Children and Youth Services Review 124 (2021) 105960

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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Intervention of adolescent’ mental health during the outbreak of COVID-19

using aerobic exercise combined with acceptance and commitment therapy
Wenxin Xu *, Wei Shen , Shen Wang
Institute of Physical Education and Sport Science, Fujian Normal University, Fuzhou 350117, China

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To explore the intervention effect of aerobic exercise in combination with acceptance and commitment
Adolescents therapy on mental health of adolescents during the outbreak of COVID-19 based on the theory of the dual-factor
Acceptance and commitment therapy model of mental health.
Dual-factor model
Methodology: 1200 adolescents aged 12–19 in Fujian Province, China were screened by means of the dual-factor
Aerobic exercise
Mental health
model of mental health from March to April 2020. 30 vulnerable, 30 symptomatic but contented and 30 dis­
tressed adolescents were selected as the experiment objects, and these 3 types of adolescents were randomly
divided into the intervention group and the control group. Among them, the intervention group received 8 weeks
of aerobic exercise in combination with acceptance and commitment therapy, 3 times a week, about 40–60 min
each time. The control group, however, didn’t receive any intervention other than routine mental health edu­
cation. Measurements were made before and after the intervention.
Results: (1) For vulnerable, symptomatic but contented and distressed individuals, before the intervention, there
is no significant difference between the intervention group and the control group in terms of psychological
distress, well-being and psychological flexibility (P > 0.05). After the intervention, psychological distress and
experiential avoidance is significantly lower in the intervention group than in the control group, but all di­
mensions of well-being is significantly higher in the intervention group than in the control group (P < 0.05). (2)
For vulnerable, symptomatic but contented and distressed individuals, before and after the intervention, there
are significant differences in psychological distress, well-being and psychological flexibility of the intervention
group (P < 0.05), but there are no significant differences in the control group (P > 0.05).
Conclusion: Attention should be paid to the problems of mental health of adolescents caused by the sudden
outbreak of public health incidents. Aerobic exercise in combination with acceptance and commitment therapy is
feasible and effective for the intervention in mental health of adolescents.

1. Introduction major food and occupational poisoning and other events that have
caused or may cause serious damage to public health. During the
Coronavirus disease 2019 (COVID-19) not only brings about huge COVID-19 epidemic, some researchers surveyed 7,236 Chinese netizens
economic losses to the society, but also imposes heavy economic and on the basis of social websites, and the results show that the incidence
spiritual burdens on many families (Ahmed et al., 2020). In addition, it rate of generalized anxiety disorder is 35.1%, the prevalence rate of
leads to more serious psychological problems in adolescents in the on­ depression is 20.1%, and the prevalence rate of sleep disorder is 18.2%.
line learning environment. - Due to the absence of targeted drugs and The results also show that the prevalence rates of anxiety, depression
regimens, as well as the strong infectivity of COVID-19, a certain degree and sleep disorder are significantly higher in low age groups than in high
of panic has been stirred among the public, bringing a negative influence age groups (Huang & Zhao, 2020). To prevent and control the epidemic,
on mental health of the public (Chang et al., 2020). On January 30, protect health of adolescents, and minimize human-to-human trans­
2020, the WHO defined COVID-19 as a public health emergency of in­ mission of COVID-19 at school, many nations specified that offline
ternational concern. Public health emergencies refer to the sudden learning of adolescents should be changed to online learning. This
occurrence of major infectious diseases, unexplained mass diseases, chance lowers the interpersonal communication and perceived social

* Corresponding author.
E-mail address: wenxin20142014@163.com (W. Xu).

https://doi.org/10.1016/j.childyouth.2021.105960
Received 22 September 2020; Received in revised form 1 January 2021; Accepted 12 February 2021
Available online 1 March 2021
0190-7409/© 2021 Elsevier Ltd. All rights reserved.
W. Xu et al. Children and Youth Services Review 124 (2021) 105960

support of adolescents (Dun, 2020). It was pointed out in some reports comprehensive measurement of adolescents’ mental health. DFM has
that this kind of online learning at home leads to lower mental health also been verified to be completely applicable to Chinese adolescents
and more negative emotions in adolescents. Therefore, the psychologi­ due to its advantage of implementing mental health promotion plans in a
cal problems of adolescents are more prominent during the COVID-19 targeted way. Therefore, it is very necessary to apply DFM in the field of
Epidemic in such an online learning environment (Song et al., 2019) promoting mental health of adolescents.
(see Fig. 1). Previous studies have shown that physical exercise exerts a good
Traditional mental health models mainly adopt negative psycho­ intervention effect in improving the positive psychological state of ad­
pathological criteria, so that their reliability and validity are inadequate olescents and reducing their negative psychotic symptoms (Xiong et al.,
(Wang et al., 2011). With the development of positive psychology, the 2017; Rodriguez-Ayllon et al., 2019). However, physical exercise alone
tradition of simply taking negative indicators as the diagnostic basis has is slightly inadequate in improving positive mental quality of adoles­
been gradually improved. Researchers further supplemented positive cents, especially their mental quality to deal with negative stress events
indicators, for example, subjective well-being, and formed a dual-factor (Wang & Zhang, 2011). At present, acceptance and commitment therapy
model of mental health (DFM) (Antaramian et al., 2015). DFM divides (ACT) presents a good intervention effect on the improvement of mental
people into four categories according to the mental health: healthy, health. It was found in experiments that ACT has a certain efficacy in
vulnerable, symptomatic but contented and distressed individuals, and relieving negative emotions, depression and anxiety that are triggered
advocates that mental health assessment should be conducted in two by long-term chronic pain (Wright et al., 2014). Afterwards, some re­
dimensions: negative mental health indicators and positive mental searchers further expanded the application scope of ACT from the
health indicators. The former mainly refer to psychopathological perspective of positive psychology, and confirmed that ACT produces an
symptoms like depression and anxiety, while the latter mainly refer to evident effect on the improvement of adolescents’ self-compassion and
subjective well-being, which is generally composed of three compo­ well-being, and is also effective in the mental health education and
nents: life satisfaction, positive affect and negative affect. DFM quadrant prevention of psychological problems in adolescents (Armstrong et al.,
theory is one of the classification standards of DFM supported and held 2013). However, at present, there are no literatures on the application of
by many researchers (Suldo & Shaffer, 2008; Greenspoon & Saklofske, ACT in the research of mental health problems of adolescents. In sum­
2001). The advantage of DFM lies in its ability to distinguish and di­ mary, under the influence of the current epidemic, it is especially
agnose complete and partial states of mental illness and mental health, important to pay attention to mental health of adolescent. In this study,
and provide more effective prevention and intervention plans. DFM has the adolescents were first divided according to the classification stan­
been adopted by mental health professionals to monitor and identify dard of the dual-factor model, and aerobic exercise was innovatively
adolescents and adult citizens who are in need of assistance (Antaramian combined with ACT to formulate a set of acceptance and commitment
et al., 2015). Suldo and Shaffer (2008) explored the existence and val­ interventions. The application of this approach in the intervention
idity of the dual-factor model of mental health in early puberty, and experiment is expected to offer a new insight and reference for the
comprehensively measured mental health by using positive indicators of intervention in adolescents’ psychological problems in particular cases
health (i.e. subjective well-being) and traditional negative indicators of such as online learning and sudden public health emergencies.
diseases (i.e. psychopathology). Through self-reported scales, school
records and teachers’ reports, they evaluated subjective well-being,
psychopathology, academic functions, social adaptability and physical
health of 349 middle school students. This experiment supports the
effectiveness of the dual-factor model and offers a new insight for the

