Attention deficit hyperactivity disorder (ADHD): implications for physical educators.

Behaviors of children and youth with Attention Deficit Hyperactivity Disorder (ADHD) are often reported as problematic by educators and parents. Physical educators may be overwhelmed by students with ADHD.

Frequency and intensity of poor attending, impulsivity, and inappropriate and often purposeless motor behavior are easily confused with conduct problems, mood disorders, learning disabilities, or even mental retardation. The purpose of this article is to provide an understanding of the nature of ADHD, characteristics which physical educators should consider, and generally appropriate instruction strategies.

ADHD Defined

Although several authorities have reported definitions of ADHD (Barkley, 1990; Hinshaw, 1987; Whalen, 1980), the American Psychiatric Association Diagnostic and Statistical Manual (4th ed. 1994) is frequently cited on matters of defining the disorder (McBurnett, Lahey, & Pfiffner, 1993); this publication is often abbreviated as DSM-IV. According to the task force that developed the 1994 definition of ADHD, essential diagnostic features include inattention (IA) and/or hyperactivity-impulsivity (HI). Table 1 displays the diagnostic criteria.

Children exhibiting six of the nine IA symptoms and at least six of nine HI symptom are considered Combined Typed. The subtype Predominantly Inattention Type is used if six or more IA symptoms have persisted for at least 6 months, but fewer than six HI symptoms have persisted for at least 6 months. Predominantly Hyperactive-Impulsive Type is used if six or more HI symptoms have persisted for 6 months, but fewer than six IA symptoms have persisted for 6 months.

Diagnosis of ADHD is contingent on IA and HI symptoms that are more frequent and severe than expected in children or youth of comparable developmental levels. Some symptoms must have been present before age 7 and must be present in two or more settings (e.g., school, home, playground). Further, symptoms must significantly impair social, academic, or occupational functioning. Attention deficit hyper- activity disorder is not diagnosed if symptoms are more indicative of another mental disorder, for example personality, anxiety, or mood disorders.

Diagnostic criteria listed in DSM-IV make clear that predominate features of this disorder are inattention and hyperactivity-impulsivity. Table 2 displays how these symptoms are commonly manifested in educational settings. Physical educators may need to implement specific instructional strategies to counter manifestations of inattention and hyperactivity-impulsivity.

Table 2
Symptoms and Manifestation of ADHD
Symptoms         Manifestations
Inattention
                 often fails to finish
                 easily distracted
                 difficultly concentrating
                 difficultly organizing work
                 shifts between activities frequently
                 needs prompting to persist with the
                 expected activity
                 does not seem to listen
Hyperactivity-
impulsivity      motor restlessness and fidgeting
                 rusn and climbs when inappropriate
                 difficulty staying seated or standing still
                 blurts out and interrupts others
                 difficulty following routines
                 difficulty waiting turns
                 fails to follow necessary steps

Etiology and Prevalence

Medical experts, psychologists, and educators do not know precisely what causes ADHD. Some scientists have reported evidence supporting the contention that the disorder is genetically transmitted and caused by a chemical imbalance or deficiency in certain neurotransmitters. This evidence has resulted in the general belief that ADHD is a neurologically-based medical problem and not caused by environmental factors (Fowler, 1990; Riccio, Hynd, Cohen & Gonzeles, 1993).

Prevalence of ADHD is said to affect between 3-5% of all children (APA, 1994), or approximately 600,000 to 1.2 million school-age children and youth (Reid, Maag & Vasa, 1993). Substantially more boys than girls are affected; male to female ratios of 4:1 to 9:1 have been reported (APA, 1994). Prevalence figures are rough estimates because ADHD cannot be precisely defined or measured (Barkley, 1990).

Characteristics

Emotional problems are often associated with ADHD (Nathan, 1991). Inappropriate responding and the frenzy of high active motor behaviors often cause conflicts with others. As a result, it is not uncommon to find students with ADHD who have few friends and harbor intense feelings of being bad that frequently lead to low self-esteem and depression.

