key: cord-0763049-iebyl1me authors: McGuine, T.; Biese, K.; Schwarz, A.; Reardon, C.; Hetzel, S.; Brooks, M. A.; Bell, D.; Watson, A. title: High School Sports During the CoVID-19 Pandemic: The Impact of Sport Participation on the Health of Adolescents date: 2021-02-09 journal: nan DOI: 10.1101/2021.02.07.21251314 sha: 0db19f91fb6692f1055074c4a28f3cb2c52318ac doc_id: 763049 cord_uid: iebyl1me Context: During the fall of 2020, some high schools across the US allowed their students to participate in interscholastic sports while others cancelled or postponed their sport programs due to concerns regarding CoVID19 transmission. It is unknown what effect this has had on the physical and mental health of student athletes. Objective: Identify the impact of playing a sport during the CoVID19 pandemic on the health of student athletes. Design: Cross-sectional study. Setting: Sample recruited via email. Patients or Other Participants: 559 Wisconsin high school athletes (age=15.7+1.2 yrs., female=44%) from 44 high schools completed an online survey in October 2020. A total of 171 (31%) athletes played (PLY) a fall sport, while 388 (69%) did not play (DNP). Main Outcome Measure(s): Demographics included: sex, grade and sports played. Assessments included the General Anxiety Disorder-7 Item (GAD-7) for anxiety, Patient Health Questionnaire-9 Item (PHQ-9) for depression, the Pediatric Functional Activity Brief Scale (PFABS) for physical activity, and the Pediatric Quality of Life Inventory 4.0 (PedsQL) for quality of life. Univariable comparisons between the two groups were made via t-tests or chi-square tests. Means for each continuous outcome measure were compared between the groups by ANOVA models that controlled for Age, Sex, Teaching method (Virtual, Hybrid, or In-person), and the % of students eligible for free lunch. RESULTS: PLY group participants were less likely to report moderate to severe symptoms of anxiety (PLY=6.6%, DNP=44.1%, p<0.001) and depression (PLY=18.2%, DNP=40.4%, p<0.001). PLY athletes reported higher (better) PFABS scores (mean: [95%CI]), (PLY=23.2[22.0,24.5], DNP=16.4[15.0,17.8], p <0.001) and higher (better) PedsQL total scores (PLY=88.4[85.9,90.9], DNP=79.6[76.8,82.4], p <0.001). CONCLUSIONS: Adolescents who played a sport during the CoVID19 pandemic reported fewer symptoms of anxiety and depression, as well as higher physical activity and quality of life scores compared to adolescent athletes who did not play a sport. The sports offered most often by schools included boys' and girls' cross country (78%) 129 and girls' golf (72%). The sports offered least often included football (54%), boys' soccer (50%) 130 and girls' swimming (50%). 33 respectively. 34 The questionnaires ask participants to rate the frequency of anxiety or depression symptoms experienced in the past two weeks. The GAD-7 scale is a valid, 146 reliable and sensitive measure of anxiety symptoms and is able to differentiate between 147 mild and moderate GAD in adolescents. 35 Scores range from 0-21 with a higher score 148 indicating increased anxiety. In addition to the total score, GAD-7 categorical scores of 0-149 4, 5-9, 10-14, and 15-21 correspond to no, mild, moderate, and severe anxiety 150 symptoms, respectively. 36 The PHQ-9 is a 9-item screening questionnaire for depression 151 symptoms with scores ranging from 0-27 with a higher score indicating a greater level of 152 depression. The PHQ-9 has demonstrated high sensitivity and specificity for depression 153 screening in adolescent patients aged 13 to 17 years. 37 In addition to the total score, 154 PHQ-9 categorical scores of 0-4, 5-9, 10-14, 15-19 and > 20 correspond to minimal or 155 none, mild, moderate, moderately severe and severe depression symptoms, 156 respectively. 38 for sex and fall sport participation. Participants were classified as playing a fall sport (PLY) or 175 as not playing a fall sport (DNP). The characteristics for the schools attended by the participants included the type of 177 instructional delivery method and the % of students eligible for free or reduced lunch. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314 doi: medRxiv preprint schools that delivered all instruction online. The % of students eligible for free or reduced lunch 198 (mean + SD) for the schools was 25.9 + 10.3%. One hundred forty-eight (86.5%) of the 199 participants in the PLY group attended schools that offered all fall sports, with 40.3% (n = 69) 200 attending school in-person. Participants in the PLY group were most likely to report playing 201 volleyball (n = 66, 38.6%), football (n = 53, 31%) and boys' soccer (n = 22, 12.9%). Participants 202 in the DNP group most commonly reported that they had intended to play football (n = 160, 203 41.2%), and volleyball (n = 51, 13.1%). Seventy nine participants (20.4%) did not play a fall 204 sport but intendede to play a high school winter or spring sport. A summary of the participant 205 characteristics is found in Table 1 . The PLY participants were more likely to report GAD-7 symptom scores of 0 to 4, indicating no CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 9, 2021. Athletes that played high school sports in the fall of 2020 demonstrated significantly lower 247 symptoms of anxiety and depression than those athletes who did not play a sport. Specifically, . