Organized Sports Participation in Children With and Without ADHD: the Roles of SelfPerceived Peer Relations and Physical

Abilities by Jennifer Carol Gander

Bachelor of Science Clemson University, 2007 Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Science in Public Health in Epidemiology The Norman J. Arnold School of Public Health University of South Carolina 2011

Accepted by: Robert McKeown, Director of Thesis Bo Cai, Reader Steve Cuffe, Reader Lacy Ford, Vice Provost and Dean of Graduate Studies

UMI Number: 1506037

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 Copyright by Jennifer Gander, 2011 All Rights Reserved.

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DEDICATION To my loving family and friends whose words of wisdom and encouragement carried me through this process

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ACKNOWLEDGEMENTS

I would like to thank Dr. Robert McKeown, my thesis director, for his patience and guidance throughout this process as well as my graduate career. His knowledge and experience have made my time at University of South Carolina memorable and enjoyable. I would also like to thank Dr. Bo Cai and Dr. Steve Cuffe, other members of my thesis committee. Their insight allowed me to create a refined and significant finished product that we can use to help clinicians and families better understand ADHD. I also extend many thanks and a multitude of gratitude to my family, friends and coworkers near and far. Their support and comforting words allowed me the sanity and prospective to continue and excel through my graduate work. Lastly I want to thank my husband for all he has done. His unconditional love and never ending support has made this entire ordeal possible.

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ABSTRACT

Objective: Attention-deficit/hyperactivity disorder (ADHD) is characterized by impairing symptoms of inattention and/or hyperactivity and previous literature reported that children with ADHD have poor peer relationships and motor impairment which may lead to decreased participation in organized sports. The primary research aim of this study is to explore the direct and indirect effects that ADHD diagnosis, self-concept of peer relations, and self-concept of physical abilities have on sports participation. Patients and methods: Preliminary data from the South Carolina Project to Learn about ADHD in Youth (SCPLAY) was employed to investigate peer relations and physical abilities as mediators of the association between ADHD and sport participation. Three hundred and thirty children reported their level of organized sports participation. Regression and path analysis was utilized to determine significant associations and investigate mediation. Results: A higher percentage of males (68.7%) were diagnosed with ADHD and a higher proportion of participants classified themselves as non-Hispanic White (56%). Polytomous logistic regression revealed that an ADHD diagnosis was related to never participating in sports (OR=5.1; 95%CI 1.19, 21.68) and to low sports participation (OR=2.9; 95%CI 0.99, 8.18). Path analysis revealed peer relations and physical abilities were directly related to sports participation, with corresponding coefficients of -0.02 (p-

value=0.04) and 0.04 (p-value<0.001) for a single point change on the Marsh SDQ Scale, respectively. Conclusion: ADHD diagnosis is related to decrease sports participation. This study also concludes that the direct effects of peer relations and physical abilities on sports participation are significant.

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TABLE OF CONTENTS DEDICATION ACKNOWLEDGEMENTS ABSTRACT LIST OF TABLES LIST OF FIGURES LIST OF ABBREVIATIONS CHAPTER I: INTRODUCTION CHAPTER II: LITERATURE REVIEW ADHD and Sports Participation ADHD and Self Concept Peer Relations ADHD and Self Concept Physical Abilities Summary CHAPTER III: METHODS Research Objectives Data Source Measures Statistical analysis CHAPTER IV: MANUSCRIPT Abstract Introduction Methods Results Discussion Conclusion References 20 22 24 27 28 33 39 11 12 16 17 3 6 8 10 ii iii iv ix x xi 1

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CHAPTER V: SUMMARY REFERENCES

42 46

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LIST OF TABLES Table 1.Frequencies and weighted percentages of demographic characteristics stratified by ADHD diagnosis status Table 2. Logistic regression of sports participation on ADHD while controlling sex, SES, race/ethnicity, ADHD medication status, and comorbid psychiatric disorders Table 3. Description of the indirect paths analyzed as well as their respective estimate, standard error, and p-values 34 35

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LIST OF FIGURES

Figure 1. Theoretical framework to assess the direct and indirect effect of ADHD diagnosis, self-concept of physical abilities, on sports participation and the direct effect of self-concept of peer relations on sports participation Figure 2. Coefficients (and standard errors) for the direct effect of ADHD Diagnosis, self-concept of physical abilities, and self-concept of peer relations on sports participation

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LIST OF ABBREVIATIONS ADHD .................................................................... Attention deficit/hyperactivity disorder CDC ................................................................ Centers for Disease Control and Prevention HRBS .....................................................................................Health Risk Behavior Survey Peer relations .......................................................................... Self-concept of peer relations Physical abilities ............................................................... Self-concept of physical abilities SCPLAY ...................................... South Carolina Project to Learn about ADHD in Youth SDQ-I ............................................................................... Self-Description Questionnaire I

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CHAPTER I INTRODUCTION Attention-deficit/hyperactivity disorder (ADHD) is a common neuropsychiatric disorder affecting up to 9.5% of children 4-17 years of age 1 with higher prevalence in boys 2. This disorder is characterized by impairing symptoms of inattention and/or hyperactivity and poor social relationships and physical abilities are two consequences associated with ADHD. Problems with peer relationships are severe and persistence and can affect 52-82% of children with an ADHD diagnosis 3,4. This problem typically manifests itself in peer rejection that can develop in social groups. When a child with an ADHD diagnosis is placed in to a play group of unfamiliar, non-ADHD children unaware of their peers disorder the complaints about behavior started within minutes5. These problems with peer relationships become more evident in middle and high school students as the social environment changes and peer interactions assume a new importance 5. Poor physical abilities is often referred to as Developmental Coordination Disorder (DCD) and can occur in 30-50% of children diagnosed with ADHD 6. The potential for children with ADHD to have poor physical abilities is well documented 2 and can include fine motor skills, ball skills, balance, bilateral coordination, and strength 2,7-9. Other literature shows that boys with ADHD not only preferred individual sports over team sports, but they also used domain specific vocabulary less frequently 8.

Participation in organized sports is an important tool to fight against childhood obesity, which has tripled in the past three decades. Children diagnosed with ADHD have been shown to be at a higher risk for overweight or obesity 10-13. Overweight and obesity result from an extended positive energy balance 11 and previous research has noted that obese children are at an increase risk for becoming obese adults 14. Increasing childrens physical activity level could help decrease the risk of childhood obesity15 but past studies conclude that children with ADHD participate in less physical activity than their peers 16. This could be due to a number of reasons. For instance, children with ADHD have poor peer relationships and have a tendency to fall victim to bullying 3. Strong correlations have been found between long duration of bullying and high frequency of bullying with poor performance in physical education class 17. Although previous literature has concluded the problems children with ADHD experience with team or organized sports, no studies have analyzed the significant relationships between peer relationships, physical abilities, and organized sports participation. The purpose of this thesis is to explore the relationship between a diagnosis with ADHD and organized sports participation and whether this relationship is mediated by self-concept of peer relations and physical abilities.

