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Effective Strategies for Promoting Mental Health Literacy in Youth Fitness Programs

Faigenbaum, Avery D. Ed.D., FACSM, ACSM-EP; Rebullido, Tamara Rial Ph.D., CSPS; Zaichkowsky, Leonard Ph.D.

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ACSM's Health & Fitness Journal: 5/6 2022 - Volume 26 - Issue 3 - p 12-19
doi: 10.1249/FIT.0000000000000765
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The Latin phrase mens sana in corpore sano is frequently translated as a healthy mind in a healthy body. This phrase captures the synergy between our mental health and our physical health and highlights the importance of mental health literacy. The concept of mental health literacy includes not only one's beliefs about mental health but also one's knowledge of preventive strategies, ability to recognize warning signs, and awareness of effective treatment options for mental health disorders (1). From this perspective, mental health literacy can be viewed as foundational for effective functioning as a youth fitness specialist because mental health literacy is grounded in an understanding of how to obtain and maintain positive mental health (2). The World Health Organization defines mental health as “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (3).

Mental health problems affect 10% to 20% of children and adolescents worldwide, and the available data highlight associations between childhood mental disorders and poor cardiometabolic health (4,5). Furthermore, the 2019 novel coronavirus (COVID-19) has affected the everyday lives of children and adolescents in an unprecedented manner, and well-founded concerns over the lasting effects of COVID-19 on youth health and functioning are increasing (6,7). Throughout the COVID-19 pandemic, there has been an observable decline in physical activity among school-age youth, and performance losses in cardiorespiratory and muscular fitness have been reported (8,9). Concerted efforts are needed to raise awareness about the link between physical health and mental health while reinforcing positive lifestyle behaviors that support the holistic well-being of individuals and their community. Notably, an international consensus statement endorsed by the American College of Sports Medicine promotes the role of exercise interventions with trained exercise practitioners for all mental health conditions regardless of age (10).

The positive association between physical activity and mental health in youth is now well recognized, and these findings have important implications for designing and implementing youth fitness programs (11–13). However, the focus on enhancing the physical health of school-age youth seems to prevail while stigmatizing attitudes toward mental health disorders persist (2,13,14). Mental health illiteracy limits one's ability to recognize warning signs of distress and can lead to poor help-seeking behaviors for youth living with mental health problems (2). General youth physical activity guidelines that focus on the accumulation of at least 60 minutes per day of moderate to vigorous physical activity (MVPA) overlook the potential mental health rewards of modest amounts of physical activity and more personalized interventions that call attention to learning new skills, socializing with friends, practicing teamwork, and feeling proud. Viewed from this perspective, emphasizing the quantitative aspects of youth fitness programs (e.g., how much, how often, and how hard) undermines qualitative efforts to maintain adherence, to enhance mental health, and to realize the holistic benefits of youth fitness programs (13,15,16).

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At present, a vast majority of children and adolescents are insufficiently active, and half of all mental health disorders develop by age 14 years (17,18). Thus, it seems prudent to intervene early in life with nonstigmatizing interventions that are consistent with the physical abilities and mental health needs of all youth regardless of body size, training experience, or athletic prowess. By improving mental health literacy, knowledge about mental health problems may increase, perceived confidence in helping others with mental health problems may improve, and stigmatizing attitudes against ill-mental health may begin to wane (Sidebar 1). The aim of this article is to explore the link between physical inactivity and ill-mental health in children and adolescents and recommend practical strategies for promoting mental health literacy in school- and community-based youth fitness programs. For ease of discussion, the term “youth” refers to both children and adolescents.

