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Pediatric Physical Therapy:
doi: 10.1097/PEP.0b013e3181b13a82
Research Report

Parental and Environmental Factors Associated with Physical Activity Among Children Participating in an Active Video Game

Paez, Sadye PhD, MSPT; Maloney, Ann MD; Kelsey, Kristine PhD; Wiesen, Chris PhD; Rosenberg, Angela PT, DrPH

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Author Information

Program in Human Movement Science, Division of Physical Therapy in Allied Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill

Address correspondence to: Sadye Paez, PhD, MSPT, 600 Audubon Lake Drive #4B31, Durham, NC 27713. Email sadye.paez@cdl.unc.edu

Grant Support: Supported by an unrestricted grant from “Get Kids in Action,” a partnership between the Gatorade Company via The University of North Carolina at Chapel Hill, School of Public Health, under the Linking Interventions for Children (LINC) project, a series of childhood obesity prevention pilot projects. Supported in part by National Institutes of Health grants T-32-MH19011 (to A.M.) and T-32 HD 40127 (to T.C.B.).

This manuscript was completed while the first author, Sadye Paez, was a PhD student at the University of North Carolina at Chapel Hill.

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Abstract

Purpose: Parental and intervention-specific environmental supports were examined as potential reinforcers for physical activity and use of a video game, Dance Dance Revolution (DDR), among a cohort of 7- to 8-year-old children.

Methods: Sixty children were randomized to an intervention (n = 40) or a control (n = 20) group. Physical activity was measured with accelerometry and DDR logs. Parental support for their child’s physical activity was assessed via a questionnaire. DDR-specific environmental supports were captured on an environmental home screen and the DDR log.

Results: At baseline, the absence of other video games and parent DDR participation was associated with child participation in DDR. At follow-up, DDR participation of siblings and friends was associated with child participation in DDR.

Conclusion: The primary findings of this study suggest that parental and peer participation in DDR may play a role in children’s initial and sustained participation in DDR.

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INTRODUCTION

The obesity epidemic is quickly becoming a public health crisis in the United States and throughout the world. Specifically in the United States, body weights have increased by approximately 10% during the past 2 decades, nearly doubling the prevalence of clinical obesity across all regions of the country and all social strata and ethnic groups.1 During this same period, the prevalence of overweight has more than doubled for adolescents (ages 12–19 years) and more than tripled for children (ages 6–11 years).2 Further, data from the National Longitudinal Survey of Youth indicated that the prevalence of childhood overweight in the south has increased by 6.2% annually between 1986 and 1998, a significantly higher rate than has been observed in other US regions.3

Many investigators and healthcare professionals have attempted to identify primary causal agents, such as biological, psychological, and behavioral factors to explain the obesity epidemic. However, there is little consensus on individual factors as sole predictors of current and future obesity.4 A review of temporal trends during the past 20 years in the United States indicated decreased interest in physical activities1 along with an increased partiality toward sedentary lifestyles, such as the use of labor-saving devices (eg, increased availability of convenience foods and increased use of automobiles and televised entertainment).

Regular participation in physical activity has been shown to be important for overall physical and psychosocial health in children and adolescents.5 However, prepubertal children spend only an average of 30 min/day participating in physical activity; pubertal and postpubertal children spend even less time participating in physical activity, averaging 8 to 10 min/day.6 Decreased participation in physical activity has been linked to increased adiposity and body mass index (BMI).7 There is also a trend of increased participation in sedentary activities such as computers and video games by children and adolescents.8 This trend has also been associated with an increased risk of pediatric obesity.9

Dance dance revolution (DDR) is an active dance videogame that has shown possibility as a medium to increase physical activity and to supersede sedentary behaviors. DDR uses a game console that links to dance pad sensors to measure whether each individual player is dancing the correct steps in the correct sequence with proper timing. The resultant DDR feedback reports the accuracy of the dance steps, encouraging the individual to earn points by sustaining footwork precision. The machine provides auditory (“Boo!”, “Great!”) and visual feedback and monitors the individual’s scores and total time on the machine. DDR has gained broad appeal among youth and among some and has led to reports of significant weight loss (in nonpeer-reviewed testimonials at www.getupmove.com).

