Skip to main content

Physical activity and mental health in children and adolescents with intellectual disabilities: a meta-analysis using the RE-AIM framework

Abstract

Background

Children and adolescents with intellectual disabilities (IDs) tend to have lower levels of physical activity and poorer mental health than their typically developing peers. Studies on the effects of physical activity on the mental health of children with IDs using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework are scarce.

Methods

A systematic literature review using six databases (CINAHL, Eric, PsycINFO, PubMed, SPORTDiscus, and Web of Science) was conducted from January 2000 to September 2021. Studies reporting at least one physical activity intervention and mental health outcome in children and adolescents with IDs aged between 5 and 17 years were included in the meta-analysis. Preferred Reporting Items for Systematic Review and Meta-Analysis guideline, Comprehensive Meta-Analysis, and the RE-AIM framework were utilized.

Results

A total of 15 studies that met the inclusion criteria were included in the meta-analysis. The effects of physical activity on mental health in children and adolescents with IDs were significant and large (Hedges’ g = 0.897, p < 0.01), with medium effects on psychological health (Hedges’ g = 0.542, p < 0.01) and large effects on cognitive function (Hedges’ g = 1.236, p < 0.01). Randomized controlled trial (RCT) design and intervention components (> 120 minutes per week, therapeutic, and aerobic exercise) demonstrated the strongest effects. Moreover, study background (publication year, study location, and sample size), participant characteristics (age and sex), and Maintenance (RE-AIM framework) moderated the effects of physical activity on mental health. Based on the RE-AIM framework, there were higher proportions in the dimensions of Reach and Effectiveness than Adoption, Implementation, and Maintenance.

Conclusions

Physical activity appears to have positive effects on mental health, including psychological health and cognitive function, in children and adolescents with IDs. Physical activity interventions using the RE-AIM framework are recommended to assess short- and long-term impacts and translate scientific evidence into practice.

Trial registration

The protocol for this meta-analysis was registered with PROSPERO (CRD42021256543).

Background

Intellectual disabilities (IDs) refer to a broad range of mental impairments preventing individuals from participating in daily life to the same text as typically developing (TD) individuals [1]. The classification of ID level is determined using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) [2]. Globally, the prevalence of IDs is approximately 1%, with a higher ratio in men than women, with roughly 85% falling within the mild level [3]. Compared to peers with TD, the rate of mental health problems in children and adolescents with IDs is three to four times higher [4, 5], and they are more likely to be exposed to socio-economic disadvantages [6].

According to the World Health Organization (WHO), mental health could be determined based on psychological factors, and mental health promotion involves the improvement of psychological health [7]. Psychological health has been used to represent positive and negative feelings in personal and social life, including psychological well- and ill-being [8]. Mental health includes basic cognitive skills and the ability to cope with function in social roles [9]. Psychological health and cognitive function are important elements of mental health and have gained attention in physical activity studies [10,11,12].

Recent WHO guidelines on physical activity and sedentary behavior recommended that children and adolescents living with a disability should engage in at least 60 minutes per day of moderate-to-vigorous physical activity across the week, with at least three days of vigorous-intensity aerobic activities per week [13]. Physical activity has been found to have beneficial effects on mental health in children and adolescents with disabilities [14]. However, children and adolescents with IDs engage in lower levels of physical activity than their peers with TD [15,16,17].

Previous reviews with meta-analyses indicated that physical activity had positive moderate-to-large effects on psychosocial well-being (Hedges’ g = 0.682, p < 0.01) and positive influence on emotional problems in children and adolescents with IDs [18, 19]. These reviews explored the moderating effects of study background (e.g., sample size and study design), participant characteristics (e.g., age and ID level), and intervention components (e.g., type and setting); however, cognitive function outcomes were under-researched. Moreover, some reviews and meta-analyses reported the effects of physical activity on cognitive function in children and adolescents with other disabilities. For instance, physical activity had positive effects on cognitive function in children and adolescents with social, emotional, and behavioral disabilities [20]. Exercise interventions had positive small-to-moderate effects (Hedges’ g = 0.342, p < 0.01) on executive function in children and adolescents with autism spectrum disorder [21]. Exercise had a positive moderate-to-large effect (Hedges’ g = 0.611, p < 0.01) on cognitive function in children and adolescents with attention-deficit/hyperactive disorder [22]. Participant characteristics, such as age, and intervention components, such as session and content, moderated the effects of physical activity on cognitive function in children with disabilities [22, 23]. Extant studies called for an examination of the moderating effects of sex and intervention duration [20].

Previous reviews indicated the moderating effects of publication year on mental health outcomes in TD populations [24, 25], and social, cultural, and environmental factors were potential barriers to physical activity participation for children with disabilities [26]. Due to the intellectual impairments in children and adolescents with IDs, their mental health outcomes were self-reported and reported by their teachers and parents simultaneously [27]. Teachers and parents could identify more severe mental health problems than children themselves [28]. However, the moderating roles of publication year, study location, and outcome reporter in the effects of physical activity on mental health were under-explored in children and adolescents with IDs.

Antikainen and Ellis (2011) [29] and McGoey et al. (2015) [30] indicated that the interventions had no long-term follow-up assessments and focused on internal rather than external validity, which may reduce the generalizability to ecological settings [29, 30]. The five-step Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework [31, 32] has been used to guide physical activity interventions and evaluate external validity of theory-based physical activity interventions [29, 33, 34], and to examine the impact of translational research in the disability research [35].

Several research gaps existed in previous literature. First, while previous systematic reviews with meta-analyses examined the effects of physical activity on psychological health in children and adolescents with IDs [18, 19], the effects of physical activity on mental health, including psychological health and cognitive function, in children and adolescents with IDs were under-researched. Second, the quality of previous systematic reviews and meta-analyses in children and adolescents with IDs was evaluated using risk of bias, which showed moderate to high risk [18, 19]; however, external validity, such as generalizability or applicability, based on the RE-AIM framework in children and adolescents with IDs was not examined. Third, while previous systematic reviews and meta-analyses in children and adolescents with IDs reported the moderating roles of study background, participant characteristics, and intervention components using subgroup analyses [18, 19], other moderating effects, such as study location, overcome reporter, and the RE-AIM framework, were under-explored. Therefore, our meta-analysis aimed to (1) determine the effects of physical activity on mental health, including psychological health and cognitive function, in children and adolescents with IDs, (2) evaluate physical activity interventions in children and adolescents with IDs using the RE-AIM framework, and (3) examine the moderating roles of the study background, participant characteristics, intervention components, and the RE-AIM framework.

