Perceived coaches' health promotion activity, maintenance of participation in sports, and lifestyle habits among emerging adults: a four-year follow-up study.

OBJECTIVES: This study focused on how adolescents' perceptions of coaches' health promotion activity predict maintained participation and dropout in organized sports in emerging adulthood. In addition, differences in lifestyle habits between maintainers, dropouts, and nonparticipants in organized sports were explored. MATERIALS AND METHODS: Overall, 616 adolescents reported organized sports participation in the Finnish Health Promoting Sports Club (FHPSC) study at ages 15 and 19. Of these, 323 reported coach's health promotion activity on health topics at the age of 15. An index of a coach's general health promotion activity was formed. At age 19, all study participants reported their lifestyle habits. RESULTS: Among males, those who had perceived coaches' general health promotion activity as frequent were more likely to be maintainers than dropouts (48.6% vs. 20.0%) (p = .002). Among females, there was no significant difference (32.0% vs. 28.4%). Logistic regression analysis adjusted for gender showed that perceiving coach's general health promotion activity as frequent increased the odds of being a maintainer rather than a dropout. Moreover, maintainers had higher odds of having healthy lifestyle habits when compared to nonparticipants (related to physical activity; sleep; fruit and vegetable consumption; and cigarette use) or dropouts (related to physical activity; and cigarette use). In addition, dropouts had higher odds of having healthy lifestyle habits than nonparticipants (related to sleep; and cigarette use). CONCLUSIONS: Perceiving coaches' health promotion activity as frequent was related to maintained participation in organized sports among males. Maintainers were more likely to have more healthy lifestyle habits than nonparticipants and dropouts. There is a need to invest in coaches' health promotion activity when it is infrequent. A more detailed understanding is needed of coaches' health promotion activity that supports both maintained participation in sports, especially among females, and healthy lifestyle habits in emerging adulthood.

There is a need to invest in coaches' health promotion activity when it is infrequent in order to support adolescents' continued participation in organized sports and healthy lifestyle habits in emerging adulthood.

Health Benefits of Different Sports: a Systematic Review and Meta-Analysis of Longitudinal and Intervention Studies Including 2.6 Million Adult Participants.

BACKGROUND: Several reviews have examined the health benefits of participation in specific sports, such as baseball, cricket, cross-country skiing, cycling, downhill skiing, football, golf, judo, rugby, running and swimming. However, new primary studies on the topic have recently been published, and the respective meta-analytic evidence needs to be updated. OBJECTIVES: To systematically review, summarise and appraise evidence on physical health benefits of participation in different recreational sports. METHODS: Searches for journal articles were conducted in PubMed/MEDLINE, Scopus, SpoLit, SPORTDiscus, Sports Medicine & Education Index and Web of Science. We included longitudinal and intervention studies investigating physical health outcomes associated with participation in a given sport among generally healthy adults without disability. RESULTS: A total of 136 papers from 76 studies conducted among 2.6 million participants were included in the review. Our meta-analyses of available evidence found that: (1) cycling reduces the risk of coronary heart disease by 16% (pooled hazard ratio [HR] = 0.84; 95% confidence interval [CI]: 0.80, 0.89), all-cause mortality by 21% (HR = 0.79; 95% CI: 0.73, 0.84), cancer mortality by 10% (HR = 0.90; 95% CI: 0.85, 0.96) and cardiovascular mortality by 20% (HR = 0.80; 95% CI: 0.74, 0.86); (2) football has favourable effects on body composition, blood lipids, fasting blood glucose, blood pressure, cardiovascular function at rest, cardiorespiratory fitness and bone strength (p < 0.050); (3) handball has favourable effects on body composition and cardiorespiratory fitness (p < 0.050); (4) running reduces the risk of all-cause mortality by 23% (HR = 0.77; 95% CI: 0.70, 0.85), cancer mortality by 20% (HR = 0.80; 95% CI: 0.72, 0.89) and cardiovascular mortality by 27% (HR = 0.73; 95% CI: 0.57, 0.94) and improves body composition, cardiovascular function at rest and cardiorespiratory fitness (p < 0.010); and (5) swimming reduces the risk of all-cause mortality by 24% (HR = 0.76; 95% CI: 0.63, 0.92) and improves body composition and blood lipids (p < 0.010). CONCLUSIONS: A range of physical health benefits are associated with participation in recreational cycling, football, handball, running and swimming. More studies are needed to enable meta-analyses of health benefits of participation in other sports. PROSPERO registration number CRD42021234839.

