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Psychosocial Correlates of Physical Activity in Healthy Children FREE

Richard S. Strauss, MD; Daria Rodzilsky, RD; Gail Burack, PhD; Michelle Colin, RD
[+] Author Affiliations

From the Childhood Weight Control Program, Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, Robert Wood Johnson Medical School, University of Medicine & Dentistry of New Jersey, New Brunswick.


Arch Pediatr Adolesc Med. 2001;155(8):897-902. doi:10.1001/archpedi.155.8.897.
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Background  Understanding the determinants of physical activity in children is critical for the treatment and prevention of childhood obesity. Social-cognitive theory has been used to understand behavioral patterns in children.

Objectives  To explore the relationship between health beliefs, self-efficacy, social support, and sedentary activities and physical activity levels in children and to examine the relationship between physical activity and children's self-esteem.

Methods  Ninety-two children aged 10 to 16 years completed the study. Physical activity was monitored for 1 week with a motion detector (Actitrac; IM Systems, Baltimore, Md). Moderate-level activity and high-level activity were defined based on the results of treadmill testing. Health beliefs, self-efficacy, social influences, and time spent in sedentary behaviors were determined through questionnaires. Self-esteem was measured using the Piers-Harris Children's Self-Concept Scale. Chronic anxiety was measured with the Revised Children's Manifest Anxiety Scale.

Results  There was a significant decline in physical activity levels between ages 10 and 16 years, particularly in girls. Preteen girls spent approximately 35% more time in low- and high-level activity than did teenage girls (P<.001). Overall, children spent 75.5% of the day inactive, with a mean ± SD of 5.2 ± 1.8 hours watching television, sitting at the computer, and doing homework. In contrast, only 1.4% of the day (12.6 ± 12.2 minutes) was spent in vigorous activity. Time spent in sedentary behaviors was inversely correlated with the amount of moderate-level activity (P<.001) but not high-level activity. In contrast, time spent in high-level activity correlated with self-efficacy scores (P<.001) and social influences scores (P<.005). High-level physical activity was also associated with improved self-esteem (P<.05). Higher health beliefs scores were not correlated with physical activity levels.

Conclusions  Children and adolescents are largely sedentary. Correlates of high- and low-level physical activity are different. Time spent on sedentary activities is inversely correlated with moderate-level activity, while self-efficacy and social influences are positively correlated with more intense physical activity. In addition, increased high-level physical activity is an important component in the development of self-esteem in children.

PREVIOUS RESEARCH has demonstrated that most children are largely sedentary. Using data from the Muscatine Study, Janz et al1 found that pubertal and postpubertal children spend only 8 to 10 minutes per day in aerobic activity. Livingstone and colleagues2 also showed that girls aged 7 to 15 years spend, on average, 8 to 10 minutes per day in vigorous physical activity, while boys of the same age spend approximately 30 minutes per day in vigorous activity.

Determinants of levels of childhood physical activity are complex. Social-cognitive theory involves analyzing the effects of parental and peer influences, child beliefs, and personality on the adoption of a particular behavior, in this case physical activity. It is now widely accepted that family, peers, and school affect physical activity levels in children.3 Access to physical activities, such as the location of parks and schools, and opportunities to participate in games or sports are also factors affecting sports involvement.4 Similarly, parents who play with their children regularly and provide transportation to activities have more-active children.5 Personality characteristics, such as achievement, motivation, self-confidence, independence, and one's perceived ability to be active (ie, self-efficacy), are also associated with physical activity levels.6,7

It has also been suggested that physical activity, particularly sports participation, may affect the development of self-esteem in adolescents.8 However, most previous studies have been limited by including only small numbers of adolescents, no objective measurements of physical activity, and outdated global self-esteem scores with no subscales. Nevertheless, low to moderate correlations between self-reported physical activity and global self-esteem in adolescents have been reported by Ferguson,7 Butcher,9 and Sherrill10 and their colleagues; however, neither Ferguson et al nor Butcher specified which self-esteem scale was used.

The aims of this study, therefore, were to describe social and cognitive factors associated with physical activity in children aged 10 to 16 years. This study also aimed to further explore the relationship between sedentary activities (such as television viewing) and physical activity, and the relationship between physical activity and self-esteem in children.

