2015 ArKAHPERD JUNE Vol. 50

1

June 2015 Volume 50 – Number 1

Arkansas Association for Health, Physical Education, Recreation, & Dance

2

May 2015 – Arkansas Journal – Volume 50 – Number 1

CONTENTS

News and Information

Award Qualifications . . . . . . . 3

Message from the President. . . . . . . 4

ArkAHPERD Board of Directors. . . . . . 5

Special Topic

Arkansas Decreases Physical Education Requirement

by Andy Mooneyhan ASU, Mitchum Parker UCA . . . . 6

Faculty Peer Reviewed Articles

Adherence of Wellness Principles in Physical & Health Educators: Can

the Physical Dimension Predict Overall Wellness:

by Keri Essinger, WKU . . . . . 8

Reducing Breast Cancer Through the Utilization of the Health Belief Model:

A Literature Review

by Kendra Guilford, U of B, Lorit Turner, U of Alabama,and

Sharon Hunt U of Arkansas . . . . . . . 16

Preventing Sleep Deprivation through Behavior Modification: A Review

by Kathryn Jones UAB, Lori Turner, U of Alabama, Sharon Hunt U of Arkansas 27

Accessibility of Public Schools’ Extracurricular Activities for Homeschooled Students

by David Lavetter ASU . . . . . . . . 43

The Effects of Using Physical Activity in the Classroom to Enhance

Children’s Cognition by Blair McAlister ASU & Blair Dean ASU . . . 51

Student Submission Peer Reviewed Article

Arkansas High School Athletics: The Most Important Test That is Sometimes

Never Given by James Hines ASU . . . . . . . . . 66

3

Lifetime Achievement Award

Candidate must meet the following qualifications:

A. Be at least 30 years of age and have earned a Master’s degree or its equivalent.

B. Have served the profession for at least five years prior to the nomination.

C. Be a current member of ArkAHPERD. Former members who have retired from professional work may be exempt.

D. Be of high moral character and personal integrity who by their leadership and industry have made outstanding and noteworthy contributions to the advancement of our profession in the state of Arkansas. To indicate leadership or meritorious contributions,

the nominator shall present evidence of the nominee’s successful experiences in any two of the following categories of service:

1. Service to the association. 2. Advancement of the profession through

leadership of outstanding programs. 3. Advancement of the profession through

presentation, writings, or research.

Any ArkAHPERD member may submit nominations by sending six (6) copies of the candidate’s qualifications to Janet Forbess, [email protected].

TEACHER OF THE YEAR

Teacher awards are presented in the areas of elementary physical education, middle school physical education, secondary physical education, dance, and health.

Candidate must meet the following qualifications:

A. Have served the profession for at least three years prior to the nomination.

B. Be a member of AAHPERD & ArkAHPERD. C. Be of high moral character and personal integrity

who by their leadership and industry have made outstanding and noteworthy contributions to the advancement of teaching in the state of Arkansas.

D. Be employed by a public school system in the state of Arkansas.

E. Have a full time teaching contract, and have a minimum of 60% of their total teaching responsibility in the nominated area.

F. Have a minimum of five years teaching experience in the nominated area.

G. Conduct a quality program. They must submit three letters of recommendation and agree to make complete NASPE application if selected.

Any ArkAHPERD member may submit nominations by contacting Bennie Prince, [email protected].

HIGHER EDUCATOR OF THE YEAR

Candidate must meet the following qualifications:

Scholarships

STUDENT

A. Have served the profession for at least three years prior to the nomination.

B. Be a member of ArkAHPERD C. Be of high moral character and personal

integrity who by their leadership and industry have made outstanding and noteworthy contributions to the advancement of teaching , research, or service in the state of Arkansas.

D. Be employed by an institution of higher education in the state of Arkansas.

Any ArkAHPERD member may submit nominations by sending a copy of the candidate’s qualifications to

Agneta Sibrava, [email protected].

ArkAHPERD awards four scholarships annually for students majoring in HPERD. They include the Newman McGee, Past President’s, Jeff Farris Jr., and John Hosinski scholarships. Students must possess a minimum 2.5 GPA. [See your academic advisor for details.]

Research Award

Research awards of $100, $50, and $25 are awarded to undergraduate and graduate students who are members of ArkAHPERD. Students must submit an abstract and a complete paper to Rockie Pederson, [email protected] by October 1. Papers selected for the research awards must be presented by the student in an oral or poster format at the November convention.

ArkAHPERD Web Site: http://www.arkahperd.com

AWARD QUALIFICATIONS

4

Hello ArkAHPERD Members,

Thank you for believing in this public health and physical education teacher

and giving me the opportunity to serve as your association president through

the fall of 2015. Working together, we have no limits!

There are many highlights within our organization for which we can be proud:

• Our membership is strong and continues to grow as we work toward our goals.

• We have added additional summer workshops to reach out to those that may not

be able to attend our state convention.

• We are continuing our collaboration with the American Heart Association through

the Jump and Hoops for Heart programs and Let’s Move to raise funds to help our

Association continue the fight against heart disease.

• Future professionals are active within the organization as new leaders.

• Social media outlets are enabling the organization to connect our members with

other professionals at a state, regional, and national level.

• Our state convention is not only educational but also entertaining as we have our

workshops and time to network and play with other state professionals.

The Time is Now is this year’s theme. With all of the uncertainty that is going on in the state

legislature, now is the time for us to show that there is more than just rolling out the ball; but

that we believe in our programs and that our students’ health is of the greatest importance.

Advocating for quality health and physical education programs is crucial. Staying current

with needs, trends, and current research is critical to this advocacy. The Time is Now for all

of us to step up, encourage each other, and do our part. Help to send letters to our legislators,

lead professional development, or become an active board member.

I encourage you to mark your calendars for convention 2015 in Eureka Springs. It will be

one you don’t want to miss! Make a difference in someone else’s life by modeling a

healthy and active lifestyle.

Thank you, Leah Queen,

PRESIDENT ArkAHPERD

Message from the President

5

ArkAHPERD Board of Directors

Executive Committee Leah Queen President [email protected] Allen Mooneyhan President-elect [email protected] Brett Stone Past-president [email protected] Andy Mooneyhan Executive Director [email protected]

Division Vice Presidents/VP-elects Leah Queen Health [email protected]

John Kutko Physical Education [email protected]

Allen Mooneyhan Recreation [email protected]

Cathryn Gaines Dance [email protected]

Jan Caldwell Athletics & Sports [email protected]

Shellie Hanna Exercise Science [email protected]

Dennis Perkey Athletic Training [email protected]

Claudia Benevidas Sports Management [email protected]

Agneta Sibrava Higher Education & Research [email protected]

University of Central Arkansas Future Professional

University of Central Arkansas Future Professional

District Senators Jeremy Mabry District I [email protected]

Shelia Jackson District II [email protected]

Kelly Spencer District III [email protected]

Amanda Turner District IV [email protected]

January Schultz District V [email protected]

Cyndra Robinson District VI [email protected]

Standing Committees Leah Queen Executive Committee [email protected]

Bennie Prince Teacher Awards [email protected]

Rockie Pederson Student Awards [email protected]

Bennie Prince Publications [email protected]

Janet Forbess Lifetime Achievement Award [email protected]

Andy Mooneyhan Constitution/Membership [email protected]

Additional Committee Members Mitch Parker Web [email protected]

Carhryn Gaines JRFH/HOOPS [email protected]

Janet Forbess Convention Planning [email protected]

6

Special Topic- Peered Review Article Arkansas Decreases Physical Education Requirement

by Andy Mooneyhan ASU, Mitchum Parker UCA

Arkansas is decreasing its required physical education time. House Bill 1527, “an Act to

provide flexibility to school districts in scheduling Art, Music, and Physical education and for

other purposes” has made its way through the Arkansas legislature and is now Act 1079. The bill,

in part, decreases the required physical education time in Arkansas schools from 60 minutes per

week to 40 minutes per week. After a call from ArkAHPERD members to contact state house and

senate leaders the bill moved on to the Governor’s office. Governor Asa Hutchinson signed the bill

into law laying the way for a decrease in physical education in Arkansas.

At a time of high obesity rates and declining health of today’s children it seems the national

scene is looking to promote physical education and activity time. The national Society for Health

and Physical Educators (SHAPE) recommends 150 minutes of instructional physical education for

elementary school children. The Department of Health and Human Services (HHS) issues the

Physical Activity Guidelines for Americans that went even further in recommending 60 minutes of

activity every day for children 6-17. According to a SHAPE (2015) America press release, the

Senate Health, Education. Labor & Pensions Committee introduced bipartisan legislation, the

Every Child Achieves Act of 2015 that would elevate the role of physical education as an academic

subject (SHAPE 2015). Clearly national organizations and agencies are realizing a need for

increased physical education and activity time and even the federal government seems to be

moving forward in establishing the importance of physical education. During a time of obese

children and adults and the plethora of associated diseases and conditions it is time to increase

standards and actively combat this health concern – NOT decrease standards.

Currently Arkansas is one of the leading obese states, with only Mississippi and West

Virginia reporting higher obesity rates (CDC, 2013). Arkansas has however in the past placed a

focus on the health of its citizens in relation to fighting obesity and taking steps to decrease

associated health disparities. In fact, Arkansas began to make progress with health initiatives and

governmental support such as Act 1220 and ADE nutrition & physical activity rules. These

initiatives focused on healthier Arkansas children and provided a model for the nation. The

initiatives increase of quality physical education and time allocated for physical activity as well as

redefined the push for appropriate nutrition in our schools.

Beginning in 2012 we began to reverse the progress we had made. Couched in what

appears to be a very stringent set of regulations from Arkansas Department of Education was the

removal of the ACT 1220 requirements for trained physical educators and proper PE facilities in

elementary schools. The 2012 ADE Rules further eroded the process by allowing for non-certifies

physical education teachers in the classroom. Arkansas seems to be making decisions that no

longer focus on increased physical education and activity time needed to improve the health of our

children

The most recent decrease in physical education further jeopardizes the health of Arkansas

children. Act 1079 effectively decreases time in physical education for our children and appears to

continue the unfathomable push toward further regress. Arkansas is doing the opposite of what is

being done on the national scene in regards to physical education and activity as it decreases the

required time in physical education for Arkansas children. This is likely to bear directly on health

7

care costs and lost revenue in the state. Aetna (2015) stated the following related to escalating

healthcare cost and corresponding chronic diseases.

“The growing burden of chronic diseases adds significantly to escalating health care

costs. Researchers predict a 42 percent increase in chronic disease cases by 2023,

adding $4.2 trillion in treatment costs and lost economic output.18 Much of this cost

is preventable, since many chronic conditions are linked to unhealthy lifestyles. For

example, obesity accounts for an estimated 12 percent of the health spending

growth in recent years” – AETNA,2015

Physical education is often among the first causalities of standardized testing, budget cuts,

and misinformation. This is erroneously believed to increase student tests scores and overall

performance. However these subjects have been shown to promote only positive effects on

academic performance. With PE, not only does the research demonstrate that increased time in

physical education does not negatively impact student performance (CDC, 2013), but has gone so

far as to demonstrate a direct link between PE and academic improvement (Crawley, Frisvold &

Meyerhoefer, 2012).

ArkAHPERD has identified specific senators to work with and will be formulating a plan

of action related to bringing about positive change to physical education in Arkansas. Interested

senators want to examine what physical education in Arkansas really consists of and look at ways

to make sure it leads to improved health of Arkansas children. The Governor’s office has been

contacted and ArkAHPERD representatives are awaiting a response on a request to meet. With

change coming ArkAHPERD will continue to address and push for appropriate health and physical

education. As we address these important issues we will remember that the health of our children is

at stake.

References 1. Aetna, 2015. The Facts About Rising Health Care Cost. http://www.aetna.com/health-

reform-connection/aetnas-vision/facts-about-costs.html

2. Center for Disease Control (CDC), 2013. Obesity Prevalence Maps: Obesity prevalence in

2013 varies across states and territories. http://www.cdc.gov/obesity/data/prevalence-

maps.html

3. Center for Disease Control (CDC), 2013. Supporting Quality Physical Education and

Physical Activity in Schools.

http://www.cdc.gov/healthyyouth/npao/pdf/LWP_PEPA_Brief_2012_13.pdf

4. Crawley, J.; Frisvold, D. &Meyerhoefer, C. 2012. The Impact if Physical Education on

Obesity among Elementary School Children. IZA Discussion Paper No. 6807.

http://ftp.iza.org/dp6807.pdf

5. Department of Health &Human Services (HHS), 2015. Physical Activity Guidelines.

http://www.health.gov/paguidelines/default.aspx

SHAPE, 2015. SHAPE America Salutes Inclusion of Physical Education as a Core Subject.

http://www.shapeamerica.org/pressroom/2015/pe-as-a-core-subject.cfm.

8

Faculty Peered Review Article

Adherence of Wellness Principles in Physical and Health Educators: Can the Physical Dimension Predict

Overall Wellness?

Keri Essinger Ph.D Western Kentucky University

Introduction

Historically, physical educators have believed they need to model positive behaviors in regards to

physical activity (Spencer, 1998). In fact, physiologists, sociologists, and educational theorists consider

modeling to be one of the earliest ways in which children are socialized into their community (Gould &

Roberts, 1981). Research regarding modeling in the physical education and health field has primarily

focused on physical activity. However, recent evidence reveals that health and well-being are holistic and

much more than just physical.

Wellness is comprised of six dimensions, which were first proposed by Hettler. Components of the

six-dimension model include physical, emotional, intellectual, social, occupational, and spiritual wellness.

Hettler’s model is designed to emphasize the person creating a balance in life. The model highlights the

importance of creating co-existing areas that comprise one’s life and overall wellness status (National

Wellness Institute [NWI], 2006). Areas that affect wellness such as one’s social well-being, stress,

environment, spirituality, and occupation can also play a major part in overall health. All the dimensions of

health are interrelated and impact one another. The ability to deal with stress is an example of how one

dimension can affect another.

Despite the advances in knowledge regarding self-destructive behaviors, the progress the United

States has made toward healthy behaviors has been minimal, and the main focus has been on the physical

dimension (U.S. Department of Health and Human Services [USDHHS], 2000). When one looks at the

magnitude of what the United States is facing in the fight for the health of individuals health, it becomes

clear that researchers cannot focus only on issues pertaining to the physical dimension such as the obesity

crisis. There are other issues as well. In 2007, the teen suicide rate increased by 8% for 10-to-24-year-olds

following a previous suicide decline of more than 28%, the highest it has been in 15 years (CDC, 2004).

Healthy People 2010 indicated that while fitness is a key component in maintaining a healthy

lifestyle, it is no more important than the other components of wellness (USDHHS, 2000). However, when

discussing whether or not our physical and health educators are healthy, we often test them using a variety

of body composition tests and physical activity level, leaving out other components of wellness (Brandon &

Evans, 1988; Cardinal, 2001; La Vine & Ray, 2006; Whitley, Sage, & Butcher, 1988). Limited research

was found regarding wellness adherence of physical and health educators. Research regarding physical and

health educators as role models for students in the physical dimension was more substantial. Research in

this area commonly assesses the fitness dimension of wellness, basing role modeling on whether or not the

participants are adhering to recommendations within the physical dimension (Cardinal, 2001; Clark, Blair,

& Culan, 1988; La Vine & Ray, 2006; Spencer, 1998 Whitley et al., 1988). Researchers feel the physical

dimension determines if a physical educator is a positive representation of good health. Researchers have

stated that educators must exhibit positive health behaviors, and that fitness must be a way of life in order

for health and physical educators to portray themselves as role models (Bucher & Thaxton, 1981; Johnson,

1985).

Studies in the area of role modeling and adherence to a wellness lifestyle have mainly stayed within

the physical dimension. In an attempt to examine the area outside the physical dimension of wellness, Clark

et al. (1988) conducted a study addressing the lifestyle characteristics of health and physical educators.

They asked questions related to health and fitness knowledge, physical education instruction, physical

activity levels, intramural and interscholastic programs, and demographic information. However, the only

9

area focused on in the discussion was the results of the physical activity levels of participants.

Despite the shift in focus in physical and health education from purely physical to a more balanced

wellness approach as evidenced by new mandates and laws (Chen & Ennis, 2004), little research was found

to assess actual wellness lifestyle behaviors of physical and health educators. Of the research reviewed,

little evidence was found to demonstrate whether or not physical and health educators are modeling positive

wellness behaviors outside the physical dimension. If we know improved wellness in all dimensions leads

to optimum health, then all dimensions need to be evaluated when assessing a person’s wellness. Physical

and health educators need to model positive health behaviors in all dimensions of wellness, not just the

physical dimension.

The purpose of this study was to determine to what extent physical and health educators adhere to

wellness principles. A secondary purpose was to determine if using exclusively the physical/nutritional

dimension of wellness could serve as a strong predictor of physical and health educators’ overall wellness.

The following research questions were used to guide the research:

1. To what extent do physical education and health educators demonstrate wellness?

2. Can the physical/nutritional dimension of wellness predict overall wellness?

Methods

This study involved kindergarten through 12th-grade physical and health educators from throughout

the state of Arkansas. They were contacted using a variety of electronic mail lists and/or calling the schools

for access to email addresses. The participants in the survey ranged in age from 24 to 71 with a mean age of

43.5. They had varying levels of teaching experience and varying levels of education ranging from

bachelors to doctoral degrees (31 Baccalaureate, 33 Masters, 3 Doctorate, 1 Other). Prior to contact with

the participants, the researcher was granted permission through the University of Arkansas Institutional

Review Board to carry out the research. All participants volunteered for the study and the researcher

obtained informed consent from each. Participants were given information regarding their wellness status

upon completion and provided the researcher’s contact information if they had any questions or concerns

following their participation in the research.

Instrumentation

The TestWell

HLQ was used to evaluate the overall wellness of the subjects and to determine

whether the physical dimension was correlated with the overall composite score of wellness. TestWell® is

based on the six-dimensional model of wellness conceived by Hettler over 25 years ago. This six-

dimensional model emphasizes the importance of creating a balance in the many different areas that

comprise a person’s life. Each of these affects the others and determines overall wellness status. TestWell®

is designed to help the individual assessment taker become aware of these different areas and to help him or

her identify areas that need improvement. The National Wellness Institute (NWI) developed the 100-item

instrument, which has 10 questions in each of 10 different categories. The categories include the following

dimensions: Physical/Nutrition, Self-Care, Safety, Environmental, Social, Emotional Awareness (sexuality),

Emotional Management, Intellectual, Occupational, and Spiritual.

The questionnaire uses a five-point Likert scale. Scores in the dimensions of wellness are computed

by adding the scores of specific categories together (Richards, 1996).

The NWI recommendations for interpretation of TestWell® scores are stated in Table 1. The

TestWell® HLQ has been found to be internally valid and reliable. The internal consistency coefficients for

the instrument as well as physical and non-physical factors suggest internal consistency. The test-retest

correlation coefficient was 0.96 (McClanahan, 1990). Plyometric properties of the TestWell® have also

been measured against two other instruments, the Wellness Inventory (WI) and Lifestyle Coping Inventory (LCI). The three instruments were highly correlated with one another with coefficient alpha scores at 0.79,

0.70, and 0.82 respectively (Palombi, 1994). Permission to use the survey and website was done by

purchasing a number of questionnaires, as well as paying a set-up fee.

Procedures

10

An electronic mail was sent to approximately 400 educators via the listserv of the Arkansas

Department of Education (ADE). The participants of this survey were volunteers, and the researcher

obtained informed consent from each participant through the TestWell® website. Participants who did not

give consent were not given access to the survey. In the email, participants were given information and

instructions as to where they would be able to access the survey, accept the informed consent, take the 100-

item survey, and complete the demographic questions. Upon completion of the 100-item survey,

participants had the option of viewing their results through the TestWell® center, and receiving resources

that could potentially help them make positive behavioral changes concerning wellness. This was an

incentive that was stated in the electronic mail.

Statistical Analyses

Descriptive variables were analyzed using frequencies, means, and standard deviations. Pearson

correlation coefficient analyses were calculated to investigate the effects that the physical/nutritional

dimension have on predicting overall wellness of physical and health educators. Correlation Matrices were

used to ensure that all significant differences were a result of the TestWell® dimensions independently

showing significance. Pearson product–momentum correlations were calculated between overall wellness

and the physical/nutritional dimension. Correlations between .10 and .29 were classified as small,

correlations between .30 and .49 were classified as moderate, and correlations ≥ .50 were considered large

(Glass & Hopkins, 1984; Kirk, 1982). Statistical calculations were considered significant at the alpha level

of p < .05. The SPSS 17.0 statistical package was used to analyze all data. Data was imported from the

TestWell® website into the SPSS program.

