NR 25166

Fundamental movement skills and associated physical activity
experiences of children with ADHD
William J. Harvey
Department of Kinesiology and Physical Education
McGill University, Montreal
February, 2006
A thesis submitted to McGill University in partial fulfillment of the requirements for the degree
ofDoctor ofPhilosophy in Kinesiology and Physical Education
©William J. Harvey, 2006

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2
Abstract
Excessive activity has been a prominent feature in the symptomatology of attention-deficit
hyperactivity disorder (ADHD) for more than four decades. While overactivity has helped to
identify persons with ADHD, the movement skill proficiency and physical activity experiences
of children with ADHD have been overlooked (Harvey & Reid, 1997). This dissertation is a
series of four original manuscripts that explore relationships between adapted physical activity
(APA) and ADHD. The fust manuscript, a review paper, discusses important issues related to
ADHD. It suggests many children with ADHD experience poor levels ofphysical fitness and
movement skill difficulties when compared to children without ADHD (Harvey & Reid, 2003).
Numerous reference citations for seminal review articles on ADHD were provided. The second
manuscript, another review paper, explored research methods used in movement performance
studies about ADHD. Twenty new APA research questions about ADHD were posed (Harvey &
Reid, 2005). Issues surrounding identification of ADHD, data collection procedures, and
strategies to improve AP A research about ADHD were also provided. The two review papers,
when combined, are a substantial and original contribution to the ADHD literature. The third
manuscript is a study about the effects of stimulant medication on the fundamental movement
skill performance for 22 children with ADHD and a comparison oftheir movement skills to age-
and gender-matched peers without ADHD. Multivariate statistical analyses revealed no
significant effect ofmethylphenidate on the performance criteria of the TGMD-2 (Ulrich, 2000)
for the children with ADHD. Significant differences between the children with and without
ADHD were found on both locomotor skills and object control skills. A movement skill profile
was developed for each group and they are unique contributions to the movement performance
literature. The fourth manuscript is a study that explores the lived physical activity experiences
3
of six boys with and without ADHD. Semi-structured interviews revealed sorne similarities
among both groups about their physical activity experiences. However, qualitative differences
were apparent on key aspects ofskill proficiency. It is concluded that more in-depth APA
research about people with ADHD is necessary to gain a clearer understanding of the children's
unique physical activity needs.

4
Résumé
L'activité excessive est une caractéristique marquante dans la symptomatologie du trouble
d'attention avec hyperactivité (TDAH) depuis plus de quatre décennies. Si toutefois
l'hyperactivité a aidé à identifier les personnes atteintes de TDAH, la capacité motrice et
l'activité physique des enfants atteints de TDAH ont été négligées (Harvey & Reid, 1997). Cette
dissertation est une série de quatre manuscrits originaux qui explorent les relations entre
l'activité physique adaptée (APA) et le TDAH. Le premier manuscrit, un article de révision,
discute de sujets importants reliés au TDAH. Il suggère que plusieurs enfants atteints du TDAH
ne sont pas en bonne forme physique et vivent des difficultés avec la capacité motrice lorsqu'on
compare à des enfants non-atteints du TDAH (Harvey & Reid, 2003). Plusieurs citations de
référence portant des articles de révision sur le IDAH ont été fournies. Le deuxième manuscrit,
un autre article de révision, explore les méthodes de recherche utilisées pour réaliser des études
sur la capacité motrice sur le TDAH. Vingt nouvelles questions de recherche sur l'APA ont été
posées (Harvey & Reid, 2005). Les points entourant l'identification du TDAH, les procédures
de collecte des données et les stratégies pour améliorer la recherche sur l' AP A et le IDAH ont
également été apportées. Les deux articles, lorsque combinés, sont une contribution substantielle
et originale à la littérature sur le IDAH. Le troisième manuscrit décrit une étude sur les effets
des médicaments stimulants sur la performance fondamentale de la capacité motrice pour 22
enfants atteints du IDAH, et une comparaison de leur capacité motrice à un groupe d'enfants du
même âge et du même sexe qui sont non-atteints du TDAH. Des analyses statistiques
comportant plusieurs variantes n'ont démontré aucun effet significatif de la méthylphénidate sur
le critère du TGMD-2 (Ulrich, 2000) pour les enfants atteints du TDAH. Des différences
significatives entre les enfants atteints et non-atteints du IDAH ont été retrouvées sur les
5
habiletés locomotrices et le contrôle d'objet. Un profil de capacité motrice a été développé pour
chaque groupe et ils sont une contribution unique à la littérature de la performance du
mouvement. Le quatrième manuscrit est une étude qui explore les expériences d'activité
physique vécues de six garçons atteints et non-atteints du TDAH. Des entrevues semi-
structurées ont démontré quelques similitudes entre les deux groupes portant sur leurs
expériences d'activité physique. Toutefois, des différences qualitatives étaient apparentes lors
des aspects clés sur les habiletés. TI a été conclu qu'une recherche plus approfondie sur l'APA et
sur les personnes atteintes d'un TDAH est nécessaire pour bénéficier d'une meilleure
compréhension des besoins uniques de l'activité physique chez les enfants.

6
Acknowledgements
There are many people to thank in this doctoral dissertation. First, 1 would like to thank
aIl of the professors who have served on my doctoral committees and provided much appreciated
mentorship and guidance. 1 had the distinct pleasure and honor to learn from and work with my
dissertation supervisor, Dr. Greg Reid. He has challenged me to learn and perform to the best of
my abilities each and every day. Greg patiently edited my work and, with time and teaching, he
has enabled me to become independent in my research skills and professional practice. Thank
you for your guidance, candor and friendship over these many years.
Three specific committee members have helped me enormously. They assisted in the
design of the two latter studies of the dissertation. Yet, they contributed so much more.
Dr. A.E. (Ted) Wall was an instrumental part ofmy student life by providing much guidance and
support. He always maintained high professional standards and always demanded my very best.
Dr. Carl Frederiksen opened my eyes to the beauty ofbeing a "sleuth" and maintaining a positive
focus on learning. Carl re-instilled a love for learning in me and, importantly, he re-introduced
statistics to me in a way that 1 have acquired a new found interest in the domain and a deep
respect for his teaching skills. Dr. Margaret Downey has long suffered my "5-minute" talks that
would usually last for much longer. Peggy would listen patiently, reflect and always provide
critical feedback that only a master teacher can provide. Thanks are extended to aIl of you for the
tremendous learning experiences and the opportunity to venture into a new and exciting life
journey.
1 would like to thank the foIlowing co-authors for their assistance and contributions to the
thesis. Dr. Natalie Grizenko and Dr. Ridha Joober were open-minded and allowed this physical
activity research to be included in their ADHD research program at the Douglas Hospital. In
7
addition to the opportunity to observe reliably diagnosed persons with ADHD, we were able to
learn much more about research in psychiatry. Dr. Valentin Mbekou and Mrs. Marina Ter-
Stepanian, also from the Douglas Hospital, were vital for the interpretation of psychological tests
as weIl as training me to reliably conduct the required screening interviews. Dr. Gordon Bloom
and Ms. Kerri Staples from McGill University contributed to my understanding of qualitative
research with theoretical and practical feedback on important methodological issues. Thank you
to Human Kinetics for permitting two published review papers to be reproduced and placed in
this thesis. This dissertation was made special by the contributions of Kelly Norman and
Myriam Rabbat at Riverview Elementary School. A very special thank you is especially
extended to aIl participants and their parents for taking part in both studies.
Thanks to great old and new friends who played key roles in data collection (Johanne
Bellingham, Anna Polotskaia), psychological testing (Jenn Felsher, Rebecca Simon), translation
.
of the abstract (Johanne Bellingham) and conceptual discussions (Andrew Chiarelli, Meghann
Llyod, Joe Nolan, & Andrea Prupas). Many thanks are also extended to aIl ofmy colleagues,
friends and family members who had the pleasure of enduring my ranting and raving about the
pros and cons of the latest physical activity studies about children with ADHD. Finally, thanks
Mom for always encouraging me and never losing faith in me. Thanks Chantal for your ongoing
support, dailyencouragement and unconditionallove. 1 dedicate this thesis to both ofyou and to
the memory ofmy late father. 1 miss him more and more every day.
8
Table of Contents
page
Title page 1
Abstract 2
Résumé 4
Acknowledgements 6
Table of Contents 8
List of Figures, Appendices, and Tables 11
Introduction 13
Chapter 1 Theoretical Perspectives 16
Rationale for themy selection 16

The knowledge-based approach 17
Barkley's model of self-regulation 21
Implications for ADHD research 26
References 28
Bridging Manuscripts and Contributions of Authors 32
Chapter 2 Attention-DeficitIHyperactivity Disorder: A Review of 33

Research on Movement SkiU Performance and Physical Fitness
Abstract 33
Issues 34
Definition and Symptomatology 34
Etiology 35
Nomenclature and Classification 36
Comorbidity, Treatment, & Developmental Course 37
Purpose 38
Method 38
Search Strategies 38
Categorization 39
Results and Discussion 40
Motor Processes 40
Movement Performance 42
Retrospective Views 42
Movement peiformance embedded in large descriptive studies 43
Skill Performance 46
Physical Fitness 50
Conclusions 52
References 55
Authors' Notes 67
Acknowledgements 67
9
Table of Contents, Conf d
page
Chapter Three Attention-DeficitIHyperactivity Disorder:

APA Research Challenges 69
Abstract 69
Method 71
Discussion 73
Research Question 73
Participants 77
Sampling Design 77
Identification & Diagnosis 80
Gender Differences 82
Instruments 83
Data Collection Procedures 84
Methods of Analysis 91
Summary and Future Directions 93
References 95
Acknowledgement 103
Chapter Four Fundamental movement slrills and children with

attention-deficit hyperactivity disorder: Stimulant
effects and peer comparisons 105
Abstract 105
Introduction 106
Method 111
Participants 111
Assessment 114
Design and Procedures 116
Data Analysis 118
The effects of stimulant medication 118
Children with and without ADHD 119
Results 120
Reliability 120
Discussion 124
References 133
10
Table of Contents, Cont' d
Page
Chapter Five Physical activity experiences of boys with and without
ADHD 142
Abstract 142
Introduction 143
Method 147
Participants 147
Movement Skill Assessment 148
Interview 149
Data Analysis 151
Trustworthiness 151
Results 153
Movement Skill Assessment 154
Interview 154
Deliberate Play 156
Knowing About Doing 157
Personal Feelings 162
Discussion 164
Conclusions 169
References 171
Chapter Six Summary 178
Introduction 178
References 185
11
List of Figures, Appendices and Tables
page
Chapter 1 Theoretical Perspectives
Figure 1.0. Knowledge About Action 18

Figure 1.1. A knowledge-based model of information processing 20
Appendix A: McGill University ERB certificate 187
AppendixB: Douglas Hospital ERB certificate 188
Appendix C: Consent form for ADHD participants 189
AppendixD: Consent form for control group participants 191
Chapter 2 Attention-DeficitIHyperactivity Disorder: A Review of

Research on Movement SkiU Performance and Physical Fitness
AppendixE: Table 1 Historical Review ofDSM nomenclature 193

AppendixF: Table 2 Movement Performance 194
AppendixG: Table 3 Physical Fitness 198
Chapter Three Attention-DeficitIHyperactivity Disorder: APA

Research Challenges
Appendix H: Table 1 Assessment Instruments for Movement Behavior of 200

Persons with ADHD
Chapter Four Fundamental movement skills and children with

attention-deficit hyperactivity disorder: Stimulant
eft'ects and peer comparisons
Appendix 1: Table 1 Performance criteria for TGMD-2locomotor skills 201

Appendix J: Table 2 Performance criteria for TGMD-2 object control skills 202
Appendix K: Table 3 Reliability ofTGMD-2 203
Appendix K: Table 4 Means, standard deviations and effect sizes: GMDQ
scores for participants with ADHD 203
Appendix L: Table 5 Means, standard deviations and effect sizes for the
locomotor skills of participants with ADHD 204
AppendixM: Table 6 Means, standard deviations and effect sizes for the object
control skills of participants with ADHD 205
Appendix N: Figure 1 GMDQ scores of children with and without ADHD 206
Appendix 0: Univariate results for GMDQ 207
AppendixP: Univariate results for locomotor and object control skills 209
Appendix Q: Univariate results for individuallocomotor skills 212
AppendixR: Univariate results for individual object control skills 220
12
List of Figures, Tables and Appendices, Cont'd
page
Appendix S: Figure 2 Locomotor skill profiles 228

Appendix T: Figure 3 Object control skill profiles 229
Chapter Five Physical activity experiences of boys with and without

ADHD
Appendix U: Interview Guide 230

Appendix V: Table 1 Physical Activity Categories 233
Appendix W: Table 2 TGMD-2 scores ofboys with and without ADHD 234
Appendix W: Table 3 Deliberate Play 234
Appendix X: Table 4 Knowing about Doing 235
Appendix X: Table 5 Personal Feelings 235
13
Introduction
Attention-deficit hyperactivity disorder (ADHD) is a problem of considerable importance,
given the number of people affected, the multi-dimensional nature of the disorder, and the potential
for a lifetime of disability-related impairments. It affects a substantial number of school-aged
children, as prevalence rates of ADHD are between 2% and 14% of elementary school-aged
populations in North America (Scahill & Schwab-Stone, 2000). The disorder constitutes as much
as 50010 of child psychiatry clinical populations (Cantwell, 1996), with a range of associated
developmental problems that may continue into adulthood (JVeiss & Hechtman, 1993). Moreover,
there is converging evidence of physical activity problems linked to children with ADHD
(Harvey & Reid, 2003). For example, children with ADHD lack the ability to regulate their
behavior in physical activity environments (Alexander, 1990) and may experience significant
difficulties in performing both quantitative (Beyer, 1999; Miyahara, Mobs, & Doll-Tepper, 1995,
2001; Piek, Pitcher, & Hay, 1999; Wade, 1976) and qualitative (Harvey & Reid, 1997) aspects of
fundamental movement skill performance. Burton and Miller (1998) suggest that fundamental
skills include locomotor skills that are used to propel a human body through space (e.g., walking,
running, etc.) and object control skills which include manipulating an object in action situations
(e.g., throwing, catching, kicking, etc.).
There were three main research questions in this study. What are the effects of stimulant
medication on the fundamental movement skill performance of children with ADHD? Are there
differences in the movement skills of children with and without ADHD? What are the
similarities and differences in the physical activity experiences of children with and without
ADHD? Since converging evidence has, only lately, suggested that children with ADHD may
experience movement skill problems, adapted physical activity (AP A) researchers have not yet
14
attempted to explore and explain tbis phenomenon (Harvey & Reid, 2003). Furthermore, little
available information suggests that children with ADHD possess the factual information
necessary to successfully regulate their own movement behaviors and complete fundamental
movement skills or sport specific skills. The lack of empirical investigations which explore these
underlying factors is apparent and a meager understanding of the movement behavior of children
with ADHD has resulted. Therefore, tbis study explored the physical activity experiences of
cbildren with and without ADHD by using the knowledge-based approach to motor development
(Wall, McClements, Bouffard, Findlay, & Taylor, 1985). In summary, the three purposes ofthis
study were to assess the effects of stimulant medication on the movement skill performance of
cbildren with ADHD, compare the movement skills of chi 1dren with and without ADHD, and
describe the physical activity experiences of children with and without ADHD.
There are six chapters in the doctoral dissertation. The frrst chapter, theoretical
perspectives, inc1udes a rationale for the two main theoretical approaches that guided the
research and a description ofboth paradigms. A brief review of the knowledge-based approach
to motor development (Wall et al., 1985) supports the use ofthis theory as the major driving
framework. The hybrid model of executive functions (Barkley, 1997) is described as an
additional guiding theory, with paraUels drawn to the knowledge-based approach. Implications
for physical activity research about ADHD are then provided. Chapter two contains a review
manu script about ADHD research in the movement behavior area. The frrst manuscript is a
review of movement behavior studies about ADHD that has been published in the Adapted
Physical Activity Quarterly (Harvey & Reid, 2003). Chapter three, the second manuscript, a
review ofmethods used in physical activity studies about ADHD, has also been published in the
Adapted Physical Activity Quarterly (Harvey & Reid, 2005). The next two chapters are
15
manuscripts that addressed the three main research questions. Chapter four is an assessment of
the effects of stimulant medication on the qualitative components of fundamental movement skill
performance of22 children with ADHD and a comparison of the movement skills to gender- and
age-matched children without ADHD. This manuscript is currently in the peer review process.
Chapter five is a manuscript that describes the physical activity experiences of six boys with and
without ADHD. It is also in the review process. The dissertation concludes with chapter six
where a summary of the relevant findings and recommendations for the future are provided.
16
Chapter One
Theoretical Perspectives
Rationa/e for theory selection
Harvey and Reid (2003) suggested that movement behavior research about ADHD
lacked theoretical models and recommended that scholarly paradigms be incorporated in future
research. The knowledge-based approach to motor development (Wall et al., 1985) and the
hybrid model of executive functions (Barkley, 1997) were used to frame the CUITent doctoral
research project. There were three major reasons for selecting these theories. First, the
knowledge-based framework was the main gui ding theory to analyze and understand
fundamental movement skill performance since it is derived from contexts ofhuman action and
based on principles ofpsychology. Since the theory draws on empirical information and theories
from educational psychology, cognitive science, motor development and sport expertise, it
provided the opportunity to bOITOW paradigms and methods from these domains in order to test
more specific relationships between constructs of interest, for example, self-regulation and
physical activity. In fact, the knowledge-based approach to motor development and sport
expertise (Wall et al., 1985; Wall, Reid, & Harvey, in press) is a unique blend of developmental,
educational and sport psychology that was identified as a significant theoretical framework in
APA (Reid, 1992). Second, Barkley (1997), a renowned medical scientist-practitioner in the area
of ADHD, created a hybrid model of executive functioning to describe relationships between
response inhibition, cognitive functions, and behavioral actions, hypothesized to be responsible
for self-regulation. Specific clinical implications, including aspects of motor control, are
provided in this model for persons with ADHD. Finally, there is overlap between the knowledge-
based approach to motor development (Wall et al., 1985) and the hybrid model ofexecutive
17
functions (Barkley, 1997) as information-processing and cognitive psychology are two major
underlying assumptions for both paradigms. Both grand theories attempt to explain self-
regulation. One framework is related to general psychology and psychiatry, with a specific focus
on ADHD (Barkley, 1997), while the other framework is linked to motor development and sport
psychology (Wall et al., 1985; Wall et al., in press). The strong association ofpsychological
constructs between each framework was a major reason for the theory selection. For example,
the theories share many important commonalities such as the importance of cerebral
development, the relationship of various behaviors to different brain regions, the value of a
developmental perspective, the construction ofvarious forms ofknowledge, the role oflanguage
in child development and cognitive functioning, and a sharing of much technicallanguage. Thus,
appropriate theoreticallinks could be made between the two models in order to gain an in-depth
understanding of the relationship between ADHD and physical activity.
The knawledge-based approach
Wall and his colleagues (1985) created a holistic model to describe and explain human
movement. According to this theoretical framework, there are at least two unique components to
consider for each individual person. The first, structural capacity, refers to the physiological and
genetic factors that a person brings to bear on anY situation (Wall et al., 1985). Acquired
knowledge, also referred to as knowledge about action, is the second important component that
each individual possesses. This knowledge is related to experience and it is stored in long-term
memory. Figure 1.0 illustrates the five interacting components of the knowledge-based model.
Procedural knowledge, dec1arative knowledge, and affective knowledge are the three knowledge
bases that operate at a basic cognitive level while metacognitive knowledge and metacognitive
skills function at the higher, or meta, level of cognition where there may be conscious regulation
18
Metacognitive Knowledge Metacognitive Skills
1
Declarative Knowledge Procedural Knowledge
Affective Knowledge
Structural Capacity
Figure 1.0 Knowledge About Action