SUBJECTS

Ninety-five of 96 consecutive healthy children between the ages of 10 and 16 years were recruited for the study between March 23 and June 12, 2000. Children were recruited from suburban and urban families through the pediatrics clinics at University of Medicine & Dentistry of New Jersey, New Brunswick, and 2 work sites, representing mixed ethnicities and socioeconomic status. Approximately 16 (17%) children were Hispanic or African American, 19 (20%) were from single-parent families, and 20 (21%) had parents who were professionals. Complete data were available on 92 children (44 boys and 48 girls). Informed consent was obtained at the time of recruitment, and each family received a stipend after completion of the study. Approval for the study was obtained from the institutional review board of Robert Wood Johnson Medical School, University of Medicine & Dentistry of New Jersey.

MEASUREMENT OF SOCIAL AND COGNITIVE FACTORS

Each child was asked to complete the children's physical activity questionnaire developed by Saunders et al.11 This questionnaire consists of 3 scales to measure psychosocial correlates of exercise in children as young as 10 years: the Self-Efficacy, Social Influences, and Health Beliefs scales (Table 1). Parents completed questionnaires concerning the amount of time each child spent on sedentary activities.

Table Graphic Jump LocationTable 1. Items for Measuring Psychosocial Correlates of Behavior*
MEASUREMENT OF PHYSICAL ACTIVITY

Levels of habitual physical activity were assessed with a biaxial accelerometer (Actitrac; IM Systems, Baltimore, Md). The detector is approximately half the size of a beeper and is worn on the child's waist. Previous pilot testing had established a high correlation (r2>0.96) between activity readings using this detector and those from other larger triaxial motion detectors. Children were instructed to wear the monitor during waking hours for 1 week. Acceleration was sampled 40 times a second and integrated over 30-second intervals. Habitual physical activity levels were categorized by units of acceleration based on treadmill testing during previous pilot data collection (Table 2). Similar cutoffs for physical activity levels have been previously reported.12 Because children spent minimal time in vigorous activity, high activity and vigorous activity times were grouped together. Individual activity levels and self-efficacy were further categorized as high or low based on the 25th and 75th percentiles of the entire cohort, respectively.

Table Graphic Jump LocationTable 2. Activity Levels Defined Using Motion Detector
MEASUREMENT OF SELF-ESTEEM AND ANXIETY

The Piers-Harris Children's Self-Concept Scale and the Revised Children's Manifest Anxiety Scale were used to assess self-esteem and anxiety. The Piers-Harris Children's Self-Concept Scale is an 80-item standardized self-report inventory designed to assess children's feelings about themselves.13 The Revised Children's Manifest Anxiety Scale measures chronic (as opposed to acute situational) anxiety.14 Total anxiety scores measured by the Revised Children's Manifest Anxiety Scale were correlated with anxiety subscores measured in the Piers-Harris inventory (r = 0.82, P<.001), suggesting a high level of consistency with the questionnaires.

DATA ANALYSIS

Data were analyzed using commercially available software (SPSS version 8.0; SPSS Inc, Chicago, Ill). Differences in continuous variables were assessed using the independent t test or 1-way analysis of variance. Differences in proportions were compared by means of χ2 tests. Multivariate regression analysis was used to assess the effect of social and cognitive variables and sedentary behavior time on physical activity levels after controlling for age and sex. Logistic regression analysis was used to determine the relationship between high and low levels of physical activity and high and low levels of sedentary behavior and self-efficacy. A small number of outliers greater than 3 SDs from the predicted models were excluded.

Children spent a mean ± SD of 24.5% ± 6% of waking hours in moderate- or high-level physical activity (Table 3). Sixteen percent of their time was spent in moderate-level activity (ie, walking or playing), with vigorous activity constituting only 1.4% of waking time (mean ± SD, 12.6 ± 12.2 min/d). Children spent 10.4 ± 0.8 hours per day relatively motionless. Overall, these children spent 5.2 ± 1.8 hours per day doing homework, sitting at the computer, or watching television, while the remaining 4.5 ± 0.7 hours per day of sedentary time primarily were at school.

Physical activity levels were related to age and sex. Before age 13 years, similar levels of physical activity were present in girls and boys (P = .43); however, after age 13, boys were significantly more active than were girls (total activity time: 23.5% ± 4.7% vs 19.0% ± 3.8%; P<.05). Moderate- and high-level activity decreased significantly between ages 10 and 16 years for both sexes (Table 4). Among girls, overall time spent at all physical activity levels was 35% higher in preteens compared with that in teenage girls (P<.001).

