INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 46(2) 169-178, 2013
IS THERE ANY RELATIONSHIP BETWEEN ADHD SYMPTOMS AND CHOOSING SPORTS EDUCATION AT THE UNIVERSITY?
CEM GÖKÇEN, M.D.
UGUR ABAKAY
AHMET ÜNAL, M.D.
HASAN BAYAR, M.D.
GÖKAY ALPAK, M.D.
FERIDUN BÜLBÜL, M.D.
Gaziantep University, Turkey ÜMIT SERTAN ÇÖPOGLU, M.D. Government Hospital of Ceylanpinar, Turkey
ABSTRACT
Objective: The goal of our study was to compare the incidence of Attention Deficit Hyperactivity Disorder (ADHD) observed in students at the School of Physical Education and Sports (SPES), which is a school that provides higher education in athletics, with that observed in students studying in other departments of the university. Our hypothesis was that people with ADHD most commonly turn to sports. Method: The study enrolled 318 (75.7% of 420) students who were studying in the SPES of Gaziantep University; 277 students from the medical, nursing, administration, and engineering faculties were enrolled to serve as a control group. All students enrolled in the study were informed about the study before the lesson, and the students who agreed to participate provided written consent. Scales used in this study were: a sociodemographic information form which was prepared by the investigators, the Wender-Utah Rating Scale (WURS), and the Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale (ADD/ADHD). Results: WURS scores were significantly higher (25.07 ± 15.15 versus 21.37 ± 14.28; p = 0.002) in the SPES group than the control group. In 169 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.46.2.d http://baywood.com
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addition, the percentage of subjects with a WURS score above the cut-off of 36 was higher in the SPES group than the control group (22.4% versus 15.2%; p: 0.028). The two groups were not significantly different in terms of the subscales of the ADD/ADHD scale. A correlation was found between the educational achievement of the students in the SPES group and the ADD/ADHD-inattention subscale (r = .111, p = 0.015) and WURS scale (r = .113, p = 0.011). Conclusions: More systematic studies with larger samples in this domain will be useful in obtaining a clearer picture regarding professional attraction of people with ADHD to sports. (Int’l. J. Psychiatry in Medicine 2013;46:169-178)
Key Words: attention deficit hyperactivity disorder, sport, education
INTRODUCTION Attention deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders in children, affecting approximately 3-7%. ADHD is diagnosed based on the presence of symptoms of inattention, hyperactivity, and/or impulsivity for at least 6 months in at least two domains of life. Additionally, the symptoms must have been initially observed prior to the age of seven [1]. The presence of these symptoms continues into adulthood in 50 to 80% of individuals and can cause numerous impairments in social, academic, and occupational functioning [2-4]. The correlation between sports and psychiatric disorders is an interesting one, with the following descriptions available in the literature: (i) athletes may obtain high levels of success despite having a primary psychiatric disorder; (ii) athletes may have chosen the athletic arena as a means of coping with a disorder; (iii) sports may precipitate or exacerbate psychiatric illness in athletes [5, 6]. Based on anecdotal reports, ADHD appears to be more prevalent in athletes than non-athletes, which may be because those with ADHD are drawn to physical activity, which is an example of athletes choosing the athletic arena to cope with a disorder [7]. In addition, individuals with ADHD often have greater success in the athletic arena than in the classroom. This may be explained by the fact that children with ADHD are competitive, which leads them to seek any physiological or psychological expression that will give them an advantage over their competition [8]. However, athletes with ADHD face unique challenges. Children and adolescents with ADHD often demonstrate poor motor skills, coordination, and balance, and these challenges likely have an effect on their athletic success [9, 10]. There are a limited number of studies that investigate psychiatric disorders in athletes. A recent review stated that the majority of studies on athletes focused
