§ SPORTS BEHAVIOR OF CHILDREN WITH ADHD

§ EARLY vs. LATE ONSET OF ADHD SYMPTOMS - DOES IT
  MATTER?
====================================================
SPORTS BEHAVIOR OF CHILDREN WITH ADHD

Although considerable research on the social behavior and peer relations of
children with ADHD has been published in recent years, I have not seen any
studies examining the behavior of children with ADHD in the context of
athletic activities. Participation in sports is an important activity for
children, as success in sports can have positive effects on their peer
relations, self-esteem, and social development. Therefore, studies of how
children with ADHD tend to fare in this context are important to conduct.

A recently published study in the Journal of Attention Disorders provides an
initial look at this interesting area (Johnson, R.C., & Rosen, L.A., 4,
150-160, 2000). The objective of this study was to provide an examination of
how children with ADHD fared in sports activities - both team sports and
individual sports - in relation to children without ADHD.

Based on what is known about the social behavior of children with ADHD in
general, the authors predicted that children with ADHD:
1) Would stick with individual sports longer than team sports because their
"mistakes" during team sports would produce negative feedback from peers.
2) Would display more aggression during sports activities.
3) Would be more emotionally reactive following a win or loss.
4) Would be more likely to be disqualified during sports activities.

Participants in this study included the parents of 34 children with ADHD and
41 comparison children. All children were males averaging an age of
approximately 12 years. Of the ADHD children, 75% were being treated with
medication at the time of the study. Parents of the ADHD children in the
study were recruited from ADHD support groups in several different cities in
the Rocky Mountain region. Parents of comparison children were recruited
from parent-teacher organizations at the schools attended by children in the
ADHD sample.

To learn about the children's experiences in sports activities, parents
completed a 21-item Sports Behavior Checklist that inquired about children's
experiences in both team and individual sports. The questions on this scale
were constructed to learn about children's displays of aggression during
sports activities ("Has your child ever been involved in a physical argument
during a team sport?"), emotional reactivity ("In your opinion, does your
child overreact to team sports wins or losses?"), and their experiences with
both injury and disqualification. Identical questions were asked about team
and individual sports activities so that a comparison between them could be
made. Parents responded to each question on a 1 (rarely) to 5 (often) rating
scale. Parents were also asked about the length of their child's involvement
in both team and individual sports.

RESULTS

As predicted, a number of differences in the sports behavior and experience
were found between children with ADHD and comparison children. In terms of
experience, while boys in both groups were involved with individual sports
for comparable time periods, boys with ADHD had significantly less
experience in team sports activities.

Across both team and individual sports contexts, boys with ADHD were rated
by their parents as more likely to display aggression, to show higher levels
of emotional reactivity following a win or defeat, and as more likely to be
disqualified from a sports contest.  They were not, however, more likely to
be injured. Although ADHD boys were rated as having more behavioral
difficulties during sports than the comparison boys, the absolute level of
problems that parents reported was not high. Thus, even though parents of
ADHD boys indicated that their sons were more likely to have problems with
aggression than parents of comparison boys, their ratings did not suggest
that the problems were of a large magnitude.

The authors also compared how children in both groups performed in team vs.
individual sports settings. As expected, boys - regardless of ADHD status -
were more likely to behave aggressively, to be emotionally reactive, and to
be injured when involved in team sports compared to individual sports.

SUMMARY AND IMPLICATIONS

The results of this study indicate that boys with ADHD are, according to
their parents, more likely than non-ADHD boys to experience increased levels
of aggression, emotional reactivity, and disqualification in both team and
individual sports settings. However, parents' ratings did not suggest that
the level of problems experienced by boys with ADHD was large in magnitude,
and both groups of boys tended to have fewer problems when playing
individual sports. Perhaps because of their greater difficulty participating
appropriately in team sports, boys with ADHD had been involved in team
sports for significantly fewer years than the comparison boys.

