Where does physical activity fit into preschool postpandemic? A qualitative exploration with parents, teachers and administrators

OBJECTIVES

During the preschool years, children depend on adult caregivers to provide opportunities for physical activity (PA). Research has focused on measuring PA in preschool, as well as barriers and facilitators to children's PA but caregiver perceptions remain largely unknown especially in light of the COVID-19 pandemic. This study aims to understand the value of PA in preschool following the pandemic from three types of adult caregivers, parents of a young child (n=7), preschool teachers (n=7) and preschool administrators (n=7).

METHODS

In-depth qualitative interviews were conducted to explore the following research questions: (a) how do caregivers describe the importance of PA in preschool postpandemic? (b) how do caregivers support and prioritise PA in preschool postpandemic and what challenges do they face in doing so? and (c) how do caregivers interact with one another to promote PA? Qualitative answers were coded using a codebook developed to answer the research questions of interest.

RESULTS

Parents, teachers and administrators all described valuing PA for preschoolers, but each caregiver type described a different way of promoting it. All the caregivers listed barriers that inhibit their ability to prioritise and promote PA, some heightened postpandemic. Lastly, there were limited caregiver interactions when it came to promoting PA, with the burden largely falling on teachers.

CONCLUSION

Our findings indicate that one particularly important area for intervention is supporting parents, teachers and preschool administrators in creating a shared understanding of the importance of PA for young children and ways to collaborate to promote it.

Advocacy for Equitable Recess in Washington State

Recess in schools is a critical opportunity for children to engage in important behaviors that can promote their health and well-being, and daily recess is recommended by the American Academy of Pediatrics and other national organizations. In Washington state, school recess is not equitably provided, with parents reporting a wide range from as little as 10 minutes to >45 minutes daily. State laws can help promote equitable and high-quality recess, but most states in the United States do not have recess laws. In 2023, a bill (Senate Bill 5257) mandating a minimum of 30 minutes of daily recess for all elementary students with provisions for other recess best practices (including not withholding recess as punishment and encouraging movement breaks for middle/high-schoolers) passed with bipartisan support in the Washington state Legislature and was signed into law. In this case study, we describe the process undertaken and lessons learned by the cross-sector coalition that spearheaded the advocacy efforts, which included pediatricians, parents, educators, community organizations, and youth.

Individual and Neighborhood Level Predictors of Children's Exposure to Residential Greenspace

Inequities in urban greenspace have been identified, though patterns by race and socioeconomic status vary across US settings. We estimated the magnitude of the relationship between a broad mixture of neighborhood-level factors and residential greenspace using weighted quantile sum (WQS) regression, and compared predictive models of greenspace using only neighborhood-level, only individual-level, or multi-level predictors. Greenspace measures included the Normalized Difference Vegetation Index (NDVI), tree canopy, and proximity of the nearest park, for residential locations in Shelby County, Tennessee of children in the CANDLE cohort. Neighborhood measures include socioeconomic and education resources, as well as racial composition and racial residential segregation. In this sample of 1012 mother-child dyads, neighborhood factors were associated with higher NDVI and tree canopy (0.021 unit higher NDVI [95% CI: 0.014, 0.028] per quintile increase in WQS index); homeownership rate, proximity of and enrollment at early childhood education centers, and racial composition, were highly weighted in the WQS index. In models constrained in the opposite direction (0.028 unit lower NDVI [95% CI: - 0.036, - 0.020]), high school graduation rate and teacher experience were highly weighted. In prediction models, adding individual-level predictors to the suite of neighborhood characteristics did not meaningfully improve prediction accuracy for greenspace measures. Our findings highlight disparities in greenspace for families by neighborhood socioeconomic and early education factors, and by race, suggesting several neighborhood indicators for consideration both as potential confounders in studies of greenspace and pediatric health as well as in the development of policies and programs to improve equity in greenspace access.

Associations of residential green space with internalizing and externalizing behavior in early childhood

BACKGROUND

Green space exposures may promote child mental health and well-being across multiple domains and stages of development. The aim of this study was to investigate associations between residential green space exposures and child mental and behavioral health at age 4-6 years.

METHODS

Children's internalizing and externalizing behaviors in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) cohort in Shelby County, Tennessee, were parent-reported on the Child Behavior Checklist (CBCL). We examined three exposures-residential surrounding greenness calculated as the Normalized Difference Vegetation Index (NDVI), tree cover, and park proximity-averaged across the residential history for the year prior to outcome assessment. Linear regression models were adjusted for individual, household, and neighborhood-level confounders across multiple domains. Effect modification by neighborhood socioeconomic conditions was explored using multiplicative interaction terms.

RESULTS

Children were on average 4.2 years (range 3.8-6.0) at outcome assessment. Among CANDLE mothers, 65% self-identified as Black, 29% as White, and 6% as another or multiple races; 41% had at least a college degree. Higher residential surrounding greenness was associated with lower internalizing behavior scores (-0.66 per 0.1 unit higher NDVI; 95% CI: -1.26, -0.07) in fully-adjusted models. The association between tree cover and internalizing behavior was in the hypothesized direction but confidence intervals included the null (-0.29 per 10% higher tree cover; 95% CI: -0.62, 0.04). No associations were observed between park proximity and internalizing behavior. We did not find any associations with externalizing behaviors or the attention problems subscale. Estimates were larger in neighborhoods with lower socioeconomic opportunity, but interaction terms were not statistically significant.

CONCLUSIONS

Our findings add to the accumulating evidence of the importance of residential green space for the prevention of internalizing problems among young children. This research suggests the prioritization of urban green spaces as a resource for child mental health.

Physical activity and TV viewing parenting practices for toddlers among South Asian and white families in the UK: born in Bradford 1000 study

BACKGROUND

Children of South Asian (SA) origin in the UK have lower levels of physical activity (PA), compared to their White counterparts. Parents play an important role in establishing PA habits among young children. The aim of this study was to compare PA and television (TV) viewing parenting practices for young children between SA British (SAB) and White British (WB) parents living in the UK.

METHODS

We conducted a secondary analysis of the Born in Bradford (BiB) 1000 study, using survey data at child ages 24 and 36 months. The study sample included three groups of mothers (n = 1,149): foreign-born SAB (n = 458), UK-born SAB (n = 276), and WB (n = 455). Mothers completed a survey about parenting practices (i.e., PA supports, PA restrictions, TV viewing restrictions) at child age 24 months and child PA and TV viewing behaviors at child ages 24 and 36 months. Parenting practices were compared among the three groups. Multivariable linear regression analyses compared children's weekly walking frequency and daily TV viewing hours by parenting practices in the three groups.

RESULTS

The foreign-born SAB group showed the lowest frequencies of PA-supportive parenting practices (verbal encouragement: 3.7 ± 3.1 times/week; logistic support: 1.5 ± 1.8 times/week) and the highest frequencies of PA-restrictive parenting practices (7.8 ± 7.7 times/week) among the three groups (p < 0.01). Children of Foreign-born SAB mothers had the most frequent TV watching during a mealtime (4.0 ± 3.1 times/week) among the three groups (p < 0.01). Less frequent PA-supportive parenting practices and SA ethnicity were associated with lower walking frequency at 24 and 36 months of age among children (p < 0.01). More frequent exposure to TV at mealtimes and SA ethnicity were associated with higher TV viewing time at 24 and 36 months of age among children (p < 0.01).