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on eating disorders and substance abuse and that studies concerned with ADHD, anxiety disorders, and bipolar disorder are needed [11]. The School of Physical Education and Sports (SPES) accepts students via university and a special ability exam that includes an evaluation of candidates’ physical and sporting preferences. Higher and detailed education related to all fields of physical education and sports is given over the 4 years of school. Graduated students have the opportunity to become physical education teachers, sport managers, and/or coaches. The goal of the present study was to compare the incidence of ADHD observed in students at the SPES, which is a school that provides higher education in athletics, with that observed in students studying in other departments of the university. Our hypothesis was that greater proportions of students with ADHD would seek out SPES degrees. MATERIALS AND METHODS The study enrolled 318 (75.7% of 420) students of the SPES of Gaziantep University, and 277 students from the medical, nursing, administration, and engineering departments to serve as a control group. The only exclusion criterion was an unwillingness to participate in the study. All students enrolled in the study were informed about the study before the lesson, and the students who agreed to participate provided written consent. The scales were distributed to the students during class. The study protocol was reviewed and approved by the institutional ethics committee. Assessment Tools Sociodemographic Information Form
This is a 13-question form that was prepared by the investigators to obtain information about age, gender, educational achievement, consumption of alcohol, smoking status, income status, educational background of the parents, and psychiatric history of the participants and their first-degree relatives. Educational achievement of participants was evaluated by grade point average which was obtained from the school secretary. Grade point average scores were classified as from A to E (A:100-85, B:84-70, C:69-55, D:54-45, E:44-0). Wender Utah Rating Scale (WURS)
The Wender Utah Rating Scale (WURS) was developed by Ward et al. to evaluate the symptoms of ADHD in childhood [12]. The WURS consists of 25 self-report items scored on a 5-point Likert scale. It is graded from 0 to 100 points and can determine major depression with an 81% accuracy rate, ADHD with an 86% accuracy rate, and healthy controls with a 99% accuracy rate. The
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cut-off for “healthy” is defined as a score of 46 [12]. The validity and reliability of the scale were validated in Turkish by Öncü et al. [13]. Using the Turkish version of the scale, the cut-off value of 36 or greater accurately classified 82.5% of adults who were diagnosed with ADHD (sensitivity), 90.8% of the control group (specificity), and 66.7% of the depression group. The test-retest correlation (total score) of the scale was 0.81, and the item total score correlation was between 0.31 and 0.75. Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale (ADD/ADHD)
This scale was developed by Turgay and was tested for validity, reliability, and normativity by Gunay et al. [14, 15]. This scale is a self-assessment and self-report scale. When developing the adult ADD/ADHD scale, 18 of the diagnostic criteria symptoms in the DSM-IV were reframed for patient understanding. The first part of the scale has nine inattention questions, and the second part has nine hyperactivity/impulsivity questions. The third part of the scale consists of the most frequently associated symptoms of ADHD, but these symptoms are not among the DSM-IV ADHD diagnostic criteria. The severity and frequency of the symptoms are placed on a Likert scale with 0, 1, 2, and 3 describing “not at all,” “just a little,” “pretty much,” and “very much.” “Pretty much” and “very much” ratings are considered clinically significant. Statistics For statistical evaluation, we used SPSS for Windows version 18.0 (SPSS Inc., Chicago, Illinois, USA). All data were expressed as the mean ± standard deviation (SD). The between-group comparisons were performed using an independent samples t-test. The correlation between variables was analyzed using the Kendall’s tau-b correlation test. In all comparisons, p < 0.05 was considered statistically significant. RESULTS Students in the SPES and control group did not differ in terms of age, gender, or income status. While no difference was detected for maternal education between students in the SPES and control group, paternal education of students in the control group was greater than that of students in the SPES. The groups did not differ in terms of the students’ or students’ family psychiatric history. The rates of alcohol consumption and smoking were higher in the SPES group than the control group (Table 1). When scores were compared between the two groups, it was found that WURS scores were significantly higher (25.07 ± 15.15 versus 21.37 ± 14.28; p = 0.002) in the SPES group than the control group. In addition, the percentage of subjects with a WURS score above the cut-off of 36 was higher in the SPES group than
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Table 1. Sociodemographic Variables SPESa Age
Control
21.50 ± 2.02 21.43 ± 1.86
Gender
p 0.651 0.106
211 107
166 111
Cigarette smoking Yes No
102 216
66 211
Alcohol use Yes No
53 265
29 248
17 301
19 258
19 299
23 254
9.74 ± 6.13
9.98 ± 6.03
0.631
11.79 ± 4.27 12.51 ± 3.82
0.033
Male
Female
Psychiatric treatment Yes No
0.028
0.032
0.492
0.336
Psychiatric history in family
Yes No Maternal education (years) Paternal education (years) Income Low Moderate High
0.613 60 231 27
59 196 22
aSPES = School of Physical Education and Sports. Note: Bold represents p < 0.05.
