HHS Public Access Author manuscript Author Manuscript

Child Adolesc Ment Health. Author manuscript; available in PMC 2017 May 01. Published in final edited form as: Child Adolesc Ment Health. 2016 May ; 21(2): 109–114. doi:10.1111/camh.12139.

The association of organized and unorganized physical activity and sedentary behavior with internalizing and externalizing symptoms in Hispanic adolescents Asfour Lila1, Maryann Koussa1, Tatiana Perrino2, Mark Stoutenberg1, and Guillermo Prado2 Guillermo Prado: [email protected]

Author Manuscript

1Department

of Public Health Sciences, University of Miami Miller School of Medicine, FL, USA

2Division

of Prevention Science and Community Health, Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, FL 33136

Abstract Background—Literature suggests that physical activity (PA) and sedentary behavior may be associated with adolescent mental health symptoms. A gap in the literature is whether different types of PA have unique impacts on internalizing and externalizing symptoms. This study separately assesses the association of organized PA, unorganized PA, and sedentary behavior with internalizing and externalizing symptoms.

Author Manuscript

Method—This study analyzed baseline data from a randomized controlled trial of a preventive intervention with 575 Hispanic adolescents. Using separate multivariable linear mixed models, the relationship between the independent variables of PA and sedentary behavior and the dependent variables of internalizing and externalizing symptoms was evaluated. Results—Organized PA was not associated with internalizing or externalizing symptoms; however, higher levels of unorganized PA were associated with greater internalizing and externalizing symptoms. Increased sedentary behavior was also associated with higher levels of externalizing symptoms, but not internalizing symptoms. Conclusions—Implications of this study highlight the need to examine types of PA separately as they may differentially deferentially influence adolescent mental health symptoms. Potential explanations for these findings and suggested further analyses are discussed.

Author Manuscript

Keywords Physical activity; sedentary behavior; mental health; adolescent; Hispanic

Introduction The period between childhood and adulthood can be a stressful and challenging transition for many adolescents. Internalizing (i.e. depression, anxiety) and externalizing (i.e. aggressiveness, law breaking behavior) symptoms often emerge during late childhood and

The authors declare that they have no competing or potential conflicts of interest.

Lila et al.

Page 2

Author Manuscript

adolescence, an important time-point for preventive interventions (National Research Council/Institute of Medicine, 2009; Robinson, Kendall, Jacoby, Hands, Beilin, et al., 2011; Rönnlund & Karlsson, 2006). As a critical period of development and rapid change, it is important to enhance our understanding of risk and protective factors that may impact internalizing and externalizing symptoms during adolescence. Understanding the determinants of internalizing and externalizing symptoms may be especially important for minority populations, such as Hispanics, who access and utilize mental health services less frequently (Karnik, Jones, Campanaro, Haapanen, & Steiner, 2006) and who may benefit the most from preventive interventions.

Author Manuscript

Findings from the literature on rates of internalizing and externalizing symptoms among Hispanics compared to other groups have varied (Alegría, Canino, Shrout, Woo, Duan, et al., 2008; Anderson, Mayes, 2010; McLaughlin, Hilt, & Nolen-Hoeksema, 2007). Yet, data from the Centers for Disease Control & Prevention’s (CDC) Youth Risk Behavior Surveillance System show that compared to non-Hispanic white and non-Hispanic black adolescents, Hispanic adolescents reported the highest prevalence of ‘feeling sad or hopeless’, ‘seriously considered attempting suicide’, ‘attempted suicide one or more times’, or ‘made a plan about how they would attempt suicide’ (CDC, 2013). While rates of externalizing symptoms have not been shown to be disproportionately high among Hispanic youth, Hispanic adolescents report higher rates of related risk behaviors such as riding with a driver who has been drinking alcohol and being offered, sold, or given an illegal drug on school property (CDC, 2013). Moreover, Hispanic youth are exposed to factors that are known to intensify the risk of developing both internalizing and externalizing symptoms, including cultural stress and socioeconomic adversity (Cano, Schwartz, Castillo, Romero, Huang, et al., 2015; Reiss, 2013).

