Sports Preferences in children and adolescents in psychiatric care – evaluation of a new Questionnaire (SPOQ)

Abbreviations

ADHD: Attention Deficit Hyperactivity Disorder; DEPR: Depression; ED: Eating Disorder; et al.: et alia; OCD: Obsessive-Compulsive Disorder; ODD: Oppositional Defiant Disorder; OMD: Other Mental Disorders; P/AD: Phobia/Anxiety Disorders; S/AD: Stress/Adjustment Disorder; SPOQ: Sports Preference Questionnaire

Key practitioner message

One in 3 patients is not physically active

- High coping with daily life through physical activity in eating disorder patients

- Lowest self-perception of physical fitness in patients with anxiety disorders

- The presence of a trainer most important in ADHD patients

Background

The positive effect of physical activity on general health is well known and has already been proven in numerous studies. For example, reduced risk of cardiovascular disease, stroke, and cancer as well as improved stress regulation through regular exercise have been shown [1,2].

Physical activity is also a very effective and suitable means of preventing mental illness and improving mental health [3-6]. When investigating the psychological effects of physical activity, positive effects on mood, psychological well-being, and the concept of self and body could be demonstrated [4,7]. The effect of exercise has also been investigated at the neurobiological level. Changes in the metabolism of serotonin and dopamine in the brain have been demonstrated [8]. These messenger substances play a decisive role in the development and maintenance of many mental illnesses such as depression, anxiety disorder, and attention deficit hyperactivity disorder [9-11].

Under the right conditions in organized sports, children and adolescents may develop daily life skills such as moral reasoning, emotional control, personal responsibility, and the ability to work in teams and set goals [12]. In the literature there are a few specific sports therapeutic approaches for mentally ill children and adolescents, for example in the areas of climbing therapy, archery, and endurance training [13-16]. A German study with ADHD patients showed that both long-term, natural sports therapy, and high-intensity interval training (HIT) tend to have a positive influence on the main symptoms, self-esteem, and social competence [17]. Nevertheless, there are only a few confirmatory studies on the content, methodology, and structure of sports therapies that do not allow generalized statements on the effects and mechanisms of action in mentally ill children and adolescents [18].

While the effects of physical activity on health have been well researched, it still seems to be largely unclear what psychological conditions need to be in place for effective sports intervention in mentally ill children and adolescents. According to Lambert, a good therapeutic relationship acts as a supporting factor in psychotherapy [19]. Since a competent coach also has a therapeutic function in sports therapy, he could play a comparable role. The search for pleasure in physical activity seems to be the strongest predictor of commitment [20]. Therefore, the sports therapy offered should be as suitable as possible and tailored to the needs and interests of the individual. However, a correlation between the prevalence of eating disorders and aesthetic sports such as ballet or gymnastics, but also athletics should be considered [21,22]. Psychotherapy research has shown that resource-activating strategies achieve higher therapeutic success [23]. This finding could be integrated into sports therapy by focusing on the patients’ athletic abilities and personal goals. Kirkaldy, et al. also points out that more positive feedback regarding physical activity and social recognition leads to a better self-image [5]. This seems to be of particular importance, as people with mental disorders often feel, that they have insufficient athletic self-efficacy [24]. In the long term, sports therapy according to the above-mentioned aspects could be a good way to achieve regular exercise and thus an improvement in physical fitness and mental health, even beyond the therapeutic intervention.

However, there are almost no scientific findings on the athletic behavior of mentally ill children and adolescents and the successful implementation of sports therapy in child and adolescent psychiatry. Therefore, the aim of the present study is to explore basic findings as a first step of evidence-based sports therapy in the child and adolescent psychiatric setting. To collect new data in our clinic, existing questionnaires on athletic behavior were considered, for example, the ATPAD scale [25], AMS-Sport [26], and EMI-2 [27]. Another very detailed questionnaire for sports interests asks about sports, sports games, and orientation [28]. However, no questionnaire was found that captures physical activity preferences considering the aspects of self-perception, resource activation, and problem-solving in the context of a structured sports therapy history. Therefore, the Sport Preference Questionnaire (SPOQ) was developed. The purpose of the SPOQ is to explore the athletic behavior of mentally ill children and adolescents, subjectively assessed physical fitness and perceived psychological effects of physical activity, and formulate general as well as disorder-specific hypotheses.