DANCER, a 10-week intervention studying the feasibility of DDR to increase physical activity, was 1 of the 8 pilot studies that aimed to develop and evaluate strategies to prevent childhood obesity through the promotion of physical activity and healthy diet using education, outreach, and research, ultimately linking primary care and family-based programs. Recent peer-reviewed studies demonstrated that playing DDR increased energy expenditure by 172% ± 68 compared with sedentary screen time among cohorts of children and adolescents10; more precisely, energy expenditure when playing DDR was equivalent to playing tennis.11 However, a 6-month study using DDR as a weight-management intervention for children and adolescents who are obese reported that isolated use of DDR was not sufficiently motivating to yield sustained use, even for more than 3 months,12 suggesting that youths may need external motivators to continue participation in this activity.

The core assumption of interpersonal health behavior models is that each individual’s social and physical environments have a profound impact on health-related behaviors and health status. One model widely used to describe the psychosocial dynamics affecting health behavior and health behavior change is Bandura’s social cognitive theory (SCT).13

The SCT tenets of observational learning and reinforcements support the role of parents as credible sources to influence health behavior change in their children; in particular, parental support and modeling have been shown to reinforce children’s participation in physical activity.14 Parents are household policy makers or gatekeepers, acting to foster and reinforce healthy and unhealthy familial attitudes.15 Girls reported higher levels of physical activity when at least 1 parent provides a high level of overall support.16 Other reports have consistently noted that parental involvement in physical activities predicts youth physical activity17,18 and may be imperative in reversing the trend in pediatric obesity.19 Reports from a 6-month feasibility study of DDR as a weight-loss tool among a cohort of overweight children and adolescents recommended peer or family support as an incentive to increase sustained participation in this active video game12; however, the benefit of this support has not been rigorously studied. General parental supports for their child’s physical activity included in this study were (1) parental participation in physical activities with their child, (2) parental enjoyment of participating in their own physical activity, (3) parental encouragement of their child’s physical activity, and (4) parental transportation of child.

Environmental factors also play a significant role in reinforcing children’s participation in physical activities. The SCT constructs of environment and situation provide the theoretical underpinning for the role of a DDR-specific milieu. Several studies have explored the association among physical environment, participation in physical activity, and obesity.20,21 External motivators, such as the elimination of situational barriers,20 have been linked to the eradication of the obesogenic environment. Explicit to DDR, there are limited subjective and objective data supporting the role of specific factors to increase participation. DDR-specific environmental supports included in this study were (1) size of television, (2) other video games in home, (3) location of DDR, and (4) DDR participation by others.

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Purpose

The aim of this study was to determine whether general parental and DDR-specific environmental supports were associated with participation in moderate and vigorous physical activity and DDR.

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METHODS

Study Population

DANCER was conducted in the homes of 7- to 8-year-old children (n = 60) in Chapel Hill, NC. Participants were recruited through postings in schools, libraries, malls, and e-mail solicitation on the University of North Carolina at Chapel Hill (UNC-CH) campus list serve. Potential participants were screened for the following inclusion criteria: (1) boys and girls between the ages of 7 and 8 years, (2) any ethnic or racial group, (3) any weight or BMI, (4) guardian willing to give medical release for their child’s participation, and (5) guardian willing to record DDR sessions for the child. Exclusion criteria included individuals with significant somatic or mental illness that precluded regular use of DDR (ie, photosensitive epilepsy, broken bones, exercise-induced asthma) or individuals who had played DDR, StepMania, or other forms of Bemani video games more than twice before enrollment.

