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1 (ISSN ) ORIGINAL ARTICLE A RANDOMIZED CONTROLLED TRIAL ON THE EFFICACY OF MEDHYA RASAYANA TABLET ON ACADEMIC STRESS AND PERFORMANCE IN SCHOOL CHILDREN KULKARNI REENA, 1* KUMAR ABHIMANYU 2 1 Associate Professor, Department of Kaumarabhritya, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, BM Road, Hassan , Karnataka, India 2 Director, All India Institute of Ayurveda, Department of AYUSH, Ministry of Health and Family Welfare, Government of India, Gautampuri, Mathura Road, Sarita Vihar, New Delhi Corresponding author: address: drreenakulkarni@gmail.com Access this article online: Published by Atreya Ayurveda Publications, Ilkal (India) All rights reserved. Received on: 07/05/2013, Revised on: 14/05/2013, Accepted on: 08/06/2013 Abstract Background: School children and academics are not exempted from stress. In Indian context, especially for high school children, the demands to be placed high, parental pressures, the future career option and time bound targets along with inherent biological variations of adolescence create paramount stress. Such stress can be detrimental if not well managed. Despite of loss of lives consequent upon stress and poor performance, academic stress is less researched. Psychotherapy is the current gold standard. Hence this trial aims to evolve the risk factors, common manifestations and adaptations with the academic stress, remedial measures with herbal medicine. Objectives: Evaluation of efficacy and safety of oral administration of medhya rasayana (MR) on manifestations of academic stress and to improve the academic performance. Setting and design: Study was carried out in Sri Dharmastala Manjunatheshwara College of Ayurveda and Hospital (SDMCA&H), Hassan, Karnataka, south India, from December December Interventional, single blinded, randomized psychotherapy-placebo controlled efficacy trial. Materials and methods: 164 children of either sex, studying in tenth standard with normal intelligent quotient (IQ), average and above average stress as indicated from the scores on academic anxiety scale (AASC) and Sarason s Test anxiety scale (TASC), consciously willing to participate in the trial were randomized in to three groups (GP) medhya (M) and medhya with psychotherapy (MP) and control Placebo with psychotherapy (PP) group. M-group received MR, MP-group with MR and psychotherapy while PP-group given placebo with psychotherapy over 3 months. Stress identified by test anxiety and academic anxiety scores, clinical manifestations and performances were evaluated before, after therapy and after exams. Children suffering from chronic systemic illnesses, developmental disorders, psychiatric illness, post traumatic stress disorder and not willing to participate in the trial were excluded. Results: On statistical analysis using paired and unpaired t test, cross tabs and repeated measures ANOVA, study reveals at par efficacy of trial drug with psychotherapy on clinical manifestations (P=0.000), reducing the stress (P=0.000 for both academic and test anxiety) and hence improving the performance (P=0.000). No adverse reactions documented. Conclusions: MR is effective in management of academic stress and improving academic performance in children. Keywords: ayurveda, academic stress, academic performance, anxiolytic activity, medhya rasayana, nootropics, psychotherapy, satvavajaya. Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3

2 Back ground Academic stress is referred to as elements related to school, studies, family and others that potentially disrupt the physical and psychological homeostasis, besides hampers the performance in academics. Children in India spend one third of their waking time in school related activities, with girls spending more time than boys, mainly because academics is given prime importance by parents and society alike. 1 Children in secondary school are at the verge of completion of compulsory elementary education relatively more stressed as they are competing to choose different pre university or professional level education in accordance with the interest of own. Every parent expects a phenomenal performance from their child irrespective of the cadre and skill resulting in stress. Similarly in the schools also emphasis is on grade points instead of appraising the creative skills. Inherent instability of adolescence owing to biological, physical, emotional and hormonal and pressure to perform well in examinations and or test and time allocated makes academic environment very stressful. Thus schooling has become a source of physical, mental, emotional and even financial stress. Stress in academics effect both positively and negatively if not well managed. Stress when has negative impact, an individual becomes disorganized, disoriented and therefore less able to deal with, thus resulting in stress related health problems. Failure to cope up with the demands may result in poor scholastic performances or even the extreme to lose life. In spite of loss of lives secondary to poor stress management academic stress in children received less attention. Studies on academic stress in Indian context mainly focused on professional and management courses especially with psychotherapy as modality. In Ayurveda academic stress is referred to as Chittodvega. 