High School Sports During the CoVID-19 Pandemic: The Impact of Sport Participation on the Health of Adolescents

23 Context: During the fall of 2020, some high schools across the US allowed their students to 24 participate in interscholastic sports while others cancelled or postponed their sport programs 25 due to concerns regarding CoVID19 transmission. It is unknown what effect this has had on the 26 physical and mental health of student athletes. 27

Identify the impact of playing a sport during the CoVID19 pandemic on the health of 28 student athletes. 29 Design: Cross-sectional study. 30 Setting: Sample recruited via email. 31 Patients or Other Participants: 559 Wisconsin high school athletes (age=15.7+1.2 yrs., 32 female=44%) from 44 high schools completed an online survey in October 2020. A total 33 of 171 (31%) athletes played (PLY) a fall sport, while 388 (69%) did not play (DNP). 34 Main Outcome Measure(s): Demographics included: sex, grade and sports played. 35 Assessments included the General Anxiety Disorder-7 Item (GAD-7) for anxiety, Patient Health 36 Questionnaire-9 Item (PHQ-9) for depression, the Pediatric Functional Activity Brief Scale 37 (PFABS) for physical activity, and the Pediatric Quality of Life Inventory 4.0 (PedsQL) for quality 38 of life. Univariable comparisons between the two groups were made via t-tests or chi-square 39 tests. Means for each continuous outcome measure were compared between the groups by 40 ANOVA models that controlled for Age, Sex, Teaching method (Virtual, Hybrid, or In-person), 41 and the % of students eligible for free lunch. 42

PLY group participants were less likely to report moderate to severe symptoms of 43 anxiety (PLY=6.6%, DNP=44.1%, p<0.001) and depression (PLY=18.2%, DNP=40.4%, 44 p<0.001). PLY athletes reported higher (better) PFABS scores (mean: [95%CI]), 45 (PLY=23.2[22.0,24.5], DNP=16.4[15.0,17.8], p <0.001) and higher (better) PedsQL total scores 46 (PLY=88.4[85.9,90.9], DNP=79.6[76.8,82.4], p <0.001). 47 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint

Adolescent athletes who played a sport during the CoVID19 pandemic 48 reported fewer symptoms of anxiety and depression, as well as higher physical activity and 49 quality of life scores compared to adolescent athletes who did not play a sport. 50 51 Key words: Public health, CoVID-19, Youth, Depression 52

word count: 300 53 Manuscript word count: 3931 54 55 Key points: 56 1) High school students who played a sport during the CoVID-19 pandemic in the fall of 57 2020 were less likely to report anxiety and depression symptoms than athletes who did 58 not play a sport. 59 2) High school students who played a sport during the CoVID-19 pandemic in the fall of 60 2020 reported higher physical activity and quality of life scores compared to high school 61 athletes who did not play a sport. 62 3) Participation in high school sports may have significant physical and mental health 63 benefits for US adolescent athletes during the CoVID-19 pandemic. 64 65 66 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint

67 An estimated 8.4 million US high school students participate in interscholastic athletics 68 each year.1 Adolescent sport participation is recognized to have profound positive influences on 69 the health and well-being of adolescent students as evidenced by higher academic 70 achievement, greater levels of physical activity and decreased levels of anxiety and depression 71 compared to students who do not participate in athletics.2-6 Additionally, research has shown 72 that high school sport participation is one of the most important factors for life-long physical 73 activity and health.7-12 74 During the spring of 2020, CoVID-19, the disease caused by the novel SARS-CoV-2 75 coronavirus, reached pandemic levels in the US. Schools were closed and high school sports 76 were cancelled to slow the spread of the disease. Experts have suggested that while necessary 77 to slow the community spread of the virus, the CoVID-19 mitigation strategies may nonetheless 78 have profound mental and physical health consequences for students.13-18 For example, experts 79 have indicated that the CoVID-19 pandemic will make it more likely that youth will engage in 80 sedentary activities and increase the prevalence of childhood obesity.19-23 81 Research has also shown that females, older athletes, team sport participants and 82 athletes from areas with higher levels of poverty reported more symptoms of anxiety and 83 depression, as well as lower levels of physical activity and health related quality of life (HRQoL) 84 in May 2020 during the widespread shutdown.24 Another study reported that adolescent 85 athletes in May 2020 reported more mental health symptoms, as well as lower physical activity 86 and HRQoL scores compared to similar samples of adolescent athletes prior to the CoVID-19 87 pandemic. 