Physical Activity Developmental Chapters INFANCY

Overview The first year of life is marked by dramatic changes in the amount and type of physical activity displayed. Infants spend the first days of life sleeping and eating. However, 1 year later, when they become toddlers, they usually are crawling and probably have taken a few independent steps. Motor skill development begins with the involuntary reflexes that ensure the newborn infant's survival. Over the next few months, these reflexes disappear as the infant slowly gains voluntary control over body movements. With increasing control comes more physical activity. Sitting up, rolling over, crawling, standing, and eventually walking expand the infant's level of physical activity. Motor skill development, like other aspects of the infant's development, is an individual process. Infants usually acquire motor skills in the same order, but the rate at which they acquire them is individual. For example, some infants walk as early as 9 months, whereas others do not walk until after their first birthday. The way infants are held and handled, the toys they play with, and their environment all influence their motor skill development. Parents can influence the quality of the infant's movements by providing a stimulating environment. Physical activity should be promoted from the time infants are born. Motor skills do not just appear. Motor skills, like cognitive skills, flourish when the infant is exposed to a stimulating environment. Physical activity opportunities and nurturing of motor skill development during the first year of life establish the foundation for physical activity behaviors.

INFANCY Growth and Physical Development

Immediately after birth, infants lose approximately 6 percent of their body weight because of fluid loss and some breakdown of tissue. Infants usually regain their birthweight by 10 to 14 days after birth, and thereafter weight gain proceeds at a slower rate. Typically, infants' birthweight doubles by 4 to 6 months and triples by age 1. On average, infants gain 5 to 7 oz per week in the first 4 to 6 months and 3 to 5 oz per week from 6 to 18 months. Infants usually increase in length by 50 percent in the first year, but the rate of increase slows down during the second half of the year. From birth to 6 months, infants gain approximately 1 inch per month, and from 6 to 12 months of age, they gain about a 1/2 inch per month. These enormous changes make it difficult for infants to control their rapidly growing bodies. In addition, the head and trunk constitute about 70 percent of infants' body length and most of its mass, making it difficult for them to achieve upright postures or any form of locomotion. However, this large mass offers infants weight-training opportunities. As infants roll over, crawl to get a favorite toy, or walk along furniture, their head and trunk may be difficult to control, but they benefit from the physical challenge by increasing motor control and muscle development.

Muscles are not well developed at birth; therefore, most of the first year of life involves building muscle mass. Infants need arm muscles to pick up objects. They need leg muscles to crawl, stand, and eventually walk. They need their head and trunk muscles to control these two large body parts. And they need arm and leg muscles to move their trunks. Neural development in infants involves the connection of 200 billion neurons, the conducting cells of the nervous system. Stimulation is critical to neural development. Without stimulation (e.g., visual, auditory, tactile), these cells die. With stimulation, these cells create elaborate networks that promote sensory and motor skill development. Stimulation can be provided in many ways (e.g., by hanging a mobile over the infant's crib, which may motivate the infant to reach, or by placing a toy just out of reach, which may motivate the infant to roll over).

INFANCY Healthy Lifestyles

Infants' vitality and successful development depend on good nutrition during the first year of life. Full-term infants who are fed on demand usually consume the amount they need to grow well. But feeding infants is much more complex than simply offering food when they are hungry, and it serves purposes far beyond supporting their physical growth. Feeding provides opportunities for emotional bonding between the parent and infant. Infants improve their hand-eye coordination and fine motor skills as they begin to feed themselves. In addition to interaction during feeding times, infants need play time to explore objects, engage in activities that stimulate their senses, and experience movement and action.

Building Partnerships
Partnerships among health professionals, families, and communities are essential for ensuring that families receive guidance on physical activity during infancy. Health professionals can have a tremendous impact on decisions about physical activity as they inform families about the importance of physical activity for motor skill development. They provide an opportunity for families to discuss, reflect on, and decide which options best suit their circumstances. Health professionals also identify and contact community resources that help families. The community may also need to help families by providing programs that Encourage families to promote physical activity in infants. Teach families about physical and motor skill development during infancy. Give infants the opportunity to be physically active.

In addition, communities can provide (1) affordable, skilled child care providers who promote physical activity in infants, (2) safe environments for indoor and outdoor physical activity, and (3) support for families of infants with special health care needs.

Strengths, and Issues and Concerns

During health supervision visits, health professionals should emphasize the physical activity strengths of the infant, family, and community (Table 1) and address any physical activity issues and concerns (Table 2).

Table 1. Physical Activity Strengths During Infancy

Infant Enjoys playing with parents, siblings, grandparents, and others Enjoys physical activity (e.g., movement, play) Enjoys playing with objects and toys Is curious and explores environment through a variety of physical activities Moves in new ways when challenged with interesting activities Family Spends time playing with the infant Encourages the infant to move and explore Provides a stimulating environment that promotes play and physical activity Participates in physical activity themselves Community Encourages families to promote play and physical activity in their infants Provides programs that teach families about physical and motor skill development Provides programs that give infants the opportunity to be physically active Provides affordable, skilled child care providers who promote physical activity in infants Provides safe environments for indoor and outdoor physical activity Provides support for families of infants with special health care needs

Table 2. Physical Activity Issues and Concerns During Infancy

Infant Was born prematurely Experiences developmental delays Experiences discomfort with physical activity Has health problems Family Lacks knowledge of physical and motor skill development Has health problems that affect the amount of time spent with the infant Has a work schedule or other commitments that reduce the amount of time spent with the infant Community Lacks programs that promote physical activity in infants Lacks affordable, skilled child care providers who promote physical activity in infants Does not provide support for families of infants with special health care needs

INFANCY Physical Activity Supervision

An infant's level of physical activity should be assessed as part of health supervision visits. (For more information on health supervision, see Bright

Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, listed under Suggested Reading in this chapter.) Health professionals can begin by gathering information about the infant's level of physical activity. This can be accomplished by selectively asking key interview questions listed in this chapter, which provide a useful starting point for identifying physical activity issues and concerns. Health professionals can then use this chapter's screening and assessment guidelines, and counseling guidelines, to provide families with anticipatory guidance. Interview questions, screening and assessment, and counseling should be used as appropriate and will vary from visit to visit, infant to infant, and family to family. Desired outcomes for the infant, and the role of the family, are identified to assist health professionals in promoting physical activity.

INFANCY Interview Questions

The following questions are intended to be used selectively to gather information, to address the family's issues and concerns, and to build partnerships. Do you have any concerns about Julia's development? How often do you play with her? Do both you and your spouse play with Alexander? What are some physical activities you do with him? How often during the day is Julia in an open environment, such as on the living room floor? How do you carry her? Is Alexander distressed when you gently bounce him or swing him around? Is he interested in his environment? What are his favorite toys? Do toys motivate him to move? Is Julia interested in objects, toys, and people around her? What are some of her achievements? Are you comfortable with Alexander's increasing independence? Do you encourage him to be independent? Are you pleased he can stand by himself? Are you worried that he might hurt himself? When Alexander is awake, how much time does he spend in an infant safety seat or swing, on the floor, on your lap, or in someone's arms? How does Julia's development compare to that of your other children when they were this age?

Do you have any questions?

INFANCY Screening and Assessment

Measure the infant's length, weight, and head circumference, and plot these on a standard growth chart (see Tool H: CDC Growth Charts). Deviation from the expected growth pattern (e.g., a major change in growth percentiles on the chart) should be evaluated. This may be normal or may indicate a problem (e.g., difficulties with eating). Examine the infant for other medical problems that may interfere with motor skill development. Determine whether the infant has a history of ear infections. Determine whether the infant has a heart murmur. Assess the symmetry of the infant's arms and legs. Assess the infant's muscle tone in the arms and legs (i.e., resistance to joint extension). Assess the infant's motor skill development. The Bayley Scales of Infant Development are often used for this purpose (Table 3).1 Table 3. Motor Skill Development During Infancy This table is currently not available on the Web site.

INFANCY Counseling
Health professionals can use the following information to provide anticipatory guidance to families. Anticipatory guidance provides information on the infant's physical status and on what to expect as the infant enters the next developmental period, and fosters the promotion of physical activity. General Encourage parents to attend classes to learn about promoting physical activity during infancy. Suggest that they participate in parent-infant play groups. Infants need the opportunity to move. Encourage parents to provide objects and toys and to play games to encourage their infants to move and do things for themselves. Gently turning, rolling, bouncing, and swaying infants are excellent ways to increase their muscle strength and to help them develop important connections between the brain and muscles. Tell parents that rough-and-tumble activities are not appropriate for infants. Infants usually signal their distress (e.g., by crying) if the physical activity is too vigorous, overwhelming, or disconcerting. Parents should pay attention to these signals and stop the physical activity if needed. Encourage parents to ask the child care provider how much time the infant spends moving around (i.e., not sitting in an infant safety seat or sleeping).

Physical Development Infants need physical activity from the time they are born. Encourage parents to nurture their infants' motor skill development and to promote physical activity.

Infants need to develop head and trunk control. When infants are 3 months old, parents can encourage this control by (1) placing the infant on their laps, facing them; (2) holding the infant's hands and encouraging the infant to stand; and (3) pulling the infant up into a standing position. When the infant is pulled up, the infant should stand with the parent's support. If the infant can hold the upright posture, the parent can gently sway the infant side to side.

Safety Infants need a safe environment for physical activity.

INFANCY Table 4. Desired Outcomes for the Infant, and the Role of the Family
Infant Educational/Attitudinal Enjoys moving Enjoys playing with parents, siblings, grandparents, and others Behavioral Achieves motor skills milestones at an appropriate age Plays with objects and toys and explores the environment Health/Physical Status Develops the strength and postural control to walk Develops the fine motor skills needed to pick up objects, toys, and food and manipulate them with both hands

Family Educational/Attitudinal Understands the importance of physical activity (e.g., movement, play) Recognizes developmentally appropriate motor skills Behavioral Plays with the infant Promotes physical activity in the infant Health/Physical Status Recognizes delays in motor skill development

INFANCY I'm Afraid Natalie Might Break!

Natalie is Susan and Jacob's first baby. They are the first among their friends to have a baby. They have no family members living nearby. Susan brings Natalie in to see Dr. Fuentes for her 6-month health supervision visit, and the physician notices that Susan handles Natalie like a china doll. Natalie exhibits very little head and trunk control. When placed on her stomach, she fusses and raises

her head only to see what's in front of her. When a toy is placed in front of her, Natalie looks at the toy but doesn't reach for it. Dr. Fuentes determines that Natalie's height and weight are normal. She is alert and happy. However, her motor skill development is lagging--most noticeably in head and trunk control. Dr. Fuentes asks Susan how she and Jacob interact with Natalie. Susan admits that she and Jacob are not very sure of themselves when it comes to holding and playing with Natalie. Susan discloses that she is afraid Natalie might "break" if she lets her move around too much. In fact, Natalie spends most of the day in her infant seat or crib. Dr. Fuentes asks Susan to show her how she carries, undresses, and bathes Natalie. The demonstrations confirm that Susan is gentle and extremely careful--so much so that Natalie remains passive. With as much gentleness as Susan exhibited, Dr. Fuentes picks up Natalie. However, Dr. Fuentes encourages Natalie to sit while he holds her firmly under the arms. Dr. Fuentes carefully moves Natalie from side to side to show Susan how she can move Natalie without hurting her. The secret, Dr. Fuentes says, is to encourage Natalie to move independently. "Natalie's head and trunk are almost two-thirds of her weight, and she has to learn to control them. You and Jacob need to give Natalie opportunities to strengthen her muscles and her brain's connections to the muscles, while offering support if she needs it. Tonight, spend some time with Natalie sitting on your lap facing you; hold her gently but firmly, and let her sway back and forth and side to side. Make it a game. Talk to her and encourage her. As long as you are gentle but hold her firmly, she won't break."

