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In a pilot study Lanningham-Foster et al. Despite the positive results on PA during the two week intervention period the authors did acknowledge that such a project may not be feasible on a large scale. A more feasible approach would be the utilization of standing desks in a regular classroom, which did result in a reduction in sedentary behaviour but did not affect PA.

The incorporation of daily PE has become a popular topic and several programs have implemented daily PE lessons that were supervised by the PE as well as the classroom teacher 29 , Despite positive effects of daily PE on PA, fitness and body composition it remains difficult to convince policy makers to implement daily PE in the general school system. Fairclough and Stratton, therefore, suggest to put more emphasis on activity time during PE, independent of the question of daily PE or not An increased participation in out-of-school PA may be facilitated by increased physical fitness, which was shown as a result of more PE Such a change in leisure time PA may also be achieved by educational approaches during PE that emphasize the benefits of PA after school.

In addition, school-children were given the opportunity to communicate with exercise science students via internet to assist with individual goal-setting and strategies to overcome barriers for an active lifestyle and a healthy diet. Due to the limited time in PE, information, motivation, and education for an active lifestyle should also occur during classroom education. Further, short active breaks in the classroom are commonly used to support the theoretical information on benefits of PA 3 , 21 , 34 , Even though these short breaks may not have a huge impact on daily PA time, they could serve as examples for active choices in the home environment, which would result in a reduction in sedentary time and could potentially contribute to increased overall PA if performed regularly after school.

In addition to the effect on sedentary time and possibly PA, active breaks have been shown to increase attention and cognitive performance 13 , Despite the implementation of various school-based programs to promote PA, evidence on the effects on total daily PA and particularly the transferability beyond the school setting remains inconclusive Several PA promotion programs try to include the parents into the intervention.

Information and education materials are predominantly used to engage parents in the program, but homework for the entire family and teacher-parent meetings may further facilitate parental engagement. As these programs rely on different strategies to promote PA, such approaches are referred to as multi-component intervention programs.

School-based multi-component strategies, including the family, have been shown to be more successful in increasing PA levels in children compared to programs that rely on a single strategy only 11 , 28 , The intervention mapping protocol IMP 2 was used as a theoretical framework for the program development. The IMP is a problem- and theorydriven protocol that was especially developed to guide the design of evidence-based intervention programs.

The protocol describes the interactive process of a health promotion program development in six steps: needs assessment; the identification of outcomes and change objectives; the selection of theory based methods and practical strategies; the program development; generation of adoption and implementation plan; and the evaluation 1. Based on these six steps of the IMP the intervention specifically addresses a promotion of PA along with a reduction in media consumption and sugar-sweetened beverages. Providing active and healthy choices is a key aspect of the program that is predominantly implemented by the classroom teacher.

In addition to flexibility on program implementation and higher acceptance in the teaching community, the utilization of classroom teachers, rather than external experts, allows for a cost-effective and, therefore, sustainable implementation of the intervention over a prolonged period of time. Interested teachers are trained in a series of 3 workshops by experienced colleagues who have undergone extensive training in the implementation of the program. These so-called consulting teachers also provide additional support beyond the workshop series if needed and are engaged in the future development of the intervention program.

Teaching materials have been developed by an interdisciplinary team of scientists in collaboration with experienced primary school teachers in accordance with the current primary school curriculum and consist of 20 lesson plans each for grades 1 through 4. All materials can be directly applied in a classroom setting. In addition, there are 56 activity cards with short exercises that can be performed in the classroom.

Teachers are asked to provide two active breaks per day, lasting 5 to 7 minutes, during their lessons. In grades 3 and 4 there are additional index cards, which provide exercises that can be performed by the children during breaks or recess. These exercises may also serve as active choices for after-school activities. In addition, seven parent letters and materials for two parent-teacher meetings per school-year are provided. The program is currently evaluated via a cluster-randomized study, including almost children in southwest Germany A pilot study already showed positive effects on body fatness and waist-to-height ratio 8 , 7.

The results also indicate a less pronounced age-related decline in PA, which has been shown previously in a similar intervention program implemented by external experts The reliance on external experts, however, increases intervention costs, which hinders sustainability. It may also negatively affect acceptability of the program in the school faculty. In addition to positive effects on PA, a teacher-implemented intervention focusing on motor abilities during PE increased physical fitness The positive effects of multi-component interventions on fitness, PA and body fat percentage have already been reported in pre-school children 44 , which could facilitate sports participation at a young age beyond the intervention and enhance the chances for an active lifestyle throughout childhood and adolescence, possibly into adulthood.