Note. From Wall et al. (in press)
of motor control.
Procedural knowledge was described as knowing how to act and includes the entire
process and production ofa motor action (Wall et al., 1985). In other words, an individual's
movement includes both information-processing and a resultant behavioral response. Thus,
procedural knowledge involves both a cognitive component about
knowing about the movement skill and a physical component about the movement skill.
Declarative knowledge was described as knowing about action. It represents factual information
that is highly contextual and specific to various movement skills and sport-specific skills.
Declarative knowledge is stored in schemas where nodes ofknowledge are highly interconnected
by intricate conceptual networks, that is, deep maps of rich semantic information. This type of
knowledge is influenced by morphological, biomechanical, and environmental constraints while
verbal labels for action, or key feedback words, and basic skilllearning strategies are invaluable
19
declarative components of movement skill acquisition and performance. Thus, declarative
knowledge enables the development and execution ofskilled action (Wall et al., 1985). Affective
knowledge was described as feelings about action and it represents subjective feelings attached
to movement (Wall et al., 1985). Emotion plays an enormous role in the acquisition,
development, and performance ofspecific movements and sport skills (Wall et al., 1985; Wall et
al., in press). Affective knowledge is placed directly abovestructural capacity in the knowledge-
based model because it illustrates the close relationship between the person' s cognitive system,
the human physiological system, and the performance environment.
Metacognitive knowledge about action is knowledge about what one knows or does not
know or "knowing about knowing how to move" (Wall et al., 1985, p. 31). It was described as a
higher form of declarative knowledge where there is conscious awareness of all other knowledge
bases, namely; the procedural, declarative, affective, and metacognitive skill knowledge bases.
Metacognitive skills, the higher level of procedural knowledge, incorporates the use of
metacognitive knowledge in proficient movements based on previous successful and
unsuccessful experiences (Wall et al., 1985). Planning, monitoring, and evaluating are the
executive functions that integrate the higher level knowledge, leading to adaptable problem
solving and improved learning and performance (Wall et al., in press). Therefore, knowledge of
results and planning for future actions are part of an iterative process, where both constructs
integrate via reflection before and after skill performance and with respect to any available
knowledge base to enable highly automatized actions. Take for example, a competitive biathlete
who must cross-country ski many kilometers at a very fast pace and then suddenly stop and use a
rifle to shoot at a target as accurately as possible or be penalized with extra laps to ski.
Undoubtedly, the person's respiratory rate, heart rate, blood pressure, and galvanic skin
20
responses are aU elevated during the event. Yet the athlete learns how to control heart rate and
blood pressure by decreasing the skiing pace going into the shooting area. Breathing is also
controUed during target shooting in order to increase upper body stability and assist in visual
acuity. It is hypothesized that these planned measures would have a positive effect on shooting
accuracy, with a positive decrease in anxiety levels, galvanic skin responses, and voluntary
muscular activity. Renee, there can be much conscious control in a performance environment,
reflecting metacognitive knowledge and metacognitive skills.
The knowledge-based approach is the major driving theory of the CUITent research project
because there is empirical support for the model as a vehicle to explore the movement behavior
of children with disabilities. According to the knowledge-based model of information
processing, Wall (2001) hypothesized that relevant environmental information is identified,
coded, and processed with a perceptual mechanism. The perceived information is then forwarded
to a decision making mechanism where a decision is made about which response to select, given
the saliency of the encoded information, finally the response, or action, is executed. This model
interconnects the mechanisms themselves with both feed forward and feed backward loops and
the higher level knowledge process~s of metacognition (self-awareness) and metacognitive skills
(self-regulation)(See Figure 1.1).
Self-Awareness Self Regulation
Figure 1.1 A knowledge-based model of information processing

Note. From Wall, 2001, p. 51
21
Knowledge-based studies that explored fundamental movement skills in relation to persons with
disabilities specifically indicate that children with disabilities demonstrate problems related to
perception (Lefebvre & Reid, 1998), decision making (Bouffard & Wall, 1991), and response
execution (Kourtessis & Reid, 1997; Marchiori, Wall, & Bedingfield, 1987; Todd, 1988). Since
the knowledge-based approach has been used successfully in AP A research, it is a credible
framework to use as the major driving theory of the CUITent research project.
Barkley's model ofself-regulation
Barkley (1997) created a hybrid model of executive functioning that explained the
underlying mechanisms of self-regulation, with specifie implications for persons with ADHD.
The theory was described as a developmental neuropsychological model of human self-
regulation (Barkley, 1997, 1998). The theory is developmental because Barkley refers to
cognition as being developed in the external physical world in an overt form oflanguage (e.g.,
self-talk) and proceeds to be more fully developed with private, covert, and inner thoughts of the
mind (Vygotsky, 1978, 1986). The theory also possesses a neuropsychological component
because Medical research findings indicated deficiencies in the prefrontal, striatal-limbic brain
areas ofpersons with ADHD (Barkley 1997, 1998). Tannock (1998) also suggested that
biological and genetic factors are the two major causes for ADHD.
Response inhibition, executive functions, and motor control are the three main levels of
Barkley' s model of se1f-regulation. While the knowledge-based model and the hybrid model of
executive functioning do not have direct matches between major constructs, links to the
knowledge-based approach will be made in the description of each level of the Barkley model.
Response inhibition includes the inability to: (a) inhibit behavioral responses where
immediate positive or negative reinforcement is available, (b) stop ongoing behavioral responses,
22
and (c) use interference control where the individual can disregard multiple stimuli in order to
inhibit behavioral responses (Barkley, 1997). Response inhibition is considered to have an
indirect, but vital, influence on each individual' s executive functioning and a direct influence on
individual motor behavior.
A conceptual key to thÏs model is the assumption that a person must take necessary and
adequate reflection time when planning and making decisions. Therefore, Barkley (1997, 1998)
suggested that human beings may need to act in at least three different ways in order to meet the
variable demands of the environment. First, in order for a person to be successful in attaining
long-term goals, it is vital to establish short-term goals without being completely gratified by the
successful completion of the short-term goals. In other words, it is important to take extra time to
delay personal gratification untillong-term goals have been successfully completed. Second, the
individual must be able to deduce performance errors, stop the actual behavior under self-
evaluation, and take appropriate reflection time to plan solutions for the perceived error in order
to produce more effective self-regulation. Finally, the person must also be able to shut out
external and internaI sources of stimuli that may negatively affect behavior. A person must use
reflection and planning time efficiently in order to be proficient in the successful self-regulation
of their behavior. Thus, response inhibition has an indirect effect on executive functioning
because the person may or may not choose to use additional time to be reflective or to plan future
actions. The additional time enables the executive functions to be called upon for reflection in an
organized and efficient manner. Thus, the direct influence of response inhibition on individual
motor behavior may or may not be tempered by planning and reflection, with the resultant action
being carried out with either more thought and planning or with minimal cognitive input and a
decreased temporal period. Many of the same constructs are also valued in the knowledge-based
23
approach to motor development. For example, studies about the development of expertise would
suggest the importance of the individual' s ability to identify salient cues from their own
movements and the environmental display in order to perform in a more proficient manner (Wall
et aI., in press). In fact, it is this attention to detail that distinguishes novice and expert
performers (Ericsson, 2003). Error deduction, planning, monitoring, and taking the necessary
time to reflect are aIso important metacognitive components of the knowledge-based approach
(Bouffard & Wall, 1990; Wall et al., in press).
Nonverbal working memory, verbal working memory, self-regulation of
affect/motivation/arousal, and reconstitution are the four executive functions responsible for
much ofhuman self-regulation (Barkley, 1997). Nonverbal working memory was defined as "the
capacity to maintain intemally represented information in mind or on line that will be used to
control a subsequent response" (Barkley, 1998). It was described as a "covert sensing to the self'
where individuals produce mental representations ofbehavioral sequences. Barkley suggested
that imitation is a very important component of this executive function as visual and verbal
information about the sensory-motor world are initially formed in an overt manner, which, in
tum, become directed inward in the form of private thought and speech. This executive function
is closely related to procedural knowledge as proponents of the knowledge-based approach
would also indicate, for example, that imitation, or an image of the act, is vital ta reproduce
skilled movements (Wall, 2001).
Verbal working memory was conceptuaIized as the intemalization of speech. Barkley
(1997, 1998) emphasized the key role oflanguage in the development of self-regulatory
behavior. Self-talk, in particular, is mentioned as a vital part ofverbal working memory. The
individual performs self-directed speech in order to reflect and describe events before responding
24
by using self-talk to label, describe, and verbally question key elements of events and situations.
Self-questioning leads to greater levels of reflection and thoughts that become internalized.
Again, the direction of self-regulatory speech commences in the physical world and, with time
and experience, is directed inward. This external-internal relationship of language and thought
was hypothesized as an iterative process (Vygotsky, 1978, 1986). The verbal working memory
function is closely related to declarative knowledge in the knowledge-based approach because
individuals create verbal labels for action and intricate schematic networks of domain-specifie
knowledge, leading to higher levels of self-awareness or metacognition.
The self-regulation of affectJmotivation/arousal was defined as the ability to self-motivate
in order to achieve goal-directed actions. Barkley emphasized the importance of linking affective
responses to individual covert visual images and covert self-speech. He indicated the importance
of controlling emotional responses to various events that, in tum, may lead to increased time for
reflection and greater individual ability to inhibit responses in the face of environments, highly
charged with negative or positive reinforcers. Thus, a person who can visualize different
solutions, with appropriate and relevant self-directed speech, may be in a better position to
control their emotional responses to varied events. Again, the development of emotional
reactions is expected to be more extroverted when flfst experiencing an event with a progressive
internalization of emotional thoughts. This executive function is almost identical to the affective
component of the knowledge-based approach. For example, subjective feelings are attached to
movements, experiences, and different environmental displays. Emotional control is vital to skill
automatization and the development of expert performers (Wall, 2001).
Reconstitution was defined as the internalization ofplay. Barkley (1997, 1998)
emphasized the importance ofbreaking down behavior into its sequential and component parts
25
(e.g., analysis) and then, in tum, the individual may create new behavioral sequences by using a
novel combination ofpreviously learned behavioral components (e.g., synthesis). This executive
function also has the unique property ofcreating new verbal (e.g., linguistic) and non-verbal
(e.g., gross motor and fine motor skills) behavioral responses for the purposes ofself-regulation.
Furthermore, self-awareness, problem-solving, and creativity are important elements of the
reconstitution function of the hybrid model. Personal awareness, creativity, and self-evaluation
are also key metacognitive skills from a knowledge-based perspective.
Motor behavior is described in the hybrid model of executive functions as motor
control/fluency/syntax to illustrate the complexity ofhuman behavior. Barkley (1997, 1998)
described the importance of internalizing thought when producing goal-directed actions. The
external to internaI process of action leads to purposive, intentional, and future-oriented motor
behaviors. He also suggested that non-essential sensory information and behavior unrelated to an
action, may be suppressed or minimized during physical performance. Motor behavior was also
hypothesized as directly influenced by response inhibition and all four executive functions. This
component of the hybrid model could also be described as procedural knowledge (Wall et al.,
1985) since there is a physical component to this type ofknowledge, also known as motor
memory. Interestingly, proficient movers use this tacit knowledge to their advantage to perform
skills in a highly proficient manner. There is no need for deliberate and conscious control of the
component parts of a skill, rather the proficient moyer is able to perform the physical action
automatically and pay attention to other salient environmental cues in order to successfully
complete the goal-directed action. Again, it is this difference in attention to detail that separates
the novice from the expert performer.

26
Implications for ADHD research
Children with ADHD have been described as having a developmental disability in
response inhibition and self-regulation (Barkley, 1997, 1998). There are two key aspects of
Barkley' s model of self-regulation with regards to movement-related clinical applications. First,
Barkley (1997) mentions that time should be considered as the ultimate disability because people
with ADHD have an impaired sense of temporal reality that may negatively affect their behavior.
For example, a person with ADHD may be appeased by successful completion of short-term
goals and continually seek to obtain immediate gratification from the environment. Yet by not
taking the time to reflect and failing to complete long-term goals, the executive functions do not
fully develop and the intemalization ofbehavior to thought is affected, further delaying the
development of self-regulatory behavior (Barkley, 1997, 1998). Second, he suggests that
children with ADHD may experience an inability to proceduralize their declarative knowledge
which he refers to as point ofperformance problems. In other words, "ADHD is more a problem
of doing what one knows rather than ofknowing what to do" (Barkley, 1997, p. 335).
The CUITent doctoral research project examined the fundamental movement skill
performance of children with ADHD. Converging evidence suggests that children with this
disorder may demonstrate problems related to movement skills (Harvey & Reid, 2003). Thus,
there seems to be a problem of procedural knowledge about action for children with ADHD.
Chapter four is a study that addressed questions related to the movement skills of children with
ADHD, thus expanding the authors' prior research and our CUITent knowledge base about the
movement skill problems ofthis population. Ethics certificates and consent were obtained (See
appendices A, B, C & D).

27
No physical activity researcher has asked why children with ADHD experience
difficulties in perfonning fundamental movement skills nor has anyone studied the decision-
making of children with ADHD in daily physical activities (Harvey & Reid, 2003). Since
Barkley (1997, 1998) alluded to a discrepancy between procedural knowledge and declarative
knowledge, the focus of chapter five was a qualitative approach where the physical activity
experiences ofboys with and without ADHD were explored to gain in-depth knowledge about
individual movement skill proficiency and involvement in various physical activity contexts. Semi-
structured interviews provided rich personal insights into constructs like activity preference, play,
skilllearning, observationallearning, and individual feelings about movement perfonnance. Thus,
chapter five was an initial attempt to describe general aspects of self-regulatory behavior in
physical activity for children with ADHD. The notion that persons with a disability can regulate
their own movement behavior has led physical activity researchers to explore self-regulation in
physical activity, especially for children with DeD (Reid, Harvey, Lloyd, & Bouffard, 2002).
Since children with ADHD seem to have a developmental delay in self-regulation (Barkley 1997,
1998), they seemed to be the perfect candidates to study in order to better understand the
different cognitive processes about action involved in self-regulation.
In summary, this chapter has provided a rationale for the two main theoretical approaches
that guided the CUITent research project. Descriptions of the knowledge-based approach (Wall et
al., 1985) and the hybrid model of executive functions (Barkley, 1997) were provided to support
the use of the theories as the key underlying frameworks. Implications for ADHD research were
provided. Finally, the remaining thesis chapters were described briefly.

28
References
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Barkley, RA (1997). ADHD and the nature of self~ontrol. New York: Guilford Press.
Barkley, RA (1998). Attention-deficit hyperactivity disorder: A handhookfor diagnosis

nd
and treatment (2 ed.). New York: Guilford Press.
Beyer, R (1999). Motor proficiency ofboys with attention deficit hyperactivity disorder.
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Cantwell, D.P. (1996). Attention deficit disorder: Areview of the past 10 years. Journal of
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improve AP A research. Adapted Physica/ Activity Quarter/y, 22, 1-20.
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Lefebvre, C., & Reid, G. (1998). Prediction in baIl catching by children with and without
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Miyahara, M., Mobs, 1., & Doll-Tepper, G. (1995). Subtypes ofclinically identified
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Miyahara, M., Mobs, 1., & Doll-Tepper, G. (2001). Severity ofhyperactivity and the
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Piek, IP., Pitcher, T.M., & Hay, D.A (1999). Motor coordination and kinaesthesis in boys
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Reid, G. (1992). Editorial on theory, exchange, and terminology. Adapted Physical
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Reid, G., Harvey, W.I, Lloyd, M., & Bouffard, M. (2002). A pilot study ofself-directed
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motor learning in children with DCD. Paper presentation about the microgenetic analysis
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Scahill, L., & Schwab-Stone, M. (2000). Epidemiology of ADHD in school-age children.
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65-69.
Todd, T. (1988). A comparison of metacognitive and procedural knowledge of bail
catching by physically awkward and non-awkward children. Unpublished master' s thesis,
McGill University, Montreal, Quebec, Canada.
Vygotsky, L.S. (1978). Mind In Society. Cambridge, MA: Harvard University Press.
Vygotsky, L.S. (1986). Thought and language. (A Kozulin, Trans.). Cambridge, MA:
Harvard University Press. (Original work published as Myslenie 1 rec in 1934).
Wade, M.G-. (1976). Effects ofmethylphenidate on motor skill acquisition of hyperactive
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rev). Course text for the Psychology ofMotor Performance, McGill University. Montreal,
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31
Wall, A.E., Reid, G., & Harvey, W.J. (in press). Interface of the Knowledge-based and
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The Guilford Press.

