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Association between physical exercise and psychosocial problems in 96 617 Dutch adolescents in secondary education: a cross-sectional study

Association between physical exercise and psychosocial problems in 96 617 Dutch adolescents in... Abstract Background Psychosocial problems negatively affect school performance, social skills and mental development. In recent years, researchers have investigated the relationship between physical activity and psychological health. With this large school-based study, we examined whether physically inactive adolescents and slightly active adolescents experience more psychosocial problems compared with active adolescents. Methods This study is based on the Dutch National Youth Health Monitor. This monitor uses a, school-based, cross-sectional questionnaire conducted among 96 617 adolescents in 2015. To examine the association between physical exercise and psychosocial problems, multi-level linear regression was carried out. Results The weighted average Strengths and Difficulties Questionnaire score of active adolescents was lower than that of inactive adolescents. Adolescents who are inactive had 12% (β = 1.12; 95% CI: 1.10–1.14; P <0 .001) more psychosocial problems compared with active adolescents. Further, inactive adolescents had a higher score on the subscales emotional problems (β = 1.19; 95% CI: 1.17—1.22; P < 0.001) and problems with peers (β = 1.16; 95% CI: 1.14—1.19; P < 0.001). There was no statistical significant difference in total score of the Strengths and Difficulties Questionnaire between active and slightly active adolescents. Conclusion Physically active adolescents have fewer psychosocial problems compared with physically inactive adolescents. Not only is this association significant, but there is an indication that it is also of clinical relevance. Introduction According to the population-based studies, 20% of the Dutch adolescents have some degree of psychosocial problems.1,2 Psychosocial problems can be a psychological problem as well as a social problem. These adolescents may have anxious feelings and thoughts and also may have problems in social interaction with others.3 Psychosocial problems among adolescents negatively affect school performance, social skills and mental development. Moreover, they lead to high social costs and are a major cause of increased health care use in later life.4–7 Researchers have investigated the relationship between physical activity and psychological health. Several cross-sectional studies have shown that regular exercise is associated with a lower risk of psychosocial problems in adults and children.8–16 In a large-scale population study, however, no positive association was found between physical exercise and psychological health after controlling for several confounders.17 Various longitudinal studies have shown that people who exercise regularly are less likely to develop symptoms of anxiety or depression.8,18–23 In contrast, some longitudinal studies found no relationship between exercise and mental health.24–26 The focus of these studies is on the association between physical exercise and psychological health instead of psychosocial problems. The youth health care in the Netherlands focuses on psychosocial problems in children. Encouraging adolescents to perform more physical activity might be an effective intervention to prevent psychosocial problems. Using data of a large school-based study, we examined whether physically inactive adolescents and slightly active adolescents experience more psychosocial problems compared with active adolescents. Methods Study design This study is based on a secondary data analysis of the National Dutch Youth Health Monitor 2015 from the National Institute for Public Health and Environment and 25 Municipal Public Health Service (MPHS). This monitor is a school-based cross-sectional questionnaire conducted among adolescents in the second and fourth grade of regular secondary education. The Dutch Youth Health Monitor is conducted every 4 year by all 25 MPHS offices in the Netherlands. Recruitment and study population The sampling frame consisted of all regular secondary schools in the Netherlands enlisted with the ministry of education. A stratified sampling procedure was used. A proportional number of schools by educational level was randomly selected (N = 567). In total, 376 of the 567 contacted schools enrolled (66%). The schools that did not participate were too busy or had no interest. The Dutch Youth Health Monitor included adolescents in the second and fourth grade at regular Dutch secondary schools. A total of 96 617 adolescents completed the online self-report questionnaire during a regular lesson at school in the period of October–December 2015. Measures The monitor consists of 75 questions (189 items). The following are examples of topics were included in the questionnaire: grade, age, level of education, sex, ethnicity, family composition, living environment, perceived health, perceived happiness, psychosocial health, height and weight, physical exercise, nutrition, smoking, alcohol, drugs, school experience, bullying, social media, gaming and sexuality. The Dutch Youth Health Monitor includes validated instruments such as the Strengths and Difficulties Questionnaire (SDQ) and several questions about health and lifestyle. The Dutch version of the SDQ was used to measure the degree of psychosocial problems.27 The SDQ consists of 25 items with three possible answers: not true, somewhat true and certainly true. The SDQ is divided into five subscales: emotional problems, conduct problems, hyperactivity, peer problems and pro-social behavior. The total SDQ score is a fully dimensional measure: an increase in the total SDQ score corresponds with an increase in the risk of mental health disorder.28 Compared with the other scales, an opposite interpretation applies for the pro-social behavior scale. Hence, a higher score means more pro-social behavior. Widenfelt et al.29 and Muris et al.30 examined psychometric properties of the Dutch translation of the self-reported SDQ in adolescents. They concluded that the psychometric properties of the self-reported Dutch translation of the SDQ are acceptable. In 2017, the Dutch National Health council concluded on the basis of recent scientific insights that no advice can be given about the amount of exercise in relation to the positive effects on health of children. Therefore, the Dutch National Health council still advises to maintain the recommendation of at least 1 h of moderate intensive exercise every day.31 In this study, physical exercise was measured with a single-item question: ‘For how many days per week do you practice a sport or engage in physical exercise for at least one hour? Include all kinds of sports or exercise you do in a day.’ Response choices were: (Almost) Never, 1 day per week, 2 days per week, 3 days per week, 4 days per week, 5 days per week, 6 days per week and every day. Adolescents were considered active, according to the Dutch standard of healthy exercise, by answering ‘every day’ to this question.32 In this study, adolescents were considered inactive if they exercised <3 days a week. With regard to the respondents’ psychosocial health, we compared the respondents who answered ‘every day’ (active), as a reference group, with those who answered ‘3–6 days per week’ (slightly active) and with those who answered ‘<3 days a week’ (inactive). Probable sources of confounding were identified in the literature.10,14,19,26,33,34 The following covariates and related categories (between brackets) were included in the analysis: gender, grade (2 or 4), age(12–13, 14–15, 16–17) household situation (parents living together vs. other answers), ethnicity (non-immigrant, non-Western, Western immigrant), urbanization (highly, moderately, not urbanized), educational level (low, intermediate, high), use of soft drugs last month (no/yes), lifetime use of hard drugs (no/yes), lifetime use of soft drugs (no/yes), alcohol or binge drinking previous four weeks (no/yes) and being bullied in the past 3 months (no/yes). These covariates are divided into three categories: demographic, socialeconomic and lifestyle covariates. Statistical methods To examine the adjusted associations between physical exercise and psychosocial problems, multi-level linear regression was carried out with random effects to account for clustering of adolescents within schools. The total SDQ score and the categorical variable physical exercise were included in the model. A second multi-level model was fitted for the adjusted association between physical exercise and psychosocial problems with a fixed effect for the following demographic covariates: gender, grade, age, household situation, ethnicity and urbanization. A third multi-level model was fitted for the above-mentioned association with fixed effects for the demographic covariates and the following socioeconomic covariate: educational level. A fourth multi-level model was fitted with fixed effects for demographic, socioeconomic and the following lifestyle covariates: lifetime use of hard drugs, use of soft drugs and alcohol last month, binge drinking and being bullied. These four models were also fitted in a multi-level model to determine the association between the five