Exercise in prevention and treatment of anxiety and depression among children and young people
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
1.To determine whether exercise interventions reduce and/or prevent anxiety and/or depression among children and young people compared to other treatments or no treatment.
2.If so, what are the characteristics of the most effective interventions?
Background
Background
The problem: Psychological problems represent one of the main challenges to modern societies. There is an on going debate as to the magnitude of the problem. Prevalence figures are dependent upon case definitions and identification procedures. Sonuga‐Barke reports a prevalence of psychological problems in children and adolescents between 10 and 20% (Sonuga‐Barke 1997; Kurtz 1992). Kurtz reports that 7‐10 % of children in the UK are estimated to suffer from moderate to severe mental health problems that hinder normal development (Kurtz 1992). Haggerty suggests there is evidence of a worsening trend, particularly in socially disadvantaged populations (Haggerty 1996). Prior considers 4‐7% of the child population to be in need of psychological treatment (Prior 1992). The stability of problems seems higher than formerly anticipated. Resent research shows that about half the children in need of psychological treatment at four years of age still belonged to the group with serious symptoms at 10 years of age. Depression and anxiety are the two most common disorders (Crawford 2002). Whether the prevalence is closer to 4 or 20% in children up to 18, it is still a common disorder, and the burden presented to health professionals and families as well as to the child itself is significant.
It is common to divide psychological problems into two main groups. Aggression and attention/hyperactivity/impulse regulation are often called externalising problems. Anxiety, depression and psychosomatic symptoms are in the same way called internalising problems. There is some overlap between these two main problem groups. The stability of problems seems to be approximately the same in both groups. The instruments used in studies of externalising and internalising problems are well validated and the cut‐off point set at levels that indicate problems affecting child and/or family function.
Rationale for intervention: Treatment of psychological problems is usually through serotonin enhancing pharmaceuticals. Less common is psychotherapy, sometimes incorporating stress management techniques and occasionally exercise (Biddle 2000) or physical activity (Ekeland 2003). A substantial proportion of people are reluctant or unwilling to consider pharmacological treatment, and between 30 and 50% fail to respond to initial treatment (Crawford 2002). This makes early intervention, designed to prevent mental illness and to promote good mental health, an important policy focus. There is an acceptance among medical authorities that physical activity is an important part of healthy living (WHO 1995). So far, developments in the use of exercise in health promotion and treatment have focused on the impact of exercise on reducing the risk of physical health problems such as CHD, some types of cancer, diabetes, obesity, and to a lesser extent musculo‐skeletal problems such as low back pain and osteoporosis (Biddle 2000). To date, much less attention has been paid to the contribution of exercise to the prevention and treatment of mental disorders, illnesses, and general mental malaise (Biddle 2000). There are several benefits that are associated with the use of exercise. First, exercise is cheap. Second, moderate exercise has few side effects and may even give positive side effects. Third, exercise can be self‐sustaining in that the individual can maintain it once the basic skills have been learnt (Crawford 2002). Fourth, many common non‐drug treatments, such as cognitive behavioral therapy, can be expensive and often in short supply (Biddle 2000).
Rational for this review: There is strong evidence of the positive physical health outcomes of living a physically active life (Blair 1992; Pate 1995; Erikssen 1998). In addition to reducing the load of risk factors in the community and improving the efficacy of social, health and pedagogical services, a series of non‐traditional, general, non‐stigmatising and positive measures is an important area for consideration. Many forms of physical activity have qualities that satisfy these requirements. Since the 1970s there has been an increasing body of research on mental health outcomes of physical activity, and the results indicate positive effects for adults (Erikssen 1998). A recent Cochrane review indicates a positive effect from physical activity on self‐esteem (Ekeland 2003). Similar positive effects on specific problems like depression, anxiety, hyperactivity and conduct problems in children and adolescents have been reported (Biddle 1993; Calfas 1994; Mutrie 1998). However, these latter reviews have not been updated. Given the existence of new evidence, a current review of the effectiveness of exercise‐based interventions in treatment of anxiety and depression among children and young people is needed.