32
Bridging Manuscripts and Contributions of Authors
Chapter one was named theoretical perspectives as it described the two major theories that
guided this doctoral dissertation. Implications for physical activity research in ADHD were
provided. In tum, these ideas led to four original papers that explore the relationship between
ADHD and physical activity. The next study is a review of research on the movement performance
and physical fitness of children with ADHD. It is the frrst article in the cohesive series offour
original dissertation manuscripts. Discussions about key issues in ADHD were also highlighted
(definition, symptomatology, nomenclature, etc.) in order to provide an update of information on
the disorder and reference citations for seminal review articles to physical activity researchers and
practitioners. The relative contributions of the two authors were as follows. As frrst author, 1 was
responsible for 85% of the manuscript and involved in all aspects of the research, writing and
editing of the manuscript. Dr. Greg Reid was responsible for the other 15% of the work involved
by ensuring the reliability of the research process, with multiple reads of the text, editing and
suggestions for text improvement.

33
ChapterTwo
Attention-DeficitIHyperactivity Disorder:
A Review ofResearch on Movement Skill Performance and Physical Fitness
From W.J. Harvey and G. Reid, 2003, Adapted Physical Activity Quarterly 20(1): 1-25. © 2003 by
Human Kinetics Publishers. Reprinted with permission from Human Kinetics (Champaign, IL).
Abstract
The purpose of this study was to present a comprehensive review of research on the movement
performance and physical fitness of children with attention-deficitlhyperactivity disorder (ADHD)
and ofIer research recommendations. Movement behaviors of children with ADHD were described
on the basis of 49 empirical studies published between 1949 and 2002. Major results indicated that
(a) children with ADHD are at risk for movement skill difficulties, (b) children with ADHD are at
risk for poor levels ofphysical fitness, (c) comorbidity may exist between ADHD and
developmental coordination disorder (DCD), and (d) few interventions have focused on movement
performance and physical fitness of children with ADHD. Numerous reference citations for
seminal review articles on ADHD are provided so that potential researchers or program planners
might enter the vast ADHD literature with sorne ease.

34
Attention-Deficit/Hyperactivity Disorder:
A Review ofResearch on Movement Skill Performance and Physical Fitness
Attention-deficit/hyperactivity disorder (ADHD) is a complex combination of
developmental problems with important medical, educational, and social implications (Cantwell,
1996). Little information is available about conducting physical activity programs for persons with
ADHD. Only one literature review, in 1989, focused on children with ADHD in physical activity
(Churton, 1989), and only a few sources address physical education (e.g., Bishop & Beyer, 1995;
Craft, 2000; Sherrill, 1998). Therefore, a comprehensive review of the movement performance and
physical fitness of children with ADHD is justified as substantial changes have been made in
ADHD (e.g., Stubbe, 2000a), and new physical activity studies have been conducted since 1989
(e.g., Harvey & Reid, 1997; Piek, Pitcher, & Hay, 1999; Yan & Thomas, 2002).
At least 50 textbooks and over 6,000 scientific articles are devoted to ADHD (Barkley,
1995), with different nomenclature used over tÏme (Barkley, 1998). Tannock (1998) suggested that
a comprehensive review of ADHD and related knowledge domains was not feasible because of the
sheer volume of published literaturel . Following is an overview of four issues of concem to aIl
educators and researchers. Under each issue, we describe the particular relevance to adapted and
general physical education.
Issues
Definition and Symptomatology
ADHD is defined in the Diagnostic and Statistical Manual olMental Disorders (DSM-IV-
TR) of the American Psychiatric Association (AP A, 2000) with five specified diagnostic criteria:
(a) 6 to 12 behavioral symptoms must be identified; (b) symptoms must be evident before the age
of7 years; (c) behaviors must be exhibited in at least two different settings; (d) significant
35
impainnent in social, academic, or occupational functioning should be observed~ and (e) symptoms
should not be better explained by another disorder (APA, 2000). Children who demonstrate these
symptoms are usually identified first by parents or teachers (AP A, 2000) and subsequently referred
to and assessed by clinical professionals (Reeve, 1990). Physical activity specialists should
understand that there is a difference between children with ADHD and children who are simply
overactive, because overactivity is only one indication of the disorder. In fact, the overactivity must
be excessive and inappropriate to enter the definition of ADHD.
The DSM-IV-TR (APA, 2000) groups behavioral symptoms into two lists, representing
clusters of inattention (e.g., often has difficulty sustaining attention in tasks or play activities) and
hyperactivity-impulsivity (e.g., is often "on the go" or often acts as if "driven by a motor"). A child
with ADHD must demonstrate six ofnine symptoms for a diagnosis of the inattentive subtype, six
of nine symptoms for a diagnosis of the hyperactive-impulsive subtype, or six symptoms from both
inattention and hyperactivity-impulsivity for the combined subtype (APA, 2000). See Craft (2000)
or Sherrill (1998) for explanations of the diagnostic criteria.
Eti%gy
The etiology of ADHD is unclear (Cantwell, 1996) and controversial (Stubbe, 2000b).
Conceptual models about ADHD and associated causal factors depend upon the individual
professional discipline and underlying assumptions of the clinician, researcher, or author. See
Barkley (1997, 1998) for discussions of etiology. However, there is considerable agreement that
ADHD should be considered a multidimensional disorder consisting of interacting neurological,
genetic, and psychosocial causal factors (Tannock, 1998). Physical activity specialists should be
aware of the probable biological basis for the lack of self-control that people with ADHD exhibit,
36
which in tum, may become more erratic in environments with decreasing amounts of social
support (Barkley, 1997).
Nomenclature and Classification
Professionals and researchers should be cognizant of contemporary nomenclature and
know that terminology changes over time. Nomenclature has been the subject of considerable
debate (McBurnett, Lahey, & Pfiffner, 1993), and there is little doubt that the many classification
terms and subtyping terminology can lead to confusion. For example, there have been numerous
classification terms which are further complicated by subtyping terminology (See Table 1,
Appendix E). Comparing findings from studies based on different nomenclature must be done
cautiously. McBumett et al. (1993) offers a discussion ofterminological comparisons using DSM
over time. See Barkley (1998) for an excellent review on nomenclature and history of ADHD.
Two main terms are currently used, depending upon which of two classification systems
are followed. North America is largely influenced by the DSM-lV-IR and the term ADHD. In
Europe, the International Classification ofDiseases (lCD-JO) of the World Health Organization
(WHO, 1992) has a large following, and the term hyperkinetic disorders (HKS) is used. A child
identified with ADHD using DSM-IV-IR criteria may not be diagnosed with HKS using ICD-JO
criteria. Tripp, Luk, Schaughency, and Singh (1999) suggested that identification with thelCD is
more stringent and, therefore, fewer children are diagnosed with HKS than with ADHD. Both
classification systems provide symptom lists for their diagnostic criteria. However, the ICD system
specifies that a person must meet criteria for all three major diagnostic categories (attention,
hyperactivity, and impulsivity), whereas the DSM system identifies persons who present symptom
criteria of either inattention or hyperactivity-impulsivity categories or both. See Rasmussen and
Gillberg (1999) for comparison of symptom lists.

37
Cultural differences also exist between Europe and North America, as sorne Europeans view
ADHD as a rare disorder, with a prevalency rate of approximately 1%, affected by delinquency
problems (Taylor et al., 1998). The disorder is considered to be more prevalent in North America
with estimates ranging between 2% and 14% of elementary school-aged populations (Scahill &
Schwab- Stone, 2000). See Taylor et al. (1998) for a discussion of cross-Atlantic classification
differences.
Comorbidity, Treatment, and Developmental Course
There is no single method of diagnosis or intervention because there is no definitive cause
of ADHD (Cantwell, 1996). Diagnosis of ADHD may be based upon combinations of age-
appropriate symptoms, clinical tests, and observations (Hechtman, 2000). The diagnostic process
should also include comorbidity (Cantwell, 1996) as there is a high probability of ADHD
coexisting with one or more of the following disorders: developmental coordination disorder
(DCD), oppositional defiant disorder, conduct disorder, anxiety, depression, and learning
disabilities. See Pliszka (2000) and Rasmussen and Gillberg (1999) about comorbidity.
Multimodal treatment approaches are recommended for persons with ADHD
(Mercugliano, 1999) because there is not one definitive cause ofthe disorder and comorbidity is so
frequent. For example, Damico, Damico, and Armstrong (1999) suggested combined intervention
approaches that include pharmacological therapy, behavior management, cognitive-behavioral
therapy, direct communicative interventions, and educational programs.
ADHD is considered a lifelong disorder because longitudinal research indicates that adults
are also a:ffected (Weiss & Hechtman, 1993). Previously it was hypothesized to be only a
childhood problem. The next decade promises identification studies that explore the age of onset
criterion and symptomological changes with age (Barkley & Biederman, 1997). See Weiss and
38
Hechtman (1993) and Silver (2000) for information about adult ADHD. Physical activity
interventions and research programs should be developed with the understanding that children with
ADHD may have at least one comorbid disorder (Szatmari, Offord, & Boyle, 1989) and the effects
of ADHD may vary with the age of the participants (Barkley & Biederman, 1997).
Purpose
The purpose of this study was to present a comprehensive review of research on the
movement performance and physical fitness of children with ADHD and offer research
recommendations. The review and discussion attempt to answer two main questions: Is the
movement performance of children with ADHD similar to their age- and gender-matched peers
without disabilities? Do children with ADHD demonstrate similar levels of physical fitness when
compared to their age- and gender-matched peers without disabilities ?
Method
Search Strategies
Computer searches were conducted in the SPORTDiscus (1949- March, 2002), Current
Contents/Ali Editions (Week 26, 1993-Week 07,2002), ERIC (1966-February, 2002), MEDLINE
(1966-March, 2002), and PsychINFO (1967-January, 2002) databases. Key words reflected a link
to human movement science (e.g., motor, fitness, health, exercise, physiology, sport, recreation)
and psychology, with special attention paid to chronology (e.g., attention deficit, attention deficit
hyperactivity disorder [1987-2002], attention deficit disorder [1980-2002], hyperkinesis,
hyperactivity, minimal brain dysfunction [1949-2002]). The footnote chasing approach was also
used to identify studies that may have been missed (White, 1994).
39
Categorization
The categorization of studies was developed according to the taxonomy of movement skills
by Burton and Miller (1998). Studies were placed into motor process and movement performance
categories. Motor process studies were identified by dependent variables reflecting underlying
internal factors believed to affect observable movement. These studies involved measures of
perceptual-motor, psychomotor, or sensorimotor processes which can be referred to as "descriptors
of motor processes rather than movement skills" (Burton & Miller, p. 44). For example,
perceptual-motor processes were inferred from a finger tapping task in one study (Gordon &
Kantor, 1979). AIthough the major purpose of this paper was to review the movement performance
of children with ADHD, motor processes were discussed briefly to provide a global picture of
movement behavior.
Movement performance is observable behavior. Thus, movement performance studies
reflected an "observable act of moving" or a "goal-directed movement that can be described in
terms of quantity or quality" (Burton & Miller, 1998, p. 43; Burton & Rodgerson, 2001). These
studies were subdivided into four categories, reflecting different movement performance and
research methods contexts: (a) retrospective views, (b) movement performance embedded in large
descriptive studies, (c) skill performance, and (d) physical fitness. Retrospective studies have
parents or teachers recall significant developmental events in the lives of children (e.g.,
Ottenbacher, 1979; Rasmussen & Gillberg, 1983). Movement performance embedded in large
descriptive studies emphasize multiple dependent variables associated with general development.
Movement behavior inferences from these studies are limited because very few movement skills or
health-related variables are tested. Movement data embedded in larger studies have been noted also
in DCD research (Sugden & Wright, 1998).

40
Researchers of skill performance usually assessed locomotor and object control skills as the
main dependent variables. Physical fitness studies were defmed by testing variables that measured
health-related components of physical fitness including cardiorespiratory endurance, body
composition, muscular strength and endurance, and flexibility (American College of Sports
Medicine [ACSM], 2000). Physical fitness studies were placed in the movement performance
category because fitness is a foundational component in the movement skills model of Burton and
Miller (1998). For example, five of the eleven commonly assessed foundation areas (e.g., body
composition, -body size and morphology, cardiovascular endurance, flexibility/range of motion,
and muscular strength and endurance) reflect aspects of physical fitness.
Results and Discussion
Forty-nine studies, published between 1949 and 2002, were identified that examined the
movement behavior of children with ADHD. The investigations were categorized as either motor
processes (22) or movement performance (27). Movement performance studies included
retrospective views (5), large descriptive studies (10), skill performance (10), and physical fitness
(4). One study (Harvey & Reid, 1997) was included in the categories of skill performance and
physical fitness, while another study (Doyle, Wallen, & Whitmont, 1995) was included in the
retrospective views and skill performance categories. AlI studies in each category are identified in
the reference list. 2
Motor Processes
The motoT processes of children with ADHD have been examined in studies that
emphasize sensorimotor, motor control, and fine motor variables. Sensorimotor investigations tend
to minimize gross motor output but highlight sensory or perceptual output. For example, tasks of
visual motor performance (Cakirpaloglu & Radil, 1992; Conners & Delamater, 1980; Conrad,
41
Dworkin, Shai, & Tobiessen, 1971; Korkman & Pesonen, 1994; Millichap, Aymat, Sturgis,
Larsen, & Egan, 1968) and fmger tapping (Gordon & Kantor, 1979) have been used to measure
motor processes of males with ADHD. While contributing to our overall understanding of ADHD,
the implications for physical activity curricula and instruction are not always obvious, given that
the assessment tasks are quite distinct from usual ones in physical education.
A number of motor process studies have also explored aspects of motor control. Boys with
ADHD have been linked to motor overflow (Denclda, Rudel, Chapman, & Krieger, 1985; Denclda
& Rudel, 1978), impaired timing of motor responses (Hefley & Gorman, 1986; Rubia, Taylor,
Taylor, & Sergeant, 1999; Werry, Elkind, & Reeves, 1987; Yan & Thomas, 2002), and motor soft
signs (Denclda & Rudel, 1978; McMahon & Greenberg, 1977; Reeves, Werry, Elkind, &
Zametkin, 1987; Sandberg, Rutter, & Taylor, 1978). In a recent motor control study (Yan &
Thomas, 2002), children with ADHD took more time than children without ADHD to complete
rapid arm aiming movements, with more variable speed and accuracy of the arm movements. Yan
and Thomas (2002) suggested that children with ADHD use more on-line corrections when
performing accuracy tasks in comparison to their peers without ADHD. It would appear that
additional research is necessary to investigate aspects of motor control. While such studies often do
not employ ecologically-valid tasks from the viewpoint of adapted physical activity specialists,
collectively these investigations may shed light on unique motor control strategies and the overall
motor behaviour associated with ADHD.
Poor motor coordination has been suggested as a condition experienced by many children
with ADHD (Conners, Rothschild, Eisenberg, Stone-Schwartz, & Robinson, 1968; Gillberg,
Carlstrom, Rasmussen, & Waldenstrom, 1983; Hefley & Gorman, 1986; Knights & Hinton, 1969;
Palkes, Stewart, & Kahana, 1968; Pereira, Eliasson, & Forssberg, 2000; Taylor, Schachar,
42
Thorley, & Weiselberg, 1986a; Taylor et al., 1986b). The term motor coordination may be
misleading, as the identified studies were usually based on neuropsychological tests that required
fine motor skill performance. Motor skills may be classified into fme and gross motor skills by the
precision ofmovement (Burton & Miller, 1998). The occasional confusion between fme and gross
motor skills was underscored when the first author asked a renowned psychiatrist, a specialist for
children with ADHD, what physical educators could do to help children with ADHD improve their
gross motor skills. "Teach them how to hold a pencil" was the response. While Szatmari and
Taylor (1984) also stated that coordinated finger movements reflect skill acquisition, they
questioned the clinical utility of this type of neurodevelopmental sign. Thus, the researchers might
have been more correct to describe their findings as suggesting that children with ADHD have
poor fine motor coordination rather than a general motor coordination deficit.
Movement Peiformance
Retrospective views. Retrospective studies usually report teacher (Ottenbacher, 1979) and
parent observations of poor movement skills in children with ADHD. For example, mothers
reported their children performed poorly in sports, gymnastics, and fine movement skills (Stewart,
Pitts, Craig, & Dieruf, 1966) while other parents have perceived their children as c1umsy
(Rasmussen & Gillberg, 1983; Szatmari et al., 1989).
Although the observations ofboth parents and teachers are invaluable, conclusions are
usually based in a context of memory that is susceptible to decay and alteration (Offer, Kaiz,
Howard, & Bennett, 2000). These perceptions can also be imprecise as excessive activity may
overshadow real problems of coordination (Keogh, 1978). Furthermore, an underlying assumption
of these studies is that most parents possess adequate amounts of motor development knowledge
for comparison purposes. Moreover, Rasmussen and Gillberg (1983) asked parents to answer only
43
one question: "How would you describe your child' s gross motor control (e.g., movement control
in activities like walking, running, climbing, hopping on one leg)? Is if average (0), Better than
average (1), Somewhat clumsy (2), or Awkward (3) (p. 128)." Doyle, Wallen, and Whitmont
(1995) reported that parents underrated their children's performance on a single question in
comparison to the actual results obtained on the Bruininks-Oseretsky Test of Motor Proficiency or
BOTMP (Bruininks, 1978). While potentially informative, retrospective views hardly represent a
comprehensive analysis of movement behavior.
Empirical investigations should be conducted in concert with retrospective research to
understand the factors underlying the perceptions of parents in relation to their children' s
movement skills. For example, what is the role of social factors (e.g., socioeconomic level, cultural
background, gender, age, etc.) in parental observations? Are the parents proficient movers or do
they also experience problems of movement behavior? How important is physical activity in the
family context? Such research may explore the ability of parents to comment on the skill
proficiency of their children and their ability and experience in fostering skill acquisition.
Furthermore, children with ADHD should be asked about their own perceptions oftheir movement
skill proficiency and involvement in play, physical activity, and sports. Qualitative research studies
have been recommended to document the health-related behaviors of children with ADHD
(Kendall, 1997), and these types of investigations could provide rich and thick personal
descriptions about the movement skills and experience of children with ADHD.
Movement performance embedded in large descriptive studies. Movement performance
has been assessed in large descriptive studies where the research focus is broad, covering multiple
developmental factors, but the examination of specific movement skills is rather narrow. For
example, Ho et al. (1996) collected a wealth of information about children (e.g., developmental
44
history, sociodemographic data, family relationship, intelligence, reading ability, academic
performance, motor activity level, attention performance, neurological statu s, and motor
clumsiness), but movement performance was represented by catching, only one of39 testing items.
In addition, only two items (e.g., catching and rolling a tennis baIl by foot) were used to assess
movement performance ofchildren with ADHD in several studies (e.g., Ho et al., 1996; Luk,
Leung, & Yuen, 1991; Tripp & Luk, 1997).
A number of large descriptive studies have compared the movement performance of
children with and without ADHD. Tripp and Luk (1997) reported that children with ADHD, ages
5.5 to 12.9 years, demonstrated no significant differences on ball catching and rolling a tennis baIl
by the foot, while Ho et al. (1996) found that 7-year-old children with ADHD performed
significantly poorer when catching a tennis ball. Furthermore, in a longitudinal study (Moffitt,
1990) of children from the ages 3 to 15 years, the scores of males with ADHD were significantly
lower on the Bayley Scale (Bayley, 1969) at 3 years of age, and on the McCarthy Motor Scale
(McCarthy, 1972) at 5 years of age than the control groups.
Longitudinal research indicates that children with comorbid ADHD and DCD, known in
Scandinavian countries as deficits in attention, motor control, and perception or DAMP (Blondis,
1999), are at risk for movement difficulties in both fine and gross movement skills (Gillberg, 1985,
Gillberg, Gillberg, & Groth, 1989; Hellgren, Gillberg, Gillberg, & Enkerskog, 1993; Rasmussen,
Gillberg, Waldenstrom, & Svenson, 1983). However, these large epidemiological studies have
focused mainly on the prevalency of ADHD with DCD (Kadesjo & Gillberg, 1998) or the motor
profiles of children with DAMP as measured by a single neurodevelopmental screening test
(Gillberg, 1985; Gillberg et al., 1989; Hellgren et al., 1993; Rasmussen et al., 1983), rather than on
a comprehensive observation of their movement performance.