sub-scale scores of the SDQ and physical exercise. The logarithmically transformed regression coefficients of the total SDQ score corrected for demographic, socioeconomic and lifestyle covariates appeared to be most relevant in this study. The relative differences between the regression coefficients in total SDQ score of inactive and active adolescents presented in this model were considerable compared with the other models. Therefore, both adjusted and unadjusted models are presented in table 3. All analyses were conducted in MlwIN V.2.22 and SPSS 20. The normality of the primary outcome measures was visually inspected. The outcome variables were log transformed because they were positively skewed. The distribution of the total SDQ score ranges from 0 to 40. It is not possible to logarithmically transform zeros. For that reason we added a constant to each answer on the 25 items [log(x + 1)] to make all results positive and not zero.35,36 No imputation technique was used. The fractions of missing values of the outcome variables and independent variables were very small (<0.5%). The influence of missing values on the association between physical exercise and psychosocial problems was considered to be very low. We used a database of 96 617 adolescents. Due to this size, a very small effect size could be statistically significant.37 Therefore, a P values smaller than 0.001 was considered statistically significant. Results Most adolescents in our sample were 14 or 15 years old (44%), living with both their parents (76%), had a non-immigrant background (81%) and had a low educational level (52%). Almost a third of the adolescents had consumed alcohol in the previous month (32%) and more than a fifth had used alcohol excessively in the previous 4 weeks (23%). Few adolescents had ever used hard drugs (4%) or had used soft drugs in the previous 4 weeks (5%). As shown in table 1, more girls than boys were inactive (19% vs. 15%). Other noteworthy differences in this sample were that older adolescents were more often inactive than younger adolescents (23% vs. 14%). Furthermore, adolescents who have a non-Western background and adolescents who were attending a lower level of education were more often inactive, compared with non-immigrant adolescents (27% vs. 15%) and adolescents who attend a higher level of education (21% vs. 10%). Finally, adolescents who had ever used hard drugs or had used soft drugs in the previous 4 weeks were more likely to be inactive compared with adolescents who had never used hard drugs (21% vs. 16%) or used soft drugs in the past 4 weeks (23% vs. 16%). Table 1 Adolescents demographic, socio-economic and lifestyle characteristics in relation to physical exercise levels, N (%) Physical exercise Active Slightly active Inactive Total Covariates n % n % n % n Gender     Male 10.206 21 31.191 64 7.006 15 48.403     Female 8.403 18 30.333 63 9.069 19 47.805 Age     12–13 7.243 20 23.918 66 4.927 14 36.088     14–15 8.024 19 27.039 64 7.106 17 42.169     16–17 3.339 19 10.561 59 4.040 23 17.940 Grade     Second class 9.791 20 31.578 65 7.481 15 48.850     Fourth class 8.818 19 29.946 63 8.594 18 47.358 Household situation     Living with two parents 14.347 20 47.582 65 10.935 15 72.864     Other answers 4.242 18 13.893 60 5.123 22 23.258 Ethnicity     Non-western immigrant 15.216 20 51.092 66 11.574 15 77.882     Western immigrants 1.149 19 3.662 60 1.236 20 6.047     Non-western immigrants 2.234 18 6.753 55 3.252 27 12.239 Urbanization     (Very) highly urbanized 7.080 18 23.722 62 7.574 20 38.376     Moderately urbanized 3.827 19 12.893 64 3.359 17 20.079     Not urbanized 7.702 20 24.909 66 5.142 14 37.753 Level of education     Low (vmbo) 9.507 19 29.969 60 10.618 21 49.821     Intermediate (havo) 5.137 19 17.794 67 3.498 13 26.429     High (vwo) 3.965 20 14.034 70 1.959 10 19.958 Use of soft drugs (previous month)     No 17.475 19 58.576 64 14.869 16 90.920     Yes 1.060 22 2.682 55 1.094 23 4.836 Hard drug use (life time)     No 17.547 19 58.916 64 15.006 16 91.469     Yes 875 23 2.195 57 806 21 3.876 Use of alcohol (previous month)     No 11.357 19 38.227 64 9.926 17 59.510     Yes 5.710 20 17.601 63 4.823 17 28.134 Binge drinking (previous month)     No 12.986 19 43.842 64 11.239 17 68.067     Yes 4.119 21 12.088 61 3.545 18 19.752 Being bullied     No 16.512 19 54.638 64 13.667 16 84.817     Yes 1.943 18 6.408 61 2.221 21 10.572 Physical exercise Active Slightly active Inactive Total Covariates n % n % n % n Gender     Male 10.206 21 31.191 64 7.006 15 48.403     Female 8.403 18 30.333 63 9.069 19 47.805 Age     12–13 7.243 20 23.918 66 4.927 14 36.088     14–15 8.024 19 27.039 64 7.106 17 42.169     16–17 3.339 19 10.561 59 4.040 23 17.940 Grade     Second class 9.791 20 31.578 65 7.481 15 48.850     Fourth class 8.818 19 29.946 63 8.594 18 47.358 Household situation     Living with two parents 14.347 20 47.582 65 10.935 15 72.864     Other answers 4.242 18 13.893 60 5.123 22 23.258 Ethnicity     Non-western immigrant 15.216 20 51.092 66 11.574 15 77.882     Western immigrants 1.149 19 3.662 60 1.236 20 6.047     Non-western immigrants 2.234 18 6.753 55 3.252 27 12.239 Urbanization     (Very) highly urbanized 7.080 18 23.722 62 7.574 20 38.376     Moderately urbanized 3.827 19 12.893 64 3.359 17 20.079     Not urbanized 7.702 20 24.909 66 5.142 14 37.753 Level of education     Low (vmbo) 9.507 19 29.969 60 10.618 21 49.821     Intermediate (havo) 5.137 19 17.794 67 3.498 13 26.429     High (vwo) 3.965 20 14.034 70 1.959 10 19.958 Use of soft drugs (previous month)     No 17.475 19 58.576 64 14.869 16 90.920     Yes 1.060 22 2.682 55 1.094 23 4.836 Hard drug use (life time)     No 17.547 19 58.916 64 15.006 16 91.469     Yes 875 23 2.195 57 806 21 3.876 Use of alcohol (previous month)     No 11.357 19 38.227 64 9.926 17 59.510     Yes 5.710 20 17.601 63 4.823 17 28.134 Binge drinking (previous month)     No 12.986 19 43.842 64 11.239 17 68.067     Yes 4.119 21 12.088 61 3.545 18 19.752 Being bullied     No 16.512 19 54.638 64 13.667 16 84.817     Yes 1.943 18 6.408 61 2.221 21 10.572 Table 1 Adolescents demographic, socio-economic and lifestyle characteristics in relation to physical exercise levels, N (%) Physical exercise Active Slightly active Inactive Total Covariates n % n % n % n Gender     Male 10.206 21 31.191 64 7.006 15 48.403     Female 8.403 18 30.333 63 9.069 19 47.805 Age     12–13 7.243 20 23.918 66 4.927 14 36.088     14–15 8.024 19 27.039 64 7.106 17 42.169     16–17 3.339 19 10.561 59 4.040 23 17.940 Grade     Second class 9.791 20 31.578 65 7.481 15 48.850     Fourth class 8.818 19 29.946 63 8.594 18 47.358 Household situation     Living with two parents 14.347 20 47.582 65 10.935 15 72.864     Other answers 4.242 18 13.893 60 5.123 22 23.258 Ethnicity     Non-western immigrant 15.216 20 51.092 66 11.574 15 77.882     Western immigrants 1.149 19 3.662 60 1.236 20 6.047     Non-western immigrants 2.234 18 6.753 55 3.252 27 12.239 Urbanization     (Very) highly urbanized 7.080 18 23.722 62 7.574 20 38.376     Moderately urbanized 3.827 19 12.893 64 3.359 17 20.079     Not urbanized 7.702 20 24.909 66 5.142 14 37.753 Level of education     Low (vmbo) 9.507 19 29.969 60 10.618 21 49.821     Intermediate (havo) 5.137 19 17.794 67 3.498 13 26.429     High (vwo) 3.965 20 14.034 70 1.959 10 19.958 Use of soft drugs (previous month)     No 17.475 19 58.576 64 14.869 16 90.920     Yes 1.060 22 2.682 55 1.094 23 4.836 Hard drug use (life time)     No 17.547 19 58.916 64 15.006 16 91.469     Yes 875 23 2.195 57 806 21 3.876 Use of alcohol (previous month)     No 11.357 19 38.227 64 9.926 17 59.510     Yes 5.710 20 17.601 63 4.823 17 28.134 Binge drinking (previous month)     No 12.986 19 43.842 64 11.239 17 68.067     Yes 4.119 21 12.088 61 3.545 18 19.752 Being bullied     No 16.512 19 54.638 64 13.667 16 84.817     Yes 1.943 18 6.408 61 2.221 21 10.572 Physical exercise Active Slightly active Inactive Total Covariates n % n % n % n Gender     Male 10.206 21 31.191 64 7.006 15 48.403     Female 8.403 18 30.333 63 9.069 19 47.805 Age     12–13 7.243 20 23.918 66 4.927 14 36.088     14–15 8.024 19 27.039 64 7.106 17 42.169     16–17 3.339 19 10.561 59 4.040 23 17.940 Grade     Second class 9.791 20 31.578 65 7.481 15 48.850     Fourth class 8.818 19 29.946 63 8.594 18 47.358 Household situation     Living with two parents 14.347 20 47.582 65 10.935 15 72.864     Other answers 4.242 18 13.893 60 5.123 22 23.258 Ethnicity     Non-western immigrant 15.216 20 51.092 66 11.574 15 77.882     Western immigrants 1.149 19 3.662 60 1.236 20 6.047     Non-western immigrants 2.234 18 6.753 55 3.252 27 12.239 Urbanization     (Very) highly urbanized 7.080 18 23.722 62 7.574 20 38.376     Moderately urbanized 3.827 19 12.893 64 3.359 17 20.079     Not urbanized 7.702 20 24.909 66 5.142 14 37.753 Level of education     Low (vmbo) 9.507 19 29.969 60 10.618 21 49.821     Intermediate (havo) 5.137 19 17.794 67 3.498 13 26.429     High (vwo) 3.965 20 14.034 70 1.959 10 19.958 Use of soft drugs (previous month)     No 17.475 19 58.576 64 14.869 16 90.920     Yes 1.060 22 2.682 55 1.094 23 4.836 Hard drug use (life time)     No 17.547 19 58.916 64 15.006 16 91.469     Yes 875 23 2.195 57 806 21 3.876 Use of alcohol (previous month)     No 11.357 19 38.227 64 9.926 17 59.510     Yes 5.710 20 17.601 63 4.823 17 28.134 Binge drinking (previous month)     No 12.986 19 43.842 64 11.239 17 68.067     Yes 4.119 21 12.088 61 3.545 18 19.752 Being bullied     No 16.512 19 54.638 64 13.667 16 84.817     Yes 1.943 18 6.408 61 2.221 21 10.572 The weighted average total SDQ score of active adolescents [9.33 ± 5.05 (SD)] was lower that of the inactive adolescents (10.97 ± 5.45; see table 2). There is no difference between the active and slightly active adolescents (9.30 ± 4.83). Table 2 Total SDQ and subscale scores in relation to physical exercise levels, mean (SD) Scale Inactive Slightly active Active Total Range Mean (SD) Mean (SD) Mean (SD) Mean (SD) Total difficulties score 0–40 10.97 (5.45) 9.30 (4.83) 9.33 (5.05) 9.59 (5.02) Emotional problems 0–10 2.87 (2.29) 2.33 (2.09) 2.08 (2.04) 2.37 (2.13) Conduct problems 0–10 1.86 (1.63) 1.54 (1.38) 1.70 (1.54) 1.63 (1.46) Hyperactivity 0–10 4.28 (2.40) 4.02 (2.36) 4.16 (2.48) 4.09 (2.39) Peer problems 0–10 1.97 (1.65) 1.41 (1.44) 1.39 (1.48) 1.50 (1.50) Pro-social behavior 0–10 7.54 (1.91) 7.92 (1.68) 8.00 (1.75) 7.87 (1.74) Scale Inactive Slightly active Active Total Range Mean (SD) Mean (SD) Mean (SD) Mean (SD) Total difficulties score 0–40 10.97 (5.45) 9.30 (4.83) 9.33 (5.05) 9.59 (5.02) Emotional problems 0–10 2.87 (2.29) 2.33 (2.09) 2.08 (2.04) 2.37 (2.13) Conduct problems 0–10 1.86 (1.63) 1.54 (1.38) 1.70 (1.54) 1.63 (1.46) Hyperactivity 0–10 4.28 (2.40) 4.02 (2.36) 4.16 (2.48) 4.09 (2.39) Peer problems 0–10 1.97 (1.65) 1.41 (1.44) 1.39 (1.48) 1.50 (1.50) Pro-social behavior 0–10 7.54 (1.91) 7.92 (1.68) 8.00 (1.75) 7.87 (1.74) Table 2 Total SDQ and subscale scores in relation to physical exercise levels, mean (SD) Scale Inactive Slightly active Active Total Range Mean (SD) Mean (SD) Mean (SD) Mean (SD) Total difficulties score 0–40 10.97 (5.45) 9.30 (4.83) 9.33 (5.05) 9.59 (5.02) Emotional problems 0–10 2.87 (2.29) 2.33 (2.09) 2.08 (2.04) 2.37 (2.13) Conduct problems 0–10 1.86 (1.63) 1.54 (1.38) 1.70 (1.54) 1.63 (1.46) Hyperactivity 0–10 4.28 (2.40) 4.02 (2.36) 4.16 (2.48) 4.09 (2.39) Peer problems 0–10 1.97 (1.65) 1.41 (1.44) 1.39 (1.48) 1.50 (1.50) Pro-social behavior 0–10 7.54 (1.91) 7.92 (1.68) 8.00 (1.75) 7.87 (1.74) Scale Inactive Slightly active Active Total Range Mean (SD) Mean (SD) Mean (SD) Mean (SD) Total difficulties score 0–40 10.97 (5.45) 9.30 (4.83) 9.33 (5.05) 9.59 (5.02) Emotional problems 0–10 2.87 (2.29) 2.33 (2.09) 2.08 (2.04) 2.37 (2.13) Conduct problems 0–10 1.86 (1.63) 1.54 (1.38) 1.70 (1.54) 1.63 (1.46) Hyperactivity 0–10 4.28 (2.40) 4.02 (2.36) 4.16 (2.48) 4.09 (2.39) Peer problems 0–10 1.97 (1.65) 1.41 (1.44) 1.39 (1.48) 1.50 (1.50) Pro-social behavior 0–10 7.54 (1.91) 7.92 (1.68) 8.00 (1.75) 7.87 (1.74) The logarithmically transformed coefficients of the unadjusted and adjusted models that estimate the association between the frequency of physical exercise and psychosocial problems are presented in table 3. Both unadjusted as adjusted coefficients between active and inactive adolescents are significant. Table 3 Multi-level linear regression results of continuous (logarithmically transformed) mean of the total SDQ score and the five subscales of the SDQ; unadjusted and adjusted models representing the effect of the difference on the SDQ score between active (reference), slightly active and inactive adolescents [β (95% (CI)] Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 0.012 –0.001 to .025 0.152* 0.132 to 0.172 0.013 –0.000 to 0.026 0.111* 0.091 to 0.131 Emotional problems 0.090* 0.074 to 0.106 0.251* 0.228 to 0.274 0.073* 0.057 to 0.089 0.178* 0.155 to 0.201 Conduct problems −0.047* –0.060 to –0.033 0.032* 0.012 to 0.052 –0.032* –0.045 to –0.019 0.025* 0.005 to 0.045 Hyperactivity −0.016 –0.032 to 0.000 0.032** 0.012 to 0.052 –0.010 –0.026 to 0.006 0.028* 0.005 to 0.051 Peer problems 0.025* 0.009 to 0.041 0.203* 0.183 to 0.223 0.023* 0.007 to 0.039 0.152* 0.132 to 0.172 Pro-social behavior –0.008* –0.015 to –0.001 –0.056* –0.066 to –0.046 –0.016 –0.023 to –0.009 −0.063* −0.073 to −0.053 Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 0.012 –0.001 to .025 0.152* 0.132 to 0.172 0.013 –0.000 to 0.026 0.111* 0.091 to 0.131 Emotional problems 0.090* 0.074 to 0.106 0.251* 0.228 to 0.274 0.073* 0.057 to 0.089 0.178* 0.155 to 0.201 Conduct problems −0.047* –0.060 to –0.033 0.032* 0.012 to 0.052 –0.032* –0.045 to –0.019 0.025* 0.005 to 0.045 Hyperactivity −0.016 –0.032 to 0.000 0.032** 0.012 to 0.052 –0.010 –0.026 to 0.006 0.028* 0.005 to 0.051 Peer problems 0.025* 0.009 to 0.041 0.203* 0.183 to 0.223 0.023* 0.007 to 0.039 0.152* 0.132 to 0.172 Pro-social behavior –0.008* –0.015 to –0.001 –0.056* –0.066 to –0.046 –0.016 –0.023 to –0.009 −0.063* −0.073 to −0.053 a Adjusted for gender, grade, household situation, ethnicity, urbanization, level of (secondary) education, use of soft drugs, hard drug use, recent use of alcohol, recent excessive alcohol use, being bullied. * P < 0.001 Table 3 Multi-level linear regression results of continuous (logarithmically transformed) mean of the total SDQ score and the five subscales of the SDQ; unadjusted and adjusted models representing the effect of the difference on the SDQ score between active (reference), slightly active and inactive adolescents [β (95% (CI)] Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 0.012 –0.001 to .025 0.152* 0.132 to 0.172 0.013 –0.000 to 0.026 0.111* 0.091 to 0.131 Emotional problems 0.090* 0.074 to 0.106 0.251* 0.228 to 0.274 0.073* 0.057 to 0.089 0.178* 0.155 to 0.201 Conduct problems −0.047* –0.060 to –0.033 0.032* 0.012 to 0.052 –0.032* –0.045 to –0.019 0.025* 0.005 to 0.045 Hyperactivity −0.016 –0.032 to 0.000 0.032** 0.012 to 0.052 –0.010 –0.026 to 0.006 0.028* 0.005 to 0.051 Peer problems 0.025* 0.009 to 0.041 0.203* 0.183 to 0.223 0.023* 0.007 to 0.039 0.152* 0.132 to 0.172 Pro-social behavior –0.008* –0.015 to –0.001 –0.056* –0.066 to –0.046 –0.016 –0.023 to –0.009 −0.063* −0.073 to −0.053 Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 0.012 –0.001 to .025 0.152* 0.132 to 0.172 0.013 –0.000 to 0.026 0.111* 0.091 to 0.131 Emotional problems 0.090* 0.074 to 0.106 0.251* 0.228 to 0.274 0.073* 0.057 to 0.089 0.178* 0.155 to 0.201 Conduct problems −0.047* –0.060 to –0.033 0.032* 0.012 to 0.052 –0.032* –0.045 to –0.019 0.025* 0.005 to 0.045 Hyperactivity −0.016 –0.032 to 0.000 0.032** 0.012 to 0.052 –0.010 –0.026 to 0.006 0.028* 0.005 to 0.051 Peer problems 0.025* 0.009 to 0.041 0.203* 0.183 to 0.223 0.023* 0.007 to 0.039 0.152* 0.132 to 0.172 Pro-social behavior –0.008* –0.015 to –0.001 –0.056* –0.066 to –0.046 –0.016 –0.023 to –0.009 −0.063* −0.073 to −0.053 a Adjusted for gender, grade, household situation, ethnicity, urbanization, level of (secondary) education, use of soft drugs, hard drug use, recent use of alcohol, recent excessive alcohol use, being bullied. * P < 0.001 After the antilog procedure, the average total SDQ score of adolescents who were inactive was 1.12 times higher than that of adolescents who were active (β = 1.12; 95% CI: 1.10–1.14; P < 0.001; see table 4). In other words, inactive adolescents were likely to have psychosocial problems compared with active adolescents. Table 4 Multi-level linear regression results of continuous mean after the antilog procedure of the total SDQ score and the five subscales of the SDQ; unadjusted and adjusted models representing the effect of the difference on the SDQ score between active (reference), slightly active and inactive adolescents [β (95% (CI)] Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 1.01 1.00 to 1.02 1.16* 1.14 to 1.19 1.01 1.00 to 1.03 1.12* 1.10 to 1.14 Emotional problems 1.09* 1.08 to 1.11 1.29* 1.26 to 1.32 1.08* 1.06 to 1.09 1.19* 1.17 to 1.22 Conduct problems 0.95* 0.94 to 0.97 1.03* 1.01 to 1.05 0.97* 0.96 to 0.98 1.03* 1.01 to 1.05 Hyperactivity 0.98 0.97 to 1.00 1.03* 1.01 to 1.05 0.99 0.97 to 1.01 1.03* 1.01 to 1.05 Peer problems 1.03* 1.01 to 1.04 1.23* 1.20 to 1.25 1.02* 1.01 to 1.04 1.16* 1.14 to 1.19 Pro-social behavior 0.99* 0.99 to 1.00 0.95* 0.94 to 0.96 0.98 0.98 to 0.99 0.94* 0.93 to 0.95 Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 1.01 1.00 to 1.02 1.16* 1.14 to 1.19 1.01 1.00 to 1.03 1.12* 1.10 to 1.14 Emotional problems 1.09* 1.08 to 1.11 1.29* 1.26 to 1.32 1.08* 1.06 to 1.09 1.19* 1.17 to 1.22 Conduct problems 0.95* 0.94 to 0.97 1.03* 1.01 to 1.05 0.97* 0.96 to 0.98 1.03* 1.01 to 1.05 Hyperactivity 0.98 0.97 to 1.00 1.03* 1.01 to 1.05 0.99 0.97 to 1.01 1.03* 1.01 to 1.05 Peer problems 1.03* 1.01 to 1.04 1.23* 1.20 to 1.25 1.02* 1.01 to 1.04 1.16* 1.14 to 1.19 Pro-social behavior 0.99* 0.99 to 1.00 0.95* 0.94 to 0.96 0.98 0.98 to 0.99 0.94* 0.93 to 0.95 a Adjusted for gender, grade, household situation, ethnicity, urbanization, level of (secondary) education, use of soft drugs, hard drug use, recent use of alcohol, recent excessive alcohol use and being bullied. * P < 0.001. Table 4 Multi-level linear regression results of continuous mean after the antilog procedure of the total SDQ score and the five subscales of the SDQ; unadjusted and adjusted models representing the effect of the difference on the SDQ score between active (reference), slightly active and inactive adolescents [β (95% (CI)] Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 1.01 1.00 to 1.02 1.16* 1.14 to 1.19 1.01 1.00 to 1.03 1.12* 1.10 to 1.14 Emotional problems 1.09* 1.08 to 1.11 1.29* 1.26 to 1.32 1.08* 1.06 to 