The authors of this study suggest that parents of boys with ADHD may want to
steer their sons towards individual sports rather than towards team sports
where they are more likely to have difficulty. This may be a useful strategy
for some children with ADHD, but it should not be assumed that just because
a child has ADHD, he or she is unlikely to have a successful experience
participating in team sports. Thus, if an ADHD child is eager to participate
in Little League or soccer, for example, a useful approach would be to plan
ways to increase his or her likelihood for success rather than assume it
will not work out and deny the child an opportunity.

There are several ways that parents can do this. First, for children who
benefit from taking medication, taking medication prior to a team sports
activity can be helpful. In fact, one prior study has documented gains in
the areas of game awareness and performance when 7 to 9-year-old ADHD boys
received medication prior to a Little League game.

Second, parents can work to find a coach who understands the difficulties
their child may have in a team sport and who will be able to work patiently
and effectively with him or her. Although no research on this issue has been
conducted, it is reasonable to hypothesize that finding the right coach for
a child with ADHD can be as important to that child's enjoyment and success
in an athletic activity as getting the right teacher can be for that child's
enjoyment and success at school.

Third, children with ADHD may have greater difficulty in some team sports
than others.  For example, standing in the outfield for inning after inning
can be the kind of experience that results in a child with ADHD losing
attention quickly. Sports such as soccer or basketball typically involve
less waiting and standing around, and may be less likely to lead to such
difficulties. This will not be true for all children with ADHD, of course,
but the point is to find sports that hold the greatest interest value for
your child.

Finally, parents can review the rules and behavioral expectations with their
child prior to participation in both team and individual sports. Children
with ADHD tend to be more emotionally reactive, and providing them with
frequent reminders of how they need to conduct themselves before a game can
be quite helpful. Working out signals which parents can provide their child
to encourage them to pay attention to the game, or to calm down could also
prove helpful. In addition, providing incentives for appropriate behavior
during games and practices-similar to the types of behavioral incentive
systems developed to encourage appropriate behavior at school or home-can
also be considered.

Although this initial study of the sports behavior of boys with ADHD (work
in this area with girls is needed as well) indicates some greater level of
difficulty, parents should not regard this with discouragement. The
strategies suggested above can be quite helpful, and I have worked with many
children who had very positive experiences in both team and individual
sports activities despite having ADHD. It may take a bit more effort from
parents to help their child have such a positive experience, but the results
can be well worth it.
 

EARLY vs. LATE ONSET OF ADHD SYMPTOMS-DOES IT MATTER?

One controversial aspect of current diagnostic criteria for ADHD is the
requirement that in addition to displaying a certain number of inattentive
and/or hyperactive-impulsive symptoms, some of these symptoms must have been
present and caused some impairment prior to the age of 7. (For a complete
discussion of current diagnostic criteria, click here.

This age-of-onset criteria was included in DSM-IV (the diagnostic manual for
all psychiatric disorders, including ADHD) based on findings that most
children with ADHD first exhibited symptoms in early childhood, and in
response to concerns that when ADHD symptoms appear after age 7, they often
may be due to school failure or stress rather than to ADHD. Thus, by
requiring ADHD symptoms to have been evident and causing impairment before
the age of 7 for the diagnosis to be appropriate, it was hoped that children
whose symptoms first emerged at later ages for a variety of other reasons
would not be misdiagnosed as having ADHD.

This age-of-onset criteria assumes that there is a meaningful difference
between children whose ADHD symptoms emerge relatively early in life from
those whose symptoms first become evident later on. Several ADHD experts (in
particular, Dr. Joseph Biederman and Dr. Russell Barkley) have questioned
the validity of this assumption and suggested that the age 7 cutoff is
arbitrary and not based in science. As a result, there are concerns that
this may actually deny diagnoses and services to youths who suffer from
ADHD-related difficulties.

For example, a child who met all symptomatic criteria for ADHD except for
the age-of-onset criteria currently would not be given the diagnosis and
could thus be denied access to educational services that would otherwise be
provided. In addition, treatment options typically considered for a child
with ADHD might be discarded. Clearly, it is potentially problematic to have
this unsubstantiated age-of-onset cutoff in the official diagnostic criteria
for ADHD. Research to establish the validity of this requirement is needed.

