Journal ofhttp://jad.sagepub.com/ Attention Disorders
Effects of Physical Activity Intervention on Motor Proficiency and Physical Fitness in Children With ADHD: An Exploratory Study Chien-Yu Pan, Yu-Kai Chang, Chia-Liang Tsai, Chia-Hua Chu, Yun-Wen Cheng and Ming-Chih Sung Journal of Attention Disorders published online 14 May 2014 DOI: 10.1177/1087054714533192 The online version of this article can be found at: http://jad.sagepub.com/content/early/2014/05/14/1087054714533192
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research-article2014
JADXXX10.1177/1087054714533192Journal of Attention DisordersPan et al.
Article
Effects of Physical Activity Intervention on Motor Proficiency and Physical Fitness in Children With ADHD: An Exploratory Study
Journal of Attention Disorders 1–13 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714533192 jad.sagepub.com
Chien-Yu Pan1, Yu-Kai Chang2, Chia-Liang Tsai3, Chia-Hua Chu1, Yun-Wen Cheng1, and Ming-Chih Sung1
Abstract Objective: This study explored how a 12-week simulated developmental horse-riding program (SDHRP) combined with fitness training influenced the motor proficiency and physical fitness of children with ADHD. Method: Twelve children with ADHD received the intervention, whereas 12 children with ADHD and 24 typically developing (TD) children did not. The fitness levels and motor skills of the participants were assessed using standardized tests before and after the 12-week training program. Results: Significant improvements were observed in the motor proficiency, cardiovascular fitness, and flexibility of the ADHD training group following the intervention. Conclusion: Children with ADHD exhibit low levels of motor proficiency and cardiovascular fitness; thus, using the combined 12-week SDHRP and fitness training positively affected children with ADHD. ( J. of Att. Dis. XXXX; XX(X) XX-XX) Keywords ADHD, physical activity, motor performance, physical fitness.
ADHD is characterized by persistent symptoms of inattention and/or hyperactivity-impulsivity that are inconsistent with the developmental level of children who are affected. This condition negatively affects society and numerous areas in the lives of affected children such as financial costs, family function, academic performance, and both physical and mental health (American Psychiatric Association, 2013; Biederman, 2005; Bledsoe, Semrud-Clikeman, & Piliszka, 2010). Moreover, children with ADHD have exhibited various motor skill deficits, including those related to motor proficiency (Beyer, 1999), fine motor skills (Liavasani & Stagnitti, 2013; Pitcher, Piek, & Hay, 2003; Scharoun, Bryden, Otipkova, Musalek, & Lejcarova, 2013), and gross motor development (Harvey et al., 2009; Pan, Tsai, & Chu, 2009; Pitcher et al., 2003; Scharoun et al., 2013); furthermore, these children may be at risk of poor physical fitness (Harvey & Reid, 2003). The underlying factors influencing the movement skills and physical fitness levels of children with ADHD have not been thoroughly examined; however, it has been proposed that children with ADHD lack the ability to regulate their skill performance in various physical activity contexts (Barkley, 1997; Harvey, Fagan, & Kassis, 2003). Because physical activity is a critical part of a healthy lifestyle for all people (U.S. Department of Health and Human Services, 1996), these impairments, and the social and behavioral deficits associated with
ADHD, frequently challenge affected children when participating in various extracurricular physical activities. Because motor skills are a critical determinant of physical activity and fitness levels in children with (Pan, 2014) and without disabilities (Barnett, van Beurden, Morgan, Brooks, & Beard, 2008), it is reasonable to hypothesize that children with ADHD might exhibit low fitness levels. However, few empirical studies have reported detailed data on the movement skill performance and physical fitness levels of children with ADHD. Among the few studies that have explored this topic, Harvey and Reid (1997) assessed the fundamental gross motor skills and fitness conditions of 19 children with ADHD (age = 7-12 years). They observed that the locomotor skills and fitness conditions (VO2max, situps, push-ups, flexibility) of these children were substantially less than average. In a subsequent study, Harvey and Reid (2003) reviewed 49 empirical studies that examined 1
National Kaohsiung Normal University, Taiwan National Taiwan Sport University, Taoyuan, Taiwan 3 National Cheng Kung University, Tainan, Taiwan 2
Corresponding Author: Chien-Yu Pan, Department of Physical Education, National Kaohsiung Normal University, No.116, He-Ping First Road, Kaohsiung 80201, Taiwan. Email: [email protected]
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movement skill performance; however, only 4 of these studies focused on the physical fitness of children with ADHD. They concluded that children with ADHD are at risk of inactivity and poor health compared with chronologically age-matched peers who lack disabilities. Nevertheless, their conclusion regarding fitness was tentative because scant research has examined the physical fitness of children with ADHD. Few studies have addressed how stimulant medications affect the motor performance and/or physical fitness of children with ADHD. Harvey et al. (2007) compared the fundamental movement skills of 22 children with ADHD with those of typically developing (TD) peers, and assessed how stimulant medications affected the movement skill performance of the children with ADHD; children with ADHD exhibited lower locomotor and object control subtest scores compared with age-matched control children. However, a nonsignificant difference was observed when the movement skills of children with ADHD taking medication were compared with those of children in a placebo trial group. Harvey et al. suggested that factors other than medication, such as lack of physical skills and experience, poor social skills, failure to regulate performance, comorbidities, a lack of motivation, and time constraints or performance conditions, are critical influencing variables; however, this requires further research. In a recent study, Verret, Gardiner, and Beliveau (2010) compared physical fitness and motor performance among three groups of children: children with ADHD who were prescribed stimulant medication, children with ADHD who were not prescribed medication, and a control group. Body composition and locomotor skills were the only two parameters that significantly differed among the groups. The children with ADHD who were taking medication had a lower average body mass index (BMI) than did those in the control group, and both groups of children with ADHD had lower raw scores for locomotor skills than did those in the control group. Moreover, the difference in gross motor performance was nonsignificant between the children with ADHD taking and not taking medication. Verret et al. concluded that, regardless of whether children with ADHD used stimulant medication, their fitness levels were comparable with those of children without ADHD. In addition, children with ADHD exhibited lower locomotor skill levels compared with those in the control group regardless of whether they used stimulant medication. The literature lacks sufficient evidence to establish a clear conclusion regarding the motor performance and/or fitness levels of medication-treated or medication-free children with ADHD. Scant information is available on conducting physical activity programs for children with ADHD, and information is lacking regarding how such programs affect the movement performance and/or physical fitness levels of these children. Smith et al. (2013) examined the effects of
an 8-week (5 days per week, 30 min per day) before-school physical activity intervention program that was designed to maximize the moderate-to-vigorous physical activity (MVPA) of 17 children, Grades K-3, who were at risk of developing ADHD. Each day, the participants completed four stations (each lasting 6 min) within small groups (approximately 5 children). One trained staff member supervised each station to foster sustained MVPA within the context of games and activities that required participants to use various motor skills. In addition to these stations, one large-group warm-up aerobic running activity was conducted for 1 to 2 min each day. The authors observed significant increases in the motor proficiency of the participants, including both gross motor and fine motor tasks, and concluded that sustained involvement in structured physical activity may benefit ADHD functioning. Verret, Guay, Berthiaume, Gardiner, and Beliveau (2012) examined the effect of a 10-week (3 times per week for 45-min periods) lunch-time MVPA program on the physical fitness and movement skills of 21 children with ADHD (age = 7-12 years). All sessions included three periods: (a) a warm-up; (b) progressive aerobic, muscular, and motor skills exercises; and (c) cool down. The heart rate of each child was measured once a week to monitor intensity of the program. The children with ADHD were assigned to physical activity (n = 10) and control groups (n = 11), and assessed before and after undergoing 10 weeks of training. The results indicated that the program improved the muscular capacities (push-ups) and motor skills (locomotor and total motor skills) of the children. Thus, additional research is warranted to elucidate how physical activity interventions affect children with ADHD. Maintaining appropriate physical activity and healthrelated physical fitness levels is critical for developing healthy lifestyles; thus, identifying task-specific interventions for children with ADHD is critical for enhancing their motor functions and fitness levels, and encouraging them to adopt physically active lifestyles. The few available studies have suggested that consistent involvement in physical activity is vital when considering physical activity as a strategy for addressing the motor skills and physical fitness levels of children with ADHD (Smith et al., 2013; Verret et al., 2012); however, no consensus exists regarding the optimal components, frequency, or intensity of physical activity interventions. Therefore, a 12-week (1 day per week, 90 min per day) physical activity intervention that involved a simulated developmental horse-riding program (SDHRP) and fitness training was developed in this study. Based on the accumulating evidence of the role of SDHRPs in improving the motor functions of children with disabilities (Wuang, Wang, Huang, & Su, 2010), we hypothesized that combining an SDHRP with a fitness training program would facilitate remediating the movement skill difficulties and fitness levels of children with ADHD. The short-term
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Pan et al. Table 1. Participant Demographics.