the control group (22.4% versus 15.2%; p = 0.028). The two groups were not significantly different in terms of the subscales of the ADD/ADHD scale (Table 2). A correlation was found between the educational achievement of the students in the SPES group and both the ADD/ADHD-inattention subscale (r = .111, p = 0.015) and WURS scale (r = .113, p = 0.011). There was no significant correlation between educational achievement and ADD/ADHDhyperactivity subscale (r = .028, p = 0.532), ADD/ADHD-associated symptoms
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Table 2. Comparison of Groups’ Scale Scores SPESa
Control
p
ADD/ADHDa Inattention Hyperactivity Associated symptoms Total
7.28 ± 4.10 7.95 ± 5.15 26.54 ± 13.60 41.78 ± 20.36
7.83 ± 3.44 7.29 ± 5.09 26.41 ± 12.65 41.54 ± 18.46
0.083 0.120 0.903 0.879
WURSa
25.07 ± 15.15
21.37 ± 14.28
0.002
aSPES = School of Physical Education and Sports; ADD/ADHD = Adult ADD/ADHD
DSM-IV Based Diagnostic Screening and Rating Scale; WURS = Wender Utah Rating Scale. Note: Bold represents p < 0.05.
subscale (r = .088, p = 0.047), and ADD/ADHD-total symptoms subscale (r = .081, p = 0.068). DISCUSSION Based on the the ADD/ADHD scale, no difference was found between the SPES group and control group, while scores on the WURS were significantly higher in the SPES group. The ADD/ADHD scale screens for existing ADHD symptoms, but the WURS is based on symptoms observed during childhood. Therefore, SPES students who remembered having ADHD symptoms during childhood were numerous, but at the time of evaluation, these symptoms were not manifested any differently than other students. This makes sense because the prevalence of ADHD is reported to decrease with time [16, 17]. Hill and Schoener found that ADHD symptoms decreased with advanced age, and they predicted that the rate of ADHD decreases by 50% every 5 years [18]. The fact that the childhood symptoms of the students in the SPES group decreased during adulthood, reaching a level similar to that of the control group, may be explained by the progressive reduction of symptoms of the disease over time. Furthermore, the decrease in ADHD symptoms may also be explained by the regular athletic activities performed by the students in the SPES. The potential of physical activity (PA) as a treatment for ADHD is supported by the fact that recent animal models have shown that PA results in increased cerebral blood flow [19, 20]. Additionally, PA increases the availability of dopamine and norepinephrine in synaptic clefts of the central nervous system [21]. Anecdotal reports from children and teachers suggest that activity/exercise may mitigate the impulsivity and inattentiveness that characterize ADHD [22, 23]. Gapin and Etnier surveyed 68 parents of children diagnosed with ADHD and found that a significantly greater
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percentage of parents reported positive effects of regular PA on symptoms in general (54%), symptoms of inattention (63%), and symptoms of hyperactivity (53%) than controls [24]. McKune et al. demonstrated that behavior, as measured by parental ratings on the Conners’ Parent Rating Scale, improved after a 5-week exercise program [25]. These findings suggest that it is important to examine chronic PA as a potential way to mitigate behavioral symptoms of ADHD. This result also may be due to the retrospective recall bias of the symptoms by the participants, because we did not have information of childhood ADHD symptoms from participants’ parents. When theories about the high incidence of childhood ADHD symptoms in students in the SPES and the trend of people with ADHD to select sport-related areas are concomitantly considered, we can assert that departments of physical education and sports, such as SPES, are more commonly preferred by people with ADHD. Therefore, if the students who had childhood ADHD symptoms and are now SPES have an opportunity for a proper treatment, they may have better sportive and educational achievements. Children with ADHD may be more unsuccessful in athletics due to weak motor skills, coordination, and balance problems reported in the literature [9, 10]. In our study, there was significant but not robust correlation between academic failure and both ADD/ADHD subscale scores and WURS scores. Although there are different opinions about the effect of pharmacological agents used for treating ADHD on the performance of athletes with ADHD, it appears that the majority of patients with ADHD notice improved athletic performance following the administration of CNS stimulant medications. Improvements observed in performance due to concentration and fine motor coordination may be, to some degree, counterbalanced by a reduction of aggression [26]. In addition, it has been reported that people with ADHD were more successful in some sports, such as football and ice hockey where activity is continuous, compared to other sports, such as