Breathing Techniques for the Enhancement of Cognitive Function and Stress Reduction in 14–17-Year-Old Adolescent Athletes: A Scoping Review

Rationale

Research indicates that adolescent participation in organized sports reaches its highest levels up to the age of 14, after which a marked decline is observed (Deng and Fan, 2022; Eime et al., 2020; Kjønniksen et al., 2008; Lagestad and Mehus, 2018). A significant contributing factor to this dropout trend is stress associated with performance demands (Emmonds et al., 2024; ICOACHKIDS, n.d.). Adolescents (Hardin et al., 2017; Kleinert and Horton, 2016; Pediatrics, 2017; van Sluijs et al., 2021) involved in organised sports are exposed to multiple sport-related stressors, which may negatively affect both physical performance and mental well-being (Redzic et al., 2024). At the same time, stress is a normal and unavoidable component of sport participation and, when present at appropriate levels, can even enhance athletic performance (Burton, 1988; Tossici et al., 2024). There is a distinction between training-related and competition-related stress (Silva III, 1990). While there might be more stress associated with the competition season (Chou et al., 2021), even regular training sessions can lead to burnout and a subsequent dropout (Silva III, 1990).

Self-regulatory skills play an important role in helping athletes manage stress and maintain cognitive focus during training and competition (Migliaccio et al., 2023). Cognitive functions, such as executive functions (working memory, inhibitory control, decision-making), processing speed and attention are crucial for athletic performance under stress conditions (Diamond, 2013; Hernández-Mendo et al., 2019). These functions can be improved through attentional tasks that require sustained attention, quick reaction time, and attention control (García-Madruga et al., 2016), and these attentional tasks are inherent in a variety of breathing techniques, such as diaphragmatic breathing, alternate nostril breathing, and slow-paced breathing, among others (Ferreira et al., 2015; S.-H. Lee et al., 2023; Yadav and Mutha, 2016). These and other specific breathing techniques can have an impact on physiology by lowering stress hormones, activating the parasympathetic nervous system, increasing Heart Rate Variability (HRV) (Laborde et al., 2022; Pagaduan et al., 2022; Pruneti et al., 2023; Shaffer and Meehan, 2020), synchronizing interhemispheric activity, as well as improving vigilance, focus, attentional flexibility, reaction times, and intra- and inter-hemispheric theta coherence (Mitsea et al., 2022).

Adolescence represents a developmental period characterised by heightened stress reactivity and ongoing maturation of cognitive control systems. Compared to adults, adolescents tend to exhibit increased sympathetic nervous system activation through heightened reactivity of the sympathetic–adrenomedullary (SAM) pathway and the hypothalamic–pituitary–adrenal (HPA) axis (Pham et al., 2023; Romeo, 2013; Spear, 2013), increased emotional volatility (Weissman et al., 2018), poorer impulse control (Icenogle et al., 2019; Javadi et al., 2014), and less mature executive control capacities (Luna, 2009). These developmental characteristics may increase vulnerability to stress while simultaneously limiting the ability to regulate it effectively.

Previously such methods as Psyching-up (Dhaouadi et al., 2025), cognitive- coordination training (Li et al., 2026), psychological skills training (He, 2026; Wang et al., 2025), personalized psychological interventions (Li et al., 2024), cognitive behavioral therapy (Dones et al., 2025), and mindfulness-based cognitive therapy (Peter et al., 2022) have shown a positive effect on various cognitive function and mental health domains for adolescents. But some of these techniques might be relatively time consuming, difficult to imply, and financially non-feasible for most coaches in a practical day-to-day situation. In this context, breathing techniques have already demonstrated benefits in various adolescent and youth populations, including improvements in stress regulation, emotional control, and attentional functioning (Aranberri-Ruiz et al., 2022; Hunt et al., n.d.; Laborde et al., 2017; Sellakumar, 2015). Dones et al. (2025) concluded that mindfulness based interventions, which usually have some form of breathing techniques incorporated, have no significant difference in reducing social anxiety in adolescents, as compared to cognitive behavioral therapy. Despite these claims, a “pure” breathing technique might prove to be shorter and easier to imply, adding to compliance, autonomy and self-efficacy of the athlete.

