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

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.

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.].

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).

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.

ClinicalTrials.gov, Identifier: NCT05266833.