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Running head: JFRIESEN RESEARCH PROPOSAL

APSY 605: Research Proposal Jo Friesen University of Calgary

JFRIESEN RESEARCH PROPOSAL Introduction Purpose


The purpose of this research is to investigate the relationship between physical activity and selfreported anxiety levels in fifth and sixth grade students. While some anxiety is normal and healthy (Mash & Barkley, 2003), the pressure to balance social obligations, academic responsibilities and family expectations can lead some young people to feel their anxiety is overwhelming. Increased physical activity is linked with decreased anxiety levels in adults (Guszkowska, 2008; Taylor, Sallis & Needle, 1985), and this study aims to examine whether increasing physical activity in children will have a beneficial effect on their anxiety levels as well. Literature Review Anxiety is one of the most common psychiatric disorders affecting children and adolescents (Mash & Barkley, 2003). Prevalence in the general population ranges from 10-20% for children and it is estimated that as few as 20% of children with an anxiety disorder receive the necessary intervention (Mash & Barkley, 2003). Considering that studies have shown that children who do not receive treatment are more likely to experience the disorder as adults (Mash & Barkley, 2003), that 50-70 % of children who meet criteria for diagnosis will continue to meet criteria two years later (McLoone, Hudson & Rapee, 2006) and that children with anxiety disorders have a higher risk for developing depression (Rapee et al., 2010), the need for prevention, early intervention and accurate assessment is evident. Current treatments for childhood anxiety focus primarily on cognitive-behavioral therapy (CBT), at times coupled with other interventions, such as parent education (Bernstein, Layne, Egan & Tennison, 2005; Dadds et al, 1999; van der Leedon & Widenfelt, 2011). While Dadds et al. (1999) found no immediate difference in anxiety levels in children between a CBT treatment group and a control group, six month follow-up results did show lower anxiety levels in the CBT treatment group. In a study of 56 children, Bernstein et al. (2005) found that group CBT and group CBT with parent training both resulted in significantly more effective results when compared with a no-treatment control group, with a greater

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benefit found in the group that received both CBT and parent training. In a recent study, van der Leedon & Widenfelt (2011) proposed a stepped care approach, in which additional levels of intervention both CBT and family-based - were added for children who did not respond to initial interventions. Rapee et al, (2010), evaluated an early intervention program geared towards educating parents of children who were preschool aged. They found that by middle childhood, these children were less likely to report anxiety symptoms or be diagnosed with an anxiety disorder compared to children whose parents did not receive such intervention (Rapee et al, 2010.) These studies offer a promising look at intervention efficacy, however all of these models require significant parental effort, and acknowledgement of their childs difficulty with anxiety. If as many as 80% of children have undiagnosed or unrecognized anxiety symptoms (Mash & Barkley, 2003), there is value in looking at additional strategies which may be effective in reaching a wider variety of children. Another area of intervention has focused on school-based intervention programs. By offering programs within schools, more children are able to participate and that participation is not as dependent on parental factors, such as finances, time or competency (McLoone, Hudson & Rapee, 2006). McLoone et al. (2006) reviewed three school based interventions; the FRIENDS program, the Cool Kids program and the Skills for Social and Academic Success program. All three programs focused on children who were already displaying symptoms of anxiety and were based on limited session, group CBT theory. While all three programs demonstrated improvement in anxiety levels, some additional concerns about social stigma and missed academic opportunities were raised by parents and teachers. Another area of research in anxiety reduction looks at the relationship between physical activity and anxiety levels. Guszowska (2008) found that vigorous exercise (for as short as ten minutes) reduced anxiety symptoms as efficiently as relaxation and that effects lasted for several hours after exercise. Some studies have found exercise as effective as both meditation and CBT in adults, while other studies have demonstrated that the value of exercise is related to initial anxiety levels with higher anxiety levels benefiting more from physical activity (Bahrke, & Morgan, 1978; Taylor, Sallis &Needle, 1985). While some of these reductions may be related to the physiological benefits of exercise, some studies