A study published in a recent issue of the Journal of the American Academy
of Child and Adolescent Psychiatry offers the best data currently available
on this important issue (Willoughby, M.T., et al., 39, 1512-1519, 2000).
Participants in the study were part of a large study designed to determine
the prevalence of a variety of childhood psychiatric disorders and the
impact of different disorders on children and their families.

A representative sample of 4500 students, grouped by ages 9, 11, and 13, was
recruited from 11 counties in western North Carolina. Parents completed an
initial screening instrument designed to detect child behavior problems.
When this score exceeded a pre-determined cutoff, these parents and children
were invited to participate in a more detailed assessment that involved
thorough psychiatric interviews of both parents and children over a 4-year
span. In addition, a sample of children whose behavior problem screening
score fell below the cutoff was recruited to serve as comparison subjects.

The authors identified children who met symptomatic criteria for ADHD based
on the results of an extensive parental interview. Parents also provided
information about the age at which their child's symptoms first became
evident. These ADHD participants were then divided into 6 mutually exclusive
groups:

*   Those with the inattentive subtype of ADHD with onset of symptoms before
     age 7;

*   Those with the inattentive subtype of ADHD with onset of symptoms after
      age 7;

*    Those with the combined subtype of ADHD with onset of symptoms before age
      7;

*    Those with the combined subtype of ADHD with onset of symptoms after age 7;

*    Those with the hyperactive-impulsive subtype of ADHD with onset of
      symptoms before age 7;

*    Those with the hyperactive-impulsive subtype of ADHD with onset of
      symptoms after age 7;

Note: The inattentive subtype refers to children showing large numbers of
inattentive symptoms but relatively few hyperactive-impulsive symptoms. The
exact opposite is true for children with the hyperactive-impulsive subtype,
while children with the combined subtype display high numbers of both types
of symptoms. A seventh group was comprised of children who never met symptomatic
criteria for ADHD. They served as a comparison group.

Once these groups were identified, children with each subtype of ADHD whose
symptoms emerged either before or after the age of 7 were compared to one
another, and to children without ADHD symptoms. Children were compared on a
variety of different dimensions, including: the number of settings in which
they were currently struggling, the presence of other psychiatric problems
in addition to ADHD symptoms, if they had required mental health services
during the past 3 months, and the degree to which their symptoms were
adversely affecting their parents.

If the age at which ADHD symptoms first emerge is important for making valid
diagnoses of ADHD, then one would expect children in the early vs.
late-onset groups to differ on these factors. However, if there were no
differences between children in the early vs. late-onset group, the utility
of including age of onset in the diagnostic criteria would be questionable.

RESULTS

The authors first examined whether there were differences between ADHD
subtypes in the age when parents reported the emergence of symptoms. For
each subtype of ADHD, a substantial proportion of parents reported that
their child's symptoms had always been present and were unable to identify a
specific year when they first emerged. This is consistent with the widely
held belief that ADHD is typically evident in early childhood. Differences
in the age of onset between the subtypes were also evident, with 26% of
parents of inattentive youth reporting symptom onset after age 7, compared
to only 13% for the combined subtype and 8% for the hyperactive-impulsive
subtype. (Because symptom onset before age 7 was reported for over 90% of
children with the hyperactive-impulsive subtype, comparison of early vs.
late-onset groups was not possible.)

For the inattentive subtype, both early and late-onset children were more
likely than comparison children to be impaired in 2 or more settings, to
have used a greater number of services during the past 3 months, and to have
behavioral and/or emotional problems that parents perceived as creating
difficulty in their own lives. Early-onset children were more likely than
comparison children to display strong oppositional behavior while late-onset
children were more likely to be depressed. When early vs. late-onset
inattentive children were compared to one another, they did not differ on
any measure of comorbidity, impairment, or impact on parental functioning.

For the combined subtype, children in the early and late-onset groups were
more likely than comparison children to be impaired in multiple settings,
and to have used a greater number of services during the past 3 months.
Early-onset children were also more likely to be diagnosed with conduct
disorder (CD), oppositional defiant disorder (ODD), or an anxiety disorder,
and their parents reported that their children's problems caused more
difficulty for their own functioning. When the early vs. late-onset groups
were directly compared, the early-onset group was at an increased risk for
both ODD and CD, and also appeared more likely to be depressed. They were
also more likely to be receiving services and to have a greater number of
negative impacts on their parents' functioning.