Other multi-component approaches emphasized community engagement in addition to the in-school intervention. Shared activities between schools and local fitness clubs 15 as well as information on the benefits of a healthy lifestyle via print media and local radio 19 are examples of a combination of school-based interventions and community involvement. Even though, specific strategies are based on the needs of individual schools there are 6 aspects that should be addressed — school environment, PE, classroom action, family and community, extracurricular, and school spirit.

While PA was significantly increased in 9- to year-old boys there was no change in PA levels in girls These results indicate that sex specific differences in the promotion of PA during childhood and adolescence need to be considered more strongly when designing and implementing programs to promote PA in youth. Even though numerous intervention programs have been implemented to promote PA during childhood and adolescence there is currently only limited evidence on the efficacy of different approaches, particularly regarding long-term sustainability.

More research, therefore, is needed to enhance the understanding regarding effective strategies to ensure sufficient PA as this is an important aspect in public health. Multi-component strategies seem to be the most promising approach Changes in traditional classroom education and the implementation of active breaks along with accessibility of open spaces during recess and after school are important aspects in the promotion of PA Intervention programs should also be implemented over a prolonged period of time in order to achieve sustainable changes in health behaviour 28 , Along with the prolonged engagement in PA promotion, long-term evaluation of different intervention strategies, following participants beyond the intervention period, should be implemented.

In addition, the evaluation should differentiate between direct outcomes, such as increased PA due to the engagement in specific exercise programs, and the transferability out of the specific intervention setting 4.

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Increasing the understanding of mediators of behaviour change may further contribute to the development of effective intervention strategies Finally, compliance with different programs needs to be considered, as intervention programs can only be successful if the population is willing to participate. Our results further support this statement by showing that patients perceiving their own coping potential as high experienced lower severity of depressive symptoms across time points. Similar to our previous outcomes of the cross sectional analysis Matuz et al.

Coping had rather an effect on quality of life.

Search for information and support significantly predicted high quality of life over time. Problem focused coping attempts have been repeatedly reported as being more adaptive for patients with chronic diseases Young, ; Keefe et al. Avoidant coping has on the contrary lost its predictive power for quality of life at T2. Coping strategies people employ and their utility are likely to vary as the adaptive tasks of illness change Blalock et al.

For example, breast cancer patients who reported frequent use of cognitive avoidance prior to breast biopsy showed less distress at that point, however, higher distress scores after cancer diagnosis and after surgery Stanton and Snider, ; Lutgendorf et al. Avoidant coping strategies may be useful at acute points of specific crisis in the progress of the illness, however, over time avoidance is typically related to maladjustment. Based on our results this seems to be true also for ALS. It may prevent them from taking measures necessary for coping with the disease in the future, such as seeking information about assistive technology for communication or artificial nutrition.

Unexpectedly, perceived social support did not continue to predict quality of life at T2. Consequences of chronic disease can be abrupt and distinctive e. Changes in patients' social relations and networks can proceed with an uneven course Stanton et al. The current cross-sectional results at T2 support this notion by revealing significant contribution of social support in explaining the variance of quality of life indices, yet this time by the individual contribution of the subscale protective buffering.

Thus, people with ALS manifesting more protective behavior toward their partners, e. Whereas partners' overprotection including protective buffering is considered an unsupportive behavior Schokker et al. Being more protective with their partners presumably helps ALS patients in reducing their own perception of being a burden and eventually increases their perception of self-efficacy.

Last but not least, cross sectional regression revealed that none of the adjustment outcomes could be significantly predicted by illness parameters. Severe functional impairment as well as ALS duration are not necessarily related to poorer quality of life and depressive mood. With these results we contribute to the still ongoing debate among ALS care specialists over the role of severity of physical impairment and illness related characteristics in maintaining mental health and quality of life in people with ALS.

Our both cross sectional and longitudinal findings indicate that psychosocial aspects are better predictors of adjustment to ALS than illness related characteristics. Overall, the analyses presented here extend the literature on psychological aspects in ALS and can guide psychological interventions developed for people with ALS. Although mainly limited by the sample size and the drop outs due to death and illness progression, our results enriched the understanding of psychosocial adjustment to ALS.

Empirical evidence is provided for the predictive utility of the adaptation of the stress-coping model in finding those factors that promote or hinder psychosocial adjustment to ALS. Also, the current study contributes to a better conceptualization of adjustment, showing that ALS necessitates adjustment in multiple life domains as the diseases advances.

