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Impact of COVID-19 on physical and mental functioning in adolescents with disabilities in a sports nongovernmental organization

Impacto da COVID-19 no funcionamento físico e mental de adolescentes com deficiência em organização não governamental esportiva

Abstract

Objective:

This study aimed to assess physical and mental health, and health-related quality of life (HRQL) parameters in adolescents with physical disabilities enrolled in a sports nongovernmental organization (NGO) versus adolescents without disabilities during coronavirus disease 2019 (COVID-19) pandemic.

Methods:

This cross-sectional study included 30 adolescents with disabilities and 86 adolescents without disabilities who responded to an online questionnaire with sociodemographic data and self-rated healthcare routine information during the COVID-19 quarantine. Validated self-report versions of the Strengths and Difficulties Questionnaire (SDQ), Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0), Pittsburgh Sleep Quality Index (PSQI), and Pediatric Outcome Data Collection Instrument (PODCI) were also applied.

Results:

The median of emotional [4 (0–10) vs. 5 (0–10), p=0.018] and prosocial [7 (0–10) vs. 9 (3–10), p=0.006] problems was lower in adolescents with disabilities versus adolescents without disabilities. Adolescents with disabilities had significantly lower global function [68 (21–99) vs. 94 (67–100), p<0.001] and higher happiness scores in the PODCI scale [90 (65–100) vs. 80 (0–100), p=0.016] compared to controls. Logistic regression analysis demonstrated that physical activity/week (OR=1.03; 95%CI 1.01–1.05, p=0.002) was higher in adolescents with disabilities compared to adolescents without disabilities. However, housework activities (OR=0.14; 95%CI 0.04–0.43, p=0.001) and screen time ≥3 h/day (OR=0.09; 95%CI 0.02–0.38, p=0.001) were lower in adolescents with disabilities compared to adolescents without disabilities.

Conclusion:

Adolescents with disabilities attending a sports NGO were not at higher risk of adverse health-related indicators; despite showing reduced physical function, they reported more physical activity, higher happiness, and less screen time compared to adolescents without disabilities during the COVID-19 pandemic.

COVID-19 pandemic; Adolescents; Disabled persons; Mental health; Nongovernmental organization; Sports for persons with disabilities

Resumo

Objetivo:

Avaliar os parâmetros de saúde física e mental, de qualidade de vida relacionada à saúde (QVRS), em adolescentes com deficiência física matriculados em organização não governamental (ONG) esportiva vs. em adolescentes sem deficiência, durante a pandemia da doença do coronavírus 2019 (COVID-19).

Métodos:

Este estudo transversal incluiu 30 adolescentes com deficiência e 86 adolescentes sem deficiência que responderam a questionário online com dados sociodemográficos e informações de rotina de saúde autoavaliadas durante a quarentena da COVID-19. Versões validadas de autorrelato do Strengths and Difficulties Questionnaire (SDQ), Pediatric Quality of Life Inventory 4.0 (PedsQL4.0), Pittsburgh Sleep Quality Index (PSQI) e Pediatric Outcome Data Collection Instrument (PODCI) também foram aplicadas.

Resultados:

A mediana de problemas emocionais [4(0–10) vs. 5(0–10),p=0,018] e pró-social [7(0–10) vs. 9(3–10),p=0,006] foi menor em adolescentes com deficiência vs. adolescentes sem deficiência. Adolescentes com deficiência tiveram função global significantemente inferior [68(21–99) vs. 94(67–100),p <0,001] e pontuações de felicidade mais altas do PODCI [90(65–100) vs. 80(0–100),p=0,016] em comparação com o grupo sem deficiências. A análise de regressão logística demonstrou que a atividade física/semana (odds ratio — OR=1,03; intervalo de confiança — IC95%=1,01–1,05,p=0,002) foi maior nos adolescentes com deficiência. No entanto, atividades domésticas (OR=0,14; IC95%=0,04–0,43,p=0,001) e tempo de tela ≥3 horas/dia (OR=0,09; IC95%=0,02–0,38,p=0,001) foram menores nos adolescentes com deficiência.

Conclusões:

Os adolescentes com deficiência que frequentam uma organização não governamental (ONG) esportiva não tiveram maior risco de apresentar indicadores adversos à saúde; apesar de apresentarem função física reduzida, relataram mais atividade física, maior felicidade e menos tempo de tela em comparação com adolescentes sem deficiência durante a pandemia da COVID-19.

Palavras-chave:
Pandemia por COVID-19; Adolescentes; Deficiência física; Saúde mental; Organização não governamental; Esportes para pessoas com deficiência

INTRODUCTION

A global sanitary crisis due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection developed at the end of 2019, and since March 2020, the World Health Organization has been reinforcing quarantine and social isolation to prevent the spread of the coronavirus disease 2019 (COVID-19).11. Hellewell J, Abbott S, Gimma A, Bosse NI, Jarvis CI, Russell TW, et al. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. Lancet Glob Health. 2020;8:e488-96. https://doi.org/10.1016/S2214-109X(20)30074-7
https://doi.org/10.1016/S2214-109X(20)30...
This has greatly affected the routines and lives of people worldwide and some groups have been particularly vulnerable to falling into physical decline and emotional distress.22. Choi KR, Heilemann MV, Fauer A, Mead M. A second pandemic: mental health spillover from the novel coronavirus (COVID-19). J Am Psychiatr Nurses Assoc. 2020;26:340-3. https://doi.org/10.1177/1078390320919803
https://doi.org/10.1177/1078390320919803...
Adolescence is one of the most challenging stages of life due to hormonal changes that represent entrance into maturity of mental and physical development.33. Silva CA, Queiroz LB, Fonseca CB, Silva LE, Lourenço B, Marques HH. Spotlight for healthy adolescents and adolescents with preexisting chronic diseases during the COVID-19 pandemic. Clinics (Sao Paulo). 2020;75:e1931. https://doi.org/10.6061/clinics/2020/e1931
https://doi.org/10.6061/clinics/2020/e19...
This makes adolescents an at-risk group for suffering drastic consequences due to isolation.44. Safadi MA, Silva CA. The challenging and unpredictable spectrum of covid-19 in children and adolescents. Rev Paul Pediatr. 2020;39:e2020192. https://doi.org/10.1590/1984-0462/2020/38/2020192
https://doi.org/10.1590/1984-0462/2020/3...
,55. Lindoso L, Astley C, Queiroz LB, Gualano B, Pereira RM, Tannuri U, et al. Physical and mental health impacts during covid-19 quarantine in adolescents with preexisting chronic immunocompromised conditions. J Pediatr (Rio J). 2021;S0021-7557(21)00136-4. https://doi.org/10.1016/j.jped.2021.09.002
https://doi.org/10.1016/j.jped.2021.09.0...