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acknowledged that the physical activity may have been effective, at least in part, due to the fact that it distracted participants from certain cognitive processes, offered social reinforcement or allowed participants to experience skill development (Guszowska, 2008, Taylor, Sallis & Needle, 1985). When it comes to the benefits of physical exercise for children, it is important to first acknowledge that most children do not get the recommended amounts of physical activity (Picard, 2010; Strauss, Rodzilsky, Burack & Colin, 2001). Strauss et al. (2001) evaluated 95 healthy children and looked at the relationship between their current level of physical activity and their measures of anxiety. They found not only very low averages of daily physical activity (12-13 per day), they found that girls in particular demonstrate significant decreases in activity levels from age 10-16 (Strauss et al., 2001). Of note, they found no relationship between physical activity levels and anxiety levels and postulated it may be due to the fact that the levels of exercise they were observing in the children was not prolonged or vigorous to demonstrate any results (Strauss et al., 2001). While research that specifically looks at the relationship between a childs physical activity level and their level of anxiety is sparse and inconclusive, there remains opportunity to further research this field. While CBT and family-based therapies have proven efficacy in lowering anxiety levels for some children (Bernstein et al., 2005; Dadds et al, 1999; van der Leedon & Widenfelt, 2011), these strategies are limited based on availability, cost and the under-diagnosing of anxiety disorders in children. Moving treatment options into the school system has shown some promise, but still has limitations in terms of the stigma attached to some, but not all, children being involved, and currently still require the anxiety to be previously diagnosed (McLoone, Hudson & Rapee, 2006). One area of research that has shown promise with adults is the effectiveness of increased physical activity on lowering anxiety (Guszkowska, 2008; Taylor, Sallis & Needle, 1985). While research into this area with children is limited thus far, there is value at looking into a treatment option that could be readily utilized with all students within the school system. This study will look at the effect of increased physical activity during the school day on anxiety levels in upper-elementary aged children. If there is a significant positive effect found, this research could lay the foundation to developing realistic, wide-spread interventions within the school system.

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Research Question and Hypothesis The goal if this study is to evaluate the effect of increased levels of physical activity on anxiety levels in fifth and sixth grade children. For this study, increase physical activity will be determined by involving children in a 30-minute exercise program, four times per week, which includes at least 20-minutes of moderate-to-vigorous activity. Anxiety levels will be measured by the childs score on a self-report questionnaire (the MASC-10). This research is designed to answer the following question: What effect will adding 30 minutes of additional physical activity, four days a week, for six weeks, have on self-reported levels of anxiety? In response to this research questions, the following hypothesis is proposed: Participants in the active treatment group (30 minutes of physical activity, four days per week) will report a greater decrease in anxiety levels after six weeks than their control or inactive treatment group counterparts. Methods Participants The participants for this research study will consist of six classrooms of fifth and sixth grade students selected from six schools located in East Vancouver. In order to facilitate the research design (using one instructor as outlined below), schools needed to be chosen based on proximity to one another. In this case, schools were chosen based on their proximity to the Broadway/Commerical SkyTrain Station, with the closest six schools selected for participation in this study. Within this population fifth and sixth grade students in a selected area of East Vancouver six clusters of students will be chosen, one from each of the six schools. This will be done by selecting one classroom randomly from all fifth and sixth grade classrooms at each school. Once the six classrooms are selected, the groups will be randomly assigned to the control group (2 classrooms), the inactive treatment group (2 classrooms) or the active treatment group (2 classrooms).

JFRIESEN RESEARCH PROPOSAL


Prior to the start of the study, approval for the study will need to be obtained from all six school principals. Preliminary conversations with all six principals yielded interest in participation, curiosity about the potential results and willingness to facilitate teacher and parent support. Once classrooms are chosen, additional informed consent will be needed from all students and their respective parents/guardians. As a part of this consent process, parents and students will be informed about the confidentiality aspects of the study, and that each student involved will receive an ID# which will allow the researcher to accurately record pre- and post-test data, but will not allow for individual results to be associated with specific children. Parents, school principals, classroom teachers and activity instructor all of whom will know the children individually will not be informed of specific MASC-10 results. This is both to protect confidentiality, and to ensure that those who will be interacting with the children during the study are blind to their assessed levels of anxiety. Since the nature of the study may raise concerns about anxiety levels for parents and children, each family will receive debriefing information explaining the full nature of the study, the general results and information on whom to contact for further assessment if there are ongoing concerns about their childs level of anxiety. In addition, support will be needed from the classroom teacher in regards to the pre- and post-testing sessions and, for the active and inactive groups, scheduling adjustments to accommodate the 30-minute treatment session for the six weeks of the study. It is expected that in giving their consent to study, the principals at each school will have also secured the necessary support from the selected teachers. Measures This study will use the short form of the Multidimensional Anxiety Scale for Children (MASC; March, 1997), the MASC-10, as a method of assessing anxiety. The MASC is a 39-item self-report measure using a 4-point Likert scale, and is designed for use with individuals aged 8-19 (March et al., 1997). It is designed to assess young people on anxiety symptoms across four major factors (physical symptoms, social anxiety, harm avoidance, separation anxiety) (March et al., 1997). It has been recommended for use in a variety of settings, including schools (Christopher, 2002). The MASC-10 is a ten item short form, which includes questions from all for scales and is recommended for general anxiety