CONCLUSIONS

This study demonstrated that SAB parents, particularly those who are foreign-born, apply parenting practices for their young children that are less supportive of PA and more supportive of TV viewing, and their children have lower PA and higher TV viewing time, compared with their WB counterparts.

Physical activity and social interaction assessments in schoolyard settings using the System for Observing Outdoor Play Environments in Neighborhood Schools (SOOPEN)

BACKGROUND

The schoolyard environment provides key opportunities to promote physical activity and socioemotional development for children. Schoolyards can also serve as a community park resource outside of school hours. We aimed to: (i) implement and evaluate reliability of the System for Observing Outdoor Play Environments in Neighborhood Schools (SOOPEN), (ii) assess schoolyard use by children during recess and community members of all ages outside of school hours, and (iii) investigate relationships of schoolyard and children´s group characteristics with physical activity levels and prosocial interactions.

METHODS

In this cross-sectional study, we observed student and community visitor behavior using SOOPEN at three urban elementary schoolyards in Tacoma, Washington, USA, prior to renovations intended to expand each facility's use as a community park in neighborhoods with poor park access. We assessed interrater reliability using intraclass correlation coefficients and described current levels of schoolyard use (at the group level), physical activity, and prosocial behavior. Physical activity was assessed on a five-point scale and dichotomized to indicate moderate-to-vigorous physical activity (MVPA). Social interactions were coded as prosocial, antisocial, or neutral. We examined associations of selected schoolyard features and group characteristics with group MVPA and prosocial behavior during recess using modified Poisson regression to estimate prevalence ratios (PR) and 95% confidence intervals (CI).

RESULTS

We observed a total of 981 activity-defined, informal groups in the schoolyards, and achieved good to excellent interrater reliability using SOOPEN. Community use of the schoolyards during evenings and weekends was limited (n = 56 groups). During 26, 25-50 min recess periods (n = 833 groups), 19% of groups were engaged in MVPA. Schoolyard areas with paved surfaces were associated with more MVPA (PR = 1.52, 95% CI: 1.04, 2.23) compared to field/grass areas; supervised groups were associated with less MVPA than groups not directly supervised by an adult (PR = 0.59, 95% CI: 0.36, 0.96). Schoolyard characteristics were not associated with prosocial behavior. Mixed-gender groups were associated with more MVPA and more prosocial behavior.

CONCLUSIONS

Our study using SOOPEN, a reliable new activity observation tool, highlights the multi-dimensional dynamics of physical activity and social interactions in schoolyards, which could be leveraged to promote healthy behaviors during and outside of school hours.

Structural Inequities in Self-compassion and Parental Burnout

Objectives

When parenting-related stressors and coping resources are chronically imbalanced, there is risk of parental burnout, and consequent negative impact on parent and child wellbeing. The objective of this study was to determine the relations between structural and social determinants of health inequities, self-compassion (a theoretically indicated coping practice), and parental burnout during the COVID-19 pandemic.

Method

Participants were parents (n = 2324) with at least one child aged 4-17 in the household recruited from NORC's AmeriSpeak Panel (a probability-based panel providing coverage of 97% of the US household population). Parents completed an online or telephone questionnaire in English or Spanish in December 2020. Structural equation modeling was used to test a system of relations between income, race and ethnicity, parental burnout, and parent and child mental health. Indirect effects and moderation by self-compassion were also tested.

Results

On average, parents experienced symptoms of burnout several days per week. Symptoms were the most frequent among parents with the least income, as well as female-identified and Asian parents. More self-compassion was associated with less parental burnout, and fewer parent and child mental health difficulties. Black and Hispanic parents were more self-compassionate compared to white parents, helping to explain similar levels of parental burnout and relatively better mental health outcomes, despite comparatively more stressors.

Conclusions

Self-compassion is a potentially promising target for interventions aiming to address parental burnout; however, such efforts must not detract from critical structural changes to reduce parenting stressors, particularly those impacting parents experiencing systemic racism and other forms of socioeconomic disadvantage.

Preregistration

This study is not preregistered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-023-02104-9.

Parent Behavior Management Training for Child ADHD Enhanced to Address Health Behaviors: Comparison of Telemedicine "Telegroup" Versus In-Person Delivery

OBJECTIVE

ADHD is associated with suboptimal health behaviors including physical activity (PA). LEAP is a parent BMT group program enhanced to focus on health behaviors, integrated with mHealth technology. Little is known about implementing BMT via telemedicine "telegroups."

METHODS

Children ages 5 to 10 with ADHD and their caregiver wore activity trackers and participated in an 8 to 9 week parent BMT and social media group emphasizing PA, sleep, and screen use. A 7-day child accelerometer-wear and parent and teacher measures were completed pre- and post-group. Groups were in-person prior to the COVID-19 pandemic and in telegroup format during the pandemic.

RESULTS

Thirty-three families participated in person and 23 participated via virtual telegroup. Group attendance was superior for telegroup with equivalent satisfaction and skill use. Changes in health behavior and clinical outcomes were equivalent.

CONCLUSIONS

LEAP is a feasible and novel BMT intervention that can be delivered in an accessible telegroup format with high participation and acceptability.

Feasibility and acceptability of at-home play kits for middle school physical activity promotion during the COVID-19 pandemic

BACKGROUND

Schools are central to providing opportunities for youth physical activity (PA), however such opportunities were limited during the COVID-19 pandemic. Identifying feasible, acceptable, and effective approaches for school-based PA promotion amid pandemic-related barriers can inform resource allocation efforts in future circumstances necessitating remote instruction. The aims of this study were to: (1) describe the pragmatic, stakeholder-engaged and theory-informed approach employed to adapt one school's PA promotion efforts to pandemic restrictions, leading to the creation of at-home "play kits" for students, and (2) assess the feasibility, acceptability, and preliminary effectiveness of this intervention.

METHODS

Intervention activities occurred in one middle school (enrollment: 847) located in a Federal Opportunity Zone in the Seattle, WA area, with control data from a nearby middle school (enrollment: 640). Students at the intervention school were eligible to receive a play kit during the quarter they were enrolled in physical education (PE) class. Student surveys were completed across the school year (n = 1076), with a primary outcome of days/week that the student engaged in ≥ 60 min of PA. Qualitative interviews (n = 25) were conducted with students, staff, parents, and community partners, and focused on play kit acceptability and feasibility.

RESULTS

During remote learning play kits were received by 58% of eligible students. Among students at the intervention school only, students actively enrolled in PE (versus not enrolled) reported significantly more days with ≥ 60 min of PA in the previous week, however the comparison between schools was not statistically significant. In qualitative interviews, most students reported the play kit motivated them to participate in PA, gave them activity ideas, and made virtual PE more enjoyable. Student-reported barriers to using play kits included space (indoors and outdoors), requirements to be quiet at home, necessary but unavailable adult supervision, lack of companions to play outdoors, and inclement weather.