Table Graphic Jump LocationTable 4. Correlates of Physical Activity in Children Aged 10 to 16 Years

Correlates of moderate- and high-level activity were different (Table 4). Time spent on sedentary activities was inversely correlated with moderate activity. Children who spent the least time participating in sedentary behaviors were significantly more likely to have high levels of moderate activity compared with children who spent the most time in sedentary behaviors (odds ratio, 9.14; 95% confidence interval, 1.53-55.00). In particular, television time (β = − .29, P<.01) and computer time (β = −.29, P<.01) were inversely correlated with moderate activity. Health beliefs, self-efficacy, and social influences scores were not significantly correlated with moderate activity. Multivariate regression analysis demonstrated that only age and sedentary behavior time independently correlated with moderate activity levels (r2 = 0.35, P<.001), with approximately 10% of the variance in moderate activity explained by sedentary behavior time.

Increased levels of high activity were primarily associated with increased self-efficacy and social influences scores. Time spent on sedentary activities was not correlated with high activity. Similarly, higher health beliefs scores were not correlated with high activity levels. In contrast, all 3 measures of self-efficacy were significantly correlated with high activity. Overall, children with increased levels of self-efficacy were significantly more likely to have increased levels of high activity compared with children with low levels of self-efficacy (odds ratio, 4.07; 95% confidence interval, 1.03-16.30). In addition, social influences scores were significantly associated with increased high activity. Multivariate regression analysis demonstrated that age, sex, and self-efficacy were significant independent correlates of high activity (r2 = 0.29, P<.001), with approximately 10% of the variance in high activity explained by self-efficacy scores.

Mean ± SD Piers-Harris self-esteem scores were 58.3 ± 10.7, similar to previous findings.15 There was no significant difference in total self-esteem scores between age (P = .42) and sex (P = .47). Similar results were observed with each of the 6 self-esteem subscales. Behavior, happiness, intellectual, and popularity self-esteem subscores were significantly decreased in children with low levels of high activity (Table 5). In contrast, self-esteem subscores were not related to moderate activity levels. In addition, neither anxiety score was related to physical activity levels.

Table Graphic Jump LocationTable 5. Physical Activity and Self-Esteem*

Overall, children spent more than 10 hours each day sedentary. In contrast, children were involved in vigorous physical activity only 12 to 13 minutes per day. These data also demonstrate a significant decline in physical activity as children progress through adolescence. In particular, girls have a significant decrease in physical activity levels between ages 10 and 16 years. Similar decreases in physical activity between the 6th and 12th grades have been previously described in schoolchildren.16 Data from the Youth Risk Behavior Surveillance System also demonstrated a significant decline in physical activity among girls during high school.17

In 1977, Bandura18 first postulated that behavioral changes were predominantly mediated by self-efficacy—the belief that one can successfully perform a desired behavior. According to Bandura, "Efficacy expectations determine how much effort people will expend and how long they will persist in the face of obstacles and aversive experiences."18(p193) Self-efficacy measures are tailored to assess specific behaviors. In this study, self-efficacy comprised a child's belief in his or her ability to become physically active, even in the presence of barriers to physical activity or alternative activities. As such, self-efficacy was a major correlate of high-level activity in children. Reynolds19 and Saunders11 and their colleagues also demonstrated that self-efficacy was significantly correlated with self-reported levels of physical activity in adolescents. In addition, Sallis et al20 have shown that self-efficacy was the strongest correlate of exercise behaviors in a community sample of adults. Therefore, programs that enhance children's beliefs in their ability to exercise may actually increase motivation to be physically active.

In contrast, the health belief model postulates that the likelihood of adopting a particular behavior is related to an individual's perception that the behavior will either improve or damage his or her health.21 In this study, health beliefs about the benefits of physical activity were not related to actual activity levels. O'Connell and colleagues21 also demonstrated that the health belief model was minimally associated with adolescents' exercise participation. Similarly, Sallis et al20 showed that health beliefs contributed only minimally to physical activity in a community sample. These results are not surprising; after all, it is well-known that adolescents frequently smoke cigarettes and consume alcohol and other drugs despite detailed knowledge of the health detriments of these behaviors. Unfortunately, parents and physicians tend to use the health belief model most frequently to get children to be active, admonishing, for example: "If you exercise, you'll lower your cholesterol." "The best way to lower your blood pressure is to exercise." "If you're more active, you'll lose weight and have more energy."