Methods

Protocol

This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines (PRISMA) [36]. The PRISMA guidelines contain 27 items (see Additional file 1), and a protocol for this meta-analysis was registered with PROSPERO (CRD42021256543).

Search strategy

A systematic search was conducted using CINAHL (EBSCO), Education Resources Information Center (ERIC, EBSCO), PsycINFO (OVID), Pubmed (NIBI), SPORTDiscus (EBSCO), and Web of Science databases on September 10, 2021. The publication date was from January 1, 2000 to September 9, 2021, and the search was conducted by two researchers (WY and XL). Four terms were used in the search: (1) intellectual disability, (2) children and adolescents, (3) physical activity, and (4) mental health. The search strategy for the SPORTDiscus database is presented in Additional file 2.

Selection procedure and eligibility criteria

After all duplicates were removed, two researchers (WY and XL) independently screened the titles, abstracts, and full text of the search studies. References were imported and uploaded to Endnote X9. The researchers resolved any disagreements through discussion, and a third researcher (CHPS) deliberated to reach a final decision. The Kappa statistic was calculated (fair [0.40–0.59], good [0.60–0.74], and excellent [≥0.75]) to evaluate inter-rater reliability [22]. A total of 4879 original articles were obtained from six databases. After 1769 duplicates were removed, 3110 articles remained; however, 3045 articles were excluded after their titles and abstracts were screened, five articles were excluded as reports could not be retrieved, and 60 abstracts met the inclusion criteria with an inter-rater reliability of k = 0.62. A further 46 articles were removed after their full texts were screened for the following reasons: 14 due to study design, 13 due to age, 10 due to intervention components, three due to disability type, two due to outcome, two due to language, and one each due to publication year and study quality. One article was included via citation searching. Therefore, 15 articles were included, with an inter-rater reliability of k = 0.73. Figure 1 shows the PRISMA flow diagram of the search and screening process.

Fig. 1
figure 1

The PRISMA flow diagram of the search and screening process

The inclusion and exclusion criteria followed the PICOS framework, which included population, intervention, comparison, outcome, and study design [37]. Inclusion criteria for eligible studies were as follows: (1) population of children and adolescents aged between 5 and 17 years with IDs, including mental retardation, mental disabilities, intellectual impairments, and cognitive impairments, (2) intervention being physical activity, sports, exercise, games, and training, (3) comparison of physical inactivity, sedentary behavior, and daily activity, (4) at least one measured and reported outcome on mental health, and (5) study design being intervention, including randomized controlled trial (RCT) and non-RCT, published in a peer-reviewed journal with full-text in English from January 2000 to September 2021.

The exclusion criteria were (1) children and adolescents with developmental disabilities or learning disabilities, (2) lack of comparison groups, (3) observational studies, qualitative studies, or reviews, publication as a conference poster, conference abstract, protocol, or commentary, and publication earlier than January 2000.

Data extraction

Data extraction followed the Cochrane handbook for systematic reviews of interventions [38]. Two researchers extracted data from each of the eligible studies: (1) study background, including name of the first author, publication year, study location, outcome reporter (self-report and teacher/parent proxy-report), study design (RCT and non-RCT), and sample size, (2) participant characteristics, including age, sex, and ID level, (3) intervention components, including type, setting, and protocol (duration per week, total session, and total duration), (4) measures and outcomes of mental health, including psychological health (anxiety, depression, emotional self-control, self-competence, self-esteem withdrawn, and self-worth) and cognitive function (accuracy, cognitive flexibility, executive function, inhibition control, reaction time, and working memory).

Quality assessment

The 21-item validated quality evaluation tool based on the RE-AIM framework (see Additional file 3) was used to code eligible articles on the degree to which indicators of internal and external validity were reported [35], and improve the translatability and impact of health interventions [33]. In the RE-AIM framework, Reach refers to the percentage and risk characteristics of participants. A sample question was “What percent of potentially eligible participants were excluded and included, and how representative were they?” Effectiveness indicates the positive and negative consequences of the intervention. A sample question was “What are the positive and negative outcomes for participants, including quality of life?” Adoption is the proportion and representativeness of intervention personnel and protocol. A sample question was “What percent of settings and intervention agents within these settings were excluded and included, and how representative were they?” Implementation assesses the participants’ adherence to intervention, and the extent to which personnel deliver intervention as intended. A sample question was “To what extent were the various intervention components delivered as intended?” Maintenance evaluates the extent to which the intervention becomes a routine of daily life. A sample question was “What were the long-term effects, and indicators of program level maintenance?“ [32]. The quality assessment was conducted by two researchers (WY and XL) independently. The Kappa statistic values for consistency were 0.65 for Reach, 0.63 for Effectiveness, 0.72 for Adoption, 0.67 for Implementation, and 0.82 for Maintenance, indicating good to excellent inter-rater reliability. The disagreements were resolved by discussion, and researchers gained consensus in the coding by revisiting the included articles.

Meta-analytic procedures

We used Comprehensive Meta-Analysis (CMA; version 3.0) to conduct the meta-analysis. Only studies that reported sufficient statistical data from pre- and post-test in experimental and control groups were included in the meta-analysis. A random-effects model was used to measure heterogeneity distributed effect size, as it uses sample error and between-study variance to estimate effect size [22]. Standardized mean differences (SMD) for continuous outcomes with different measurement units were calculated and weighted, and the mean (M), sample size (N), and standard deviation (SD) were the primary methods for effect size calculations. Hedges’ g and its 95% confidence interval (CI) were used in this meta-analysis, which could correct the overestimated effect size for small sample size, and Cohen’s d was used for large sample size [22, 39]. Effect size values of 0.20 indicates small, 0.50 indicates medium, and 0.80 indicates large effect size [40]. The statistical heterogeneity (I2) was assessed using a p value calculated for Q statistics, indicating small (≤25%), medium (50%), and large (≥75%) heterogeneity [21]. Except for the holistic meta-analyses for mental health, subgroup analyses of psychological health and cognitive function were conducted based on specific outcomes. The meta-regression was used to explore the moderating effects of study background (publication year, study location, outcome reporter, study design, and sample size), participant characteristics (age, sex, and ID level), intervention components (type, setting, duration per week, total session, and total duration), and RE-AIM framework.