baseball where the game is broken into intervals [27]. In another study, pediatric psychiatrists evaluated suitable sports for children with ADHD. The “most suitable sport” was found to be swimming, followed by wrestling, track/sprints, track/field events, ski/snowboarding, dance, and distance running/cross country. The least suitable sport, or position, was considered to be baseball catcher, followed by football quarterback, equestrian events, hockey goalie, soccer goalie, golf, and gymnastics [28]. Therefore, directing people with ADHD to sports that are most suitable for them can be helpful for improved performance. In this study, alcohol consumption and smoking rates were found to be higher in the SPES group, which provides information about the athletes compared to other university students. These results may have been found for two reasons. First, in previous studies, alcohol consumption was found to be greater in athletes than the normal population [29]. In addition, it is known that athletes commonly smoke to relax before and after games, to increase their concentration, and to decrease
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boredom [30]. Second, compared to controls, young people with ADHD in previous studies are more likely to smoke cigarettes and consume alcohol [31, 32]. When the paternal education level of both groups was compared, we found that duration of education was significantly shorter for the fathers of students in the SPES compared to the control group. Mannuzza et al. reported that individuals with ADHD had a shorter duration of education and experienced more class failure and drop-out compared to the general population [33]. However, the observed shorter paternal duration of education may be due to many factors. In addition, this result may demonstrate that fathers of athletic children could have symptoms of ADHD. The scarcity of studies that investigate psychiatric diseases in the families of athletes makes it difficult to comment definitively on this issue. There are some limitations of this study: (1) ADHD diagnosis was based on scales instead of psychiatric interviews; (2) information about childhood ADHD symptoms was gathered from only participants themselves instead of both participants and their parents; (3) a cross-sectional design was used instead of a longitudinal design; and (4) participants with positive psychiatric history were not excluded from the study. More systematic studies in this domain that have larger samples will be beneficial for obtaining a clearer result about the attraction of people with ADHD to sports.
REFERENCES 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (4th ed.). Washington, DC, 2000. 2. Elliott H. Attention deficit hyperactivity disorder in adults: A guide for the primary care physician. Southern Medical Journal 2002;95:736-742. 3. Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: A meta-analysis of follow-up studies. Psychological Medicine 2006;36:159-165. 4. Barkley RA, Fischer M, Smallish L, et al. Young adult outcome of hyperactive children: Adaptive functioning in major life activities. Journal of the American Academy of Child and Adolescent Psychiatry 2006;45:192-202. 5. Baum AL. Psychopharmacology in athletes. In Begel D, Burton RW, editors. Sport psychiatry (pp. 249-259). New York, NY: WW Norton & Company, 2000. 6. Baum AL. Sport psychiatry: How to keep athletes in the game of life, on or off the field. Current Psychiatry 2003;2:51-56. 7. Burton RW. Mental illness in athletes. In Begel D, Burton RW, editors. Sport psychiatry (pp. 61-81). New York, NY: WW Norton & Company, 2000. 8. Conant-Norville DO, Tofler IT. Attention deficit/hyperactivity disorder and psychopharmacologic treatments in the athlete. Clinical Sports Medicine 2005;24: 829-843. 9. Harvey WJ, Reid G. Motor performance of children with attention deficit hyperactivity disorder: A preliminary investigation. Adaptive Physical Activity Questionnaire 1997;14:189-202.
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10. Harvey WJ, Reid G, Grizenko N, et al. Fundamental movement skills and children with attention-deficit hyperactivity disorder: Peer comparisons and stimulant effects. Journal of Abnormal Child Psychology 2007;35:871-882. 11. Reardon CL, Factor RM. Sport psychiatry: A systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Medicine 2010;40:961-980. 12. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: An aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. American Journal of Psychiatry 1993;150:885-890. 13. Oncu B, Olmez S, Senturk V. Validity and Reliability of the Turkish Version of the Wender Utah Rating Scale for Attention-Deficit/Hyperactivity Disorder in Adults. Turkish Psikiyatri Derg 2005;16:252-259. 14. Turgay A. Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale, Ontario, Canada, 1995. 