Sedentary Behaviour Guidelines Research Articles

Prevalence and socio-economic distribution of eating, physical activity and sedentary behaviour among South Australian children in urban and rural communities: baseline findings from the OPAL evaluation

To identify current prevalence and sociodemographic distribution of adherence to national diet and physical activity and sedentary behaviour guidelines among Australian primary school children. Cross-sectional survey of children (n=4637, 9-11 years) participating at baseline in the South Australian Obesity Prevention and Lifestyle (OPAL) programme evaluation. Self-reported diet, physical activity (PA) and screen time (ST) behaviours were assessed via questionnaire. Children were classified as meeting or not meeting each guideline (two or more serves of fruit, five or more serves of vegetables, two or less serves of discretionary food, ≥60min of PA, and ≤2h of ST per day). Although 65% of children met fruit recommendations, only 22% met vegetable recommendations (17% consumed no vegetables). Approximately one-quarter (28%) of children met discretionary food recommendations. Only 17% of children met the ST recommendations and 33% met PA recommendations. Less than 1% of children metall five recommendations. Rural children were more likely to meet both PA (OR=1.45, 95% CI: 1.21-1.74, P<0.001) and ST (OR=1.37, 95% CI: 1.14-1.66, P<0.01) recommendations than urban counterparts. Children at least socio-economic disadvantage performed better than those at greatest disadvantage for most behaviours. Improvement in Australian children's diet and physical activity and sedentary behaviours, particularly urban children and those at greatest socio-economic disadvantage, is urgently warranted.

Why are children sedentary: an examination using the International Study of Childhood Obesity, Lifestyle and the Environment.

Physical inactivity and sedentary behaviour have been independently associated with a wide range of negative health indicators including obesity, poor cardio-metabolic health, and poor psychosocial health. The overarching objective of this research was to gain a better understanding as to why children are sedentary and where we need to focus public health messages and interventions to reduce sedentary behaviour. Specifically, I aimed to provide insight on current awareness of sedentary behaviour guidelines, determine important correlates of total sedentary time (SED) and screen time (ST) in Canadian children, and understand correlates of SED and ST in a global context. The primary dataset used for this project was the International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE). Background work was completed to review current literature on knowledge and awareness of Canadian physical activity and sedentary behaviour guidelines (in all age groups) and to understand the representativeness of the ISCOLE dataset. In addition to the 2 background papers, this dissertation includes 3 manuscripts, all prepared for submission in scientific, peer-reviewed journals: Canadian physical activity and screen time guidelines: do children know?, Correlates of objectively measured sedentary time and self-reported screen time in Canadian children, and Correlates of total sedentary time and screen time in 9-11 year-old children around the world: The International Study of Childhood Obesity, Lifestyle and the Environment. Overall, this work showed the majority of children around the world are accumulating large amounts of sedentary time, and exceeded current screen time guidelines. We found that the large majority of Canadian children are not aware of screen time guidelines; however, a greater proportion of children could identify physical activity guidelines. We also identified a number of correlates of SED and ST in Canadian children and in children around the world. The most common correlates included weight status and access to electronics in the house. Taken together, this work suggests that public health messaging should focus on increasing awareness of screen time guidelines. While increasing awareness of the guidelines, messaging can be tailored to promoting healthy weight status and reducing (or removing) children's access to electronic devices in hopes of reducing overall time spent sedentary.

A review of the assessment and prevalence of sedentarism in older adults, its physiology/health impact and non-exercise mobility counter-measures.

This literature review focuses on aspects of sedentary behaviour (SB) in elderly. Since it has been identified as a distinct health risk, independent of physical activity, SB is a significant issue. This is particularly true for an ageing population as evidence shows that older adults (aged ≥65 years) are the most sedentary age group (on average 8.5–9.6 h daily sitting time). Accurate SB assessment is important for understanding this habitual behaviour and its impact. However, SB measurement is challenging, regardless of the method used. Although negative associations of SB in elderly have been reported for several health outcomes, evidence is inconclusive, apart from the evidence on the adverse SB effect on the all-cause mortality rate. Generally, strategies have been proposed to counteract SB, of which breaking prolonged sedentary bouts with at least light-intensity physical activity seems to be the most promising. Overall, further research in elderly is required to increase the evidence and to either support or refute the current findings. Moreover, further research will help to develop informed SB guidelines for an optimal strategy to counteract SB and its health effects in older adults.