1.09 1.19* 1.17 to 1.22 Conduct problems 0.95* 0.94 to 0.97 1.03* 1.01 to 1.05 0.97* 0.96 to 0.98 1.03* 1.01 to 1.05 Hyperactivity 0.98 0.97 to 1.00 1.03* 1.01 to 1.05 0.99 0.97 to 1.01 1.03* 1.01 to 1.05 Peer problems 1.03* 1.01 to 1.04 1.23* 1.20 to 1.25 1.02* 1.01 to 1.04 1.16* 1.14 to 1.19 Pro-social behavior 0.99* 0.99 to 1.00 0.95* 0.94 to 0.96 0.98 0.98 to 0.99 0.94* 0.93 to 0.95 Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 1.01 1.00 to 1.02 1.16* 1.14 to 1.19 1.01 1.00 to 1.03 1.12* 1.10 to 1.14 Emotional problems 1.09* 1.08 to 1.11 1.29* 1.26 to 1.32 1.08* 1.06 to 1.09 1.19* 1.17 to 1.22 Conduct problems 0.95* 0.94 to 0.97 1.03* 1.01 to 1.05 0.97* 0.96 to 0.98 1.03* 1.01 to 1.05 Hyperactivity 0.98 0.97 to 1.00 1.03* 1.01 to 1.05 0.99 0.97 to 1.01 1.03* 1.01 to 1.05 Peer problems 1.03* 1.01 to 1.04 1.23* 1.20 to 1.25 1.02* 1.01 to 1.04 1.16* 1.14 to 1.19 Pro-social behavior 0.99* 0.99 to 1.00 0.95* 0.94 to 0.96 0.98 0.98 to 0.99 0.94* 0.93 to 0.95 a Adjusted for gender, grade, household situation, ethnicity, urbanization, level of (secondary) education, use of soft drugs, hard drug use, recent use of alcohol, recent excessive alcohol use and being bullied. * P < 0.001. Additionally, it was relatively more common for inactive adolescents to have emotional problems (β = 1.19; 95% CI: 1.17–1.22; P < 0.001), conduct problems (β = 1.03; 95% CI: 1.01–1.05; P < 0.001), hyperactivity (β = 1.03; 95% CI: 1.00–1.05; P < 0.001), problems with peers (β = 1.16; 95% CI: 1.14–1.19; P < 0.001) and exhibit less pro-social behavior (β = 0.94; 95% CI: 0.93–0.95; P < 0.001) compared with active adolescents. The association between the average SDQ score of active adolescents and that of slightly active adolescents was almost statistically significant according to our threshold of 0.001 (β = 1.01; 95% CI: 1.00–1.03; P = 0.0012). Emotional problems (β = 1.08; 95% CI: 1.06–1.09; P < 0.001) were more common in slightly active adolescents compared with active adolescents. The weak but statistically significant association of conduct problems and problems with peers between these groups: 0.97 (95% CI: 0.96–0.98; P < 0.001) and 1.02 (95% CI: 1.01–1.04; P < 0.001), respectively. Discussion The aim of this study was to explore whether inactive and slightly active adolescents experience more psychosocial problems compared with active adolescents. Main findings of this study Our data provide evidence of an inverse association between the physical activity level of adolescents in the Netherlands and the extent of their psychosocial problems. Inactive adolescents experience more psychosocial problems than active adolescents. Similarly, inactive adolescents experience more emotional and conduct problems, hyperactivity, problems with peers and show less pro-social behavior. The differences between slightly active and active adolescents are less distinctive. For example, there is no statistical significant difference in total SDQ score between active and slightly active adolescents. Clinical relevance also plays a role in the interpretation of the observed association. Beforehand, we considered a result clinically relevant if the difference in adjusted regression (β) coefficient between active and inactive adolescents was greater than one point. Depending on the baseline value, an increase in one point on the SDQ scale could imply that an adolescent will be referred to a psychologist by the MPHS. The difference in weighted average total SDQ score between active and inactive adolescents is more than 1.5 point (table 2). This indicates, to our standards, a clinically relevant difference in psychosocial problems. However, due to the skewness of the distribution, we had to logarithmically transform the outcome measures. Therefore, the regression coefficients have to be interpreted as a ratio between those groups of adolescents instead of a difference. As a consequence, clinical relevance could not been deduced from these regression coefficients. What is already know on this topic The above-mentioned findings corroborates with earlier cross-sectional findings.11,13,14,16 These studies showed that lack of exercise was associated with various psychological problems. Psychosocial problems consist partly of psychological problems, making these findings relevant. However, these results are not in line with some longitudinal studies.24–26 Furthermore, Stavrakakis et al. focused on the onset of depressive disorders and physical activity but found no evidence of such an effect of physical activity on depression.22,38 This implies that the association we found in our data might be of limited value. On the other hand, the same Stavrakakis also studied the prospective relationship between physical activity and depressive symptoms in adolescents and found a weak statistically significant negative association.22,39 This shows that the relationship between physical activity and psychological health is complex. Genetic and biological factors, personality traits and environmental factors such as socialeconomic status and lifestyle habits interact and jointly affect psychosocial problems.22,38 In combination with these factors, sufficient physical exercise might prevent or mitigate psychosocial problems. What this study adds It was known in advance that most studies showed that physical exercise were associated with psychological problems. However, none of these studies focused on psychosocial problems. Psychosocial health is the outcome measure of the SDQ, widely used in youth care. This research has shown that physical exercise is also associated with less of psychosocial health. Finally, we used the data of the nationwide Dutch Youth Health Monitor conducted among almost 100 000 adolescents. Because of this number of participants, the results presented in this research are, as far as we know, unique. Limitations of this study The first weakness of this study is the cross-sectional design, which implies that a causal direction cannot be determined. Therefore, it may be that a lack of exercise causes psychosocial problems, but it is also possible that psychosocial problems lead to less exercise. Finally, it is also possible for an underlying factor to affect both physical exercises as psychosocial problems. The direction of causation can be established in a randomized controlled trial or in a prospective design. Second, the amount of physical activity was determined with a single-item question. This question covered the number of days per week of moderately intensive exercise for at least 1 h. Additional information about the exact amount and intensity was not collected. Information about the type of exercise, such as team sport or an individual activity, could deepen our understanding. Conclusion This study shows that physically active adolescents have fewer psychosocial problems than inactive adolescents. This association is not only statistically significant, but we think that it is also of clinical relevance. Inactive adolescents experience more emotional and conduct problems, hyperactivity, problems with peers and they show less pro-social behavior. Compared with active adolescents, slightly active adolescents experienced more emotional problems and problems with peers. However, slightly active adolescents experienced fewer conduct problems compared with active adolescents. Acknowledgements The data set of the Youth Health Monitor 2015 was provided by the Dutch National Institute for Public Health and Environment and 25 Municipal Public Health Service. Conflicts of interest: None declared. Key points Previous studies have demonstrated that 20% of the Dutch adolescents have some degree of psychosocial problems. Previous research investigated the relationship between physical activity and psychological health. However, none of these studies focused on psychosocial problems. We used the data of the nationwide Dutch Youth Health Monitor conducted among almost 100 000 adolescents. This study shows that physically active adolescents have fewer psychosocial problems than inactive adolescents. The amount of physical activity was determined with a single-item question. Information about the manner of exercise could deepen our understanding about the association between physical activity and psychosocial health. References 1 Theunissen MHC , Vogels AGC , Reijneveld SA . Work experience and style explain variation among pediatricians in the detection of children with psychosocial problems . Acad Pediatr 2012 ; 12 : 495 – 501 . Google Scholar CrossRef Search ADS PubMed 2 Crone MR , Bekkema N , Wiefferink CH , et al. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Association between physical exercise and psychosocial problems in 96 617 Dutch adolescents in secondary education: a cross-sectional study

Kuiper, J; Broer, J; van der Wouden, J C
The European Journal of Public Health , Volume Advance Article (3) – Jan 8, 2018
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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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1101-1262
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1464-360X
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10.1093/eurpub/ckx230
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Abstract