CHAPTER II LITERTURE REVIEW The following literature review will reiterate findings from several studies on the relationships of ADHD and sports participation, ADHD and peer relationships, ADHD and physical ability, peer relationships and sports participation, and physical ability and sports participation, which can improve the understanding of ADHDs effect on children involvement in sports. ADHD and Sports Participation Children diagnosed with ADHD have been shown to be at a higher risk for overweight or obesity 10-13. Overweight and obesity result from an extended positive energy balance 11 and previous research has noted that obese children are at an increase risk for becoming obese adults 14. The prevalence of overweight children has more than tripled in the past three decades, increasing from seven percent in 1980 to approximately 20% in 2008 18,19. Low physical activity has been assumed to be linked to the etiology of obesity and overweight but one might assume that one of the impairing symptoms of ADHD, hyperactivity, would counteract the risk of obesity by increasing physical activity
11,20

. Ninety seven boys with a mean age of 14 years participated in a cross sectional

study 11 aimed at determining the prevalence of overweight and obesity in ADHD diagnosed children using objectively measured body mass index (BMI). The prevalence

of overweight and obesity was determined to be higher in the sample of ADHD children than the study population. A study utilizing the National Survey for Childrens Health analyzed information for more that 66,000 children and adolescents 13. The data was gathered through interviewer administered questions to the parents selected for the survey. The study revealed that nonmedicated children diagnosed with ADHD had 1.5 times the odds for being overweight than their peers without ADHD. Lack of physical activity has been hypothesized to be a leading factor in developing or maintaining childhood obesity 21-23. People speculate that since a comorbidty of ADHD is hyperactivity, children diagnosed with ADHD should not have a problem being physically active. However, some research speculates that the quality of physical activity has a stronger protective influence than the quantity of physical activity
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. Ness et al confirmed this relationship and investigated accelerometer measured

physical activity in children while using lean and fat mass, alongside BMI, as indicators of obesity 15. Physical activity was classified as total physical activity and time spent in moderate to vigorous physical activity. After capturing the childrens physical activity levels for seven days, the study reported a strong negative dose-response relationship between physical activity and fat mass. Children with ADHD typically report a greater preference for and participation in individual activities 8. Children with ADHD were also significantly less likely to engage in spontaneous play and participate in organized sports compared to children without ADHD 8. Kim and Mutyala, et al completed a cross sectional study investigating health behaviors and obesity among children with ADHD in the United States 16. The study

took advantage of the 2003 data available from the National Survey of Childrens Health (NSCH) and included more than 66 thousand children between the age of 6-17 years. The NSCH interviewed parents covering several different topics. The ADHD exposure variable was derived from two questions, Has a doctor or health professional ever told you that your child has ADHD and Is your child currently taking medication for ADHD and categorized as: ADHD ever: currently taking medication, ADHD ever: child not taking medication presently, never told child has ADHD. Physical activity, biking riding, playing video games, computer use, sleep, and participation in organized sports comprised some of the obesity related health variables recorded by NSCH and analyzed in this study. Low physical activity was more prevalent in boys and girls without ADHD than boys and girls with ADHD, in either medication category; however boys and girls with ADHD were less likely to participate in organized sports. Participation in organized sports was shown to be a significant predictor of obesity in boys with ADHD taking medication. Along with preventing obesity in children with ADHD, participation in team or organized sports may also have positive emotional impacts 24. Kiluk determined that the number of sports children with ADHD are involved in is significantly correlated with anxious-depressed scores, as well as internalizing problems and affective problems. Both boys and girls experienced a significant decrease in anxious-depressed scores when they participated in 3 or more sports compared to 0 to 2 sports 24. The control group, children diagnosed with a learning disability, was found to have no significant correlation or improvement in the relationship between sports participation and anxious-depressed score.

ADHD and Self Concept Peer Relations Peer relationships are the primary context where children learn conflict resolution, negotiation, and cooperation 25. However, many children with ADHD experience low peer regard, frequent rejections, and difficulties making and maintaining friendships 26,27. Restlessness, verbal outburst, intrusiveness, and inability to behave in a manner appropriate in a social setting are common symptoms of ADHD 3 but other children consistently report this behavior as impolite, selfish, apathetic, and offensive 28. This mix of reduced inhibition and diminished tolerance/acceptance can lead to a child diagnosed with ADHD experience social failure. The potential for children with ADHD to suffer from peer rejection is well recognized and the prevalence ranges from 52 to 82% 4. Many studies have found a significant difference in number and quality of friendships experienced by children with ADHD 4,29-32. The Multimodal Treatment of Children with ADHD 33 analyzed a subsample of 330 youth with and without (n=165) an ADHD diagnosis to assess friendship 33. The study utilized sociometric nominations, the gold standard, where both child with ADHD and peer in control group had to nominate each other as friends. Results depicted that more than half of children with ADHD had no reciprocating friends while only 42% had one or more reciprocating friend. In comparison, only 32% of children in control group had no reciprocating friends but 61% had one or more friends. Problems with peers may cause or contribute to future maladjustment. Children who experience peer rejection participate less in class, avoid school, drop out, and are more likely to have less educational and occupational success as adults 34,35. Children diagnosed with ADHD are at a higher risk for future problems due to their current psychopathology and their disturbed peer relationships 36. There are hypothesis
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explaining the relationship between peer rejection and adjustment 36. The first hypothesis assumes a causal link between peer relationships and later problems and suggests that children with poor peer relations will have poor adaptive social and cognitive behavior. A second hypothesis states that poor peer relations and poor social adjustments are caused by underlying behavioral deviance or the lack of social skills. In regards to the first hypothesis, ADHD children exhibit lower frequencies of neutral nonverbal behaviors and they show higher rated of highly intense, unmediated behaviors that often inappropriate within the given context 36. These negative behaviors have been shown to increase in frequency in situations with little or no adult supervision
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. Boys diagnosed with ADHD have difficulties recognizing their problem areas and

their motivation for corrective action are quite low 38. Low corrective action might be caused by positive illusory bias in both social and behavioral domains (Murray-close). The second hypothesis was exemplified in a study design that investigated behaviors emerging in blinded play groups 37. These play groups contained one child diagnosed with ADHD, Pelham and Bender 37 found that the child with ADHD commonly emerged as the most disliked member, sometimes as early as the first play session 37,38. Correlation analysis determined that the rejection of ADHD children was due to their higher-than-average rate of off-task, intrusiveness, noncompliant, and destructive behavior. A more recent study during a summer program 29 improved upon Pelham and Benders findings by conducting a similar study with peer interaction while accounting for social behaviors and nonbehavorial traits 29. The main finding was that social behaviors, more specifically externalizing features of aggression and noncompliance,

contributed significantly to the prediction of initial peer impressions of previously unfamiliar ADHD and comparison boys. Additionally, the initial impressions and measures of aggression and noncompliance accounted for sizeable portions of variance in the end-of-program sociometric indices 4.5 weeks later 29. This reinforces the findings

that negative reputations develop quickly within peer groups and are hard to dismiss once established 39. It is also supports the finding that peer rejection is a group process and not an individual characteristic 40.

