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Physical Activity, Sedentary

Behavior, and Symptoms of Major

Depression in Middle Childhood
Tonje Zahl, MSC,a,b Silje Steinsbekk, PhD,b Lars Wichstrm, PhDa,b

OBJECTIVE: The prospective relation between physical activity and Diagnostic and Statistical abstract
Manual of Mental Disorders-defined major depression in middle childhood is unknown,
as is the stability of depression. We therefore aimed to (1) determine whether there are
reciprocal relations between moderate-to-vigorous physical activity (MVPA) and sedentary
behavior, on one hand, and Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition defined symptoms of major depressive disorder, on the other and (2) assess the
extent of stability in depressive symptoms from age 6 to 10 years.
METHODS: A community sample of children living in Trondheim, Norway, comprising a total
of 795 6-year-old children was followed up at 8 (n = 699) and 10 (n = 702) years of age.
Physical activity was recorded by accelerometry and symptoms of major depression were
measured through semistructured clinical interviews of parents and children. Bidirectional
relationships between MVPA, sedentary activity, and symptoms of depression were
analyzed through autoregressive cross-lagged models, and adjusted for symptoms of
comorbid psychiatric disorders and BMI.
RESULTS: At both age 6 and 8 years, higher MVPA predicted fewer symptoms of major
depressive disorders 2 years later. Sedentary behavior did not predict depression, and
depression predicted neither MVPA nor sedentary activity. The number of symptoms of
major depression declined from ages 6 to 8 years and evidenced modest continuity.
CONCLUSIONS: MVPA predicts fewer symptoms of major depression in middle childhood, and
increasing MVPA may serve as a complementary method to prevent and treat childhood

aNTNU Social Reseach, Trondheim, Norway; and bDepartment of Psychology, Norwegian University of Science WHATS KNOWN ON THIS SUBJECT: Moderate-
and Technology, Trondheim, Norway to-vigorous physical activity (MVPA) reduces the
likelihood of depression in adolescents and adults,
Ms Zahl carried out initial analyses and drafted initial manuscript; Dr Steinsbekk conceptualized,
designed, and supervised the study; Dr Wichstrm obtained funding and conceptualized, and is cross-sectionally associated with depression
designed, and supervised the study; and all authors approved the nal manuscript as submitted. in children. However, the prospective relation
between MVPA, sedentary time, and depression in
DOI: 10.1542/peds.2016-1711
childhood is unknown.
Accepted for publication Nov 8, 2016
WHAT THIS STUDY ADDS: Objectively measured
Address correspondence to Tonje Zahl, MSC, NTNU Social Research, Dragvoll All 38B, 7048
MVPA at ages 6 and 8 predict fewer symptoms
Trondheim, Norway. E-mail:
of depression in children 2 years later, whereas
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). sedentary activity is prospectively unrelated to
Copyright 2017 by the American Academy of Pediatrics depression. Depression does not forecast reduced
FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant physical activity in children.
to this article to disclose.
FUNDING: This research was supported by grants 228685 and 213793 from the Research Council To cite: Zahl T, Steinsbekk S, Wichstrm L. Physical Activity,
of Norway and grant FO5148 from the Norwegian Extra Foundation for Health and Rehabilitation. Sedentary Behavior, and Symptoms of Major Depression in
Middle Childhood. Pediatrics. 2017;139(2):e20161711

