Attention-Deficit Hyperactivity Disorder: What’s movement got to do with it? Billy Harvey, Ph.D. Department of Kinesiology & Physical Education McGill University National Adapted Physical Education Conference, November, 2010 Riverside, California

What is ADHD?  Complex Psychiatric Disorder  Lifelong (Weiss & Hechtman, 1993)  Most Thoroughly Researched Disorder In Childhood Psychiatry (Barkley, 1995)  3-5% of Children Are Affected (Cantwell, 1996)

What is AD/HD?  More males are affected than females - Normal pop = 3:1, Clinical pop = 9:1 (APA, 2001; Brown et al., 1991; Szatmari et al., 1989)  Usually Identified In Early School Years (APA, 2001)  Symptoms must be pervasive and age inappropriate (APA, 2001)  Inattention, Impulsiveness, Hyperactivity

Etiology  unknown  syndrome of behaviors  Neurological  Neurological (e.g. frontal lobe, cerebral blood flow)  Genetics  Genetics (e.g. hereditary)  Psychosocial  Psychosocial (e.g. environment )

NomenclatureNomenclature  6 major changes since the 1900’s  50 textbooks and more than 6,000 scientific articles (Barkley, 1995), with differing nomenclature over time.  Affect understanding of the disorder over time + research designs.

DSM Nomenclature Historical Review  DSM-I (1952) NONE  DSM-II (1968) Hyperkinetic Syndrome of Childhood  DSM-III (1980) Attention Deficit Disorder (ADDH, ADD-H)  DSM-III-R (1987) ADHD (pervasive, situational)  DSM-IV (1994, 2001) ADHD (Inattentive, Hyperactive- Impulsive, Combined Sub-Types)

What is ADHD? COMORBIDITY  65% > 1 Disorder, 40% Conduct Disorder, 24% Emotional Disturbance (Szatmari et al., 1989)  30% also have Learning Disability (DuPaul & Stoner, 1994)  50% experience academic underachievement (Barkley, 1998)  Differential diagnosis by experienced clinicians

ADHD Learning Disabilities Oppositional Defiant Disorder Anxiety Disorders Mood Disorders Personality Disorders Tourette’s Syndrome Conduct Disorder COMORBIDITY Substance Abuse Developmental Coordination Disorder

3 Key Clinical Issues (Barkley, 1997)  Lack of Self-Control  Point of Performance Problems  An Impaired Sense of Time

ADHD behaviors (Barkley, 1995)  Difficulty Sustaining Attention  Information filtering not as problematic  Children with ADHD probably get bored with or lose interest in their work much faster  Children with ADHD seem to be drawn to the most rewarding, fun, or reinforcing aspects of any situation

ADHD behaviors (Barkley, 1995)  Problems of deferring gratification & controlling impulses  Take shortcuts, extra risks  Poor money managers  Impulsive thinkers  Overactive  Difficulty Following Instructions  Inconsistent work performance

Personal Strengths (Litner & Ostiguy, 2000)  Resiliency  Ingenuity  Creativity  Spontaneity  Boundless Energy  Sensitivity to Others  Inquisitiveness  Imaginative  Resourceful  Full of Ideas  Observant  Empathetic ?

Treatment  Multi-Modal Treatment Approach (Cantwell, 1996)  Behavior Management & Medication Treatment (Whalen & Henker, 1991) MEDICATIONS:  Ritalin, Dexedrine, Cylert, Adderall (Sawyer & Brown, 1998)  Sleep Disturbance, Appetite Disturbance, Headaches, Stomachaches (Barkley et al., 1990)  Minor Increases In Blood Pressure & Heart Rate (Knights & Hinton, 1969)

Literature Review (Harvey & Reid, 2003, 2005)  At Risk for movement behavior problems: poor fine motor coordination, balance, and fundamental movement skills  Perceptions of Teacher & Parents  Similar problems as children with DCD?

