Fostering Health, Wellness and Adapted Recreational Exercise for Students

By: Katie Heilman

The Why…

In today’s society where technology is King, a more sedentary lifestyle among America’s youth has followed. When you mix in other factors, such as access and education on nutritious food, as well as socioeconomic status, it’s no wonder that childhood obesity has become a serious national, and global, health concern. Healthcare providers and researchers have long been tracking the trend of America’s expanding waistlines across the lifespan, and have documented especially concerning trends in the data for children and adolescence. The Non-communicable Disease Risk Factor Collaboration (NCD-RisC), is a worldwide network of health researchers and practitioners whose aim is to systematically document the worldwide trends and variations in non-communicable disease risk factors. In 2016, they found that the prevalence of obesity was about 20% or more in several countries in Polynesia and Micronesia, the Middle East and north Africa, the Caribbean, and the USA, with 50 (24-89) million girls and 74 (39-125) million boys worldwide being obese.1 The American Academy of Pediatrics, the World Health Organization (WHO), American Psychological Association and countless other health and research agencies, have been tracking the increase in screen time in babies, children and adolescence and how it affects their health and development- both physically and behaviorally.2  According to a systematic review of reviews published by University College London (UCL) psychologist Neza Stiglic, PhD, and Russell Viner, PhD, a professor of adolescent health at UCL ( BMJ Open , Vol. 9, No. 1, 2019 ), most research on obesity focused on television viewing and found that more time spent watching TV was associated with a higher body mass index or body fat composition. Multiple studies also found that screen use of more than two hours a day was correlated with depressive symptoms. The reviewers found moderate evidence linking screen time to poorer quality of life, higher caloric intake and less-healthy diets. Evidence linking screen time to other problems, such as behavior issues, anxiety, and low feelings of well-being and self-esteem, was weak, with studies on these outcomes returning mixed results. 2,3

In the 1970’s, the US childhood obesity rate was 5.6%.4 Since then, the US has been on a steady upward trend. Currently, the Centers for Disease Control and Prevention (CDC) reports “Childhood obesity is a serious problem in the United States, putting children and adolescents at risk for poor health. Obesity prevalence among children and adolescents is still too high. For children and adolescents aged 2-19 years in 2017-2020:

  • The prevalence of obesity was 19.7% and affected about 14.7 million children and adolescents.
  • Obesity prevalence was 12.7% among 2- to 5-year-olds, 20.7% among 6- to 11-year-olds, and 22.2% among 12- to 19-year-olds. Childhood obesity is also more common among certain populations.
  • Obesity prevalence was 26.2% among Hispanic children, 24.8% among non-Hispanic Black children, 16.6% among non-Hispanic White children, and 9.0% among non-Hispanic Asian children.
  • Obesity-related conditions include high blood pressure, high cholesterol, type 2 diabetes, breathing problems such as asthma and sleep apnea, and joint problems.”5

This translates to approximately 1 in every 5 students in the US are overweight or obese. Most children do not participate in the daily recommended levels of physical activity. Most participate in more than 2 hours/day of sedentary “screen time” and most have unhealthy diets.6 Children with chronic conditions and disabilities have more sedentary lifestyles and have higher rates of obesity compared to peers.7.8 

According to the WHO, in a 24-hour day;

Children 3-4 years of age should:

  • Spend at least 180 minutes in a variety of types of physical activities at any intensity, of which at least 60 minutes is moderate- to vigorous-intensity physical activity, spread throughout the day; more is better;
  • Not be restrained for more than 1 hour at a time (e.g., prams/strollers) or sit for extended periods of time.
    • Sedentary screen time should be no more than 1 hour; less is better.
  • When sedentary, engaging in reading and storytelling with a caregiver is); encourage; and 
  • Have 10-13h of good quality sleep, which may include a nap, with regular sleep and wake-up times.9

Children and adolescents aged 5-17 years:

  • Should do at least an average of 60 minutes per day of moderate-to-vigorous intensity, mostly aerobic, physical activity, across the week.
  • Should incorporate vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, at least 3 days a week.
  • Should limit the amount of time spent being sedentary, particularly the amount of recreational screen time.9

Adults aged 18–64 years:

  • Should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week
  • Should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits.
  • May increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits.
  • Should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits, and
  • To help reduce the detrimental effects of high levels of sedentary behavior on health, all adults and older adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity.9

Meanwhile, we see recess times cut down to 15-20 minutes. Physical education classes are typically once per week at the elementary levels, or daily for a 6-week rotation during the entire school year. In some states and school districts, physical education is being completely cut due to budgetary eliminations! 

The How…

The APTA Guide to Physical Therapy Practice defines scope of practice to include a role in prevention, health promotion, wellness, fitness and screening activities. The goals of physical therapy intervention are to minimize impairments, activity limitations, participation restrictions, and health costs while achieving optimal function. As pediatric physical therapists, the goal is to work towards having the family and child adopt fitness as an important activity and to carry the fitness program forward.10

As school practitioners, how do we foster healthy lifestyle changes, improve their social and emotional connections with their peers, and educate our school communities? Luckily, we possess a unique set of knowledge, skills, and access to our student’s daily lives that we can use to help shape their growth and learning! This means not just helping them to access their educational environment, but fostering their physical, mental, and social health! We can contribute our expertise to helping our students and school communities to create programming that supports these needs. Getting healthy is about developing healthy habits and creating opportunities to regularly engage in these healthy habits. 