45
For example, Rasmussen et al. (1983) tested 112 children, ranging from 6.8 to 8.3 years, on
a neurodevelopmental screening test (Gillberg, 1983). Fine and gross movement skills were
hopping on one leg, standing on one leg, walking on lateral sides of the feet, supination and
pronation ofboth forearms (diadochokinesis), cutting out a paper circle, a labyrinth test,
observance of choreatiform movements, a pencil grip, walking on tiptoe for 20 paces, and hopping
with both feet together. Children with DAMP demonstrated significantly lower scores than
children without disabilities over the course of a 10 year period. The actual percentage of persons
with DAMP who demonstrated poor movement performance dropped from 62% (Rasmussen et al.,
1983) to 300!o after 3 years (Gillberg, 1985),25% after 6 years (Gillberg et al., 1989), and 200!o
after 10 years (Hellgren et al., 1993). These results indicate that sorne children with DAMP may
experience movement difficulties into early adulthood. However, it should be noted that
misclassification rates were approximately 14% (Rasmussen et al., 1983), and interrater reliability
for overall clumsiness was only .55 (Gillberg, 1985). Because the same test items were used over
10 years, test demands may have dec1ined with development, partly accounting for the fewer
individuals being c1assified as poor in motor performance. While the developmental validity of the
testing methods can be questioned, the 20% of children who demonstrated movement difficulties
into late adolescence must have had serious movement problems. These fmdings are the only
empirical evidence that supports the notion that movement performance difficulties can be lifelong
in persons with both ADHD and DCD.
Kadesjo and Gillberg (1998) also assessed 409 seven-year-old children on the same
neurodevelopmental screening test and a physical education motor skills test, the Folke Bernadotte
test (Bille et al., 1985 as cited by Kadesjo & Gillberg, 1998). The testing items for the physical
46
education assessment were not provided. Results indicated that 6.6% of the sample had DAMP and
500/0 ofchildren with ADHD also had DeD.
In general, evidence from the large descriptive studies point to movement performance
difficulties associated with ADHD. However, few movement skills are typically assessed, and
these are usually unrelated to physical activity curricula. Practitioners and researchers require more
detailed information to meet the needs ofindividuals with ADHD.
Skill peiformance. Problems with skill performance have been linked also to children with
ADHD between the agesof5 to 18 years (See Table 2, Appendix F). These studies can be
c1ustered into three groups: (a) intergroup comparison, (b) intragroup comparison, and (c)
intervention effectiveness.
Intergroup comparison research assesses the movement skills of children with ADHD in
relation to norms or control groups. Beyer (1999) tested 112 males on items from the long form of
the BOTMP. Boys with ADHD (N = 56), receiving stimulant medication, performed significantly
below their age-matched male peers with a learning disability (N = 56), who were not receiving
stimulant medication, on four items (bilateral coordination, strength, visual motor coordination,
and upper limb speed and dexterity). Significant differences were not found between the groups for
balance, upper limb coordination, and response speed.
Doyle et al. (1995) used the short form of the BOTMP to test 38 children with ADHD. In
contrast to Beyer (1999), they found that most participants performed movement skills
significantly better than the age and gender norms provided in the BOTMP. However, Bruininks
recommended the short form of the BOTMP be used as "a brief survey of general motor
proficiency" (p. 13), or a screening instrument, because it Is not as detailed as the long form. The
results ofBeyer (1999), perhaps, should be accorded higher relevance.

47
The balancing skills of children with ADHD have also been investigated in several studies.
Piek et al. (1999) tested 48 males on both the Movement ABC, or MABC (Henderson & Sugden,
1992), and the Test ofKinaesthetic Sensitivity (Lazlo & Bairstow, 1985 as cited by Piek et al.,
1999). In comparison to age-matched peers, overall balance scores were significantly lower for
boys with ADHD-C (combined subtype), while manual dexterity scores on the MABC were
significantly lower for boys with ADHD-PI (predominantly-inattentive subtype). There were no
significant differences between any of the groups on the Test ofKinaesthetic Sensitivity.
Wade (1976) compared balance skills of 12 children with ADHD and 12 children without
ADHD on a stabilometer task. While no statistical comparisons were performed, children with
ADHD spent less time balancing when compared to their age- and weight-matched peers without a
disability.
The quality of movement skill patterns of children with ADHD, most of whom were taking
stimulant medication, has been described as "below average" (Harvey & Reid, 1997). After testing
19 children with ADHD on the Test of Gross Motor Development or TGMD (Ulrich, 1985),
Harvey and Reid reported that the children performed locomotor and object control skills below
the 35th percentile when compared to age-matched norms.
Other studies have explored intragroup comparisons. Piek et al. (1999) found that both
overall balance and manual dexterity scores on the MABC were significantly lower for boys with
ADHD-C (combined subtype) when compared to boys with ADHD-PI (predominantly-inattentive
subtype). Miyahara, Mobs, and Doll-Tepper (1995) tested 23 children with hyperkinetic disorders
(HKS) on the MABC and then performed cluster analyses that revealed two motor subtypes: "free
from severe motor incoordination" and "manual incoordination." Manual dexterity and overall
48
balance significantly distinguished between the two different motor subtypes. No performance
differences were found between the two groups in ball catching.
Two other studies also employed an intragroup group approach and focused on the
comorbidity ofHKS or ADHD with DCD. The fust study by Miyahara, Mobs, and Doll-Tepper
(2001) examined the overlap between HKS and DCD by the performance on the.MABC of 47
children with HKS. Considerable overlap between HKS and DCD was noted in the school (35%),
support group (54%), and the hospital (55%) sampi es.
The second comorbidity study assessed 162 children with and without ADHD (Kaplan,
Wilson, Dewey, & Crawford, 1998). Thirty-three percent met criteria for one disorder only. Of
these, 5% had ADHD, 16% had DCD, and 12% had a reading disability (RD). Twenty-four
percent met the criteria for two disorders. Ofthese, 14% had DCD and RD, 6% had ADHD and
DCD, and 4% had ADHD and RD. Overall, comorbidity of ADHD, DCD, and RD was reported
for 14% of the children. These figures suggest that the overlap between ADHD and DCD may be
substantial. Future research should explore this comorbid relationship to determine if the precise
movement difficulties are similar in the comorbid condition and when they occur in isolation. In
addition, do comorbid or singular cases respond to intervention similarly? (Henderson &
Henderson, 2002).
Treatment interventions related to movement performance in children with ADHD have
also been investigated. Hodge, Murata, and Porretta (1999) examined the effects ofthree different
preparatory conditions on the skills ofthrowing for accuracy, ball catching, and fUnning for 46
children with ADHD. The preparatory conditions were no warm-up, a task-specific warm-up, and
mental preparation or visual imagery that were carried out during the fIfSt 5 min of a single 60 to
90 min long testing session. This was a randomized posttest-only control group design where
49
participants were randomly assigned to one of the three groups. The participants performed (a) five
trials ofthrowing a beanbag at a target from a distance of 15 ft (4.57 m), (b) five trials of catching a
sponge ball tossed from 6 ft (l.83 m), and (c) two 40-yd dashes (36.6 m). Throwing accuracy was
significantly better in the visual imagery group when compared to the other groups. Significant
differences were not found between the groups on the ball catching task and the dash. There were
no main effects of gender or interactions.
Wade (1976) tested the effects ofmethylphenidate (Ritalin) on the balance skills of 12
children with ADHD with the use of the stabilometer task in a counterbalanced and placebo-
controlled experiment. There was a 3-week time delay between placebo and medication conditions.
The balance skills of the children improved significantly during the .medication condition.
Pelham et al. (1990) examined the effects ofmethylphenidate on attention and baseball
skills of 17 boys with ADHD in a double-blind and placebo-controlled study. The attention of the
boys improved significantly while playing baseball, but their basebali skills did not.
We should investigate the movement performance and physical activity experiences of
children with ADHD from a number of different perspectives. Longitudinal studies need to be
conducted, because movement performance changes over age have not been explored. We aiso
know little about the physical activity patterns of chiidren with ADHD and influencing factors.
Research should be conducted on the efficacy ofthese interventions in enhancing movement
performance and skill acquisition. Because pharmacological treatment interventions are not always
effective for children with ADHD (Wilens & Spencer, 2000), optimal intervention techniques
should be examined for children on and off medication. Furthermore, as self-regulation seems to
be a problem for children with ADHD (Barkley, 1997), future research should address the
effectiveness of self-regulation strategies in movement performance. Even at a descriptive level,

50
we know little about the movement performance of children with ADHD since the most commonly
used tests, the BOTMP and MABC, are quite limited in the number of movement skills assessed
and may not be relevant to top down programming (Block, 2000, p. 120).
Physicalfitness. Few studies have focused on the physical fitness ofchildren with ADHD,
although related phenomena such as heart rate (HR) have been investigated. For example,
methylphenidate significantly elevates HR during rest (porges, Walter, Korb, & Sprague, 1975).
However, resting HR may be affected by interactions between stimulant medication dosage and the
amount oftime after ingestion. Kelly, Rapport, and DuPaul (1988) stated the amount of ingested
medication may elevate posttest resting HR values on tests of attention. They suggested that
premedication HR may also affect postmedication resting HR and the premedication resting HR
value may be used as a covariate. See Kelly et al. for a thorough discussion about the effects of
stimulants upon resting HR.
Other studies have more specifically explored the physical fitness of children with ADHD
between the ages of5 to 12 years (See Table 3, Appendix G). Boileau, Ballard, Sprague, Sleator,
and Massey (1977) found the HRs of 20 children with ADHD were elevated both at rest and
during aS-min submaximal treadmill walk, when medicated with methlyphenidate compared to a
placebo condition. Oxygen consumption was also significantly lower during the exercise condition
when the children were medicated. Thus, medication has an effect on physical fitness assessment.
Ballard (1977) conducted one of the most comprehensive investigations on health-related
fitness of children with ADHD who were all receiving stimulant medication. Twenty-seven
children with ADHD demonstrated significantly higher levels ofbody fat, with significantly higher
blood pressure and HRs at rest, exercise, and recovery conditions when compared to 23 children
without disabilities.
51
Harvey and Reid (1997) found similar results in their physical fitness field testing.
Compared to normative data, 19 children with ADHD, most of whom were taking stimulant
medication, demonstrated high levels of adipose tissue (75 th percentile). Performance was below
the 25th percentile on a V02max field test (Leger, Lambert, Goulet, Rowan, & Dinelle, 1984), a
shuttle run test (CAHPER, 1980), and a sit-up test (Fitness Canada, 1985). Flexibility and push-ups
were also performed below the 40th percentile (Fitness Canada, 1985).
These three studies (Ballard, 1977; Boileau et al., 1977; Harvey & Reid, 1997) provide an
initial picture ofhealth-related fitness. The findings indicate that children with ADHD are at risk to
develop problems associated with health-related physical fitness.
Trocki-Ables, French, and O'Connor (2001) described the effects of different reinforcers
on the performance ofthe 1 mile/1.6 km walk/run test (Cooper Institute For Aerobics Research,
1992) for 5 boys with ADHD. Each boy was asked to complete the walk/run test as quickly as
possible on each of29 trials. One trial was held each day during a 6-week data collection period.
There were three data collection phases. The frrst phase was three initial trials that served as
baseline. The intervention phase consisted of 24 trials where reinforcers were randomly provided
with either a token (primary), verbal praise (secondary), or in combination, when the individuallap
time fell below the baseline average. The last phase of the data collection period was a
generalization period where two trials were conducted without reinforcement. Trocki-Ables et al.
concIuded that boys with ADHD perform the walk/run test in less time when provided with
combined primary and secondary reinforcers rather than primary or secondary reinforcers alone.
Clearly, there is a lack ofphysical fitness research about children with ADHD. Existing
research should be considered as preliminary because the studies have relatively small sample sizes
with wide age range variability. Yet interesting questions do arise from careful observation of the
52
existing findings. For example, the effects of stimulant medication on respiratory rates need to be
examined as methylphenidate produced significant increases in respiratory rate during rest and
significant decreases in respiratory rate during exercise (Ballard, 1977; Boileau et al., 1977).
Furthermore, no researcher has examined the effects of stimulant medication on HR. during high
intensity exercise. Also, we should use longitudinal studies to examine relationships between
persons with ADHD, health-related physical fitness, and exercise. For example, are children with
ADHD "at risk" for developing cardiovascular heart disease? Are the physical fitness findings
reflective of the current sedentary lifestyles of North American children?
Studies about the health-related fitness of adolescents and adults with ADHD are also
needed (Hartmann, 1993). Research questions about adult ADHD may be found in a review about
the properties of stimulant medications, with many ethical implications for adapted physical
activity (Hickey & Fricker, 1999). For example, stimulant medications are banned in many sports
competitions. Hickey and Fricker questioned whether guidelines should be created to accept the
performance of athletes who have ADHD and have stopped taking medication at least 24 hr prior
to competition.
Conclusions
Our fust conclusion deals with the enormity of the ADHD literature. There are many
exciting avenues ofresearch and practice in ADHD and adapted physical activity, but it is difficult
to achieve a thorough conceptual grasp of the disorder. Adapted physical activity will be
influenced by definition, diagnosis, etiology, nomenclature, classification, and treatment in ADHD.
We conclude that the movement skills of children with ADHD are at risk when compared
to chronological age-matched peers, although as noted throughout the paper there is much to be
learned. The reviewed studies present converging evidence that supports the description of children
53
with ADHD as having problems of movement performance from the vantage point of parents,
teachers, and researchers. This performance is not a function of overactivity that masks valid
assessment, given deficits noted in both quantitative (Beyer, 1999; Harvey & Reid, 1997;
Miyahara et al., 1995,2001; Piek et al., 1999) and qualitative (Harvey & Reid, 1997) performance.
Our conclusion is based on aggregate data. We recognize that sorne individuals with ADHD may
excel in movement skills. Moreover, there is growing evidence that ADHD and DCD might be
comorbid conditions. The aggregate is therefore influenced by those who also have DCD. Future
research should describe movement skills in ADHD when those who warrant the specific
designation ofDCD are eliminated from the participant pool. Would ADHD still be associated
with inferior movement skill performance?
We conclude tentatively that children with ADHD are at risk for poor levels ofphysical
fitness in comparison to their chronological age-matched peers. We are more careful with this
conclusion than with movement skills because the literature is not as complete about health-related
fitness. The relationship between the physical activity levels of children with ADHD and physical
fitness needs to be explored. Comprehensive fitness assessment batteries with large sample sizes
are strongly recommended to observe if children with ADHD possess different physiological
markers than their age- and gender-matched peers without disabilities. Clearly, the interaction
between physiological responses and medication should also be addressed in the exercise context.
It will be crucial to develop collaborative research projects with professionals in
psychology, psychiatry, or special education. Detailed physical activity information may be
invaluable for clinical intervention. Increased sample size, diagnostic reliability, and opportunities
to explore movement issues of children with ADHD, DCD, or DAMP may also be realized.
Much of the existing movement behavior research is atheoretical. Future physical activity
54
researchers should use theoretical models to guide their research. For example, Barkley (1997) has
developed a comprehensive theoretical framework to explain the underlying mechanisms of
ADHD. Movement behavior is an element included in this paradigm, which could be tested by
physical activity researchers. The activity-deficit hypothesis (Bouffard, Watkinson, Thompson,
Causgrove Dunn, & Romanow, 1996) could also be an explanation for the movement skill
difficulties of children with ADHD, where poor movement skills may lead to a diminution of
affect, or vice versa, resulting in reduced social interaction, decreased levels of physical activity,
and diminished physical fitness and health.
It is hoped that this article will benefit adapted physical activity practitioners and
researchers. There remain many unexplored physical activity questions to stimulate further
research. In tum, the findings may prove beneficial for the health and welfare of people with
ADHD and their families.