INFANCY Frequently Asked Questions About Physical Activity in Infancy

How can I encourage my baby to be physically active? Babies need physical activity from the time they are born. Provide your baby with opportunities that encourage her to move. Offer her a challenge (for example, a toy just out of reach) and see how she reacts. She will let you know if you push her too much. When babies move, their arms and legs often look jerky and uncoordinated. Remember, your baby is learning a lot of new skills in her first year. When a baby's brain and muscles learn how to work together, her movements will get smoother. What's the best way to carry my baby? Carry your baby in a way that makes him feel secure and comfortable. Try to vary the position. For example, instead of always carrying your baby so that he faces backward, carry him so that he faces forward, to give him the opportunity to look in the direction you are going. Should I use a walker to help my baby learn to walk? Babies should never be placed in an infant walker (baby walker) because of the considerable risk of injury and even death. The risk of injury from the use of walkers is even greater in homes with stairs. Make sure your child care provider does not use walkers. My baby's head flops over to the side when she is upright. Should I support her head? Yes, offer light but firm support. Try to offer less support each time, so that eventually she will be able control her head herself.

My friend's baby, who is the same age as mine, is sitting on his own, but my baby can't do this yet. Should I be worried? Babies develop at different rates. As long as your baby attains motor skills at an appropriate age, there is nothing to worry about. What can I expect my baby to do as he grows? Newborn to 1 Month Your baby will have rooting, sucking, and swallowing reflexes. He will begin to develop the ability to start and stop sucking. He will wake up and fall asleep easily. 3 to 4 Months Your baby will raise her head when she is on her stomach. She will follow objects and sounds with her eyes. She will put her hand in her mouth a lot. She will sit with support. 6 Months Your baby's torso will move in the direction of his head when he turns his head while lying on his back. He will reach for objects and pick them up with one hand. He will hold his hands together. He will sit with support. 7 to 9 Months Your baby will reach for pieces of food and pick them up between her thumb and forefinger. 9 to 12 Months Your baby will play games such as peek-a-boo. He will explore toys with his eyes and mouth, and will transfer a toy from one hand to the other. He will sit and crawl, and may walk without support.

Physical Activity Developmental Chapters EARLY CHILDHOOD Overview

During early childhood (ages 1 to 4), a child's world expands to include friends, schoolmates, and others in the community. The child's physical, cognitive, social, and emotional development are tightly linked. For this reason, physical activity affects not only the physical health of children but also their overall health status. Early childhood is divided into two stages: the toddler stage, ages 1 to 2, and the young child stage, ages 3 to 4. The toddler stage can be stressful for parents as toddlers develop a sense of independence. As they get older, children become more interested in trying new activities. Early childhood is a key period for promoting physical activity. During these years, fundamental motor skills, basic movement patterns that all children tend to develop (e.g., walking, running, galloping, jumping, hopping, skipping, throwing, catching, striking, kicking, balancing), begin to develop. If children are encouraged to be physically active, these skills can develop into advanced patterns of motor coordination that can last a lifetime. Unfortunately, many children barely acquire fundamental motor skills and some will not develop advanced patterns of motor coordination because they are not encouraged to participate in physical activities that provide opportunities to practice these skills.

Participation and instruction in various physical activities help children develop motor skills. Although other factors (e.g., genetics) influence whether a child will become an athlete, physical activity in early childhood helps ensure that children will have the motor skills they need throughout life. Children will not develop motor skills without intervention. Children of this age usually play and explore; however, many spend only 10 to 20 percent of their time participating in gross motor physical activities, which require whole-body participation (e.g., walking, running, climbing). Many children spend too much time participating in sedentary behaviors (e.g., watching television and videotapes, playing computer games, playing with toys that do not require the child to move). Children benefit from physical activity in a number of ways. Physical activity can Give children a feeling of accomplishment. Reduce the risk of certain diseases (e.g., coronary heart disease, hypertension, colon cancer, diabetes mellitus), if children continue to be active during adulthood. Promote mental health.

EARLY CHILDHOOD Growth and Physical Development

A child's birthweight quadruples by 2 years of age. Between the ages of 2 and 5, children gain an average of 4 1/2 to 6 1/2 pounds per year and grow 2 1/2 to 3 1/2 inches per year. The child's head and trunk size are large in proportion to the rest of the body, making locomotion more difficult. However, as the legs grow, the child is able to move faster and more easily. Skeletal growth is steady in early childhood, and nonintensive physical activity does not damage growing bones. Joints are flexible, and they get even more flexible during this period. During early childhood, other physical changes take place that enhance the child's ability to move and participate in physical activity: Muscles continue to grow. The nervous system continues to develop. Vision and visual perception improve. (Children's vision does not fully mature before ages 6 or 7. Imprecise eye movements limit their ability to track and judge the speed of moving objects.) Kinesthesia--the sense that detects body position, weight, and movement of the muscles, tendons, and joints--improves. Sense of balance improves. Cognition improves.

EARLY CHILDHOOD Healthy Lifestyles

Early childhood is a key time for promoting the development of motor skills and physical activity behaviors. Most children are active but may not have the opportunity to play and explore because of space or safety concerns, or because their parents do not encourage them to be physically active. Children in early childhood should be encouraged to participate in physical activity. Simple games such as "Simon Says," chase, and tag are appropriate. Physical activities (e.g., tumbling, gymnastics, dancing) tailored to the developmental needs of children are also appropriate. Because most children need to develop motor skills, they are not ready for organized sports, which require visual acuity, control, and balance.

Building Partnerships
Partnerships among health professionals, families, and communities are essential for ensuring that families receive guidance on physical activity. Health professionals need to give parents the opportunity to discuss physical activity issues and concerns affecting their children, and need to identify and contact community resources to help parents promote physical activity in their children. The community can help promote physical activity by providing programs that Encourage families to promote physical activity in children. Teach families about physical and motor skill development during early childhood. Give children the opportunity to be physically active. In addition, communities can provide (1) affordable, skilled child care providers who promote physical activity in children, (2) safe environments for physical activity, and (3) support for families of children with special health care needs. Many children spend time with child care providers or participate in Head Start or other preschool programs that provide opportunities for physical activity. Children in community programs can be introduced to new activities and may try them more readily if their peers seem to be enjoying them.

In addition, communities can provide (1) affordable, skilled child care providers who promote physical activity in infants, (2) safe environments for indoor and outdoor physical activity, and (3) support for families of infants with special health care needs.

Strengths, and Issues and Concerns

During health supervision visits, health professionals should emphasize the physical activity strengths of the child, family, and community (Table 5) and address any physical activity issues and concerns (Table 6).

Table 5. Physical Activity Strengths During Early Childhood

Child
Participates in

Family
Encourages the child to

Community
Promotes physical activity

physical activity Enjoys physical activity Enjoys playing with parents, siblings, grandparents, and others Enjoys playing with objects and toys In addition to walking, often runs, gallops, jumps, and skips Enjoys throwing, catching, hitting, and kicking a ball Enjoys climbing and balancing activities

participate in physical activity Provides opportunities for the child to participate in physical activity Supervises the child during physical activity Ensures that the child uses appropriate safety equipment (e.g., helmet) during physical activity Participates in physical activity with the child Provides positive role model by participating in physical activity

Provides programs that teach families about physical and motor skill development Provides opportunities for children to participate in physical activity Provides affordable, skilled child care providers who promote physical activity in children Maintains policies (e.g., preservation of green space) and provides environmental support (e.g., wellmaintained sidewalks) that promote physical activity Provides safe environments for indoor and outdoor physical activity (e.g., walking and biking paths, playgrounds, parks, recreation centers) Provides support for families of children with special health care needs

Table 6. Physical Activity Issues and Concerns During Early Childhood

Child
Has health problems Experiences motor skill or developmental delays Experiences discomfort with physical activity Is afraid to try new physical activities Is more interested in sedentary behaviors (e.g., watching television and videotapes, playing computer games) Lacks friends or siblings to be physically active with

Family
Lacks knowledge of physical and motor skill development Does not encourage the child to participate in physical activity Does not advocate for physical education in programs Does not provide positive role model by participating in physical activity Does not participate in physical activity with the child Has health problems that affect the amount of time spent with the child Has a work schedule or other commitments that reduce the amount of time spent with the child Lacks space or equipment for physical activity

Community
Lacks programs that promote physical activity in children Lacks affordable, skilled child care providers who promote physical activity in children Lacks safe environments for indoor and outdoor physical activity (e.g., walking and biking paths, playgrounds, parks, recreation centers) Lacks policies (e.g., preservation of green space) and does not provide environmental support (e.g., wellmaintained sidewalks) that promote physical activity Does not provide support for families of children with special health care needs

EARLY CHILDHOOD

PHYSICAL ACTIVITY SUPERVISION

A child's level of physical activity should be assessed as part of health supervision visits. (For more information on health supervision, see Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, listed under Suggested Reading in this chapter.) Health professionals can begin by gathering information about the child's level of physical activity. This can be accomplished by selectively asking key interview questions listed in this chapter, which provide a useful starting point for identifying physical activity issues and concerns. Health professionals can then use this chapter's screening and assessment guidelines, and counseling guidelines, to provide families with anticipatory guidance. Interview questions, screening and assessment, and counseling should be used as appropriate and will vary from visit to visit, child to child, and family to family. Desired outcomes for the child, and the role of the family, are presented to assist health professionals in promoting physical activity.

EARLY CHILDHOOD Interview Questions

The following questions are intended to be used selectively to gather information, to address the family's issues and concerns, and to build partnerships. Do you have any concerns about Benita's development? How often do you play with her? What are some physical activities you do with Ethan? How often does he get a chance to run? How often does Benita play with a ball? How does her development compare to that of your other children when they were her age? How much television do you allow Ethan to watch each day? Is your neighborhood safe enough for him to play outside? Do you participate in physical activity? If so, which ones? Did you participate in physical activity when you were a child?