25 88 During summer 2020, school districts across the US made determinations regarding 89 whether to allow interscholastic sports to resume based on input from various health and sport 90 associations while recognizing that various sports would possibly pose varying risks for the 91 transmission of CoVID-19 depending on the nature of the sport. 26-28 During fall 2020, fourteen 92 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint states in the US (27%) allowed full fall sport participation, and 30 states (60%) allowed modified 93 sport participation, with the remaining 6 states and the District of Columbia (13%) not allowing 94 any interscholastic athletic participation.29 In addition, within each state that allowed full or 95 modified participation, individual school districts were allowed to determine which sports they 96 offered. Some schools allowed all their fall sports, while other districts sponsored a portion of 97 their sports while postponing or cancelling other sports.29 98 A drawback to the recent studies regarding the impact of CoVID-19 on the health of 99 adolescent athletes is the difficulty discerning if the health changes reported were primarily due 100 to restrictions on sport participation or due to other factors such as the lack of in-person school 101 attendance, the increased economic uncertainty or concerns about contracting the SARS-CoV-2 102 coronavirus. There is a need, therefore, to determine if sport participation independently affects 103 the health of adolescent athletes during the CoVID-19 pandemic. 104 We are not aware of research to date that has specifically documented how sport 105 participation during the CoVID-19 pandemic affects the mental and physical health of 106 adolescent athletes. This information may assist sports medicine providers, school 107 administrators and health care policy experts with implementing strategies to improve the short-108 term and long-term mental and physical health of adolescent athletes in the months and years 109 to come as we transition from the CoVID-19 pandemic.30,31Therefore, the purpose of this study 110 was to measure the impact of sport participation on the mental and physical health of 111 adolescent athletes during the CoVID-19 pandemic. To measure this impact, we compared 112 self-report data on anxiety, depression, physical activity and HRQoL for a cohort of athletes who 113 played a sport with a similar cohort of athletes who did not play a sport in Wisconsin during fall 114 2020. We hypothesize that adolescent student athletes who played a sport will report 115 significantly better mental health, physical activity and HRQoL than athletes who did not play a 116 sport. 117 118 . 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119 This study was approved by the University of Wisconsin Health Sciences Institutional Review 120 Board in September 2020. 121 Wisconsin allowed individual school districts to determine whether to sponsor 122 interscholastic teams during the fall of 2020.32 The traditional fall sports (prior to the CoVID-19 123 pandemic) offered in Wisconsin high schools included cross country, football, volleyball (boys 124 and girls), golf (girls), swim (boys and girls), tennis (girls), and soccer (boys). Approximately 125 305 (60%) of the 510 schools opted to sponsor teams for all fall sports, while 104 (20%) opted 126 to offer a limited number of sports, and the remaining 101 (20%) offered no fall sports at their 127 schools. 128 The sports offered most often by schools included boys’ and girls’ cross country (78%) 129 and girls’ golf (72%). The sports offered least often included football (54%), boys’ soccer (50%) 130 and girls’ swimming (50%).33 131 Wisconsin high school athletes (male and female, grade: 9–12, age: 13-19) were 132 recruited to participate in the study by completing an anonymous online survey in October 2020. 