Sports-related factors predicting maintained participation and dropout in organized sports in emerging adulthood: A four-year follow-up study.

This study explored sports-related factors predicting organized sports participation in emerging adulthood. In the Finnish Health Promoting Sports Club (FHPSC) study, 354 sports club participants aged 15 at baseline reported their main sport, onset age, training volume, current competitive level, and future competitive orientation and participated in the follow-up study at age 19. There were differences in the proportions of maintainers and dropouts in a few sports: football (maintainers 58.6%), and among females, skating (maintainers 60.7%), and swimming (dropouts 80.0%). A binary logistic regression analysis showed that those who had started their main sport by school age (females OR 3.05/95% CI 1.34, 6.98; males OR 3.97/95% CI 1.48, 10.64) and had competed at national top level plus had aimed at success at the adult level competitions in future (females OR 3.42/95% CI 1.16, 10.09; males OR 3.58/95% CI 1.12, 11.41; among females, also had competed at national top level plus had aimed at success at junior level competitions [OR 3.42/95% CI 1.20, 9.78]) were more likely maintainers than dropouts. Early onset in the main sport and competitiveness were related to maintained sports participation while the opposites were related to dropouts in the current organized sports system.

Meanings Attributed to Physical Activity and Changes in Self-Reported and Accelerometer-Measured Physical Activity among Recent Retirees.

Retirement poses opportunities and challenges for maintaining and adopting physically active habits, which may have major implications for health and functional ability in later life. Qualitative studies suggest that a broad range of meanings of physical activity should be considered when promoting physical activity among retirees. The current study utilized the Physical Activity Relationship (PAR) approach to examine the importance of meanings attributed to physical activity and their associations with physical activity over time. A total of 230 recently retired participants (65.2 years old, 83% women) responded to a 54-item inventory assessing the importance of meanings attributed to physical activity at baseline. Eight meaning dimensions were identified through exploratory factor analysis. Differences in their importance across gender and occupational background were examined using t-tests and ANOVA. Associations between meaning dimensions and self-reported and accelerometer-measured physical activity over 12 months were examined with general linear models. Dimensions defined as Physical Fitness, Positive Mood, and Belonging were positively associated with changes in self-reported and accelerometer-measured physical activity. Additionally, the importance of several meaning dimensions varied across occupational background. In conclusion, physical activity promotion among retirees should focus on physical fitness, positive mood, and social belonging. Furthermore, meanings attributed to physical activity may vary across occupational backgrounds.

Young People in the Social World of Physical Activities: Meanings and Barriers.

Physical inactivity has become one of the leading risk factors for non-communicable diseases (NCDs) and death worldwide. From the future perspective it is alarming that in the group of young people few meet the recommendations. In this respect, physical activity promotion in general and physical education have challenges and new approaches are needed. In this study, the theoretical framework is based on the physical activity relationship (PAR) approach and the barriers were grouped according to the ecological model. The aim of the study was firstly to present both the meanings and barriers of physical activity in a comprehensive Finnish population of 11-15 year old (n = 2728) and secondly to examine how the number of important meanings and mentioned barriers associate with each other with physical activity levels. Data were collected using a questionnaire. To examine how the meanings and barriers associate with each other and with the PA level, chi-squared test (χ2), Pearson correlation and General linear model (ANCOVA) were used. Logistic regression was applied to estimate effect sizes by odds ratios and 95% confidence intervals. According to the results, the associations between physical activity with the meanings and barriers were reverse and linear. The more important the meanings were found to be, the more likely the study participants were physically active, whereas the more barriers participants reported, the less active they were. The approach which utilizes meanings and barriers has a lot of untapped potential for the promotion of physical activity and physical education. With the right actions, some barriers could be removed or dampened, and by opening up and deepening meanings, PAR could be strengthened.

Finnish late adolescents' physical activity during COVID-19 spring 2020 lockdown.