2 Though earlier publications referred anxiety neurosis as chittodvega, use of the same term for academic stress may be justifiable as it is studied under GAD itself. 3 It is being a clinical condition prominently involving mind and higher mental faculties, use of medhya rasayana (nootropic herbs) and satvavajaya chikitsa (Psychological interventions) are hailed. Moreover, recently researchers have evidenced that there is an increase in number of children who approach for management of academic problems and counseling. About 75 percent of children are stressed either at school or at family. 4 In India stress in children and adolescents is slightly greater than 20%. [1] In every age more than 90% of the school children of the state are facing above normal levels of stress and tension. 98.2% of the children aged 4 to 17 years showed medium to moderate and even severe stress. 5 Hence it was planned to study the effect of medhya rasayana in alleviating academic stress there by to improve the and to compare the same with the standard therapy. Academic stress diagnosed on the criteria of generalized anxiety disorders (GAD). 6 Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). It can be identified with in children who otherwise well, presenting with any of the features like difficult to control the worry, restlessness or feeling keyed up on the edge, being easily fatigued, difficulty in concentrating or mind going blank, irritability, muscle tension, sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep), 7 stomach aches and headaches and so on. MATERIALS AND METHODS Selection of drug Trial drug medhya rasayana is a poly herbal formulation in the form of tablet extensively used to boost higher mental faculties and to treat many psychiatric illnesses. Four nootropic herbs described in rasayana chikitsa of Charaka Samhita 8 are combined with pharmaceutical modification to get concentrated medicament and to facilitate the easy administration and defined dosage form. Control drug Red colored placebo capsules of 500mg used along with psychological interventions. Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3

3 Procurement of the drug Ingredients of study drug MR tablet are namely mandooka parni (Centella asiatica Linn), guduchi (Tinospora cordifolia (Wild) Miers), yastimadhu (Glycirrhiza glabra Linn) and shankhapushpi (Evolvulus alsinoides Linn.) were first identified and authenticated from authorities at SDM Ayurveda Pharmacy, Kuthpady, Udupi, Karnataka. The raw materials except shankhapushpi (Evolvulus alsinoides Linn.) were collected from authorized dealers of raw drugs supplying to SDM Ayurveda Pharmacy, Kuthpady, Udupi. Shankhapushpi was collected from m/s Dhanwantari vana, the Garden for Medicinal plants in Bangalore, Governament of Karnataka undertaking. The placebo capsules were obtained from Bangalore ayurveda pharmacy, Dhanvantari road Bangalore-9, Karnataka. Method of preparation of Medhya Rasayana tablet 10 litres of guduchi kashaya 9 (prepared using 8 kg guduchi), 8 kg of shankhapushpi kalka 10 and 10 litres of mandukaparni swarasa 11 (derived from 16 kg fresh plant) were prepared separately and later mixed thoroughly and heated on mandagni (mild fire).when decoction became thick, 8 kg yastimadhu churna (powder) was added and heated till it became semi solid in consistency (method of preparation of rasakriya). 12 Tablets of 250 mg (drug weight) were punched and packed in air tight containers. Standardization of Investigational drug Physico-chemical characterization, determination of total ash, acid insoluble ash and water soluble ash, loss on drying at 110 C, water soluble extractive, and alcohol soluble extractive tests were done at Bangalore Test house as per Ayurvedic Pharmacopoeia of India (API) 13 standards. Assay for bitter substances and glycyrrhizin contents were done as per the 14 protocol in standardization of botanicals. Disintegration time of the tablets was assessed as per Indian Pharmacopoeia (IP). 