133 Emails were sent to athletic trainers and coaches from 44 schools to solicit their athletes to 134 participate in the study. The survey included 69 items and included a section to solicit 135 demographic information, followed by 3 validated instruments used to measure physical activity, 136 mental health and HRQoL in adolescents. Demographic responses regarding the participant’s 137 age, grade and school name, as well as any high school sport in which they competed during 138 the fall and planned to compete in if the sport was offered by the school during the winter and 139 spring of the 2020/21 school year were collected. The remainder of the survey consisted of an 140 assessment of mental health, physical activity level and HRQoL. 141 Mental health 142 The General Anxiety Disorder-7 Item (GAD-7) and Patient Health Questionnaire-9 Item 143 (PHQ-9) surveys were used to evaluate anxiety and depression symptoms, 144 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint respectively.34 The questionnaires ask participants to rate the frequency of anxiety or 145 depression symptoms experienced in the past two weeks. The GAD-7 scale is a valid, 146 reliable and sensitive measure of anxiety symptoms and is able to differentiate between 147 mild and moderate GAD in adolescents.35 Scores range from 0-21 with a higher score 148 indicating increased anxiety. In addition to the total score, GAD-7 categorical scores of 0–149 4, 5-9, 10–14, and 15–21 correspond to no, mild, moderate, and severe anxiety 150 symptoms, respectively.36 The PHQ-9 is a 9-item screening questionnaire for depression 151 symptoms with scores ranging from 0-27 with a higher score indicating a greater level of 152 depression. The PHQ-9 has demonstrated high sensitivity and specificity for depression 153 screening in adolescent patients aged 13 to 17 years.37 In addition to the total score, 154 PHQ-9 categorical scores of 0–4, 5–9, 10–14, 15–19 and > 20 correspond to minimal or 155 none, mild, moderate, moderately severe and severe depression symptoms, 156 respectively.38 157 Physical Activity 158 Physical activity level was assessed with the Hospital for Special Surgery Pediatric 159 Functional Activity Brief Scale (PFABS). This validated 8-item instrument was designed to 160 measure the activity of active children between 10 and 18 years old for the past month. 161 Scores range from 0 to 30 with a higher score indicating greater physical activity.39,40 162 Health Related Quality of Life 163 HRQoL was measured with Pediatric Quality of Life Inventory 4.0 (PedsQL). The 23-item 164 PedsQL questionnaire assesses HRQoL for the previous 7 days. A physical summary score 165 (physical function) and psychosocial (a combination of emotional, social and school function) 166 summary score, as well as the total PedsQL scores can be calculated, with scores ranging from 167 0 to 100 and a higher score indicating greater HRQoL. The PedsQL has been validated for use 168 in children ages 2 to 18.41,42 169 Statistical analyses 170 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint Statistical analyses were performed for participants who provided a valid, complete survey. 171 Participants were excluded if they did not complete the entire survey, were not in grades 9 -12, 172 or indicated they did not plan to play interscholastic sports at their school. Participants’ 173 demographic variables were summarized (mean [SD] or N [%]) overall and by study participants 174 for sex and fall sport participation. Participants were classified as playing a fall sport (PLY) or 175 as not playing a fall sport (DNP). 176 The characteristics for the schools attended by the participants included the type of 177 instructional delivery method and the % of students eligible for free or reduced lunch. The type 178 of instructional delivery method (online only, in person or hybrid [a combination of in person and 179 online]) was determined by reviewing information on each school’s website. The % of the 180 students eligible for free or reduced lunch for each school was obtained from the publicly 181 available data available online through the Wisconsin Department of Public Instruction.43 182 Means (mean, [95%CI]) for each continuous outcome measure were reported and 183 compared between fall sport participation groups by ANOVA models that controlled for age, sex, 184 type of teaching method and % of students who were eligible for free or reduced lunch. Ordinal 185 logistic regression models were used to estimate the percentages of level of depression (PHQ-186 9) and anxiety (GAD-7) by group. These models controlled for the same covariates listed 187 above. All tests had a 0.05 significance level. Analyses were conducted in R for statistical 188 computing version 3.5. 189 190