Several theoretical frameworks have been proposed to explain the physiological and neurocognitive mechanisms underlying different breathing techniques. Slow-paced breathing involves reducing the breath rate (Shao et al., 2024) and is often combined with diaphragmatic breathing, which can regulate the balance of the sympathetic and parasympathetic nervous system activation through the nervus vagus (Bordoni et al., 2018). Such breathing patterns may also affect the functioning of the central nervous system through changes in interoceptive processing, carbon dioxide levels, and cerebral blood flow (Goheen et al., 2023; Nakamura et al., 2022). Nose breathing is associated with nitric oxide production in the airways (vasodilatating and bronchodilatating effect), reduced breath rate, reduced hypocapnia (Harbour et al., 2022), increased use of diaphragm (Trevisan et al., 2015), and affecting the cortical and sub-cortical areas of the brain (Folschweiller and Sauer, 2021; Maric et al., 2020; Zelano et al., 2016). Techniques involving HRV biofeedback are commonly explained through the concept of Respiratory Sinus Arrhythmia (RSA), which states that heart rate fluctuates in correspondence to breathing (Neff et al., 2003; Yasuma and Hayano, 2004). Slowing the breath to an individual frequency (resonance frequency) would then maximize RSA and therefore increase the HRV (Steffen et al., 2017).

Although the effects of breathing techniques have been broadly studied for adults, the specific effects and mechanisms of these techniques for children and adolescents are more scarce. It is important to understand that the brain development actively continues throughout adolescence (Choudhury et al., 2008) and has a certain sequential order, where the prefrontal cortex develops last (Gogtay et al., 2004). Also the hormonal development is overgoing rapid transformation, leading to high impulsivity (Best and Ban, 2021; Lang et al., 2022). The incomplete maturation of the prefrontal cortex and ongoing hormonal fluctuations in adolescence compromise executive function and sustained concentration, making complex motor-cognitive tasks such as controlled breathing more difficult than in adults with fully developed prefrontal and hormonal systems. Another, more apparent, factor involves physical changes: as the body continues its rapid development throughout adolescence, emerging body composition characteristics can play an important role in breathing mechanics and lung capacity (Mahmoud et al., 2018; Ofenheimer et al., 2024; Peralta et al., 2019), possibly causing a somewhat yet unskillful breathing stereotype that could even lead to a dysfunctional breathing (Karkouli et al., 2024; Vahlkvist et al., 2023), influencing the performance of the breathing techniques.

Despite the wide range of research on breathing techniques for adults (Borges et al., 2021; Zaccaro et al., 2018), the evidence specific to adolescent athletes remains fragmented, and there is a lack of clarity regarding their application in the adolescent sports population. To date, no review has synthesised the range of breathing techniques used in this population or clarified their potential effects on stress regulation and cognitive performance. Consequently, there is limited guidance for practitioners and researchers on the application of breathing-based interventions in adolescent sport contexts.

Objectives

The primary objective of this scoping review is to explore which types of breathing techniques can best be used to improve cognitive function (in particular, Attention and Executive Function) and stress management (in particular, management of acute stress, chronic stress, and trait or state anxiety) among adolescent athletes.

Protocol and registration

Since there were no human subjects or new data collection involved in this scoping review, no ethical approval or exemption was required from the IRB/Ethics Committee. Data collection and procedure was conducted in May 2024 and was based on the methodological guidelines proposed by the Joanna Briggs Institute Manual for Evidence Synthesis (“JBI Manual for Evidence Synthesis – JBI Global Wiki,” n.d.), with the protocol registered in the Center for Open Science (Semjonova et al., 2024). Results were reported in accordance with the extension of preferred reporting items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Peters et al., 2020; Tricco et al., 2018).

Eligibility Criteria

Individual studies published from January 2000 to December 2023, to capture all relevant interventions, were included. Only studies published in English were included and grey literature, such as dissertations, was included, although none were included in the final analysis.

Information sources

The selection of keywords used included terms related to cognitive function (e.g., cognitive functioning, selective attention, divided attention, working memory), stress (e.g., anxiety, strain), and various breathing techniques (e.g., diaphragmatic breathing, deep breathing, yoga breathing, pranayama, resonance breathing, slow breathing, box breathing, cyclic hyperventilation, physiologic sigh) among adolescent athletes (see Appendix A of all key relevant keywords).