Potential impacts of COVID-19 pandemic on adolescents with disabilities go beyond their developmental stage or the deleterious effects of the virus on their vulnerable organism. The necessary emergency measures of social distancing have broadened the gap they confront in terms of access to health and rehabilitation services.33. Silva CA, Queiroz LB, Fonseca CB, Silva LE, Lourenço B, Marques HH. Spotlight for healthy adolescents and adolescents with preexisting chronic diseases during the COVID-19 pandemic. Clinics (Sao Paulo). 2020;75:e1931. https://doi.org/10.6061/clinics/2020/e1931
https://doi.org/10.6061/clinics/2020/e19...
Moreover, they are at risk of engaging in more sedentary behaviors as they are already generally less active compared to their healthy peers.66. Pinto AJ, Roschel H, Sá Pinto AL, Lima FR, Pereira RM, Silva CA, et al. Physical inactivity and sedentary behavior: overlooked risk factors in autoimmune rheumatic diseases? Autoimmun Rev. 2017;16:667-74. https://doi.org/10.1016/j.autrev.2017.05.001
https://doi.org/10.1016/j.autrev.2017.05...
This may be due to scarce facilities and infrastructure adapted to their needs, as well as lack of specialized and integrated health teams that can provide personalized care for this population.

Previous studies reported that sports nongovernmental organizations (NGOs) have attempted to create inclusive environments and extend the outcomes of participation for people with disabilities.77. Lorenzo T, McKinney V, Bam A, Sigenu V, Sompeta S. Mapping participation of disabled youth in sport and other free-time activities to facilitate their livelihoods development. BJOT. 2019;82:80-9. https://doi.org/10.1177/0308022618817281
https://doi.org/10.1177/0308022618817281...
,88. Grangeiro PM, Laurentino MF, Gomes FG, Alvarez DS, Moreira CA, Souza NA, et al. Telehealth for children and adolescents with physical disabilities during COVID-19 pandemic. Acta Ortopédica Bras. https://doi.org/10.1590/1413-785220223001e248102
https://doi.org/10.1590/1413-78522022300...
The aim of the present study was to assess sociodemographic data, physical and psychosocial functioning, and health-related quality of life (HRQL) parameters in adolescents with physically disabling conditions compared to adolescents without disabilities quarantined during the COVID-19 pandemic.

METHOD

The NGO of this study is dedicated to providing rowing and canoeing on a regular basis to young patients with physical conditions that result in disabilities. At this NGO, sports activities ground personal development in an inclusive environment along with the assistance of an interdisciplinary health team (e.g., physical educator, physical therapist, psychologist, and social worker). During the pandemic, due to a state mandate, all in-person activities were suspended. Then, weekly video activities were sent via WhatsApp containing exercises prescribed by physical education professionals and physiotherapists, which were performed regularly under virtual supervision. In addition, following an interdisciplinary method, virtual sessions mediated by a psychologist and a social worker aimed to develop social and emotional skills, awareness of citizenship, and effective participation in society.

The inclusion criteria of this study were as follows: participants regularly attending the NGO’s online activities during the pandemic, aged between 10 and 18 years, and with at least one physical disability without a known diagnosis of intellectual disability. From July to October 2020, 63 adolescents were invited to complete an online survey as a cross-sectional assessment related to the pandemic period. At least six invitations were sent by email or WhatsApp. Participation was voluntary and required approval of parent/legal guardians. Of the 63 adolescents, 33 patients were excluded due to cognitive dysfunction that would impair capability to complete the survey (n=8), restricted Internet access (n=9), no approval from the parents/legal guardians or no desire to participate by the adolescents (n=13), and failure to complete the questionnaire (n=3). Thus, a total of 30 adolescents were included in the disability group for this study. Adolescents diagnosed with physical disabilities were classified according to diagnostic criteria. A control group of 86 age-matched adolescents with no disabilities were recruited by advertising on various social media platforms and completed the same survey as the former group, after parent/legal guardian approval.

Study data were collected and managed using Research Electronic Data Capture (REDCap).99. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377-81. https://doi.org/10.1016/j.jbi.2008.08.01
https://doi.org/10.1016/j.jbi.2008.08.01...
This study was approved by the Brazilian National Committee for Research Ethics (CONEP number 4.081.961). All parents/legal guardians and adolescents signed the informed consent and assent terms, respectively.

Participants responded to the online questionnaires considering the previous month. It had five parts, and the median time necessary for each group to complete the online questionnaires was 45 min. The first part of the survey contained 37 questions about sociodemographic data, school data, adherence to COVID-19 public health guidelines, and impact of quarantine on daily routine during the COVID-19 pandemic. In addition, the following situations were assessed using a visual analog scale (VAS)1010. Klimek L, Bergmann KC, Biedermann T, Bousquet J, Hellings P, Jung K, et al. Visual analogue scales (VAS): measuring instruments for the documentation of symptoms and therapy monitoring in cases of allergic rhinitis in everyday health care: position paper of the german society of allergology (AeDA) and the German Society of Allergy and Clinical Immunology (DGAKI), ENT Section, in collaboration with the working group on Clinical Immunology, Allergology and Environmental Medicine of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNOKHC). Allergo J Int. 2017;26:16-24. https://doi.org/10.1007/s40629-016-0006-7
https://doi.org/10.1007/s40629-016-0006-...
(ranging from 0 to 10): fear of COVID-19 (0=no fear to 10=with extreme fear), physical activity per week (0=without any physical activity to 10=physical activity daily), and sleep quality scale (0=insomnia to 10=no abnormality).

