High School Sports During the COVID-19 Pandemic: The Effect of Sport Participation on the Health of Adolescents

A Family-Based Approach to Promoting Pediatric Mental Health Recovery in Response to the COVID-19 Pandemic

OBJECTIVE

The purpose of this scoping review is to identify strategies from existing literature, for school-based professionals to share with parents, that may be used on a family-level to help the recovery from the effects of the COVID-19 pandemic on pediatric mental health.

DATA SOURCE

This scoping review consists of a comprehensive PubMed, CINAHL, and Google Scholar database search.

STUDY INCLUSION AND EXCLUSION CRITERIA

Studies published between 2020 and 2023 that were written in English, originated in the United States, and evaluated pediatric mental health in the context of the COVID-19 pandemic were considered for inclusion in the scoping review.

DATA EXTRACTION AND DATA SYNTHESIS

One researcher independently conducted the PubMed, CINAHL, and Google Scholar literature search. Subsequently, results were reviewed independently by two additional researchers.

RESULTS

Title and abstract review were conducted for 2563 articles. After excluding studies not written in English, studies with international origin, and studies which were not relevant to this scoping review, 101 studies remained for full-text review. After full-text review, 32 studies (31.68%) were deemed relevant and concordant with the inclusion criteria and were included in this scoping review. We identified five prominent themes: 1) maintaining daily life and routines, 2) the importance of physical activity and the pandemic's effect on student athletes' mental health, 3) the use of screen time, 4) the effect of parent and caregiver stress on their children's mental health, and 5) the effect of pandemic-related health disparities and racism on pediatric mental health.

DISCUSSION

This scoping review focused on interventions and practices which can be implemented at the family level to help children and adolescents recover from the effects of the COVID-19 pandemic on their mental health.

Association between physical activity and mental health problems among children and adolescents: A moderated mediation model of emotion regulation and gender

BACKGROUND

Studies suggests a correlation between physical activity and mental health, particularly in children and adolescents. However, the specific mechanisms underlying this relationship is not fully understood. This study was designed to investigate the potential mediating role of emotion regulation and the moderating influence of gender through a moderated mediation model.

METHODS

A sample size of 4763 students (mean age = 11.12 ± 1.48 years, 52.8 % females) from seven schools in Shenzhen, China, was recruited during the period of October to November 2023. The participants were administered self-reported questionnaires assessing physical activity, mental health, and emotion regulation. The moderated mediation model was analyzed. Data analysis was conducted using SPSS 25.0.

RESULTS

The results indicate a negative correlation between physical activity and mental health problems (all p < 0.001). This association was partially mediated by both cognitive reappraisal and expressive suppression (all p < 0.001). Additionally, gender significant moderated the path between physical activity and emotion regulation, specifically cognitive reappraisal (p < 0.001) and expressive suppression (p < 0.01).

LIMITATIONS

As a result of the cross-sectional design, no causal relationship could be established, and measurement bias should be noted.

CONCLUSION

Physical activity is found to have a positive effect on the mental health problem of children and adolescents with emotion regulation serve as a partial mediator in the relationship. Additionally, in the mediation model, gender influences the first half of the path.

The Association Between Meeting Physical Activity Guidelines and Mental Health Among High-School Students in the United States During the COVID-19 Pandemic

PURPOSE

Physical activity (PA) is associated with mental health outcomes in high-school students, yet many students do not meet the recommended PA levels. Furthermore, both PA levels and mental health were severely impacted by the COVID-19 pandemic. The aim of this study was to assess whether the number of PA recommendations students met during the COVID-19 pandemic was associated with their self-reported mental health (including their experiences with stress, anxiety, and depression) during the COVID-19 pandemic.

METHODS

Students completed the Adolescent Behaviors and Experiences Survey, where they reported PA behaviors, mental health, and COVID-19-related experiences (as control variables) during the pandemic.

RESULTS

Each PA recommendation that was met was associated with a 17% decrease in the odds of students self-reporting that they experienced stress, anxiety, or depression most of the time or always during the COVID-19 pandemic.

DISCUSSION

Students should be provided with opportunities to participate in PA to obtain the physical and mental health benefits, especially in the event of a crisis like the pandemic.

Physical activity on the mental health of children and adolescents during COVID-19 pandemic-induced school closures-A systematic review

PROPOSE

To review published Physical Activity (PA) on the Mental Health of Children and Adolescents aged 5 to 18 years during COVID-19 pandemic-induced school closures.

METHODS

From the database creation to April 2022, 10 databases are retrieved, with 4427 records filtered, 14 included in this research. The research takes Agency for Healthcare Research and Quality (AHRQ) evaluation standards.

RESULTS

The thesis selects 14 studies from 6 countries, involving 400009 children and adolescents. These studies happened during the lockdown of COVID-19 (from December 2019 to April 2021). During the lockdown of COVID-19, schools were closed, which was considered part of a more extensive lockdown. Schools were closed for 1 to 4 weeks. There were 10 high quality studies (71.4%) and 4 medium quality studies (28.6%). 4 studies report that the pandemic reduces the time of PA but increases the time of watching screen and sitting. 10 studies (71.4%) identify that PA is positive for the mental health, because it helps reduce mental symptoms to a certain extent, especially anxiety, depression, and emotional disorders. 5 studies show that PA may not improve the mental health of children and adolescents under 12 during the pandemic. 4 studies indicate that the influence of PA on mental health of children and adolescents is determined by the amount of activity, including the extent, intensity, frequency, and duration, etc.