The presence of outliers was investigated by analyzing relative residual values of included studies, and a standard score (z-score) more than or equal to a positive or negative value of 1.96 was considered a large residual value [41]. A sensitivity analysis (i.e., one study removed procedure in CMA software) was used to inspect the impact of retention/removal of outliers and their influence on the overall effect size. Studies should be retained when the overall effect size after removal remains significant and within the 95% CI [41]. To decrease potential publication bias, a funnel plot calculating the standard error and effect size was used, and Duval and Tweedie’s trim and fill method (i.e., random-effects model) was utilized to measure the publication-bias adjusted effect size and the number of studies required to balance the plot [22]. In addition, Begg and Mazumdar rank correlation and Egger’s regression intercept were performed to test for publication bias [42]. A statistical significance of p < 0.05 was set for all tests.

Results

Characteristics of included studies

Table 1 shows the descriptive characteristics of the 15 included studies. There were a total of 630 participants, with 313 participants involved in trials of psychological health, and the remaining 317 cognitive function. Of 15 included articles, nine [43,44,45,46,47,48,49,50,51] studies (60%) examined psychological health, and six [52,53,54,55,56,57] (40%) cognitive function. As for measures of mental health, six [43,44,45,46,47,48] studies (40%) focused on psychological well-being using the Checklist for Pupil Evaluation and Self-perception Profile, three [49,50,51] studies (20%) measured psychological ill-being using Child Behavior Checklist, 12-item Anxiety/Depression Scale, and Withdrawn Behavior Checklist, five [53,54,55,56,57] studies (33.3%) used reaction time measurements, such as Cognitive Performance, and two [52, 54] studies (13.3%) used Flanker test (inhibition control), Go/No-Go test (accuracy), NIH Toolbox Cognitive Battery (working memory), and Wisconsin Card Sorting Test-64 card version (executive function).

Table 1 Descriptive characteristics of included studies (n=15)

The sample size ranged from 20 to 132 participants with a mean age of 13.16 years, including five [43, 51, 52, 54, 55] studies (40%) with children (5–11 years) and 10 studies [44,45,46,47,48,49,50, 53, 56, 57] (60%) with adolescents (12–17 years) [8]. Regarding sex, six [44, 45, 49,50,51, 53] studies (40%) included all male participants, three [46,47,48] studies (20%) all female participants, and six [43, 52, 54,55,56,57] studies (40%) included men and women. Mental health outcomes in 12 studies [44,45,46,47,48, 51,52,53,54,55,56,57] (80%) were self-reported, and the other three studies [43, 49, 50] (20%) used reports provided by teachers or parents. Nine studies [43, 45, 49, 50, 52,53,54,55, 57] (60%) adopted the RCT design, and six [44, 46,47,48, 51, 56] studies (40%) employed non-RCT design. Ten studies [44,45,46,47,48,49,50, 53, 56, 57] (66.7%) were conducted in Europe (five in France, two in Turkey, and one each in Greece, Germany, and Servia), three [43, 52, 55] (20%) in Asia (one each in Hong Kong, Taiwan, and India), and one each [51, 54] (13.3%) in America and Australia. As for the identification of the ID, eight studies [44, 45, 47,48,49,50, 52, 53] (53.3%) used Wechsler Intelligence Scale for Children [58], two studies [46, 57] (13.3%) used American Association on Mental Retardation [59], two studies [51, 54] (13.3%) followed the DSM-V criteria [2], and one study [56] (6.7%) followed the American Association on Intellectual and Developmental Disabilities [60]. Four studies [43, 44, 52, 57] (26.7%) focused on mild ID, eight studies [45,46,47,48, 50, 53,54,55] (53.3%) focused on mild to moderate ID, and three studies [49, 51, 56] (20%) focused on overall ID.

Collectively, eight studies [44,45,46,47,48,49,50, 52] (53.3%) were conducted in community settings, such as Special Olympics, and five studies [43, 51, 53, 54, 56] (33.3%) were conducted in schools. There were five types of intervention: six studies [44,45,46,47,48, 50] (40%) used competitive sports, such as basketball, swimming, and soccer, three studies [54, 55, 57] (20%) used cognitive exercise, such as fitness training and yoga, three studies [43, 52, 53] (20%) used therapeutic exercise, two studies [49, 51] (13.3%) used non-competitive sports, such as unified sports soccer, and two studies [52, 56] (13.3%) used aerobic exercise, such as cycling. For intervention protocol, nine studies [43, 45, 48,49,50,51,52,53, 57] (60%) conducted interventions less than 50 sessions in total, and five studies [44, 46, 47, 54, 55] (33.3%) ≥50 intervention sessions in total. Furthermore, nine studies [44,45,46,47,48, 50, 53, 54, 57] (60%) included training of ≤120 minutes per week, and five studies [43, 49, 51, 52, 55] (33.3%) used training of > 120 minutes per week. The total intervention duration ranged from 250 minutes to 16,680 minutes.

Quality assessment

Table 2 shows the proportion of physical activity interventions reporting components of the RE-AIM framework. The total score of the RE-AIM framework was 40.5%, and among the five dimensions, Reach showed the highest proportion (76%), followed by Effectiveness (56.7%), Implementation (37.8%), Adoption (23.3%), and Maintenance (8.9%). In the Reach dimension, all included studies reported methods of identifying the target population and inclusion criteria; however, only four studies [45, 49, 50, 52] (26.7%) reported the participation rate. In the Effectiveness dimension, measures/results for at least one follow-up got the highest proportion (100%); and only three studies [49,50,51] (20%) reported quality of life or potential negative outcomes. In the Adoption dimension, no studies reported adoption rate of delivery agent or setting, one study [49] (6.7%) reported inclusion and exclusion criteria of delivery agent or setting, and two studies [43, 56] (13.3%) reported level of expertise of delivery agent. In the Implementation dimension, all included studies reported intervention duration and frequency; no studies reported measures of cost of implementation. In the Maintenance dimension, two studies (13.3%) reported assessed outcome ≥6 months post intervention [44, 45] and indicators of program level maintenance [50, 54], and no studies included measures of cost of maintenance. Across all included studies, inclusion rates of individual RE-AIM evaluation ranged from 27.7 to 66%. The proportion of physical activity interventions reporting the RE-AIM framework of included studies is presented in Additional file 4.