The search was conducted on the following databases:

(1) Science Direct;

(2) Scopus;

(3) Cochrane;

(4) ProQuest;

(APA PsycArticles®‎ (1894 – current), APA PsycTherapy®‎, MEDLINE®‎ (1946 – current), PTSDpubs‎ (1871 – current);

(5) PsycINFO (the dissertations section);

(6) Google Scholar;

(7) The Web of Science (all databases);

(8) EBSCOhost Complete

(Medline ultimate, Academic search complete, Rehabilitation and sports medicine source, Consumer edition, Health source nursing edition, Medline)

The reference list of all included sources of evidence was screened for additional studies.

For a full search strategy description, see Appendix B.

Selection of Evidence Sources

GP and GS conducted a thorough search of the databases, compiling identified citations, and uploading them to Rayyan software (Ouzzani et al., 2016; “Rayyan – Intelligent Systematic Review – Rayyan,” 2021), which was then used to manage duplicates. The selection of titles and abstracts for eligibility was carried out by GP and GS. There was a 95% agreement rate between the primary and secondary reviewer. Any discrepancies were resolved in consultation with a third researcher (AL).

Subsequently, the full text of the selected articles were reviewed. The reference lists of these studies were manually screened for further relevant results. A total of five articles were deemed eligible for the objectives of this scoping review.

Data charting process

GP and GS independently extracted the relevant evidence using a pre-developed Microsoft Excel spreadsheet (“Free Online Spreadsheet Software,” n.d.), coded as study descriptors (title, author, year, country, design), participant characteristics (age group, diagnosis, sport, sample size), intervention characteristics (type, breathing technique, duration, control condition), and outcomes (measurement tools and key findings). Variables such as study design, sport, and intervention type were coded as nominal categories, while age and sample size were recorded as continuous values.

After this process, the rest of the researchers provided suggestions and corrections.

Data items

The extracted data included detailed information including source, study design, sample, type of breathwork used, breathwork protocol, outcome variables, and results. For a full data charting example, see Appendix C.

Synthesis of results

Despite the inclusion of only five articles, the range of breathing techniques examined posed challenges for direct comparison due to the heterogeneity in the descriptions and procedures of the breathing techniques used. Studies were instead grouped descriptively by intervention type (slow-paced breathing, HRV biofeedback, yogic breathing, relaxation breathing), and further charted by source and study design, sample characteristics, type of breathwork and protocol, outcome variables, and results.

Methodological quality was assessed using the PEDro (Physiotherapy Evidence Database tool) ten point scale (de Morton, 2009), and showed a wide variety of methodological quality ranging from one to five points in the final selection of the studies. For a more detailed methodological quality assessment, please see Appendix D.

No substantial missing data was detected; therefore, it was not necessary to contact the authors of the selected studies. Most of the statistical data were still available for descriptive analysis, with calculations and data presentation performed using Microsoft Excel (“Free Online Spreadsheet Software,” n.d.). Frequencies and means were calculated, where appropriate.

Selection of sources of evidence

The data selection process can be followed by viewing an adapted PRISMA 2020 flow diagram (Please see Figure 1. PRISMA flow chart of selection of sources of evidence).

Figure 1

Characteristics of sources of evidence

In two of the studies, the participants practiced swimming (Hakked et al., 2017; Vacher et al., 2023), one had volleyball (Cunha et al., 2022), one had football and basketball (Dziembowska et al., 2016), and one had pistol shooting (G. Lee et al., 2023).

In the context of this scoping review, a study was considered eligible if there were at least some participants aged 14 – 18 years old. The participant age across all of the studies varied from thirteen (Hakked et al., 2017) to 21 years (Dziembowska et al., 2016).

Results of individual sources of evidence

Synthesis of results

All of the breathing techniques implemented had a positive effect on some of the outcome variables set before the intervention was performed, and none reported any adverse effects. For a short summary, please see Figure 2. Short summary of the results.

Figure 2

For a more comprehensive summary, please see Table 1. Synthesis of results.

Summary of evidence

The findings of this scoping review suggest that there are various breathing techniques that can be implemented for the adolescent athlete population to reduce stress and improve cognitive function. The included studies present a variety of breathing techniques (i.e. HRV biofeedback, slow-paced breathing (SPB), Yogic breathing practices), exercise duration (five to thirty minutes), and measurement strategies for outcome variables (i.e. different questionnaires, and physiological tests), which made the studies heterogenous and difficult to compare. More future studies are needed with more homogeneous samples and more similar intervention types to make a comparison of efficacy possible.