Author Manuscript Author Manuscript

The literature has documented that physical activity (PA) is associated with protection against depression and other internalizing and externalizing symptoms (Hoare, Skouteris, Fuller-Tyszkiewicz, Millar, & Allender, 2014; Rusby, Westling, Crowley, & Light, 2014). Research suggests that PA can influence mental health outcomes directly through its effects on physiological mechanisms, such the regulation of cortisol and production of endorphins that promote positive mood states (Hartea, Eifert, & Smith, 1995). In addition, a recent meta-analytic review of cross-sectional studies focusing on adolescent mental health showed a significant inverse relationship between depressive symptoms and PA (Hoare et al., 2014), supporting the notion that PA may be a potential protective factor for internalizing symptoms. While the direction of the relationship between these variables cannot be confirmed through cross-sectional studies, longitudinal studies have found prospective relationships between PA and youth mental health, as well as reciprocal relationships in which these variables may influence each other across time (Biddle & Asare, 2011). Despite the documented potential benefits of PA, approximately 80 percent of adolescents fail to engage in sufficient PA to meet the guidelines for youth (U.S. Department of Health and Human Services, 2012). Along with limited levels of PA, high levels of sedentary behavior may also be a risk factor for internalizing and externalizing symptoms in adolescents. Increasing levels of sedentary behavior are associated with poorer mental health outcomes in both adults and youth (Rusby et al., 2014; Biddle & Asare, 2011). Given that

Child Adolesc Ment Health. Author manuscript; available in PMC 2017 May 01.

Lila et al.

Page 3

Author Manuscript

sedentary behavior (e.g., watching television, playing videogames) often takes place in solitude, it may limit opportunities for social connectedness and can reinforce loneliness and depressive symptoms (Epstein, Roemmich, Paluch, & Raynor, 2005; Hoare et al., 2014; Robinson et al., 2011).While the relationship between sedentary behavior and internalizing symptoms has been widely examined, evidence on the relationship between sedentary behavior and externalizing symptoms is still limited.

Author Manuscript

Although many studies have found an association between PA and sedentary behavior with mental health, these studies have often examined PA as a single, general construct, when it is possible that different types of PA may have distinct influences on mental health outcomes. Separating activities into unique categories of ‘organized’ (e.g., high school sports team) and ‘unorganized’ (e.g., impromptu neighborhood basketball game) PA may help identify how these contribute uniquely to mental health symptoms. While some studies have analyzed differences between organized versus unorganized PA and physiological health, to our knowledge none have analyzed the specific risk and protective factors associated with mental health (Bengoechea, Sabiston, Ahmed, & Farnoush, 2010; Hoare et al., 2014). This study extends the literature by examining whether overall, organized, and unorganized PA, as well as sedentary behavior, are differentially associated with adolescent internalizing and externalizing symptoms in a large community sample of Hispanic adolescents. As such, the present analyses can continue to build our understanding of the potential role of different types of PA and sedentary behavior on adolescent mental health, which may be especially important among Hispanic youth who may experience disproportionate risk of poor mental health outcomes. Although these analyses are cross-sectional, they are unique and important in their focus on Hispanic adolescents, an understudied group.

Author Manuscript

Methods Participants Participants in this research study were enrolled in a recently completed randomized controlled trial evaluating the effectiveness of Familias Unidas, a family-based, culturallysensitive prevention intervention which has been shown to reduce substance use and risky sexual behavior among Hispanic adolescents (Prado, Pantin, Huang, Cordova, Tapioa, et al., 2012). The current analyses examine baseline data to explore the association between various forms of PA and sedentary behavior with internalizing and externalizing symptoms. This study was approved by both the University of Miami and the Miami Dade County Public School’s (MDCPS) Institutional Review Boards.