Table 2 The proportion of physical activity interventions reporting components of the RE-AIM framework

Summary of findings

Effects of physical activity on mental health

Among 15 included studies, the pooled effect size for children and adolescents with IDs is shown in Fig. 2. There was a large effect of physical activity on overall mental health (Hedges’ g = 0.897, 95% CI = [0.659, 1.136], p < 0.01) with a medium heterogeneity (Q = 121.153, df = 31, p < 0.01, I2 = 74.413%). The effects of physical activity on psychological health from nine studies were medium (Hedges’ g = 0.542, 95% CI = [0.374, 0.709], p < 0.01) with no significant heterogeneity (Q = 14.804, df = 15, p > 0.05, I2 = 0%). The effect size on cognitive function from six studies was significant and large (Hedges’ g = 1.236, 95% CI = [0.871, 1.600], p < 0.01) with a large heterogeneity (Q = 66.683, df = 15, p < 0.01, I2 = 77.560%).

Fig. 2
figure 2

Forest plot for effects of physical activity (experimental) vs. control on measures of mental health in children and adolescents with intellectual disabilities. Note. A random-effects model was used to measure heterogeneity distributed effect size; A: psychological health; B: cognitive function; CI: confidence interval

Moderator analyses

Table 3 shows the meta-regression results regarding the moderating effects of study background, participant characteristics, intervention components, and the RE-AIM framework. Publication year (Q = 5.41, df = 1, R2 = 22%, p < 0.05), study location (Q = 23.63, df = 2, R2 = 60%, p < 0.01), sample size (Q = 6.82, df = 1, R2 = 32%, p < 0.01), age (Q = 8.00, df = 1, R2 = 37%, p < 0.01), intervention type (Q = 14.14, df = 4, R2 = 39%, p < 0.01), intervention duration per week (Q = 5.83, df = 1, R2 = 25%, p < 0.05), and Maintenance (Q = 4.24, df = 1, R2 = 11%, p < 0.05) were significant moderators in the effects of physical activity on mental health in children and adolescents with IDs. Trends were observed in the moderating effects of study design (Q = 3.71, df = 1, R2 = 15%, p = 0.05) and sex (Q = 5.63, df = 2, R2 = 26%, p = 0.06). However, other potential factors had no moderating effects (p > 0.05).

Table 3 Moderators in the effects of physical activity on mental health in children and adolescents with intellectual disabilities

Subgroup analyses

Subgroup analyses (see Additional file 5) demonstrated that physical activity had positive effects on mental health in children (Hedges’ g = 1.272, p < 0.01), adolescents (Hedges’ g = 0.656, p < 0.01), boy-only (Hedges’ g = 0.762, p < 0.01), girl-only (Hedges’ g = 0.519, p < 0.01), and mixed groups (Hedges’ g = 1.153 p < 0.01). Moreover, significant and positive effects of physical activity on mental health were found in children and adolescents with mild ID (Hedges’ g = 1.137, p < 0.01), mild to moderate ID (Hedges’ g = 0.865, p < 0.01), and overall ID (Hedges’ g = 0.630, p < 0.01). Furthermore, intervention studies in various locations, such as Asia (Hedges’ g = 1.730, p < 0.01), Europe (Hedges’ g = 0.656, p < 0.01), and America and Australia (Hedges’ g = 0.586, p < 0.05), found positive effects on mental health in children and adolescents with IDs. Outcomes reported by children and adolescents with IDs (Hedges’ g = 0.953, p < 0.01) and their parents and teachers (Hedges’ g = 0.634, p < 0.01) showed positive physical activity effects on mental health. Interventions using RCT design (Hedges’ g = 1.056, p < 0.01) had stronger effects on mental health than those with non-RCT design (Hedges’ g = 0.560, p < 0.01).

Therapeutic (Hedges’ g = 1.521, p < 0.01) and aerobic exercise (Hedges’ g = 1.251, p < 0.01) showed stronger effects on mental health than cognitive exercise (Hedges’ g = 0.950, p < 0.05), non-competitive sports (Hedges’ g = 0.568, p < 0.01), and competitive sports (Hedges’ g = 0.509, p < 0.01). Children and adolescents with IDs who exercised more than 120 minutes per week (Hedges’ g = 1.244, p < 0.01) had better mental health outcomes than those who exercised ≤120 minutes per week (Hedges’ g = 0.654, p < 0.01). Intervention settings, such as school (Hedges’ g = 0.932, p < 0.01) and community (Hedges’ g = 0.764, p < 0.01), had significant and positive effects on mental health.

Sensitivity analysis and publication bias

Eight studies [43, 48, 50,51,52,53, 55, 57] were found to be outliers (z-score ranged from 2.269 to 8.233), and “one study removed” sensitivity analysis was performed. Results showed that all pooled outcomes were stable to the sequential removal of outliers (Hedges’ g ranged from 0.827 to 0.924), which remained significant and within the 95% CI. Therefore, these eight studies were retained in the final analysis. The funnel plot of publication bias is illustrated in Fig. 3. Based on Duval and Tweedie’s trim and fill method, publication-bias adjusted effect size was 0.924 (95% CI [0.806, 1.042]), and no studies were needed to balance the plot. The results of Begg and Mazumdar’s (z = 0.438, p > 0.05) and Egger’s tests (intercept = − 0.987, 95% CI [− 4.189, 2.215], p > 0.05) indicated that the conclusion of the meta-analysis was not susceptible to publication bias.

Fig. 3
figure 3

Funnel plot for visual inspection of publication bias

Discussion

Our meta-analysis demonstrated that physical activity had significant and large effects on mental health in children and adolescents with IDs, with medium effects on psychological health and large effects on cognitive function. Similarly, previous reviews found medium effects of physical activity on psychosocial health in children with IDs [19] and working memory in children and adolescents with learning disabilities [23]. Possible mechanisms of the effects of physical activity on mental health may be explained by physiological reasons, such as physical activity benefitting mental function [61], modulating neuroinflammation, inhibiting neuronal integrity, and enhancing neurotrophin levels, neurogenesis, and vascularization [62]. A review noted that physical activity might induce change in neurological, psychological, and behavioral parameters, such as increased neural activity within the prefrontal cortex and the functional activity of monoamines related to mood, and improved coping efficacy through the mediation of hippocampal neurogenesis activity and activation of the hypothalamic-pituitary-adrenal axis [8].