CONCLUSIONS

In this narrative synthesis of reports from the class suspension period, reports that PA has a improve on the mental health of children and adolescents to a certain extent. it is found that PA may be helpful in reducing mental health symptoms of children and adolescents who are influenced by class suspension because of the COVID-19 pandemic. Therefore, stakeholders of the mental health of children and adolescents around the world should recommend PA because it is a practicable and beneficial way for long-term mental support.

Impact of Prolonged Sport Stoppage on Knee Injuries in High School Athletes: An Ecological Study

CONTEXT

In March 2020, public health concerns resulted in school closure throughout the United States. The prolonged sport cessation may affect knee injury risk in high school athletes. The purpose of this study was to describe and compare risk of knee injuries in high school athletes during 2019-2020 and 2020-2021 academic years, and stratify by gender, severity, mechanism of injury, injury type, and knee anatomic region.

DESIGN

Historical-prospective cohort study.

METHODS

This historical-prospective cohort study included 176 schools in 6 states matched by sport participation in control and COVID years from July 1, 2019 to June 30, 2021. Injury rates per 1000 athletes per year were calculated with 95% confidence intervals. A negative binomial regression was performed to assess potential differences in knee injuries between academic years.

RESULTS

94,847 and 72,521 high school athletes participated in the 2019-2020 (19-20) and 2020-2021 (20-21) seasons. Knee injury risk was higher in the 20-21 season (19-20: 28.89% [27.82-29.96]; 20-21: 33.82% [32.50-35.14]). Risk increased for male athletes from 2019-2020 to 2020-2021 (19-20: 29.42% [28.01-30.83]; 20-21: 40.32% [38.89-41.75]). Female knee injury risk was similar between years (19-20: 25.78% [24.29-27.27]; 20-21: 26.03% [24.31-27.75]). Knee injuries increased by a ratio of 1.2 ([95% CI, 1.1-1.3], P < .001) during 2020-2021.

CONCLUSIONS

Knee injury risk and relative risk increased among males in 2020-2021. Results indicate changes in knee injury risk following return from COVID shelter in place among high school athletes and implicate potential negative downstream effects of interrupted sports training and participation on high school injury risk.

Do sports protect us from COVID-19? An evaluation of COVID-19 infection, vaccination status, and cardiac examination findings in children who exercise

AIM

The COVID-19 pandemic which has devastated the whole world for the past 3 years affects different patient groups differently. This study aims to evaluate the prevalence, symptoms, and severity of COVID-19 infection, vaccination status, and cardiac pathologies of children who exercise.

MATERIAL AND METHODS

The records of the children and adolescents who applied to our paediatric cardiology outpatient clinic for preparticipation examinations between 01.01.22 and 31.12.2022 were scanned retrospectively, and information about their COVID-19 history, the severity of infection, symptoms during the infection, at the time of the examination, and vaccination status was obtained. The results were analysed using MS Excel 2016 software.

RESULTS

The study consisted of 240 children [82 (34.17%) girls and 158 (65.83%) boys] whose mean age was 12.64 ± 2.64 years, mean weight was 50.03 ± 15.53 kg, mean height was 157 ± 15.09 cm, and mean body mass index was 19.65 ± 3.59. 129 cases had a COVID-19 history, 74 cases had no COVID-19 history, and 37 only had contact but no polymerase chain reaction positivity. 84 cases were mild, 19 were moderate, and 12 were asymptomatic. The most common symptoms were fatigue, malaise, headache, sore throat, and fever. 51 cases (35.15%) were vaccinated against COVID-19. No significant cardiac pathologies were detected in electrocardiography or echocardiography.

CONCLUSIONS

This study shows that COVID-19 infections in children who exercise are generally mild and self-limiting. Our findings suggest that exercise may have positive effects on immunity.

The association between physical activity, self-efficacy, stress self-management and mental health among adolescents

This study aimed to explore the interplay between physical activity, self-efficacy, stress self-management and mental health among adolescents. The study gathered data from an online survey conducted among 400 Chinese middle school students (mean age = 13.74 years). The collected data were analyzed using SPSS 27.0 and PROCESS 4.1. The findings indicated a positive and significant relationship between physical activity, self-efficacy, stress self-management, and mental health. Notably, the association between physical activity and mental health was entirely mediated by self-efficacy and stress self-management. Moreover, self-efficacy and stress self-management exhibited a chain mediation effect on the relationship between physical activity and mental health. It is suggested that interventions focusing on physical activity should prioritize strategies for enhancing students' self-efficacy and stress self-management skills as integral components of promoting adolescents' mental health. Future research should delve into identifying specific types of physical activities that have a greater potential to enhance self-efficacy and stress self-management abilities.

Changes in Quality of Life Among Collegiate Athletes During COVID-19

BACKGROUND

The COVID-19 pandemic has had a significant effect on the mental health of athletes. How this has affected quality of life (QoL), specifically in the college population, is poorly defined.

HYPOTHESIS

During the COVID-19 pandemic, the mental and physical QoL will have decreased in collegiate athletes as compared with before the pandemic.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Division I athletes from a total of 23 varsity teams at a single institution completed surveys between 2018 and 2022. QoL was assessed using the Veterans RAND 12-Item Health Survey (VR-12). VR-12 scores were separated into mental component scores (MCS) and physical component scores (PCS). Separate linear mixed effects models evaluated changes in MCS and PCS from pre-COVID to during COVID overall, as well as differences in changes by sex and sport type (individual, team).

RESULTS

For all athletes, the PCS increased (54.6 [95% CI 54.4-54.7] vs 55.1 [54.9-55.3]; P < 0.01) and the MCS decreased (55.2 [54.9-55.5] vs 53.5 [53.1-53.8]; P < 0.01) from pre-COVID to during COVID. When evaluating for sex, women demonstrated a greater increase in PCS (0.57 ± 0.22; P = 0.01) and greater decrease in MCS (1.06 ± 0.38; P < 0.01). With respect to sport type, individual sports demonstrated a greater decrease in MCS (1.46 ± 0.39; P < 0.01), but no interaction was identified for PCS (0.42 ± 0.23; P = 0.07).