Because medical diagnoses of ADHD are frequently associated with educational diagnoses of learning disabilities, mental retardation, or conduct disorders, it is not surprising that these students tend to perform below grade and chronological age expectations in basic academic content areas. Deficits in attention, compounded by hyperactivity and impulsivity, adversely influence academic achievement. Inattention at school may be demonstrated by not completing work correctly or not following through with an adult's requests. In addition, a student with ADHD may have difficulty staying in one place, waiting for a turn in a group, waiting in line, and thinking before acting.

Children and youth with ADHD frequently display disparities in performing gross and fine motor tasks (Freedman, 1971; Porter & Omizo, 1984; Safer Allen, 1976; Wender, 1987). However, there is likely to be considerable variability in motor performances of ADHD children and youth. Alexander (1990) presented a case study in which an adolescent diagnosed as ADHD was an outstanding member of his school's varsity ice hockey team. On the other hand, studies cited in a review of literature by Churton (1989) supported the contention that ADHD children and youth tended to perform poorly on tests measuring proficiency in visual motor tasks, perceptual-motor speed and accuracy, sensorimotor integration, and balance. It seems possible that deficits in attention and perception may interact in ways that would have adverse influences on the capacity of ADHD children and youth to move with control and efficiency.

Diagnosis

There is no simple test to determine if a child has ADHD. Diagnosis is based on assessments conducted by professionals, often a pediatrician and a psychologist, and generally includes (a) thorough medical history, (b) physical examination, (c) psychological tests, (d) application of behavior rating scales, and (e) observations of the student in a variety of settings. In addition, anecdotal records of teachers, interviews with parents, and systematic observations to quantify occurrences of inattention or hyperactivity-impulsivity are carefully considered in relation to the diagnostic process. Following interpretation of information gathered in the assessment process, professionals cooperatively assign an ADHD diagnosis if warranted. Professionals base the decision, in large part, on whether the student exhibits at least six of the IA or HI symptoms listed in DSM-IV IV (see Table 1). [TABULAR DATA TABLE OMMITTED TABLE 1]

Treatment

Drug therapy has often produced favorable effects on attending behavior (Barkley, 1977, 1990; Kavale, 1982; Lowenthal, 1993; Stevenson & Wolraich, 1989). Fagan (1985) reported 75% of school-age children and youth with ADHD benefited from drug therapy. Ritalin (methylphenidate) is often prescribed, but magnesium pemoline (Cylert) and Dexedrine have also been used.

Stimulant medications, and Ritalin in particular, produce improvements in many areas of life. It appears the medication stimulates regions of the brain believed to control the inhibitory process, arousal, and attention. This allows students with ADHD to be more sensitive to reinforcers available in the environment, thus often increasing self-control, attention span, and problem-solving. Academic achievement may approximate grade level expectations. The student may become more socially capable and less likely to emit behaviors associated with inattention or hyperactivity-impulsivity. Furthermore, Ritalin is safe for long term use, and is neither addictive nor harmful to internal organs (Forman, Hetznecker, & Dunn, 1983).

In spite of reported effectiveness of stimulant medications, drug therapy alone may not be sufficient (Fagan, 1985). Counseling intended to improve the child-parent and student-teacher relationships is often utilized. Likewise, behavior modification programs are often implemented to enhance internalization and generalization of appropriate social behaviors in home, school, and community settings (Barkley, 1990; Fowler, 1990; Goldstein & Goldstein, 1990).

Behavior modification techniques reinforcing occurrences of desired behaviors and withdrawing earned reinforcements for inappropriate behaviors have been used. Some experts recommend token economies because they usually include point charts prompting desired behaviors and include a response cost feature to decrease occurrences of inappropriate behaviors (Sullivan O'Leary, 1990; DuPaul, Guevremont, & Barkley, 1992). Point charts affixed to the student's desk or accompanying the student during the school day permit teachers to credit students for desired behaviors and deduct points for inappropriate behaviors.

Implications for Physical Educators

Students with ADHD are often misunderstood by physical educators who tend to equate inattention and hyperactivity-impulsivity with conduct disorders. The following suggestions should help physical educators accommodate students with ADHD.

