Research update: sports for children with ADHD: recreation can enhance the lives of children with ADHD.

The diagnosis of attention-deficit hyperactivity disorder (ADHD) has become so common that between two and 10 percent of school-aged children have been labeled as having ADHD, with boys three times more likely than girls to develop and be diagnosed with the disorder (Barkley, 1998). Due to the prevalence of children with ADHD or ADHD-like symptoms, it is important for park and recreation practitioners to have a basic understanding of the diagnosis, symptoms and treatment of ADHD, as well as the impact that recreation and sport can have on the lives of these children.

This understanding is important because children with ADHD may initially feel resistant about participating if they have had difficulty with previous peer interactions, may quit due to perceptions of inadequacy or present behavioral challenges for the staff.

Diagnosis and Symptoms

According to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR), ADHD is characterized by three main symptoms. The first symptom is inattention that sometimes manifests as the individual having difficulty sustaining attention, does not seem to listen to spoken instruction, has trouble following through with instructions, and frequently misplacing things (American Psychiatric Association [APA], 1994).

The second main symptom of ADHD is hyperactivity. Hyperactivity can be described as fidgeting, excessive talking, inability to remain seated or still when this is expected, or is commonly described as "on the go" (APA). The final symptom is impulsivity. The best way to describe impulsivity is a tendency to blurt out responses quickly, inability to wait for their turn, or frequently interrupts/intrudes.

A child with ADHD will most likely have all three of these symptoms to some extent, but each child will differ in the degree to which each symptom presents itself (APA).

Associated Complications

Children with ADHD are often rejected by their peers and have fewer friends than other children their age who do not have ADHD (Bagwell, Brooke, Pelham, & Hoza, 2001). Contrary to popular belief that children outgrow ADHD, it may persist into adulthood, and is associated with an increase in peer problems (Bagwell et al).

Bagwell and colleagues investigated self-reported peer acceptance, parent-reported peer rejection, and close friendships in 211 adolescents (111 of which had childhood ADHD). Results showed that adolescents who had childhood ADHD (regardless of whether or not their symptoms still persist) were more rejected by their peers as teenagers. Also, behaviors associated with ADHD may make children more likely to form friendships with deviant peers that may in turn reinforce negative behaviors (Bagwell et al).

More specific to the sport setting, Harvey and Reid (1997) observed that children with ADHD had lower performance in gross motor skills and physical fitness when compared to the normative data. The researchers concluded that the results they saw were probably caused by lack of sustained effort leading to lower training levels, lower self-esteem and lower participation. This cascade is of great concern since physical activity participation is important in regards to health status in children presently and for their future as adults (Harvey & Reid, 1997).

Pharmacological Treatment

Because ADHD can affect so many aspects of a child's life, it is important to somehow gain control over these behaviors. Several treatment options have been developed, but the most emphasized is pharmacological treatment, that uses central nervous system (CNS) stimulants, specifically methylphenidate (commonly referred to as Ritalin) (Wade, 1976). CNS stimulants help to control and improve impairments associated with ADHD such as motor coordination, sequencing, anticipation and planning (Hickey & Fricker, 1999).

Several studies have looked at the use of CNS stimulants and their relationship to sport performance. A study by Wade (1976) examined the role methylphenidate played in motor skill acquisition of hyperactive children (six receiving methylphenidate, six receiving placebo and 12 control children) through the use of a balancing task. Results showed that the placebo group had less consistent performance on the task than those on medication and the control group. Their decreased performance may not have been due to an inability to execute the task, but may have been more related to an inability to focus for an extended period of time, which was alleviated by methylphenidate (Wade).

A study conducted by Pelham and colleagues (1990) investigated the effects of methylphenidate on playing baseball by children diagnosed with ADHD. Seventeen boys with ADHD (7.8-9.9 years old) were observed for four days during a skills training session and then during a baseball game. Each day they received a different amount of medication (placebo, .3 mg/kg, and .6 mg/kg) in a random order.

The subjects were evaluated based upon skill performance and attention. The medication only had a significant effect on measures of attention, with children on medication being on-task twice as often. No significant difference was seen between levels of medication (Pelham et al, 1990).

Although research seems to show benefits of CNS stimulant medication, there is some opposition and resistance to the use of this medication because of common complications including suppression of growth, insomnia, decreased appetite, depressed mood, abdominal pain, tachycardia and drug dependence (Long, 2005). CNS stimulants have also been banned in competitive sports (Hickey, 1999).

The Role of Sport Participation

Because of the controversy involved with the use of CNS stimulant medication in treating ADHD, attention has turned to other possible modes of controlling behaviors. One realm that shows a great deal of promise is the role of sport participation. Many parents are interested in the use of both to help their children.

Children who exhibit attention-seeking behavior tend to be less accepted by their peers and less active when compared to the average child (Armstrong & Drabman, 2004). For boys, part of this may be related to poor sports performance that leads to poor self-confidence and peer rejection.

