Table of Contents  
Year : 2019  |  Volume : 51  |  Issue : 2  |  Page : 43-47

Integrated yoga therapy for teaching toothbrushing skills to children with autism spectrum disorder: A qualitative study of parents' perceptions

1 Department of Paedodontics and Preventive Dentistry, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India
2 Centre for Yoga Therapy, Education and Research, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India
3 Department of Paediatrics, Government Villupuram Medical College, Tamil Nadu Dr. M.G.R. Medical University, Chennai, Tamil Nadu, India

Date of Submission19-Aug-2019
Date of Acceptance14-Oct-2019
Date of Web Publication09-Dec-2019

Correspondence Address:
R Eswari
Department of Paedodontics and Preventive Dentistry, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ym.ym_17_19

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Background: Children with autism spectrum disorder (ASD) exhibit poor oral health due to lack of manual dexterity. Regular training methods such as visual pedagogy and video modeling (VM) for developing the skill of toothbrushing do not address the core deficits which facilitate their effective and quick learning. Hence, there arises the need of an integrated therapy which can complement these regular training techniques.
Aim: This study aimed to evaluate whether yoga can complement the regular training methods in teaching the brushing skill to children with ASD.
Materials and Methods: Two groups of 36 children with ASD aged 7–15 years were imparted visual pedagogy and VM in Group I and additional yoga in Group II. Assessment of toothbrushing skill was done by parents and teachers independently using the perception and assessment forms, respectively.
Results: By the end of 6 months, higher percentage of parents of children in Group II observed improvements in their child's brushing skill as compared to parents of children in Group I. Based on the teachers' observation, there was a statistically significant difference in the mean number of days the children watched the video completely (p = 0.001), with children in Group II watching the video for more number of days.
Conclusion: Yoga has a positive and additive role along with the regular training methods for toothbrushing in children with ASD.

Keywords: Attention, learning, motor skills, oral health, pediatric dentistry

How to cite this article:
Eswari R, Prathima G S, Sanguida A, Ramanathan M, Bhavanani AB, Harikrishnan E. Integrated yoga therapy for teaching toothbrushing skills to children with autism spectrum disorder: A qualitative study of parents' perceptions. Yoga Mimamsa 2019;51:43-7

How to cite this URL:
Eswari R, Prathima G S, Sanguida A, Ramanathan M, Bhavanani AB, Harikrishnan E. Integrated yoga therapy for teaching toothbrushing skills to children with autism spectrum disorder: A qualitative study of parents' perceptions. Yoga Mimamsa [serial online] 2019 [cited 2023 Mar 29];51:43-7. Available from:

  Introduction Top

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder which is characterized by social impairment, communication impairment, and stereotyped repetitive activities (Orellana, Martinez-Sanchis, & Silvestre, 2014).

There are no known autism-specific oral manifestations, and the oral problems that arise are due to their autism-related behaviors. In general, these children exhibit poor oral health with plaque and calculus accumulation, which is attributed to the tactile defensiveness against toothbrushing and the use of other intraoral hygiene devices (Du, Yiu, King, Wong, & Mcgrath, 2015).

Visual pedagogy (VP) and video modeling (VM) are some of the effective evidence-based methods to train children with ASD who are considered as good visual learners (Backman & Pilebro, 1999; Orellana, Martinez-Sanchis & Silvestre, 2014; Pilebro & Backman, 2005; Rayner, 2010; Sallam, Badr, & Rashed, 2013).

While the above methods work efficiently on the relative strengths of children with ASD, they do not address the core deficits of the disorder (Radhakrishna, 2010). Yoga is a powerful and promising tool in these children to improve the coordination of activities of mind, body, and emotions. It not only improves their focus and concentration, which is lacking in children with ASD (Deorari & Bhardwaj, 2014), but also shown to improve the imitation skills, gross motor skill, and attention, which are essential prerequisites for learning (Radhakrishna, 2010).

Therefore, this study was designed to assess whether yoga can complement VP and VM methods to teach toothbrushing skill in children with ASD.

  Materials and Methods Top

This comparative study was conducted in two special schools among 72 children diagnosed with ASD. After obtaining consent from parents/caregivers, children between 7 and 15 years of age with ASD belonging to moderate category assessed using Childhood Autism Rating Scale – 2 scale, who were able to understand visual or simple verbal instructions, who had not participated in similar intervention program previously, and who were not using any intervention currently for improving their toothbrushing habit were recruited, and children with comorbidities such as epilepsy were excluded from the study.

Detailed case history was recorded from the parents, and clinical examination of the children was performed. The children were divided into two groups of 36 each to train them in toothbrushing skill. In Group I, children with ASD received VP and VM and children in Group II received VP and VM along with yoga as an adjunct.

The VP provided to the children of both the groups was an album of 15 pictures demonstrating the steps of brushing in a sequential order. The parents were trained on the usage of the album at home while the child is brushing, and they were instructed to observe their child's usage of the album and also any improvement in their brushing. Their observations were recorded using the Parent's Perception Form (PPF) at the end of the 1st, 2nd, 3rd, and 6th months. The PPF contains five attributes containing questions pertaining to whether their child had to be reminded every day to brush, improvement in the independency of brushing, number of sequential steps followed by their child, improvement in brushing skill, and finally whether the parents were able to notice changes other than brushing skills in their children. The responses were recorded as proportion of parents who chose the various options under each attribute.