BACKGROUND: Physical activity (PA) is recognised as one of the leading and effective strategies to prevent non-communicable diseases that boosts the immune system to fight against diseases. Closures of schools, sport clubs and facilities because of COVID-19 reduced the opportunities to participate in PA. We aimed to examine physical activity levels of late adolescents, the contexts to be physical active and its changes during the spring 2020 lockdown. METHODS: A national representative sample of late adolescents in general upper secondary school (n = 2408, females = 64%, mean age = 17.2y, SD = 0.63) completed self-report online surveys on PA behaviours between March and June 2020. Multinominal logistic regression analyses were performed to identify correlates with PA, and decision tree analyses to ascertain the perceived changes on PA during lockdown based on sport club aspirations and levels of PA. RESULTS: Among the late adolescents, the distribution of PA frequency was 23% (0-2 days/week), 35% (3-4 days/week), 30% (5-6 days/week) and 12% (7 days/week), and differences between males and females were not statistically significant. Participation in both indoor and outdoor PA were 50 times more likely to report daily PA (OR = 54.28, CI = 15.16-194.37) than non-participation. A quarter of late adolescents were not part of a sports club, yet their PA levels increased. Although sports club members generally perceived they did less PA during lockdown, over a third of sport club members with competitive aspirations reported daily PA. CONCLUSIONS: Overall, most late adolescents reported their PA levels decreased during lockdown. Findings from this study continue to demonstrate factors associated with PA in the context of the COVID-19 lockdown.

The Impact of a 12-Month Activity Tracker Intervention on Activity Behavior Across Body Mass Index Subgroups Among Recent Retirees: Post Hoc Analysis of a Randomized Controlled Trial.

BACKGROUND: This study examined the effectiveness of a 12-month activity tracker-based intervention on activity behavior among recent retirees (Enhancing physical ACTivity and healthy aging among recent REtirees [REACT]) in subgroups based on body mass index. METHODS: REACT trial randomized 231 participants (mean age 65.2) into intervention and control groups. Main outcomes were accelerometer-measured moderate-to-vigorous (MVPA) and light physical activity (LPA) and sedentary time (SED) measured at baseline and 3-, 6-, and 12-month follow-ups. As a post hoc analysis, the intervention effect was examined among participants with normal weight (n = 77), overweight (n = 89), and obesity (n = 61). RESULTS: An intervention effect was observed among participants with obesity in LPA (time × group P = .045) mirrored by a similar, albeit nonsignificant, effect in SED (P = .067), but not in MVPA (P = .92). A transient increase of 41 minutes per day (95% confidence interval, 14 to 68) in LPA was observed at 6 months among the intervention group, with a concomitant decrease of 42 minutes per day (-72 to -12) in SED. However, these changes were not maintained at 12 months. No between-group differences in changes over time were observed among participants with normal or overweight. CONCLUSIONS: Activity trackers may be particularly suitable for promoting changes in LPA and SED among older adults with obesity. However, their long-term effectiveness might be limited.

Individual- and environmental-related correlates of moderate-to-vigorous physical activity in 11-, 13-, and 15-year-old Finnish children.

The objective of this study was to analyze the associations of various individual- and environmental-related factors with subgroups of daily, frequent, moderate and low moderate-to-vigorous physical activity (MVPA) among children and adolescents. Data were obtained from the Finnish School-age Physical Activity (FSPA) study 2016 from 4677 national representative 11-, 13-, and 15-year-old children and adolescents. MVPA and individual- and environmental-related factors were assessed by a questionnaire and analyzed by two-level logistic regression. Seventeen of the twenty-one variables were statistically significantly associated with MVPA. However, only three variables were statistically significant in all MVPA subgroups, whereby self-directed PA at least twice a week, fewer perceived barriers, and higher peer support increased the odds of participating in more MVPA. The results from this study showed essential differences among the MVPA subgroups, also supporting previous findings, whereby various individual- and environmental-based factors are associated with children and adolescents' levels of MVPA. Challenges to designing and implementing effective interventions are based on the need to account for individual differences within the population, as well as the varied connections between PA with different social and physical environments where children and adolescents' PA takes place. PA interventions with various actions at multiple levels are warranted.

Health Promotion Interventions in Sports Clubs: Can We Talk About a Setting-Based Approach? A Systematic Mapping Review.