191 A total of 559 high school athletes (age = 15.7+1.2 yrs., female = 43.6%, male = 56.4%) 192 completed the survey. Due to the convenience sampling design, information regarding the 193 response rate was unavailable. Three hundred eighty-eight (69.4%) participants reported they 194 did not play (DNP) an interscholastic sport at their school, while 171 (30.6%) reported they did 195 play (PLY) an interscholastic sport. The majority (n = 257, 66.2%) of the participants in the 196 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint DNP group attended schools that cancelled all fall sports, and 91.4% (n = 355) attended 197 schools that delivered all instruction online. The % of students eligible for free or reduced lunch 198 (mean + SD) for the schools was 25.9 + 10.3%. One hundred forty-eight (86.5%) of the 199 participants in the PLY group attended schools that offered all fall sports, with 40.3% (n = 69) 200 attending school in-person. Participants in the PLY group were most likely to report playing 201 volleyball (n = 66, 38.6%), football (n = 53, 31%) and boys’ soccer (n = 22, 12.9%). Participants 202 in the DNP group most commonly reported that they had intended to play football (n = 160, 203 41.2%), and volleyball (n = 51, 13.1%). Seventy nine participants (20.4%) did not play a fall 204 sport but intendede to play a high school winter or spring sport. A summary of the participant 205 characteristics is found in Table 1. 206 Mental Health 207 The PLY participants were more likely to report GAD-7 symptom scores of 0 to 4, indicating no 208 or minimal anxiety (PLY = 80.1% vs DNP = 26.4%), whereas the DNP athletes were more likely 209 to report scores of 10 to 21, indicating more moderate to severe anxiety than the PLY group 210 (DNP = 44.1% vs PLY = 6.6%) as shown in Figure 1. The PLY participants were more likely to 211 report PHQ-9 scores 0 to 4, indicating no or minimal depression (PLY = 57.7% vs DNP = 212 31.3%), whereas the DNP athletes were more likely to report scores of 10 to 27, indicating more 213 moderate to severe depression than the PLY group (DNP = 40.1% vs PLY = 18.2%) as shown 214 in Figure 2. The DNP group reported a higher (worse) GAD-7 score (mean, [95%CI]) than the 215 PLY group (8.4 [7.2, 9.5] vs. 3.2 [2.2, 4.3], < 0.001) as well as a higher (worse) PHQ-9 score 216 than the PLY group (7.6 [6.4, 8.8] vs. 3.9 [2.8, 4.9], < 0.001). The total GAD-7 and PHQ-9 217 scores for both groups are found in Table 2. 218 Physical Activity and HRQoL 219 Physical activity, as measured by PFABS scores (mean, [95%CI]) for the PLY group were 41% 220 higher (better) than the DNP group (PLY = 23.2 [22.0, 24.5] vs. DNP = 16.4 [15.0, 17.8], p < 221 0.001). The PFABS scores for both groups are found in Table 2. The HRQoL for athletes in the 222 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint PLY group was higher (better) than the DNP athletes. Specifically, the PedsQL physical health 223 summary scores for the PLY group were higher than the DNP group (PLY = 92.3 [90.1, 94.4] vs. 224 DNP = 86.5 [84.1, 88.9], p = 0.004), as was the psychosocial health summary score (PLY = 225 86.4 [83.3, 89.4] vs. DNP = 75.9 [72.5, 79.3], p < 0.001) and the total PedsQL score (PLY = 226 88.4 [85.9, 90.9] vs. DNP = 79.6 [76.8, 82.4], p < 0.001). The PedsQL scores for both the PLY 227 and DNP groups are found in Table 2. 228 229

230 To our knowledge, this is the first study to compare the mental health status, physical activity 231 level and HRQoL between high school athletes who were or were not able to participate in 232 interscholastic sports during the CoVID-19 pandemic. This study builds on prior research 233 demonstrating the dramatic changes in physical and mental health following the cancellation of 234 high school sports in the spring of 2020. 24,25 A limitation of the prior studies is the difficulty 235 discerning if the health changes reported were primarily due to the restrictions on sport 236 participation or the result of other factors such as sex, age, socioeconomic status or the lack of 237 in-person school attendance. After controlling for grade, sex, school instructional delivery 238