15. Gunay S, Savran C, Aksoy UM, et al. The Norm Study, Transliteral Equivalence, Validity, Reliability of Adult Hyperactivity Scale in Turkish Adult Population. Türkiye’de Psikiyatri 2006;8:98-107. 16. Cohen P, Cohen J, Kasen S, et al. An epidemiological study of disorders in late childhood and adolescence—I. Age- and gender-specific prevalence. Journal of Child Psychology and Psychiatry 1993;34:851-867. 17. Gomez-Beneyto M, Bonet A, Catala MA, et al. Prevalence of mental disorders among children in Valencia, Spain. Acta Psychiatrica Scandinavica 1994;89:352-357. 18. Hill JC, Schoener EP. Age-dependent decline of attention deficit hyperactivity disorder. American Journal of Psychiatry 1996;153:1143-1146. 19. Endres M, Gertz K, Lindauer U, et al. Mechanisms of stroke protection by physical activity. Annals of Neurology 2003;54:582-590. 20. Swain RA, Harris AB, Wiener EC, et al. Prolonged exercise induces angiogenesis and cerebral blood volume in primary motor cortex of the rat. Neuroscience 2003;117: 1037-1046. 21. Fulk LJ, Stock HS, Lynn A, et al. Chronic physical exercise reduces anxiety-like behavior in rats. International Journal of Sports Medicine 2004;25:78-82. 22. Etscheidt MA, Ayllon T. Contingent exercise to decrease hyperactivity. Journal of Child and Adolescent Psychotherapy 1987;4:192-198. 23. Silverstein JM, Allison DB. The comparative efficacy of antecedent exercise and methylphenidate: A single case randomized trial. Child Care, Health and Development 1994;20:47-60. 24. Gapin JI, Etnier JL. Parental perceptions of the effects of exercise on behavior in children and adolescents with AD/HD. Paper presented at the North American Society for the Psychology of Sport and Physical Activity, Tucson, AZ, 2010. 25. McKune AJ, Puatz J, Lombard J. Behavioural response to exercise in children with attention-deficit/hyperactivity disorder. South African Journal of Sports Medicine 2003;15:17-21. 26. Hickey G, Fricker P. Attention deficit hyperactivity disorder, CNS stimulants and sports. Sports Medicine 1999;27:11-21. 27. Stabeno M. The ADHD affected athlete. Victoria, Canada: Trafford, 2004. 28. Conant-Norville D. ADHD and youth sports: A small opinion survey of child psychiatrists. Presented at the International Society for Sport Psychiatry Annual Scientific Meeting, Atlanta, 2005.
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29. Johnson LD, O’Malley PM, Bachman JG, et al. Monitoring the future national survey on drug use, 1975-2003 (Vol. II). College students and adults ages 19-45. NIH publication no. 04 5508. Bethesda, MD: National Institute on Drug Abuse, 2004. 30. Green GA, Uryasz FD, Petr TA, et al. NCAA study of substance abuse habits of college student-athletes. Clinical Journal of Sport Medicine 2001;11:51-56. 31. Galera C, Bouvard M, Messiah A, et al. Hyperactivity-inattention symptoms in childhood and substance use in adolescence: The youth gazel cohort. Drug and Alcohol Dependence 2008;94:30-37. 32. Wilens TE, Biederman J. Alcohol, drugs, and attention-deficit/hyperactivity disorder: A model for the study of addictions in youth. Journal of Psychopharmacology 2006; 20:580-588. 33. Mannuzza S, Klein RG, Bessler A, et al. Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Archives of General Psychiatry 1993;50:565-576.
Direct reprint requests to: Cem Gökçen, MD Assistance Professor Department of Child and Adolescent Psychiatry Medicine Faculty of Gaziantep University Gaziantep, Turkey e-mail: [email protected]
IS THERE ANY RELATIONSHIP BETWEEN ADHD SYMPTOMS AND CHOOSING SPORTS EDUCATION AT THE UNIVERSITY?
CEM GÖKÇEN, M.D.
UGUR ABAKAY
AHMET ÜNAL, M.D.
HASAN BAYAR, M.D.
GÖKAY ALPAK, M.D.
FERIDUN BÜLBÜL, M.D.
Gaziantep University, Turkey ÜMIT SERTAN ÇÖPOGLU, M.D. Government Hospital of Ceylanpinar, Turkey
ABSTRACT
Objective: The goal of our study was to compare the incidence of Attention Deficit Hyperactivity Disorder (ADHD) observed in students at the School of Physical Education and Sports (SPES), which is a school that provides higher education in athletics, with that observed in students studying in other departments of the university. Our hypothesis was that people with ADHD most commonly turn to sports. Method: The study enrolled 318 (75.7% of 420) students who were studying in the SPES of Gaziantep University; 277 students from the medical, nursing, administration, and engineering faculties were enrolled to serve as a control group. All students enrolled in the study were informed about the study before the lesson, and the students who agreed to participate provided written consent. Scales used in this study were: a sociodemographic information form which was prepared by the investigators, the Wender-Utah Rating Scale (WURS), and the Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale (ADD/ADHD). Results: WURS scores were significantly higher (25.07 ± 15.15 versus 21.37 ± 14.28; p = 0.002) in the SPES group than the control group. In 169 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.46.2.d http://baywood.com
170 / GÕKÇEN ET AL.