15 High performance thin layer chromatography (HPTLC) studies were done at SDM Centre for Research in Ayurveda and Allied Sciences, Kuthpady, Udupi as per standard procedure Research design Interventional, single blinded randomized controlled efficacy trial Study Population An accessible population of children studying in class ten from various schools of in and around Hassan, including government, government aided and private sectors who were representative of target population participated in the study. Sampling Simple random sampling technique using lottery method. Group allocation was done by simple random allocation (complete randomization). Study sample Children studying in class ten from various schools of in and around Hassan with manifestations of increased stress. Sample size 164 children with increased stress and stress induced clinical manifestations, willingly participating in the study selected from 7 schools in and around Hassan after a preliminary survey on incidence of stress in high school children. Determination of sample size was based on the prevalence of stress in school children. Study setting The study was carried out in Sri Dharmastala Manjunatheshwara College of Ayurveda and Hospital (SDMCA&H), Hassan, Karnataka, south India, from December December Hassan is a district head quarters with population 1,47,000. Diagnostic Criteria Diagnosis was done on the basis of Diagnostic and statistical Manual (DSM) IV criteria for generalized anxiety disorders (due to over anxious disorder in childhood) followed by Intelligence Quotient (IQ) assessment with Draw-a-man test 18 and scoring stress levels Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3 3

4 using standard scales namely like academic anxiety scale (AASC) 19 and Sarason s Test anxiety scale (TASC). 20 Inclusion criteria Children of either sex, studying in class ten (age group years) from various schools in and around Hassan, showing manifestations of average and above average stress as indicated from the scores in AASC and TASC with normal IQ and consciously willing to participate. Exclusion criteria Children suffering from chronic systemic illnesses, developmental disorders, psychiatric illness, post traumatic stress disorder and those were consciously not willing to participate. Ethical considerations Ethical clearance was obtained from the institutional ethics committee (IEC) of SDM College of Ayurveda and Hospital, Hassan, Karnataka (IEC No. SDMCAH/IEC/02/11-12). Informed consent obtained from head of the school, children and their parents. Criteria of withdrawal Acute severe illness warranting intervention, adverse reactions and consciously not willing to continue Time and Duration of the Study The total study period was 2 years i.e. December December While, the duration of the clinical trial was 3months. Technique of Data Collection Children of normal IQ and increased stress levels as per both AASC and TASC with clinical manifestations of increased stress in the form of physical, psychological and psycho somatic complaints were included in the study with due consent of child and their parents. Children with average (scores 10-23) to high anxiety (score 30) on TASC and AASC (Upper limit:p 80 and above-very anxious and Lower limit: P average anxiety based on percentile scores) were only included. The sample size was decided based on the prevalence of academic stress in Hassan and willingness to participate. Children were asked to visit SDMCA&H, Hassan with their parents. They were thoroughly interrogated, history and facts were noted in a specialized structured clinical proforma based on ayurvedic classical frame work incorporating mental status examination and guidelines given in the practice parameters for the psychiatric assessment of children and adolescents. 21 General vital information about the child and its family, source of information, chief complaints to know manifestations of stress, history of stress, category of stress, stressors, factors relieving stress, history of past illness that precipitated stress, family history, personal history to get information on diet, appetite, bladder habits, bowel habits, allergies, addictions if any, exposure to abuse along with treatment history. Examinations included anthropometry, general physical examinations, systemic examinations with sroto pareeksha and dasahavidha pareeksha. 24 Mechanical devices such as height weight scale, measuring tape, and thermometer were used as aids in collection of data. Parent was also involved in the study by taking their feedback regarding child s difficulties, immunization status, past illnesses and treatments given, child s behavior in family and with family members, concentration and attention of the child. Parents were also requested to grade their child s intelligence as per their perception. Class teacher s feedback was also obtained in a structured format based on manasa bhava pareeksha 25 which included graded responses for positive and negative psychological disposition along with information on participation in extracurricular activities, performances and percentages obtained in midterm, preparatory and final examinations. To ensure regularity with the intervention children were visited in their schools once in every 15 days and to dispense medicine accordingly. Treatment methodology and schedule The selected children as per inclusion criteria were randomly allocated to control group (PP- GP) and trial groups (M-GP and MP-GP). Methodology of treatment for each group is summarized in table 1. Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3 4

