"Children are getting weaker, study finds"

The title of this post - "Children are getting weaker, study finds" - comes from one of the media headlines covering the study findings presented by Gavin Sandercock & Daniel Cohen [1]. In their study, the authors detail results derived from the Chelmsford Children's Fitness and Activity Survey, an initiative that has been monitoring the fitness of local children (local to Chelmsford) for about 20 years. Their results for the most recent cohort (2014) compared with previous study cohorts (2008, 1998) make for worrying reading: children are getting weaker alongside "a decrease in self-reported physical activity concurrent with the accelerated declines in fitness from 2008 to 2014."

So: "We measured; height, weight, standing broad-jump, handgrip, sit-ups and bent-arm hang in 10-year-old boys and girls from Chelmsford, England in: 2014 (n = 306), 2008 (n = 304) and 1998 (n = 310)." Researchers also asked about recent physical activity among their cohort using the Physical Activity Questionnaire for Children/Adolescents (PAQ-C), a self-report questionnaire. The collected results were analysed and among other analyses, authors "compared percentage change per year 1998–2008 with 2008–2014" across the variables being studied.

As per the headline, the results were worrying: "Pairwise comparisons showed muscular fitness of both sexes was significantly lower in 2014 than in 1998." They also observed that self-reported physical activity was lower in the later cohort. Obviously, I need to stress that this was self-reported physical activity information, so not exactly objective actigraphic data for example. Out of the several results reported relating to specific aspects of fitness across the cohorts, the issue of handgrip strength stuck out for me in light of some still emerging research suggesting that handgrip strength might have "prognostic value for mortality" according to some studies. Without wishing to make connection when none might exist, I do wonder whether such data might one day eventually tally with some other quite worrying statistics on longevity recently published?

Another detail discussed by Sandercock & Cohen is their finding that "Ten-year-olds in 2014 were taller and heavier than in 2008 and 1998 but there were no differences in BMI [body mass index]." They authors talk about this more in their media interviews: "As today's ten-year-olds are taller and heavier than the children measured six and 16 years ago we expect them to be stronger and more powerful, but this was not the case." Worrying. And it also appears that the declines in strength were increasing more rapidly in the later cohort than compared with the earlier ones, as the authors mention that from 1998 to 2008, strength (group strength) fell by just over half a percent per year, whereas from 2008 to 2014 this decline increased to 1.6% per year.

So what does this all mean for the health and well being of the next generation, and what can be done to reverse such trends? Well, health in childhood is often a good indicator of what health will look like in adulthood. I say this not only from a physiological point of view but also bearing in mind that habits bred in childhood tend to persist into adulthood. Low levels of physical activity probably also follow that pattern.

The possible reasons to account for the cohort disparities? Minus any sweeping generalisations I don't think it would be out of place to mention that things have changed quite a bit when it comes to hobbies and pastimes for at least some parts of the paediatric population. More time spent playing video games or on the Internet have perhaps replaced previous scenarios when kids would meet (in person), play out, run around, climb trees, play football and the like. I don't say that to demonise such digital pastimes (see here) but rather to point out a shifting pattern in activities that also have been noted in other relevant studies [2]. It's perhaps also worthwhile pointing out that opportunities for physical activity have also perhaps changed as a function of the environment we now live in. Why else would schools have had to implement strategies such as the daily mile for example?

Possible solutions? When I first tweeted about the publication of the Sandercock & Cohen article I added in the idea that physical activity specifically along the lines of strength and conditioning could perhaps be added to the learning curriculum. So, alongside maths and English (here in Blighty), there is also a focus on physical education too. Yes, I know physical ed(ucation) is part of the school agenda, but I actually meant something like getting kids into a gym and doing something akin to circuit training at least a few times a week. I know this is ambitious and I know that not every kid is going to be able to do this. But surely in these days of adaption and flexibility in teaching and learning, there are also ways to make such exercise open to all. And you never know, start children young with the mindset that exercise is fun and good for physical (and mental) health, and it might just serve them for a lifetime...