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314 doi: medRxiv preprint symptoms of anxiety and more than twice as likely to report moderate to severe symptoms of 250 depression even after adjusting for age, sex, type of school instruction and % of the students 251 qualifying for free and reduced lunch. This seems to suggest that while PLY athletes continue 252 to demonstrate slightly higher levels of depression and anxiety than historical values, the mental 253 health burden among DNP athletes is considerably worse. 25 In fact, the DNP group 254 demonstrates levels of moderate to severe anxiety and depression symptoms similar to those 255 identified in a nationwide sample for adolescent athletes in May 2020 (anxiety = 36.7%, 256 depression = 27.1%). 25 Given the adolescent mental health crisis that existed prior to the onset 257 of CoVID-19, and the known mental health benefits of sport participation, this data seems to 258 suggest that adolescent athletes who are unable to return to sports may be at a significantly 259 greater risk for mental health issues. Experts have pointed out that the CoVID-19 pandemic has negatively impacted the 261 mental health of youth and may be related to decreased socialization, increased family strain, and reduced access to support services. 13,44 As such, we recognize that factors beyond sport 263 participation such as the ability to attend school in-person may contribute to adolescent mental 264 health. In addition, depression and anxiety in adolescent athletes have been shown to be 265 related to sex and grade in school. Nonetheless, after controlling for the type of school 266 instructional delivery (online, in-person or hybrid), age and sex, sport participation remained 267 significantly associated with large improvements in anxiety and depression symptoms. Therefore, we can reasonably assume that the increased symptoms we identified among the 269 DNP participants are at least partly attributable to the lack of sport participation. Our results also support previous research that has demonstrated that sport participation 271 improves the mental health of youth and adolescents. 45-48 A recent study during the early stages 272 of the CoVID-19 pandemic found that 11.4% of student athletes who were unable to participate 273 in sports reported moderate to severe levels of depression symptoms, which was four times 274 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314 doi: medRxiv preprint supports the premise that sport participation may represent an important mechanism to improve played high school sports had a significantly higher level of physical activity than athletes who 281 did not play a sport. Notably, the total PFABS score for the PLY group was similar to scores Physical activity is known to have a beneficial effect on a wide range of health outcomes 292 in adolescents, including sleep, academic success, well-being, and mental health. 5,6,9,12,45-48,50 293 Therefore, it is possible that the identified decrease in mental health in the DNP group may be 294 at least partly due to the removal of the positive effects that physical activity has for 295 adolescents. In addition, childhood obesity was a public health crisis before CoVID-19, and is 296 projected to become worse due to the pandemic. 19,21,51 Decreased physical activity in 297 adolescents may also have long-term negative effects and implications in terms of increased 298 risk for obesity and cardiometabolic disease if these levels remain low for prolonged periods. 52 Chronically low levels of physical activity may also compound the mental health consequences 300 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314 doi: medRxiv preprint complex issue and requires careful consideration. Stakeholders should consider the promotion to sport in fall 2020 reported significantly higher HRQoL than those athletes unable to return to 307 sport. This is consistent with prior studies that have shown that individuals with increased 308 physical activity and/or interscholastic sport participation report higher HRQoL scores compared 309 to inactive adolescents and high school non-athletes. 54-57 Therefore, it is not surprising that 310 HRQoL scores for the PLY athletes were higher than the DNP athletes. The total PedsQL scores reported here for the PLY athletes are significantly higher than . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314 doi: medRxiv preprint outcomes among individuals exposed to adverse childhood experiences. JAMA Pediatr. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 9, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 9, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314 doi: medRxiv preprint Challenges and burden of the Coronavirus 461 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to 462 highlight clinical and research needs in the acute phase and the long return to normality Child and Adolescent Psychiatry and Mental Health World Health Organization. Considerations for school-related public health measures in the 465 context of COVID-19: annex to considerations in adjusting public health and social 466 measures in the context of COVID-19 Questionnaire-9 Item for Detecting Major Depression Among Adolescents Questionnaire Anxiety and Depression Scale: Initial Validation in Three Clinical Trials Development and validation of a pediatric 490 sports activity rating scale: the Hospital for Special Surgery Pediatric Functional Activity Brief 491 Scale (HSS Pedi-FABS) The Hospital 493 for Special Surgery Pediatric Functional Activity Brief Scale 44. Singh S, Roy D, Sinha K, Parveen S, Sharma J, Joshi G. Impact of COVID-19 and lockdown