55
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Authors' Note
1- In fact, the published literature is so large that there has been at least one meta-analysis of
meta-analyses performed (Swanson et al., 1993).
2 - Identifiers include motor processes (P), movement performance - retrospective views (MR),
movement performance - large descriptive studies: movement skills (D 1) and physical fitness
(D2), movement performance - skill performance (MS), movement performance - physical
fitness (MF).
The tirst author wishes to thank Tom Carson, Shirley Edwards, Elaine Mancina, and Sharon
Whelton for their valuable searching skills, input, and assistance. Thanks are also extended to Dr.
A.E (Ted) Wall, Dr. Natalie Grizenko, Dr. Mike Dixon, and Dr. David Kaminester for their
discussions about research.

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Chapter two is a published review paper on the movement skill performance and physical titness
ofchildren with ADHD. The review demonstrated that children with ADHD are at risk for
movement skill difficulties and poor levels of physical titness. A link with developmental
coordination disorder (DCD) was suggested. The next chapter is the second dissertation
manuscript of four original papers that explore the relationship between ADHD and physical
activity. It is a review ofresearch challenges and methods in adapted physical activity and children
with ADHD. The paper is based on the studies and information from the previous chapter and it
also builds on the information, laying the foundation for the two research studies that complete the
dissertation. The relative contributions of the two authors were as follows. As tirst author, 1 was
responsible for 90% of the manuscript and involved in all aspects of the research, writing and
editing of the manuscript. Dr. Greg Reid was responsible for the other 10% of the work involved
by ensuring the reliability of the research process, with multiple reads of the text, editing and
suggestions for text improvement.