CONCLUSION

Collegiate athletes demonstrated a decrease in their self-reported mental QoL during the COVID-19 pandemic, as compared with before the pandemic. This effect was most evident in women and in individual sports. Athletes also reported an increase in physical QoL during COVID that was also larger in women, but not related to sport.

CLINICAL RELEVANCE

This study demonstrates the impact of the COVID-19 pandemic on collegiate athletes' QoL, including negative effects on mental health. It also identifies cohorts of athletes (women, individual) who may be more significantly affected.

Name, Image, and Likeness and the Health of the Young Athlete: A Call to Action for Sports Medicine Providers and the Athletic Healthcare Network

CONTEXT

In June 2021, the National Collegiate Athletic Association (NCAA) adopted a new policy allowing NCAA athletes the opportunity to benefit and profit from their name, image, and likeness (NIL). Several state high-school associations have established policies to guide their members and students through the new era of NIL. While the potential benefits cannot be ignored, NIL presents novel responsibilities and stressors to athletes. This paper will review the paucity of literature on the effect of NIL on youth athletes and bring attention to mental health, well-being, or academic performance impacted by NIL.

EVIDENCE ACQUISITION

Articles were identified through Google and PubMed search starting from NIL policy approval (June 30, 2021). Search terms included "name, image and likeness" and "NIL."

STUDY DESIGN

Clinical commentary.

LEVEL OF EVIDENCE

Level 5.

RESULTS

Although 1 article was identified through PubMed search and numerous articles were identified through Google search, no articles directly evaluated the effects of NIL on the mental health, well-being, or academic performance of youth athletes.

CONCLUSION

It is critical for sports medicine providers and other members of the athletic healthcare network to familiarize themselves with these emerging topics to best serve their patients and communities. The athletic healthcare network must be prepared to address possible NIL-related health ramifications for our patients and their families and help them navigate a confusing and predatory landscape. We must provide resources to youth athletes to minimize the risks associated with NIL involvement and related activities, and to ensure that athletes with NIL contracts are able to balance their academic and athletic responsibilities. Fostering strong relationships between stakeholders and sports medicine staff is paramount to creating an environment that permits honest discussions about NIL and the health of athletes from youth to adulthood.

STRENGTH-OF-RECOMMENDATION TAXONOMY

N/A.

Running Habits and Injury Frequency Following COVID-19 Restrictions in Adolescent Long-Distance Runners

PURPOSE

A decline in youth running was observed at the start of the COVID-19 pandemic. We investigated whether the resumption of organized running after social distancing restrictions changed running habits or injury frequency in adolescent runners.

METHODS

Adolescents (age = 16.1 [2.1] y) who participated in long-distance running activities completed an online survey in the Spring and Fall of 2020. Participants self-reported average weekly running habits and whether they sustained an injury during the Fall 2020 season. Poisson regression models and 1-way analysis of variance compared running habits while Fisher exact test compared differences in frequencies of injuries during Fall 2020 among season statuses (full, delayed, and canceled).

RESULTS

All runners, regardless of season status, increased weekly distance during Fall 2020. Only runners with a full Fall 2020 season ran more times per week and more high-intensity runs per week compared with their Spring 2020 running habits. There were no differences in running volume or running-related injury frequency among Fall 2020 season statuses.

CONCLUSIONS

There were no significant differences in running-related injury (RRI) frequency among runners, regardless of season status, following the resumption of cross-country. Health care providers may need to prepare for runners to increase running volume and intensity following the resumption of organized team activities.

Changes in Quality of Life, Sleep, and Physical Activity During COVID-19: A Longitudinal Study of Adolescent Athletes

CONTEXT

The abrupt cessation of school and sport participation during the COVID-19 pandemic may have negative implications for adolescent mental health.

OBJECTIVES

To (1) compare mental, physical, and social health and behaviors during pandemic-related stay-at-home mandates with the same measures collected 1 to 2 years earlier and (2) evaluate the relationships between physical activity and sleep during the pandemic and changes in anxiety, fatigue, and peer relationships between assessment times.

DESIGN

Cohort study.

SETTING

Pediatric sports medicine center.

PATIENTS OR OTHER PARTICIPANTS

A total of 39 high school athletes (25 adolescent girls, 14 adolescent boys; age = 16.2 ± 0.9 years).

MAIN OUTCOME MEASURE(S)

Patient-Reported Outcome Measurement System anxiety, fatigue, and peer relationships short forms and the Pittsburgh Sleep Quality Index were completed twice (initial assessment in May 2018 or 2019, follow-up assessment in May or June 2020). Frequency and duration of physical activity and frequency of interaction with other individuals (family, peers, sport coaches, etc) were self-reported at follow-up assessment for the 2 weeks before school or sport closure and the 2 weeks before questionnaire completion.

RESULTS

Higher levels of anxiety (5.5 ± 4.0 versus 3.6 ± 3.4 points; P = .003) and fatigue (5.4 ± 3.7 versus 2.3 ± 2.5 points; P < .001) and worse sleep quality (6.6 ± 2.9 versus 4.3 ± 2.3 points; P < .001) were observed during the pandemic compared with previous assessments. Reductions in physical activity were noted between assessments (exercise duration: 86.4 ± 41.0 versus 53.8 ± 30.0 minutes; P < .001). Sleep quality but not physical activity during the pandemic predicted changes in fatigue (P = .03, β = 0.44 [95% CI = 0.06, 0.83]) and peer relationships (P = .01, β = -0.65 [95% CI = -1.16, -0.15]) from initial to follow-up assessment.