and the % of students qualifying for free and reduced lunch, our findings demonstrate 239 that athletes who did not play interscholastic sports experienced significantly worse symptoms 240 of anxiety and depression, lower levels of physical activity and worse HRQoL compared to 241 athletes who did not play sports in fall 2020. This suggests that the re-initiation of sport 242 participation may result in significant improvements in mental and physical health for 243 adolescents during the CoVID-19 pandemic. 244 245 Mental Health 246 Athletes that played high school sports in the fall of 2020 demonstrated significantly lower 247 symptoms of anxiety and depression than those athletes who did not play a sport. Specifically, 248 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint athletes in the DNP group were more than 6 times as likely to report moderate to severe 249 symptoms of anxiety and more than twice as likely to report moderate to severe symptoms of 250 depression even after adjusting for age, sex, type of school instruction and % of the students 251 qualifying for free and reduced lunch. This seems to suggest that while PLY athletes continue 252 to demonstrate slightly higher levels of depression and anxiety than historical values, the mental 253 health burden among DNP athletes is considerably worse.25 In fact, the DNP group 254 demonstrates levels of moderate to severe anxiety and depression symptoms similar to those 255 identified in a nationwide sample for adolescent athletes in May 2020 (anxiety = 36.7%, 256 depression = 27.1%).25 Given the adolescent mental health crisis that existed prior to the onset 257 of CoVID-19, and the known mental health benefits of sport participation, this data seems to 258 suggest that adolescent athletes who are unable to return to sports may be at a significantly 259 greater risk for mental health issues. 260 Experts have pointed out that the CoVID-19 pandemic has negatively impacted the 261 mental health of youth and may be related to decreased socialization, increased family strain, 262 and reduced access to support services.13,44 As such, we recognize that factors beyond sport 263 participation such as the ability to attend school in-person may contribute to adolescent mental 264 health. In addition, depression and anxiety in adolescent athletes have been shown to be 265 related to sex and grade in school. Nonetheless, after controlling for the type of school 266 instructional delivery (online, in-person or hybrid), age and sex, sport participation remained 267 significantly associated with large improvements in anxiety and depression symptoms. 268 Therefore, we can reasonably assume that the increased symptoms we identified among the 269 DNP participants are at least partly attributable to the lack of sport participation. 270 Our results also support previous research that has demonstrated that sport participation 271 improves the mental health of youth and adolescents.45-48 A recent study during the early stages 272 of the CoVID-19 pandemic found that 11.4% of student athletes who were unable to participate 273 in sports reported moderate to severe levels of depression symptoms, which was four times 274 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint higher than the rate (2.8%) reported by student athletes prior to the CoVID-19 pandemic.25 This 275 supports the premise that sport participation may represent an important mechanism to improve 276 the mental health of adolescents as society continues to attempt to mitigate the impact of 277 CoVID-19 in the months and years to come. 278 Physical Activity 279 Our study demonstrates that during the CoVID-19 pandemic, high school athletes who 280 played high school sports had a significantly higher level of physical activity than athletes who 281 did not play a sport. Notably, the total PFABS score for the PLY group was similar to scores 282 (mean, [95%CI]) for healthy high school aged athletes prior to CoVID-19 (24.7 [24.5,24.9]).25 283 Similarly, the PFABS scores for the PLY group were similar to scores for adolescents reported 284 by Donovan (23.8 + 5.3) as well as to normative data reported by Fabricant (20.2 + 7.2).40,49 285 Further, the PFABS scores for the PLY group were nearly twice as high as those reported by 286 high school athletes unable to play any sports in May 2020 (12.1 [11.7, 12.5]). Finally, the DNP 287 group reported scores that were 25% and 45% lower than scores reported by Fabricant and 288 Donovan, respectively.40,49. This may indicate that by being able to play a sport, these athletes 289 mitigated, to some degree, the low level of physical activity reported during the initial onset of 290 the CoVID-19 pandemic. 