importance of research in physical education and sports

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Physical education and sport in schools: a review of benefits and outcomes

Affiliation.

• 1 School of Education, Froebel College, Roehampton University, Roehampton Lane, London SW15 5PU, UK. [email protected]
• PMID: 16978162
• DOI: 10.1111/j.1746-1561.2006.00132.x

This paper explores the scientific evidence that has been gathered on the contributions and benefits of physical education and sport (PES) in schools for both children and for educational systems. Research evidence is presented in terms of children's development in a number of domains: physical, lifestyle, affective, social, and cognitive. The review suggests that PES have the potential to make significant and distinctive contributions to development in each of these domains. It is suggested that PES have the potential to make distinctive contributions to the development of children's fundamental movement skills and physical competences, which are necessary precursors of participation in later lifestyle and sporting physical activities. They also, when appropriately presented, can support the development of social skills and social behaviors, self-esteem and proschool attitudes, and, in certain circumstances, academic and cognitive development. The review also stresses that many of these benefits will not necessarily result from participation, per se; the effects are likely to be mediated by the nature of the interactions between students and their teachers, parents, and coaches who work with them. Contexts that emphasize positive experiences, characterized by enjoyment, diversity, and the engagement of all, and that are managed by committed and trained teachers and coaches, and supportive and informed parents, significantly influence the character of these physical activities and increase the likelihood of realizing the potential benefits of participation.

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New Research Examines Physical Education in America

By Morgan Clennin, PhD, MPH, Kaiser Permanente of Colorado, University of South Carolina, and National Physical Activity Plan

School-based physical education (PE) is recommended by the Community Guide as an effective strategy to promote physical activity among youth. Unfortunately, many have speculated that PE exposure has declined precipitously among U.S. students in the past decade. Limited resources and budgets, prioritization of core academic subjects, and several other barriers have been cited as potential drivers of these claims. However, few large-scale studies have explored the merit of these claims – leaving the answers following questions unknown:

Has PE attendance decreased among U.S. students in the past decades?

What policies and practices are in place to support quality PE?

To answer these questions, the President’s Council on Sports, Fitness & Nutrition tasked the National Physical Activity Plan Alliance (NPAPA) to review the available evidence and summarize their findings. The primary objective of this effort was to better understand PE exposure over time to inform national recommendations and strategies for PE.

The NPAPA began by establishing a collaborative partnership with experts in the federal government, industry, and academia. The group analyzed existing national data sources that could be used to examine changes in PE attendance and current implementation of PE policies and practices. These efforts culminated in a final report and two peer-reviewed manuscripts. A summary of the group’s findings are outlined below.

Key Findings:

• 1/2 of U.S. high school students did not attend PE classes—which is consistent over the 24-year period studied (1991-2015).
• The percentage of U.S. high school students reporting PE attendance did not change significantly between 1991 and 2015 for the overall sample or across sex and race/ethnicity subgroup.
• Daily PE attendance did decrease 16% from 1991 to 1995 then attendance rates remained stable through 2015.
• > 65% of schools implemented 2-4 of the 7 essential PE policies
• Implementation of PE policies varied by region, metropolitan status, and school level.
• Data indicates minority students have been disproportionately affected by cuts to school PE programs during the past two decades.

Recommendations Based on Key Findings:

• Prioritize efforts to expand collection of surveillance data examining trends in PE attendance among elementary and middle school students.
• Develop policies to improve PE access for all students in order for PE to contribute to increased physical activity among youth.
• Adopt policies and programs that prioritize PE to maximize the benefits of PE.
• Utilize the findings of these efforts to target professional development and technical assistance for PE practitioners.

The Education sector of the NPAP provides evidence-based strategies and tactics that can guide efforts to support the provision of quality PE to all students. More information, and links to the respective manuscripts, can be found on the NPAPA website: http://physicalactivityplan.org/projects/physicaleducation.html

Physical education, school physical activity, school sports and academic performance

• François Trudeau 1 &
• Roy J Shephard 2  

International Journal of Behavioral Nutrition and Physical Activity volume  5 , Article number:  10 ( 2008 ) Cite this article

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The purpose of this paper is to review relationships of academic performance and some of its determinants to participation in school-based physical activities, including physical education (PE), free school physical activity (PA) and school sports.

Linkages between academic achievement and involvement in PE, school PA and sport programmes have been examined, based on a systematic review of currently available literature, including a comprehensive search of MEDLINE (1966 to 2007), PSYCHINFO (1974 to 2007), SCHOLAR.GOOGLE.COM, and ERIC databases.

Quasi-experimental data indicate that allocating up to an additional hour per day of curricular time to PA programmes does not affect the academic performance of primary school students negatively, even though the time allocated to other subjects usually shows a corresponding reduction. An additional curricular emphasis on PE may result in small absolute gains in grade point average (GPA), and such findings strongly suggest a relative increase in performance per unit of academic teaching time. Further, the overwhelmingly majority of such programmes have demonstrated an improvement in some measures of physical fitness (PF). Cross-sectional observations show a positive association between academic performance and PA, but PF does not seem to show such an association. PA has positive influences on concentration, memory and classroom behaviour. Data from quasi-experimental studies find support in mechanistic experiments on cognitive function, pointing to a positive relationship between PA and intellectual performance.

Given competent providers, PA can be added to the school curriculum by taking time from other subjects without risk of hindering student academic achievement. On the other hand, adding time to "academic" or "curricular" subjects by taking time from physical education programmes does not enhance grades in these subjects and may be detrimental to health.

The purpose of this paper is to review relationships between physical education (PE), school physical activity (PA), school sports and academic performance. These relationships have been the subject of extensive discussion between advocates and skeptics of PE, school PA and school sports programmes. Both elements of this discussion (academic achievement and physical activity) are independent determinants of a child's health. Our intent in this article is to assess the effects on academic achievement of school PA programmes (including PE and school sports), in both elementary and high schools. Previous reviews have examined relationships between PA and academic achievement. [ 1 – 4 ] Recent research results, echoed in the media, suggest that such activity may have a positive impact on learning and memory. It is now fairly well-recognized that PA is associated with the maintenance of cognitive function in older adults [ 5 ] and offers some protection against Alzheimer's disease. [ 6 ] Cognitive dysfunctions in older adults is becoming an urgent public health problem, given the ever-rising average life expectancy and the associated growth in the proportion of old and very old individuals in most societies. A positive association between PA and cognitive health is also suspected in younger subjects, but is not as well documented in this age group. Nevertheless, any positive influence of PA on the cognitive functions of children is important for at least 2 reasons: 1) It is a potential argument for increasing PE and/or other types of school PA without risk of decreasing academic progress, and 2) It may offer a way to reduce disruptive behaviour at school and the drop-out from educational programmes. Furthermore, an important by-product of an increased participation to school PA would be an enhanced level of physical fitness.

Search methods

The databases searched included MEDLINE (1966 to 2007), PSYCHINFO (1974 to 2007), SCHOLAR.GOOGLE.COM, and ERIC, as well as the extensive personal databases of the authors. The reference lists of the articles thus identified were also consulted to identify additional potentially-relevant research. Publications in languages other than English were considered where appropriate. For the purpose of this review, we use the term academic achievement to encompass academic success, school performance and all combinations of these terms.

The outcomes of school PA/PE and academic achievement, success or performance were actual or self-reported grade point average (GPA) and determinants of GPA that could potentially be changed by the interventions (concentration, learning, classroom behaviour, engagement in learning, self-esteem, etc.). The terms physical education, physical activity and sports are, for the purposes of this review, restricted to programmes offered within the school context (i.e. instructional physical education and extracurricular physical activity, including in-school physical activity programmes, intraschool and intramural sport).

Quasi-experimental and longitudinal studies

It is not surprising that no randomized controlled trials were identified, as they are not practicable in this type of research setting. Quasi-experimental protocols are usually indicated when causality cannot be tested by a random controlled trial in milieux such as the school setting. Seven quasi-experimental studies were identified (Table 1 ). Cross-sectional studies were also considered, as well as experimental or laboratory experiments on the determinants of academic performance (i.e. learning concentration, classroom behaviour, etc.).

The first documented quasi-experimental study relevant for to this paper was the Vanves (France) investigation; this involved a small group of schoolchildren tested during the 1950's. [ 7 ] Schoolchildren who spent mornings in the classroom and afternoons doing PE were said to perform better academically than children from a control class, but no further details were given. [ 7 ] Unfortunately, the specifics of these observations were not described in peer reviewed journals.

A second quasi-experimental study conducted in the Trois-Rivières region (Québec) between 1970 and 1977 involved 546 primary school students; this noted that students involved in an experimental 5 hours of physical education per week had a higher academic performance than their control counterparts who were enrolled in the normal school program for 40 min per week [ 8 ]. The supplemental 260 minutes allocated to PE was necessarily taken from time for other academic teaching (i.e. an average 14% curtailment of academic instruction). Despite this curricular change, during the last 5 years of primary school, the overall academic performance of the experimental students improved relative to the controls. During standardized Provincial examinations, children receiving the 5 hours/week of PE had higher scores in mathematics, but lower scores in English (their second language), despite the fact that 33 minutes were removed from mathematics instruction and none from English. [ 3 ]

A 2-year quasi-experimental study followed 759 Californian children in the 5th and 6th grades. [ 9 ] Subgroups of children were taught PE by either a professional physical educator (n = 178), a trained homeroom teacher (n = 312), or in the normal programme (n = 165). The professional physical educators, the trained teachers, and normal programmes offered, respectively, 80, 65, and 38 minutes per week of PE. As expected, those taught by the professional physical educators achieved greater fitness (cardiovascular and muscle endurance). [ 10 ] Also, the groups taught by the professional physical educators and trained teachers had smaller declines in academic performance despite allocating more time to PE. Four of 8 statistical comparisons disclosed an advantage for students in the experimental groups; one comparison was advantageous to control students, while the remaining 3 were equal. The group who spent the most time on PE (i.e. those with a professional physical educator) showed no negative effects on academic achievement and indeed the decline of academic results during the 2 years of the intervention was smaller than that observed in the control subjects. [ 9 ]

In South Australia, the 500-student SHAPE trial added 1.25 hours per day of endurance fitness training to the curriculum of 10-year-old primary school students. [ 11 ] Over the first 14 weeks of the study, the experimenatl group showed gains in physical work capacity and decreases in body fat relative to controls. Arithmetic and reading scores were not adversely affected by the substantial reallocation of curricular time in favour of PE. These physical benefits appeared to be maintained over the succeeding 2 years in a follow-up of 216 participants. These follow-up evaluations showed (non-significant) trends for better arithmetic and reading grades in experimental students, as well as beneficial changes in teachers' ratings of classroom behaviour. [ 12 ]

The 16-month Action School BC! project involved a population of 287 British Columbian primary school children (4th and 5th years: 9–11-years olds). PA was delivered by classroom teachers, amounting to 47 minutes more per week in interventional than in control schools (139 ± 62 vs. 92 ± 45 minutes, P < 0.001). [ 13 ] Despite a corresponding decrease in academic time, the academic performance of the experimental group, as measured by the Canadian Achievement Test, remained unchanged; indeed, data analysis revealed a trend towards an enhanced academic performance in the intervention schools (the average score rising from 1,595 to 1,672 units).

Another interventional study of 6 th grade (11 year-old) students covered a single school term. Fifty-five minutes/day of PE were included in the curriculum, vs. the same allocation of time for arts or computer sciences; the two groups performed equally well in mathematics, sciences and English. [ 14 ] Finally, an intervention in Israel involved 92 preschool and 266 first grade children. [ 15 ] The experimental manipulation here was a school-based movement education programme, and children in the experimental group showed greater reading skills and arithmetic scores than controls. [ 15 ]

Taken together, these quasi-experimental data suggest that the enriched PE programmes demanded a substantial reduction in the time allocated for academic tuition. Since the children achieved at least equally despite the reduced teaching time, the evidence seems strong that the efficiency of learning was enhanced. [ 3 ] Despite the variety of programme durations and locations, a common and valuable by-product was a significant increase in various measures of physical fitness (PF).

Cross-sectional studies

Cross-sectional studies commonly have difficulty in controlling for potential biases, particularly socio-economic status (SES). SES remains the strongest predictor of academic achievement [ 16 ] and is also one of the strongest predictors of PA participation in children (e.g. in Canada [ 17 ]; Italy [ 18 ] and Estonia [ 19 ]). Cross-sectional studies generally indicate a positive association with academic achievement. Some of these studies did control for confounders such as SES, and still most of them found a positive association between physical activity and academic achievement (Table 2 ).

Positive results on GPA

Nelson and Gordon-Larsen [ 20 ] analyzed results from the US National Longitudinal Study of Adolescent Health; they observed that adolescents who were active in school were more likely to have high grades. Even after adjustment for demographics and SES, the risk ratio of higher grades was 1.20 for mathematics and 1.21 for English among adolescents who were active at school. Within middle to upper middle SES categories, a cross-sectional study of suburban high school seniors (52 girls and 37 boys) found that the more active group had higher GPA. [ 21 ]

4,690 Hong Kong children from primary 5 to secondary 7 (i.e. grades 5 to 12) completed a pre-validated questionnaire relating their sports and exercise participation to perceived academic performance. [ 22 ] Low correlations were seen for the whole sample (r = 0.10, P < 0.01; r = 0.17, P < 0.01 for females; r = 0.06, NS for males). GPA was not a significant correlated with PA participation when all school bands were confounded; however, the high band showed a positive link between GPA and PA participation, whereas students in the low band showed a negative relationship between PA participation and GPA. [ 23 ] These reports suggest that the relationship between PA and academic performance is influenced by the type of students and/or the school that they attend. Deliberate stratification of students by learning ability is by no means universal, but we cannot exclude the possibility that spontaneous, unplanned banding may also influence the strength of observed relationships.

Dwyer et al. [ 24 ] made a cross-sectional survey of 9000 Australian schoolchildren between the ages of 7 and 15 years (500 in each age/sex stratum drawn from 109 schools, i.e. 10 girls and 10 boys per school). Depending on the group, a linear regression analysis with good control of confounding variables demonstrated a significant association between academic achievement and PA (a combination of lunchtime PA and minutes of PA the preceding week). In all subjects aged 9–12 years, school performance was positively associated with ratings of PA during the preceding week. In girls 10–15 years old and boys 8–15 years old, academic achievement was also positively associated with the estimates of lunchtime PA. The correlation coefficients between PA and academic achievement, although low (r = 0.08 to 0.19) were statistically significant, suggesting that PA was contributing to academic achievement in both boys and girls. Data from the Youth Risk Behavior Survey likewise showed that a perception of little or no involvement in PA was associated with a perception of low academic performance. [ 25 ] Another cross-sectional study from England also controlled for SES; this again reported a positive association between school sports participation and academic achievement. [ 26 ]

Researchers from Iceland designed a study included other health behaviours. [ 27 ] They found small but significantly positive univariate associations of PA with self-reported school performance (r = -0.11 with absenteeism and r = 0.09 with grades). When confounders were considered, these associations were further weakened, but nevertheless remained statistically significant predictors if selected health behaviours and psychological variables were included in the prediction model. [ 27 ]

Negative or null outcomes on GPA

In 6,923 grade 6 New Brunswick children (age 11 years), PA showed a weak inverse association with academic achievement, but a positive association with self-esteem. [ 28 ] A study on 232 English boys and girls (13–16 years old) found no relationship between self-reported PA and GPA. Moreover, in children aged 13, 14, or 16 years, the durartion of PA was negatively correlated with marks for English (r = -0.29 to -0.30). [ 29 ] To our knowledge, these are the only 2 studies to observe negative associations between PA (but not PE) and academic achievement.

A survey of 117 Australian primary schools found no deterioration of literacy and numeracy results in primary school grades 3, 5 and 7 when more time was allocated to PE. [ 30 ] SES was the strongest predictor of both literacy and numeracy scores. A recent analysis of Hong Kong pre-adolescent boys reported that a high level of PA at school was associated with high self-esteem, but not with academic achievement. [ 31 ]

Even studies that failed to find a positive relationship between PA/PE and GPA have generally found no decrease in academic achievement as a consequence of increased participation in PA (Table 2 ). Clearly, the absence of an elevation in GPA should not be interpreted as a negative outcome. This is well illustrated by a survey conducted in Virginia's primary schools. [ 32 ] A reduction in the time allocated for PE (or the arts) did not improve performance in other subjects like mathematics or reading. Moreover, increasing the time allocated to PE (or the arts) at the expense of other academic subjects was not detrimental to test scores in these subjects. [ 32 ] Taken together, these observations suggest that if academic achievements are maintained while spending less time on a specific discipline, the intervention has increased academic efficacy.