Abstract Background Psychosocial problems negatively affect school performance, social skills and mental development. In recent years, researchers have investigated the relationship between physical activity and psychological health. With this large school-based study, we examined whether physically inactive adolescents and slightly active adolescents experience more psychosocial problems compared with active adolescents. Methods This study is based on the Dutch National Youth Health Monitor. This monitor uses a, school-based, cross-sectional questionnaire conducted among 96 617 adolescents in 2015. To examine the association between physical exercise and psychosocial problems, multi-level linear regression was carried out. Results The weighted average Strengths and Difficulties Questionnaire score of active adolescents was lower than that of inactive adolescents. Adolescents who are inactive had 12% (β = 1.12; 95% CI: 1.10–1.14; P <0 .001) more psychosocial problems compared with active adolescents. Further, inactive adolescents had a higher score on the subscales emotional problems (β = 1.19; 95% CI: 1.17—1.22; P < 0.001) and problems with peers (β = 1.16; 95% CI: 1.14—1.19; P < 0.001). There was no statistical significant difference in total score of the Strengths and Difficulties Questionnaire between active and slightly active adolescents. Conclusion Physically active adolescents have fewer psychosocial problems compared with physically inactive adolescents. Not only is this association significant, but there is an indication that it is also of clinical relevance. Introduction According to the population-based studies, 20% of the Dutch adolescents have some degree of psychosocial problems.1,2 Psychosocial problems can be a psychological problem as well as a social problem. These adolescents may have anxious feelings and thoughts and also may have problems in social interaction with others.3 Psychosocial problems among adolescents negatively affect school performance, social skills and mental development. Moreover, they lead to high social costs and are a major cause of increased health care use in later life.4–7 Researchers have investigated the relationship between physical activity and psychological health. Several cross-sectional studies have shown that regular exercise is associated with a lower risk of psychosocial problems in adults and children.8–16 In a large-scale population study, however, no positive association was found between physical exercise and psychological health after controlling for several confounders.17 Various longitudinal studies have shown that people who exercise regularly are less likely to develop symptoms of anxiety or depression.8,18–23 In contrast, some longitudinal studies found no relationship between exercise and mental health.24–26 The focus of these studies is on the association between physical exercise and psychological health instead of psychosocial problems. The youth health care in the Netherlands focuses on psychosocial problems in children. Encouraging adolescents to perform more physical activity might be an effective intervention to prevent psychosocial problems. Using data of a large school-based study, we examined whether physically inactive adolescents and slightly active adolescents experience more psychosocial problems compared with active adolescents. Methods Study design This study is based on a secondary data analysis of the National Dutch Youth Health Monitor 2015 from the National Institute for Public Health and Environment and 25 Municipal Public Health Service (MPHS). This monitor is a school-based cross-sectional questionnaire conducted among adolescents in the second and fourth grade of regular secondary education. The Dutch Youth Health Monitor is conducted every 4 year by all 25 MPHS offices in the Netherlands. Recruitment and study population The sampling frame consisted of all regular secondary schools in the Netherlands enlisted with the ministry of education. A stratified sampling procedure was used. A proportional number of schools by educational level was randomly selected (N = 567). In total, 376 of the 567 contacted schools enrolled (66%). The schools that did not participate were too busy or had no interest. The Dutch Youth Health Monitor included adolescents in the second and fourth grade at regular Dutch secondary schools. A total of 96 617 adolescents completed the online self-report questionnaire during a regular lesson at school in the period of October–December 2015. Measures The monitor consists of 75 questions (189 items). The following are examples of topics were included in the questionnaire: grade, age, level of education, sex, ethnicity, family composition, living environment, perceived health, perceived happiness, psychosocial health, height and weight, physical exercise, nutrition, smoking, alcohol, drugs, school experience, bullying, social media, gaming and sexuality. The Dutch Youth Health Monitor includes validated instruments such as the Strengths and Difficulties Questionnaire (SDQ) and several questions about health and lifestyle. The Dutch version of the SDQ was used to measure the degree of psychosocial problems.27 The SDQ consists of 25 items with three possible answers: not true, somewhat true and certainly true. The SDQ is divided into five subscales: emotional problems, conduct problems, hyperactivity, peer problems and pro-social behavior. The total SDQ score is a fully dimensional measure: an increase in the total SDQ score corresponds with an increase in the risk of mental health disorder.28 Compared with the other scales, an opposite interpretation applies for the pro-social behavior scale. Hence, a higher score means more pro-social behavior. Widenfelt et al.29 and Muris et al.30 examined psychometric properties of the Dutch translation of the self-reported SDQ in adolescents. They concluded that the psychometric properties of the self-reported Dutch translation of the SDQ are acceptable. In 2017, the Dutch National Health council concluded on the basis of recent scientific insights that no advice can be given about the amount of exercise in relation to the positive effects on health of children. Therefore, the Dutch National Health council still advises to maintain the recommendation of at least 1 h of moderate intensive exercise every day.31 In this study, physical exercise was measured with a single-item question: ‘For how many days per week do you practice a sport or engage in physical exercise for at least one hour? Include all kinds of sports or exercise you do in a day.’ Response choices were: (Almost) Never, 1 day per week, 2 days per week, 3 days per week, 4 days per week, 5 days per week, 6 days per week and every day. Adolescents were considered active, according to the Dutch standard of healthy exercise, by answering ‘every day’ to this question.32 In this study, adolescents were considered inactive if they exercised <3 days a week. With regard to the respondents’ psychosocial health, we compared the respondents who answered ‘every day’ (active), as a reference group, with those who answered ‘3–6 days per week’ (slightly active) and with those who answered ‘<3 days a week’ (inactive). Probable sources of confounding were identified in the literature.10,14,19,26,33,34 The following covariates and related categories (between brackets) were included in the analysis: gender, grade (2 or 4), age(12–13, 14–15, 16–17) household situation (parents living together vs. other answers), ethnicity (non-immigrant, non-Western, Western immigrant), urbanization (highly, moderately, not urbanized), educational level (low, intermediate, high), use of soft drugs last month (no/yes), lifetime use of hard drugs (no/yes), lifetime use of soft drugs (no/yes), alcohol or binge drinking previous four weeks (no/yes) and being bullied in the past 3 months (no/yes). These covariates are divided into three categories: demographic, socialeconomic and lifestyle covariates. Statistical methods To examine the adjusted associations between physical exercise and psychosocial problems, multi-level linear regression was carried out with random effects to account for clustering of adolescents within schools. The total SDQ score and the categorical variable physical exercise were included in the model. A second multi-level model was fitted for the adjusted association between physical exercise and psychosocial problems with a fixed effect for the following demographic covariates: gender, grade, age, household situation, ethnicity and urbanization. A third multi-level model was fitted for the above-mentioned association with fixed effects for the demographic covariates and the following socioeconomic covariate: educational level. A fourth multi-level model was fitted with fixed effects for demographic, socioeconomic and the following lifestyle covariates: lifetime use of hard drugs, use of soft drugs and alcohol last month, binge drinking and being bullied. These four models were also fitted in a multi-level model to determine the association between the five sub-scale scores of the SDQ and physical exercise. The logarithmically transformed regression coefficients of the total SDQ score corrected for demographic, socioeconomic and lifestyle covariates appeared to be most relevant in this study. The relative differences between the regression coefficients in total SDQ score of inactive and active adolescents presented in this model were