There is evidence that children with behavioral disorders are less successful in sporting events and have low self-efficacy in this domain (Armstrong & Drabman, 2004). Is it possible that through improving sports performance, children with ADHD can improve their social status, self-efficacy and futures altogether?

Armstrong and Drabman (2004) addressed the hypothesis that improving sports performance will lead to an increase in self-confidence and greater peer acceptance. To investigate this, a program was developed in which boys were trained in a specific sport so as to improve their skills. These boys were then placed in a position where they could display their improvements in front of their peers. An association between improvements in sports performance and an increase in positive social interactions emerged (Armstrong & Drabman, 2004).

The boys also reported greater self-efficacy, self-confidence and happiness. Teachers reported that boys in this program showed more persistence in the classroom and a decrease in attention-seeking behaviors (Armstrong & Drabman, 2004).

Sport Participation and Children with ADHD

Seeing that sport participation seems to have a positive effect on the lives of children with ADHD, specifically boys, it is important that sport be structured so that they can reap the greatest benefits. Several studies have looked at the sport setting and the use of behavioral interventions.

Much of the focus in the research on improving behavior in children with ADHD in a sports setting has been on the use of rewards and reinforcement. Binder, Dixon and Ghezzi (2000) studied the use of rewards in three preschool children with ADHD. The impulsivness of children with ADHD generally leads them to choose small immediate rewards instead of larger delayed ones (Binder et al, 2000).

The children were initially asked to choose between these two types of rewards. To assess if the use of a distraction affected impulsive behaviors, the children were then asked if they wanted the small item now or the large item after they played a game. Variation in both the duration of the reward delay and instruction used during the delay were also studied to determine if they also had an affect on behavior. Binder et al were able to increase self-control and reverse impulsivity through the use of a progressive delay, activity during the delay, and variations in instruction (Binder et al, 2000).

Several researchers applied the known effectiveness of a reward system in controlling ADHD behaviors to the sports setting. Realizing that athletic competence and poor sportsmanship affect sport participation of children with ADHD, Hupp and Reitman (1999) investigated the use of a behavioral intervention to improve both athletic competence and sportsmanship (1999).

Three children (8 to 11 years old) with ADHD were in a three-week basketball camp to try to improve their skill level via training, and their sportsmanship via reinforcement. Participants in the study developed basketball skills, increased sportsmanlike behavior and heightened their interest in the sport. There was also evidence that using reinforcement of sportsmanlike behavior decreased unsportsmanlike behavior, increased sportsmanlike behavior and increased some aspects of performance (Hupp & Reitman).

Further, increasing variability of reinforcement may help to sustain the improvements in behavior and modeling good sportsmanlike behavior may also help in further improvements. At the end of the training, those who were involved reported more interest and enjoyment in basketball.

Although the improvements seen in competence were not drastic, minor increases in competence and interest may be ample to increase participation. Sport training has been shown to positively influence social status and self-concept. The current study was relatively low in intensity showing that results can be seen without implementing a high intensity program (Hupp & Reitman, 1999).

Reitman and colleagues (2001) compared the use of a reward system to the use of medication. Participants in this study were rated on attentive behavior and disruptive behavior at baseline and then were given tokens for their positive behaviors. The results indicated that under none of the circumstances was medication more effective than behavioral interventions. In most situations, the combination of both medication and behavioral intervention was the most effective (Reitman et al, 2001).

A similar study was conducted by Hupp and colleagues (2002) to determine the effects of promised delayed rewards, immediate rewards via a token economy and medication on sportsman-like behavior. Five children previously diagnosed with ADHD took part in a three-week program in which a kickball game took place each morning. In general, the delayed rewards did not increase sportsmanship, but when tokens were given contingent upon their behavior overall, sportsmanship did increase.

Another study by Gulley and colleagues (2003) sought to evaluate the use of differential reinforcement of alternative behavior (DRA) (offering a choice of rewards based upon a specific length of appropriate behavior), DRA plus response cost (including a loss of free time for disruptive behavior), and DRA plus time-out. All of the treatments proved to be effective for different children. This study offered evidence for the effectiveness of several different behavioral interventions to be used in the sports setting and the importance of individual attention.

Exploring tactics beyond rewards, Flood and colleagues (2002) looked at the effects of training peers to reinforce on-task behavior and extinguish off-task behavior in children with ADHD. Three 10-year-old children with ADHD were given tasks consisting of math problems. They were then either reprimanded for off-task behavior by a peer or teacher (peer-attention treatment), or were praised for on-task behavior by a peer or teacher.

Peer-mediated reinforcement and prompting served to decrease off-task behavior in two of the three subjects (Flood et al, 2002). In regards to a sport setting, the facilitation of teamwork by a coach may help ADHD children to stay on task and produce better performance results.