Effects of PA on elements considered to favour academic performance

Many factors like classroom behaviour, self-esteem, self-image, school satisfaction and school connectedness have been postulated as determinants of academic achievement.

Classroom behaviour

Self-identification as a school athlete vs. a «jock» is associated with a lower rate of reported misconduct at school [ 33 ], with the exception of binge drinking. [ 34 ] In the American linguistic context, the word "jock" refers to an individual whose life is oriented toward sport; it is not necessarily a pejorative term. However, it should not be confused with the focused and planned life of a typical athlete.

In the Trois-Rivières study, competencies linked to behaviour were similar overall in the experimental vs. the control group. [ 35 ] A German cross-sectional study (CHILT) compared 12 intervention schools (n = 668) vs. 5 control schools (n = 218), finding that PF was associated with concentration in 6–7 years old children. [ 36 ]

Evans et al. [ 37 ] reported a lower rate of inappropriate talking among emotionally, or behaviourally-disturbed children who were participating in a jogging and football exercise programme. Furthermore, a meta-analysis on the effect of exercise prior to classes led to the conclusion that most exercise interventions significantly reduced disruptive behaviours in disturbed students. [ 38 ] These effects could reflect in part better teacher attitudes towards these children, as seen in the Trois-Rivières [ 3 ] and the Australian [ 1 ] quasi-experimental studies.

Other psychosocial effects

Better self-esteem or self-image [ 20 , 39 ] and body image [ 40 ] are commonly associated with high levels of PA. Many studies have also linked school sport or PA programmes with other psychosocial outcomes, such as school satisfaction and school connectedness, regardless of ethnic group [ 41 ]. Both school connectedness and school satisfaction are factors preventing drop-out from school. [ 42 ]

A recent analysis of data from the National Longitudinal Study of Adolescent Health [ 20 ] found evidence of a positive association between PA and components of mental health, including self-esteem, emotional well-being, spirituality, and future expectations. When participation in PA/sports also included parental involvement, the behavioural risk profile became even more positive.

A cross-sectional questionnaire study of 245 Finnish adolescents [ 43 ] observed no association between PA level and school satisfaction and the trend to a weak correlation between PA level and problems at school was not statistically significant. However, PA was correlated with global school satisfaction (r = -0.21 for boys) and absence of a depressive mood state (-0.20 and -0.26 for girls and boys, respectively).

What are the acute effects of PA on cognitive function?

Many authors have documented the acute effects of PA on cognitive function. Three recent reviews and/or meta-analyses examined these studies. [ 44 – 46 ] In a meta-analysis of 44 studies, Sibley and Etnier [ 45 ] concluded that PA was positively associated with better cognitive functioning in children. Some groups, particularly middle school students (grades 6–8, aged 11–13 years) and younger, seemed to benefit more from PA. Sibley and Etnier [ 45 ] noted that unpublished studies had a higher effect size than published reports, suggesting that no bias had occurred from a failure to publish non-significant results.

Brisswalter et al. [ 44 ] reviewed published studies into the effects of exercise on various tasks. They concluded that the optimal intensity for decisional tasks covered a wide range (~40–80% VO 2 max). An exercise duration of more than 20 minutes was most efficient in increasing the performance of perceptual and decisional tasks. [ 44 , 46 ] Tomporowki [ 47 ] suggested an upper limit of 60 minutes might arise from the adverse effects of dehydration on cognitive functions.

The literature generally suggests a positive effect of acute physical exercise on cognition. Other activities, like involvement in music also have the potential to increase reading skills, although in this case there is no positive influence on PF. [ 48 ]

Relationship of PF with academic achievement

What is the effect of a high level of PF on academic performance? Is good cognitive functioning associated with above average PF? If so, is this a consequence of PF per se, or of better overall physical health? When analyzed globally, the literature does not indicate any clear linkage between PF and either academic achievement or intellectual performance. As early as 1969, Railo found no relationship between PF and either of these outcomes. [ 49 ] More recently, Etnier et al. [ 50 ] concluded from a meta-regression analysis that the empirical literature did not support a link between cardiovascular PF and academic achievement. However, this meta-analysis revealed a weakness in the literature: there was little data on the relationship between PF and academic achievement in school-aged children. Indeed, only 1 of the 37 studies identified included this age group.

When the definition of PF includes aspects other than cardiovascular fitness, there seems evidence of positive correlations between various measures of psychomotor performance, cognitive abilities and academic achievement. [ 51 , 52 ] Psychomotor performance shares many common neurological mechanisms with cognitive functions.

A 2001 cross-sectional study on California children disclosed a positive relationship between reading and mathematics results (as measured by Stanford Achievement Test-9) and results on a field test of physical fitness (the Fitnessgram). Despite a huge sample of students from grades 5, 7 and 9 (n = 954,000), potential selection biases were not considered, making it difficult to conclude that PA was linked to increased academic performance. [ 53 ] When found, any effects of PF were small. Another weak association between PF and academic achievement was observed in South Korean children (grades 5, 8, and 11); in this study, the association was much smaller than that between academic achievement and regular meal eating. [ 54 ] Dwyer et al. [ 24 ] measured muscle fitness in 9,000 Australian students. They found significant but weak associations, ranging from r = -0.10 to -0.19 for running distances of 50 m and 1.6 km, and from r = 0.10 to 0.22 for sit-ups and standing long jump, respectively.

School sports and academic achievement

The connection between school sports and intellectual achievement has been a long-standing issue since Davis and Cooper [ 55 ] first reported a positive association between school sports participation and academic achievement. It remains the subject of recent investigations. The competitive dimension of most sports introduces particular problems, even in the school context, as the educational dimension tends to be relegated to a secondary level. The literature comprises mainly cross-sectional data and the results are more equivocal than for PA; unfortunately, most of the earlier studies did not control for biases common to athletic and academic achievements. [ 56 , 57 ]

Data from the longitudinal Maryland Adolescent Development in Context Study included 67% African-Americans and 33% European-Americans; it found that participation in extracurricular PA was a significant predictor of better academic results and of higher academic expectations. [ 58 ] Furthermore, sports participation by 8th grade African-American males resulted in aspirations to continue their studies toward college, with less likelihood of acting inappropriately in school. [ 59 ] In their female counterparts, sports participation also resulted in higher aspirations and in a reduction of absenteeism.

Cooper et al. [ 60 ] found that even after eliminating confounding factors, extracurricular activities, including sports and PA were predictors of better academic achievement in 2,200 American high school students. Their conclusion is in line with the point that Marsh made in 1992, that such activities may have an effect on academic achievement by increasing motivation and investment in school. [ 61 ] Another study of 11,957 American adolescents found that even after standardization for SES, sports participation with parental presence was associated with an increased probability of good grades in English and mathematics, the Adjusted Relative Risk being 1.23 for both subjects. [ 20 ] Dexter [ 62 ] examined the relationship between sports knowledge, sport performance and academic ability, the last being measured by scores on the British General Certificate of Secondary Education (GCSE). They observed a small but significant positive correlation between sports performance and GCSE score for both mathematics and English.

Melnick et al. [ 63 ] detected no relationship between academic achievement and sports participation in 3,686 African-American and Hispanic students from the "High-school and Beyond Study". However, sports participation was associated with a lower drop-out rate. Therefore, they suggested that if sports participation contributes to academic achievement, it may do so indirectly, by encouraging retention in school. Fisher et al. [ 64 ] also observed no association between sports involvement and self-reported grades in an ethnic mix of 838 grade 9 to 12 students (predominantly 63% African-American and 27% Hispanic).

Harvard students involved in varsity teams had a slightly lower GPA than their peers, but reported a higher degree of satisfaction with their university experience. [ 65 ] This also seemed the case in other institutions examined by Light. Athletes have more friends and a stronger sense of belonging to their institution. They are, according to Light, "the happiest on campus". Generally, this same trend is seen among high-school athletes. Students engaged in extracurricular PAs do not achive different academic scores than their peers, but they feel a greater engagement with their institution. [ 66 , 67 ] This may reflect in part the greater attention directed towards these specific students. Indeed, participants in extracurricular activities (including sports) have more interactions with significant adults than non-participants. [ 66 ]

Sport is a very complex phenomenon. There are many cultures within school sports, and any effect on academic achievement is influenced by gender, race, type of sport, type and level of athletic involvement. White and McTeer [ 68 ] suggested that the status of a given sport may influence its effect on academic achievement. Their results showed that high-status sports had a positive influence on English grades but they saw no evidenceof an effect of such sports on mathematics grades. They suggested that academic performance was more likely to be affected by cultural factors in subjective subjects like English than in mathematics. Any influence of school sports participation may also differ between girls and boys [ 33 ], and between various ethnic and cultural groups. [ 69 ]

In conclusion, the available literature suggests that sport is more likely to benefit academic achievement if offered in school rather than in other sport contexts, given the proximity of educational resources and environment. This may be particularly important for team sports, which often seem associated with risky behaviours, particularly binge drinking of alcohol. [ 70 ] When sports-involved students identify themselves as athletes rather than «jocks», such risky behaviours seem less prevalent. [ 67 ] Greater academic coaching of school athletes could be a factor favouring their academic achievement. [ 67 ] School sports should be monitored closely, with the intent of avoiding a drift away from educational objectives. It appears that satisfaction with sports vs. satisfaction with school work is predicted by a differing psychological domain (perceived ability vs. task orientation). [ 71 ] It may be helpful to create an environment where both types of endeavour find common ground, i.e. school may be the best setting in which sports can be directed towards task orientation and skills acquisition, without decreasing the pleasure and satisfaction of being good at sports and PA. As noted in various long-term follow-ups, elite and varsity level athletes later tend to experience greater educational and labour market success than non athletes. [ 34 , 67 , 72 , 73 ] Current evidence suggests that this effect may be mediated by racial group. [ 74 ]

Populations with special educational needs

Academic integration of children with various behavioural and developmental problems is a growing trend in industrialized countries. The question arises in terms of their academic achievement. Reviews of exercise programmes for children with learning disabilities [ 75 , 76 ] have suggested that in order to increase the likelihood of positive outcomes, such programmes should have a low student-instructor ratio. Benefits (with the exception of increased PF) may reflect increased attention toward the participants.

In hyperactive impulsive children, PA is associated with global satisfaction in boys and an absence of depressive emotions in both sexes. [ 77 ] An outdoor education programme also decreased behavioural problems in children with attention deficit hyperactivity disorder. [ 78 ]

In children with reading disabilities, a school-based programme of balance and coordination training, throwing, catching, and stretching produced significant improvements in both reading and semantics. [ 79 ] Positive changes were maintained for at least 18 months following the programme, reducing the likelihood of a Hawthorne effect. [ 80 ]

Four pupils with emotional and behavioural disorders were directly studied before and after a 10-week PE intervention. Back in class, there was an increase (13.8%, or a little more than 23 minutes) in the amount of time spent focused on the tasks they were supposed to be performing. [ 81 ] A 10-week PA intervention in children with learning disabilities improved classroom behaviour and the perception of academic competence was increased. [ 76 ] However, a similar outcome was seen in the control group, indicating that there had been no specific effect from the programme.

The effects of school PA upon children with learning problems thus remains an open field for research.

Is the potential beneficial effect of PE, school PA and sport supported by fundamental research?

The positive association observed between PA and intellectual performance among children in quasi-experimental studies should be supported by mechanistic, experimental evidence. No one can deny the important role of neurosciences in the comprehension of academic achievement. [ 82 ] Most research on the relationships between PA and cognition has centered on the hippocampus, a brain region that mediates memory and learning in mammals, and on changes in the cerebral circulation. The hippocampus has an important role in the consolidation of memory. One major mechanism essential to its functions is long-term potentiation, or LTP. LTP leads to an enhancement of nervous influx following a first series of stimuli.

Exercise and learning mechanisms

Hippocampal LTP is the most credible physiological explanation for learning and memory in mammals, including humans. [ 83 ] LTP leads to an increase of synaptic efficacy following an increase of synaptic traffic. [ 83 ] It was shown recently that PA favours hippocampal LTP. [ 84 ] Chronic exercise favourably influences the hippocampus through 3 mechanisms:

1) Heightened neurogenesis, i.e. an increased formation of new neurons after chronic PA, as demonstrated in the adult mouse [ 85 , 86 ],

2) Augmented LTP itself, i.e. enhanced neuronal transmission in the hippocampus. Different methods employed to measure cognitive functions, and scores on these tasks are well correlated with a better performing hippocampus [ 87 ]. Radial maze learning, i.e. an hippocampal spatial learning, is increased in both male and female rats exercised by voluntary running. The performance of this task does not seem to be influenced by changes in fitness of the animal, as is the case for the Morris water maze. However, if the water maze is used, it remains possible to control for an animal's level of fitness. Other studies using the Morris water maze have also reported improved performance. [ 85 , 88 ] Exercise has no effect on glutamate receptors in the hippocampus in aged rats [ 89 ], reinforcing the view that post-receptor mechanisms are responsible for stronger LTP in active animals. However, this point remains to be confirmed in the hippocampus of younger animals,

3) Chronic exercise creates a favourable environment for LTP by increasing the hippocampal concentrations of neuroprotective factors like brain-derived neurotrophic factor (BDNF) [ 90 ] and of other growth factors such as insulin-like growth factor (IGF-1), nerve growth factor, and fibroblast growth factor 2 (FGF-2).

The brain concentration of some antioxidants is also increased in trained animals, thus protecting hippocampal cells from oxidative damage. [ 91 ] Radak et al. [ 92 ] studied the acute effects of exercise (2 hours). Oxidative damage to macromolecules was reduced through an increase of glutathion synthetase activity and a reduction in the deleterious, inactivity-related efflux of glutamate (the neurotransmitter of learning in the hippocampus). Acute exercise also normalized certain memory functions, particularly orientation time to novelty and passive avoidance reactions.

To our knowledge, these mechanisms of enhanced learning and memory have never been explored in animals at a developmental stage corresponding to school-age children. We hypothesize that, given the higher brain plasticity of childhood, the changes seen in older brains may have an even greater magnitude in the developing brain. The data suggest that the brain structures involved in learning and memory, although more complex, function much like skeletal muscle. To enhance function (i.e. increase memory and learning), periods of stimulation must be followed by a recovery period when supercompensation can take place, and the new proteins associated with learning and memory consolidation can be synthesized.

Discussion and Conclusion

Available data suggest that school PA (PE instruction, free time PA or school sport) could become a consistent component of PA to meet current guidelines for children and adolescents without impairing academic achievement, even if curricular time for so-called academic subjects is curtailed. In his classical work "The Adolescent Society," James S. Coleman advanced the concept of a zero-sum model. [ 93 ] This hypothesized that if time was taken from academic programmes to allow other pursuits, academic achievement would suffer. This concept may be applicable if time is spent in paid employment while attending school [ 94 ], but it does not seem to apply to extracurricular activities like sports or curricular PE. [ 95 ] In contrast, such activities are likely to increase attachment to school and self-esteem which are indirect but important factors in academic achievement.

Parents concerned about decreases in study and homework time may be better advised to question the time their children spend on TV and computer games rather than the time that they devote to PE, PA or sports in school. Indeed, the more children watch TV, the greater the decline in their academic results. [ 96 ] At least one Canadian study found that the time devoted to PA was positively associated with the time that school-aged children spent in reading. [ 97 ] Parents interested in the health and academic success of their offspring should focus on the increased prevalence of various metabolic pathologies in which sedentary behaviour plays a key etiologic role, for example, obesity and type 2 diabetes, both of which are beginning at an ever younger age. [ 98 ] Such pathologies have the potential to affect school performance adversely, although this is an area where more research is needed. [ 99 ] In one recent article, obese 3 rd grade girls (8 years old) did not have poorer academic results after control for SES, but relative to normal weight girls they exhibited more displaced behaviours like arguing and fighting, as well as more depressive symptoms like loneliness and sadness [ 100 ].

Engagement in PE instruction would probably be increased if grades were allocated for performance in PE, particularly in high school. The engagement of girls, particularly, decreases when PE is not considered incalculating their GPA. [ 101 , 102 ] However, between grade 8 and 12, the school drop-out rate for adolescents of both sexes is reduced by sport participation [ 103 ]

Another problem that remains to be resolved, despite a call for action from the Surgeon General in 1996, is the heterogeneity in provision of PE [ 104 ], extracurricular sports and other school PA programmes [ 105 ], schools with a low SES being particularly disadvantaged. School sport would appeal to more students if emphasis was placed on its educational potential rather than its competitive side. Potential drifting of objectives should be monitored to avoid a «subversion» of the educational mission and ensure a maximisation of positive effects such as academic achievement and long term adherence to physical activity. The current emphasis on a limited range of team sports should be modified to provide opportunities for students who are interested in and have the skills relevant to other sport ventures, thus attracting a wider range of students.