Results

Preliminary data analysis included those on participant demographics. The following tables

illustrate descriptive variables. Table 2 lists frequency, percent, and mean ages of female and male

participants. Table 3 shows the frequency of individuals in the 40-and-over and under-40 age groups.

Tables 2–4 give the mean ages of each group. Table 4 presents frequencies of participants who taught both

health and physical education, or just physical education.

To what extent do physical and health educators demonstrate wellness was evaluated in research

question one. The data revealed physical educators and health educators demonstrated an overall composite

score of 773 and 795 respectively. Mean and standard deviations of each dimension of the TestWell® are

listed in Table 5.

Pearson product–momentum correlations were calculated between overall wellness and the physical

dimension of wellness subset to answer research Question #2; Can the Physical/Nutritional Dimension of

Wellness Predict Overall Wellness? Table 6 shows the results of the correlation analyses of the

physical/nutritional dimension of wellness as compared to the overall score. Results show there was a

moderate correlation (r2 = 0.44) for participants on overall wellness as compared to the physical/nutritional

dimension.

Discussion

The purpose of this study was to determine the extent to which physical and health educators adhere

to wellness principles, and to determine if using exclusively the physical/nutritional dimension of wellness

could serve as a strong predictor of physical and health educators’ overall wellness.

Research Question # 1: The Extent to Which Physical Educators and Health Educators Demonstrate

Wellness The researcher used descriptive statistics such as means and standard deviation to show the extent

to which physical educators and those who teach both health and physical education demonstrate wellness.

The data concerning the physical/nutritional dimension coincides with research on inactivity and

tobacco use (CDC, 2004). The lowest score was in the physical/nutritional dimension, ( = 63.79). While

these scores are not quite in the “room for improvement” area, the NWI suggests that anyone with a score

below the 80s in a single dimension should look to make positive improvements in that dimension. Since a

score of 60 is the cut off for the “good” category, the participants’ scores were not ideal for their profession.

The dimensions with the second and third lowest scores displayed were the environmental ( =  

X

X

11

67.47) and self-care ( = 69.85) dimensions. Though not in the low 60s, all of these scores were still at

least 10 points below the “excellent” rating that the NWI encourages individuals to use as their goal. The

last dimension in which participants did not reach a rating of 80 was the emotional management dimension (

= 75.76), with scores in the mid 70s.

The highest scores were demonstrated in the safety dimension ( = 92.00). In all other

dimensions—spiritual, occupational, social, and emotional awareness (sexuality)—scores were above 80

and considered “excellent.” This data supports past research, which states that many Americans have yet to

achieve overall wellness (Omizmo et al., 1992). Physical and health educators are doing a “good” job,

according to NWI standards, in the extent to which they demonstrate overall wellness. However, all things

considered, particularly their level of education and expectations of others, physical and health educators

should be looking to demonstrate wellness at the “excellent” level. Further research in this area may want

to look at whether specific dimensions and overall wellness show significant differences between the

physical and health educators, and non-health and physical education teachers.

Research Question #2: Physical/Nutritional Dimensions Predictability of Overall Wellness The researcher used a Pearson product–momentum correlation between overall wellness and the

subset physical dimension of wellness to calculate the physical/nutritional dimension’s predictability of

overall wellness. The results of the correlations showed there was a moderate correlation combined (r2 =

0.44) on overall wellness as compared to the physical/nutritional dimension. These results are very

important for future research in the areas of wellness and role modeling. Past research into role modeling in

physical education used primarily the physical dimension as the determining factor of whether physical and

health educators were positive role models (Brandon & Evans, 1988; Bucher & Thaxton, 1981; Cardinal,

2001; Clark et al., 1988; Johnson, 1985, La Vine & Ray 2006; Spencer, 1998, Whitley et al., 1988). Some

might say that is the way it should be. NASPE’s definition of a physically educated person describes,

among other things, one who “is physically fit.” If this were the case, then should not all professional

wrestlers with low body fat be considered positive role models? Does that mean that NFL wide receivers

and secondary players are better choices for role models than offensive linemen (who are not known for

their physique) like Will Shields, who is second only to Brett Favre in consecutive games played, has gone

to the Pro Bowl twelve times and all-pro nine times and was once named NFL Man of the Year, but may

have a higher BMI and not look physically fit? Shields works out and gives back to the community just like

many who live a balanced life of wellness. However, he will never have a physique like that of some of the

players in other positions. Does that mean that he is not “well” and cannot be a role model? Translating that

back to the classroom, is it fair to say that only the very physically fit educators can be role models? That is

not to say that one should not be working towards better physical/nutritional health at all times. But are we

really serving our students’ needs by saying a person is only a role model if their BMI is under a certain

number and they exercise a certain amount per week? That should be an equal part of total wellness, but

not the sole focus.

Limitations

The study had several limitations. First, while the TestWell® instrument was valid and reliable, the

nature of the data collection resulted in an initial low N. The instrument was too long for many physical and

health educators to want to complete. The sample was large enough for descriptive statistics and

correlations, but the sample ideally could have included more males. Another unforeseen issue brought to

the attention of the researcher was the nature of the questions in the survey. Some of the questions

regarding wellness dealt with sexual health and the researcher received feedback that there were physical

and health educators who stopped taking the survey upon reaching those questions. Lastly, those who

ultimately chose to participate may have been a limitation. The mean score of the entire group for

intellectual wellness was 79.03, which is almost within “excellent” range. This shows that the group who

chose to participate cares about intellectual health, learning, professional development, and potentially

helping a colleague by taking a survey.

X

X

X

12

Conclusions Physical and health educators are demonstrating wellness at a level that coincides with what one

would expect of the general population, not what would be expected of individuals who teach physical

education and health. Much previous research states that physical and health educators are exhibiting

positive role modeling behaviors. However, the physical/nutritional dimension only showed a moderate

correlation with overall wellness, and much of what was found in this study indicated that physical and

health educators are showing no greater modeling behaviors in wellness than anyone else in the population.

Should physical and health educators even be expected to be wellness models? Upon completion of this

study, there are many more questions that need to be answered.

References

Brandon, L. J., & Evans, R. L. (1988). Are physical educators fit? Perceived and measured physical fitness

of physical educators. Journal of Physical Education, Recreation and Dance, 59(7), 73–75.

Bucher, C. A., & Thaxton, N. A. (1981). Physical education and sport: Change and challenge. St. Louis,

MO: Mosby.

Cardinal, B. J. (2001). Role modeling attitudes and physical activity and fitness promoting behaviors of

HPERD professionals and preprofessionals. Research Quarterly for Exercise and Sport, 72(1), 84–

90.

Centers for Disease Control. (2004, March 4). Physical Inactivity and Poor Nutrition Catching up to

Tobacco as Actual Cause of Death. Retrieved April 12, 2009, from

http://www.cdc.gov/od/oc/media/pressrel/fs040309.html

Chen, A., & Ennis, C. (2004). Goals, interests, and learning in physical education. Journal of Educational

Research, 97(6), 329–338.

Clark, D. G., Blair, S. N., & Culan, M. R. (1988). Are HPE teachers good role models? Journal of Physical

Education, Recreation & Dance, 59(7), 76.

Gould, D., & Roberts, G. C. (1981). Modeling and motor skill acquisition. Quest, 33(2), 214–230.

Johnson, M. W. (1985). Physical education—fitness or fraud? A call for curriculum reform. Journal of

Physical Education, Recreation and Dance, 57, 33–55.

La Vine, M. & Ray, C. (2006). Physical activity patterns of PETE majors: Do they walk the talk? Physical

Educator, 63(4), 184–195.

National Wellness Institute. (2006). Retrieved January 28, 2009, from http://www.nationalwellness.org/

Omizmo, M., Omizmo, S. A., & D’Andrea, M. J. (1992). Promoting wellness among elementary school

children. Journal of Counseling and Development, 71, 194–202.

Palombi, B. (1992). Psychometric properties of wellness instruments. Journal of Counseling &

Development, 71(2), 221–225.

Spencer, A. (1998). Physical educator: Role model or roll the ball out? Journal of Physical Education,

Recreation & Dance, 69(6), 58–63.

13

U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and

improving health. Washington, DC: Author.

Whitley, J. D., Sage, J. N., & Butcher, M. (1988). Cardiorespiratory fitness: Role modeling by P.E.

instructors. Journal of Physical Education, Recreation & Dance, 59(7), 81. Table 1 Interpretation of TestWell

® Scores

Interpretation of Scores

In Each Section Overall Wellness

80–100 Excellent 800–1000 Excellent

60–79 Good 600–799 Good

Less than 60 Room for Improvement Less than 600 Room for Improvement

Table 2

Gender Frequencies

Gender Frequency Percent

X age of group

Female 50 73.5 43.92

Male 18 26.5 42.00

Table 3

Age Frequencies

Age Frequency Percent

X age of group

< 40 years old 28 41.3 32.78

≥ 40 years old 40 58.8 50.80

Table 4

Teaching Concentration Frequencies

Teaching Concentration Frequency Percent

X age of group

Health and Physical Education 35 41.3 44.83

Physical Education 33 58.8 41.91

Table 5 Descriptive Statistics for Total Sample (n = 68)

Wellness Section Mean SD

Physical/Nutrition 63.79 14.21

Self-Care 69.85 14.89

Safety 92.00 8.13

Environment 67.47 15.24

Social 87.09 11.67

Emotional Awareness 86.29 12.82

Emotional Management 75.76 11.67

Intellectual 79.03 12.64

Occupational 82.56 11.75

14

Spiritual 80.74 13.32

Overall Wellness 784.59 84.77

Table 6

Correlation (Physical/Nutrition Dimension and Overall Wellness)

Group Pearson r2 p-value

Whole Group 0.660 0.44 *0.001

*p < .05

Call for Presentations

For anyone wanting to present at the 2015 State Convention, the

proposal form is on the ArkAHPERD web page.

Congratulations!

Ronnie Bates, Meghan Head, Natalie

McNeely

2014 HFH Coordinators of the Year

15

Faculty Peered Review Article

REDUCING BREAST CANCER THROUGH THE UTILIZATION OF THE HEALTH BELIEF

MODEL: A LITERATURE REVIEW

Kendra Guilford, U of B, Lorit Turner, U of Alabama, Sharon Hunt U of Arkansas

INTRODUCTION

Many of the risk factors linked to the leading causes of morbidity and mortality in present

day America are clearly associated with health behavior and lifestyle choices (U.S. Department of

Health and Human Services [USDHHS], 2009). Chronic health diseases remain a leading public

health concern in the U.S. and have been for decades (Centers for Disease Control [CDC], 2008).

Because of its significance in terms of both incidence and mortality, a specific chronic disease that

warrants scrupulous reflection is cancer. An estimated 1,437,180 Americans received a new

diagnosis of invasive cancer in 2008; 565,650 Americans died in the same year due to this chronic

disease (CDC, 2009). For 2008, the overall annual cost of cancer for our country was $228.1

billion (CDC, 2009). Moreover, because of an increasing American population, cancer costs are

very likely to increase, as well (CDC, 2009).

A major goal outlined in Healthy People 2010 is to reduce the number of new cases of

cancer, cancer-related illnesses, and cancer-related deaths in our country (Loerzel & Busby, 2005).

Healthy People 2020 also contains a newly proposed objective specifically related to cancer: “to

increase education to the U.S. public about cancer risks and prevention” (USDHHS, 2009).

Furthermore, a myriad of organizations throughout the country – both governmental and private –

are dedicated solely to reducing health disparities in cancer in our nation at the local, state, and

national levels (American Cancer Society [ACS], 2009; Loerzel & Busby, 2005).

Because of its associated issues of depression, disfigurement, body image, and sexuality –

coupled with overwhelming financial constraints – breast cancer is unique from other forms of

cancer. Moreover, because it has significantly infiltrated virtually all classifications of women in

our country, in terms of ethnicity, socio-economic status, and religion, breast cancer has mandated

national (and global) attention. A major proposed objective of Healthy People 2020 that was

retained from Healthy People 2010 is to “reduce the female breast cancer death rate.” (USDHHS,

2009). An additional objective has also been proposed for Healthy People 2020 that directly

relates to the breast cancer incidence in our nation: “to decrease incidence of late-stage disease

breast cancer.” Accordingly, our federal government has increased funding for early detection,

diagnosis, and prognosis of breast cancer from $36.4 million to $73.2 million. Even more, the total

number of projects dedicated solely to early detection, diagnosis, and prognosis of breast cancer in

our country has risen from 197 to over 288 (NCI, 2009).

The overriding impact of community, social, environmental, and intrapersonal factors on

breast cancer incidence cannot be ignored. Factors such as diet, exercise, gender roles, income,

education, culture, and individual attitudes and beliefs are all interconnected in the schema of

underlying issues contributing to the prevalence of breast cancer.

According to the American Cancer Society (ACS) (2009), an estimated 192,370 women

were diagnosed with breast cancer in 2009, with 40,170 women dying from the disease. Although

the overall mortality rate due to breast cancer is on a decline (CDC, 2009); Welch, Miller, &

James, 2008), the incidence of breast cancer has risen gradually over the past century (Wood,

16

2009). This disease is currently considered the most common cancer (other than skin cancer), and

the second leading cause of cancer death among women in the U.S., surpassed only by lung cancer

(NCI, 2009). One out of every eight American women will develop breast cancer at some point in

her life. Each year in the United States, more than 192,000 women are diagnosed with breast

cancer (NIH,2009), and 250,000 U.S. women living with the disease are under the age of 40 (CDC,

2009). Moreover, younger women with breast cancer tend to experience worse outcomes and more

advanced disease than older women (CDC, 2009).

Impact of Breast Cancer

The overall impact of breast cancer ranges from the financial to the physiological to the

psychological and social (ACS, 2007). In the late 1990s, for instance, the total cost of illness for

breast cancer was an estimated $3.8 billion, $1.8 billion of which represented medical care costs.

The associated annual costs for breast cancer-specific medical treatment are now estimated at $8.1

billion (NCI, 2009); Welch et al., 2008). Even more, our country currently spends approximately

$548.7 million dollars in breast cancer research alone (NCI, 2009).

Even among women with comprehensive insurance, the financial burden of a breast cancer

diagnosis can still be quite considerable. Direct medical and nonmedical expenses such as

treatment, childcare, transportation, and income lost due to cancer-related morbidity and treatment

add to the financial constraints for many women, (Arozalla et al., 2004). Moreover, studies have

shown that women with cancer are more likely than men to have to pay for transportation, nursing

care, and housecleaning, to have inadequate family support, and to be without a spouse or

significant other.

In their study examining the financial burden of breast cancer, Arozullah et al. (2004)

interviewed a total of 156 women about cancer-related-out-of-pocket costs, as well as their

knowledge and use of cancer insurance policies. To be included in the study, participants had to be

over the age of 18, had to have received a confirmed breast cancer diagnosis within the past 24

months, and had to have a life expectancy greater than 6 months. Specifically, the researchers

assessed the women’s age, insurance status, education, marital status, ethnicity, time since

diagnosis, caregiver status, wages, annual household income, time missed from work, and out-of-

pocket costs related to cancer treatment during the previous 3 months. Patients’ age ranged from

29 to 78 years, with a mean of 52 years. Eighty percent of the patients described themselves as

white, 10% as black, 5% as Latino, and 4% as Asian. After conducting the study, researchers

found that the monthly financial burden of breast cancer averaged $1,455 per month. Individual

estimates ranged from $0 to $15,700 per month (Arozullah et al., 2004). In addition, researchers

found half (50%) of the overall financial burden associated with breast cancer was directly related

to lost income. In essence, this study showed that the financial impact of breast cancer can be quite

substantial, even among women fortunate enough to have comprehensive health insurance policies;

the impact can be even greater among women without health insurance. This study highlighted the

need for more affordable programs that provide reimbursements for medical and nonmedical costs

incurred after a breast cancer diagnosis, particularly for low-income women (Arozullah et.al.,

2004).

The burden of breast cancer exceeds financial factors to include physiological and

emotional concerns for women (NCI, 2009). Generally, early breast cancer does not cause

symptoms. However, as the tumor grows, the look and feel of the breast can be altered. These

physiological changes women experience include a change in the actual size or shape of the breast;

a lump or thickening in or near the breast or underarm area; scaly, red, or swollen skin on the

17

breast, nipple, or areola (dark area of skin at the center of the breast); a nipple that is turned inward

into the breast; and discharge from the nipple, particularly bloody discharge (NCI, 2009).

Other physiological consequences are also associated with breast cancer. Surgery is the

most common treatment for breast cancer (ACS, 2007). If a woman has to undergo a mastectomy

(surgical removal of the breast), in addition to potential permanent disfigurement, she is likely to

experience subsequent numbness and tingling in the chest area, underarm, shoulder, and arm.

These feelings usually go away within a few weeks or months, but for some women, numbness

does not ever subside (NCI, 2009). Removal of the breast due to breast cancer can also cause a

shift in weight, constant fatigue, and chronic pain (ACS, 2007). Removal of the breast may also

cause the women to feel off balance; this imbalance can, in turn, lead to discomfort in the neck and

back.

A mastectomy is regularly coupled with removal of the lymph nodes under the arm. This

procedure slows the flow of lymph fluid. Consequently, the fluid may build up in the arm and

hand, causing severe swelling. This swelling is known as lymphedemia. It can develop

immediately after surgery, or it can develop gradually over a duration of several months or even

years after surgery (NCI, 2009).

Aside from the physiological concerns, women may also experience psychological and

social consequences of breast cancer (Helms, O’Hea, & Corso, 2008). Just as various forms of

treatment for breast cancer can have potentially disfiguring effects in the physical sense, research

has indicated that the actual loss or mutilation of a woman’s breast can also have negative

psychosocial consequences (Helms et al., 2008).

For example, women often worry about the cancer one day coming back, or recurring.

They may also experience feelings of depression and isolation (ACS, 2007). Breast cancer also

affects a woman’s body image and feelings towards sexuality (Sheppard & Ely, 2008). Because

the breast is considered to be an integral component of a woman’s femininity and sexuality, breast

cancer may elicit coping strategies that are distinctly different from other kinds of cancer

(Choumanova, Wanat, Barrett, & Koopman, 2006). Many women are forced to deal with issues

related to body image because they oftentimes find that breast cancer treatment changed the way

they looked; such changes include hair loss, skin-related issues, and weight gain or loss (NIH,

2009).

Roid & Fitts (1998) suggest that body image refers to a mental image or picture of the

“physical self” that encompasses perceptions and beliefs associated with an individual’s skills, state

of health, sexuality, and physical appearance. Body image is accepted as being an essential

component of sexual health. According to Vaeth (1986), when a disease or disfiguring treatment

regimen jeopardizes the physical beauty of a woman’s body, it has the potential to negatively affect

the value of her body to herself and others (such as spouses or intimate partners). Moreover, the

breast has a social connotation of motherhood, femininity, and sexuality (Kahn et al., 2000). In this

view, for several women, the experience with and subsequent effects of breast cancer are

oftentimes interpreted as a “grievous assault on her femininity and her fundamental sense of herself

as a woman” (Vaeth, 1986).

Sheppard & Ely (2008) conducted a search of Medline databases in their investigation of

breast cancer and how it relates to sexuality. The authors relied on key words including “breast

cancer,” “body image,” “sexuality,” ”cancer,” “marriage,” and “relationship” to identify articles

related to their chosen theme. Their search of breast cancer-related literature revealed a few key

findings. First, as previously assumed, their research confirmed that breast cancer is intensely

18

distressing not only for the patient, but for her family, as well (Henson, 2002). Moreover, 50% of

women were shown to experience sexual difficulties following breast cancer treatment (Burbie &

Polinski, 1992). Common side effects cited include vaginal dryness and irritation, painful

intercourse, lowered libido, and hair loss (Sheppard & Ely, 2008). Another interesting finding

revealed from the author’s systematic review of the literature was that after a breast cancer

experience, many women reported feeling more self-conscious, less attractive, and as having an

overall poorer body image than their healthier counterparts (Sheppard & Ely, 2008).