Author Manuscript

Inclusion criteria for the parent study required adolescents to: (a) self-identify as Hispanic, (b) be enrolled in 8th grade at baseline, (c) reside with an identified parent or caregiver who was willing to participate, (d) live within the areas of the participating middle schools, (e) and have no plans to leave South Florida for the duration of the study. A total of 746 participants from 18 middle schools in MDCPS system completed the baseline assessment. For the present analyses, only students who indicated that their level and type of activities during the preceding two weeks were representative of their typical level of activity were

Child Adolesc Ment Health. Author manuscript; available in PMC 2017 May 01.

Lila et al.

Page 4

Author Manuscript

included in the analyses. Thus, the resulting sample size for analysis consisted of 575 Hispanic adolescents. Measures All measures were collected by self-report surveys administered to adolescents using audio computer-assisted self-administered interview (ACASI). These surveys presented text onscreen while a pre-recorded voice reads the text to the participant. Socio-demographic variables

Author Manuscript

Survey questions asked participants to report their gender, place of birth, and family income. For the analyses, place of birth was categorized into U.S.- vs. foreign-born. Family income information was collected in categories (e.g., ‘under $5,000/year’; ‘$5,000–$9,999/year’; ‘10,000–$14,999’). For the analyses, family income was categorized into less than $30,000 per year vs. $30,000 or more per year. This cut-point of $30,000 per year was selected because the U.S. poverty threshold for a family of four in 2015 was $24,250 as delineated by the U.S. Department of Health and Human Services (DHHS, 2015), which provides an estimate of socioeconomic disadvantage. Using $30,000 per year as the cut-point provides a conservative approximation to this threshold. Physical activity

Author Manuscript

Levels of overall, organized, unorganized PA, and sedentary behavior were measured using a modified version of the Physical Activity Questionnaire for Adolescents (PAQ-A), which has been previously validated in diverse adolescent groups (Janz, Lutuchy, Wenthe, & Levy, 2008; Kowalski, Crocker, & Donen, 2004; Martínez-Gómez, Gómez-Martínez, Wärnberg, Welk, Marcos et al., 2011). Specifically designed for adolescents, the PAQ-A gathers selfreport data based on individual recall of PA in the past seven days. A sample PAQ-A question is: ‘How many times did you ride a bicycle in the last 7 days?’ Overall PA is a unitless mean summary activity score, determined by the mean score of participant involvement in 24 different types of PA, including sports, exercise, physical games, or dance. To assess level of involvement in each subcategory of PA, every activity was then categorized into organized (e.g., school sports team) or unorganized PA (e.g., neighborhood soccer game), as decided by the adolescent. Time spent engaging in sedentary behavior was calculated using five questions (Cronbach’s α=.91) that inquired about time spent watching television, playing video games, text messaging, internet use and time spent on the telephone. These questions were scored on a five-point scale, with higher values indicating greater time spent engaged in these behaviors, and summed to provide a total rating of sedentary behavior.

Author Manuscript

Internalizing and externalizing symptoms The Youth Self-Report was used to measure adolescent reports of internalizing and externalizing symptoms, as well as total problems (Achenbach & Edelbrock, 1991). This 112-item survey uses a three-point Likert scale ranging from ‘Not True’ to ‘Very True’ or ‘Often True’. A sample item is ‘I am unhappy, sad or depressed’. Subscales assess specific internalizing and externalizing symptoms and total problems. Internalizing symptoms are a sum of the Anxious/Depressed, Withdrawn, and Somatic Complaints; externalizing

Child Adolesc Ment Health. Author manuscript; available in PMC 2017 May 01.

Lila et al.