Sidebar 1: Mental health first aid for adults assisting young people*

All types of first aid require an action plan to help someone who is injured and in need of help. Although regular first aid includes airway, breathing, and compressions (ABCs), mental health first aid includes an action plan to help someone with mental health challenges. The Youth Mental Health First Aid action plan can be remembered with the mnemonic ALGEE (19):

A: assess for risk of suicide or harm

L: listen nonjudgmentally

G: give reassurance and information

E: encourage appropriate professional help

E: encourage self-help and other support strategies

*For more information about Youth Mental Health First Aid, see www.mentalhealthfirstaid.org

Youth Physical Inactivity and Ill-Mental Health

Although the relationship between physical inactivity and ill-mental health appears bidirectional and complex, it is becoming increasingly evident that insufficient physical activity during the growing years is associated with impairments in physical function, self-perceptions, health-related quality of life, and mental health (11,20,21). Because the decline in MVPA tends to emerge early in life (about 6 years of age) (18), developmentally appropriate interventions are needed to alter the current trajectory toward physical inactivity and related comorbidities in modern-day youth. A conceptual model of interacting effects by which physical inactivity can lead to ill-mental health (and vice versa) in youth is shown in Figure 1.

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Figure 1:
Conceptual model for the interacting effects of physical inactivity and mental ill-health in youth.

Too many children and adolescents are physically inactive throughout the day and poor mental health remains common. Without regular opportunities to engage in well-designed and properly instructed fitness programs, youth are more likely to become disinterested, disengaged, and predisposed to functional limitations, activity-related injuries, and adverse health outcomes (16,18). Because a prerequisite level of muscular fitness is needed to jump, sprint, kick, and throw proficiently, less active (and weaker) youth may eventually regress along the physical literacy continuum as their physical self-perceptions (e.g., perceived competence and confidence) and task self-efficacy (e.g., confidence in ability to complete a specific action) begin to wane (15). Lower physical self-perceptions are important correlates of physical inactivity and sedentary behaviors in youth (22).

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Less active youth have been found to have lower life satisfaction and more mood disturbances as compared with more active peers (23,24), and significant associations between physical activity and self-concept (i.e., beliefs about oneself) have been consistently reported (25). Without regular opportunities to gain competence and confidence in their abilities to be physically active in different settings, youth may be less able (and therefore less willing) to participate in exercise and sport activities due to feelings of weakness, vulnerability, or embarrassment (15,16). Over time, physically inactive youth may replace nonessential MVPA with sedentary behaviors such as electronic games and social media use. Further, physically inactive youth have fewer positive social interactions with active peers, fitness professionals, and sport coaches. In support of these observations, findings from the Global School-based Health Survey found that self-perceived loneliness was associated with leisure time sedentary behavior in adolescents (26). These are missed opportunities for youth to make new friends, overcome challenges, work together, and be more psychologically resilient (16,27). Without regular exposure to developmentally appropriate fitness activities in supportive settings at school and in the community, physically inactive youth may be less able to withstand and recover from the stressors of daily life. These impairments in mental health resilience may increase the risk of unhealthy behaviors and mental health issues (27).

Physically inactive youth are more likely to have health risk factors. Although higher levels of MVPA are associated with a higher health-related quality of life, health-related risk factors (e.g., poor diet, inadequate sleep, and excessive screen time) can interact and adversely influence perceptions of functioning across physical and psychosocial domains (21,28). For example, physically inactive youth are more likely to be overweight (29), and the physical literacy (i.e., competence, confidence, and motivation to participate in physical activity) of overweight children tends to be lower than normal weight youth (30). Additionally, overweight youth tend to experience greater parent distress and peer victimization, which are associated with a lower quality of life (31). Lower health-related quality of life scores have been reported in youth who spend the most time in screen-viewing activities, whereas regular MVPA tends to be associated with higher perceived health-related quality of life (32). Of note, young athletes who did not play a sport during the COVID-19 pandemic reported lower quality of life scores and more symptoms of anxiety and depression than others who did play sport (33). An increasing body of evidence suggests significant associations between physical inactivity and both increased ill-mental health (i.e., anxiety and depression) and lower psychological well-being (i.e., satisfaction with life and happiness) in children and adolescents (11,21,34).

Physically inactive youth are less likely to experience the mere joy of moving and more likely to suffer from adverse health consequences. In light of the global crisis in youth physical inactivity, which worsened during restrictions related to COVID-19 (8,9), there appears to be a pandemic within a pandemic with broad implications for mental and physical well-being (35). Youth fitness specialists have an extraordinary opportunity to enhance the mental and physical health of children and adolescents in pandemic times by designing and implementing fitness programs that are consistent with the developmental needs, interests, and abilities of all participants.

