Look Into `Rx-ercise`

The family of three sat at the table, looking from one to another, then at me. “We are worried about him,” the anxious mother admitted to me. “Since he's gotten into middle school he's different. He doesn't talk to us; he spends most of his time alone on the computer, or playing video games.”

The harried-looking father added, “We've tried everything, but he keeps saying that if his grades are OK, we should leave him alone.” The mother interjected, “He doesn't help around the house, either,” adding a long sigh.

I looked at Kyle and asked, “What do you think?” He shrugged his shoulders. “It doesn't matter to me,” he said. No matter what I do, it's always the same thing. They don't care, I don't care; it's all just … boring.” All three had a dejected look.

This is hardly an unusual scenario. Children today have fewer opportunities for informal socialization, with neighborhood sports giving way to television and video games. Increased stress from school and demands from one's peer group often clash with family responsibility and values. What is different about this family is the approach it soon embarked upon to change the apathy, the blaming, and the feelings of helplessness. As part of my services, they were mandated to incorporate daily physical exercise as a family ritual.

This engagement in exercise, which took place over a one-month period, became an integral part of the family's program, which focused on reconnecting the family members and improving the home's emotional atmosphere. I employ this same strategy with students referred to my social skills classes. Prior to engaging them in the class, we stretch and take a 15-minute brisk walk. The youths are not always keen on it before, but when we return to the class, we are all ready to get to work.

Since I have incorporated exercise into my routines, I have observed that both the students in my classes and my private clients make better decisions, have more positive energy, and enjoy better social contacts. Why does adding exercise to a therapeutic approach yield results? The answer lies in the brain's production of serotonin during exercise.

A new twist on prevention

The “Just Say No” philosophy and abstinence-only methods have fallen short in keeping kids off drugs. Fear tactics and threats of mandatory drug testing for student athletes have served to alienate those likely to try drugs, and has kept those who already have experimented out of the very programs that could help them identify alternative pro-social behaviors. Proactive alternatives require substituting a positive behavioral choice for the negative one. Mandating exercise removes choice related to engagement in exercise, but still allows some indepen-dence in selecting the activity in which to participate.

As important as the exercise that my clients receive is their examination of emotions and capacity before and after the activity. After consistent, repeated engagement, the student or client can construct a pattern of increased well-being, higher levels of concentration, and improved physical ability. This empowers that person to re-create this heightened state independently.

Today's schools have focused their attention, and their reward system, on achievement on standardized tests. This has been accomplished in some districts by cutting back on or eliminating recess, gym, and after-school, noncompetitive sports. Families are working harder than ever to provide for children's multiple 21st century necessities, which often requires both parents to work multiple jobs. The young child's day is structured around school, aftercare (or TV), dinner, homework, and bed. Time for parents and children to “play” together has all but disappeared. In its place, children learn to expect a high level of entertainment supplied to them—entertainment that alters the brain's chemical makeup.

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Table 1. Intervention for at-risk families

• In addition to your normal advice, prescribe an activity for the first week that is non-negotiable, such as walking.

• Have family members log in when they do the exercise, describing how they feel before and after.

• Discuss the outcome with the family and either continue with the same program or allow the family to initiate a choice of group activity. Have members continue the log.

Advantages for the family:

• There is no cost for filling this prescription.

• The exercise requirement forces the family to alter schedules, demonstrating the activity as a daily priority.

• As serotonin levels rise as a result of the activity, a feeling of well-being among family members will provide instant feeling of reward.

• Serotonin levels do not fall precipitously, so the positive feeling provides energy after the activity is done.

• The family has designated time together.

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Table 2. School-based intervention

• In-school suspension could require participation in a physical activity and an evidence-based decision-making program to address the unwanted behavior.

• Evaluate the efficacy of an out-of-school suspension (exclusion) and explore the possibility of integrating a policy of mandated participation in a designated evidence-based behavioral program coupled with an in-school exercise program.