Al-Ghazal, Fallowfield, & Blamey (1999) conducted a research study on 577 women to

assess the effects of breast cancer on psychological functioning and cosmetic satisfaction of the

breast. At their post-operative follow-up visit, participants completed a written questionnaire. The

researchers categorized the women according to the type of breast cancer surgery received –

lumpectomy, breast reconstruction, or simple mastectomy. Researchers found an overwhelming

91% of women in the lumpectomy group to be at least moderately satisfied with their breast’s

cosmetic appearance, compared to 80% in the breast reconstruction group, and 73% in the simple

mastectomy group (Al-Ghazal et al., 1999). The researchers also found that 10% of the women in

the simple mastectomy group were clinically depressed. This study suggested that the more

invasive the surgery for breast cancer, the greater the effect on the woman’s sense of cosmetic

satisfaction and psychological well-being (Al-Ghazal et al., 1999).

Hair loss is another issue with which many women with breast cancer are forced to deal

(ACS, 2007). The concept of hair possesses many connotations according to any given cultural

group. Hair is really associated with life, life processes, and personal growth (Batchelor, 2001).

Further, hair has also been linked to gender, beauty, maturity, age, and even religious affiliation

(Freedman, 1994; Helms et al., 2008). Thus, when an individual loses his or her hair, the crisis can

be associated with a loss of sexuality, individuality, and attractiveness (Helms, et al., 2008). It is

widely known that many of the chemical agents used in a common form of breast cancer treatment

– chemotherapy – cause hair loss, also known as alopecia.

It is important to note that in addition to body image concerns, some treatments for breast

cancer, such as chemotherapy, can actually alter a woman’s hormone levels and may reduce her

sexual interest or response (ACS, 2007). Some studies even suggest that younger women tend to

have more problems with these issues than older women (ACS, 2007).

Knowledge certainly is a basic requirement for any individual to maintain proper health.

Therefore, knowledge objectives are a vital element of virtually all health promotion activities

(Simon, 2006; Royse & Dignan, 2009). In the greater attempt to disseminate knowledge and

increase awareness about a given health-related issue such as breast cancer, researchers develop

and deliver health interventions tailored to a specific target population. Interventions that yield

desirable changes are ideally based on at least one theoretical framework (Glanz, Rimer, & Lewis,

2002). Theories help guide researchers’ investigation into why people do or do not engage in

specific health behaviors (NCI, 2009). They are useful during the various stages of planning,

implementing, and evaluating an intervention. Moreover, theories help explain behavior and

suggest ways to achieve behavior change (Glanz, Rimer, & Lewis, 2002).

The Health Belief Model (HBM) is a prime example of value-expectancy theory, which has

gained recognition for use in examining and describing health screening behaviors and associated

factors (Glanz, Rimer, & Lewis, 2002). It is considered the most widely used model for predicting

BSE behavior (Champion, 1984). The HBM has been used in several studies as a theoretical

framework to study BSE and other breast cancer detection behaviors (Champion, 1984; 1999).

Because of its long record of use in several studies exploring health behaviors in general, and

19

cancer screening behaviors, specifically, the purpose of this literature review is to examine the use

of the Health Belief Model to enhance breast cancer prevention and screening behaviors.

Health Belief Model

Researchers create and implement interventions as a major means by which to disseminate

knowledge and increase awareness about a given health problem, such as breast cancer.

Interventions that yield desirable changes are ideally based on at least one theoretical framework

(Glanz, Rimer, & Lewis, 2002). Health-behavior theories assist researchers by organizing their

inquiry into why people do or do not engage in specific health behaviors (NCI, 2009). They are

valuable during different stages of planning, implementing, and evaluating an intervention.

Theories also help explain behavior and suggest ways to achieve behavior change (Glanz, Rimer,

& Lewis, 2002).

The Health Belief Model (HBM) is an example of a health behavior theory that considers

one’s overall perceived risk of an illness as a precursor to positive, preventive behavior (Wendt,

2005; Janz & Becker, 1984). It was originally postulated in the 1950’s by social psychologists in

the U.S. Public Health Service (Janz & Becker, 1984); Rosenstock, 1974; Glanz, Rimer, & Lewis,

2002). Perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues

to action comprised the initial core components of the model; in 1977, Bandura added the self-

efficacy component to the HBM (Janz, Champion, & Strecher, 2002). This theory is known as a

value-expectancy theory and known to now be the most widely used model for predicting Breast

Self-Examination (BSE) behavior (Champion, 1990). The fundamental premise of the HBM is that

an individual’s desire to evade illness, coupled with a belief that a particular health action would

avert onset of the illness, can be interpreted and explained in relation to a number of diseases.

More detailed analysis can estimate an individual’s perceived susceptibility, severity, and cues to

action to attempt to reduce overall risk for a particular illness or disease (Glanz, Rimer & Lewis,

2002).

Earlier studies using the HBM centered typically on primary and tertiary preventive

behaviors. Janz and Becker (1984) conducted an extensive literature review of the usage of the

HBM in research beginning in the early 1970’s through 1984. Their review encompassed 46

studies including both prospective (n=18) and retrospective (n=28) studies investigating a

conglomeration of preventive-health behaviors and sick-role behaviors. The results of their review

suggested that the HBM concepts are valuable tools in research studies in that they can serve as

predictors in examining health behavior (Janz & Becker, 1984).

The year 1984 proved to be a major turning point for the HBM and research focusing on

cancer screening behaviors. In that year, Champion initiated an innovative research instrument that

directly linked the HBM constructs to breast cancer screening behaviors. (Prior to 1984, the HBM

was not frequently used to explain such behaviors). Champion used a convenience sample of 301

females who were at least 16 years of age and literate (Champion, 1984). The sample was

stratified for variation in socioeconomic status. Champion distributed written questionnaires via

postal service, as well as by hand; these collection methods yielded a 47% return rate. A retest

questionnaire mailed randomly later produced a 95% return rate. Champion (1984) concluded

from this study that her scales for susceptibility, seriousness, and barriers were internally consistent

and reliable. Additionally, she revised the benefits and health motivation scales due to their being

rejected for inconsistency (Champion, 1984).

Expanding her previous work studying HBM and BSE, Champion (1999) modified scales

20

used in measuring perceived susceptibility, benefits, and barriers to breast cancer screening

behaviors – and applied them to mammography, as well. Criteria for participant eligibility in this

study included not having had a mammogram in the last 15 months, not having had breast cancer,

and being able to read and write English (Champion, 1999). Additional scale items were presented

to participants via two focus group sessions. Results of the newly modified scales indicated

internal consistency ranging from .75 to .88, and test reliabilities between .59 and .72. Thus, these

scales represented an improvement from those Champion had developed earlier (Champion, 1999).

Since Champion’s work, the HBM has been used in a variety of populations and settings to explore

a wide range of health beliefs and behaviors.

Although the participants in Champion’s study included women age 50 and older, her

revised scale is applicable to virtually any age of adult women. This notion rests on the idea that

despite mammography screening being a current breast cancer screening recommendation for older

women; younger women should still be well informed and made aware of it, as they will certainly

encounter mammography screening later in life. Therefore, Champion’s (1999) revised scale

served a major component in assessing the level of breast cancer knowledge, beliefs, and screening

behaviors in this current study examining emerging adult women.

Relying on the main components of HBM, a cross-sectional, community-based study

examining why some women have either an optimistic or pessimistic bias about their breast cancer

risk was completed by Katapodi, Dodd, Facione, Humphreys, & Lee earlier (2010).

They utilized HBM to measure family history of breast cancer, worry about getting breast cancer,

overall knowledge about breast cancer risk factors, as well as women’s perceived susceptibility of

getting breast cancer. Consistent with findings in other studies, family history and breast cancer

worry were found to be significant predictors of personal risk judgments for the women surveyed.

Another finding was that women who overestimate their breast cancer risk may suffer unnecessary

stress, and anxiety, and may overuse health services (Katapodi et al., 2009).

In their study of the effects of peer and group education on knowledge , beliefs, and breast

self-examination practices of Turkish female university students, Karayurt et al. (2009) also used

the Health Belief Model as a theoretical basis. The study was conducted during the 2006-2007

academic year and included a total of 193 participants. Researchers used a written questionnaire to

collect data at baseline and after six months on socio-demographic characteristics, knowledge of

breast cancer and breast self-examination, frequency of breast self-examination practice, and

Champion’s Health Belief Model Scale (CHBMS). Specifically, the CHBMS was comprised of a

total of 42 items with six subscales, and used a 5-point Likert scale from 1 “strongly disagree” to 5

“strongly agree.” In compliance with the major constructs of HBM, CHBMS included subscales

related to susceptibility, seriousness, benefits, barriers, confidence/self-efficacy, and health

motivation. Results of the study showed that mean knowledge scores increased from 42.08 to

65.26 after peer education and from 41.44 to 63.74 after group education. The rate of regular

breast self-examination also increased significantly for both groups. Perceived benefits and

confidence related to breast self-examination increased and perceived barriers decreased

significantly after both interventions, as well. Thus, from this study the authors concluded that

both interventions (peer and group) are beneficial in increasing breast awareness among young

women (Karayurt et al., 2009).

Norman & Brain (2005) applied an extended Health Belief Model (HBM) to the prediction

of breast self-examination among women with a family history of breast cancer. This study also

examined the impact of breast cancer worries and past behavior on breast cancer screening

practices. Researchers compiled a written questionnaire measuring HBM variables (as used in

21

previous research studies), worry, and demographic variables. Specifically, researchers utilized the

Breast Cancer Worry Scale by Lerman et al. (1991) to assess the frequency of concerns about

developing breast cancer and the impact of breast cancer worries on mood and daily functioning.

Items were rated on a 4-point response scale, with high scores indicating breast cancer worries.

Respondents were asked to indicate the frequency with which they performed breast self-

examination. Finally, they were asked to indicate the number of first and second-degree relatives

affected with breast cancer as a measure of family history of breast cancer. Study results

emphasized the importance of focusing on over-performance and under-performance of breast self-

examination for breast cancer prevention. The study also highlighted a need for health

interventions designed to enhance women’s overall confidence in their ability to perform breast

self-examination. And, attempts to reduce worry related to breast cancer may encourage more

appropriate and effective breast self-examination, according to the study (Norman & Brain, 2005).

Wendt (2005) also applied the Health Belief Model to her examination of how female

undergraduates perceive their future risk of breast cancer and coronary heart disease. Participants

included 137 female undergraduate students attending a small liberal arts college in the

northeastern region of the U.S. Participants were asked to complete a written survey, which

assessed items such as perceived illness frequency, level of worry, awareness of risk factors,

cognitive variables, mental image, health behaviors, seriousness, etc. Demographic variables

included year in college, age, and ethnic/racial composition. Results of the study indicated

unrealistic pessimism regarding the women’s personal risk of breast cancer among peers. When

compared to coronary heart disease, participants were significantly more worried about getting

breast cancer; yet, they were less aware of breast cancer risk factors. Further, perceived risk of

breast cancer was not associated with breast self-examinations.

In summary, the HBM has been especially valuable in examining various concepts in

primary care, preventive medicine, and public health. It has been repeatedly utilized as a

theoretical framework to examine a range of health behaviors, including those associated with

chronic illness and disease, such as breast cancer. Additionally, the HBM model has been

frequently applied to the investigation of individual health-related beliefs, and more importantly, it

can suggest ways for women to achieve behavior changes that could potentially reduce their risk of

developing breast cancer in the first place.

References

Al-Ghazal, S. K., Fallowfield, L., & Blamey, R.W. (1999). Does cosmetic outcome from

treatment of primary breast cancer influence psychosocial morbidity? European Journal of

Surgical Oncology, 25, 571-573.

American Cancer Society (2007a). Breast Cancer Facts and Figures 2007-2008. Atlanta:

American Cancer Society. [Electronic Version]. P. 1-26.

American Cancer Society. Cancer Facts and Figures 2008. Atlanta:

American Cancer Society; 2009. [Electronic Version]. P. 1-11.

Arozulla, A.M., Calhoun, E.A., Wolf, M., Finley, D.K., Fitzner, K.A., Heckinger, E.A., Gorby,

N.S., Schumock, G.T., & Bennett, C.L. (2004). The financial burden of cancer: Estimates

from a study of insured women with breast cancer. Journal of Supportive Oncology, 2:3,

271-278.

22

Batchelor, D. (2001). Hair and cancer chemotherapy: Consequences and nursing care – a

literature study. European Journal of Cancer Care, 10, 147-163.

Burbie, G.E. & Polinsky, M.L. (1992). Intimacy and sexuality after cancer treatment: Restoring

a sense of wholeness. Journal of Psychosocial Oncology. 10: 19-33.

Centers for Disease Control and Prevention (2009). Overview: Breast Cancer. Available at

www.cdc.gov/cancer/cata.

Champion, V.L. (1984). Instrument development for health belief model constructs.

Advances in Nursing Science, 73-87.

Champion, V.L. (1990). Breast self-examination in women 35 or older: A prospective

study. Journal of Behavioral Medicine, 13(6), 523-539.

Champion, V.L. (1999). Revised susceptibility, benefits, and barriers scale for mammography

screening. Research in Nursing & Health, 22, 341-348.

Choumanova, I., Wanat, S., Barrett, R., & Kooper, C. (2006). Religion and spirituality in coping

with breast cancer: Perspectives of Chilean women. Breast Journal, 12(4), 349-352.

Freedman, T.G. (1994). Social and cultural dimensions of hair loss in women treated for breast

cancer. Cancer Nursing, 17: 4: 334-341.

Glanz, K., Rimer, B., & Lewis, F.M. (2002). Health Behavior and Health Education, 3rd

ed.

San Francisco: Jossey-Bass.

Helms, R.L., O’Hea, E.L., & Corso, M. (2008). Body image issues in women with breast cancer.

Psychology, Health & Medicine, 13:3, 313-325.

Henson, H. (2002). Breast cancer and sexuality. Sexual Disability. 2002: 20-24.

Janz, N.K. & Becker, M.H. (1984). The health belief model: A decade later.

Health Education & Behavior, 11(1), 1-47.

Kahn, M.A., Sehgal, A., Mitra, B., Agarwal, P.N. & Malik, V.K. (2000).

Psychobehavioral impact of mastectomy. Journal of the Indian Academy of Applied

Psychology, 26: 1-2, 65-71.

Karayurt, O., Dicle, A., & Malak, A.t. (2009). Effects of peer and group education on

knowledge, beliefs and breast self-examination practice among university students

In Turkey. Turkish Journal of Medical Science. 39:1: 59-66.

Katapodi, M.D., Dodd, MlJ., Facione, N.C., Humphreys, J.C., & Lee, K.A. (2010). Why

some women have an optimistic or pessimistic bias about their breast cancer risk.

23

Cancer Nursing, 33, 64-73.

Lerman, C., Trock, B., Rimer, B.K., Jepson, C., Brody, D., & Boyce, A. (1991). Psychological

side effects of breast cancer screening. Health Psychology, 10, 259-267.

National Cancer Institute. (2009). Theory at a Glance. Washington, DC: National Institute

of Health.

Norman, P. & Brain, K. (2005). An application of an extended health belief model to the

prediction of breast self-examination among women with a family history of breast

cancer. British Journal of Health Psychology, 10, 1-16.

Roid, G. & Fitts, W. (1998). Tennessee Self Concept Scale: Revised Manual.

Los Angeles, CA: Western Psychological Services, 1998.

Rosenstock, I.M. (1974). The health belief model and preventive health behavior. Health

Education Monographs, 2: 328-335.

Royse, D. & Dignan, M. (2009). Improving cancer knowledge and screening awareness: Test

of a telephone interviewer intervention. Journal of Cancer Education, 24: 315-318.

Sheppard, L.A. & Ely, S. (2008). Breast cancer and sexuality. The Breast Journal, 14:

176-181.

Simon, C.E. (2006). Breast Cancer Screening: Cultural Beliefs and Diverse Populations.

Health & Social Work, 31, 36-43.

U.S. Department of Health and Human Services, National Institutes of Health, National

Cancer Institute: What you need to know about breast cancer. (2009).

Vaeth, J.M. (1986). Body image, self-esteem, and sexuality in cancer patients.

2nd

edition, San Francisco, CA: Karger, 1986.

Welch. C., Miller, C.W., & James, N.T. (2008). Sociodemographic and health-related

determinants of breast and cervical cancer screening behavior, 2005. Nursing Research,

2010: 59, 51-57.

Wendt, S.J. (2005). Perception of future risk of breast cancer and coronary heart disease in

female undergraduates. Psychology, Health & Medicine, 10(3): 253-262.

Wood, M.E. (2009). Theoretical framework to study exercise motivation for breast cancer

risk reduction. Oncology Nursing Forum, 35, 89-95.

24

Faculty Peered Review Article

Preventing Sleep Deprivation through Behavior Modification: A Review

by Kathryn Jones UAB, Lori Turner, U of Alabama, Sharon Hunt U of Arkansas

Introduction

Sleep deprivation occurs when sleep is insufficient in quantity or quality

(American Academy of Sleep Medicine, 2008; HHS, n.d.-a). Short sleep is often defined

as averaging less than seven hours and long sleep defined as more than nine hours of

sleep in a night (Gallicchio & Kalesan, 2009). This can include being out of sync with

your circadian rhythm and sleeping at the wrong time of the day, excessive daytime

sleepiness, poor quality of sleep or diagnosis of a sleep disorder (American Academy of

Sleep Medicine, 2008; HHS, n.d.-a).

Estimates suggest 50 to 70 million Americans suffer from some form of sleep

disorder (Institute of Medicine, 2006) and almost 40% of adults have reported falling

asleep without meaning to during daytime activity in a given month (HHS, n.d.-a). The

National Sleep Foundation Sleep in America Poll (2008) found that 11% of respondents

were at risk for a diagnosis of insomnia, 14% for a diagnosis of obstructive sleep apnea

and 11% for restless leg syndrome, three of the most commonly diagnosed sleep

disorders. Sixty-five percent of these respondents reported experiencing sleep problems a

few nights a week, including difficulty falling asleep, waking during the night and not

feeling refreshed the next morning; 44% of all respondents reported getting less than

seven hours of sleep on workdays (National Sleep Foundation, 2008). Sleep disturbances

affect a substantial amount of the population.

Immediate effects of sleep deprivation include difficulty concentrating,

completing tasks (National Sleep Foundation, n.d.-d), and coping with change (HHS,

n.d.-a). Prolonged sleep deprivation can expand to a host of harmful effects on a person’s

physical and mental health, creating and exacerbating a multitude of health conditions

(HHS, n.d.-a; National Sleep Foundation, n.d.-d). Studies have found significant

relationships between insomnia and depression and anxiety after controlling for other

confounding variables (Taylor, Lichstein, Durrence, Reidel, & Bush, 2005). Insomnia is

predictive of the development of depression, anxiety, psychiatric distress, alcohol and

drug abuse and suicide (Taylor, Lichstein & Durrence, 2003). Individually diagnosed

mood disorders and anxiety are associated with severe insomnia symptoms, as well as

comorbid diagnoses with both anxiety and a mood disorder. Sixty percent of respondents

with comorbid anxiety and mood disorders indicated at least one insomnia symptom and

45% of individual diagnoses of anxiety or mood disorder only groups indicated at least

one insomnia symptom (Soehner, Allison, & Harvey, 2012).

Depression is often associated with sleep onset and anxiety with sleep

maintenance. Cross-sectional analyses revealed the risk of participants reporting

insomnia was four times greater with high anxiety. Prospective analyses showed that

both depression and anxiety were associated with developing insomnia at one year follow

up, demonstrating the interrelatedness of insomnia with depression and anxiety (Jansson

& Linton, 2006).

Stress is the primary cause of short-term sleep difficulties. Relationships with

family and friends, work or school related stressors, serious illness and death of a family

26

member are often sources of increased stress that influence sleep. If sleep is not managed

well at this juncture, sleep difficulties can persist after the initial stressor has passed

(National Sleep Foundation, n.d.-d).