CONCLUSIONS

A pre-existing community organization-school partnership lent itself to a rapid response to meet student needs at a time when school staff and resources were highly constrained. The intervention developed through this collaborative response-play kits-has potential to support middle school PA during future pandemics or other conditions that necessitate remote schooling, however modifications to the intervention concept and implementation strategy may be needed to improve reach and effectiveness.

Barriers and facilitators to comprehensive, school-based physical activity promotion for adolescents prior to and during the COVID-19 pandemic: a qualitative study

This study aimed to identify barriers and facilitators to comprehensive, school-based physical activity (PA) promotion among adolescents prior to and during the coronavirus disease of 2019 (COVID-19) pandemic, considering the perspectives of students, parents, and school staff. Data were collected from 2020 to 2021 using semi-structured individual interviews with students (n = 15), parents (n = 20), and school staff (n = 8) at a Title I middle school (i.e. high percentage of students from low-income families). Two theoretical frameworks guided analysis: the Comprehensive School Physical Activity Program framework and Bronfenbrenner's ecological systems theory. Using an iteratively developed codebook, data were coded, thematically analyzed, and synthesized. PA barriers and facilitators were present throughout the school day, at home, and in the community. Key determinants included pandemic-induced challenges (e.g. COVID-19 exposure); neighborhood characteristics/weather (e.g. neighborhood safety); school-family communication/collaboration; implementation climate (i.e. school staff's support for programming); time, spatial, and monetary resources (e.g. funding); staffing capacity/continuity and school champions; staffing creativity and adaptability; PA opportunities before, during, and after school; and child's motivation/engagement. Efforts to improve school-based PA programs, irrespective of pandemic conditions, should include strategies that address factors at the community, school, family and individual levels. School-family communication/collaboration, school staff programming support, and PA opportunities throughout the day can help promote comprehensive, school-based PA.

Problematic Child Media Use During the COVID-19 Pandemic

OBJECTIVES

Assess how family stressors (including structural stressors, social determinants of health inequities, and parent psychological distress) relate to media rule implementation and problematic child media use during the coronavirus disease 2019 pandemic.

METHODS

Nationally representative survey of 1000 United States parents with at least one 6 to 17 year old child was conducted in October through November 2020.

RESULTS

Problematic use was greater in families where parents were employed full time, present in the home (eg, working from home), had low levels or formal educational attainment, and were experiencing more psychological distress. Although there was a small decline in the number of media-related rules implemented during the pandemic (fewer parents enforced screen limits on weekdays or weekends or limited screen use at mealtimes), there was no association between rule implementation and problematic media use.

CONCLUSIONS

Family stressors were associated with problematic child media use during the coronavirus disease 2019 pandemic. As we emerge from the pandemic, it will be important to help parents adjust their family's media practices cognizant of the fact that additional children may have developed problematic screen use behaviors. Such efforts should center the role of structural and social determinants of health inequities on the stressors that families experience and that impact media use.

Cross-sectional association of light sensor-measured time outdoors with physical activity and gross motor competency among U.S. preschool-aged children: the 2012 NHANES National Youth Fitness Survey

Background

Time spent outdoors (outdoor time) has been suggested to be beneficial for physical activity (PA) and healthy development among preschool-aged children. The aim of this study was to quantify PA level and gross motor competency associated with light sensor-measured daily outdoor time in a representative sample of U.S. children aged 3 to 5 years.

Methods

The study sample included 301 participants (149 girls) aged 3 to 5 years from the 2012 U.S. National Health and Examination Survey National Youth Fitness Survey. ActiGraph GT3X+ accelerometers with a built-in ambient light sensor were used to measure PA (expressed in monitor-independent movement summary [MIMS]) and outdoor time. The Test of Gross Motor Development-Second Edition (TGMD-2) was used to assess gross motor skills. Multivariable linear regression models were fit to predict daily and gross motor scores by daily outdoor time.

Results

Average daily outdoor time was 95 min (median of 84 min; interquartile range of 52 to 123 min). Means of daily outdoor time and daily MIMS were not significantly different between boys and girls. Among girls, every additional 10 min of daily outdoor time was associated with an additional 540 daily total MIMS (95% CI = 372, 708). Among boys, every additional 10 min of daily outdoor time was associated with an additional 296 daily total MIMS (95% CI = 131, 460). Every additional 10 min of daily outdoor time was associated with a 0.1-point (95% CI = 0.001, 0.130) higher object control standard score. Daily outdoor time was not associated with a locomotor standard score.

Conclusions

In a representative sample of U.S. preschool-aged children, daily outdoor time was positively associated with daily PA. The contribution of outdoor time to PA was greater among girls than boys, suggesting that providing outdoor opportunities is critical for promoting PA, particularly among girls.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13239-0.

Park access and mental health among parents and children during the COVID-19 pandemic

BACKGROUND

Time spent outdoors and in nature has been associated with numerous benefits to health and well-being. We examined relationships between park access and mental health for children and parents during the COVID-19 pandemic. We also explored associations between park access and co-participation of parent and child in time outdoors, and child and parent physical activity.

METHODS

We used data from 1,000 respondents to a nationally representative U.S. survey of parent-child dyads during October-November 2020. Park access was defined as an affirmative response to: "do you have a park that you can safely walk to within 10 min of your home?" Child mental health was operationalized as the Strengths and Difficulties Questionnaire (SDQ) total difficulties score. The Patient Health Questionnaire-4 (PHQ-4) total score assessed parent mental health and the International Physical Activity Questionnaire (IPAQ) assessed parent physical activity. Child physical activity and co-participation in outdoor activity were reported as number of days in the prior week. Linear regression was used to examine relationships between park access and health outcomes in models adjusted for child and parent characteristics and COVID-19 impact.

RESULTS

Our sample included 500 parents of children ages 6-10 years, and 500 parent-child dyads of children ages 11-17 years. Park access was associated with a lower SDQ total score among children (β: -1.26, 95% CI: -2.25, -0.27) and a lower PHQ-4 total score among parents (β: -0.89, 95% CI: -1.39, -0.40). In models stratified by child age, these associations were observed for SDQ scores among adolescents ages 11-17 and for PHQ-4 scores among parents of children ages 6-10 years. Park access was also associated with 0.50 more days/week of co-participation in outdoor time (95% CI: 0.16, 0.84), and higher levels of parent physical activity (β: 1009 MET-min/week, 95% CI: 301, 1717), but not child physical activity (β: 0.31 days/week, 95% CI: -0.03, 0.66).

CONCLUSIONS

Park access was associated with better mental health among children and parents, and more parent physical activity and parent-child co-participation in outdooractivity during the COVID-19 pandemic. Access to nearby parks may be an important resource to promote health and well-being, for both individuals and families.

A Framework for Pediatric Health Care Providers to Promote Active Play in Nature for Children

Aim:

Time outdoors and contact with nature are positively associated with a broad range of children’s health outcomes. Pediatricians are uniquely positioned to promote active play in nature (APN) but may face challenges to do so during well child visits. The objective of this study was to understand barriers to children’s APN, before and during the COVID-19 pandemic, and how health care providers could promote APN.

