organized sports participation in children with and without adhd the roles of self perceived peer...
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Organized Sports Participation in Children With and Without ADHD: the Roles of Self-
Perceived 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
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All rights reserved
INFORMATION TO ALL USERSThe quality of this reproduction is dependent on the quality of the copy submitted.
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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-
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value=0.04) and 0.04 (p-value
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TABLE OF CONTENTS
DEDICATION ii
ACKNOWLEDGEMENTS iii
ABSTRACT iv
LIST OF TABLES ix
LIST OF FIGURES x
LIST OF ABBREVIATIONS xi
CHAPTER I: INTRODUCTION 1
CHAPTER II: LITERATURE REVIEW
ADHD and Sports Participation 3
ADHD and Self Concept Peer Relations 6
ADHD and Self Concept Physical Abilities 8
Summary 10
CHAPTER III: METHODS
Research Objectives 11
Data Source 12
Measures 16Statistical analysis 17
CHAPTER IV: MANUSCRIPT
Abstract 20
Introduction 22
Methods 24
Results 27Discussion 28
Conclusion 33
References 39
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CHAPTER V: SUMMARY 42
REFERENCES 46
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LIST OF TABLES
Table 1.Frequencies and weighted percentages of demographic 34
characteristics stratified by ADHD diagnosis status
Table 2. Logistic regression of sports participation on ADHD while 35
controlling sex, SES, race/ethnicity, ADHD medication status,
and comorbid psychiatric disorders
Table 3. Description of the indirect paths analyzed as well as their 38
respective estimate, standard error, and p-values
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LIST OF FIGURES
Figure 1. Theoretical framework to assess the direct and indirect effect 36
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 37
Diagnosis, self-concept of physical abilities, and self-conceptof peer relations on sports participation
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LISTOFABBREVIATIONS
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 age1with 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 diagnosis3,4
. 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 importance5.
Poor physical abilities is often referred to as Developmental Coordination Disorder
(DCD) and can occur in 30-50% of children diagnosed with ADHD6. The potential for
children with ADHD to have poor physical abilities is well documented2and can include
fine motor skills, ball skills, balance, bilateral coordination, and strength2,7-9
. Other
literature shows that boys with ADHD not only preferred individual sports over team
sports, but they also used domain specific vocabulary less frequently8.
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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 obesity10-13
. Overweight and obesity
result from an extended positive energy balance11
and previous research has noted that
obese children are at an increase risk for becoming obese adults14
.
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 peers16
. 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
bullying3. Strong correlations have been found between long duration of bullying and
high frequency of bullying with poor performance in physical education class17
.
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.
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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 obesity10-13
.Overweight and obesity result from an extended positive
energy balance11
and previous research has noted that obese children are at an increase
risk for becoming obese adults14. The prevalence of overweight children has more than
tripled in the past three decades, increasing from seven percent in 1980 to approximately
20% in 200818,19
. 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
study11
aimed at determining the prevalence of overweight and obesity in ADHD
diagnosed children using objectively measured body mass index (BMI). The prevalence
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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 adolescents13
. 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
21. 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 obesity15. 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 activities8. Children with
ADHD were also significantly less likely to engage in spontaneous play and participate in
organized sports compared to children without ADHD8.
Kim and Mutyala, et al completed a cross sectional study investigating health
behaviors and obesity among children with ADHD in the United States16
. The study
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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 impacts24
. 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 sports24
.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.
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ADHD and Self Concept Peer Relations
Peer relationships are the primary context where children learn conflict resolution,
negotiation, and cooperation25
. However, many children with ADHD experience low
peer regard, frequent rejections, and difficulties making and maintaining friendships26,27
.
