The prevalence of negative school behaviors remains a significant health problem in the U.S [1]. For example, with respect to behaviors that contribute to intentional injuries, according to the Youth Risk Behavior Surveillance Survey, 36.6% of high school students reported having been in a physical fight in the past month, with 14.8% of the fights occurring on school property, 3.5% were injured in a physical fight and five percent of students missed school because of feeling unsafe [1]. Results of studies attempting to reduce such aggressive behaviors in schools have been mixed. A school-based violence prevention curriculum reportedly reduced self-reported aggressive behaviors among middle school boys in 2 of 6 classes only [2]. On the other hand, an 18-session violence-prevention curriculum [3], resulted in decreased frequency of self-reported violence and other problem behaviors in 6^th grade boys, but not in girls [4]. Few studies have focused on observable behavioral outcomes and findings have been mixed [5]. 'Students for Peace', a multi-component violence prevention project with 9000 middle school students, failed to reduce fights at school and absenteeism due to feeling unsafe at school [6]. Violence prevention education has been reported to reduce suspension rates [7].

It has been hypothesized that the high prevalence of negative school behaviors is in part due to greater exposure to chronic psychosocial stress, e.g., inadequate economic resources, family disintegration, information overload, media violence [8–11]. Self-reported feelings of anger have been shown to be predictive of aggression in youth [12]. The escalating prevalence of anger and violence in youth has been associated in part with increased levels of anxiety and stress [13].

School systems are increasingly interested in reducing negative school behaviors, however, they have had difficulty identifying programs that are effective and easy to implement on a broad scale [14]. Given the urgent need and the readiness of school boards to address these needs, the testing and implementation of promising intervention programs is of great urgency. One approach to the growing problem of school-related conduct problems may be to provide skills in stress reduction. Few studies have examined whether stress reduction programs improve school behavior in youth.

Research suggests that behavioral stress reduction via the Transcendental Meditation^® (TM) program may hold promise in the improvement of school-related behaviors in youth. Research has demonstrated that TM produces improvements in mental health, including reduction of various forms of psychological distress, such as depression, anxiety, hostility and emotional instability [15–21]. TM has been shown to reduce aggression [22], and to increase overall relaxation in adults [23].

Black college students and adults increased significantly on an overall mental health factor and showed a greater reduction in self-reported anxiety and neuroticism after one year of TM practice [24]. Although findings have not been entirely consistent [25], improved academic performance has been reported in high school students practicing TM [26], and in African American college students practicing a simple meditation process [27]. In a medium-sized chemical manufacturing company, with employees practicing TM over a six-year period, days lost through illness or injury decreased by 50 per cent and absenteeism declined by 89 per cent [28]. These findings suggest that examination of the effects of TM on improving school-related behaviors in youth is warranted.

This study was part of a larger study examining the impact of stress reduction via TM on high normal blood pressure levels in adolescents. The results of this study on blood pressure have been reported previously and indicated a beneficial impact of TM on cardiovascular functioning at rest and during stress [29]. This is the first report of a controlled trial of stress reduction via TM as a means of improving school-related conduct behaviors. In the present study, African American youth with high normal blood pressure (BP) were randomly assigned to either a 4-month TM program experimental group or a health education control group. Based on previous findings it was predicted that youth who practiced TM would exhibit greater decreases in school absenteeism, rule infractions, and days suspended from pre-test to 4 month post-test than controls.

To our knowledge this is the first clinical trial examining the impact of a behavioral stress-reduction intervention on a quality of life-related issue (school behavior) in youth. This study examined the impact of a four-month participation in the TM program on absenteeism, rule infractions, and suspension rates in adolescents with high normal BP. The findings were not attributable to baseline differences in anthropometrics since the TM and control groups were similar on these parameters at pre- and post-intervention, and both groups were similar in their expectations of health benefits at pre-intervention. Evaluation of impact of possible moderators, such as exposure to environmental stress, i.e., neighborhood stress, showed no differences between the groups. All subjects resided in the same geographical locale (i.e., lower socioeconomic status neighborhoods), and none participated in any formal lifestyle programs during the intervention period, besides school sports and/or physical education.

Counterbalancing interventions between schools controlled for school-to-school variations in which unknown characteristics of a particular school population or policies of operation could have differentially impacted implementation of the protocol. A previously reported beneficial impact on cardiovascular functioning was shown by decreases in systolic blood pressure from pre- to post-intervention in the TM group compared to controls [29]. The TM group also exhibited greater decreases in systolic blood pressure reactivity to acute laboratory behavioral stressors [29]. These physiological benefits are corroborated with behavioral and psychological benefits in the present study.

The present findings compare favorably with the results of another skills-based approach upon conduct related behaviors. Changes in suspension status among 1523 high school students was compared across groups exposed to school-based violence prevention. Those exposed in a class-specific violence prevention education intervention showed a 71% reduction in suspension rate [7]. The present study showed a reduction in suspensions of 83% during the 4-month intervention. Improvement in overall mental health factor and reduction in anxiety and neuroticism in African American college students was previously shown after one year of TM practice [24]. These findings are encouraging and indicate a combination of anger management, conflict resolution skills testing and stress reduction may be particularly beneficial and need to be examined.

The present study extends previous findings, with incorporation of a randomized controlled study design and use of documented records of behavior rather than typical self-report data which are open to the problem of social desirability. Counterbalancing treatment assignment by school decreased likelihood of within-school intervention contamination owing to potential inter-subject interactions, and unanticipated between-school differences. Efforts were made to provide comparable instruction time and attention at school to both groups. Similar to the present findings, previous findings using health education as a control, reportedly did not impact the attitudinal or behavioral preferences for non-aggressive conflict resolution among 6^th grade students [40].

One strength of the intervention is that the TM technique was taught in a standardized manner by a qualified TM instructor. Subjective meditation experiences were monitored by the TM instructor via self-reports and additional instruction was provided when necessary. Daily group TM practice in the presence of the instructor facilitated successful practice. The present findings are supported by other TM studies which have shown reductions in aggression [22], anxiety [41], stress-related neuromodulators, such as cortisol [42], and blood pressure [43] in Caucasian American adults. Since the present study was conducted in inner-city public high schools, with African American students with high normal blood pressure, empirical evaluation is needed to determine if the findings may be generalizable to other students.

Although the present findings are promising, there are several limitations of the study. First, the limited sample size and duration of evaluation was not long enough to provide sufficient frequencies of occurrences for several measures such as specific categories of suspension rates such as physical fighting, weapon carrying and drug possession. A similar sample size of 34 subjects was sufficient to demonstrate the impact of TM on blood pressure and cardiovascular reactivity to stress in adolescents [29]. Second, a follow-up evaluation beyond that of the 4-month intervention to determine whether the TM effect was sustained or if students reverted to negative behaviors was not conducted. Future studies should attempt to determine the mechanisms responsible for the impact of TM on school-related conduct problems and attendance by assessing possible changes in perceived negative affective and/or behavioral impact of stressors and/or utilizing mock conflict-evoking scenarios to determine possible changes in behavioral response patterns.

The TM group exhibited a decrease in absentee periods, rule infractions and suspension days due to behavior-related problems compared to the CTL group. The findings also indicate a potential beneficial impact upon anger expression in African American females. The successful implementation of the intervention suggests the feasibility of school-based stress reduction programs in efforts to improve both physical and behavioral risk factors in youth.

VB and FT designed the study, secured funding and supervised the execution of the study. VB recruited subjects and supervised the intervention. VB, LB and FT analyzed the data. All authors contributed the manuscript preparation and approved the final paper.