Many questions remain to be clarified on the relationship between academic performance, PE, school PA and sports. However, to paraphrase Eccles et al. [ 67 ], "We now know enough about the kinds of programs likely to have positive effects on children and adolescents' development." The literature strongly suggests that the academic achievement, physical fitness and health of our children will not be improved by limiting the time allocated to PE instruction, school PA and sports programmes.

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F. Trudeau is holder of a joint initiative grant from Social Science and Humanity Research Council/Sport Canada. R. J. Shephard is collaborator on the same grant.

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Effects of different types of exercise intensity on improving health-related physical fitness in children and adolescents: a systematic review

• Xianxian Zhou 1 ,
• Jiayu Li 1 &
• Xiaoping Jiang 1  

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A substantial body of empirical evidence reveals that physical activity is associated with a wide range of positive physical and mental health outcomes. However, an absence of comprehensive syntheses is observed concerning the varying effects of different exercise intensities on the improvement of physical health among children and adolescents. The aim of this review is to systematically investigate the effects of different exercise intensities on the physical fitness of children and adolescents, to analyses the optimal exercise intensities for improving physical fitness, and to provide a relevant theoretical basis for optimizing school physical education curricula. A systematic search strategy was used in this study in four online databases (PubMed, Scopus, EBSCO and Web of Science). Intervention studies that met the inclusion criteria underwent a thorough screening process, and their methodological quality was assessed utilizing the PEDro scale. The selected literature was systematically analyzed and evaluated through induction, summary, analysis, and evaluation. These findings indicate that high-intensity exercise training exerts significant positive effects on body composition, cardiopulmonary function and muscle fitness in children and adolescents. Therefore, we suggest that schools should focus on high-intensity sports in their physical education curriculum, which can further improve the student's PHYSICAL FITNESS.

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Introduction.

Overweight and obesity in children and adolescents have become a global public health problem 1 . The prevalence of obesity in children and adolescents has been reported to have increased from 0.7% to 5.6% 2 . The persistence of overweight and obesity into adulthood has the potential to lead to chronic diseases, including type 2 diabetes, cardiometabolic disorders, and a range of psychosocial problems 3 , 4 , 5 , 6 , Numerous studies have shown that physical activity is one of the most important interventions to reduce physical health and psychological problems in adolescents 7 , 8 , 9 . WHO recommends that children and adolescents should engage in an average of 60 min of moderate to high-intensity physical activity (MVPA) per day to obtain health benefits 10 , however, more than 80%of adolescents fail to reach the minimum recommended amount of physical activity 11 . Given that adolescents have difficulty starting and following recommended guidelines for 30–60 min of moderate-intensity training per day 12 , 13 , there is a need to explore and develop engaging alternatives for youth to achieve the many health benefits of regular physical activity. Traditionally, moderate-intensity continuous training (MICT) has been the most common type of exercise recommended to improve body composition and cardiorespiratory fitness (CRF) 14 , 15 . However, in recent years, a growing body of laboratory evidence has shown that high-intensity exercise training is less time-consuming than MICT in improving body composition and other health indicators in obese children and adolescents 16 , 17 , 18 . Whether high-intensity or low-intensity exercise training is more beneficial to the PHYSICAL FITNESS of children and adolescents is still highly debated. Therefore, there is a need to further explore differences in the effectiveness of different exercise intensity interventions in improving PHYSICAL FITNESS in children and adolescents.

PHYSICAL FITNESS is a multidimensional state of being. PHYSICAL FITNESS is the body’s ability to function efficiently and effectively. It is a state of being that consists of at least FIVE HEALTH-RELATED and SIX SKILL-RELATED PHYSICAL FITNESS COMPONENTS, each of which contributes to total quality of life. The five components of health-related PHYSICAL FITNESS are BODY COMPOSITION, CARDIOVASCULAR FITNESS, FLEXIBILITY, MUSCULAR ENDURANCE, AND STRENGTH 19 . A recent narrative and meta-analysis of 20 studies evaluated the efficacy of HIIT for improving HEALTH-RELATED FITNESS (ie, cardiorespiratory fitness, muscular fitness, body composition and flexibility). The results indicated significant improvements in cardiorespiratory fitness and body composition through HIIT, with notable effects observed in these areas 13 . Previous meta-analyses have weakened the interpretation of findings due to small sample sizes. Furthermore, there is less research on exercise interventions to treat PHYSICAL FITNESS in children and adolescents than in adults, particularly in terms of exploring exercise-related variables (intensity and duration).

Therefore, this systematic review aims to systematically summarized the effects of different exercise intensities on health-related fitness in children and adolescents and to analyze which exercise intensity is more conducive to improving health-related fitness in children and adolescents.

This review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines 20 , and the Cochrane Handbook for systematic review 21 . The PRISMA checklist is presented in Additional File 1.

Search strategy

A comprehensive search was done systematically through PubMed, Scopus, EBSCO, and Web of Science up to the 5 of June 2024. Searching terms were based on adapted PICO questions to search through the aforementioned databases to access all the important articles. Free text words and medical subject heading (MeSH) terms were used. (1) children OR childhood OR pre*schooler OR schoolchildren OR preadolescent OR adolescent OR adolescence OR youth;(2) physical*activity OR physical*education OR exercise OR fitness OR sport;(3) strength OR flexibility OR motor OR endurance OR agility OR body composition OR anthropometry OR body mass index OR waist circumference OR overall adiposity OR central adiposity OR overweight OR obesity OR risk factors OR risk score cardiovascular disease OR metabolic syndrome OR blood glucose OR glucose tolerance OR insulin resistance OR insulin sensitivity OR blood lipids OR dyslipidemia OR diabetes OR blood pressure OR hypertension OR inflammatory markers OR bone mineral OR bone mineral content;(4) random OR random*controlled trial OR controlled trial OR trial. (The search strategy used for each database is provided in the supplementary material (table S2). At the same time, the reference lists of included articles and relevant reviews were retrospectively included to supplement the missing literature in the computer search. The systematic search process was conducted by XXZ and JYL. Any disagreement of an included/excluded study was resolved by the author PXJ.

Eligibility criteria of the selected studies

The inclusion criteria for articles were determined using the PICOS (Participants/Interventions/Comparisons/Outcomes/Study Design) principles, as follows. Participants (P): Children and adolescents (individuals in the 10–19 year age group 22 , including samples of overweight/obese children, but excluding samples of children with medical conditions); Interventions (I):interventions in the form of exercise, High-intensity aerobic exercise, Low-intensity aerobic training (LIT), Endurance training (ET), High-intensity interval exercise (HIIE), Moderate-intensity exercise (MIE),HIIT, moderate-intensity continuous (MICT); Comparisons (C): control group performed low to moderate intensity physical activity or no artificially designed physical exercise; Outcomes (O): assessment of at least one of the following indicators (i.e., body composition, cardiorespiratory fitness, muscular fitness, strength, flexibility, motor, endurance, agility, body composition, anthropometry, body mass index, waist circumference, overall adiposity , central adiposity , overweight , obesity ,risk factors , risk score cardiovascular disease, metabolic syndrome, blood glucose, glucose tolerance, insulin resistance, insulin sensitivity, blood lipids, dyslipidemia, diabetes, blood pressure, hypertension, inflammatory markers, bone mineral, bone mineral content); Study Design (S): controlled trial.

Exclusion criteria: (1) studies not related to the topic (non-physical activity, physical activity); (2) non-intervention studies (observational studies, systematic reviews) and studies that did not provide sufficient comparisons to compare; (3) Exclude other age groups other than 3–19 years old. The title, abstract and full text were independently assessed by two authors for eligibility. Finally, randomized controlled trials were limited to articles published in English.

Data extraction

Data extraction from the included studies was independently performed by two authors (XXZ and JYL). For each study, data were extracted for the characteristics of the study population. These include (1) first author’s surname; (2) year of publication; (3) purpose; (4) results; (5) the characteristics, sample size and age of the participants; (6) sampling type; (7) type of research; (8) Characteristics of physical exercise (type, frequency and duration). Any disagreement in data extraction was resolved by the third author PXJ (Table 1 ).

Quality assessment

Papers that met the inclusion criteria were independently assessed by two authors (XXZ and JYL). This review assessed the included literature using the Physiotherapy Evidence Database (PEDro) scale, a credit rating scale developed by the Australian Centre for Evidence-Based Practice. The PEDro scale is a valid measure of the methodological quality of clinical trial 23 . The scale consisted of randomized grouping (2 items), blinding (3 item), data reporting (3 item), data analysis (1 item), and follow-up (1 item), with a total of 10 criteria. Each item was recorded as 1 point when it appeared in the article and 0 points when it was not reflected, for a total score of 0 to 10 points. To avoid subjective opinions, two reviewers assessed the opinions, and the third judged the differences. It classifies papers into three levels: high quality above 8, medium quality 4–7, and low quality below 4 points. Disagreements were solved by a third party (PXJ) (Table 2 ).

Data synthesis and analysis

Due to the heterogeneity of the studies, no meta-analysis was performed. Instead, intervention characteristics for each study were summarized and analyzed and then recorded in a standardized form created by the authors. The effectiveness of the intervention was calculated using the formula: number of effective trials (post-intervention scores significantly higher than pre-intervention or control scores)/total number of trials. Data analysis was performed by the first author XXZ and then validated by the second author JYL.

Literature screening process and results

A preliminary search of the database yielded 10,030 relevant studies. We first imported the documents into the document management software Endnote, and after removing duplicate documents and screening titles and abstracts, we excluded 9990 articles. Of the remaining 40 articles, 30 articles were obtained after screening and checking the full text, and the irrelevant articles were eliminated. The reasons for the exclusion based on the full text were: (1) no intervention studies (3 articles); (2) The age does not meet (3 articles); (3) non-full text (2 articles); (4) non-English articles (2 articles). The PRISMA flowchart is shown in Fig.  1 .

Flow chart of literature retrieval.

The systematic search of relevant literature published as of 5 June 2024 found 30 relevant articles, the earliest of which was published in 1999. The study included 30 related papers from the United States, Canada, Brazil, Denmark, Spain, China, Australia, the United Kingdom, Singapore, France, Portugal, Colombia, and Switzerland.

Study characteristics were summarized in Table 1 , and the final analysis included 6494 children and adolescents with participants ranging in age from 5 to 18 years, with most studies including healthy children and adolescents, but nine studies including overweight or obese children. Study sizes ranged from 10 to 2166. Physical activity interventions mainly included HIIT (8/30; 27%), aerobic training (5/30; 17%), resistance training (2/30; 7%), physical education (1/30; 3%), endurance training (1/30; 3%), acute exercise (1/30; 3%) and other interventions. Outcome measures: body mass index, waist circumference, body fat, cardiorespiratory fitness, and muscle fitness (muscular endurance, muscle strength and muscular flexibility). Quality scores for 30 studies are shown in Table 2 . The studies ranged in their scores from 3 to 10. Only two studies achieved high-quality scores (≥ 8) (Table 2 ). One study scored below 4. Blinding techniques ranged from 0 to 3 in this study, with only one study scoring 3 and four scoring 1; Fifteen studies scored 0.

Effects of different exercise intensity on BODY COMPOSITION in children and adolescents

A total of 11 studies in this study assessed the effects of different exercise intensities on body composition (weight, BMI, body fat, waist circumference, fat-free mass, and other relevant indicators), of which 9 showed that high-intensity exercise interventions had a positive effect on overweight or obese children and adolescents, but 2 had no positive effect.

Weight, BMI and body fat

A total of 8 of the 11 studies assessed changes in body weight, BMI, adiposity, or percentage of body fat measured. Six of the eight studies, reported positive effects of high-intensity exercise interventions on body weight, BMI, or body fat in overweight and obese child adolescents. However, 2 studies showed moderate or no positive effects of high-intensity exercise interventions on BMI, and body fat in overweight or obese children and adolescents.

Tadiotto et al. conducted a 12-week HIIT and MIIT intervention study and found significant reductions in (body mass index) BMI-z, (waist-to-height ratio) WHtR, and LDL-c in HIIT 28 . Benson et al. compared the effects of high-intensity progressive resistance training (PRT) on body composition in obese children and showed that an 8-week PRT intervention resulted in significant improvements in adiposity, percentage body fat, and body mass index 34 . Recent findings have shown that after 12 weeks of HIIT and MICT interventions, there was a significant reduction in BMI and body fat mass in the HIIT group compared to the control group, as well as a significant reduction in visceral adipose tissue (− 53 g vs. − 17 g, p  < 0.01), LDL cholesterol was reduced only in the HIIT group, whereas in MICT only the body fat percentage was significantly reduced (− 17.2%, p  < 0.05) 31 . In addition, Winn et al. compared the effects of HIIT on adolescents over a 6-month period and showed that after a 6-month school HIIT intervention, BMI was maintained in the HIIT group and significantly increased in the control group, and that HIIT was an effective tool for maintaining BMI 47 .

In a study assessing the effect of different exercise intensities on energy expenditure for spontaneous physical activity in adolescents, Paravidino et al. found that the mean energy expenditure was 82, 286 and 343 kcal in the control, moderate and vigorous exercise groups, respectively ( p  < 0.001), and the results suggest that high intensities are more conducive to an increase in energy expenditure, and thus to weight loss 27 . Saidi et al. studied the effect of vigorous exercise on subsequent dietary intake in obese adolescent girls and showed a significant reduction in adiposity in the exercise group compared to the control group ( p  < 0.02) 45 .

In the present study, 2 studies reported no significant effects of different intensities of exercise on body composition in overweight or obese children and adolescents. Gomes et al. compared the effects of different aerobic training intensities over a period of 12 on the body composition of obese adolescents, and showed a decrease in body weight, BMI, and body fat in both the intervention and control groups after a 12-week intervention ( p  < 0.001), but these results could not be attributed solely to aerobic training intensity due to the multidisciplinary intervention 40 . In another study, Costigan et al. conducted an 8-week study of aerobic training (AEP) and resistance and aerobic programming (RAP) with 68 secondary school students, and the results showed a moderate effect of the BMI intervention for participants in the AEP and RAP groups. It may be related to the small sample size 43 .

Waist circumference

Three randomized controlled trials assessed changes in waist circumference and all found beneficial effects. (Insert literature), a study conducted by Farah et al., showed that after 6 months of high-intensity aerobic training (HIT) and low-intensity aerobic training (LIT), significant beneficial changes in waist circumference were found only in the HIT group 24 . Benson et al. investigated the effects of 8 weeks of high-intensity progressive resistance training (PRT) on body composition in obese children and compared the effects between the experimental and control groups, showing that significant changes in waist circumference were obtained in the intervention group after 8 weeks of PRT training 34 . Costigan et al. conducted an 8-week study of aerobic training (AEP), resistance and aerobic programming (RAP) with 68 secondary school students and showed that participants in the AEP and RAP groups had significant changes in waist circumference ( p  = 0.024) 43 .

Fat-free mass

Only 1 study evaluated the effect of different exercise intensities on fat-free mass. Leppanen et al. investigated the effect of physical activity intensity and sedentary behaviours (ST) on body composition in 4 years old children. The results showed that the higher the intensity of moderate-to-vigorous exercise, the lower the percentage of fat (%FM, p  = 0.015), the VPA (high intensity) and MVPA (moderate-to-vigorous exercise intensity) the higher the fat-free mass index (FFMI, p  = 0.002 and p  = 0.011) Time spent on VPA was associated with higher FFMI 38 .

Effects of different exercise intensities on CARDIOPULMONARY FUNCTION (CRF) in children and adolescents

A total of 16 studies investigated the effects of different exercise intensity interventions on cardiorespiratory fitness, and positive effects were found in all studies. In general, cardiorespiratory fitness improved with high-intensity exercise interventions. The included studies assessed vascularity, heart rate, lipids, insulin sensitivity, inflammatory markers, diabetes, and other relevant indicators.

Blood vessels

A total of 4 out of 16 studies investigated the effects of exercise intensity interventions on blood vessels in children and adolescents. Four studies demonstrated that high-intensity training interventions had a positive effect on blood vessels.