EARLY CHILDHOOD Screening and Assessment

Measure the child's length or height and weight, and plot these on a standard growth chart (see Tool H: CDC Growth Charts). Deviation from the expected growth pattern (e.g., a major change in growth percentiles on the chart) should be evaluated. This may be normal or may indicate a problem (e.g., difficulties with eating). Assess the child's visual acuity and eye movement. Vision problems hinder the development of motor-visual (hand-eye) coordination, an important component of physical activity. Assess the child's coordination. Poor coordination may result from lack of physical activity or other factors, or it may be a symptom of developmental coordination disorder (DCD). If DCD is suspected, refer the child for neurodevelopmental assessment. (See the Developmental Coordination Disorder chapter.) Assess the child's motor skill development (Table 7). Children usually acquire fundamental motor skills by a particular age.1

Table 7. Motor Skill Development During Early Childhood

Motor Skill Running Galloping Jumping Hopping Skipping Age Range 1 1/2 to 2 years 2 to 2 1/2 years 2 1/2 to 3 years 3 to 4 years 4 to 5 years

EARLY CHILDHOOD Counseling

General Children should be physically active every day or nearly every day, as part of play, games, physical education, planned physical activities, recreation, and sports, in the context of family, school, and community activities. Encourage parents to promote daily physical activity (e.g., walking, running, riding a tricycle or bike, dancing, playing with a ball or at the playground, playing on equipment that requires balance, playing games such as "Simon Says"). Developmentally appropriate organized activities such as tumbling, gymnastics, and dancing are excellent for children if they are taught by qualified, experienced instructors. Encourage parents to wait until their children are 6 years old before beginning organized sports. In early childhood, children are too young to understand rules and strategies and to handle the emotional and social stress sometimes associated with organized sports. Encourage parents to let children do things for themselves (e.g., letting them climb up into the child safety seat). Explain to parents how to encourage their children to participate in physical activity. For example, parents can play with their children before watching television, then gradually extend playtime and decrease television time. Encourage parents to participate in physical activity with their children and to be positive role models by participating in physical activity themselves. Discuss with parents the importance of using child care providers who promote physical activity and have the space and equipment for it.

Physical Development

Children do not develop catching, throwing, and kicking skills by a specific age. However, if children have not attempted any of these activities by age 4, they may have difficulties keeping up with their peers. Tell parents that organized sports, which require visual acuity, control, and balance, are inappropriate for children less than 6 years old because they need time to develop their motor skills.

Injury Prevention Emphasize that children should be supervised when they participate in physical activity. Emphasize the importance of safety equipment (e.g., helmets, goggles) when children participate in physical activity. (See the Injury chapter.) Emphasize the importance of reducing children's exposure to sunlight while playing outdoors and thus their risk of developing skin cancer. Recommend that parents practice preventive strategies such as (1) applying a broad-spectrum sunscreen with a sun protection factor (SPF) rating of 15 or greater to children's exposed skin 30 minutes before they go outdoors, (2) reapplying sunscreen every 2 hours, and (3) ensuring that children wear broad-spectrum child-sized sunglasses and brimmed hats and clothing that protect the skin as much as possible.

Safety If the safety of the environment or neighborhood is a concern, help parents find other settings for physical activity (e.g., Boys and Girls Clubs of America, recreation centers, churches and other places of worship). Remind parents that children can do many activities indoors with soft equipment that can be used in tight spaces (e.g., playing tag or hide-and-seek, tossing a ball, crawling through an obstacle course).

EARLY CHILDHOOD Table 8. Desired Outcomes for the Child, and the Role of the Family
Child Educational/Attitudinal Enjoys physical activity Behavioral Participates in daily physical activity Uses appropriate safety equipment (e.g., helmet, goggles) during physical activity Health/Physical Status Improves motor skills, coordination, and muscle tone Grows and develops at an appropriate rate Maintains good health

Family Educational/Attitudinal Promotes physical activity Understands the importance of developmentally appropriate physical activity Behavioral Provides opportunities and safe places for the child to participate in physical activity Health/Physical Status Maintains good health

Has resources that allow the child to participate in physical activity

Participates in physical activity with the child Provides positive role model by participating in physical activity Advocates for physical education in programs

EARLY CHILDHOOD Why Isn't Charlie Developing Motor Skills?

Charlie Spooner, a quiet 4-year-old boy, and his mother are going to see Dr. Higgs, the family physician. Dr. Higgs notices that Charlie is content to sit in a chair and gaze at whomever is speaking. He has no interest in getting up and looking around or playing with the toys in the room. Charlie's mother is concerned that Charlie is lagging behind his sister in motor skill development. Dr. Higgs reassures Charlie's mother that boys usually take longer than girls to develop motor skills. Dr. Higgs discovers that Charlie and his sister go to different child care providers. Charlie's provider does not promote physical activity, and the children are allowed to spend hours watching television and playing with toys that do not require much physical activity. On the weekends, Charlie's parents run and bike; however, they place him in a stroller or bike seat. Charlie's mother and father wonder why their child does not seem interested in running or learning how to ride a bike. Dr. Higgs explains that Charlie needs the opportunity to try out various activities that are appropriate for his skill level. Dr. Higgs suggests that rather than focusing on running and biking, Charlie's parents should encourage him to try other activities (e.g., playing with a ball, climbing, jumping) and to make these activities fun. Dr. Higgs also provides two additional suggestions: (1) changIng child care providers to one who promotes physical activity and (2) allowing Charlie to participate in organized, supervised activities (e.g., gymnastics programs, play groups). Charlie's mother agrees to give these suggestions a try. Dr. Higgs explains that Charlie needs the opportunity to try out various activities that are appropriate for his skill level.

EARLY CHILDHOOD Frequently Asked Questions About Physical Activity in Early Childhood
How can I help my 3-year-old learn new skills, such as throwing a ball? Children go through stages as they learn something new, whether it's learning to feed themselves or to coordinate their arms and legs. Some children learn more quickly than others. Some may need extra help from an adult. All children need practice when they are learning new skills, just like adults do. What physical activities are appropriate for my child? Physical activities (for example, running, jumping, climbing, and throwing, catching, or hitting a ball) and simple games (for example, "Simon Says," chase, and tag) are appropriate for children. Your child can

also participate in developmentally appropriate organized activities (for example, tumbling, gymnastics, and dancing). Children less than 6 years old do not have the motor skills, or mental and emotional capabilities, to participate in organized sports. How often should my child participate in physical activity? Your child will benefit most from daily physical activity. Children tend to be active in spurts and know when they need to rest. My neighborhood isn't very safe. How can my child be active if he can't play outdoors? Community organizations, recreation centers, and churches and other places of worship provide opportunities for children to participate in physical activity. Work with community leaders to ensure that your child has safe places for participating in physical activity (for example, walking and biking paths, playgrounds, parks, and recreation centers). Also, your child can do many activities at home such as hopping, dancing, playing tag or hide-and-seek, tossing a ball, or crawling through an obstacle course. Why is my daughter afraid of playing on playground equipment? Be patient, and try holding on to her when she is on the equipment. If this doesn't work, try to find other activities that do not frighten her. My son is lagging behind my daughter in motor skill development even though my daughter is a year younger. Why? Boys often take longer than girls to develop motor skills. However, once boys learn a skill, they usually perform it as well as girls. Boys tend to perform better than girls in activities requiring strength (for example, throwing), and girls tend to perform better in activities requiring balance and fine motor skills (for example, tap dancing). Should I enroll my child in a gymnastics or dancing class? Classes taught by qualified and experienced instructors can be excellent for children. Always check on instructors' qualifications, and observe the classes as much as possible. Our child care provider does not encourage physical activity. What should I do? Talk to your child care provider and encourage her to incorporate physical activity into the day. If lack of space or equipment is the problem, work with her to come up with creative ideas to provide physical activity opportunities for the children. If this is not possible, consider changing child care providers to one who promotes physical activity.

MIDDLE CHILDHOOD Overview

Middle childhood, ages 5 to 10, is characterized by a slow, steady rate of physical growth. However, cognitive, emotional, and social development occur at a tremendous rate. To achieve optimal growth and development, children need to eat a variety of healthy foods and participate in physical activity. Physical activity can

Give children a feeling of accomplishment. Reduce the risk of certain diseases (e.g., coronary heart disease, hypertension, colon cancer, diabetes mellitus), if children continue to be active during adulthood. Promote mental health.

As children grow and develop, their motor skills increase, giving them an opportunity to participate in a variety of physical activities. Children may try different physical activities and establish an interest that serves as the foundation for lifelong participation in physical activity. Children are motivated to participate in physical activity by fun, previous success, variety, family support, peer participation, and enthusiastic coaching. Feelings of failure, embarrassment, competition, boredom, and rigid structure discourage participation. Children usually discontinue physical activity because of a lack of time, feelings of failure, overemphasis on competition, or the existence of overuse injuries (e.g., stress fracture, inflammation of the joints). Children in middle childhood are at various stages of cognitive, emotional, social, and motor skill development. They may not understand the meaning of competition and teamwork. They may lack the cognitive skills to grasp strategies, make rapid decisions, and visualize spatial relationships. Like the developmental milestones of infancy, such as rolling over, sitting up, crawling, and walking, most of the fundamental motor skills (e.g., running, galloping, jumping, hopping, skipping, throwing, catching, striking, kicking) required for physical activity are acquired in the same sequence. Motor skill acquisition appears to be an innate process, independent of the child's sex, age, size, weight, strength, abilities, and level of physical maturity. As with other developmental milestones, the rate at which children master motor skills varies considerably. Although children can acquire and refine fundamental motor skills faster by early instruction and practice, they are unlikely to do so until they are developmentally ready. Children usually acquire fundamental motor skills at a basic level through play; however, children need instruction and practice to fully develop these skills.1 Each fundamental motor skill is characterized by a series of developmental stages. Failure to achieve progression through all of the stages can limit proficiency in physical activities that require fully developed fundamental motor skills. Transitional motor skills are fundamental motor skills performed in various combinations and with variations (e.g., throwing for distance; throwing for accuracy). Transitional motor skills are required to participate in entry-level organized sports. Early in this developmental period, children's vision is almost mature, but it is still difficult for them to tell the direction in which a moving object is moving. Balance becomes more automatic and reaction times become quicker. With improved transitional motor skills, children are able to master complex motor skills (e.g., those required for playing more complex sports such as football or basketball). At the end of this developmental period, children's vision is fully mature.1 Motor skill development is difficult for some children. Health professionals need to assess these children to determine whether their difficulties are caused by a developmental delay or a health problem. In some cases, poor motor skill development is the result of developmental coordination disorder (DCD).2 (See the Developmental Coordination Disorder chapter.)