Programming to Promote Youth Mental Health

Because mental health and physical health are intimately connected, experiences in everyday life — at home and at school — can affect both domains of health and overall well-being. The available evidence supports the applicability of exercise as a mental health–promoting strategy that can improve physical self-perceptions, boost self-concept, promote happiness, and enhance well-being in youth (11,13,21). These findings are particularly important for physically inactive youth who suffer from mental disorders, including anxiety and depression (11,20). Physically active youth look better, think better, feel better, play better, and have more energy to participate in activities of daily life with family and friends (Figure 2). Notwithstanding the value of active transportation (e.g., walking to school) and active play (e.g., playground games), structured school- and community-based fitness interventions may be needed to activate this generation of young people who tend to be weaker, slower, and less fit than previous generations (36). Notably, troubling trends in physical fitness among modern-day youth have mirrored the dramatic increase in childhood obesity and related physical and psychosocial comorbidities (37).

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Figure 2:
Potential mental health benefits of active play, exercise, and sport activities for youth.

Current treatments for mental illness, including psychotherapy and psychotropic medications, are only modestly effective in young people, and in some cases they can have severe side effects that can lead to other health concerns (38,39). For example, antipsychotic medications carry a risk of weight gain and cardiometabolic abnormalities (e.g., central obesity, insulin resistance, and dyslipidemia) (39). In addition to offering mental health benefits for healthy children and adolescents, MVPA may be a useful adjunct to traditional care to enhance the holistic health of youth with mental health disorders (11,20). Online resources about youth mental health are available in Sidebar 2.

Sidebar 2: Online resources about youth mental health
  • - American Psychological Association, Promoting awareness of children's mental health issues

https://www.apa.org/advocacy/health/children

  • - American Psychological Association, Division 47, Education about sport and exercise psychology

https://www.apadivisions.org/division-47

  • - Centers for Disease Control and Prevention, Data and statistics on children's mental health

https://www.cdc.gov/childrensmentalhealth/data.html

  • - Mental Health: Let's Talk about it, Access to mental health information

https://www.mentalhealth.gov

  • - Mental Health America, Access to mental health resources

https://www.mhanational.org

  • - National Alliance on Mental Illness, Resources for supporting individuals and family members

https://www.nami.org

  • - National Council for Behavioral Health, Information about children's mental health

https://www.thenationalcouncil.org/topics/childrens-mental-health/

  • - National Institute on Mental Health, Information about mental health for young people

https://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml

  • - World Health Organization, Information about adolescent mental health

https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health

All types of MVPA across all domains (e.g., home, school, and community) may not affect youth mental health in the same way. The wide range of outcomes from exercise and sport activities may be influenced by the intensity, volume, and type of physical activity as well as social interactions, stressful events, quality of instruction, and the experiences of success and failure (13,16,20). For example, lower-intensity interventions may be beneficial for youth with some mental health conditions (e.g., anxiety symptoms) as well as youth with a low baseline level of fitness who may be less likely to adhere to more intense exercise programs (13). Higher intensities may be needed to reduce depression symptoms in young people (13), and higher volumes of physical activity have been found to optimize mental well-being in adolescents (21). Of interest, data from a large sample of youth from 42 countries suggest that physical activity levels are positively associated with life satisfaction and negatively associated with psychosomatic complaints in a dose-dependent manner (21). In the aforementioned report, an average of 60 minutes or more of physical activity for 6 days per week appeared optimal for overall mental well-being (21). Although some physical activity is better than none, youth fitness specialists should recognize the potential value of systematically varying the exercise stimulus over time to reduce boredom, to optimize adaptations, and to minimize the risk of injury (18).