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[1] Sandercock GRH. & Cohen DD. Temporal trends in muscular fitness of English 10-year-olds 1998–2014: An allometric approach. Journal of Science and Medicine in Sport. 2018. Aug 1.

[2] Walsh JJ. et al. Associations between 24 hour movement behaviours and global cognition in US children: a cross-sectional observational study. The Lancet Child & Adolescent Health. 2018. Set 26.

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Internet addiction and suicidal behaviours meta-analysed

"This meta-analysis provides evidence that internet addiction is associated with increased suicidality even after adjusting for potential confounding variables including depression."

That was the research bottom line reported on by Yu-Shian Cheng and colleagues [1] following their meta-analysis of the peer-reviewed research literature looking at 'internet addiction' ("internet addiction OR internet gaming disorder OR internet use disorder OR pathological internet use OR compulsive internet use OR problematic internet use") and suicidality.

Researchers, with some experience of meta-analysis it has to be said (see here and see here), trawled through the pertinent literature and settled on the analysis of some 25 studies, including over a quarter of a million participants, that looked at internet addiction and suicidal ideation, planning, and attempts. Boiling the data down, they observed some important *associations* that even held when important variables linked to suicidal behaviours - depression for example - were adjusted for. Children it seems, were also more 'vulnerable' to the link between internet addiction and suicidality. The authors caution that cause-and-effect were not proven from their analysis of the collected data, bearing in mind "the evidence was derived mostly from cross-sectional studies" but call for further investigations in this area.

This is an important area of research. As per some of the previous studies conducted on internet overuse and suicidality [2], there are some important further investigations to be undertaken on for example, the various types of online activity that might increase the risk of suicidality: "online gaming, chatting, watching movies, shopping, and gambling were associated with an increased risk of suicidal attempt." This in the context that social media use in particular, is under the spotlight when it comes to various different health issues (see here). Alongside gambling disorder, so it looks like gaming disorder is set to enter the diagnostic texts too (see here), where 'lack of control' and causing "significant impairment in personal, family, social, educational, occupational or other important areas of functioning" are key features. And minus any sweeping generalisations, 'control' *could* actually be a key element to consider when it comes to suicidal behaviours in certain circumstances.

Bearing in mind that this blog is predominantly concerned with autism research, I couldn't help but think about how the Cheng findings *might* relate to [some] autism. How for example, a diagnosis of autism also seems to elevate the risk of suicidality (see here) and how issues like depression are not uncommon in the context of autism (see here). I'm also minded to mention how compulsive internet use *might* show some important connections to the presentation of autistic traits [2] and how videogame use, in particular (see here), might have both positives and negatives in the context of autism [3].

By saying all that, I don't want to make any sweeping generalisations; the label of autism has had enough of those down the years. I don't also want to demonise the wonderful resource that is the internet, particularly when pastimes like gaming and social media use can be a good 'social' outlet for many people on the autism spectrum and beyond when used in moderation. Certainly the internet, through things like social media, provides an important voice and potentially quite a lot more to those whose voices might previously not have been heard...

But perhaps when it comes to the next stage of any research plan looking at internet overuse / addiction and suicidal behaviours it might be worth considering whether some of the features of autism or other, related labels [4] (see here) *might* also moderate any relationship. Whether there are some relevant lessons to be learned that *might* reduce the very worrying statistics on suicide and autism, and whether activities other than those done on online, could perhaps be seen as 'protective factors' when it comes to suicide risk (see here for example)?

Bear all that in mind by all means. But remember also that the paths that take someone to such suicidal behaviours are often numerous and individual. Internet overuse is probably only a small part of an often bigger and more complicated picture.

And in case anyone needs to talk or text, there's always someone who will listen (see here).

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[1] Cheng YS. et al. Internet Addiction and Its Relationship With Suicidal Behaviors: A Meta-Analysis of Multinational Observational Studies. J Clin Psychiatry. 2018 Jun 5;79(4). pii: 17r11761.