Methods:

Focus groups were conducted with 14 pediatric providers and interviews with 14 parents (7 in English, 7 in Spanish) of children ages 3 to 10 on public insurance. Dedoose was used for coding and content analysis. We contextualized this work within the WHO’s Commission on Social Determinants of Health conceptual framework.

Results:

Parents mentioned a range of material circumstances (time, finances, family circumstances, access to safe outdoor play spaces and age-appropriate activities) and behavioral/psychosocial factors (previous experiences in nature, safety, and weather concerns), many of which were exacerbated by the pandemic, that serve as barriers to children’s APN. Providers said they were motivated to talk to families about children’s APN but mentioned barriers to this conversation such as time, other pressing priorities for the visit, and lack of resources to give families.

Conclusions:

Many pre-pandemic barriers to APN were exacerbated by the COVID-19 pandemic. Well-child visits may be an effective setting to discuss the benefits of APN during and beyond the pandemic, and there is a need for contextually appropriate resources for pediatric providers and families.

Needs assessment for physical activity information during COVID-19 among a nationally representative sample of parents and children ages 6-17 in the United States: a cross-sectional study

Background

The COVID-19 pandemic presented novel barriers to youth physical activity engagement. Identifying what resources parents and children are interested in receiving can support efforts to mitigate the negative impact of the pandemic on youth physical activity behavior. This study aimed to identify physical activity-related information needs during the COVID-19 pandemic among a nationally representative sample of American parents of children 6–10 years-old and parent-child dyads of children 11–17 years-old.

Methods

A cross-sectional survey was conducted by a market research company in October–November 2020. Parents and children were asked about their interest in specific types of information about helping their family and themselves, respectively, be active (Yes/No). Weighted percentages were calculated for reported information needs and compared using two-sample test of proportions.

Results

Final analytic sample was 1000 parents (55.4% female; 74.7% White; 74.0% non-Hispanic); 500 children 11–17 years-old (52.1% male; 77.6% White). Over 40% of participants were interested in information about being active during COVID-19. Parents were more likely to be interested in information if they always (versus never) worked from home [53.3% (95% CI: 43.3–63.0%) versus 22.0% (95% CI: 14.9–31.3%), p < 0.001]; had children attending school remotely versus in-person [47.3% (95% CI:40.2–54.5%) versus 27.5% (95% CI: 19.6–37.1%), p < 0.001]; and lived in a big city versus a rural area [66.5% (95% CI:54.5–76.7%) versus 34.1% (95% CI: 22.8–47.6%), p < 0.001]. Children most interested were those who did not have resources for online activity engagement and those worried about their safety or getting infected with COVID-19. Children were also more likely to be interested if their parents worked full-time versus not working [48.6% (95% CI:41.7–55.6%) versus 31.5% (95% CI: 24.1–39.9%), p < 0.001], and lived in a big city versus a rural area [57.2% (95% CI:45.3–68.3%) versus 27.8% (95% CI:17.8–40.7%), p < 0.001].

Conclusions

Families are interested in physical activity resources, particularly those whose daily routines and opportunities for physical activity may have been most significantly impacted by the pandemic. This includes parents who always worked from home or whose children attended school remotely. Identifying felt needs is an important step in developing tailored interventions that aim to effectively and sustainably support families in promoting physical activity.

Association of Children's Physical Activity and Screen Time With Mental Health During the COVID-19 Pandemic

IMPORTANCE

Children's physical activity and screen time are likely suboptimal during the COVID-19 pandemic, which may influence their current and future mental health.

OBJECTIVE

To describe the association of physical activity and screen time with mental health among US children during the pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey was conducted from October 22 to November 2, 2020, among 547 parents of children aged 6 to 10 years and 535 parent-child dyads with children and adolescents (hereinafter referred to as children) aged 11 to 17 years and matched down to 500 children per cohort using US Census-based sampling frames. Children aged 11 to 17 years self-reported physical activity, screen time, and mental health, and their parents reported other measures. Parents of children aged 6 to 10 years reported all measures. All 1000 cases were further weighted to a sampling frame corresponding to US parents with children aged 6 to 17 years using propensity scores.

EXPOSURES

Child physical activity, screen time, COVID-19 stressors, and demographics.

MAIN OUTCOMES AND MEASURES

Mental health using the Strengths and Difficulties Questionnaire for total difficulties and externalizing and internalizing symptoms.

RESULTS

Among the 1000 children included in the analysis (mean [SD] age, 10.8 [3.5] years; 517 [52.6%] boys; 293 [31.6%] American Indian/Alaska Native, Asian, or Black individuals or individuals of other race; and 233 [27.8%] Hispanic/Latino individuals), 195 (20.9%) reported at least 60 minutes of physical activity every day. Children reported a mean (SD) of 3.9 (2.2) d/wk with at least 60 minutes of physical activity and 4.4 (2.5) h/d of recreational screen time. COVID-19 stressors were significantly associated with higher total difficulties for both younger (β coefficient, 0.6; 95% CI, 0.3-0.9) and older (β coefficient, 0.4; 95% CI, 0.0-0.7) groups. After accounting for COVID-19 stressors, engaging in 7 d/wk (vs 0) of physical activity was associated with fewer externalizing symptoms in younger children (β coefficient, -2.0; 95% CI, -3.4 to -0.6). For older children, engaging in 1 to 6 and 7 d/wk (vs 0) of physical activity was associated with lower total difficulties (β coefficients, -3.5 [95% CI, -5.3 to -1.8] and -3.6 [95% CI, -5.8 to -1.4], respectively), fewer externalizing symptoms (β coefficients,  -1.5 [95% CI, -2.5 to -0.4] and -1.3 [95% CI, -2.6 to 0], respectively), and fewer internalizing symptoms (β coefficients, -2.1 [95% CI, -3.0 to -1.1] and -2.3 [95% CI, -3.5 to -1.1], respectively). More screen time was correlated with higher total difficulties among younger (β coefficient, 0.3; 95% CI, 0.1-0.5) and older (β coefficient, 0.4; 95% CI, 0.2-0.6) children. There were no significant differences by sex.

CONCLUSIONS AND RELEVANCE

In this cross-sectional survey study, more physical activity and less screen time were associated with better mental health for children, accounting for pandemic stressors. Children engaged in suboptimal amounts of physical activity and screen time, making this a potentially important target for intervention.

Nature and Children's Health: A Systematic Review

CONTEXT

Daily outdoor play is encouraged by the American Academy of Pediatrics. Existing evidence is unclear on the independent effect of nature exposures on child health.

OBJECTIVE

We systematically evaluated evidence regarding the relationship between nature contact and children's health.

DATA SOURCES

The database search was conducted by using PubMed, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, ERIC, Scopus, and Web of Science in February 2021.

STUDY SELECTION

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In all searches, the first element included nature terms; the second included child health outcome terms.

DATA EXTRACTION

Of the 10 940 studies identified, 296 were included. Study quality and risk of bias were assessed.