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PEDIATRICS Volume 139, number 2, February 2017:e20161711 ARTICLE
Both observational and treatment studies have nearly exclusively interviews) and accelerometry-
studies13 indicate that physical measured depression by means recorded MVPA and sedentary
activity (PA)and moderate-to- of rating scales; however, the activity in a large community sample
vigorous PA (MVPA), in particular correspondence between rating of Norwegian children monitored
may reduce the likelihood of major scale scores and the results from biannually from the ages of 6 to 10
depressive disorder (MDD) and/or clinical diagnostic interviews are years controlling for BMI and other
reduce the symptoms of MDD only moderate.17 Second, studies psychiatric symptoms.
in adolescents4 and adults.57 It of the PA-depression relationship
has recently become increasingly in children and adolescents have
clear that depression can also mainly used indirect methods to METHODS
be present in young children.8,9 measure childrens PA (ie, parent
Participants, Recruitment, and
Preventive10 and treatment efforts11 report or self-report, which are
for childhood depression are only only moderately associated with
modestly effective, which suggests objectively measured PA); in The Trondheim Early Secure
that alternative or complementary fact, PA in community children Study consists of children from
interventions must be sought. may be overestimated by using the 2003 and 2004 birth cohorts
MVPA might possibly serve as a indirect methods.18 Hence, to avoid in Trondheim, Norway (n = 3456)
strategy for preventing or reducing confounding due to reporting bias, that were recruited by invitation
childhood depression. Indeed, a the PAdepression relationship letter, together with the Strengths
meta-analysis of randomized and should be investigated by using and Difficulties Questionnaire (SDQ)
quasiexperimental studies12 among objective measures of PA. Third, 416 version.26 Written consent
children in late childhood and early sedentary activity and MVPA are to participate was obtained when
adolescence suggested a small short- negatively, but far from perfectly, attending ordinary community health
term effect of PA interventions. correlated.19 In other words, some checkups for their 4-year-olds and
Given the waxing and waning of children may be periodically highly the completed SDQ was delivered. As
depression,13 it is important also to active but may nonetheless spend can be seen in Fig 1, the vast majority
discern whether long-term effects are much time engaged in sedentary (n = 3358, 97.2%) of children who
present. Toward this end, prospective behavior. A substantial amount of were invited to participate appeared
community studies might prove research has focused on MVPA; at the citys well-child clinics. The
valuable. Importantly, psychomotor however, several studies have SDQ total problem scores (20 items)
retardation is 1 symptom of MDD,14 revealed that sedentary behavior, were divided into 4 strata (cutoffs:
and depressed children show not necessarily MVPA, might predict 0 to 4, 5 to 8, 9 to 11, and 12 to
higher levels of motor inactivity depression.20,21 Thus, we will 40), where drawing probabilities
than controls,6,15 which might investigate the extent to which time increased with increasing SDQ
explain the association reported. spent in sedentary activities predicts scores (0.37, 0.48, 0.70, and 0.89
Longitudinal studies are therefore symptoms of MDD over and above in the 4 strata) to increase sample
needed to reveal whether depression the effects of MVPA. Fourth, there is variability. The PA measurements
predicts reduced PA and whether considerable comorbidity between were included beginning with the
reduced PA increases the risk for depression and other psychiatric second wave of the data collection
depression in children, as has been disorders in children,22,23 and (6 years) and onward; therefore, the
shown in adolescents and adults.5,6,16 these disorders might be related to data used in the present inquiry were
Moreover, to our knowledge, no PA, confounding the relationship taken from 6-year (2009 to 2011,
longitudinal study has examined between depression and PA as a n = 795), 8-year (2011 to 2013, n =
the relationship between PA and result. Fifth, although the evidence is 699), and 10-year (2013 to 2015,
depression in middle childhood by mixed,24 a bidirectional relationship n = 702) assessments. In all, 799
using a community based sample. between childhood depression children had usable data from at least
and BMI is indicated,25 and BMI 1 measurement, and thus constitute
To identify the potentially beneficial should therefore be controlled for. the analytical sample. Attrition was
effects of PA on depression (and vice To overcome these obstacles, we not selective according to the study
versa) in nonreferred children, we investigate the prospective reciprocal variables, except that more hours
examine the bidirectional relation relations between Diagnostic and in MVPA at age 8 predicted attrition
between MVPA and symptoms Statistical Manual of Mental Disorders, at age 10 (odds ratio = 2.38; 95%
of depression, while addressing Fourth Edition (DSM-IV) defined confidence interval [CI]: 1.22 to 4.83,
several important methodological symptoms of major depression P = .01); a bias that was adjusted
issues. First, previous observational (obtained by using diagnostic for in the analyses (see Statistical

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2 ZAHL et al
processed by using accelerometer
analysis software (ActiGraph LLC,
Pensacola, FL).