GMDQ scores: Children with & without ADHD (Harvey et al., 2007)

Locomotor Skill Profiles (Harvey et al., 2007)

Object Control Skill Profiles (Harvey et al., 2007)

Physical activity experiences of boys with ADHD (Harvey et al., 2009)

Participants  6 boys from each group  Age-matched (±6 months)  years  Average age: 10.9 yrs (ADHD), 11.1 yrs (No-ADHD)

What are the similarities and differences in the physical activity experiences of children with and without ADHD?  TGMD-2 movement skill assessments (Ulrich, 2000)  Semi-structured interviews - pilot work  17 question interview guide - PAMQ (Craig et al., 2000) - theories of expertise (Wall et al., 1985)  Parental input - summary statement & telephone interview

Findings ⇧ Differences in physical activity experiences 1. Deliberate Play Boys without ADHD referred to a variety of physical activity settings that, in turn, linked their practice and play experiences with substantial involvement of their family or friends. “Well, I don’t usually practice by myself. I take my sister or my mom. Because, for most of the sports you need more than one person to practice” (participant without ADHD).

Findings, Cont’d 2. Knowing About Doing ↓ ↓ depth of awareness in relation to terminology - Know action terms but won’t use them “Well like the meaning of slap shot. I know what it means, but yeah sometimes I’ll use words like that, but that’s the only thing. Like in football people say dive and I know what it means but I don’t use it. When I try to tell somebody something I don’t really use special words” (Participant with ADHD) Superficial knowledge about action: know names of terms but do not possess a deeper conceptual understanding

Findings, Cont’d  unaware of observational learning benefits “After I play, it’s a lot of games, there’s another team that plays after me, an older team and I watch them play and I see how they use the stick and shoot. They’re older than me and better skilled …. Yeah, I don’t watch someone with lower skills than me because I won’t learn that much” (Participant without ADHD).

Findings, Cont’d 3. Personal Feelings  Both groups spoke about positive experiences  physical awkwardness & learned helplessness o found many games to be boring o being picked last for football games o “tackled and knocked down to the ground” o “hit in the stomach by the football” o avoided being passed to by the quarterback

Concurrent scrapbook interviewing (Harvey, Wilkinson, Pressé, Grizenko & Joober, in review) Participants  9-12 years  2 Males and 1 female per group  Clinical diagnosis of ADHD, English-speaking Disposable camera to acquire pictures of their physical activity participation (e.g. home, school, or other contexts). Child developed scrapbook with research assistant (RA). RA conducted minute semi-structured interview during scrapbook development either during (concurrent) or after (consecutive) Asked open-ended questions about selected physical activity experiences from photographs Each interview videotaped with a JVC digital Handycam video recorder. Interviews are transcribed verbatim

u Scrapbook prompting more vivid details & child speak u Increase in depth of participant statements and meaning between and across themes u Gain greater insight into the day-to-day events and experiences which may influence participation u Deeper levels of knowledge were discussed u Positive outcomes u To plan or not to plan! u More information about specific experience linked to particular activities. Findings (Harvey, Wilkinson, Pressé, Grizenko & Joober, in review)

Out of the mouths of Babes: The physical activity voices of children with ADHD (Harvey, Wilkinson, Pressé, Grizenko & Joober, in preparation) Out of the mouths of Babes: The physical activity voices of children with ADHD (Harvey, Wilkinson, Pressé, Grizenko & Joober, in preparation) Participants  9-12 years  9 Males and 2 females  Clinical diagnosis of ADHD, English-speaking Disposable camera to acquire pictures of their physical activity participation (e.g. home, school, or other contexts). Child developed scrapbook with research assistant (RA). RA conducted minute semi-structured interview during scrapbook development either during (concurrent) Asked open-ended questions about selected physical activity experiences from photographs Each interview videotaped with a JVC digital Handycam video recorder. Interviews are transcribed verbatim

Findings Similar to past research u Poor performance on MABC-2 and TGMD-2 u Pictures of friends u Aware of physical inabilities u Being on organized teams (e.g., cheerleading, gymnastics, etc.). u Spoke about observational learning u Parent work schedule as a constraint Different from past research u Performance anxiety u Demonstrated good sporting values (e.g., doesn’t matter if you win, it matters if you have fun).  Superficial understanding of purpose for activities  Family discontent  Social fragmentation