Sedentary time was equally divided among viewing television, sitting at the computer, and doing homework. It is no surprise that increased levels of sedentary behaviors were associated with decreased levels of physical activity; however, previous studies2224 have tended to solely focus on television viewing as a marker for sedentary behaviors. In this study, time spent on television viewing and computer activities was equivalent, and both were inversely correlated with moderate-level physical activity but not high-level physical activity. Therefore, children who spend less time in sedentary behaviors will spend more time in moderate-level activity, such as playing, while not necessarily participating in high-level activity, such as sports. Data from the Bogalusa Heart Study indicate that increased time spent watching television, using the computer, and playing video games was not associated with decreased levels of high-level physical activity.25 Other data have also shown that television viewing has only a weak, if any, association with high-level activity, such as brisk walking, jogging, and running.26,27 Therefore, the findings that less sedentary children have increased moderate-level physical activity is important, because children spend a significantly greater proportion of their time in moderate-level activity compared with high-level activity, and moderate-level activity is particularly difficult to assess by questionnaire. Therefore, increased levels of moderate activity may account for the lower amounts of weight gain observed in children who limit television viewing.28

In this study, high-level but not moderate-level physical activity was associated with improved self-esteem scores. Positive associations between physical activity and self-esteem in adolescents have been reported by Ferguson,7 Butcher,9 and Sherrill10 and their colleagues. Page and Tucker29 demonstrated that adolescents who rarely exercise are more likely to experience loneliness, shyness, and feelings of hopelessness. In contrast, no relationship was observed between physical activity levels and anxiety. In adults, exercise must be prolonged and fairly strenuous to reduce anxiety.30,31 However, increases in lactate levels from exercise may actually exacerbate anxiety.32

Although surveys such as the Youth Risk Behavior Surveillance System suggest that approximately half of adolescents participate in regular, vigorous activity,33 studies using heart rate monitors and doubly labeled water suggest that such reports overestimate physical activity.1,2 Because questionnaires can be unreliable in assessing physical activity in children, Saris34 and Rowlands et al35 have recommended an objective assessment of activity in children, using an accelerometer, a heart rate monitor, or doubly labeled water. Accelerometers have been extensively tested and validated in children.36,37 Investigation using motion detectors with children demonstrated a high correlation (r = 0.86-0.88) between readings and observed physical activity, independent of sex.38 In addition, significant correlations exist between motion detector activity measurements and total and sedentary energy expenditure.39

Although only a limited number of children were studied, the patterns and levels of physical activity described herein are comparable to those of other larger studies.1,2 Increased numbers of children and prospective studies are needed to provide understanding of causal relationships between physical activity and psychosocial variables, especially among subgroups of children such as minorities or children who are obese. In a cross-sectional study, it is not possible to determine the degree to which self-efficacy affects physical activity or the degree to which physical activity affects self-efficacy. Nevertheless, these results provide a conceptual framework for understanding physical activity levels in healthy children, as the relationships of physical activity levels to psychosocial variables and self-esteem were significant and consistent.

In conclusion, this study demonstrates that healthy children aged 10 to 16 years rarely engage in vigorous physical activity. Computer use is a sedentary behavior that is becoming increasingly common and is associated with lower levels of physical activity. To be most effective, interventional efforts to increase physical activity should primarily target decreasing television and computer time and increasing self-efficacy. In addition, increased levels of physical activity are an important component in the development of self-esteem in children.

Accepted for publication March 16, 2001.

This study was supported by a Nestlé Nutrition Grant for Young Investigators, sponsored by the Child Digestive Health and Disease Foundation, Houston, Tex.

Corresponding author and reprints: Richard S. Strauss, MD, Childhood Weight Control Program, Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, Robert Wood Johnson Medical School, University of Medicine & Dentistry of New Jersey, One Robert Wood Johnson Place, CN 19, New Brunswick, NJ 08903-0019 (e-mail: strausrs@rwja.umdnj.edu).