Methods

SPOQ Questionnaire

The SPOQ was developed in 2015 by the authors to explore the out-of-school athletic behavior of children and adolescents between six and 18 years. As a basis for the item pool, questions were developed, which take into account the psychotherapeutic impact factors of the therapeutic relationship, resource activation, and problem-solving [29]. It can be assumed that the more present these aspects are in physical activity, the more effective is physical activity for mental health. A three-person team of a sports scientist, a psychiatrist, and a psychotherapist designed the item pool, considering the literature listed in the introduction.

Two versions were designed, the parental and the self-report version (from ten years old). The data were collected with the German versions of the questionnaire. Both German versions were translated into English by a bilingual American and were translated back by a bilingual German. In the first version, thirty-nine percent of the questions regarding the importance of the relationship with the trainer and daily coping through physical activity were left unanswered. These patients returned their unfilled SPOQ one day after submission to complete the missing data. Most patients indicated that they had overlooked the questions, which is why the layout was optimized after 2 months of data collection.

The SPOQ consists of five sections (see attachment). The first section records the frequency of physical activity in the last six months in hours per week. There is also a free field to write down another frequency. Besides, there is a statement that can be marked with a cross, indicating that the respondent has never been physically active.

The second section records up to three types of physical activity that have been regularly exercised at least in the last six months. Also, the location where the physical activity is performed is recorded. There are three answer options possible: Sports Club, Gym and Other. On a Likert scale from “Not at all” (1) to “Very much” (6), the participants specify their enjoyment of this type of activity. The numbers 2 to 5 from the Likert scale are without description.

The third section is designed as 2 statements and asks for a currently important relationship to at least 1 trainer and the current daily coping through physical activity. Again, the answers are recorded using a Likert scale from 1 to 6.

The fourth section records up to five types of activity ever tried during the participant’s lifetime. Also, the duration, expressed in months, is recorded. The enjoyment of the types of activity is measured as in the second section.

Section Five asks for the subjective assessment of the physical fitness of the patient to measure athletic self-efficacy. This assessment is done via an interval scale from “Not physically fit” (0) to “Very physically fit” (9). The numbers 2 to 8 are without description.

It takes about 5 minutes to complete the SPOQ. The parental and self-report versions of the SPOQ can be used for free disposal. The German versions can be requested from the author.

Mental disorders

The type of mental disorder was diagnosed by trained clinical psychologists or psychiatrists according to ICD-10 [30], subject to the regulations. For this purpose, semi-structured clinical interviews were used in line with Sheehan, et al. (1998). The diagnoses were confirmed with disorder-specific questionnaires if this was necessary to complete the symptom profiles.

Participation

From October 2015 to October 2017, questionnaires were handed out to 450 patients who were registered as an inpatient or outpatients with an age between 6.0 and 18.0 years at the Child and Adolescent Psychiatry. One hundred and sixty-eight inpatients received the self-report SPOQ, while 282 parents of outpatients received the parental version as part of the general registration process. It was explicitly ensured that only 1 SPOQ was available for each patient. Since the questionnaire was obligatory for inpatients, all 168 questionnaires were received back from the self-report. Two inpatients without a diagnosed disorder were excluded. One hundred and thirty-five questionnaires from the parental version were excluded because of no return or no diagnosed mental disorder. All included questionnaires covered a total of 313 patients with a mental disorder in the evaluation, 166 inpatients (self-report), and 147 outpatients (parental version). The concrete division and response rate are clearly shown in a flow chart (Figure 1).

Figure 1: Report on patient selection.

Data collection and analysis

Data were collected and managed using REDCap research electronic data capture tools [31]. Since the study design was strictly exploratory, inference statistics were not used but kept analyses on a descriptive level. The statistics were calculated with R 3.6.2 [32]. The flowchart to report patient selection, Figure 1, was made using the package “DiagrammeR” [33]. Boxplots, line plots, and heat maps to show sports preferences in boys and girls were generated with the package “ggplot2” [34].