One hundred sixty-six children were screened for participation in the DANCER study. Because of funding limitations of this pilot study, as well as qualification based on inclusion and exclusion criteria, only 61 children were invited to attend a baseline assessment. One child was medically excluded at baseline, thus, 60 children were eligible for participation in DANCER. Parent(s) provided written informed consent and children gave verbal assent. The UNC-CH Biomedical Institutional Review Board reviewed and approved this study.

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Study Design
Overview.

The DANCER study was a 10-week, randomized, wait-list delay–controlled group comparison of experimental (DDR intervention, n = 40) and control (no DDR, n = 20) groups. Each child in the DANCER study was first randomized to either the experimental group or the control group. A second randomization assigned children within the experimental group into either the enhanced (coaching) or basic (no coaching) DDR group. Sibling pairs were randomized as a single child to avoid confounding results. In addition, randomization occurred with one other stipulation, stratification by race, to distribute non-white children into each of the groups. Analysis of results treated all study participants as individuals. In addition, all statistical analyses controlled for the second randomization by analyzing basic and enhanced DDR groups as 1 experimental group. After a waiting period of 14 weeks, children initially assigned to the control condition were offered DDR equipment and the same initial training as the experimental group.

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DDR Module.

Families were supplied with all equipment necessary to play DDR in the home: the PlayStation 2 game console (Sony Corporation of America, New York, NY), DDR Max 2 game (Konami of America, Redwood City, CA), and 2 padded dance mats. Each child and their parent(s) were instructed to designate 1 dance pad for use only by the child participating in DANCER.

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Experimental Group.

Each child in the experimental group and his/her parents were provided with the necessary DDR equipment during an initial standardized training session lasting approximately 45–60 minutes. Each child was prescribed 120 minutes per week of DDR distributed over at least 4 days during each week of the experimental phase; however, children had unlimited access to the game throughout the intervention to participate more frequently or for more extended periods. In addition, children and their families were not given any instructions pertaining to participation in their other physical activities.

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Control Group.

During the waiting period of 14 weeks, children and caregivers randomized to the control group were asked to withhold engaging in DDR in any setting, however, they were not given any other prescriptions regarding physical activity or diet. Maloney et al22 provided further details on the DANCER study methods.

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Measures

Study measures included demographic information and physical examinations consisting of weight, bioelectric impedance body fat percentage, and calculated BMI using the Tanita Total Body Fat 310 (Tanita Corporation of America, Arlington Heights, IL) or the Omron 938 (Omron Healthcare, Kyoto, Japan).

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Accelerometer-Determined Physical Activity.

The primary outcome measures were accelerometer-determined and DDR-determined physical activity. Accelerometer-determined physical activity was measured as total counts of activity during a 7-day period detected by the Actigraph accelerometer (CSA; MTI Health Systems, Ft. Walton Beach, FL) at baseline (week 0) and week 10. The minimum acceptable wearing time was set a priori at 80% of waking hours for at least 4 weekdays plus 1 weekend day during each 7-day monitoring period. The daily DDR log was a self-report tool used to obtain a rough estimate of total minutes played each week.

Minute-by-minute activity counts were used to determine daily total minutes of physical activity and minutes of moderate-to-vigorous physical activity during each 30-minute segment of the 7-day monitoring period at weeks 1 and 10. Accelerometer readings were processed using methods similar to those reported by Puyau et al,23 which reported data as means ± SD (activity counts/day). Readings between 1160 and 5200 counts per minute were considered as moderate physical activity, a threshold that corresponds to 3.0 metabolic equivalents using a calibration equation developed by Treuth et al.24 Vigorous physical activity was defined as readings >5200 counts/min, a threshold that corresponds to 6.0 metabolic equivalents. Missing accelerometer data within a 7-day monitoring period were replaced via imputation based on the expectation maximization (EM) algorithm.25 The EM algorithm considers the problem of downward bias in estimation of physical activity because of missing accelerometer data when the time interval for when the child wore the monitor is not uniform each day of the monitoring period. The EM algorithm defines a standard measurement day as one in which at least 70% of the study cohort recorded data; this method results in less bias to provide a more precise and less biased estimation of physical activity performed during the 7-day monitoring period by using these observed data values to assist in predicting missing values.