Age (years) Height (cm) Weight (kg) ADHD Q (n, %) ≥131 121-130 111-120 90-110 80-89 70-79 ≤69
ADHD training (n = 12)
ADHD nontraining (n = 12)
TD nontraining (n = 24)
F
p
9.63 ± 2.48 135.13 ± 15.70 34.60 ± 12.16
9.38 ± 2.69 138.11 ± 17.39 37.46 ± 13.46
9.57 ± 2.50 138.59 ± 16.96 33.75 ± 11.75
0.03 0.18 0.37
.97 .84 .69
0 (0%) 1 (8%) 2 (17%) 6 (50%) 2 (17%) 1 (8%) 0 (0%)
0 (0%) 1 (8%) 2 (17%) 6 (50%) 2 (17%) 1 (8%) 0 (0%)
— — — — — — —
Note. TD = typically developing; Q = quotient, the higher the quotient lead levels the more severe.
objective of the program was to promote the movement skill performance and physical fitness levels of children with ADHD. The long-term goal was to provide an intervention option that can be easily incorporated into the lives of children with ADHD in community care settings. Few recommendations are available regarding tailored exercise interventions for children with ADHD. In this pilot study, we enabled teachers and parents to maximize the opportunities of their children to participate in structured physical activity.
Method Participants A total of 24 boys with ADHD and 24 TD boys, aged 7 to 14 years, participated in the study. The sampling design was purposive, meaningspecific criteria were used to select children with and without ADHD. The participants with ADHD were recruited from a local ADHD association, public schools, or through referral by a pediatric psychiatrist in a large metropolitan area in Southern Taiwan. The TD participants were recruited from similar schools or neighborhoods and were eligible to participate in the study if they (a) were age- and gender-matched to children with ADHD; (b) had no history of ADHD or ongoing medical treatment; (c) were healthy; and (d) could follow the instructions for the motor proficiency and physical fitness tests. Participants with ADHD were included if they (a) were aged 7 to 14 years; (b) had been evaluated by their pediatrician and diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., DSM-IV-TR; American Psychiatric Association, 2000) criteria; (c) had an IQ ≥ 80 on the Test of Nonverbal Intelligence (second edition); (d) their parents reported them free of intellectual disabilities, brain injuries, and diseases; and (e) could follow the instructions for the motor proficiency and
physical fitness tests. At the conclusion of the recruiting process, 24 ADHD qualified for participation, of which 16 were diagnosed as the combined type, 6 were diagnosed as the hyperactive-impulsive type, and 2 were diagnosed as the inattentive type. Fifteen were on medication and 5 manifested diagnosed associated conditions such as Asperger syndrome (n = 1), Tourette syndrome (n = 2), and oppositional defiant disorder (n = 2); the ADHD participants lacked other psychiatric disorders. All children with ADHD were matched based on age, nonverbal IQ, and ADHD type, and were randomly assigned into either the physical activity intervention (Group 1, n = 12) or ADHD nontraining control groups (Group 2, n = 12). In addition to the formal diagnosis made by a pediatrician, parent ratings were collected using the Chinese version of the ADHD test (Cheng, 2008) originally developed by Gilliam (1995) to screen for the severity of ADHD symptoms. The parents were requested to maintain their current medication regimens and behavioral management techniques throughout the intervention. The project was approved by the National Cheng Kung University Research Ethics Committee for Human Behavioral Sciences. Informed consent forms were signed by the parents and children. Table 1 lists the descriptive statistics of the participants and their diagnoses.
Physical Activity Training Program The training program was conducted in the gymnasium at the university of the primary researcher. Each physical activity training session was divided into the following categories: (a) social and floor warm-up activities (10 min); (b) the SDHRP (45 min); (c) physical fitness training (30 min); and (d) cool-down activities (5 min). The SDHRP activity was conducted in the laboratory, where each child used the riding machine. The other activities were held within a small group (six children) in the indoor basketball court
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Table 2. Physical Activity Training Program Protocol. Category
Length (min)
Content
A. Warm-up activities
10 min
Floor warm-up activities Low-tension stretching for large muscles groups
B. The SDHRP training (a) First period
15 min
(b) Second period
15 min
(c) Third period
15 min
Simulated riding skills with various arm movements Incremental increases in speed and difficulty Individual and group games on the riding machine
C. Physical fitness training (a) Progressive aerobic (b) Muscular
5 min 15 min
(c) Flexibility
10 min
D. Cool-down activities
5 min
Continuous jogging/running Push up/sit up/ball games/exercise stations Slow and relaxing movements of large muscles groups Sharing/supporting/responding
Goal Icebreaker/social interaction and communication Motor proficiency development Experience various horseback with arm movements Muscle strength and balance Friendship development Fitness level improvement Maintain moderate to vigorous intensity Muscular strength and endurance training Range of motion Review and prosocial behavior engagement
Note. SDHRP = simulated developmental horse-riding program.