In our meta-analysis, intervention components (> 120 minutes per week, therapeutic, and aerobic exercise) were moderators in the effects of physical activity on mental health in children and adolescents with IDs, which was consistent with previous reviews. For instance, high intervention frequency was more effective than low intervention frequency, and combined exercise interventions were more effective than non-aerobic exercise on cognitive function in persons with IDs [23]. Intervention type, such as resistance training, was found to have large effects on mental health in children and adolescents with IDs [19]. Therapeutic exercise has received some attention for mental health problems in children and adolescents with IDs; however, evidence is insufficient and inconclusive [63]. Although intervention setting had no moderating effects, interventions conducted in schools and communities had positive effects on mental health in children and adolescents with IDs in this meta-analysis. Previous studies indicated that intervention setting was a moderator in physical activity intervention [18]. School settings had significant effects on physical activity in children with IDs [64]. School environments were found to affect physical activity levels in children with IDs, and they were more active at schools where support for physical activity was available [65]. Therefore, more school-based intervention studies are required to improve the mental health of children and adolescents with IDs.

Our meta-analysis also indicated that study background, such as publication year and sample size, were significant moderators, and RCT design had larger effects compared with non-RCT design, which were consistent with the findings in TD populations [24, 25]. Intervention studies with more rigorous designs on physical activity and its effects on mental health in children and adolescents with IDs are required. Moreover, study location had significant moderating effects, and it reflected different cultures and social values, which could be potential barriers to physical activity participation for children with disabilities [26]. Outcome reporter did not have any moderating effects; however, a previous study found that teacher or parent reporters could identify more severe mental health problems [28]. Multiple informants, such as clinicians, teachers, and parents, are important to assess the actual effects of physical activity on mental health.

Using the RE-AIM framework, we found that the dimensions of Reach and Effectiveness had higher proportions than Adoption, Implementation, and Maintenance, which was consistent with previous reviews using the RE-AIM framework in physical activity interventions in TD populations [30, 33, 66]. We also found that Maintenance was a significant moderator in the effects of physical activity on mental health, with only two studies assessing long-term follow-up. Previous studies also recommended long-term and sustainable physical activity participation and scalable interventions for children and adolescents with disabilities [67]. To improve the quality of physical activity interventions in children and adolescents with IDs, particularly in Adoption, Implementation, and Maintenance, the following approaches are suggested: (1) reporting the inclusion/exclusion criteria and adoption rate of delivery agent/setting, (2) calculating costs of equipment and personnel, (3) adding follow-up assessments that occur at least 6 months after the completion of physical activity interventions, and (4) reporting the degree of sustaining the physical activity interventions [66].

In our meta-analysis, ID level had no moderating effects, whereas previous studies showed that ID level moderated physical activity outcomes [19] and was a strong predictor in participants who achieved WHO physical activity guidelines [68]. A previous study revealed that children with a more severe ID level were more sedentary and had less physical activity participation than those with a lower ID level [69]. The reason for the discrepancy may be that this study only included participants with mild ID, mild to moderate ID, and overall ID. Moreover, age and sex had moderating effects, which were consistent with previous studies [28]. Future studies should recruit more participants with severe or profound ID, and consider the mental age and sex distribution of children and adolescents with IDs.

To the best of our knowledge, this was the first meta-analysis using the RE-AIM framework that examined the effects of physical activity on mental health in children and adolescents with IDs. Some limitations must be addressed. First, there was a lack of evidence on the dimensions of Adoption, Implementation, and Maintenance. These three dimensions should be identified in future research to enhance the quality of physical activity interventions. Although all included studies reported at least one follow-up, only two studies assessed the outcomes ≥6 months post intervention, which suggested the need for more robust strategies to keep participants engaged in physical activity intervention and improve the extent to which intervention becomes a routine of daily life. Second, no studies focused on severe or profound ID, which may limit the generalizability of the study. Third, most included studies had small sample size, highlighting the urgent need for future physical activity intervention studies to include more participants and those with severe or profound ID. Fourth, the social value connected with physical activity may vary between cultures, future research should consider the racial or cultural characteristics of physical activity and mental health. Fifth, physical activity interventions included diverse contents, such as basketball, swimming, soccer, fitness training, yoga, and cycling, but the recommended intervention contents and participants’ feedback were under-investigated. Future studies should collect feedback from participants and target effective and preferred contents of physical activity interventions in children and adolescents with IDs.

Conclusions

Our meta-analysis indicated that physical activity appears to have positive effects on mental health, including psychological health and cognitive function, in children and adolescents with IDs. RCT design and intervention components (> 120 minutes per week, therapeutic, and aerobic exercise), showed the strongest effects. Study background (publication year, study location, and sample size), participant characteristics (age and sex), and Maintenance (RE-AIM framework) moderated the effects of physical activity on mental health in children and adolescents with IDs. Long-term follow-up and degree of sustaining the intervention are needed in future studies.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Abbreviations

CI:

Confidence interval

CMA:

Comprehensive Meta-Analysis

DSM-V:

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders

ID:

Intellectual disability

PICOS:

Population, intervention, comparison, outcome, and study design

PRISMA:

Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines

RCT:

Randomized controlled trial

RE-AIM:

Reach, Effectiveness, Adoption, Implementation, and Maintenance

SMD:

Standardized mean difference

TD:

Typically developing

WHO:

World Health Organization

References

  1. Hinckson EA, Curtis A. Measuring physical activity in children and youth living with intellectual disabilities: a systematic review. Res Dev Disabil. 2013;34(1):72–86. https://doi.org/10.1016/j.ridd.2012.07.022.

    Article  PubMed  Google Scholar 

  2. Regier DA, Narrow WE, Kuhl EA, Kupfer DJ. The conceptual development of DSM-V. Am J Psychiatry. 2009;166(6):645–50. https://doi.org/10.1176/appi.ajp.2009.09020279.

    Article  PubMed  Google Scholar 

  3. American Psychiatric Association. What is intellectual disability? Available from: https://www.psychiatry.org/patients-families/intellectual-disability/what-is-intellectual-disability [Accessed July 2021].

  4. Einfeld SL, Ellis LA, Emerson E. Comorbidity of intellectual disability and mental disorder in children and adolescents: a systematic review. J Intellect Develop Disabil. 2011;36(2):137–43. https://doi.org/10.1080/13668250.2011.572548.