Adherence to Canadian physical activity and sedentary behaviour guidelines among children 2 to 13years of age.

Active living is relevant for healthy child development and disease prevention. In 2011–2012 new Canadian Physical Activity and Sedentary Behaviour Guidelines were developed for children under four and 5–17 years of age. This cross-sectional study assessed children's adherence to the national guidelines, using a large sample of Alberta children ages 2–4 and 5–13 years in 2013.The proportions of children achieving the average daily duration of physical activity and screen time recommended were determined, and child and parental predictors of non-achievement were identified. Participants were 631 parent and child dyads. Data were collected by parental reports of physical activity and screen time during weekdays, and analysed using univariate and multivariate techniques (p < 0.05). Logistic regression models were used to examine factors associated with children's non-achievement of physical activity and screen time recommendations while adjusting for covariates.Sixty-two percent of children aged 2–4 and 26% of children aged 5–13 did not meet physical activity time recommendations, and 64% of children aged 2–4 and 23% of children aged 5–13 exceeded the maximum screen time recommendation. Several associations between parental age and education with non-achievement were observed but associations were not consistent across age groups or behaviours. Among preschoolers, those with middle-age parents were more likely to not achieve physical activity recommendations.Evidence of high non-achievement of the recommendations among children 2–4 years highlights the need for increased programming targeting preschool children. Further research is required to identify modifiable risk factors that may inform future health promotion efforts.

The descriptive epidemiology of total physical activity, muscle-strengthening exercises and sedentary behaviour among Australian adults – results from the National Nutrition and Physical Activity Survey

BackgroundThe current Australia's Physical Activity and Sedentary Behaviour Guidelines recommend that adults engage in regular moderate-to-vigorous-intensity physical activity (MVPA) and strength training (ST), and minimise time spent in sedentary behaviours (SB). However, evidence about the specific individual and concurrent distribution of these behaviours in Australia is scarce. Therefore, the aim of this study was to determine the prevalence and sociodemographic correlates of MVPA, ST and SB in a national-representative sample of Australian adults.MethodsData were collected using face-to-face interviews, as part of the National Nutrition and Physical Activity Survey 2011–12. The population-weighted proportions meeting the MVPA (≥150 min/week), ST (≥2 sessions/week) and combined MVPA-ST guidelines, and proportions classified as having ‘low levels of SB’ (<480 min/day) were calculated, and their associations with selected sociodemographic and health-related variables were assessed using multiple logistic regression analyses. This was also done for those at potentially ‘high-risk’, defined as insufficient MVPA-ST and ‘high-sedentary’ behaviour.ResultsOut of 9345 participants (response rate = 77.0 %), aged 18–85 years, 52.6 % (95 % CI: 51.2 %–54.0 %), 18.6 % (95 % CI: 17.5 %–19.7 %) and 15.0 % (95 % CI: 13.9 %–16.1 %) met the MVPA, ST and combined MVPA-ST guidelines, respectively. Female gender, older age, low/medium education, poorer self-rated health, being classified as underweight or obese, and being a current smoker were independently associated with lower odds of meeting the MVPA, ST and combined MVPA-ST guidelines. A total of 78.9 % (95 % CI: 77.9 %–80.0 %) were classified as having low levels of SB. Females, older adults and those with lower education were more likely to report lower levels of SB, whilst those with poor self-rated health and obese individuals were less likely to report lower levels of SB (i.e. SB = ≥480 min/day). A total of 8.9 % (95 % CI: 8.1 %–9.6 %) were categorised as individuals at potentially ‘high-risk’. Those with poorer self-rated health, obese individuals, those aged 25–44, and current smokers were more likely to be in the ‘high risk’ group.ConclusionsThe large majority of Australian adults do not meet the full physical activity guidelines and/or report excessive SB. Our results call for public health interventions to reduce physical inactivity and SB in Australia, particularly among the subgroups at the highest risk of these unhealthy behaviours.

Contribution of the After-School Period to Children's Daily Participation in Physical Activity and Sedentary Behaviours.