VM is a 3-min video demonstrating the steps of brushing similar to VP, which was played at the school daily once by the teachers to the children of both the groups. The teachers were instructed to observe the children's level of concentration in watching the video. The observations were recorded in the Teacher's Assessment Form (TAF) as the number of days the children did not watch the video or completely/partially watched the video.

Yoga imparted to the children in our study was based on an integrated yoga therapy module devised by qualified and experienced yoga therapists. Formal training was undertaken by the principal investigator, and an hourly session of yoga was imparted to the children of Group II daily for 3 months under the guidance of a yoga therapist and supervision of a pediatrician. The schedule consisted of warm-up, loosening and harmonizing practices, yogic breathing practices (pranayama), and calming relaxation practices [Table 1].
Table 1: Yoga techniques imparted to the 35 children with autism spectrum disorder in the study

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Statistical analysis

Statistical analysis was carried out using the IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. (IBM Corp., Armonk, NY). Comparison of categorical variables between the groups was done using Chi-square test. The TAF scores were compared between the groups using independent t-test. The PPF was presented as percentage of parent's response. p<0.05 was considered statistically significant.

  Results Top

The demographic details of the enrolled children are given in [Table 2]. There were three dropouts in Group I and one in Group II as they discontinued from the school.
Table 2: Distribution of gender and age between the two groups

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According to parents' perception, in Group II, the proportion of children who had to be reminded every day to brush decreased across various time periods (68.6% at the 1st month vs. 57.1% at the 2nd month vs. 42.9% at the 3rd month vs. 28.6% at the 6th month). In addition, the number of children who started brushing independently improved over time (14.3% at the 1st month vs. 14.3% at the 2nd month vs. 17.1% at the 3rd month vs. 25.7% at the 6th month). Such a change was not reported by the parents in Group I. By the end of the 6th month, 42.9% of the children in Group II had started following all the sequential steps in picture album on brushing technique steps, whereas none in the other group performed so. At the end of the 6th month, 94.3% of the parents in Group II expressed an overall improvement in their children's brushing skill compared to 37.5% of the parents in Group I [Table 3]. The improvement in skills other than brushing among children in Group II is presented in [Table 4].
Table 3: Responses of parents to the Parent's Perception Form

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Table 4: Parent's perception form question number 5 - other changes observed by the parents in their children

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Based on the TAF, the mean number of days the children completely watched the video was 31.21 ± 9.04 and 55.08 ± 10.20 for Group I and Group II, respectively, which shows a statistically significant difference between the two groups [Table 5].
Table 5: Teachers' assessment on video modeling at the end of 6 months

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  Discussion Top

In our study on 68 children (after dropouts) with ASD of moderate category, concurrent use of yoga with VP and VM was beneficial in terms of improved brushing skills as observed by the parents and teachers. In addition, holistic improvement in child's behavior in the form of socializing, attention, development of self-help skills, and communication was observed.

In the yoga techniques practiced by the children of Group II, the warm-up practices were given to help improve flexibility, create awareness, and enhance energy circulation throughout the body. Asanas are psychophysiological practices that form the basis of mind–body integration activity which also stretches the musculature, loosens the stiff joints, promotes better circulation, and enhances mobility and range of motion. Physical functioning becomes more integrated and less stressful, enabling the child to become aware, more focused, and remain organized. Pranayama alleviates stress and enhances memory and comprehension. The combination of asanas and pranayama enhances and balances various physiological functioning, helping to reduce emotional blockages and negative habitual patterns that can obstruct the flow of vital energy within the mind–body complex (Ramanathan & Bhavanani, 2018).

Asanas such as Ardhakati chakrasana and Meru asana, included in our schedule, stimulate the vestibular and proprioceptive systems and increase strength and coordination. These asanas also keep hyperactivity in check (Kenny, 2002; Radhakrishna, Nagarathna, & Nagendra, 2010), increase blood flow to the brain, and activate and rejuvenate brain cells, thereby promoting dexterity, mental health, creativity, concentration, and memory (Ramanathan & Bhavanani, 2018). Pawanmuktasana soothes the nervous system and thereby calms the mind. It also increases blood supply to the brain and improves concentration (Gupta & Awasthi, 2014).

The practice of pranayama augments stamina, mental balance, and strength and induces better sleep by the improved circulation of vital energy. It helps to harness energy, thereby reducing hyperactivity, resulting in improved attention and focus (Kenny, 2002).