Too little sleep can also affect your overall quality of life and social functioning

(HHS, n.d.-a). In a nationally representative sample, researchers observed significant

impairments in social functioning, cognitions, quantity and quality of work completed

and time out of role for normal daily activities in participants reporting severe insomnia

symptoms (Soehner et al., 2012). A qualitative study exploring quality of life in

individuals with insomnia found persistent themes of struggling through, isolation and

impediments to the desired self because of insomnia. Social functioning was impacted

through lack of enthusiasm or energy resulting in self-imposed social inclusion, inability

to plan social functions due to unstable sleep patterns, and diminished responsiveness in

social situations. The authors noted that participants frequently reported increased

irritability and changes in mood (Kyle, Espie & Morgan, 2010).

People who do not get enough sleep are at higher risk for developing heart

disease, cardiovascular disease, high blood pressure, infections, diabetes, obesity and

strokes (American Academy of Sleep Medicine, 2008; Cappuccio et al., 2008; National

Sleep Foundation, n.d.-c; Sabanayagam & Shankar, 2010; U.S. Department of Health and

Human Services, [HHS] 2011). Insomnia may serve as a stressor that initiates the

development of a predisposed disease state. Conversely, it may be symptomatic of a

disease or disorder and manifest before the onset of the full disorder (Taylor et al., 2003).

The National Highway Traffic Safety Administration reports between 2005 to

2009, an average of 2.5% of fatal automobile crashes and 2.2% of injuries from crashes

were caused by drowsy driving (2011). Williamson and Feyer (2000) found that sleep

deprivation results in impairments to cognitive and motor functioning that were similar to

levels of alcohol consumption that were at or above a blood alcohol level of 0.05%,

suggesting that drowsy driving is as potentially dangerous as intoxicated driving. The

National Sleep Foundation 2008 Sleep in America Poll found that 32% of respondents

admitted to having driven while drowsy and 36% of respondents reported having nodded

off or fallen asleep while driving in the past month.

Numerous studies have looked at the effects of short and long sleep on mortality.

Short sleep is often defined as averaging less than seven hours and long sleep defined as

more than nine hours of sleep in an a night (Gallicchio & Kalesan, 2009). In a meta-

analysis of 23 studies assessing sleep duration and all-cause and/or cause-specific

mortality, Gallicchio and Kalesan (2009) found that both short and long sleepers have an

increased risk of all-cause mortality than those who averaged seven to eight hours of

sleep each night. Another population-based meta-analysis of all-cause mortality and

sleep found that short sleepers had a 12% increased risk of death and long sleepers had a

30% increased risk of death (Cappuccio, D’Elia, Strazzullo, & Miller, 2010).

Sabanayagam & Shankar (2010) found that there was a positive association for both short

and long sleepers with cardiovascular disease in a large nationally representative study.

Sleep is clearly affecting health and mortality in a significant way.

The incidence of shift work in the United States has increased in recent history as

our world has globalized into a 24-hour society. The rise in shift workers in a variety of

sectors, including health care, customer service, safety and law enforcement and

transportation could be associated with greater health and safety risks due to sleep

27

deprivation. The National Sleep Foundation (n.d.-b) reports that shift workers are often

working in some of the most dangerous jobs, including police, firefighters, medical

personnel and other security personnel. The risks of poor attention, errors, and accidents

associated with sleep deprivation could lead to a higher incidence of injury and death

(National Sleep Foundation, n.d.-b).

Approximately $100 billion dollars are spent each year on direct and indirect

costs associated with sleep deprivation (National Sleep Foundation, n.d.-d). Sleep

deprivation results in nearly $50 billion dollars in lost productivity each year (HHS,

2011). As such, sleep deprivation is a neglected determinate of health status with the

potential for serious consequences (Luyster, Strollo, Zee, & Walsh, 2012).

Purpose

The purpose of this review is to conduct a narrative review of the literature

regarding sleep deprivation, sleep hygiene and theories that can address improving sleep,

specifically behavior modification. This paper explores studies using behavior

modification theory concepts to reduce sleep deprivation and improve people’s ability to

get sufficient quality sleep through methods commonly referred to as sleep hygiene.

Methods

Articles reviewed were obtained from PubMed and CINAHL Plus, as well as

reference lists from articles chosen for the review. Search terms included “sleep

deprivation” and “sleep hygiene” to provide a broad scope from which to select articles.

Inclusion criteria were articles that utilized adult human subjects ages 18 and older and

were in academic journals or listed as journal articles. Exclusion criteria included studies

that had a very narrow and specific target population, such as sleep deprivation in people

with schizophrenia or Alzheimer’s or a very specific medical condition such as traumatic

brain injury or in post-partum women. The articles chosen were intended to represent the

population at large and to focus on behavior modification.

Results

Ten articles were chosen for this review to highlight the myriad of approaches

that behavior modification could take under the broad scope of sleep hygiene techniques

used to improve sufficient sleep. The U.S. Department of Health and Human Services

(n.d.-a) and National Sleep Foundation (n.d.-a, n.d.-d) promote the adoption of broad

sleep hygiene techniques to improve sufficient and quality sleep.

The basic components of sleep hygiene as recommended by the National Sleep

Foundation (n.d.-a) include:

(a) Adhere to the same bed and waking time. This may help you to

regulate your body’s internal clock and to better fall asleep and stay asleep

during the night.

(b) Practicing a relaxing bedtime ritual, particularly away from bright

lights, helps you to unwind. This may help differentiate sleep from things

that create excitement, anxiety or stress, which sometimes make it more

difficult to fall asleep or stay asleep through the night.

(c) Avoiding naps, particularly in the afternoon, can help you feel tired

enough to sleep at night.

(d) Daily exercise is a great way to improve both physical and mental

health. Any activity, from vigorous to light, may help you settle into a

regular sleep routine.

28

(e) Sleep in a cool, dark room with minimal noise. Rooms between 60 and

67 degrees are optimal, with little to no disturbing noise. Disturbing

noises could include your partner’s snoring. To reduce light and noise,

consider using blackout curtains, sleep masks, white noise machines,

earplugs, or fans.

(f) Sleep on comfortable pillows and mattresses. The life span of a

mattress is between eight to ten years, and older mattresses may be

contributing to your difficulty sleeping. Pillows that are the correct

support for your favored sleeping position may also help. A comfortable

and attractive sleeping space makes the bedroom more inviting and

encourages a more restful night.

(g) Manage your circadian rhythm, your body’s natural internal clock, by

exposing yourself to bright light during the day and minimal light in the

evening.

(h) Avoid alcohol, cigarettes, caffeine and heavy meals in the evening as

each of these can disrupt sleep. Eating at least two to three hours before

bed is recommended.

(i) Avoid electronics before bed as the type of light from screens like

televisions, phones, and tablets is activating to the brain. This may make

it harder for you to fall and stay asleep.

(j) Use your bed only for sleep and sex. This helps to strengthen the

association of the bed with sleep instead of waking activities. If you

cannot sleep, get out of bed, go to another room, and do a relaxing activity

until you feel sleepy. Return to bed only when you feel sleepy (National

Sleep Foundation, n.d.-a).

Multicomponent or cognitive behavioral therapy is an effective behavior

modification technique for improving sleep hygiene (Edinger & Sampson, 2003; Edinger

et al., 2009; Epstein, Sidani, Bootzin, & Belyea, 2012; Espie, Inglis, Tessier, & Harvey,

2001; Mimeault & Morin, 1999; Ritterband et al., 2009; Rybarczyk, Lopez, Benson,

Alsten, & Stepanski, 2002). Sleep hygiene as psycho-education, sleep restriction therapy,

stimulus control (Stepanski & Wyatt, 2003; Morin, Bootzin, Buysse, Edinger, Espie,

Lichstein, 2006) relaxation techniques and cognitive behavioral therapy (Morin et al.,

2006) are terms used to describe subsets of sleep hygiene instructions. Many studies

utilize a multicomponent treatment design including two or more of these subsets in their

interventions (Morin et al., 2006) and different studies combined different subsets of

sleep hygiene techniques to create multicomponent or cognitive behavioral therapy.

Studies in this review utilized combinations of sleep education, often called sleep

hygiene within the study, stimulus control, sleep restriction (Edinger & Sampson, 2003;

Edinger et al., 2009; Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001), cognitive

therapy (Mimeault & Morin, 1999; Ritterband et al., 2009) and relaxation therapy (Espie

et al., 2001; Rybarczyk et al., 2002). Researchers used subjective measures of improved

sleep including sleep diaries and questionnaires (Edinger & Sampson, 2003; Mimeault &

Morin, 1999; Ritterband et al., 2009) and a combination of subjective and objective

measures including actigraphy and polysomnagraphy (Edinger et al., 2009, 2001; Epstein

et al., 2012; Espie et al., 2001; Rybarczyk et al., 2002).

Stimulus control therapy is concerned with associating the bedroom with sleep

29

instead of wakeful activities that may interfere with sleep (Bootzin, 1977). The

behavioral components of stimulus control therapy are (a) go to sleep only when sleepy;

(b) do not use your bed for anything but sleep and sex (i.e. don’t watch television, eat,

read, etc.); (c) if unable to fall asleep, get up and go to another room and don’t return to

bed until sleepy; (d) get up at the same time each day and (e) do not nap during the day

(Bootzin, 1977).

Sleep restriction therapy assumes that people spend too much time in bed

attempting to sleep, which leads to more wakefulness in bed and fragmented sleep. By

curtailing time spent in bed, the person will create a more consistent sleep-wake schedule

where the time spent in bed is spent sleeping (Spielman, Saskin, & Thorpy, 1987). In

comparing control groups to stimulus control and sleep restriction as stand-alone

treatments as well as the two in combination, Epstein et al. (2012) found no difference in

treatment outcomes with all treatment groups showing improvement in sleep measures

compared to the control group.

Sleep hygiene as an educational component of treatment is often concerned with

modifying factors associated with the bedroom, such as light and noise, as well as diet

and exercise (Espie et al., 2001; Pallesen, Nordhus, Kvale, Nielson, Havik, Johnsen, &

Skotskift 2003; Ritterband et al., 2009). Sleep education also gives information

regarding the function of sleep and sleep needs, including information about circadian

rhythms (Edinger & Sampson, 2003; Edinger et al., 2009, 2001; Rybarczyk et al., 2002).

This is typically paired with another subset of sleep hygiene techniques as an intervention

or used as the control group in studies.

Relaxation therapy can include progressive muscle relaxation (Means, Lichstein,

Epperson, & Johnson, 2000; Edinger et al., 2001) deep breathing, autogenic training and

imagery (Rybarczyk et al., 2002). College students with insomnia treated with relaxation

therapy including progressive muscle relaxation revealed improvements in sleep

outcomes compared to students with insomnia who were in the control group (Means et

al., 2000).

In comparing sleep education paired with either stimulus control or relaxation

tapes, researchers found no significant differences in treatment effectiveness between the

two interventions. Both treatment groups showed improvements in sleep parameters

compared to the wait list control group. These gains were maintained at six month follow

up (Pallesen et al., 2003).

Behavioral treatments to improve sleep are efficacious and benefits are sustained

over time (Edinger & Sampson, 2003; Edinger et al., 2009, 2001; Epstein et al., 2012;

Espie et al., 2001; Means et al., 2000; Mimeault & Morin, 1999; Pallesen et al., 2003;

Ritterband et al., 2009; Rybarczyk et al., 2002). Specifically, stimulus control therapy,

sleep restriction therapy, multicomponent cognitive behavioral therapy, and relaxation

training have been shown to be well-established treatment modalities (Morin et al., 2006;

Morgenthaler et al., 2006). Stimulus control therapy has often been considered the

standard to which other behavioral therapies have been compared (Bootzin & Epstein,

2011) and meta-analysis suggests that it may be the most effective single-component

intervention for insomnia (Morin et al., 2006).

Literature utilizing health education and promotion theories and interventions is

sparse. In an attempt to address this gap in the literature, Knowlden and Sharma (2014)

developed a behavior prediction model for sleep with college students using the health

30

belief model. The results of the study indicate that their model explained 34% of

variance in sleep behaviors. The health belief model constructs of perceived severity,

perceived barriers, cues to action and self-efficacy were significant predictors in the

model. Vincent, Lewycky, and Finnegan (2008) also created a measure using health

belief model constructs to ascertain barriers to engagement in stimulus control and sleep

restriction for improving sleep. The authors found that perceived barriers were

significantly associated with adherence to the sleep hygiene behaviors studied, affecting

improvements in sleep outcomes.

Robbins and Niederdeppe (2015) conducted a study utilizing integrative model of

behavioral prediction to examine predictors of healthy sleep behaviors in college

students. Their results indicate attitudes and perceived behavioral control as the strongest

predictors of engaging in sleep behaviors. This provides avenues for future studies to

create and implement interventions based on these constructs to improve sleep in this

population.

Implications

Psychological practices have used sleep hygiene instructions to demonstrate

effective ways to improve sufficient sleep through behavior modification (Edinger &

Sampson, 2003; Edinger et al., 2009, 2001; Epstein et al., 2012; Espie et al., 2001; Means

et al., 2000; Mimeault & Morin, 1999; Pallesen et al., 2003; Ritterband et al., 2009;

Rybarczyk et al., 2002). However, the lack of literature in health education and health

promotion (Knowlden & Sharma, 2014), specifically the lack of health education theory

based interventions, displays a gap in the research. Health education theories could

provide multiple avenues of exploration for models and interventions to improve

sufficient quality sleep. Knowlden and Sharma (2014) and Robbins and Niederdeppe’s

(2015) research employing the health belief model and integrative model of behavioral

prediction demonstrates that health education theories can be useful ways to create

models and work towards interventions to improve sleep. These studies are limited,

however, by their use of a convenience sample of college students. There is a need for

the creation of more measures and models using health education and promotion theories

to design interventions to address sleep deprivation with a wider population.

A clinical psychologist typically administers cognitive behavioral therapy for

improving sleep. It usually takes between six to eight sessions that last one to one and

half hours. This may be too long of a treatment modality to implement in settings outside

traditional therapy (Edinger et al., 2001). In this review, there was a wide variance of

session lengths, from two sessions to nine weeks of access to the intervention. This

variance poses a challenge to understanding what length of treatment can produce

clinically significant results.

Trained psychologists or therapists usually administer cognitive behavioral

therapy. This may create missed opportunities for other health care practitioners or

educators to assist in improving sufficient quality sleep. Research studying the impact of

cognitive behavioral therapy on general practice in medicine has been limited and sleep is

not always addressed in health care visits. Doctors may be unaware of the psychological

literature that promotes sleep hygiene behaviors. The traditional expectations about drug

therapy may outweigh a form of therapy that is often lengthy (Edinger & Sampson, 2003;

Espie et al., 2001).

This review highlights three studies that used methods other than the more

31

traditional clinical psychologist providing multicomponent cognitive behavioral therapy

for improving sleep. One study utilized a six session model with primary care nurses

providing the therapy (Espie et al., 2001). Other studies utilized a self-help approach to

administer the intervention via the internet (Ritterband et al., 2009) and mailed

bibliotherapy participants could complete at home (Mimeault & Morin, 1999). These

studies provide evidence that a wide variety of treatment modalities could be effective in

promoting improved sleep hygiene techniques. Future research should explore additional

ways that people could receive interventions to improve sleep that may be easier for a

wider population to access.

There is a need to increase understanding about the importance of sleep and its

relation to chronic health conditions and to train a wider variety of health care

professionals to better assess and educate patients through a general medical practice and

preventive care visits. Future research should continue to explore ways to implement

sleep hygiene practices in a wider variety of settings as clinical psychologists are in short

supply, particularly those who may have a strong interest in sleep, and pursuing sleep

hygiene in that setting may be time consuming and expensive (Espie et al., 2001). One

question of note is if the social stigma of attending counseling with a psychologist or

therapist could influence how people engage in that form of treatment to improve

sufficient sleep. This could be a future research question to help understand potential

barriers to treatment.

Few studies research how improving sufficient sleep results in improvements in

daytime functioning such as life satisfaction and daytime alertness (Pallesen et al., 2003;

Zammit, Weiner, Damato, Sillup, & McMillan, 1999). Pallesen et al. (2003) found that

improvements in daytime variables were smaller compared to the nocturnal variables

studied. The daytime variable gains evident at post treatment had disappeared by follow

up. Future studies should include more variables assessing daytime functioning and life

satisfaction, further enhancing the knowledge of how improving sleep interacts with

multiple aspects of people’s lives and wellbeing.

Differences in operational definitions of sleep hygiene techniques make it hard to

compare results across studies (Stepanski & Wyatt, 2003). The term “sleep hygiene”

often has different meanings in different studies, sometimes referring to the broad set of

recommendations, but most often referring to a small subset of instructions. Subsets of

traditional sleep hygiene techniques, such as multicomponent cognitive behavioral

therapy, may also contain different elements between studies. As such, replicating the

study findings may be a challenge. This also presents uncertainty as to which

components are truly necessary to see the improvements in sufficient sleep.

The only consistent sleep outcome measures from the studies included in this

review were sleep diaries. Some researchers only utilized subjective sleep data (Edinger

& Sampson, 2003; Mimeault & Morin, 1999; Ritterband et al., 2009). Within these

studies, the subjective measures varied greatly beyond the standard sleep diary. A few

studies used a combination of subjective and objective sleep outcome measures (Edinger

et al., 2009, 2001; Epstein et al., 2012; Espie et al., 2001; Rybarczyk et al., 2002),

however again there was variance as to which measures were utilized. These variances

create additional challenges in comparing results across studies and understanding the

mechanisms that promote sufficient sleep. Future studies should have larger populations

utilizing both subjective and objective measures of sleep outcomes (Edinger & Sampson,

32

2003).

The strategy summary table included in this review highlights the two main

behavior modification constructs that sleep hygiene techniques fall under, stimulus

control and reinforcement. Stimulus control is a process that strengthens a behavior or

increases the likelihood that a behavior will occur again in the future when a specific

antecedent stimulus is present prior to the desired behavior (Kazdin, 2001; Miltenberger,

2001). The sleep hygiene techniques recommended by the National Sleep Foundation

(n.d.-a) and described previously in this review fit best under the construct of stimulus

control.

Applying a reinforcing behavior is also recommended in the strategy summary

table. Reinforcement is a process that strengthens a behavior or increases the probability

that a behavior will occur again in the future by using a positive or negative reinforcer

following the desired behavior. Positive reinforcers are the stimuli or events proffered

after a behavior. Negative reinforcers are the removal of stimuli or events after a

behavior (Kazdin, 2001; Miltenberger, 2001). A token or reward system for following

through on the behavior modifications made using sleep hygiene techniques may increase

the persistence of these new behaviors. This is an example of creating a positive

reinforcement for sleep hygiene behaviors.

33

Behavior modification techniques for reducing sleep deprivation.

Construct Definition Application for increasing

sufficient sleep

Reinforcement Process that strengthens a

behavior or increases the

probability a behavior will

occur again in the future,

can have positive or

negative reinforcers

Create token/reward

system for following

sleep hygiene

techniques

Stimulus Control Process that strengthens a

behavior or increases the

probability a behavior will

occur again in the future

when a specific antecedent

stimulus is present prior to

the behavior

Go to sleep only

when sleepy

Use your bed for

sleep and sex only

If you aren’t asleep

in 20 minutes get out

of bed until sleepy

again

Get up at the same

time every morning

Do not nap

Exercise daily

Evaluate your room

for temperature,

noise, and light

Sleep on comfortable

mattress and pillows

Avoid bright light in

the evenings

Avoid alcohol,

cigarettes and heavy

meals before bed

Keep the same

bedtime and wake up

time

Practice a relaxing

bedtime ritual, like

progressive muscle

relaxation

Avoid electronic

devices before bed

Constructs adapted From Miltenberger, 2001*

*Constructs of behavior modification include punishment, extinction and respondent

conditioning, however sleep hygiene techniques did not fit in the criteria for these

constructs.