5 Table 1: Methodology of interventions in control and study groups PP group (control group) M group (study group I) MP group (study group II) Psychological intervention for cognitive and behavioral modifications with Diet counseling 500 mg placebo capsule twice daily after food with water for a period of 3 months. Psychological interventions included 5 minutes loosening exercises involving neck rotations (from right to left and then left to right), shoulder rotations, waist rotations, knee rotations and ankle rotations 3 times each clockwise and anti clock wise on both right and left. This was followed by pranayama (breathing exercises) for 10 min that included kapalabhati 40 times, bhastrika 20 times, bhramari 3 times, nadi shodhana pranayama for 10 times and lastly 3 chantings of Aa+Oo+Ma kara for 3 times and ending with yoga nidra (Deep relaxation concentrating on body parts). The methodology of practice of these breathing techniques was as taught by The Art of Living Foundation (a nonprofit service organization). 26 Children asked to practice these every day preferably in the morning for 15 minutes. Specified do s included to have a calm study area and a specified study time. The study of one subject at a time for a period of 45 minutes followed by 5 minutes recollection of the same subject studied with closed eyes and writing down the important points in a quick recall book. 10 min relaxation advised before taking up next subject. Utility of acronyms and mnemonics, writing meaning of difficult words in the study book, wall charts whenever necessary and group discussions with the friends and teachers encouraged. Daily revisions of the important mathematical equations were advised. They were also said about play and its benefits, hobbies, music etc as the source of relaxation. Children were allowed to watch TV one hour daily, go on a walk and Sunday outing with a slot for revision of subjects studied in that particular week. 2 tablet of MR (250mg) twice daily after food with water in the morning and bed time for a period of 3 months. 2 tablet of MR (250mg) twice daily after food with water in the morning and bed time for a period of 3 months. Psychological intervention for cognitive and behavioral modifications with diet counseling as in control group. Diet modifications suggested included use of plenty of water, milk, fresh vegetables, fruits, sprouted grains and egg. Restrictions suggested included bakery foods, aerated drinks, junk foods, excess use non vegetarian diet, excess TV watching, reading in hurry and by hearting without understanding the meaning, skipping meals and sleep. Children in all the groups were visited once in 15 days, assessed before, in the middle of the study, before exams and after exams to document levels of stress and their performance. Study was planned such that medication was completed at least 10 days prior to the exams. Follow up was done after exam. Assessment criteria All the groups were assessed before, during, after the study (before exams) and after exams on the basis of subjective and objective criteria with regards to stress manifestations, assessment using AASC, TASC and School progress records. Adverse effect evaluation criteria Evaluation and reporting of adverse effect was done as per the guidelines of national pharmacovigilence program for Ayurveda, Siddha and Unani (ASU) drugs. Data analysis Statistical evaluation of the data obtained was done using means, standard deviation, percentage, mean difference, paired t test, unpaired t test, cross tabs and repeated measures ANOVA using SPSS version Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3 5

6 Flow Diagram Assessed for eligibility (n=575) Enrollment Excluded (n=336) Not meeting inclusion criteria (n=336) Declined to participate (n=75) Other reasons (n=0) Randomized (n=164) Allocation M-Group Allocated to intervention (n= 96 ) Received allocated intervention (n=64 ) Did not receive allocated intervention (n= 32 ), not willing MP-Group Allocated to intervention (n=83 ) Received allocated intervention (n=55) Did not receive allocated intervention (n=28), not willing PP-Group Allocated to intervention (n=60) Received allocated intervention (n= 45) Did not receive allocated intervention (n=15), not willing Follow-Up Lost to follow-up (give reasons) (n=0) Discontinued intervention (give reasons) (n=10), unknown Lost to follow-up (give reasons) (n=0) Discontinued intervention (give reasons) (n=6) Not reported Lost to follow-up (give reasons) (n=0) Discontinued intervention (give reasons) (n=5) Not reported Analysis Analysed (n=49) Excluded from analysis (n=0) Analysed (n=49) Excluded from analysis (n=0) Analysed (n=45) Excluded from analysis (n=0 ) Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3