ADHD and Self Concept of Physical Ability A childs psychosocial functioning can be negatively affected when gross motor functions are impaired 41,42. Children with motor impairment suffer from ridicule both on and off the playground 43 and its well documented that poor relationships with peers may lead to motor problems 44,45. Children with motor impairment are less likely to participate in vigorous, active play and may avoid structured physical activity as a coping strategy to deal with the risk of failure and humiliation 43. A Canadian cross-sectional investigation including children age 8-14 years found that children with motor skills impairment were significantly less likely to participate in organized or free play compared to children without motor impairment 43. Each child completed the validated short-form Bruininks-Oseretsky Test of Motor Proficiency which examines balance, reaction time, and bilateral coordination and children were classified as motor impaired or non-impaired based on their age-adjusted standard score. Children with impaired motor performance not only participated less in organized play, but are more likely to

select sedentary lifestyles and are less likely to enjoy physical education classes compared to their peers 43. Gross motor performance is important in the lives of school children because it is essential in participation in games and sports. Development of gross motor skills in school-aged children is mediated by interaction with peers in games and play. Gross motor skills required for these interactions can include running, jumping, and throwing balls 7,8. Literature shows that children with developmental or emotional disorders often exhibit motor problems 7. ADHDs effects on physical abilities has been described as more a problem of doing what one knows rather than of knowing what to do 43. Although excessive activity is commonly associated with ADHD 8, this hyperactivity differs in purpose and outcome from movement skills in a physical activity context. A study with 48 age-matched boys employed a movement assessment battery to determine if any difference in manual dexterity, balance, and ball skills exists between children with and without ADHD. The study concluded a significant difference in manual dexterity and balance between the ADHD and control groups 2. The study was not able to determine a difference between the groups of boys in regards to ball skills 2. Although, a more recent study with a larger sample (n=157) reported that children with ADHD had significant worse balls skills than the comparison group without an ADHD diagnosis 46. The study also concluded that there was a significant difference between the subtypes of ADHD: inattentive, hyperactive, and combined type. ADHD-Inattentive performed the worst within the subtypes, while ADHD-Hyperactive performed the best.

Physical therapy intervention produces significant improvements in physical abilities of children with ADHD 47. This four-week, intensive, physical therapy intervention included a cognitive, task-specific approach, attention to performance skills, and self-control in the ability to perform the activities. Fifty percent of children in the intervention group improved their movement assessment battery score to normal, while an additional 35% also improved their score (although not to the normal range) 47. This improvement was still noticeable after 3 months of cessation from the intervention program. Summary Obesity is becoming a considerable problem among todays youth while children with ADHD are an increased risk for becoming obese. Physical activity in the form of team or organized sports can be a significant tool used to fight the threat of obesity although children with ADHD are not utilizing it as much as their peers 16. There has been vast research completed that encompassed the role of either peer relations or physical abilities and sports participation in children with and without ADHD. However, no literature has investigated the mediating roles these variables may have on the relationship between ADHD status and sports participation. Therefore, the purpose of this thesis is to explore how both of these variables work simultaneously to transform the relationship between ADHD and sports participation.

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CHAPTER III METHODOLOGY Research Objectives The purpose of this thesis is to investigate the relationship between a diagnosis of ADHD and participation in team or organized sports and whether or not this relationship is mediated by either self-concept of peer relationships or self-concept of physical abilities or both. The following are the more specific questions this thesis attempts to answer:

1.) Comparing children diagnosed with ADHD versus children without an ADHD diagnosis, is there a significant difference in organized sports participation?

2.) Comparing children diagnosed with ADHD versus children without an ADHD diagnosis, is there a significant difference between self-concept of their social interaction using the Marsh Self-Description Questionnaire Peer Relations (Marsh SDQ PR)scale?

3.) Comparing children diagnosed with ADHD versus children without an ADHD diagnosis, is there a significant difference in self-concept of their physical abilities

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using the Marsh Self-Description Questionnaire Physical Abilities (Marsh SDQ PA) scale?

4.) Does peer relations significantly influence participation in organized sports?

5.) Does physical abilities significantly influence participation in organized sports?

6.) What are the direct and indirect effects that ADHD diagnosis, self-concept of peer relations, and self-concept of physical abilities have on organized sports participation?

Data Source Preliminary data from the South Carolina Project to Learn about ADHD in Youth (SC PLAY) was employed to answer the aforementioned research questions. SCPLAY is a population based study funded by the Centers for Disease Control and Prevention (CDC) through the Department of Epidemiology and Biostatistics within the University of South Carolinas Arnold School of Public Health. SC PLAYs goal was to determine risk behaviors, demographics, and other correlates and characteristics of both diagnosed and undiagnosed ADHD children as well as children without ADHD within a community sample of school-aged children. The study began in 2003 and will conclude in the Spring of 2012. All study protocols were approved by the Institutional Review Boards at the Center for Disease Control and Prevention and the University of South Carolina.

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To address the DSM-IV48 criteria for ADHD, SC PLAY implemented a twophase design. The first phase consisted of elementary teachers throughout one school district completing behavioral screenings for each child in their classroom. At conclusion of Phase I, children were classified in to two categories: high or low screen. The second phase involved the parents or guardians of the children who were invited to participate in a direct, structured interview assessment of ADHD. This two-phase research design enabled a DSM-IV based case definition to be generated and applied in order to produce weighted estimates of ADHD. Phase I: Sampling Population and Screening Sampling Population One large school district in South Carolina was included in this study. This school district consisted of 15 elementary schools and approximately 8,700 students, of which 4606 were screened. The target population was children in kindergarten through 5th grade and an estimate of ADHD prevalence in the district was derived using populationbased methodologies described below. Screening The screening process was performed using information collected from the teachers. Each teacher was asked to complete the Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS) 49, Strengths and Difficulties Questionnaire (SDQ) 50, and two questions, Has this child been diagnosed with ADHD or ADD? and Is this child on medication for ADHD or ADD? for each child in their classroom. The teachers received monetary compensation for each screener they completed and returned to the research staff. Parents also completed a screening form that included the same to questions the

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teachers were asked regarding ADHD diagnosis and treatment. The data gathered from both the teachers and parents were used to divide children in to two categories: high screen and low screen. High screen consists of children likely to have ADHD based on the following: 1) had six or more ADHD core symptoms on either the hyperactive/impulsive items or the inattentive items of the VADTRS, combined with intermediate impairment ratings on SDQ, 2) reported by parent or teacher having been ever diagnosed with ADHD or 3) reported by parent or teacher as taking medicine for ADHD. Low screen sample was frequency matched to the high screen sample on gender. The research staff could not access any identifying information about the children except a six-digit identification number while the school personnel retained the names and identification numbers of the participants but retained no assessment results. The high and low screen strata were used to recruit an eligible subsample. The initial subsample contained all high screen children and a random sample of low screen children, frequency matched to the high screen children on sex. School personnel matched identification numbers to names and addresses of the students and then mailed out recruitment letters to the students home. Once consent was gathered from eligible families, parents completed the diagnostic phase (Phase II) below.