The subsequent four parts used the following instruments validated in Brazilian Portuguese: Strengths and Difficulties Questionnaire (SDQ),1111. Stivanin L, Scheuer CI, Assumpção Jr FB. SDQ (Strengths and Difficulties Questionnaire): identification of children readers behavioral characteristics. Psic: Teor Pesq. 2008;24:407-13. https://doi.org/10.1590/S0102-37722008000400003
https://doi.org/10.1590/S0102-3772200800...
Pittsburgh Sleep Quality Index (PSQI),1212. Passos MH, Silva HA, Pitangui AC, Oliveira VM, Lima AS, Araújo RC. Reliability and validity of the Brazilian version of the Pittsburgh Sleep Quality Index in adolescents. J Pediatr (Rio J). 2017;93:200-6. https://doi.org/10.1016/j.jped.2016.06.006
https://doi.org/10.1016/j.jped.2016.06.0...
Pediatric Outcome Data Collection Instrument (PODCI)1313. Monte FA, Ferreira MN, Petribu KC, Almeida NC, Gomes JB, Mariano MH, et al. Validation of the Brazilian version of the Pediatric Outcomes Data Collection Instrument: a cross-sectional evaluation in children and adolescents with juvenile idiopathic arthritis. BMC Pediatr. 2013;13:177. https://doi.org/10.1186/1471-2431-13-177
https://doi.org/10.1186/1471-2431-13-177...
, and Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0).1414. Garcia LF, Manna TD, Passone CG, Oliveira LS. Translation and validation of Pediatric Quality of Life Inventory™ 3.0 Diabetes Module (PedsQL™ 3.0 Diabetes Module) in Brazil-Portuguese language. J Pediatr (Rio J). 2018;94:680-8. https://doi.org/10.1016/j.jped.2017.09.009
https://doi.org/10.1016/j.jped.2017.09.0...

Questions of a sociodemographic nature included age, sex, ethnicity, number of rooms in the home, and number of household members. Level of education was assessed by asking if individuals attended elementary school, middle school, high school, or were not studying; respondents also informed if they were attending school before the COVID-19 pandemic (yes/no answer); if they were attending public school (yes/no answer); and the amount of time spent with school homework during the COVID-19 pandemic (no homework, ≤3 h/day, and >3 h/day). Questions were also asked to determine individuals’ COVID-19 information source (family and friends, health professional, social media/television/radio); if they considered COVID-19 information they were receiving reliable (yes/no answer); and about their compliance to the “Stay-Home” policy (yes/no answer).

Several questions evaluated the respondents routine during the COVID-19 quarantine to determine if there were household members with COVID-19 (yes/no answer); if daily routine changed after the “physical distancing” policy (yes/no answer); time dedicated to housework (no housework, ≤1 h/day, and >1 h/day); time taking care of elderly (not taking care, ≤1 h/day, and >1 h/day); sleep duration (≤8 h/day and >8 h/day); sleep after midnight (yes/no answer); sleep difficulty (yes/no answer); amount of screen time (≤3 h/day, 4–6 h/day, and ≥7 h/day); if screen time increased during the pandemic (yes/no answer); alcohol use during the pandemic (increased, did not change, decreased, and do not drink alcohol); financial status during the pandemic (worsened, did not change, and improved), and household members working outside the home (yes/no answer).

The second part of the survey was the self-report portion of SDQ for adolescents from 11 to 17 years. SDQ contains 25 items, grouped under 5 subscales (i.e., emotional problems, conduct problems, hyperactivity/inattention, peer problems, and prosocial behavior). Each item could be answered as “not true,” “somewhat true,” and “certainly true” and scores ranged from 0 to 2 for each answer. The subscales scores ranged from 0 to 10. The scores of emotional, conduct, hyperactivity/inattention, and peer problems subscales generate the total difficulties score, which ranges from 0 to 40.

The third part was the PSQI, a questionnaire that consists of 19 questions considering sleep quality and sleep disorders in the previous month. This instrument assesses seven sleep categories: subjective quality of sleep, sleep latency, sleep duration, sleep efficiency, sleep disorders, use of medication, and daytime dysfunction. Scores for each category varies from 0 to 3, with a total score ranging from 0 to 21. A total score above 5 points suggests poor quality of sleep.

The fourth part was the PODCI, a generic HRQL scale developed to evaluate musculoskeletal conditions in the adolescent. This questionnaire contains 83 questions that generate five-subscale scores ranging from 0 to 100 (upper extremity and physical functioning, transfer and basic mobility, sports and physical functioning, pain/comfort, and happiness) and a PODCI global function score. Lower scores are indicative of lower HRQL.

The fifth part of the survey was the self-report version of the PedsQL 4.0. This is a generic version of global assessment in four multidimensional scales (i.e., physical, emotional, social, and school functioning) over the previous month. The questionnaire consists of 23 items, which are scored using a five-point scale (0 never=100 points; 1 almost never=75 points; 2 sometimes=50 points; 3 often=25 points; and 4 almost always=0 points). The total scale score is a sum of two main scales, the physical health summary score, which represents physical functioning, and the psychosocial health summary score, which represents the sum of emotional, social, and school functioning. All score ranges from 0 to 100, and higher score reflects higher HRQL.