Fig. 1. Experiment sample selection process.

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W. Xu et al. Children and Youth Services Review 124 (2021) 105960

2. Objects and methodology psychological flexibility. In this study, the Cronbach’s α of this scale is
0.88 and the reliability and validity are good. Currently, quite a few
2.1. Research objects studies have taken psychological flexibility as the intervention goal of
ACT. Therefore, whether individual psychological flexibility has been
The objects of this study are 1200 adolescents in Fujian Province of improved is also the best indicator reflecting the intervention effect of
China aged 12–19 years, with an average age of 13.99 ± 0.49. A total of ACT (Cao et al., 2013).
1,200 copies of the questionnaire were distributed, and 1,018 valid
copies were collected after the invalid ones were eliminated, and the
recovery rate is 84.83%. The questionnaire includes gender (460 males 2.3. Research methods
and 558 females), age (13–19 years) and whether the only child or not
(413 with yes and 605 with no). All the participants got involved on a The copies of the questionnaire were distributed in a collective way
voluntary basis. Before the survey, they had been informed of the in the community. Unified questionnaire instructions were used. The
research purpose, content and intervention methods and all the scales objects of this study are adolescents in the community. The data were
were filled in anonymously. This study was approved by the medical input and sorted out using Excel 15.41 and SPSS24.0 was used to
ethics branch of Fujian Medical Association before the implementation analyze the data.
of intervention. The first step after being approved by the medical ethics
branch was to contact and explain the content of the study to the school 2.3.1. Grouping
administrators and teachers and to get their approval and support. 1,018 students were selected according to the following criteria:
Secondly, the purpose, method and content of the study were explained after psychological measurement with the dual-factor model of mental
to the participants, with emphasis on voluntary participation and the health (the results are shown in Table 2), they were divided into four
requirements of participation. Then, the purpose and method of the types: healthy, vulnerable, symptomatic but contented and distressed
study were explained to the parents (guardians) of the participants, to individuals. Then, volunteers for this study were recruited from these
obtain their permission and support, and ensure that each participant three groups: vulnerable, symptomatic but contented and distressed
has a guardian to sign the informed consent. Finally, the participants individuals. Exclusion criteria: ① those who were at risk of suicide; (2)
were determined through the three steps above, and then the partici­ those who took psychotropic drugs or received psychotherapy in the last
pants were asked to sign the informed consent. three months; (3) those who were unwilling to take part in this study, or
cannot ensure to participate in this study for 8 successive weeks. ④
2.2. Tools through one-on-one interviews, the researchers excluded those who
were unfit for group intervention based on ACT. With the informed
(1) General Health Questionnaire (GHQ-12) (Goldberg & Hillier, consent of the volunteers, 30 adolescent who met the requirements
1979) was developed by Taiwan scholar Zheng Tai’an who incorporated above were selected from each type as the experiment objects, and
Chinese cultural characteristics into General health Questionnaire-12 randomly divided into the intervention group and the control group
(GHQ-12). This scale is composed of 12 items and the standard (Details are shown in Table 1).
scoring method of GHQ-12 was employed in this study. 0 point would be
scored for the first two options of the question and 1 point would be 2.3.2. Intervention plan
scored for the last two options of the question. The total score ranges The intervention group received aerobic exercise in combination
from 0 to 12. A higher score means worse mental health. Among them, 3 with ACT as an online intervention for 8 weeks, 3 times a week, about
points is the cut-off value. Domestic studies have shown that this scale 40 ~ 60 min each time, while the control group didn’t receive any
has a high sensitivity in epidemiological surveys of all kinds of mental intervention. Before and after the intervention, measurements were
diseases. It is a suitable screening tool for mental disorder and can be adopted to compare the effects. During the intervention experiment, 1
used in the dual-factor model of mental health. The internal consistency vulnerable individual in the intervention group did not join in the
of the study is 0.807 (Li & Li, 2015). intervention of ACT. 2 symptomatic but contented individuals and 3
(2) W-E Well-being Scale (Tennant et al. 2007), also known as distressed individuals dropped out. Finally, there are 14 vulnerable, 13
Warwick-Edinburgh Mental Well-being Scale (WEMWBS), was devel­ symptomatic but contented and 12 distressed individuals in the inter­
oped by Tennant et al. (2007). There are a total of 14 positively worded vention group. In the control group, only 1 distressed individual drop­
items and Likert’s 5-point scoring method is employed. The original ped out. Finally, there are 15 vulnerable, 15 symptomatic but contented
scale has been widely used in the UK, showing good reliability and and 14 distressed individuals in the control group.
validity, with its test–retest reliability being 0.83 and internal consis­ According to their personal preferences, the intervention group
tency reliability being 0.91. It has been proved to be suitable for the selected jogging, yoga, basketball and other activities for aerobic exer­
evaluation of positive mental health and has the following three char­ cise intervention. All activities were conducted in the form of group
acteristics: first of all, it is concise and easy-to-operate; secondly, it in­ activity, except jogging of which the time and frequency was recorded
tegrates positive emotions (3, 5, 7 and 14), positive psychological by punching in a sports APP. The sports APP used in this experiment is
functioning (1, 6, 8, 9, 10 and 11) and interpersonal relationship satis­ Keep (Ma & Yuan, 2018). This punch-in software can connect a sports
faction (2, 4, 12 and 13) that reflect mental health, basically consistent watch to the computer side, and record all details of the exercise such as
with Keyes and Annas’ (2009) proposal that positive mental health is calorie consumption and length of exercise etc. by means of punch-in.
mainly divided into emotional well-being, psychological well-being and The punch-in plan can be preset by the members of the research team.
social well-being. Thirdly, it can be applied to students and general If the exercise plan established is not finished on time, reminders would
population and has good reliability and validity. The Cronbach’s α of
this scale in this study is 0.83. Table 1
(3) Acceptance and Action Questionnaire-2nd Edition (AAQ-II) Measurement grouping standard of the dual-factor model.
(Bond et al., 2011). This scale was originally developed by Bond et al. Subjective well-being < Subjective well-being ≥
based on the acceptance dimension of ACT theory and is used to assess 56 56
the level of experiential avoidance. Cao et al. (2013) introduced it to Psychological distress < Vulnerable Healthy
China and revised it into the Chinese version which is composed of 7 3
items in total, scoring from 1 (never) to 7 points (always). Those with Psyological distress ≥ 3 Distressed Symptomatic but
contented
high scores have higher levels of experiential avoidance, as well as lower