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screening and group administration, with administration time taking approximately five minutes (Christopher, 2002). The reliability and validity for the MASC are considered satisfactory, and it has good test-retest reliability within a time frame as short as three weeks (Caruso, 2002). Research Design This study will use three groups (control, inactive and active), who are each tested at two time periods (pre- and post-test), yielding a 3x2 research design. The students in all three groups will be assessed for general anxiety level at the beginning of the study period, and again at the end of the six-week intervention. The MASC-10 will be used for both assessments. The control group (two classrooms) will participate in only the testing component of the study. They will complete the MASC-10 during the pre-test phase, and again at the end of the six weeks. Other than testing, no changes will be made to their regular classroom schedule or curriculum. This group will help to control for general changes in anxiety over time, whether due to maturation, global events, or natural fluctuations, as well as account for effects related to participating in the study, including test-retest effects and simply being involved in testing. The active group (two classrooms) will participate in both the pre- and post-test of the MASC-10, as well as participate in a physical activity for 30 minutes a day, four days a week for six weeks. During the six-week treatment phase of the study, this group will be taken from their regular classroom activities to participate in a physical activity (an aerobic dance class). The inactive group will participate in both the pre- and post-test of the MASC-10. In addition, they will serve as an alternative treatment group to help to control for factors other than physical activity that may have an impact on anxiety levels. The inactive group will participate in an activity outside the classroom on the same schedule as the active group. This group will work with the same instructor as the active group. Students from the selected classrooms will not be included in the study if parental or child consent is not obtained or if they have physical or cognitive disabilities that would prevent them from participating

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in all activities of the group to which they are assigned. Their participation in activities will be done at their teachers discretion, but their results will not be included in the study. This will allow for a more standardized administration of activities, but will limit the generalizability of the study results (i.e. to special populations). Procedures Once consent has been received from all six schools, as well as the selected children and their parents, an intervention schedule will be developed with the four teachers involved with the active and inactive groups. The schedule will consist of 30 minute periods set aside, 4 days per week (Mon-Thurs only as Fri is a half-day for some of the schools) to allow their students to participate in the assigned activity. The teacher will not be required to lead the activity, however they will be responsible to ensure that the schedule is kept and enough time is provided to allow for the full 30-minute activity each day. The schedule will be designed to fit with the teachers regular schedule, to allow for enough travel time for the instructor to be at all four schools each day and to allow for variability in what time of day each activity is offered, to balance out any time of day effects that may otherwise occur. Due to the nature of what we are evaluating (physical activity) and our hypothesis that increasing physical activity (regardless of each students individual base rate) will decrease anxiety levels, it will be important that the intervention activity does not replace any physical activities (such as Physical Education) on the regular schedule. While it will ultimately be up to the principal and/or classroom teacher as to what weekly activities to replace for the six-weeks, the goal is to replace those activities in a way that does not create added anxiety on the students. This may include ensuring a class favorite activity is not replaced or that additional pressures are not placed on the student to make up time missed in the classroom (e.g. if Social Studies is cut short in the classroom, we do not want students to have the extra pressure of additional homework, so instead would be asking the teacher to make other adjustments). The intervention activities will consist of the following: Active Group: Students will participate in a six-week dance/aerobic club. Students will be allowed to choose their own partner to work with (including one group of three if there are an