CONCLUSIONS

Mental and physical health declined during stay-at-home mandates compared with assessments 1 to 2 years earlier. Physical activity behaviors and sources of social interaction underwent changes after school and sport cessation. Sleep quality may have provided some protection against declining adolescent mental health during the pandemic, although this relationship requires further investigation.

Does Increased Physical Activity Explain the Psychosocial Benefits of Sport Participation During COVID-19?

CONTEXT

Although the return to sports during COVID-19 has been associated with improvements in mental health and quality of life (QOL), whether these benefits are primarily due to increases in physical activity (PA) is unknown.

OBJECTIVE

To determine whether PA increases were responsible for the improvements in mental health and QOL among adolescents who returned to sport during the COVID-19 pandemic.

DESIGN

Cross-sectional study.

SETTING

Wisconsin secondary schools.

PATIENTS OR OTHER PARTICIPANTS

A total of 559 adolescent athletes (age = 15.7 + 1.2 years, females = 43.6%) from 44 schools completed a survey in October 2020.

MAIN OUTCOME MEASURE(S)

Demographic information, whether they had returned to sport participation, school instruction type, anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-9), QOL (Pediatric Quality of Life Inventory 4.0), and PA (Hospital for Special Surgery Pediatric Functional Activity Brief Scale). Mediation analysis was used to assess whether the relationships between sport status and anxiety, depression, and QOL were mediated by PA.

RESULTS

At the time of the study, 171 (31%) had returned to play and 388 (69%) had not. Athletes who had returned to play had less anxiety (3.6 ± 0.4 versus 8.2 ± 0.6, P < .001) and depression (4.2 ± 0.4 versus 7.3 ± 0.6, P < .001) and higher QOL (88.1 ± 1.0 versus 80.2 ± 1.4, P < .001) and more PA (24.0 ± 0.5 versus 16.3 ± 0.7, P < .001). Physical activity explained a significant, but small, proportion of the difference in depression (22.1%, P = .02) and QOL (16.0%, P = .048) but not anxiety (6.6%, P = .20) between athletes who had and those who had not returned to play.

CONCLUSIONS

Increased PA was responsible for only a small portion of the improvements in depression and QOL among athletes who returned to sports. This suggests that most of the mental health benefits of sport participation for adolescents during the COVID-19 pandemic were independent of the benefits of increased PA.

Physical activity and mental health in children and youth during COVID-19: a systematic review and meta-analysis

BACKGROUND

The coronavirus disease (COVID-19) and universal mitigation strategies have fundamentally affected peoples' lives worldwide, particularly during the first two years of the pandemic. Reductions in physical activity (PA) and increased mental health (MH) problems among children and youth have been observed. This systematic review and meta-analysis investigated the relationship between physical activity (PA) and mental health (MH) among children and youth during the COVID-19 pandemic.

METHODS

Four electronic databases (EMBASE, PsycINFO, PubMed, and Web of Science) were systematically searched to identify studies that (1) examined the relationship between PA and MH among children and youth (aged 2-24 years old) and (2) were published in peer-reviewed journals in English between January 2020 and December 2021. Relationships between PA and two MH aspects (i.e., negative and positive psychological responses) among children and youth at different age ranges and those with disabilities or chronic conditions (DCC) were synthesized. Meta-analyses were also performed for eligible studies to determine the pooled effect size.

RESULTS

A total of 58 studies were eventually included for variable categorization, with 32 eligible for meta-analyses. Our synthesis results showed that greater PA participation was strongly related to lower negative psychological responses (i.e., anxiety, depression, stress, insomnia, fatigue, and mental health problems) and higher positive psychological responses (i.e., general well-being and vigor) in children and youth during COVID-19. The pattern and strength of relations between PA and MH outcomes varied across age ranges and health conditions, with preschoolers and those with DCC receiving less attention in the existing research. Meta-analysis results showed that the magnitude of associations of PA with negative (Fisher's z = - 0.198, p < 0.001) and positive (Fisher's z = 0.170, p < 0.001) psychological responses among children and youth was weak. These results were linked to age of participants, study quality, and reporting of PA-related information.

CONCLUSIONS

PA participation and MH among children and youth deteriorated during the COVID-19 pandemic and were closely associated with each other. For the post-COVID-19 era, additional research on age- and health condition-specific relationships between PA and MH outcomes from a comprehensive perspective is warranted. (Word count: 344 words).

Symptoms of depression and anxiety among elite high school student-athletes in Sweden during the COVID-19 pandemic: A repeated cross-sectional study

The COVID-19 pandemic precipitated numerous changes in daily life, including the cancellation and restriction of sports globally. Because sports participation contributes positively to the development of student-athletes, restricting these activities may have led to long-term mental health changes in this population. Using a repeated cross-sectional study design, we measured rates of depression using the Patient Health Questionnaire-2 and anxiety using the Generalized Anxiety Disorder-2 scale in student-athletes attending elite sport high schools in Sweden during the second wave of the pandemic (February 2021; n = 7021) and after all restrictions were lifted (February 2022; n = 6228). Depression among student-athletes decreased from 19.8% in 2021 to 17.8% in 2022 (p = .008, V = .026), while anxiety screening did not change significantly (17.4% to 18.4%, p > .05). Comparisons between classes across years revealed older students exhibited decreases in depressive symptoms, while younger cohorts experienced increases in symptoms of anxiety from 2021 to 2022. Logistic regressions revealed that being female, reporting poorer mental health due to COVID-19, and excessive worry over one's career in sports were significant predictors of both depression and anxiety screenings in 2022. Compared to times when sports participation was limited, the lifting of restrictions was associated with overall reduced levels of depression, but not anxiety.