next to the laboratory. Table 2 lists the training categories, content, and goals. Before the study, a workshop was held to introduce the physical activity training program to all parents, children with ADHD, and research assistants. The parents requested that the 12-week physical activity training program be held once per week for an extended period rather than holding multiple short sessions each week; thus, the activities were scheduled to ensure adequate attendance. The attendance was recorded daily and the children were awarded a star on a chart for each day they attended. Children who earned high attendance rates received an award (valued U.S.$10) on the final day of the program. The program intensity was monitored using a heart-rate monitor (Polar S-725X); however, problems arose partway through the program and children removed the device as soon as they became uncomfortable, or it slipped off when they became sweaty. To avoid confounding the results, no formal measures of physical exertion were captured during the sessions. Six research assistants completed the training course prior to the study. One research assistant served as a primary SDHRP instructor with two research assistants supporting the SDHRP sessions, and the remaining three (one of whom was a primary instructor) assisted with the physical fitness sessions. Because the amount of horseback riding apparatus was limited, 6 children in Group 1 simultaneously underwent the treatment for the first 90 min, and the remaining 6 children underwent identical treatment immediately following the first 90-min phase. During each SDHRP and physical fitness session, groups of three children with ADHD were always paired with the same
assistant. Most research assistants had previous experience working with children with ADHD, and all research assistants were undergraduate or graduate students in the department of physical education. The 12-week physical activity training program comprised 12 sessions (1 session per week, 90 min per session). The primary researcher supervised all sessions. SDHRP session. The SDHRP was developed based on previous research (Bass, Duchowny, & Llabre, 2009; Wuang et al., 2010) and the operating instructions of the JOBA horseback riding apparatus (model EU7805, Panasonic Electric Works Co., Ltd, Hikone, Japan), specifically emphasizing the learning of motor skill proficiency and aerobic fitness. The program was tailored to each child; for example, the lesson plans were carefully prepared based on the current motor skill performance levels of the children, and their personal preferences were noted based on the open-ended answers provided by parents. The SDHRP comprised three consecutive 15-min periods. During the first period, the child rode the JOBA (EU7805) electric riding machine to experience various horseback movements that promoted awareness, sensitivity, and coordination. The equipment had seven preset movement cycles and one manual control cycle, which was programmed to a set where the saddle slid/swung back and forth, swayed left and right, then returned to the initial position. In addition to the simulated riding skills, the participants simultaneously performed various arm movements using equipment (e.g., basketball, volleyball, tennis ball, table tennis ball, dumbbell, rubber band) or no equipment
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Pan et al. (e.g., punch, jab, cross, hook). The compact disc provided with the JOBA horseback riding apparatus shows examples of these arm movements. During the second period, the participants continually performed a series of exercises from the first period, and the speed and difficulty of the movement cycle was incrementally increased. The device features various preset (5 speeds) and manual (9 speeds) speed programs and various seat angles, enabling the instructor to vary the intensity of the workout from gentle to vigorous, and to increase the amount of muscle strength and flexibility required to maintain proper balance. Because riding exercise is a rhythmic activity that forced the children to use their large muscle groups for a long time, it can be considered a form of aerobic exercise. The third period of the SDHRP was focused on individual and group games on the riding machine. The games were led by the primary instructor, and focused on gross and fine motor control as well as social interaction skills, for example, catch and throw, table tennis balancing, and a lacrosse stick and ball relay. These activities were used because they targeted specific aspects of motor control and social interaction. Catch and throw stimulated motor development and social interaction between the participants and instructors. Table tennis balancing promoted body coordination and gross motor development; in this activity, the participants held a table tennis ball on a paddle while riding the electric riding machine. If the table tennis ball fell, then the participant was disqualified from the contest, and the winner was the final person balancing the ball. The lacrosse stick and ball relay gave participants the opportunity to expand their skills by working as a team and handing the ball off to their teammates to the goal line. These exercises targeted the gross and fine motor coordination skills of the participants as well as their friendship development. Physical fitness session. The primary objective of the fitness session was to address the health-related needs of the participants, emphasizing aerobic activity, muscular strength and endurance, and flexibility. Each session involved 5 min of running and low-tension stretching of the large muscle groups, then 15 min of physical activities that focused on maintaining the motivation of the participants and encouraging their active participation in the program. Finally, 10 min of slow and relaxing movements were conducted, targeting the large muscle groups. Aerobic running activities, basketball, exercise stations, and ball games were examples of the physical activities designed to foster the development of various motor skills and the fitness levels of the participants during the fitness training sessions.
Motor Proficiency and Fitness Measures Motor proficiency. The gross and fine motor skills of each participant were assessed based on the Bruininks–Oseretsky
Test of Motor Proficiency, Second Edition (BOT-2; Bruininks & Bruininks, 2005). This standardized instrument is an individually administered measure for youths aged 4 to 21 years. The test comprises eight subtests, and each pair of subtests is related to an area of motor function and scored as one motor-area composite, forming the following composites (the related subtests are shown in parentheses): (a) fine manual control (fine motor precision and fine motor integration), (b) manual coordination (manual dexterity and upper-limb coordination), (c) body coordination (bilateral coordination and balance), and (d) strength and agility (running speed and agility, strength). The four motor-area composite scores were combined as a total motor composite score, representing the overall motor proficiency score. The mean age-adjusted score for the subtests was 15 ± 5, whereas the mean score of the composites (derived by summing the subtest scale scores and converting them to a quotient) was 100 ± 15. The BOT-2 is a valid and reliable tool for evaluating children, adolescents, and young adults with developmental coordination disorders and intellectual disabilities (Bruininks & Bruininks, 2005). The interrater reliability, test–retest reliability, and internal consistency were moderate to strong (>0.80). The content validity, internal structure, and relations to other measures of motor performance were strong (r = .80; Bruininks & Bruininks, 2005). Physical fitness. The 20-m progressive aerobic cardiovascular endurance run (PACER), isometric push-up, curl-up, and back-saver sit-and-reach tests from the Brockport Physical Fitness Test (BPFT; Winnick & Short, 1999) were used to assess the fitness levels of the children. Measurements of weight and height (to the nearest 0.1 kg and 0.1 cm) were recorded using a bioelectrical impedance analyzer (MFBIA8, InBody 720, Biospace). The 20-m PACER multistage shuttle run was used to assess cardiovascular fitness according to the estimation of the maximal VO2. To conduct the PACER test, a 20-m distance was measured and marked with tape at each end. The participants ran back and forth across the 20-m distance for as long as possible at a specified pace that was progressively increased each minute during the test. The test was terminated when the children could no longer maintain the pace for two laps. The participant scores were recorded as the number of completed repetitions. The PACER test has demonstrated acceptable concurrent validity and criterionreferenced validity with the measured VO2max and estimated VO2max (Mao & Lin, 2006; Morrow, Jackson, Disch, & Mood, 2000). The isometric push-up test was used to measure upper body muscular strength and endurance. The participants attempted to sustain a raised push-up position for 40 s. The participants assumed a front-leaning rest position with their hands positioned directly beneath their shoulders and arms
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extended, the entire body in a straight line, and toes touching the floor. Scoring was terminated at 40 s or when the correct front-leaning rest position was no longer held. The curl-up test was used to measure abdominal strength and endurance. The participants completed as many curl-ups as possible (maximum = 75) at a cadence of 1 curl every 3 s. The participants lay in a supine position on a mat with their knees bent at approximately 140°, and their feet flat on the floor. Their hands were placed on the front of the thighs rather than on the mat alongside the body. As the participants curled, the hands slid along the thighs until the fingertips contacted the patellae. The participant scores were recorded as the number of completed curl-ups or when 75 repetitions were completed. The logical validity of the curl-up has been substantiated in previous research (Noble, 1981). The back-saver sit-and-reach test was used to assess the flexibility of the hamstring muscles and lower back. The object of this test is to reach across a sit-and-reach box while keeping one leg straight. In the back-saver sit-andreach test, the participants removed their shoes and sat at the test apparatus with one leg straight against the end of the testing instrument and the other leg bent with the foot flat on the floor beside the knee of the straight leg. The sit-andreach box was approximately 30 cm high and 30 cm wide. The participants extended their arms forward over the measuring scale with their palms facing downward, and one hand placed on top of the other. The participants reached directly forward along the scale by using both hands 4 times and held the position of the fourth reach for at least 1 s. After measuring one side, the participants switched their leg positions and repeated the procedure.