ObjectivesChildren’s after-school physical activity (PA) and sedentary behaviours (SB) are not well understood, despite the potential this period holds for intervention. This study aimed to describe children’s after-school physical activity and sedentary behaviours; establish the contribution this makes to daily participation and to achieving physical activity and sedentary behaviours guidelines; and to determine the association between after-school moderate- to vigorous-intensity physical activity (MVPA), screen-based sedentary behaviours and achieving the physical activity and sedentary behaviour guidelines.MethodsChildren (n = 406, mean age 8.1 years, 58% girls) wore an ActiGraph GT3X accelerometer. The percentage of time and minutes spent sedentary (SED), in light- physical activity (LPA) and MVPA between the end-of-school and 6pm (weekdays) was calculated. Parents (n = 318, 40 years, 89% female) proxy-reported their child’s after-school participation in screen-based sedentary behaviours. The contribution that after-school SED, LPA, MVPA, and screen-based sedentary behaviours made to daily levels, and that after-school MVPA and screen-based sedentary behaviours made to achieving the physical activity/sedentary behaviour guidelines was calculated. Regression analysis determined the association between after-school MVPA and screen-based sedentary behaviours and achieving the physical activity/sedentary behaviours guidelines.ResultsChildren spent 54% of the after-school period SED, and this accounted for 21% of children’s daily SED levels. Boys spent a greater percentage of time in MVPA than girls (14.9% vs. 13.6%; p<0.05), but this made a smaller contribution to their daily levels (27.6% vs 29.8%; p<0.05). After school, boys and girls respectively performed 18.8 minutes and 16.7 minutes of MVPA, which is 31.4% and 27.8% of the MVPA (p<0.05) required to achieve the physical activity guidelines. Children spent 96 minutes in screen-based sedentary behaviours, contributing to 84% of their daily screen-based sedentary behaviours and 80% of the sedentary behaviour guidelines. After-school MVPA was positively associated with achieving the physical activity guidelines (OR: 1.31, 95%CI 1.18, 1.44, p<0.05), and after-school screen-based sedentary behaviours were negatively associated with achieving the sedentary behaviours guidelines (OR: 0.97, 95%CI: 0.96, 0.97, p<0.05).ConclusionsThe after-school period plays a critical role in the accumulation of children’s physical activity and sedentary behaviours. Small changes to after-school behaviours can have large impacts on children’s daily behaviours levels and likelihood of meeting the recommended levels of physical activity and sedentary behaviour. Therefore interventions should target reducing after-school sedentary behaviours and increasing physical activity.

An objective assessment of toddlers' physical activity and sedentary levels: a cross-sectional study.

BackgroundLittle evidence exists on the physical activity and sedentary time of Canadian toddlers; this study objectively measured such behaviors and compared participants’ activity levels to national guidelines. Levels of screen-viewing among toddlers were also explored.MethodsForty toddlers (mean age = 25.7 months) wore Actical accelerometers for seven consecutive days (15 s epoch). Parents/guardians completed a wear-time log and a demographic and screen-viewing questionnaire. Descriptive analyses were used to determine participants’ levels of physical activity and sedentary time, to identify whether toddlers were meeting physical activity/sedentary guidelines, and to explore demographic variables. T-tests were used to assess whether toddlers’ activity levels differed based on cut-points applied and various demographic and screen-related variables. Regression analyses were conducted to examine associations between toddlers’ sedentary time and screen-viewing levels.ResultsToddlers engaged in 37.27 (SD = 3.79) to 49.40 (SD = 3.29) mins/hr of sedentary time, 9.79 (SD = 2.90) to 18.78 (SD = 3.22) mins/hr of light-intensity physical activity (LPA), 0.82 (SD = 0.72) to 3.95 (SD = 1.93) mins/hr of moderate- to vigorous-intensity physical activity (MVPA), and 10.60 (SD =3.29) to 22.73 (SD = 3.97) mins/hr of total physical activity (TPA), based on the Trost et al. and the Canadian Health Measures Survey (CHMS) cut-points respectively; these rates were significantly different (p <.001). On at least 1 day, 17.5 % (Trost et al. cut-points) and 97.5 % (CHMS cut-points) of the sample met or exceeded the Canadian physical activity guidelines. No statistically significant differences in sedentary time or physical activity (all intensities) based on sex were reported (p <.001); however, LPA (CHMS cut-points) did significantly differ based on childcare attendance (p <.05). Approximately 93.2 % of participants watched television, and 56.8 % utilized computers. Only 18.8 and 25.0 % of children under 2 years and 70.8 and 62.5 % of 2–3 years olds met the screen-use recommendation of the sedentary behavior guidelines on weekdays and weekend days, respectively.Discussion and conclusionThe implications of this work suggest that a greater understanding of toddlers’ activity patterns is needed; additional mechanisms of promoting active behaviors among this group should be explored.