Upper Quarter Injury Rates and Risk in United States High School Athletes Prior To and During the Prolonged Sport Stoppage

Background

Upper quarter injuries are a serious problem in high school sports. The distinctive differences in males and females and within sports concerning specific upper quarter body parts necessitates the need to evaluate these injuries across these groups. The COVID-19 pandemic has created an opportunity to evaluate the potential added burden abrupt and prolonged sport stoppage had on upper quarter injury risk.

Hypothesis/Purpose

To 1) describe and compare upper quarter injury rates and risk in high school athletes in the 2019-2020 and 2020-2021 academic school years; 2) examine injuries by gender, sport, injury type, and location of injury.

Methods

An ecological study of the athletes from 176 high schools over six states, matching high schools between 2019-2020 (19-20) and 2020-2021 (20-21) years was performed. Injuries were reported by at least one high school athletic trainer assigned to each school into a centralized database and data collected from July 1, 2019, to June 30, 2021. Injury rates were calculated per 1,000 athletes per academic year. Interrupted time series models assessed the incidence ratio between academic years.

Results

A total of 98,487 athletes from all sports participated in 19-20 and 72,521 in 20-21. Upper quarter injury rates increased in from 19-20 [41.9 (40.6, 43.1)] to 20-21 [50.7 (48.1, 51.3)]. Upper quarter injury risk [1.5 (1.1, 2.2)] was greater in 20-21 compared to 19-20. Females did not demonstrate increased injury rates between 19-20 [31.1 (29.4, 32.7)] to 20-21 [28.1 (26.4, 30.0)]. Males reported increased injury rates from 19-20 [50.3 (48.5, 52.2)] to 20-21 [67.7 (65.2, 70.2)]. Increased injury for the shoulder, elbow, and hand were reported in 20-21. Collision, field, and court upper quarter injury rates were increased in 20-21.

Discussion

Upper quarter injury rates and injury risk were greater during the 2020-2021 school year than in the prior year. Males demonstrated increased upper quarter injury rates, while females did not. Return to play protocols for high school athletes should be considered following abrupt sport stoppage.

Level of Evidence

2.

Impact of COVID-19 on the physical activity, quality of life and mental health of adolescent athletes: a 2-year evaluation of over 17 000 athletes

PURPOSE

To evaluate the changes in mental health, quality of life (QOL) and physical activity (PA) among adolescent athletes during the COVID-19 pandemic as organised sports resumed.

METHODS

Adolescent athletes completed surveys including demographic and sport participation information, 7-item Generalized Anxiety Disorder, 9-item Patient Health Questionnaire, Pediatric Quality of Life Inventory and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale in May 2020 following COVID-19-related sport cancellations (Spring20) and after returning to sports in May 2021 (Spring21). The groups were balanced by inverse propensity score weighting and compared using analysis of variance models and ordinal regression models.

RESULTS

17 421 participants were included (Spring20=13 002; Spring21=4419; 16.2±1.2 years; 53% female). Anxiety was significantly lower (better) in Spring21 (Spring20=7.0, 95% CI 6.9 to 7.1; Spring21=4.9, 95% CI 4.8 to 5.0, p<0.001), as was the prevalence of moderate to severe anxiety (Spring20=29.4%, Spring21=17.1%, p<0.001). Depression was significantly improved in Spring21 (Spring20=7.6, 95% CI 7.5 to 7.7; Spring21=4.6, 95% CI 4.5 to 4.8, p<0.001), as was the prevalence of moderate to severe depression (Spring20=32.2%, Spring21=15.4%, p<0.001). Athletes in Spring21 reported higher QOL (Spring20=79.6, 95% CI 79.3 to 79.9; Spring21=84.7, 95% CI 84.4 to 85.0, p<0.001) and increased levels of PA (Spring20=13.8, 95% CI 13.6 to 13.9; Spring21=22.7, 95% CI 22.6 to 22.9, p<0.001).

CONCLUSION

Early COVID-19 sports restrictions were associated with worsening mental health in adolescents. In 2021, after returning to sports, athletes reported significant improvements in mental health, QOL and PA, although mental health adversities remain an important priority.

The association of families' socioeconomic and demographic characteristics with parents' perceived barriers to returning to youth sport following the COVID-19 pandemic

Developmentally appropriate sport contexts have the potential to positively influence young people's physiological, psychological, and social outcomes. However, little is known about how families returned to sport in the wake of COVID-19-related restrictions or how socioeconomic and demographic factors influenced parents' perceptions of barriers to returning. A nationally representative sample (N = 6183) of American youth sport parents completed a questionnaire in which they provided demographic information and answered questions related to the barriers they perceived in returning to sport, such as the risk of their child getting sick. Structural equation modeling was used to examine the relationships among a range of socioeconomic and demographic factors and these barriers to returning. Results suggest that parents from racially minoritized and urban neighborhoods held higher levels of concern over health-related and practical barriers to returning to sport. Findings highlight the importance of designing available, equitable, and appropriate youth sport contexts.

Prevalence of mental health symptoms in children and adolescents during the COVID-19 pandemic: A meta-analysis

The COVID-19 pandemic and its accompanying infection control measures introduced sudden and significant disruptions to the lives of children and adolescents around the world. Given the potential for negative impacts on the mental health of youths as a result of these changes, we conducted a systematic review and meta-analysis to examine the prevalence of depressive symptoms, anxiety symptoms, and sleep disturbances in children and adolescents during the pandemic. We searched major literature databases for relevant cross-sectional or longitudinal studies that included primary and secondary school students or children and adolescents ≤18 years of age. Prevalence values were extracted, logit-transformed, and pooled. Based on 191 included studies with 1,389,447 children and adolescents, we found the pooled prevalence of depressive symptoms, anxiety symptoms, and sleep disturbances to be 31%, 31%, and 42%, respectively. Age, grade levels, education levels, gender, geographical regions, and electronics use were correlated with the prevalence of mental health symptoms. The prevalence of mental health symptoms also increased with time, although signs of recovery and stabilization were also observed. Overall, the results from this review demonstrate the need for increased mental health research, monitoring, and intervention for children and adolescents during the current and future pandemics.