• Require 30 minutes per day of physical activity.

Advantages for the school:

• Physical activity is directly linked to youths' positive growth and development.

• Exercise programs have been documented to reduce urges for alcohol and tobacco.

• Students who engage in physical activity are more likely to have positive emotional and social development.

• Schools will be proactive in developing physically fit, competent, critical thinkers—even among their high-risk students.

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Table 3. Intervention for private-practice client

• Begin a session with a short period of exercise (a brisk walk, jumping jacks, running in place, jump rope). If this is a session conducted routinely, time the activity for physical competence, and observe over time how the level of ability changes.

• Encourage or mandate involvement in a daily physical activity.

• Respect the struggle the client faces to engage in the activity, and assist the client to choose an activity that reflects the client's strengths.

Advantages for the client:

• Heightened capacity to focus after exercise.

• Promoting a sense of competence in participating in an activity resulting from repetitive engagement.

• Developing an area of physical competence, which can evolve into a social networking connection.

• Encourages self-direction as client gains capacity to relieve stress; promotes a sense of well-being.

Then these children enter adolescence, and the rules change again. They see less parental engagement and fewer structured activities, but not fewer demands, and their brains are wired for high-yield entertainment. Alcohol, tobacco, and other drug use in this population often occurs in order to self-medicate depression, cope with anger, and moderate feelings of low self-esteem. Stress also can precipitate and exacerbate depression, decreasing energy levels and concurrently producing a drop in the level of serotonin,1 which is responsible in part for activation of brain pleasure centers.2 With repeated exposure to the negative environment, a further decrease in the naturally circulating level of serotonin occurs.

Why should exercise be mandated? Exercising requires intention and a level of decision making that students, families, and others who are feeling depressed may be unable to self-initiate. Parents of teens do not routinely consider factoring in 30 minutes a day to spend in a physical activity with their child, and it is an unusual teen who will request this from a parent. When a counselor or physician includes exercise as a structured part of the intervention, the responsibility of intention is no longer on the client, and the activity becomes a new, prescribed ritual. This approach alters the typical “stages of change” progression from precontemplation, contemplation, preparation, action, and maintenance to that of action, contemplation, preparation, adjustment, and maintenance. It can be seen as a jump start to positive, proactive change.

The natural high

Serotonin affects multiple functions of the body, including appetite, sleep, memory/learning, temperature regulation, cardiovascular function, muscle contraction, and endocrine system regulation.3 Serotonin and endorphins are part of the endogenous opioid system, acting as natural reinforcers to self-regulate toward increased activation of the brain's pleasure centers.2 Beta-endorphin, a chemical released from the pituitary gland, has been credited with producing a euphoric feeling after engagement in physical activity, affording individuals the reinforced feeling of well-being without use of drugs or alcohol. Routine physical exercise, or engagement in an activity that burns calories, can also increase and maintain high levels of serotonin in the brain.

Increasing mandated/prescribed exercise in schools, through morning walks or other forms, can help youths experience the thrill of the “high” without the risk of substance use. It can support the development of self-worth based upon goal achievement. A school program that focuses on physical health and trains students accordingly will teach students how to induce a natural state of well-being, increase opportunities to socialize without using substances, teach self-efficacy, and increase students' perception of environmental and self-control.2

With this knowledge it is a natural crossover to offer increased physical activity to students, families, and clients who are known to be at high risk for depression and addiction (tables 1-3), helping separate them from the culture of drugs and introducing them to lifelong physical fitness.

References

1. Karran K, Hafen B, Frandsen K, et al. Mind/Body Health: The Effects of Attitudes, Emotions and Relation-ships. San Francisco:Benjamin Cum-mings; 2002.
2. Read J, Brown R. The role of physical exercise in alcoholism treatment and recovery. Prof Psychol: Research and Prac 2003; 34:49-56.
3. Byrd A. Serotonin and its uses. Serendip 1999 (Bryn Mawr College).