All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) for Windows 24.0 (IBM Corp., Armonk, NY, USA). Results were described as a number (frequency) for categorical variables and median (minimum–maximum) or mean±standard deviation (SD) for continuous variables according to non-normal or normal distribution, respectively. Scores that had non-normal and normal distributions were compared using a Mann-Whitney U test and t-test, respectively. Differences between categorical variables were evaluated according to Fisher’s exact test or Pearson’s chi-square test, as indicated. Spearman rank correlation coefficient was used for testing correlations between continuous variables. Logistic regression analyses model (Backward Stepwise) was performed using adolescents with disabilities as a dependent variable and variables that presented a statistical significance level of p<0.2 in the univariate analyses as independent variables, including analyses of both populations of adolescents with disabilities and adolescents without disabilities. Statistical significance was accepted at p<0.05.

RESULTS

Adolescents with physical disabilities diagnosis participated in the present study and had the following diagnosis: cerebral palsy1515. Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005;47:571-6. https://doi.org/10.1017/s001216220500112x
https://doi.org/10.1017/s001216220500112...
[n=16 (54%)], myelomeningocele1616. Liptak GS, Dosa NP. Myelomeningocele. Pediatr Rev. 2010;31:443-50. https://doi.org/10.1542/pir.31-11-443
https://doi.org/10.1542/pir.31-11-443...
[n=2 (7%)], Down’s syndrome1717. Roizen NJ, Patterson D. Down’s syndrome. Lancet. 2003;361:1281-9. https://doi.org/10.1016/S0140-6736(03)12987-X
https://doi.org/10.1016/S0140-6736(03)12...
[n=2 (7%)], spinal cord injury1818. Rabinstein AA. Traumatic spinal cord injury. Continuum (Minneap Minn). 2018;24:551-66. https://doi.org/10.1212/CON.0000000000000581
https://doi.org/10.1212/CON.000000000000...
[n=1 (3%)], autism spectrum disorder1919. Sharma N, Mishra R, Mishra D. The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5): what is new for the pediatrician? Indian Pediatr. 2015;52:141-3. https://doi.org/10.1007/s13312-015-0589-y
https://doi.org/10.1007/s13312-015-0589-...
[n=3 (10%)], Legg-Calvé-Perthes disease2020. Leroux J, Amara SA, Lechevallier J. Legg-Calvé-Perthes disease. Orthop Traumatol Surg Res. 2018;104(1S):S107-12. https://doi.org/10.1016/j.otsr.2017.04.012
https://doi.org/10.1016/j.otsr.2017.04.0...
[n=3 (10%)], juvenile systemic lupus erythematosus2121. Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40:1725. https://doi.org/10.1002/art.1780400928
https://doi.org/10.1002/art.1780400928...
[n=1 (3%)], bilateral hip dysplasia2222. Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics. Pediatrics. 2000;105:896-905. https://doi.org/10.1542/peds.105.4.896
https://doi.org/10.1542/peds.105.4.896...
[n=1 (3%)], and ataxia2323. Ashizawa T, Xia G. Ataxia. Continuum (Minneap Minn). 2016;22:1208-26. https://doi.org/10.1212/CON.0000000000000362
https://doi.org/10.1212/CON.000000000000...
[n=1 (3%)].

Demographic data revealed no differences between the two groups for age [14 (10–18) years vs. 14 (10–18) years, p=0.854], female sex (43% vs. 61%, p=0.104), and Caucasian race (57% vs. 52, p=0.681) (Table 1). Answers regarding the impact of COVID-19 quarantine showed no differences in relation to public school attendance (87% vs. 84%, p=0.701), reliable COVID-19 information (50% vs. 61%, p=0.430), and school homework (p=0.377) (Table 2). Conversely, adolescents with disabilities reported lower frequencies of housework activities (p<0.001) and had less screen exposure (p<0.001) compared to adolescents without disabilities (Table 2).

Table 1.
Sociodemographic data of the adolescents with physical disabilities versus adolescents without physical disabilities.
Table 2.
Impact of COVID-19 quarantine reported by adolescents with physical disabilities versus adolescents without physical disabilities.

The median of hyperactivity/inattention [6 (2–9) vs. 4 (0–8), p=0.002] and conduct problems [3 (0–7) vs. 2 (0–6), p=0.015] was significantly higher in adolescents with disabilities compared to adolescents without disabilities, whereas the median of emotional [4 (0–10) vs. 5 (0–10), p=0.018] and prosocial [7 (0–10) vs. 9 (3–10), p=0.006] problems was lower in adolescents with disabilities (Table 3). No differences were shown for peer problems, impact score, and total difficulties score between groups, or for overall sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, sleep medication use, daytime dysfunction, and PSQI total score in both groups (Table 3).

Table 3.
Strengths and Difficulties Questionnaire score, Pittsburgh Sleep Quality Index, Pediatric Outcome Data Collection Instrument, and Pediatric Quality of Live Inventory 4.0 reported by adolescents with physical disabilities versus adolescents without physical disabilities during quarantine of COVID-19 pandemic.

Adolescents with disabilities had significantly lower scores for global function of the PODCI [68 (21–99) vs. 94 (67–100), p<0.001], upper extremity and physical functioning [96 (4–100) vs. 100 (42–100), p=0.001], transfer and basic mobility [77 (6–100) vs. 100 (73–100), p<0.001], and sports and physical functioning [42 (0–95) vs. 87.5 (42–100), p<0.001] compared to adolescents without disabilities (Table 3). During the pandemic, the median score on the happiness PODCI scale [90 (65–100) vs. 80 (0–100), p=0.016] was significantly higher in adolescents with disabilities attended by the NGO compared with adolescents without disabilities in the control group (Table 3). No differences between groups were evident for total PedsQL or its subscales (Table 3).

There was a significant negative Spearman rank correlation coefficient between online exercise/physiotherapy activities in min/week and age (r=−0.395, p=0.037) in adolescents with disabilities during the COVID-19 pandemic. A significant positive Spearman rank correlation coefficient was shown between online exercise/physiotherapy activities in min/week and school functioning score (r=+0.630, p<0.001) and between online exercise/physiotherapy activities in min/week and PedsQL 4.0 total scale score (r=+0.386, p=0.043) in adolescents with disabilities during the COVID-19 pandemic.