RESULTS

The strongest evidence for type of nature exposure was residential green space studies (n = 147, 50%). The strongest evidence for the beneficial health effects of nature was for physical activity (n = 108, 32%) and cognitive, behavioral, or mental health (n = 85, 25%). Physical activity was objectively measured in 55% of studies, and 41% of the cognitive, behavioral, or mental health studies were experimental in design.

LIMITATIONS

Types of nature exposures and health outcomes and behaviors were heterogenous. Risk of selection bias was moderate to high for all studies. Most studies were cross-sectional (n = 204, 69%), limiting our ability to assess causality.

CONCLUSIONS

Current literature supports a positive relationship between nature contact and children's health, especially for physical activity and mental health, both public health priorities. The evidence supports pediatricians in advocating for equitable nature contact for children in places where they live, play, and learn.

Evaluating the Feasibility and Acceptability of the Lifestyle Enhancement for ADHD Program

OBJECTIVE

To evaluate the feasibility and acceptability of the Lifestyle Enhancement for Attention Deficit Hyperactivity Disorder (ADHD) Program (LEAP), a novel parent behavior management training program that promotes physical activity (PA) and positive health behaviors and is enhanced with mobile health technology (Garmin) and a social media (Facebook) curriculum for parents of children with ADHD.

METHODS

The study included parents of children ages 5-10 years diagnosed with ADHD who did not engage in the recommended >60 min/day of moderate to vigorous PA based on parent report at baseline. Parents participated in the 8-week LEAP group and joined a private Facebook group. Children and one parent wore wrist-worn Garmin activity trackers daily. Parents completed the Treatment Adherence Inventory, Client Satisfaction Questionnaire, and participated in a structured focus group about their experiences with various aspects of the program.

RESULTS

Of 31 children enrolled, 51.5% had ADHD combined presentation, 36.3% with ADHD, predominately inattentive presentation, and 12.1% had unspecified ADHD (age 5-10; M = 7.6; 48.4% female). Parents attended an average of 86% of group sessions. On average, parents wore their Garmins for 5.1 days/week (average step count 7,092 steps/day) and children for 6.0 days/week (average step count 9,823 steps/day). Overall, parents and children were adherent to intervention components and acceptability of the program was high.

CONCLUSIONS

Findings indicate that the LEAP program is an acceptable and feasible intervention model for promoting PA among parents and their children with ADHD. Implications for improving ADHD symptoms and enhancing evidence-based parent training programs are discussed.

Plans of US Parents Regarding School Attendance for Their Children in the Fall of 2020: A National Survey

IMPORTANCE

As schools consider reopening for in-person instruction prior to availability of a coronavirus disease 2019 (COVID-19) vaccine, families may be weighing their priorities regarding school attendance.

OBJECTIVE

To characterize the association of planned in-person school attendance during the COVID-19 pandemic with factors, including family socioeconomic characteristics, and parent attitudes and beliefs about their child's school attendance.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional survey study. Data were collected from June 2, 2020, to June 5, 2020, weighted to reflect population norms, and analyzed using ordered probit regression. A sample of US parents (of children ages 5-17 years) were recruited using a nonprobability survey panel with stratification by socioeconomic characteristics.

MAIN OUTCOMES AND MEASURES

The main outcome was parent-reported plan to send their child to school or keep their child home, conditional on their school opening for in-person instruction. Additional measures assessed family socioeconomic characteristics, medical vulnerability, worry about COVID-19 and multisystem inflammatory syndrome, confidence in their child's school, and homeschooling difficulties.

RESULTS

The sample of 730 parents was balanced by parent sex (53% women) with successful oversampling for Black (28%; n = 201) and Hispanic (27%; n = 200) participants. In estimates weighted to US population norms, 31% (95% CI, 27% to 34%) of participants indicated they would probably or definitely keep their child home this fall, and 49% indicated that they would probably or definitely send their child to school this fall. Factors associated with planning to keep children home included lower income (38% with incomes <$50 000 vs 21% with incomes $100 000-$150 000 per year; difference, 17%; 95% CI, 9% to 26%), being unemployed (40% unemployed vs 26% employed; difference, 14%; 95% CI, 5% to 25%), and having a flexible job (33% with flexible jobs vs 19% with inflexible jobs; difference, 14%; 95% CI, 5% to 30%). Planning to keep children home was also associated with fear of COVID-19 (B = 0.19; P < .001), fear of multisystem inflammatory syndrome (B = 0.12; P = .04), confidence in schools (B = -0.22; P < .001), and challenges of homeschooling (B = -0.12; P = .01). Race and ethnicity were not significantly associated with plans to keep children home.

CONCLUSIONS AND RELEVANCE

In this survey study, many parents planned to keep children home in fall 2020. Schools need to act soon to address parental concerns and provide options for what will be available for them should they opt to keep their child home. Structural barriers, such as lack of workplace flexibility and potential school-level inequities in implementation of preventive measures, must be acknowledged and addressed where possible.

Cell Phone Use Policies in US Middle and High Schools

This survey study examines cell phone policies at US middle and high schools, practices of students and faculty, and principals’ attitudes about cell phone use during school.

Two Approaches to Increase Physical Activity for Preschool Children in Child Care Centers: A Matched-Pair Cluster-Randomized Trial

Early childhood education settings are critical for promoting physical activity (PA) but intervention effects are often small. The aim of this study was to develop, test, and compare two approaches to increasing physical activity among preschoolers at child care centers: one focused on a teacher-led PA curriculum (Active Play!) and the other on increasing outdoor child-initiated free play time (Outdoor Play!). We conducted a matched-pair cluster-randomized study in 10 centers in and around Seattle, WA, USA (n = 97 children, mean age 4.6). Pre- and post-intervention data were collected from observations and accelerometers. At pre-intervention, 19% of Active Play! and 25% of Outdoor Play! children achieved >120 min/day of PA during child care. The total opportunity for PA increased in both interventions (Active Play! = 11 min/day; Outdoor Play! = 14 min/day), with the largest increase in outdoor child-initiated free playtime (Active Play! = 19 min/day; Outdoor Play! = 24 min/day). No changes in sedentary time, light or moderate- to vigorous-intensity PA (MVPA) were observed in either intervention and there was no difference between interventions in the percentage of children attaining more than 120 min/day of PA. A small (<3 min/day) relative increase in teacher-led outdoor activity was observed in the Active Play! intervention. Both intervention strategies led to an increase in active play opportunities, predominantly outdoors, but neither was able to substantially increase the intensity and/or duration of children's PA. Future studies are needed to better understand and inform sustainable approaches to increase PA in early learning settings.

Examining Relationships between Food Procurement Characteristics and Nutritional Quality in Washington State Child Care Settings

BACKGROUND

Sixty percent of US children 5 years old and under receive up to two-thirds of their daily nutrition in early care and education (ECE) settings. Although participation in the federal Child and Adult Care Food Program (CACFP) is shown to improve nutrition, little is known about the relationship between procurement practices (where and how child care programs purchase food) and nutrition in ECE settings or whether these practices differ depending on participation in CACFP.