Phase II: Case Ascertainment The diagnostic phase took place an average of 13 months after the subsample was identified, ranging from 2-27 months. One parent from the consenting families, typically the mother, completed a series of questions including paper-based questionnaires and computer-assisted interviews. The computer version of the Diagnostic Interview

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Schedule for Children-IV (DISC-IV) 51 was administered by trained interviewers and consisted of modules that incorporated a range of psychiatric disorders. The instruments used in the screening and case ascertainment are described in the following Materials section. Paper surveys captured parent reported demographics as well as health risk behaviors. The interviews were conducted in person by a member of the research team, and written measures were collected either in person or by mail. The results from each interview were reviewed by a clinician and parents were notified of possible diagnosis of disorder and given referral information if necessary. Upon completion of the surveys, the parents were compensated with a gift card. Strict triage protocols were established and enforced to identify risks of harm to self or others or probable abuse. Case Definition A common DSM-IV definition was developed by researchers in South Carolina and a collaborative site in Oklahoma, in conjunction with CDC project staff based on symptoms and impairment. A positive diagnosis for ADHD was given if the child had initially been classified as high screen and met at least six of the eighteen ADHD symptoms for either or both the inattentive or hyperactive/impulsive subtype while also reporting significant impairment. Significant impairment was classified as reporting severe impairment in one or more domains or moderate impairment in at least two domains. Children in the low screen group had to present with no less than four out of nine symptoms within a single subtype while reporting moderate impairment on the teacher report to be diagnosed with ADHD. Children taking any medication for ADHD at the time the DISC-IV was administered were excluded from the study if symptom

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criteria were not met. This exclusion was enacted because it would be difficult to determine if the ADHD medication reduced the symptoms or the child was misdiagnosed and therefore would have never attained the threshold of symptoms. Measures Case ascertainment of ADHD was guided by the computer based DISC-IV 51. The DISC-IV was contained modules to diagnosis ADHD and other psychiatric disorders including Conduct Disorder, General Anxiety Disorder, Major Depression/Dysthymic Disorder, Mania/Hypomania, Obsessive Compulsive Disorder, Oppositional Defiant Disorder, Post-Traumatic Stress Syndrome, Separation Anxiety Disorder, and Social Phobia. These diagnoses were based on DSM-IV diagnostic criteria. DISC-IV was designed to be administered by trained interviewers that do not have clinical experience. All participating parents and their children over the age of nine answered the DISC-IV selected modules. Data on participation in team or organized sports was provided by a Health Risk Behavior Survey (HRBS) which is a modified version of CDCs Youth Risk Behavior Survey. For the purpose of this analysis, two versions of HRBS were administered to participating children depending on their age. The Elementary School version was utilized for children under the age of ten and contained 41 questions that allowed the child to report on topics ranging from dietary behavior, school performance, injury, tobacco/drug use, and physical activity. The Middle School version is similar to the Elementary School version by covering the same topics but asking a total of 54 questions. In either version of HRBS, team/organized sports participation was captured using the single question, How often do you participate in organized or team sports? with

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possible answers: never, daily, twice a week, weekly, every other week, once a month, less than once a month. Self-concept data was captured using the Self-Description Questionnaire I 52 for participating children age eight through twelve. The questionnaire was administered by interviewers and captured self-concept and self-perception. For the purpose of this thesis, two of the four non-academic areas of self-concept were utilized (peer relations, physical abilities). Marsh I allows the children to answer each questions on a five-point scale with the answers ranging from false and somewhat false to somewhat true and true. Validation of the Marsh I was published in 1990 52. Statistical Analysis The district-stratified, multistage, stratified sampling scheme was accounted for in analysis by incorporating sampling weights that reflect differential sampling and nonresponse which produce estimates similar to the demographics of the sampled population. All regression models were performed using the SAS-callable SUDAAN software 53 with an alpha of significance set at 0.05. To assess the overall impact each independent variable (ADHD diagnosis, peer relations, and physical abilities) has on organized sports participation, path analysis was implemented using Mplus software 54. The analysis employed 481 assessments completed in year one and two. Descriptive statistics were provided with the use of PROC DESCRIPT in SUDAAN. Race and ethnicity were combined to form three categories: Non-Hispanic White, NonHispanic Black, and Other. Social economic status (SES) reflects the parents income as well as highest level of education completed and then divided in to tertiles. Other

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descriptive variables included ADHD medication status and co-morbid psychiatric disorders captured through the DISC interview. Age and sex were also accounted for. A population t-score of self-concept for both peer relations and physical abilities was generated and used for the regression models. These t-scores were calculated by using a collective score from the SDQ-I and normalized to have a mean equal to 50 and a standard deviation of ten. The initial regression model investigated the relationship between ADHD diagnosis and organized sports participation while controlling for certain confounders (age, sex, race/ethnicity, SES, medication status, and co-morbid psychiatric disorders). These confounders were consistently controlled for in the other regression models analyzed. Polytomous logistic regression models were explored through PROC MULTILOG while linear models explored through PROC REGRESS in SUDAAN. Path analysis was used to simultaneously scrutinize the relationship of multiple independent variables and their direct and indirect effect on organized sports. The analysis was done by simultaneous modeling several related regression relationships using Mplus 54. The direct analysis was performed for ADHD diagnosis, peer relations, and physical abilities on sports participation while controlling for the aforementioned covariates. The regression models were completed to determine the indirect effects of ADHD diagnosis, peer relations, and physical abilities effect on sports participation and also ADHD diagnosis and physical abilities indirect effects on peer relations. Coefficients for each relationship were recorded and consistently used to determine an overall effect.

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CHAPTER IV MANUSCRIPT
Organized Sports Participation in Children With and Without ADHD: the Roles of Self-Perceived Peer Relations and Physical Abilities

Jennifer Gander, MS1,2, Bo Cai, PhD2, Steven Cuffe, MD3, Joe Holbrook, PhD2, and Robert McKeown, PhD, FACE2. To be submitted to Pediatrics
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ABSTRACT Objective Attention-deficit/hyperactivity disorder (ADHD) is characterized by impairing symptoms of inattention and/or hyperactivity and previous literature reported that children with ADHD have poor peer relationships and motor impairment which may lead to decreased participation in organized sports. The primary research aim of this study is to explore the direct and indirect effects that ADHD diagnosis, self-concept of peer relations, and selfconcept of physical abilities have on sports participation. Patients and methods Preliminary data from the South Carolina Project to Learn about ADHD in Youth (SCPLAY) was employed to investigate peer relations and physical abilities as mediators of the association between ADHD and sport participation. Three hundred and thirty children reported their level of organized sports participation using a Health Risk Behavior Survey derived from the CDCs Youth Risk Behavior Survey. Regression and path analysis was utilized to determine significant associations and investigate mediation. Results A higher percentage of males (68.7%) were diagnosed with ADHD and a higher proportion of participants classified themselves as non-Hispanic White (56%). Polytomous logistic regression revealed that an ADHD diagnosis was related to never participating in sports (OR=5.1; 95%CI 1.19, 21.68) and to low sports participation

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(OR=2.9; 95%CI 0.99, 8.18). Path analysis revealed peer relations and physical abilities were directly related to sports participation, with corresponding coefficients of -0.02 (pvalue=0.04) and 0.04 (p-value<0.001) for a single point change on the Marsh SDQ Scale, respectively. Conclusion ADHD diagnosis is related to decrease sports participation. This study also concludes that the direct effects of peer relations and physical abilities on sports participation are significant.