[2] Lin IH. et al. The association between suicidality and Internet addiction and activities in Taiwanese adolescents. Compr Psychiatry. 2014 Apr;55(3):504-10.

[3] Mazurek MO. & Wenstrup C. Television, video game and social media use among children with ASD and typically developing siblings. J Autism Dev Disord. 2013 Jun;43(6):1258-71.

[4] Wang B. et al. The association between attention deficit/hyperactivity disorder and internet addiction: a systematic review and meta-analysis. BMC Psychiatry. 2017;17:260.

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"To Be Quite Honest, If It Wasn't for Videogames I Wouldn't Have a Social Life at All"

The quote heading this post - "To Be Quite Honest, If It Wasn't for Videogames I Wouldn't Have a Social Life at All" - comes from the findings reported by Erinn Finke and colleagues [1]. They looked at "the perceptions of individuals with autism spectrum disorder (ASD) who play videogames as their primary leisure activity regarding the role of videogames in their lives and their motivations for playing videogames."

I've kinda touched on this topic before on this blog (see here) and some of the ins-and-outs of 'pathological' videogame use in the context of autism. On that blogging occasion, I mentioned how one has to be a little careful about 'demonising' an activity that (a) is enjoyed by millions of people, some of whom are and some aren't diagnosed with an autism spectrum disorder, and (b) could, through the wonders of online gaming, provide a valuable 'social' outlet to a population who either might prefer limited face-to-face contact or are in many ways, discriminated against when it comes to more traditional forms of social inclusion and participation (see here). Apparently this area is also something that has been mentioned at the INSAR conference this year too. The downsides to gaming: well, every moment sat in front of a screen is a moment that could have been used in other more physically active pursuits (something that is quite a big issue when it comes to quite a proportion of the autism spectrum). I might also add that mention of the word 'online' can sometimes mean opening up a whole can of worms...

Finke et al relied on a qualitative study methodology that involved asking young adults about their experiences of videogame playing. Bearing in mind the small number of participants under study, authors observed that "participants perceived playing videogames to have a positive impact on their lives and their development." Aside from the enjoyment angle (an important angle by all accounts), participants mentioned about the 'social' element to their videogame playing. Interesting too was another comment from Finke: "The motivations for playing videogames described are similar to those reported by typically developing populations." Why would they be any different?

The authors see the potential value of videogaming when it comes to "teaching" in the context of autism but I'm slightly reluctant to take up this idea for a few reasons. Foremost is the idea that not every activity where autism is mentioned really needs to be 'medicalised' or indeed, 'interventionised' (if there is such a word). I think back to all the discussions about Lego 'therapy' (see here) for example, and how it would be really easy to turn a pastime that is really enjoyable into something more like schooling, and then onward potentially make it less enjoyable. I would also mention that the types of videogames likely to be enjoyed by those on the autism spectrum are probably the same types of videogames that everyone else likes to play. So developing new 'autism-specific' games with intervention(s) in mind are not likely to go down too well in the context of gaming choice and their applicability to larger audiences. Indeed, it could be seen as discriminatory. And yes, then there is also the notion that 'interventionising' videogames will probably also promote yet more sedentary behaviours, something which we should all be keen to discourage (and I have my views about which physical activities might be considered favourable for many young people both on and off the spectrum).

Music to close and Céline Dion with a special guest... Deadpool? Although, his heart probably will go on given his renowned healing abilities...

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[1] Finke EH. et al. "To Be Quite Honest, If It Wasn't for Videogames I Wouldn't Have a Social Life at All": Motivations of Young Adults With Autism Spectrum Disorder for Playing Videogames as Leisure. Am J Speech Lang Pathol. 2018 Apr 2:1-18.

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Should anyone be concerned about pathological video game use in relation to autism?

