The SPOQ was created in 2015 by the authors to investigate the out-of-school athletic behavior of children and adolescents aged six to 18. The item pool includes questions based on psychotherapy criteria such as therapeutic connection, resource activation, and problem-solving (29). We expected that physical activity with more of these features would be more useful for mental health. The item pool was constructed by a team of sports scientists, psychiatrists, and psychotherapists, taking into account the literature stated in the introduction. Two versions were designed, the parental and the self-report version (from ten years old). The data were collected with the German versions of the questionnaire. Both German versions were translated into English by a bilingual American and were translated back by a bilingual German. In the first version, thirty-nine percent of the questions regarding the importance of the relationship with the trainer and daily coping through physical activity were left unanswered. These patients were returned their unfilled SPOQ one day after submission to complete the missing data. Most patients indicated that they had overlooked the questions, which is why the layout was optimized after 2 months of data collection.

The SPOQ consists of five sections (see attachment). The first section records the frequency of physical activity in the last six months in hours per week. There is also a free field to write down another frequency. Besides, there is a statement that can be marked with a cross, indicating that the respondent has never been physically active.

The second section records up to three types of physical activity that have been regularly exercised at least in the last six months. Also, the location where the physical activity is performed is recorded. There are three answer options possible: Sports Club, Gym and Other. On a Likert scale from “Not at all” (1) to “Very much” (6), participants specify their enjoyment of this type of activity. The numbers 2–5 on the Likert scale are without description.

The third section is designed as 2 statements and asks for a currently important relationship with at least 1 trainer and the current daily coping through physical activity. Again, answers are recorded using a Likert scale from 1 to 6.

The fourth section records up to five types of activity ever tried during the participant's lifetime. Also, the duration, expressed in months, is recorded. The enjoyment of types of activities is measured as in the second section.

Section Five asks for the subjective assessment of the physical fitness of the 163 patients to measure their athletic self-efficacy. This assessment is done via an interval scale from “Not physically fit” (0) to “Very physically fit” (9). The numbers 2–8 are without description.

It takes about 5 min to complete the SPOQ. The parental and self-report versions of the SPOQ can be used for free disposal. The German versions can be requested from authors.

The type of mental disorder was diagnosed by trained clinical psychologists or psychiatrists according to ICD-10 (30), subject to the regulations. For this purpose, semi-structured clinical interviews were used in line with Sheehan et al. (31). The diagnoses were confirmed with disorder-specific questionnaires if this was necessary to complete the symptom profiles.

From October 2015 to October 2017, questionnaires were send to 450 patients, of whom were registered as an inpatients or outpatients at the Child and Adolescent Psychiatry from the ages of 6.0–18.0 years. One hundred and sixty-eight inpatients received the self-report SPOQ, while 282 parents of outpatients received the parental version as part of the general registration process. It was explicitly ensured that only 1 SPOQ was available for each patient. Since the questionnaire was obligatory for inpatients, all 168 questionnaires were received back from the self-report. Two inpatients without a diagnosed disorder were excluded. One hundred and thirty-five questionnaires from the parental version were excluded because of no return or no diagnosed mental disorder. All included questionnaires covered a total of 313 patients with a mental disorder in the evaluation, 166 inpatients (self-report), and 147 outpatients (parental version). The concrete division and response rate are clearly shown in a flow chart (Figure 1).

Data were collected and managed using REDCap research electronic data capture tools (32). Since the study design was strictly exploratory, we did not use inference statistics but kept analyses on a descriptive level. The statistics were calculated with R 3.6.2 (33). The flowchart to report patient selection, Figure 1, was made using the package “DiagrammeR” (34). Boxplots, line plots, and the heatmaps to show sports preferences in boys and girls were generated with the package “ggplot2” (35).

Boxplots, Figures 2–6, were generated by diagnosis group and type of questionnaire for the frequency of physical activity, enjoyment of physical activity (related to the first-mentioned physical activity), the importance of a trainer, daily coping through physical activity, and subjectively perceived physical fitness. Therefore, N counts for the number of considered cases and NA for the number of missing values. Two line plots, Figures 7, 8, were generated to show the mean of subjectively perceived physical fitness by age, respectively frequency of physical activity, separated for gender and type of questionnaire. Six patients reported more than 10 h of physical activity per week in the self-report questionnaire. We assumed that corresponding patients were not able to estimate the actual time. Therefore, the following data were considered missing. To present the first-mentioned type of physical activity for girls, and boys heatmaps, Figures 9, 10, were created. Therefore, the mentioned types of physical activity were later aggregated into six branches by the authors. The weight, the percentage of the mentioned type in the corresponding diagnosis group, was shown through gray gradation. Table 1 shows the main characteristics of the data.

An ethics vote with the number 837.515.15 (10833) from the ethics review board of the Landesärztekammer Rheinland-Pfalz exists for this study. Following the advice of the ethics review board, we did not assess individual informed consent statements since the procedure was fully integrated in our clinical routine assessment.

