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ENQUIRE PROJECT DETAILS BY GENERAL PUBLIC |
| Project Details |
| Funding Scheme : | General Research Fund | ||||||||||||
| Project Number : | 14619720 | ||||||||||||
| Project Title(English) : | A Cluster Randomized Controlled Trial of School-based Physical Activity Intervention on Mental Health and Risk Behaviours in Adolescents with Special Educational Needs | ||||||||||||
| Project Title(Chinese) : | 校本體力活動干預對有特殊教育需要青少年的心理健康和危險行為的集群隨機對照研究 | ||||||||||||
| Principal Investigator(English) : | Prof Sit, Cindy Hui-ping | ||||||||||||
| Principal Investigator(Chinese) : | |||||||||||||
| Department : | Dept of Sports Science & Physical Education | ||||||||||||
| Institution : | The Chinese University of Hong Kong | ||||||||||||
| E-mail Address : | sithp@cuhk.edu.hk | ||||||||||||
| Tel : | 39434126 | ||||||||||||
| Co - Investigator(s) : |
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| Panel : | Humanities, Social Sciences | ||||||||||||
| Subject Area : | Education | ||||||||||||
| Exercise Year : | 2020 / 21 | ||||||||||||
| Fund Approved : | 791,930 | ||||||||||||
| Project Status : | Completed | ||||||||||||
| Completion Date : | 31-12-2023 | ||||||||||||
| Project Objectives : |
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| Abstract as per original application (English/Chinese): |
Mental health problems such as anxiety and depression are the leading disease burden, affecting up to 20% of adolescents globally. Mental health problems are associated with risk behaviours such as school dropouts, aggression, suicidal ideation and suicide. Evidence indicates that adolescents with special educational needs (SEN) such as attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorders (ASD) have poorer mental health and higher risk behaviours than those with typical development. More than half of all mental health problems emerge during adolescence and continue into adulthood, so early effective interventions are therefore important. Little is known about the associations of physical activity with reduced mental health problems and risk behaviours in adolescents with SEN. Recently, our research team has conducted a pilot school-based physical activity intervention in this group and found immediate positive effects on increased physical activity and reduced anxiety, depression and suicidal ideation. We also found that physical activity was strongly associated with resilience, an ability to overcome obstacles and achieve positive outcomes in the face of diversity and life stresses. Future research is needed to determine whether improved mental health can translate into decreases in risk behaviours in the longer term. Grounded in the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) framework, this study is the first cluster randomized controlled trial (RCT) to examine the effects of a school-based physical activity intervention on the mental health and risk behaviours of adolescents with SEN. It is also the first study to use salivary cortisol as a biomarker of stress in Hong Kong adolescents with SEN. Based on a power calculation, 240 adolescents with SEN in twelve Hong Kong secondary mainstream schools will be cluster randomized allocated into either a 12-week physical activity intervention or a control condition. Measurements of mental health and risk behaviours will be conducted at (i) baseline, (ii) post-intervention (immediately after 12-week intervention), (iii) 3-month after post-intervention, and (iv) 12-month after post-intervention. This cluster RCT brings experts in physical activity interventions together, and the findings will assist educators and education and healthcare policy makers to develop early treatment strategies and to introduce school-based health promotion practices for adolescents with SEN. In the longer term, our aim is to develop a territory-wide school-based physical activity policy (lunchbreak “exercise-snack” program) in mainstream schools in Hong Kong. 心理健康問題如焦慮及抑鬱是主要的疾病負荷，影響全球多達20％的青少年。心理健康問題與危險行為相關，例如輟學、攻擊性行為、企圖自殺及自殺。證據顯示有特殊教育需要青少年（如注意力不足/過度活躍症、自閉症）的心理健康較一般青少年為差，而危險行為則較高。多於一半以上的心理健康問題於青春期出現，並持續到成年期，因此早期有效的干預是非常重要。對於有特殊教育需要的青少年，體力活動與減少心理健康問題及危險行為的關聯知之甚少。最近，我們的研究小組開展一項針對有特殊教育需要青少年的校本體力活動試驗，結果發現體力活動干預對增加體力活動，減少焦慮、抑鬱和企圖自殺有正面的影響。我們也發現體力活動與心理彈性密切相關，心理彈性是一種在面對多樣的生活壓力時，具有克服障礙及取得積極結果的能力。我們需要進行進一步的研究以確定改善心理健康是否可以長遠地降低危險行為。這項研究以國際健康功能與身心障礙分類系統-兒童和青少年版（ICF-CY）為理論框架，首次採用集群隨機對照的方法檢驗校內體力活動干預對有特殊教育需要青少年的心理健康和危險行為的影響。這也是香港首個採用唾液皮質醇來檢測有特殊教育需要青少年的壓力研究。根據統計功效計算，香港十二所主流中學的240名有特殊教育需要的青少年將以群組形式被隨機分為12週的體力活動干預組和控制組。心理健康和危險行為的評估將分別於（i）基線、（ii）干預後12週、（iii）干預後3個月、以及（iv）干預後12個月進行。這項集群隨機對照研究將會集多位體力活動干預專家之合作，研究結果將幫助教育工作者和教育、醫療保健政策制定者訂立早期干預政策，並為有特殊教育需要的青少年引入校本健康促進活動。長遠來看，我們的目標是在香港主流學校制定以全港學校為基礎的體力活動政策（午休「運動零食」計劃）。 |