Conclusion

Sport participation is important to all children, due to its relationship to physical activity and therefore chronic disease regardless of ADHD diagnosis. Some of the benefits of sport participation include a decrease in risky behaviors and increased integration into social settings (Kremarik, 2000). Specific to children with ADHD, participation in a sport can help to increase peer relations, which are often negative (Bagwell et al, 2001).

Improved peer relations can increase a child's happiness and self-confidence. Also, it may be possible to stop the cascade of lack of sustained effort leading to lower training levels, lower self-esteem and lower participation in these children through the use of sport and behavioral interventions.

It is the responsibility of both parents and coaches to facilitate this to improve the overall quality of life of these children. The sport setting shows much promise and may provide a path for children with ADHD to learn how to control their behaviors and interact positively with their peers, which will hopefully overflow into their everyday lives.

Research Into Action: Providing Sports and Activities for Children with ADHD

The sport setting proposes some difficulties for children with ADHD, but behavioral intervention tactics may be able to address these difficulties without the use of medication.

* Training of parents, teachers and coaches may significantly help children with ADHD.

* Provide activities within a structured environment.

* Give frequent and immediate consequences for a child's inappropriate behavior.

* Increase the use of prompts and cues in regards to rules and time intervals.

* Anticipate future tasks and break down these tasks into short actions.

* Use rewards for appropriate behavior.

* Provide individual attention.

Through the use of these different interventions it may be possible to facilitate a positive sports setting through which children with ADHD will learn to control their behaviors, enhance interactions with their peers, and enhance their overall quality of life.

References:

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. 4th Text Revised ed. Arlington, VA: American Psychiatric Publishing, Inc.

Armstrong, K., & Drabman, R. (2004). The clinical use of sports skills tutoring with grade school boys referred for school behavioral problems. Child and Family Behavior Therapy, 16, 43-48.

Bagwell, C., Brooke, M., Pelham, W., Hoza, B. (2001). Attention-deficit hyperactivity disorder and problems in peer relations: predictions from childhood to adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1285-1292.

Barkley, R. (1998). Attention-deficit hyperactivity disorder. Scientific American, 279(3), 66-72.

Binder, L., Dixon, M., Ghezzi, P. (2000) A procedure to teach self-control to children with attention deficit hyperactivity disorder. Journal of Applied Behavior Analysis, 33, 233-237.

Flood, W., Wilder, D., Hood, A., Masuda, A. (2002). Peer-mediated reinforcement plus prompting as treatment for off-task behavior in children with attention-deficit hyperactivity disorder. Journal of Applied Behavior Analysis, 35, 199-204.

Gulley, V., Northrup J., Hupp S., Spera, S, et al. (2003). Sequential evaluation of behavioral treatments and methylphenidate dosage for children with attention deficit hyperactivity disorder. Journal of Applied Behavior Analysis, 36, 375-378.

Harvey, W., Reid, G. (1997). Motor performance of children with attention-deficit hyperactivity disorder: a preliminary investigation. Adapted Physical Activity Quarterly, 14, 189-202.

Hickey, G., Fricker, P. (1999). Attention deficit hyperactivity disorder, CNS stimulants, and sport. Sports Medicine, 27(1), 11-21.

Hupp, S., Reitman, D. (1999). Improving sports skills and sportsmanship in children diagnosed with attention-deficit/hyperactivity disorder. Child and Family Behavior Therapy, 21(3), 35-51.

Hupp, S., Reitman, D., Northup J, et al. (2002). The effects of delayed rewards, tokens, and stimulant medication on sportsmanlike behavior with ADHD-diagnosed children. Behavior Modification, 26(2), 148-162.

Kremarik, F. (2000). A family affair: Children's participation in sports. Canadian Social Trends, 20-24.

Long, P. W. (2005). Methylphenidate. Retrieved Apr. 02, 2006, from Internet Mental Health Web site: http://www.mentalhealth.com/.

Pelham, W., McBurnett, K., Harper, G., Milich, R., et al. (1990). Methylphenidate and baseball playing in ADHD children: Who's on first?. Journal of Consulting and Clinical Psychology, 58(1), 130-133.

Reitman, D., Hupp S., O'Callaghan P., Gulley, V, et al. (2001). The influence of a token economy and methylphenidate on attentive and disruptive behavior during sports with ADHD-diagnosed children. Behavioral Modification, 25(2), 305-323.

Wade, M. (1976). Effects of methylphenidate on motor skill acquisition of hyperactive children. Journal of Learning Disabilities, 9, 443-447.

By Carolyn Lullo , M.S., and Marieke Van Puymbroeck, Ph.D., CTRS, CRC 

Carolyn Lullo recently graduated from the University of Illinois at Urbana-Champaign with a master's degree in Kinesiology, Exercise physiology. She received a bachelor's degree from Miami University in 2005 where she majored in Exercise Science. Her current interests are in physical well-being as it pertains to the college-age population. Marieke Van Puymbroeck, Ph.D., CTRS, CRC is an assistant professor at Indiana University. Her interests are leisure and health, caregiving and therapeutic recreation.