291 Physical activity is known to have a beneficial effect on a wide range of health outcomes 292 in adolescents, including sleep, academic success, well-being, and mental health.5,6,9,12,45-48,50 293 Therefore, it is possible that the identified decrease in mental health in the DNP group may be 294 at least partly due to the removal of the positive effects that physical activity has for 295 adolescents. In addition, childhood obesity was a public health crisis before CoVID-19, and is 296 projected to become worse due to the pandemic.19,21,51 Decreased physical activity in 297 adolescents may also have long-term negative effects and implications in terms of increased 298 risk for obesity and cardiometabolic disease if these levels remain low for prolonged periods.52 299 Chronically low levels of physical activity may also compound the mental health consequences 300 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint of the current crisis and increase the risk 46,50 Returning high school sport opportunities is a 301 complex issue and requires careful consideration. Stakeholders should consider the promotion 302 of physical activity for adolescents a top priority during the CoVID-19 pandemic. 303 Health Related Quality of Life 304 HRQoL is a measurement of well-being, and well-being has been associated with self-perceived 305 health, longevity, and healthy behaviors.53 We found that adolescent athletes who had returned 306 to sport in fall 2020 reported significantly higher HRQoL than those athletes unable to return to 307 sport. This is consistent with prior studies that have shown that individuals with increased 308 physical activity and/or interscholastic sport participation report higher HRQoL scores compared 309 to inactive adolescents and high school non-athletes.54-57 Therefore, it is not surprising that 310 HRQoL scores for the PLY athletes were higher than the DNP athletes. 311 The total PedsQL scores reported here for the PLY athletes are significantly higher than 312 scores (mean [95%CI]) reported by high school athletes when sports were cancelled (76.7, 313 [76,0, 77.5]). 24 Further, the total PedsQL scores reported by the PLY athletes are similar to 314 scores (mean + SD) recorded in 14 to 18 year-old athletes prior to the pandemic by Lam (89.4 + 315 9.6 to 90.5 + 10.2), Snyder (89.5 + 10.1 to 93.6 + 7.6) and McGuine (90.9 [90.5,91.3] 25,55,56 The 316 increased scores for the PLY group may also be attributed to aspects of sport participation 317 beyond the opportunity for structured physical activity such as goal setting, emotional support 318 and social interaction with teammates. This may suggest hat by playing a sport, adolescents 319 may be able to return to a “normal” or “expected” level of HRQoL similar to those recorded prior 320 to the CoVID-19 pandemic. 321 On the other hand, the total PedsQL scores for the DNP athletes were lower than 322 reported Peds QL scores in non-athletes (84.7 + 12.7 to 85.8 + 11.4) reported by Lam et. al.56 323 Interestingly, the DNP scores are similar to scores reported in populations of youth age 5 – 18 324 with chronic conditions such as asthma (74.8 + 16.5), cardiac disease (77.4 + 14.5) and 325 diabetes (80.3 + 12.9) reported by Varni.58 The reduced HRQoL in the DNP group may be due 326 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint in part to the decreased physical activity levels we noted previously. Since HRQoL is 327 multifactorial, however, the scores reported by the DNP group are also likely impacted by other 328 aspects of the lack of sport participation such as the continued loss of social interaction and loss 329 of identity. Nonetheless, this difference persisted after controlling for school instructional 330 delivery type, grade, sex, as well as the % of students eligible for free and reduced lunch, 331 suggesting that the differences we noted may be attributable to the lack of sport participation 332 itself. Further, the fact that the PLY group reported HRQoL similar to data collected prior to the 333 pandemic may indicate that providing sport opportunities can positively impact multiple 334 dimensions of adolescent health. Moving forward, validated health and well-being 335 measurements provide a common metric for future studies to compare their results with our 336 reported data.53 These metrics may help policy makers with future decisions that may affect the 337 health and well-being of student athletes in the coming months and years as we transition 338 beyond the immediate impacts of the CoVID-19 pandemic.59-61 339 340

