for the breathing classes, CO₂TT and STAI-State were both done each week once before and once after that day's breathing practices and the breath science video. **Only for participants in the breathing classes.

Figure 2

(A) Percent of breathing group participants completing breathing exercises, by class & week. GP, guided-pace breathing group. (B) Percent of breathing group participants completing breath science education videos, by class & week. GP, guided-pace breathing group. (C) Percent of all participants completing STAI-state & CO₂TT assessments, by class & week. GP, guided-pace breathing group; SP,-1, self-paced group 1; SP,-2, self-paced group 2. CO₂TT, carbon dioxide tolerance test; STAI, State-Trait Anxiety Inventory.

Figure 3

(A) Mean (95% confidence intervals) student ratings of the breathing curriculum (n =13 student respondents). (B) Mean (95% confidence intervals) student ratings of the study assessments (n = 17 student respondents). CO₂TT, carbon dioxide tolerance test; STAI, State-Trait Anxiety Inventory.