Procedure The standardized procedure and scoring method documents for the BOT-2 and BPFT tests administered in this study were independently translated from English to Chinese by the primary researcher and a certified bilingual occupational therapist (OT). A second certified bilingual OT participated in a meeting in which the translated versions were compared with the original versions of the BOT-2 and BPFT test items. The language clarity and relevance of the test items were assessed and revised based on agreement when necessary. No major changes were made to the test items, but the semantics were adjusted to produce the final translated testing booklets. Both OTs had at least 10 years of clinical experience in pediatric rehabilitation. The primary researcher earned her master’s and doctoral degrees in the United States and previously used the BOT-2 and BPFT tests to evaluate the outcomes of more than 200 children and adolescents with and without disabilities. Prior to the assessment, two graduate students majoring in adapted physical education were formally trained by the
primary researcher and provided written instructions regarding all procedures and scoring methods involved in the tests. Each assistant was provided with a Chinese version of the booklet containing the standardized administration procedures specified in the original English version of the test manual. Both assistants were adequately trained to be competent examiners; after carefully studying the content they practiced administering and scoring the test items to a group of three TD children. The complete assessment was conducted on a single occasion. To monitor the reliability of the evaluations, both assistants were tested using a criterion-test videotape. Immediately before and after the 12-week intervention, the parents of children in each group were contacted and scheduled for pre- and posttests at their convenience. Each assessment was completed in 2 weeks. In the primary preand postintervention assessments, all participants individually performed the BOT-2 and fitness tests at the gym of the primary researcher’s university, and all sessions were videotaped. All tests were individually administered by the two trained graduate students, and the primary researcher supervised all test sessions. The graduate students were not aware of the group status of the children they assessed. The recorded video was sent to each graduate student after being randomly sorted to minimize the possible carry-over and order effects in rating. The raters were allowed to replay the recordings to complete their ratings.
Statistical Analysis The means and standard deviations were calculated for all variables. The analyzed dependent variables were the BOT-2 measures (total motor composite score, four motorarea composite scores, and eight subtest scores) and physical fitness scores (20-m PACER, isometric push-up test, curl-up test, back-saver sit-and-reach test, and BMI). The group equivalence was tested using a one-way analysis of variance (ANOVA) and multivariate analysis of variance (MANOVA) to determine the usefulness of controlling for initial differences in physical fitness and motor proficiency levels. To assess the effects of the program, an analysis of covariance was conducted, comparing the groups based on the posttraining scores, which were adjusted for differences in the pretraining scores. The analysis of covariance (ANCOVA) assumptions were established using a “pretest by group” interaction test for each dependent variable. Because the data were fit based on the homogeneity of regression assumption, one-way ANCOVA and MANCOVA were used to control the pretraining data and evaluate the significance of the posttraining differences among the groups. Tukey’s post hoc test was performed when significant differences were observed between groups regarding the fitness results. When the MANCOVA indicated significance, a one-way ANCOVA
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Pan et al. Table 3. Summary of Pre-Training Differences Using MANOVA for Motor Proficiency and ANOVA for Physical Fitness Measures.
Motor proficiency Total motor composite Composites Fine manual control Manual coordination Body coordination Strength and agility Subtests Fine motor precision Fine motor integration Manual dexterity Upper-limb coordination Bilateral coordination Balance Running speed and agility Strength Physical fitness BMI (kg/m2) 20-m PACER Isometric push-up (s) Curl-up Sit-and-reach (cm) Right leg Left leg
1. ADHD training (n = 12)
2. ADHD nontraining (n = 12)
3. TD nontraining (n = 24)
F
Post hoc
42.83 ± 5.75
42.67 ± 4.62
59.29 ± 8.28
34.00**
1, 2 < 3
34.92 ± 5.00 50.75 ± 8.84 43.00 ± 7.05 51.58 ± 7.18
35.25 ± 2.38 50.67 ± 6.91 42.50 ± 4.70 51.00 ± 8.14
46.50 ± 11.50 61.04 ± 7.37 53.58 ± 8.78 65.25 ± 6.29
10.41** 10.94** 12.39** 23.87**
1, 2 < 3 1, 2 < 3 1, 2 < 3 1, 2 < 3
6.17 ± 2.48 10.00 ± 3.25 15.42 ± 5.16 15.08 ± 3.42 13.67 ± 4.75 10.83 ± 3.93 17.08 ±4.85 14.33 ± 1.93
6.83 ± 1.34 9.67 ± 1.92 15.75 ± 4.20 14.92 ± 3.00 14.42 ± 1.68 10.75 ± 3.60 17.83 ±2.79 13.42 ± 4.40
11.50 ± 4.71 16.21 ± 5.74 20.25 ± 3.40 17.13 ± 4.34 18.42 ± 3.15 14.33 ± 4.84 23.13 ± 2.85 18.38 ± 3.63
11.40** 12.01** 7.82** 1.85 10.34** 3.98 16.46** 10.02**
1, 2 < 3 1, 2 < 3 1, 2 < 3 — 1, 2 < 3 — 1, 2 < 3 1, 2 < 3
18.32 ± 2.98 12.582 ± 6.39 33.25 ± 12.26 3.33 ± 6.96
19.26 ± 4.73 11.25 ± 5.34 34.42 ± 12.03 4.58 ± 7.91
17.06 ± 2.52 22.71 ± 14.94 39.25 ± 2.69 6.04 ± 8.53
1.89 2.37** 2.38 0.48
— 1, 2 < 3 — —
27.04 ± 6.91 26.50 ± 8.22
26.71 ± 7.45 26.58 ± 7.53
25.23 ± 4.98 24.48 ± 6.12
0.44 0.52
— —
Note. TD = typically developing. Level of significance: **p < .01.
was performed on each subcomponent of the BOT-2 as a follow-up. The effect size was computed and reported as a partial η2 value for the ANCOVA and MANCOVA/follow-up ANCOVA evaluations. Subsequently, the effect sizes (Cohen’s d) were calculated to quantify the magnitude of changes in the dependent variables between the pre- and postassessment scores within the groups. The effect sizes were calculated by dividing the mean change in a test score by the standard deviation of the test score at the baseline to quantify the magnitude of change between the scores. All statistical analyses were performed using SPSS software version 18.0 (SPSS Inc., USA), and the level of significance was set at p < .01.
Results Group Comparability Pretraining. The results indicated significant differences between the groups regarding the total motor composite score and the individual motor composite and subtest scores, excepting the scores for the upper-limb coordination and balance subtests (Table 3). The post hoc pairwise
comparisons demonstrated that both ADHD groups performed significantly poorer than the TD group did regarding the total motor composite, four motor composite pairs (fine manual control, manual coordination, body coordination, strength and agility), and six subtests (fine motor precision, fine motor integration, manual dexterity, bilateral coordination, running speed and agility, strength); however, the differences between the ADHD groups were nonsignificant. Regarding the fitness results, nonsignificant differences were observed among the groups in all tests except for the 20-m PACER; these results indicated that both ADHD groups performed significantly poorer than the TD group did regarding cardiovascular fitness. Posttraining. Table 4 lists a summary of the posttraining effects of the motor proficiency and physical fitness measures. After accounting for pretraining differences, the MANCOVA results for the BOT-2 performance across the posttraining period indicated a significant difference in the posttraining total motor proficiency (partial η2 = 0.51); both ADHD groups performed significantly worse compared with the TD group, and the ADHD nontraining group performed significantly worse compared with the ADHD
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Table 4. Summary of Posttraining Effects Using MANCOVA for Motor Proficiency and ANCOVA for Physical Fitness Measures.
Motor proficiency Total motor composite Composites Fine manual control Manual coordination Body coordination Strength and agility Subtests Fine motor precision Fine motor integration Manual dexterity Upper-limb coordination Bilateral coordination Balance Running speed and agility Strength Physical fitness BMI (kg/m2) 20-m PACER Isometric push-up (s) Curl-up Sit-and-reach (cm) Right leg Left leg
1. ADHD training (n = 12)
2. ADHD nontraining (n = 12)
3. TD nontraining (n = 24)
F
Post hoc
57.25 ± 10.86
44.50 ± 5.84
64.21 ± 7.23
21.15**
2 < 1; 1, 2 < 3
45.67 ± 6.07 60.25 ± 10.69 52.00 ± 8.01 62.75 ± 10.78
36.17 ± 4.57 50.58 ± 7.72 43.50 ± 4.19 53.92 ± 9.53
48.38 ± 10.37 64.42 ± 7.65 57.38 ± 5.78 68.25 ± 6.67
8.32** 5.93** 12.52** 7.78**
2
Effects of Physical Activity Intervention on Motor Proficiency and Physical Fitness in Children With ADHD: An Exploratory Study Chien-Yu Pan, Yu-Kai Chang, Chia-Liang Tsai, Chia-Hua Chu, Yun-Wen Cheng and Ming-Chih Sung Journal of Attention Disorders published online 14 May 2014 DOI: 10.1177/1087054714533192 The online version of this article can be found at: http://jad.sagepub.com/content/early/2014/05/14/1087054714533192
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research-article2014
JADXXX10.1177/1087054714533192Journal of Attention DisordersPan et al.