7 Observations and results A total of 164 children from 7 schools in and around Hassan city participated in the clinical trial. 13 students dropped out in the course of the study. Female preponderance (63.4%) over male (36.6%) was seen indicating girl students more prone to academic stress. 27.4% from government, 36.0% from aided schools and 36.6% from private schools. As many of 64.6% Table 2: Socio demographic data Type of School Area of School Gender SES Analysis of prakrti (physical and mental disposition) revealed about half of the children (55.5%) were vatapitta, 29.9% vatakapha, 8.5% pittakapha, Sannipata 2.4% and least 1.2% were of kapha prakriti. While a maximum of 73.8% were of rajasika and 20.7% tamasika and least (5.5%) of satwika nature. 89.6% were belonged nuclear family set up. Among the category of stress, pressure ranked (25%), next was competition (20.1%) while 17.7% students felt combination of competition and pressure precipitated stress in them. On the whole classmate was the person to precipitate stress (23.5%) while 22.5% of girls expressed mother was cause of their stress. Among major life changes reported were death of close associates (54.1%) and Character were from urban while 35.4% were from rural schools. Socio economic classification as per Kuppuswamy SES revealed 6.71% were of Upper class, 25.61% upper middle, 51.83% lower middle and belonged to upper lower class. There were no children belonging to lower lower class. Socio demographic data summarized in table 2. Observations Government 45 Aided 59 Private 60 Urban 106 Rural 58 Male 60 Female 104 Upper class 11 upper middle 42 lower middle 85 upper lower 26 change of school (24.3%). 42% children reported lack of encouragement in home and alcohol (23.9%) was highest abuse prevalent in the family. Clinical manifestation of stress in the highest grade were fear of exam (67.98%), reduced memory (47.56%), head ache (37.80%), restlessness (32.32%), irritability (26.22%) and excessive sweating (25.61%) while least was urinary frequency (6.1%). Success in the treatment was assessed by charting the reduction in the stress levels as well improvement in the exam performance. The response of therapy in all the groups for stress manifestations [table 3], AASC [table 4, table 5 and Figure1] and TASC [table 6, table 7 and Figure2] are studied at various stages of the research. Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3

8 Table 3: Response of medhya rasayana and psychotherapy on features of stress Name of Group Group Name of Session p C.C BT % BE % FU % Value M-GP * Worries about exams/future Restlessness MP-GP * PP-GP * M-GP * MP-GP * PP-GP * Fatigue M-GP * MP-GP * PP-GP * Irritability M-GP * MP-GP * PP-GP % * Headache M-GP * MP-GP * PP-GP * M-GP * Repeated body ache MP-GP * PP-GP * Sleep Disturbance Repeated pain In abdomen/ diarrhea/others Shortness of breath M-GP * MP-GP * PP-GP * M-GP MP-GP PP-GP M-GP * MP-GP * PP-GP * Palpitations M-GP * MP-GP * PP-GP * Repeated burst outs (cry) Urinary frequency M-GP MP-GP * PP-GP * M-GP MP-GP * PP-GP M-GP * Excessive sweating MP-GP PP-GP M-GP * Repeated MP-GP * Illness PP-GP * M-GP * Reduced memory MP-GP * PP-GP * Refusal to go to school M-GP MP-GP * PP-GP *-0.001(highly significant), M-GP: medhya group, MP-GP: medhya rasayana with psychotherapy group, PP-GP: placebo with psychotherapy group Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3 8

9 Table 4: Mean of academic anxiety and results of effect of medhya rasayana on academic anxiety in children of both study and control group Name of group Before Treatment-AASCacademic anxiety scale Before exams-aasc- academic anxiety scale After exams-aasc- academic anxiety scale Mean S.D Mean S.D Mean S.D decrease M-GP MP-GP PP-GP Total M-GP: medhya group, MP-GP: medhya rasayana with psychotherapy group, PP-GP: placebo with psychotherapy group Table 5: Result of repeated measure ANOVA for mean scores on academic anxiety and results of effect of medhya rasayana on academic anxiety in children of both study and control group source sum of squares df mean square F sig. Tests of within-subjects effects Change Change * group Error(change) Tests of between-subjects effects Intercept Group Error Table 6: Mean scores on test anxiety and results of effect of medhya rasayana on test anxiety in children of both study and control group Name of group Before Treatment -TASC-test anxiety scale Before exams-tasc- test anxiety scale After exams-tasc- test anxiety scale Mean S.D Mean S.D Mean S.D decrease M-GP MP-GP PP-GP Total M-GP: medhya group, MP-GP: medhya rasayana with psychotherapy group, PP-GP: placebo with psychotherapy group Table 7: Result of repeated measure ANOVA for Mean scores on Test Anxiety and results of effect of Medhya Rasayana on test anxiety in children of both study and control group Source Tests of within-subjects effects Sum of squares df Mean square F Sig. Change Change * group Error(change) Tests of between-subjects effects Intercept Group Error M-GP: medhya group, MP-GP: medhya rasayana with psychotherapy group, PP-GP: placebo with psychotherapy group Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3 9