Bond et al. investigated the effect of exercise intensity on protecting the vascular system from high-fat diets in adolescents study by intervening with high-intensity interval exercise (HIIE) and moderate-intensity exercise (MIE) in 20 adolescents, and showed that exercise intensity plays an important role in protecting the vascular system from the deleterious effects of HFM, and that in the adolescent population, performing HIIE may be more effective than MIE in Provides better vascular benefits 26 . In a study examining the effects of sprint interval exercise on post-exercise metabolism and blood pressure in adolescents, it was shown that acute sprint interval exercise leads to an increase in short-term oxygen uptake and a decrease in blood pressure in adolescents 37 . Farpour-Lambert et al. investigated the effect of physical activity on systemic blood pressure in adolescent obese children, and after a 3-month intervention, significant changes in systolic and diastolic blood pressure were obtained in the intervention group compared to the control group 51 . Buchan et al. investigated whether a high-intensity training (HIT) intervention could improve the CVD risk profile of adolescents in a time-effective manner, and after a 7-week HIT intervention, a significant reduction in systolic blood pressure was obtained in the intervention group compared to the control group 41 .

Insulin sensitivity

Of the 16 studies, only 2 randomized controlled trials assessed the effect of exercise intensity on insulin sensitivity. Only one study showed that a high-intensity exercise intervention could have a positive effect on insulin sensitivity. In the first randomized controlled trial, the Davis study found that after the intervention, the high-dose aerobic training group had a greater reduction in insulin (AUC), which could be effective in reducing metabolic risk 36 . However, in another randomized trial of 106 overweight and obese adolescents who underwent high-intensity endurance training (ET) and moderate-intensity (ET) for 6 months, the results showed that ET significantly improved cardiorespiratory fitness in obese adolescents, but the effect of exercise intensity on insulin sensitivity and triglycerides remained unclear due to lack of compliance 25 .

Inflammation

A total of 3 out of 16 studies assessed the effect of exercise intensity interventions on inflammation, with only 2 showing a positive effect of high-intensity exercise interventions on the prevention of inflammation. The results of the study by Ramirez-Velez et al. suggest the utility of high-intensity aerobic and resistance training as a means of modulating the levels of certain pro-inflammatory interleukins in adolescent subjects, thereby playing an important role in the prevention of diseases associated with low-grade inflammation, such as cardiovascular disease and type 2 diabetes 30 . A study by Tadiotto et al. found that C-reactive protein (CRP) was significantly reduced in the HIIT group, promoting beneficial changes in obesity and inflammatory processes 28 . However, in a study conducted by Buchan et al. with 89 adolescent students to assess whether the HIIT intervention could improve the cardiovascular disease risk profile of secondary school students in a time-effective manner, after a 7-week intervention, the results showed no significant differences between groups for any of the nine biochemical risk markers for cardiovascular disease, but significantly improved cardiorespiratory fitness 41 .

Two of the 16 studies showed that high-intensity exercise interventions had a positive effect on heart rate. In one study examining the effect of exercise intensity on blood pressure and heart rate in obese adolescents, after a 6-month period of HIT and LIT, beneficial changes in HR and HRV occurred only in the HIT group 24 . In a randomized controlled trial, Ketelhut et al. assessed the effect of implementing school-specific HIIT in a physical education curriculum on various hemodynamics parameters and heart rate variability, and after a 12-week intervention, the results showed that significant changes in heart rate were obtained in the intervention group ( p  = 0.010) 52 .

In addition, five other studies have all demonstrated the beneficial effects of high-intensity exercise interventions on cardiorespiratory fitness. Grasten et al. examined the effects of moderate-to-vigorous physical activity and ST with cardiorespiratory fitness in schoolchildren from 2017 to 2020, assessing accelerometer based MVPA by using waist-worn activity monitors and CRFs at four measurement points using the 20-m shuttle run test and ST, which showed a positive correlation between MVPA and CRF, and a negative correlation between ST and CRF 42 . Taber et al. conducted a moderate and vigorous exercise intervention with 1,029 eighth-grade girls and measured cardiorespiratory fitness using the Modified Physical Exercise Capacity Test (MPCT), which showed that vigorous exercise was positively associated with cardiorespiratory fitness 35 . Dias et al. showed that after 12 weeks of HIIT and MICT interventions, the HIIT group had a significant increase in relative peak VO2 compared to MICT, which was very effective in improving cardiorespiratory fitness 32 . Both studies by Gerber et al. and Leppanen et al. showed that higher levels of MVPA were associated with higher CRF scores 39 .

Effects of different exercise intensities on FLEXIBILITY in children and adolescents

Only two studies assessed changes in flexibility and no effects were found. The first study, conducted by Buchan et al., showed that after a 7-week period of high-intensity interval exercise, the intervention group showed an increase in vertical performance, and 10-m sprint speed ( p  <  = 0.05), while the control group showed a significant decrease in both flexibility and vertical performance 41 . The most recent study, conducted by Juric et al. investigated the effects of a HIIT intervention lasting 12 weeks on balance, coordination, speed, flexibility, strength, and agility in 10- to 15-year-old students, and showed no significant effects. This may be because short-term HIIT interventions of only two 10-min sessions per week do not provide sufficient stimulation for fitness (muscular strength, muscular endurance, power, speed, flexibility, and balance) enhancement 50 .

Effects of different exercise intensities on MUSCLE FITNESS in children and adolescents

Five studies assessed changes in muscle fitness, and four showed that high-intensity exercise interventions had a positive impact on muscle fitness in children and adolescents. Larsen et al. explored whether the musculoskeletal fitness of 8–10 year old schoolchildren is affected by frequent high-intensity physical education classes, and showed that after a 10-month intervention of varying intensities, the intervention group had higher scores for changes in bone mineral content (BMC) and bone mineral density (aBMD) change scores were higher, suggesting that well organized high-intensity physical education sessions can promote the development of musculoskeletal fitness in young children 29 . A study of the effects of different resistance training programs on the development of muscular strength and endurance in children found a significant increase in leg extension muscular endurance with low repetition-heavy loads and high repetition-heavy loads, with high repetition-medium loads being significantly greater than low repetition-heavy loads training, and in the chest press exercise only the high repetition-medium loads exercise group had significantly greater muscular strength and muscular endurance than the control group 33 . Benson et al. found that an 8-week PRT (two sets of high-intensity exercises targeting major muscle groups) intervention resulted in significant increases in upper body strength and lower body strength compared to a control group 34 . Leppanen et al. investigated the effect of physical activity intensity on PHYSICAL FITNESS in children by using the PREFIT PHYSICAL FITNESS test to measure PHYSICAL FITNESS (that is, cardiorespiratory fitness, lower and upper body muscular strength and motor fitness), and the results showed that replacing sedentary, low- or moderate-intensity exercise with 5 min of high-intensity exercise per day promoted an increase in muscle strength 38 .

However, Videira-Silva et al. showed no significant improvement in muscular endurance in participants in the 12-week HIIT group 49 . That's because the study, which only had two 10-min short-term high-intensity interval exercise sessions per week, failed to provide enough stimulation for fitness enhancement. Therefore, long-term, high-intensity training may be necessary to effectively improve muscle fitness in children and adolescents.

This review aimed to summarize the effects of physical activity of different exercise intensities on the PHYSICAL FITNESS of children and adolescents. The analysis included 30 interventional studies from 15 countries. 30 studies were assessed as above average, with good reason to believe that different exercise intensities had different effects on PHYSICAL FITNESS in children and adolescents. Based on strict restrictions on the nature of the intervention included in the studies, the studies included in the study span the years 1999 to 2024 (Table 1 ). It can be guessed that since 1999, researchers have gradually found differences in improving the PHYSICAL FITNESS of adolescents with different exercise intensities. In addition, from the perspective of regions and countries where the literature is published, relevant research is mainly concentrated in developed countries and some developing countries. This may be because, with the increase in material wealth, the PHYSICAL FITNESS of children and adolescents has received a high level of attention. Judging from the number of relevant published literature, there is still a lack of research on the effects of different exercise intensities on the PHYSICAL FITNESS of children and adolescents internationally. Therefore, this study aims to draw the attention of more draw the attention of more researchers from different regions and countries to this topic and encourage the conduction of controlled trials with high-quality evidence to further demonstrate the positive effects of different exercise intensities.

This study shows that high intensity exercise training has significant effects in improving body composition. It was mainly more effective in reducing visceral fat. These results align with a previous review by Batacan et al., which synthesized 65 studies and showed that HIIT can significantly improve waist circumference and body fat percentage in people who are overweight or obese 54 . A meta-analysis of adolescents found that exercise interventions of different intensities were differentially effective in reducing body weight and body mass index, and that high-intensity aerobic exercise and high-intensity aerobic exercise combined with high-intensity resistance training were more effective than low- and moderate-intensity exercise interventions 55 . We suspect that this may be due to the fact that high-intensity exercise leads to excessive post-exercise oxygen consumption and the substrate for this energy oxidation is fat, during high-intensity exercise the body needs to secrete more adrenaline and noradrenaline to control the muscles, and in addition the body has to maintain high metabolic levels for a longer period of time even after exercise. All of these effects lead to an increase in the body's resting metabolic levels, which further stimulates fat burning and leads to weight loss 56 , 57 . It is also interesting to note that Buchan and Kargarfard, when exploring the effects of HIIT on body composition in normal and obese adolescents, did not find any good changes in body composition or waist circumference in the intervention group. Both studies claimed that the lack of effect on body composition was due to the short duration of the training (duration of 7 and 8 weeks) 58 , 59 . Therefore, we suggest that relevant scholars pay more attention to the optimal training time when high-intensity exercise training can effectively improve the body composition of children and adolescents, and provide more effective training programs to reduce the obesity rate of children and adolescents at home and abroad.

This study showed that both high-intensity exercise training and moderate to low-level exercise training can improve cardiorespiratory fitness in children and adolescents, but high-intensity exercise training has a more significant effect on cardiorespiratory function. This finding coincides with previous conclusions 60 , 61 , 62 . A meta-analysis of adolescents aged 11–17 years found that high-intensity exercise training has a significant effect on improving cardiorespiratory fitness in adolescents compared to moderate-intensity exercise 60 , which is consistent with our findings. The mechanism by which this occurs may be due to the fact that high-intensity training increases the oxidative capacity of skeletal muscle more efficiently than conventional training methods. For example, in terms of the molecular adaptive mechanisms of skeletal muscle oxidative capacity, high-intensity exercise activates the activity of AMPK and MAPK exercise-responsive kinases 63 , 64 , while increasing the amount of mRNA for PGC-qα, a transcription factor that regulates the oxidative function of mitochondria. With the activation of the joints leading to increased transcription of mitochondrial substances, this allows the body's aerobic and anaerobic capacity to be enhanced, leading to improved cardiorespiratory fitness 65 . We therefore recommend that schools should incorporate high-intensity program in their physical education curricula so as to improve the cardiorespiratory fitness of children and adolescents and to reduce the probability of children and adolescents suffering from cardiovascular diseases in adulthood.

Muscle fitness is widely recognized as a key fitness component for maintaining overall health and is negatively correlated with obesity 66 .In this review, five studies confirmed the effects of different exercise intensities on muscle fitness function in children and adolescents. A systematic study of school-age children and adolescents suggests that high-intensity physical activity is more beneficial in building muscle 67 . Our findings are supported by Smith et al.'s study, where strenuous physical activity was positively associated with muscle fitness in children and adolescents 68 . In addition, only 1 study in this study showed that high-intensity training was effective in improving muscle flexibility. Muscle flexibility can be expressed as the normal physiological range of joint motion 69 . If adequate flexibility is lacking, daily activities will become difficult. In addition, reduced flexibility can also lead to musculoskeletal injuries 70 . Therefore, maintaining (or increasing) flexibility is essential as it maintains normal joint motion, thereby reducing the risk of injury 71 . A study of adolescents aged 14–17 years found that a 12-week, high-intensity training intervention resulted in adolescents displaying greater flexibility 72 , which is consistent with our findings. Furthermore, in the literature included in this review, only 1 study showed that high-intensity training improves muscle flexibility, but there was insufficient evidence that muscle flexibility is associated with high-intensity training. We speculate that on the one hand, this may be related to limitations in the assessment of muscle flexibility. The currently commonly used methods of assessing muscle flexibility (sitting and stretching) are unable to detect a lack of function due to muscle laxity 73 ; the other side of the coin is that most of the current research on muscle flexibility has focused on the elderly population, with less attention paid to children and adolescents. This is due to the fact that muscle flexibility decreases with age, leading to increased joint stiffness and progressive loss of balance, which increases the risk of falls in older adults 73 . Overall, appropriate levels of flexibility have positive implications for the PHYSICAL FITNESS of children and adolescents, and exploring scientifically sound methods of assessing flexibility and research on flexibility in children and adolescents should receive more attention.

Research limitations and prospects

Although this review discusses the effects of different exercise intensities on the PHYSICAL FITNESS of children and adolescents from four aspects, its limitations should be properly examined. This review provides direction for further research on the effects of different exercise intensities on the PHYSICAL FITNESS of children and adolescents. Although an extensive literature search was conducted, including articles published before 2024, it is possible that some relevant literature may have been overlooked due to variations in keywords used in this study. Additionally, we conducted an extensive literature search in four major databases, but some published non-English foreign studies may have been missed in this review as our search was limited to English-language journal articles.

Despite these limitations, this review systematically collated the literature reports on the different effects of different exercise intensities on the PHYSICAL FITNESS of children and adolescents. Future research could explore higher-quality randomize controlled trials to provide more convincing evidence for optimal exercise intensity to improve the health of children and adolescents. Future research should also focus on the effect of different exercise intensities on muscle flexibility. At the same time, more comprehensive exercise evaluation is needed to support high-intensity exercise training as an effective exercise program to improve the PHYSICAL FITNESS of children and adolescents.

Conclusions

This systematic review demonstrates a positive association between high-intensity exercise training and PHYSICAL FITNESS in children and adolescents. High-intensity exercise training yields notable improvement in body composition (reduced body mass index, waist circumference, and body fat), cardiopulmonary function, and muscle strength in children and adolescents. Furthermore, the high-intensity training group outperforms both the moderate-intensity group and the control group in terms of improving physical fitness. Specifically, participation in HIIT exhibits a more significant effect on improving PHYSICAL FITNESS in children and adolescents. Based on the findings, we recommend that schools optimize their physical education programs by incorporating more high-intensity physical activities, thereby promoting the healthy growth of children and adolescents through effective exercise.

Moreover, the study highlights that the effects of high-intensity physical activity on the PHYSICAL FITNESS of children and adolescents may be influenced by factors such as average age, overweight or obesity of participants. Therefore, further refinement of the study design is necessary, along with additional high-quality research, particularly randomized controlled trials, to ensure the long-term reliability of the results. Additionally, in terms of measurement of related indicators, this study primarily relies on manual measurement and automated equipment, which may introduce measurement errors. Subsequent studies could consider using more advanced instruments to assess relevant indicators of the PHYSICAL FITNESS of children and adolescents.

Data availability

Data is provided within the manuscript or supplementary information files.

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Zhou, X., Li, J. & Jiang, X. Effects of different types of exercise intensity on improving health-related physical fitness in children and adolescents: a systematic review. Sci Rep 14 , 14301 (2024). https://doi.org/10.1038/s41598-024-64830-x

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Mr. emmanuel aboagye, akrokerri college of education.

Emmanuel Aboagye is a PhD Science Education Student (Physical Education and Sport Management) and a tutor at Akrokerri College of Education. His research interest is Multidisciplinary, with publications on general education topics and sports management areas. His PhD thesis is on elite female football coaches in Africa. Some of his notable publications include "COVID-19 and E-Learning: Challenges of Tutors at Colleges of Education in Ghana" and "Teachers' Perceptions of the New Educational Curriculum in Ghana". He has over 900 citations on Google Scholar and is also visible on ResearchGate. He has attended educational conferences in Ghana and abroad, with a recent AIESEP conference at the University of Jyväskylä, Finland this year. 

Mr. Ishmael Owen Opoku, Konongo Odumase Senior High School

Ishmael Owen Opoku is a dedicated Physical Education Tutor at Konongo Odumase Senior High School in the Ashanti Region of Ghana. His research interests and areas of specialization include physical activity and sports participation, motivation to engage in physical activities and sports, health promotion and education, and sports management. With a strong commitment to fostering a culture of physical health and athletic excellence among his students, Ishmael continually seeks to inspire and motivate young athletes to achieve their best. His contributions to the field of physical education are well-regarded, and he is actively involved in advancing sports participation and health education in his community. 