Article
Effects of Physical Activity Intervention on Motor Proficiency and Physical Fitness in Children With ADHD: An Exploratory Study
Journal of Attention Disorders 1–13 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714533192 jad.sagepub.com
Chien-Yu Pan1, Yu-Kai Chang2, Chia-Liang Tsai3, Chia-Hua Chu1, Yun-Wen Cheng1, and Ming-Chih Sung1
Abstract Objective: This study explored how a 12-week simulated developmental horse-riding program (SDHRP) combined with fitness training influenced the motor proficiency and physical fitness of children with ADHD. Method: Twelve children with ADHD received the intervention, whereas 12 children with ADHD and 24 typically developing (TD) children did not. The fitness levels and motor skills of the participants were assessed using standardized tests before and after the 12-week training program. Results: Significant improvements were observed in the motor proficiency, cardiovascular fitness, and flexibility of the ADHD training group following the intervention. Conclusion: Children with ADHD exhibit low levels of motor proficiency and cardiovascular fitness; thus, using the combined 12-week SDHRP and fitness training positively affected children with ADHD. ( J. of Att. Dis. XXXX; XX(X) XX-XX) Keywords ADHD, physical activity, motor performance, physical fitness.
ADHD is characterized by persistent symptoms of inattention and/or hyperactivity-impulsivity that are inconsistent with the developmental level of children who are affected. This condition negatively affects society and numerous areas in the lives of affected children such as financial costs, family function, academic performance, and both physical and mental health (American Psychiatric Association, 2013; Biederman, 2005; Bledsoe, Semrud-Clikeman, & Piliszka, 2010). Moreover, children with ADHD have exhibited various motor skill deficits, including those related to motor proficiency (Beyer, 1999), fine motor skills (Liavasani & Stagnitti, 2013; Pitcher, Piek, & Hay, 2003; Scharoun, Bryden, Otipkova, Musalek, & Lejcarova, 2013), and gross motor development (Harvey et al., 2009; Pan, Tsai, & Chu, 2009; Pitcher et al., 2003; Scharoun et al., 2013); furthermore, these children may be at risk of poor physical fitness (Harvey & Reid, 2003). The underlying factors influencing the movement skills and physical fitness levels of children with ADHD have not been thoroughly examined; however, it has been proposed that children with ADHD lack the ability to regulate their skill performance in various physical activity contexts (Barkley, 1997; Harvey, Fagan, & Kassis, 2003). Because physical activity is a critical part of a healthy lifestyle for all people (U.S. Department of Health and Human Services, 1996), these impairments, and the social and behavioral deficits associated with
ADHD, frequently challenge affected children when participating in various extracurricular physical activities. Because motor skills are a critical determinant of physical activity and fitness levels in children with (Pan, 2014) and without disabilities (Barnett, van Beurden, Morgan, Brooks, & Beard, 2008), it is reasonable to hypothesize that children with ADHD might exhibit low fitness levels. However, few empirical studies have reported detailed data on the movement skill performance and physical fitness levels of children with ADHD. Among the few studies that have explored this topic, Harvey and Reid (1997) assessed the fundamental gross motor skills and fitness conditions of 19 children with ADHD (age = 7-12 years). They observed that the locomotor skills and fitness conditions (VO2max, situps, push-ups, flexibility) of these children were substantially less than average. In a subsequent study, Harvey and Reid (2003) reviewed 49 empirical studies that examined 1
National Kaohsiung Normal University, Taiwan National Taiwan Sport University, Taoyuan, Taiwan 3 National Cheng Kung University, Tainan, Taiwan 2
Corresponding Author: Chien-Yu Pan, Department of Physical Education, National Kaohsiung Normal University, No.116, He-Ping First Road, Kaohsiung 80201, Taiwan. Email: [email protected]
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movement skill performance; however, only 4 of these studies focused on the physical fitness of children with ADHD. They concluded that children with ADHD are at risk of inactivity and poor health compared with chronologically age-matched peers who lack disabilities. Nevertheless, their conclusion regarding fitness was tentative because scant research has examined the physical fitness of children with ADHD. Few studies have addressed how stimulant medications affect the motor performance and/or physical fitness of children with ADHD. Harvey et al. (2007) compared the fundamental movement skills of 22 children with ADHD with those of typically developing (TD) peers, and assessed how stimulant medications affected the movement skill performance of the children with ADHD; children with ADHD exhibited lower locomotor and object control subtest scores compared with age-matched control children. However, a nonsignificant difference was observed when the movement skills of children with ADHD taking medication were compared with those of children in a placebo trial group. Harvey et al. suggested that factors other than medication, such as lack of physical skills and experience, poor social skills, failure to regulate performance, comorbidities, a lack of motivation, and time constraints or performance conditions, are critical influencing variables; however, this requires further research. In a recent study, Verret, Gardiner, and Beliveau (2010) compared physical fitness and motor performance among three groups of children: children with ADHD who were prescribed stimulant medication, children with ADHD who were not prescribed medication, and a control group. Body composition and locomotor skills were the only two parameters that significantly differed among the groups. The children with ADHD who were taking medication had a lower average body mass index (BMI) than did those in the control group, and both groups of children with ADHD had lower raw scores for locomotor skills than did those in the control group. Moreover, the difference in gross motor performance was nonsignificant between the children with ADHD taking and not taking medication. Verret et al. concluded that, regardless of whether children with ADHD used stimulant medication, their fitness levels were comparable with those of children without ADHD. In addition, children with ADHD exhibited lower locomotor skill levels compared with those in the control group regardless of whether they used stimulant medication. The literature lacks sufficient evidence to establish a clear conclusion regarding the motor performance and/or fitness levels of medication-treated or medication-free children with ADHD. Scant information is available on conducting physical activity programs for children with ADHD, and information is lacking regarding how such programs affect the movement performance and/or physical fitness levels of these children. Smith et al. (2013) examined the effects of
an 8-week (5 days per week, 30 min per day) before-school physical activity intervention program that was designed to maximize the moderate-to-vigorous physical activity (MVPA) of 17 children, Grades K-3, who were at risk of developing ADHD. Each day, the participants completed four stations (each lasting 6 min) within small groups (approximately 5 children). One trained staff member supervised each station to foster sustained MVPA within the context of games and activities that required participants to use various motor skills. In addition to these stations, one large-group warm-up aerobic running activity was conducted for 1 to 2 min each day. The authors observed significant increases in the motor proficiency of the participants, including both gross motor and fine motor tasks, and concluded that sustained involvement in structured physical activity may benefit ADHD functioning. Verret, Guay, Berthiaume, Gardiner, and Beliveau (2012) examined the effect of a 10-week (3 times per week for 45-min periods) lunch-time MVPA program on the physical fitness and movement skills of 21 children with ADHD (age = 7-12 years). All sessions included three periods: (a) a warm-up; (b) progressive aerobic, muscular, and motor skills exercises; and (c) cool down. The heart rate of each child was measured once a week to monitor intensity of the program. The children with ADHD were assigned to physical activity (n = 10) and control groups (n = 11), and assessed before and after undergoing 10 weeks of training. The results indicated that the program improved the muscular capacities (push-ups) and motor skills (locomotor and total motor skills) of the children. Thus, additional research is warranted to elucidate how physical activity interventions affect children with ADHD. Maintaining appropriate physical activity and healthrelated physical fitness levels is critical for developing healthy lifestyles; thus, identifying task-specific interventions for children with ADHD is critical for enhancing their motor functions and fitness levels, and encouraging them to adopt physically active lifestyles. The few available studies have suggested that consistent involvement in physical activity is vital when considering physical activity as a strategy for addressing the motor skills and physical fitness levels of children with ADHD (Smith et al., 2013; Verret et al., 2012); however, no consensus exists regarding the optimal components, frequency, or intensity of physical activity interventions. Therefore, a 12-week (1 day per week, 90 min per day) physical activity intervention that involved a simulated developmental horse-riding program (SDHRP) and fitness training was developed in this study. Based on the accumulating evidence of the role of SDHRPs in improving the motor functions of children with disabilities (Wuang, Wang, Huang, & Su, 2010), we hypothesized that combining an SDHRP with a fitness training program would facilitate remediating the movement skill difficulties and fitness levels of children with ADHD. The short-term
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Pan et al. Table 1. Participant Demographics.