10 Performance assessment involved evaluation of scores in 3 exams. To remove the bias, increase in scores (in %) were predetermined as follows. Same as before (0-10%), mild improvement (10-25%), moderate improvement (25-50%), good improvement (50-75%) and very good improvement (>75%). Observations on the same are summarized below [table 8 and table 9]. Table 8: Mean performance scores of mid-term, preparatory and final exams for both males and females in various groups Mid-term Preparatory Final Name of group Gender Change Mean S.D Mean S.D Mean S.D Male M-GP MP-GP PP-GP Female Total Male Female Total Female Total Male Total Female Total M-GP: medhya group, MP-GP: medhya rasayana with psychotherapy group, PP-GP: placebo with psychotherapy group Table 9: Result of repeated measure ANOVA for performances Source Dependent Variable Sum of Squares Df Mean Square F Sig. Tests of Between-Subjects effects Name of Group MID PREP FINAL Gender MID PREP FINAL Name of Group* gender MID PREP Tests of within-subjects Effects FINAL Sum Source of Squares Df Mean Square F Sig. Intercept Name of Group Error PREP-Preparatory exams, FINAL-Final exams, MID-Midterm exams The main findings of the study are as follows: MR was effective in reducing academic stress in the domains of academic anxiety with effect size significant value (r=0.59) and test anxiety with effect size 0.51, in total scores of academic anxiety and test anxiety and self-reported clinical manifestations of academic stress. satvavajaya chikitsa (psychological interventions) also showed equal effectiveness in the same domains (effect size r=0.52 and 0.45 respectively for AASC and TASC). On the whole MP-GP (combined therapy) showed maximum benefits (effect size r=0.6 and 0.66 respectively for AASC and TASC); indicating combination of MR and Psychological interventions with relaxation techniques gives better and lasting effects. Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3

11 Discussion The aim of the study was to assess and compare the efficacy of MR on academic stress in school children by reducing the stress levels and hence to promote their academic performances against standard therapy (psychotherapy). The study drug MR was effective in reducing academic stress in the domains of academic anxiety and test anxiety, in total scores of academic anxiety and test anxiety and self-reported clinical manifestations of academic stress. It also increased academic performance as shown by increase mean total scores of marks obtained in class and board exams. The results were on par with the standard therapy. The combined therapy had an edge over both study and standard therapy indicating that MR with psychological interventions and relaxation techniques gives better and lasting effects in the management of academic stress. There were no significant influences of socioeconomic status and parental education on academic stress. Probable mode of action of study drug The ingredients of MR tablet are tikta (bitter), kashaya (astringent) and madhura rasa (sweet) predominant, sheeta (cold) potency, madhura vipaka, snigdha (unctuous) and sara (propelling) in nature with obvious alleviating action on all doshas. Specific action of these all is medhya (nootropic). By virtue of tikta rasa 27 it helps in removing agnimandya (reduced digestive power), improves taste, reduces thirst, removes kleda (unwanted metabolic waste). These may be attributed to free radical scavenging and 28 antioxidant activity, high hydrophilic and lipophilic oxygen radical absorbance capacity (ORAC) 29 and causes vishadyata (Clarity) - anti-lipid peroxidative 30 and LDL oxidation, inhibition of scopolamine induced memory impairment 33 and pentobarbitone-induced 34 sleep, reduction of serum and tissue cholesterol, phospholipids and free fatty acids 35 Kashaya 36 nature helps to equalise (Samshamana) the vitiated doshas, clears off unwanted metabolites (kledahara) and sandhanakara (Establishes connectivity) madhura rasa 37 and vipaka influences shadindriya prasadana (nourishing and augmenting all sensory perceptions) at cytosolic as well as at gene expression level, 38 improves strength, and complexion. It also alleviates vitiated pitta and vata and hence reduces rajas (abnormal provocation of neurons) by anxiolytic 34,39 and anti-stress 40 activities. Tamas (neuronal inertia) removed by spasmolytic effect in smooth muscles and potentiated the effect of acetylecholine in isolated tracheal chain and skeletal muscles, 41 scopolamine induced amnesia. 42 By virtue of jeevana (Promotive) alleviates daha (burning sensation and hot flushes) and murccha (altered consciousness). It can be attributed to increased circulation into the CNS system, balance of the sugar levels in the blood, 43 and anti-hypoxic effects induced by sodium nitrite, 44 Sthairyakara (stabilising) nature resultant up on neuro-protection by directly or indirectly modulating activities of ATPases 45 and establishes connectivity. Exhibit interaction with GABAergic modulators 34 immuno-stimulation and increasing the synthesis of acetylcholine. 