Dr Samuel Richard Marcourt, Kwame Nkrumah University of Science and Technology

Samuel Richard Marcourt is a PhD Science Education Student (Physical Education and Sport Management) at the Kwame Nkrumah University of Science and Technology, and a tutor at Wesley College of Education. His research interest is in general education and sports management. His PhD theses to is on evaluating the economic impact of community sports facilities on resident in Ghana. His commitment to sports management and organisation attracted the LOC of the 2023 13 th ALL AFRICAN GAMES held in Ghana to make him a stadium manager for cricket

Mr. Kouassi Junior Tano, University in Ghana

Kouassi Junior Tano holds a first degree in Management Studies from Central University in Ghana and a postgraduate honours degree in Sport Management from the University of Johannesburg. He has almost three years of work experience as a sport manager at the University of the Witwatersrand (Wits Sport), South Africa. Additionally, he completed a year of national service at Kwame Nkrumah University of Science and Technology, College of Health Sciences, Department of Physiotherapy and Sport Science, serving as a Teaching Assistant to the Sport Management Program.

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Using emerging technologies to promote physical activity: the perspective of university students in ghana, mr. emmanuel aboagye.

Mr. Ishmael Owen Opoku

Dr samuel richard marcourt, mr. kouassi junior tano.

Despite research advocating the importance of developing and testing new interventions to promote physical activity in emerging adults, such literature is extinct among Ghanaian university students. This study examined the potential of emerging technologies in promoting physical activity among such populations in Ghana. Using semi-structured interviews, we conveniently examined the perspectives of 22 students at the Kwame Nkrumah University of Science and Technology to determine how emerging technologies can promote physical activities and the challenges of using them. The results showed that the students are aware of the existence of some of these technologies. The following themes emerged from the study on the benefits of using emerging technologies to promote physical activities; promote motivation and engagement, personalised coaching and feedback and social support. Further, the results revealed challenges such as cost, over-dependency on technology, and technical issues which are mainly connected with network issues. Based on the findings we recommend that fitness enthusiasts should educatestudents on how to use some of the technological devices to promote their physicality. Further, we proposed cost-effective techniques such as the use of calisthenic activities to promote physical activity and health among university students to reduce costs.

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• View Frequently Approved Prerequisites for the PT program . To speak with an admissions specialist about your coursework or request an unofficial transcript evaluation, please call 843-792-2536 or email [email protected] . The Office of Enrollment Management offers unofficial transcript evaluations between March 1 and June 30.
• Basic science courses must be courses for science majors . Basic science courses identified in chart above with an *.
• Biology : Prerequisite courses must be offered through the Department of Biology or a Basic Science Department. In addition to Biology I and Biology II, acceptable courses include genetics, cell biology, zoology, human biology and disease and similar courses. Unacceptable courses include botany, exercise physiology taken in Exercise Science and Physical Education departments, and human physiology when used as the physiology prerequisite.
• Human Anatomy and Physiology including the labs : Anatomy and Physiology may be taken separately or may be combined and taken as two, four-hour courses. However, if you start a two-part course sequence, you must complete both parts (Anatomy and Physiology I & II). If only a 3-semester credit hour course in anatomy is offered, a comparative anatomy or kinesiology course is recommended in addition to the human anatomy course. Also, Vertebrate Anatomy is accepted if Human Anatomy is not offered. Exercise physiology will not meet the Human Physiology requirement.
• Introductory Statistics : This course should include parametric and nonparametric statistics.
• ** Psychology : Includes 3 semester credit hours of Introductory Psychology and 3 semester credit hours of upper-level psychology such as Human Growth and Development, Child Development, or Abnormal Psychology.
• Dual enrollment courses are accepted for prerequisite courses so long as the course appears on your college transcripts.
• Advanced placement credits are accepted for prerequisite courses. Submit your official scores report demonstrating a score of 3 or higher.
• We do not accept transfer of credit, or credit for experiential learning. Applicants do not receive credit for previous coursework and/or experience.

Application Process

• Complete the MUSC Application . Opens July 1, 2024
• Official transcripts from all colleges or universities attended for all college credit courses.
• GRE Scores.
• Two references: One physical therapist and one professor or advisor (see above).
• Personal statement.
• Log of physical therapy experience.

All above information must be received on or before the application deadline to be considered for admission to the program. It is the applicant's responsibility to review the progress of his/her application by viewing the Application Progress Portal  and ensure that all application materials (including official reference forms, and all official transcripts are received by the application deadline).

Admissions Timeline

International Applicants

MUSC’s Hybrid DPT program is unable to admit international students requiring an F-1 visa. Applications will only be accepted from U.S. citizens, permanent residents, or those holding other valid nonimmigrant visa classifications that allow participation in lawful study while in the United States.

Use of Marijuana and/or CBD Products

Marijuana is a Schedule 1 drug and is illegal to purchase in South Carolina. Apart from a narrow and limited scope of codified/documented medical exceptions, it is illegal for individuals to use marijuana/tetrahydrocannabinol (THC) in South Carolina. Although cannabidiol (CBD) products may be purchased and used in South Carolina, please be aware that CBD products may contain higher levels of THC than represented on packaging and use of CBD products can result in a positive drug screen for THC/marijuana. Be aware that current drug testing methods cannot accurately ascertain the origins of THC metabolites (i.e., whether from marijuana or CBD products). Your academic program has the authority to conduct random and/or scheduled drug testing; if your test result is reported as positive for THC metabolites (even if you only used a CBD product), your ability to be accepted into the program, progress in the program, and/or successfully complete the program may be negatively impacted.

Scholarship Eligibility

MUSC offers scholarships for which you may be eligible. Some are awarded based on academic achievement; others are awarded based on community service, for example. However, the majority of scholarships awarded at MUSC are based on financial need. This means those scholarships are only awarded to students who need some financial assistance to cover the cost of tuition and fees. If you would like to be considered for a financial need-based scholarship, you must have an up-to-date Free Application for Federal Student Aid (FAFSA) on file. Make sure you list Medical University of South Carolina on your FAFSA form, along with MUSC’s code: 003438. We encourage you to submit the FAFSA as early as possible. It is recommended to submit the FAFSA in January if you plan to enroll in the Fall.

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Committee on Physical Activity and Physical Education in the School Environment; Food and Nutrition Board; Institute of Medicine; Kohl HW III, Cook HD, editors. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington (DC): National Academies Press (US); 2013 Oct 30.

Educating the Student Body: Taking Physical Activity and Physical Education to School.

• Hardcopy Version at National Academies Press

4 Physical Activity, Fitness, and Physical Education: Effects on Academic Performance

Key messages.

• Evidence suggests that increasing physical activity and physical fitness may improve academic performance and that time in the school day dedicated to recess, physical education class, and physical activity in the classroom may also facilitate academic performance.
• Available evidence suggests that mathematics and reading are the academic topics that are most influenced by physical activity. These topics depend on efficient and effective executive function, which has been linked to physical activity and physical fitness.
• Executive function and brain health underlie academic performance. Basic cognitive functions related to attention and memory facilitate learning, and these functions are enhanced by physical activity and higher aerobic fitness.
• Single sessions of and long-term participation in physical activity improve cognitive performance and brain health. Children who participate in vigorous- or moderate-intensity physical activity benefit the most.
• Given the importance of time on task to learning, students should be provided with frequent physical activity breaks that are developmentally appropriate.
• Although presently understudied, physically active lessons offered in the classroom may increase time on task and attention to task in the classroom setting.

Although academic performance stems from a complex interaction between intellect and contextual variables, health is a vital moderating factor in a child's ability to learn. The idea that healthy children learn better is empirically supported and well accepted ( Basch, 2010 ), and multiple studies have confirmed that health benefits are associated with physical activity, including cardiovascular and muscular fitness, bone health, psychosocial outcomes, and cognitive and brain health ( Strong et al., 2005 ; see Chapter 3 ). The relationship of physical activity and physical fitness to cognitive and brain health and to academic performance is the subject of this chapter.

Given that the brain is responsible for both mental processes and physical actions of the human body, brain health is important across the life span. In adults, brain health, representing absence of disease and optimal structure and function, is measured in terms of quality of life and effective functioning in activities of daily living. In children, brain health can be measured in terms of successful development of attention, on-task behavior, memory, and academic performance in an educational setting. This chapter reviews the findings of recent research regarding the contribution of engagement in physical activity and the attainment of a health-enhancing level of physical fitness to cognitive and brain health in children. Correlational research examining the relationship among academic performance, physical fitness, and physical activity also is described. Because research in older adults has served as a model for understanding the effects of physical activity and fitness on the developing brain during childhood, the adult research is briefly discussed. The short- and long-term cognitive benefits of both a single session of and regular participation in physical activity are summarized.

Before outlining the health benefits of physical activity and fitness, it is important to note that many factors influence academic performance. Among these are socioeconomic status ( Sirin, 2005 ), parental involvement ( Fan and Chen, 2001 ), and a host of other demographic factors. A valuable predictor of student academic performance is a parent having clear expectations for the child's academic success. Attendance is another factor confirmed as having a significant impact on academic performance ( Stanca, 2006 ; Baxter et al., 2011 ). Because children must be present to learn the desired content, attendance should be measured in considering factors related to academic performance.

• PHYSICAL FITNESS AND PHYSICAL ACTIVITY: RELATION TO ACADEMIC PERFORMANCE

State-mandated academic achievement testing has had the unintended consequence of reducing opportunities for children to be physically active during the school day and beyond. In addition to a general shifting of time in school away from physical education to allow for more time on academic subjects, some children are withheld from physical education classes or recess to participate in remedial or enriched learning experiences designed to increase academic performance ( Pellegrini and Bohn, 2005 ; see Chapter 5 ). Yet little evidence supports the notion that more time allocated to subject matter will translate into better test scores. Indeed, 11 of 14 correlational studies of physical activity during the school day demonstrate a positive relationship to academic performance ( Rasberry et al., 2011 ). Overall, a rapidly growing body of work suggests that time spent engaged in physical activity is related not only to a healthier body but also to a healthier mind ( Hillman et al., 2008 ).

Children respond faster and with greater accuracy to a variety of cognitive tasks after participating in a session of physical activity ( Tomporowski, 2003 ; Budde et al., 2008 ; Hillman et al., 2009 ; Pesce et al., 2009 ; Ellemberg and St-Louis-Deschênes, 2010 ). A single bout of moderate-intensity physical activity has been found to increase neural and behavioral concomitants associated with the allocation of attention to a specific cognitive task ( Hillman et al., 2009 ; Pontifex et al., 2012 ). And when children who participated in 30 minutes of aerobic physical activity were compared with children who watched television for the same amount of time, the former children cognitively outperformed the latter ( Ellemberg and St-Louis-Desêhenes, 2010 ). Visual task switching data among 69 overweight and inactive children did not show differences between cognitive performance after treadmill walking and sitting ( Tomporowski et al., 2008b ).

When physical activity is used as a break from academic learning time, postengagement effects include better attention ( Grieco et al., 2009 ; Bartholomew and Jowers, 2011 ), increased on-task behaviors ( Mahar et al., 2006 ), and improved academic performance ( Donnelly and Lambourne, 2011 ). Comparisons between 1st-grade students housed in a classroom with stand-sit desks where the child could stand at his/her discretion and in classrooms containing traditional furniture showed that the former children were highly likely to stand, thus expending significantly more energy than those who were seated ( Benden et al., 2011 ). More important, teachers can offer physical activity breaks as part of a supplemental curriculum or simply as a way to reset student attention during a lesson ( Kibbe et al., 2011 ; see Chapter 6 ) and when provided with minimal training can efficaciously produce vigorous or moderate energy expenditure in students ( Stewart et al., 2004 ). Further, after-school physical activity programs have demonstrated the ability to improve cardiovascular endurance, and this increase in aerobic fitness has been shown to mediate improvements in academic performance ( Fredericks et al., 2006 ), as well as the allocation of neural resources underlying performance on a working memory task ( Kamijo et al., 2011 ).

Over the past three decades, several reviews and meta-analyses have described the relationship among physical fitness, physical activity, and cognition (broadly defined as all mental processes). The majority of these reviews have focused on the relationship between academic performance and physical fitness—a physiological trait commonly defined in terms of cardiorespiratory capacity (e.g., maximal oxygen consumption; see Chapter 3 ). More recently, reviews have attempted to describe the effects of an acute or single bout of physical activity, as a behavior, on academic performance. These reviews have focused on brain health in older adults ( Colcombe and Kramer, 2003 ), as well as the effects of acute physical activity on cognition in adults ( Tomporowski, 2003 ). Some have considered age as part of the analysis ( Etnier et al., 1997 , 2006 ). Reviews focusing on research conducted in children ( Sibley and Etnier, 2003 ) have examined the relationship among physical activity, participation in sports, and academic performance ( Trudeau and Shephard, 2008 , 2010 ; Singh et al., 2012 ); physical activity and mental and cognitive health ( Biddle and Asare, 2011 ); and physical activity, nutrition, and academic performance ( Burkhalter and Hillman, 2011 ). The findings of most of these reviews align with the conclusions presented in a meta-analytic review conducted by Fedewa and Ahn (2011) . The studies reviewed by Fedewa and Ahn include experimental/quasi-experimental as well as cross-sectional and correlational designs, with the experimental designs yielding the highest effect sizes. The strongest relationships were found between aerobic fitness and achievement in mathematics, followed by IQ and reading performance. The range of cognitive performance measures, participant characteristics, and types of research design all mediated the relationship among physical activity, fitness, and academic performance. With regard to physical activity interventions, which were carried out both within and beyond the school day, those involving small groups of peers (around 10 youth of a similar age) were associated with the greatest gains in academic performance.

The number of peer-reviewed publications on this topic is growing exponentially. Further evidence of the growth of this line of inquiry is its increased global presence. Positive relationships among physical activity, physical fitness, and academic performance have been found among students from the Netherlands ( Singh et al., 2012 ) and Taiwan ( Chih and Chen, 2011 ). Broadly speaking, however, many of these studies show small to moderate effects and suffer from poor research designs ( Biddle and Asare, 2011 ; Singh et al., 2012 ).

Basch (2010) conducted a comprehensive review of how children's health and health disparities influence academic performance and learning. The author's report draws on empirical evidence suggesting that education reform will be ineffective unless children's health is made a priority. Basch concludes that schools may be the only place where health inequities can be addressed and that, if children's basic health needs are not met, they will struggle to learn regardless of the effectiveness of the instructional materials used. More recently, Efrat (2011) conducted a review of physical activity, fitness, and academic performance to examine the achievement gap. He discovered that only seven studies had included socioeconomic status as a variable, despite its known relationship to education ( Sirin, 2005 ).

Physical Fitness as a Learning Outcome of Physical Education and Its Relation to Academic Performance

Achieving and maintaining a healthy level of aerobic fitness, as defined using criterion-referenced standards from the National Health and Nutrition Examination Survey (NHANES; Welk et al., 2011 ), is a desired learning outcome of physical education programming. Regular participation in physical activity also is a national learning standard for physical education, a standard intended to facilitate the establishment of habitual and meaningful engagement in physical activity ( NASPE, 2004 ). Yet although physical fitness and participation in physical activity are established as learning outcomes in all 50 states, there is little evidence to suggest that children actually achieve and maintain these standards (see Chapter 2 ).

Statewide and national datasets containing data on youth physical fitness and academic performance have increased access to student-level data on this subject ( Grissom, 2005 ; Cottrell et al., 2007 ; Carlson et al., 2008 ; Chomitz et al., 2008 ; Wittberg et al., 2010 ; Van Dusen et al., 2011 ). Early research in South Australia focused on quantifying the benefits of physical activity and physical education during the school day; the benefits noted included increased physical fitness, decreased body fat, and reduced risk for cardiovascular disease ( Dwyer et al., 1979 , 1983 ). Even today, Dwyer and colleagues are among the few scholars who regularly include in their research measures of physical activity intensity in the school environment, which is believed to be a key reason why they are able to report differentiated effects of different intensities. A longitudinal study in Trois-Rivières, Québec, Canada, tracked how the academic performance of children from grades 1 through 6 was related to student health, motor skills, and time spent in physical education. The researchers concluded that additional time dedicated to physical education did not inhibit academic performance ( Shephard et al., 1984 ; Shephard, 1986 ; Trudeau and Shephard, 2008 ).