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| Realisation of objectives: | Grounded in the International Classification of Functioning, Disability, and Health (ICF) framework, the study was the first cluster randomized controlled trial (cRCT) to examine the effects of a school-based physical activity intervention on the mental health and risk behaviours of Hong Kong adolescents with SEN. It was also the first study to use salivary cortisol as a biomarker of stress in adolescents with SEN. As proposed in the protocol, a total of 200 participants would be included, with consideration for potential attrition. Due to the influence of the COVID-19 pandemic, the research team faced unpredictable and significant challenges. Eventually, we recruited 170 participants from nine secondary mainstream schools in Hong Kong, encompassing the New Territories, Kowloon, and Hong Kong Island. Of the 170 participants, 48 were diagnosed with ADHD, 28 with ASD, and 94 with comorbid conditions such as ASD-ADHD. Among the nine participating schools, four were cluster-allocated to the intervention condition, while the other five were allocated to the control condition. A 12-week PA intervention was delivered in the intervention schools during school hours, and participants were required to perform activities at a moderate intensity level (50-60% of the maximum heart rate), which was objectively measured using a Polar heart rate monitor. To achieve Objective 1, a series of assessments at baseline (prior to intervention), immediately after intervention (immediate effect), 3-month post-intervention (short-term effect), and 12-month post-intervention (longer-term effect) were performed. Primary outcome variables consisted of mental health in terms of psychological ill-being (stress, anxiety, and depression) and psychological well-being (self-concept and resilience), which were assessed by self-reported questionnaires. In addition to self-reported measures, salivary cortisol was collected as an objective biomarker to assess the stress level of participants. Secondary outcome variables were risk behaviour involving aggression and suicidal ideation. To achieve Objective 2, information on gender and SEN types was collected through the participants’ schools and/or parents. Confounding variables were also collected. They were demographic variables (age and family socio-economic status), sex- and age-adjusted body mass index (BMI), cognitive ability using the Raven’s Colored Progressive Matrices Test, and health-related behaviours including accelerometer-measured physical activity, cardiorespiratory fitness measured with the Pacer test and the Brockport Physical Fitness Test Kit, and self-reported eating and sleep behaviours. | ||||||||||||
| Summary of objectives addressed: |
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| Research Outcome | |||||||||||||
| Major findings and research outcome: | This project was the first to employ a cRCT design to examine the immediate and sustained effects of a school-based physical activity intervention on mental health and risk behaviors among Hong Kong adolescents with SEN. Our results showed that all neurodevelopmental disorder groups, except for male adolescents with ADHD, exhibited at least one symptom of anxiety, depression, or stress (ranging from mild to severe). As predicted, we found that moderate-to-vigorous physical activity (MVPA) significantly predicted lower self-reported anxiety and stress levels in adolescents with ADHD, with gender serving as a moderating factor. While we did not observe any significant differences in outcomes among the ASD, ADHD, and ASD-ADHD groups. Moreover, higher levels of MVPA in adolescents with ADHD were associated with improved psychological well-being (resilience and physical self-concept). In terms of behavioral risk factors, MVPA was linked to a statistically significant decrease in hostility levels in female adolescents with ADHD. Conversely, in male adolescents with comorbid ASD-ADHD, each additional minute of vigorous physical activity (VPA) was associated with a small but significant increase in physical aggression. After participating in a 12-week school-based physical activity intervention, adolescents with SEN showed significant reductions in self-reported stress, risk behaviors, and sleep disturbances. These improvements were maintained for three months following the intervention. Interestingly, we noted a temporary increase in cortisol levels immediately after the physical activity intervention among adolescents with ADHD, which suggests a potential regulation of the hypothalamic-pituitary-adrenal (HPA) axis—often lower in individuals with ADHD. However, this increase did not persist at the three-month follow-up. Overall, our findings indicate that a school-based physical activity intervention, involving moderate to higher levels of physical activity, can be an effective strategy for improving mental health and reducing risk behaviors in adolescents with SEN, with some benefits remaining in the short term (up to three months). | ||||||||||||