Age (years) Height (cm) Weight (kg) ADHD Q (n, %) ≥131 121-130 111-120 90-110 80-89 70-79 ≤69
ADHD training (n = 12)
ADHD nontraining (n = 12)
TD nontraining (n = 24)
F
p
9.63 ± 2.48 135.13 ± 15.70 34.60 ± 12.16
9.38 ± 2.69 138.11 ± 17.39 37.46 ± 13.46
9.57 ± 2.50 138.59 ± 16.96 33.75 ± 11.75
0.03 0.18 0.37
.97 .84 .69
0 (0%) 1 (8%) 2 (17%) 6 (50%) 2 (17%) 1 (8%) 0 (0%)
0 (0%) 1 (8%) 2 (17%) 6 (50%) 2 (17%) 1 (8%) 0 (0%)
— — — — — — —
Note. TD = typically developing; Q = quotient, the higher the quotient lead levels the more severe.
objective of the program was to promote the movement skill performance and physical fitness levels of children with ADHD. The long-term goal was to provide an intervention option that can be easily incorporated into the lives of children with ADHD in community care settings. Few recommendations are available regarding tailored exercise interventions for children with ADHD. In this pilot study, we enabled teachers and parents to maximize the opportunities of their children to participate in structured physical activity.
Method Participants A total of 24 boys with ADHD and 24 TD boys, aged 7 to 14 years, participated in the study. The sampling design was purposive, meaningspecific criteria were used to select children with and without ADHD. The participants with ADHD were recruited from a local ADHD association, public schools, or through referral by a pediatric psychiatrist in a large metropolitan area in Southern Taiwan. The TD participants were recruited from similar schools or neighborhoods and were eligible to participate in the study if they (a) were age- and gender-matched to children with ADHD; (b) had no history of ADHD or ongoing medical treatment; (c) were healthy; and (d) could follow the instructions for the motor proficiency and physical fitness tests. Participants with ADHD were included if they (a) were aged 7 to 14 years; (b) had been evaluated by their pediatrician and diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., DSM-IV-TR; American Psychiatric Association, 2000) criteria; (c) had an IQ ≥ 80 on the Test of Nonverbal Intelligence (second edition); (d) their parents reported them free of intellectual disabilities, brain injuries, and diseases; and (e) could follow the instructions for the motor proficiency and
physical fitness tests. At the conclusion of the recruiting process, 24 ADHD qualified for participation, of which 16 were diagnosed as the combined type, 6 were diagnosed as the hyperactive-impulsive type, and 2 were diagnosed as the inattentive type. Fifteen were on medication and 5 manifested diagnosed associated conditions such as Asperger syndrome (n = 1), Tourette syndrome (n = 2), and oppositional defiant disorder (n = 2); the ADHD participants lacked other psychiatric disorders. All children with ADHD were matched based on age, nonverbal IQ, and ADHD type, and were randomly assigned into either the physical activity intervention (Group 1, n = 12) or ADHD nontraining control groups (Group 2, n = 12). In addition to the formal diagnosis made by a pediatrician, parent ratings were collected using the Chinese version of the ADHD test (Cheng, 2008) originally developed by Gilliam (1995) to screen for the severity of ADHD symptoms. The parents were requested to maintain their current medication regimens and behavioral management techniques throughout the intervention. The project was approved by the National Cheng Kung University Research Ethics Committee for Human Behavioral Sciences. Informed consent forms were signed by the parents and children. Table 1 lists the descriptive statistics of the participants and their diagnoses.
Physical Activity Training Program The training program was conducted in the gymnasium at the university of the primary researcher. Each physical activity training session was divided into the following categories: (a) social and floor warm-up activities (10 min); (b) the SDHRP (45 min); (c) physical fitness training (30 min); and (d) cool-down activities (5 min). The SDHRP activity was conducted in the laboratory, where each child used the riding machine. The other activities were held within a small group (six children) in the indoor basketball court
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Table 2. Physical Activity Training Program Protocol. Category
Length (min)
Content
A. Warm-up activities
10 min
Floor warm-up activities Low-tension stretching for large muscles groups
B. The SDHRP training (a) First period
15 min
(b) Second period
15 min
(c) Third period
15 min
Simulated riding skills with various arm movements Incremental increases in speed and difficulty Individual and group games on the riding machine
C. Physical fitness training (a) Progressive aerobic (b) Muscular
5 min 15 min
(c) Flexibility
10 min
D. Cool-down activities
5 min
Continuous jogging/running Push up/sit up/ball games/exercise stations Slow and relaxing movements of large muscles groups Sharing/supporting/responding
Goal Icebreaker/social interaction and communication Motor proficiency development Experience various horseback with arm movements Muscle strength and balance Friendship development Fitness level improvement Maintain moderate to vigorous intensity Muscular strength and endurance training Range of motion Review and prosocial behavior engagement
Note. SDHRP = simulated developmental horse-riding program.