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W. Xu et al. Children and Youth Services Review 124 (2021) 105960

be given unceasingly in the form of alarm clock on the watch. The < 56 are considered to have low subjective well-being (Jiang, 2009).
punch-in data of all the participants can be shared on the computer, so The best cut-off value of the Chinese version of GHQ-12 is 3 points.
that the members of the research team can monitor exercise quality, so Those with an average score ≥ 3 points are considered to have high
as to guarantee the authenticity and reliability of the study. The inter­ mental illness, and those with a score < 3 are considered to have low
vention time in this experiment is 8 weeks, 3 times a week, 40 ~ 60 min mental illness (Li & Li, 2015).
each time. During the intervention, the researchers should communicate According to the criteria of the dual-factor model of mental health, as
with the participants in a timely manner and learn about their inner well as the results shown in Table 2, it can be found that 49.31% of the
thoughts, feeling, effect of the exercise, etc. While the control group did adolescents surveyed are completely healthy during the outbreak;
not participate in aerobic exercise and basically did not take any long- 15.03% were vulnerable; 13.06% were symptomatic but contented, and
term and regular physical exercise. Both the intervention group and 22.59% were distressed. Among those who are vulnerable, symptomatic
the control group took results of Study I as the pre-test results and but contented and distressed, 30 adolescents were selected from each
received a post-test uniformly after the intervention. type as the experiment objects with their consent, and randomly and
Before the intervention, an online informed consent meeting was equally divided into the intervention group and the control group.
held to give an outline of the intervention, explain the discipline and
requirements of group activity and collected signed informed consent 3.2. Intervention effect of aerobic exercise in combination with
forms from all members of the intervention group. In the intervention acceptance commitment therapy on vulnerable individuals
stage, two postgraduates in psychology who had the experience of
leading group psychological counseling and received systematic train­ From Table 3, it can be learned that before the intervention, there is
ings on ACT (one was the main leader of the team and the other was an no significant difference between the intervention group and the control
assistant) served as the researchers, and two clinical psychologists group in terms of psychological distress, well-being and psychological
served as the counselors. The ACT intervention was carried out on flexibility, indicating that the two groups have the same baseline levels.
weekends, once a week, about 40–50 min each time, for 6 successive However, after the intervention, the intervention group is significantly
weeks. During the intervention in the intervention group, the control lower than the control group in psychological distress and experiential
group did not receive any materials related to the content of the avoidance, but significantly higher than the control group in all di­
intervention. mensions of well-being, indicating that the intervention is somewhat
The ACT intervention was scheduled as follows: Week 1: consoli­ effective.
dating understanding about sudden public health emergencies and From Table 4, it can be seen that there are significant differences
emotions, and learning to make peace with emotions. Week 2: inspiring before and after the intervention in the intervention group in terms of
team members to accept themselves, including their own merits and psychological distress, well-being and psychological flexibility (P <
demerits, etc. Week 3: learning to respond to all kinds of ideas in the 0.05), but no significant differences in the control group, which further
brain using cognitive defusion. Week 4: helping team members establish illustrates the effect of intervention.
correct and active values. Week 5: encouraging members to fight for
their dreams and fulfill their commitments. Week 6: summing up the 3.3. Intervention effect of aerobic exercise in combination with
activities, sharing growth and changes in this intervention, recom­ acceptance commitment therapy on symptomatic but contented individuals
mending books on positive psychology, and reminding members to take
action. From Table 5, it can be learned that before the intervention, there is
no significant difference between the intervention group and the control
2.4. Statistical analysis group in terms of psychological distress, well-being and psychological
flexibility of symptomatic but contented individuals, indicating that
The data were analyzed by SPSS15.0 statistical software, and the both groups are at the same baseline level. After the intervention, the
quantitative data were expressed as mean ± standard deviation (m ± intervention group is significantly lower than the control group in psy­
SD). Because most of the interaction of group and time in this study is chological distress and experiential avoidance, but significantly higher
statistically significant, the objects were divided into different groups than the control group in all dimensions of well-being, indicating that
and different time for independent effect analysis. The specific methods the intervention is somewhat effective.
include: t test was used to analyze whether there is significant difference From Table 6, it can be seen that there are significant differences
in each variable between the two groups before and after the interven­ before and after the intervention in the intervention group in terms of
tion; Paired t-test was used to analyze whether there is significant dif­ psychological distress, well-being and psychological flexibility (P <
ference in each variable before and after the intervention in each group, 0.05), but no significant differences in the control group, which further
with P < 0.05 suggesting that the difference is statistically significant. indicates the effect of the intervention.