Many researchers and authorities have recognized the important role that sports clubs can play in public health. In spite of attempts to create a theoretical framework in the early 2000s, a thorough understanding of sports clubs as a setting for health promotion (HP) is lacking. Despite calls for more effective, sustainable, and theoretically grounded interventions, previous literature reviews have identified no controlled studies assessing HP interventions in sports clubs. This systematic mapping review details how the settings-based approach is applied through HP interventions in sports clubs and highlights facilitators and barriers for sports clubs to become health-promoting settings. In addition, the mapped facilitators and barriers have been used to reformulate previous guidelines of HP in sports clubs. Seven databases were searched for empirical research published between 1986 and 2017. Fifty-eight studies were included, principally coming from Australia and Europe, describing 33 unique interventions, which targeted mostly male participants in team sports. The settings-based approach was not yet applied in sports clubs, as more than half of the interventions implemented in sports club targeted only one level of the socio-ecological model, as well as focused only on study participants rather than the club overall. Based on empirical data, the analysis of facilitators and barriers helped develop revised guidelines for sports clubs to implement settings-based HP. This will be particularly useful when implementing HP initiatives to aid in the development of sports clubs working with a whole setting approach.

Does sports club participation contribute to physical activity among children and adolescents? A comparison across six European countries.

Aims: Insufficient physical activity (PA) is one of the largest public health challenges of our time and requires a multisectoral public-health response. PA recommendations state that all children and adolescents should accumulate at least 60 minutes of moderate-to-vigorous PA (MVPA) daily and carry out vigorous PA (VPA) three times weekly. While participation in sports club activities is known to enhance the probability of reaching the recommended overall PA level, less is known about the contribution of sports club participation to VPA, and few cross-national comparisons have been carried out. The purpose of this paper is to study whether participation in sports club activities is associated with meeting the overall PA and VPA recommendations among children and adolescents across six European countries, namely Belgium (Flanders), Czech Republic, Finland, France, Ireland and Sweden. Methods: Analyses were carried out on existing self-reported national data sets using descriptive statistics and logistic regression. Results: Results indicate that approximately two-thirds of children and adolescents take part in sports club activities in the given countries. Sports club participants were more likely to meet the overall PA recommendations (OR 2.4-6.4) and VPA recommendation (OR 2.8-5.0) than non-participants. Conclusions: The extent to which overall PA and/or VPA is gained through sports club participation versus other settings needs to be further studied. Nonetheless, it can be argued that sports clubs have an important position in PA promotion for younger populations.

Motor skills in association with physical activity, sedentary time, body fat, and day care attendance in 5-6-year-old children-The STEPS Study.

PURPOSE: This study examined how motor skills are associated with physical activity (PA), sedentary time, body fat, and day care attendance among young children. Also, the motor skills of healthy weight children were compared to those who were overweight or obese. METHODS: The study population consisted of five to six years old children (n = 111; 45 boys) who participated in the longitudinal STEPS Study carried out in Southwest Finland in 2013-2014. Motor skills were measured with the Bruininks-Oseretsky test, second edition (BOT-2) including fine manual control, manual coordination, body coordination, and strength and agility. Moderate-to-vigorous intensity PA (MVPA) and sedentary time were objectively measured with hip-worn accelerometers. Body mass index (BMI) was calculated based on measured weight and height. Body fat percentage (BF%) was measured using segmental multifrequency bio impedance analysis. Day care attendance was measured with parental questionnaires. Linear regression analyses were adjusted by age, sex, and parental education. RESULTS: Day care attendance was positively associated with body coordination and strength and agility. Lower BF% in girls was associated with higher strength and agility scores. There were no associations between manual coordination or fine manual control and the explanatory variables. Objectively measured MVPA and sedentary time showed no associations with motor skills. Overweight children had significantly lower scores in all motor skill composites (P < 0.05) than healthy weight children, except in fine manual control where the association was non-significant (P = 0.202). CONCLUSIONS: Early prevention of overweight and obesity may be of importance and day care attendance may be beneficial for motor skill development.

Association of Self-Perceived Physical Competence and Leisure-Time Physical Activity in Childhood-A Follow-Up Study.