Team-up with physicians, other educators, and parents. Since medications are commonly used to manage ADHD, physical educators are encouraged to inquire regarding anticipated affects of exercise on actions of a medication or side effects that might threaten the safety of students while engaging in physical activity. Stimulants, especially Ritalin, when prescribed at appropriately low dosages, are probably the safest, resulting in the fewest adverse side effects. Of side effects usually seen with use of stimulants, the most common include appetite reduction and sleep difficulties; much less common are nausea and headaches. An additional consideration educators should be made aware of is the rebound effect as the body metabolizes the medication out of the system. Anastopoulos, DuPaul, Barkley (1991) reported morning medication administration may result in a temporary increase of irritability and noncompliance a few hours after the last dose it taken.

Seeking advice and collaborating with the school psychologist and classroom teacher assigned to a student with ADHD can be helpful. Generally, behavior management programs implemented in the home and classroom can be discussed and procedures selected for application to physical education settings. For example, if a token economy system with response cost features operates successfully in the classroom, it would be useful for the physical educator to understand procedures whereby application to the physical education setting can be realized. In one school, a student with ADHD carried an index card to the physical educator who awarded or withdrew points based on the student's compliance with rules regarding attending and impulsivity. At the end of each class session, the card was returned to student's classroom teacher who entered the points into the token economy system operating in the classroom.

Parents may be useful sources of information regarding preferred physical activities. If preferred physical activities are developmentally appropriate physical education content, physical educators may elect to use preferred activities as reinforcers. For example, a physical educator could create the contingency whereby gaining access to operating a wheel toy near the close of the class session is contingent upon complying with rules relative to attending and compliance with teacher cues.

Structure the environment. One of the most frequently cited principles for delivery of instruction to students with ADHD is to establish a structured environment (Fagan, 1985; Jansma & French, 1995; Sherrill, 1993). The following teaching tips are generally consistent with this principle.

* Establish routines for beginning and

ending class sessions and routines for

making transitions from one activity to

another. For example, an elementary

school physical educator may choose

to use a routine to begin class involving

students taking a standing position

in a circle formation. Rules regarding

student conduct are cited and continually

reinforced (e.g., Rule No. 1--"Listen

to the teacher and do what the

teacher says"; Rule No. 2--"Keep

your hands and feet to yourself"). Following

recitation of rules, an introductory

activity can be initiated.

Transition routines might entail use of

a signal (e.g., the word freeze) requiring

students to stop activity and listen

for the next cue. Some teachers have

found that returning to a circle formation

in the center of the gymnasium is

an effective transition routine (Gering,

Bishop West, 1992). An ending

routine might involve the cue to lineup

quietly at the gymnasium door after

which students engage in imitating

hand jives presented by the physical

educator until the classroom teacher

arrives to escort students to the classroom

* Minimize waiting time in which students

are not engaged in motor activity.

Explanations and demonstrations

should be long enough to provide

meaningful cues, but not so lengthy as

to increase impulsivity. Activities that

require waiting in line or waiting one's

turn must be carefully monitored.

Marlow (1980) reported a variation of

traditional softball that minimized

waiting time. All players on the batting

team engaged in base running

when the ball was put in play. Similarly,

all players on the fielding team

engaged in fielding; one player retrieves

the struck ball, while all others

are engaged in partner catch with other

balls.

* Eliminate objects or events that are

distracting. It may be necessary to reduce

environmental space by creating

learning stations. Folding gymnastics

mats positioned vertically are sometimes

useful for creating a space

whereby distracting visual stimuli can

be eliminated. Many teachers are

likely to find that cones can also serve

to mark instructional areas and prompt

students to remain within the space

rather than engage irrelevant stimuli.

* Enhance relevant stimuli to counter inattention.

This can be accomplished in

a variety of ways. Some physical educators

have used environmental cues

like pasted down foot prints to prompt

appropriate footwork. At learning stations,

still graphics of movements to be

performed can enhance earlier verbal

cues. Sometimes large or novel targets

can be useful. One elementary school 

physical educator used a target in the

image of a clown's face with a balloon

affixed as the nose. This target may be

more relevant than selecting a spot on

the wall.

* Carefully manipulate the tempo of

each class session. It may be helpful

to alternate vigorous with less intense

activities. For example, alternating

movement education challenges

wherein students remain in their personal

space moving slowly and with

little force can be alternated with challenges

where students travel in general

space at a fast rate or with strong force.