SUMMARY AND CONCLUSIONS

The results of this study suggest that the age-of-onset criteria have
different clinical implications depending on the ADHD subtype. For youth
with the inattentive subtype of ADHD, symptom onset after age 7 occurs about
one quarter of the time, and there does not appear to be any difference
between early and late-onset groups in a number of meaningful clinical
outcomes. In addition, children with the inattentive subtype of ADHD were
clearly struggling relative to non-ADHD comparison children regardless of
whether their symptoms emerged early or late. There is thus little support
in these data for the requirement of an onset of symptoms prior to the age
of 7 for the inattentive subtype of ADHD. In fact, one could plausibly argue
from these data that such a requirement would be likely to increase the
number of incorrect diagnoses by precluding a diagnosis of children with
ADHD who really do have the condition.

However, a very different picture emerged for children with the combined
subtype of ADHD. Among these children, those with an early onset of symptoms
differed from those in the late-onset group on a number of dimensions and
clearly had worse clinical outcomes. Thus, even though children in the
late-onset group were struggling relative to comparison children, they were
not as impaired as those whose symptoms began earlier in life. This pattern
of findings suggests that the age-of-onset criteria is meaningful for the
combined subtype and argues against dropping it as some have suggested.
Doing so would result in the identification of a much more heterogeneous
group of children as having the combined subtype of ADHD.

In regards to the clinical implications of these results, it appears that
clinicians should be cautious about ruling out a diagnosis of ADHD for an
inattentive child just because that child's symptoms were not evident until
later in life. This could result in a child's inattentive symptoms being
incorrectly attributed to some other condition such as a mood or anxiety
disorder, and prevent the child from getting appropriate treatment. Although
there are instances where a child's inattentive symptoms reflect the impact
of such conditions rather than ADHD, and clinicians always need to be
vigilant about this possibility, it is the practice of ruling out ADHD as a
diagnosis for inattentive children with a late onset of symptoms that is
potentially problematic. (Note: In the current diagnostic system, it would
still be possible to diagnose such children as "ADHD, not otherwise
specified".)

Parents should be aware that the emergence of significant attention problems
in older children does occur and may reflect ADHD for which appropriate
treatment is required. Sometimes such symptoms do not become evident until
children have moved further along in school when the academic and
organizational demands increase substantially from the early elementary
grades. Suddenly, a bright child who has always done well is struggling, and
these problems can be wrongly attributed to laziness, lack of motivation, or
an emotional problem like depression. When a parent is told that their child
couldn't have ADHD because they never showed such struggles before,
attributions are likely to be made and the consequences can be quite
harmful.

For a child who begins showing inattentive and hyperactive-impulsive
symptoms consistent with the combined subtype diagnosis at a later age,
results from this study suggest that caution in making an ADHD diagnosis is
appropriate. Children with a late onset of combined symptoms seem to differ
from those with earlier symptom onset, raising the possibility that their
symptoms occur for reasons other than ADHD.

Therefore, when a child begins to show such symptoms at an older age,
parents should raise questions if their child's health care provider
initiates traditional treatment for ADHD without first considering other
explanations for their child's symptoms.

As the authors acknowledge, there are limitations to the current study that
preclude any definitive answer to the question of whether requiring
age-of-onset criteria for diagnosing ADHD is appropriate, and additional
work in this area is required. For example, it would be key to learn whether
children with early vs. late-onset combined-type symptoms showed different
patterns of response to stimulant medication treatment, different long-term
outcomes, and different patterns of results on neuropsychological tests. The
same would be true for children with early vs. late-onset inattentive
symptoms. These kinds of data would help address this question more
definitively, and would be enormously helpful in refining current diagnostic
guidelines. Hopefully such information will become available shortly.

******I hope you enjoyed the above reviews and found them informative. If
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Sincerely,

David Rabiner, Ph.D.
Senior Research Scientist
Duke University