69
Chapter Three
Attention-DeficitlHyperactivity Disorder:
AP A Research Challenges
From W.J. Harvey and G. Reid, 2005, Adapted Physical Activity Quarterly 22(1): 1-20. © 2005 by
Human Kinetics Publishers. Reprinted with permission from Human Kinetics (Champaign, IL).
Abstract
The purpose of this paper is to present a critical analysis of the research methods in adapted
physical activity studies about children with attention-deficit hyperactivity disorder (ADHD).
The strengths and weaknesses ofvarious research methods are discussed by (a) three main types
ofresearch questions, (b) identification and description ofresearch participants, (c) reliability and
validity of assessment instruments, (d) data collection procedures, and (e) quantitative and
qualitative methods of data analysis. Strategies to improve research are embedded in each of the
five main categories. It is concluded that substantial methodological inconsistencies exist in the
current ADHD physical activity literature base. Future research would be strengthened by
incorporating recommended suggestions.
.
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Attention-DeficitIHyperactivity Disorder: AP A Research Challenges
There is a growing awareness of the physical activity challenges of children with
attention-deficitlhyperactivity disorder (ADHD) because they demonstrate poor motor planning
(e.g., Yan & Thomas, 2002), movement skill problems (e.g., Beyer, 1999) and poor levels of
physical fitness (e.g., Ballard, 1977). Adapted physical activity (APA) researchers may have
difficulty designing studies about the movement behavior of children with ADHD because little
information is readily available about pertinent research methods used in ADHD physical activity
studies. For example, few reviews have been written about the movement performance and
physical fitness ofpersons with ADHD (Churton, 1989; Harvey & Reid, 2003; Hickey & Fricker,
1999), with no book chapters or reviews devoted specifically to conducting physical activity
research for persons with the disorder. The lack of information is not surprising, given our field
borrows much research methodology from other professional domains (Reid & Stanish, 2003).
This paper builds upon our previous work (Harvey & Reid, 2003) where we provided an
overview of issues germane to persons with ADHD (e.g., a contemporary definition of ADHD,
symptomatology, etiology, nomenclature, classification, comorbidity, treatment and developmental
course). We suggested that children with ADHD were at risk for problems of movement skill
performance and physical fitness. Readers can observe important characteristics of each study in
the tables provided for the review (e.g., year, purpose, number of participants, diagnostic
framework, prescribed medications if any, statistical analyses, and findings). By careful scrutinyof
these tables, AP A researchers may notice that considerable methodological inconsistencies and
weaknesses exist in the physical activity literature base about ADHD. We wanted to provide
insights to these research issues but, unfortunately, space did not permit these methodological
extensions. For example, stimulant medication is prescribed as a common treatment modality for
71
a substantial number of children with ADHD (Wilens & Spencer, 2000) and it has been part of
many AP A research designs. Yet we will demonstrate that the use of this medication has been
inconsistent and not well controlled in approximately 45% of the identified movement
performance studies. Results may be confounded by extraneous factors, like medication, leading
to questions about the quality ofphysical activity research conducted in ADHD. Since a critical
and detailed review ofresearch methods is warranted, the purpose ofthis paper is to anaIyze the
following question. What research methods were used to explore the movement performance of
children with ADHD in APA studies? New physical activity research questions and strategies to
improve future APA research designs are included in the review, with links to proven methods
used in ADHD research by other professional domains. Interested readers are encouraged to
consult our previous review article in order to acquire generaI information about issues in ADHD
and observe specifie findings about the movement performance of children with ADHD.
Method
Categorization and identification of pertinent studies followed those identified by Harvey
and Reid (2003). The taxonomy ofmovement skills, developed by Burton and Miller (1998), was
used to categorize motor process and movement performance studies. Motor process studies were
identified by dependent variables reflecting underlying internaI factors believed to affect
observable movement (Burton & Miller, 1998). Movement performance studies were identified
with dependent variables that reflected observable or goaI-directed movements that could be
described in quantitative or qualitative terms (Burton & Miller, 1998). These categories were used
to identify studies only from AP A research in order to include investigations that focused on
variables directly related to functionaI movement skill performance and to exclude a number of
72
studies embedded in large behavioral observation research investigations where the primary focus
or interest was not on movement-related behavior (Harvey & Reid, 2003).
An extensive search strategy, similar to Harvey and Reid (2003), was used. The
SPORTDiscus (1830-April, 2004), CUITent Contents/AIl Editions (Week 27, 1993-Week 20,
2004), ERIC (1966-April, 2004), MEDLINE (1966-April, week 4,2004), and PsychINFO (1967-
May, week 1,2004) databases were searched electronicaIly. Keywords linked human movement
science and psychology. Specific search terms included attention deficit, attention deficit
hyperactivity disorder, attention deficit disorder, deficits in attention, motor control and perception
(DAMP), hyperkinesis, hyperactivity, minimal brain dysfunction, motor, fitness, health, exercise,
physiology, sport, and recreation. The footnote chasing approach was also employed to search for
relevant studies that may have been overlooked (White, 1994).
Twenty studies are identified within the time frame of 1830 to May, 2004. Five studies
explore the motor pro cesses of children with ADHD from a contemporary motor control approach
(Eliasson, Rosblad, & Forssberg, 2004; Pit cher, Piek, & Barrett, 2002; Sheppard, Bradshaw,
Georgiou, Bradshaw, & Lee, 2000; Vickers, Rodrigues, & Brown, 2002; Yan & Thomas, 2002).
Fifteen studies examine the movement performance of children with ADHD. Twelve ofthese
studies focus on movement skills (Beyer, 1999; Christiansen, 2000; Doyle, Wall en, & Whitmont,
1995; Harvey & Reid, 1997; Hodge, Murata, & Porretta, 1999; Kaplan, Wilson, Dewey, &
Crawford, 1998; Miyahara, Mobs, & Doll-Tepper, 1995,2001; Pelham et al., 1990; Piek, Pitcher,
& Hay, 1999; Pit cher, Piek, & Hay, 2003; Wade, 1976) and four studies explore physical fitness
(Ballard, 1977; Boileau, Ballard, Sprague, Sleator, & Massey, 1977; Harvey & Reid, 1997;
Trocki-Ables, French, & O'Connor, 2001). Each study is evaluated on the basis of the research
question, participants, instruments, specific data collection procedures, and methods of analysis
73
because strong research methodology includes the careful use ofthese categories (Thomas &
Nelson, 2001). Each category is presented separately because prediction of future research
conditions is difficult at best, with specific conditions varying from one situation to the next,
leaving sorne decisions to make only after a critical analysis by each professional (Bouffard &
Strean, 2003). Therefore, we provide as much information as possible for the APA researcher to
make informed decisions throughout the research process.
Discussion
Research Question
One of the most important aspects of research is the choice of an interesting research
question (Loehle, 1990) that emanates from the review(s) of relevant literature, identification of
a phenomenon ofinterest and a related problem(s). The ensuing hypotheses help to frame the
research study and answer questions related to the research problem. Sherrill and O'Connor
(1999) stated that strong APA methodology should include an explicit statement of the research
question. Since the research questions and hypotheses were not written explicitly in a majority of
the AP A studies about ADHD, these statements can be only inferred from the general purpose
stated for each study. Therefore, a brief summary of the literature is necessary here to provide
explicit statements for three main types of research questions posed, with the associated findings,
in order to grasp the questions and findings that have guided the majority of the published
research.
The fust type of research question involves an intergroup comparison where researchers
ask if performance differences exist between children with and without ADHD on various
dependent variables in motor processes and movement performance. There is converging
evidence that children with ADHD demonstrate poor motor skills, movement skills and levels of
74
physical fitness in comparison to children without ADHD (Ballard, 1977~ Beyer, 1999~
Christiansen, 2000; Doyle et al., 1995; Eliasson et al., 2004; Piek et al., 1999; Pitcher et al., 2002,
2003; Sheppard et al., 2000; Vickers et al., 2002; Wade, 1976; Yan & Thomas, 2002). An
intragroup comparison is the purpose of the second main research question. Do motor skills
and/or movement skills differ between children with ADHD ofvarying subtypes? Motor process
and movement performance differences were found between children with the predominantly-
inattentive (PI), predominantly hyperactive-impulsive (ID), and combined (C) ADHD subtypes
(Eliasson et al., 2004; Kaplan et al., 1998; Miyahara et al., 1995,2001; Piek et al., 1999; Pitcher
et al., 2002, 2003). The third type of research question involves treatment. First, what are the
effects of stimulant medication on movement skill performance and physical fitness? Children
with ADHD have increased the amount oftime spent in balance on a stabilometertask (Wade,
1976), attention during baseball games (Pelham et al., 1990) and gaze frequency during a ping
pong task, with no effect on visual tracking (Vickers et al., 2002) and the performance of
baseball skills (Pelham et al., 1990). Blood pressure and heart rates of children with ADHD
increased significantly during a submaximal treadmill test. Second, what are the effects of
movement-specific interventions on movement performance? Children with leaming disabilities
and ADHD have demonstrated significant improvements in throwing accuracy with the use of a
mental preparation intervention (Hodge et al. 1999) while children with ADHD significantly
improved running performance times when provided with both primary and secondary
reinforcement (Trocki-Ables et al., 2001).
Research questions and hypotheses should be clearly indicated in AP A studies about
ADHD in order to gain a clear understanding of the major questions that drive the exploration,
description, and conceptualization of the movement behavior ofchildren with ADHD. For
75
example, we recommend posing two general questions. First, we need to ask how children with
ADHD develop movement skills over time because, as we will indicate, all of the identified AP A
studies are cross-sectional in nature. Second, no APA researcher has explored the reasons for the
observed inadequate skiU performance so we also need to ask why children with ADHD perform
movement skills poorly when compared to their peers without ADHD?
The lack of research questions and hypotheses provides the unique opportunity to
recommend the development of a variety of AP A research programs, based on different
theoretical approaches, to acquire a more stiuctured understanding about movement performance
from an ADHD perspective. In other words, we recommend research programs that are based on
conceptual meaning (e.g., constructs) where the basic unit ofanalysis (e.g., persons with ADHD)
can be observed from different perspectives and hypotheses can be tested in a variety of contexts.
For example, the inhibitory model of executive functioning (Barkley, 1997) and the knowledge-
based approach to motor development (WalL McClements, Bouffard, Findlay, & Taylor, 1985)
are potential frameworks to explore the movement behavior of children with ADHD. First,
Barkley (1997) hypothesized two of the central problems of ADHD to be an impaired
conceptualization of time and point of performance problems or, in other words, an inability to
perform what one knows. For example, how would the performance ofchildren with ADHD be
atTected on time constrained tasks? Would performance differences between children with and
without ADHD become smaller or larger when movement tasks were slowed down or speeded
up? Barkley (1997) contends that the timing of motor responses and the anticipation of future
events are impaired in children with ADHD. Second, Wall and bis colleagues (1985) developed a
heuristic framework to explore the development of skilled performance in physical activity and it
could be used to inquire about the potentiallinks between movement skill performance and
76
acquired knowledge. For example, are children with and without ADHD able to perform what
they know? Do they share similar or dissimilar experiences that guide the acquisition and
development of movement skills? Are there differences in knowledge and experience between
children with and without ADHD who demonstrate low and high levels of movement skill
proficiency?
Other theoretical paradigms may be of value in understanding ADHD. For example,
motivational theories will be important vehicles to explore the relationship of ADHD and
movement performance and it would be beneficial to describe and explore the causal attributions
of children with ADHD when placed in conditions of movement success and failure. For
example, do children with ADHD attribute their success in physical activity contexts to external
causes (e.g., task was too easy) or internaI causes (e.g., great amount of effort was expended)?
Do they employ internaI or external causal attributions when they face failure in physical activity
situations? Researchers could also ask what impact these causal attributions may have on
adherence to participation in different activities (e.g., leisure and recreation pursuits, physical
education, competitive sports, exercise programs, etc.). In turn, researchers could explore
perceptions ofself-efficacy and self-regulatory processes (Bandura, 1997). For example, how do
children with ADHD feel about their participation in physical activities? What physical activities
do they prefer and why? Do children with ADHD feel confident about their own movement and
sport specific skills? Do children with ADHD feel confident when they participate in individual
or team sports? Do children with and without ADHD regulate their own skill leaming and
behavior in similar ways? Finally, the accumulation and use of more research information may
lead to greater amounts of intervention studies. For example, what types of instructional
programs are most successful for children with ADHD and why? Would a task-specific approach
77
be best for children with ADHD to learn movement skills? Would children with ADHD perform
movement skills better after attribution re-training programs that build upon success and
encourage full participation? What types of recreation and sport programs are most important to
children with ADHD and why? Can children with ADHD be taught how to regulate their
personal involvement in physical activity, recreation, and leisure? What are the opportunities and
barri ers to participation that may affect the personal empowerment of children with ADHD?
Clearly, a paradigmatic approach is recommended for structured understandings ofpersons with
ADHD and their movement skills. Furthermore, there is a need to develop lines of research that
focus on the specific conceptual issues relevant to children with ADHD and their movement skills.
Thus, there are many opportunities to develop basic and applied AP A research programs about
ADHD.
Participants
A thorough description of research participants is generally recommended in journal
articles and texts devoted to physical activity research methodology (e.g., Sherrill & O'Connor,
1999; Thomas & Nelson, 2001). The following three sub-sections deal with a) descriptive
information about the participants in sampling designs, b) participant identification and
diagnosis, and c) issues related to gender and ADHD.
Sampling Design. Sampling designs were not usually reported in the identified studies. AlI
investigations were purposive and cross-sectional. Small sample size is a common problem in AP A
research (Bouffard, 1993) and a similar situation may be observed in APA research about persons
with ADHD. The average total sample size was 51.3 participants. While the average sample size
seems large, there are a few important considerations to note. First, four studies had large numbers
of participants (e.g., N = 112: Beyer, 1999; N = 169; Kaplan et al., 1998, N = 143: Pitcher et al.,
78
2002, 2003) that inflated the average sample size. The average total sample size is 31.3 when the
four large studies are excluded. Thus, 80% of the identified studies had smaller total sample sizes.
While a sample size of 31 participants appears to be adequate, or even robust, the age range of
most studies is usually extensive and, therefore, the number of participants per chronological age
level is quite low.
A similar pattern of inflated average sample size can be observed in the 12 AP A studies
that employed control groups (Ballard, 1977; Beyer, 1999; Christiansen, 2000; Eliasson et al.,
2004; Kaplan et al., 1998; Piek et al., 1999; Pitcher et al., 2002, 2003; Sheppard et al., 2000;
Vickers et al., 2002; Wade, 1976; Yan & Thomas, 2002). For example, the average total sample
size of 64.5 participants (ADHD avg. = 43.4, control avg. = 21) drops to an average of35.6
participants (ADHD = 18.5, control avg. = 15.9) when the four large studies are excluded. Six of
the 12 APA studies utilized control groups with an equal number of participants (Beyer, 1999;
Eliasson et al., 2004; Piek et al., 1999; Sheppard et al., 2000; Wade, 1976; Yan & Thomas, 2002).
Thus, six studies had unequal numbers of participants in each group (Ballard, 1977; Christiansen,
2000; Kaplan et al., 1998; Pitcher et al., 2002, 2003; Vickers et al., 2002) that is problematic
because matching groups on gender and age was not performed. In faet, only two studies overall
(Piek et al., 1999; Sheppard et al., 2000) incorporated matching on gender, age and IQ in their
research designs. The appropriateness of comparing groups with unequal numbers of males and
females in studies related to movement performance is questionable (Sherrill & Williams, 1996).
There were unequal numbers offemales and males in the analysis oftwo studies (Ballard, 1977;
Kaplan et al., 1998) which lead to confounds between gender and the nature of ADHD. For
example, are differences a funetion of typical gender influences on movement performance or
ADHD per se? However, this problem may be best addressed by using equal numbers of males
79
and females in the research design in order to eliminate cross gender analysis and increase both
sample size and the robustness of research designs. The eight remaining AP A studies did not
employ control groups because a norm-referenced test was used (Doyle et al., 1995; Harvey &
Reid, 1997; Miyahara et al., 1995,2001) or an intervention method was assessed (Boileau et al.,
1977; Hodge et al. 1999; Pelham et al., 1990; Trocki-Ables et al., 2001). The average total sample
size for these eight studies was 27 participants.
Thus, generalizations about the movement performance of children with ADHD are not
based on large numbers of children with the disorder. For example, the number of participants with
ADHD, who were assessed in the 20 AP A studies, ranged from 5 to 169 participants per study for
a total of 697 participants with ADHD out of the total 924 participants. Furthermore, the ages of
the participants varied between 4 to 18 years, with an average age range of 4.1 years. Since
movement skills change with age, it is important to seek groups of children within restricted age
ranges. Again, the issue is not total sample size but rather that the samples are typically small,
given the wide age ranges of the participants. Therefore, we must take into account the limitations
of small sample size and age range variability when composing samples and understanding the
results of our research. At the same time, we must realize the challenges to be expected in
obtaining large numbers of participants with ADHD, especially with restricted age ranges. For
example, it might not seem difficult to obtain a large sample of children with ADHD because they
represent 3 to 7 percent of the school-aged population (APA, 2000). Yet access to samples of
children with ADHD may be challenging because they are often involved in large clinical
observation studies where the primary focus or interest is not on movement-related behavior
(Harvey & Reid, 2003). Thus, it is important to collaborate with teaching, clinical and research
professionals in education, psychology and psychiatry in order to gain access to greater numbers of
80
children with ADHD. For example, a strategy to obtain larger sample sizes can be observed in
multi-modal intervention studies where data is collected in many difTerent sites across North
America (Hechtman, 2000). While such a grand scale operation may not always be possible, the
use of a similar approach on a smaller scale at the level of a state, province, or municipality may be
feasible. The AP A researcher should try to control the sample size and age range issues by : a)
including as many participants as possible, and b) using a narrow age range as possible. Thus, APA
researchers must create opportunities that will increase their sample sizes. Sample size will also be
afTected by the identification process of ADHD and gender difTerences that exist with the disorder.
Identification and Diagnosis. The AP A researcher needs to know if participants with
ADHD are diagnosed in a valid and reliable manner. Usually, children with ADHD are initially
identified by their parents and teachers (AP A, 2000) and they are referred to physicians,
psychiatrists, pediatricians, neurologists, and psychologists for assessment and diagnosis. Multiple
diagnostic methods and sources of information are recommended when making the diagnosis of
ADHD (Anastopoulos & Shelton, 2001). Thus, diagnoses should be based on combinat ions of
age-appropriate symptoms, clinical tests, and observations (Anastopoulos & Shelton, 2001~
Hechtman, 2000). Researchers should be aware that heterogeneous samples are more likely the
norm rather than the exception. For example, it is common for persons with ADHD to be
diagnosed with at least one other disorder (Barkley, 1998) and it can take approximately 2 years to
obtain a sample of 20 participants with pure ADHD (personal communication, Dr. L. Hechtman,
1997). Refer to Harvey and Reid (2003) for a list of potential comorbid conditions.
The diagnostic process is not as simple and straightforward as APA researchers might
expect. For example, a comprehensive assessment and a determination of comorbid disorders are
involved in the difTerential diagnosis where the diagnostic professional must be able to take into
81
account the assessment findings and rule out any disorders that are similar in nature to ADHD
(Weiss & Hechtman, 1993). Two different diagnostic frameworks are used to identify children
with either ADHD or hyperkinetic disorders (HKS). Thirteen AP A studies used the criteria from
the Diagnostic and Statisfical Ma11Ual ofMental Disorders, or DSM, (APA, 2000) to identify
children with ADHD (e.g., Beyer, 1999; Christiansen, 2000; Doyle et al., 1995; Eliasson et al.,
2004; Harvey & Reid, 1997; Kaplan et al., 1998; Pelham et al., 1990; Piek et al., 1999; Pitcher et
al., 2002, 2003; Sheppard et al., 2000; Vickers et al., 2002; Yan & Thomas, 2002). Two studies
(e.g., Miyahara et al., 1995,2001) identified children with HKS with the criteria of the ICD-10, the
International Classification ofDiseases (WHO, 1992). Diagnostic frameworks were not reported
in five studies (e.g., Ballard, 1977; Boileau et al., 1977; Hodge et al., 1999; Trocki-Ables et al.,
2001; Wade, 1976). Thus, the reporting of diagnostic framework has been variable.
Pertinent questions about identification and diagnosis can be asked when composing
samples ofpeople with ADHD. One of the main identification and diagnostic research issues about
participants with ADHD lies in a difference between the educational and medical systems. For
example, Hodge et al. (1999) defined their participants as persons with learning disabilities and
attention deficit disorder who were identified by qualified educational personnel. In fact, all
children had been coded by educational diagnostic teams in the appropriate manner as required by
the Individuals with Disabilities Education Act of the United States of America. Since the study
was conducted in North America, it is assumed that the school psychologist(s) used the DSM
framework to diagnose ADHD. Yet, this may not always be the case and, if possible, it would be
beneficial to state which diagnostic criteria and assessment instruments were used to define the
disorder. For example, Harvey and Reid (1997) reported that the DSM framework and information
gathered on the Child Behavior Checklist (Achenbach & Edelbrock, 1983) were used in ADHD
82
diagnoses from a clinical center. The main point is that AP A researchers need to secure sampi es of
children who are identified by qualified diagnostic dinicians. In fact, it is strongly recommended to
incorporate experienced professionals for improved reliability of ADHD diagnoses (Hennessey,
1982; cited by McBumett, Lahey, & Pfiffner, 1993). We recommend that researchers state the
relevant framework used to diagnose participants with ADHD. Furthermore, it will be beneficial to
describe the identification process and the physical site where the participants are drawn trom (e.g.,
school, community dinic, hospital, etc.) for replication purposes. The procedures may allow AP A
researchers to identify samples of children with ADHD trom a variety of sources, enabling the
study of children who are affected by the disorder to varying degrees.
Gender differences. The CUITent understanding of movement performance for children with
ADHD is mainly trom a male perspective, with little female representation. For exainple, more
males than females have been included in the majority of movement performance studies on
ADHD. There was approximately 35 female participants (e.g., ADHD = 31, No-ADHD = 4) ofthe
924 participants who were included in APA research designs. Unfortunately, one large study did
not include the number of females with ADHD, assessed in movement performance (Kaplan et al.,
1998), which would have slightly increased the number offemale participants.
Gender differences should be expected because more males are affected with ADHD than
females by ratios of approximately 2: 1 and 9: 1 in general and clinical populations respectively
(AP A, 2000). Potential reasons for these gender differences follow. The DSM symptom criteria
may identify more boys as they were the majority of the participants in the DSM-IV field trials
(Barkley, 2003). AIso, boys are more often referred for and identified with ADHD since they
exhibit more extemalizing and disruptive behaviors when compared to girls who may be diagnosed
at later ages, with intemalized ADHD symptoms and a greater trend toward inattentive behaviors
83
than males (Biederman et al., 1999~ Gaub & Carlson, 1997). Since gender differences in
identification have been recognized, we expect more females to be diagnosed with ADHD over the
next few decades. APA researchers should explore the role of gender in movement skiU
acquisition and performance of children with ADHD. Therefore, when possible, we recommend
that females be included in movement performance studies on ADHD in order to provide a
thorough description of the movement skills of aIl people with ADHD and to represent general
and clinical ADHD populations. Since boys and girls may have different social experiences in
movement and sport activities (Sherrill & Williams, 1996), we also recommend in-depth studies
offemales with ADHD in a variety ofphysical activity contexts. Applied behavior analysis and
qualitative research designs may be more easily applied since it may be difficult to access large
numbers of females with the disorder.
Instruments
The choice of a measurement instrument is linked to the question of interest, area of
investigation, and psychometrie properties of the selected instrument(s). While it is important
that measurement instruments are reliable (Thomas & Nelson, 2001), it is also important that
valid references are made from the measurement results (Yun & Ulrich, 2002). Reliability and
validity seem to be achieved in a majority of the identified AP A studies. One test of movement
behavior was usually administered in each identified AP A study. A finger tapping task (pitcher
et al., 2002), a linear positioning task (Yan & Thomas, 2002), a digitizing tablet for arm
movements (Eliasson et al., 2004), and a kinematical analysis of a ping pong task (Vickers et al.,
2002) are examples of the types of tests used in motor control studies. Background research
information is often provided about the properties of each motor control testing instrument, thus
indicating credible testing methods and results. The majority of movement performance studies
84
also used a single measurement instrument (See Table l, Appendix H). Given the difficulties
observed with the composition of participant samples, the identification of ADHD, and gender
differences~ we must question the depth of our understanding of the movement skill learning and
performance of children with ADHD, especially since few comprehensive batteries of movement
behavior have been performed. For example, only one study (Harvey & Reid, 1997) used a series
of tests to describe the movement skills of children with ADHD by administering the Test of
Gross Motor Development (Ulrich, 1985), a V02max test (Leger, Lambert, Goulet, & Dinelle,
1984), a shuttle run test (CAHPER, 1980), and tests of sit-ups, push-ups, and flexibility (Fitness
Canada, 1985). Yet this study was limited by a small sample size and the lack of a control group
(Harvey & Reid, 1997). Control groups of children without ADHD may not have been necessary
when investigating a treatment intervention for children with ADHD (e.g., Boileau et al., 1977;
Hodge et al. 1999; Pelham et al., 1990; Trocki-Ables et al., 2001). Yet there are potential
generational effects when, instead of control groups, norm-referenced tests were used for
comparison purposes in movement performance (e.g., Doyle et al., 1995~ Harvey & Reid, 1997).
Thus, there may be a superficial understanding of the movement performance of children
with ADHD because the research has been limited by the depth of each investigation or the
significant limitations indicated above. There is a need to incorporate multiple testing batteries to
explore a variety of fundamental movement skills and specific sport skills to obtain a better
understanding of the movement performance ofchildren with ADHD.
Data Collection Procedures
The research environment, motivation, and medication use are three major factors in the
organization of APA studies in ADHD. Since children with ADHD can behave quite differently
than their peers without ADHD (Cooper & Bilton, 2002), the AP A researcher should structure
85
research environments so children may perform experimental tasks at optimal performance levels
(Houghton et al., 2004; Lawrence et al., 2002). For example, variable task performance may be
expected due to problems of response inhibition, or delayed responding, and understanding of tasks
(Barkley, 1997, 1998). In an attempt to control forthese effects, children with ADIID should be
allowed to perform at their own pace with additional demonstrations provided when they do not
seem to understand (Douglas, 1980a, 1980b). The AP A researcher should also be aware of other
leaming conditions of children with ADHD to optimize performance conditions. For example, the
children may experience less behavioral problems with novel tasks or environments, but this may
diminish with time (Zentall, 1993). Children with ADHD may talk excessively during non-
instructional times (Zentall, 1993) and spend less time on-task than controls (Seidel & Joschko,
1990). Therefore, it would be beneficial to provide instructions in a clear, brief, and overt manner
to address the behavioral issues or listening difficulties of children with ADHD (pfiffner &
Barkley, 1990). It is recommended to collect data individually since the unique behavioral
problems and learning styles of children with ADIID may affect optimal movement performance
(Harvey & Reid, 1997). For example, the frrst author attempted to collect physical activity data on
four children with ADIID at the same time to maximize the efficiency of data collection. This
aggregate data collection strategy was quickly changed to an individual approach after the
observation was made that the children would tease others during task performance, and in tum,
not pay attention to their own specifie task demands.
Motivation is an important factor when designing APA research (Wall, 1990). For
example, learned helplessness has been linked to children with ADHD (Milich & Okazaki, 1991)
and its influence could have detrimental effects on the children's movement performance. The
APA researcher may assist the individual with ADHD in optimal performance by being positive,
86
encouraging, and using successful reinforcement strategies during the research process (Harvey &
Reid, 1997). For example, successfullearning experiences may be facilitated by consistent and
immediate rewards for appropriate compliance to tasks (Douglas & Parry, 1994). However,
children with ADHD may become very fiustrated when expected rewards are not provided
(Douglas & Parry, 1994). Reinforcers must be changed from time to time because the children may
experience satiation to behavior management consequences (pfiffner & Barkley, 1990). Immediate
individual performance feedback and academic tasks that are sensitive to an individual's ability and
learning pace should also facilitate learning (Cooper & Bilton, 2002). Children with ADHD may
perform better on demanding tasks during the morning since their performance can be affected by
fatigue and the time of day (Zagar & Bowers, 1983). Therefore, we recommend that researchers try
to (a) exhibit positive behaviors during the data collection period, (b) allow participants with
ADHD to perform experimental tasks at their own pace, (c) keep a steady pace during data
collection by providing instructions in a clear and direct fashion, (d) maximize the time efficiency
of data collection by not getting involved in long discussions or argumentative behaviors, and (e)
collect data during the morning.
Medication usage is an extremely complex factor to consider when designing research
studies about ADHD. Stimulant medication has been the most widely used treatment approach for
children with ADHD (Wilens & Biederman, 1992; Wilens & Spencer, 2000). In fact, stimulants
are used to treat over 1 million school-age children per year in the United States (Greenhill,
Halperin, & Abikoff, 1999; Jensen et al. 1999). Thus, AP A researchers should be aware of
stimulant medication administration as research findings may be affected by dosing schedules,
individual practices, and side-effects. These practices are individualized and differential
intervention modalities may affect the results ofan investigation if the researcher is not aware. For
87
example, methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and amphetamine
compounds (Adderall) seem to be the most popular stimulant prescriptions due to rapid clinical
effects and short half-lives (Wilens & Spencer, 2000). These stimulants are usually administered
two to three times per day in an oral pill form. The medications are also available in a slow release
format to avoid noon dosing regimens, ensure that medication is taken, have lasting effects into the
aftemoon, and avoid social stigma (Weiss & Hechtman, 1993). The APA researcher shouid note
individual dosage levels, time of medication ingestion, and, if necessary, search for experimental
differences due to these practices.
Yet, stimulant medications are not the only prescription option for the pharmacological
treatment of the chiidren (Wilens & Spencer, 2000). Therefore, researchers should inquire about
the different types of medications that the participants are taking. For example, the anti-
hypertensive medication, Cionidine, has aiso been prescribed for children with ADHD who are
poor responders to psycho stimulant treatment and for children with motor tics (Steingard,
Biederman, Spencer, Wilens, & Gonzalez, 1993). Clonidine may be used to decrease the problems
of insomnia associated with methylphenidate use because sleepiness, sedation, lowered blood
pressure, and decreased motor activity are possible si de effects of Clonidine use (Steingard et al.,
1993; Wilens, Biederman, & Spencer, 1994). Therefore, researchers are well-advised not to
assume that stimulant medications are the only prescriptions they need to be aware of when
designing their studies. Thus, it is very important for the AP A researcher to ask if participants are
receiving medication and, if so, what types of medication are prescribed?
Each prescribed medication has a potential side-effect that may have an influence on the
outcome of a research study. Thus, awareness of medication side effects is important for the AP A
researcher because the results of an investigation may be affected by individual reactions to