3. Results 3.4. Intervention effect of aerobic exercise in combination with

acceptance commitment therapy on distressed individuals
3.1. Mental health of adolescents
From Table 7, it can be seen that for distressed individuals, before the
According to the studies by relevant scholars, most people score 45 intervention, there is no significant difference between the intervention
~ 56 in the W-E Well-being Scale. Those with an average score ≥ 56 are group and the control group in all dimensions. However, after the
considered to have high subjective well-being, while those with a score intervention, the intervention group is significantly lower than the

Table 2
Mental health distribution of adolescents.
Healthy Vulnerable Symptomatic but contented Distressed

Grouping standard Psychological distress < 3 Psychological distress < 3 Psychological distress ≥ 3 Psychological distress ≥ 3
Subjective well-being ≧ 56 Subjective well-being < 56 Subjective well-being ≧ 56 Subjective well-being < 56
N 502 153 133 230
Percent 49.31% 15.03% 13.06% 22.59%

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W. Xu et al. Children and Youth Services Review 124 (2021) 105960

Table 3
Comparison between the intervention group and the control group in terms of pre-test results of vulnerable individuals before and after intervention (M ± SD).
Item Before intervention T After intervention T

Experimental group Control group Experimental group Control group

Psychological distress 1.50 ± 0.51 1.53 ± 0.51 − 0.17 0.57 ± 0.51 1.40 ± 0.63 − 3.85**
Well-being 47.57 ± 2.84 49.86 ± 2.92 − 1.11 52.86 ± 2.82 48.20 ± 3.01 3.88**
Positive emotions 12.71 ± 1.27 11.93 ± 1.03 1.82 13.28 ± 1.27 11.73 ± 1.38 3.08**
Positive psychological functioning 20.85 ± 0.94 20.13 ± 1.18 1.80 22.21 ± 1.12 20.86 ± 1.35 2.90**
Interpersonal relationship satisfaction 13.28 ± 1.38 12.20 ± 1.69 0.15 13.78 ± 0.70 12.46 ± 1.30 3.36**
Experiential avoidance 19.35 ± 1.46 20.40 ± 1.54 − 1.87 18.35 ± 1.21 19.86 ± 1.24 − 3.30**

Table 4
Comparison between the intervention group and the control group in terms of mental health and experiential avoidance of vulnerable individuals before and after
intervention.
Item Before intervention T After intervention T

Experimental group Control group Experimental group Control group

Psychological distress 1.50 ± 0.51 0.57 ± 0.51 4.76** 1.53 ± 0.51 1.40 ± 0.63 1.46
Well-being 48.64 ± 2.97 52.86 ± 2.82 − 4.23** 49.87 ± 2.92 48.20 ± 3.56 1.26
Positive emotions 12.71 ± 1.27 14.93 ± 1.20 − 6.62** 11.93 ± 1.03 11.73 ± 1.38 0.44
Positive psychological functioning 20.85 ± 0.94 22.21 ± 1.12 − 4.18** 20.13 ± 1.18 20.86 ± 1.35 − 1.41
Interpersonal relationship satisfaction 13.28 ± 1.38 14.72 ± 1.20 − 4.16** 13.20 ± 1.70 12.47 ± 1.30 1.70
Experiential avoidance 19.35 ± 1.46 17.71 ± 0.99 3.54** 20.40 ± 1.55 19.86 ± 1.25 1.19

Table 5
Comparison between the intervention group and control group in terms of mental health and experiential avoidance of symptomatic but contented individuals before
and after intervention (M ± SD).
Item Before intervention T After intervention T

Experimental group Control group Experimental group Control group

Psychological distress 5.23 ± 1.36 5.13 ± 1.12 0.21 3.00 ± 1.29 4.86 ± 0.74 − 4.77**
Well-being 57.69 ± 3.30 57.46 ± 2.47 0.21 62.38 ± 3.23 57.86 ± 3.36 3.62**
Positive emotions 13.31 ± 1.31 14.00 ± 1.36 − 1.36 15.46 ± 1.56 14.13 ± 1.45 2.33**
Positive psychological functioning 24.15 ± 1.62 24.13 ± 1.46 0.04 25.92 ± 1.70 24.20 ± 1.47 2.87**
Interpersonal relationship satisfaction 17.46 ± 1.26 18.01 ± 1.07 − 1.22 19.54 ± 1.51 17.67 ± 1.11 3.77**
Experiential avoidance 29.38 ± 2.98 28.00 ± 2.50 1.33 20.53 ± 3.45 27.40 ± 1.50 − 6.98**

Table 6
Comparison between the intervention group and control group in terms of mental health and experiential avoidance of symptomatic but contented individuals before
and after intervention (M ± SD).
Item Before intervention T After intervention T

Experimental group Control group Experimental group Control group

Psychological distress 5.23 ± 1.36 3.00 ± 1.29 4.76** 5.13 ± 1.36 4.86 ± 0.74 1.46
Well-being 57.69 ± 3.30 62.38 ± 3.22 − 3.75** 57.46 ± 2.47 57.86 ± 3.35 ¡0.35
Positive emotions 13.31 ± 1.31 15.46 ± 1.56 − 4.94** 14.00 ± 1.36 14.13 ± 1.45 − 0.20
Positive psychological functioning 24.15 ± 1.62 25.92 ± 1.71 − 2.76** 24.13 ± 1.45 24.20 ± 1.47 − 0.13
Interpersonal relationship satisfaction 17.46 ± 1.26 19.54 ± 1.50 − 3.57** 18.03 ± 1.06 17.67 ± 1.12 0.89
Experiential avoidance 29.54 ± 2.98 20.54 ± 3.45 6.34** 28.00 ± 2.50 27.40 ± 1.50 1.14