MIDDLE CHILDHOOD Growth and Physical Development

Middle childhood's slow, steady growth occurs until the onset of puberty, which occurs late in middle childhood or in early adolescence. Children gain an average of 7 pounds in weight, and 2 1/2 inches in height, per year. They have growth spurts, which are usually accompanied by an increase in appetite and food intake. Conversely, a child's appetite and food intake decrease during periods of slower growth. Body composition and body shape remain relatively constant during middle childhood. During preadolescence and early adolescence (9 to 11 years in girls; 10 to 12 years in boys), the percentage of body fat increases in preparation for the growth spurt that occurs during adolescence. This body fat increase occurs earlier in girls than in boys, and the amount of increase is greater in girls. Preadolescents, especially girls, may appear to be "chunky," but this is part of normal growth and development. During middle childhood, boys have more lean body mass per inch of height than girls. These differences in body composition become more significant during adolescence. During middle childhood, children may become overly concerned about their physical appearance. Girls especially may become concerned that they are overweight and may begin to eat less. Parents should reassure their daughters that an increase in body fat during middle childhood is part of normal growth and development and is probably not permanent. Boys may become concerned about their stature and muscle size and strength. During middle childhood, children's muscle strength, motor skills, and stamina increase. Children acquire the motor skills necessary to perform complex movements, allowing them to participate in a variety of physical activities. For females, most physical growth is completed by 2 years after menarche. (The mean age of menarche is 12 1/2 years.) Males begin puberty about 2 years later than females. Before puberty, there are no significant differences between boys and girls in height, weight, strength, endurance, and motor skill development. Therefore, throughout middle childhood, boys and girls can participate in physical activity on an equal basis. Late-maturing children, who have a prolonged period of prepubertal growth, usually have longer limbs than other children and often attain greater height. A temporary decline in coordination and balance may occur during puberty because of rapid growth. Some children may be unable to perform a physical activity as well as they did the previous year. This can be frustrating for children, parents, and teachers, particularly if they misinterpret this decline as a lack of skill or effort. Early-maturing boys have a temporary physical advantage over other boys their age because they are taller, heavier, and stronger. These boys usually achieve the most success in physical activity programs (e.g., hockey, football, basketball), which may lead to unrealistic expectations that they will continue to be outstanding athletes. Conversely, late-maturing boys have a temporary physical disadvantage. These boys may achieve the most success in physical activities in which size is not important (e.g., racquet sports, martial arts, running, wrestling). For girls, the onset of puberty is associated with an increase in body fat that may result in a decline in physical activity performance. Girls, parents, and teachers need to understand, and girls need to accept, the physical changes of puberty, because attempts to prevent these changes can lead to dieting or eating disorders. In addition, the increase in body fat and decrease in muscle flex may result in less fluid movements during the growth spurt and may increase the risk of overuse injuries in girls. Girls entering

puberty are at particularly high risk for dropping out of physical activities, making anticipatory guidance particularly important to encourage continued participation.

MIDDLE CHILDHOOD Healthy Lifestyles

Parents are a major influence on a child's level of physical activity. By participating in physical activity (e.g., biking, hiking, playing basketball or baseball) with their children, parents emphasize the importance of regular physical activity and show their children that physical activity can be fun. Parents' encouragement to be physically active significantly increases a child's activity level.3 Children are also influenced to participate in physical activity by other family members, peers, teachers, and people depicted in the media. Teachers also influence a child's level of physical activity. Physical education should be provided at school every day, and enjoyable activities should be offered. To achieve optimal growth and development, children need a variety of healthy foods that provide sufficient energy, protein, carbohydrates, fat, minerals, and vitamins. They need three meals per day plus snacks. During middle childhood, mealtimes take on more social significance, and children become affected by external influences (e.g., their peers, the media) regarding eating behaviors and attitudes toward food. Children also eat more meals away from home (e.g., at child care facilities, school, homes of friends and relatives). Parents and other family members continue to have the most influence on children's eating behaviors and attitudes toward food. Parents need to make sure that healthy foods are available, and they can be positive role models by practicing healthy eating behaviors themselves. In addition, parents need to provide guidance to help children make healthy food choices away from home.

Building Partnerships
Partnerships among health professionals, families, and communities are essential for ensuring that families receive guidance on physical activity. Health professionals need to give families the opportunity to discuss physical activity issues and concerns, and need to identify and contact community resources to help parents promote physical activity in children. However, there are many barriers. Some children do not have opportunities for participating in physical activity, and some live in unsafe neighborhoods. Communities need to provide physical activity programs through schools, recreation centers, and churches and other places of worship, and provide safe places for children to play.

Strengths, and Issues and Concerns

During health supervision visits, health professionals should emphasize the physical activity strengths of the child, family, and community (Table 9) and address any physical activity issues and concerns (Table 10).

Table 9. Physical Activity Strengths During Middle Childhood

Child
Participates in

Family
Encourages the child to

Community
Promotes physical activity

physical activity Enjoys physical activity Develops a positive attitude toward physical activity Is aware of and has opportunities to participate in physical activity Wants to improve motor skills Feels competent when participating in physical activity Is developing a sense of responsibility for own health Has positive role models for physical activity

participate in physical activity Provides opportunities for the child to participate in physical activity Supervises the child during physical activity Ensures that the child uses appropriate safety equipment (e.g., helmet, wrist guards, elbow and knee pads) during physical activity Participates in physical activity with the child Provides positive role model by participating in physical activity

Provides programs that teach families about physical and motor skill development Provides opportunities for children to participate in physical activity Maintains policies (e.g., preservation of green space) and provides environmental support (e.g., wellmaintained sidewalks, bicycle racks outside public facilities) that promote physical activity Provides safe environments for indoor and outdoor physical activity (e.g., walking and biking paths, playgrounds, parks, recreation centers) Provides support for families of children with special health care needs

Table 10. Physical Activity Issues and Concerns During Middle Childhood

Child
Has health problems Experiences motor skill or developmental delays Lacks opportunities to participate in physical activity Lacks friends or siblings to be physically active with Does not enjoy physical activity Does not feel competent when participating in physical activity Is embarrassed about appearance or lack of coordination Is shy or fearful of physical activity Has had unsuccessful or unpleasant experiences with physical activity Is more interested in sedentary behaviors (e.g.,

Family
Does not encourage the child to participate in physical activity Does not advocate for physical education in schools Does not provide positive role model by participating in physical activity Does not participate in physical activity with the child Has health problems that affect the amount of time spent with the child Has a work schedule or other commitments that reduce the amount of time spent with the child Lacks space or

Community
Lacks programs that promote physical activity in children Lacks safe environments for indoor and outdoor physical activity (e.g., walking and biking paths, playgrounds, parks, recreation centers) Lacks policies (e.g., preservation of green space) and does not provide environmental support (e.g., wellmaintained sidewalks, bicycle racks outside public facilities) that promote physical activity Does not provide support for families of children with special health care needs

watching television and videotapes; playing computer games)

equipment for physical activity

MIDDLE CHILDHOOD Physical Activity Supervision

A child's level of physical activity should be assessed as part of health supervision visits. (For more information on health supervision, see Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, listed under Suggested Reading in this chapter.) Health professionals can begin by gathering information about the child's level of physical activity. This can be accomplished by selectively asking key interview questions listed in this chapter, which provide a useful starting point for identifying physical activity issues and concerns. Health professionals can then use this chapter's screening and assessment guidelines, and counseling guidelines, to provide families with anticipatory guidance. Interview questions, screening and assessment, and counseling should be used as appropriate and will vary from visit to visit, child to child, and family to family. Desired outcomes for the child, and the role of the family, are identified to assist health professionals in promoting physical activity.

MIDDLE CHILDHOOD Interview Questions

The following questions are intended to be used selectively to gather information, to address the family's issues and concerns, and to build partnerships. For the Child Do you think physical activity is important? Why (or why not)? Do you think you are getting enough physical activity? Why (or why not)? Which physical activities do you participate in? How often? For how long each time? Do you participate in physical activities at school? If so, which ones? How often? Do you participate in physical activities in your neighborhood? If so, which ones? How often? Do you participate in any physical activities with your parents (for example, walking, biking, hiking, skating, swimming, or running)?

Are there any physical activities you enjoy but don't participate in? If so, which ones? Why? Are there any physical activities you don't enjoy? If so, which ones? Why? Do you feel that you are good at physical activities? If so, which ones? If not, why? Do you think you are in good shape? Can you keep up with your friends and other children your age? Do you always have something available to drink during and after physical activity? Do you use appropriate safety equipment when you participate in physical activity? For example, do you use a helmet when you go skate-boarding, skating, or biking? Have you been injured while participating in physical activity? How much time each day do you spend watching television and videotapes or playing computer games? For the Parent Is Thomas currently going through a growth spurt? Do you have any concerns about his development? Do you have questions or concerns about Susan's participation in physical activity? Does she participate in regular physical activity (for example, most, if not all, days of the week)? Does Thomas participate in physical education at school? If so, how often? What does he do after school? Does he partici-pate in physical activity? Are there any physical activities that Susan enjoys but does not participate in? If so, which ones? Why? Are there any physical activities that she doesn't enjoy? If so, which ones? Why? During the past 6 months, has Thomas been involved in physical activity programs? If so, which ones? During the past 6 months, has he trained for any physical activities? If so, which ones? Do you feel that Susan is too active? If so, why? Do you feel that she is not active enough? If so, why? Are there any physical activity programs in Thomas's school? In the community? If so, do you think he would participate if encouraged? How can you help him become more active? What barriers would make this difficult? Do you and Susan participate in physical activities together? If so, which ones? How often? How much time each day do you allow her to watch television and videotapes or play computer games?

Do you know where to take Thomas in a medical emergency? Is your neighborhood safe enough for him to play outside?

MIDDLE CHILDHOOD Screening and Assessment

If a child wants to participate in a sports program, a preparticipation physical examination may be useful. In addition to the screening and assessment guidelines that follow, health professionals can refer to resources such as a preparticipation physical evaluation.4 Obtain a complete medical history of the child, including (1) history of previous injuries and hospitalizations, (2) family history of sudden cardiac death, and (3) history of dizziness or fainting during or after physical activity.4 You may want to inquire about conditions affecting sports participation.5, 6 Measure the child's height and weight, and plot these on a standard growth chart (see Tool H: CDC Growth Charts). Deviation from the expected growth pattern (e.g., a major change in growth percentiles on the chart) should be evaluated. This may be normal or may indicate a problem (e.g., difficulties with eating). Height and weight measurements can be used to indicate nutrition and growth status. Changes in weight reflect a child's short-term nutrient intake and serve as general indicators of nutrition status and overall health. Low height-for-age may reflect long-term, cumulative nutrition or health problems. Body mass index (BMI) can be used as a screening tool to determine nutrition status and overall health. Calculate the child's BMI by dividing weight by the square of height (kg/m2) or by referring to a BMI chart. Compare the BMI to the norms listed for the child's sex and age on the chart. (See the Obesity chapter.) Some children have a high BMI because of a large, lean body mass resulting from physical activity, high muscularity, or frame size. An elevated skinfold (i.e., above the 95th percentile on CDC growth charts) can confirm excess body fat in children. Assess the child's general health status, including medical conditions and recent illnesses. Assess the child's cardiovascular, pulmonary, and musculoskeletal systems. Obtain the child's blood pressure. Determine whether the child is taking any medications. Assess the child's motor skill development (Table 11). Assess the child's physical maturity. Assess the child's level of physical activity by o Determining how much physical activity the child participates in on a weekly basis. o If possible, evaluating how the child's physical fitness compares to national standards (e.g., by reviewing the results of the child's President's Council on Physical Fitness and Sports test).