Parent views on physical activity and their child with ADHD Harvey, Pressé, Wilkinson, Joober & Grizenko (in preparation) Parent views on physical activity and their child with ADHD Harvey, Pressé, Wilkinson, Joober & Grizenko (in preparation) 5 Parents, English-speaking 5 Parents, English-speaking Age Range: years Average: 44.2 years Age Range: years Average: 44.2 years Years of Education Range: years Average: 14.6 years Years of Education Range: years Average: 14.6 years Family Income: 2 > $40,000 2 between $30,000-$40,000 1 Not available Family Income: 2 > $40,000 2 between $30,000-$40,000 1 Not available

Different from past research  Retrospective & Current parent perspectives  Explored perceived parental involvement in PA  Parent knows the movement problems of their child  Children with ADHD seldom organized PA (Supported by child interviews)  HOWEVER, parents did not state or did not seem aware of their child’s perceived ability to plan!  School teachers are perceived as not aware of ADHD implications  Purpose of getting involved in PA is secondary to the activity itself (e.g., socialization, improved discipline Vs. playing hockey or practicing karate)

“At Risk” for Health-Problems?  Increased Resting Heart Rate & Blood Pressure During Tests of Attention (Cohen et al., 1971; Knights & Hinton, 1969, Porges et al., 1975)  Poor Cardio-Respiratory Endurance (Ballard, 1977; Boileau et al., 1977; Harvey & Reid, 1997)  BMI & Body Composition? (Ballard, 1977; Harvey & Reid, 1997, Verret et al., 2010; Waring, & Lapane, 2008)  Poor Muscular Strength/Endurance & Flexibility? (Harvey & Reid, 1997)  Data Suggest Poor Overall Health Conditions?

Lack of Treatment Interventions  Boys with ADHD spent significantly more time on a balancing task when medicated with MPH (Wade, 1976)  Visual Imagery enabled boys with both LD + ADHD to significantly improve their throwing accuracy (Hodge et al., 1999)  Medication & increased HR / BP (Boileau et al., 1977)  Combined reinforcement & 1 mile run (Trocki-Ables et al., 2001)

Caution  The data suggest that we must be careful not to assume that a person with ADHD is a proficient mover because of overactivity  Do not place the children into a failure set  Question the general assumption that a poor learner is a good mover  Teachers / Kinesiologists do NOT diagnose ADHD

Show Me The Money, Cont’d  “The challenge is even greater since leisure service providers often do not have the knowledge, training, or experience to work effectively with youth with ADHD” (Ostiguy & Litner, 1999, p. 14)  Similar phenomenon in Adapted Physical Education (Terry Rizzo)  Need to know instructional strategies that work for all children

Managing the Environment (Sherrill, 1998)  Cruickshank (1967) & Lehtinen (1947)  Establishment of a highly structured program  Reduction of environmental space  Elimination of irrelevant auditory & visual stimuli  Enhancement of the stimulus value of the instructional materials

TEACHING METHODS  Structured Teaching Environment (Bishop & Beyer, 1995; Craft, 1995; Sherrill, 1993)  Consistent Behavioral Expectations & Transitional Routines (Litner & Ostiguy, 2000)  “Extraneous Stimuli Control” (Sherrill, 1993)  “Instructional Stimulus Enhancement” (Sherrill, 1993)  Positive Verbal Reinforcement (Bishop & Beyer, 1995)

Inclusion of Children with BD in PHE? (Panou & Harvey, in preparation) Planning Teacher Actions Teacher Knowledge Administrative Support & Social Context Teacher Affect Educational Outcomes

Instructional models may be developed to enhance inclusion  To help students with ADHD to gain the skills necessary to function independently  Students with disabilities in mainstream PE report that no one wants them as partners.  Physical inclusion alone is not likely to lead to social interaction unless interaction experiences are planned!!!

A Model of Social Skill Training (Harvey, Fagan, & Kassis, 2003) Responsibility Respect Self-Control Participation - Based on Hellison’s approach - Decrease stress & improve trust of children with ADHD - Animator / Teacher as a Facilitator & Learner - Construction of Mutual Language & Understanding

Leisure & Physical Activity Concerns  Early Identification & Intervention  Potential, Perceived, or Actual Individual Conditions  Support Systems Family, school, Community, Non-Profit Organazations, Internet)

Leisure & Physical Activity Concerns  Teaching Methods Instructional Style, Extensive Instruction, Involve Children in Learning.  Leisure Opportunities For Children, Adolescents, & Adults  Exercise & Health

Thank you!!!