Physical activity in adolescence is well known to promote optimal physical and mental health outcomes both immediately and over the long term [1-5]. Despite the benefits, most youth in the United States do not meet recommendations set forth by the Physical Activity Guidelines for Americans, 2nd Edition [6,7]. Youth with psychiatric disorders, who represent 1 in 5 children and adolescents in the United States per year [8], fall even further behind [9], contributing to a disproportionate risk of chronic disease [10]. Importantly, physical activity and sleep are bidirectionally associated, where physical activity contributes to improved sleep quality and duration, and vice versa [11]. Sleep disturbance rates are notably higher among youth with psychiatric conditions and likely exacerbate mental health symptoms [12], highlighting the value of treatments that can address both low physical activity and poor sleep simultaneously.

Youth with psychiatric disorders face unique barriers that reduce the likelihood of participating in physical activity programming, such as social isolation and peer exclusion, dislike of competition, preference for solitary activity, motor delays, dysregulation, medication side effects, and negative experiences with previous programming [13]. For youth with physical, cognitive, or self-regulatory challenges, additional parent or caregiver support and action may be required for engagement in physical activity [14]. There is a critical need for health programming to reduce chronic disease disparities in this population through the adaptation and use of behavioral health programming that overcomes these reported barriers by providing pragmatic support to parents and youth in multiple settings [14].

Physical activity interventions, in conjunction with traditional mental health treatment (ie, psychotherapy), have been shown to improve symptoms related to psychiatric conditions such as autism spectrum disorder [15], depression [16], anxiety [17], and attention-deficit/hyperactivity disorder [18]. Improvements in sleep similarly benefit a wide range of cognitive, affective, and behavioral outcomes in youth with psychiatric disorders [19]. For these reasons, mental health treatment providers are encouraged to use exercise as medicine through behavioral prescriptions [20] and to promote positive sleep hygiene [21]. Despite evidence of the importance of physical activity and sleep in mental health treatment, there are mixed reports of clinician uptake, with several studies documenting that physical activity interventions remain underused [22] and only a small proportion of clinicians providing recommendations that are consistent with scientific evidence and national guidance [23]. This may be due, in part, to a lack of clinician training and practical barriers for clients [24].

GamerFit is a theory-based exergaming (ie, gaming that requires physical exertion) and telehealth physical activity coaching intervention that has shown efficacy in promoting physical activity and sleep [25,26] and consequently in producing positive psychosocial outcomes (ie, self-regulation, affect, health related quality of life, and social support) among youth aged 13 to 17 years with psychiatric diagnoses [27]. It was adapted from the evidence-based GameSquad intervention designed for youth with overweight and obesity [25]. Adaptations were made to accommodate the needs of youth with heterogeneous and comorbid psychiatric diagnoses based on disability-informed empowerment theory [28]. This 12-week intervention uses a mobile app that incorporates telehealth coaching, exergaming challenges, and on-demand exercise videos to increase physical activity levels and improve sleep hygiene [25]. Exergames are video games that require exertion or physical activity from the user and may be more pleasant and enjoyable than traditional modes of physical activity based on user characteristics, including leisure time preferences [29]. GamerFit participants use an app that includes a menu of exergames to select (and then play the games on a separate video game console); progressive physical activity and sleep hygiene planning and tracking; step tracking that automatically syncs with a Fitbit (Fitbit Inc), which automatically uploads data to the app for self-monitoring and coach monitoring; real-time automated feedback; prerecorded videos using peer modeling to promote health behaviors; and preset motivational texting encouraging youth to engage in at least 60 minutes per day of moderate-to-vigorous physical activity and to achieve 8 to 10 hours per day of quality sleep. App users, with an accompanying caregiver, schedule telehealth sessions with a trained coach once weekly for 12 weeks, to set physical activity and sleep goals and to overcome barriers to achieving weekly goals. The coaches are trained in motivational and goal-setting principles and, importantly, do not need to have a specific license or background in mental health treatment or exercise physiology. The app and intervention were designed by the research team and developed by a third-party developer; it is not available in the public domain. This intervention offers a solution to overcome youth and family barriers to engagement in physical activity by providing structured, child-focused programming in the home setting and accountability with a telehealth coach.

The next step of this work was to translate GamerFit for clinical use to improve accessibility for youth with psychiatric disorders. To do so, the purpose of this study was to explore clinician feedback on incorporating GamerFit into ongoing mental health treatment, ultimately to help clinicians make physical activity and sleep prescriptions.