Symptoms of MDD
The Preschool Age Psychiatric
Assessment (PAPA),31 a psychiatric
interview completed by parents using
a structured protocol, with both
mandatory and optional follow-up
questions, was used to assess MDD
symptoms at 6 years. A sum score
of DSM-IV defined MDD symptoms
constituted the outcome. At 8 and 10
years of age, the Child and Adolescent
Psychiatric Assessment (CAPA)32
was used. Both parents and children
were interviewed and a symptom
was considered to be present if it was
reported by either child or parent.
The PAPA and CAPA interviewers
(n = 9) had at least a Bachelors
degree in a relevant field and were
instructed by the developers of the
PAPA and CAPA. For the PAPA, 9%
of the interview audio recordings
were recoded by blinded raters, as
were 15% of the CAPA interviews.
The interrater reliability between
multiple pairs of raters was 0.90 for
symptoms of MDD in the PAPA and
0.83 in the CAPA.
Sample recruitment and follow-up.
Symptoms of Other Psychiatric
Analysis). The study was approved minutes of activity per day were
Symptoms of anxiety (consisting
by the Regional Committee of included. Detailed information on
of number of symptoms of social
Medical and Health Research Ethics, accelerometer compliance is shown
phobia, separation anxiety,
Mid-Norway. in Supplemental Table 3. Because
generalized anxiety, and specific
young childrens activity is often
Measurements phobias), attention-deficit/
intermittent with short bursts, we hyperactivity (ADHD), oppositional
Physical Activity employed the commonly used 10 defiant (ODD), and conduct disorders
The children were instructed to wear seconds epoch length.27 We applied (CDs) were assessed following the
an ActiGraph GT3X accelerometer the Evenson et al29 cutoff point of same procedures as for symptoms
(Manufacturing Technology, Inc, 2296 cpm for MVPA because it of MDD. Only the parents were
Fort Walton Beach, FL) around their has shown superior classification interviewed by using the CAPA with
waist for 7 consecutive days, 24 ability in children across the ages respect to ADHD. The interrater
hours a day, and only remove it relevant to the current study.30 reliabilities for PAPA/CAPA ranged
when bathing or showering. Only Minutes per day with 100 cpm from 0.85 to 0.97.
daytime activity (06:0023:59) was was considered sedentary activity,
included. Sequences of consecutive a cutoff that is widely used and has Body Mass Index
zero counts lasting 20 minutes excellent classification accuracy.30 In The childrens weight was measured
were interpreted as nonwear time.27,28 the analyses, MVPA and sedentary by using a digital scale (Tanita
Only those participants with 3 activity were represented in BC20MA), and the height was
days of recordings and 480 hours per day intervals. Data were assessed by using the Heightronic

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PEDIATRICS Volume 139, number 2, February 2017 3
Digital Stadiometer (QuickMedical
Model 235A). Correction for indoor
clothing (0.5 kg) was applied. BMI
was calculated as kg/m2.