Radhakrishna et al. (2010) observed complete relaxation resulting in a calm state of mind in children with ASD, with integrated approach to yoga therapy. Improvements in sensory integration and attention and increased verbal receptivity for commands were also observed (Radhakrishna et al., 2010). Singh & Singh (2014) found that the children were able to perform “inserting pegs task,” indicating improved fine motor skills such as eye–hand coordination and grip strength following pranayama training (Singh & Singh, 2014). Bhavanani, Ramanathan, & Harichandrakumar (2012) reported the effect of Mukha Bhastrika on reaction time in mentally challenged individuals (Ramanathan, Eswari, Bhavanani, Prathima, & Sanguida, 2019), and recently, Ramanathan et al. (2019) reported reduced reaction time in children with ASD following yoga training (Bhavanani et al., 2012). This reduced reaction time signifies an improved sensory motor performance, greater arousal, faster rate of information processing, and improved concentration (Bhavanani et al., 2012; Ramanathan et al., 2019). Radhakrishna (2010) concluded that the integrated yoga therapy module to children with ASD improved imitation skills (Radhakrishna, 2010).

Therefore, the biological role of yoga in improving the brushing skills in our children is justified by the fact that the children in Group I also were learning the brushing skill, but at a slower pace when compared to children in Group II.

To the best of our knowledge, this is the first study to utilize the application of yoga in the field of pediatric dentistry to children with special health-care needs. Due to the positive results observed in this study and a by-stander effect of a holistic improvement, yoga therapy was included in their school as a routine schedule to all the children.

  Conclusion Top

The children with ASD who underwent training with VP and VM along with concurrent yoga training were able to learn the toothbrushing skill more effectively and quickly when compared to the children who were trained by the regular methods alone. Therefore, it can be concluded that yoga has a positive and additive role as an adjunct along with the regular training methods of VP and VM. Yoga training provides a platform for easier training of self-help skills such as toothbrushing habit.


This was a short-term interventional study that was conducted only in two schools in Puducherry. Therefore, further multicentric studies done for longer periods are needed to be conducted to validate the present findings.


We would like to thank the parents of children who took part in this study and the teachers of the special schools for lending a supporting hand.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.[15]

  References Top

Backman, B., & Pilebro, C. (1999). Visual pedagogy in dentistry for children with autism. ASDC Journal of Dentistry for Children, 66, 325-331.  Back to cited text no. 1
Bhavanani, A. B., Ramanathan, M., & Harichandrakumar, K. T. (2012). Immediate effect of Mukha Bhastrika (A bellows type of Pranayama) on reaction time in mentally challenged adolescents. Indian Journal of Physiology and Pharmacology, 56 (2), 174-180.  Back to cited text no. 2
Deorari, M., & Bhardwaj, I. (2014). Effect of yogic intervention on autism spectrum disorder. Yoga Mimamsa, 46, 81-84.  Back to cited text no. 3
Du, R. Y., Yiu, C. K., King, N. M., Wong, C. N., & Mcgrath, C. P. (2015). Oral health among preschool children with autism spectrum disorders: A case-control study. Autism, 19 (6), 746-751.  Back to cited text no. 4
Gupta, A., & Awasthi, H. H. (2014). A critical review of clinical application of yogasanas W.S.R. to Pavanamuktasana. IAMJ, 2 (6), 1087-1098.  Back to cited text no. 5
Kenny, M. (2002). Integrated movement therapy: Yoga-based therapy as a viable and effective intervention for autism spectrum and related disorders. International Journal of Yoga Therapy, 12 (1), 71-79.  Back to cited text no. 6
Orellana, L. M., Martínez-Sanchis S, & Silvestre, F. J. (2014). Training adults and children with an autism spectrum disorder to be compliant with a clinical dental assessment using a TEACCH-based approach. Journal of Autism and Developmental Disorders, 44, 776-785.  Back to cited text no. 7
Pilebro, C., & Backman, B. (2005). Teaching oral hygiene to children with autism. International Journal of Paediatric Dentistry, 15, 1-9.  Back to cited text no. 8
Radhakrishna, S. (2010). Application of integrated yoga therapy to increase imitation skills in children with autism spectrum disorder. International Journal of Yoga, 3 (1), 26-30.  Back to cited text no. 9
Radhakrishna, S., Nagarathna, R., & Nagendra, H. R. (2010). Integrated approach to yoga therapy and autism spectrum disorders. Journal of Ayurveda and Integrative Medicine, 1 (2), 120-124.  Back to cited text no. 10
Ramanathan, M., & Bhavanani, A. B. (2018). Addressing autism spectrum disorder through yoga as a complementary therapy. Journal of Basic, Clinical and Applied Health Science, 2 (2), 3-6.  Back to cited text no. 11
Ramanathan, M., Eswari, R., Bhavanani, A. B., Prathima, G. S., & Sanguida, A. (2019). Yoga training enhances auditory and visual reaction time in children with autism spectrum disorder: A case – Control study. Journal of Basic Clinical and Applied Health Science, 2, 8-13.  Back to cited text no. 12
Rayner, C. S. (2010). Video-modelling to improve task completion in a child with autism. Developmental Neurorehabilitation, 13, 225-230.  Back to cited text no. 13
Sallam, M., Badr, S. B., & Rashed, M. A. (2013). Effectiveness of audiovisual modeling on the behavioral change toward oral and dental care in children with autism. Indian Journal of Dentistry, 4, 184-190.  Back to cited text no. 14
Singh, S., & Singh, J. P. (2014). Impact of pranayama on fine motor coordination ability of children with intellectual impairment. Creative Education, 5, 273-278.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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