Reducing Sleep Deprivation through Behavior Modification Literature Review Matrix

Author, Date

Results Study Objective Participant

Demographics

Behavior

Modification

Construct

Study Design

Edinger, Olsen,

Stechuchak,

Means,

Lindeberger,

Kirby, &

Carney, 2009

To evaluate the

efficacy of CBT

compared to basic

sleep hygiene control

patients with primary

or comorbid insomnia

N = 81, 11

women

Mean age =

54.2 years, SD

= 13.7 years

Stimulus

Control

Randomized

parallel group

clinical trial,

Sleep diary,

actigraphy, 4

sessions, 6 month

follow up

Treatment group showed

significant improvements

over control group, 75%

of patients with primary

insomnia reported normal

sleep by post treatment

Edinger &

Samson, 2003

To assess

effectiveness of

abbreviated CBT with

primary care patients

N = 20, 2

women

Mean age =

51.0 years, SD

= 13.7 years

Stimulus

Control

Randomized

controlled trial,

Sleep diary, Self-

Efficacy Scale, 2

sessions, 3 month

follow up

ACBT group showed

significantly improved

SOL, WASO, SE

Results maintained at

follow up

Edinger,

Wohlgemuth,

Radtke, Marsh

& Quillian, 2001

To evaluate the

efficacy of CBT,

relaxation training

and placebo for

treating primary sleep

maintenance

insomnia

N = 75, 35

women Mean

age = 55.3

years

Stimulus

Control

Randomized,

double blind

placebo

controlled trial,

Sleep diary, 6

month follow up

CBT produced larger

improvements across the

majority of outcomes

measures compared to

relaxation training and

placebo

Epstein, Sidani,

Bootzin, &

Belyea, 2012

Compare placebo,

single component

(stimulus control or

sleep restriction) and

multicomponent

(stimulus control and

N = 179, 115

women, Mean

age = 68.9

years, SD = 8.0

years

Stimulus

Control

Randomized

controlled trial,

Sleep diary,

Actigraphy, 6

sessions, 3 month

and 1 year follow

Treatment groups

showed significant

improvements compared

to control group,

Treatment improvements

maintained at one year

sleep restriction)

behavioral treatments

for insomnia

up follow up

Espie, Inglis,

Tessier &

Harvey, 2001

Investigate

effectiveness of CBT

delivered by primary

care nurses

N = 139, 95

women, Mean

age = 51.4

years, SD =

17.1 years

Stimulus

Control

Randomized

controlled trial,

Sleep diary, Penn

State Worry

Questionnaire,

Epworth

Sleepiness Scale,

6 sessions, 1 year

follow up

CBT group showed

significant improvements

Treatment gains were

maintained at follow up,

84% of patients initially

using hypnotics were

drug free at follow up

Means,

Lichstein,

Epperson, &

Johnson, 2000

Compared students

on self-reported sleep

variables and

explored changes in

daytime functioning

after using

progressive relaxation

treatment for

insomnia

N = 118, 85

women, Mean

age = 21.2

years, SD = 5.2

years

Stimulus

Control

Randomized

controlled trial.

Sleep diary, IIS,

DBAS, ESS,

FSS, PSWQ, 3

sessions, 2

months follow up

Progressive relaxation

training compared to

control group resulted in

improvements. Students

with insomnia reported

more perceived impaired

day time functioning than

students without

insomnia

Mimeault &

Morin, 1999

Assess effectiveness

of self-help CBT with

and without guidance

for insomnia

N = 54, 32

women, Mean

age = 50.80

years, SD =

12.64 years

Stimulus

Control

Randomized

controlled trial,

Sleep diary, 6

sessions, 3 month

follow up

Both treatment

conditions were

comparable at follow up,

suggesting both

demonstrated effective

treatment gains over time

Pallesen,

Nordhus, Kvale,

Nielson, Havik,

Johnsen, &

Skjotskift, 2003

Compare two

behavioral

interventions for

insomnia treatment in

an older population

N = 55, 46

women, Mean

age = 69.8

years, SD =

6.53 years

Stimulus

control

Participants

randomized to

immediate

treatment or

waitlist, Sleep

diary, 4 sessions,

6 month follow

up

Treatment groups

exhibited improvements,

treatment gains

maintained at follow up,

Participants reported

improvements in daytime

functioning and life

satisfaction after

treatment

Ritterband,

Thorndike,

Gonder-

Frederick,

Magee, Bailey,

Saylor & Morin,

2009

Evaluate efficacy of

CBT via the internet

for adults with

insomnia

N = 44

34 women

Mean age =

44.86 years

SD = 11.03

years

Stimulus

Control

Randomized

controlled trial

Sleep diary, ISI

9 weeks access to

internet

intervention, 6

month follow up

Internet group exhibited

significant changes in

WASO and SE

Internet group showed

significant reductions in

ISI and maintained

reductions at 6 month

follow up

Rybarczyk,

Lopez, Benson,

Alsten &

Stepanski, 2002

Assess efficacy of

behavioral

interventions on

insomnia with

comorbid medical

illness in an elderly

population

N = 38, 22

women, Mean

age = 67.8

years

Stimulus

Control

Randomized

controlled trial,

Sleep diary,

Health Survey,

Pain

Questionnaire,

Life satisfaction

measure, 6-8

sessions, 4 month

follow up

CBT is an effective

treatment for insomnia in

older adults with

comorbid medical illness

37

References

American Academy of Sleep Medicine. (2008). Sleep deprivation. Retrieved from

http://www.aasmnet.org/resources/factsheets/sleepdeprivation.pdf

Bootzin, R.R. (1977). Effects of self-control procedures for insomnia. In R. Stuart (Ed.),

Behavioral self-management: Strategies, techniques, and outcomes (pp. 176-196). New

York: Brunner/Mazel.

Bootzin, R. R., & Epstein, D. R. (2011). Understanding and treating insomnia. Annual Review of

Clinical Psychology, 7, 435–458. doi:10.1146/annurev.clinpsy.3.022806.091516

Cappuccio, F.P., D’Elia, L., Strazzullo, P., & Miller, M.A. (2010). Sleep duration and all-cause

mortality: A systematic review and meta-analysis of prospective studies. Sleep, 33(3), 349-

354.

Cappuccio, F.P., Taggart, F.M., Kandala, N.B., Currie, A., Peile, E., Stranges, S., & Miller, M.A.

(2008). Meta-analysis of short sleep duration and obesity in children and adults. Sleep,

31(5), 619-626.

Edinger, J. D., Olsen, M. K., Stechuchak, K. M., Means, M. K., Lineberger, M. D., Kirby, A., &

Carney, C. E. (2009). Cognitive behavioral therapy for patients with primary insomnia or

insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical

trial. Sleep, 32, 499–510.

Edinger, J. D., & Sampson, W. S. (2003). A primary care “friendly” cognitive behavioral insomnia

therapy. Sleep, 26, 177–182.

Edinger, J.D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001).

Cognitive behavioral therapy for treatment of chronic insomnia. Journal of the American

Medical Association, 285(14), 1856-1864.

Epstein, D. R., Sidani, S., Bootzin, R. R., & Belyea, M. J. (2012). Dismantling multicomponent

behavioral treatment for insomnia in older adults: A randomized controlled Trial. Sleep,

35(26), 797-805. doi:10.5665/sleep.1878

Espie, C. A., Inglis, S. J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive

behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in

general medical practice. Behaviour research and therapy, 39, 45–60. doi:10.1016/S0005-

7967(99)00157-6

Gallicchio, L., & Kalesan, B. (2009). Sleep duration and mortality: A systematic review and meta-

analysis. Journal of Sleep Research 18, 148-158.

Institute of Medicine. (2006). Sleep disorders and sleep deprivation: An unmet public health

problem. Washington, DC: The National Academies Press.

Jansson, M. & Linton, S.J. (2006). The role of anxiety and depression in the development of

insomnia: Cross-sectional and prospective analyses. Psychology & Health, 21(3), 383-397.

Kazdin, A. E. (2001). Behavior modification in applied settings (6th

ed). Belmont, California:

Wadsworth/Thomson Learning.

Knowlden, A.P. & Sharma, M. (2014). Health belief structural equation model predicting sleep

behavior of employed college students. Family & Community Health, 37(4), 271-278.

Kyle, S.D., Espie, C.A., & Morgan, K. (2010). “… Not just a minor thing, it Is something major,

which stops you from functioning daily”: Quality of life and daytime functioning in

insomnia. Behavioral Sleep Medicine, 8, 123-140. doi: 10.1080/15402002.2010.487450

Luyster, F.S., Strollo Jr, P.J., Zee, P.C., & Walsh, J.K. (2012). Sleep: A health imperative. Sleep,

35(6), 727-734. doi: 10.5665/sleep.1846

38

Means, M. K., Lichstein, K. L., Epperson, M. T., & Johnson, C. T. (2000). Relaxation therapy for

insomnia: Nighttime and day time effects. Behaviour Research and Therapy, 38, 665–678.

doi:10.1016/S0005-7967(99)00091-1

Miltenberger, R. G. (2001). Behavior modification: Principles and procedures (2nd

ed). Belmont,

California: Wadsworth/Thompson Learning.

Mimeault, V., & Morin, C. M. (1999). Self-help treatment for insomnia: bibliotherapy with and

without professional guidance. Journal of Consulting and Clinical Psychology, 67, 511–

519. doi:10.1037/0022-006X.67.4.511

Morgenthaler, T., Kramer, M., Alessi, C., Friedman L., Boehlecke, B., Brown, T.,…Swick, T.

(2006). Practice parameters for the psychological and behavioral treatment of insomnia: An

update. An American Academy of Sleep Medicine Report. Sleep, 29(11), 1415-1419.

Morin, C.M., Bootzin, R.R., Buysse, D.J., Edinger, J.D., Espie, C.A., & Lichstein, K.L. (2006).

Psychological and behavioral treatment of insomnia: Update of the recent evidence. Sleep,

29(11), 1398-1414.

National Highway Traffic Safety Administration. (2011). Drowsy driving. Retrieved from

http://www-nrd.nhtsa.dot.gov/Pubs/811449.pdf

National Sleep Foundation. (2008). Sleep in America poll: Sleep, performance and the workplace.

Retrieved from http://sleepfoundation.org/sites/default/files/2008%20POLL%20SOF.PDF

National Sleep Foundation. (n.d.-a). Healthy Sleep Tips. Retrieved

from http://sleepfoundation.org/sleep-tools-tips/healthy-sleep-tips

National Sleep Foundation. (n.d.-b). Shift Work. Retrieved from

http://www.sleepfoundation.org/article/sleep-topics/shift-work-and-sleep

National Sleep Foundation. (n.d.-c). Sleep Studies. Retrieved

from http://www.sleepfoundation.org/article/sleep-topics/sleep-studies

National Sleep Foundation. (n.d.-d). The abc’s of zzz’s- when you can’t sleep. Retrieved from

http://sleepfoundation.org/how-sleep-works/abcs-zzzzs-when-you-cant-sleep

Pallesen, S., Nordhus, I.H., Kvale, G., Nielson, G.H., Havik, O.E., Johnsen, B.H., & Skotskift, S.

(2003). Behavioral treatment of insomnia in older adults: An open clinical trial comparing

two interventions. Behavior Research and Therapy, 41, 31-48.

Ritterband, L. M., Thorndike, F. P., Gonder-Frederick, L. A., Magee, J. C., Bailey, E. T., Saylor, D.

K., & Morin, C. M. (2009). Efficacy of an Internet-based behavioral intervention for adults

with insomnia. Archives of General Psychiatry, 66, 692–698. doi:10.1016/S8756-

3452(09)79335-1

Robbins, R. & Niederdeppe, J. (2015). Using the integrative model of behavioral prediction to

identify promising message strategies to promote healthy sleep behavior among college

students. Health Communicaition, 30, 26-38. doi: 10.1080/10410236.2013.835215

Rybarczyk, B., Lopez, M., Benson, R., Alsten, C., & Stepanski, E. (2002). Efficacy of two

behavioral treatment programs for comorbid geriatric insomnia. Psychology and aging, 17,

288–298. doi:10.1037/0882-7974.17.2.288

Sabanayagam, C. & Shankar, A. (2010). Sleep duration and cardiovascular disease; Results from

the national health interview study. Sleep, 33(5), 593-598.

Soehner, A.M., Allison, M.A., & Harvey, G. (2012). Prevalence and functional consequences of

severe insomnia symptoms in mood and anxiety disorders: Results from a nationally

representative sample. Sleep, 35(10), 1367-1375. doi: http://dx.doi.org/10.5665/sleep.2116

Spielman, A.J., Saskin, P., & Thorpy, M.J. (1987). Treatment of chronic insomnia by restriction of

39

time in bed. Sleep, 10(1), 45-56.

Stepanski, E. J. & Wyatt, J. K. (2003). Use of sleep hygiene in the treatment of insomnia. Sleep

Medicine Reviews, 7(3), 215-225. doi: http://dx.doi.org/10.1053/smrv.2001.0246

Taylor, D.J., Lichstein, K.L., & Durrence, H.H. (2003). Insomnia as a health risk factor.

Behavioral Sleep Medicine, 1(4), 227-247.

Taylor, D.J., Lichstein, K.L., Durrence, H.H., Reidel, B., & Bush, A.J. (2005). Epidemiology of

insomnia, depression and anxiety. Sleep, 28(11), 1457-1464.

Thank you to our 2014 Platinum Sponsors

ArkAHPERD 2015 State Convention

November 5-6

Best Western Inn of the Ozarks

207 W. Van Buren

Eureka Springs, AR 72632

Phone: 1-479-253-9768

2014 Teacher of the Year Awards

Elementary TOY – Brad Cowger

Middle School TOY – Leah Queen

High School TOY – Mike Morrison

Health Education TOY – Laura Abbott

40

Faculty Peered Review Article

Accessibility of Public Schools’ Extracurricular Activities for Homeschooled Students

by David Lavetter

Introduction

A growing number of parents in the United States are home-schooling their children as an

alternative to sending them to public or private schools. U.S. Department of Education (NCES,

2014) showed 2.3 million U.S. children were homeschooled in 2010, an increase of 52.2% since

2003 (1.1M). For various reasons, parents or guardians believe that they can provide an equivalent

or superior educational experience. Familiar reasons given for homeschooling are: Customize or

individualize the curriculum and learning environment for each child, academically challenge each

student more than schools can, use pedagogical approaches other than those practiced in public

schools, enrich family relationships between children and parents, and sometimes among siblings,

provide guided social interactions with youthful peers and adults in similar homeschool groups,

provide a safer environment for children and youth (e.g. bullying), and impart a particular set of

values, religious beliefs, and principles to students (Ray, 2015).

Yet, increasingly, homeschool parents have become interested in taking advantage of

extracurricular activities offered at public schools. Though a variety of reasons exist for parents

choosing to homeschool their children, many states’ extracurricular participation policies also vary.

In 1991, Washington was the first state to allow homeschooled students on public school teams

(Colb, 2005). Many states have since followed. The purpose of this paper discusses the legalities of

extracurricular participation in public schools of homeschooled students.

According to Homeschool Legal Defense Association (HLDA, 2013), homeschooling is

legal in every state; though requirements vary (districts within some states can also vary).

Currently, 36 states (Appendix, Table 1) allow home-school participation in public school extra-

curricular activities. States use a unique vocabulary describing their activities. Pay attention to the

meanings of various terminologies used by particular states and school districts. For example,

“extra-curricular,” “co-curricular,” “curricular,” “interscholastic,” “program,” “activity,” etc.

should be given due proper attention to distinguish one from another. How a state defines these

terms is essential. Additionally, many states’ policies can vary with the specific requirements to be

eligible to participate as a homeschooled extracurricular participant (HLDA, 2013).

Statutory Law Case Law

AZ, AR, CO, FL, ID, IL, IA, LA, MA, ME,

MN, MO, NE, NV, NH, NM, ND, OH, OR,

PA, RI, SC, SD, TN, TX, UT, VA, VT, WA,

WI, WY

MA, MI, MT, NJ, WV

Table 1. States allowing extra-curricular participation for homeschooled students (HLDA, 2013).

In states, where homeschooling has been an alternative to private and public school education,

plaintiffs’ arguments are usually focused on statutory and constitutional rights to participate in

extracurricular activities. Opponents cite a double standard under which public school students

must follow academic and attendance rules to play sports while homeschoolers do not.

Consider a few legal questions related to homeschoolers’ participation in school activities:

Do homeschoolers have a general right to send their children to a limited component (e.g.

interscholastic athletics) of the public school?

41

For those states that disallow extra-curricular participation for homeschoolers, does the “all-

or-nothing” consumption of the public school’s benefits place schools at greater risk for

potential lawsuits?

Does the greater right, to attend school, include the lesser right, to participate in extra-

curricular activities?

Are extra-curricular activities an inseparable part of public school education?

In states, where homeschooling has been an alternative to private and public school

education, plaintiffs’ arguments are usually focused on statutory and constitutional rights to

participate in extracurricular activities. Opponents cite a double standard under which public school

students must follow academic and attendance rules to play sports while homeschoolers do not. In

Davis v. Massachusetts Interscholastic Athletic Association (1995), the plaintiff filed suit because

defendant wouldn’t allow her to try out for the high school softball team. Plaintiff alleged actions

were arbitrary, capricious, and in violation of the Constitution of the Commonwealth of

Massachusetts and of the 14th

amendment. At issue is whether the plaintiff’s Equal Protection

rights are violated. As noted, religion is commonly a factor cited for some choosing to homeschool.

Thus, the Free Exercise Clause may also be applied by courts to determine if the school’s

participation policy is neutral and generally applicable for all students.

Trefelner et al. v. The Burrell School District (2009) concluded there is no reason to

distinguish between religiously motivated home education programs and other forms of religiously

motivated education programs, such as attending a parochial school. If the decision to enroll a

student in an education program is motivated by religion, then that action is protected by the Free

Exercise Clause if the policy is not neutral. The court found the district’s participation policy was

neutral and generally applicable.

Are homeschoolers’ constitutional rights violated when they are not allowed to participate

in interscholastic athletics? In Snyder v. Charlotte Public School Dist. (1985), the State Supreme

court held that public school’s extracurricular programs are open to all students unconditional upon

compulsory attendance law. Yet, Reid et al. v. Kenowa Hills Public Schools (2004), found that

state statutes do not require public schools to admit homeschooled students to their athletic

programs and that students do not have a statutory right to participate in interscholastic athletics.

As seen, state laws vary whether Equal Protection may be granted to homeschoolers.

Arkansas Law (Act 1469)

With the enactment of House Bill 1789 on April 22, 2013, homeschool students may now

participate in interscholastic activities at their resident school district in the state of Arkansas. The

term “interscholastic activity” means an activity between schools subject to the regulations of the

Arkansas Activities Association and is (1) outside the regular curriculum of the school district and

includes such things as an athletic activity, a fine arts program, or a special interest club or group

and (2) taught by an individual with a minimum of a high school diploma (Arkansas Code §6-15-

509).

Further, homeschooled student is defined as a student legally enrolled in an Arkansas home

school. The must enroll in school (at least one class per school day) and report to the district with

11 school days of fall or spring semesters. To engage in extracurricular activities, the homeschooler

(or parent) must provide notice to the principal of the student’s intention to pursue participation in

the activity prior to the signup, tryout, or participation deadlines established for public school

students. Participation is not guaranteed, but the homeschool student has an opportunity to try out

for the respective extracurricular teams or student organizations (Arkansas Code §6-15-509).

Additionally, “…the student’s parent must inform the principal in the notice that the student

42

has demonstrated academic eligibility by obtaining either a test score at or above the 30th

percentile on the Stanford Achievement Test, 10th edition, or another nationally recognized norm-

referenced test within the previous 12 months. In the alternative, the student may achieve a

minimum score on a test approved by the state board of education. Additionally, the homeschool

student must meet the same eligibility criteria established for participation by public school

students. A student who withdraws from an Arkansas Activities Association member school to be

homeschooled is prohibited from participating in an interscholastic activity for a minimum of 365

days from the student’s withdrawal” (Arkansas Code §6-15-509, ACT 1789, p. 1).

Expectedly, the student is required to meet the school’s criteria for joining the team, club,

or other extracurricular activity such as standards of behavior, or codes of conduct, academic

qualifications, class attendance policies, drug testing, practice times, exculpatory agreements (e.g.

waivers), medical exams, and possible activity fees (Arkansas Code § 6-15-509). A full description

of the code is as follows:

Arkansas Code Annotated § 6-15-509 (State of Arkansas 89th

General Assembly, 2013, pp. 1-3).

(a) The General Assembly recognizes that all students should have equal access to interscholastic

activities as a complement to the academic curriculum.

