Organized Sports Participation in Children With and Without ADHD the Roles of Self Perceived Peer Relations and Physical Abilities

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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.

    In the unlikely event that the author did not send a complete manuscriptand there are missing pages, these will be noted. Also, if material had to be removed,

    a note will indicate the deletion.

    All rights reserved. This edition of the work is protected againstunauthorized copying under Title 17, United States Code.

    ProQuest LLC.789 East Eisenhower Parkway

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    UMI Number: 1506037

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    ii

    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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    12.Fitzpatrick, D. and E. J. Watkinson (2003). "The lived experience of physicalawkwardness: 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 andadolescents 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 everydayactivities 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 TreatmentStrategies 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 motorlearning difficulties." Health Sciences Papers and Journal Articles: 15.

    17.Harvey, W. J., G. Reid, et al. (2009). "Physical activity experiences of boys withand without ADHD." Adapt Phys Activ Q 26(2): 131-150.

    18.Holtkamp, K., K. Konrad, et al. (2004). "Overweight and obesity in children withAttention-Deficit/Hyperactivity Disorder." Int J Obes Relat Metab Disord 28(5):

    685-689.

    19.Hoza, B., D. A. Waschbusch, et al. (2000). "Attention-deficit/hyperactivitydisordered 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 childrenwith 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/hyperactivitydisorder: 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 peerproblems 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.

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    24.Muthen, L. and B. Muthen (2007). Mplus User's Guide (5th edition). LosAngelas, Authors.

    25.Piek, J. P., T. M. Pitcher, et al. (1999). "Motor coordination and kinaesthesis inboys 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 withADHD." Dev Med Child Neurol 45(8): 525-535.

    27.Raggio, D. J. (1999). "Visuomotor perception in children with attention deficithyperactivity disordercombined type." Perceptual and motor skills.

    28.Shaffer, D., P. Fisher, et al. (2000). "NIMH Diagnostic Interview Schedule forChildren 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 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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    46

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