Table 11. Motor Skill Development During Middle Childhood

Age Motor Skills Being Range Developed

56 Years o Fundamental (e.g., running, galloping, jumping, hopping, skipping, throwing, catching, striking, kicking)

Appropriate Physical Activities

o o o Activities that focus on having fun and developing motor skills rather than on competition Simple activities that require little instruction Repetitive activities that do not require complex motor and cognitive skills (e.g., running, swimming, tumbling, throwing and catching a ball) Activities that focus on having fun and developing motor skills rather than on competition Activities with flexible rules Activities that require little instruction Activities that do not require complex motor and cognitive skills (e.g., entry-level baseball, soccer) Activities that focus on having fun and developing motor skills rather than on competition Activities that require entry-level complex motor and cognitive skills Activities that continue to emphasize motor skill development but that begin to incorporate instruction on strategy and teamwork

79 Years o o

Fundamental Transitional (e.g., throwing for distance; throwing for accuracy)

o o o o

1011 Years

o o

Transitional Complex (e.g., playing basketball)

o o o

MIDDLE CHILDHOOD Counseling

General Children should be physically active every day or nearly every day, as part of play, games, physical education, planned physical activities, recreation, and sports, in the context of family, school, and community activities. Physical activity is recommended on most, if not all, days of the week. Explain that children can achieve this level of activity through moderate physical activities (e.g., brisk walking for 30 minutes) or through shorter, more intense activities (e.g., skating or playing basketball for 15 to 20 minutes). It is critical for children to understand the importance of physical activity. This may encourage them to stay active during adolescence, when their level of physical activity tends to decline. Encourage children to find physical activities they enjoy and can continue into adulthood.

Discuss with parents how children can incorporate physical activity into their daily lives (e.g., by using the stairs instead of taking the elevator or escalator; by walking or riding a bike instead of riding in a car). Many elementary schools include physical education in their curricula. Schools that participate in the President's Council on Physical Fitness and Sports program usually conduct testing when children are in middle childhood. Encourage parents to take the results of their child's fitness test to the health professional to discuss positive results as well as suggestions for improvement. Encourage parents to participate in physical activity with their children and to be positive role models by participating in physical activity themselves.

Physical Development Discuss physical development with children and their parents, and tell them the approximate time they should expect accelerated growth. For girls, this may occur at ages 9 to 11, typically 1 to 2 years before the onset of menarche; for boys, this may not occur until about age 12 or older. Help girls entering puberty to understand and accept the physical changes of puberty that may alter their appearance and physical activity performance. Explain to older children that some of their peers may start puberty earlier than they do, reassuring them that their development is normal. Explain the growth chart to children and their parents and discuss how the children compare to others their age. Emphasize that a healthy body weight is based on a genetically determined size and shape rather than on an ideal, socially defined weight. Tell parents and their children that, before puberty, cardiorespiratory conditioning such as intensive endurance training (e.g., swimming thousands of yards) is of limited value for future performance.

Injury Prevention Encourage parents to make sure that children drink plenty of fluids when they are physically active. Before puberty, children are at increased risk for heat-related illness because their sweat glands are not fully developed and they cannot cool themselves as well as adolescents can. (See the Heat-Related Illness chapter.) Emphasize the importance of using appropriate safety equipment (e.g., helmets, wrist guards, elbow and knee pads) when participating in physical activity. (See the Injury chapter.) Inform parents and their children that the risk of injury is higher during periods of rapid growth. For children interested in weight or strength training, recommend doing several sets of multiple repetitions and using weights that provide low resistance. Emphasize the importance of appropriate safety equipment and supervision by a qualified adult. Children should not participate in maximal weightlifting, powerlifting, or bodybuilding until their growth and physical maturation are complete. Emphasize the importance of reducing children's exposure to sunlight while playing outdoors and thus their risk of developing skin cancer. Recommend that parents practice preventive strategies such as (1) applying a broad-spectrum sunscreen with a sun protection factor (SPF) rating of 15 or greater to children's exposed skin 30 minutes before they go outdoors, (2) reapplying sunscreen every 2 hours, and (3) ensuring that children wear broad-spectrum child-size sunglasses and brimmed hats and clothing that protect the skin as much as possible.

Safety If the safety of the environment or neighborhood is a concern, help parents and children find other settings for physical activity (e.g., Boys and Girls Clubs of America, recreation centers, churches and other places of worship). Remind parents that children can do many activities indoors with soft equipment that can be used in tight spaces (e.g., modified versions of bowling, basketball, darts, or golf).

Substance Use Warn parents and children about the dangers of using alcohol, tobacco, and other drugs. Warn parents and children about the risks of using performance-enhancing products (e.g., protein supplements, anabolic steroids). (See the Ergogenic Aids chapter.)

Special Issues Emphasize that achieving and maintaining a healthy weight is best accomplished through healthy eating behaviors and regular physical activity. (See the Nutrition chapter.) Encourage children, especially those who are overweight, to limit sedentary behaviors (e.g., watching television and videotapes, playing computer games) to 1 to 2 hours a day. Explain that weight loss should not occur during middle childhood, with the possible exception of the child whose BMI is between the 85th and 95th percentiles for age and sex and who has complications, or the child whose BMI is at or above the 95th percentile for age and sex. (See the Obesity chapter.) Encourage parents of children with special health care needs to allow their children to participate in physical activity for cardiovascular fitness within the limits of their medical or physical conditions. Explain that adaptive physical education is often helpful and that a physical therapist can help identify appropriate activities for children with special health care needs. (See the Children and Adolescents with Special Health Care Needs chapter.)

MIDDLE CHILDHOOD Table 12. Desired Outcomes for the Child, and the Role of the Family
Child Educational/Attitudinal Enjoys physical activity Understands the importance of physical activity Behavioral Participates in daily physical activity Participates in physical activities that can be sustained throughout life Uses appropriate safety equipment (e.g., helmet, wrist guards, elbow and knee pads) during physical activity Health/Physical Status Grows and develops at an appropriate rate Maintains good health

Family Educational/Attitudinal Promotes physical activity Understands the importance of developmentally appropriate physical activities Has resources that allow the Behavioral Provides opportunities and safe places for the child to participate in physical activity Participates in physical Health/Physical Status Maintains good health

child to participate in physical activity

activity with the child Provides positive role model by participating in physical activity Advocates for physical education in schools

MIDDLE CHILDHOOD I Don't Like Sports!

Dr. Smith encourages Alex's parents to be positive role models for Alex by participating in physical activity themselves. Alex, a 10-year-old boy, is seeing Dr. Smith for a physical examination. Dr. Smith asks Alex if he participates in physical activity or sports. Alex replies, "I don't like sports!" His parents explain, "Alex would rather play inside with his cars and trucks, watch TV, or play computer games. He tried basketball last year but couldn't keep up with the other kids." Dr. Smith performs a complete physical examination and reviews Alex's medical history, growth, and development. She reassures Alex's parents that their son is healthy and has no medical or physical conditions that would prevent him from participating in physical activity. Dr. Smith also reassures Alex's parents that some boys develop motor skills more slowly than other boys their age. She explains that children grow at different rates and that some of Alex's 10-year-old friends may be entering puberty, even though Alex hasn't yet. Dr. Smith says that Alex's temporary physical disadvantage should not be misinterpreted as a lack of skill or ability. She emphasizes that it is important for Alex's parents to encourage him when he gets frustrated with physical activity. Dr. Smith says that Alex may have a more positive experience if he tries activities with less emphasis on size (e.g., racquet sports, martial arts, running, wrestling), noncompetitive activities, and activities such as walking, hiking, biking, skating, and swimming. Dr. Smith explains that many of these activities can be done together as a family and can be sustained throughout life. Dr. Smith encourages Alex's parents to be positive role models for Alex by participating in physical activity themselves. She advises them to limit the amount of time Alex spends watching television and videotapes and playing computer games to 1 to 2 hours a day, and to designate a specific period of time for physical activities that Alex enjoys. Dr. Smith helps the family identify physical activities that Alex likes and is willing to try, and activities that Alex and his parents can do together. Dr. Smith indicates that she will follow up on these activities at Alex's next visit.

MIDDLE CHILDHOOD Frequently Asked Questions About Physical Activity in Middle Childhood
Which physical activities are best for my child?

Your child will benefit from developmentally appropriate physical activities he enjoys. Physical activities that can be sustained throughout life are ideal (for example, walking, hiking, biking, skating, dancing, and swimming). My child participates in a lot of sports. Does she need to participate in physical education at school? Yes. Physical education will help your child learn about the importance of physical activity, develop motor skills, introduce her to physical activities that can be sustained throughout life, and keep physically fit. My neighborhood isn't very safe. How can my child be physically active if he can't play outdoors? Encourage your child's school to provide after-school and weekend physical activity programs. Also, community organizations, recreation centers, and churches and other places of worship provide opportunities for children to participate in physical activity. Work with community leaders to ensure that your child has safe places for participating in physical activity (for example, walking and biking paths, playgrounds, parks, and recreation centers). Also, your child can do many activities at home with soft equipment that can be used in tight spaces. Examples include modified versions of bowling, basketball, darts, and golf. Additional activities your child can do at home include stretching, calisthenics, aerobics, and dancing. My child likes to watch television and play computer games. She is not interested in sports. How can I encourage her to be more physically active? There are many physical activities that a child can enjoy other than sports (for example, walking, biking, hiking, dancing, skating, and swimming). Limit the amount of time your child spends watching television and videotapes and playing computer games to 1 to 2 hours a day, and designate a specific period of time for physical activities she enjoys. Be sure to give her positive feedback when she is physically active. How can I make sure my child's coach doesn't put too much pressure on him? Don't be afraid to tell the coach that you want your child to have fun and to develop a positive attitude toward physical activity. Explain that you don't want your child to be pressured. Tell the coach that your child tends to discontinue physical activity if he thinks he's going to fail or if there is too much emphasis on competition. When can my child participate in coed physical activity? Before puberty there are no significant differences between boys and girls in height, weight, strength, and endurance. Therefore, boys and girls can usually participate together in physical activity until puberty.

Physical Activity Developmental Chapters ADOLESCENCE

Adolescence (ages 11 to 21), the transition between childhood and adulthood, is one of the most dynamic periods of human development. Adolescence is characterized by dramatic physical, cognitive, social, and emotional changes. These changes, along with adolescents' growing independence, search for identity, concern with appearance, need for peer

acceptance, and active lifestyle, can significantly affect their physical activity behaviors. Adolescents benefit from participating in physical activity. Physical activity can Give adolescents a feeling of accomplishment. Reduce the risk of certain diseases (e.g., coronary heart disease, hypertension, colon cancer, diabetes mellitus), if adolescents continue to be active during adulthood. Promote mental health.