Athletic disruptions caused by the COVID-19 pandemic negatively affect high school student-athletes social-emotional well-being

To examine whether high school student-athletes who experienced more COVID-19 disruptions had increased anxiety, increased dejection, increased anger, decreased excitement, and decreased happiness as measured by the validated Sports Emotion Questionnaire (SEQ). During the COVID-19 pandemic high school student-athletes faced disruptions which resulted in cancelation of competitions, reduced in-person training sessions, and quarantine of athletes. The impact of these disruptions on the mental health and well-being of student-athletes is unknown. An anonymous cross-sectional online survey was electronically distributed to high school student-athletes in one school district during the spring of the 2020 to 21 academic year. Basic demographic questions, sport information, and personal and team disruptions were collected. Multivariate linear regression was used to assess correlation between each emotional domain on the SEQ with independent variables such as personal or teammate quarantines, cancelations, season, sport gender, indoor or outdoor location, and level of competition. 125 surveys were returned representing 28 different sports. Student-athletes who were personally quarantined (22.4%) during their athletic season experienced greater dejection (β = 0.78, P = .003) and greater anger (β = 0.78, P = .005). Those with teammates quarantined (61.6%) experienced more anxiety (β = 0.30, P = .048). Spring sports, which faced fewer restrictions, were associated with less anger (β = -0.48, P = .048). Student-athletes who were directly affected by COVID-19 disruptions experienced increased anxiety, more dejection, and more anger. Public health authorities and school districts should minimize disruptions to athletic participation using established COVID-19 safety protocols to avoid causing harm to athletes' social-emotional well-being. If athletics must be disrupted, student-athletes should receive wellness support and virtual or remote training options.

Influence of High School Socioeconomic Status on Athlete Injuries during the COVID-19 Pandemic: An Ecological Study

Background

It is presently unclear how the cessation of high school sport has affected injury incidence at different socioeconomic levels. The COVID-19 pandemic may have disproportionately affected athletes of lower socioeconomic status, potentially increasing injury risk in this population.

Purpose

To 1) Describe athlete injury incidence prior to and during the 2019-2020 and 2020-2021 school years in high school athletes by socioeconomic status; 2) Investigate the association between socioeconomic status and injury incidence in high school athletes.

Study Design

Ecological Study.

Methods

High schools were matched between the 2019-2020 and 2020-2021 school years. All athletes from all sports were included. High school socioeconomic status was determined by the school district median household income. Socioeconomic strata were defined as <$30,000, $30,000-50,000, $50,001-100,000, and >$100,000. Injury incidence proportion with 95% confidence interval (95% CI) was calculated for each academic year. Mixed effects negative binomial models with robust errors were performed to assess the association between the incidence proportion ratio and high school median household income. Six states and 176 high schools were included (2019-2020: 98,487 athletes; 2020-2021: 72,521 athletes).

Results

Injury incidence increased in three of four socioeconomic strata during the 2020-2021 year (<$30,000: 2019-2020: 15.6 (13.1-18.1), 2020-2021: 26.3 (23.1-29.6); $30,000-50,000: 2019-2020: 7.8 (7.1-8.6), 2020-2021: 14.9 (13.8-15.9); $50,001-100,000: 2019-2020: 15.1 (14.7-15.4), 2020-2021: 21.3 (20.9-21.8); >$100,000: 2019-2020: 18.4 (18.1-18.8), 2020-2021: 17.3 (16.8-17.7)). An association was observed between injury incidence ratio and log median high school household income in 2019-2020 [1.6 (1.1-2.5)] but not 2020-2021 [1.1 (0.8-1.6)] school years.

Conclusions

Athletes from lower socioeconomic high schools reported increased injury incidence compared to higher socioeconomic high schools during the 2020-2021 academic school year. These results highlight the increased COVID-19 pandemic vulnerability in athletes from lower socioeconomic high schools. High school sport stakeholders should consider how abrupt sport stoppage can affect lower socioeconomic athletes.

Level of Evidence

2.

Understanding Youth Athlete Motivation, Training, and Activity Progression During and After the COVID-19 Sports Interruption

Background

COVID-19 restrictions created a period of disrupted sports participation for youth athletes. The physical conditioning, sports training habits, and patterns of sports activity resumption upon returning to normal sports activity are currently unknown.

Purpose/Hypothesis

This study aimed to determine the extent to which youth athletes maintained their training levels during the early stages of the COVID-19 pandemic and understand the strategies that enhanced motivation and adherence to a training regimen while in isolation. A secondary aim was to analyze how youth athletes returned to activity and identify injuries associated with prolonged sports interruption.

Study Design

Observational / Survey Study.

Methods

A survey designed to determine activity changes, type of organized instruction, and athlete preferences for training support were distributed by email using snowball sampling methodology to athletes 14-21 years old who were involved in competitive sports when pandemic restrictions were enacted. As sports activities resumed, a follow-up survey was distributed to the same respondents to identify feelings of preparedness, training habits, and injuries.