METHODS

We assessed self-reported nutrition practices and procurement practices by CACFP participation using a 2013 cross-sectional survey of 690 Washington ECE centers ("Centers") and 1260 family homes (family home child care [FHCCs]) serving children aged 2-5 years old using validated survey tools. We examined the relationship between procurement variables (i.e., main store and main mode) and nutrition scores using multinomial logistic regression models that adjusted for sociodemographic and program characteristics.

RESULTS

In-person shopping was the primary mode of shopping for all programs, regardless of CACFP participation. Some Centers but very few FHCCs reported online shopping as their primary mode. Centers and non-CACFP FHCCs shopped primarily at megastores (Costco, Target, etc.). CACFP FHCCs used both megastores and grocery stores (Albertsons, QFC, etc.) at similar rates. Adjusted multinomial models found that shopping online or at two or more stores was associated with higher nutritional quality of foods served by programs.

CONCLUSIONS

Understanding the procurement behaviors of ECE programs helps to illuminate and prioritize potential interventions that would support healthy food purchases.

A Comparison of Preschoolers' Physical Activity Indoors versus Outdoors at Child Care

The aims of this study were to quantify and examine differences in preschoolers’ indoor and outdoor sedentary time and physical activity intensity at child care using GPS devices and accelerometers. We conducted an observational study of 46 children (mean age 4.5 years, 30 boys, 16 girls) from five child care centers who wore accelerometers and GPS devices around their waists for five days during regular child care hours. GPS signal-to-noise ratios were used to determine indoor vs. outdoor location. Accelerometer data were categorized by activity intensity. Children spent, on average, 24% of child care time outdoors (range 12–37% by site), averaging 74 min daily outdoors (range 30–119 min), with 54% of children spending ≥60 min/day outdoors. Mean accelerometer activity counts were more than twice as high outdoors compared to indoors (345 (95) vs. 159 (38), (p < 0.001)), for girls and boys. Children were significantly less sedentary (51% of time vs. 75%) and engaging in more light (18% vs. 13%) and moderate-to-vigorous (MVPA) (31% vs. 12%) activity when outdoors compared to indoors (p < 0.001). To achieve a minute of MVPA, a preschooler needed to spend 9.1 min indoors vs. 3.8 min outdoors. Every additional 10 min outdoors each day was associated with a 2.9 min increase in MVPA (2.7 min for girls, 3.0 min for boys). Preschool-age children are twice as active and less sedentary when outdoors compared to indoors in child care settings. To help preschoolers achieve MVPA recommendations and likely attain other benefits, one strategy is to increase the amount of time they spend outdoors and further study how best to structure it.

Trends and Knowledge Gaps in the Study of Nature-Based Participation by Latinos in the United States

Mounting evidence supports health and well-being benefits associated with nature experiences, while also highlighting race- and class-based inequalities in access and exposure. We synthesized the literature on nature contact by Latinos in the United States to assess the state of knowledge and strategically identify research needs to improve outcomes and reduce health disparities for this rapidly growing ethnic group. Our systematic review revealed 108 articles with a notable increase in number of papers over the past 3 decades. We noted that the body of research is focused on certain demographic targets (adults in urban areas) with a relative dearth of knowledge for others (children, seniors, and rural areas). Our analysis also revealed strong compartmentalizing of studies into research &ldquo;clusters&rdquo; based on nonoverlapping topics and types of outcomes that are measured. Although one-third of studies explored health outcomes, these studies rarely examined other outcomes or research topics. Moreover, less than 7% of studies reported on interventions. Given the potential for nature contact to enhance health and well-being, there is substantial need for multidisciplinary research that explores interactions between social, cultural, and economic factors, and how those ultimately relate to nature contact and outcomes for Latinos in the United States.

A comparison of parent and childcare provider's attitudes and perceptions about preschoolers' physical activity and outdoor time

BACKGROUND

Young children depend on adult caregivers to provide opportunities for physical activity. Research has focused on barriers and facilitators to children's physical activity while in childcare, but parental influences remain largely unknown. This study examines parent's attitudes about preschoolers' physical activity and outdoor time, compares them with those of childcare providers and determines the association between parental attitudes and preschoolers' measured activity.

METHODS

Parents and childcare providers from 30 childcare centres were surveyed regarding attitudes towards preschoolers' physical activity and outdoor time. Children's moderate-to-vigorous physical activity was determined by using 24-h accelerometry. Parent and childcare providers' responses were compared. Mixed-effect linear regression examined moderate-to-vigorous physical activity and sedentary time as outcomes with parental attitudes as predictors, family demographics as covariates and centre as a random effect.

RESULTS

Three hundred eighty-eight parents and 151 childcare providers participated. On average, children were 4.3 (0.7) years old. Parents and childcare providers both considered daily physical activity important for preschoolers, but providers rated the importance of daily outdoor time higher on a 10-point scale (8.9 vs. 7.6, P < 0.001). More parents than providers believed that children would get sick by playing outside in the cold (25 vs. 11%, P < 0.05). Parents were more comfortable with their child playing outside at childcare compared with outside at home (8.9 vs. 6.9, P < 0.001). Lower income parents felt less comfortable than higher income parents with their child playing outside either near home or at childcare. Neither home nor total child activity levels were associated with most parental attitudes queried.

CONCLUSIONS

While parents and childcare providers value daily physical activity for children, some parents expressed discomfort about their young children engaging in outdoor play, especially around home and in cold weather. These findings highlight the importance of childcare-based interventions to promote preschoolers' physical activity and outdoor play.

Nature Contact and Human Health: A Research Agenda

BACKGROUND

At a time of increasing disconnectedness from nature, scientific interest in the potential health benefits of nature contact has grown. Research in recent decades has yielded substantial evidence, but large gaps remain in our understanding.

OBJECTIVES

We propose a research agenda on nature contact and health, identifying principal domains of research and key questions that, if answered, would provide the basis for evidence-based public health interventions.

DISCUSSION

We identify research questions in seven domains: a) mechanistic biomedical studies; b) exposure science; c) epidemiology of health benefits; d) diversity and equity considerations; e) technological nature; f) economic and policy studies; and g) implementation science.

CONCLUSIONS

Nature contact may offer a range of human health benefits. Although much evidence is already available, much remains unknown. A robust research effort, guided by a focus on key unanswered questions, has the potential to yield high-impact, consequential public health insights. https://doi.org/10.1289/EHP1663.

The relationship between physical activity and diet and young children's cognitive development: A systematic review

OBJECTIVE

Given the high prevalence of suboptimal nutrition and low activity levels in children, we systematically reviewed the literature on the relationship between physical activity and dietary patterns and cognitive development in early childhood (six months to five years).

METHODS

In February 2016, we conducted two different searches of MEDLINE, PsycINFO, and ERIC. Each search included either physical activity (including gross motor skills) or diet terms, and neurocognitive development outcome terms. Included studies were in English, published since 2005, and of any study design in which the physical activity or diet measure occurred prior to age five.

RESULTS

For physical activity, twelve studies (5 cross-sectional, 3 longitudinal and 4 experimental) were included. Eleven studies reported evidence suggesting that physical activity or gross motor skills are related to cognition or learning. Both acute bouts and longer term exposures showed benefit. For diet, eight studies were included consisting of secondary analyses from longitudinal cohort studies. A healthier dietary pattern was associated with better cognitive outcomes in all studies, although some of the reported associations were weak and the measures used varied across the studies.