Table 7
Comparison between the intervention group and control group in terms of mental health and experiential avoidance of distressed individuals before and after
intervention (M ± SD).
Item Before intervention T After intervention T

Experimental group Control group Experimental group Control group

Psychological distress 6.41 ± 1.37 6.43 ± 1.39 − 0.02 4.33 ± 1.07 6.29 ± 1.33 − 4.08**
Well-being 38.75 ± 1.95 39.07 ± 2.40 − 0.37 42.08 ± 1.38 39.50 ± 2.37 3.31**
Positive emotions 10.25 ± 1.13 10.21 ± 1.12 0.08 12.25 ± 1.13 11.14 ± 0.77 2.94**
Positive psychological functioning 19.58 ± 2.11 19.07 ± 1.85 0.66 21.83 ± 1.75 18.71 ± 1.86 4.38**
Interpersonal relationship satisfaction 12.08 ± 0.90 11.71 ± 0.61 1.23 13.33 ± 1.23 12.43 ± 0.64 2.39*
Experiential avoidance 33.58 ± 1.51 32.71 ± 1.38 1.54 30.75 ± 1.28 32.57 ± 1.55 − 3.22**

control group in psychological distress and experiential avoidance, but and after the intervention in the intervention group and it is noteworthy
significantly higher than the control group in well-being. that after the intervention, the control group has significantly higher
From Table 8, it can be seen that there is significant difference before positive emotions and interpersonal relationship satisfaction than before

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W. Xu et al. Children and Youth Services Review 124 (2021) 105960

Table 8
Comparison between the intervention group and control group in terms of mental health and experiential avoidance of distressed individuals before and after
intervention (M ± SD).
Item Before intervention T After intervention T

Experimental group Control group Experimental group Control group

Psychological distress 6.41 ± 1.38 4.33 ± 1.07 9.10** 6.43 ± 1.39 6.28 ± 0.74 0.49
Well-being 38.75 ± 1.95 42.08 ± 1.37 − 5.28** 39.07 ± 2.40 39.50 ± 2.37 ¡0.38
Positive emotions 10.25 ± 1.13 12.25 ± 1.13 − 7.27** 10.21 ± 1.12 11.14 ± 1.12 − 2.74*
Positive psychological functioning 19.58 ± 2.11 21.83 ± 1.75 − 2.25** 19.07 ± 1.86 18.71 ± 1.85 0.61
Interpersonal relationship satisfaction 12.08 ± 0.96 13.33 ± 1.23 − 2.39** 11.71 ± 0.61 12.43 ± 0.64 − 3.68**
Experiential avoidance 33.58 ± 1.50 30.75 ± 1.28 4.93** 32.71 ± 1.38 32.57 ± 1.55 0.46

the intervention. health (Suldo et al., 2019). But Suldo et al. pointed out that targeted
interventions should be adopted for different types of mental health
4. Discussion problems. For vulnerable individuals, their psychological distress and
subjective well-being are both low. Previously, this group was excluded
4.1. Mental health of adolescents during the epidemic in numerous intervention researches, because according to the tradi­
tional viewpoints, those who do not show negative psychopathological
The mental health of 1,018 adolescents was first investigated in this symptoms require no intervention (Dong et al., 2018). However, Suldo
study. According to the classification standard, healthy individuals ac­ and Shaffer (2008) thought it necessary to intervene in vulnerable in­
count for 49.31% of the total number, vulnerable individuals for dividuals, especially to improve their subjective well-being. It was
15.03%, symptomatic but contented individuals for 13.06%, and dis­ documented in previous studies that physical exercise can not only
tressed individuals for 22.59%. This finding is basically consistent with effectively improve individuals’ positive emotions, for example,
those of Suldo and Shaffer (2008) and Suldo et al. (2016). In the online self-satisfaction (Garcia & Archer, 2016), but also work well for those
learning environment during the epidemic, adolescents have low psy­ with mild psychological distress, such as mild depression and anxiety
chological distress, high subjective well-being and high mental health, (Gujral et al., 2019).
which is probably closely related to the active psychological building ACT based on mindfulness focuses on improving psychological
and counseling for adolescents ever since the outbreak (Zhu et al., flexibility of individuals, helping individuals defuse negative experi­
2020). Notably, vulnerable and distressed individuals were also found in ences cognitively, lowering their experiential avoidance, and enhancing
this study to make up certain proportions. This finding is similar to the their subjective well-being (Xu et al., 2019). Influenced by the epidemic,
results of the investigation by Golberstein, Wen and Miller (2020). adolescents have less direct contact with the outside world, lack inter­
Hence, it can be seen that a part of adolescents still have low subjective personal interaction with peers and have a narrow space in family life.
well-being during the epidemic (Li & Li, 2020). As for the reasons, first The heavy tasks in online learning and other reasons lower their positive
of all, the infectivity and severity of COVID-19 have led to a certain emotional experience and result in their dissatisfaction with interper­
degree of psychological panic among adolescents, and brought about a sonal relationship (Duan et al., 2020). Nevertheless, the intervention of
negative impact on their mental health. Secondly, this should be related ACT is able to enhance psychological flexibility of adolescents, so that
to the shift of adolescents’ learning mode from school learning to they no longer avoid unpleasant experience and emotions in the current
full-time online learning. It was indicated in some studies that in an life, but accept and commit to acting with self-value, so that their sub­
information-based learning environment, physical and mental health of jective well-being is increased.
students were more vulnerable and they are most likely to suffer from
poor spirits and decreased physical health, etc., so that their subjective
4.3. Intervention effect of aerobic exercise in combination with ACT on
well-being is negatively affected. This result also suggests that even if
mental health of symptomatic but contented individuals
some adolescents do not show obvious psychological problems for the
time being, it is still necessary to take psychological defense measures on
According to the results of this study, before the intervention,
adolescents universally and give them positive support, in order to
symptomatic but content individuals in the two groups are at the same
protect their mental health and help potential vulnerable and symp­
baseline level, but after the intervention, the intervention group has
tomatic but contented individuals to restore to a healthy level as far as
significantly lower psychological distress and experiential avoidance,
possible.
but significantly higher subjective well-being. On the other hand, there
is no significant difference before and after the intervention in the
4.2. Intervention effect of aerobic exercise in combination with ACT on control group. This finding is consistent with that of consistent with that
mental health of vulnerable individuals of Bauer et al. (2020) who conducted sports and mental health inter­
vention in German adolescents during the epidemic. First of all, symp­
According to the results of this study, after the intervention by aer­ tomatic but contented individuals have not only high psychological
obic exercise in combination with ACT, compared with the control distress (i.e. negative psychological state), but also high subjective
group, vulnerable individuals in the intervention group have signifi­ well-being. Suldo and Shaffer (2008) contended that due to a high
cantly lower psychological distress, but significantly higher subjective positive psychological state, symptomatic but contented individuals
well-being (including positive emotions, positive psychological func­ perceive decreasing pain and discomfort. But at the same time, it should
tioning and interpersonal relationship satisfaction), and significantly be noted that this group also has higher negative psychological symp­
lower experiential avoidance. This result is consistent with those of toms. Without necessary intervention, their positive psychological state
Chen, Hu, He and Lai (2018) and Mansfield et al. (2018). According to may be negatively affected, and this group is more likely to be converted
the dual-factor model of mental health, mental health includes both the to distressed individuals. According to the results of this study, it can be
absence of negative psychological symptoms and the presence of posi­ learned that in the online learning environment during the epidemic,
tive psychological state. On this account, minimizing negative psycho­ -symptomatic but contented individuals account for about 12% of all the
logical state and improving positive psychological state should also be adolescents, a figure that cannot be ignored. There are two reasons why
taken into consideration when carrying out intervention in mental the intervention of aerobic exercise in combination with ACT can