The period of adolescence is divided into three stages. Early adolescence, ages 11 to 14, includes pubertal and cognitive changes. Middle adolescence, ages 15 to 17, is a time of increased independence and experimentation. During late adolescence, ages 18 to 21, adolescents make important personal and vocational decisions. These stages provide a useful context for understanding body-image issues and concerns of adolescents, as well as a framework for providing adolescents with the information they need to participate in physical activity. ADOLESCENCE

Growth and Physical Development

The increased rate of growth that occurs during adolescence is second only to the rate of growth that occurs during the first year of life. During this period, adolescents achieve the final 15 to 20 percent of their adult height, gain 50 percent of their adult body weight, and accumulate up to 40 percent of their adult skeletal mass.1 The peak period of growth usually occurs at sexual maturity rating (SMR) 2 to 3 in females and 3 to 4 in males. The mean age of the initiation of the growth spurt is 9 1/2 years in females and 11 1/2 years in males. The mean age of peak height velocity are 11 1/2 years in females and 13 1/2 years in males. For females, most physical growth is completed by about 2 years after menarche. (The mean age of menarche is 12 1/2 years.) Males begin their pubertal growth spurt about 2 years later than females, and they typically experience their major growth spurt and increase in muscle mass during middle adolescence. During adolescence, strength increases in both males and females, and strength can be increased further by participation in strength-training programs, especially from mid-puberty onward.2-5 On average, the percentage of body fat in males remains the same, whereas the percentage of body fat in females increases significantly.2,5 Height and strength during and after puberty affect the ability of adolescents to compete in some sports, such as football and basketball. However, in other sports, such as tennis and soccer, these attributes may be less important. The age at which the pubertal growth spurt occurs and the speed with which adolescents experience puberty vary greatly and may affect participation in physical activity and sports. For example, although early-maturing boys are often the most successful participants in Little League, they may not be the best athletes in high school.2,4,5 Physical activity and nutrition can affect adolescents' energy levels and influence growth and body composition. Inadequate nutrition can delay sexual maturation, slow or stop linear growth, and compromise peak bone mass. Participating in regular physical activity and practicing healthy eating

behaviors can help adolescents achieve normal body weight and body composition, thereby reducing their risk of obesity. The changes associated with puberty can affect adolescents' satisfaction with their appearance. For males, the increased size and muscular development that come with physical maturation can improve their body image. However, physical maturation among females--in particular, the normal increase in body fat--may lead to dissatisfaction with their bodies, which may result in weight concerns and dieting. Anticipatory guidance can help prepare adolescents and their parents for changes associated with puberty. Because adolescents are usually interested in their growth and development, health supervision visits provide an opportunity for health professionals to discuss the importance of healthy eating behaviors, regular physical activity, and a positive body image. Cognitive capacities increase dramatically during adolescence. During early adolescence, adolescents have a growing capacity for abstract thought, but their thinking still tends to be concrete and oriented toward the present. During middle adolescence, they become more capable of problem solving and abstract and future-oriented thinking. During late adolescence, they continue to refine their ability to reason logically and solve problems. These cognitive changes can help adolescents understand the importance of physical activity, because adolescents are beginning to reflect on their behavior and understand its consequences.

ADOLESCENCE Healthy Lifestyles

By participating in physical activity (e.g., biking, hiking, playing basketball) with their adolescents, parents can emphasize the importance of regular physical activity and show their adolescents that physical activity can be fun. Parents' encouragement to be physically active may increase the adolescent's activity level. Teachers also play an important role in promoting physical activity in adolescents. Physical education should be provided at school every day, and enjoyable activities should be offered. Adolescents spend a lot of time with their friends, and peer influence and group conformity are important. Because much of their physical activity occurs in group settings, adolescents' participation in physical activity may be influenced by peers. Some common chronic diseases of adulthood can be prevented or delayed if adolescents develop a physically active lifestyle and continue to be physically active as adults.6 Although adolescents may understand the importance of physical activity, most spend little time thinking about their future health, especially their health in older adulthood.2 Many types of physical activities provide health benefits. Although aerobic activities (e.g., running, biking), which increase maximum oxygen intake, were emphasized in the past, health professionals have learned that moderate physical activity also provides health benefits. Competitive sports appeal to some adolescents, but others enjoy noncompetitive activities (e.g., walking, running, swimming, biking, dancing) that provide variety and opportunities for socialization and success. The best physical activities are those that adolescents enjoy.3 Only about two-thirds of males and one-half of females participate in the recommended amount of moderate physical activity (e.g., 15 minutes of

running, 30 minutes of brisk walking, 45 minutes of playing volleyball).7 In addition, many adolescents become less active as they approach adulthood.7 More evidence-based research is needed on how to increase physical activity during adolescence or how to ensure that those who are physically active in adolescence remain so in adulthood.3,4,6 Ideally, adolescents will discover physical activities that they will continue to enjoy as adults.

Building Partnerships
Partnerships among health professionals, families, and communities are essential for ensuring that families receive guidance on physical activity. Health professionals need to give adolescents and parents the opportunity to discuss physical activity issues and concerns, and need to identify and contact community resources to help parents promote physical activity in their adolescents. Communities need to provide programs and safe places for adolescents to participate in physical activity.

Strengths, and Issues and Concerns

During health supervision visits, health professionals should emphasize the physical activity strengths of the adolescent, family, and community (Table 13) and address any physical activity issues and concerns (Table 14).

Table 13. Physical Activity Strengths During Adolescence

Adolescent Participates in physical activity Develops a positive attitude toward physical activity Enjoys physical activity Is aware of and has opportunities to participate in physical activity Wants to improve motor skills Feels competent when participating in physical activity Takes responsibility for own health Understands the importance of physical activity Has positive role models for physical activity Family Encourages the adolescent to participate in physical activity Provides opportunities for the adolescent to participate in physical activity Ensures that the adolescent uses appropriate safety equipment (e.g., helmet, wrist guards, elbow and knee pads) during physical activity Participates in physical activity with the adolescent Provides a positive role model by participating in physical activity Community Promotes physical activity Provides opportunities for adolescents to participate in physical activity Maintains policies (e.g., preservation of green space) and provides environmental support (e.g., wellmaintained sidewalks, bicycle racks outside public facilities) that promote physical activity Provides safe environments for indoor and outdoor physical activity (e.g., walking and biking paths, playgrounds, parks, recreation centers) Provides support for families of adolescents with special health care needs

Table 14. Physical Activity Issues and Concerns During Adolescence

Adolescent Family Community

Has health problems Experiences motor skill or developmental delays Lacks opportunities to participate in physical activity Lacks friends or siblings to be physically active with Does not enjoy physical activity Does not feel competent when participating in physical activity Is embarrassed about appearance or lack of coordination Is shy or fearful of physical activity Has had unsuccessful or unpleasant experiences with physical activity Is more interested in sedentary behaviors (e.g., watching television and videotapes; playing computer games)

Does not encourage the adolescent to participate in physical activity Does not advocate for physical education in schools Does not provide positive role model by participating in physical activity Does not participate in physical activity with the adolescent Has health problems that affect the amount of time spent with the adolescent Has a work schedule or other commitments that reduce the amount of time spent with the adolescent Lacks space or equipment for physical activity

Lacks programs that promote physical activity in adolescents Lacks safe environments for indoor and outdoor physical activity (e.g., walking and biking paths, playgrounds, parks, recreation centers) Lacks policies (e.g., preservation of green space) and does not provide environmental support (e.g., wellmaintained sidewalks, bicycle racks outside public facilities) that promote physical activity Does not provide support for families of adolescents with special health care needs

ADOLESCENCE Physical Activity Supervision

An adolescent's level of physical activity should be assessed as part of health supervision visits. (For more information on health supervision, see Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, listed under Suggested Reading in this chapter.) Health professionals can begin by gathering information about the adolescent's level of physical activity. This can be accomplished by selectively asking key interview questions listed in this chapter, which provide a useful starting point for identifying physical activity issues and concerns. Health professionals can then use this chapter's screening and assessment guidelines, and counseling guidelines, to provide families with anticipatory

guidance. Interview questions, screening and assessment, and counseling should be used as appropriate and will vary from visit to visit, adolescent to adolescent, and family to family. Desired outcomes for the adolescent, and the role of the family, are identified to assist health professionals in promoting physical activity.

ADOLESCENCE Interview Questions

The following questions are intended to be used selectively to gather information, to address the family's issues and concerns, and to build partnerships. For the Adolescent Do you think physical activity is important? Why (or why not)? Do you think you are getting enough physical activity? Why (or why not)? Which physical activities do you participate in? How often? For how long each time? Do you participate in physical activities at school? If so, which ones? How often? Do you participate in physical activities in your neighborhood? If so, which ones? How often? Do you participate in any physical activities with your parents (for example, walking, biking, hiking, skating, swimming, or running)? Are there any physical activities you enjoy but don't do? If so, which ones? Why? Are there any physical activities you don't enjoy? If so, which ones? Why? Do you feel that you are good at physical activities? If so, which ones? If not, why? Do you think you are in good shape? Can you keep up with your friends and other adoles-cents your age? Do you always have something available to drink during and after physical activity? Do you use appropriate safety equipment when you participate in physical activity? For example, do you use a helmet when you go skate-boarding, skating, or biking? Have you been injured while participating in physical activity? How much time each day do you spend watching television and videotapes or playing computer games?

For the Parent Do you have questions or concerns about John's participation in physical activity? Does he participate in regular physical activity (for example, most, if not all, days of the week)? Does Rebecca participate in physical education at school? If so, how often? What does she do after school? Does she participate in physical activity? Are there any physical activities John enjoys but does not do? If so, which ones? Why? Are there any physical activities he doesn't enjoy? If so, which ones? Why? During the past 6 months, has Rebecca been involved in physical activity programs? If so, which ones? During the past 6 months, has she trained for any physical activities? If so, which ones? Do you feel that John is too active? If so, why? Do you feel that he is not active enough? If so, why? Are there any physical activity programs in Rebecca's school? In the community? If so, do you think she would participate if encouraged? How can you help her become more active? What barriers would make this difficult? Do you and John participate in physical activities together? If so, which ones? How often?

How much time each day do you allow him to watch television and videotapes or play computer games? Do you know where to take Rebecca in a medical emergency? Is your neighborhood safe enough for her to participate in physical activity outside?