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DDR-Determined Physical Activity.

DDR data were reported as means ± SD (min/day). A subanalysis was used to determine the cutoff point for high versus low as an average of 127.95 and 61.69 minutes, respectively, into high versus low exposure groups for DDR compliance.

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General Parental Support.

The Parent Activity Level and Child Learning Questionnaire from Trost17 was adapted for use in this study to measure caregiver perception of their child’s learning abilities, parental participation in physical activities, and general parental support of physical activity. Definitions of physical, moderate, and vigorous activity were used as defined by the National Center for Chronic Disease Prevention and Health Promotion. Parental support habits for their child’s physical activity were measured at baseline using 4 items adapted from the Parent Activity Level and Child Learning Questionnaire.

General parental support measured the weekly frequency with which parents encouraged the child to do physical activity, participated in physical activity with the child, watched the child participate in physical activity, and drove the child to a place where he/she could engage in physical activity. The general parental support questions inquired about all physical activities and were not specific to DDR. The original scale by Trost et al was adapted so that parents could respond on a 6-point (specifying amount of days ranging from 0 to 7 days) versus 5-point (endpoints ranging from none to daily) scale. The adapted questionnaire recorded responses for each question, which were then combined into a summary score and reported as mean ± SD at week 0 (baseline). A subanalysis was conducted to dichotomize subjects into high versus low general parental support groups.

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Home Environment.

The home environmental screen was used to capture the conditions under which each participant lived and played as perceived by a member of the research team. Items included physical impediments (eg, lack of space), practical barriers (eg, second floor apartment), and human interference in participation in DDR (eg, parents, friends, siblings). This screen was also used to collect information on the location of DDR, size of the television that was being used for DDR, and presence and type of other video games in the home environment. This 11-item scale was administered at week 1 during the initial DDR training session in each child’s home.

Several items from the basic home environmental screen were used to determine DDR-specific environmental support. The following environmental factors from the basic home environmental screen were collected: size of television (small, ≤13 in; medium, 14–18 in; large, ≥19 in), availability of other video games in the household (yes/no), and location of DDR (living room/family room, child’s room, den/playroom, and others). In addition, DDR participation of others (ie, parents, siblings, and peers) was captured on the DDR log and was used as an indication of DDR-specific physical activity as part of the DDR-specific environmental support factors used in analyses. DDR participation of others was reported as the number of sessions played with the child at weeks 1 and 10.

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Statistical Analysis.

Data were analyzed using SPSS v.14.1. Descriptive statistics summarized characteristics of the sample. Student t tests were computed between general parental support and participation in physical activity as measured by the CSA accelerometer at baseline (week 0) and follow-up (week 10). Chi square tests were computed between general parental support and participation in physical activity as measured by the DDR log at baseline (week 1) and follow-up (week 10). Logistic regressions were used to describe associations between DDR-specific environmental support factors (ie, size of television, availability of other video games, location of DDR, and DDR participation of others) and participation in physical activity as measured by the DDR log for the experimental group at baseline (week 1) and follow-up (week 10). Post hoc the variable for location of DDR was eliminated from analysis because there was only 1 case of child’s bedroom and all other cases corresponded to family rooms or dens, which were determined to serve essentially the same purpose. Consequently, it was surmised that the lack of variation in location of DDR would not result in meaningful findings.

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RESULTS

Descriptive Statistics

One hundred twenty-two prospective participants were screened to participate in DANCER, of which 60 participants were enrolled (Fig. 1). As reported by Maloney et al,22 the experimental and control groups were similar in age, sex, race, physical measurements, and family characteristics (Table 1). In addition, Maloney et al also discussed the findings for all the groups (enhanced, basic, and control) in terms of weight, bioelectric impedance body fat percentage, calculated BMI, and activity as measured by accelerometers.