considerable compared with the other models. Therefore, both adjusted and unadjusted models are presented in table 3. All analyses were conducted in MlwIN V.2.22 and SPSS 20. The normality of the primary outcome measures was visually inspected. The outcome variables were log transformed because they were positively skewed. The distribution of the total SDQ score ranges from 0 to 40. It is not possible to logarithmically transform zeros. For that reason we added a constant to each answer on the 25 items [log(x + 1)] to make all results positive and not zero.35,36 No imputation technique was used. The fractions of missing values of the outcome variables and independent variables were very small (<0.5%). The influence of missing values on the association between physical exercise and psychosocial problems was considered to be very low. We used a database of 96 617 adolescents. Due to this size, a very small effect size could be statistically significant.37 Therefore, a P values smaller than 0.001 was considered statistically significant. Results Most adolescents in our sample were 14 or 15 years old (44%), living with both their parents (76%), had a non-immigrant background (81%) and had a low educational level (52%). Almost a third of the adolescents had consumed alcohol in the previous month (32%) and more than a fifth had used alcohol excessively in the previous 4 weeks (23%). Few adolescents had ever used hard drugs (4%) or had used soft drugs in the previous 4 weeks (5%). As shown in table 1, more girls than boys were inactive (19% vs. 15%). Other noteworthy differences in this sample were that older adolescents were more often inactive than younger adolescents (23% vs. 14%). Furthermore, adolescents who have a non-Western background and adolescents who were attending a lower level of education were more often inactive, compared with non-immigrant adolescents (27% vs. 15%) and adolescents who attend a higher level of education (21% vs. 10%). Finally, adolescents who had ever used hard drugs or had used soft drugs in the previous 4 weeks were more likely to be inactive compared with adolescents who had never used hard drugs (21% vs. 16%) or used soft drugs in the past 4 weeks (23% vs. 16%). Table 1 Adolescents demographic, socio-economic and lifestyle characteristics in relation to physical exercise levels, N (%) Physical exercise Active Slightly active Inactive Total Covariates n % n % n % n Gender     Male 10.206 21 31.191 64 7.006 15 48.403     Female 8.403 18 30.333 63 9.069 19 47.805 Age     12–13 7.243 20 23.918 66 4.927 14 36.088     14–15 8.024 19 27.039 64 7.106 17 42.169     16–17 3.339 19 10.561 59 4.040 23 17.940 Grade     Second class 9.791 20 31.578 65 7.481 15 48.850     Fourth class 8.818 19 29.946 63 8.594 18 47.358 Household situation     Living with two parents 14.347 20 47.582 65 10.935 15 72.864     Other answers 4.242 18 13.893 60 5.123 22 23.258 Ethnicity     Non-western immigrant 15.216 20 51.092 66 11.574 15 77.882     Western immigrants 1.149 19 3.662 60 1.236 20 6.047     Non-western immigrants 2.234 18 6.753 55 3.252 27 12.239 Urbanization     (Very) highly urbanized 7.080 18 23.722 62 7.574 20 38.376     Moderately urbanized 3.827 19 12.893 64 3.359 17 20.079     Not urbanized 7.702 20 24.909 66 5.142 14 37.753 Level of education     Low (vmbo) 9.507 19 29.969 60 10.618 21 49.821     Intermediate (havo) 5.137 19 17.794 67 3.498 13 26.429     High (vwo) 3.965 20 14.034 70 1.959 10 19.958 Use of soft drugs (previous month)     No 17.475 19 58.576 64 14.869 16 90.920     Yes 1.060 22 2.682 55 1.094 23 4.836 Hard drug use (life time)     No 17.547 19 58.916 64 15.006 16 91.469     Yes 875 23 2.195 57 806 21 3.876 Use of alcohol (previous month)     No 11.357 19 38.227 64 9.926 17 59.510     Yes 5.710 20 17.601 63 4.823 17 28.134 Binge drinking (previous month)     No 12.986 19 43.842 64 11.239 17 68.067     Yes 4.119 21 12.088 61 3.545 18 19.752 Being bullied     No 16.512 19 54.638 64 13.667 16 84.817     Yes 1.943 18 6.408 61 2.221 21 10.572 Physical exercise Active Slightly active Inactive Total Covariates n % n % n % n Gender     Male 10.206 21 31.191 64 7.006 15 48.403     Female 8.403 18 30.333 63 9.069 19 47.805 Age     12–13 7.243 20 23.918 66 4.927 14 36.088     14–15 8.024 19 27.039 64 7.106 17 42.169     16–17 3.339 19 10.561 59 4.040 23 17.940 Grade     Second class 9.791 20 31.578 65 7.481 15 48.850     Fourth class 8.818 19 29.946 63 8.594 18 47.358 Household situation     Living with two parents 14.347 20 47.582 65 10.935 15 72.864     Other answers 4.242 18 13.893 60 5.123 22 23.258 Ethnicity     Non-western immigrant 15.216 20 51.092 66 11.574 15 77.882     Western immigrants 1.149 19 3.662 60 1.236 20 6.047     Non-western immigrants 2.234 18 6.753 55 3.252 27 12.239 Urbanization     (Very) highly urbanized 7.080 18 23.722 62 7.574 20 38.376     Moderately urbanized 3.827 19 12.893 64 3.359 17 20.079     Not urbanized 7.702 20 24.909 66 5.142 14 37.753 Level of education     Low (vmbo) 9.507 19 29.969 60 10.618 21 49.821     Intermediate (havo) 5.137 19 17.794 67 3.498 13 26.429     High (vwo) 3.965 20 14.034 70 1.959 10 19.958 Use of soft drugs (previous month)     No 17.475 19 58.576 64 14.869 16 90.920     Yes 1.060 22 2.682 55 1.094 23 4.836 Hard drug use (life time)     No 17.547 19 58.916 64 15.006 16 91.469     Yes 875 23 2.195 57 806 21 3.876 Use of alcohol (previous month)     No 11.357 19 38.227 64 9.926 17 59.510     Yes 5.710 20 17.601 63 4.823 17 28.134 Binge drinking (previous month)     No 12.986 19 43.842 64 11.239 17 68.067     Yes 4.119 21 12.088 61 3.545 18 19.752 Being bullied     No 16.512 19 54.638 64 13.667 16 84.817     Yes 1.943 18 6.408 61 2.221 21 10.572 Table 1 Adolescents demographic, socio-economic and lifestyle characteristics in relation to physical exercise levels, N (%) Physical exercise Active Slightly active Inactive Total Covariates n % n % n % n Gender     Male 10.206 21 31.191 64 7.006 15 48.403     Female 8.403 18 30.333 63 9.069 19 47.805 Age     12–13 7.243 20 23.918 66 4.927 14 36.088     14–15 8.024 19 27.039 64 7.106 17 42.169     16–17 3.339 19 10.561 59 4.040 23 17.940 Grade     Second class 9.791 20 31.578 65 7.481 15 48.850     Fourth class 8.818 19 29.946 63 8.594 18 47.358 Household situation     Living with two parents 14.347 20 47.582 65 10.935 15 72.864     Other answers 4.242 18 13.893 60 5.123 22 23.258 Ethnicity     Non-western immigrant 15.216 20 51.092 66 11.574 15 77.882     Western immigrants 1.149 19 3.662 60 1.236 20 6.047     Non-western immigrants 2.234 18 6.753 55 3.252 27 12.239 Urbanization     (Very) highly urbanized 7.080 18 23.722 62 7.574 20 38.376     Moderately urbanized 3.827 19 12.893 64 3.359 17 20.079     Not urbanized 7.702 20 24.909 66 5.142 14 37.753 Level of education     Low (vmbo) 9.507 19 29.969 60 10.618 21 49.821     Intermediate (havo) 5.137 19 17.794 67 3.498 13 26.429     High (vwo) 3.965 20 14.034 70 1.959 10 19.958 Use of soft drugs (previous month)     No 17.475 19 58.576 64 14.869 16 90.920     Yes 1.060 22 2.682 55 1.094 23 4.836 Hard drug use (life time)     No 17.547 19 58.916 64 15.006 16 91.469     Yes 875 23 2.195 57 806 21 3.876 Use of alcohol (previous month)     No 11.357 19 38.227 64 9.926 17 59.510     Yes 5.710 20 17.601 63 4.823 17 28.134 Binge drinking (previous month)     No 12.986 19 43.842 64 11.239 17 68.067     Yes 4.119 21 12.088 61 3.545 18 19.752 Being bullied     No 16.512 19 54.638 64 13.667 16 84.817     Yes 1.943 18 6.408 61 2.221 21 10.572 Physical exercise Active Slightly active Inactive Total Covariates n % n % n % n Gender     Male 10.206 21 31.191 64 7.006 15 48.403     Female 8.403 18 30.333 63 9.069 19 47.805 Age     12–13 7.243 20 23.918 66 4.927 14 36.088     14–15 8.024 19 27.039 64 7.106 17 42.169     16–17 3.339 19 10.561 59 4.040 23 17.940 Grade     Second class 9.791 20 31.578 65 7.481 15 48.850     Fourth class 8.818 19 29.946 63 8.594 18 47.358 Household situation     Living with two parents 14.347 20 47.582 65 10.935 15 72.864     Other answers 4.242 18 13.893 60 5.123 22 23.258 Ethnicity     Non-western immigrant 15.216 20 51.092 66 11.574 15 77.882     Western immigrants 1.149 19 3.662 60 1.236 20 6.047     Non-western immigrants 2.234 18 6.753 55 3.252 27 12.239 Urbanization     (Very) highly urbanized 7.080 18 23.722 62 7.574 20 38.376     Moderately urbanized 3.827 19 12.893 64 3.359 17 20.079     Not urbanized 7.702 20 24.909 66 5.142 14 37.753 Level of education     Low (vmbo) 9.507 19 29.969 60 10.618 21 49.821     Intermediate (havo) 5.137 19 17.794 67 3.498 13 26.429     High (vwo) 3.965 20 14.034 70 1.959 10 19.958 Use of soft drugs (previous month)     No 17.475 19 58.576 64 14.869 16 90.920     Yes 1.060 22 2.682 55 1.094 23 4.836 Hard drug use (life time)     No 17.547 19 58.916 64 15.006 16 91.469     Yes 875 23 2.195 57 806 21 3.876 Use of alcohol (previous month)     No 11.357 19 38.227 64 9.926 17 59.510     Yes 5.710 20 17.601 63 4.823 17 28.134 Binge drinking (previous month)     No 12.986 19 43.842 64 11.239 17 68.067     Yes 4.119 21 12.088 61 3.545 18 19.752 Being bullied     No 16.512 19 54.638 64 13.667 16 84.817     Yes 1.943 18 6.408 61 2.221 21 10.572 The weighted average total SDQ score of active adolescents [9.33 ± 5.05 (SD)] was lower that of the inactive adolescents (10.97 ± 5.45; see table 2). There is no difference