Objectives
1.To determine whether exercise interventions reduce and/or prevent anxiety and/or depression among children and young people compared to other treatments or no treatment.
2.If so, what are the characteristics of the most effective interventions?
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials.
Types of participants
Children and young people aged 0‐20 years, with or without anxiety and depression. Trials that include children and young people with psychotic or borderline conditions, autism, physical handicap, eating disorders and/or chronic somatic/physical diseases will not be included.
Types of interventions
Interventions that include gross motor, vigorous activity of clearly specified quality, other than "ordinary" physical activity with a duration of minimum 4 weeks.
The control group may be waiting list, a non‐intervention group or a group receiving an intervention other than physical activity.
Types of outcome measures
Children's anxiety and depression measured by self‐report, health personnel report, parent report and/or teacher report with a standardised procedure.
Primary outcome:
Change in depression or anxiety
Decrease in prevalence of anxiety or depression.
Secondary outcome:
Change in psychological wellbeing, social functioning or quality of life.
Search methods for identification of studies
Electronic searches.
Relevant trials will be identified from the CCDAN Specialised register CCDANCTR‐Studies using the following search terms;
Diagnosis = Anxiety or Depress* or Dysthymic Disorder
and
Age Group = Children or Adolescent
and
Intervention = Exercise
We shall also search the Cochrane Central Register of Controlled Trials (CENTRAL) (latest issue available), MEDLINE (1966‐), EMBASE(1982‐), CINAHL (1982‐), PsychINFO (1887‐), ERIC (1965‐) and Sportdiscus (1949‐) using a variation of the search listed below (please see Table 1);
| PsycINFO |
| Database: Psycinfo Ovid |
Database: Medline Ovid
1. Anxiety/
2. exp Anxiety Disorders/
3. Anxiety, Separation/
4. Depressive Disorder/
5. Depression, involutional/
6. Dysthymic disorder/
7. Seasonal affective disorder/
8. Child behavior disorders/
9. nervousness.tw.
10. anxiety.tw.
11. angst.tw.
12. anxiousness.tw.
13. apprehension.tw.
14. neurocirculatory asthenia.tw.
15. cardiac neurosis.tw.
16. effort syndrome.tw.
17. hyperkinetic heart syndrome.tw.
18. obsessive compulsive disorder$.tw.
19. obsessive compulsive neuros?s.tw.
20. phobic disorder$.tw.
21. phobic neuros?s.tw.
22. phobia$.tw.
23. stress disorder$.tw.
24. combat disorder$.tw.
25. war neuros?s.tw.
26. combat neuros?s.tw.
27. depression.tw.
28. depressive$.tw.
29. involutional paraphrenia.tw.
30. involutional psychosis.tw.
31. melancholia.tw.
32. seasonal affective disorder$.tw.
33. seasonal mood disorder$.tw.
34. dysphoria.tw.
35. bipolar affective disorder$.tw.
36. bipolar mood disorder$.tw.
37. dysthymic disorder$.tw.
38. fear.tw.
39. bipolar disorder$.tw.
40. panic.tw.
41. or/1‐40
42. Exercise/
43. Exercise Therapy/
44. Dance Therapy/
45. Tai Ji/
46. Walking/
47. Yoga/
48. Exertion/
49. Physical fitness/
50. Dancing/
51. "Play and Playthings"/
52. exp Sports/
53. "Physical Education and Training"/
54. exercis$.tw.
55. physical fitness.tw.
56. exertion.tw.
57. physical effort.tw.
58. human physical condition$.tw.
59. physical activit$.tw.
60. physical endurance.tw.
61. physical strength.tw.