Fig. 1
Fig. 1
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Table 1
Table 1
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In the experimental group, 100% of parents completed the Parent Activity Level and Child Learning Questionnaire (to measure general parental support for child’s physical activity) at baseline. Weekly mean of general parental support ranged from 0.75 to 4.50; the range of values were indicative of <1 day to 6 days/wk of parental support for their child’s physical activity. Individual determinants of frequency for which parents supported their child’s physical activity on a weekly basis are shown in Table 2. The weekly mean of general parental support was 2.675, a value that corresponds to 2 days/wk of supporting children’s participation in physical activity through encouragement, direct participation, observation, and transportation.

Table 2
Table 2
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The basic home environmental screen was also completed for all children in the experimental group (n = 40) at baseline to obtain data regarding DDR-specific environmental support. Most children in the experimental group (60%) had a large-sized television, between 19 and 26 in, with the remaining children at either end of the spectrum, with a 27-in or larger (20%) or a 13-in or smaller (12.5%) set. Approximately half of the children had at least 1 other video game in their home, with Playstation (20%) and Nintendo (12.5%) as the most common systems.

The DDR logs also measured DDR-specific environmental support of parent and peer participation in DDR with the child in the study. At week 1, parent and peer (ie, siblings and friends) participation in DDR with the child ranged from 0 to 5 and 0 to 6 sessions and averaged 1.40 ± 1.516 and 1.58 ± 1.662 sessions, respectively. At week 10, parent and peer participation in DDR ranged from 0 to 4 and 0 to 5 sessions and averaged 0 0.53 ± 1.012 and 1.03 ± 1.510 sessions, respectively. Throughout the 10 weeks of the intervention, DDR participation of others ranged from 0 to 61 sessions, with a mean of 21.72 ± 17.133 total sessions. More specifically, throughout the 10 weeks of the study, parent and peer participation in DDR ranged from 0 to 29 and 0 to 43 sessions and averaged 9.18 ± 8.524 and 13.38 ± 12.610 sessions, respectively.

Accelerometers were worn by 100% of participants for each 7-day monitoring period. Mean wearing times were 90% and 73% of waking hours at weeks 0 and 10, respectively. The DDR participation logs were returned at rates of 75% and 55% at weeks 1 and 10, respectively.

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General Parental Support

At baseline, mean differences between high and low general parental support were not significant to explain differences in child participation in physical activity [t(37)mpa = −0.331, p = 0.742; t(28.061)vpa = −1.279, p = 0.211]. Postintervention (week 10), mean differences between high and low general parental support were also not significant to explain differences in child’s participation in physical activity [t(18)mpa = −1.000, p = 0.324; t(36)vpa = −0.758, p = 0.453].

Testing for the effect of general parental support on DDR participation revealed that, at baseline (week 1), DDR participation and general parental support were not statistically significant [χ2 (1, n = 40) = 3.558, p = 0.059]. Postintervention (week 10), mean differences between high and low general parental supports were also insignificant for differences in DDR participation [χ2 (1, n = 40) = 0.382, p = 0.536].

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DDR-Specific Environmental Support

Logistic regressions were conducted to determine how well DDR-specific environmental factors (size of television, availability of other video games in the household, location of DDR, and DDR participation by peers and parents) predicted child participation in DDR. Coefficients for each predictor at baseline and follow-up are presented in Tables 3 and 4. Further analyses were conducted post hoc to differentiate DDR participation of others into parental and peer (ie, siblings and friends) groups at baseline and follow-up; results for these logistic regressions are given in Tables 5 and 6.