    Article  Google Scholar 

  5. Munir KM. The co-occurrence of mental disorders in children and adolescents with intellectual disability/intellectual developmental disorder. Curr Opin Psychiatry. 2016;29(2):95. https://doi.org/10.1097/YCO.0000000000000236.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Emerson E, Einfeld S, Stancliffe RJ. The mental health of young children with intellectual disabilities or borderline intellectual functioning. Soc Psychiatry Psychiatr. 2010;45(5):579–87. https://doi.org/10.1007/s00127-009-0100-y.

    Article  Google Scholar 

  7. World Health Organization. Mental health: strengthening our response. Available from https://www.who.int/en/news-room/fact-sheets/detail/mental-health-strengthening-our-response. [Accessed 30 July 2021].

  8. Rodriguez-Ayllon M, Cadenas-Sánchez C, Estévez-López F, et al. Role of physical activity and sedentary behavior in the mental health of preschoolers, children and adolescents: a systematic review and meta-analysis. Sports Med. 2019;49(9):1383–410. https://doi.org/10.1007/s40279-019-01099-5.

    Article  PubMed  Google Scholar 

  9. Galderisi S, Heinz A, Kastrup M, Beezhold J, Sartorius N. Toward a new definition of mental health. World Psychiatry. 2015;14(2):231. https://doi.org/10.1002/wps.20231.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Biddle SJ, Ciaccioni S, Thomas G, Vergeer I. Physical activity and mental health in children and adolescents: an updated review of reviews and an analysis of causality. Psychol Sport Exerc. 2019;42:146–55. https://doi.org/10.1016/j.psychsport.2018.08.011.

    Article  Google Scholar 

  11. Biddle SJ, Asare M. Physical activity and mental health in children and adolescents: a review of reviews. Br J Sports Med. 2011;45(11):886–95. https://doi.org/10.1136/bjsports-2011-090185.

    Article  PubMed  Google Scholar 

  12. Lubans D, Richards J, Hillman C, et al. Physical activity for cognitive and mental health in youth: a systematic review of mechanisms. Pediatrics. 2016;138(3):e20161642. https://doi.org/10.1542/peds.2016-1642.

    Article  PubMed  Google Scholar 

  13. Bull FC, Al-Ansari SS, Biddle S, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54(24):1451–62. https://doi.org/10.1136/bjsports-2020-102955.

    Article  PubMed  Google Scholar 

  14. Martin Ginis KA, van der Ploeg HP, Foster C, et al. Participation of people living with disabilities in physical activity: a global perspective. Lancet. 2021;398(10298):443–55. https://doi.org/10.1016/S0140-6736(21)01164-8.

    Article  PubMed  Google Scholar 

  15. McGarty AM, Downs SJ, Melville CA, Harris L. A systematic review and meta-analysis of interventions to increase physical activity in children and adolescents with intellectual disabilities. J Intellect Disabil Res. 2018;62(4):312–29. https://doi.org/10.1111/jir.12467.

    CAS  Article  PubMed  Google Scholar 

  16. Sit CH, Yu JJ, Huang WY, et al. Results from Hong Kong’s 2019 report card on physical activity for children and youth with special educational needs. J Exerc Sci Fit. 2020;18(3):177–82. https://doi.org/10.1016/j.jesf.2020.05.004.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Sit CH, McKenzie TL, Cerin E, Chow BC, Huang WY, Yu J. Physical activity and sedentary time among children with disabilities at school. Med Sci Sports Exerc. 2017;49:292–7. https://doi.org/10.1249/MSS.0000000000001097.

    Article  PubMed  Google Scholar 

  18. Borland RL, Cameron LA, Tonge BJ, Gray KM. Effects of physical activity on behaviour and emotional problems, mental health and psychosocial well-being in children and adolescents with intellectual disability: a systematic review. J Appl Res Intellect Disabil. 2022;35(2):399–420. https://doi.org/10.1111/jar.12961.

    Article  PubMed  Google Scholar 

  19. Kapsal NJ, Dicke T, Morin AJ, et al. Effects of physical activity on the physical and psychosocial health of youth with intellectual disabilities: a systematic review and meta-analysis. J Phys Act Health. 2019;16(12):1187–95. https://doi.org/10.1123/jpah.2018-0675.

    Article  PubMed  Google Scholar 

  20. Ash T, Bowling A, Davison K, Garcia J. Physical activity interventions for children with social, emotional, and behavioral disabilities—a systematic review. J Dev Behav Pediatr. 2017;38(6):431–45. https://doi.org/10.1097/DBP.0000000000000452.

    Article  PubMed  Google Scholar 

  21. Liang X, Li R, Wong SHS, Sum RKW, Wang P, Yang B, et al. The effects of exercise interventions on executive functions in children and adolescents with autism Spectrum disorder: a systematic review and Meta-analysis. Sports Med. 2022;52(1):75–88. https://doi.org/10.1007/s40279-021-01545-3.

    Article  PubMed  Google Scholar 

  22. Liang X, Li R, Wong SHS, Sum RKW, Sit CHP. The impact of exercise interventions concerning executive functions of children and adolescents with attention-deficit/hyperactive disorder: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2021;18(1):68. https://doi.org/10.1186/s12966-021-01135-6.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Peijnenborgh JC, Hurks PM, Aldenkamp AP, Vles JS, Hendriksen JG. Efficacy of working memory training in children and adolescents with learning disabilities: a review study and meta-analysis. Neuropsychol Rehabil. 2016;26(5–6):645–72. https://doi.org/10.1080/09602011.2015.1026356.

    Article  PubMed  Google Scholar 

  24. Conn VS. Anxiety outcomes after physical activity interventions: meta-analysis findings. Nurs Res. 2010;59(3):224–31. https://doi.org/10.1097/NNR.0b013e3181dbb2f8.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Ludyga S, Gerber M, Pühse U, Looser VN, Kamijo K. Systematic review and meta-analysis investigating moderators of long-term effects of exercise on cognition in healthy individuals. Nat Hum Behav. 2020;4(6):603–12. https://doi.org/10.1038/s41562-020-0851-8.

    Article  PubMed  Google Scholar 

  26. Shields N, Synnot AJ, Barr M. Perceived barriers and facilitators to physical activity for children with disability: a systematic review. Br J Sports Med. 2012;46(14):989–97. https://doi.org/10.1136/bjsports-2011-090236.

    Article  PubMed  Google Scholar 

  27. Golubović S, Skrbić R. Agreement in quality of life assessment between adolescents with intellectual disability and their parents. Res Dev Disabil. 2013;34(6):1863–9. https://doi.org/10.1016/j.ridd.2013.03.006.