Accounting for Sitting and Moving: An Analysis of Sedentary Behavior in Mass Media Campaigns.

Mass media campaigns are an important tool for promoting health-related physical activity. The relevance of sedentary behavior to public health has propelled it to feature prominently in health campaigns across the world. This study explored the use of messages regarding sedentary behavior in health campaigns within the context of current debates surrounding the association between sedentary behavior and health, and messaging strategies to promote moderate-to-vigorous physical activity (MVPA). A web-based search of major campaigns in the United Kingdom, United States, Canada, and Australia was performed to identify the main campaign from each country. A directed content analysis was then conducted to analyze the inclusion of messages regarding sedentary behavior in health campaigns and to elucidate key themes. Important areas for future research were illustrated. Four key themes from the campaigns emerged: clinging to sedentary behavior guidelines, advocating reducing sedentary behavior as a first step on the activity continuum and the importance of light activity, confusing the promotion of MVPA, and the demonization of sedentary behavior. Strategies for managing sedentary behavior as an additional complicating factor in health promotion are urgently required. Lessons learned from previous health communication campaigns should stimulate research to inform future messaging strategies.

Mothers’ perceptions of the UK physical activity and sedentary behaviour guidelines for the early years (Start Active, Stay Active): a qualitative study

ObjectivesHigher levels of physical activity (PA) during early childhood have been associated with improved health outcomes, whereas sedentary behaviour (SB) has been associated with poorer health outcomes in children. In...

Australia and Other Nations Are Failing to Meet Sedentary Behaviour Guidelines for Children: Implications and a Way Forward.

Australia has joined a growing number of nations that have evaluated the physical activity and sedentary behavior status of their children. Australia received a "D minus" in the first Active Healthy Kids Australia Physical Activity Report Card. An expert subgroup of the Australian Report Card Research Working Group iteratively reviewed available evidence to answer 3 questions: (a) What are the main sedentary behaviors of children? (b) What are the potential mechanisms for sedentary behavior to impact child health and development? and (c) What are the effects of different types of sedentary behaviors on child health and development? Neither sedentary time nor screen time is a homogeneous activity likely to result in homogenous effects. There are several mechanisms by which various sedentary behaviors may positively or negatively affect cardiometabolic, neuromusculoskeletal, and psychosocial health, though the strength of evidence varies. National surveillance systems and mechanistic, longitudinal, and experimental studies are needed for Australia and other nations to improve their grade. Despite limitations, available evidence is sufficiently convincing that the total exposure and pattern of exposure to sedentary behaviors are critical to the healthy growth, development, and wellbeing of children. Nations therefore need strategies to address these common behaviors.

Knowledge and awareness of Canadian Physical Activity and Sedentary Behaviour Guidelines: a synthesis of existing evidence.

The aim of this review was to consolidate and synthesize existing evidence regarding current knowledge and awareness of the Canadian Physical Activity (PA) and Sedentary Behaviour (SB) Guidelines. MEDLINE, Embase, and PsycINFO were searched for peer-reviewed publications pertaining to the guidelines. Content experts, key organizations (i.e., ParticipACTION and the Canadian Fitness and Lifestyle Research Institute), journal Web sites, and service organizations (i.e., the Canadian Society for Exercise Physiology (CSEP) and the Public Health Agency of Canada) were consulted for additional evidence. Scientific publications (n = 6) and research from ParticipACTION and the Canadian Fitness and Lifestyle Research Institute reported that awareness of the guidelines is low, especially with respect to the SB guidelines. Less than 10% of survey respondents from the Canadian population were aware of the PA guidelines, and less than 5% were aware of the SB guidelines. Information on the guidelines was available on 51% of public health unit and CSEP partner Web sites. Online metrics (e.g., downloads, site accessions) from CSEP, the Public Health Agency of Canada, and journal Web sites showed that online accession of the guidelines was high (e.g., all "highly accessed" on journal Web sites). This review showed that awareness of the Canadian PA and SB Guidelines is low among the general population but higher among the scientific and stakeholder communities. Governmental, nongovernmental, and stakeholder organizations should collaborate in creating sustained, long-term, and well-resourced communication plans to reach the Canadian population to raise awareness of PA and SB guidelines and should implement programs to facilitate their uptake.