ABSTRACT WORD COUNT : 250 Abbreviations: CDC, Centers for Disease Control and Prevention; peer relations, selfconcept of peer relations; physical abilities, self-concept of physical abilites
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INTRODUCTION Attention-deficit/hyperactivity disorder (ADHD) is characterized by impairing symptoms of inattention and/or hyperactivity and affects 9.5% of children between the ages of 4-17 year 1. Although one might assume that the impairing symptom of hyperactivity would increase a childs physical activity level and protect against the risk of obesity, children diagnosed with ADHD have been shown to be at a higher risk for overweight or obesity
10-13

. Literature speculates that it might not be a childs lack of physical activity but the

quality of the activity that is causing the problem. Children with ADHD typically report a greater preference for participation in individual activities 8. Children with ADHD were also significantly less likely to engage in spontaneous play and participate in organized sports compared to children without ADHD 8. Children with ADHD are not only at a higher risk of obesity but also experience low peer regard, frequent rejections, and difficulties making and maintaining friendships
26,27

. ADHD children exhibit lower frequencies of neutral nonverbal behaviors, and they

show higher rate of highly intense, unmediated behaviors that are often inappropriate within the given context 36. Hoza concluded that boys diagnosed with ADHD have difficulties recognizing their problem areas and their motivation for corrective action is low 38. Difficulties with peer relationships may also be influenced by motor impairment 43 which may present itself in children diagnosed with ADHD 2,7. Motor impairment within this group of children has been described as more a problem of doing what one knows
22

rather than of knowing what to do 43. Previous literature shows significant impairment in balance 2, manual dexterity 2, and ball skills 46. Reports show that children with motor impairment are less likely to participate in vigorous, active play and may avoid structured physical activity as a coping strategy to deal with the risk of failure and humiliation 43. Children with impaired motor performance not only participated less in organized play, but were more likely to select sedentary lifestyles and less likely to enjoy physical education classes compared to their peers 43. There has been significant evidence to support independent effects of poor peer relationships and motor impairment on a childs participation in team or organized sports participation. However, no literature has investigated the mediating roles these variables may have on the relationship between ADHD status and sports participation. Figure 1 illustrates the primary research aim of this study which is to explore the direct and indirect effects that ADHD diagnosis, self-concept of peer relations, and self-concept of physical abilities have on sports participation.

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METHODS Data source Preliminary data from the South Carolina Project to Learn about ADHD in Youth (SCPLAY) was employed to investigate the mediating effects of self-concept of peer relations (hereafter peer relations) and self-concept of physical abilities (hereafter physical abilities) on sport participation. SCPLAY is a population based study funded by the Centers for Disease Control and Prevention (CDC) through the Department of Epidemiology and Biostatistics within the University of South Carolinas Arnold School of Public Health. The observational study consists of 481 child participants and their parents that began in 2003 and is scheduled to conclude in 2012. Population sampling One large school district in South Carolina containing 15 elementary schools and approximately 8,700 students was included in this study. The target population was children in kindergarten through 5th grade and an estimate of ADHD prevalence in the district was derived using population-based methodologies described below. SCPLAY implemented a two-phase design to account for the DSM-IV criteria. The first phase consisted of elementary teachers throughout one school district completing behavioral screenings for each child in their classroom. At conclusion of Phase I, children were classified in to two categories: high or low ADHD screen. The second phase involved the parents or guardians of selected children who were invited to participate in a direct,

24

structured interview assessment of ADHD. This two-phase research design enabled a DSM-IV based case definition to be generated and applied in order to produce weighted estimates of ADHD. Measures Case ascertainment of ADHD was guided by the computer based DISC-IV
51

and

all participating parents and their children over the age of nine answered the DISC-IV selected modules. Data on sports participation was provided by a Health Risk Behavior Survey (HRBS) which is a modified version of CDCs Youth Risk Behavior Survey. For the purpose of this analysis, two versions of HRBS were administered to participating children, depending on their age. Sports participation was captured using the single question, How often do you participate in organized or team sports? with possible answers: never, daily, twice a week, weekly, every other week, once a month, less than once a month. Self-concept data was captured using the Self-Description Questionnaire I 52 for participating children age eight through twelve. The questionnaire was administered by interviewers and captured self-concept and self-perception. Marsh I allows the children to answer each question on a five-point scale with the answers ranging from false and somewhat false to somewhat true and true. Validation of the Marsh I was published in 1990 52 and two of the four non-academic areas of self-concept were utilized (peer relations, physical abilities). A normalized t-score of peer relations and

physical abilities was generated and used for the regression models. These normalized scores were calculated by using a collective score from the SDQ-I and normalized to

25

have a mean equal to 50 and a standard deviation of ten. Age, sex, ADHD medication status, and co-morbid psychiatric disorders were accounted for in the analysis. Race and ethnicity were combined to form three categories: Non-Hispanic White, Non-Hispanic Black, and Other. Social economic status (SES) reflects the parents income as well as highest level of education completed and then divided in to tertiles.

Statistical analysis The district-stratified, multistage, stratified sampling scheme was accounted for in analysis by incorporating sampling weights that reflect differential sampling and nonresponse which produce estimates similar to the demographics of the sampled population. The analysis employed 481 assessments completed in year one and two. All regression models were performed using the SAS-callable SUDAAN software 53 with an alpha of significance set at 0.05. Path analysis was used to simultaneously scrutinize the relationship of multiple independent variables and their direct and indirect effect on organized sports. The analysis was done by simultaneous modeling several related regression relationships using Mplus 54. The direct analysis was performed for ADHD diagnosis, peer relations, and physical abilities on sports participation while controlling for the aforementioned covariates. The regression models were completed to determine the indirect effects of ADHD diagnosis, peer relations, and physical abilities effect on sports participation and also ADHD diagnosis and physical abilities indirect effects on peer relations. Coefficients for each relationship were recorded and consistently used to determine an overall effect.

26

RESULTS There were 330 children who reported their participation in organized sports. The mean age of children was similar in both children diagnosed with ADHD and their peers and a higher percentage of males (68.7%) were diagnosed with ADHD. Most of the participants classified themselves as either non-Hispanic White (56%) or non-Hispanic Black (40%) with all other Race/Ethnicities comprising the remaining 4%.

Logistic Regression Polytomous logistic regression, Table 1, revealed that children with ADHD had five times higher odds for low sports participation (OR=5.09; 95%CI 1.19,21.68) when compared to children without ADHD. Children with ADHD were also more likely to never participate in sports than their peers without ADHD (OR=2.85; 95%CI 0.99,8.18). Females were two times more likely to never participate in organized sports (OR=2.47; 95%CI 1.2,5.08). Children with parents reporting a low SES were more likely to frequently participate in sports compared to their peers reporting a higher SES. Race/Ethnicity and currently taking ADHD medication did not make a significant difference in sports participation in either category.

Path Analysis

27

Direct path analysis concluded that peer relations and physical abilities direct effect was significantly associated with sports participation with a coefficient of -0.02 (pvalue=0.04) and 0.04 (p-value<0.001), respectively. Figure 1 shows that physical abilities also had a significant direct effect on peer relations (p-value<0.001). ADHD diagnosis was found to be only significantly directly related to physical abilities with a coefficient of -2.3 (p-value=0.03). Indirect path analysis concluded ADHD diagnosis did not significantly affect sports participation through any other of the proposed path ways, which can be viewed in Table 3. A result that was approaching significance was ADHD diagnosis indirect effect on sports participation through physical abilities (coeff= -0.09), although not significant with an alpha=0.05. However, physical abilities indirect effect on sports participation through peer relations was significant (p-value=0.03).