Longitudinal follow-up investigating the long-term benefits of enhanced physical education experiences is encouraging but largely inconclusive. In a study examining the effects of daily physical education during elementary school on physical activity during adulthood, 720 men and women completed the Québec Health Survey ( Trudeau et al., 1999 ). Findings suggest that physical education was associated with physical activity in later life for females but not males ( Trudeau et al., 1999 ); most of the associations were significant but weak ( Trudeau et al., 2004 ). Adult body mass index (BMI) at age 34 was related to childhood BMI at ages 10-12 in females but not males ( Trudeau et al., 2001 ). Longitudinal studies such as those conducted in Sweden and Finland also suggest that physical education experiences may be related to adult engagement in physical activity ( Glenmark, 1994 ; Telama et al., 1997 ). From an academic performance perspective, longitudinal data on men who enlisted for military service imply that cardiovascular fitness at age 18 predicted cognitive performance in later life (Aberg et al., 2009), thereby supporting the idea of offering physical education and physical activity opportunities well into emerging adulthood through secondary and postsecondary education.

Castelli and colleagues (2007) investigated younger children (in 3rd and 5th grades) and the differential contributions of the various subcomponents of the Fitnessgram ® . Specifically, they examined the individual contributions of aerobic capacity, muscle strength, muscle flexibility, and body composition to performance in mathematics and reading on the Illinois Standardized Achievement Test among a sample of 259 children. Their findings corroborate those of the California Department of Education ( Grissom, 2005 ), indicating a general relationship between fitness and achievement test performance. When the individual components of the Fitnessgram were decomposed, the researchers determined that only aerobic capacity was related to test performance. Muscle strength and flexibility showed no relationship, while an inverse association of BMI with test performance was observed, such that higher BMI was associated with lower test performance. Although Baxter and colleagues (2011) confirmed the importance of attending school in relation to academic performance through the use of 4th-grade student recall, correlations with BMI were not significant.

State-mandated implementation of the coordinated school health model requires all schools in Texas to conduct annual fitness testing using the Fitnessgram among students in grades 3-12. In a special issue of Research Quarterly for Exercise and Sport (2010), multiple articles describe the current state of physical fitness among children in Texas; confirm the associations among school performance levels, academic achievement, and physical fitness ( Welk et al., 2010 ; Zhu et al., 2010 ); and demonstrate the ability of qualified physical education teachers to administer physical fitness tests ( Zhu et al., 2010 ). Also using data from Texas schools, Van Dusen and colleagues (2011) found that cardiovascular fitness had the strongest association with academic performance, particularly in mathematics over reading. Unlike previous research, which demonstrated a steady decline in fitness by developmental stage ( Duncan et al., 2007 ), this study found that cardiovascular fitness did decrease but not significantly ( Van Dusen et al., 2011 ). Aerobic fitness, then, may be important to academic performance, as there may be a dose-response relationship ( Van Dusen et al., 2011 ).

Using a large sample of students in grades 4-8, Chomitz and colleagues (2008) found that the likelihood of passing both mathematics and English achievement tests increased with the number of fitness tests passed during physical education class, and the odds of passing the mathematics achievement tests were inversely related to higher body weight. Similar to the findings of Castelli and colleagues (2007) , socioeconomic status and demographic factors explained little of the relationship between aerobic fitness and academic performance; however, socioeconomic status may be an explanatory variable for students of low fitness ( London and Castrechini, 2011 ).

In sum, numerous cross-sectional and correlational studies demonstrate small-to-moderate positive or null associations between physical fitness ( Grissom, 2005 ; Cottrell et al., 2007 ; Edwards et al., 2009; Eveland-Sayers et al., 2009 ; Cooper et al., 2010 ; Welk et al., 2010 ; Wittberg et al., 2010 ; Zhu et al., 2010 ; Van Dusen et al., 2011 ), particularly aerobic fitness, and academic performance ( Castelli et al, 2007 ; Chomitz et al., 2008 ; Roberts et al., 2010 ; Welk et al., 2010 ; Chih and Chen, 2011 ; London and Castrechini, 2011 ; Van Dusen et al., 2011 ). Moreover, the findings may support a dose-response association, suggesting that the more components of physical fitness (e.g., cardiovascular endurance, strength, muscle endurance) considered acceptable for the specific age and gender that are present, the greater the likelihood of successful academic performance. From a public health and policy standpoint, the conclusions these findings support are limited by few causal inferences, a lack of data confirmation, and inadequate reliability because the data were often collected by nonresearchers or through self-report methods. It may also be noted that this research includes no known longitudinal studies and few randomized controlled trials (examples are included later in this chapter in the discussion of the developing brain).

Physical Activity, Physical Education, and Academic Performance

In contrast with the correlational data presented above for physical fitness, more information is needed on the direct effects of participation in physical activity programming and physical education classes on academic performance.

In a meta-analysis, Sibley and Etnier (2003) found a positive relationship between physical activity and cognition in school-age youth (aged 4-18), suggesting that physical activity, as well as physical fitness, may be related to cognitive outcomes during development. Participation in physical activity was related to cognitive performance in eight measurement categories (perceptual skills, IQ, achievement, verbal tests, mathematics tests, memory, developmental level/academic readiness, and “other”), with results indicating a beneficial relationship of physical activity to all cognitive outcomes except memory ( Sibley and Etnier, 2003 ). Since that meta-analysis, however, several papers have reported robust relationships between aerobic fitness and different aspects of memory in children (e.g., Chaddock et al., 2010a , 2011 ; Kamijo et al., 2011 ; Monti et al., 2012 ). Regardless, the comprehensive review of Sibley and Etnier (2003) was important because it helped bring attention to an emerging literature suggesting that physical activity may benefit cognitive development even as it also demonstrated the need for further study to better understand the multifaceted relationship between physical activity and cognitive and brain health.

The regular engagement in physical activity achieved during physical education programming can also be related to academic performance, especially when the class is taught by a physical education teacher. The Sports, Play, and Active Recreation for Kids (SPARK) study examined the effects of a 2-year health-related physical education program on academic performance in children ( Sallis et al., 1999 ). In an experimental design, seven elementary schools were randomly assigned to one of three conditions: (1) a specialist condition in which certified physical education teachers delivered the SPARK curriculum, (2) a trained-teacher condition in which classroom teachers implemented the curriculum, and (3) a control condition in which classroom teachers implemented the local physical education curriculum. No significant differences by condition were found for mathematics testing; however, reading scores were significantly higher in the specialist condition relative to the control condition ( Sallis et al., 1999 ), while language scores were significantly lower in the specialist condition than in the other two conditions. The authors conclude that spending time in physical education with a specialist did not have a negative effect on academic performance. Shortcomings of this research include the amount of data loss from pre- to posttest, the use of results of 2nd-grade testing that exceeded the national average in performance as baseline data, and the use of norm-referenced rather than criterion-based testing.

In seminal research conducted by Gabbard and Barton (1979) , six different conditions of physical activity (no activity; 20, 30, 40, and 50 minutes; and posttest no activity) were completed by 106 2nd graders during physical education. Each physical activity session was followed by 5 minutes of rest and the completion of 36 math problems. The authors found a potential threshold effect whereby only the 50-minute condition improved mathematical performance, with no differences by gender.

A longitudinal study of the kindergarten class of 1998–1999, using data from the Early Childhood Longitudinal Study, investigated the association between enrollment in physical education and academic achievement ( Carlson et al., 2008 ). Higher amounts of physical education were correlated with better academic performance in mathematics among females, but this finding did not hold true for males.

Ahamed and colleagues (2007) found in a cluster randomized trial that, after 16 months of a classroom-based physical activity intervention, there was no significant difference between the treatment and control groups in performance on the standardized Cognitive Abilities Test, Third Edition (CAT-3). Others have found, however, that coordinative exercise ( Budde et al., 2008 ) or bouts of vigorous physical activity during free time ( Coe et al., 2006 ) contribute to higher levels of academic performance. Specifically, Coe and colleagues examined the association of enrollment in physical education and self-reported vigorous- or moderate-intensity physical activity outside school with performance in core academic courses and on the Terra Nova Standardized Achievement Test among more than 200 6th-grade students. Their findings indicate that academic performance was unaffected by enrollment in physical education classes, which were found to average only 19 minutes of vigorous- or moderate-intensity physical activity. When time spent engaged in vigorous- or moderate-intensity physical activity outside of school was considered, however, a significant positive relation to academic performance emerged, with more time engaged in vigorous- or moderate-intensity physical activity being related to better grades but not test scores ( Coe et al., 2006 ).

Studies of participation in sports and academic achievement have found positive associations ( Mechanic and Hansell, 1987 ; Dexter, 1999 ; Crosnoe, 2002 ; Eitle and Eitle, 2002 ; Stephens and Schaben, 2002 ; Eitle, 2005 ; Miller et al., 2005 ; Fox et al., 2010 ; Ruiz et al., 2010 ); higher grade point averages (GPAs) in season than out of season ( Silliker and Quirk, 1997 ); a negative association between cheerleading and science performance ( Hanson and Kraus, 1998 ); and weak and negative associations between the amount of time spent participating in sports and performance in English-language class among 13-, 14-, and 16-year-old students ( Daley and Ryan, 2000 ). Other studies, however, have found no association between participation in sports and academic performance ( Fisher et al., 1996 ). The findings of these studies need to be interpreted with caution as many of their designs failed to account for the level of participation by individuals in the sport (e.g., amount of playing time, type and intensity of physical activity engagement by sport). Further, it is unclear whether policies required students to have higher GPAs to be eligible for participation. Offering sports opportunities is well justified regardless of the cognitive benefits, however, given that adolescents may be less likely to engage in risky behaviors when involved in sports or other extracurricular activities ( Page et al., 1998 ; Elder et al., 2000 ; Taliaferro et al., 2010 ), that participation in sports increases physical fitness, and that affiliation with sports enhances school connectedness.

Although a consensus on the relationship of physical activity to academic achievement has not been reached, the vast majority of available evidence suggests the relationship is either positive or neutral. The meta-analytic review by Fedewa and Ahn (2011) suggests that interventions entailing aerobic physical activity have the greatest impact on academic performance; however, all types of physical activity, except those involving flexibility alone, contribute to enhanced academic performance, as do interventions that use small groups (about 10 students) rather than individuals or large groups. Regardless of the strength of the findings, the literature indicates that time spent engaged in physical activity is beneficial to children because it has not been found to detract from academic performance, and in fact can improve overall health and function ( Sallis et al., 1999 ; Hillman et al., 2008 ; Tomporowski et al., 2008a ; Trudeau and Shephard, 2008 ; Rasberry et al., 2011 ).

Single Bouts of Physical Activity

Beyond formal physical education, evidence suggests that multi-component approaches are a viable means of providing physical activity opportunities for children across the school curriculum (see also Chapter 6 ). Although health-related fitness lessons taught by certified physical education teachers result in greater student fitness gains relative to such lessons taught by other teachers ( Sallis et al., 1999 ), non-physical education teachers are capable of providing opportunities to be physically active within the classroom ( Kibbe et al., 2011 ). Single sessions or bouts of physical activity have independent merit, offering immediate benefits that can enhance the learning experience. Studies have found that single bouts of physical activity result in improved attention ( Hillman et al., 2003 , 2009 ; Pontifex et al., 2012 ), better working memory ( Pontifex et al., 2009 ), and increased academic learning time and reduced off-task behaviors ( Mahar et al., 2006 ; Bartholomew and Jowers, 2011 ). Yet single bouts of physical activity have differential effects, as very vigorous exercise has been associated with cognitive fatigue and even cognitive decline in adults ( Tomporowski, 2003 ). As seen in Figure 4-1 , high levels of effort, arousal, or activation can influence perception, decision making, response preparation, and actual response. For discussion of the underlying constructs and differential effects of single bouts of physical activity on cognitive performance, see Tomporowski (2003) .

Information processing: Diagram of a simplified version of Sanders's (1983) cognitive-energetic model of human information processing (adapted from Jones and Hardy, 1989). SOURCE: Tomporowski, 2003. Reprinted with permission.

For children, classrooms are busy places where they must distinguish relevant information from distractions that emerge from many different sources occurring simultaneously. A student must listen to the teacher, adhere to classroom procedures, focus on a specific task, hold and retain information, and make connections between novel information and previous experiences. Hillman and colleagues (2009) demonstrated that a single bout of moderate-intensity walking (60 percent of maximum heart rate) resulted in significant improvements in performance on a task requiring attentional inhibition (e.g., the ability to focus on a single task). These findings were accompanied by changes in neuroelectric measures underlying the allocation of attention (see Figure 4-2 ) and significant improvements on the reading subtest of the Wide Range Achievement Test. No such effects were observed following a similar duration of quiet rest. These findings were later replicated and extended to demonstrate benefits for both mathematics and reading performance in healthy children and those diagnosed with attention deficit hyperactivity disorder ( Pontifex et al., 2013 ). Further replications of these findings demonstrated that a single bout of moderate-intensity exercise using a treadmill improved performance on a task of attention and inhibition, but similar benefits were not derived from moderate-intensity exercise that involved exergaming ( O'Leary et al., 2011 ). It was also found that such benefits were derived following cessation of, but not during, the bout of exercise ( Drollette et al., 2012 ). The applications of such empirical findings within the school setting remain unclear.

Effects of a single session of exercise in preadolescent children. SOURCE: Hillman et al., 2009. Reprinted with permission.

A randomized controlled trial entitled Physical Activity Across the Curriculum (PAAC) used cluster randomization among 24 schools to examine the effects of physically active classroom lessons on BMI and academic achievement ( Donnelly et al., 2009 ). The academically oriented physical activities were intended to be of vigorous or moderate intensity (3–6 metabolic equivalents [METs]) and to last approximately 10 minutes and were specifically designed to supplement content in mathematics, language arts, geography, history, spelling, science, and health. The study followed 665 boys and 677 girls for 3 years as they rose from 2nd or 3rd to 4th or 5th grades. Changes in academic achievement, fitness, and blood screening were considered secondary outcomes. During a 3-year period, students who engaged in physically active lessons, on average, improved their academic achievement by 6 percent, while the control groups exhibited a 1 percent decrease. In students who experienced at least 75 minutes of PAAC lessons per week, BMI remained stable (see Figure 4-3 ).

Change in academic scores from baseline after physically active classroom lessons in elementary schools in northeast Kansas (2003–2006). NOTE: All differences between the Physical Activity Across the Curriculum (PAAC) group ( N = 117) and control (more...)

It is important to note that cognitive tasks completed before, during, and after physical activity show varying effects, but the effects were always positive compared with sedentary behavior. In a study carried out by Drollette and colleagues (2012) , 36 preadolescent children completed two cognitive tasks—a flanker task to assess attention and inhibition and a spatial nback task to assess working memory—before, during, and after seated rest and treadmill walking conditions. The children sat or walked on different days for an average of 19 minutes. The results suggest that the physical activity enhanced cognitive performance for the attention task but not for the task requiring working memory. Accordingly, although more research is needed, the authors suggest that the acute effects of exercise may be selective to certain cognitive processes (i.e., attentional inhibition) while unrelated to others (e.g., working memory). Indeed, data collected using a task-switching paradigm (i.e., a task designed to assess multitasking and requiring the scheduling of attention to multiple aspects of the environment) among 69 overweight and inactive children did not show differences in cognitive performance following acute bouts of treadmill walking or sitting ( Tomporowski et al., 2008b ). Thus, findings to date indicate a robust relationship of acute exercise to transient improvements in attention but appear inconsistent for other aspects of cognition.

Academic Learning Time and On- and Off-Task Behaviors

Excessive time on task, inattention to task, off-task behavior, and delinquency are important considerations in the learning environment given the importance of academic learning time to academic performance. These behaviors are observable and of concern to teachers as they detract from the learning environment. Systematic observation by trained observers may yield important insight regarding the effects of short physical activity breaks on these behaviors. Indeed, systematic observations of student behavior have been used as an alternative means of measuring academic performance ( Mahar et al., 2006 ; Grieco et al., 2009 ).

After the development of classroom-based physical activities, called Energizers, teachers were trained in how to implement such activities in their lessons at least twice per week ( Mahar et al., 2006 ). Measurements of baseline physical activity and on-task behaviors were collected in two 3rd-grade and two 4th-grade classes, using pedometers and direct observation. The intervention included 243 students, while 108 served as controls by not engaging in the activities. A subgroup of 62 3rd and 4th graders was observed for on-task behavior in the classroom following the physical activity. Children who participated in Energizers took more steps during the school day than those who did not; they also increased their on-task behaviors by more than 20 percent over baseline measures.