341 This study has several limitations. First, the data provided were self-reported from online 342 surveys and not the result of a clinical examination conducted by a health care provider. 343 However, our findings are consistent with reports from experts and US Centers for Disease 344 Control who have stated that CoVID-19 will impact the mental and physical health of 345 youth.13,14,62 Second, we acknowledge that there may be a response bias for participants. We 346 cannot know for certain if the sample is representative of all the athletes at the schools or 347 biased towards athletes who were more likely to respond if they experienced the most profound 348 impacts on their health. Third, due to the survey delivery method, our sample may be biased 349 towards athletes from higher socioeconomic groups with easy access to internet services. 350 Fourth, we used the % of students eligible for free and reduced lunch for each school as a 351 measure of economic status for individual respondents. However, we felt that this would be 352 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint more accurate as a measure of economic status rather than asking students to accurately report 353 their household income. Finally, we recognize that mental health and overall well-being are 354 complex and are potentially affected by other factors for which we were not able to account in 355 our study and which could confound the results. Specifically, we did not ask the respondents 356 whether they had any fears of contracting the CoVID-19 virus. Nonetheless, we were able to 357 control for sex, age, and school instruction and the % of kids eligible for free or reduced lunch to 358 help better define the impacts of sport participation during CoVID-19. 359 360

361 In this study, we found that adolescent athletes who were able to return to sport participation in 362 fall 2020 reported dramatically lower symptoms of anxiety and depression, higher physical 363 activity levels and higher HRQoL, even after adjusting for grade, sex, and the type of school 364 instructional delivery. As we continue through the CoVID-19 pandemic, it is our hope that this 365 information will help inform public health experts, school administrators, and sports medicine 366 and mental health providers regarding the potential physical and mental health benefits 367 associated with the participation in organized sports for adolescents. We recognize that 368 returning to organized sports is a complex issue and requires careful consideration. 369 Nonetheless, research continues to suggest that sport participation during the CoVID-19 370 pandemic is associated with significant mental and physical health benefits in adolescents. 371 Word Count = 3927 372 373 374

375 We gratefully acknowledge and thank all of the student athletes who participated in this study. 376 377 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint

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Frontiers in Sports and Active Living, 2020 (2) 552 PMC7739668. 553 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint 62. US Centers for Disease Control. Mental Health, Substance Use, and Suicidal Ideation 554 During the COVID-19 Pandemic — United States, June 24–30, 2020. Morbididty and 555 Mortality Weekly Report. https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm. 556 Accessed 11/20/21 557 558 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint Title: High School Sports During the CoVID19 Pandemic: The Impact of High School Sports on 559 the Health of Student Athletes. 