BACKGROUND: The basis of self-perceived physical competence is built in childhood and school personnel have an important role in this developmental process. We investigated the association between initial self-perceived physical competence and reported leisure-time physical activity (LTPA) longitudinally in 10-, 12-, and 15-year-old children. METHODS: This longitudinal follow-up study comprises pupils from an elementary school cohort (N = 1346) in the city of Turku, Finland (175,000 inhabitants). The self-perceived physical competence (fitness and appearance) and LTPA data were collected with questionnaires. The full longitudinal data were available from 571 pupils based on repeated studies at the ages of 10, 12, and 15 years in 2004, 2006, and 2010. We analyzed the association of self-perceived physical competence and LTPA using regression models. RESULTS: Self-perceived physical competence was positively associated with LTPA at all ages (10 years p < .05, 12 years p < .0001, 15 years p < .0001). Increase in the self-perceived physical fitness scores was likely to associate with higher LTPA at each age point (10 years [odds ratio, OR] = 1.18, 95% confidence interval, CI: 1.09-1.27; 12 years [OR] = 1.27, 95% CI: 1.18-1.37; and 15 years [OR] = 1.28, 95% CI: 1.19-1.38). CONCLUSIONS: Self-perceived physical competence is associated with LTPA in children and adolescents, and the association is strengthened with age.

Association between amount of sleep, daytime sleepiness and health-related quality of life in schoolchildren.

AIMS: To analyse the association between amount of sleep and daytime sleepiness and health-related quality of life in schoolchildren during adolescence and to study the effect of age on this association. BACKGROUND: Sufficient sleep is essential for the health of children and adolescents. Sleep influences almost all dimensions of life. DESIGN: A 5-year prospective follow-up study (2004-2010) following 568 Finnish schoolchildren aged between 10-15. METHODS: The amount of sleep and perceived daytime sleepiness were assessed by a special questionnaire added to The Health Behaviour in School-aged Children questionnaire. The Finnish version of the Paediatric Quality of Life Inventory was used to assess health-related quality of life. The data were collected in 2004, 2006 and 2009/2010. Data were analysed with hierarchical linear mixed models. RESULTS/FINDINGS: The more daytime sleepiness occurred, the lower the health-related quality of life was and similar linear association was seen in every age group. The amount of sleep was significantly positively linearly associated with health-related quality of life but not persistent across age groups. Positive association was significant at 15 years of age but not at other age groups. Similar linear association between daytime sleepiness and school-related sub scores was also found. CONCLUSION: Sufficient sleep is essential for health-related quality of life and should be protected and measured in the school health service.

The factors associated with toddlers' screen time change in the STEPS Study: A two-year follow-up.

BACKGROUND AND OBJECTIVES: Early childhood screen time seems to persist into later childhood. This study examined the factors affecting the screen time change during the first two years of toddler's lives in Finland. We hypothesized that parents' sedentary behaviour and physical activity habits correlate significantly with children's screen time change. METHODS: The data consists of 1797 mothers, 1658 fathers and their 1827 children from the STEPS Study (Steps to the healthy development) in Southwest Finland. Screen time change during the two-year follow-up was calculated for those (n=634) who had both 13 and 36months screen time measures (13months, n=940; 36months, n=845). Demographic correlates and parental behavioural correlates were measured with questionnaires, and anthropometric measurements in study visits. RESULTS: The mean change in the children's screen time was a 55min increase from 13 to 36months. A linear mixed model analysis showed that the father's longer duration of sitting time was statistically significantly associated with a smaller increase in screen time of the child. Parents' physical activity was not associated with children's screen time change. The mother's advanced education, a younger age, and a lower screen time, the child attending day care and the child's lower body mass index were associated with children's smaller increase in screen time. CONCLUSION: The mother's advanced education as well as the father's sitting time, including sitting at the office, implied that children of higher educated parents have a smaller increase in screen time. Future studies should focus on studying why parental education has a greater influence on children's screen time change than parents' behaviour.

Health benefits of different sport disciplines for adults: systematic review of observational and intervention studies with meta-analysis.

The aim was to assess the quality and strength of evidence for the health benefits of specific sport disciplines. Electronic search yielded 2194 records and the selection resulted in 69 eligible studies (47 cross-sectional, 9 cohort, 13 intervention studies). 105 comparisons between participation and non-participation groups in 26 different sport disciplines were reported. Moderately strong evidence showed that both running and football improve aerobic fitness and cardiovascular function at rest, and football reduces adiposity. Conditional evidence showed that running benefits metabolic fitness, adiposity and postural balance, and football improves metabolic fitness, muscular performance, postural balance, and cardiac function. Evidence for health benefits of other sport disciplines was either inconclusive or tenuous. The evidence base for the health benefits of specific sports disciplines is generally compromised by weak study design and quality. Future research should address the health effects of different sport disciplines using rigorous research designs.