CONCLUSIONS

Physical activity and healthy diets in early childhood are associated with better cognitive outcomes in young children. The paucity of literature and the variability in the type and quality of measures used highlight the need for more rigorous research. Given that the early childhood years are critical for both obesity prevention and neurocognitive development, evidence that the same healthy behaviors could promote both should inform future interventions.

Active play opportunities at child care

BACKGROUND AND OBJECTIVES

Physical activity (PA) is important for children's health and development, yet preschoolers are not meeting PA recommendations. The objective of this study was to examine different PA opportunities at child care and how variation in indoor versus outdoor and free versus teacher-led opportunities relate to children's PA.

METHODS

An observational study of 98 children (mean age 4.5 years, 49% girls) from 10 child care centers. Classrooms were observed for at least 4 full days per center (total 50 days) to categorize time into (1) not an active play opportunity (APO); (2) naptime; (3) APO, outdoor free play; (4) APO, outdoor teacher-led; (5) APO, indoor free play; and (6) APO, indoor teacher-led. Children wore accelerometers during observations. Linear regression models examined the influence of APO categories on moderate-vigorous physical activity (MVPA) and sedentary time.

RESULTS

Children's activity was 73% sedentary, 13% light, and 14% MVPA. For 88% of time children did not have APOs, including 26% time as naptime. On average, 48 minutes per day were APOs (41% sedentary, 18% light, and 41% MVPA), 33 minutes per day were outdoors. The most frequent APO was outdoor free play (8% of time); outdoor teacher-led time was <1%. Children were more active and less sedentary outdoors versus indoors and during the child-initiated APOs (indoors and outdoors) versus teacher-led APOs.

CONCLUSIONS

Preschoolers were presented with significantly fewer than recommended opportunities for PA at child care. More APOs are needed for children to meet recommendations, particularly those that encourage more outdoor time, more teacher-led and child-initiated active play, and flexibility in naptime for preschoolers.

Parental factors in children's active transport to school

OBJECTIVE

Identify non-distance factors related to children's active transport (AT) to school, including parental, home, and environment characteristics. Understanding the factors related to children's AT to school, beyond distance to school, could inform interventions to increase AT and children's overall physical activity.

STUDY DESIGN

Participants were in the Neighborhood Impact on Kids Study, a longitudinal, observational cohort study of children aged 6-11 and their parents in King County, WA and San Diego County, CA between 2007 and 2009. Parents reported frequency and mode of child transport to school, perceived neighbourhood, home and family environments, parental travel behaviours, and sociodemographics.

METHODS

Children living less than a 20 minute walk to school were in this analysis. Children classified as active transporters (walked/bicycled to or from school at least once per week) were compared with those not using AT as often.

RESULTS

Children using AT were older and had parents who reported themselves using active transport. Having a family rule that restricts the child to stay within sight of the parent or home and more parent working hours were related to lower odds of a child using AT.

CONCLUSIONS

Children's AT to school is associated with parental AT to work and other locations. Interventions should be considered that enable whole family AT, ameliorate safety concerns and decrease the need for parental supervision, such as walking school buses.

Indoor versus outdoor time in preschoolers at child care

BACKGROUND

Being outdoors may have health benefits including being more physically active. Understanding the relationship between outdoor time and health is hampered by the difficulty of measuring outdoor time.

PURPOSE

To examine the accuracy and validity of light-sensor and GPS methods for quantifying outdoor time among those aged 3-5 years at child care.

METHODS

A total of 45 children (mean age 4.5 years, 64% boys) from five child care centers wore portable accelerometers with built-in light sensors and a separate GPS device around their waists during child care, providing 80,648 episodes (15 seconds each) for analysis. Direct observation (gold standard) of children being outdoors versus indoors was conducted for 2 days at each center. GPS signal-to-noise ratios, processed through the Personal Activity and Location Measurement System were used to define indoor versus outdoor locations. Receiver operating characteristic (ROC) analyses were used to determine thresholds for defining being indoors versus outdoors. Data were collected in Fall 2011, analyzed in 2012.

RESULTS

Mean observed outdoor time was 63 [±44; range: 18-152] minutes/day. Mean light-sensor levels were significantly higher outdoors. The area under the ROC curve for location based on light sensor for all weather conditions was 0.82 (range: 0.70 on partly cloudy days to 0.97 on sunny days); for GPS, it was 0.89. The light sensor had a sensitivity of 74% and specificity of 86%. GPS had a sensitivity of 82% and specificity of 88%.

CONCLUSIONS

A light sensor and a GPS device both distinguish indoor from outdoor time for preschoolers with moderate to high levels of accuracy. These devices can increase the feasibility and lower the cost of measuring outdoor time in studies of preschool children.

Frequency of parent-supervised outdoor play of US preschool-aged children

OBJECTIVE

To characterize preschoolers’ daily parent-supervised outdoor play frequency and associated factors.

DESIGN

Cross-sectional using data from the Early Childhood Longitudinal Study–Birth Cohort.

SETTING

Nationally representative US sample.

PARTICIPANTS

Preschool-aged children.

MAIN OUTCOME MEASURE

Parent-reported outdoor play frequency.

RESULTS

The sample size of 8950 represented approximately 4 million children. Sixty percent of mothers worked outside the home, 79% exercised 0 to 3 days per week, and 93% perceived their neighborhood to be safe. Forty-four percent of mothers and 24% of fathers reported taking their child outside to play at least once per day. Fifty-one percent of children were reported to go outside to play at least once per day with either parent. Fifty-eight percent of children who were not in child care went outside daily. A child’s odds of going outside daily were associated with sex (odds ratio [OR] for girls, 0.85;95% CI, 0.75-0.95), having more regular playmates (OR for ≥ 3 playmates, 2.03; 95% CI, 1.72-2.38), mother’s race/ethnicity (OR for Asian, 0.51, 95% CI, 0.43-0.61; black,0.59, 95% CI, 0.49-0.70; Hispanic, 0.80, 95% CI, 0.67-0.95), mother’s employment (OR for full time, 0.70; 95%CI, 0.62-0.81), and parent’s exercise frequency of 4 days or more per week (OR, 1.50; 95% CI, 1.28-1.75). We did not find significant association of outdoor play with child’s time spent watching television, household income, mother’s marital status, or parent’s perceptions of neighborhood safety.

CONCLUSIONS

About half the preschoolers in this sample did not have even 1 parent-supervised outdoor play opportunity per day. Efforts to increase active outdoor play should especially target children who are girls and nonwhite. Outdoor play opportunities at child care are critical for children of parents who work outside the home.

The frequency of outdoor play for preschool age children cared for at home-based child care settings

OBJECTIVE

Given that more than 34% of U.S. children are cared for in home-based child care settings and outdoor play is associated with physical activity and other health benefits, we sought to characterize the outdoor play frequency of preschoolers cared for at home-based child care settings and factors associated with outdoor play.