Logistic regression analysis including both adolescents with and without physical disabilities (n=116) demonstrated that adolescents with disabilities had an increase OR of physical activity/week assessed by VAS (OR=1.03 95%CI 1.01–1.05 p=0.002), however, with lower housework activities (OR=0.14; 95%CI 0.04–0.43, p=0.001) and screen time ≥3 h/day (OR=0.09; 95% CI 0.02–0.38, p=0.001). The R22. Choi KR, Heilemann MV, Fauer A, Mead M. A second pandemic: mental health spillover from the novel coronavirus (COVID-19). J Am Psychiatr Nurses Assoc. 2020;26:340-3. https://doi.org/10.1177/1078390320919803
https://doi.org/10.1177/1078390320919803...
of the Nagelkerke test was 0.359 (Table 4).

Table 4.
Logistic regression analysis including both adolescents with and without physical disabilities (n=116) in which adolescents with disabilities had increased or decreased odds ratio in the following independent variables. The R22. Choi KR, Heilemann MV, Fauer A, Mead M. A second pandemic: mental health spillover from the novel coronavirus (COVID-19). J Am Psychiatr Nurses Assoc. 2020;26:340-3. https://doi.org/10.1177/1078390320919803
https://doi.org/10.1177/1078390320919803...
of the Nagelkerke test was 0.359.

DISCUSSION

To the best of our knowledge, this is the first study to report on the impact of social isolation during the COVID-19 pandemic on physical and mental health, and HRQL in adolescents with physical disability who are attended by a sports NGO. Overall, the adolescents with disabling conditions enrolled in this NGO during the pandemic were not at higher risk of adverse health-related indicators. We also demonstrated that with their engagement in the proposed online activities, these adolescents reported increased physical activity per week, less housework, and less screen time than adolescents without disabilities.

The strengths of this study were the evaluation of a unique subgroup of adolescents with disabling conditions enrolled in a sports NGO. The fundamental premise lies in the value of a community-based initiative with solid and long-term work to promote physical and mental health for children and adolescents with disabling conditions even before the pandemic, and its ongoing efforts throughout of quarantine using virtual assistance88. Grangeiro PM, Laurentino MF, Gomes FG, Alvarez DS, Moreira CA, Souza NA, et al. Telehealth for children and adolescents with physical disabilities during COVID-19 pandemic. Acta Ortopédica Bras. https://doi.org/10.1590/1413-785220223001e248102
https://doi.org/10.1590/1413-78522022300...
. Another strength was the use of a global semi-structured self-reported questionnaire, including adolescent habits and problems, and healthcare routines during the COVID-19 pandemic. We also used validated international self-report instruments with high reliability to measure psychosocial functioning in adolescents1111. Stivanin L, Scheuer CI, Assumpção Jr FB. SDQ (Strengths and Difficulties Questionnaire): identification of children readers behavioral characteristics. Psic: Teor Pesq. 2008;24:407-13. https://doi.org/10.1590/S0102-37722008000400003
https://doi.org/10.1590/S0102-3772200800...
as well as two generic tools of HRQL,1313. Monte FA, Ferreira MN, Petribu KC, Almeida NC, Gomes JB, Mariano MH, et al. Validation of the Brazilian version of the Pediatric Outcomes Data Collection Instrument: a cross-sectional evaluation in children and adolescents with juvenile idiopathic arthritis. BMC Pediatr. 2013;13:177. https://doi.org/10.1186/1471-2431-13-177
https://doi.org/10.1186/1471-2431-13-177...
,1414. Garcia LF, Manna TD, Passone CG, Oliveira LS. Translation and validation of Pediatric Quality of Life Inventory™ 3.0 Diabetes Module (PedsQL™ 3.0 Diabetes Module) in Brazil-Portuguese language. J Pediatr (Rio J). 2018;94:680-8. https://doi.org/10.1016/j.jped.2017.09.009
https://doi.org/10.1016/j.jped.2017.09.0...
namely, sleep quality and sleep disorder tools.1212. Passos MH, Silva HA, Pitangui AC, Oliveira VM, Lima AS, Araújo RC. Reliability and validity of the Brazilian version of the Pittsburgh Sleep Quality Index in adolescents. J Pediatr (Rio J). 2017;93:200-6. https://doi.org/10.1016/j.jped.2016.06.006
https://doi.org/10.1016/j.jped.2016.06.0...
The simultaneous inclusion of these parameters allowed a broad characterization of the interaction of physical, mental, and HRQL variables for these adolescents.

The collaborative work of a multidisciplinary team contributes to the development of socioemotional skills and citizenship awareness aiming for psychosocial growth and more participation in society.2424. King G, Keenan S, McDougall C, Oake M. Investigating a participation-based friendship intervention for youth with disabilities: effects on goal attainment, social self-efficacy, and engagement. Phys Occup Ther Pediatr. 2020;40:152-67. https://doi.org/10.1080/01942638.2019.1646376
https://doi.org/10.1080/01942638.2019.16...
The NGO of this study has been designed in a way that sports activities (e.g., rowing and canoeing) create the milieu for an integrated and supportive approach from a multidisciplinary health team (i.e., physical educator, physical therapist, psychologist, and social worker) toward a more positive self-concept for adolescence development.

During the pandemic, as in-person sports activities were not possible, this NGO rapidly developed intervention programs aiming to maintain physical activity in their adolescent attendees with disabilities, including an Internet-based intervention orienting therapeutic exercises and home-based physical activity, as well as virtual counseling sessions to improve social and emotional skills.88. Grangeiro PM, Laurentino MF, Gomes FG, Alvarez DS, Moreira CA, Souza NA, et al. Telehealth for children and adolescents with physical disabilities during COVID-19 pandemic. Acta Ortopédica Bras. https://doi.org/10.1590/1413-785220223001e248102
https://doi.org/10.1590/1413-78522022300...