6
W. Xu et al. Children and Youth Services Review 124 (2021) 105960

effectively reduce the negative psychological symptoms of symptomatic learning environment, got in touch with their peers and took part in
but contented individuals and significantly improve their positive psy­ interpersonal activities, etc., which satisfies their basic psychological
chological state. First of all, it is easy for adolescents to engage in aerobic demands and enhanced their positive emotions (Luo et al., 2017).
exercise, which is a simple and easy-to-operate form of physical exercise,
during the epidemic, (Chen, 2020). Exercise itself can help adolescents 5. Conclusion
stretch their body and develop a sense of power, further enhance their
physical self-image and cultivate their self-identity. It also allows ado­ During the sudden public health emergency of the COVID-19, health
lescents to discharge the sense of helplessness or pressure induced by adolescents still account for nearly 50%, but the proportions of symp­
online learning and anxiety induced by the inability to interact with tomatic but contented adolescents and distressed adolescents are high,
others (Bailey et al., 2017). To sum up, physical exercise can improve which suggests grim mental health status of adolescents. Noticeably,
and alleviate the physical symptoms of adolescents and directly promote aerobic exercise in combination with ACT effectively improves subjec­
their mental health. Secondly, exercise in combination with ACT, more tive well-being of vulnerable, symptomatic but contented and distressed
importantly, lowers experiential avoidance of adolescents and enhance individuals, lowers their psychological distress, and especially has a
their psychological flexibility. Previous studies have demonstrated and prominent intervention effect on the vulnerable group. This indicates
proved the positive effect of ACT on the improvement of psychotic that we should not only pay attention to negative psychological distress
symptoms, including pain, depression and anxiety, etc. (Hughes et al., of adolescents during the epidemic of sudden public health emergencies,
2017). What’s more, Casey et al. (2018) found that compared with but also keep an eye on changes in their positive psychological state.
physical exercise intervention alone, the comprehensive intervention of Educators and parents involved should encourage adolescents to exer­
exercise in combination with ACT can improve individuals’ persistence cise moderately, provide them psychological counseling whenever
in physical exercise, thus maximizing the intervention effect. necessary, enhance their psychological flexibility and lower their
experiential avoidance. Nevertheless, there are still some shortcomings
4.4. Intervention effect of aerobic exercise in combination with ACT on in this study. First of all, the intervention lasted only 8 weeks, but it is a
mental health of distressed individuals long-term process for changes in psychological flexibility. Therefore, in
future studies, the intervention time can be prolonged appropriately.
Similarly, aerobic exercise in combination with ACT can significantly Secondly, the relationship among psychological distress, subjective
lower psychological distress of distressed individuals, significantly in­ well-being and experiential avoidance was not explored in depth. Pre­
crease their subjective well-being, lower their experiential avoidance vious studies have shown that ACT affects mental health by improving
and enhance their psychological flexibility. A slight difference is that psychological flexibility and lowering experiential avoidance. There­
distressed individuals in the control group have significantly higher fore, the mediating role of psychological flexibility can be further
positive emotions and interpersonal relationship satisfaction after the examined in future studies. Thirdly, aerobic exercise and ACT were
intervention. Suldo and Shaffer (2008) showed clearly that social conducted simultaneously in this study. In the future, other control
functioning, learning adaptability and physical health of distressed in­ groups can be established to investigate the differences between aerobic
dividuals are lower than those of other types. Particularly during the exercise alone and aerobic exercise in combination with ACT.
COVID-19, due to the fear of the spread of this disease and ballyhoo of Compliance with ethical standards
social media, etc., adolescents generally have a low sense of self-efficacy All procedures performed in studies involving human participants
as to whether they can resist this disease or not (Davis et al., 2020). were in accordance with the ethical standards of the institutional and/or
Aerobic exercise intervention can directly reinforce their bodily func­ national research committee and with the 1964 Helsinki declaration and
tions, enhance their vitality in physical exercise and improve their its later amendments or comparable ethical. Informed consent was ob­
physiological health (Luo et al., 2020). As mentioned above, ACT can tained from all individual participants included in the study.
promote the intervention effect of physical exercise. Funding
In addition, ACT can effectively improve psychological flexibility of This study was supported by The National Social Science Fund of
adolescents, lower their experiential avoidance and help them accept China (19BTY017).
their existing unpleasant life experience. More importantly, they can
accept, defuse, be mindful and make commitments and take actions with CRediT authorship contribution statement
an observational self-value orientation (Xu et al., 2019). However,
Hayes et al. (2006) pointed out that ACT focuses on changing in­ Wenxin Xu: Conceptualization, Methodology, Investigation, Writing
dividuals’ psychological functioning, rather than changing their symp­ - original draft, Writing - review & editing. Wei Shen: Data curation,
toms. The lower the previous psychological functioning, the longer it Visualization, Investigation, Writing - original draft. Shen Wang:
takes to change. And this is the reason why the number of distressed Investigation, Supervision, Software, Writing - review & editing.
individuals in the intervention group who have changed after the
intervention is lower than that of symptomatic but contented in­
Declaration of Competing Interest
dividuals. Specifically, symptomatic but contented individuals have a
higher level of positive psychology, which can help promote the inter­
The authors declare that they have no known competing financial
vention effect. However, distressed individuals have impaired positive
interests or personal relationships that could have appeared to influence
psychological functioning and severe negative psychological symptoms,
the work reported in this paper.
so that longer-term intervention is required to improve their mental
health (Suldo et al., 2019). This also indirectly reveals that the inter­
vention mode of aerobic exercise in combination with ACT -is effective Appendix A. Supplementary material
for the promotion of mental health of distressed individuals. This in­
dicates that in the future, the intervention time for distressed individuals Supplementary data to this article can be found online at https://doi.
can be extended appropriately. Moreover, for distressed individuals in org/10.1016/j.childyouth.2021.105960.
the control group, the significant increase in positive emotions and
interpersonal relationship satisfaction is probably caused by factors in References
the external environment. With the decrease of the level of epidemic
Ahmed, Z., Ahmed, O., Aibao, Z., Hanbin, S., & Ahmad, A. (2020). Epidemic of covid-19
prevention and control, schools across the country have gradually in china and associated psychological problems. Asian Journal of Psychiatry, 2020
resumed classes, while students have also gradually entered an offline (51), Article 102092.