* Reinforce students for appropriate attending

and motor behaviors when

they occur. Effectiveness of social

praise as a reinforcer has been well

documented (Walker & Shea, 1995).

In some cases, verbal prompts cuing

a student to refocus on relevant

stimuli are more helpful than reprimands

for inattention. For instance,

"Jonathan, who do you need to be

watching?" is more appropriate than,

"Jonathan, watch me."

* Ensure that students are successful in

performing motor tasks. For students

who show disparities in motor performances,

it may be more appropriate to

emphasize accuracy or control

rather than speed. Enlarging the size

of targets, striking implements, and

objects to be struck may be helpful.

Other measures increasing probability

of successful performances may be indicated--for

example, striking a stationary

object rather than a moving

object or slowing the tempo of a folk

dance.

Content Considerations. Relaxation training has frequently been cited as appropriate physical education content for students who emit behaviors associated with inattention or hyperactivity-impulsivity (Jansma & French, 1994; Sherrill, 1993). The purpose of relaxation training is to prevent or minimize neuromuscular tension. Texts by Arnheim and Sinclair (1979), Dunn and Fait (1989), Sherrill (1993), have entire chapters devoted to relaxation activities to minimize muscular tensions.

Sometimes students with ADHD have difficultly persisting in relaxation training. Elementary school physical education specialists may find an imagery game useful. In the game rag doll, students assume a back lying position on a gymnastics mat. The teacher invites students to imagine their limbs, trunk, and head as if they were rag dolls. The teacher holds a rag doll to model lack of tension in body parts. The teacher provides verbal cues whereby students are to process the sensation associated with reduced muscle tension and move body parts as they perceive a rag doll would move. Nichols (1994) presented several activities whereby students explore sensations associated with muscular tension and relaxation.

Creative dance and rhythmic activities may also effect favorable outcomes among students with ADHD. In one case study, creative dance was associated with lower occurrences of hyperactivity-impulsivity than low organized games (Gering, Bishop, & West, 1992). Through utilizing a movement education approach, paired with music that encourages reduced force, students are able to engage in a series of movements likely to enhance fundamental motor patterns, components of health-related physical fitness, and sensory-motor integration. Purcell (1990) offered several suggestions for using imagery in children's dances. Dances based on images of slowly, softly, lightly, smoothly, or effortlessly may encourage students to move with reduced force.

Low organized games may be associated with occurrences of hyperactivity and impulsivity. Rheinheimer and Bishop (1993) conducted a study to determine if differences in on-task time were discernible across content areas of low organized games, movement education, and imagery and relaxation activities. It is important to note that low organized games presented in this study were modified to minimize waiting time and ensure success in performing game tasks. It is likely low organized games modified to counter inattention or hyperactivity-impulsivity are appropriate content for students with ADHD.

What About Youth Sports?

Youth sports may afford participants with ADHD the same benefits thought to be afforded to non-disabled players. Alexander (1990) cited a case in which a youth with ADHD had been integrated into interscholastic hockey, while Decker and Voege (1992) cited a case of an eight-year-old with ADHD who was successfully accommodated in a youth soccer league. Successful integration of youth sport players may not occur unless specific measures are taken to counter manifestations of inattention and hyperactivity-impulsivity. The Youth Sports Participation Profile (Voege, Barr, & Decker, 1989) was developed to help parents, coaches, and youth sport administrators in planning measures to accommodate players with ADHD.

Summary

Children and youth with ADHD exhibit inattention and/or hyperactivity-impulsivity that may pervade all areas of life. Although drug therapy, counseling, and behavioral interventions often produce favorable outcomes, physical educators can be overwhelmed by behaviors of students with ADHD. Physical educators are likely to find collaboration with physicians, psychologists, other educators, and parents an effective means to assure consistency in applying interventions across settings. Carefully selecting physical education content that can be delivered in a structured manner is likely to ensure students with ADHD the objectives of physical education instruction. Youth sport experiences are likely to be more meaningful for players with ADHD if care is given to how typical symptoms associated with the disorder can be countered.