Recent evidence suggests that, during quarantine, adolescents with physical deficiency were less involved in physical activity and had greater screen exposure time.2525. Masi A, Diaz AM, Tully L, Azim SI, Woolfenden S, Efron D, et al. Impact of the COVID-19 pandemic on the well-being of children with neurodevelopmental disabilities and their parents. J Paediatr Child Health. 2021;57:631-6. https://doi.org/10.1111/jpc.15285
https://doi.org/10.1111/jpc.15285...
,2626. Summers J, Baribeau D, Mockford M, Goldhopf L, Ambrozewicz P, Szatmari P, et al. Supporting children with neurodevelopmental disorders during the COVID-19 pandemic. J Am Acad Child Adolesc Psychiatry. 2021;60:2-6. https://doi.org/10.1016/j.jaac.2020.09.011
https://doi.org/10.1016/j.jaac.2020.09.0...
Interestingly, using multivariate analysis, our study showed that, despite having less participation in domestic tasks, adolescents with disabilities attended by the NGO spent less time in front of computer screens, cell phones, and tablets and performed more physical activities compared to adolescents without disabilities. Corroborating with what is observed in daily practice for patients with these conditions, Spearman rank correlations emphasized the relevance of online physical activities, particularly in older ages, reflecting in higher school functioning and HRQL scores. Indeed, the most important goal for the NGO of this study since the beginning of quarantine was the promotion of activities with no disabilities for these patients to avoid sedentary behaviors.

The impact on mental health, as well as emotional well-being, has also been reported during isolation, with adolescents appearing to be more vulnerable to psychological disorders in other cohorts.2727. Loades ME, Chatburn E, Higson-Sweeney N, Reynolds S, Shafran R, Brigden A, et al. Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry. 2020;59:1218-39. https://doi.org/10.1016/j.jaac.2020.05.009
https://doi.org/10.1016/j.jaac.2020.05.0...
Our study showed that adolescents attended by a sports NGO did not appear to be an at-risk group for poor mental functioning outcomes related to COVID-19, since they showed less emotional problems compared to adolescents with no disabilities. The high scores of conduct problems and hyperactivity/inattention and reduced prosocial scores reported by adolescents with disabling conditions compared to controls with no disabilities may be intrinsically related to developmental disabilities observed in our patients. Our data support the idea that the practice of physical activity does not only promote good musculoskeletal conditioning but also reduce the incidence of negative feelings, especially during setbacks such as those faced during the pandemic.2828. Zhang Y, Zhang H, Ma X, Di Q. Mental health problems during the COVID-19 pandemics and the mitigation effects of exercise: a longitudinal study of college students in China. Int J Environ Res Public Health. 2020;17:3722. https://doi.org/10.3390/ijerph17103722
https://doi.org/10.3390/ijerph17103722...
In fact, we observed that higher engagement in the online exercise program was associated with better overall school functioning and HRQL, which suggests the importance of this intervention. Also, we observed an association between lower exercise with increasing age, which confirms that older adolescents are more refractory to physical activity, and may need more focused strategies to improve their adherence.

Although the global function score was lower (as was expected) in adolescents with disabilities compared to adolescents in the control group, perception of happiness in the former was significantly higher, similar to other studies.2929. Dalise S, Tramonti F, Armienti E, Niccolini V, Caniglia-Tenaglia M, Morganti R, et al. Psycho-social impact of social distancing and isolation due to the COVID-19 containment measures on patients with physical disabilities. Eur J Phys Rehabil Med. 2021;57:158-65. https://doi.org/10.23736/S1973-9087.20.06535-1
https://doi.org/10.23736/S1973-9087.20.0...
This may be due to the fact that this feeling of well-being and joy is more latent in people who practice physical activities on a regular basis.3030. Zhang Z, Chen W. A systematic review of the relationship between physical activity and happiness. J Happiness Stud. 2019;20:1305-22. https://doi.org/10.1007/s10902-018-9976-0
https://doi.org/10.1007/s10902-018-9976-...

The multidisciplinary and multiprofessional approach with simultaneous online appointments may have safeguarded the effect of stressors during this catastrophic period in these subgroups of disabling conditions.

We are aware that our research has some limitations. The first is the limited number of adolescents in the study, which is a natural limitation of a real-life nonprofit organization that seeks to challenge barriers to maintain youngsters with heterogeneous sets of diagnoses active. The second limitation is the study’s cross-sectional design, precluding any direct causative relationships between the COVID-19 pandemic and changes in lifestyle, overall health, and HRQL. Third, our sample was heterogeneous in terms of chronic conditions, levels of functionality, and socioemotional backgrounds. Another limitation refers to the sample losses observed herein, which is partially due to the intrinsic challenges associated with surveying adolescents, including variability in motivation, cognitive abilities, and maturity level of the respondent. Finally, socioeconomic class was not evaluated herein; however, we assessed other relevant sociodemographic data that were similar in both groups, such as number of rooms in the residence, number of household members, and public-school attendance.

In conclusion, adolescents with physical disabilities attended by a sports NGO during COVID-19 pandemic were not at higher risk of adverse indicators or poorer HRQL. Despite showing reduced physical function, the adolescents with disabilities reported more physical activity, higher happiness, and less screen time than those without disabilities during the current pandemic. This study highlights the importance of NGOs to unload the demands on the health system via an inclusive and caring environment. Further longitudinal studies will be necessary to assess the cumulative impact and long-term effects of this unprecedented crisis on these adolescents with disabling conditions.