(b) As used in this section:

(1) “Athletic activity” means a varsity sport or another competitive sports-related contest,

game, event, or exhibition that involves an individual student or teams of students either

among schools within the resident school district or between schools outside of the resident

school district;

(2) “Home-schooled student” means a student legally enrolled in an Arkansas home school;

(3) “Interscholastic activity” means an activity between schools subject to regulations of the

Arkansas Activities Association that is:

(a) Outside the regular curriculum of a school district, including without limitation

an athletic activity, a fine arts program, or a special interest club or group; and

(b) Taught by an individual with a minimum of a high school diploma;

(4) “Parent” is a legal guardian or legal custodian;

(5) “Resident school” is the school to which the student would be assigned by the resident

school district; and

(6) “Resident school district” means the school district in which the home-schooled

student’s parent resides as determined under § 6-18-202.

(c) A home-schooled student shall not participate in interscholastic activities at a

public school other than the student’s resident school.

(d) A resident school district may permit a home-schooled student to participate in

an interscholastic activity if:

(1) For the purpose of subsection (g) of this section, the home-schooled

student reports to the resident school district within the first eleven (11) days of the

fall or spring semester of the resident school district; and

(2) The home-schooled student or his or her parent advises the principal of

the resident school in writing of the student’s request to participate in the

interscholastic activity before the signup, tryout, or participation deadlines

established for students enrolled in the resident school.

(e) The principal of the resident school shall permit a home-schooled student to

pursue participation in an interscholastic activity of the resident school if the student or the

student’s parent:

43

(1) Before the signup, tryout, or participation deadlines established for

students enrolled in the resident school, provides to the principal a notice of the

student’s desire to pursue participation; and

(2) Informs the principal in the notice that the student has demonstrated

academic eligibility by obtaining:

(A) A minimum test score of the thirtieth percentile on the Stanford

Achievement Test Series, Tenth Edition, or another nationally recognized

norm-referenced test in the previous twelve (12) months; or

(B) A minimum score on a test approved by the State Board of

Education.

(f) If a home-schooled student’s written request to participate in the interscholastic

activity is approved under this section, the student:

(1) Although not guaranteed participation in an interscholastic activity, shall

have an equal opportunity to try out and participate in interscholastic activities

without discrimination; and

(2) Shall not participate unless he or she meets the criteria for participation

in the interscholastic activity that apply to students enrolled in the resident school

district, including:

(A) Tryout criteria;

(B) Standards of behavior and codes of conduct; and

(C) The academic criteria under subdivision (e)(2) of this section;

(D) Practice times;

(E) Required drug testing;

(F) Permission slips, waivers, and physical exams; and

(G) Participation or activity fees.

(g) A home-schooled student who participates in an interscholastic activity may be:

(1) Required to be at school not more than one (1) period per school day; and

(2) Transported by the resident school district to and from interscholastic

activities as the resident school district transports other students who are enrolled in

the resident school.

(h) A student who withdraws from an Arkansas Activities Association member

school to be home-schooled shall not participate in an interscholastic activity in the resident

school district for a minimum of three hundred sixty-five (365) days after the student

withdraws from the member school.

Equal Protection and Free Exercise Clause

The concept of equal protection stands for the principle that all persons similarly situated

should be treated alike. “No state shall make or enforce any law which shall abridge the privileges

or immunities of citizens of the United States; nor shall any State deprive any person of life,

liberty, or property, without due process of law; nor deny to any person within its jurisdiction the

equal protection of the laws.” (U.S. Const. Amend XIV, § 1). The Free Exercise Clause may also

be applied by courts to determine if the school’s participation policy is neutral and generally

applicable for all students. “Congress shall make no law respecting an establishment of religion, or

prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the

right of the people peaceably to assemble, and to petition the Government for a redress of

grievances.” (U.S. Const. Amend. I § 1) (Italics added).

In Swanson v. Guthrie Independent School District (1998) an Oklahoma student was not

44

allowed to attend school on part-time basis to be enrolled only in foreign language, and vocal

music. The school district had no policy related to homeschool participation at the time. Following

the hearing, the district instituted a new policy but had limited applications. The plaintiffs claimed

under the Free Exercise Clause, students should be able to attend public school on part-time basis.

Yet, the courts found the district’s policy is neutral and of general application; it applies to all

persons who might wish to attend public school on a part-time basis (including home schooled

students). School district was granted summary judgment due to the neutrality of the policy (no

need to show a compelling governmental interest). The case law in this area establishes that parents

simply do not have a constitutional right to control each and every aspect of their children's

education and oust the state's authority over that subject. Federal District court affirmed.

In Trefelner (2009), a homeschooled plaintiff in Pennsylvania filed for a complaint for 1st and

14th

Amendments violation. The plaintiffs requested temporary restraining order in order to

participate in extra-curricular activities. Burrell instituted Policy No. 122, Co-Curricular Activities

whereby a student must attend the full curricula of classes each day the student is to participate in

an extracurricular activity offered by Burrell. After the adoption of Burrell's Policy No. 122, PA's

Public School Code, 24 PA, STAT. § 1-1-1 et seq. was amended to permit students who are home

schooled or students who attend charter schools to participate in extracurricular activities offered

by the school district in which they reside. Although plaintiffs raised an equal protection claim,

there is significant overlap between their equal protection claim and free exercise claim. Courts did

not distinguish between religiously motivated home education programs and other forms of

religiously motivated education programs, such as attending a parochial school. Courts view them

similarly. If the decision to enroll a student in an education program is motivated by religion, then

that action is protected by the Free Exercise Clause if the policy is not neutral. If a policy is

"neutral" and "generally applicable" with respect to religion, then it need not be justified by a

compelling governmental interest even if the law has the incidental effect of burdening a particular

religious belief or practice.

Exceptions to the policy, however, were made as the state Public School Code mandated

exceptions for purposes (i.e. home schooled children and students attending charter schools). These

exemptions undermined Burrell's policy to the same extent that permitting plaintiff to participate in

the marching band would undermine the policy. If the state-mandated exceptions were not made,

then the policy would violate state law. The Court of Appeals did not question whether the decision

to home-school a child was religiously motivated; it analyzed whether the courts found defendant

did not articulate any compelling reasons for their policy (Trefelner, 2009).

For collegiate athletics participation, the following outlines both National Association of

Intercollegiate Athletics (NAIA), and National Collegiate Athletic Association (NCAA) policies

for home-schooled students:

NAIA Initial Eligibility

Provide proof student received certificate (or equivalent) granted by the appropriate state

agency verifying successful home schooling requirements completion.

Achieve a minimum score of 18 on ACT or 860 on SAT.

If student resides in a state that has no home school requirements or a state agency that can

verify completion of requirements, student will need to seek an exception to the standard

rule under the process in Article V, Section L of the NAIA Bylaws.

In prior requests, a student who has scored well on the ACT or SAT has had an outstanding

chance of receiving an exception (NAIA, 2014).

NCAA Eligibility

45

Register with NCAA Eligibility Center (send required materials to Center)

Standardized test score

Transcript (core course requirements)

Proof of high school graduation

Proof homeschool was conducted in accordance with state law

List of textbooks used (NCAA, 2014).

Private School States

At least nine states do not have homeschool statutes. In these states homeschools are legally

considered private schools. Consequently, homeschoolers usually have more freedom from

burdensome state requirements. It is difficult to write a law allowing equal access for

homeschoolers when a “homeschool” is not defined by statute. In these situations, homeschoolers

do not want to lose the freedoms they have as private schools, and state officials are not usually

willing to throw access open to all private school students. Access legislation can be worded so that

it does not change the private school status of home educators, but such a bill has yet to pass in a

private school state (HSLDA, 2013).

While athletic association rules are not “law,” public schools are generally constrained to

operate within them, or their teams could be disqualified. Therefore, in states where case law has

established precedence in this area, state associations have followed suit. A trend of allowing

access for homeschooled students continues to increase under statutory state law during the last

decade. Generally, we shall probably see homeschool students to have greater access to limited

school activities, such as interscholastic athletics, as we look to the future.

References

Arkansas Code §6-15-509. ACT 1789 (2013). State of Arkansas 89th

General Assembly, Regular

Session 2103. Retrieved from ftp://www.arkleg.state.ar.us/Bills/2013/Public/HB1789.pdf.

Colb, S.F. (2005). Should parents who home-school their children have access to public school

extracurricular programs? Retrieved from http://writ.news.findlaw.com/colb/20050630.html

Davis v. Massachusetts Interscholastic Athletic Assoc. (1995), Inc. 3 Mass. L. Rep. 375, 1995

Mass. Super., LEXIS 791

Homeschool Legal Defense Association (HSLDA) (2013, September). State laws concerning

participation of homeschool students in public school activities. Retrieved from

http://www.hslda.org/docs/nche/Issues/E/Equal_Access.pdf

National Center for Education Statistics (NCES) (2014). Retrieved from

http://nces.ed.gov/pubs20014/2014030.pdf

NAIA (2014). NAIA Homeschool Eligibility Policy. Retrieved from

http://naia.cstv.com/memberservices/legislative/currentissues/FreshmenEligibilityRequirem

ents.htm

NCAA (2014). NCAA Homeschool Eligibility Policy. Retrieved from

http://www.ncaa.org/wps/ncaa?ContentID=417

Ray, B.D. (2015). Research facts on homeschooling. National Home Education Research Institute.

Retrieved from http://www.nheri.org/research/research-facts-on-homeschooling.html.

Reid et al. v. Kenowa Hills Public Schools (2004). 2004 Mich. App. LEXIS 645.

Snyder v. Charlotte Public School Dist. (1984). 417 Mich. 104; 365 N.W. 2d 151.

Swanson v. Guthrie Independent School District No. I-L (1998). 135 F.3d 694; 1998 U.S. App.

LEXIS 1259.

Trefelner v. The Burrell School District (2009). U.S. Dist. (PA) LEXIS 78785

46

Important Dates

National Coaching Conference

2015 PETE & HETE Conference

June 9-12, 2015

October 27-31, 2015

Morgantown, WV

Atlanta, GA

ArkAHPERD Convention November 5-6, 2015 Eureka Springs, AR

Southern District Convention February 10-13, 2016 Williamsburg, VA

2016 SHAPE America Convention April 5-9, 2016 Minneapolis, MN

ArkHEART Course-PD Opportunity

Course:

This six week course provides an introduction and review of the

heart and associated diseases. Take the course to refresh you

knowledge in the anatomy, function and diseases of the heart.

Cost:

Free to AHA event holders (JUMP or HFH)

Registration:

Sign up by contacting the ArkAHPERD office (a JUMP or HFH

event must be held)

Course Dates:

Spring and Fall courses offered

47

Faculty Peered Review Article

The Effects of Using Physical Activity in the Classroom to Enhance Children’s Cognition by Blair

McAlister ASU & Blair Dean ASU

Introduction

The No Child Left Behind Act of 2001 (NCLB) is a United States Act of Congress about

the education of children. The NCLB supports standards-based education reorganization, which is

based on the notion that setting high standards and measurable goals can improve individual

outcomes in education. Although the Act has recognized strengths: high learning expectations, the

attention on subgroups that have been known to trail behind, improved alignment, and better use of

data; some school administrators have voiced negative concern (Wada, 2009). The popularity of

NCLB's measures has been fiercely argued (Wada, 2009). A primary criticism suggests that

NCLB could reduce effective instruction and children’s learning because it may cause states to

lower achievement goals and encourage teachers to "teach to the test," (Wada, 2009).

NCLB’s primary focus has been on improving skills in reading, writing, and mathematics,

in order to become more competitive in the global market. With an overemphasis placed on core

subjects (reading, writing and math), an adverse effect has occurred in subjects labeled as “not

tested core curriculum” such as history, music, art and physical education (Wada, 2009). While

long term effects have yet to be measured, the short term effects may be detrimental for the non-

tested subject areas (Wada, 2009). Reports indicate that the majority of federal funding for schools

is earmarked for core tested subjects (Burgeson, 2004). This unbalance in funding has caused

instruction in other subjects to decrease by 71% (Burgeson, 2004). NCLB standards have caused

educators to teach to the measurable skills tested on State Benchmark exams. Teachers are

encouraged to spend the majority of their time teaching these measured skills for testing so that

improvement is seen among the student body. For instance, if a school body is going to be tested on

how students recite the Pledge of Allegiance, teachers are going to spend the majority of their time

teaching the Pledge of Allegiance, not the National Anthem (Wada, 2009). Reading, writing, and

mathematics are the focus of testing, therefore, schools will spend their funding, time, and energy

to prepare children for these content area skills. For this reason, the NCLB has been frequently

cited as one of the main causes for the strain on physical education (Wada, 2009).

The adverse effect on physical education is one of the many noted reasons childhood

obesity is growing in occurrence. It is no secret that childhood obesity is a serious problem in the

United States; according to a report from the White House Task Force on Obesity, one in three

children are now obese and $117 billion is spent annually to treat obesity-related diseases (Wada,

2009). Alarming research predicts parents of this generation could outlive their children due to

increased sedentary lifestyles (Sanders, 2003). Children who have poor nutritional habits are at a

greater health risk than children who participate in alcohol, drugs, and tobacco combined.

Likewise, being overweight can impair school performance in many ways, including health-related

absenteeism (Story, 2006). Among the health conditions linked with being overweight in school-

aged children are asthma, joint problems, type 2 diabetes, depression and anxiety, and sleep apnea

(Story, 2005). Social problems—such as being teased or bullied—loneliness, or low self-esteem,

can also affect how well children perform in school (Story, 2005)

48

Just as the previously discussed negative effects of childhood obesity are undisputable, so

are the positive benefits of a quality physical education program. The quality of physical education

classes is also crucial in their effect on childhood obesity. In physical education, programs,

children learn the importance and value of being physically active. Children learn that daily

physical activity helps: build and maintain healthy bones, muscles, and joints; control weight, build

lean muscle; and lower high blood pressure. Likewise, recent studies concluded that regular

physical activity reduces the feelings of depression and anxiety; and through its effects on mental

health, enhances cognitive function (Rice, 2009). It is believed that physically active children have

a greater chance of being healthy for a lifetime (Sanders, 2003).

Moreover, “research suggests a strong correlation between children’s fitness and their

academic performance as measured by grades in core subjects and standardized test scores”

(Hellmich, 2010). It is a widely accepted concept that being physically active increases physical

health. It is also reported that good physical health is linked to brain health. There are several

reasons why physical activity is beneficial for the brain: increasing the blood and oxygen flow to

the brain, increasing growth factors that help create new nerve cells, and increasing chemicals in

the brain that help cognition, such as dopamine, norepinephrine, and serotonin (Dean, 2009).

Any time a child engages in physical activity, oxygen reaches the brain with more ease,

resulting in improved focus and cognition. Youth receiving additional physical activity tend to

show improved attributes such as increased brain function and nourishment, higher energy/

concentration levels, improved somatotypes, increased self-esteem and better behavior which all

support cognitive learning (Elliott, 2002). However, as of late, children are spending an alarming

amount of time sitting and remaining inactive during the school day.

Research suggests that children and teens need 60 minutes of physical activity daily for

adequate health (President’s Council, 2010). However, in many schools, opportunities for children

to be physically active are few and far between and becoming increasingly so. This is true because

time away from math, reading, and writing is viewed as academic time wasted. If instruction does

not directly lead to improved test scores it is discouraged or not allowed. Cardon’s (2003) research

results indicate that children in traditional schools spend 97% of the lesson time sitting (Cardon,

2003). Consequently, schools have become information rich and movement poor. “Physical

education cannot be viewed as merely a desirable option in a school system. It is an absolute

necessity, and it must be built into the curriculum to ensure that all children participate fully in a

program that will challenge them close to their limits,” (Instructor Web, 2010). Although there is a

significant fear of losing valuable instruction time to extra physical education, research shows

teachers who implement physical activity into classroom instruction will observe multiple

improvements in a child’s learning.

Enhancing academic learning through physical activities, resulting in an active hands-on

classroom, will find children with an increase in brain functioning, creating more connections for

learning (Scheuer, 2003). Also, implementation of an active classroom will see improvements in

memory formation, concentration, and social behaviors. Research has shown that when additional

time is devoted to physical activity, it does not interfere with learning and in some instances even

has accelerated learning (Noffsinger, 2005). This multi-sensory approach to teaching helps children

by allowing them to learn through more than one of the senses (Dean, 2009). Incorporating

49

physical activities across the curriculum is the breath of fresh air for children who learn by doing,

not by sitting. American teachers cannot advocate to battle childhood obesity when children are

imprisoned to their desks.

Statement of the Problem

Schools must fit many subjects and activities into the school day and must balance state and

local resources, priorities, and needs for education. In recent years, however, the comprehensive

curriculum has been eroding, especially in the wake of the federal No Child Left Behind Act of

2001, which focuses on student achievement in defined core academic subjects (Burgeson, 2004).

As states develop or select standardized tests to hold schools and children accountable, content that

is not tested, such as physical education, has become a lower priority (Story, 2006). But, as noted,

time devoted to physical education does not lessen performance in other areas and can, in fact,

enhance both children’s readiness to learn and academic achievement (Sallis, 1999). The fact that

mandatory physical education classes have been watered down and recess time has decreased in

many school districts across the nation (Landers & Kretchmar, 2008) suggests a lack of

understanding among school administrators and the American public of the connection between

children’s physical and mental well-being.

Purpose of Study

Schools are unique in their ability to promote physical activity and increase energy

expenditure— and thereby help reduce childhood obesity. Knowledge of the effects of physical

activity on brain function is highly pertinent to teachers. This information should become part of

the knowledge base of teachers and should be included in the professional training of teacher

candidates. Education of the American public, including those who make critical decisions

regarding curriculum and budget allocation, is also necessary. The purpose of this paper is to

review the basic scientific findings of the role of movement as a significant vehicle to enhance

academic learning in the classroom.

Significance of Study

Due to NCLB standards, teachers have begun to base instruction on standardized testing or

“teaching to the test,” which has caused physical education to plummet. As a result, childhood

obesity is at an all-time high in America. This study is significant to the American teacher because

children will not adequately learn to the best of their ability if their physical needs are not met.

Because of recent legislation, teachers are evaluated based on their children’s test scores. If

implementing physical activity into the classroom can assist in achieving educational goals and

enhance children’s learning, the teacher will find this research to be very valuable.

Also, further educating the American public is needed regarding the benefits of physical

activity on the overall health, emotions, and intellectual capacity. It seems rational for teachers and

exercise professionals first to become familiar with the important research findings about the

effects of physical activity on the brain and cognitive function. This information may give

professionals a better understanding of the mechanisms by which physical activity might enhance

learning. With more knowledge, professionals may exert greater influence on children, parents, and

those who make curriculum and budgetary decisions that affect school curriculum (e.g., principals,

school board members).

50

Review of Literature on Benefits of Physical Activity Introduction

With one in three children being classified as obese, (Wada, 2009), teachers must become

knowledgeable of the precedence physical activity plays in a child’s overall physical health.

Because children spend more waking moments in the classroom than at home, teachers should view

time spent in the classroom as opportune times to increase a child’s physical health, thus,

increasing their quality of life. The benefits of physical activity on children’s health are

undisputable, and should drive a teacher’s lesson planning.

Physical Activity and Improved Mental Clarity

“Physical activity will positively affect blood flow and oxygen to the brain, thereby

improving mental clarity” (National Association for Sport and Physical Education, 2011). When

individuals are physically active, blood circulation is increased resulting in an increase of oxygen

and glucose that reaches the brain. Research has shown that movement activities stimulate every

area of the brain, thus forming new connections between brain cells (Dean, 2009). When neurons,

specialized cells that send and receive signals within the body, receive these new connections, brain

activity is increased (MedicineNet, 2003). These special connections between neurons, also called

synapses, are associated with memory formation and storage in the cerebellum of the brain (Kleim,

2002). Children’s brains contain trillions of neurons waiting for synapses; therefore, educators

should provide rich movement experiences to accommodate this connection, which will stimulate

the brain and engage students in the formation of memory.

Physical Activity and Improved Attention Span

“Physical activity will also positively affect connections between nerves in the brain,

thereby improving attention and information-processing skills” (National Association for Sport and

Physical Education, 2011). Brain activity can be increased with the slightest of movements. For

example, “a 5-15% increase in blood and oxygen flow to the brain is created when one stands.”

This causes participants to become more alert, (Cummins). Also, blood pools in the seat and feet

after about twenty minutes of being seated. This moves essential blood circulation away from the

brain. Research results indicate that children in traditional schools spend approximately 97 % of the

lesson time sitting at their desks (Cardon, 2003). Without conditioning, research suggests that an

average child’s formal attention span, in minutes, is about as long as the age of the child (Bickta).