To maintain interest, promote adherence, and avoid overtraining, it seems reasonable to begin with light- to moderate-intensity activities a few days per week and gradually progress depending on preferences and abilities. Youth fitness specialists need to understand the essentials of pediatric exercise science and be skilled in teaching children and adolescents with different needs, goals, and abilities. Yet in addition to bad food and an addiction to screens, a poor understanding about how and why youth engage physical activity (including sport) has been described as a “three-headed monster” attacking our children's health (40). For example, physical education can provide an opportunity for school-age youth to learn about movement as they gain confidence and competence in their physical abilities in a supportive setting. However, survey data from adults in which they rated their retrospective experiences in physical education found that feelings of embarrassment, lack of enjoyment, and bullying were not uncommon in the context of school lessons (41). Similarly, youth sport can challenge young athletes to enhance their physical skills, learn about persistence, and create strong social bonds, yet the risks of burnout, unhealthy behaviors, and hazing are concerning (42).

Because the establishment of healthy behavior patterns early in life can improve mental well-being, an informed framework for enhancing the MVPA experience is needed to affect young minds in positive ways (15,16,20). In addition to encouraging participation in different physical activities throughout the day, programming to promote mental health should be infused into youth fitness programs. When properly planned, delivered, and progressed, youth fitness programs can be an acceptable, feasible, and nonstigmatizing intervention that provides all participants with an opportunity to make friends, have fun and feel good about their accomplishments (13,16).

In addition to considering the characteristics of the participants (e.g., health history and preferences), the design and delivery of the exercise session should spark an ongoing interest in physical activity as participants achieve physical (e.g., skill development), psychosocial (e.g., improved mood), and cognitive (e.g., better thinking) outcomes. This is where the art and science of designing youth programs come into play because an understanding of the physical needs of children and adolescents needs to be balanced with a genuine appreciation for the mental needs of youth who are active in different ways and for different reasons than older populations. Guiding principles and a pragmatic set of seven “F-strategies” for promoting mental health literacy in youth fitness programs are discussed below and summarized in the Table.

TABLE - Recommended F-Strategies for Promoting Mental Health Literacy in Youth Fitness Programs
Principle F-Strategies
Fun Support participation in a range of physical activities that are consistent with interests, abilities, and curiosities; include elements of choice, maximize feelings of competence, and provide opportunities for creative play by modifying traditional games; use motivational music at times
Flow Match the challenge of the activities with the skill level of the participants; alternate high-intensity activities with less intense games and mind body practices; progress or regress activities based on confidence, competence, and physical abilities
Friends Provide regular opportunities for youth to effectively interact with peers, develop positive social connections, and experience a sense of belonging; design group activities that encourage communicating with others
Feelings Provide praise, listen to concerns, display care, and publicly recognize efforts; facilitate opportunities for learning and discovery with supportive instructional practices; avoid elimination games and do not use exercise as punishment
Fairness Consider differences in maturation and training experience; acknowledge good sportsmanship, recognize fair play, and regularly change teams/partners; maximize opportunities for all to participate and experience personal improvement
Feedback Provide a rational for activities and offer specific suggestions to improve performance, support motivation, and reinforce desired behaviors; match feedback to the age and training level of the participants
Flourish Spend time outside in natural settings and encourage youth to interact with surroundings, listen to sounds and experience nature; play in parks, exercise outside, and practice green exercise in nature-based settings

Fun. Years ago researchers recognized that feelings of enjoyment were important motivators for continued participation in exercise and sport, and more recent findings continue to underscore the importance of making physical activities enjoyable for all youth (43). A variety of experiences that are intrinsically motivating and socially engaging are needed to encourage and sustain participation in exercise and sport activities. Of note, the most common reason for youth sport dropout is that it is not fun anymore (42).

Flow. Although there are several ways to view the concept of enjoyment, levels of enjoyment are influenced by the difficulty of the task (challenge) and the personal abilities (skills) of the individual (44). As such, enjoyment is highest when the challenge of a task matches the skill level of the individual. Csikszentmihalyi et al. (44) described this concept in which a person becomes fully immersed in an activity as a state of “flow.” This concept highlights the importance of continually matching the challenges of selected physical activities with the skill levels of the participants to reduce the risk of negative consequences, including dropout and injury. Although gains in physical abilities will require increasing the challenge of the exercise or sport program over time, regressions in physical abilities due to illness, injury, or quarantine will require modifying the challenge to match the current skill level to maintain motivation and enjoyment.