Boxplots, Figures 2-6, were generated by diagnosis group and type of questionnaire for the frequency of physical activity, enjoyment of physical activity (related to the first-mentioned physical activity), the importance of a trainer, daily coping through physical activity, and subjectively perceived physical fitness. Therefore, N counts for the number of considered cases and NA for the number of missing values. Two line plots, Figures 7,8, were generated to show the mean of subjectively perceived physical fitness by age, respectively frequency of physical activity, separated for gender and type of questionnaire. Six patients reported more than 10 hours of physical activity per week in the self-report questionnaire. It could be assumed that corresponding patients were not able to estimate the actual time. Therefore, the following data were considered missing. To present the first-mentioned type of physical activity for girls, and boys heatmaps, Figures 9,10, were created. Therefore, the mentioned types of physical activity were later aggregated into six branches by the authors. The weight, the percentage of the mentioned type in the corresponding diagnosis group, was shown through gray gradation. Table 1 shows the main characteristics of the data.

Figure 2: DEPR = Depression; ED = Eating disorder; ADHD = Attention deficit hyperactivity disorder; P/AD = Phobia/Anxiety disorder; OCD = Obsessive compulsive disorder; S/AD = Stress/Adjustment disorder; ODD = Oppositional defiant disorder; OMD = Other mental disorders.

Figure 3: DEPR = Depression; ED = Eating disorder; ADHD = Attention deficit hyperactivity disorder; P/AD = Phobia/Anxiety disorder; OCD = Obsessive compulsive disorder; S/AD = Stress/Adjustment disorder; ODD = Oppositional defiant disorder; OMD = Other mental disorders.

Figure 4: DEPR = Depression; ED = Eating disorder; ADHD = Attention deficit hyperactivity disorder; P/AD = Phobia/Anxiety disorder; OCD = Obsessive compulsive disorder; S/AD = Stress/Adjustment disorder; ODD = Oppositional defiant disorder; OMD = Other mental disorders.

Figure 5: DEPR = Depression; ED = Eating disorder; ADHD = Attention deficit hyperactivity disorder; P/AD = Phobia/Anxiety disorder; OCD = Obsessive compulsive disorder; S/AD = Stress/Adjustment disorder; ODD = Oppositional defiant disorder; OMD = Other mental disorders.

Figure 6: DEPR = Depression; ED = Eating disorder; ADHD = Attention deficit hyperactivity disorder; P/AD = Phobia/Anxiety disorder; OCD = Obsessive compulsive disorder; S/AD = Stress/Adjustment disorder; ODD = Oppositional defiant disorder; OMD = Other mental disorders.

An ethics vote with the number 837.515.15 (10833) from the ethics review board of the Landesärztekammer Rheinland-Pfalz exists for this study. As a routine procedure, informed consent statements were not needed to fill out the questionnaire.

Results

Patients

A total number of 313 patients were included in the analyses. They could be grouped into eight diagnostic categories according to the predominant mental disorder: Depression (DEPR) N= 72, median age = 15.1, Eating Disorders (ED) N = 24, median age = 15.6, Attention Deficit Hyperactivity Disorder (ADHD) N = 66, median age = 10.4, Phobia/Anxiety Disorders (P/AD) n = 22, median age = 15.7, Obsessive-Compulsive Disorder (OCD) n = 11, median age = 16.1, Stress/Adjustment Disorder (S/AD) n = 46, median age = 12.3, Oppositional Defiant Disorder (ODD) n = 16, median age = 13 and Other Mental Disorders (OMD) n = 56, median age = 11.9. Comorbid mental disorders were not considered.

In the inpatient group (self-report), DEPR was the predominant disorder, accounting for 33% of cases. The median age was 15.1 years, and 58% were female. In the outpatient group (parental version), ADHD was the leading disorder with 35% of the cases. The median age was 10.6 years, and 66% were male.

The complete main characteristics, overall and subdivided by questionnaire type, can be found in Table 1.

Athletic behavior

On average, patients with ED stated a higher frequency of physical activity than the other diagnosis groups (Figure 2). In all diagnostic groups, high enjoyment of physical activity was reported with medians between 5 and 6, however, with a wide variety in the group of patients with DEPR (Figure 3). The importance of a trainer was rated very low with a median of 1 in almost all groups. Only patients with ADHD and ODD and parents of children with ADHD rated it higher at the median (Figure 4). In the assessment of daily coping through physical activity, there was a wide range. In the self-report, patients with ED and OCD gave the highest scores, and patients with DEPR and P/AD had the lowest scores, on average (Figure 5). There is a discrepancy between self-report and parental versions regarding subjectively perceived physical fitness. In the external assessment, higher values were indicated, on average. Physical fitness was rated particularly low in the self-assessment of patients with DEPR and P/AD (Figure 6).