DISCUSSION To our knowledge this is the first study to investigate the mediating effects of both physical abilities and peer relations. ADHD diagnosis was significantly related to sports participation with utilizing logistic regression. However, in path analysis, once physical abilities and peer relations are controlled for, the significant effect of ADHD diagnosis disappears. This allows the study to conclude that physical abilities and peer relations have mediating effects on the relationship between ADHD diagnosis and sports participation.

28

Participation in sports and physical activity can be affected by several factors, one of those being peer relationships. Our study illustrated that peer relations has a significant effect on sports participation. Other studies concur that any child has the potential to be bullied but it occurs more if the child appears to be different of fragile17. Having a lack of social skills can make a child seem different and has been associated with being a victim of bullying17. In a retrospective study capturing the prevalence of bullying in physical education classes, 69 university students in Sweden reported being a victim of bullying during childhood17. The study also demonstrated that below average performance in physical education class was a significant risk factor of being bullied (OR=3.5). This report also concluded that poor motor skills were strongly related to long duration of victimization and increased frequency. Our analysis also shows that self-report of physical abilities is significantly related to a childs participation in sports, a higher self-concept score leads to higher participation in sports. Children with ADHD have been shown to have problems with balance2, manual dexterity2, and balls skills46. Barkley55 reported that children diagnosed with ADHD usually struggle in motor activities which demand inhibiting and sequencing the motor action. The direct effects displayed by our path analysis showed that children diagnosed with ADHD had more poor physical abilities score. Past literature supports our findings that children with low self-perception of physical abilities will be more likely to choose a sedentary lifestyle43. Also, children with motor impairments are less likely to participate in active play 56-58 and this avoidance might by a coping strategy to prevent ridicule and humiliation 59.

29

The indirect effect path analysis explained that, although ADHD diagnosis did not directly affect sports participation, ADHD may affect participation in sports through peer relations and/or physical abilities. A significant indirect relationship was detected when peer relations was the mediating variable between physical abilities and sport participation. Physical abilities also had a close significant indirect effect when test ADHD diagnosis and sports participation. This finding is comparable to other studies which reported children diagnosed with ADHD had poorer self-concept of physical abilities and therefore opted out of spontaneous play or organized sports8. Past research has illustrated peer relations mediating effects between ADHD diagnosis and sports participation. Many children with ADHD experience social obstacles26,27 that may be due to their common restlessness, verbal outburst, intrusiveness, and inability to behave in a manner appropriate in a social setting3. It is this unfortunate mix of reduced inhibition by the child with ADHD and their peers diminished tolerance that can lead to social failure, bullying, or ridicule in the physical education class or other organized sports. Our findings support this association of mediating affects between ADHD diagnosis and sports participation. Peer relations mediating effect becomes more significant when physical abilities score is also included in the model. Raggio et al concluded that motor impairment could be related to the impulsive behavior typically exhibited by children with ADHD 60. Similar to motor impairment negatively affecting peer relations, children that actively participate in sports may experience reduced anxiety, increased self-esteem, and elevated feelings of wellbeing 61.

30

The reported findings are supported by the strengths in sampling technique and classification of ADHD. The SC PLAY data was sampled from one, large school district which enables a larger generalizability than if the sample was clinically based. SC PLAY utilized teachers and parent as a valuable source of information to help gather basic diagnostic and demographic data on students within the schools. In addition to the unique sampling technique, SC PLAY employed a rigorous definition to classify ADHD. The information gathered from the teacher and parent reports were used to identify possible ADHD cases and thorough diagnostic interviews and psychiatric reviews were applied to make the final research classification. However, an initial possible limitation to this sampling technique was the over sampling of children with ADHD. This oversampling was purposely employed to increase case finding and enhance power and to account for this difference, gender matching case to controls was utilized and statistical weights based on the sample population were implemented and carried throughout the analysis. Another limitation present in this study was this limited number of participants because of the measures applied. Only the Marsh Self-Description Questionnaire I, which was developed and validated for children between 8-12 years of age, was implemented on a large enough scale to enable the development of normalized scores. For this reason, age restriction criterion was applied to SC PLAYs Years 1 and 2 to only include those children while children younger than 8 were excluded. Participation in sports might be helpful for children diagnosed with ADHD on multiple fronts. Sports participation can be protective13 against children with ADHD becoming overweight or obese11 or help decrease anxious and depressed feelings. A

31

study encompassing 97 children, 6-14 years old, found that children with ADHD who participated in 3 or more sports display significantly less anxiety or depressed symptoms compared to those who participated in fewer sports (p-value 0.02 in boys and 0.01 in girls)24. Although getting a child diagnosed with ADHD to initiate participation in organized sports may be more complicated than merely signing them up. There are a variety of treatment options in place to help address this issue. Many experts agree that the first step to treatment is to educate the family as to the challenges their child with ADHD will face 5. Medication, carefully titrated, seems to be the primary form of treatment 5,33,62 used, with various other interventions being secondary5,62. Past literature has shown the effectiveness of psychosocial treatment to help with behavior modification62. One study determined the effects of a combined drug and behavioral treatment which proved effective 33. Bandura A et al. stated that self-perceptions are derived from four principle sources of information: past performance, vicarious experiences, verbal persuasion, physiological state 63. Therefore, a suitable and successful physical abilities intervention should include (1) enjoyable activities designed so children with ADHD can experience success, (2) create opportunities for these children to observe influential peers/adults perform these activities, (3) emphasize verbal encouragement and positive reinforcement, (4) decrease the anxiety associated with participation in sports by eliminating competition or grading23.

32

CONCLUSION Children with ADHD may experience a diversity of symptoms and be at an increased risk for a variety of outcomes. Participation in organized sports can provide many benefits for children with ADHD but getting them initially involved may be complicated. Clinicians should continue to include both children and parents in multimodal interventions that encompass the social, motor, and process skills of the child within specific and relevant contexts 64.

33

Table 1. Frequencies and weighted percentages of demographic characteristics stratified by ADHD diagnosis status Categorical Variables Sports Participation Never Low High (ref) Sex Male (ref) Female SES Low Middle High (ref) Race / Ethnicity NH White (ref) NH Black Other ADHD Medication No (ref) Yes Comorbid Diagnosis No (ref) Yes ADHD N Weighted (n=73) percent 30 8 35 48 25 9 19 36 42 26 3 22 51 32 41 Mean (n=73) 51.2 51.1 9.8 46.4 11.7 41.9 67.3 32.7 13.3 30.3 56.4 44.4 52.9 2.7 29.8 70.2 43.3 56.7 No ADHD Total N Weighted N Weighted (n=257) Percent (n=330) Percent 94 17 146 174 83 69 72 104 142 104 9 200 57 218 39 Mean (n=257) 53.9 53.5 9.8 37.7 6.6 55.7 50.0 50.0 26.3 30.1 43.6 40.3 57.0 2.7 87.9 12.1 87.1 12.9 124 25 181 222 108 78 91 140 184 130 12 222 108 250 80 Mean (n=330) 53.7 53.3 9.8 38.6 7.1 54.4 51.7 48.3 25.1 30.1 44.7 40.7 56.6 2.7 82.3 17.7 82.9 17.1

Numeric Variables Peer Relations Physical Abilities Age

95% CI (48.7, 53.8) (48.8,53.4) (9.4, 10.1)

95% CI (52.5, 55.3) (52.4, 54.7) (9.6, 9.9)