88
medication. The four most commonly reported side effects of stimulant medication, likely to affect
children with ADHD to varying degrees, are sleep disturbance, appetite suppression, headaches,
and stomachaches (Barkley, McMurray, Edelbrock, & Robbins, 1990). It is also important to be
aware that other less commonly reported side-effects have been identified with the use of stimulant
medication. For example, these side-effects are growth disturbance, weight loss, mood
disturbances, chronic tic disorders, behavioral rebound, seizure disorder, increased lethargy and
fatigue, and increases in heart rate and blood pressure (Barkley, 1977; Barkley et al., 1990;
DuPaul, Barkley, & Connor, 1998). Sorne children with ADHD may receive drug-free periods
during weekends, school vacations, and holidays as a consequence of severe reactions to
medication (DuPaul et al., 1998; Wilens & Spencer, 2000). However, an experimental confound
may arise if the AP A researcher is unaware that a participant(s) may be receiving these drug
holidays during the data collection period. Thus, side-effect information is important to inquire
about and understand before data are collected so the researcher can plan and prepare research
designs that can best explain the influence of medication on their results.
It is evident that the control of medication is vital to research designs since children with
ADHD may experience numerous side-effects from prescribed medication. Unfortunately, there is
variability across AP A studies with regard to medication usage. Stimulant medication was
controlled in the research design for I1of20 APA studies. For example, all children with ADHD
received stimulant medication in seven studies (e.g., Ballard, 1977; Beyer, 1999; Boileau et al.,
1977; Pelham et al., 1990; Sheppard et al., 2000; Vickers et al., 2002; Wade, 1976) and they did
not receive it at all during four other studies (e.g., Eliasson et al., 2004; Pitcher et al., 2002, 2003;
Yan & Thomas, 2002). Experimental control was exerted over the medication factor, thus
maximizing or minimizing the influence of the stimulant medication on the results. However, there
89
is less control over medication in the remaining nine AP A studies. For example, we could not
determine if the children with ADHD received stimulant medication in five studies because
medication usage was not reported by the authors (e.g., Christiansen, 2000; Hodge et al., 1999;
Kaplan et al., 1998; Miyahara et al., 2001; Trocki-Ables et al., 2001). Furthermore, the use of
stimulant medication was variable during the data collection in four other studies (e.g., Doyle et al.,
1995; Harvey & Reid, 1997; Miyahara et al., 1995; Piek et al., 1999). For example, 17 out of 19
participants received medication in one study (Harvey & Reid, 1997) while only 8 out of 48
participants received medication in another investigation (Piek et al., 1999).
It would be preferable to have either all children under medication or none at all during
data collection in order to maximize or minimize the extraneous influence of medication on
movement performance. However, potential conflicts ofinterest between research methodology
and ethics are possible. The major consideration when renioving children with ADHD from
medication is that the children may experience severe negative effects in daily functioning due to
the medication withdrawal. Thus, the AP A researcher may not always be able to exert control over
the administration ofmedication as it might be considered unethical to have a participant(s)
withdraw from a much needed pharmacological treatment. Yet the inability to control the
independent variable (e.g., medication) may impinge on the results.
Therefore, we recommend a variety of investigations to explore the effects of stimulant
medication on the performance and learning ofmovement skills for children with ADHD. For
example, do the movement skills of children with ADHD improve while they are receiving
stimulant medication? Do children with ADHD learn movement skills better when they are or are
not receiving stimulant medication? Double-blind and placebo-controlled designs may help to
answer such questions. For example, the participants are unaware whether or not they are receiving
90
a tablet of either medication or a non-medicinal ingredient (e.g., placebo-controlled) and both the
participants and all researchers are unaware of the specifie assignment of medication or placebo to
individual participants (e.g., double-blind).
Placebo-controlled investigations are possible because of the short half-lives and quick
washouts of stimulant medication. Since methylphenidate is eliminated (e.g., metabolized
completely, washed out) from the body within 24 hours (DuPaul et al., 1998), children with
ADHD may refrain from medication for short periods oftime with minimallifestyle disturbance.
However, the AP A researcher must be aware that inconsistent medication use could cause negative
effects upon the lives of the participants and their families. For example, Wade (1976) employed a
three week wash-out period for a study that examined the effects of methylphenidate on a
balancing task. While the research design was appropriate for the timeframe (e.g., 1970's), it is
now understood that the washout period could be shortened, with less stress placed on the children
with ADHD and their families. The personal intrusion, created by removing medication for
extended periods oftime, may be too high a priee for the children and their families to pay.
Therefore, we must be sensitive to the needs of participants while, at the same time, attempting to
control for the influence of medication. Therefore, the AP A researcher can design cross-sectional
studies oflimited time duration, with placebo-control conditions because of the short-halflife of
methylphenidate. Applied behavior analyses may also be useful when observing the effects of
receiving or removing medication on the skilllearning and performance of children with ADHD.
With time and research evidence, we should know which types of studies are possible to conduct in
relation to the strict control of stimulant medication.
ln summary, AP A researchers need to ask pertinent questions about medication and their
participants with ADHD. First, are the participants receiving medication as a treatment for ADHD?
91
We expect that stimulant medication will be an important design factor to consider since it has
been proven very effective for children with ADHD in the short-term and it is used by a significant
number of children with ADHD (Jensen et al. 1999). Second, the AP A researcher needs to ask if it
is necessary or possible for the participants with ADHD to refrain from taking their medication(s)?
The AP A researcher should provide evidence that stimulant medication will have a negligible
effect on movement performance if it is deemed unnecessary to have participants with ADHD
refrain from taking their medication during data collection. Third, specifie prescriptions and dosage
levels should be reported to provide more accurate participant information if medications are
administered during a study. Researchers should also report if no medications are taken by
participants. Fourth, the AP A researcher should ask if participants reported any side-effects during
the data collection period. Since the side-effects of medication are variable and idiosyncratic
(DuPaul et al., 1998), it may be beneficial to investigate if side effects can aecount for individual
skill performances that, in turn, may be considered as outlier data. Finally, the APA researcher
should ask if participants are experiencing severe behavioral reactions due to the withdrawal of
medication. If so, the decision to exc1ude the participant may be made since the health and welfare
of the individual is the primary ethical concern in our research designs. Consult the following
literature reviews concerning the pharmacological treatment of persons with ADHD (Wilens &
Biederman, 1992; Wilens & Spencer, 2000).
Methods ofAnalysis
Most of the identified studies used a quantitative approach for data analysis. For example,
between-group (Ballard, 1977; Beyer, 1999; Boileau et al., 1977; Christiansen, 2000; Doyle et
al., 1995; Eliasson et al., 2004; Piek et al. 1999; Pitcher et al., 2002; Sheppard et al., 2000;
Vickers et al., 2002; Yan & Thomas, 2002) and within-group (Hodge et al., 1999; Miyahara et
92
al., 1995~ 2001~ Kaplan et al., 1998~ Pelham et al., 1990; Piek et al., 1999; Pitcher et al., 2002,
2003; Vickers et al., 2002; Wade, 1976) statistical approaches were used to analyze the
movement performance of children with ADHD. The movement performance of children with
ADHD has also been explored with an applied behavior analysis approach on the etfects of
reinforcement on performance in a field-based physical fitness test (Trocki-Ables et al., 2001)
and a description of fundamental movement skill performance (Harvey & Reid, 1997). While
these standard analyses have provided reliable movement-related information, there are a few
methodological concerns that are of importance during the analysis phase.
First, we know little about the influence of potentially important independent variables on
the movement behavior of children with ADHD. For example, what are the etfects of
socioeconomic status (SES) on the fundamental movement skills of children with ADHD?
Family income level could have an effect on individual participation in physical activity and
sport due to the rising financial costs associated with organized sports and community recreation
programs. Furthermore, parentallevels of education could be important when determining the
value and emphasis placed on physical activity, health and wellness that, in turn, may have
effects on participation levels. Therefore, it may be important to match groups of children with
and without ADHD on SES, family in come, and parent education levels. It may also be
important to inquire whether or not the parents have ADHD as there is a genetic link with the
disorder (APA, 2000). Perhaps parents also experience difficulty in movement performance,
leading to a decreased family value placed on physical activity. Next, few studies have been
designed to observe the effects of intervention programs. Since intervention studies are important
and unique contributions to AP A research about all children with ADHD, it may be beneficial to
use applied behavior analysis (e.g., times series designs, reversaI designs) to measure
93
intervention outcomes at both individual and group levels. Clearly, more applied research should
be conducted on the fundamental movement skills and physical fitness of children with ADHD.
Additionally, small sample size is an important ADHD issue related to analysis and it may be
beneficial to use repeated measures designs to increase statistical power. FinaIly, the qualitative
paradigm has not been used to explore and explain the movement behavior of children with
ADHD. Thus, it is important to have children with ADHD express their own feelings and
perceptions about their movement and sport behaviors.
Summary and Future Directions
ADHD is a significant challenge in the schools, clinics, and hospitals of communities aIl
over North America. Converging evidence suggests that children with ADHD demonstrate
movement skill problems (Harvey & Reid, 2003). Yet substantial methodological inconsistencies
exist in the AP A research database and they must be addressed in order to confirm the results of
past research. Generally, the use oflongitudinal designs, with developmentally-sensitive
assessment instruments, is recommended since aU of the AP A studies have been cross-sectional
in nature. The following specific methods are suggested to strengthen AP A designs and to
answer the main questions of interest. First, research questions and hypotheses should be clearly
articulated. Two general questions are suggested to guide future ADHD research. For example,
we need to ask how children with ADHD develop movement s10lls over time and why children
with ADHD perform movement s10lls poorly when compared to their peers without ADHD?
Theoretical frameworks and the development of a line of research are recommended to guide
future research about children with ADHD and movement behavior. Next, it is recommended
that as much general descriptive information about the participants with and without ADHD be
collected. For example, the sampling design could be explicitly stated, with a description of the
94
process of participant identification and a naming of the relevant diagnostic frameworks used to
diagnose ADHD, thus improving the credibility of the participant identification and diagnosis.
The inclusion offemales is suggested for a representative description of the movement behavior
of general and clinical populations for all people with ADHD. Further, the influence ofkey
independent variables needs to be explored in order to identify plausible explanatory factors for
the poor movement behavlor of children with ADHD. Since our current AP A research base
seems to lack a depth ofunderstanding of the movement problems with ADHD, we recommend
the use of multiple assessment batteries to acquire greater amounts of information about the
phenomenon. AIso, it is crucial to understand specific methods used to aid data collection in the
organization of APA studies in ADHD (e.g., research environment, motivation, & medication).
We recommend the combination of quantitative and qualitative methods, along with the use of
repeated measures designs and applied behavior analysis designs, as necessary and
complimentary analytical approaches to understand the various correlates of movement behavior
associated with ADHD.
There is a unique opportunity to have a significant AP A treatment impact on a substantial
number of people atTected by ADHD and to gain much insight about the movement behavior,
skilllearning and individual perceptions of the movement experiences ofpersons with ADHD.
As such, physical activity research about ADHD will continue to be a fertile area of
investigation.
95
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Aclmowledgement
The authors thank Dr. David Porretta and the reviewers for their critical feedback and valuable
suggestions. The first author extends many thanks to bis mentors at McGill University and Dr.
Claudine Sherrill for the encouragement to search and attempt to understand as much as possible
about persons with ADHD in physical activity.
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Chapter three is a published manuscript that explored research challenges and methods in
adapted physical activity and children with ADHD. The strengths and weaknesses ofvarious
research methods in the identified adapted physical activity research studies were discussed.
While substantial methodological inconsistencies were identified in the CUITent ADHD physical
activity literature base, strategies to improve research were provided. Chapter four is the third and
next manuscript offour original papers that explore the relationship between ADHD and physical
activity. It was designed on the basis of the information provided in the two preceding review
papers. The study, a placebo controlled and double blind research design, represents one of the
more tightly controlled research investigations in physical activity and persons with ADHD. There
were six co-authors and their relative contributions were as follows. As frrst author, 1 was
responsible for 80% of the manuscript and involved in aIl aspects of the research, data collection,
statistical analyses, writing and editing of the manuscript. Dr. Greg Reid was responsible for the
other 10010 of the work involved by ensuring the reliability of the research process, with multiple
reads of the text, editing and suggestions for text improvement. The remaining 10010 of the work
was shared by the following people. Dr. Natalie Grizenko performed the diagnoses of ADHD
while also providing feedback on key design issues. Dr. Valentin Mbekou verified the
interpretation of psychological tests. Mrs. Marina Ter-Stepanian trained the first author to
conduct the required screening interviews and assisted in the coordination of data collection. Dr.
Ridha Joober contributed by providing valuable feedback on research design issues. AlI four co-
authors also provided feedback on the text as part of this collaborative process.
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Chapter Four
Fundamental movement skills and children with ADHD:
Stimulant effects and peer comparisons
Co-authors: William J. Harvey, Greg Reid (McGill University), Natalie Grizenko , Valentin
Mbekou, Marina Ter-Stepanian, and Ridha Joober (Douglas Hospital)
Abstract
The purpose of this study was to assess the effects of stimulant medication on the fundamental
movement skill performance of22 children with attention-deficit hyperactivity disorder
(ADHD), from 6 to 12 years of age, and to compare their movement skills to gender- and age-
matched peers without ADHD. Results from the placebo-controlled and double-blind study
indicated stimulant medication had no significant effect on the movement skill patterns of
children with ADHD. Repeated measures analyses revealed significant performance differences
between children with and without ADHD (p::::; .001). It is concluded that children with ADHD
may be at risk for developmental delays in movement skill performance. Future research avenues
are discussed.
Key words: attention-deficit hyperactivity disorder, boys, methylphenidate, movement skills

106
Fundamental movement skills and children with ADHD:
Stimulant effects and peer comparisons
Many children with attention-deficit hyperactivity disorder (ADHD) do not fare weIl in
movement-related activities (Alexander, 1990; Berenyi, 1996; Harvey, Fagan, & Kassis, 2003) but
the problems associated with their movement skills are an enigma for physical activity
professionals. Movement skills are prerequisites for the performance of sport-specifie skills and
functional involvement in many physical activities (Burton & Miller, 1998). Since 2% to 14% of
North American school-aged children are affected by ADHD (Scahill & Schwab-Stone, 2000), a
considerable number of children with the disorder may be experiencing movement skill
difficulties (Gillberg, 2003).
Burton and Miller (1998) distinguished between movement skill assessments that are
product-oriented or process-oriented. Product-oriented assessments are concerned with the
movement outcome, or product, usually the quantitative result of a movement skill performance.
For example, movement skills may be measured in time (e.g., seconds on a balance task), distance
(e.g., the length of a standing long jump), or number of successful attempts (e.g., the number of
hockey pucks striking specific locations of a hockey net). Process-oriented assessments usually
involve the qualitative aspects, or process, ofhow a skill is performed (Burton & Miller, 1998).
Movement skills may be measured qualitatively through the identification of specifie behavioral
criteria related to successful performance. For example, there are three performance criteria
required for catching a ball in the Test of Gross Motor Development-2, or TGMD-2, (Ulrich,
2000). First, there is a preparation phase where the performer's hands are in front of the body, with
the elbows tlexed. Next, the arms extend from the body and reach for the ball as it arrives. Finally,
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the ball is caught by the hands only rather than trapped against the body. Thus, movement skills are
broken down into component parts that reflect skilled performance.
The majority of adapted physical activity (APA) research about ADHD suggests the
movement skills of children with the disorder are quantitatively different from their peers without
ADHD (Beyer, 1999; Christiansen, 2000; Doyle, Wallen, & Whitmont, 1995; Harvey & Reid,
1997; Hodge, Murata., & Porretta., 1999; Kaplan, Wilson, Dewey, & Crawford, 1998; Miyahara,
Mobs, & Doll-Tepper, 1995,2001; Pelham et al., 1990; Piek, Pitcher, & Hay, 1999; Pitcher, Piek,
& Hay, 2003; Wade, 1976). This underscores the importance of distinguishing between movement
skills and the general overactive behavior that typifies ADHD. Excessive activity may not lead to
proticient movement skill performance (Keogh, 1978) or high levels of physical fitness (Harvey &
Reid, 1997). In fact, overactivity is simply one indication of the clinical disorder (AP A, 2000). Yet,
only one investigation has explored the process, or qualitative components, of movement skill
performance for children with ADHD. Harvey and Reid (1997) reported that 19 children with
ADHD demonstrated fewer performance criteria on the locomotor skills (e.g., run, gallop, hop,
leap, horizontal jump, skip, and slide) and object control skills (e.g., two-hand strike, stationary
bounce, catch, kick, and overhand throw) subtests when compared to the norms of the original
TGMD (Ulrich, 1985). However, the study was limited by a small sample size, lack ofa control
group, and an inability to control for medication. These facts are not surprising as small sample
sizes, an inability to control for important independent variables related to movement skills, and
other methodological weaknesses have been identified in AP A studies about movement skills
and children with ADHD (Harvey & Reid, in press). For example, the use of stimulant
medication for children with ADHD was not well-controlled in approximately 45% of the
research studies on ADHD and movement skill performance.