ADOLESCENCE Screening and Assessment

If an adolescent wants to participate in a sports program, a preparticipation physical examination may be useful. In addition to the screening and assessment guidelines that follow, health professionals can refer to resources such as a preparticipation physical evaluation.8 Obtain a complete medical history of the adolescent, including (1) history of previous injuries and hospitalizations, (2) family history of sudden cardiac death, and (3) history of dizziness or fainting during or after physical activity.8 You may want to inquire about conditions affecting sports participation.9 Measure the adolescent's height and weight, and plot these on a standard growth chart (see Tool H: CDC Growth Charts). Deviation from the expected growth pattern (e.g., a major change in growth percentiles on the chart) should be evaluated. This may be normal or may indicate a problem (e.g., difficulties with eating). Height and weight measurements provide reliable indicators of nutrition and health status. Changes in weight reflect an adolescent's short-term nutrition intake and serve as general indicators of nutrition status and overall health. Low height-for-age may reflect long-term, cumulative nutrition or health problems. Body mass index (BMI) can be used as a screening tool to determine nutrition status and overall health. Calculate the adolescent's BMI by dividing weight by the square of height (kg/m2) or by referring to a BMI chart. Compare the BMI to the norms listed for the adolescent's sex and age on the chart. (See the Obesity chapter.) Some adolescents have a high BMI because of a large, lean body mass resulting from physical activity, high muscularity, or frame size. An elevated triceps skinfold (i.e., above the 95 percentile on CDC growth charts) can confirm excess body fat in adolescents. Assess the adolescent's general health status, including medical conditions and recent illnesses. Assess the adolescent's cardiovascular, pulmonary, and musculoskeletal systems. Obtain the adolescent's blood pressure. Determine whether the adolescent is taking any medications. Assess the onset of menarche. Assess the adolescent's physical maturity. Assess the adolescent's level of physical activity by o Determining how much physical activity the adolescent participates in on a weekly basis. o If possible, evaluating how the adolescent's physical fitness compares to national standards (e.g., by reviewing the results of the adolescent's President's Council on Physical Fitness and Sports test).

ADOLESCENCE Counseling
General Adolescents should be physically active every day or nearly every day, as part of play, games, physical education, planned physical activities, recreation, and sports, in the context of family, school, and community activities. Physical activity is recommended on most, if not all, days of the week. Explain that adolescents can achieve this level of activity through moderate physical activities (e.g., brisk walking for 30 minutes) or through shorter, more intense activities (e.g., jogging or playing basketball for 15 to 20 minutes). Moderate to vigorous physical activities (e.g., jogging, playing basketball or racquet sports, dancing, skating, biking) are those that require as much effort as brisk walking. The goal for adolescents is to engage in these activities at least three times a week for at least 20 minutes each time. Encourage adolescents to find physical activities they enjoy and can continue into adulthood. Discuss how adolescents can incorporate physical activity into their daily lives (e.g., by using the stairs instead of taking the elevator or escalator; by walking or riding a bike instead of driving or riding in a car). Encourage adolescents to participate in a variety of noncompetitive physical activities they enjoy (e.g., biking, in-line skating, jogging, swimming). Many adolescents enjoy participating in organized physical activity programs with friends and peers. Adolescents need to choose activities they enjoy and that make them feel competent. Encourage adolescents to take on new challenges that will increase their self-confidence (e.g., becoming physically active or learning a new sport). Teach them to set reasonable but challenging goals. Encourage parents to participate in physical activity with their adolescents and to be positive role models by participating in physical activity themselves.

Injury Prevention Encourage adolescents to drink plenty of fluids when they are physically active. (See the Heat-Related Illness chapter.) Emphasize the use of appropriate safety equipment (e.g., helmets, wrist guards, elbow and knee pads) when the adolescent participates in physical activity. (See the Injury chapter.) Discuss the importance of an appropriate pace when beginning a new activity. Encourage adolescents to avoid doing too much too soon. Discuss the importance of using proper technique during weight or strength training, emphasizing sets of low resistance and high repetition. Emphasize the importance of adolescents reducing their exposure to sunlight while participating in physical activity outdoors and thus their risk of developing skin cancer. Recommend preventive strategies such as (1) applying a broad-spectrum sunscreen with a sun protection factor (SPF) rating of 15 or greater to exposed skin 30 minutes before going outdoors, (2) reapplying sunscreen every 2 hours, and (3) wearing broad-spectrum sunglasses and brimmed hats and clothing that protect the skin as much as possible. Determine whether adolescents who are involved in organized sports are being properly supervised. Make sure that adolescents enjoy participating in sports and are not being compelled to participate by an adult.

Safety If the safety of the environment or neighborhood is a concern, help parents and adolescents find

other settings for physical activity (e.g., Boys and Girls Clubs of America, recreation centers, churches and other places of worship). Remind adolescents that they can do many activities indoors (e.g., calisthenics, aerobics, dancing, weight or strength training).

Special Issues Emphasize that achieving and maintaining a healthy weight is best accomplished through healthy eating behaviors and regular physical activity. (See the Nutrition chapter.) Encourage adolescents, especially those who are overweight, to limit sedentary behaviors (e.g., watching television and videotapes, playing computer games) to 1 to 2 hours per day. (See the Obesity chapter.) Encourage adolescents with special health care needs to participate in physical activity for cardiovascular fitness within the limits of their medical or physical conditions. Explain that adaptive physical education is often helpful and that a physical therapist can help identify appropriate activities. (See the Children and Adolescents with Special Health Care Needs chapter.)

Substance Use Warn adolescents about the risk of using alcohol, tobacco, and other drugs. Adolescents, particularly males, may be interested in using protein supplements or anabolic steroids to try to build muscle mass. Discourage the use of these products, and encourage healthy eating behaviors and participation in a supervised strength-training program. (See the Ergogenic Aids chapter.)

ADOLESCENCE Table 15. Desired Outcomes for the Adolescent, and the Role of the Family
Adolescent Educational/Attitudinal Enjoys physical activity Understands the importance of physical activity Understands the role of physical activity in achieving and maintaining an appropriate body weight Behavioral Participates in daily physical activity Participates in physical activities that can be sustained throughout life Uses appropriate safety equipment (e.g., helmet, wrist guards, elbow and knee pads) during physical activity Health/Physical Status Grows and develops at an appropriate rate Maintains good health

Family Educational/Attitudinal Behavioral Health/Physical Status

Promotes physical activity Understands the importance of developmentally appropriate physical activities Has resources that allow the adolescent to participate in physical activity

Provides opportunities and safe places for the adolescent to participate in physical activity Participates in physical activity with the adolescent Provides positive role model by participating in physical activity Advocates for physical education in schools

Maintains good health

ADOLESCENCE

Does Jane Need to Be More Active?

Dr. Munoz discusses the benefits of physical activity, including improving Jane's overall health status and sense of well-being. Jane Jones, who is 15 years old, is seeing Dr. Munoz for an annual physical examination. Jane and her mother first fill out a questionnaire about Jane's physical activity participation and other aspects of Jane's health. The responses indicate that Jane is not physically active. Dr. Munoz discusses the benefits of physical activity, including improving Jane's overall health status and sense of well-being. He then recommends that Jane incorporate physical activity into her daily routine (e.g., by walking or biking rather than riding in or driving a car; by taking the stairs rather than using the elevator or escalator; by doing chores that require effort, such as vacuuming and mowing the lawn). Dr. Munoz also recommends that Jane start participating in a specific physical activity. He suggests brisk walking, biking, skating, or dancing on most, if not all, days of the week. Dr. Munoz suggests that Jane do these activities with a friend to make them more fun. He also encourages her to try other activities. Jane agrees to give Dr. Munoz's suggestions a try, and her mother promises to support her efforts.

ADOLESCENCE Frequently Asked Questions About Physical Activity in Adolescence

Will vigorous physical activity affect my son's growth and physical development? Encourage your son to eat a variety of healthy foods for growth, physical development, and his level of physical activity. Growth and physical development in teenagers who are training and competing in vigorous physical activities, especially activities that emphasize low body weight (for example, distance running, gymnastics, and ballet), may be compromised if their caloric expenditure exceeds their food intake. Can my daughter participate in physical activity during her menstrual period? Yes. In fact, there are benefits associated with being physically active during the menstrual period (for

example, less cramping and lighter menstrual flow). Girls and female adolescents who experience symptoms such as severe cramping, nausea, vomiting, headache, lightheadedness, and heavy menstrual flow tend to avoid physical activity during their period. If your daughter has any of these symptoms, which usually can be managed, take her to a health professional for evaluation. Our teenager is growing fast. Does he have a higher risk of injury? During the growth spurt, injuries such as muscle strains, sprains, and overuse are possible. The fact that they occasionally occur does not mean that your son should avoid physical activity. When can my teenager lift weights? With proper training and supervision, most teenagers can safely lift weights. Teenagers should not try to lift maximal amounts of weight until they are physically mature (on average, age 16 for males and 2 years after menarche for females). (The mean age of menarche is 12 1/2 years.) In addition, teenagers should not try to lift weights beyond their capabilities, and excessive repetitions and power lifting are not recommended. Should I sign my daughter up for an after-school sports program? After-school sports programs are a good idea if your daughter is interested in them. She may need encouragement but should not be compelled to participate. My neighborhood isn't very safe. How can my teenager participate in physical activity? Encourage your teenager's school to provide after-school and weekend physical activity programs. Also, community organizations, recreation centers, and churches and other places of worship provide opportunities for teenagers to participate in physical activity. Work with community leaders to ensure that your teenager has safe places for participating in physical activity (for example, walking and biking paths, playgrounds, parks, and recreation centers). Also, your teenager can do many activities at home with soft equipment that can be used in tight spaces. Examples include modified versions of bowling, basketball, darts, and golf. Additional activities your teenager can do at home include stretching, calisthenics, aerobics, dancing, and weight or strength training.

OBESITY
Obesity is defined as the presence of excess adipose (fatty) tissue in the body. The term "overweight" may connote a milder degree of excess fat than "obesity," but there are no clearly defined criteria to distinguish between the two terms. Thus, the two terms are used interchangeably.1 Although its underlying causes are not fully understood, obesity is a complex chronic disease involving genetics, metabolism, and physiology, as well as environmental and psychosocial factors. Unhealthy eating behaviors and low levels of physical activity are contributing to the continuing increase in the prevalence of obesity among children and adolescents. 2

Significance
Obesity is a major public health problem. Studies have shown a dramatic increase in the prevalence of obesity among children (including those younger than 5 years of age) and adolescents.3,4 Data from the National Center for Health Statistics (NCHS) indicate that more than 1 in 5 children and adolescents in the United States are overweight.3

Few studies have examined the long-term effect of childhood or adolescent obesity on adult morbidity and mortality. Longitudinal studies of children followed into young adulthood suggest that overweight children may become overweight adults, particularly if obesity is present during adolescence.57 Overweight during adolescence affects blood pressure and blood lipid, lipoprotein, and insulin levels in adolescents.8 Perhaps the most widespread consequences of childhood and adolescent obesity are psychosocial, including discrimination.8,9 Health professionals need to be aware of the demographic and personal risk factors for childhood and adolescent obesity and be diligent in their prevention efforts and screening.2 Children and adolescents are considered at high risk for overweight if One or both parents are overweight. They are from families with low incomes. They have a chronic disease or disability that limits mobility.