Acknowledgments

Our gratitude to Ulysses Doria-Filho for the statistical analysis support. We would like to recognize the contributions of Eloisa Bonfá, Eurípedes C. Miguel, Uenis Tannuri, Lucia M. A. Campos, Benito Lourenço, Ricardo K. Toma, Karina Medeiros, Andréia Watanabe, Vera P. M. F. R. Barros, Caio B. Casella, Alberto C. Helito, Lorena V. M. Martiniano, Luana C. A. Miranda, Debora N. D. Setoue, Nicolas Y. Tanigava, Deborah F. P. Roz, Ligia P. Saccani, Adriana M. E. Sallum, Amanda Y. Iraha, Bruna C. Mazzolani, Claudia R. P. Santos, Claudia A. Martinez, Claudia B. Fonseca, Fabiana I. Smaira, Hamilton Roschel, Helena T. Miyatani, Isabela G. Marques, Jane Oba, Katia Kozu, Luiz E. V. Silva, Nádia E. Aikawa, Louise Cominato, Paulo R. A. Pereira, Ruth R. Franco, Simone S. Angelo, Sofia M. Sieczkowska, Tathiane C. Franco, and Vivianne Viana. We gratefully acknowledge the work of Fernanda G. L. Gomes, Daniela S. Alvarez, Cesar A. Moreira, Natália A. Souza, Jennifer M. Balbino, Enio S. Ferreira, Gabriel M. Santos, Sueli F. Costa, Tauana V. L. Verde, Thiago Rodrigues, Caio. H. A. Cruz, Candido Leonelli, and Ricardo M. Macéa. We thank Bryan Saunders for language revision.