Janz  KFGolden  JCHansen  JRMahoney  LT Heart rate monitoring of physical activity in children and adolescents: the Muscatine Study. Pediatrics. 1992;89256- 261
Livingstone  MBCoward  WAPrentice  AM  et al.  Daily energy expenditure in free-living children: comparison of heart-rate monitoring with the doubly labeled water (2H2(18)O) method. Am J Clin Nutr. 1992;56343- 352
Taylor  WCBaranowski  TSallis  JF Family determinants of childhood physical activity: a social-cognitive model. Dishman  RKed.Advances in Exercise Adherence Champaign, Ill Human Kinetics1994;319- 342
Greendorfer  SLEwing  ME Race and gender differences in children's socialization into sport. Res Q Exerc Sport. 1981;52301- 310
Sallis  JFAlcaraz  JEMcKenzie  TLHovell  MFKolody  BNader  PR Parental behavior in relation to physical activity and fitness in 9-year-old children. Am J Dis Child. 1992;1461383- 1388
Reynolds  KDKillen  JDBryson  SW  et al.  Psychosocial predictors of physical activity in adolescents. Prev Med. 1990;19541- 555
Ferguson  KJYesalis  CEPromrehn  PRKirkpatrick  MB Attitudes, knowledge, and beliefs as predictors of exercise intent and behavior in schoolchildren. J Sch Health. 1989;59112- 115
Sonstroem  RJ Exercise and self-esteem. Exerc Sport Sci Rev. 1984;12123- 155
Butcher  J Socialization of adolescent girls into physical activity. Adolescence. 1983;18753- 766
Sherrill  CHolguin  OCaywood  AJ Fitness, attitude toward physical education, and self-concept of elementary school children. Percept Mot Skills. 1989;62411- 414
Saunders  RPPate  RRFelton  G  et al.  Development of questionnaires to measure psychosocial influences on children's physical activity. Prev Med. 1997;26241- 247
DuRant  RHBaranowski  TJohnson  MThompson  WO The relationship among television watching, physical activity, and body composition of young children. Pediatrics. 1994;94449- 455
Piers  EVHarris  DB The Piers-Harris Children's Self-Concept Scale.  Los Angeles, Calif Western Psychological Services1969;
Reynolds  CRRichmond  BO Revised Children's Manifest Anxiety Scale.  Los Angeles, Calif Western Psychological Services1985;
Kaplan  KMWadden  TA Childhood obesity and self-esteem. J Pediatr. 1986;109367- 370
Kelder  SHPerry  CLKnut-Inge  KLytle  LL Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors. Am J Public Health. 1994;841121- 1126
Wolf  AMGortmaker  SLCheung  LGray  HMHerzog  DBColditz  GA Activity, inactivity, and obesity: racial, ethnic, and age differences among schoolgirls. Am J Public Health. 1993;831625- 1627
Bandura  A Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84191- 215
Reynolds  KDKillen  JDBryson  SW  et al.  Psychosocial predictors of physical activity in adolescents. Prev Med. 1990;19541- 551
Sallis  JFHaskell  WLFortmann  SPVranizan  KMTaylor  CBSolomon  DS Predictors of adoption and maintenance of physical activity in a community sample. Prev Med. 1986;15331- 341
O'Connell  JKPrice  JHRoberts  SMJurs  SGMcKinley  R Utilizing the health belief model to predict dieting and exercising behavior of obese and nonobese adolescents. Health Educ Q. 1985;12343- 351
Robinson  TNHammer  LDKillen  JD  et al.  Does television viewing increase obesity and reduce physical activity? cross-sectional and longitudinal analyses among girls. Pediatrics. 1993;91273- 280
Dietz  WHGortmaker  SL Do we fatten our children at the television set? obesity and television viewing in children and adolescents. Pediatrics. 1985;75807- 812
Dietz  WHGortmaker  SL TV or not TV: fat is the question. Pediatrics. 1993;91499- 501
Gortmaker  SLMust  ASobol  AMPeterson  KColditz  GADietz  WH Television viewing as a cause of increasing obesity among children in the United States, 1986-1990. Arch Pediatr Adolesc Med. 1996;150356- 362
Myers  LStrikmiller  PKWebber  LSBerenson  GS Physical and sedentary activity in school children grades 5-8: the Bogalusa Heart Study. Med Sci Sports Exerc. 1996;28852- 859
Katzmarzyk  PTMalina  RMSong  TMKBouchard  C Television viewing, physical activity, and health-related fitness of youth in the Quebec Family Study. J Adolesc Health. 1998;23318- 325
Robinson  TN Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA. 1999;2821561- 1567
Page  RMTucker  LA Psychosocial discomfort and exercise frequency: an epidemiological study of adolescents. Adolescence. 1994;29183- 191
Morgan  WPRoberts  JAFeinerman  AD Psychological effect of acute physical activity. Arch Phys Med Rehabil. 1977;52442- 449
Morgan  WP Affective beneficence of vigorous physical activity. Med Sci Sports Exerc. 1985;1794- 100
Pitts  FNMcClure  NJ Lactate metabolism in anxiety neurosis. N Engl J Med. 1967;2771329- 1336
Not Available, Physical Activity and Health: A Report of the Surgeon General.  Atlanta, Ga National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, US Dept of Health and Human Services1996;
Saris  WHM Habitual physical activity in children: methodology and findings in health and disease. Med Sci Sports Exerc. 1986;18253- 263
Rowlands  AVEston  RGIngledew  DK Measurement of physical activity in children with particular reference to the use of heart rate and pedometry. Sports Med. 1997;24258- 272
Klesges  LMKlesges  RC The assessment of children's physical activity: a comparison of methods. Med Sci Sports Exerc. 1987;19511- 517
Welk  GJCorbin  CB The validity of the Tritrac-R3D Activity Monitor for the assessment of physical activity in children. Res Q Exerc Sport. 1995;66202- 209
Noland  MDanner  FWeWalt  KMcFadden  MKotchen  JM The measurement of physical activity in young children. Res Q Exerc Sport. 1990;61146- 153
Eston  RGRowlands  AVIngledew  DK Validation of the Tritrac-R3D Activity Monitor during typical children's activities. Armstrong  NKirby  BWelsman  Jeds.Children and Exercise XIX London, England E & FN Spon1997;132- 138