Implementing movement activities into the regular classroom will stimulate the brain by increasing

oxygen and blood flow, resulting in more effective memory formation and longer attention spans.

Physical Activity and Improved Physical Health

“Physical activity will help to build strong bones and muscles” (National Association for

Sport and Physical Education, 2011). Children require more than a balanced diet with proper

amounts of calcium and protein to build strong bones and muscles. Participation in movement

activities at an early stage of life helps lower the risk of chronic back and neck pain (Vorvick,

2011). “Osteoporosis, the disease that causes bones to become less dense and more prone to

fractures, has been called “a pediatric disease with geriatric consequences,” because the bone mass

attained in childhood and adolescence is an important determinant of lifelong skeletal health”

(National Institute of Health, 2011). Action taken to increase a child’s physical health will be

51

reflected in his/her life as an adult. Muscles get stronger when they are used and conditioned.

Similarly, bones will strengthen as they are conditioned through physical activity (National

Institute of Health, 2011). When teachers invest in each child’s physical health and well-being, they

will find that children miss less school because of health-related absenteeism.

Physical Activity and Decreased Obesity-Related Health Risks

“Physical activity decreases the likelihood of developing obesity and risk factors for

diseases such as type 2 diabetes and heart disease” (National Association for Sport and Physical

Education, 2011). The single greatest risk factor for contracting diseases such as Type 2 Diabetes

and heart disease is excess weight (WebMD, 2010). One of the greatest ways to reduce excess

weight is by remaining physically active. Research concludes that one in three children is now

obese and $117 billion is spent annually to treat obesity-related diseases like Type 2 Diabetes and

heart disease (Wada, 2009). Children spend more waking hours at school than at home. Because of

this, teachers should propose ways in which they can facilitate activities that will increase

children’s health and fitness.

Physical Activity and Positive Mental Health

“Physical activity promotes positive mental health and can reduce anxiety and depression”

(National Association for Sport and Physical Education, 2011). The Surgeon General’s Report on

Physical Activity and Health (Landers: Research Digest, 1996) concludes that physical activity

appears to relieve symptoms of depression and anxiety and improve mood” and that “regular

physical activity may reduce the risk of developing depression (Landers). “Studies have shown

that the process of exercise brings about both short- and long-term psychological enhancement

and mental well-being. Physical activity has been found to have a positive causal effect on self-

esteem changes in adults (Wilderdom, 2006). Aerobic activity can increase vigor and promote

clear thinking” (Wilderdom, 2006). Being physically fit, in most cases, brings about a sense of

improved self-esteem among individuals. Children who have improved self-esteem and mental

health will participate more eagerly in the classroom. There will also be an increased positive social

atmosphere in a classroom where children have increased mental health.

Review of Literature Benefits of Physical Activity to Enhance Cognitions Introduction

Providing children with an effective education will better prepare them for success in school

and life. To provide children with quality education, teachers must stay current with teaching

strategies that will ensure the best academic results. New research supports the idea of

implementing physical activity in the regular classroom to support children’s learning (Hellmich,

2010). Although there are several noted benefits of a physically active classroom, some educators

maintain reservations about lending core subject instructional time to alternative or not-traditional

forms of learning through physical activity.

Because of high-stakes testing involved in education for teachers and children alike,

teachers may view time away from direct instruction as academic time wasted. Teachers may feel

that implementing an active classroom will involve too much extra preparation, limited classroom

space for movement, as well as, the need for extra materials and equipment (Bonwell, 1991).

Although these reservations exist, they should not prevent the teacher from incorporating physical

activity into the curriculum. Active learning can occur within the confines of a small classroom

52

area, on a carpet square or in the limited space around each child’s desk. Children of all ages can

develop spatial awareness and motor control while moving within limited space, reaping the

benefits of learning while being physically active.

Physical Activity and Cognition

Physical activity has capabilities of improving brain function which helps nerve cells to

multiply, thus, creating more connections necessary for learning (Rice, 2009). A healthy body will

nourish its brain, producing a healthier brain, which is necessary for increased improved learning.

Research suggests that “students who exhibit fitness achievement have increased odds of passing

state English and math tests” (Rice, 2009). One researcher believes, “the human qualities we

associate with the mind can never exist separate from the body, because movement is an

indispensable part of learning and thinking, as well as all integral parts of mental processing”

(Blakemore, 2003). Therefore, in the classroom, it is possible to uncover a very natural connection

between physical activity and the way one’s brain functions. As teachers plan and implement a

curriculum, they should pay close mind to the nourishment they are providing for children and their

brains.

Classroom Connection

When teaching mathematics, movement activities may be integrated throughout the lesson

in order to better engage students and in order to increase “sensory input and movement, which

assist the brain in learning more productively” (Pennington, 2010). With an experimental group of

children, a movement method of teaching the concept of fractions was carried out to give a more

dynamic means of experiencing this subject (Pennington, 2010). For example, the children could

“jump fractional distances on a measuring line,” and “beat the fractional rhythm of a song”

(Pennington, 2010). The teachers involved in this experiment, “claimed that the activities had a

positive effect because children stayed on task, needed little redirection, clearly enjoyed the

activities, and met the learning standards” (Pennington, 2010).

Using Physical Activity to Enhance Memory

The human brain’s memory formation may see significant improvements in short and long

term memory when more than one mode of information is used to present the new material (Rice,

2009). Traditionally, auditory or visual components are used by teachers in the classroom. When

movement components are combined with visual or auditory components, connections are

strengthened, making retrieval possible with more ease (Rice, 2009). In the classroom, teachers

may modify the traditional lesson format by integrating movement activities with typical visual or

auditory activities.

Classroom Connection

When planning lessons, teachers should integrate movement activity with visual or auditory

components, in order to, increase memory formation and retrieval among children. For example,

children may observe visual pictures or diagrams of particles in the various states of matter (solids,

liquids, and gases). To enhance memory formation, the teacher may also introduce a movement

activity, demonstrating what the particles of each state of matter may look like. Children will move

inside an area set up by cones, in a cluster-like movement (Dean, 2009). For a very open space,

53

students will be able to move around freely, much like gas particles (Dean, 2009). Then, as the

cones are placed closer together, making it more difficult for children to move around in a cluster,

the children are demonstrating particles found in a solid (Dean, 2009). This is a great visual for

children as they work to understand the differences between a solid, liquid, and a gas (Dean, 2009).

Physical Activity and Attention Span

Many teachers frequently struggle to maintain each child’s attention throughout the school

day. They may attempt to engage children by frequently asking questions about material being

discussed, moving about the room, and changing the tone of their voice. However, teachers may

find that attention may be increased by incorporating bouts of movement activities throughout the

school day (Rice, 2009). Research suggests that teachers who integrated movement activities

throughout the school day, observed children with improved on-task behaviors by 20 percent (Rice,

2009).

Classroom Connection

Almost all experienced early childhood teachers can attest to the difficulties of maintaining

a classroom of learning, with squirming children who have short attention spans. When children

begin exhibiting off-task behaviors, the learning process is handicapped, sometimes for the entire

classroom of learners. In order to combat struggling attention spans, teachers may implement

movement activities into the regular academic schedule to increase concentration among children.

For example, in kindergarten and first grade, teachers may implement movement activities into

handwriting and learning the alphabet by “painting the alphabet” (Dean, 2009). Instead of

remaining seated, monotonously reciting the alphabet or practicing handwriting on manuscript

paper, teachers may have children use different body parts to paint the alphabet on an imaginary

canvas (Dean, 2009). This activity provides children with hands-on alphabet practice and may

rescue faltering attention spans among the class.

Physical Activity and Mood

When children are actively involved in movement activities throughout the school day, their

mental health may see noticeable improvements, thus, getting children “in the mood to learn,”

(Rice, 2009). When children engage themselves in as little as fifteen minutes of movement activity,

their mood may significantly be elevated (Rice, 2009). Research has also found that creativity may

be significantly increased following bouts of movement activity (Rice, 2009). When children

exhibit increased self-esteem and an overall positive mood in the classroom, teachers may find that

those children are more willing to and more conditioned to learn the academic material being

presented.

Classroom Connection

“Vygotsky, (1978), founder of the social cognition theory, which encouraged play,

considered play as the most important learning activity for children” (Pennington). When teachers

integrate movement activities with the academic material being taught, children have a deeper

connection with this idea of socially learning among their peers through play. A science lesson with

the objective of having children classify animals according to their structures, can easily be

transformed into an exciting movement game called, “The Great Zoo Escape.” Children will work

54

with classmates to rescue the escaped animals (pictures of animals) and return them to their homes

in the zoo, using their knowledge of the characteristics of mammals, birds, reptiles, fish, and

amphibians. Not only are children receiving a hands-on learning experience regarding the

classification of animals, but they are receiving opportunities to improve their mood and mental

health.

Programs and Research Supporting Physical Activity in the Classroom

The researched benefits ensure that children will benefit from the integration of physical

activity throughout the regular classroom curriculum, which results in programs being implemented

to carry out this idea of an active classroom. The Let’s Move in School initiative promotes this idea

of physical education implementation for schools across the United States (American Alliance for

Health, Physical Education, Recreation and Dance, 2011). This initiative highlights staff

involvement, physical activity during school, physical activity after school, and family/community

involvement (American Alliance for Health, Physical Education, Recreation and Dance, 2011).

Schools wishing to take part in the Let’s Move in School initiative follow a physical activity plan in

which they participate in drop-in physical activity opportunities throughout the day, have physical

activity integrated into classroom lessons, have physical activity breaks in the classroom, and when

appropriate, have regularly scheduled recess (American Alliance for Health, Physical Education,

Recreation and Dance, 2011). This initiative thrives on the consistency of the availability of

physical activity offered throughout the school day (American Alliance for Health, Physical

Education, Recreation and Dance, 2011).

Another successful use of physical activity implementation throughout the school day is

found in a school’s research experiment using an experimental and control group of children in the

fourth grade (American College of Sports Medicine, 2006). Researchers used pedometers to assess

children’s physical activity during school hours (American College of Sports Medicine, 2006). The

experimental group of children had their amount of physical activity measured with a pedometer,

along with, having participation in ten minute “energizers” (American College of Sports Medicine,

2006). These activities require little planning and no equipment, but provide spurts of increased

physical activity opportunities for this group of children (American College of Sports Medicine,

2006). The control group of children received no “energizer” activities (American College of

Sports Medicine, 2006). Researchers found that the experimental group had increased on-task

behaviors, verbal and motor behavior that follows the class rules and is appropriate to the learning

situation, by eight percent (American College of Sports Medicine, 2006).

Conclusion

Classrooms that promote physical activity provide teachers with opportunities to educate the whole

child. Teachers will find themselves teaching physical health, social health, mental health, and

emotional health, along with content area curriculum assessed on Standardized exams. Teachers are

held to the standard of providing children with a free and appropriate education. Assessing the

benefits of an active classroom, while heeding the warnings of an increased obesity rate, will find

educators searching for reforms in education that can be found in the components of an active

classroom. Many movement activities can be carried out with children standing behind or beside

their desks. Large spaces are not a necessity. Also, teachers will be enlightened to know that many

movement activities can be implemented in a very short amount of time, with few lesson plan

55

adjustments. Extravagant equipment and preparation is not a necessity. However, movement in the

classroom is a necessity for all children.

Implications for Teachers

The main role of a teacher is to teach children in a manner which yields positive outcomes,

especially on State standardized exams. Because stakes are high for both teachers and children,

classroom instruction time is held in high regards. A teacher must be able to account for the use of

all instruction time, and how this time spent has met State standards, giving children all of the tools

they need to succeed in performing Proficient or Above Proficient on standardized exams. Teachers

simply cannot afford to give valued instructional time to subjects or matters not tested on these

high-stakes exams.

At the same time, because of the emphasis placed on these exams, many schools whose

mission statements are to teach the whole child are proving unsuccessful at meeting the special

needs of children regarding the physical domain. Childhood obesity levels are at an all-time high,

but children spend the majority of their day being inactive (Cardon, 2003). The school day permits

little time for teachers to educate the physical child. A physically unfit child will not perform at

his/her highest potential (Hellmich, 2010). These children may exhibit a higher absentee rate, lower

attention span, and lower energy levels (Story, 2006). Teachers are caught at a crossroad between

focusing on a child’s physical health or their academic achievement.

Research, however, has linked a child’s physical health with his/her academic achievement

(Hellmich, 2010). With this research, teachers may develop and implement an active classroom

with the peace of mind knowing that the children will deliver the desired results of academic

learning and testing. Teachers must balance direct instruction with a more hands-on approach to

learning. This could easily be achieved through minor modifications in child grouping for lessons

and teaching methods used for lessons. A more active type of learning will not only increase blood

and oxygen flow to the brain for children; moreover, it will also increase social and academic

performance (NASPE, 2011). Children who remain active may have increased health and body

image (NASPE, 2011). Also, most of the active learning methods consist of social interactions

among cooperative groups of children. Children need this time of social learning to ensure that they

have grasped social milestones, along with the academic material being taught. When teachers

implement movement activities into the curriculum, children will build more brain connections,

which help store and retrieve information (Kleim, 2002). Children who learn using both sides of

their brain, will find that the information is more organized and retrievable in their memories

(Kleim, 2002). Teachers that implement movement activities throughout the curriculum may find

that their students have a longer attention span. Teachers must realize that implementation of

movement activities across the curriculum will increase physical health, while increasing children’s

learning. This realization will serve as motivation to educators as they make modifications to their

lesson plans in order to plan to teach the whole child.

Teachers must become knowledgeable about health matters regarding children. Resources

that provide easy-to-follow strategies for increasing physical activity and for improving food

choices among children are available to the public, especially through the internet. Also, teachers

may take advantage of professional development options that explore childhood obesity prevention

and overall nutrition. A child’s overall physical health, along with his/her mental health, must take

56

precedence in the school system today. A teacher’s knowledge of a child’s basic nutritional and

exercise needs will assist in the development of an active classroom. In the largest respect,

knowledge of health matters regarding children will leave educators with the knowledge that

children need to be active. They should not remain seated for the majority of the day. This

knowledge will serve as a motivation for teachers in their implementation of an active classroom,

for the sake of the children’s health and well-being.

Teachers should also advocate for teaching the whole child: Mental, Intellectual, Social,

Emotional, and Physical. In a school system, teachers serve as the main advocate for children. The

regular classroom teacher spends the majority of the day with the children. Therefore, the regular

classroom teacher will have a greater voice in making sure that all of the children’s needs are being

met. Many schools’ mission statements contain a clause about meeting students’ diverse needs in

order to assist children in reaching their full academic potential. A classroom that uses physical

activity as a vehicle to learning will aide in fulfilling a mission statement about meeting children’s

diverse needs.

Teachers must make appropriate accommodations in lesson planning to ensure that children

are receiving adequate physical activity throughout the school day. Just as teachers accommodate

various learning styles and needs, they must also take into account whether or not children’s

diverse physical needs are being met. All children require physical activity to remain healthy. A

short recess or physical education class is not adequate physical activity for children each day.

Teachers have the opportunity to implement an active classroom, ensuring that children are

receiving physical activity, as well as, proper academic instruction.

Teachers may inform parents of the importance of physical health, in regards to their child.

Teachers send home progress reports of educational achievement and conduct for each child

several times throughout the school year. Teachers should also inform parents of the importance of

continuing healthy habits for each child at home. The teacher can communicate strategies used in

the classroom to provide opportunities for movement, as well as, healthy food options the child and

parent can explore. Enforcing a healthy lifestyle at school is not enough to ensure that children

pursue a life of health. Children need to be given this information and reinforcement at school and

in their home. Teachers can play a huge role in this process at home by providing parents with easy,

healthy alternative habits for their child in regards to food choices and the amount of time spent

being physically active. With encouragement and support from the classroom teacher, parents may

be more apt to try new strategies with their child.

Perhaps one of the greatest contributors to the success of the implementation of an active

classroom is the knowledge and attitude of the classroom teacher. Teachers should be aware of the

high health risks that affect overweight children. They should also be aware of the increased

occurrence of childhood obesity. Knowledge of the high risks, along with the ways to combat the

issue, will serve as a motivation for teachers to make modifications to their lesson plans that

accommodate children’s physical health needs. The regular classroom teacher will actively combat

this growing issue by implementing an active classroom.

57

How to Implement Physical Activity throughout the School Day

Aside from reservations teachers may have regarding active classrooms, the implementation

of active classrooms can easily take place. The implementation of active classrooms does not

require huge amounts of time, preparation, space, or supplies. Teachers must first seek the many

benefits linked to the active learning in order to be grounded in motivation for the implementation.

When beginning the implementation of an active classroom, teachers must first create

boundaries for movement activities, which include basic rules, procedures, and space restrictions.

Classroom set-up will depend on the desired type of movement in the classroom. For some

activities, children may only need a small space behind their chair. For other activities, the teacher

may wish to provide a specific “activity space” that can be designated by carpet or tape.

In order to condition children to the routine of movement in the regular classroom, teachers

should routinely provide movement activities each day. Movement activities need to be a normal

occurrence, not a “special treat” for children. “A good rule of thumb is to allow children to change

activities after 20 minutes; therefore, a short movement activity break would be suitable following

a long session in which the children have been sitting and working at their desks,” (Erwin). A great

way to implement daily routine movement activities is to create “activity cards” which provide

random movement exercises, such as, hopping, crunching, or doing jumping jacks, which can be

used throughout each lesson. For example, a teacher may draw out two activity cards, hopping and

crunching. During a true/false questioning session, children will hop for ‘true’ and crunch for

‘false,’ (Erwin). This provides an easy movement implementation that keeps students on their toes

throughout the learning process.

Physical activity can also be implemented with the aid of music and the arts. Music

provides a vehicle for this implementation because of its natural tendency to cause involuntary

movement. “Music evokes movement and children require movement for their development and

growth,” (Musikgarten, 2011). “Music engages the brain while stimulating neural pathways

associated with such higher forms of intelligence as abstract thinking, empathy, and mathematics.

Music’s melodic and rhythmic patterns provide exercise for the brain and help memory. Who

among us learned the ABC’s without the ABC song?” Also, “Developmentally appropriate music

activities involve the whole child-the child’s desire for language, the body’s urge to move, the

brain’s attention to patterns, the ear’s lead in initiating communication, the voice’s response to

sounds, as well as, the eye-hand coordination associated with playing musical instruments,”

(Musikgarten, 2011). Teachers and publishers have provided multitudes of educational music and

dance that may teach content material in math, language arts, science, and social studies. Music

could be implemented during transition times. Transitions may be used as an opportunity to

energize children’s bodies.

For teachers who feel that they lack the creativity or time to implement movement activities

across the curriculum, short body “energizers” may be used to increase blood and oxygen flow

throughout the body. These activities could be as simple as reaching up toward the sky, then down

to the floor. Also, children could hop while counting or reciting information. Teachers should ask

themselves, “Could this learning activity be carried out while moving?” Teachers can invest in the

resource known as “Brain Gym” which “consists of 26 simple and pleasant movements aiming at

improving learning skills through the use of both brain hemispheres,” (BrainGym, 2010). Brain

58

Gym activities may be carried out in a very short amount of time, with no supplies, and little

necessary space.

When appropriate, movement activities may be integrated through dramatic arts. Dramatic

arts can most easily be integrated throughout the curriculum in the form of role-playing. Not only

does this implementation provide movement activities, but it also boosts children’s creativity, self-

expression, and social skills. “Role playing encourages the use of critical thinking because it

involves analyzing and problem solving, therefore, role play is a cognitive learning method,”

(Hartman).

Similar to all areas of running an effective classroom, teachers must plan for this

integration. When plans are made and motivation is established, teachers will be more apt to carry

out an active classroom. The benefits of an active classroom are undeniable. Teachers looking to

teach the whole child: mind, physical body, and emotions, will make the modifications needed to

give students a vehicle for physical health, as well as, for academic success.

Experiences of an Intern

As an early childhood education intern, one is constantly reminded of the importance of

adequately teaching and meeting all academic standards set out by the state. In other respects,

interns are presented with materials that inspire teachers to look at a child’s education beyond the

scope of his/her academic achievement. Many schools have constructed mission statements which

claim to seek ways of educating the whole child. The concept of teaching the whole child revolves

around the idea of meeting a child’s mental, emotional, physical, and academic needs.