addition, the percentage of subjects with a WURS score above the cut-off of 36 was higher in the SPES group than the control group (22.4% versus 15.2%; p: 0.028). The two groups were not significantly different in terms of the subscales of the ADD/ADHD scale. A correlation was found between the educational achievement of the students in the SPES group and the ADD/ADHD-inattention subscale (r = .111, p = 0.015) and WURS scale (r = .113, p = 0.011). Conclusions: More systematic studies with larger samples in this domain will be useful in obtaining a clearer picture regarding professional attraction of people with ADHD to sports. (Int’l. J. Psychiatry in Medicine 2013;46:169-178)
Key Words: attention deficit hyperactivity disorder, sport, education
INTRODUCTION Attention deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders in children, affecting approximately 3-7%. ADHD is diagnosed based on the presence of symptoms of inattention, hyperactivity, and/or impulsivity for at least 6 months in at least two domains of life. Additionally, the symptoms must have been initially observed prior to the age of seven [1]. The presence of these symptoms continues into adulthood in 50 to 80% of individuals and can cause numerous impairments in social, academic, and occupational functioning [2-4]. The correlation between sports and psychiatric disorders is an interesting one, with the following descriptions available in the literature: (i) athletes may obtain high levels of success despite having a primary psychiatric disorder; (ii) athletes may have chosen the athletic arena as a means of coping with a disorder; (iii) sports may precipitate or exacerbate psychiatric illness in athletes [5, 6]. Based on anecdotal reports, ADHD appears to be more prevalent in athletes than non-athletes, which may be because those with ADHD are drawn to physical activity, which is an example of athletes choosing the athletic arena to cope with a disorder [7]. In addition, individuals with ADHD often have greater success in the athletic arena than in the classroom. This may be explained by the fact that children with ADHD are competitive, which leads them to seek any physiological or psychological expression that will give them an advantage over their competition [8]. However, athletes with ADHD face unique challenges. Children and adolescents with ADHD often demonstrate poor motor skills, coordination, and balance, and these challenges likely have an effect on their athletic success [9, 10]. There are a limited number of studies that investigate psychiatric disorders in athletes. A recent review stated that the majority of studies on athletes focused
ADHD AND SPORTS EDUCATION /
171
on eating disorders and substance abuse and that studies concerned with ADHD, anxiety disorders, and bipolar disorder are needed [11]. The School of Physical Education and Sports (SPES) accepts students via university and a special ability exam that includes an evaluation of candidates’ physical and sporting preferences. Higher and detailed education related to all fields of physical education and sports is given over the 4 years of school. Graduated students have the opportunity to become physical education teachers, sport managers, and/or coaches. The goal of the present study was to compare the incidence of ADHD observed in students at the SPES, which is a school that provides higher education in athletics, with that observed in students studying in other departments of the university. Our hypothesis was that greater proportions of students with ADHD would seek out SPES degrees. MATERIALS AND METHODS The study enrolled 318 (75.7% of 420) students of the SPES of Gaziantep University, and 277 students from the medical, nursing, administration, and engineering departments to serve as a control group. The only exclusion criterion was an unwillingness to participate in the study. All students enrolled in the study were informed about the study before the lesson, and the students who agreed to participate provided written consent. The scales were distributed to the students during class. The study protocol was reviewed and approved by the institutional ethics committee. Assessment Tools Sociodemographic Information Form
This is a 13-question form that was prepared by the investigators to obtain information about age, gender, educational achievement, consumption of alcohol, smoking status, income status, educational background of the parents, and psychiatric history of the participants and their first-degree relatives. Educational achievement of participants was evaluated by grade point average which was obtained from the school secretary. Grade point average scores were classified as from A to E (A:100-85, B:84-70, C:69-55, D:54-45, E:44-0). Wender Utah Rating Scale (WURS)