Figures

Tables

Table Graphic Jump LocationTable 1. Items for Measuring Psychosocial Correlates of Behavior*
Table Graphic Jump LocationTable 2. Activity Levels Defined Using Motion Detector
Table Graphic Jump LocationTable 4. Correlates of Physical Activity in Children Aged 10 to 16 Years
Table Graphic Jump LocationTable 5. Physical Activity and Self-Esteem*

References

Janz  KFGolden  JCHansen  JRMahoney  LT Heart rate monitoring of physical activity in children and adolescents: the Muscatine Study. Pediatrics. 1992;89256- 261
Livingstone  MBCoward  WAPrentice  AM  et al.  Daily energy expenditure in free-living children: comparison of heart-rate monitoring with the doubly labeled water (2H2(18)O) method. Am J Clin Nutr. 1992;56343- 352
Taylor  WCBaranowski  TSallis  JF Family determinants of childhood physical activity: a social-cognitive model. Dishman  RKed.Advances in Exercise Adherence Champaign, Ill Human Kinetics1994;319- 342
Greendorfer  SLEwing  ME Race and gender differences in children's socialization into sport. Res Q Exerc Sport. 1981;52301- 310
Sallis  JFAlcaraz  JEMcKenzie  TLHovell  MFKolody  BNader  PR Parental behavior in relation to physical activity and fitness in 9-year-old children. Am J Dis Child. 1992;1461383- 1388
Reynolds  KDKillen  JDBryson  SW  et al.  Psychosocial predictors of physical activity in adolescents. Prev Med. 1990;19541- 555
Ferguson  KJYesalis  CEPromrehn  PRKirkpatrick  MB Attitudes, knowledge, and beliefs as predictors of exercise intent and behavior in schoolchildren. J Sch Health. 1989;59112- 115
Sonstroem  RJ Exercise and self-esteem. Exerc Sport Sci Rev. 1984;12123- 155
Butcher  J Socialization of adolescent girls into physical activity. Adolescence. 1983;18753- 766
Sherrill  CHolguin  OCaywood  AJ Fitness, attitude toward physical education, and self-concept of elementary school children. Percept Mot Skills. 1989;62411- 414
Saunders  RPPate  RRFelton  G  et al.  Development of questionnaires to measure psychosocial influences on children's physical activity. Prev Med. 1997;26241- 247
DuRant  RHBaranowski  TJohnson  MThompson  WO The relationship among television watching, physical activity, and body composition of young children. Pediatrics. 1994;94449- 455
Piers  EVHarris  DB The Piers-Harris Children's Self-Concept Scale.  Los Angeles, Calif Western Psychological Services1969;
Reynolds  CRRichmond  BO Revised Children's Manifest Anxiety Scale.  Los Angeles, Calif Western Psychological Services1985;
Kaplan  KMWadden  TA Childhood obesity and self-esteem. J Pediatr. 1986;109367- 370
Kelder  SHPerry  CLKnut-Inge  KLytle  LL Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors. Am J Public Health. 1994;841121- 1126
Wolf  AMGortmaker  SLCheung  LGray  HMHerzog  DBColditz  GA Activity, inactivity, and obesity: racial, ethnic, and age differences among schoolgirls. Am J Public Health. 1993;831625- 1627
Bandura  A Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84191- 215
Reynolds  KDKillen  JDBryson  SW  et al.  Psychosocial predictors of physical activity in adolescents. Prev Med. 1990;19541- 551
Sallis  JFHaskell  WLFortmann  SPVranizan  KMTaylor  CBSolomon  DS Predictors of adoption and maintenance of physical activity in a community sample. Prev Med. 1986;15331- 341