Through the process of researching how movement can be implemented into the regular

classroom, the researcher was inspired by the importance and significance of teaching the whole

child. Much like one would care for a plant by providing soil with nutrients, water, and sunlight, a

teacher must seek to provide children with all of the elements they need in order to be a nourished

individuals, that includes having their physical needs met. If an individual provides a plant with soil

only, it will not reach its full potential. In the same respects, if a teacher provides only academic

information to a child, they will not reach their full potential. A brain full of rich academic

information is near useless to a physically unhealthy and unable body. As a future teacher, one

must nourish all of the parts of a child.

One aspect of educating the whole child that seems to be overlooked much of the time is

ensuring that all students are having their physical needs met. Through this research experience and

classroom teaching experience, the researcher encountered numerous benefits of integrating

physical activity across the curriculum. The most noticeable outcome among children is their

motivation to learn and a decrease in off-task behaviors during instructional time. These results, in

and of themselves, have served as motivation to the researcher in making learning an active and

rewarding experience for children, socially, emotionally, physically, and academically, through the

implementation of an active classroom.

59

References

American College of Sports Medicine. (2006). Classroom-based physical activity helps kids stay on

task. American College of Sports Medicine, Retrieved from

http://www.acsm.org/AM/Template.cfm?Section=Home_Page&template=/CM/Content

Display.cfm&ContentID=5340

American Alliance for Health, Physical Education, Recreation and Dance.(2011). Improving health

and academic performance. Retrieved from http://www.aahperd.org/letsmoveinsch ool/

Bickta, D. (2011). Attention span. Retrieved from http://www.spring-

ford.net/staff/dbick/Attention%20span.htm

Blakemore, C. (2003). Movement is essential to learning. The Journal of Physical Education,

Recreation, and Dance, 74. Retrieved from

http://www.questia.com/googleScholar.qst?docId=5002567833

Bonwell, C. (1991). Active learning: creating excitement in the classroom. The National Teaching

and Learning Forum, Retrieved from

http://www.oid.ucla.edu/units/tatp/old/lounge/pedagogy/downloads/active-learning-eric.pdf

BrainGym. (2010). About brain gym. Retrieved from http://www.edu-kinesthetics.com/

Burgeson, C. (2004). Physical education's critical role in educating the whole child and reducing

childhood obesity. State Education Standard 5, 2.

Cardon, G. (2003). Sitting habits in elementary school children. Medicine and Science in Sports

and Exercise, 35(5).

Cummins, I. (2003). Movement in the classroom. Retrieved from www.tflta.org/cummins.doc

Dean, B. (2009). Academotion 100 action-packed activities for teachers of young children.

Dubuque, IA: Kendall/Hunt Pub Co.

Elliott, E. (2002). The importance of movement and physical activity. PBS Teachers, Retrieved

from http://www.pbs.org/teachers/earlychildhood/articles/physical.html

Erwin, H. (2011). Implementing classroom-based physical activity. Retrieved from

http://www.pelinks4u.org/articles/erwin0610.htm

Hartman. (2011). Benefits of role play. Retrieved from

http://condor.admin.ccny.cuny.edu/~mr9643/Benifits%20of%20Role%20Play.htm

Hellmich, N. (2010, February 14). Study: physical activity can boost student performance. USA

Today, Retrieved from http://www.gophersport.com/resources/index.cfm?PAGE_ID=312

Instructor Web. (2010). The role of physical education in cognitive development. Retrieved from

http://www.instructorweb.com/doc/physicalcog.asp

60

Kleim, J. (2002, January 23). Synapse formation is associated with memory storage in the

cerebellum. Retrieved from http://www.pnas.org/content/99/20/13228.short

Landers, D. (2006). The influence of exercise on mental health. The PCPFS Research Digest,

2(12), Retrieved from http://www.fitness.gov/mentalhealth.htm

Landers, D, & Kretchmar, S. (2008). Focus and folk knowledge. Journal of Physical Education,

Recreation and Dance, 79(6), Retrieved from

http://www.aahperd.org/publications/journals/joperd/Focus-and-Folk-Knowledge.cfm

Lawler-Prince, D, & Stillwell, J. (2008). Preventing childhood obesity: helping preschool children

become healthy and fit. Little Rock, AR: Southern Early Childhood Association.

MedicineNet. (2003). Definition of neuron. Retrieved from

http://www.medterms.com/script/main/art.asp?articlekey=7785

Musikgarten. (2011). Benefits of music and movement. Retrieved from

http://www.musikgarten.org/music_movement.cfm

National Association for Sport and Physical Education. (2011). Active kids and academic

performance. Retrieved from http://www.aahperd.org/letsmoveinschool/upload/NASPE-

AcademicsBrochureFINAL.pdf

National Institute of Health. (2011). Kids and their bones. Retrieved from

http://www.niams.nih.gov/Health_Info/Bone/Bone_Health/Juvenile/default.asp

Noffsinger, J. 2005, November, 20. Phys ed cuts may leave children's health behind. FOX News.

Pennington, E. (2010). Brain-based learning theory: the incorporation of movement to increase

learning. Digital Commons, Liberty University, Retrieved from

http://digitalcommons.liberty.edu/doctoral/290/

Physical Activity Today. (2010). American alliance for health, physical education, recreation and

dance. Physical Activity Today, Retrieved from

http://www.aahperd.org/rc/publications/physicalactivitytoday/upload/Nov_Dec-2010-

PAT.pdf

Rice, M. (2009). Benefits of an active classroom. PediaStaff, Retrieved from

http://www.pediastaff.com/resources-benefits-of-an-active-classroom--september-2009

Sallis, J. (1999). Effects of health-related physical education on academic achievement: project

spark. Research Quarterly for Exercise and Sport, 70(2)

Sanders, S. (2003, July). Physically active for life. Retrieved from

http://www.pbs.org/teachers/earlychildhood/articles/activeforlife.html

Scheuer, L. (2003). Does physical activity influence academic performance. The New P.E. and

Sports Dimension

61

Story, M. (2006). Are obesity, nutrition, and physical activity linked with school performance.

Childhood Obesity

The President's Council on Physical Fitness and Sports. (2010). President's council on fitness,

sports, and nutrition. The President's Council on Physical Fitness and Sports, Retrieved

from http://www.fitness.gov/resources_factsheet.htm

U.S. Department of Health and Human Services. (2000). Healthy people 2010. Healthy People

2010 Conference Edition, 2(22)

Vorvick, L. (2011, March 16). Exercise's effects on bones and muscles. The New York Times,

Retrieved from http://health.nytimes.com/health/guides/specialtopic/physical-

activity/exercise's-effects-on-bones-and-muscles.html

Wada, M. (2009). Critical mass crisis: child obesity. ESPN, Retrieved from

http://sports.espn.go.com/espn/otl/news/story?id=4015831

WebMD. (2010). Type 2 diabetes in children. Diabetes Health Center, Retrieved from

http://diabetes.webmd.com/type-2-diabetes-in-children

Wilderdom Store. (2006 , February). Physical games and activities for groups. Retrieved from

http://wilderdom.com/games/PhysicalActivities.html#More

Woods, D. (2010). Arkansas state profile. American Alliance for Health, Physical Education,

Recreation and Dance- AAHPERD, Retrieved from

http://www.aahperd.org/naspe/publications/upload/Arkansas-profile.pdf

62

Student Submission Peer Reviewed Article

Arkansas High School Athletics: The Most Important Test That is Sometimes Never Given by

James Hines ASU

Introduction

Professional athletes (Bennett, 2012) and in some cases billionaire owners of professional teams are

prime examples that no matter how much money you possess, someone suffering from substance

abuse cannot buy a fast and easy cure. Proper treatment typically involves helping the individual

stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at

work, and in society (National Institute on Drug Abuse (NIH), 2009). A combination of medication

and behavioral therapy, are important to the overall therapeutic process that often begins with

detoxification, followed by individualized treatment and relapse prevention (NIH, 2009). Statistics

collected from the 2011 Youth Risk Behavior Surveillance System (YRBSS) survey of 13-18 aged

high school students, shows the importance of addressing the behavior and implementing

preventive measurements (Sharma & Branscum, 2013). Based on research by the National Council

on Alcoholism and Drug Dependence (NCADD, 2015), parents and coaches should be aware that

each year more teens enter addiction treatment for marijuana dependence than all other illegal

drugs combined. Research provided through the Youth Risk Behavior Survey (YRBS, 2013), is

now showing that high school age students are graduating to more intense and hardcore drugs such

as ecstasy, heroin, and methamphetamines . The purpose of this paper is to:: (1) look into the

effects of drug and alcohol use; (2) present high school drug abuse statistics; (3) promote drug

awareness for high school sport; and (4) present information on substance prevention programs.

Effects of Drug and Alcohol Use

Numerous studies and literature address the negative health effects of substance use. Alcohol abuse

may impair an athlete’s performance through the loss of motor skills, dehydration, and the creation

of mood swings (NCAA Drug Policy, 2015). The National Council on Alcoholism and Drug

Dependence (NCADD, 2015), found that psychiatric problems such as depression, anxiety, and

suicide may develop with excessive alcohol use. The Mayo Clinic, (2015), defines alcoholism as “a

chronic and often progressive disease that includes problems controlling drinking, being

preoccupied with alcohol, continuing to use alcohol even when it causes problems, having to drink

more to get the same effect, or having withdrawal symptoms when you rapidly decrease or stop

drinking”. Deterioration of neurological aspects of performance, delayed injury recovery, and the

potential for an athlete to collapse or die from cardiac arrest are serious consequences that can

result from athletes abusing substances (Thomas, Dunn, Swift, & Burns, 2010). As of now,

although treatment is available, there is no cure for alcoholism. Alcoholism awareness and

prevention is the only way to ensure that high school students do not become victims of alcohol

dependence. Once the disease has been created within the body, the victim’s only hope for sobriety

is some form of treatment (National Institute on Alcohol Abuse and Alcoholism, 2014).

63

During the impressionable years of high school, some people experiment with drugs, while others

succumb to addiction (Sharma& Branscum, 2013). Perceptual misjudgments, time disorientation,

and confusion are other ramifications associated with subjecting the human body to drug abuse

(Thomas, et al, 2010). Drugs are chemicals and while each drug produces different physical effects,

all abused substances disrupt the normal function of the brain and responses to issues of self-

control, judgment, emotion, motivation, memory and learning (NCADD, 2015). For instance, the

drug cocaine and the crystal form crack can constrict blood vessels, increase body temperature,

cause headaches and abdominal pain (National Institute on Drug Abuse, 2013). Although a hotly

debated topic of conversation, the drug marijuana is not legal in the state of Arkansas and research

regarding high school age use suggests negative consequences. People who started smoking

marijuana heavily in their teens and had an ongoing cannabis use disorder lost an average of eight

IQ points between ages 13 and 38 (National Institute on Drug Abuse, 2013). Substance use

disorders have been shown to have a lifetime prevalence of 11.4% in the age group 13 to 18 years

(Sharma & Branscum, 2013; Merikangas, et al., 2010).

High School Drug and Alcohol Use Statistics

Results from the Youth Risk Behavior Surveillance System (YRBSS) conducted in 2011 found that

in the United States 44.7% of the students had ever smoked a cigarette, 70.8% had taken at least

one drink of alcohol, 39.9% had used marijuana, and 3% had used cocaine (Sharma, M, &

Branscum, P,2013; Eaton et al., 2012). The 2013 Youth Risk Behavior Survey (YRBS) found that

among high school students, during the past 30 days, 35% drank some amount of alcohol and 21%

binge drank. The National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2015), defines

binge drinking as a pattern of drinking that brings a person’s blood alcohol concentration to 0.08

grams percent or above. Community-based efforts are required to monitor the activities of youth

and decrease youth access to alcohol (CDC, 2015).

A study conducted by Dunn, (2014) found that throughout the literature there was not a consensus

on adolescent substance use based on sport participation. A key issue in fighting substance abuse

and dependence is the complex nature of the problem that involves multiple behavioral and social

factors (Sharma & Branscum, 2013). Most users begin using drugs habitually while they are in

school, due to the large number of young people, schools possess the opportunity to adopt and

enforce important educational policies (Sharma & Branscum, 2013; Faggiano, 2005).

High School Sports Awareness

When researching the Arkansas Activities Association (AAA) handbook, there is no mention of a

universal drug testing policy or recommendations for its implementation. There is evidence that

drug-testing policies are being implemented individually by high schools throughout the state of

Arkansas. In Texas, the University Interscholastic League includes an athletic coach code that

seeks to emphasize a chemical awareness program that informs and educates students of the

damaging effects of anabolic steroids and other illegal drugs (Texas UIL Constitution). This simple

64

statement acknowledges the requirement of responsibility for coaches and the importance of

establishing a substance free message at an early period of a child’s life.

Without direct influence from the AAA, schools may refrain from adequately sending a substance

free statement due to a variety of factors. Research shows students who are subject to testing report

significantly less marijuana and other illegal drug use and also have more positive attitudes toward

testing (R. Dupont, M. D. Campbell,T. G. Campbell, C. L. Shea, & H. S. Dupont, 2013). Two

factors that could potentially hinder drug and substance testing are the financial cost of performing

the tests and the possible lack of education on the schools legal ability to conduct the tests. As the

nationwide trend of requesting parents to financially contribute to interscholastic athletic programs

grows (H. Boyle, 2013), adding a small fee to each participant could fund a drug testing policy.

Research conducted by the NCADD (2015), shows that the younger the person begins using

substances, the greater the chance they will abuse illegal substances in the future.

Substance Use Prevention Programs

If financial issues are so dire that a small fee could result in the loss of athlete participation, at the

very least coaches and administrators should frequently speak to their athletes regarding drug and

alcohol use. Providing knowledge, refusal, and decision making skills are key components of

effective evidence based prevention programs (Kumar, R., O’Malley, P.M., Johnston, L.D., &

Laetz, V.B., 2013). Providing knowledge, or awareness of the harm that substances can commit to

the student’s body can deter the student from using substances. Teaching students how to properly

navigate situation where they must refuse substances and overcome peer pressure is a crucial aspect

of effective prevention programs. The highest rated effective component of the prevention program

came from teaching students to develop positive decision making skills that require maturity and

responsibility (Kumar, et. al, 2013). Many schools that institute prevention programs choose to

select from different established programs and health education texts to meet their needs (Kumar, et

al. 2013). This may direct the athlete’s behavior by giving them the information regarding the

substances and trusting them to make responsible long-term life choices about their health. Locally

developed An example is The Lion’s Quest prevention program, which teaches life skills at all

grade levels and actively solicits participation from family, community members, and the school

(Kumar, et al.,2013). The Lion’s Quest prevention program goes beyond the classroom to cultivate

social and emotional learning as a critical element of education that creates safe and supportive

classrooms and nurture healthy, well-balanced young men and women (“About Lions Quest”,

2015).

Conclusion

Fighting teenage drug and alcohol use is a difficult task for parents, teachers and coaches. While

there is research prevention programs, the intensity and efficiency of the programs vary depending

on the school and the instructor. AAA should consider a way to work with its member schools to

develop an effective substance prevention program for high school athletes in the state of Arkansas.

65

High school athletic departments taking the necessary steps to treat potential substance abuse like

the disease it can become is imperative to students understanding the negative ramifications that

can come from their actions at a young age. Although AAA like many other state athletic

associations do not mandate or control drug testing, providing resources to help ensure healthy high

school students and Arkansans can prove to be a sound investment. When reviewing these statistics

and researching the 1995 landmark Vernonia School District V. Acton drug testing case, the need

for substance abuse policies in high school activities, especially ones as life threatening as playing

sports. With the both national and state government cutting funding for educational programs,

Office of Safe and Healthy Students (OSHS, 2011), organizations like AAA are needed more than

ever the live up to its purpose and mission statement and invest in drug testing and prevention

programs for the betterment of Arkansas high school athletes. Currently, athletic departments

throughout the state of Arkansas are conducting their own drug tests to keep their athletes safe on

and off the playing field. Debunking stereotypes and in some cases ignorant traditions that high

school students should be experimenting with substances is the first step. There is no guaranteed

method to achieving a team of substance free athletes. Each coach must develop a program that

works in their community. Information is available online via multiple substance abuse prevention

and treatment programs. Future research is needed in the state of Arkansas to determine the success

rate of schools in the state that conduct their own drug testing. Research studies to find the reasons

why some schools refrain from drug testing is also needed.

References

About AAA. (2015). In Mission Statement. Retrieved from http://www.ahsaa.org/page/1/aaa

About Lions Quest. (2015). In About Lions Quest. Retrieved from http://www.lionsquest-

.org/mission.php

Alcoholism Definition. (2014) In Diseases and Conditions Alcoholism. Retrieved from

http://www.mayoclinic.org/diseases-conditions/alcoholism/basics/definition/CON-

20020866

Alcohol's Effects on the Body. (2015). In Overview of Alcohol Consumption. Retrieved from

http://www.niaaa.nih.gov/alcohol-health/alcohols-effects-body

Bennett, D. (2013). Harm reduction and NFL drug policy. Journal Of Sport & Social Issues, 37(2),

160-175.

Boyle, H. (2013). As sports fees rise, A young athlete learns that if you can't pay, you can't play.

Health Affairs, 32(7), 1326-1329. doi:10.1377/HLTHAFF.2012.1222

Dunn, M. S. (2014). Association between physical activity and substance use behaviors among

high school students participating in the 2009 Youth Risk Behavior Survey. Psychological

Reports, 114(3), 675-685. doi:10.2466/18.06.PR0.114k28w7

66

Dupont, R. L., Campbell, M. D., Campbell, T. G., Shea, C. L., & Dupont, H. S. (2013). Self-

reported drug and alcohol use and attitudes toward drug testing in high schools with

random student drug testing. Journal Of Child & Adolescent Substance Abuse, 22(2), 104-

119. doi:10.1080/1067828X.2012.730354

Frequently Asked Questions/Facts. (2015). In Learn About Alcohol. Retrieved from

https://ncad d.org /learn -about-alcohol/faqsfacts

Kumar, R., O'Malley, P., Johnston, L., & Laetz, V. (2013). Alcohol, tobacco, and other drug use

prevention programs in U.S. schools: A descriptive summary. Prevention Science, 14(6),

581-592. doi:10.1007/s11121-012-0340-z

NCAA Drug Policies Brochure. (2014). In Understanding the NCAA’s Drug Testing Policies.

Retrieved from http://www.ncaa.org/health-and-safety/policy/drug-testing

Sharma, M., & Branscum, P. (2013). School-based drug abuse prevention programs in high school

students. Journal of Alcohol and Drug Education, 57(3), 51-65.

Substance Abuse Treatment. (2014). In General. Retrieved from http://www.cdc.gov/pw-

ud/substance-treatment.html

Understanding Drugs and Drug Dependence. (2015). In Frequently Asked Questions/Facts.

Retrieved from https://ncadd.org/learn-about-drugs

What is Marijuana. (2015). In The Science of Drug and Alcohol Abuse. Retrieved from

http://www.drugabuse.gov/publications/drugfacts/marijuana

Lifetime Achievement Award - Congratulations!!!

Annette Holeyfield

Higher Educator of the Year - Congratulations!!!

Valarie Hilson

67

Arkansas Association for Health, Physical Education,

Recreation and Dance

Editorial Board

Janea Snyder Bennie Prince Brian Church

NEW GUIDELINES FOR AUTHORS

Material for publication and editorial correspondence should be address to Andy

Mooneyhan, PO Box 240, State University, AR 72467 [[email protected]]. Deadline for the

submission is March 1. Guidelines for materials submitted are those of the Publication Manual

of the American Psychological Association. For manuscripts, submit 3 copies. The title should

be included on a separate page with the author(s) name, position, address, phone number and

email address. The title of the manuscript, without the author(s) name, should appear on the

first page of the manuscript. Download the template online to use. If accepted, original copy of

the manuscript must be submitted on disk, or zip drive saved in Microsoft Word or Text format.

The Arkansas Journal is indexed in the Physical Education Index.

The Arkansas Journal is published annually in April with a subscription cost of $10.00. To obtain a hard copy contact ArkAHPERD Executive Director Andy Mooneyhan

The opinions of the contributors are their own and do not necessarily reflect those of ArkAHPERD or the journal editors. ArkAHPERD does not discriminate in this or any of its programs on the basis of race, religion, sex, national origin, or disabling condition.

Co-Editors

Bennie Prince Shelli Henehan