Table 3
Table 3
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Table 4
Table 4
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Table 5
Table 5
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Table 6
Table 6
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Qualitative Findings

Ninety-five percent of parents reported that they liked DDR as a form of physical activity for their child. In addition, 91% of parents stated that they liked DDR as a form of physical activity for themselves. Most parents noted that having DDR in their home was not (49%) or was minimally (40%) disruptive. Further, 85% of parents were “very” likely to recommend DDR to other children and their parents.

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DISCUSSION

The purpose of this study was to examine the association between general parental support and DDR-specific environmental support with participation in moderate and vigorous physical activity and DDR for 7- to 8-year-old children participating in the DANCER study.

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General Parental Support

The results indicated that general parental support for child physical activity was reported as being encouraged 5–6 days per week as opposed to direct participation, transportation, or observation of their child’s physical activity, which was reported to only take place approximately 2 days per week for each support factor. General parental support, particularly parental encouragement of physical activities, has been shown to be an important correlate of youth physical activity.17 In this study, however, general parental support was not associated with child participation in moderate and vigorous physical activity or DDR at baseline or follow-up in this study. Similar results of low parental participation in physical activities with their children26 were also reported in this study, despite high levels of parental encouragement of physical activity.

Several reasons may explain this lack of association between parental support for child physical activity and actual participation in physical activity by that child. First, parents reported a mean weekly frequency of general support for physical activity consisting of 2 days per week. This reported mean weekly frequency might not have occurred enough to include the addition of a new and specific activity, namely, DDR. Future studies may want to examine the dose for supporting physical activity and association with actual participation in physical activity. Second, parents were reporting their supportive behavior for general physical activity on this questionnaire at baseline (before DDR participation); however, these general behaviors were analyzed for an association with a specific activity, DDR. Given the generality of the questionnaire for physical activity (encouragement, direct participation, observation, and transportation) and the specificity of DDR, the questionnaire may not have been sensitive or specific enough to reflect associations between parental and child behaviors.

However, this study found a trend noted at week 1 for general parental support with child DDR participation (p = 0.059) that may be related to the construct of reinforcement from the SCT. According to the SCT, parental support influences and bolsters children’s participation in healthy activities, such as participation in physical activities. Other studies have reported that parental support influences youth participation in physical activity.16,27 This finding potentially lends support to the vital role of parents influencing child participation in physical activity through encouragement alone. This finding may be particularly useful to physical therapists as a way to motivate parents to participate in their child’s rehabilitation both within and outside the clinic as the child is learning new skills by encouraging their child’s participation and involvement in movement-based activities.

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DDR-Specific Environmental Support

Among the selected DDR-specific environmental supports, the absence of other video games and DDR participation of others (ie, parents, siblings, and peers) was significant for child participation in the DDR. Approximately 50% of the children in this study had other video games in their home before acquiring the Playstation 2, approximately equal to that of national rates.28 At baseline, the absence of other video games was significant (p = 0.037) for explaining differences in youth participation in the DDR with an odds ratio of 3.97%. This finding suggests that, at baseline, children who did not have other video games in their home were more likely to participate in DDR than children who did have other video games in the home. This suggests that the novelty of a video game may encourage children to participate in DDR. In addition, traditional sedentary video games in the home may also act as a competitive interest for children choosing an alternatively active video game, particularly at the onset of learning this new skill. Particular to video gaming, children who have a choice between passive versus active video games in their home may continue to select the passive video game because the choice to be passive may be more attractive than shifting to an active alternative.

However, at week 10, the absence of other video games was not a significant predictor for youth participation in the DDR. Children who had and children who did not have other video games were as equally likely or not likely to choose to participate in the DDR. The novelty of having a video game in the home may have initially motivated children to play DDR; however, the newness of a video game, particularly among children who previously did not have a console in their home, may not have been sufficient to motivate sustained participation in the DDR among this cohort. This finding parallels the report of Madsen et al16 that DDR alone was not adequate for sustained play among obese youths.