next to the laboratory. Table 2 lists the training categories, content, and goals. Before the study, a workshop was held to introduce the physical activity training program to all parents, children with ADHD, and research assistants. The parents requested that the 12-week physical activity training program be held once per week for an extended period rather than holding multiple short sessions each week; thus, the activities were scheduled to ensure adequate attendance. The attendance was recorded daily and the children were awarded a star on a chart for each day they attended. Children who earned high attendance rates received an award (valued U.S.$10) on the final day of the program. The program intensity was monitored using a heart-rate monitor (Polar S-725X); however, problems arose partway through the program and children removed the device as soon as they became uncomfortable, or it slipped off when they became sweaty. To avoid confounding the results, no formal measures of physical exertion were captured during the sessions. Six research assistants completed the training course prior to the study. One research assistant served as a primary SDHRP instructor with two research assistants supporting the SDHRP sessions, and the remaining three (one of whom was a primary instructor) assisted with the physical fitness sessions. Because the amount of horseback riding apparatus was limited, 6 children in Group 1 simultaneously underwent the treatment for the first 90 min, and the remaining 6 children underwent identical treatment immediately following the first 90-min phase. During each SDHRP and physical fitness session, groups of three children with ADHD were always paired with the same
assistant. Most research assistants had previous experience working with children with ADHD, and all research assistants were undergraduate or graduate students in the department of physical education. The 12-week physical activity training program comprised 12 sessions (1 session per week, 90 min per session). The primary researcher supervised all sessions. SDHRP session. The SDHRP was developed based on previous research (Bass, Duchowny, & Llabre, 2009; Wuang et al., 2010) and the operating instructions of the JOBA horseback riding apparatus (model EU7805, Panasonic Electric Works Co., Ltd, Hikone, Japan), specifically emphasizing the learning of motor skill proficiency and aerobic fitness. The program was tailored to each child; for example, the lesson plans were carefully prepared based on the current motor skill performance levels of the children, and their personal preferences were noted based on the open-ended answers provided by parents. The SDHRP comprised three consecutive 15-min periods. During the first period, the child rode the JOBA (EU7805) electric riding machine to experience various horseback movements that promoted awareness, sensitivity, and coordination. The equipment had seven preset movement cycles and one manual control cycle, which was programmed to a set where the saddle slid/swung back and forth, swayed left and right, then returned to the initial position. In addition to the simulated riding skills, the participants simultaneously performed various arm movements using equipment (e.g., basketball, volleyball, tennis ball, table tennis ball, dumbbell, rubber band) or no equipment
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Pan et al. (e.g., punch, jab, cross, hook). The compact disc provided with the JOBA horseback riding apparatus shows examples of these arm movements. During the second period, the participants continually performed a series of exercises from the first period, and the speed and difficulty of the movement cycle was incrementally increased. The device features various preset (5 speeds) and manual (9 speeds) speed programs and various seat angles, enabling the instructor to vary the intensity of the workout from gentle to vigorous, and to increase the amount of muscle strength and flexibility required to maintain proper balance. Because riding exercise is a rhythmic activity that forced the children to use their large muscle groups for a long time, it can be considered a form of aerobic exercise. The third period of the SDHRP was focused on individual and group games on the riding machine. The games were led by the primary instructor, and focused on gross and fine motor control as well as social interaction skills, for example, catch and throw, table tennis balancing, and a lacrosse stick and ball relay. These activities were used because they targeted specific aspects of motor control and social interaction. Catch and throw stimulated motor development and social interaction between the participants and instructors. Table tennis balancing promoted body coordination and gross motor development; in this activity, the participants held a table tennis ball on a paddle while riding the electric riding machine. If the table tennis ball fell, then the participant was disqualified from the contest, and the winner was the final person balancing the ball. The lacrosse stick and ball relay gave participants the opportunity to expand their skills by working as a team and handing the ball off to their teammates to the goal line. These exercises targeted the gross and fine motor coordination skills of the participants as well as their friendship development. Physical fitness session. The primary objective of the fitness session was to address the health-related needs of the participants, emphasizing aerobic activity, muscular strength and endurance, and flexibility. Each session involved 5 min of running and low-tension stretching of the large muscle groups, then 15 min of physical activities that focused on maintaining the motivation of the participants and encouraging their active participation in the program. Finally, 10 min of slow and relaxing movements were conducted, targeting the large muscle groups. Aerobic running activities, basketball, exercise stations, and ball games were examples of the physical activities designed to foster the development of various motor skills and the fitness levels of the participants during the fitness training sessions.
Motor Proficiency and Fitness Measures Motor proficiency. The gross and fine motor skills of each participant were assessed based on the Bruininks–Oseretsky
Test of Motor Proficiency, Second Edition (BOT-2; Bruininks & Bruininks, 2005). This standardized instrument is an individually administered measure for youths aged 4 to 21 years. The test comprises eight subtests, and each pair of subtests is related to an area of motor function and scored as one motor-area composite, forming the following composites (the related subtests are shown in parentheses): (a) fine manual control (fine motor precision and fine motor integration), (b) manual coordination (manual dexterity and upper-limb coordination), (c) body coordination (bilateral coordination and balance), and (d) strength and agility (running speed and agility, strength). The four motor-area composite scores were combined as a total motor composite score, representing the overall motor proficiency score. The mean age-adjusted score for the subtests was 15 ± 5, whereas the mean score of the composites (derived by summing the subtest scale scores and converting them to a quotient) was 100 ± 15. The BOT-2 is a valid and reliable tool for evaluating children, adolescents, and young adults with developmental coordination disorders and intellectual disabilities (Bruininks & Bruininks, 2005). The interrater reliability, test–retest reliability, and internal consistency were moderate to strong (>0.80). The content validity, internal structure, and relations to other measures of motor performance were strong (r = .80; Bruininks & Bruininks, 2005). Physical fitness. The 20-m progressive aerobic cardiovascular endurance run (PACER), isometric push-up, curl-up, and back-saver sit-and-reach tests from the Brockport Physical Fitness Test (BPFT; Winnick & Short, 1999) were used to assess the fitness levels of the children. Measurements of weight and height (to the nearest 0.1 kg and 0.1 cm) were recorded using a bioelectrical impedance analyzer (MFBIA8, InBody 720, Biospace). The 20-m PACER multistage shuttle run was used to assess cardiovascular fitness according to the estimation of the maximal VO2. To conduct the PACER test, a 20-m distance was measured and marked with tape at each end. The participants ran back and forth across the 20-m distance for as long as possible at a specified pace that was progressively increased each minute during the test. The test was terminated when the children could no longer maintain the pace for two laps. The participant scores were recorded as the number of completed repetitions. The PACER test has demonstrated acceptable concurrent validity and criterionreferenced validity with the measured VO2max and estimated VO2max (Mao & Lin, 2006; Morrow, Jackson, Disch, & Mood, 2000). The isometric push-up test was used to measure upper body muscular strength and endurance. The participants attempted to sustain a raised push-up position for 40 s. The participants assumed a front-leaning rest position with their hands positioned directly beneath their shoulders and arms
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Journal of Attention Disorders
extended, the entire body in a straight line, and toes touching the floor. Scoring was terminated at 40 s or when the correct front-leaning rest position was no longer held. The curl-up test was used to measure abdominal strength and endurance. The participants completed as many curl-ups as possible (maximum = 75) at a cadence of 1 curl every 3 s. The participants lay in a supine position on a mat with their knees bent at approximately 140°, and their feet flat on the floor. Their hands were placed on the front of the thighs rather than on the mat alongside the body. As the participants curled, the hands slid along the thighs until the fingertips contacted the patellae. The participant scores were recorded as the number of completed curl-ups or when 75 repetitions were completed. The logical validity of the curl-up has been substantiated in previous research (Noble, 1981). The back-saver sit-and-reach test was used to assess the flexibility of the hamstring muscles and lower back. The object of this test is to reach across a sit-and-reach box while keeping one leg straight. In the back-saver sit-andreach test, the participants removed their shoes and sat at the test apparatus with one leg straight against the end of the testing instrument and the other leg bent with the foot flat on the floor beside the knee of the straight leg. The sit-andreach box was approximately 30 cm high and 30 cm wide. The participants extended their arms forward over the measuring scale with their palms facing downward, and one hand placed on top of the other. The participants reached directly forward along the scale by using both hands 4 times and held the position of the fourth reach for at least 1 s. After measuring one side, the participants switched their leg positions and repeated the procedure.
Procedure The standardized procedure and scoring method documents for the BOT-2 and BPFT tests administered in this study were independently translated from English to Chinese by the primary researcher and a certified bilingual occupational therapist (OT). A second certified bilingual OT participated in a meeting in which the translated versions were compared with the original versions of the BOT-2 and BPFT test items. The language clarity and relevance of the test items were assessed and revised based on agreement when necessary. No major changes were made to the test items, but the semantics were adjusted to produce the final translated testing booklets. Both OTs had at least 10 years of clinical experience in pediatric rehabilitation. The primary researcher earned her master’s and doctoral degrees in the United States and previously used the BOT-2 and BPFT tests to evaluate the outcomes of more than 200 children and adolescents with and without disabilities. Prior to the assessment, two graduate students majoring in adapted physical education were formally trained by the
primary researcher and provided written instructions regarding all procedures and scoring methods involved in the tests. Each assistant was provided with a Chinese version of the booklet containing the standardized administration procedures specified in the original English version of the test manual. Both assistants were adequately trained to be competent examiners; after carefully studying the content they practiced administering and scoring the test items to a group of three TD children. The complete assessment was conducted on a single occasion. To monitor the reliability of the evaluations, both assistants were tested using a criterion-test videotape. Immediately before and after the 12-week intervention, the parents of children in each group were contacted and scheduled for pre- and posttests at their convenience. Each assessment was completed in 2 weeks. In the primary preand postintervention assessments, all participants individually performed the BOT-2 and fitness tests at the gym of the primary researcher’s university, and all sessions were videotaped. All tests were individually administered by the two trained graduate students, and the primary researcher supervised all test sessions. The graduate students were not aware of the group status of the children they assessed. The recorded video was sent to each graduate student after being randomly sorted to minimize the possible carry-over and order effects in rating. The raters were allowed to replay the recordings to complete their ratings.