O'Connell  JKPrice  JHRoberts  SMJurs  SGMcKinley  R Utilizing the health belief model to predict dieting and exercising behavior of obese and nonobese adolescents. Health Educ Q. 1985;12343- 351
Robinson  TNHammer  LDKillen  JD  et al.  Does television viewing increase obesity and reduce physical activity? cross-sectional and longitudinal analyses among girls. Pediatrics. 1993;91273- 280
Dietz  WHGortmaker  SL Do we fatten our children at the television set? obesity and television viewing in children and adolescents. Pediatrics. 1985;75807- 812
Dietz  WHGortmaker  SL TV or not TV: fat is the question. Pediatrics. 1993;91499- 501
Gortmaker  SLMust  ASobol  AMPeterson  KColditz  GADietz  WH Television viewing as a cause of increasing obesity among children in the United States, 1986-1990. Arch Pediatr Adolesc Med. 1996;150356- 362
Myers  LStrikmiller  PKWebber  LSBerenson  GS Physical and sedentary activity in school children grades 5-8: the Bogalusa Heart Study. Med Sci Sports Exerc. 1996;28852- 859
Katzmarzyk  PTMalina  RMSong  TMKBouchard  C Television viewing, physical activity, and health-related fitness of youth in the Quebec Family Study. J Adolesc Health. 1998;23318- 325
Robinson  TN Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA. 1999;2821561- 1567
Page  RMTucker  LA Psychosocial discomfort and exercise frequency: an epidemiological study of adolescents. Adolescence. 1994;29183- 191
Morgan  WPRoberts  JAFeinerman  AD Psychological effect of acute physical activity. Arch Phys Med Rehabil. 1977;52442- 449
Morgan  WP Affective beneficence of vigorous physical activity. Med Sci Sports Exerc. 1985;1794- 100
Pitts  FNMcClure  NJ Lactate metabolism in anxiety neurosis. N Engl J Med. 1967;2771329- 1336
Not Available, Physical Activity and Health: A Report of the Surgeon General.  Atlanta, Ga National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, US Dept of Health and Human Services1996;
Saris  WHM Habitual physical activity in children: methodology and findings in health and disease. Med Sci Sports Exerc. 1986;18253- 263
Rowlands  AVEston  RGIngledew  DK Measurement of physical activity in children with particular reference to the use of heart rate and pedometry. Sports Med. 1997;24258- 272
Klesges  LMKlesges  RC The assessment of children's physical activity: a comparison of methods. Med Sci Sports Exerc. 1987;19511- 517
Welk  GJCorbin  CB The validity of the Tritrac-R3D Activity Monitor for the assessment of physical activity in children. Res Q Exerc Sport. 1995;66202- 209
Noland  MDanner  FWeWalt  KMcFadden  MKotchen  JM The measurement of physical activity in young children. Res Q Exerc Sport. 1990;61146- 153
Eston  RGRowlands  AVIngledew  DK Validation of the Tritrac-R3D Activity Monitor during typical children's activities. Armstrong  NKirby  BWelsman  Jeds.Children and Exercise XIX London, England E & FN Spon1997;132- 138

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
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Indicate what change(s) you will implement in your practice, if any, based on this CME course.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
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