These findings hold significant implications for physical therapy and motor learning; as children are learning new skills to play DDR, it would be beneficial to remove potential barriers of sedentary activities (passive video games, computers, and television). This study may also lend support for parents to encourage continued DDR participation by introducing new DDR games to signing their child up for DDR contests.

DDR participation of others also influenced children’s initial and long-term (10 weeks) participation in DDR. At baseline, parents and peers engaged in DDR with the child for approximately 1–2 sessions. Peers participated more frequently in DDR with the child; however, it was parental participation in DDR that was directly associated with child’s participation in DDR (p = 0.010, odds ratio = 3.745). At week 10, both parents and peers participated in DDR less frequently (approximately 0.5–1 day); however, peers continued to participate in DDR with the child at a greater extent than parents. Alternatively, at week 10, peer participation in DDR was directly associated with the DANCER child’s participation in DDR (p = 0.015, odds ratio = 8.403) versus parent participation.

The involvement of significant others in physical activities has been shown to be related to more physical activity involvement among children29 and adolescents,30 and the findings of this study have implications for future studies and interventions for youth participation in physical activities, either using DDR or another medium. The current findings indicate that, at baseline, parents have an important role at the onset of a child learning a novel video game. This finding supports the role of parents to encourage use of DDR and potentially helps to bolster a child’s confidence at this early stage by creating a supportive learning environment.

Participation of peers has a significant role in sustaining a child’s participation in DDR and perhaps other physical activities. The findings from this study indicated that peers played DDR with the child at a much higher frequency per week than parents, suggesting that social interactions with friends and siblings could be more important for creating and sustaining interest in physical activities. Although children seem to need additional support from their parents initially, their level of self-sufficiency at DDR may increase quickly, and the focus may shift from learning to interacting on a social and/or competitive level with peers.

Subjective reports also supported the significance of peer DDR support to increase children’s participation in DDR. Social interaction was cited as a contributing factor of child participation in DDR, ie, “playing with brother contributed significantly (to child’s success”). Parents also reported greater child attentiveness when playing with peers (“when he played with friends, he was more focused”). However, some parents (31%) felt that playing DDR with a peer did not help their child to be successful at DDR. Some parents reported that practicing DDR (ie, the repetition made the game a success) and playing new songs (the game had different levels of achievement that motivated child to keep going and/or do better) contributed to child success in DDR. Family competition (“he liked more competition between him and mother and father than friends” and “he loved beating our [parents’]) scores!”) also helped children succeed in DDR. Several qualitative themes also suggested that most parents liked DDR as a form of physical activity for their child and were likely to recommend DDR to other families; the small percentage of families that noted that they would not recommend DDR to other families reported disruptions due to reasons other than DDR itself (Table 7). These reports suggest that the role of the family and peers may be important to a child’s participation in DDR. These subjective and objective findings should be taken into consideration for future study designs promoting participation in physical activity by youths.

Table 7
Table 7
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Subjective and objective findings from this study also support physical therapists’ emphasizing the role of parents at the onset of a child learning a new skill and the role of peers for mastery of a skill. The therapist may also want to consider integrating children at similar stages into a playgroup to encourage peer interaction for learning motor skills as a supplement to one-on-one physical therapy. For a specific activity such as DDR, it is important to create a supportive learning environment; it is likely that this translates to other motor skills.

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Limitations

There are several limitations in this study that may have confounded statistical findings. Most of the sample, although randomly drawn, was primarily from the area surrounding Chapel Hill, NC. The educational and economic status of most participating households was higher than societal norms (>90% parents were college graduates, and >70% household incomes were greater than $60,000 per year). Further, as previously reported by Maloney et al,22 baseline sedentary screen time was less than half the national average. Children also had a lower baseline BMI than reported in Chapel Hill, NC, overall (cohort mean BMI, 17.6). These sample characteristics indicate that the DANCER cohort is not representative at a national level or of the state as a whole. However, this cohort did include several households with lower socioeconomic status and educational level. In addition, several ethnicities were also in this cohort, including Asian, African American, Hispanic/Latino, Middle Eastern, Kazakh/Russian, and Ukrainian. There were also some temporal limitations noted during the DANCER study that may have affected participation in DDR. Families reported conflicting interests for other physical and recreational activities, holidays, and school, and, thus, seasonal effect may have confounded results.