Examining communication- and media-based recreational sedentary behaviors among Canadian youth: Results from the COMPASS study

To examine the prevalence of different communication- and media-based sedentary behaviors and examine how they are associated with modifiable risk behaviors and key demographic correlates among a large sample of youth. Data from 23,031 grade 9 to grade 12 students in Year 1 (2012-2013) of the COMPASS study (Canada) were used to examine the prevalence of sedentary behaviors by gender and by grade. The between-school variance in sedentary behaviors was calculated and models were developed to examine how modifiable risk factors and demographic correlates were associated with sedentary behaviors. Youth averaged 494 (± 313) min/day of sedentary behavior and 96.7% of the sample exceeded the sedentary behavior guidelines of no more than 2h per day. Significant between-school random variation in the sedentary behaviors was identified. Substance use, weight status, ethnicity, and gender were the main predictors of the sedentary behaviors examined. The vast majority of youth in the COMPASS sample are considered highly sedentary. The evidence clearly suggests we need to develop more effective methods of intervening, that school-based programming is warranted, and that gender-specific programming may be required.

A Group Motor Skills Program for Children with Coordination Difficulties: Effect on Fundamental Movement Skills and Physical Activity Participation

ABSTRACTAims: Children with coordination difficulties are at risk of low levels of physical activity (PA) participation. This intervention examined the effects of a multidisciplinary program that emphasized parent participation on motor skill performance and PA. Methods: Ten boys (5–7 years) completed a group program consisting of conditioning exercises and activities designed to address child-selected goals. Motor proficiency and PA participation were assessed before and after the program using the Test of Gross Motor Development (TGMD-2) and triaxial accelerometers, respectively. Rating scales captured child and parent perceptions of performance for each child's goals. Results: TGMD-2 subtest raw scores, age equivalent and percentile scores improved, along with parent ratings of their child's performance. Six children reported skill improvements. On average, moderate to vigorous PA improved by 10 min per day although these gains were not significant. Time spent in sedentary activities was unchanged. None of the children met the Canadian PA and sedentary behaviour guidelines. Conclusions: The results support effectiveness of a group program to improve gross motor performance and levels of PA in children with coordination difficulties. Gains in both of these domains also have the potential to impact quality of life and reduce health risks associated with inactivity.

A qualitative examination of the perceptions of parents on the Canadian Sedentary Behaviour Guidelines for the early years.

BackgroundMinimizing sedentary behavior, in particular screen-based sedentary behavior, during the early years is important for healthy growth and development. Consequently, new Canadian Sedentary Behaviour Guidelines for the Early Years (aged 0–4 years) were recently released. Researchers are unclear what messages should supplement the guidelines when disseminating them to parents and when using the guidelines in behaviour-change interventions to increase adoption. The objective of this study was to qualitatively examine parents’ perceptions of the new Canadian Sedentary Behaviour Guidelines for the Early Years.MethodsParents with a child ≤4 years who attended a child care centre were purposefully recruited from child care centres. A total of 7 semi-structured focus groups with 2 to 5 parents were conducted from August to November, 2013 by a trained and experienced moderator. Participants were asked a series of open-ended questions pertaining to the Sedentary Behaviour Guidelines information sheet. Initial themes were identified followed by further review and analysis.ResultsFor the most part parents thought the guidelines were clear and did not disagree with the recommendations per se. However, some confusion arose around the value of some sedentary activities, such as reading and coloring, for social and cognitive development. Many parents described feeling guilty after reading the guidelines and perceived several barriers in meeting the daily recommendations. Common barriers included the need to balance multiple demands of family life, the prevalence and accessibility of screen technology, and the weather and built environment where families live. Parents expressed the importance of communicating the guidelines early enough for good habits to be established and the need for realistic strategies and ideas to help them meet the recommendations.ConclusionsOverall the findings indicate that gain-framed messages around the role of screen-based and non-screen-based sedentary behavior for children’s cognitive and social development might be most effective for adoption of the guidelines. Furthermore, providing parents the guidelines early with resources for minimizing sedentary behavior should also be considered. Future research is needed in other demographic groups of parents to confirm these findings.