Multi Tiered Systems of Support (MTSS) serves as an umbrella framework that encompasses Response to Intervention (RtI) and Positive Behavioral Intervention and Supports (PBIS) frameworks. 11 Therapists should remember that in RtI/MTSS models of service, our clients are not only the students, but also the teachers and support staff. State physical therapy practice acts may dictate the extent to which PTs may participate in RtI, particularly with regard to direct access. Individual school district policies may also delineate implementation procedures as well. Therapists should provide support to teachers and staff in order to enhance student participation in their educational environment through the following means:

• Universal screenings

• Professional development

• Collaboration with teachers and staff

• Referral process to special education12

The RtI Subcommittee of the School-based Physical Therapy Special Interest Group, Section on

Pediatrics of the American Physical Therapy Association recommends the following guidelines on how PTs can support students in general education at the various tiers:

Tier 1: Universal Intervention

• Provide in-services to teachers on typical development and indicators of academic readiness.

• Assist with environmental design to reduce or enhance performance.

• Provide in-services to administrators, teachers, and other staff members on strategies to promote alertness through incorporation of movement activities.

• Provide in-services to teachers and staff on possible environmental modifications that can maximize posture to enhance learning and participation.

• Provide in-services to administration on benefits of including recess in the students’ school day.

• Provide in-services to staff on PTs’ role in RtI and provide resources and equipment guides.12

Tier 2: Targeted Intervention

• Participate in building-level/problem-solving process at grade/class subgroup level.

• Suggest alternative materials to promote participation and performance for remediation and enrichment.

• Explore environmental triggers to behaviors in daily routines.

• Suggest purposeful activities for classroom and leisure time.12

Tier 3: Intensive Interventions

• Participate in the problem-solving process at the individual student level.

• Conduct a physical therapy assessment as part of the full and individual evaluation under IDEA.12

Suggested RtI Resources12

Getting Teacher and Student buy in…

As therapists, we know that making activities meaningful to our students and teachers is what will foster better carryover and consistency. Talk to your school district administrators… Your Special Services Directors, Curriculum Directors, your building Principals, Intervention Specialists and Teachers who are your go-to resources for honing in on the needs of your district. Where is the need and priority? Which other therapists and staff members do you already have good working relationships with that you can collaborate and co-teach with? Start small and then build your growth. Here are some other jumping off point ideas:

  • Every Moment Counts- Refreshing Recess
  • Get your IEP students involved in their school extracurricular sports teams! 
    • Section 9 of the IEP- School districts are required to provide students with disabilities the same opportunities to participate in nonacademic/extracurricular activities as non-disabled peers. The law states that the following:

Non Academic services:

(1) Each school district must take steps, including the provision of supplementary aids and services determined appropriate and necessary by the child’s IEP team, to provide nonacademic and extracurricular services and activities in the manner necessary to afford children with disabilities an equal opportunity for participation in those services and activities.

(2) Nonacademic and extracurricular services and activities shall include counseling services, athletics, transportation, health services, recreational activities, special interest groups or clubs sponsored by the school district, referrals to agencies that provide assistance to individuals with disabilities, and employment of students, including both employment by the school district and assistance in making outside employment available.

“Supplementary aids and services” means aids, services, and other supports that are provided in regular education classes, other education-related settings, and in extracurricular and nonacademic settings, to enable children with disabilities to be educated with nondisabled children to the maximum extent appropriate in accordance with the requirements for least restrictive environment.


  1. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017 Dec 16;390(10113):2627-2642. doi: 10.1016/S0140-6736(17)32129-3. Epub 2017 Oct 10. PMID: 29029897; PMCID: PMC5735219.
  2. American Psychological Association (2020, April 1) “What do we really know about kids and screens? Research by psychologists and others is giving us a better understanding of the risks and potential benefits of children’s and teens’ use of digital devices.” Accessed 3/17/2023.
  3. Stiglic N, Viner RMEffects of screentime on the health and well-being of children and adolescents: a systematic review of reviewsBMJ Open 2019;9:e023191. doi: 10.1136/bmjopen-2018-023191
  4. Centers for Disease Control and Prevention ( 2015, August) Data Briefs- Prevalence of Obesity Among Children and Adolescents in the United States and Canada. 
  5. Centers for Disease Control and Prevention (2022, May 17). “Childhood Obesity Facts.” Accessed: March 16, 2023.
  6. Centers for Disease Control and Prevention (n.d). “Youth Risk Behavior Surveillance System.” Accessed: March 16, 2023. 
  7. Bandini LG, Curtin C, Hamad C, Tybor DJ, Must A. “Prevalence of over-weight in children with developmental disorders in the continuous National Health and Nutrition Examination Survey (NHANES) 1999-2002. J Pediatr. 2005;146(6):738-743.
  8. Rimmer JH, Rowland JL, Yamaki K. Obesity and secondary conditions in adolescents with disabilities: addressing the needs of an underserved population. J Adolesc Health. 2007;41:224-229.
  9. World Health Organization (2022, October 5) Fact Sheets- Physical Activity. Accessed 03/17/2023. 
  10. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd Ed. (Online). Retrieved from: Accessed 03/17/2023.
  11. Jean E. Polichino, OTR, MS, FAOTA: “Implementing RtI for School-based PTs & OTs: Supporting Struggling Learners. Presented July 2018. Accessed 03/17/2023. 
  12. The Academy of Pediatric Physical Therapy (2012). Fact Sheet Resource- “FAQs on Response to Intervention (Rtl) For School-based Physical Therapists” Accessed 03/17/2023. 

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