Statistical Analysis

Reciprocal relations between PA

and the symptoms of MDD were
examined in Mplus 7.31,33 using FIGURE 2
Autoregressive cross-lagged relations between MVPA, sedentary behavior, and major depressive
autoregressive cross-lagged analysis symptoms. MVPA and sedentary activity were represented in hours per day intervals. Correlations
within a structural equation among the variables within each time point and the nonsignicant paths are not shown to simplify
framework. The symptoms of MDD, the model illustration, as are the autoregressive paths from 6 to 10 years.
MVPA, and sedentary activity at age
10 were regressed on measures TABLE 1 Descriptive Statistics
of these variables and covariates Descriptives of Study Variables (Possible Range) N M SD
at age 8, whereas age 8 measures
1. Number of MDD symptoms 6 y (0 to 9) 793 0.52 0.73
were regressed on measures at age 2. Number of MDD symptoms 8 y (0 to 9) 697 0.46 0.79
6, as shown in Fig 2. To allow for 3. Number of MDD symptoms 10 y (0 to 9) 629 0.52 0.90
sleeper effects (ie, the effects from 4. MVPA 6 y (hours per day) 697 1.19 0.40
age 6 to age 10 measures bypassing 5. MVPA 8 y (hours per day) 607 1.18 0.43
6. MVPA 10 y (hours per day) 684 1.09 0.40
measures at age 8), autocorrelated
7. Sedentary 6 y (hours per day) 689 8.58 0.84
paths were allowed from ages 6 to 8. Sedentary 8 y (hours per day) 607 9.22 1.06
10. Measures obtained at the same 9. Sedentary 10 y (hours per day) 634 9.94 1.07
time point in time (ie, at ages 6, 8, 10. Anxiety 6 y (0 to 21) 793 0.87 1.52
and 10, respectively) were allowed 11. Anxiety 8 y (0 to 21) 697 0.89 1.25
12. ADHD 6 y (0 to 18) 793 1.30 2.24
to correlate. To examine overall
13. ADHD 8 y (0 to 18) 688 1.20 2.40
changes in level of MDD, sedentary 14. CD 6 y (0 to 9)a 793 0.22 0.50
activity and MVPA latent growth 15. CD 8 y (0 to 15) 697 0.30 0.60
curve analyses were conducted. 16. ODD 6 y (0 to 8) 793 0.96 0,47
Because the attrition analyses 17. ODD 8 y (0 to 8) 697 1.08 1.39
18. BMI 6 y 658 15.60 1.51
indicated that the data were missing
19. BMI 8 y 675 16.62 1.97
not at random (MNAR), missing a Six items in the CD scale were removed at age 6 because they were not considered age appropriate.
data were handled according
to a full information maximum
likelihood procedure. Because RESULTS years (Mgrowth= 0.32 [95% CI, 0.27
counts of depressive symptoms are The descriptive statistics are shown to 0.37]) and increased further from
right skewed,34 a robust maximum in Table 1. The rate of DSM-IV defined ages 8 to 10 years (Mgrowth= 0.36
likelihood estimator was used, which MDD diagnosis, ranged from 0.3% [95% CI, 0.30 to 0.42]). Regarding
is robust to moderate deviations (age 6) to 0.4% (age 8), underscoring rank order stability, Table 2 shows
from normality. As oversampling was the need, at this age, to analyze MDD that the symptoms for MDD and
applied on the basis of mental health continuously as symptom counts. sedentary activity were modestly
problems, the data were weighted Supplementary piecewise growth stable, whereas we found higher
back with a factor determined curve analyses revealed that MDD stability for MVPA.
as the number of children in the decreased from ages 6 to 8 years
population in each stratum divided (Mgrowth= 0.13 [95% CI, 0.17 to Cross-Sectional Findings
by the number of participants in 0.10]) but increased from ages 8 The symptoms of MDD were
each stratum to arrive at correct to 10 years (Mgrowth= 0.03 [95% CI, negatively correlated with MVPA at
population estimates. To examine 0.00 to 0.06]). Minutes of MVPA per ages 8 and 10, but were unrelated
gender differences in the estimates, a day did not change from ages 6 to 8 to sedentary activity (Table 2). As
Wald test was employed to compare years (Mgrowth= 0.17 [95% CI, 1.35 expected, the symptoms of MDD
the fit of 2 models, one in which the to 1.01]) but decreased from ages 8 covaried with the symptoms of other
path at hand was fixed as identical for to 10 years (Mgrowth= 2.62 [95% CI, disorders at all time points. The
the 2 genders and the other in which 3.75 to 1.49]). Finally, sedentary symptoms of these other disorders
the path was freely estimated.26 activity increased from ages 6 to 8 were generally unrelated to MVPA

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4 ZAHL et al
and sedentary activity, although we










found higher MVPA among 6-year-old
children who had more symptoms of





anxiety disorders and less sedentary







activity among those 6-year-old
children who had elevated symptoms






of ADHD.



Prospective Associations





The main results from the
autoregressive cross-lagged







model examining the bidirectional


relationships between MVPA,
sedentary activity, and major







depression are shown in Fig 2.

For complete model results, see

Supplemental Table 4.







The model did fit the data well (2 =

21.76, df = 24, P = .59, comparative






fit index = 1.00, Tucker-Lewis index =


1.007, root mean square error of


approximation = 0.000). At both 6





and 8 years, higher levels of MVPA


predicted fewer symptoms of MDD 2

years later. The reduction was 0.20





symptoms of depression per daily

hour spent in MVPA. The effect of



MVPA on depression from age 8 to



10 was seemingly stronger than the


effect from age 6 to 8. Standardized



coefficients revealed effect sizes of



0.08 (at age 6 to 8) and 0.11 at


age 8 to 10), respectively. However,


when comparing a model in which


these 2 path coefficients were fixed

as equal with a model in which they

were freely estimated, no significant

difference was found (Wald = 0.41,


df = 1, P = .41). A similar procedure

TABLE 2 Bivariate Correlations Between Study Variables


was used to test for the gender-


specific effects of MVPA on later



symptoms of MDD, and no such


differences were found (6 to 8 years:

Wald = 0.47, df = 1, P = .49; 8 to 10

years: Wald = 0.34, df = 1, P = .56).