62. (tai ji or walking or walks or yoga or dance or dancing or sport or sports or baseball$ or basketball$ or softball$ or rugby or soccer or football$ or bicycling or boxing or golf or gymnastic$ or calisthenic$ or gong fu or gongfu or judo or martial arts or karate or kung fu or tae kwon do or aikido or mountaineering or tennis or badminton or running or jogging or skating or lacrosse or squash or skateboard$ or snowboard$ or skiing).tw.
63. physical train$.tw.
64. physical education.tw.
65. or/42‐64
66. adolescent/ or exp child/
67. exp Students/
68. (child$ or adolescen$ or pediatric$ or paediatric$).tw,jw.
69. (boy$ or girl4 or kid$ or school$ or preschool$ or juvenil$ or under?age$ or teen$ or minor$ or pubescen$ or young people or young person$ or youth$ or student$).tw.
70. or/66‐69
71. randomized controlled trial.pt.
72. controlled clinical trial.pt.
73. Randomized Controlled Trials/
74. Random Allocation/
75. Double‐Blind Method/
76. Single‐Blind Method/
77. or/71‐76
78. limit 77 to animal
79. limit 77 to human
80. 78 and 79
81. 78 not 80
82. 77 not 81
83. clinical trial.pt.
84. exp clinical trials/
85. clin$ with trial$.tw.
86. PLACEBOS/
87. placebo$.tw.
88. random$.tw.
89. exp research design/
90. or/83‐89
91. limit 90 to animal
92. limit 90 to human
93. 91 and 92
94. 91 not 93
95. 90 not 94
96. Comparative Study/
97. exp evaluation studies/
98. Follow‐Up Studies/
99. Prospective Studies/
100. (control$ or prospectiv$ or volunteer$).tw.
101. or/96‐100
102. limit 101 to animal
103. limit 101 to human
104. 102 and 103
105. 102 not 104
106. 101 not 105
107. 82 or 95 or 106
108. 41 and 65 and 70 and 107
References from published studies
References from included primary reports and relevant reviews will be scanned and the "related articles" utility will be used.
Unpublished literature
Unpublished and on‐going trials will be identified by correspondence with authors and field experts. Grey literature will be sought by contacting experts and searching SIGLE (System for Information on Grey Literature in Europe).
Hand searching
We will consider hand searching key journals for additional studies:
Clinical Child Psychology and Psychiatry
The list of journals and years will be modified if necessary.
Data collection and analysis
1. Study selection ‐ criteria for evaluating eligibility of retrieved studies
Studies identified will be scanned independently by two reviewers (LL and LVN) who will exclude the studies that are obviously of no interest according to the inclusion criteria above. LL and LN will judge titles and abstracts of potentially relevant studies independently against the inclusion criteria. Full copies of those deemed eligible by one of the reviewers will be retrieved for closer examination. If there is uncertainty or disagreement, consensus will be reached by discussion and consultation with a third reviewer EE. A log of all studies which initially appear to meet the inclusion criteria but, based on the full text reports, do not meet the inclusion criteria will be detailed in a table of excluded studies.
2. Quality assessment
Two reviewers (LL and LN) will independently assign each selected study to quality categories as described in the Cochrane Collaboration Handbook (Clarke 2001). Each category is outlined below. Uncertainty or disagreement will be solved by discussion with EE or KBH. The authors of studies will be contacted for clarification if the information is unclear. Blinding of providers and patients is unlikely to be applicable and will not be used as a criterion to assess internal validity of included trials.
Prevention of selection bias
Generation of allocation sequence
MET = Resulting sequences are unpredictable (explicitly stated use of either computer‐generated random numbers, table of random numbers, drawing lots or envelopes, coin tossing, shuffling cards, or throwing dice).
UNCLEAR = Vague statement that the study was randomised but not describing the generation of the allocation sequence.
NOT MET = Explicit description of inadequate generation of sequence, e. g. (e.g., using case record numbers, alternation, date of admission, date of birth).
Concealment of allocation (randomisation procedure)
MET = Participants and investigators cannot foresee assignment, e.g. central randomisation performed at site remote from trial location, sequentially numbered, sealed, opaque envelopes).