Results

Of the155 subjects (mean age 16.1 ± 2 years, 64.5% female) that completed the initial survey, 98% reported a stoppage of in-person sports participation and 70% decreased their exercise/training volume, with 41% (n=63) reporting > 50% reduction. Most athletes (86%) received instruction from coaches, with written workouts (70%) being most common; however, most athletes (70%) preferred instructor-led, group training sessions. Of the 43 subjects that completed the follow-up survey (34% response rate), there was an increase in athletic exposures compared to mid-pandemic levels, and 25% reported sustaining a sports-related injury shortly after resuming sports activities.

Conclusions

Pandemic-related sports restrictions resulted in a significant reduction in youth athlete training and conditioning. Coaches attempted to maintain training via the use of written workouts; however, athletes preferred instructor-led, group training sessions. There was a rapid resumption of sports activities, which may have contributed to the high rate of injuries in this study.

Level of Evidence

3.

The Potential Impact of COVID-19 on Health-Related Quality of Life in Children and Adolescents: A Systematic Review

This was a systematic review of studies examining the effect of COVID-19 on the health-related quality of life (HRQoL) of children and adolescents. The review was conducted by examining the current literature and analyzing up-to-date evidence. The studies were extracted from three major databases (CINAHL Complete, MEDLINE, and Web of Science) and analyzed. Studies on children and adolescents whose HRQoL has been affected by COVID-19 were included based on the eligibility criteria. Ultimately, eight studies met these criteria. The evidence of the selected studies was analyzed; the research design, age categories, respondents, evaluation tools, gender differences, and variability before and during COVID-19 were systematically reviewed. This review found differences in these groups regarding oral symptoms, functional limitations, emotional well-being, and social well-being. Furthermore, this review highlighted the relative paucity of studies that comprehensively investigate the latest evidence of changes in the HRQoL of children and adolescents due to COVID-19 in preparation for the post-COVID era.

The Effect of COVID-19 Lockdown on PHQ Depression Screening Scores for High School Athletes

Adolescent behavioral health was in crisis before COVID-19. The shutdown and reopening of in-person learning and extracurricular activities may have worsened this crisis. We examined high school athletes’ depression before and during the pandemic. Data were collected as part of a pilot program incorporating Patient Health Questionnaire (PHQ) screenings during high school sports physicals before the COVID-19 lockdown and three timepoints after. Statistical comparisons were made using logistic regression. A total of 927 individual scores were analyzed: 385 from spring 2020; 145 from fall 2020; 163 from fall 2021; and 234 from spring 2022. Fall 2020 students were 3.7 times more likely to have elevated PHQ-2 scores than spring 2020 students (95% CI = 1.8, 7.6). Fall 2021 and spring 2022 scores did not differ significantly from pre-pandemic, although trends of elevated scores persisted (OR = 1.6; 95% CI = 0.7, 3.5, and OR = 1.2; 95% CI = 0.6, 2.4, respectively). A significant difference in PHQ-9 depression severity classification was detected over time (p < 0.01). Elevated PHQ scores were found after the onset of the COVID-19 pandemic. After the initial peak in fall 2020, scores decreased but did not reach pre-pandemic levels.

The Impact of Statewide Limitations of Practice on High School Injury Incidence During the COVID-19 Season: An Ecological Study

BACKGROUND

Abrupt training stoppage can increase injury incidence and risk following return to sport. The rate of coronavirus disease 2019 (COVID-19) infections in the general population has resulted in the abrupt stoppage of high school education and sport. The objective of this study was to (1) compare injury incidence proportion (IP) and excess injury in high school athletes before and during the COVID-19 pandemic; and (2) stratify by identified gender.

HYPOTHESIS

The COVID-19 academic year will demonstrate increased injury incidence, and injury incidence will be similar between genders.

STUDY DESIGN

Ecological.

LEVEL OF EVIDENCE

Level 2.

METHODS

High schools (6 states; 176 high schools) were matched between prepandemic and pandemic years. Injury IP with 95% confidence interval (CI) was calculated. Interrupted time series models with robust errors were performed to assess the IP ratio and excess injury incidence between prepandemic and pandemic academic calendar years.

RESULTS

A total of 98,487 athletes participated in high school sport in the prepandemic year and 72,521 athletes in the pandemic year; 15,477 injuries were reported in the prepandemic year compared with 14,057 injuries during the pandemic year. Injury IP (CI) was 15.7 (15.5-15.9) and 19.4 (19.1-19.7) for the prepandemic and pandemic years, respectively. Injury incidence ratio increased by 1.3 (1.2-1.5) between the prepandemic and pandemic years. Excess injuries were 1812 greater in the pandemic year compared with the prepandemic year. Female and male athlete incidence ratios were similar.

CONCLUSION

Prolonged sport stoppage due to the COVID-19 pandemic resulted in increased injury incidence compared with the previous high school academic year.

CLINICAL RELEVANCE

High school sports stakeholders should consider longer periods of ramp up for training in lieu of future sport stoppages compared with usual preseason training. These data may also have more generalizable implications to other abrupt sport and physical activity stoppage scenarios such as earthquakes and hurricanes.

Associations of lockdown stringency and duration with Google searches for mental health terms during the COVID-19 pandemic: A nine-country study

OBJECTIVES

We examined the associations of lockdown stringency and duration with Google searches for four mental health concepts (i.e., "Anxiety," "Depression," "Suicide," "Mental Health") in nine countries (i.e., Hungary, India, Iran, Italy, Paraguay, Serbia, South Africa, Spain, Turkey) during the COVID-19 pandemic.

METHODS

We retrieved national-level data for each country from Google Trends and the Global Panel Database of Pandemic Policies. In our primary analysis, we used data from all countries to estimate a set of multilevel regression models examining associations of overall lockdown stringency and lockdown duration with relative search volumes for each mental health term. We repeated the models after replacing overall lockdown stringency with each of the lockdown stringency components.