95% CI (52.4, 54.9) (52.2, 54.4) (9.6, 9.9)

34

Table 2 Logistic regression of sports participation on ADHD while controlling sex, SES, race/ethnicity, ADHD medication status, and comorbid psychiatric disorders Sports Participation Never vs High Low vs High Lower OR 95% CI OR 95% CI 2.85 0.99, 8.18 5.09 1.19, 21.68 2.47 1.2, 5.08 2.77 0.83, 9.23 0.34 0.63 0.98 2.93 0.52 1.08 0.14, 0.79 0.25, 1.60 0.45, 2.13 0.53, 16.27 0.20, 1.37 0.37, 3.12 0.22 0.35 2.02 9.84 0.66 0.48 0.03, 1.78 0.08, 1.49 0.46, 8.85 0.74, 130.04 0.17, 2.56 0.11, 2.1

ADHD Diagnosis Female SES Low Middle Race / Ethnicity NH Black Other ADHD Medication Comorbid Diagnosis

35

Sex

SES

Self-Concept Physical Abilities ADHD Diagnosis Sports Participation Self-Concept Peer Relations

Race/Ethnicity

Medication Comorbid diagnosis

Figure 1 Theoretical framework to assess the: direct effect of ADHD diagnosis on physical abilities, peer relations, and sports participation; direct effect of physical abilities on peer relations and sports participation; peer relations direct effect on sports participation; indirect effects of ADHD diagnosis, self-concept of physical abilities on sports participation.

36

Sex

SES

-2.30 (1.07)*

Self-Concept Physical Abilities

0.63 (0.04)**

0.04 (0.01)**

Race/Ethnicity

ADHD Diagnosis

-0.13 (0.16)

Sports Participation
-0.02 (0.01)*

Medication

-1.15 (0.26)

Self-Concept Peer Relations

Comorbid
* p-value < 0.05 ** p-value < 0.001

Figure 2 Coefficients (and standard errors) for the direct effect of: ADHD diagnosis on physical abilities and peer relations; ADHD diagnosis, physical abilities, and peer relations on sports participation; and physical abilities direct effect on peer relations.

37

Table 3 Description of the indirect paths analyzed as well as their respective estimate, standard error, and p-values Estimate ADHDPhysical AbilitiesSports Participation ADHDPeer RelationsSports Participation ADHDPhysical AbilitiesPeer RelationsSports Participation Physical Abilities Peer Relations Sports Participation -0.09 0.04 0.02 -0.01 Standard Error 0.05 0.27 0.02 0.005 p-value 0.06 0.12 0.14 0.03

38

REFERENCES 1. Agranat-Meged, A. N., C. Deitcher, et al. (2005). "Childhood obesity and attention deficit/hyperactivity disorder: a newly described comorbidity in obese hospitalized children." Int J Eat Disord 37(4): 357-359. 2. Bandini, L. G., C. Curtin, et al. (2005). "Prevalence of overweight in children with developmental disorders in the continuous national health and nutrition examination survey (NHANES) 1999-2002." J Pediatr 146(6): 738-743. 3. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory, Prentice-Hall, Inc. 4. Barkley, R. A. (1997). "Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD." Psychol Bull 121(1): 65-94. 5. Bejerot, S., J. Edgar, et al. (2010). "Poor performance in physical education - a risk factor for bully victimization." Acta Paediatr. 6. Biddle, S. (1993). "Children, exercise and mental health." International journal of sport psychology 24(2): 200-216. 7. Biederman, J. and S. V. Faraone (2005). "Attention-deficit hyperactivity disorder." Lancet 366(9481): 237-248. 8. Bouffard, M., E. J. Watkinson, et al. (1996). "A test of the activity deficit hypothesis with children with movement difficulties." Adapted Physical Activity Quarterly 13: 61-73. 9. Cairney, J., J. A. Hay, et al. (2005). "Developmental coordination disorder, generalized self-efficacy toward physical activity, and participation in organized and free play activities." J Pediatr 147(4): 515-520. 10. Cantell, M. H., M. M. Smyth, et al. (1994). "Clumsiness in adolescence: Educational, motor, and social outcomes of motor delay detected at 5 years." Adapted Physical Activity Quarterly 11: 115-115. 11. Emck, C., R. Bosscher, et al. (2009). "Gross motor performance and selfperceived motor competence in children with emotional, behavioural, and pervasive developmental disorders: a review." Dev Med Child Neurol 51(7): 501517.
39

12. Fitzpatrick, D. and E. J. Watkinson (2003). "The lived experience of physical awkwardness: Adults' retrospective views." Adapted Physical Activity Quarterly 20(3): 279-297. 13. Gau, S. S., H. C. Ni, et al. (2010). "Psychiatric comorbidity among children and adolescents with and without persistent attention-deficit hyperactivity disorder." Aust N Z J Psychiatry 44(2): 135-143. 14. Gol, D. and T. Jarus (2005). "Effect of a social skills training group on everyday activities of children with attention deficit hyperactivity disorder." Developmental Medicine & Child Neurology 47(8): 539-545. 15. Group, M. C. (1999). "A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder." Arch Gen Psychiatry 56(12): 1073-1086. 16. Hands, B. P. and D. Larkin (2006). "Physical fitness of children with motor learning difficulties." Health Sciences Papers and Journal Articles: 15. 17. Harvey, W. J., G. Reid, et al. (2009). "Physical activity experiences of boys with and without ADHD." Adapt Phys Activ Q 26(2): 131-150. 18. Holtkamp, K., K. Konrad, et al. (2004). "Overweight and obesity in children with Attention-Deficit/Hyperactivity Disorder." Int J Obes Relat Metab Disord 28(5): 685-689. 19. Hoza, B., D. A. Waschbusch, et al. (2000). "Attention-deficit/hyperactivity disordered and control boys' responses to social success and failure." Child Dev 71(2): 432-446. 20. Kiluk, B. D., S. Weden, et al. (2009). "Sport participation and anxiety in children with ADHD." J Atten Disord 12(6): 499-506. 21. Marsh, H. W. (1990). Self description questionnaire-I manuel. MacArthur, Australia, University of Western Sydney. 22. Mrug, S., B. Hoza, et al. (2001). "Children with attention-deficit/hyperactivity disorder: peer relationships and peer-oriented interventions." New Dir Child Adolesc Dev(91): 51-77. 23. Murray-Close, D., B. Hoza, et al. (2010). "Developmental processes in peer problems of children with attention-deficit/hyperactivity disorder in the Multimodal Treatment Study of Children With ADHD: Developmental cascades and vicious cycles." Dev Psychopathol 22(4): 785-802.