UNCLEAR = Vague statement that the study was randomised but not describing the concealment of the allocation sequence.
NOT MET = Explicit statement that allocation was not concealed OR statement indicating that participants or investigators can foresee upcoming assignment (e. g., open allocation schedule, unsealed or non‐opaque envelopes).
Baseline assessment
MET: Adequate when table of participants show similarity (i.e. age, disorder, BMI, activity level)
UNCLEAR: Sufficient information could not be obtained
NOT MET: The groups show considerable diversity
Prevention of Detection Bias
Outcome assessment
MET: Assessor unaware of the assigned treatment when collecting outcome measures
UNCLEAR: Blinding of assessor not reported and cannot be verified by contacting investigators
NOT MET: Assessor aware of the assigned treatment when collecting outcome measures.
Prevention of Performance Bias
Co‐intervention
MET: Interventions other than exercise avoided, controlled or used similarly across comparison groups.
UNCLEAR: Use of interventions other than exercise not reported and cannot be verified by contacting the investigators
NOT MET: Dissimilar use of interventions other than exercise across comparison groups, i. e. differences in the care provided to the participants in the comparison groups other than the intervention under investigation.
Prevention of Attrition Bias
Losses to follow‐up
MET: Losses to follow up less or equal than 20% and equally distributed between comparison groups
UNCLEAR: Losses to follow up not reported
NOT MET: Losses to follow up greater than 20% or not equally distributed between comparison groups
Intention‐to‐treat
MET: intention to treat analysis performed or possible with data provided
UNCLEAR: intention to treat not reported, and cannot be verified by contacting the investigators
NOT MET: intention to treat analyses not done and not possible for reviewers to calculate independently.
An overall assessment of internal validity will be based on a summary of these seven methodological criteria. Other methodological issues will be documented in the data extraction form (Appendix 1).
3. Data extraction
Two reviewers will independently extract data information from the full text report on study characteristics using a specially design data extraction form. Discrepancies will be resolved by consensus.
Data will preferably be extracted as baseline and follow up. Change in score will not be included in a possible pooling.
Both dichotomous and continuous data will be considered as primary outcomes depending on reported results. The following will be used to decide what the primary outcome of a study is:
A: What the author states as the primary outcome.
B: Most frequently used outcome in our included studies.
C: Where there is no apparent reason for choice according to 1 or 2 the reported scales/scores will if possible be be added and divided.
Missing data will be obtained from authors when possible. If intention to treat analyses are not done this will be reflected in the rating of quality.
Data will be checked and entered into RevMan 4.2 for analysis using double data entry. The reviewers will not be blinded to the names of authors, journals or institutions. If possible we will ask authors to confirm our methodological rating and the data abstraction. The data will be presented in a "Table of Included Studies."
4. Analysis
The comparisons of interest are:
A) Any form of physical activity/exercise compared to any form of control group that does not include the provision of physical acticity or exercise.
B) Comparisons of different forms of physical activity/exercise with each other.
It is likely that included studies will employ a variety of outcome measures at different time points, and subgroup analysis will be performed as appropriate. We plan to group outcomes according to:
A) Different levels of study quality
B) Severity of disease
C) Different intensity and duration of intervention (physical activity)
D) Different types of intervention (physical activity)
For dichotomous outcomes we will calculate an overall relative risk (with 95% CI). Weighted mean difference will be calculated for continuous outcomes with identical instruments (with 95% CI). Standard mean difference will be calculated if the outcome measure instruments are similar, but not identical across studies. Both random effects model and fixed effect model will be used.
Heterogeneity between included trials will be tested. If heterogeneity is found the following factors will be considered as possible explanations: differences in the type, intensity or length/period of the intervention, compliance, participant characteristics such as age, disease severity, gender. If the nature of the included studies do not allow for pooling of results (clinically or statistically) a narrative (qualitative) summary from studies will be used to present the results.
| PsycINFO |
| Database: Psycinfo Ovid |