Restlessness, verbal outburst, intrusiveness, and inability to behave in a manner
appropriate in a social setting are common symptoms of ADHD3but other children
consistently report this behavior as impolite, selfish, apathetic, and offensive28
. 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
ADHD4,29-32
.The Multimodal Treatment of Children with ADHD33
analyzed a
subsample of 330 youth with and without (n=165) an ADHD diagnosis to assess
friendship33.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 relationships36
. There are hypothesis
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explaining the relationship between peer rejection and adjustment36
. 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 context36
. These negative behaviors
have been shown to increase in frequency in situations with little or no adult supervision37
. Boys diagnosed with ADHD have difficulties recognizing their problem areas and
their motivation for corrective action are quite low38
. 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 groups37
. These play groups contained one child
diagnosed with ADHD, Pelham and Bender37found that the child with ADHD
commonly emerged as the most disliked member, sometimes as early as the first play
session37,38
. 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 program29
improved upon Pelham and
Benders findings by conducting a similar study with peer interaction while accounting
for social behaviors and nonbehavorial traits29
. The main finding was that social
behaviors, more specifically externalizing features of aggression and noncompliance,
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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 later29
. This reinforces the findings
that negative reputations develop quickly within peer groups and are hard to dismiss once
established39
. It is also supports the finding that peer rejection is a group process and not
an individual characteristic40
.
ADHD and Self Concept of Physical Ability
A childs psychosocial functioning can be negatively affected when gross motor
functions are impaired41,42
. Children with motor impairment suffer from ridicule both on
and off the playground43
and its well documented that poor relationships with peers may
lead to motor problems44,45
. 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 humiliation43.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 impairment43
.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
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select sedentary lifestyles and are less likely to enjoy physical education classes
compared to their peers43
.
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
balls7,8
. Literature shows that children with developmental or emotional disorders often
exhibit motor problems7.
ADHDs effects on physical abilities has been described as more a problem of
doing what one knows rather than of knowing what to do43
.Although excessive activity
is commonly associated with ADHD8,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 groups2. The study was
not able to determine a difference between the groups of boys in regards to ball skills2.
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
diagnosis46
.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.
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Physical therapy intervention produces significant improvements in physical
abilities of children with ADHD47
. 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 peers16
. 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 ADHDdiagnosis, is there a significant difference in organized sports participation?
2.) Comparing children diagnosed with ADHD versus children without an ADHDdiagnosis, 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 ADHDdiagnosis, 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 peerrelations, 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 two-
phase 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 population-
based 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-IV51
.
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 I52
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 non-
response which produce estimates similar to the demographics of the sampled population.
All regression models were performed using the SAS-callable SUDAAN software53
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 software54
.
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, 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. 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 Mplus54
.The direct analysis was performed for ADHD diagnosis, peer relations,
and physical abilities onsports 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, MD
3, Joe Holbrook, PhD
2,and
Robert McKeown, PhD, FACE2. To be submitted toPediatrics
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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 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 (p-
value=0.04) and 0.04 (p-value
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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
year1. 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 activities8. Children with ADHD
were also significantly less likely to engage in spontaneous play and participate in
organized sports compared to children without ADHD8.
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 context36
.Hoza concluded that boys diagnosed with ADHD have
difficulties recognizing their problem areas and their motivation for corrective action is
low38
.
Difficulties with peer relationships may also be influenced by motor impairment43
which may present itself in children diagnosed with ADHD2,7
.Motor impairment within
this group of children has been described as more a problem of doing what one knows
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rather than of knowing what to do43
.Previous literature shows significant impairment in
balance2,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 humiliation43
.
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 peers43
.
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,
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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-IV51
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 I52for
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 199052
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
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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 non-
response 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 software53
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 Mplus54
.The direct analysis was performed for ADHD diagnosis, peer relations,
and physical abilities onsports 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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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
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Direct path analysis concluded that peer relations and physical abilities direct
effect was significantly associated with sports participation with a coefficient of -0.02 (p-
value=0.04) and 0.04 (p-value
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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.Barkley55reported 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 play56-58
and this avoidance might by a coping strategy to prevent
ridicule and humiliation59
.
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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 ADHD60
.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 well-
being61
.
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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
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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
treatment5,33,62
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 effective33
.
Bandura A et al. stated that self-perceptions are derived from four principle
sources of information: past performance, vicarious experiences, verbal persuasion,
physiological state63
. 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
.