The Wender Utah Rating Scale (WURS) was developed by Ward et al. to evaluate the symptoms of ADHD in childhood [12]. The WURS consists of 25 self-report items scored on a 5-point Likert scale. It is graded from 0 to 100 points and can determine major depression with an 81% accuracy rate, ADHD with an 86% accuracy rate, and healthy controls with a 99% accuracy rate. The
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cut-off for “healthy” is defined as a score of 46 [12]. The validity and reliability of the scale were validated in Turkish by Öncü et al. [13]. Using the Turkish version of the scale, the cut-off value of 36 or greater accurately classified 82.5% of adults who were diagnosed with ADHD (sensitivity), 90.8% of the control group (specificity), and 66.7% of the depression group. The test-retest correlation (total score) of the scale was 0.81, and the item total score correlation was between 0.31 and 0.75. Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale (ADD/ADHD)
This scale was developed by Turgay and was tested for validity, reliability, and normativity by Gunay et al. [14, 15]. This scale is a self-assessment and self-report scale. When developing the adult ADD/ADHD scale, 18 of the diagnostic criteria symptoms in the DSM-IV were reframed for patient understanding. The first part of the scale has nine inattention questions, and the second part has nine hyperactivity/impulsivity questions. The third part of the scale consists of the most frequently associated symptoms of ADHD, but these symptoms are not among the DSM-IV ADHD diagnostic criteria. The severity and frequency of the symptoms are placed on a Likert scale with 0, 1, 2, and 3 describing “not at all,” “just a little,” “pretty much,” and “very much.” “Pretty much” and “very much” ratings are considered clinically significant. Statistics For statistical evaluation, we used SPSS for Windows version 18.0 (SPSS Inc., Chicago, Illinois, USA). All data were expressed as the mean ± standard deviation (SD). The between-group comparisons were performed using an independent samples t-test. The correlation between variables was analyzed using the Kendall’s tau-b correlation test. In all comparisons, p < 0.05 was considered statistically significant. RESULTS Students in the SPES and control group did not differ in terms of age, gender, or income status. While no difference was detected for maternal education between students in the SPES and control group, paternal education of students in the control group was greater than that of students in the SPES. The groups did not differ in terms of the students’ or students’ family psychiatric history. The rates of alcohol consumption and smoking were higher in the SPES group than the control group (Table 1). When scores were compared between the two groups, it was found that WURS scores were significantly higher (25.07 ± 15.15 versus 21.37 ± 14.28; p = 0.002) in the SPES group than the control group. In addition, the percentage of subjects with a WURS score above the cut-off of 36 was higher in the SPES group than
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173
Table 1. Sociodemographic Variables SPESa Age
Control
21.50 ± 2.02 21.43 ± 1.86
Gender
p 0.651 0.106
211 107
166 111
Cigarette smoking Yes No
102 216
66 211
Alcohol use Yes No
53 265
29 248
17 301
19 258
19 299
23 254
9.74 ± 6.13
9.98 ± 6.03
0.631
11.79 ± 4.27 12.51 ± 3.82
0.033
Male
Female
Psychiatric treatment Yes No
0.028
0.032
0.492
0.336
Psychiatric history in family
Yes No Maternal education (years) Paternal education (years) Income Low Moderate High
0.613 60 231 27
59 196 22
aSPES = School of Physical Education and Sports. Note: Bold represents p < 0.05.
the control group (22.4% versus 15.2%; p = 0.028). The two groups were not significantly different in terms of the subscales of the ADD/ADHD scale (Table 2). A correlation was found between the educational achievement of the students in the SPES group and both the ADD/ADHD-inattention subscale (r = .111, p = 0.015) and WURS scale (r = .113, p = 0.011). There was no significant correlation between educational achievement and ADD/ADHDhyperactivity subscale (r = .028, p = 0.532), ADD/ADHD-associated symptoms
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Table 2. Comparison of Groups’ Scale Scores SPESa
Control
p
ADD/ADHDa Inattention Hyperactivity Associated symptoms Total
7.28 ± 4.10 7.95 ± 5.15 26.54 ± 13.60 41.78 ± 20.36
7.83 ± 3.44 7.29 ± 5.09 26.41 ± 12.65 41.54 ± 18.46
0.083 0.120 0.903 0.879
WURSa
25.07 ± 15.15
21.37 ± 14.28
0.002
aSPES = School of Physical Education and Sports; ADD/ADHD = Adult ADD/ADHD
DSM-IV Based Diagnostic Screening and Rating Scale; WURS = Wender Utah Rating Scale. Note: Bold represents p < 0.05.