Practicing mental health clinicians participated in 1 of 2 focus groups to review the GamerFit intervention and provide feedback on incorporating this program into ongoing mental health treatment to facilitate physical activity and sleep prescriptions. GamerFit was widely perceived as important, clinically feasible, appealing, and appropriate for the target population (ie, youth with common, often comorbid, psychiatric diagnoses). Clinicians identified suggested adaptations to improve clinical workflow and usability as well as suggestions to improve patient engagement.

Many clinicians reported that physical activity and sleep are important aspects of supporting optimal mental health and expressed a desire to incorporate health behavior counseling into their treatment practices. However, they did not feel confident in their training and abilities to incorporate robust eHealth-based physical activity and sleep interventions within sessions with clients. Moreover, there were mixed findings regarding the use of screens for health promotion: some clinicians viewed this as an opportunity to appeal to client interests in media and gaming and to improve accessibility, particularly for those without safe environments for other forms of physical activity, whereas others were more hesitant, given the already high levels of screen time in youth. These findings are consistent with other reports from mental health clinicians on the utility of eHealth in psychiatry, as described by Nicholas et al [31], who found enthusiasm for improving accessibility to treatment in a widely available manner that overcomes resource limitations and simultaneously reduces mental health stigma as a barrier to care. Furthermore, eHealth interventions offer clients the opportunity to access support and to engage with treatment in real time as needed.

In addition to concerns about sedentary behavior associated with screen time, ensuring client confidentiality and data privacy is essential in the design and implementation of eHealth programming. Transparency in data collection purposes and use, as well as established trust between the user, clinician, and the technology or platform itself, are required to overcome this obstacle [31]. eHealth interventions embedded within mental health treatment practices also offer opportunities to enhance real-time self-monitoring, extend clinicians’ assessment of clients within their natural environment (eg, including caregiver involvement), and facilitate data processing to support personalized treatment plans and decision-making [32].

The next finding of this qualitative study was the perceived feasibility and acceptability of the GamerFit intervention in the clinical setting. Overall, the intervention was deemed to be practical, with some aspects perceived to be more engaging than others (eg, health coaching as a critical component, whereas in-app journaling for self-monitoring behavior goals was seen as less likely to be completed). Furthermore, suggestions were made for adapting the intervention based on client age and diagnoses, for example, linking in-app earned rewards with age-appropriate tangible rewards or using the sleep prescription to avoid oversleeping among some youth with depression. The biggest concerns about feasibility and acceptability were potential technical challenges and the likelihood that some clients would require support from parents or caregivers.

Results of this study will be used to help match future features with clinician and client needs (ie, integration into electronic medical records systems and an expanded selection of exergames) [33]. eHealth interventions are widely effective in treating mental health disorders when used alongside psychotherapy, particularly when they are guided (vs unguided) [34], as is the case with the GamerFit intervention. Previous studies have shown that children with psychiatric disorders prefer eHealth interventions that use features such as videos, limited text, personalization options, opportunities to connect with others, and texting reminders [35], all of which are incorporated into the GamerFit intervention. Future iterations of GamerFit will likely provide more evidence on how to best support users with technological challenges, and the inclusion of a health coach is intended to overcome support needs that would typically be required of parents and caregivers. Caregivers are often resource depleted (ie, limited in time and energy) and constrained in taking on additional responsibilities. The GamerFit app may help overcome these limitations by applying external accountability and motivation through remote health coaching, thereby encouraging engagement in healthy physical activity and sleep practices.

Limitations of the study included the relatively homogenous sample of participants in the focus groups in terms of race and gender. However, this sample is representative of the demographic majority of the US psychology workforce [36]. An additional limitation is the potential of eHealth interventions to widen the divide in health disparities for those with limited digital literacy and device ownership [31]. Digital literacy and access to technology; data storage; Wi-Fi capabilities; compliance with wearing the Fitbit; and the cognitive abilities and planning skills needed to adhere to the scheduled appointments with the health coach and to complete the physical activity, sleep, and exergaming goals must be considered in the design and implementation of this treatment option.

This study facilitates the translation of a research-based intervention to real-world application for the alleviation of mental and physical health symptoms among a population at elevated risk via direct input from key collaborators (ie, the mental health clinicians). These findings will inform the adaptation and integration of GamerFit as an adjunct to clinical practice with specific considerations for the user (ie, clinician and client) experience, resources, and capabilities.