40

24. Muthen, L. and B. Muthen (2007). Mplus User's Guide (5th edition). Los Angelas, Authors. 25. Piek, J. P., T. M. Pitcher, et al. (1999). "Motor coordination and kinaesthesis in boys with attention deficit-hyperactivity disorder." Dev Med Child Neurol 41(3): 159-165. 26. Pitcher, T. M., J. P. Piek, et al. (2003). "Fine and gross motor ability in males with ADHD." Dev Med Child Neurol 45(8): 525-535. 27. Raggio, D. J. (1999). "Visuomotor perception in children with attention deficit hyperactivity disordercombined type." Perceptual and motor skills. 28. Shaffer, D., P. Fisher, et al. (2000). "NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses." J Am Acad Child Adolesc Psychiatry 39(1): 28-38. 29. Shah, B., B. Barnwell, et al. (1996). SUDAAN Use's Manuel, Release 7.0. Research Triangle Park, NC, Research Triangle Institute. 30. Trost, S. G., L. M. Kerr, et al. (2001). "Physical activity and determinants of physical activity in obese and non-obese children." Int J Obes Relat Metab Disord 25(6): 822-829. 31. Visser, S., R. Bitsko, et al. (2010). "Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children." MMWR 59(44): 1439-1442. 32. Waring, M. E. and K. L. Lapane (2008). "Overweight in children and adolescents in relation to attention-deficit/hyperactivity disorder: results from a national sample." Pediatrics 122(1): e1-6. 33. Whalen, C. K., L. D. Jamner, et al. (2002). "The ADHD spectrum and everyday life: experience sampling of adolescent moods, activities, smoking, and drinking." Child Dev 73(1): 209-227. 34. Wolraich, M. L., C. J. Wibbelsman, et al. (2005). "Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications." Pediatrics 115(6): 1734-1746.

41

CHAPTER V SUMMARY Attention-deficit/hyperactivity disorder (ADHD) affects 9.5% of children and is characterized by impairing symptoms of inattention and/or hyperactivity 1. Research also shows that children diagnosed with ADHD have more problems with peer relationships, increased difficulty with motor skills, and are less likely to participate in organized sports. However, previous studies have not investigated the mediating effects of peer relationships and physical abilities between ADHD diagnosis and sports participation. The purpose of this thesis was to examine the direct effects of ADHD diagnosis, selfconcept of peer relations, and self-concept of physical abilities on sports participation as well as the indirect of ADHD diagnosis and self-concept of physical abilities. Data from South Carolina Project to Learn about ADHD in Youth (SC PLAY) years 1 and 2 were used to complete the analysis SCPLAY is a population based study funded by the Centers for Disease Control and Prevention (CDC) through the Department of Epidemiology and Biostatistics within the University of South Carolinas Arnold School of Public Health and their goal was to determine risk behaviors, demographics, and other correlates and characteristics of both diagnosed and undiagnosed ADHD children as well as children without ADHD. One large school district, containing 15 elementary school and over 8,700 students, in South Carolina was included in this study with the target population as kindergarten through 5th grade.

42

SC PLAY implemented a two-phase design to account for DSM-IV criteria. The first phase utilized information gathered from teachers and parents that enabled SC PLAY to identify children that may have a diagnosis of ADHD. The second phase was an in-depth survey and computer-based interview conducted with the parent to ascertain demographic and health risk behaviors as well as a more precise diagnosis of ADHD. Polytomous logistic regression and path analysis were employed to determine statistical significant associations. There were 330 children who reported their participation in organized sports. Children diagnosed with ADHD were more likely to never participate and less likely to have high sports participation compared to children without ADHD. Logistic regression revealed that children with ADHD were significantly five times higher risk for low sports participation in when compared to children without ADHD. Children with ADHD were also more likely to never participate in sports than their peers without ADHD (OR=2.85). Currently taking ADHD medication did not make a significant difference in sports participation in either category. The results from the path analysis showed that peer relations and physical abilities direct effect was significantly associated with sports participation. ADHD diagnosis was found to be only significantly directly related to physical abilities. Indirect path analysis concluded ADHD diagnosis did not significantly indirectly effect sports participation through any of the proposed path ways. A result that was approaching significance was ADHD diagnosis indirect effect on sports participation through physical abilities.

43

The direct effect of peer relations and physical abilities on sports participation calculated in this analysis support previous findings. In a retrospective study capturing the prevalence of bullying in physical education classes, 69 university students in Sweden reported being a victim of bullying during childhood17. The study also demonstrated that below average performance in physical education class was a significant risk factor of being bullied (OR=3.5). The Swedish report also concluded that poor motor skills were strongly related to long duration of victimization and increased frequency. This is concurrent with other literature which states that children with low self-perception of physical abilities will be more likely to choose a sedentary lifestyle43. Also, children with motor impairments are less likely to participate in active play
56-58

and this avoidance

might by a coping strategy to prevent ridicule and humiliation 59. The mediating effects of physical abilities between ADHD diagnosis and sports participation presented in this study concur with previous findings that children with ADHD have problems with balance2, manual dexterity2, and balls skills46. Barkley55 reported that children diagnosed with ADHD usually struggle in motor activities which demand inhibiting and sequencing the motor action. Also, children with motor impairments are less likely to participate in active play 56-58 and this avoidance might by a coping strategy to prevent ridicule and humiliation 59. Participation in sports might be help children diagnosed with ADHD on multiple fronts. Sports participation can be protective13 against children with ADHD becoming overweight or obese11 or help decrease anxious and depressed feelings. Although getting a child diagnosed with ADHD to initiate participation in organized sports may be more convoluted than signing them up. There are a variety of treatment options in place to

44

help address this issue. Many experts agree that the first step to treatment is to educate the family as to the challenges their child with ADHD will face 5. Medication, carefully titrated, seems to be the primary form of treatment5,33,62 used with various interventions being secondary5,62. Clinicians need to continue to make interventions be multimodal and include both children and parents while encompassing the social, motor, and process skills of the child within specific and relevant contexts 64.

45

REFERENCES 1. Visser S, Bitsko R, Dnaielson M, Perou R. Increasing Prevalence of ParentReported Attention-Deficit/Hyperactivity Disorder Among Children. MMWR. November 12, 2010 2010;59(44):1439-1442. Piek JP, Pitcher TM, Hay DA. Motor coordination and kinaesthesis in boys with attention deficit-hyperactivity disorder. Dev Med Child Neurol. Mar 1999;41(3):159-165. Murray-Close D, Hoza B, Hinshaw SP, et al. Developmental processes in peer problems of children with attention-deficit/hyperactivity disorder in the Multimodal Treatment Study of Children With ADHD: Developmental cascades and vicious cycles. Dev Psychopathol. Nov 2010;22(4):785-802. Hoza B, Mrug S, Gerdes AC, et al. What aspects of peer relationships are impaired in children with attention-deficit/hyperactivity disorder? J Consult Clin Psychol. Jun 2005;73(3):411-423. Wolraich ML, Wibbelsman CJ, Brown TE, et al. Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications. Pediatrics. Jun 2005;115(6):1734-1746. Fliers EA, Franke B, Lambregts-Rommelse NN, et al. Undertreatment of Motor Problems in Children with ADHD. Child Adolesc Ment Health. Aug 21 2009;15(2):85-90. Emck C, Bosscher R, Beek P, Doreleijers T. Gross motor performance and selfperceived motor competence in children with emotional, behavioural, and pervasive developmental disorders: a review. Dev Med Child Neurol. Jul 2009;51(7):501-517. Harvey WJ, Reid G, Bloom GA, et al. Physical activity experiences of boys with and without ADHD. Adapt Phys Activ Q. Apr 2009;26(2):131-150. Tseng MH, Henderson A, Chow SM, Yao G. Relationship between motor proficiency, attention, impulse, and activity in children with ADHD. Dev Med Child Neurol. Jun 2004;46(6):381-388.

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