Because MDD symptoms are heavily


right-skewed with many children


evincing no symptoms and just a


few evincing many symptoms, there

is a possibility that the obtained


, not applicable.

effect of MVPA on MDD was due to

7. Sedentary

8. Sedentary

9. Sedentary
6. MVPA 10 y

12. ADHD 6 y
13. ADHD 8 y
3. MDD 10 y
4. MVPA 6 y
5. MVPA 8 y

16. ODD 6 y
17. ODD 8 y
18. BMI 6 y
19. BMI 8 y
10. Anxiety

11. Anxiety
1. MDD 6 y
2. MDD 8 y

skewness and count nature of MDD

*** P < .001.
14. CD 6 y
15. CD 8 y

** P < .01.
* P < .05.
10 y

symptoms. We therefore run the path





analysis treating MDD symptoms as

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PEDIATRICS Volume 139, number 2, February 2017 5
having a negative binominal (count) symptoms of MDD, 2 potential adolescents and adults has suggested
distribution. MVPA still predicted mechanisms related to PAs 2 not that sedentary behavior may increase
reduced numbers of MDD symptoms mutually exclusive components depression.20 It is thus likely that the
from age 6 to 8 (B = 0.58 [95% (the activity and the physical effect of sedentariness on depression
CI: 0.95 to 0.21], P = .001) and components), can be hypothesized. is age-dependent. However, because
from age 8 to 10 (B = 0.58 [95% CI: Treatment studies applying activity psychomotor retardation and loss
1.03 to 0.13], P = .002). Moreover, scheduling have indicated that of energy are among the symptoms
depression did not predict later increasing activity, not necessarily of MDD, it is essential to adjust for
MVPA, and no effects of sedentary just PA, may reduce depression.38 previous MDD when examining
activity on depression, or vice versa, Several explanations for this MDD- sedentary activitys contribution to
were detected. reducing effect have been proposed: MDD, which has been investigated
(1) Engaging in activities may distract only to a limited extent.21,49 Further,
DISCUSSION from ruminating over negative in many of these prospective
events, and ruminations may worsen studies, self-reports of inactivity
To aid the preventive and treatment or prolong depression.39,40 (2) A and depression have been applied
efforts of depression among children, substantial part of MVPA in children that may inflate their relationship
we examined the bidirectional consists of play or sports activities,41 on a prospective basis, due to the
relations between MVPA, sedentary and playing or engaging in sports common methods that are employed.
activity, and MDD symptoms over may bolster self-efficacy and self- Moreover, it is essential to adjust
3 waves of data collection in a large esteem in children, which has been for lack of MVPA when estimating
community sample of children. suggested to prevent depression.42,43 the effects of sedentariness because
Higher levels of MVPA at 6 and 8, (3) Finally, when children are MVPA and sedentary activity are
respectively, predicted fewer MDD physically active, they tend to be negatively correlated. In sum, the lack
symptoms 2 years later. No effects of with other children.41 Although peer- of comparable studies underscores
sedentary activity were found for MDD rejections and bullying also occur in the need to replicate our findings.
symptoms, and MDD symptoms did sports,44 physically active children
not predict later PA (or lack thereof). may be more socially integrated in Levels of PA and Symptoms of MDD
peer groups than less active children. During Middle Childhood
MVPA Predicts Fewer Depressive
Symptoms Such peer acceptance, which is The level of symptoms of MDD
likely to result in social support, is a was stable from 6 to 10 years.
The identified effects of PA on
potential buffer against depression.45 MDD symptoms evidenced some
depression extend findings from homotypical continuity, which
observational studies of adolescents Regarding the physical component extends the findings from short-term
and adults35 by documenting that of PA, several physiologic and longitudinal studies on MDD in young
this relationship is also present in biochemical mechanisms have been children.9,50 The observed reduction
middle childhood. We further add proposed, such as the demonstration in MVPA and increase in sedentary
to existing knowledge by showing of PA leading to higher availability of behavior are consistent with findings
that predictive effects are present neurotransmitters, which is assumed from previous research.19
when we examine interview-based to have antidepressant effects.46,47 In
DSM-defined symptoms of MDD addition, regular PA has a favorable Limitations
rather than questionnaires, and impact on neuronal functions and Although individuals fulfilling the DSM
when applying objectively measured structure along with increased cutoff of 5 or more MDD symptoms
PA, and account for the potential cognitive functions.48 do not seem qualitatively different
effects of other psychiatric disorders
from those with just under cutoffs,51
and BMI. Although the effects of No Prospective Relation Between and even though the correlates and
MVPA were small, they are similar Sedentary Activity and Symptoms of predictors of subclinical depression
to those obtained by psychosocial MDD
are similar to those of the disorder,52
intervention programs in children36
Our study is the first to objectively our findings do not necessarily
and adolescents.37 Along with the
examine sedentary activity and generalize to the disorder itself. Thus,
fact that nearly all children can be
later depression in early and research with substantially larger
targeted in efforts to increase MVPA,
middle childhood, and we find samples is required to determine
the gains at the population level
no prospective relation between whether objectively measured MVPA
might be substantial.
sedentary behavior and symptoms would decrease the risk of MDD in
Although the current study did not of MDD. Although there are some community children. Nonetheless,
address why PA may reduce future important exceptions,49 research on because previous research has