Friends. The social benefits of youth fitness programs include interacting with peers, working with fitness specialists, teamwork, and sportsmanship. Well-designed youth fitness programs can decrease feelings of loneliness as participants cooperate with peers, share thoughts with others, and develop a sense of belonging (26). The social benefits of youth fitness programs also can extend into the community as participants exercise in different locations, learn about other cultures, and build stronger relationships with parents, teachers, and health care providers.

Feelings. Although negative feelings such as anger, frustration, and fear can turn youth away from exercise and sport, positive feelings of happiness, joy, and hope can keep youth engaged. Although it is important to acknowledge negative feelings, it is just as important to let youth know that positive feelings during and after physical activity can have a favorable effect on their health and well-being. Encourage participants to talk about their needs and worries and share ideas about making the exercise experience more pleasant and welcoming. By helping youth feel as though they belong, youth fitness specialists can help to foster positive youth development (45).

Fairness. The concept of fairness does not suggest that all participants should perform the same exercises or get a prize after every session. Rather, youth fitness specialists should guide participants in the right direction with programming that is equitable but not necessarily equal. Because youth of the same chronological age may differ in body size and training experience, it is not fair for all participants to perform the same exercises at the same intensity. By creating an environment in which participants are mindful of their weaknesses, aware of their strengths, and respectful of the physical abilities of others, youth fitness specialists can foster fairness in a mastery climate in which the emphasis is on learning, cooperation, effort, and enjoyment (46).

Feedback. Providing participants with meaningful feedback in a positive and supportive manner can improve exercise technique, build confidence, affect motivation, and reinforce learning. By starting with a positive observation, participants may be more receptive to constructive feedback regarding exercise technique or attitude. Because children and adolescents learn best in different ways (e.g., auditory or visual), it may be helpful to combine different types of instruction when providing feedback. In some cases, it may be appropriate to address the entire group whereas individual feedback may be best received one on one.

Flourish. The psychosocial and physiological health outcomes of green exercise (i.e., MVPA in natural settings such as parks, forests, or lakes) in children and adolescents should not be overlooked. Outdoor exercise helps youth use their imagination, socialize with others, and interact with nature (47). Exercising outside also provides a needed break from screens such as smartphones and video games and an opportunity for some sun exposure. As the associations between nature exposure and health continue to be explored, youth fitness specialists should appreciate the link between green exercise and improved mental health.

Conclusion

Interrelated factors can influence the mental health outcomes (both positive and negative) of youth fitness programs, and as such, the complexity of this field of study is recognized. Nevertheless, given the global pandemic of youth physical inactivity and worrisome trends in ill-mental health, concerted efforts are needed to support the healthy psychological development of modern-day children and adolescents. There is a clear need for developmentally appropriate interventions that promote mental health literacy and spark an ongoing interest in exercise and sport activities.

Youth fitness specialists should receive training in basic mental health literacy and should be advocates for positive lifestyle behaviors. Focusing on the physical and mental health needs of youth, implementing enjoyable and educative exercise interventions, and imbedding effective pedagogical practices into youth fitness programs can help to maximize participation, improve physical fitness, and enhance mental health in children and adolescents. Over half a century ago Dr. Brock Chisholm, the first director-general of the World Health Organization, famously said, “Without mental health there can be no true physical health.” In light of current trends, these words should resonate with youth fitness specialists.

BRIDGING THE GAP

Empirical evidence supports the notion that regular participation in engaging, enjoyable, and educative exercise sessions can enhance mental health and well-being in youth. Youth fitness specialists should be cognizant of the physical and mental needs of children and adolescents who are active in different ways and for different reasons than older populations. This is where the art and science of designing and implementing youth fitness programs comes into play. A pragmatic set of “F-strategies” can be useful for promoting mental health literacy in youth fitness programs.

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Keywords:

Children; Exercise; Mental Health; Physical Activity; Youth Fitness

Copyright © 2022 by American College of Sports Medicine.