Results from Finland's 2014 Report Card on Physical Activity for Children and Youth.

The Finnish 2014 Report Card on Physical Activity (PA) for Children and Youth is the first assessment of Finland's efforts in promoting and facilitating PA opportunities for children and youth using the Active Healthy Kids Canada grading system. The Report Card relies primarily on research findings from 6 Research Institutes, coordinated by the University of Jyväskylä. The Research Work Group convened to evaluate the aggregated evidence and assign grades for each of the 9 PA indicators, following the Canadian Report Card protocol. Grades from A (highest) to F (lowest) varied in Finland as follows: 1) Overall physical activity-fulfillment of recommendations (D), 2) Organized sport participation (C), 3) Active play (D), 4) Active transportation (B), 5) Sedentary behaviors (D), 6) Family and peers (C), 7) School (B), 8) Community and the built environment (B), and 9) Government (B). This comprehensive summary and assessment of indicators related to PA in Finnish children and youth indicates that Finland still has many challenges to promote a physically active life style for youth.

The change in child self-assessed and parent proxy-assessed Health Related Quality of Life (HRQL) in early adolescence (age 10-12).

AIMS: To examine the development of self-assessed and parent proxy-assessed health related quality of life (HRQL) in pre-adolescent schoolchildren. METHODS: The population (n = 1,346) consisted of the total cohort of children starting 4th grade (age 10) in 2004 in primary schools in a Finnish city of 175,000 inhabitants. HRQL was assessed using the Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0). The baseline study was conducted in 2004 (child age 10) and follow-up in a panel setting in 2006 (child age 12). The response rate for the children was 80% (n = 1,094) in 2004 and 85% (n = 1,139) in 2006. The response rate for children having responded both in 2004 and 2006 was 73% (n = 986). For parents of the children, one parent participated in the parents' survey (n = 999 in 2004, n = 888 in 2006). RESULTS: HRQL scores increased significantly in the two-year follow up (child t = 10.16-5.95, p < 0.0001, parent-proxy t = 6.35-2.76, p < 0.0001-0.006). Correlation between baseline and follow-up assessments was significant (child r = 0.4-0.5, p < 0.0001, parent r = 0.47-0.57, p < 0.0001). The correlation between baseline HRQL and change was negative (child r =-0.67 to -0.56, p < 0.0001, parent r =-0.62 to -0.46, p < 0.0001). Correlation between child and parent assessments increased from baseline (r = 0.20-0.39, p < 0.0001) to follow up (r = 0.3-0.42, p < 0.0001). CONCLUSIONS: Child-assessed and parent proxy-assessed HRQL scores increase, suggesting HRQL improves, when children grow from age 10 to age 12. Baseline HRQL may not strongly predict future HRQL in early adolescence. The correlation between child self-assessment and parent proxy-assessment is fragile.

Health related quality of life in 10-year-old schoolchildren.

OBJECTIVE: The purpose of this study was to investigate the health related quality of life (HRQL) in a total cohort of general school children. METHODS: The study population consisted of the children starting 4th grade (age 9-10) in Finnish primary schools in autumn 2004 (n = 1,346) and their parents in a city of 175,000 inhabitants. Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0) was used for assessment of HRQL. The response rate was 81% for the children (n = 1,091). Most children had parents who participated (n = 999). RESULTS: The children reported highest HRQL mean values in physical (85.00, SD 10.95) and social (84.71, SD 14.28), and lowest in school (78.89, SD 14.53) and emotional (75.43, SD 15.67), functioning scales. Girls reported significantly lower emotional (t = -2.43, P = 0.02) functioning than boys. Child self reports show lower social (t = -2.57, P = 0.01) and school (t = -3.44, P = 0.0006) functioning, and higher emotional (t = 5.82, P < 0.0001) and physical (t = 4.79, P < 0.0001) functioning than their parent-proxy assessments. CONCLUSIONS: Interventions aiming at supporting the emotional and school functioning of the school children are recommended. Parents may overestimate the social and school functioning and underestimate the physical and emotional functioning compared to their children's own perceptions.