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odd number of students) and activities will include a mix of instructor lead activities and opportunities for students to create their own dance routine with their partner. This activity will provide an opportunity for students to have a break from their regular classroom activities, to socialize with a chosen peer, and to experience the challenge of learning a skill that will be new for most of the students. The class will be designed so that at least 20 minutes of the time is dedicated to moderate-vigorous physical activity. Inactive Group: Students will participate in a six-week chess club. This activity will provide many of the same factors as the Active Group including: a break from regular classroom activities, opportunity for socializing with a chosen partner, listening to music and the challenge of learning a new skill. It is anticipated that in both groups there may be some anxiety involved with choosing, or being chosen as a partner, working with a partner and learning a new activity. It is also anticipated that levels of interest, speed of skill development and level of effort will vary amongst the participants. However, it is hoped that Inactive group will offer some control for these factors, thereby allowing more support for the physical activity aspect of the Active Group to be considered an important factor in any significant differences between the two groups. The Inactive group will also help to control for other confounds that have been considered in prior research into the effects of exercise, as described above in the literature review. The intervention activities will all be led by the same instructor over the course of the six weeks. Using only one instructor will keep costs at a minimum, will help to ensure that the activities are kept as similar as possible at each school and help to control for any effects related to group leadership. In order to ensure adequate supervision, instruction and care for the children, applicants for the position will need to have a British Columbia Teachers Certificate, as well as the skills to develop and implement the curriculum for both the Active and Inactive group. The instructor will work together with the lead

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researcher to develop a curriculum that offers an equal amount of socialization, new skill development and instructor led vs. self-directed activities for each of the two groups. At the beginning of the six-week research period, all six classrooms of students will take the MASC10. The assessment will be conducted by the lead researcher within the classroom, with each child completing the self-report measure on their own within the group setting. Since the MASC-10 requires a fourth grade reading level (March, 1997), questions will be read aloud to all students as they work through the assessment in order to ensure all children can participate without being singled out. All pretesting will be done on the Wednesday and Thursday of the week prior to the start of the active/inactive group activities. Post-testing will occur using the same format, immediately following the six-week intervention. Post-test assessments will be scheduled at all six schools on the Monday and Tuesday following the end of the active/inactive group activities. During the six-week intervention phase, the control group will experience no change to their regular activities and classroom schedule. The active and inactive groups will participate as scheduled in their assigned research activity, however teachers for all four classrooms will be asked to otherwise keep procedures and activities the same as usual. Parents will also be asked to keep to their childs regular schedule throughout the duration of the study. A general timeline for the research procedures is as follows: Recruitment Phase Development Phase Obtain principal approval Recruit & hire instructor Curriculum development with instructor Schedule development with teachers Informed consent from children & parents Week 1: In class MASC-10 Assessment on Wednesday & Thursday Week 2-7: Active and Inactive treatment group interventions Development of debriefing materials for families pending general results Week 8: In class MASC-10 Assessment on Monday & Tuesday; Scoring Data analysis Report writing Final debriefing information to families Debriefing with principals and teachers Recommendations

Testing/Treatment Phase

Report Phase

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Data Analysis Data analysis will be done using a 3 (control, inactive, active) x 2 (pre- and post-test) factorial ANOVA looking at the MASC-10 scores. These results will be used to evaluate the main effects of group and time, as well as to investigate the interaction between variables. If significant differences are found, an additional post-hoc analysis, Tukeys HSD, will be used to look into where the differences lie and magnitude of effects analysis will be done to determine effect size. Conclusion Expected Outcomes and Significance It is expected that this research study will provide some initial insight into the effect increasing physical activity levels has on general measures of anxiety for upper-elementary aged children. It is expected that those children who were a part of the active group will see a greater decrease in their MASC-10 scores than either of the other two groups control or inactive. While there are many factors that play into anxiety levels, having a control group and an inactive treatment group will help to isolate whether or not physical activity is one factor that lessons anxiety levels. This research will also contribute to the somewhat limited knowledge base that exists in this area, and will help to guide and direct further research studies. It may also offer practical significance beyond its results by bringing attention to the concerns of anxiety levels in children, as well as the need for increased physical activity. Parents, teachers and principals may benefit from added awareness and an increase desire to pay attention to and get involved with their childrens development in these areas. A positive result in the study could also guide future school curriculum and practices. Limitations and Future Research There are certain limitations associated with this research design. In order to develop a workable research design, schools were selected based on geography and within those schools, students were sampled in clusters, rather than individually. Both of these factors impact the random selection aspect of the study, which limits the generalizability of the study and leaves the results more vulnerable to confounds unrelated to physical activity. However, some of this vulnerability is controlled for by using