In addition, members of certain racial/ethnic groups such as African-American female children and adolescents and Hispanic and American Indian/Alaska Native children and adolescents are considered at high risk for overweight.24

Prevention
Enough is known to guide efforts to reverse the trend of increasing obesity. 2 Because obesity is difficult to treat, efforts need to focus on prevention. Although genetic influences largely determine whether a child or adolescent will become overweight, environmental influences may determine the manifestation and extent of obesity. The primary strategies for preventing obesity are healthy eating behaviors (see the Nutrition chapter), regular physical activity, and reduced sedentary behaviors (e.g., watching television and videotapes, playing computer games). These strategies are part of a healthy lifestyle that should be developed during early childhood. The goal is to promote and model positive attitudes toward eating and physical activity without emphasizing body weight. Behavioral techniques are needed to encourage healthy eating and physical activity behaviors.

OBESITY Nutrition
Parents need information on how to encourage their children and adolescents to practice healthy eating behaviors, beginning in childhood.2 Suggestions include Gradually weaning infants from the bottle at about 9 to 10 months of age. Switching children from whole milk to reduced- fat, low-fat, or fat-free milk after 2 years of age. Gradually reducing children's fat intake to no more than 30 percent of their daily calories by age 5. 10 Limiting the consumption of high-sugar foods, including juices. Being aware of portion sizes, especially of high-fat and high-sugar foods. Limiting the consumption of convenience and fast foods. Encouraging family members to drink water. Encouraging children and adolescents to make healthy food choices based on the Dietary Guidelines for Americans and the Food Guide Pyramid. (See the Nutrition chapter.)

Physical Activity
Moderate amounts of physical activity are recommended on all, if not most, days of the week. 11 Children and adolescents can achieve this level of activity through intense activities (e.g., hiking for 30 minutes) or through shorter, more intense activities (e.g., jogging or playing basketball for 15 to 20 minutes). Parents, recreation program staff, and health professionals need to promote physical activity in children and adolescents and help them increase their physical activity levels and decrease sedentary activities. For example, parents can playfully chase their children around the yard or playground, or encourage their children and adolescents to dance to music before dinner or ride a stationary bike while watching television.2 Parents can also get their children and adolescents involved in physical activity programs or organized sports, which can help increase skill levels and self-confidence, foster teamwork, and increase energy expenditures.

Screening
Body mass index (BMI) can be used to screen children and adolescents for obesity (Figure 6). BMI is 2 calculated by dividing weight by the square of height (kg/m ) and can be plotted on a standard growth chart (see Tool H: CDC Growth Charts). BMI reflects body mass rather than body fat but correlates with measures of subcutaneous and total body fat in children and adolescents. Some children and adolescents have a high BMI because of a large, lean body mass resulting from physical activity, high muscularity, or frame size. An elevated triceps skinfold (i.e., above the 95th percentile on the CDC growth chart) can confirm excess body fat in children and adolescents.1 Health professionals can use the following screening guidelines to determine whether a child older than 2 years or an adolescent is overweight:1 Children and adolescents with a BMI at or above the 95th percentile for age and sex are considered overweight and should receive an in-depth assessment. Children and adolescents with a BMI between the 85th and 95th percentiles for age and sex are considered at risk for becoming overweight and should be screened and evaluated, with attention focused on family history and secondary complications of obesity, including hypertension and dyslipidemia. Children and adolescents with an annual increase of 3 to 4 BMI units should be evaluated.

Figure 6. Recommended Overweight Screening Procedures

Figure 6 is available only in the print version of this publication.

OBESITY Assessment
In-depth assessments are required to identify children and adolescents with positive screens who are truly overweight, to diagnose any underlying causes and to provide a basis for treatment.

Medical History
A thorough medical history must be conducted to identify any underlying syndromes or secondary complications.

Family History
A family history is needed to identify risks for obesity. These risks include the presence of obesity, eating disorders, type 2 diabetes mellitus, cardiovascular disease, hypertension, dyslipidemia, and gallbladder disease in parents, siblings, aunts, uncles, and grandparents. 7

Dietary History
A dietary history identifies eating practices, including the quantity, quality, and timing of foods consumed, and eating behaviors that may lead to excessive caloric intake and obesity.

Physical Activity History

A physical activity history is needed to determine children's and adolescents' physical activity levels as well as how much time they spend participating in sedentary behaviors. Contraindications to physical activity (e.g., uncontrolled asthma, joint disease) should be noted.

Physical Examination
A physical examination identifies children's and adolescents' degree of overweight and any potential syndromes and complications of obesity.

Laboratory Tests
Degree of overweight, family history, and the physical examination will guide the choice of laboratory tests.

OBESITY Psychological Evaluation Readiness to Change

A weight-management program for children, adolescents, or their families who are not ready to change may be both ineffective and harmful because it can affect the child's or adolescent's self-esteem and impair future weight-loss efforts. A practical way to address readiness is to ask members of the family how concerned they are about a family member's weight, whether they believe weight loss is possible, and what practices need to be changed. Assess family readiness with questions such as "How concerned are you about this issue?" "Have you thought about or tried to lose weight? If so, what did you try, and when did you try it?" In families with younger children, parents who are ready to change can successfully modify the family's diet and physical activity behaviors. Therapeutic efforts should focus on families that are concerned about their child's or adolescent's weight and ready to make changes. Families that are not ready to change may express a lack of concern about the child's or adolescent's obesity, may believe that obesity is inevitable and cannot be changed, or may lack interest in modifying eating and physical activity behaviors. Unless a serious complication of obesity already exists, families that are not ready to change should be given information on the health consequences of obesity and told that help is available when they are ready. Health professionals should continue to foster a positive relationship with the family so that future treatment may be possible.

Eating Disorders
Children and adolescents who feel that they are unable to control their food intake or who induce vomiting or use laxatives to control weight may have an eating disorder. Children and adolescents with eating disorders need referral to an eating disorder treatment program that incorporates medical and psychological assessment and treatment and nutrition counseling.

Depression
Overweight children and adolescents who are depressed may exhibit sleep disturbances, hopelessness and sadness, and appetite changes. As with eating disorders, depression in children and adolescents requires medical and psychological assessment and treatment.

OBESITY Treatment
The primary goals of a program to treat uncomplicated obesity are for children and adolescents to achieve healthy eating behaviors, participate in regular physical activity, and achieve psychological well-being, instead of ideal body weight. The first step toward weight control for children older than 2 years of age and adolescents who are overweight is weight maintenance, which can be achieved by making modest changes in food intake and by participating in physical activity. If weight loss is recommended by a health professional for medical reasons, the child or adolescent should lose only about 1 pound per month.1 An appropriate goal for children and adolescents who are overweight is a BMI at or below the 85th percentile, although such a goal should be secondary to the primary goal of practicing healthy eating behaviors and participating in regular physical activity.

Counseling
Health professionals can use the following guidelines for counseling children and adolescents who are overweight, and their families, to help children and adolescents obtain and maintain a healthy weight:1 Begin intervention early. Health professionals should initiate treatment suggestions described when children 3 years of age or older become overweight. Tell parents that children or adolescents should never be placed on a restricted diet to lose weight, except when a health professional recommends one for medical reasons and supervises it. Recommend that parents focus on gradually changing the entire family's eating and physical activity behaviors instead of singling out the child or adolescent who is overweight. Help children and adolescents who are overweight deal with teasing. Encourage parents to monitor their child's or adolescent's eating and physical activity behaviors. Start slowly. Ask parents to suggest one or two eating or physical activity behaviors to change, and help them monitor the changes. Encourage parents to promote physical activity in their children and adolescents, and make it fun.

Encourage children and adolescents to participate in physical activities they enjoy. Recommend that parents plan activities each week to encourage all family members to participate in physical activity. Encourage parents to be sensitive to the needs of their children and adolescents who are overweight. For example, some children and adolescents who are overweight may have difficulty with certain physical activities or may feel embarrassed when participating in them. Encourage children and adolescents to incorporate physical activity into their daily lives (e.g., by using the stairs instead of taking an elevator or escalator, by walking or riding a bike instead of riding in a car). Encourage parents to be positive role models by practicing healthy eating behaviors and participating in regular physical activity themselves. Encourage parents to participate in physical activity with their children and adolescents. Encourage children and adolescents to reduce sedentary behaviors (e.g., watching television and videotapes, playing computer games). En-courage parents to limit these activities to 1 to 2 hours per day. Encourage parents to praise their children and adolescents who have obtained or maintained a healthy weight. Inform parents, children, and adolescents about the health consequences of obesity. Recommend that parents focus on permanent behavior changes to help their children and adolescents obtain and maintain a healthy weight. Children and adolescents should avoid short-term diets and physical activity programs aimed at rapid weight loss. Norms for a healthy appearance vary across cultures. Counsel parents, children, and adolescents within the context of their culture.

Referral
Children and adolescents with serious complications of obesity need to be referred to a physician or pediatric obesity treatment program. Complications that indicate referral include pseudotumor cerebri, sleep apnea, obesity hypoventilation syndrome, Blount's disease (tibia vara), slipped capital femoral epiphysis, severe overweight (above the 99th percentile), and severe overweight in children younger than 2 years of age.1

OBESITY Frequently Asked Questions About Physical Activity and Obesity

How can I encourage my daughter to be more physically active? Encourage active, spur-of-the-moment physical activity and play.

Enroll your daughter in planned physical activities (for example, swimming, martial arts, gymnastics, or dancing). Participate in physical activity together (for example, play ball or bike, dance, or skate). Plan at least one special physical activity (for example, taking a hike or riding a bike) each week. Incorporate physical activity with your daughter into your daily life (for example, by using the stairs instead of taking an elevator or escalator, and by walking or riding a bike instead of driving a car). Involve your daughter in family chores (for example, raking leaves or walking the dog). For every hour your daughter reads, watches television and videotapes, or plays computer games, encourage her to take a 10-minute physical activity break. What should I do if my son seems overweight? If your son is growing, eats healthy foods, and is physically active, you do not need to worry about whether he is overweight. If he appears overweight, take him to a health professional for evaluation, and focus on gradually changing the entire family's eating and physical activity behaviors instead of singling out your son. The following tips will also be helpful, regardless of how much your son weighs: Be a positive role model by practicing healthy eating behaviors and participating in regular physical activity yourself. Plan family physical activities that everyone enjoys (for example, hiking, biking, or swimming). Limit to 1 to 2 hours per day the amount of time your son watches television and videotapes and plays computer games.

My daughter is overweight. How can I get her school to help? Discuss with school staff your concerns about your daughter's weight and state that you would like their assistance in developing a coordinated effort involving both nutrition and physical activity. Explain that you want to help her develop healthy eating and physical activity behaviors. Often the child nutrition program director can help with choosing foods acceptable to both parent or child. How much physical activity is appropriate for my son, who is overweight? Children and adolescents who are overweight but have no medical complications usually benefit from moderate amounts of physical activity on all, if not most, days of the week. Your son can achieve this level of activity through intense activities (for example, hiking for 30 minutes) or through shorter, more intense activities (for example, jogging or playing basketball for 15 to 20 minutes). How can I help my daughter, who is overweight, become more physically active? Be sensitive to your daughter's needs. Children and adolescents who are overweight may feel uncomfortable or embarrassed about participating in physical activity. Help your daughter find physical activities she enjoys and is comfortable with, and plan fun physical activities for the family.