Existing psychological interventions in ALS can be rendered more efficacious by including the current findings. Whereas cognitive therapeutic strategies targeting appraisal of coping potential and available social resources can be more efficient for depression, behavioral therapy directed toward coping effectiveness training could improve quality of life in ALS. Moreover, dyadic interactions should receive more attention, specifically about reciprocal protective buffering behavior that could assist couples in coping with the challenges faced during illness.

The main limitations of the present study are related to the small sample size which over time due to drop outs lead to an inadequate predictors:sample size ratio for regression modeling at the last two time points. The generalizability of the results should be therefore considered with caution. Moreover, some of the used measures showing moderately strong psychometrical characteristics pose limitations.

Finally, due to a relative high variability and wide range of the time between the measurement time points 3—6 months , which were unavoidable for clinical and organizational reasons results should be interpreted with caution. In future studies more information about dropouts would be desirable to ensure that not only those who manage to adjust well remain in the sample.

Despite these limitations we conclude that psychological strategies exist to cope well with ALS—against all odds—and effort should be invested toward improving support instead of further legalizing euthanasia. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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We thank patients and caregivers for their readiness to participate in the study. We are grateful to Adrian Furdea for designing and making the figures. Matuz received research support in form of a Ph. National Center for Biotechnology Information , U. Journal List Front Psychol v. Front Psychol. Published online Sep Author information Article notes Copyright and License information Disclaimer.

This article was submitted to Psychology for Clinical Settings, a section of the journal Frontiers in Psychology. Received Mar 23; Accepted Jul The use, distribution or reproduction in other forums is permitted, provided the original author s or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

This article has been cited by other articles in PMC. Associated Data Supplementary Materials Table1. DOCX 21K. Abstract For the current study the Lazarian stress-coping theory and the appendant model of psychosocial adjustment to chronic illness and disabilities Pakenham, has shaped the foundation for identifying determinants of adjustment to ALS. Keywords: ALS, coping, depression, quality of life, longitudinal assessment.

Introduction Being diagnosed with ALS constitutes for the afflicted person and its social environment a sudden and, considering the whole range of consequences, an unknown, critical life event. Open in a separate window. Figure 1. Materials and methods Materials and Methods have been taken from our previous work Matuz et al.

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Measures Background data Patients' demographic data referred to age, sex, marital status, level of education, and living arrangement and communication abilities, and were obtained with a semi-structured interview. Illness parameters Three illness related variables were assessed: duration of illness month since diagnosis , dependence on life sustaining treatment ventilation and nutrition , and physical disability [ALS Function Rating Scale Cedarbaum et al. Social support The Berlin Social Support Scales BSSS, Schulz and Schwarzer, was developed based on a multidimensional approach and includes five subscales measuring both cognitive and behavioral aspects of social support: perceived available social support, actually received social support, need for support, search for support, and protective buffering.

Coping strategies Coping strategies can be classified in four categories: problem-management, problem-appraisal, emotion-management , and emotional-avoidance Terry and Hynes, Statistical analysis Normal distribution of the data was tested with Kolmogorov—Smirnov Test.

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Results Most of the patients had spinal onset and sporadic form of ALS. Table 1 Background information. Higher education refers to a duration longer than 10 years. Table 2 Descriptives for depression and quality of life over the measurement time points. Figure 2. Predictors of psychosocial adjutment: descriptives and longitudinal analysis With mean scores ranging between Table 3 Mean scores of model variables. Regression analyses A regression was conducted to determine whether stress-coping model variables that were identified at T1 as being significant predictors continued to predict depression and respectively quality of life at T2.

Table 4 Summary of regression analysis of stress-coping variables at T1 predicting psychological adjustment to amyotrophic lateral sclerosis at T2. Figure 3. Table 5 Summary of regression analyses on the two adjustment variables with the subscales of each stress—coping predictors separately at T2. Discussion Short and long-term psychosocial adjustment to ALS For our longitudinal study the adaptation of Lazarian stress-coping theory to chronic illness and disabilities Pakenham, has shaped the foundation for identifying determinants of adjustment to ALS.

Implications for clinical and home healthcare Overall, the analyses presented here extend the literature on psychological aspects in ALS and can guide psychological interventions developed for people with ALS. Limitations The main limitations of the present study are related to the small sample size which over time due to drop outs lead to an inadequate predictors:sample size ratio for regression modeling at the last two time points.

Conclusions Despite these limitations we conclude that psychological strategies exist to cope well with ALS—against all odds—and effort should be invested toward improving support instead of further legalizing euthanasia. Conflict of interest statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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