Page 5

Author Manuscript

symptoms are a sum of the Delinquent Behavior and Aggressive Behavior subscales; and total problems are a sum of all the subscales including Social Problems, Thought Problems, Attention Problems, and Other Problems in addition to the above subscales. Statistical analysis To characterize the sample, frequencies (with percentages) or means (with standard deviations) were calculated for socio-demographic variables, PA, and internalizing and externalizing symptom variables for the sample, as well as stratifying by gender, family income level, and birthplace. Separate linear models were estimated to evaluate whether there was a significant relationship between the dependent variables and gender, income level, and birthplace.

Author Manuscript

To investigate the relationship between the independent variables of PA and sedentary behavior and the dependent variables of internalizing and externalizing symptoms, separate multivariable linear mixed models were estimated. Each model controlled for age, gender, household income, and birthplace of the adolescent as these variables have been previously associated with PA and mental health (Bengoechea et al., 2010; Dinh, Roosa, Tein, & Lopez, 2002). The reference group in these models is males for gender, ≥$30,000/year for household, and U.S. born for birthplace. Analyses were conducted using Mplus (version 7) and were adjusted for cluster sampling as students were clustered within schools.

Results

Author Manuscript

Table 1 describes the sample demographics and self-reported levels of PA, sedentary behaviors and internalizing and externalizing symptoms. Results are displayed for the overall sample, and are also stratified and compared by gender, income, and birthplace. The sample consisted of the 575 Hispanic adolescents with males comprising 55% of the sample. All participants were Hispanic and the majority of the adolescents were born in the U.S. (55%). Participants were predominantly from low-income families with 63% having an annual household income less than $30,000. The mean age of the participants was 13.8 years.

Author Manuscript

Levels of overall, organized, and unorganized PA were all significantly greater in males than females. The mean overall PA score was 1.59±0.53 for males and 1.45±0.41 for females, the mean organized PA was 1.34±0.51 for males and 1.27±0.39 for females, and the mean unorganized PA was 1.37±0.49 for males and 1.25±0.36 for females. Overall and unorganized PA levels were also significantly greater in high-income compared to lowincome groups (overall PA means: high income=1.56±0.52 and low income=1.47±0.44; unorganized PA means: high income=1.35±0.46 and low income=1.26±0.40), but there were no statistically significant differences in organized PA by income. Organized PA was statistically greater in foreign born (1.37±0.51) than U.S. born (1.26±0.41) adolescents, but there were no statistical differences in unorganized or overall PA by place of birth. There were no statistically significant differences in sedentary behavior by gender, income, or place of birth.

Child Adolesc Ment Health. Author manuscript; available in PMC 2017 May 01.

Lila et al.

Page 6

Author Manuscript

In terms of mental health symptoms, females reported significantly greater internalizing symptoms (female=11.82 ±9.21, male=8.31±7.73) and total problems (female= 40.55±27.71, male=34.70±24.48), but not externalizing symptoms. Adolescents born in the U.S. reported significantly greater levels of externalizing symptoms (U.S. born=10.67±8.75, foreign born=8.04±7.55) and total problems (U.S. born=40.87±26.48, foreign born=32.99±25.06), but not internalizing symptoms. Internalizing symptoms, externalizing symptoms, and total problems did not significantly differ by household income.

Author Manuscript

Table 2 shows the results from the multivariable models assessing associations between the different categories of PA and sedentary behavior with internalizing and externalizing symptoms, controlling for age, gender, household income, and birthplace. Greater levels of overall PA were significantly associated with more externalizing symptoms (β=2.70, p=0.04), but not with total problems or internalizing symptoms. Organized PA was not significantly associated with either internalizing, externalizing or total problems. However, higher levels of unorganized PA were significantly associated with higher levels of internalizing symptoms (β=2.80, p=0.04), externalizing symptoms (β=4.44, p

The association of organized and unorganized physical activity and sedentary behavior with internalizing and externalizing symptoms in Hispanic adolescents.

Literature suggests that physical activity (PA) and sedentary behavior may be associated with adolescent mental health symptoms. A gap in the literatu...
120KB Sizes 3 Downloads 6 Views