METHODS

Cross-sectional study of 1900 preschoolers (representing approximately 862,800 children) cared for in home-based child care settings (including relative and nonrelative care) using the nationally representative Early Childhood Longitudinal Study, Birth Cohort.

RESULTS

Only 50% of home-based child care providers reported taking the child outside to walk or play at least once/day. More than one-third of all children did not go outside to play daily with either their parent(s) or home-based child care provider. There were increased odds of going outside daily for children cared for by nonrelatives in the child's home compared with care from a relative. Children with ≥3 regular playmates had greater odds of being taken outdoors by either the parents or child care provider. We did not find statistically significant associations between other child level (age, sex, screen-time), family level (highest education in household, mother's race, employment, exercise frequency), and child care level (hours in care, provider's educational attainment, perception of neighborhood safety) factors and frequency of outdoor play.

CONCLUSIONS

At a national level, the frequency of outdoor play for preschoolers cared for in home-based child care settings is suboptimal. Further study and efforts to increase outdoor playtime for children in home-based child care settings are needed.

Home environment relationships with children's physical activity, sedentary time, and screen time by socioeconomic status

Background

Children in households of lower socioeconomic status (SES) are more likely to be overweight/obese. We aimed to determine if home physical activity (PA) environments differed by SES and to explore home environment mediators of the relation of family SES to children’s PA and sedentary behavior.

Methods

Participants were 715 children aged 6 to 11 from the Neighborhood Impact on Kids (NIK) Study. Household SES was examined using highest educational attainment and income. Home environment was measured by parent report on a survey. Outcomes were child’s accelerometer-measured PA and parent-reported screen time. Mediation analyses were conducted for home environment factors that varied by SES.

Results

Children from lower income households had greater media access in their bedrooms (TV 52% vs. 14%, DVD player 39% vs. 14%, video games 21% vs. 9%) but lower access to portable play equipment (bikes 85% vs. 98%, jump ropes 69% vs. 83%) compared to higher income children. Lower SES families had more restrictive rules about PA (2.5 vs. 2.0). Across SES, children watched TV/DVDs with parents/siblings more often than they engaged in PA with them. Parents of lower SES watched TV/DVDs with their children more often (3.1 vs. 2.5 days/week). Neither total daily and home-based MVPA nor sedentary time differed by SES. Children’s daily screen time varied from 1.7 hours/day in high SES to 2.4 in low SES families. Media in the bedroom was related to screen time, and screen time with parents was a mediator of the SES--screen time relationship.

Conclusions

Lower SES home environments provided more opportunities for sedentary behavior and fewer for PA. Removing electronic media from children’s bedrooms has the potential to reduce disparities in chronic disease risk.

Physical activity and beverages in home- and center-based child care programs

OBJECTIVE

To describe and compare obesity prevention practices related to physical activity and beverages in home- and center-based child care programs.

METHODS

A telephone survey of licensed home- and center-based child care programs in Florida, Massachusetts, Michigan, and Washington between October and December 2008.

RESULTS

Most programs reported almost universal access to outdoor play areas and staff who frequently engage in and lead physical activities. About half of the programs reported ≤ 60 minutes of outdoor play time per day for preschoolers. Fewer home-based programs offered a variety of fixed and portable play equipment. Over a third of the programs did not have adequate indoor space for all physical activities. Over two thirds of programs offered juice 3 or 4 times per week or more.

CONCLUSIONS AND IMPLICATIONS

Many child care programs could increase active opportunities (by increasing outdoor time and providing better spaces for indoor physical activity) and decrease juice provision.

The impact of menu labeling on fast-food purchases for children and parents

BACKGROUND

Nutrition labeling of menus has been promoted as a means for helping consumers make healthier food choices at restaurants. As part of national health reform, chain restaurants will be required to post nutrition information at point-of-purchase, but more evidence regarding the impact of these regulations, particularly in children, is needed.

PURPOSE

To determine whether nutrition labeling on restaurant menus results in a lower number of calories purchased by children and their parents.

METHODS

A prospective cohort study compared restaurant receipts of those aged 6-11 years and their parents before and after a menu-labeling regulation in Seattle/King County (S/KC) (n=75), with those from a comparison sample in nonregulated San Diego County (SDC) (n=58). Data were collected in 2008 and 2009 and analyzed in 2010.

RESULTS

In S/KC, there was a significant increase from pre- to post-regulation (44% vs 87%) in parents seeing nutrition information, with no change in SDC (40% vs 34%). Average calories purchased for children did not change in either county (823 vs 822 in S/KC, 984 vs 949 in SDC). There was an approximately 100-calorie decrease for the parents postregulation in both counties (823 vs 720 in S/KC, 895 vs 789 in SDC), but no difference between counties.

CONCLUSIONS

A restaurant menu-labeling regulation increased parents' nutrition information awareness but did not decrease calories purchased for either children or parents.

Preschoolers' total daily screen time at home and by type of child care

OBJECTIVE

To assess preschoolers' cumulative daily screen time, measure the contributions of the home and the child care setting to this total, and characterize children that are most at risk for excessive screen time.

STUDY DESIGN

We used data from the Early Childhood Longitudinal Study-Birth Cohort, to calculate daily screen time based on reports by preschooler's parents and care providers.

RESULTS

The sample size of 8950 represented approximately 4 million children. By preschool age, >80% of children were in some child care. On average, children in this study were exposed to 4.1 hours of screen time daily, including 3.6 hours at home and 0.4 hours in child care. Children in centers had the lowest screen time (3.2 hours) compared with children in parental care only (4.4 hours), home-based care (5.5 hours), and Head Start (4.2 hours). Even when adjusted for relevant covariates, these differences remained significant (P < .001).

CONCLUSIONS

Preschoolers' cumulative screen time exceeds recommendations and most previous estimates. Pediatric clinicians are uniquely positioned to encourage families to discuss screen time with their children's caregivers and to advocate for high quality child care. Efforts to decrease screen time in homes and home-based child care settings are needed.

Nutrition menu labeling may lead to lower-calorie restaurant meal choices for children

OBJECTIVE

Our aim was to determine whether nutrition labeling on menus would lead to lower-calorie choices for children.

METHODS

We performed a randomized, controlled experiment in a primary care pediatric clinic in Seattle, Washington. Parents of children 3 to 6 years of age presenting for an appointment were eligible. Parents were ineligible if they never ate fast food, if they were not English speaking, if their child was too sick, or if they had already participated. This was a convenience sample, with randomization performed in blocks of 6. Parents were presented with a McDonald's menu and were asked to select meals for themselves and their child. The menus were identical for both groups except for the presence of nutrition information for the intervention group.

RESULTS

There were 99 participants, for a participation rate of 82%. There were no significant differences in demographic characteristics between the groups. Parents in the intervention arm ordered an average of 102 fewer calories for their children than did control subjects (567.1 cal vs 671.5 cal; P = .04). With adjustment for parent's gender, race, education, and BMI, fast food frequency, and child's BMI z score, the difference remained significant (P = .004). There was no difference in energy between the 2 groups in the parents' choices for themselves.

CONCLUSION

This study is the first to suggest that labeled menus may lead to significantly lower calorie content in restaurant meals purchased for children.