A total number of 313 patients could be taken into account. They could be grouped into eight diagnostic categories according to the predominant mental disorder: Depression (DEPR) N = 72, median age = 15.1, eating disorders (ED) N = 24, median age = 15.6, attention deficit hyperactivity disorder (ADHD) N = 66, median age = 10.4, phobia/anxiety disorders (P/AD) n = 22, median age = 15.7, obsessive compulsive disorder (OCD) n = 11, median age = 16.1, stress/adjustment disorder (S/AD) n = 46, median age = 12.3, oppositional defiant disorder (ODD) n = 16, median age = 13 and other mental disorders (OMD) n = 56, median age = 11.9. Diagnostic group assignment was done by the primary psychiatric diagnosis on the first axis of the multi-axial diagnostic system (ICD-10) irrespectively from comorbidities.

In the inpatient group (self-report), DEPR was the predominant disorder, accounting for 33% of cases. The median age was 15.1 years, and 58% were female. In the outpatient group (parental version), ADHD was the leading disorder with 35% of the cases. The median age was 10.6 years, and 66% were male.

The complete main characteristics, overall and subdivided by questionnaire type, can be found in Table 1.

On average, patients with ED stated a higher frequency of physical activity than the other diagnosis groups (Figure 2). In all diagnostic groups, high enjoyment of physical activity was reported with medians between 5 and 6, however, with a wide variety in the group of patients with DEPR (Figure 3). The importance of a trainer was rated very low with a median of 1 in almost all groups. Only patients with ADHD and ODD and parents of children with ADHD rated it higher at the median (Figure 4). In the assessment of daily coping through physical activity, there was a wide range. In the self-report, patients with ED and OCD gave the highest scores and patients with DEPR and P/AD the lowest scores, on average (Figure 5). There is a discrepancy between self-report and parental version regarding subjectively perceived physical fitness. In the external assessment, higher values were indicated, on average. Physical fitness was rated particularly low in the self-assessment of patients with DEPR and P/AD (Figure 6).

If we look at the mean values of subjectively perceived physical fitness as a function of age, the parental questionnaire for girls shows only minor deviations (mean values between 5.0 and 6.6). For boys, the mean value in the parental assessment varies similarly to the girls between 5.0 and 6.7, but with a dip at the age of 14 to 15 years (mean value 3.7). In self-perception, physical fitness at the age of 10–11 years is initially rated good on average by both genders (mean value 7.4 for girls and 6.3 for boys). However, at ages 12–13 for girls and 14–15 for boys, the mean drops sharply to 3.4 and 4.5, respectively (Figure 7). Let us now consider the dependence of subjectively perceived physical fitness on the frequency of physical activity. In the parent ratings, the average perception of fitness increases steadily with frequency for both genders (from 4.4 to 7.8 for boys and 4.9 to 8.3 for girls). However, gender differences are evident in self-perceptions. While girls’ perceived fitness also increases on average with frequency (from 3.3 to 4.9), there seems to be no clear relationship for boys. With no or little physical activity, they rate their fitness on average considerably better than girls (mean 5.0 for boys vs. 3.3 for girls in the no physical activity group). Compared to the parental assessment, the self-assessment is generally worse, except for the assessment of the boys in the group without physical activity (Figure 8).

The heatmaps revealed that 33% of male patients were tied to ball sports, while 32% of all male patients did not participate in sports (Figure 9). Among female patients, 32% were tied to aesthetic sports, while 24% of all female patients did not participate in sports (Figure 10).

The return of the self-report SPOQ was 100% due to the treatment obligation for inpatients. The individuals needed between five and ten minutes for form completion. The parental-version was an addition to the registration form. The first section was missing 35% of the information, the second section 33%, the third section 54%, the fourth section 37%, and the last section was missing only 6%. We concluded that after completing the 12-page registration form, parents most likely did not want to engage in the specific topic of physical activity. The fewest missing items were in the last section, as this was probably the quickest to answer and, as the last question, had a higher visual focus.

This study has several limitations: The study design is exploratory in nature. However, this is feasible for developing new instruments in new fields. Additionally, the SPOQ was cross-validated with the Strengths and Difficulties Questionnaire (SDQ) (46) and the EMI-2 (27), but not with other sport-specific instruments. Further, we did not formally test the questionnaire for reliability, which should be addressed in additional studies.

Inpatients and outpatients were not equally distributed between self-rating and parent rating, which limits the interpretation of the data since outpatients usually have lower scores on psychopathology as compared with inpatients. Nevertheless, the observed trend seem to be quite robust against the above mentioned confounding. Thus, the questionnaire evaluated in a population of 313 patients serves to generate hypotheses in an area with highly unmet research needs.

Only a few studies examine the athletic behavior of children and adolescents with mental disorders so far. A study with 1.2 million young adults showed that not exercising leads to a higher mental health burden (4). Our results revealed deficits in the frequency of physical activity per week. Almost 1 in 3 patients currently is not physically active (Figures 9, 10). Achieving an appropriate physical activity in children and adolescents should therefore be the primary task of sports therapy. The SPOQ is freely available for other institutions. The next step should be an efficacy study measuring the effects of a sports therapy program and testing hypotheses generated here.