Selected References

Alexander, J.L. (1990). Hyperactive children: Which sports have the right stuff? Physician and Sportsmedicine, 18(4), 105-108. Anastopoulsos, A.D., DuPaul, G.J., & Barkley, R.A. (1991). Stimulant medication and parent training therapies for attention deficit-hyperactivity disorder. Journal of Learning Disabilities, 24(4), 210-218. Arnheim, D.D., & Sinclair, W.A. (1979). The clumsy child: A program of motor therapy. St. Louis MO: C.V. Mosby Co. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Barkley, R.A. (1977). A review of stimulant drug research with hyperactive children. Journal of Child Psychology and Psychiatry, 18, 137-165. Barkley, R.A. (1990). Attention deficit hyperactivity disorder. A handbook for diagnosis and treatment. New York: Gilford Press. Churton, M.W. (1989). Hyperkinesis: A review of literature. Adapted Physical Activity Quarterly, 6, 313-327. Decker, J.,& Voege, D. (1992). Integrating children with attention deficit disorder with hyperactivity into youth sport. Palaestra, 8(4), 16-20. Dunn, J.M., & Fait, H.F. (1989). Special physical education: adapted, individualized, developmental (6th ed.). Dubuque, IA: W.C. Brown Publishers. DuPaul, G.J., Guevremont, D.C., & Barkley, R.A. (1992). Behavioral treatment of attention-deficit hyperactivity disorder in the classroom. The use of the attention training system. Behavior Modification, 16, 204-225. Fagen, J.E. (1985). Hyperactivity, impaired attention, and related problems. In R.H.A. Haslam & P.J. Valletutti (Eds.) Medical problems in the classroom: The teacher's role in diagnosis and management (pp. 3221-241). Austin, TX: Pro Ed. Forman, M.A., Hetznecker, W. H., & Dunn, J.M. (1983). Attention deficit disorder. In R.E. Behrman & V.D. Vaughan (Eds.), Nelson Textbook of Pediatrics (pp. 82-86). Philadelphia, PA: Sunders Publishing Co. Freedman, D.X. (1971). Report of the conference on the use of stimulant drugs in the treatment of behaviorally disturbed young children. Washington, DC: U.S. Dept. of Health, Education, and Welfare. Fowler, M.C. (1990). Maybe you know my kid: A parent's guide to identifying, understanding, and helping your child with ADHD. New York, NY: Birch Lane Press. Gering. T., Bishop, P., West, J. 1992). High active behavior during creative dance and games of low organization. Unpublished manuscript, University of Nebraska at Kearney, Kearney, NE. Goldstein, S., & Goldstein, M. (1990). Managing attention disorders in children. New York, NY: John Wiley Son. Hinshaw, S.P. (1987). On the distinction between attentional deficits/hyperactivity and conduct problems/aggression in child psychopathology. Psychological Bulletin, 101, 443-463. Jansma, P., & French, R. (1994). Special physical education: Physical activity, sports, and recreation. Englewood Cliffs, NJ: Prentice Hall. Kavale, K. (1982). The efficacy of stimulant drug treatment of hyperactivity: A meta analysis. Journal of Learning Disabilities, 15, 280-289. Lowenthal, B. 1993). The use of medication for children with attention deficit disorders. Journal of special Education, 17, 135-140. Marlow, M. (1980). Game analysis: designing games for handicapped children. Teaching Exceptional Children, 12(2),48-51. McBurnett, K., Lahey, B.B., & Pfiffner, L.J. (1993). Diagnosis of attention deficit disorders in DSM-IV: Scientific basis and implications for education. Exceptional Children, 60, 125-131. Nathan, W. (1991). Combining therapy and medication shown effective by ADHD children. Gifted Child Today, 14(3), 36. Nichols, B. (1994). Moving and learning: The elementary physical education experience. (3rd ed. . St. Louis, MO. Porter, S., & Omizo, M. (1984). 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Paul Bishop is a professor in the Department of Health, Physical Education, and Recreation at the University of Nebraska at Kearney.

He is coordinaor of the adapted physical education program and Director of the After School Enrichment Program which provides motor development opportunities for primary grade children with disabilities.

Robbi Beyer is an assistant professor within the Division of Health, Physical Education, and Recreation at the University of Wisconsin-Oshkosh where she supervises the academic program within the department related to adapted physical education.