between the active and slightly active adolescents (9.30 ± 4.83). Table 2 Total SDQ and subscale scores in relation to physical exercise levels, mean (SD) Scale Inactive Slightly active Active Total Range Mean (SD) Mean (SD) Mean (SD) Mean (SD) Total difficulties score 0–40 10.97 (5.45) 9.30 (4.83) 9.33 (5.05) 9.59 (5.02) Emotional problems 0–10 2.87 (2.29) 2.33 (2.09) 2.08 (2.04) 2.37 (2.13) Conduct problems 0–10 1.86 (1.63) 1.54 (1.38) 1.70 (1.54) 1.63 (1.46) Hyperactivity 0–10 4.28 (2.40) 4.02 (2.36) 4.16 (2.48) 4.09 (2.39) Peer problems 0–10 1.97 (1.65) 1.41 (1.44) 1.39 (1.48) 1.50 (1.50) Pro-social behavior 0–10 7.54 (1.91) 7.92 (1.68) 8.00 (1.75) 7.87 (1.74) Scale Inactive Slightly active Active Total Range Mean (SD) Mean (SD) Mean (SD) Mean (SD) Total difficulties score 0–40 10.97 (5.45) 9.30 (4.83) 9.33 (5.05) 9.59 (5.02) Emotional problems 0–10 2.87 (2.29) 2.33 (2.09) 2.08 (2.04) 2.37 (2.13) Conduct problems 0–10 1.86 (1.63) 1.54 (1.38) 1.70 (1.54) 1.63 (1.46) Hyperactivity 0–10 4.28 (2.40) 4.02 (2.36) 4.16 (2.48) 4.09 (2.39) Peer problems 0–10 1.97 (1.65) 1.41 (1.44) 1.39 (1.48) 1.50 (1.50) Pro-social behavior 0–10 7.54 (1.91) 7.92 (1.68) 8.00 (1.75) 7.87 (1.74) Table 2 Total SDQ and subscale scores in relation to physical exercise levels, mean (SD) Scale Inactive Slightly active Active Total Range Mean (SD) Mean (SD) Mean (SD) Mean (SD) Total difficulties score 0–40 10.97 (5.45) 9.30 (4.83) 9.33 (5.05) 9.59 (5.02) Emotional problems 0–10 2.87 (2.29) 2.33 (2.09) 2.08 (2.04) 2.37 (2.13) Conduct problems 0–10 1.86 (1.63) 1.54 (1.38) 1.70 (1.54) 1.63 (1.46) Hyperactivity 0–10 4.28 (2.40) 4.02 (2.36) 4.16 (2.48) 4.09 (2.39) Peer problems 0–10 1.97 (1.65) 1.41 (1.44) 1.39 (1.48) 1.50 (1.50) Pro-social behavior 0–10 7.54 (1.91) 7.92 (1.68) 8.00 (1.75) 7.87 (1.74) Scale Inactive Slightly active Active Total Range Mean (SD) Mean (SD) Mean (SD) Mean (SD) Total difficulties score 0–40 10.97 (5.45) 9.30 (4.83) 9.33 (5.05) 9.59 (5.02) Emotional problems 0–10 2.87 (2.29) 2.33 (2.09) 2.08 (2.04) 2.37 (2.13) Conduct problems 0–10 1.86 (1.63) 1.54 (1.38) 1.70 (1.54) 1.63 (1.46) Hyperactivity 0–10 4.28 (2.40) 4.02 (2.36) 4.16 (2.48) 4.09 (2.39) Peer problems 0–10 1.97 (1.65) 1.41 (1.44) 1.39 (1.48) 1.50 (1.50) Pro-social behavior 0–10 7.54 (1.91) 7.92 (1.68) 8.00 (1.75) 7.87 (1.74) The logarithmically transformed coefficients of the unadjusted and adjusted models that estimate the association between the frequency of physical exercise and psychosocial problems are presented in table 3. Both unadjusted as adjusted coefficients between active and inactive adolescents are significant. Table 3 Multi-level linear regression results of continuous (logarithmically transformed) mean of the total SDQ score and the five subscales of the SDQ; unadjusted and adjusted models representing the effect of the difference on the SDQ score between active (reference), slightly active and inactive adolescents [β (95% (CI)] Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 0.012 –0.001 to .025 0.152* 0.132 to 0.172 0.013 –0.000 to 0.026 0.111* 0.091 to 0.131 Emotional problems 0.090* 0.074 to 0.106 0.251* 0.228 to 0.274 0.073* 0.057 to 0.089 0.178* 0.155 to 0.201 Conduct problems −0.047* –0.060 to –0.033 0.032* 0.012 to 0.052 –0.032* –0.045 to –0.019 0.025* 0.005 to 0.045 Hyperactivity −0.016 –0.032 to 0.000 0.032** 0.012 to 0.052 –0.010 –0.026 to 0.006 0.028* 0.005 to 0.051 Peer problems 0.025* 0.009 to 0.041 0.203* 0.183 to 0.223 0.023* 0.007 to 0.039 0.152* 0.132 to 0.172 Pro-social behavior –0.008* –0.015 to –0.001 –0.056* –0.066 to –0.046 –0.016 –0.023 to –0.009 −0.063* −0.073 to −0.053 Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 0.012 –0.001 to .025 0.152* 0.132 to 0.172 0.013 –0.000 to 0.026 0.111* 0.091 to 0.131 Emotional problems 0.090* 0.074 to 0.106 0.251* 0.228 to 0.274 0.073* 0.057 to 0.089 0.178* 0.155 to 0.201 Conduct problems −0.047* –0.060 to –0.033 0.032* 0.012 to 0.052 –0.032* –0.045 to –0.019 0.025* 0.005 to 0.045 Hyperactivity −0.016 –0.032 to 0.000 0.032** 0.012 to 0.052 –0.010 –0.026 to 0.006 0.028* 0.005 to 0.051 Peer problems 0.025* 0.009 to 0.041 0.203* 0.183 to 0.223 0.023* 0.007 to 0.039 0.152* 0.132 to 0.172 Pro-social behavior –0.008* –0.015 to –0.001 –0.056* –0.066 to –0.046 –0.016 –0.023 to –0.009 −0.063* −0.073 to −0.053 a Adjusted for gender, grade, household situation, ethnicity, urbanization, level of (secondary) education, use of soft drugs, hard drug use, recent use of alcohol, recent excessive alcohol use, being bullied. * P < 0.001 Table 3 Multi-level linear regression results of continuous (logarithmically transformed) mean of the total SDQ score and the five subscales of the SDQ; unadjusted and adjusted models representing the effect of the difference on the SDQ score between active (reference), slightly active and inactive adolescents [β (95% (CI)] Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 0.012 –0.001 to .025 0.152* 0.132 to 0.172 0.013 –0.000 to 0.026 0.111* 0.091 to 0.131 Emotional problems 0.090* 0.074 to 0.106 0.251* 0.228 to 0.274 0.073* 0.057 to 0.089 0.178* 0.155 to 0.201 Conduct problems −0.047* –0.060 to –0.033 0.032* 0.012 to 0.052 –0.032* –0.045 to –0.019 0.025* 0.005 to 0.045 Hyperactivity −0.016 –0.032 to 0.000 0.032** 0.012 to 0.052 –0.010 –0.026 to 0.006 0.028* 0.005 to 0.051 Peer problems 0.025* 0.009 to 0.041 0.203* 0.183 to 0.223 0.023* 0.007 to 0.039 0.152* 0.132 to 0.172 Pro-social behavior –0.008* –0.015 to –0.001 –0.056* –0.066 to –0.046 –0.016 –0.023 to –0.009 −0.063* −0.073 to −0.053 Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 0.012 –0.001 to .025 0.152* 0.132 to 0.172 0.013 –0.000 to 0.026 0.111* 0.091 to 0.131 Emotional problems 0.090* 0.074 to 0.106 0.251* 0.228 to 0.274 0.073* 0.057 to 0.089 0.178* 0.155 to 0.201 Conduct problems −0.047* –0.060 to –0.033 0.032* 0.012 to 0.052 –0.032* –0.045 to –0.019 0.025* 0.005 to 0.045 Hyperactivity −0.016 –0.032 to 0.000 0.032** 0.012 to 0.052 –0.010 –0.026 to 0.006 0.028* 0.005 to 0.051 Peer problems 0.025* 0.009 to 0.041 0.203* 0.183 to 0.223 0.023* 0.007 to 0.039 0.152* 0.132 to 0.172 Pro-social behavior –0.008* –0.015 to –0.001 –0.056* –0.066 to –0.046 –0.016 –0.023 to –0.009 −0.063* −0.073 to −0.053 a Adjusted for gender, grade, household situation, ethnicity, urbanization, level of (secondary) education, use of soft drugs, hard drug use, recent use of alcohol, recent excessive alcohol use, being bullied. * P < 0.001 After the antilog procedure, the average total SDQ score of adolescents who were inactive was 1.12 times higher than that of adolescents who were active (β = 1.12; 95% CI: 1.10–1.14; P < 0.001; see table 4). In other words, inactive adolescents were likely to have psychosocial problems compared with active adolescents. Table 4 Multi-level linear regression results of continuous mean after the antilog procedure of the total SDQ score and the five subscales of the SDQ; unadjusted and adjusted models representing the effect of the difference on the SDQ score between active (reference), slightly active and inactive adolescents [β (95% (CI)] Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 1.01 1.00 to 1.02 1.16* 1.14 to 1.19 1.01 1.00 to 1.03 1.12* 1.10 to 1.14 Emotional problems 1.09* 1.08 to 1.11 1.29* 1.26 to 1.32 1.08* 1.06 to 1.09 1.19* 1.17 to 1.22 Conduct problems 0.95* 0.94 to 0.97 1.03* 1.01 to 1.05 0.97* 0.96 to 0.98 1.03* 1.01 to 1.05 Hyperactivity 0.98 0.97 to 1.00 1.03* 1.01 to 1.05 0.99 0.97 to 1.01 1.03* 1.01 to 1.05 Peer problems 1.03* 1.01 to 1.04 1.23* 1.20 to 1.25 1.02* 1.01 to 1.04 1.16* 1.14 to 1.19 Pro-social behavior 0.99* 0.99 to 1.00 0.95* 0.94 to 0.96 0.98 0.98 to 0.99 0.94* 0.93 to 0.95 Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 1.01 1.00 to 1.02 1.16* 1.14 to 1.19 1.01 1.00 to 1.03 1.12* 1.10 to 1.14 Emotional problems 1.09* 1.08 to 1.11 1.29* 1.26 to 1.32 1.08* 1.06 to 1.09 1.19* 1.17 to 1.22 Conduct problems 0.95* 0.94 to 0.97 1.03* 1.01 to 1.05 0.97* 0.96 to 0.98 1.03* 1.01 to 1.05 Hyperactivity 0.98 0.97 to 1.00 1.03* 1.01 to 1.05 0.99 0.97 to 1.01 1.03* 1.01 to 1.05 Peer problems 1.03* 1.01 to 1.04 1.23* 1.20 to 1.25 1.02* 1.01 to 1.04 1.16* 1.14 to 1.19 Pro-social behavior 0.99* 0.99 to 1.00 0.95* 0.94 to 0.96 0.98 0.98 to 0.99 0.94* 0.93 to 0.95 a Adjusted for gender, grade, household situation, ethnicity, urbanization, level of (secondary) education, use of soft drugs, hard drug use, recent use of alcohol, recent excessive alcohol use and being bullied. * P < 0.001. Table 4 Multi-level linear regression results of continuous mean after the antilog procedure of the total SDQ score and the five subscales of the SDQ; unadjusted and adjusted models representing the effect of the difference on the SDQ score between active (reference), slightly active and inactive adolescents [β (95% (CI)] Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 1.01 1.00 to 1.02 1.16* 1.14 to 1.19 1.01 1.00 to 1.03 1.12* 1.10 to 1.14 Emotional problems 1.09* 1.08 to 1.11 1.29* 1.26 to 1.32 1.08* 1.06 to 1.09 1.19* 1.17 to 1.22 Conduct problems 0.95* 0.94 to 0.97 1.03* 1.01 to 1.05 0.97* 0.96 to 0.98 1.03* 1.01 to 1.05 Hyperactivity 0.98 0.97 to 1.00 1.03* 1.01 to 1.05 0.99 0.97 to 1.01 1.03* 1.01 to 1.05 Peer problems 1.03* 1.01 to 1.04 1.23* 1.20 to 1.25 1.02* 1.01 to 1.04 1.16* 1.14 to 1.19 Pro-social behavior 0.99* 0.99 to 1.00 0.95* 0.94 to 0.96 0.98 0.98 to 0.99 0.94* 0.93 