Looking at the mean values of subjectively perceived physical fitness as a function of age, the parental questionnaire for girls shows only minor deviations (mean values between 5.0 and 6.6). For boys, the mean value in the parental assessment varies similarly to the girls between 5.0 and 6.7, but with a dip at the age of 14 to 15 years (mean value 3.7). In self-perception, physical fitness at the age of 10 to 11 years is initially rated good on average by both genders (mean value 7.4 for girls and 6.3 for boys). However, at ages 12 to 13 for girls and 14 to 15 for boys, the mean drops sharply to 3.4 and 4.5, respectively (Figure 7). Let us now consider the dependence of subjectively perceived physical fitness on the frequency of physical activity. In the parent ratings, the average perception of fitness increases steadily with frequency for both genders (from 4.4 to 7.8 for boys and 4.9 to 8.3 for girls). However, gender differences are evident in self-perceptions. While girls’ perceived fitness also increases on average with frequency (from 3.3 to 4.9), there seems to be no clear relationship for boys. With no or little physical activity, they rate their fitness on average considerably better than girls (mean 5.0 for boys versus 3.3 for girls in the no physical activity group). Compared to the parental assessment, the self-assessment is generally worse, except for the assessment of the boys in the group without physical activity (Figure 8).

Figure 7: Subjectively perceived physical fitness by age and gender.

Figure 8: Subjectively perceived physical fitness by frequency of physical activity and gender.

The heatmaps revealed that 33% of male patients had preferences for ball sports, while 32% of all male patients did not participate in sports (Figure 9). Among female patients, 32% had preferences for aesthetic sports, while 24% of all female patients did not participate in sports (Figure 10).

Figure 9: DEPR = Depression; ED = Eating disorder; ADHD = Attention deficit hyperactivity disorder; P/AD = Phobia/Anxiety disorder; OCD = Obsessive compulsive disorder; S/AD = Stress/Adjustment disorder; ODD = Oppositional defiant disorder; OMD = Other mental disorders; Ball sports = Handball, Soccer, Basketball; Racket sports = Table Tennis, Tennis, Badminton; Aesthetic sports = Dancing, Gymnastics, Vaulting; Martial arts = Karate, Judo, Boxing; Fitness/Endurance training = Gym, Weight training, Cycling, Jogging; Other sports = Swimming, Climbing, Athletics.

Figure 10: DEPR = Depression; ED = Eating disorder; ADHD = Attention deficit hyperactivity disorder; P/AD = Phobia/Anxiety disorder; OCD = Obsessive compulsive disorder; S/AD = Stress/Adjustment disorder; ODD = Oppositional defiant disorder; OMD = Other mental disorders; Ball sports = Handball, Soccer, Basketball; Racket sports = Table Tennis, Tennis, Badminton; Aesthetic sports = Dancing, Gymnastics, Vaulting; Martial arts = Karate, Judo, Boxing; Fitness/Endurance training = Gym, Weight training, Cycling, Jogging; Other sports = Swimming, Climbing, Athletics.

Feasibility

The return of the self-report SPOQ was 100% due to the treatment obligation for inpatients. The individuals needed between five and ten minutes for form completion. The parental version was an addition to the registration form. The first section was missing 35% of the information, the second section was 33%, the third section was 54%, the fourth section was 37%, and the last section was missing only 6%. It could be concluded that after completing the 12-page registration form, parents most likely did not want to engage in the specific topic of physical activity. The fewest missing items were in the last section, as this was probably the quickest to answer and, as the last question, had a higher visual focus.

Discussion

The study provided an overview of the athletic behavior of mentally ill children and adolescents, subjectively assessed physical fitness, and perceived psychological effects of physical activity. One out of 3 patients reported not being physically active at all. Self-reported physical fitness was perceived on average to be worst by patients with P/AD and DEPR and generally declined during puberty. Patients with ED reported on average a particularly high frequency of physical activity and saw it as an important resource to cope with their daily lives. The presence of a trainer was generally considered very unimportant, but not in ADHD patients.

In a survey of 118 girls and 127 boys without mental disorders, in addition to swimming for both sexes, aesthetic sports for girls and sports games for boys were cited as preferred physical activities [35]. In our child and adolescent psychiatric population, patients only sporadically reported swimming as a preferred sport. However, 41% of all physically active female patients mentioned aesthetic sports, and 55% of all physically active male patients reported ball and racket sports as their first sport (Figures 9,10). These findings must be considered in the development of resource-based sports therapy programs. Another task is to find suitable sports for the third of patients who have not been physically active so far.