subscale (r = .088, p = 0.047), and ADD/ADHD-total symptoms subscale (r = .081, p = 0.068). DISCUSSION Based on the the ADD/ADHD scale, no difference was found between the SPES group and control group, while scores on the WURS were significantly higher in the SPES group. The ADD/ADHD scale screens for existing ADHD symptoms, but the WURS is based on symptoms observed during childhood. Therefore, SPES students who remembered having ADHD symptoms during childhood were numerous, but at the time of evaluation, these symptoms were not manifested any differently than other students. This makes sense because the prevalence of ADHD is reported to decrease with time [16, 17]. Hill and Schoener found that ADHD symptoms decreased with advanced age, and they predicted that the rate of ADHD decreases by 50% every 5 years [18]. The fact that the childhood symptoms of the students in the SPES group decreased during adulthood, reaching a level similar to that of the control group, may be explained by the progressive reduction of symptoms of the disease over time. Furthermore, the decrease in ADHD symptoms may also be explained by the regular athletic activities performed by the students in the SPES. The potential of physical activity (PA) as a treatment for ADHD is supported by the fact that recent animal models have shown that PA results in increased cerebral blood flow [19, 20]. Additionally, PA increases the availability of dopamine and norepinephrine in synaptic clefts of the central nervous system [21]. Anecdotal reports from children and teachers suggest that activity/exercise may mitigate the impulsivity and inattentiveness that characterize ADHD [22, 23]. Gapin and Etnier surveyed 68 parents of children diagnosed with ADHD and found that a significantly greater
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percentage of parents reported positive effects of regular PA on symptoms in general (54%), symptoms of inattention (63%), and symptoms of hyperactivity (53%) than controls [24]. McKune et al. demonstrated that behavior, as measured by parental ratings on the Conners’ Parent Rating Scale, improved after a 5-week exercise program [25]. These findings suggest that it is important to examine chronic PA as a potential way to mitigate behavioral symptoms of ADHD. This result also may be due to the retrospective recall bias of the symptoms by the participants, because we did not have information of childhood ADHD symptoms from participants’ parents. When theories about the high incidence of childhood ADHD symptoms in students in the SPES and the trend of people with ADHD to select sport-related areas are concomitantly considered, we can assert that departments of physical education and sports, such as SPES, are more commonly preferred by people with ADHD. Therefore, if the students who had childhood ADHD symptoms and are now SPES have an opportunity for a proper treatment, they may have better sportive and educational achievements. Children with ADHD may be more unsuccessful in athletics due to weak motor skills, coordination, and balance problems reported in the literature [9, 10]. In our study, there was significant but not robust correlation between academic failure and both ADD/ADHD subscale scores and WURS scores. Although there are different opinions about the effect of pharmacological agents used for treating ADHD on the performance of athletes with ADHD, it appears that the majority of patients with ADHD notice improved athletic performance following the administration of CNS stimulant medications. Improvements observed in performance due to concentration and fine motor coordination may be, to some degree, counterbalanced by a reduction of aggression [26]. In addition, it has been reported that people with ADHD were more successful in some sports, such as football and ice hockey where activity is continuous, compared to other sports, such as baseball where the game is broken into intervals [27]. In another study, pediatric psychiatrists evaluated suitable sports for children with ADHD. The “most suitable sport” was found to be swimming, followed by wrestling, track/sprints, track/field events, ski/snowboarding, dance, and distance running/cross country. The least suitable sport, or position, was considered to be baseball catcher, followed by football quarterback, equestrian events, hockey goalie, soccer goalie, golf, and gymnastics [28]. Therefore, directing people with ADHD to sports that are most suitable for them can be helpful for improved performance. In this study, alcohol consumption and smoking rates were found to be higher in the SPES group, which provides information about the athletes compared to other university students. These results may have been found for two reasons. First, in previous studies, alcohol consumption was found to be greater in athletes than the normal population [29]. In addition, it is known that athletes commonly smoke to relax before and after games, to increase their concentration, and to decrease
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boredom [30]. Second, compared to controls, young people with ADHD in previous studies are more likely to smoke cigarettes and consume alcohol [31, 32]. When the paternal education level of both groups was compared, we found that duration of education was significantly shorter for the fathers of students in the SPES compared to the control group. Mannuzza et al. reported that individuals with ADHD had a shorter duration of education and experienced more class failure and drop-out compared to the general population [33]. However, the observed shorter paternal duration of education may be due to many factors. In addition, this result may demonstrate that fathers of athletic children could have symptoms of ADHD. The scarcity of studies that investigate psychiatric diseases in the families of athletes makes it difficult to comment definitively on this issue. There are some limitations of this study: (1) ADHD diagnosis was based on scales instead of psychiatric interviews; (2) information about childhood ADHD symptoms was gathered from only participants themselves instead of both participants and their parents; (3) a cross-sectional design was used instead of a longitudinal design; and (4) participants with positive psychiatric history were not excluded from the study. More systematic studies in this domain that have larger samples will be beneficial for obtaining a clearer result about the attraction of people with ADHD to sports.
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Direct reprint requests to: Cem Gökçen, MD Assistance Professor Department of Child and Adolescent Psychiatry Medicine Faculty of Gaziantep University Gaziantep, Turkey e-mail: [email protected]