| Potential for further development of the research and the proposed course of action: |
ADHD and ASD are common neurodevelopmental disorders among school-aged adolescents worldwide, including in Hong Kong, where these conditions account for more than 40% of the SEN population in secondary schools. The development of feasible and cost-effective physical activity intervention strategies to alleviate primary mental health challenges and reduce secondary risk behaviors among adolescents with SEN is thus of considerable importance. Based on the key findings of this project, it is worth considering certain gaps and directions for future research in this field. First, the COVID-19 pandemic significantly disrupted school recruitment, data collection, and intervention implementation. Schools faced intermittent closures and stringent safety measures, which limited face-to-face interactions and delayed scheduled follow-up assessments. As a result, multiple project extensions were required to accommodate these unforeseen circumstances. Second, these pandemic-related challenges may have influenced the mental health of adolescents with SEN. Increased stress and anxiety during such a disruptive period could have affected the outcomes, and the results should be interpreted with caution. Future research should consider the pandemic context when examining mental health outcomes and be prepared for potential disruptions that can influence intervention delivery and data collection. Third, the pandemic experience highlights the need to integrate assistive technologies into PA intervention implementation. Virtual PA sessions, online platforms, and mobile applications could help maintain program accessibility and adherence, even when in-person activities are not feasible. Such technology-enhanced strategies offer a more flexible, scalable approach to delivering interventions under varying circumstances, ultimately contributing to more resilient and sustainable models for promoting mental health and reducing risk behaviors among adolescents with SEN. | ||||||||||||
| Layman's Summary of Completion Report: | Adolescence is a critical developmental period for establishing physical, mental and social well-being across the human life span. Mental health problems such as anxiety and depression affect up to 20% of adolescents globally. Mental health problems are associated with risk behaviours. Adolescents with SEN have poorer mental health and higher risk behaviours than those with typical development. Grounded in the International Classification of Functioning, Disability and Health (ICF) framework, this project was the first to examine whether a 12-week school-based physical activity intervention was effective (both short- and long-term) in improving mental health and risk behaviours in adolescents with SEN using a cluster randomized controlled trial. The effectiveness of our intervention was determined using multi-dimensional outcomes, including psychological ill-being (stress, anxiety, and depression), psychological well-being (self-concept and resilience), and risk behaviour (aggression and suicidal ideation). Our findings showed that moderate physical activity reduced stress and improved resilience, which was sustained over a three-month follow-up. Our findings supported that our intervention appears to be effective in improving mental health and risk behaviours in adolescents with SEN. The findings gained are of significance in assisting educators and healthcare policymakers in introducing school-based health promotion practices for adolescents with SEN in Hong Kong. | ||||||||||||
| Research Output | |||||||||||||
| Peer-reviewed journal publication(s) arising directly from this research project : (* denotes the corresponding author) |
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| Recognized international conference(s) in which paper(s) related to this research project was/were delivered : |
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| Other impact (e.g. award of patents or prizes, collaboration with other research institutions, technology transfer, etc.): |
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| SCREEN ID: SCRRM00542 |