A systematic review of a similar in-class, academically oriented, physical activity plan—Take 10!—was conducted to identify the effects of its implementation after it had been in use for 10 years ( Kibbe et al., 2011 ). The findings suggest that children who experienced Take 10! in the classroom engaged in moderate to vigorous physical activity (6.16 to 6.42 METs) and had lower BMIs than those who did not. Further, children in the Take 10! classrooms had better fluid intelligence ( Reed et al., 2010 ) and higher academic achievement scores ( Donnelly et al., 2009 ).

Some have expressed concern that introducing physical activity into the classroom setting may be distracting to students. Yet in one study it was sedentary students who demonstrated a decrease in time on task, while active students returned to the same level of on-task behavior after an active learning task ( Grieco et al., 2009 ). Among the 97 3rd-grade students in this study, a small but nonsignificant increase in on-task behaviors was seen immediately following these active lessons. Additionally, these improvements were not mediated by BMI.

In sum, although presently understudied, physically active lessons may increase time on task and attention to task in the classroom setting. Given the complexity of the typical classroom, the strategy of including content-specific lessons that incorporate physical activity may be justified.

It is recommended that every child have 20 minutes of recess each day and that this time be outdoors whenever possible, in a safe activity ( NASPE, 2006 ). Consistent engagement in recess can help students refine social skills, learn social mediation skills surrounding fair play, obtain additional minutes of vigorous- or moderate-intensity physical activity that contribute toward the recommend 60 minutes or more per day, and have an opportunity to express their imagination through free play ( Pellegrini and Bohn, 2005 ; see also Chapter 6 ). When children participate in recess before lunch, additional benefits accrue, such as less food waste, increased incidence of appropriate behavior in the cafeteria during lunch, and greater student readiness to learn upon returning to the classroom after lunch ( Getlinger et al., 1996 ; Wechsler et al., 2001 ).

To examine the effects of engagement in physical activity during recess on classroom behavior, Barros and colleagues (2009) examined data from the Early Childhood Longitudinal Study on 10,000 8- to 9-year-old children. Teachers provided the number of minutes of recess as well as a ranking of classroom behavior (ranging from “misbehaves frequently” to “behaves exceptionally well”). Results indicate that children who had at least 15 minutes of recess were more likely to exhibit appropriate behavior in the classroom ( Barros et al., 2009 ). In another study, 43 4th-grade students were randomly assigned to 1 or no days of recess to examine the effects on classroom behavior ( Jarrett et al., 1998 ). The researchers concluded that on-task behavior was better among the children who had recess. A moderate effect size (= 0.51) was observed. In a series of studies examining kindergartners' attention to task following a 20-minute recess, increased time on task was observed during learning centers and story reading ( Pellegrini et al., 1995 ). Despite these positive findings centered on improved attention, it is important to note that few of these studies actually measured the intensity of the physical activity during recess.

From a slightly different perspective, survey data from 547 Virginia elementary school principals suggest that time dedicated to student participation in physical education, art, and music did not negatively influence academic performance ( Wilkins et al., 2003 ). Thus, the strategy of reducing time spent in physical education to increase academic performance may not have the desired effect. The evidence on in-school physical activity supports the provision of physical activity breaks during the school day as a way to increase fluid intelligence, time on task, and attention. However, it remains unclear what portion of these effects can be attributed to a break from academic time and what portion is a direct result of the specific demands/characteristics of the physical activity.

• THE DEVELOPING bRAIN, PHYSICAL ACTIVITY, AND BRAIN HEALTH

The study of brain health has grown beyond simply measuring behavioral outcomes such as task performance and reaction time (e.g., cognitive processing speed). New technology has emerged that has allowed scientists to understand the impact of lifestyle factors on the brain from the body systems level down to the molecular level. A greater understanding of the cognitive components that subserve academic performance and may be amenable to intervention has thereby been gained. Research conducted in both laboratory and field settings has helped define this line of inquiry and identify some preliminary underlying mechanisms.

The Evidence Base on the Relationship of Physical Activity to Brain Health and Cognition in Older Adults

Despite the current focus on the relationship of physical activity to cognitive development, the evidence base is larger on the association of physical activity with brain health and cognition during aging. Much can be learned about how physical activity affects childhood cognition and scholastic achievement through this work. Despite earlier investigations into the relationship of physical activity to cognitive aging (see Etnier et al., 1997 , for a review), the field was shaped by the findings of Kramer and colleagues (1999) , who examined the effects of aerobic fitness training on older adults using a randomized controlled design. Specifically, 124 older adults aged 60 and 75 were randomly assigned to a 6-month intervention of either walking (i.e., aerobic training) or flexibility (i.e., nonaerobic) training. The walking group but not the flexibility group showed improved cognitive performance, measured as a shorter response time to the presented stimulus. Results from a series of tasks that tapped different aspects of cognitive control indicated that engagement in physical activity is a beneficial means of combating cognitive aging ( Kramer et al., 1999 ).

Cognitive control, or executive control, is involved in the selection, scheduling, and coordination of computational processes underlying perception, memory, and goal-directed action. These processes allow for the optimization of behavioral interactions within the environment through flexible modulation of the ability to control attention ( MacDonald et al., 2000 ; Botvinick et al., 2001 ). Core cognitive processes that make up cognitive control or executive control include inhibition, working memory, and cognitive flexibility ( Diamond, 2006 ), processes mediated by networks that involve the prefrontal cortex. Inhibition (or inhibitory control) refers to the ability to override a strong internal or external pull so as to act appropriately within the demands imposed by the environment ( Davidson et al., 2006 ). For example, one exerts inhibitory control when one stops speaking when the teacher begins lecturing. Working memory refers to the ability to represent information mentally, manipulate stored information, and act on the information ( Davidson et al., 2006 ). In solving a difficult mathematical problem, for example, one must often remember the remainder. Finally, cognitive flexibility refers to the ability to switch perspectives, focus attention, and adapt behavior quickly and flexibly for the purposes of goal-directed action ( Blair et al., 2005 ; Davidson et al., 2006 ; Diamond, 2006 ). For example, one must shift attention from the teacher who is teaching a lesson to one's notes to write down information for later study.

Based on their earlier findings on changes in cognitive control induced by aerobic training, Colcombe and Kramer (2003) conducted a meta-analysis to examine the relationship between aerobic training and cognition in older adults aged 55-80 using data from 18 randomized controlled exercise interventions. Their findings suggest that aerobic training is associated with general cognitive benefits that are selectively and disproportionately greater for tasks or task components requiring greater amounts of cognitive control. A second and more recent meta-analysis ( Smith et al., 2010 ) corroborates the findings of Colcombe and Kramer, indicating that aerobic exercise is related to attention, processing speed, memory, and cognitive control; however, it should be noted that smaller effect sizes were observed, likely a result of the studies included in the respective meta-analyses. In older adults, then, aerobic training selectively improves cognition.

Hillman and colleagues (2006) examined the relationship between physical activity and inhibition (one aspect of cognitive control) using a computer-based stimulus-response protocol in 241 individuals aged 15-71. Their results indicate that greater amounts of physical activity are related to decreased response speed across task conditions requiring variable amounts of inhibition, suggesting a generalized relationship between physical activity and response speed. In addition, the authors found physical activity to be related to better accuracy across conditions in older adults, while no such relationship was observed for younger adults. Of interest, this relationship was disproportionately larger for the condition requiring greater amounts of inhibition in the older adults, suggesting that physical activity has both a general and selective association with task performance ( Hillman et al., 2006 ).

With advances in neuroimaging techniques, understanding of the effects of physical activity and aerobic fitness on brain structure and function has advanced rapidly over the past decade. In particular, a series of studies ( Colcombe et al., 2003 , 2004 , 2006 ; Kramer and Erickson, 2007 ; Hillman et al., 2008 ) of older individuals has been conducted to elucidate the relation of aerobic fitness to the brain and cognition. Normal aging results in the loss of brain tissue ( Colcombe et al., 2003 ), with markedly larger loss evidenced in the frontal, temporal, and parietal regions ( Raz, 2000 ). Thus cognitive functions subserved by these brain regions (such as those involved in cognitive control and aspects of memory) are expected to decay more dramatically than other aspects of cognition.

Colcombe and colleagues (2003) investigated the relationship of aerobic fitness to gray and white matter tissue loss using magnetic resonance imaging (MRI) in 55 healthy older adults aged 55-79. They observed robust age-related decreases in tissue density in the frontal, temporal, and parietal regions using voxel-based morphometry, a technique used to assess brain volume. Reductions in the amount of tissue loss in these regions were observed as a function of fitness. Given that the brain structures most affected by aging also demonstrated the greatest fitness-related sparing, these initial findings provide a biological basis for fitness-related benefits to brain health during aging.

In a second study, Colcombe and colleagues (2006) examined the effects of aerobic fitness training on brain structure using a randomized controlled design with 59 sedentary healthy adults aged 60-79. The treatment group received a 6-month aerobic exercise (i.e., walking) intervention, while the control group received a stretching and toning intervention that did not include aerobic exercise. Results indicated that gray and white matter brain volume increased for those who received the aerobic fitness training intervention. No such results were observed for those assigned to the stretching and toning group. Specifically, those assigned to the aerobic training intervention demonstrated increased gray matter in the frontal lobes, including the dorsal anterior cingulate cortex, the supplementary motor area, the middle frontal gyrus, the dorsolateral region of the right inferior frontal gyrus, and the left superior temporal lobe. White matter volume changes also were evidenced following the aerobic fitness intervention, with increases in white matter tracts being observed within the anterior third of the corpus callosum. These brain regions are important for cognition, as they have been implicated in the cognitive control of attention and memory processes. These findings suggest that aerobic training not only spares age-related loss of brain structures but also may in fact enhance the structural health of specific brain regions.

In addition to the structural changes noted above, research has investigated the relationship between aerobic fitness and changes in brain function. That is, aerobic fitness training has also been observed to induce changes in patterns of functional activation. Functional MRI (fMRI) measures, which make it possible to image activity in the brain while an individual is performing a cognitive task, have revealed that aerobic training induces changes in patterns of functional activation. This approach involves inferring changes in neuronal activity from alteration in blood flow or metabolic activity in the brain. In a seminal paper, Colcombe and colleagues (2004) examined the relationship of aerobic fitness to brain function and cognition across two studies with older adults. In the first study, 41 older adult participants (mean age ~66) were divided into higher- and lower-fit groups based on their performance on a maximal exercise test. In the second study, 29 participants (aged 58-77) were recruited and randomly assigned to either a fitness training (i.e., walking) or control (i.e., stretching and toning) intervention. In both studies, participants were given a task requiring variable amounts of attention and inhibition. Results indicated that fitness (study 1) and fitness training (study 2) were related to greater activation in the middle frontal gyrus and superior parietal cortex; these regions of the brain are involved in attentional control and inhibitory functioning, processes entailed in the regulation of attention and action. These changes in neural activation were related to significant improvements in performance on the cognitive control task of attention and inhibition.

Taken together, the findings across studies suggest that an increase in aerobic fitness, derived from physical activity, is related to improvements in the integrity of brain structure and function and may underlie improvements in cognition across tasks requiring cognitive control. Although developmental differences exist, the general paradigm of this research can be applied to early stages of the life span, and some early attempts to do so have been made, as described below. Given the focus of this chapter on childhood cognition, it should be noted that this section has provided only a brief and arguably narrow look at the research on physical activity and cognitive aging. Considerable work has detailed the relationship of physical activity to other aspects of adult cognition using behavioral and neuroimaging tools (e.g., Boecker, 2011 ). The interested reader is referred to a number of review papers and meta-analyses describing the relationship of physical activity to various aspects of cognitive and brain health ( Etnier et al., 1997 ; Colcombe and Kramer, 2003 ; Tomporowski, 2003 ; Thomas et al., 2012 ).

Child Development, Brain Structure, and Function

Certain aspects of development have been linked with experience, indicating an intricate interplay between genetic programming and environmental influences. Gray matter, and the organization of synaptic connections in particular, appears to be at least partially dependent on experience (NRC/IOM, 2000; Taylor, 2006 ), with the brain exhibiting a remarkable ability to reorganize itself in response to input from sensory systems, other cortical systems, or insult ( Huttenlocher and Dabholkar, 1997 ). During typical development, experience shapes the pruning process through the strengthening of neural networks that support relevant thoughts and actions and the elimination of unnecessary or redundant connections. Accordingly, the brain responds to experience in an adaptive or “plastic” manner, resulting in the efficient and effective adoption of thoughts, skills, and actions relevant to one's interactions within one's environmental surroundings. Examples of neural plasticity in response to unique environmental interaction have been demonstrated in human neuroimaging studies of participation in music ( Elbert et al., 1995 ; Chan et al., 1998 ; Münte et al., 2001 ) and sports ( Hatfield and Hillman, 2001 ; Aglioti et al., 2008 ), thus supporting the educational practice of providing music education and opportunities for physical activity to children.

Effects of Regular Engagement in Physical Activity and Physical Fitness on Brain Structure

Recent advances in neuroimaging techniques have rapidly advanced understanding of the role physical activity and aerobic fitness may have in brain structure. In children a growing body of correlational research suggests differential brain structure related to aerobic fitness. Chaddock and colleagues (2010a , b ) showed a relationship among aerobic fitness, brain volume, and aspects of cognition and memory. Specifically, Chaddock and colleagues (2010a) assigned 9- to 10-year-old preadolescent children to lower- and higher-fitness groups as a function of their scores on a maximal oxygen uptake (VO 2 max) test, which is considered the gold-standard measure of aerobic fitness. They observed larger bilateral hippocampal volume in higher-fit children using MRI, as well as better performance on a task of relational memory. It is important to note that relational memory has been shown to be mediated by the hippocampus ( Cohen and Eichenbaum, 1993 ; Cohen et al., 1999 ). Further, no differences emerged for a task condition requiring item memory, which is supported by structures outside the hippocampus, suggesting selectivity among the aspects of memory that benefit from higher amounts of fitness. Lastly, hippocampal volume was positively related to performance on the relational memory task but not the item memory task, and bilateral hippocampal volume was observed to mediate the relationship between fitness and relational memory ( Chaddock et al., 2010a ). Such findings are consistent with behavioral measures of relational memory in children ( Chaddock et al., 2011 ) and neuroimaging findings in older adults ( Erickson et al., 2009 , 2011 ) and support the robust nonhuman animal literature demonstrating the effects of exercise on cell proliferation ( Van Praag et al., 1999 ) and survival ( Neeper et al., 1995 ) in the hippocampus.

In a second investigation ( Chaddock et al., 2010b ), higher- and lower-fit children (aged 9-10) underwent an MRI to determine whether structural differences might be found that relate to performance on a cognitive control task that taps attention and inhibition. The authors observed differential findings in the basal ganglia, a subcortical structure involved in the interplay of cognition and willed action. Specifically, higher-fit children exhibited greater volume in the dorsal striatum (i.e., caudate nucleus, putamen, globus pallidus) relative to lower-fit children, while no differences were observed in the ventral striatum. Such findings are not surprising given the role of the dorsal striatum in cognitive control and response resolution ( Casey et al., 2008 ; Aron et al., 2009 ), as well as the growing body of research in children and adults indicating that higher levels of fitness are associated with better control of attention, memory, and cognition ( Colcombe and Kramer, 2003 ; Hillman et al., 2008 ; Chang and Etnier, 2009 ). Chaddock and colleagues (2010b) further observed that higher-fit children exhibited increased inhibitory control and response resolution and that higher basal ganglia volume was related to better task performance. These findings indicate that the dorsal striatum is involved in these aspects of higher-order cognition and that fitness may influence cognitive control during preadolescent development. It should be noted that both studies described above were correlational in nature, leaving open the possibility that other factors related to fitness and/or the maturation of subcortical structures may account for the observed group differences.