46 Thus the clinical psycho- somatic manifestations of academic stress which are mainly due to dosha vitiation will be taken care by Rasa and dosha alleviating properties of MR. Thus the sense of wellbeing and alertness creates enthusiasm to be more attentive and indulge in intellective exercise. While the specific action medhya produces target action at hrdaya (CNS) 47 by improving satva guna (sensory perception and neuronal arborization mediated through neurotransmittors) Antiinflammatory, anti-ulcer, 53 immunomodulatory and overall health promotion. Thus balanced psychological, metabolic and emotional response yields in lowered stress response and hence better cognition and academic performances. Mode of action of psychological interventions Satvavajaya techniques help in regulating the pranavata which is the prime force to maintain manas (emotional sphere) and buddhi (cognition). Thus focussed mind and body can perform better. Researches also support these techniques under the heading of mind and body interventions to be beneficial in stress related Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3

12 mental and physical disorders. Breathing regulation can be very important as a selfregulation skill to reduce anxiety. 63 They help in Strengthening, balancing, and stabilizing the autonomic and stress response systems; Quieting of cortical areas involved in executive functions (such as anticipation, planning and worry); Activation of the limbic system, hippocampus, hypothalamus, amygdala, and stria terminalis may improve autonomic function, neuroendocrine release, emotional processing, 64 and social bonding. In other words they optimize stress level 65 and enhance coping 66 abilities. Perhaps the study planning and preparedness adds to increased confidence level. Thus balanced emotional response yields in lowered stress response and hence better cognition and academic performances. 64 The findings in confirmation with the fact that academic stress has negative meaningful effect on learning strategies. 67 Moreover, research on health and school outcomes during children's transition into adolescence shown low levels of negative stress experiences, high life satisfaction and high physical comfort had positive effects on teacher connectedness, school engagement, and academic achievement whereas bullying and bully victimization negatively affected these outcomes. 68 Conclusions Academic stress is most prevalent anxiety disorder of childhood, more so in girls. vatapitta prakrti with rajasika or tamasika mental disposition is at risk population. Children with Academic stress are likely to experience a substantial array of problems in emotional, social, cognitive, behavioral and psychological fronts. Academic stress aptly understood as chittodvega with predominant vata and pitta vitiation and altered rajas and tamas. MR effective in management of chittodvega (academic stress) and results were at par and even better than psychotherapy due to carry over effect. medhya rasayana combined with satvavajaya chikitsa shall be choice of therapy in full blown chittodvega. Reduced anxiety levels resulted in better academic performance as indicated by better total scores (Grade points). There were no adverse reactions documented. On the whole, considering the limitations of the study, present research could serve as an explorative research to aid in further clinical trials on the similar topics. Limitations Specific biochemical investigations not done, study is limited to single geographical area hence inferences on acculturative stress could not be drawn, the study is limited to subjects of tenth standard. Recommendations for future research Multi-centric study in larger population with wider age range and studies based on selfconcept and locus of control. References 1 Thacker N. Poor scholastic performance in children and adolescents. New Delhi. Indian Pediatr 2007;17: Agnivesha, Caraka, Dridhabala. Vimana sthana, Roganeekam Adhyaya, chapter 6, verse 5. In: Caraka Samhita. Jadhavji T, editor. reprint edi Varanasi: Choukhamba Surabharati Prakashan; p Babu G, Bhuyan GC, Prasad GP, Anitha S. Role of achara rasayana in chittodvega.. Anc Sci Life 2007;26(4): Available from: PubMed PMID: Agolla JE, Ongori H. An Assessment of academic stress among undergraduate students: the case of university of Botswana. Educational research and review 2009: Sapna Dinesh. Childhood stress. Open access article available from [accessed on 12 April 2011] 6 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, 4th ed. (Text Revision). New Delhi: Jaypee Brothers Medical Publishers (p) Ltd;2000 p Sadock BJ, Sadock VA. Kaplan and Sadock s concise text book of child and adolescent psychiatry. First Indian reprint ed. New Delhi: Wolters Kluwer (Ind) Pvt.Ltd p Journal of Ayurveda and Holistic Medicine July, 2013 Vol 1 Issue 3 12

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