560 561 List of Figures and Tables 562 563 Table 1. Participant Characteristics for Adolescent Athletes Who Did or Did Not Play a High 564 School Sport in the Fall 2020 565 566 Table 2. Comparison of Anxiety, Depression, Physical Activity and Quality of Life 567 Scores for Adolescent Athletes Who Did or Did Not Play a High School Sport in the Fall 568 2020 569 570 Figure 1. Prevalence of Anxiety Symptoms for Adolescent Athletes Who Did or Did Not 571 Play a High School Sport in the Fall 2020 572 573 Figure 2. Prevalence of Depression Symptoms for Adolescent Athletes Who Did or Did 574 Not Play a High School Sport in the Fall 2020 575 576 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint Table 1. Participant Characteristics for Adolescent Athletes Who Did or Did Not Play a 577 High School Sport in the Fall 2020 578 Variable All Participants (N = 559) Did Not Play a Fall Sport (n = 388) Did Play a Fall Sport (n =171) P-value Age 15.7 (1.2) 15.7 (1.2) 15.7 (1.2) 0.895 Sex < 0.001 Female 244 (43.6%) 151 (39.0%) 93 (54.7%) Male 313 (56.3%) 236 (61.0%) 77 (45.3%) Grade 0.173 9 130 (23.3%) 90 (23.2%) 40 (23.4%) 10 167 (29.9%) 116 (29.9%) 51 (29.8%) 11 145 (25.9%) 109 (28.1%) 36 (21.1%) 12 117 (20.9%) 73 (18.8%) 44 (25.7%) Schools 44 23 25 -- Instructional delivery method < 0.001 Online 374 (66.9%) 355 (91.4%) 19 (11.1%) Hybrid (in person and online) 113 (20.2%) 30 (7.7%) 83 (48.5%) In person 72 (12.8) 3 (0.8%) 69 (40.3%) % Students eligible for free or reduced lunch 25.9 (10.3) 22.9 (7.0) 34.0 (13.3) < 0.001 Planned Fall Sport Participation Cheer / Dance 23 (4.1%) 20 (5.2%) 3 (1.8%) Cross Country 41 (7.3%) 25 (6.4%) 16 (9.4%) Football 213 (38.1%) 160 (41.2%) 53 (31.0%) Soccer (boys) 53 (9.5%) 31 (8.0%) 22 (12.9%) Swim (girls) 20 (3.6%) 19 (4.9%) 1 (0.6%) Tennis (girls) 13 (2.3%) 3 (0.8%) 10 (5.8%) Volleyball 117 (20.9%) 51 (13.1%) 66 (38.6%) None 79 (14.1%) 79 (20.4%) 0 (0.0%) Planned Winter or Spring Sport Participation Baseball 103 (18.4%) 72 (18.6%) 31 (18.1%) Ice Hockey 22 (3.9%) 18 (4.6%) 4 (2.3%) Lacrosse 32 (5.7%) 32 (8.2%) 0 (0.0%) Soccer (girls) 205 (36.7%) 123 (31.7%) 82 (48.0%) Softball 66 (11.8%) 33 (8.5%) 33 (19.3%) Swim (boys) 4 (0.7%) 3 (0.8%) 1 (0.6%) Tennis (boys) 7 (1.3%) 7 (1.8%) 0 (0.0%) Track 120 (21.5%) 72 (18.6%) 48 (28.1%) Wrestling 35 (6.3%) 27 (7.0%) 8 (4.7%) Other sport^ 24 (4.3%) 21 (5.4%) 3 (1.8%) ^ Other sport includes: Bowling, Gymnastics, Rugby, Power lifting, Skiing (alpine and downhill). 579 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint Table 2. Comparison of Anxiety, Depression, Physical Activity and Quality of Life Scores 580 for Adolescent Athletes Who Did or Did Not Play a High School Sport in the Fall 2020 581 Variable All Participants (N = 559) Did Not Play a Fall Sport (n=388) Did Play a Fall Sport (n=171) P-value GAD-7 Total Score 6.5 (5.8, 7.2) 8.4 (7.2, 9.5) 3.2 (2.2, 4.3) < 0.001 PHQ-9 Total Score 6.3 (5.6, 7.1) 7.6 (6.4, 8.8) 3.9 (2.8, 4.9) < 0.001 PFABS Total Score 18.7 (17.9, 19.6) 16.4 (15.0, 17.8) 23.2 (22.0, 24.5) < 0.001 PedsQL Score Physical Summary Score 88.4 (86.9, 89.9) 86.5 (84.1, 88.9) 92.3 (90.1, 94.4) 0.004 Psychosocial Summary Score 79.5 (77.5, 81.6) 75.9 (72.5, 79.3) 86.4 (83.3, 89.4) < 0.001 Total Score 82.6 (80.9, 84.3) 79.6 (76.8, 82.4) 88.4 (85.9, 90.9) < 0.001 582 Reported as mean (SD), N (%), or estimated mean (95% CI) when controlling for Age, Sex, Teaching 583 delivery (in person, online or hybrid) method, and school % eligible for free or reduced lunch percentage. 584 585 586 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint Figure 1. Prevalence of Anxiety Symptoms for Adolescent Athletes Who Did or Did Not 587 Play a High School Sport in the Fall 2020 588 589 GAD-7 category percentages were estimated when controlling for age, sex teaching 590 delivery method and school % of students eligible for free and reduced lunch. 591 592 593 594 80.0% 13.4% 4.6% 2.0% 26.4% 29.6% 25.6% 18.5% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% No Anxiety Mild Anxiety Moderate Anxiety Severe Anxiety Did Play a Fall Sport (PLY) Did Not Play a Fall Sport (DNP) . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint Figure 2. Prevalence of Depression Symptoms for Adolescent Athletes Who Did or Did 595 Not Play a High School Sport in the Fall 2020 596 597 PHQ9 category percentages were estimated when controlling for age, sex teaching 598 delivery method and school % of students eligible for free and reduced lunch. 599 57.7% 23.9% 12.1% 4.5% 1.6% 31.3% 28.5% 23.7% 11.7% 4.7% 0% 10% 20% 30% 40% 50% 60% 70% Minimal or No Depression Mild Depression Moderate Depression Moderately Severe Depression Severe Depression Did Play a Fall Sport (PLY) Did Not Play a Fall Sport (DNP) . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21251314doi: medRxiv preprint