Effects of Regular Engagement in Physical Activity and Physical Fitness on Brain Function

Other research has attempted to characterize fitness-related differences in brain function using fMRI and event-related brain potentials (ERPs), which are neuroelectric indices of functional brain activation in the electro-encephalographic time series. To date, few randomized controlled interventions have been conducted. Notably, Davis and colleagues (2011) conducted one such intervention lasting approximately 14 weeks that randomized 20 sedentary overweight preadolescent children into an after-school physical activity intervention or a nonactivity control group. The fMRI data collected during an antisaccade task, which requires inhibitory control, indicated increased bilateral activation of the prefrontal cortex and decreased bilateral activation of the posterior parietal cortex following the physical activity intervention relative to the control group. Such findings illustrate some of the neural substrates influenced by participation in physical activity. Two additional correlational studies ( Voss et al., 2011 ; Chaddock et al., 2012 ) compared higher- and lower-fit preadolescent children and found differential brain activation and superior task performance as a function of fitness. That is, Chaddock and colleagues (2012) observed increased activation in prefrontal and parietal brain regions during early task blocks and decreased activation during later task blocks in higher-fit relative to lower-fit children. Given that higher-fit children outperformed lower-fit children on the aspects of the task requiring the greatest amount of cognitive control, the authors reason that the higher-fit children were more capable of adapting neural activity to meet the demands imposed by tasks that tapped higher-order cognitive processes such as inhibition and goal maintenance. Voss and colleagues (2011) used a similar task to vary cognitive control requirements and found that higher-fit children outperformed their lower-fit counterparts and that such differences became more pronounced during task conditions requiring the upregulation of control. Further, several differences emerged across various brain regions that together make up the network associated with cognitive control. Collectively, these differences suggest that higher-fit children are more efficient in the allocation of resources in support of cognitive control operations.

Other imaging research has examined the neuroelectric system (i.e., ERPs) to investigate which cognitive processes occurring between stimulus engagement and response execution are influenced by fitness. Several studies ( Hillman et al., 2005 , 2009 ; Pontifex et al., 2011 ) have examined the P3 component of the stimulus-locked ERP and demonstrated that higher-fit children have larger-amplitude and shorter-latency ERPs relative to their lower-fit peers. Classical theory suggests that P3 relates to neuronal activity associated with revision of the mental representation of the previous event within the stimulus environment ( Donchin, 1981 ). P3 amplitude reflects the allocation of attentional resources when working memory is updated ( Donchin and Coles, 1988 ) such that P3 is sensitive to the amount of attentional resources allocated to a stimulus ( Polich, 1997 ; Polich and Heine, 2007 ). P3 latency generally is considered to represent stimulus evaluation and classification speed ( Kutas et al., 1977 ; Duncan-Johnson, 1981 ) and thus may be considered a measure of stimulus detection and evaluation time ( Magliero et al., 1984 ; Ila and Polich, 1999 ). Therefore the above findings suggest that higher-fit children allocate greater attentional resources and have faster cognitive processing speed relative to lower-fit children ( Hillman et al., 2005 , 2009 ), with additional research suggesting that higher-fit children also exhibit greater flexibility in the allocation of attentional resources, as indexed by greater modulation of P3 amplitude across tasks that vary in the amount of cognitive control required ( Pontifex et al., 2011 ). Given that higher-fit children also demonstrate better performance on cognitive control tasks, the P3 component appears to reflect the effectiveness of a subset of cognitive systems that support willed action ( Hillman et al., 2009 ; Pontifex et al., 2011 ).

Two ERP studies ( Hillman et al., 2009 ; Pontifex et al., 2011 ) have focused on aspects of cognition involved in action monitoring. That is, the error-related negativity (ERN) component was investigated in higher- and lower-fit children to determine whether differences in evaluation and regulation of cognitive control operations were influenced by fitness level. The ERN component is observed in response-locked ERP averages. It is often elicited by errors of commission during task performance and is believed to represent either the detection of errors during task performance ( Gehring et al., 1993 ; Holroyd and Coles, 2002 ) or more generally the detection of response conflict ( Botvinick et al., 2001 ; Yeung et al., 2004 ), which may be engendered by errors in response production. Several studies have reported that higher-fit children exhibit smaller ERN amplitude during rapid-response tasks (i.e., instructions emphasizing speed of responding; Hillman et al., 2009 ) and more flexibility in the allocation of these resources during tasks entailing variable cognitive control demands, as evidenced by changes in ERN amplitude for higher-fit children and no modulation of ERN in lower-fit children ( Pontifex et al., 2011 ). Collectively, this pattern of results suggests that children with lower levels of fitness allocate fewer attentional resources during stimulus engagement (P3 amplitude) and exhibit slower cognitive processing speed (P3 latency) but increased activation of neural resources involved in the monitoring of their actions (ERN amplitude). Alternatively, higher-fit children allocate greater resources to environmental stimuli and demonstrate less reliance on action monitoring (increasing resource allocation only to meet the demands of the task). Under more demanding task conditions, the strategy of lower-fit children appears to fail since they perform more poorly under conditions requiring the upregulation of cognitive control.

Finally, only one randomized controlled trial published to date has used ERPs to assess neurocognitive function in children. Kamijo and colleagues (2011) studied performance on a working memory task before and after a 9-month physical activity intervention compared with a wait-list control group. They observed better performance following the physical activity intervention during task conditions that required the upregulation of working memory relative to the task condition requiring lesser amounts of working memory. Further, increased activation of the contingent negative variation (CNV), an ERP component reflecting cognitive and motor preparation, was observed at posttest over frontal scalp sites in the physical activity intervention group. No differences in performance or brain activation were noted for the wait-list control group. These findings suggest an increase in cognitive preparation processes in support of a more effective working memory network resulting from prolonged participation in physical activity. For children in a school setting, regular participation in physical activity as part of an after-school program is particularly beneficial for tasks that require the use of working memory.

Adiposity and Risk for Metabolic Syndrome as It Relates to Cognitive Health

A related and emerging literature that has recently been popularized investigates the relationship of adiposity to cognitive and brain health and academic performance. Several reports ( Datar et al., 2004 ; Datar and Sturm, 2006 ; Judge and Jahns, 2007 ; Gable et al., 2012 ) on this relationship are based on large-scale datasets derived from the Early Child Longitudinal Study. Further, nonhuman animal research has been used to elucidate the relationships between health indices and cognitive and brain health (see Figure 4-4 for an overview of these relationships). Collectively, these studies observed poorer future academic performance among children who entered school overweight or moved from a healthy weight to overweight during the course of development. Corroborating evidence for a negative relationship between adiposity and academic performance may be found in smaller but more tightly controlled studies. As noted above, Castelli and colleagues (2007) observed poorer performance on the mathematics and reading portions of the Illinois Standardized Achievement Test in 3rd- and 5th-grade students as a function of higher BMI, and Donnelly and colleagues (2009) used a cluster randomized trial to demonstrate that physical activity in the classroom decreased BMI and improved academic achievement among pre-adolescent children.

Relationships between health indices and cognitive and brain health. NOTE: AD = Alzheimer's disease; PD = Parkinson's disease. SOURCE: Cotman et al., 2007. Reprinted with permission.

Recently published reports describe the relationship between adiposity and cognitive and brain health to advance understanding of the basic cognitive processes and neural substrates that may underlie the adiposity-achievement relationship. Bolstered by findings in adult populations (e.g., Debette et al., 2010 ; Raji et al., 2010 ; Carnell et al., 2011 ), researchers have begun to publish data on preadolescent populations indicating differences in brain function and cognitive performance related to adiposity (however, see Gunstad et al., 2008 , for an instance in which adiposity was unrelated to cognitive outcomes). Specifically, Kamijo and colleagues (2012a) examined the relationship of weight status to cognitive control and academic achievement in 126 children aged 7-9. The children completed a battery of cognitive control tasks, and their body composition was assessed using dual X-ray absorptiometry (DXA). The authors found that higher BMI and greater amounts of fat mass (particularly in the midsection) were related to poorer performance on cognitive control tasks involving inhibition, as well as lower academic achievement. In follow-up studies, Kamijo and colleagues (2012b) investigated whether neural markers of the relationship between adiposity and cognition may be found through examination of ERP data. These studies compared healthy-weight and obese children and found a differential distribution of the P3 potential (i.e., less frontally distributed) and larger N2 amplitude, as well as smaller ERN magnitude, in obese children during task conditions that required greater amounts of inhibitory control ( Kamijo et al., 2012c ). Taken together, the above results suggest that obesity is associated with less effective neural processes during stimulus capture and response execution. As a result, obese children perform tasks more slowly ( Kamijo et al., 2012a ) and are less accurate ( Kamijo et al., 2012b , c ) in response to tasks requiring variable amounts of cognitive control. Although these data are correlational, they provide a basis for further study using other neuroimaging tools (e.g., MRI, fMRI), as well as a rationale for the design and implementation of randomized controlled studies that would allow for causal interpretation of the relationship of adiposity to cognitive and brain health. The next decade should provide a great deal of information on this relationship.

• LIMITATIONS

Despite the promising findings described in this chapter, it should be noted that the study of the relationship of childhood physical activity, aerobic fitness, and adiposity to cognitive and brain health and academic performance is in its early stages. Accordingly, most studies have used designs that afford correlation rather than causation. To date, in fact, only two randomized controlled trials ( Davis et al., 2011 ; Kamijo et al., 2011 ) on this relationship have been published. However, several others are currently ongoing, and it was necessary to provide evidence through correlational studies before investing the effort, time, and funding required for more demanding causal studies. Given that the evidence base in this area has grown exponentially in the past 10 years through correlational studies and that causal evidence has accumulated through adult and nonhuman animal studies, the next step will be to increase the amount of causal evidence available on school-age children.

Accomplishing this will require further consideration of demographic factors that may moderate the physical activity–cognition relationship. For instance, socioeconomic status has a unique relationship with physical activity ( Estabrooks et al., 2003 ) and cognitive control ( Mezzacappa, 2004 ). Although many studies have attempted to control for socioeconomic status (see Hillman et al., 2009 ; Kamijo et al., 2011 , 2012a , b , c ; Pontifex et al., 2011 ), further inquiry into its relationship with physical activity, adiposity, and cognition is warranted to determine whether it may serve as a potential mediator or moderator for the observed relationships. A second demographic factor that warrants further consideration is gender. Most authors have failed to describe gender differences when reporting on the physical activity–cognition literature. However, studies of adiposity and cognition have suggested that such a relationship may exist (see Datar and Sturm, 2006 ). Additionally, further consideration of age is warranted. Most studies have examined a relatively narrow age range, consisting of a few years. Such an approach often is necessary because of maturation and the need to develop comprehensive assessment tools that suit the various stages of development. However, this approach has yielded little understanding of how the physical activity–cognition relationship may change throughout the course of maturation.

Finally, although a number of studies have described the relationship of physical activity, fitness, and adiposity to standardized measures of academic performance, few attempts have been made to observe the relationship within the context of the educational environment. Standardized tests, although necessary to gauge knowledge, may not be the most sensitive measures for (the process of) learning. Future research will need to do a better job of translating promising laboratory findings to the real world to determine the value of this relationship in ecologically valid settings.

From an authentic and practical to a mechanistic perspective, physically active and aerobically fit children consistently outperform their inactive and unfit peers academically on both a short- and a long-term basis. Time spent engaged in physical activity is related not only to a healthier body but also to enriched cognitive development and lifelong brain health. Collectively, the findings across the body of literature in this area suggest that increases in aerobic fitness, derived from physical activity, are related to improvements in the integrity of brain structure and function that underlie academic performance. The strongest relationships have been found between aerobic fitness and performance in mathematics, reading, and English. For children in a school setting, regular participation in physical activity is particularly beneficial with respect to tasks that require working memory and problem solving. These findings are corroborated by the results of both authentic correlational studies and experimental randomized controlled trials. Overall, the benefits of additional time dedicated to physical education and other physical activity opportunities before, during, and after school outweigh the benefits of exclusive utilization of school time for academic learning, as physical activity opportunities offered across the curriculum do not inhibit academic performance.

Both habitual and single bouts of physical activity contribute to enhanced academic performance. Findings indicate a robust relationship of acute exercise to increased attention, with evidence emerging for a relationship between participation in physical activity and disciplinary behaviors, time on task, and academic performance. Specifically, higher-fit children allocate greater resources to a given task and demonstrate less reliance on environmental cues or teacher prompting.

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Children's Hospital of Philadelphia Researchers Find Elementary Age Children Experience More Concussions During Activities Unrelated to Sports

Children between 5 and 12 are more likely to experience worse symptoms and delays in specialist care if injured during recreation or other non-sport activities

PHILADELPHIA , June 27, 2024 /PRNewswire/ -- Researchers from Children's Hospital of Philadelphia (CHOP) found that young children between the ages of 5 and 12 were more likely to experience a concussion from recreation and other non-sport activities, yet those injuries were not seen by specialists until days later compared with sports-related concussions in the same age group.

This study suggests concussion research is needed for children outside of sports and that providing more resources and education to those providers diagnosing most concussions in this age group, particularly emergency departments and primary care, could reduce inequities in concussion care regardless of the mechanism of injury by which these patients experience concussions. The findings were recently published by the Journal of Pediatrics .

Adolescents experience high rates of sports- and recreation-related injuries, but the rate of injuries among children ages 5 through 12 is still high, at about 72.7 injuries per 1000 children. More than half of children in this age range participate in sports, as daily physical activity is recommended for optimal health and development, but with these activities comes a risk of pediatric concussion.

Most of the research into pediatric concussions has focused on adolescents and sports, which highlights a need to study concussions in younger children across all mechanisms of injury. Prior studies from nearly a decade ago reported the importance of non-sports and recreation-related concussions in elementary age children. Injuries sustained in these settings are marked by key differences in supervision at the time of injury that can influence how quickly a concussion is recognized, affecting access to and timing of care, which can lead to longer recovery times.

"In prior research, recreation-related injuries are not often differentiated from sports-related injuries, yet this study shows that these injuries can be just as serious and occur more frequently in this age group, suggesting that education and awareness about concussion needs to be emphasized to those who interact with children in these less structured settings," said senior study author Kristy Arbogast , PhD , director of the Center for Injury Research and Prevention and co-director of the Minds Matter Concussion Program at CHOP. "Patients injured outside of sports and recreation experienced a higher burden of symptoms and more changes to daily life, and delays in appropriate care could exacerbate these negative effects."

Using contemporary data from a pediatric concussion registry, researchers examined this age range and characterized concussions by their mechanisms of injury, distinguishing between injuries that occurred in organized sports and those that occurred outside of sports. They separated recreation, such as gym class, free play, or non-competitive sporting activities like biking, from other non-sports mechanisms, like motor vehicle crashes or falls, owing to the role of unstructured play in this age group. A total of 1,141 patients between the ages of 5 and 12 with concussions were evaluated within four weeks of injury and were included in this analysis. The researchers assessed whether the injury occurred during sports, recreation, or some other mechanism of injury ("non-sports-or-recreation-related"). Variations in demographics, point of healthcare entry, and clinical signs were evaluated across mechanisms.

The study found that recreation-related injuries were the most common in this age group at 37.3% of injuries, followed by non-sports-or-recreation-related concussions at 31.9%. These injuries were more likely to be seen first in the emergency department compared to sports-related concussions. Importantly, patients with recreation- or non-sports or recreation-related concussions were first evaluated by concussion specialists an average of 2 to 3 days later than sports-related concussions. Patients with concussions outside of sports and recreation also reported worse symptoms, including more visio-vestibular issues and more changes to sleep and other daily habits compared with the other patient groups.

"We see these findings as an opportunity to equip the clinical teams who may see these patients first with the latest tools for concussion diagnosis and management," said study co- author Daniel Corwin , MD , Director of Research Operations in the Division of Emergency Medicine and Emergency Department Lead of the Minds Matter Concussion Program. "These findings could also serve as a basis for school-based resources, including engagement of school nurses, to help address disparities in care across these injuries, particularly in this less well understood elementary age population of patients who sustain their injuries outside of sports."

This study was supported by the National Institute of Neurologic Disorders and Stroke of the National Institutes of Health under award numbers R01NS097549 and the Pennsylvania Department of Health.

Roby et al, "Characteristics of Pediatric Concussion across Different Mechanisms of Injury in 5–12-Year-Olds." J Pediatr. Online June 18, 2024 . DOI: 10.1016/j.jpeds.2024.114157.

About Children's Hospital of Philadelphia : A non-profit, charitable organization, Children's Hospital of Philadelphia was founded in 1855 as the nation's first pediatric hospital. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals, and pioneering major research initiatives, the hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country. The institution has a well-established history of providing advanced pediatric care close to home through its CHOP Care Network , which includes more than 50 primary care practices, specialty care and surgical centers, urgent care centers, and community hospital alliances throughout Pennsylvania and New Jersey , as well as the Middleman Family Pavilion  and its dedicated pediatric emergency department in King of Prussia . In addition, its unique family-centered care and public service programs have brought Children's Hospital of Philadelphia recognition as a leading advocate for children and adolescents. For more information, visit https://www.chop.edu .

Contact: Ben Leach Children's Hospital of Philadelphia (609) 634-7906 [email protected]

SOURCE Children's Hospital of Philadelphia

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