Paediatricians' awareness of, agreement with and use of the new Canadian Physical Activity and Sedentary Behaviour Guidelines for children and youth zero to 17 years of age.

To examine the awareness of, agreement with and use of the new Canadian Physical Activity and Sedentary Behaviour Guidelines for children and youth zero to 17 years of age in a sample of Canadian paediatricians. The findings are based on responses from 331 paediatricians across Canada who completed an online survey in February 2013. Frequencies were calculated for each question. Few paediatricians reported being very familiar with the physical activity (6% for the early years, and 9% for children and youth) or sedentary behaviour guidelines (5% for the early years, children and youth). When made aware of the guidelines, a large percentage strongly agreed or agreed with the physical activity (99% for the early years, and 96% for children and youth) and sedentary behaviour recommendations (96% for the early years, and 94% for children and youth). Of paediatricians who performed well-child visits, 16% and 27% reported almost always making physical activity and sedentary behaviour recommendations, respectively, to parents or caregivers of children in the early years, compared with 37% for both behaviours among children and youth. Thirty-nine per cent (for the early years) and 46% (for children and youth) of paediatricians reported it would be highly feasible to briefly explain the guidelines at a well-child visit. The most common barriers reported for recommending the guidelines were insufficient motivation or support from parents, caregivers or youth, and lack of time. To increase the use of these new evidence-informed guidelines, strategies are needed to increase paediatricians' awareness and reduce perceived barriers.

Why the Canadian Sedentary Behaviour Guidelines Should Reflect Sex and Gender

The world's first evidence-based sedentary behaviour guidelines were released in Canada in 2011. Based on evidence that time spent in sedentary pursuits poses important health risks, the guidelines recommend limits on the time that children and youth are sedentary throughout the day. Although the guidelines reflect differences in age, they do not include recommendations for adults, nor engage with other important determinants of health such as sex and gender, despite research suggesting that girls and boys, women and men, engage in different sedentary behaviours. For example, it has been suggested that girls spend considerable time in communication-based sedentary behaviours such as talking on the phone, texting and instant messaging, while boys are more likely to watch television and videos, or play computer games. There is also evidence suggesting that the health outcomes associated with sedentary behaviour differ for females and males, and there are gendered social and economic barriers that may influence sedentary behaviour. It is therefore time to consider sex and gender in research and policy on sedentary behaviour in order to effectively reduce time spent sedentary and to improve the health of women and men in Canada.

A cross-sectional examination of modifiable risk factors for chronic disease among a nationally representative sample of youth: are Canadian students graduating high school with a failing grade for health?

BackgroundSubstance use and weight gain among youth increase the risk for future disease. As such, the purpose of this study is to examine how many Canadian youth are currently failing to meet substance use and weight gain related public health guidelines.MethodsData from the 2010–11 Youth Smoking Survey were used to examine grade 9 to 12 students meeting seven different guidelines by sex and by grade.ResultsAmong Canadian youth, 8.8% were current smokers, 18.8% were current marijuana users, 25.5% were current binge drinkers, 22.5% were considered overweight or obese, 31.2% did not meet physical activity guidelines, 89.4% exceeded sedentary behaviour guidelines, and 93.6% reported inadequate fruit and vegetable intake. The mean number of risk factors per student was 2.9 (±1.2); only 0.5% of youth reported having none of the risk factors.ConclusionStudents rarely met all seven public health guideline examined, and the vast majority of actually reported having two or more modifiable risk factors for disease.

Paediatricians’ Awareness, Agreement, and use of the new Canadian Physical Activity and Sedentary Behaviour Guidelines (Aged 0-17 Years)

Paediatricians’ Awareness, Agreement, and use of the new Canadian Physical Activity and Sedentary Behaviour Guidelines (Aged 0-17 Years)

Obesity Traffic Stop: A Population Health Intervention Tool Combining Physical Activity and Sedentary Behaviour Guidelines

Obesity Traffic Stop: A Population Health Intervention Tool Combining Physical Activity and Sedentary Behaviour Guidelines

Type 2 Diabetes in Children and Adolescents

Type 2 Diabetes in Children and Adolescents