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Table 1. Frequencies and weighted percentages of demographic characteristics stratified
by ADHD diagnosis status
ADHD No ADHD Total
Categorical
Variables
N
(n=73)
Weighted
percent
N
(n=257)
Weighted
Percent
N
(n=330)
Weighted
PercentSports Participation
Never 30 46.4 94 37.7 124 38.6
Low 8 11.7 17 6.6 25 7.1
High (ref) 35 41.9 146 55.7 181 54.4Sex
Male (ref) 48 67.3 174 50.0 222 51.7
Female 25 32.7 83 50.0 108 48.3
SESLow 9 13.3 69 26.3 78 25.1
Middle 19 30.3 72 30.1 91 30.1
High (ref) 36 56.4 104 43.6 140 44.7Race / Ethnicity
NH White (ref) 42 44.4 142 40.3 184 40.7
NH Black 26 52.9 104 57.0 130 56.6
Other 3 2.7 9 2.7 12 2.7ADHD Medication
No (ref) 22 29.8 200 87.9 222 82.3
Yes 51 70.2 57 12.1 108 17.7Comorbid
Diagnosis
No (ref) 32 43.3 218 87.1 250 82.9
Yes 41 56.7 39 12.9 80 17.1
Numeric VariablesMean
(n=73)95% CI
Mean
(n=257)95% CI
Mean
(n=330)95% CI
Peer Relations 51.2(48.7,
53.8)53.9 (52.5, 55.3) 53.7 (52.4, 54.9)
Physical Abilities 51.1 (48.8,53.4) 53.5 (52.4, 54.7) 53.3 (52.2, 54.4)Age 9.8 (9.4, 10.1) 9.8 (9.6, 9.9) 9.8 (9.6, 9.9)
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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
OR 95% CI OR Lower95% CI
ADHD Diagnosis 2.85 0.99, 8.18 5.09 1.19, 21.68
Female 2.47 1.2, 5.08 2.77 0.83, 9.23
SESLow 0.34 0.14, 0.79 0.22 0.03, 1.78
Middle 0.63 0.25, 1.60 0.35 0.08, 1.49
Race / Ethnicity
NH Black 0.98 0.45, 2.13 2.02 0.46, 8.85Other 2.93 0.53, 16.27 9.84 0.74, 130.04
ADHD Medication 0.52 0.20, 1.37 0.66 0.17, 2.56
Comorbid Diagnosis 1.08 0.37, 3.12 0.48 0.11, 2.1
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Figure 1 Theoretical framework to assess the: direct effect of ADHD diagnosis onphysical 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 onsports participation.
Self-Concept
Peer Relations
ADHD Diagnosis
Self-ConceptPhysical Abilities
Sports
Partici ation
SES
Sex
Medication
Comorbiddiagnosis
Race/Ethnicit
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* 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.
Sex
Race/Ethnicity
SES
Medication
Comorbid
Self-Concept
Physical Abilities
Self-Concept
Peer Relations
ADHD Diagnosis Sports
Participation
0.04 (0.01)**
-0.13 (0.16)
-0.02 0.01 *
-2.30 (1.07)*
-1.15 (0.26)
0.63 (0.04)**
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Table 3 Description of the indirect paths analyzed as well as their respective estimate,
standard error, and p-values
Estimate StandardError p-value
ADHDPhysical AbilitiesSports Participation -0.09 0.05 0.06
ADHDPeer RelationsSports Participation 0.04 0.27 0.12
ADHDPhysical AbilitiesPeer
RelationsSports Participation0.02 0.02 0.14
Physical AbilitiesPeer RelationsSports
Participation-0.01 0.005 0.03
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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 ofphysical 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-ReportedAttention-Deficit/Hyperactivity Disorder Among Children." MMWR 59(44):
1439-1442.
32.Waring, M. E. and K. L. Lapane (2008). "Overweight in children and adolescentsin relation to attention-deficit/hyperactivity disorder: results from a nationalsample." Pediatrics 122(1): e1-6.
33.Whalen, C. K., L. D. Jamner, et al. (2002). "The ADHD spectrum and everydaylife: 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/hyperactivitydisorder among adolescents: a review of the diagnosis, treatment, and clinical
implications." Pediatrics 115(6): 1734-1746.
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CHAPTER V
SUMMARY
Attention-deficit/hyperactivity disorder (ADHD) affects 9.5% of children and is
characterized by impairing symptoms of inattention and/or hyperactivity1. 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, self-
concept 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.
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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.
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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 lifestyle
43
. Also, children with
motor impairments are less likely to participate in active play56-58
and this avoidance
might by a coping strategy to prevent ridicule and humiliation59
. 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 dexterity
2,and balls skills
46.Barkley
55reported 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 play56-58
and this avoidance might by a coping strategy to prevent ridicule and
humiliation59
.
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
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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 face5. 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 contexts64
.
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