Individuals with P/AD and DEPR have a more negative self-concept than the norm [36-38]. Regarding physical activity, Stadelmann, et al. [39] showed that patients with P/AD and DEPR also have a more negative self-concept compared to other mental disorders. This was also evident in our study (Figure 6). Comparing genders, the self-report in Figure 8 showed lower subjectively perceived physical fitness in girls regardless of frequency. In a survey of 332 girls and 382 boys aged 12 to 16, both boys and girls reported being bullied in sports by same-sex peers. On the other hand, predominantly girls reported bullying by opposite-sex peers [40]. This finding could be a possible explanation for the gender differences in sport self-image found in our study. If sports therapy starts early, targeted interventions could improve self-efficacy expectations and self-perception regarding one’s strength. Especially when treating P/AD and DEPR through sports therapy, this approach should be focused. Mixed-gender team building could therapeutically address bullying.

Some adult patients with ED use physical activity to regulate negative affect and emotions as a coping strategy and develop a sports addiction [41-43]. This deliberate use of physical activity as a coping strategy has been found in children and adolescents with ED (Figure 5). It makes sense to carry out a sports therapy intervention in these patients starting at a young age, in addition to psychotherapy, with the aim of a healthy approach to physical activity, to counter early the development of a sports addiction. Similar to the literature, a very large coherence was found between ED and controllable physical activity, such as individual sports like aesthetic sports and athletics (55 percent, Figure 10) [21,22]. Possibly, besides starting sports therapy at a young age, the therapy content should focus on fun and team sports to neglect sports with a high aspect of self-control and body emphasis to reach a lower level of symptoms.

Our data indicate that ADHD patients are more likely to value guidance from a trainer compared to other patients in the child and adolescent psychiatric context (Figure 4). They typically find it difficult to structure their actions due to their illness and need this from the outside [44,45]. While parents often lack the pedagogical competence to do so, children and adolescents receive clear structure, control, and action organization from a well-trained coach. As a result, they could prove to be more effective in achieving their goals in sports. Possibly, relationship work should be a major focus of sports therapy treatment for children and adolescents with ADHD and could lead to fewer symptoms.

Limitations

The findings of this study are limited as follows: An exploratory design is present. The SPOQ was cross-validated with the Strengths and Difficulties Questionnaire (SDQ) [46] and the EMI-2 [27], but not with other sport-specific instruments. In addition, the questionnaire was not tested for reliability and validity. Only one self-report or parental version of each patient is available, which means, no direct comparisons between patients and their parents are possible. Besides, the populations of the two questionnaire versions are not comparable because they differ in age structure, diagnosed diseases, and gender ratio. When interpreting the data, it must also be considered that outpatients on average have a significantly lower degree of their mental disorder than inpatients. Nevertheless, trends can be identified when the above-mentioned aspects are considered. Thus, the questionnaire serves to generate hypotheses in a very under-researched area. Helpful for this purpose is the large population of 313 patients.

Implications and future directions

Only a few studies examine the athletic behavior of children and adolescents with mental disorders so far. A study with 1.2 million young adults showed that not exercising leads to a higher mental health burden [4]. Our results revealed deficits in the frequency of physical activity per week. Almost 1 in 3 patients currently is not physically active (Figures 9,10). Achieving appropriate physical activity in children and adolescents should therefore be the primary task of sports therapy. The SPOQ is freely available for other institutions. The next step should be an efficacy study measuring the effects of a sports therapy program and testing hypotheses generated here.

Declarations

Ethics approval and consent to practice: An ethics vote with the number 837.515.15 (10833) from the ethics review board of the Landesärztekammer Rheinland-Pfalz exists for this study. As a routine procedure, informed consent statements were not needed to fill out the questionnaire. We confirm that all methods were carried out in accordance with relevant guidelines and regulations.

Availability of data and materials: The data cannot be made available to the public because of the confidentiality of the patient data.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors` contributions

FB: developed the SPOQ, collected the data, interpreted the data, wrote the manuscript

SS: developed the SPOQ

MH: developed the SPOQ

EJ: analyzed the patient data

All authors read and approved the final manuscript

SPOQ_parental_eng
SPOQ_self_eng

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