    Article  PubMed  Google Scholar 

  28. Burke NL, Storch EA. A meta-analysis of weight status and anxiety in children and adolescents. J Dev Behav Pediatr. 2015;36(3):133–45. https://doi.org/10.1097/DBP.0000000000000143.

    Article  PubMed  Google Scholar 

  29. Antikainen I, Ellis R. A RE-AIM evaluation of theory-based physical activity interventions. J Sport Exerc Psychol. 2011;33(2):198–214. https://doi.org/10.1123/jsep.33.2.198.

    Article  PubMed  Google Scholar 

  30. McGoey T, Root Z, Bruner MW, Law B. Evaluation of physical activity interventions in youth via the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) framework: a systematic review of randomised and non-randomised trials. Prev Med. 2015;76:58–67. https://doi.org/10.1016/j.ypmed.2015.04.006.

    Article  PubMed  Google Scholar 

  31. Glasgow RE, Harden SM, Gaglio B, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Public Health Front. 2019;7:64. https://doi.org/10.3389/fpubh.2019.00064.

    Article  Google Scholar 

  32. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–7. https://doi.org/10.2105/ajph.89.9.1322.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  33. O’Brien J, Finch CF. The implementation of musculoskeletal injury-prevention exercise programmes in team ball sports: a systematic review employing the RE-AIM framework. Sports Med. 2014;44(9):1305–18. https://doi.org/10.1007/s40279-014-0208-4.

    Article  PubMed  Google Scholar 

  34. Vriend I, Coehoorn I, Verhagen E. Implementation of an app-based neuromuscular training programme to prevent ankle sprains: a process evaluation using the RE-AIM framework. Br J Sports Med. 2015;49(7):484–8. https://doi.org/10.1136/bjsports-2013-092896.

    Article  PubMed  Google Scholar 

  35. Shaw RB, Sweet SN, McBride CB, Adair WK, Ginis KA. Operationalizing the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework to evaluate the collective impact of autonomous community programs that promote health and well-being. BMC Public Health. 2019;19(1):1–4. https://doi.org/10.1186/s12889-019-7131-4.

    Article  Google Scholar 

  36. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. https://doi.org/10.1136/bmj.n71.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Amir-Behghadami M, Janati A. Population, intervention, comparison, outcomes and study (PICOS) design as a framework to formulate eligibility criteria in systematic reviews. Emerg Med J. 2020;37(6):387. https://doi.org/10.1136/emermed-2020-209567.

    Article  PubMed  Google Scholar 

  38. Higgins JP, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions: John Wiley & Sons; 2019. https://doi.org/10.1002/9781119536604.

    Book  Google Scholar 

  39. Turner HM, Bernard RM. Calculating and synthesizing effect sizes. Contemp Issues Commun Sci Disord. 2006;33(Spring):42–55. https://doi.org/10.1044/CICSD_33_S_42.

    Article  Google Scholar 

  40. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. New York: Academic Press; 1988. https://doi.org/10.4324/9780203771587.

    Book  Google Scholar 

  41. Pearson N, Braithwaite RE, Biddle SJ, van Sluijs EM, Atkin AJ. Associations between sedentary behaviour and physical activity in children and adolescents: a meta-analysis. Obes Rev. 2014;15(8):666–75. https://doi.org/10.1111/obr.12188.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  42. Moreno-Peral P, Conejo-Cerón S, Rubio-Valera M, et al. Effectiveness of psychological and/or educational interventions in the prevention of anxiety: a systematic review, meta-analysis, and meta-regression. JAMA Psychiatry. 2017;74(10):1021–9. https://doi.org/10.1001/jamapsychiatry.2017.2509.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Choi PH, Cheung SY. Effects of an 8-week structured physical activity program on psychosocial behaviors of children with intellectual disabilities. Adapt Phys Act Q. 2016;33(1):1–4. https://doi.org/10.1123/APAQ.2014-0213.

    CAS  Article  Google Scholar 

  44. Maïano C, Ninot G, Bruant G, Bilard J. Effects of alternated basketball competition on perceived competence in adolescents with intellectual disabilities over a period of 13 months: a research note. Intl J Disabil Dev Educ. 2002;49(4):413–20. https://doi.org/10.1080/1034912022000028376.

    Article  Google Scholar 

  45. Maïano C, Ninot G, Erraïs B. Effects of alternated sport competition in perceived competence for adolescent males with mild to moderate mental retardation. Int J Rehabil Res. 2001;24(1):51–8. https://doi.org/10.1097/00004356-200103000-00007.

    Article  PubMed  Google Scholar 

  46. Ninot G, Maïano C. Long-term effects of athletics meet on the perceived competence of individuals with intellectual disabilities. Res Dev Disabil. 2007;28(2):176–86. https://doi.org/10.1016/j.ridd.2006.02.008.

    Article  PubMed  Google Scholar 

  47. Ninot G, Bilard J, Delignières D. Effects of integrated or segregated sport participation on the physical self for adolescents with intellectual disabilities. J Intellect Disabil Res. 2005;49(Pt 9):682–9. https://doi.org/10.1111/j.1365-2788.2005.00407.x.

    CAS  Article  PubMed  Google Scholar 

  48. Ninot G, Bilard J, Delignières D, Sokolowski M. Effects of integrated sport participation on perceived competence for adolescents with mental retardation. Adapt Phys Act Q. 2000;17(2):208–21. https://doi.org/10.1123/apaq.17.2.208.

    Article  Google Scholar 

  49. Özer D, Baran F, Aktop A, Nalbant S, Ağlamış E, Hutzler Y. Effects of a Special Olympics unified sports soccer program on psycho-social attributes of youth with and without intellectual disability. Res Dev Disabil. 2012;33(1):229–39. https://doi.org/10.1016/j.ridd.2011.09.011.

    Article  PubMed  Google Scholar 

  50. Perić DB, Milićević-Marinković B, Djurović D. The effect of the adapted soccer programme on motor learning and psychosocial behaviour in adolescents with Down syndrome. J Intellect Disabil Res.  2022;66(6):533–44. https://doi.org/10.1111/jir.12881.

  51. Ryuh Y, Choi P, Oh J, Chen CC, Lee Y. Impact of inclusive soccer program on psychosocial development of children with and without intellectual disabilities. J Dev Phys Disabil. 2019;31(5):691–705. https://doi.org/10.1007/s10882-019-09670-8.