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the test-retest method with the participants, as it allows us to measure the change in anxiety levels, rather than just comparing base levels. Our study also looked at anxiety using only one diagnostic tool the MASC-10 which is not sufficient to adequately diagnosis or assess anxiety disorders in children. It will important that parents, teachers and principals understand that no individual assessments for anxiety were done and future research may expand upon this study by utilizing more thorough anxiety assessments, which would also allow for participants to be categorized based on anxiety levels. The length of this study, six weeks, may prove to be too short to see the full effects of changes in levels of physical activity, and without follow-up, it does not allow for determination of how long any positive effects may last. Also this study does not take into account other factors such as student temperament, base levels of physical activity and student interest in the activity being offered. There would be value in future research into these factors to evaluate if any increase in physical activity has a beneficial effect on anxiety levels, or if the benefits are related to individual differences, the amount of physical activity or the type of activity. Also, some research in this area with adults is focused on the immediate positive effects of exercise on anxiety levels (Guszowska, 2008) and those effects would not be picked up by this study since re-assessment of anxiety levels were done only at the end of the treatment period. Despite the limitations, it is expected that this research will provide a solid foundation on which to base further research into the relationship between the amount of physical activity and anxiety levels in pre-teens. Building upon this research and developing a better understanding of these two factors may offer new ideas for curriculum, education, parental involvement, prevention and intervention.

JFRIESEN RESEARCH PROPOSAL References Barhrke, M. S., & Morgan, W. P. (1978). Anxiety reduction following exercise and meditation. Cognitive Therapy and Research, 2(4), 323-333. doi: 10.1007/BF01172650 Bernstein, G. A., Layne, A. E., Egan, E. A., & Tennison, D. M. (2005). School-based interventions for anxious children. American Academy of Child and Adolescent Psychiatry, 44 (11), 1118-1127. doi: 10.1097/01.chi.0000177323.40005.a1 Christopher, R. (2002). [Review of the Multidimensional Anxiety Scale for Children.] In The fourteenth mental measurement yearbook. Available from http://www.unl.edu/buros/ Caruso, J. C. (2002). [Review of the Multidimensional Anxiety Scale for Children.] In The fourteenth mental measurement yearbook. Available from http://www.unl.edu/buros/ Dadds, M. R., Holland, D. E., Laurens, K. R., Mullins, M., Barrett, P. M., & Spence, S.H. (1999). Early intervention and prevention of anxiety disorders in children: results at 2-year follow-up. Journal of Consulting and Clinical Psychology, 67(1), 145-150. doi: 10.1037/0022-006X.67.1.145 Guszkowska, M. (2008) State/trait anxiety and anxiolytic effects of acute physical exercises. Biomedical Human Kinetics, 1, 6-10. doi: 10.2478/v10101-009-0003-0 McLoone, J., Hudson, J. L., & Rapee, R. M. (2006). Treating anxiety disorders in a school setting. Education and Treatment of Children, 29 (2), 219-242. March, J. S. (1997). Manual for the Multidimensional Anxiety Scale for Children (MASC). Toronto, Canada: Multi Health Systems.

JFRIESEN RESEARCH PROPOSAL March, J. S., Parker, J. D. A., Sullivan, K., Stallings, P., & Conners, K. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36(4), 554565. Mash, E. J., & Barkley, R. A. (Ed). (2003). Child psychopathology, (2nd edition). New York: Guilford Press. Picard, A. (2010, April 27). Only 1 in 8 Canadian kids get enough exercise, report says. The Globe and Mail. Retrieved from http://www.theglobeandmail.com Rapee, R. M., Kennedy, S. J., Ingram, M., Edwards, S. L., Sweeney, L. (2010). Altering the trajectory of anxiety in at-risk young children. The American Journal of Psychiatry, 167, 1518-1525. doi: 10.1176/appi.ajp.2010.09111619 Strauss, R. S., Rodzilsky, D., Barack, G., & Colin, Michelle. (2001). Psychosocial correlates of physical activity in healthy children. Archives of Pediatrics and Adolescent Medicine,155, 897-902. Taylor, C. B., Sallis, J. F., & Needle, R. (1985). The relation of physical activity and exercise to mental health. Public Health Report, 100 (2), 195-202. van der Leedon, A. J. M., & van Widenfelt, B. M. (2011). Stepped Care Cognitive Behavioural Therapy for Children with Anxiety Disorders. A New Treatment Approach. Behavioural and Cognitive Psychotherapy, 39, 55-75. doi: 10.1017/S1352465810000500

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