Statistical Analysis The means and standard deviations were calculated for all variables. The analyzed dependent variables were the BOT-2 measures (total motor composite score, four motorarea composite scores, and eight subtest scores) and physical fitness scores (20-m PACER, isometric push-up test, curl-up test, back-saver sit-and-reach test, and BMI). The group equivalence was tested using a one-way analysis of variance (ANOVA) and multivariate analysis of variance (MANOVA) to determine the usefulness of controlling for initial differences in physical fitness and motor proficiency levels. To assess the effects of the program, an analysis of covariance was conducted, comparing the groups based on the posttraining scores, which were adjusted for differences in the pretraining scores. The analysis of covariance (ANCOVA) assumptions were established using a “pretest by group” interaction test for each dependent variable. Because the data were fit based on the homogeneity of regression assumption, one-way ANCOVA and MANCOVA were used to control the pretraining data and evaluate the significance of the posttraining differences among the groups. Tukey’s post hoc test was performed when significant differences were observed between groups regarding the fitness results. When the MANCOVA indicated significance, a one-way ANCOVA
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Pan et al. Table 3. Summary of Pre-Training Differences Using MANOVA for Motor Proficiency and ANOVA for Physical Fitness Measures.
Motor proficiency Total motor composite Composites Fine manual control Manual coordination Body coordination Strength and agility Subtests Fine motor precision Fine motor integration Manual dexterity Upper-limb coordination Bilateral coordination Balance Running speed and agility Strength Physical fitness BMI (kg/m2) 20-m PACER Isometric push-up (s) Curl-up Sit-and-reach (cm) Right leg Left leg
1. ADHD training (n = 12)
2. ADHD nontraining (n = 12)
3. TD nontraining (n = 24)
F
Post hoc
42.83 ± 5.75
42.67 ± 4.62
59.29 ± 8.28
34.00**
1, 2 < 3
34.92 ± 5.00 50.75 ± 8.84 43.00 ± 7.05 51.58 ± 7.18
35.25 ± 2.38 50.67 ± 6.91 42.50 ± 4.70 51.00 ± 8.14
46.50 ± 11.50 61.04 ± 7.37 53.58 ± 8.78 65.25 ± 6.29
10.41** 10.94** 12.39** 23.87**
1, 2 < 3 1, 2 < 3 1, 2 < 3 1, 2 < 3
6.17 ± 2.48 10.00 ± 3.25 15.42 ± 5.16 15.08 ± 3.42 13.67 ± 4.75 10.83 ± 3.93 17.08 ±4.85 14.33 ± 1.93
6.83 ± 1.34 9.67 ± 1.92 15.75 ± 4.20 14.92 ± 3.00 14.42 ± 1.68 10.75 ± 3.60 17.83 ±2.79 13.42 ± 4.40
11.50 ± 4.71 16.21 ± 5.74 20.25 ± 3.40 17.13 ± 4.34 18.42 ± 3.15 14.33 ± 4.84 23.13 ± 2.85 18.38 ± 3.63
11.40** 12.01** 7.82** 1.85 10.34** 3.98 16.46** 10.02**
1, 2 < 3 1, 2 < 3 1, 2 < 3 — 1, 2 < 3 — 1, 2 < 3 1, 2 < 3
18.32 ± 2.98 12.582 ± 6.39 33.25 ± 12.26 3.33 ± 6.96
19.26 ± 4.73 11.25 ± 5.34 34.42 ± 12.03 4.58 ± 7.91
17.06 ± 2.52 22.71 ± 14.94 39.25 ± 2.69 6.04 ± 8.53
1.89 2.37** 2.38 0.48
— 1, 2 < 3 — —
27.04 ± 6.91 26.50 ± 8.22
26.71 ± 7.45 26.58 ± 7.53
25.23 ± 4.98 24.48 ± 6.12
0.44 0.52
— —
Note. TD = typically developing. Level of significance: **p < .01.
was performed on each subcomponent of the BOT-2 as a follow-up. The effect size was computed and reported as a partial η2 value for the ANCOVA and MANCOVA/follow-up ANCOVA evaluations. Subsequently, the effect sizes (Cohen’s d) were calculated to quantify the magnitude of changes in the dependent variables between the pre- and postassessment scores within the groups. The effect sizes were calculated by dividing the mean change in a test score by the standard deviation of the test score at the baseline to quantify the magnitude of change between the scores. All statistical analyses were performed using SPSS software version 18.0 (SPSS Inc., USA), and the level of significance was set at p < .01.
Results Group Comparability Pretraining. The results indicated significant differences between the groups regarding the total motor composite score and the individual motor composite and subtest scores, excepting the scores for the upper-limb coordination and balance subtests (Table 3). The post hoc pairwise
comparisons demonstrated that both ADHD groups performed significantly poorer than the TD group did regarding the total motor composite, four motor composite pairs (fine manual control, manual coordination, body coordination, strength and agility), and six subtests (fine motor precision, fine motor integration, manual dexterity, bilateral coordination, running speed and agility, strength); however, the differences between the ADHD groups were nonsignificant. Regarding the fitness results, nonsignificant differences were observed among the groups in all tests except for the 20-m PACER; these results indicated that both ADHD groups performed significantly poorer than the TD group did regarding cardiovascular fitness. Posttraining. Table 4 lists a summary of the posttraining effects of the motor proficiency and physical fitness measures. After accounting for pretraining differences, the MANCOVA results for the BOT-2 performance across the posttraining period indicated a significant difference in the posttraining total motor proficiency (partial η2 = 0.51); both ADHD groups performed significantly worse compared with the TD group, and the ADHD nontraining group performed significantly worse compared with the ADHD
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Journal of Attention Disorders
Table 4. Summary of Posttraining Effects Using MANCOVA for Motor Proficiency and ANCOVA for Physical Fitness Measures.
Motor proficiency Total motor composite Composites Fine manual control Manual coordination Body coordination Strength and agility Subtests Fine motor precision Fine motor integration Manual dexterity Upper-limb coordination Bilateral coordination Balance Running speed and agility Strength Physical fitness BMI (kg/m2) 20-m PACER Isometric push-up (s) Curl-up Sit-and-reach (cm) Right leg Left leg
1. ADHD training (n = 12)
2. ADHD nontraining (n = 12)
3. TD nontraining (n = 24)
F
Post hoc
57.25 ± 10.86
44.50 ± 5.84
64.21 ± 7.23
21.15**
2 < 1; 1, 2 < 3
45.67 ± 6.07 60.25 ± 10.69 52.00 ± 8.01 62.75 ± 10.78
36.17 ± 4.57 50.58 ± 7.72 43.50 ± 4.19 53.92 ± 9.53
48.38 ± 10.37 64.42 ± 7.65 57.38 ± 5.78 68.25 ± 6.67
8.32** 5.93** 12.52** 7.78**
2