    Article  Google Scholar 

  52. Chen MD, Tsai HY, Wang CC, Wuang YP. The effectiveness of racket-sport intervention on visual perception and executive functions in children with mild intellectual disabilities and borderline intellectual functioning. Neuropsychiatr Dis Treat. 2015;11:2287. https://doi.org/10.2147/NDT.S89083.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Giagazoglou P, Arabatzi F, Kellis E, Liga M, Karra C, Amiridis I. Muscle reaction function of individuals with intellectual disabilities may be improved through therapeutic use of a horse. Res Dev Disabil. 2013;34(9):2442–8. https://doi.org/10.1016/j.ridd.2013.04.015.

    Article  PubMed  Google Scholar 

  54. Mazzoli E, Salmon J, Pesce C, et al. Effects of classroom-based active breaks on cognition, sitting and on-task behaviour in children with intellectual disability: a pilot study. J Intellect Disabil Res. 2021;65(5):464–88. https://doi.org/10.1111/jir.12826.

    CAS  Article  PubMed  Google Scholar 

  55. Pise V, Pradhan B, Gharote M. Effect of yoga practices on psycho-motor abilities among intellectually disabled children. J Exerc Rehabil. 2018;14(4):581–5. https://doi.org/10.12965/jer.1836290.145.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Vogt T, Schneider S, Anneken V, Strüder HK. Moderate cycling exercise enhances neurocognitive processing in adolescents with intellectual and developmental disabilities. Res Dev Disabil. 2013;34(9):2708–16. https://doi.org/10.1016/j.ridd.2013.05.037.

    Article  PubMed  Google Scholar 

  57. Yildirim NU, Erbahçeci F, Ergun N, Pitetti KH, Beets MW. The effect of physical fitness training on reaction time in youth with intellectual disabilities. Percept Mot Skills. 2010;111(1):178–86. https://doi.org/10.2466/06.10.11.13.15.25.

    Article  PubMed  Google Scholar 

  58. Petrosko J. Wechsler intelligence scale for children—revised, 1974. David Wechsler. Meas Eval Couns. 1975;7(4):265–7. https://doi.org/10.1080/00256307.1975.12022657.

    Article  Google Scholar 

  59. Luckasson R, Borthwick-Duffy S, Buntinx WH, et al. Mental retardation: definition, classification, and systems of supports. Washington: American Association on Mental Retardation; 2002. https://doi.org/10.1016/S0887-8994(03)00213-3.

    Book  Google Scholar 

  60. Schalock RL, Borthwick-Duffy SA, Bradley VJ, et al. Intellectual disability: definition, classification, and systems of supports (11th ed). Washington: American Association on Intellectual and Developmental Disabilities; 2010.

    Google Scholar 

  61. Donnelly JE, Hillman CH, Castelli D, et al. Physical activity, fitness, cognitive function, and academic achievement in children: a systematic review. Med Sci Sports Exerc. 2016;48(6):1197. https://doi.org/10.1249/MSS.0000000000000901.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Groot C, Hooghiemstra AM, Raijmakers PG, et al. The effect of physical activity on cognitive function in patients with dementia: a meta-analysis of randomized control trials. Ageing Res Rev. 2016;25:13–23. https://doi.org/10.1016/j.arr.2015.11.005.

    CAS  Article  PubMed  Google Scholar 

  63. Totsika V, Liew A, Absoud M, Adnams C, Emerson E. Mental health problems in children with intellectual disability. Lancet Child Adolesc Health. 2022;6(6):432–44. https://doi.org/10.1016/S2352-4642(22)00067-0.

    Article  PubMed  Google Scholar 

  64. Pan CY, Liu CW, Chung IC, Hsu PJ. Physical activity levels of adolescents with and without intellectual disabilities during physical education and recess. Res Dev Disabil. 2015;36C:579–86. https://doi.org/10.1016/j.ridd.2014.10.042.

    Article  PubMed  Google Scholar 

  65. Sit CH, McKenzie TL, Lian JM, McManus A. Activity levels during physical education and recess in two special schools for children with mild intellectual disabilities. Adapt Phys Act Q. 2008;25(3):247–59. https://doi.org/10.1123/apaq.25.3.247.

    Article  Google Scholar 

  66. Blackman KC, Zoellner J, Berrey LM, et al. Assessing the internal and external validity of mobile health physical activity promotion interventions: a systematic literature review using the RE-AIM framework. J Med Internet Res. 2013;15(10):e224. https://doi.org/10.2196/jmir.2745.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Lai B, Lee E, Wagatsuma M, et al. Research trends and recommendations for physical activity interventions among children and youth with disabilities: a review of reviews. Adapt Phys Act Q. 2020;37(2):211–34. https://doi.org/10.1123/apaq.2019-0081.

    Article  Google Scholar 

  68. Dairo YM, Collett J, Dawes H, Oskrochi GR. Physical activity levels in adults with intellectual disabilities: a systematic review. Prev Med Rep. 2016;4:209–19. https://doi.org/10.1016/j.pmedr.2016.06.008.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Phillips AC, Holland AJ. Assessment of objectively measured physical activity levels in individuals with intellectual disabilities with and without Down's syndrome. PLoS One. 2011;6(12):e28618. https://doi.org/10.1371/journal.pone.0028618.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Author information

Authors and Affiliations

Authors

Contributions

WY and CHPS developed the review premise. WY and XL reviewed all the identified abstracts and full texts in consultation with CHPS. WY and LX extracted the data from articles and WY checked the data. WY and LX evaluated the quality of included studies by using the RE-AIM framework in consultation with CHPS. WY prepared the tables and figures, and CHPS and LX contributed to the reviewing and editing of the paper. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Cindy Hui-Ping Sit.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1.

PRISMA 2020 Checklist.

Additional file 2.

Search strategy in SPORTDiscus database.

Additional file 3.

Coding sheet for publications reporting on the RE-AIM framework components.

Additional file 4.

Proportion of PA interventions reporting the RE-AIM framework of included studies (n = 15).

Additional file 5.

Forest plot of subgroup analyses.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Yang, W., Liang, X. & Sit, C.HP. Physical activity and mental health in children and adolescents with intellectual disabilities: a meta-analysis using the RE-AIM framework. Int J Behav Nutr Phys Act 19, 80 (2022). https://doi.org/10.1186/s12966-022-01312-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12966-022-01312-1

Keywords

  • Adolescent
  • Children
  • Physical activity
  • Cognitive function
  • Psychological health
  • Intellectual disability