"... the risk for pathological game use appears larger in adults with ASD [autism spectrum disorder] compared with TD [typically developing] adults. These findings point to pathological game use as a potentially important focus of clinical attention in adults with ASD."

So concluded the paper by Christopher Engelhardt and colleagues [1] (open-access) looking at an interesting issue - "whether adults with autism spectrum disorder (ASD) are at higher risk for pathological game use than typically developing (TD) adults" - based on reports from some 120 participants with and without a diagnosis of autism. Including one Micah Mazurek on the authorship list (who has previously talked about the effects of screen time and autism), researchers delved into self-reported time spent playing video games based on data collected from a cohort "participating in a larger study on violent video game effects" [2]. The average age of participants (with and without a diagnosis of autism) was round about the 20 years old mark.

Results: both on weekdays and weekends, the typical hours of game play were different between the groups of those with autism and those without. Interestingly, authors used a slightly different statistical approach to the traditional "null hypothesis significance tests and 95% confidence intervals" via their use of "Bayes factors to state evidence for or against our predictions" to analyse their data. Bayes and Bayesian teachings provide an alternative to the 'frequentist' considerations in treating data. Alongside asking about game play time, researchers also asked participants to complete a questionnaire on "pathological video game use" that was based on "another behavioral addiction (pathological gambling)" and covered various aspects: "salience, euphoria or relief, tolerance, withdrawal, conflict, relapse and reinstatement."

"The results indicated that adults with ASD endorsed more symptoms of video game pathology than did TD adults. This relationship was strong, enjoying 300,000-to-1 odds in Bayesian model comparison." Such sentences kinda say it all. Risk of pathological video game use was quite a bit more likely in those with autism than those without, and 'escapism' was also reported to be an important reason for such extended use.

I do want to be a little careful in this post not to (a) demonise - pathologise - video game playing and/or (b) isolate those on the autism spectrum as being 'unique' in their video gaming habits. Personally, I don't see an issue if people want to spend large sections of their days playing video games as opposed to watching television or sitting down reading a book (reading in particular, is another fine example of escapism) or doing anything else. This was a study of adults doing what many millions of people do every day, so they should have the right to do as they please in this context. With the wonders of modern technology, gaming today is also not necessarily a socially-isolated pastime so one has to be quite careful about making any sweeping generalisations in that respect too.

I have however, always been a little worried about this and other research on screen time use in the context of autism and what detrimental effects it might have for a person's physical health. Everyone is prone to a degree of 'couch-potatoing' (i.e. loafing of the sofa for hours on end) but when people are talking about nearly 3 hours every day gaming, presumably sat on a couch/sofa, this really can't be doing anyone any good in terms of their long-term physical health. We're all being told to move more (see here) and given the data emerging when it comes to the physical activity patterns of rather a lot of people on the autism spectrum (see here), there are some good grounds for encouraging more movement and more physical activity minus any nanny-stating. I appreciate that sports and exercise is not everyone's cup of tea and in particular, more needs to be done in making physical activity more attractive to many groups of people including those on the autism spectrum (see here). Efforts should continue to ensure a balance is struck between times of sedentary behaviours typically associated with gaming and times of engaging in physical activity; as far as I can see, Engelhardt et al did not ask about physical activities or other related pastimes on this research occasion. Indeed, although I am still a little apprehensive about the use of exergaming, I do wonder if this could be a good bridging point on the road to balance...

Music to close: Shape of You by Ed for one of my brood who seems to be looking forward to becoming a kumite specialist (when she graduates from Ippon kumite).

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[1] Engelhardt CR. et al. Pathological game use in adults with and without Autism Spectrum Disorder. PeerJ. 2017. e3393.

[2] Engelhardt CR. et al. Effects of Violent-Video-Game Exposure on Aggressive Behavior, Aggressive-Thought Accessibility, and Aggressive Affect Among Adults With and Without Autism Spectrum Disorder. Psychol Sci. 2015 Aug;26(8):1187-200.

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