In addition, in this study, we attempted to improve the initial scale by Trost et al17 for measuring general parental support. The adapted version, the Parent Activity Level and Child Learning Questionnaire, reported weekly frequencies of parental support habits on a 6-point versus 5-point scale with responses combined into a summary score. A limitation of both of these scales is that the construct of support was not operationally defined, so that parents were at liberty to interpret the quality and frequency of their actions that might be considered supportive. Parental perceptions of support likely differed substantially, and future studies should include operational definitions of verbal and written encouragement, physical participation, observation, and/or actions related to support of child participation in physical activities. In addition, this questionnaire did not specify a timeframe for when support was provided. Parents may have responded based on the support they gave in the past or their perception of routine support instead of actual support provided. If parents had been asked to consider their level of support specific to the past week or another specified time frame, it is possible that reliability and validity of the questionnaire would increase.

It is important to note that participation in DDR does not automatically translate into success in DDR. Qualitative reports indicated that success in DDR did occur; however, the construct was not directly measured. In this pilot study, the sample size was small, and consequently only large effects from a statistical standpoint are visible between groups. This limitation is further augmented when considering completion rates for the DDR logs of 75% and 55% at weeks 1 and 10, respectively. Further, the initial setup of DDR may be cost prohibitive for some families. As an alternative and less costly option, families may consider using StepMania, a free online dance video game system that only requires purchase of the dance pads.

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CONCLUSIONS

The primary finding of this study was that the absence of other video games and DDR-specific participation of others (parents at baseline and peers at week 10) was associated with child participation in DDR. The role of significant others in a child’s life, particularly for learning a new activity, is of specific interest for physical therapists. Children receiving physical therapy are continually learning new motor skills. Physical therapists may be able to facilitate a child learning these new skills by involving parents and peers in direct participation in the specific activity. However, this study was only 10 weeks in duration and retention of this new skill was not measured. In addition, the length of time may not have been adequate to determine short- and long-term effects of the other DDR-specific environmental supports (eg, presence of other videogames, size of television, location of DDR) that may have a vital role in sustaining participation in this activity past the duration of this study. Further investigation is needed to understand the role of general parental and DDR-specific factors that may act to influence initial and sustained participation in physical activity and DDR.

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ACKNOWLEDGMENTS

The authors acknowledge the efforts of DDR coaches: Jamie Regulski, Hillary Smith, Michael Bade, Justin Wilhelm, Jessie Campbell, and Silke Ullmann; research assistants: Jonathan Bloom, Jonas Horowitz, Cathy Jones, Amy Levine, Cheree Porter, Marta Rojas, Emily Williams, and Traci Yates. The authors are grateful to Abby Sheer and Peter Robichaux for database development. Physical examinations were provided by Drs. Adams, Ambler, and Meikranz and Maloney. The UNC-CH Center for the Study of Development and Learning generously offered their facility for data collection and their technical assistance to ensure a pleasant experience for all participants in terms of environmental logistics. The authors also recognize the invaluable support from the program in Human Movement Science at UNC-CH. The authors also thank Drs. Bulik and Brownley for review of the grant proposal, Drs. Ward and Stevens for review of the methodology and manuscript, the Subject Core lead by Julie Marks, PhD, and Larry Johnston for capably transforming data from ActiGraph.

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Keywords:

child; dancing; exercise; parent–child relations; physical activity; sibling relations; social support; video game

© 2009 Lippincott Williams & Wilkins, Inc.

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