Taking actions to maintain a healthy lifestyle, including regular engagement in physical activity (PA) and reducing sedentary behavior (SB), may protect against the development of internalizing problems among healthy youth. However, it remains unclear whether such associations exist among youth with chronic pain who often report symptoms of depression and anxiety. The study investigated the associations between independent and combined PA and/or SB patterns with indicators of internalizing problems in children and adolescents (referring to youth) aged 6–17 years. The results indicated that PA was negatively associated with anxiety and depressive symptoms. Specifically, youth with chronic pain who engaged in at least 60–minute PA for 1–3 days, 4–6 days, or every day reported significantly lower likelihood of experiencing symptoms of anxiety (OR = 0.71, 95% CI: 0.60–0.84; OR = 0.44, 95% CI: 0.36–0.53; OR = 0.50, 95% CI: 0.40–0.63, respectively; all p-value < 0.001) and depression (OR = 0.63, 95% CI: 0.53–0.75; OR = 0.38, 95% CI: 0.31–0.47; OR = 0.46, 95% CI: 0.36–0.59, respectively; all p-value < 0.001) symptoms compared to those with 0 days. Conversely, SB (operationalized via the proxy screen time) was positively associated with anxiety and depression symptoms. Youth with chronic pain who reported 4 or more hours of daily screen time had significantly higher odds of experiencing symptoms of anxiety (OR = 2.17, 95% CI: 1.52–3.09, p < 0.001) and depression (OR = 2.30, 95% CI: 1.48–3.59, p < 0.001). Furthermore, youth with chronic pain who engaged in higher PA levels and reported lower SB levels had a lower likelihood of experiencing symptoms of anxiety (OR = 0.68, 95% CI: 0.52–0.87, p = 0.003) and depression (OR = 0.49, 95% CI: 0.34–0.70, p < 0.001) symptoms compared to those with lower PA levels and higher SB levels. In conclusion, This cross-sectional study showed higher PA levels and lower SB levels were associated with a reduced likelihood of developing anxiety and depression symptoms, which are indicative of internalizing problems, among youth with chronic pain.
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