REFERENCES

  • 1.
    Hellewell J, Abbott S, Gimma A, Bosse NI, Jarvis CI, Russell TW, et al. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. Lancet Glob Health. 2020;8:e488-96. https://doi.org/10.1016/S2214-109X(20)30074-7
    » https://doi.org/10.1016/S2214-109X(20)30074-7
  • 2.
    Choi KR, Heilemann MV, Fauer A, Mead M. A second pandemic: mental health spillover from the novel coronavirus (COVID-19). J Am Psychiatr Nurses Assoc. 2020;26:340-3. https://doi.org/10.1177/1078390320919803
    » https://doi.org/10.1177/1078390320919803
  • 3.
    Silva CA, Queiroz LB, Fonseca CB, Silva LE, Lourenço B, Marques HH. Spotlight for healthy adolescents and adolescents with preexisting chronic diseases during the COVID-19 pandemic. Clinics (Sao Paulo). 2020;75:e1931. https://doi.org/10.6061/clinics/2020/e1931
    » https://doi.org/10.6061/clinics/2020/e1931
  • 4.
    Safadi MA, Silva CA. The challenging and unpredictable spectrum of covid-19 in children and adolescents. Rev Paul Pediatr. 2020;39:e2020192. https://doi.org/10.1590/1984-0462/2020/38/2020192
    » https://doi.org/10.1590/1984-0462/2020/38/2020192
  • 5.
    Lindoso L, Astley C, Queiroz LB, Gualano B, Pereira RM, Tannuri U, et al. Physical and mental health impacts during covid-19 quarantine in adolescents with preexisting chronic immunocompromised conditions. J Pediatr (Rio J). 2021;S0021-7557(21)00136-4. https://doi.org/10.1016/j.jped.2021.09.002
    » https://doi.org/10.1016/j.jped.2021.09.002
  • 6.
    Pinto AJ, Roschel H, Sá Pinto AL, Lima FR, Pereira RM, Silva CA, et al. Physical inactivity and sedentary behavior: overlooked risk factors in autoimmune rheumatic diseases? Autoimmun Rev. 2017;16:667-74. https://doi.org/10.1016/j.autrev.2017.05.001
    » https://doi.org/10.1016/j.autrev.2017.05.001
  • 7.
    Lorenzo T, McKinney V, Bam A, Sigenu V, Sompeta S. Mapping participation of disabled youth in sport and other free-time activities to facilitate their livelihoods development. BJOT. 2019;82:80-9. https://doi.org/10.1177/0308022618817281
    » https://doi.org/10.1177/0308022618817281
  • 8.
    Grangeiro PM, Laurentino MF, Gomes FG, Alvarez DS, Moreira CA, Souza NA, et al. Telehealth for children and adolescents with physical disabilities during COVID-19 pandemic. Acta Ortopédica Bras. https://doi.org/10.1590/1413-785220223001e248102
    » https://doi.org/10.1590/1413-785220223001e248102
  • 9.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377-81. https://doi.org/10.1016/j.jbi.2008.08.01
    » https://doi.org/10.1016/j.jbi.2008.08.01
  • 10.
    Klimek L, Bergmann KC, Biedermann T, Bousquet J, Hellings P, Jung K, et al. Visual analogue scales (VAS): measuring instruments for the documentation of symptoms and therapy monitoring in cases of allergic rhinitis in everyday health care: position paper of the german society of allergology (AeDA) and the German Society of Allergy and Clinical Immunology (DGAKI), ENT Section, in collaboration with the working group on Clinical Immunology, Allergology and Environmental Medicine of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNOKHC). Allergo J Int. 2017;26:16-24. https://doi.org/10.1007/s40629-016-0006-7
    » https://doi.org/10.1007/s40629-016-0006-7
  • 11.
    Stivanin L, Scheuer CI, Assumpção Jr FB. SDQ (Strengths and Difficulties Questionnaire): identification of children readers behavioral characteristics. Psic: Teor Pesq. 2008;24:407-13. https://doi.org/10.1590/S0102-37722008000400003
    » https://doi.org/10.1590/S0102-37722008000400003
  • 12.
    Passos MH, Silva HA, Pitangui AC, Oliveira VM, Lima AS, Araújo RC. Reliability and validity of the Brazilian version of the Pittsburgh Sleep Quality Index in adolescents. J Pediatr (Rio J). 2017;93:200-6. https://doi.org/10.1016/j.jped.2016.06.006
    » https://doi.org/10.1016/j.jped.2016.06.006
  • 13.
    Monte FA, Ferreira MN, Petribu KC, Almeida NC, Gomes JB, Mariano MH, et al. Validation of the Brazilian version of the Pediatric Outcomes Data Collection Instrument: a cross-sectional evaluation in children and adolescents with juvenile idiopathic arthritis. BMC Pediatr. 2013;13:177. https://doi.org/10.1186/1471-2431-13-177
    » https://doi.org/10.1186/1471-2431-13-177
  • 14.
    Garcia LF, Manna TD, Passone CG, Oliveira LS. Translation and validation of Pediatric Quality of Life Inventory™ 3.0 Diabetes Module (PedsQL™ 3.0 Diabetes Module) in Brazil-Portuguese language. J Pediatr (Rio J). 2018;94:680-8. https://doi.org/10.1016/j.jped.2017.09.009
    » https://doi.org/10.1016/j.jped.2017.09.009
  • 15.
    Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005;47:571-6. https://doi.org/10.1017/s001216220500112x
    » https://doi.org/10.1017/s001216220500112x
  • 16.
    Liptak GS, Dosa NP. Myelomeningocele. Pediatr Rev. 2010;31:443-50. https://doi.org/10.1542/pir.31-11-443
    » https://doi.org/10.1542/pir.31-11-443
  • 17.
    Roizen NJ, Patterson D. Down’s syndrome. Lancet. 2003;361:1281-9. https://doi.org/10.1016/S0140-6736(03)12987-X
    » https://doi.org/10.1016/S0140-6736(03)12987-X
  • 18.
    Rabinstein AA. Traumatic spinal cord injury. Continuum (Minneap Minn). 2018;24:551-66. https://doi.org/10.1212/CON.0000000000000581
    » https://doi.org/10.1212/CON.0000000000000581
  • 19.
    Sharma N, Mishra R, Mishra D. The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5): what is new for the pediatrician? Indian Pediatr. 2015;52:141-3. https://doi.org/10.1007/s13312-015-0589-y
    » https://doi.org/10.1007/s13312-015-0589-y
  • 20.
    Leroux J, Amara SA, Lechevallier J. Legg-Calvé-Perthes disease. Orthop Traumatol Surg Res. 2018;104(1S):S107-12. https://doi.org/10.1016/j.otsr.2017.04.012
    » https://doi.org/10.1016/j.otsr.2017.04.012
  • 21.
    Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40:1725. https://doi.org/10.1002/art.1780400928
    » https://doi.org/10.1002/art.1780400928
  • 22.
    Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics. Pediatrics. 2000;105:896-905. https://doi.org/10.1542/peds.105.4.896
    » https://doi.org/10.1542/peds.105.4.896
  • 23.
    Ashizawa T, Xia G. Ataxia. Continuum (Minneap Minn). 2016;22:1208-26. https://doi.org/10.1212/CON.0000000000000362
    » https://doi.org/10.1212/CON.0000000000000362
  • 24.
    King G, Keenan S, McDougall C, Oake M. Investigating a participation-based friendship intervention for youth with disabilities: effects on goal attainment, social self-efficacy, and engagement. Phys Occup Ther Pediatr. 2020;40:152-67. https://doi.org/10.1080/01942638.2019.1646376
    » https://doi.org/10.1080/01942638.2019.1646376
  • 25.
    Masi A, Diaz AM, Tully L, Azim SI, Woolfenden S, Efron D, et al. Impact of the COVID-19 pandemic on the well-being of children with neurodevelopmental disabilities and their parents. J Paediatr Child Health. 2021;57:631-6. https://doi.org/10.1111/jpc.15285
    » https://doi.org/10.1111/jpc.15285
  • 26.
    Summers J, Baribeau D, Mockford M, Goldhopf L, Ambrozewicz P, Szatmari P, et al. Supporting children with neurodevelopmental disorders during the COVID-19 pandemic. J Am Acad Child Adolesc Psychiatry. 2021;60:2-6. https://doi.org/10.1016/j.jaac.2020.09.011
    » https://doi.org/10.1016/j.jaac.2020.09.011
  • 27.
    Loades ME, Chatburn E, Higson-Sweeney N, Reynolds S, Shafran R, Brigden A, et al. Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry. 2020;59:1218-39. https://doi.org/10.1016/j.jaac.2020.05.009
    » https://doi.org/10.1016/j.jaac.2020.05.009
  • 28.
    Zhang Y, Zhang H, Ma X, Di Q. Mental health problems during the COVID-19 pandemics and the mitigation effects of exercise: a longitudinal study of college students in China. Int J Environ Res Public Health. 2020;17:3722. https://doi.org/10.3390/ijerph17103722
    » https://doi.org/10.3390/ijerph17103722
  • 29.
    Dalise S, Tramonti F, Armienti E, Niccolini V, Caniglia-Tenaglia M, Morganti R, et al. Psycho-social impact of social distancing and isolation due to the COVID-19 containment measures on patients with physical disabilities. Eur J Phys Rehabil Med. 2021;57:158-65. https://doi.org/10.23736/S1973-9087.20.06535-1
    » https://doi.org/10.23736/S1973-9087.20.06535-1
  • 30.
    Zhang Z, Chen W. A systematic review of the relationship between physical activity and happiness. J Happiness Stud. 2019;20:1305-22. https://doi.org/10.1007/s10902-018-9976-0
    » https://doi.org/10.1007/s10902-018-9976-0
  • Funding
    This study was supported by grants from Lei de Incentivo ao Esporte (LIE) SLIE 1915361-99 Ministério da Cidadania – Secretaria Especial do Esporte LIE 11.438/2006, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq 304984/2020-5 to CAS), Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP 2015/03756-4 to CAS), and by Núcleo de Apoio à Pesquisa “Saúde da Criança e do Adolescente” da USP (NAP-CriAd) to CAS.

Publication Dates

  • Publication in this collection
    14 Nov 2022
  • Date of issue
    2023

History

  • Received
    22 Sept 2021
  • Accepted
    30 Jan 2022
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