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6 ZAHL et al
shown that there is a continuity in enhancement58 or increased social
interactions59 may explain at least
depressive symptoms from childhood
to adolescence and later adulthood,53 some of the results. The prevalence of ADHD:attention-deficit/
that an elevated level of MDD psychiatric disorders is generally low hyperactivity disorder
symptoms increases the risk of in Norway,60 but whether the impact CAPA:Child and Adolescent
later MDD,54,55 and that subclinical of MVPA on depressive symptoms also Psychiatric Assessment
depression may entail substantial differ between countries should be CD:conduct disorder
impairment (also in the long run),56 examined in future studies. CI:confidence interval
our findings suggest that increasing DSM-IV:Diagnostic and
MVPA at the population level may lead Statistical Manual of
to reduced symptoms of depression CONCLUSIONS Mental Disorders, Fourth
and the impairment that accompanies Edition
MVPA predicts fewer future MDD
these symptoms in some children. MDD:major depressive
symptoms in middle childhood,
Second, data were MNAR, which may disorder
and such symptoms are moderately
MNAR:missing not at random
have led to biased results. However, stable from the ages of 6 to 10 years.
the selectivity of this attrition was Sedentary activity in children does
physical activity
modest and we used all available not alter the risk of future symptoms
PA:physical activity
data in a full information maximum of depression, and depression does
PAPA:Preschool Age Psychiatric
likelihood procedure, which leads to not influence the likelihood of MVPA
less biased results than complete case or inactivity. Although the effect
ODD:oppositional defiant
analysis when the data are MNAR.57 was small, our results indicate that
Nonetheless, we cannot exclude that increasing MVPA in children at
SDQ:Strengths and Difficulties
such bias along with unmeasured the population level may prevent
confounders such as self-image depression, at least at subclinical levels.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conicts of interest to disclose.

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PEDIATRICS Volume 139, number 2, February 2017 9
Physical Activity, Sedentary Behavior, and Symptoms of Major Depression in
Middle Childhood
Tonje Zahl, Silje Steinsbekk and Lars Wichstrm
Pediatrics 2017;139;; originally published online January 9, 2017;
DOI: 10.1542/peds.2016-1711
Updated Information & including high resolution figures, can be found at:
Services /content/139/2/e20161711.full.html
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2017 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Physical Activity, Sedentary Behavior, and Symptoms of Major Depression in
Middle Childhood
Tonje Zahl, Silje Steinsbekk and Lars Wichstrm
Pediatrics 2017;139;; originally published online January 9, 2017;
DOI: 10.1542/peds.2016-1711

The online version of this article, along with updated information and services, is
located on the World Wide Web at:

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2017 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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