7
W. Xu et al. Children and Youth Services Review 124 (2021) 105960

Antaramian, S. P., Huebner, E. S., Hills, K. J., & Valois, R. F. (2015). A dual-factor model survey, 112954 Psychiatry Research, 288. https://doi.org/10.1016/j.
of mental health: Toward a more comprehensive understanding of youth psychres.2020.112954.
functioning. American Journal of Orthopsychiatry, 80(4), 462–472. Hughes, L. S., Clark, J., Colclough, J. A., Dale, E., & McMillan, D. (2017). Acceptance and
Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of commitment therapy (ACT) for chronic pain. The Clinical Journal of Pain, 33(6),
acceptance and commitment therapy for adolescent obsessive-compulsive disorder. 552–568.
Journal of Cognitive Psychotherapy, 27(2), 175–190. Jiang, F. (2009). Compiling of GSES for happiness of undergraduates. Henan Social
Bailey, K. A., Gammage, K. L., & van Ingen, C. (2017). How do you define body image? Sciences, 17(2), 196–198.
Exploring conceptual gaps in understandings of body image at an exercise facility. Keyes, C. L. M., & Annas, J. (2009). Feeling good and functioning well: Distinctive
Body Image, 23, 69–79. concepts in ancient philosophy and contemporary science. Journal of Positive
Bauer, L. L., Seiffer, B., Deinhart, C., Atrott, B., Sudeck, G., Hautzinger, M., … Wolf, S. Psychology, 4(3), 197–201.
(2020). Associations of exercise and social support with mental health during Li, X. X., & Li, D. (2020). Correlation between physical activity and emotion of
quarantine and social-distancing measures during the COVID-19 pandemic: A cross- adolescents living at home during the COVID-19 pandemic. Journal of Beijing Sport
sectional survey in Germany. MedRxiv [in press]. University, 43(3), 84–91.
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., … Li, Y. M., & Li, Y. X. (2015). The factor structure of the 12-iten general health
Zettle, R. D. (2011). Preliminary psychometric properties of the acceptance and questionnaire: The multi-group analyses. Psychological Exploration, 35(4), 68–72.
action questionnaire-II: A revised measure of psychological inflexibility and Luo, J. J., Dong, H. L., Ding, Q. W., & Li, D. P. (2017). Cumulative ecological risk and
experiential avoidance. Behavior Therapy, 42(4), 676–688. adolescent internet addiction: A moderating role of effortful control. Chinese Journal
Cao, J., Ji, Y., & Zhu, Z. H. (2013). Reliability and validity of the Chinese version of the of Clinical Psychology, 25(5), 893–896.
acceptance and action questionnaire-second edition (AAQ-II) in college students. Luo, L., Zeng, X. J., Liao, X., & Yang, Y. Q. (2020). Disease cognition, coping style and
Chinese Mental Health Journal, 27(11), 873–877. exercise behavior among the public during novel coronavirus epidemic: An online
Casey, M. B., Smart, K., Segurado, R., Hearty, C., Gopal, H., Lowry, D., … Doody, C. survey. Chinese Journal of Public Health, 36(2), 156–159.
(2018). Exercise combined with Acceptance and Commitment Therapy (ExACT) Ma, L., & Yuan, L. (2018). Research on the application of keep app in College Aerobics
compared to a supervised exercise programme for adults with chronic pain: Study Class. China School Physical Education(Higher Education), 5(8), 41–44.
protocol for a randomised controlled trial. Trials, 19(1), 1–14. Mansfield, L., Kay, T., Meads, C., Grigsby-Duffy, L., Lane, J., John, A., … Payne, A.
Chang, J. H., Yuan, Y. X., & Wang, D. (2020). Mental health status and its influencing (2018). Sport and dance interventions for healthy young people (15–24 years) to
factors among college students during the epidemic of COVID-19. Journal of Southern promote subjective well-being: A systematic review. BMJ open, 8(7). e020959.
Medical University, 40(2), 171–176. Rodriguez-Ayllon, M., Cadenas-Sanchez, C., Estevez-Lopez, F., Munoz, N. E.,
Chen, W. N. (2020). Micro class design of primary and secondary school students’ home Moragonzalez, J., Migueles, J. H., … Estebancornejo, I. (2019). Role of physical
physical exercise under the epidemic situation. Teaching & Learning of Physical activity and sedentary behavior in the mental health of preschoolers, children and
Education, 40(3), 24–25. adolescents: A systematic review and meta-analysis. Sports Medicine, 49(9),
Chen, Y., Hu, M. R., He, H. J., & Lai, X. (2018). A case report of acceptance commitment 1383–1410.