The breathing techniques used in the final selection of this scoping review can be split into three categories: 1) those using some form of deep paced breathing (Cunha et al., 2022; G. Lee et al., 2023), 2) those implementing HRV biofeedback (Dziembowska et al., 2016; Vacher et al., 2023), and 3) those implementing various forms of more vigorous and relatively more unusual Yogic breathing techniques (Hakked et al., 2017). All of the techniques used have shown to have an impact on stress or anxiety, but the results should be interpreted with caution, as some of the studies reported non-significant outcomes in some of the variables, and others suffered from methodological limitations, such as small sample size, lack of a control group or lack of follow-up assessments. Cunha et al. (2022) mentions that the duration of the short breathing session (five minutes) and the overall duration of the intervention might have contributed to lack of statistical significance for most of the psychological measures, which raises an important question. The five minute session was chosen due to usual time constraints in a sports setting practice; if the session was done more often, longer, or for a longer period, would it provide better outcomes, and would the adherence rates remain the same or drop? In real life settings, it is a question of balance between practicability and effectiveness, and more studies with different time and dosage settings are necessary to provide convincing conclusions.

It should be noted that only one study evaluated the effect on cognitive function (Dziembowska et al., 2016), which measured EEG Brain waves instead of “traditional” cognitive outcomes. The most common cognitive functions tested in sports science might be attention, decision-making, executive function, and working memory (Hernández-Mendo et al., 2019; Kalén et al., 2021), and it seems that there is a general lack of research about the impact of breathing techniques on cognitive function for adolescents, with most of the studies concentrating on various forms of exercise instead of breathing techniques in particular (Liu et al., 2025). This represents a clear research gap in evidence regarding potentially cost effective tools for cognitive enhancement during this crucial period of peak physical and cognitive development.

The slow breathing techniques work mainly through the enhancement of vagal tone and baroreflex function (Russo et al., 2017), as well as affecting attentional and emotion regulation capacities (Buchanan and Janelle, 2022; Migliaccio et al., 2023), and could serve as an excellent down-regulating tool before the sports event, during time-outs or post-event (Migliaccio et al., 2023). HRV biofeedback could claim similar mechanisms and benefits as slow-paced breathing (Zaccaro et al., 2018), but tends to add an additional learning loop through the feedback mechanism, enhancing the metacognitive control over arousal (Blum et al., 2019; Lalanza et al., 2023). HRV biofeedback strategies seem to be effective, but would involve an active use of device assistance. That can be an obstacle due to device dependency, possible costs, necessary training, and limited accessibility in real-world settings, but on the other hand – real-time biofeedback can serve as a reinforcement for the busy 21st century adolescent ensuring better engagement in the practice.

The Yogic techniques mentioned provide a somewhat unusual approach. Although effective, the implementation of these techniques in real life scenarios, particularly for a western audience might face some initial difficulties due to the cultural differences regarding the unconventional elements used. The proposed mechanisms for the vigorous types of Yogic breathing could be seen as a controlled stress exposure and often involve large and rapid fluctuations in the intrathoracic pressure and ventilation, increasing the sympathetic activation, and acting as a cognitive arousal, followed by a parasympathetic rebound (Balban et al., 2023; Bentley et al., 2023). Other techniques, such as full yogic breathing and alternate nostril breathing, often include a much slower and more controlled breathing pace that integrates more of the diaphragmatic breathing pattern (Bentley et al., 2023; Zaccaro et al., 2018), with the alternate nostril breathing showing some additional sympathomimetic or sympatholytic effects (Mitsea et al., 2022), as well as benefits for attentional and motor memory capacities (Telles et al., 2013; Yadav and Mutha, 2016).

We propose that the slow-paced breathing technique currently seems to be the most simple and ready approach for real-world youth athletic settings. Coaches or other staff could easily dedicate five minutes before or after the training session for a guided breathing practice via verbal or a recorded audio instruction. Slow-paced breathing might also be the most available and easy strategy to implement in future studies.

Limitations

Among the final selection of the articles, there was a large heterogeneity in sample characteristics, breathing techniques and protocols, as well as outcome variables and measurement instruments. Only one study looked into the domain of Cognitive Function, albeit through the lens of Brain wave measurements (Dziembowska et al., 2016). Most of the studies had a small sample size (particularly the study by G. Lee et al., 2023 with n = 5), and none had a follow-up evaluation, so the results should be considered exploratory and approached with caution regarding generalisability.