RESULTS

A negative association was found between overall lockdown stringency and "Depression." Lockdown duration and the most stringent stay-at-home requirements were negatively associated with "Anxiety." Policies that recommended or required the cancelation of public events evidenced negative associations with "Depression," whereas associations between policies that required some or all levels of schooling to close and "Depression" were positive. Policies that recommended or required workplaces to close and those that enforced quarantines on non-citizens arriving from high-risk regions or closed borders entirely were negatively associated with "Suicide."

CONCLUSIONS

Lockdown duration and some lockdown policies during the COVID-19 pandemic were generally associated with significantly lower, rather than higher, Google searches for selected mental health terms. These findings could be used alongside other evidence to develop future lockdown strategies that are sensitive to mental health issues during public health crises.

A narrative review into the impact of COVID-19 pandemic on senior high school adolescent mental health

Problem

High school teenagers are facing significant challenges during the COVID‐19 pandemic. Teenagers are at risk of experiencing physical, mental, and social health problems due to the COVID‐19 pandemic. This narrative review aims to explore the impact of COVID‐19 on the emergence of mental health problems in high school adolescents.

Methods

This study employed a narrative review method. We conducted a systematic search using PRISMA on three databases: Medline, PubMed, and ScienceDirect. A total of 40 articles met the inclusion and exclusion criteria set based on the research objectives.

Findings

The study uncovered that high school adolescents had an increased risk of experiencing mental health problems, namely psychological distress, worry, loneliness, anxiety, depression, traumatic symptoms, other psychological disorders, suicide risk, sleep disorders, and psychosocial functioning. Anxiety, depression, and psychological stress were the most discussed mental health problems among high school adolescents during the COVID‐19 pandemic.

Conclusions

There is a need for efforts to identify health problems and intervene in mental health problems early in high school adolescents. Schools, mental health workers, and the government (e.g., policy stakeholders) need to implement the recommendations given as a follow‐up effort for mental health services for high school youth.

Prevalence of risk behaviors and correlates of SARS-CoV-2 positivity among in-school contacts of confirmed cases in a Georgia school district in the pre-vaccine era, December 2020-January 2021

BACKGROUND

There is a continuing risk for COVID-19 transmission in school settings while transmission is ongoing in the community, particularly among unvaccinated populations. To ensure that schools continue to operate safely and to inform implementation of prevention strategies, it is imperative to gain better understanding of the risk behaviors of staff and students. This secondary analysis describes the prevalence of COVID-19 risk behaviors in an exposed population of students and school staff in the pre-vaccine era and identifies associations between these behaviors and testing positive for SARS-CoV-2.

METHODS

From December 2020-January 2021, school staff and students exposed to confirmed COVID-19 cases in a Georgia school district were tested for SARS-CoV-2 and surveyed regarding risk behaviors in and out of school. Prevalence of risk behaviors was described by age group and school level, and associations with SARS-CoV-2 positivity were identified using chi squared tests.

RESULTS

Overall, 717 students and 79 school staff participated in the investigation; SARS-CoV-2 positivity was 9.2%. In the 2 weeks prior to COVID-19 exposure, 24% of participants reported unmasked indoor time at school, 40% attended social gatherings with non-household members, and 71% visited out-of-school indoor locations, including 19% who ate indoors in restaurants. Frequencies of risk behaviors increased by age. Among students, 17% participated in school sports, of whom 86% participated without a mask. SARS-CoV-2 positivity was significantly associated with school sports and unmasked time in sports. Among K-5 students, positivity was associated with exposure to a teacher index case.

CONCLUSIONS

This analysis highlights the high prevalence of risk behaviors in an unvaccinated population exposed to COVID-19 in school and identifies an association between student sports participation and SARS-CoV-2 positivity. These findings illustrate the importance of school-level prevention measures to reduce SARS-CoV-2 transmission, including limiting close-contact indoor sports and promoting consistent mask use in unvaccinated individuals. Future research could explore the role of community vaccination programs as a strategy to reduce COVID-19 transmission and introductions into school settings.

Is psychological resilience associated with changes in youth sport participants' health-related quality of life during the COVID-19 pandemic?

Objectives: This study investigated the quality of life of youth sport participants over the COVID-19 pandemic as moderated by psychological resilience.Methods: Participants included 93 high school sport participants (53.76% female, mean age = 15.59 ± 0.74) in a three-year longitudinal cohort study (SHRed Concussions) who completed the Connor-Davidson Resilience Scale (CD-RISC), Pediatric Quality of Life Scale (PedsQL), and Strengths and Difficulties Questionnaire (SDQ) at Year 1 (pre-pandemic, 2019-2020) and Year 2 (pandemic, 2020-2021). Change in quality of life and mental health symptoms from Year 1 to Year 2 was examined using paired t-tests and Year 1 resilience was examined as a predictor of Year 2 quality of life and mental health symptoms using linear regression.Results: Among participants with Year 1 scores before the pandemic onset, mean PedsQL (n = 74, t = -0.26 [-2.63, 2.03], p = 0.80) and SDQ (n = 74, t = 0.030 [-0.90, 0.93], p = 0.98) scores did not significantly change between Year 1 and Year 2. In unadjusted analyses, Year 1 CD-RISC scores were positively associated with predicted Year 2 PedsQL scores when Year 1 scores were controlled (β = 0.31 [0.0062, 0.61], ΔR2 = 0.02) but not with residual change in SDQ scores (β = 0.035 [-0.11, 0.18], ΔR2 = 0.001).Conclusions: Quality of life did not change significantly after the pandemic onset, and resilience was modestly protective.