therapy for a junior high school student with anorexia. Chinese Mental Health Journal, Song, M., Zhou, J. C., Ma, J., Li, Q., Zhou, J. P., Jia, Y. Y., & Ni, C. P. (2019). Relationship
32(9), 734–737. between empathy ability and perceived social support in military college students.
Davis, C., Chong, N. K., Oh, J. Y., Baeg, A., Rajasegaran, K., & Chew, C. S. E. (2020). Chinese Mental Health Journal, 33(2), 149–152.
Caring for children and adolescents with eating disorders in the current COVID-19 Suldo, S. M., & Shaffer, E. J. (2008). Looking beyond psychopathology: The dual-factor
pandemic: A Singapore perspective. Journal of Adolescent Health., 67(1), 131–134. model of mental health in youth. School Psychology Review, 37(1), 52–68.
Dong, T. T., Zhang, C. S., Zhang, Z. Q., Dong, Y. Y., & Li, F. (2018). A meta-analysis of Suldo, S. M., Storey, E. D., Obrennan, L. M., Shaunessydedrick, E., Ferron, J. M.,
mindfulness-based stress reduction for improving symptoms of post-traumatic stress Dedrick, R. F., & Parker, J. S. (2019). Identifying high school Freshmen with signs of
disorder. Chinese Mental Health Journal, 32(001), 7–14. emotional or academic risk: Screening methods appropriate for students in
Duan, L., Shao, X., Wang, Y., Huang, Y., & Zhu, G. (2020). An investigation of mental accelerated courses. School Mental Health, 11(2), 210–227.
health status of children and adolescents in china during the outbreak of covid-19. Suldo, S. M., Thalji-Raitano, A., Kiefer, S. M., & Ferron, J. M. (2016). Conceptualizing
Journal of Affective Disorders, 275, 112–118. high school students’ mental health through a dual-factor model. School Psychology
Dun, Y. (2020). Psychological care in children and adolescents during the COVID-19 Review, 45(4), 434–457.
epidemic. Chinese Mental Health Journal, 2020, 34(3): 269-270. Tennant, R., Hiller, L., Fishwick, R., Platt, S., Joseph, S., Weich, S., … Stewartbrown, S.
Garcia, D., & Archer, T. (2016). Affectivity profiling in relation to exercise: Six-months (2007). The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): Development
exercise frequency, motivation, and basic psychological needs fulfilment. Clinical and UK validation. Health and Quality of Life Outcomes, 5(1), 63.
and Experimental Psychology, 2(2), 1–6. Wang, X. Q., & Zhang, D. J. (2011). A review of the dual-factor model of mental health
Goldberg, D., & Hillier, V. F. (1979). A scaled version of the general health questionnaire. and its prospects. Chinese Journal of Special Education, 19(10), 68–73.
Psychological Medicine, 9(1), 139–145. Wright, N., Turkington, D., Kelly, O., Davies, D., Jacobs, A., & Hopton, J. (2014).
Golberstein, E., Wen, H., & Miller, B. F. (2020). Coronavirus disease 2019 (COVID-19) Treating psychosis: A clinician’s guide to integrating acceptance and commitment
and mental health for children and adolescents. JAMA pediatrics, 174(9), 819–820. therapy, compassion-focused therapy and mindfulness approaches within the
Greenspoon, P. J., & Saklofske, D. H. (2001). Toward an integration of subjective well- cognitive behavioral therapy tradition. Journal of Adolescent Health Official
being and psychopathology. Social Indicators Research, 54(1), 81–108. Publication of the Society for Adolescent Medicine, 15(3), 228–237.
Gujral, S., Aizenstein, H., Reynolds, C. F., Butters, M. A., Grove, G., Karp, J. F., & Xiong, J., Qin, Y., Gao, M., & Hai, M. (2017). Longitudinal study of a dual-factor model of
Erickson, K. I. (2019). Exercise for depression: A feasibility trial exploring neural mental health in Chinese youth. School Psychology International, 38(3), 287–303.
mechanisms. American Journal of Geriatric Psychiatry, 27(6), 611–616. Xu, Y. M., Zhang, Q., & Cao, H. (2019). Intervention effect of acceptance and
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy group treatment on improving mental health of college
commitment therapy: Model, processes and outcomes. Behaviour Research and students. Psychology: Techniques and Applications, 7(11), 648–657.
Therapy, 44(1), 1–25. Zhu, X. L., Liu, D., Yan, F., Qu, W., Fan, H. Z., Zhao, Y. L., … Tan, S. P. (2020).
Huang, Y., & Zhao, N. (2020). Generalized anxiety disorder, depressive symptoms and Psychological status of school students and employees during the COVID-19
sleep quality during COVID-19 outbreak in China: A web-based cross-sectional epidemic. Chinese Mental Health Journal, 34(6), 549–554.