to 0.95 Slightly active (ref. active) Inactive (ref. active) Slightly active (ref. active) Inactive (ref. active) Unadjusted model Adjusted modela SDQ-score β 95% CI β 95% CI β 95% CI β 95% CI Total SDQ score 1.01 1.00 to 1.02 1.16* 1.14 to 1.19 1.01 1.00 to 1.03 1.12* 1.10 to 1.14 Emotional problems 1.09* 1.08 to 1.11 1.29* 1.26 to 1.32 1.08* 1.06 to 1.09 1.19* 1.17 to 1.22 Conduct problems 0.95* 0.94 to 0.97 1.03* 1.01 to 1.05 0.97* 0.96 to 0.98 1.03* 1.01 to 1.05 Hyperactivity 0.98 0.97 to 1.00 1.03* 1.01 to 1.05 0.99 0.97 to 1.01 1.03* 1.01 to 1.05 Peer problems 1.03* 1.01 to 1.04 1.23* 1.20 to 1.25 1.02* 1.01 to 1.04 1.16* 1.14 to 1.19 Pro-social behavior 0.99* 0.99 to 1.00 0.95* 0.94 to 0.96 0.98 0.98 to 0.99 0.94* 0.93 to 0.95 a Adjusted for gender, grade, household situation, ethnicity, urbanization, level of (secondary) education, use of soft drugs, hard drug use, recent use of alcohol, recent excessive alcohol use and being bullied. * P < 0.001. Additionally, it was relatively more common for inactive adolescents to have emotional problems (β = 1.19; 95% CI: 1.17–1.22; P < 0.001), conduct problems (β = 1.03; 95% CI: 1.01–1.05; P < 0.001), hyperactivity (β = 1.03; 95% CI: 1.00–1.05; P < 0.001), problems with peers (β = 1.16; 95% CI: 1.14–1.19; P < 0.001) and exhibit less pro-social behavior (β = 0.94; 95% CI: 0.93–0.95; P < 0.001) compared with active adolescents. The association between the average SDQ score of active adolescents and that of slightly active adolescents was almost statistically significant according to our threshold of 0.001 (β = 1.01; 95% CI: 1.00–1.03; P = 0.0012). Emotional problems (β = 1.08; 95% CI: 1.06–1.09; P < 0.001) were more common in slightly active adolescents compared with active adolescents. The weak but statistically significant association of conduct problems and problems with peers between these groups: 0.97 (95% CI: 0.96–0.98; P < 0.001) and 1.02 (95% CI: 1.01–1.04; P < 0.001), respectively. Discussion The aim of this study was to explore whether inactive and slightly active adolescents experience more psychosocial problems compared with active adolescents. Main findings of this study Our data provide evidence of an inverse association between the physical activity level of adolescents in the Netherlands and the extent of their psychosocial problems. Inactive adolescents experience more psychosocial problems than active adolescents. Similarly, inactive adolescents experience more emotional and conduct problems, hyperactivity, problems with peers and show less pro-social behavior. The differences between slightly active and active adolescents are less distinctive. For example, there is no statistical significant difference in total SDQ score between active and slightly active adolescents. Clinical relevance also plays a role in the interpretation of the observed association. Beforehand, we considered a result clinically relevant if the difference in adjusted regression (β) coefficient between active and inactive adolescents was greater than one point. Depending on the baseline value, an increase in one point on the SDQ scale could imply that an adolescent will be referred to a psychologist by the MPHS. The difference in weighted average total SDQ score between active and inactive adolescents is more than 1.5 point (table 2). This indicates, to our standards, a clinically relevant difference in psychosocial problems. However, due to the skewness of the distribution, we had to logarithmically transform the outcome measures. Therefore, the regression coefficients have to be interpreted as a ratio between those groups of adolescents instead of a difference. As a consequence, clinical relevance could not been deduced from these regression coefficients. What is already know on this topic The above-mentioned findings corroborates with earlier cross-sectional findings.11,13,14,16 These studies showed that lack of exercise was associated with various psychological problems. Psychosocial problems consist partly of psychological problems, making these findings relevant. However, these results are not in line with some longitudinal studies.24–26 Furthermore, Stavrakakis et al. focused on the onset of depressive disorders and physical activity but found no evidence of such an effect of physical activity on depression.22,38 This implies that the association we found in our data might be of limited value. On the other hand, the same Stavrakakis also studied the prospective relationship between physical activity and depressive symptoms in adolescents and found a weak statistically significant negative association.22,39 This shows that the relationship between physical activity and psychological health is complex. Genetic and biological factors, personality traits and environmental factors such as socialeconomic status and lifestyle habits interact and jointly affect psychosocial problems.22,38 In combination with these factors, sufficient physical exercise might prevent or mitigate psychosocial problems. What this study adds It was known in advance that most studies showed that physical exercise were associated with psychological problems. However, none of these studies focused on psychosocial problems. Psychosocial health is the outcome measure of the SDQ, widely used in youth care. This research has shown that physical exercise is also associated with less of psychosocial health. Finally, we used the data of the nationwide Dutch Youth Health Monitor conducted among almost 100 000 adolescents. Because of this number of participants, the results presented in this research are, as far as we know, unique. Limitations of this study The first weakness of this study is the cross-sectional design, which implies that a causal direction cannot be determined. Therefore, it may be that a lack of exercise causes psychosocial problems, but it is also possible that psychosocial problems lead to less exercise. Finally, it is also possible for an underlying factor to affect both physical exercises as psychosocial problems. The direction of causation can be established in a randomized controlled trial or in a prospective design. Second, the amount of physical activity was determined with a single-item question. This question covered the number of days per week of moderately intensive exercise for at least 1 h. Additional information about the exact amount and intensity was not collected. Information about the type of exercise, such as team sport or an individual activity, could deepen our understanding. Conclusion This study shows that physically active adolescents have fewer psychosocial problems than inactive adolescents. This association is not only statistically significant, but we think that it is also of clinical relevance. Inactive adolescents experience more emotional and conduct problems, hyperactivity, problems with peers and they show less pro-social behavior. Compared with active adolescents, slightly active adolescents experienced more emotional problems and problems with peers. However, slightly active adolescents experienced fewer conduct problems compared with active adolescents. Acknowledgements The data set of the Youth Health Monitor 2015 was provided by the Dutch National Institute for Public Health and Environment and 25 Municipal Public Health Service. Conflicts of interest: None declared. Key points Previous studies have demonstrated that 20% of the Dutch adolescents have some degree of psychosocial problems. Previous research investigated the relationship between physical activity and psychological health. However, none of these studies focused on psychosocial problems. We used the data of the nationwide Dutch Youth Health Monitor conducted among almost 100 000 adolescents. This study shows that physically active adolescents have fewer psychosocial problems than inactive adolescents. The amount of physical activity was determined with a single-item question. Information about the manner of exercise could deepen our understanding about the association between physical activity and psychosocial health. References 1 Theunissen MHC , Vogels AGC , Reijneveld SA . Work experience and style explain variation among pediatricians in the detection of children with psychosocial problems . Acad Pediatr 2012 ; 12 : 495 – 501 . Google Scholar CrossRef Search ADS PubMed 2 Crone MR , Bekkema N , Wiefferink CH , et al. 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Journal

The European Journal of Public Health – Oxford University Press

Published: Jan 8, 2018

References

  • Work experience and style explain variation among pediatricians in the detection of children with psychosocial problems
    Theunissen
  • Professional identification of psychosocial problems among children from ethnic minority groups: room for improvement
    Crone
  • Presenting prevalence and management of psychosocial problems in primary care in Flanders
    Vannieuwenborg
  • The relationships between parenting stress, parenting behaviour and preschoolers' social competence and behaviour problems in the classroom
    Anthony
  • Impact of parenting practices on adolescent achievement: authoritative parenting, school involvement, and encouragement to succeed
    Steinberg
  • Primary care referral of children with psychosocial problems
    Rushton
  • Long-term economic costs of psychological problems during childhood
    Smith