108
Stimulant medication is one of the most common treatment modalities for children with
ADHD (Wilens & Biederman, 1992; Wilens & Spencer, 2000). In fact, it is an effective short-
term treatment intervention approach that is prescribed for over 1 million school-aged children
(Greenhill, Halperin, & Abikoff, 1999; Jensen et al., 1999). The effects of stimulant medication
on the movement behavior of children with ADHD include improved fine motor skills and
reaction times (Knights & Hinton, 1969; Rapport & Kelly, 1991; Shephard, Bradshaw,
Georgiou, Bradshaw, & Lee, 2000), improved performance on lower extremity response time
performance (pedersen, Surburg, Heath, & Koceja, 2004) and higher gaze frequency during a
ping pong task, with no effects of medication on visual tracking (Vickers, Rodrigues, & Brown,
2002). DuPaul, Barkley, and O'Connor (1998) suggest that positive effects of stimulant
medication intervention should be expected on most behaviors for children with ADHD,
especially when contextuallimits are set where individual behaviors are restricted and attention
focused on specifie tasks. Furthermore, increased attention to task demands (Barkley &
Cunningham, 1978) and improved on line accuracy of body movements (Yan & Thomas, 2002)
may be potential mechanisms through which movement skiU performance may be improved in
relation to stimulant medication usage.
Only two studies used a product-oriented assessment approach to examine the effects of
methylphenidate (Ritalin) on the observable movement skill performance of children with
ADHD. The first study investigated the effects ofRitalin on the attention and baseball skills of
17 boys, ages 7.8 to 9.9 years, in a double-blind and placebo-controlled design (Pelham et al.,
1990). A product-oriented assessment was used to observe the skills of catching a fly ball,
fiel ding a ground ball, throwing to fIfSt base, and batting a pitched baseball during pre-game
sessions. Game readiness, game awareness, batting judgment, and batting skills were measured
109
during actual situations where the boys were involved in leisurely games ofbasebaU. Hence, the
performance environment was cooperative rather than being highly competitive and time-
constrained. Ritalin had a significant etfect on the measures of attention (e.g., game readiness
and game awareness) but not on the performance measures (e.g., four pre-game skills, batting
judgment, and batting skills).
Performance results may have been atfected by the operational definitions of the baseball
skills. For example, the definition of a hit, or "the percentage of times at bat the boy hit in fair
territory, divided by the total number oftimes at bat" (Pelham et al., 1990, p. 13), is not in
keeping with traditional methods of calculating batting averages. The traditional definition of a
hit is that the baseball must not only be hit into play but it must also land in fair territory with the
batter reaching base safely. The reported averages for hits were 78% (placebo), 78% (0.3 mglkg
dose ofRitalin) and 81% (0.6 mglkg dose ofRitalin). These batting averages demonstrate the
number of times that the ball was put into the field of play and we would expect to see such high
success rates in less competitive and leisurely baseball games. Yet, without the use of traditional
batting averages, it would be difficult to detect ditferences due to an intervention because the
task was most certainly aneasy one. Thus, a ceiling etfect may be quite possible. Also, raw data
and change scores were not reported so it was impossible to observe the direction of performance
change due to the stimulant medication intervention. While this study was counterbalanced, there
was no mention of statistical testing for a learning etfect where the children with ADHD may
have improved their skills over time. We must also consider that the children with ADHD may
have performed very weil during the fIfSt testing sessions and changes in skill performance
would not be expected because there would be little opportunity for skill improvement. Since
means and standard deviations were not reported, it was impossible to calculate the etfect size of
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the intervention. Unfortunately, the qualitative components of the movement skill patterns were
not recorded or analyzed.
A second study used a placebo-controlled and double-blind design to examine the effects
ofRitalin on a movement skiU (Wade, 1976). It was found that Ritalin had a positive effect on
the static balance of 12 children with ADHD between 7.7 to 1l.8 years. The children spent
significantly more time in balance on a stabilometer during medication trials than the placebo
trials. In other words, the same 12 children with ADHD performed better when they crossed over
from the placebo condition to the medication condition. Statistical analysis revealed a significant
improvement in the timed balance task when they were receiving stimulant medication. The time
spent in balance, during the medication condition, was similar to the balance time of their 12
peers without ADHD. However, statistical analysis was not conducted between the groups of
children with and without ADHD. Also, with only one movement skill studied, a comprehensive
understanding of the relationship between medication and movement skill performance of children
with ADHD could not emerge. Finally, the real world significance of the balance task (e.g.,
stabilometer) can also be questioned as it unlikely represents the day to day fundamental
movement skills used by a majority of children.
ln summary, converging evidence suggests that children with ADHD may be at risk for
movement skill difficuIties. However, there are many methodological shortcomings associated
with these results. There has been only one process-oriented movement skill assessment of
children with ADHD and only two studies about the effects of stimulant medication on their
movement skills. Thus, an investigation into the effects of stimulant medication on the
fundamental movement skills of children with ADHD is warranted as well as a process-oriented
assessment of the movement skills ofchildren with and without ADHD.

III
The main purpose ofthis study was to (a) assess the effects of stimulant rnedication on
the qualitative cornponents of 12 fundamental movement skills for children with ADHD and (b)
compare the movement skill performance between children with and without ADHD. Two
hypotheses were made. First, it was hypothesized that the gross motor development quotient
(GMDQ), the locomotor skill subtest scores, and object control skill subtest scores on the
TGMD-2 (Ulrich, 2000) would be significantly greater for children with ADHD wh en they were
receiving methylphenidate (Ritalin) than when they were not receiving the medication. Second, it
was hypothesized that the GMDQ scores, the locomotor skiU subtest scores, and object control
skiU subtest scores would be significantly lower for children with ADHD, in the rnedication and
placebo conditions, when compared to their gender- and age-matched peers without ADHD.
Method
Participants
Twenty-two children with and without ADHD participated. The 22 children with ADHD
were part of a larger investigation about the effects of stimulant medication on children with
ADHD at an urban Canadian psychiatrie hospital. A formaI clinical diagnosis of ADHD was
made for each child by a qualified child psychiatrist. Thé protocol for identification of these
children was a consensus between two child psychiatrists from several sources of information.
For example, the children met the DSM-IV diagnostic criteria for ADHD (Lahey et al., 1994).
Information was derived from the parent report of the Diagnostic Interview Schedule for
Children, computerized version, or DISe-IV, (National Institute of Mental Health, 1998), and the
Child Behavior Checklist (Achenbach, 1991). Additionally, the parent and teacher questionnaires
of the Conners Global Index were administered (Conners, 1997a, 1997b). Diagnosed subtypes
for the children included inattentive (2), hyperactive-impulsive (2), and combined (18) types.
112
Comorbid diagnoses were oppositional defiant disorder (8), separation anxiety disorder (1), and
depression (1). Thus, ail children with ADHD had behavioral problems. They were also
identified as having generallearning problems as indicated by reports of clinical psychologists.
The primary author was blind to prior medication usage and this fact is a limitation to the CUITent
study.
The 22 children without ADHD were identified in an elementary school, located in close
proximity to the hospital. These children were recommended by the appropriate school personnel
(e.g., physical education teacher, c1assroom teacher) to have no prior history of major cognitive,
behaviora~ emotional, or learning problems. More specifically, a screening process was
developed to identify the control participants. The physical educator created a list of males and
females, from grades 1 to 6, who she perceived to have no major cognitive, behavioral,
emotional, or learning difficulties and be considered of average intelligence. Movement skill
level was not a criterion for inclusion in the control group. Each potential name was then
presented to the student's classroom teacher to verify if the identified child would meet the
established inclusion criteria. Consent forms were only sent home to the parents after agreement
on potential participants was reached between the classroom and physical education teachers and
a close age match was established with each child with ADHD. The physical education teacher
identified a total of 124 children. Agreement was reached with the classroom teacher on 105
children. The genders and ages of ail the children were noted and 66 consent forms were sent
home. There was a 74.2% positive retum rate (e.g. 49 of 66 replies), leaving 49 participants from
whom to select the control group.
Control participants were selected on the basis of gender and age matched to each child
with ADHD. There were 20 males and 2 females in each group, reflecting a representative
113
gender ratio in the population of children with ADHD (AP A, 2000), matched with individual
control participants by age in years and months. Participant ages ranged from 6.6 to 12.5 years.
The average age for children with ADHD was 9.7 years while peers without ADHD were 9.8
years. Matching ofages was within 6 months, with an average age difference of2.5 months at
the time oftesting. There were no significant differences between the groups for age (t (42) =-
.124, P = .902). Family income level was matched by group, with salary levels ranging between
$18,000 and $99,000.00. There were no significant differences between the groups on family
income level (t (42) = .092, P = .928).
Twenty-five potential control participants were tested on the TGMD-2. After testing was
completed, telephone interviews were conducted with one parent of each control participant
using the DISC-IV, (Shaffer et al., 2000) and the Conners Global Index Parent Questionnaire, or
CGI-P (Conners, 1997). These measures provided more evidence, other than the teacher reports
alone, that ADHD could be ruled out for each control participant. Two control participants were
excluded on the basis of the DI SC-IV testing as the parent responses indicated that two boys
might be at risk for significant attention problems. The school principal was notified so that a
professional follow-up could be conducted by the appropriate school professionals. Another boy
was excluded from the study because he refused to finish aIl the required testing. There were
significant differences between the two groups on the restless-impulsive subtest (t (42) = 12.19, P
< .001), emotional-Iability subtest (t (42) = 10.94, P < .001) and the total score (t (42) = 13.12, P
< .001) of the CGI-P. Thus, we contend that separate populations of children with and without
ADHD were assessed.
AlI participants demonstrated a total IQ score of70 or greater on the Wechsler
Intelligence Scale for Children, or WISC-III, (Wechsler, 1991) to ensure individual

114
understanding of test instructions and tasks. The IQ scores ofboys without ADHD were
calculated with a short form version of the WISC-III (Donders, 1997). There was no significant
difference between the groups on IQ (t (42) = - 1.65, P = .107). Approval was received from the
university, hospital, and school board ethics committees, with informed consent obtained from
the participants and their parents, prior to data collection.
Assessment
The fundamental movement skills of aIl participants were videotaped on two separate
occasions with a SONY Mini DV Digital Handycam (DCR-TRV18 NTSC) video recorder.
Locomotor skills and object control skills were assessed with the TGMD-2. This commonly-used
physical education test was designed to assess six locomotor skills (e.g., run, gallop, hop, leap,
horizo~taljump, and slide) and six object control skills (e.g., striking a stationary baIl, stationary
dribble, catch, kick, overhand throw, and underhand roll) where evidence ofthree to four
performance criteria may be observed on each of 12 fundamental movement skills for children
from ages 3 to 10 years (Ulrich, 2000). Tables 1 and 2 provide the specifie criteria for the 12
movement skills of the TGMD-2 (See Appendices 1 & J).
Administration of the TGMD-2 followed the testing protocol outlined by Ulrich (2000).
The test procedures were to: (a) fill in the appropriate participant information on the assessment
form, (b) provide an accurate verbal description and demonstration of each movement skill
before assessment, (c) allow one practice trial per movement skill to ensure individual
understanding, (d) provide one additional demonstration if the child appears to misunderstand
the task, and (e) administer two test trials per movement skill. A score of 0 (absent) or 1 (present)
was assigned to each performance criterion on each of the 2 trials. These scores were then
summed to obtain a raw score for each skill. Raw subtest scores were obtained by the aggregate
115
of raw scores in the six locomotor skills and the six object control skills. The raw scores of all 12
movement skills are then added to produce a total score which, in turn, is converted into the
GMDQ.
The TGMD-2 is a reliable and valid movement skill assessment instrument. Ulrich (2000)
reported acceptable coefficients ofintemal consistency, stability, and interrater reliability for the
locomotor skills subtest, the object control skills subtest, and the GMDQ ofthe TGMD-2 (See
Table 3, Appendix K). In fact, Burton and Miller (1998) acknowledged the reliability of the
TGMD as a fundamental movement skill assessment instrument. Ulrich (2000) reported different
indicators ofvalidity. Content validity was established by a panel ofthree experts who had (a)
academic training at a doctorallevel in motor development, (b) 3 years of elementary physical
education teaching experience, and (c) 3 years of experience in gross motor development
assessment. A conventional item analysis indicated that the TGMD-2 distinguished correctly
between people of different skillievels. Criterion-predictive validity was demonstrated by the
moderate to strong correlations between the TGMD-2 and the Basic Motor Generalizations
subtest of the Comprehensive Sea/es of Student Abilities (Hammill & Hresko, 1994 as cited by
Ulrich, 2000). Construct validity of the TGMD-2 was established by (a) significant correlations
between the subtests and age, (b) performance differentiation between groups of children with
high and low movement skill abilities, (c) the significant moderate correlations between the two
subtests, and (d) the loading of the two subtest scores on two separate factors in both unrotated
and rotated exploratory factor analyses and a confirmatory factor analysis. Discriminative
validity is defined as the degree that a measurement instrument distinguishes between groups on
the basis of independent criteria (Haynes, 2001). The TGMD-2 demonstrates discriminative
validity because the test items are independent movement skill criteria that can distinguish
116
between people on the basis of skillievei. For the present study, it was reasoned if significant
movement skill difTerences on the TGMD-2 were found between the groups of children with and
without ADHD, then the inferences from the results would be valid (Yun & Ulrich, 2002).
Design and procedures
A placebo-controlled and double-blind design was used to observe the efTects of
stimulant medication on the fundamental movement skills of children with ADHD. The design
was placebo-controlled because participants with ADHD received a total of 0.5 mg!kglbody
weight of methylphenidate or placebo each day. Also, the design was counterbalanced with the
participants randomly assigned to the medication condition on one week and to the placebo
condition on the next week or vice versa. The design was considered as double-blind because the
children and the first author were not aware (e.g., blind) of the specific assignment ofmedication
or placebo. The first author remained blind to this assignment during movement skill testing and
test coding.
The first author administered the TGMD-2 to children with and without ADHD between
October, 2002 and June, 2003. The locomotor skills and object control skills ofall children were
tested oh the same day (e.g., Tuesday, Wednesday, etc.) for two consecutive weeks. It was
administered to individual children between 9:40 a.m. and Il :30a.m. each testing day because
children with ADHD seem to perform better on demanding tasks during the morning as their
performance can be afTected by fatigue and the time of day (Zagar & Bowers, 1983). Since
behavioral efTects can be observed within 30 to 60 minutes after ingestion of stimulant
medication (DuPaul, Barkley, & Connor, 1998), there was between 40 to 90 minutes of elapsed
time from ingestion of the stimulant medication to the start of each skill testing session. The first
author also tested the control participants with the TGMD-2 on the same morning for two
117
consecutive weeks in order to maintain a consistent and balanced design. Ali children were
tested in an isolated gymnasium by the tirst author because individual data collection procedures
were recommended to address the unique behavioral problems and learning styles of children with
ADHD that may affect optimal movement performance (Harvey & Reid, in press). Testing time
was approximately 20 to 40 minutes per child.
Interrater reliability was obtained on the videotaped TGMD-2 trials performed by ail
children. This reliability was established through the use of an observer, trained by the primary
investigator who had much experience in movement skill assessment. For example, he
administered the original TGMD (Ulrich, 1985) approximately 500 times over the course of a 10-
year period as an adapted physical educator. The observer was a graduate student in adapted
physical activity, with five years of coaching experience in high school softball and track and
field. Since the observer earned an undergraduate degree in kinesiology and physical education,
she was familiar with the observation of important elements of movement skill patterns. The
primary investigator taught the observer to identify the criteria for each of the 12 movement
skills with a videotape that showed a 7 year-old boy performing the 12 required TGMD-2 testing
items. The videotaped performances of the children with and without ADHD were coded by the
observer only after 80% agreement had been reached with the primary investigator on a second
videotape where a 10 year-old boy performed the TGMD-2. When this training was complete,
25% oftests, spaced evenly throughout (e.g., every 4th test), were analyzed for interrater
reliability. In order to control for potential errors related to experimenter drift (Haynes, 2001),
both the primary researcher and the observer were re-evaluated on the second training video after
every 25th test. Each coder surpassed the 80% criterion level of rating agreement with the
training video during this coding pro cess, thus maintaining the reliability of each rater' s
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observations (Cone, 1999). The physical activity researchers were blind to the assigned testing
order for children with and without ADHD during the coding of the videotaped skill
performances (e.g., no medication vs. medication, trial 1 vs. trial 2).
Data analysis
The effects of stimulant medication. The Gross Motor Development Quotient (GMDQ) and
the raw scores from the locomotor skills and object control skills subtests were the dependent
measures. AlI analyses were conducted on the statistical software from the SAS System for
Windows (SAS, 2001). One repeated measures analysis of variance (ANOVA) and three
doubly-multivariate repeated measures analyses of variance (MANOVA) were used to test the
first hypothesis that the GMDQ scores, locomotor skill subtest scores, and object control skill
subtest scores on the TGMD-2 were significantly higher for children with ADHD when they
were receiving methylphenidate rather than not receiving the medication. First, a 2 X 2 (Age x
Treatment) ANOVA with repeated measures on the last factor was conducted on the GMDQ
scores. Age was considered as an important developmental factor. Therefore, children with
ADHD were placed into either a 6 to 9 year group (n = 7) or a 10 to 12 year group (n = 15). The
adjusted sums of squares (SS3) were used for the statistical analyses since the groups were not of
equal size. Hence, the parameter estimates were based on the least squares means in order to
account for the unique contribution of each dependent variable to the total variance and control
for alpha inflation (Stevens, 1996). The repeated condition was the children receiving or not
receiving stimulant medication.
Next, a 2 X 2 (Age x Treatment) doubly-multivariate repeated measures procedure was
used to analyze the data from the total raw scores of the locomotor skill and object control
subtests. This approach was used because the dependent variables were significantly correlated
119
within and across each measure. For example, the locomotor and object control skill scores of
each individual were correlated within each measure because the same person was performing
each skill on two occasions. Furthermore, scores were also expected to be significantly
correlated between the total sub-skill measures because significant correlations between
locomotor skills and object control skills were reported in the TGMD-2 (Ulrich, 2000).
Additionally, a 2 X 2 (Group x Time) doubly-multivariate repeated measures analysis was
conducted on the data from the total raw scores of the locomotor skill and object control subtests
to test for an order effect on skill performance due to testing sequence. Finally, separate 2 X 6
(Age x Treatment) doubly-multivariate repeated measures analyses were conducted on the raw
scores for the 6 locomotor skills and the 6 object control skills to explore any differences due to
individual movement skills.
Children with and without ADHD. A repeated measures analyses of variance (ANOVA)
and doubly-multivariate repeated measures analyses of variance (MANO VA) were used to test
the second hypothesis that the GMDQ scores, locomotor skill subtest scores, and object control
skill subtest scores on the TGMD-2 were significantly lower for children with ADHD in both the
placebo and medication conditions when compared to their peers without ADHD. First, a 2 X 2
X 2 (Group x Age x Condition) ANOV A with repeated measures on the last factor was
conducted on the GMDQ scores. There were 22 children with and without ADHD (N = 44) who
were placed into groups of6 to 9 year-olds or 10 to 12 year-olds. The repeated factor was the
scores on the two TGMD-2 trials. Next, a 2 X 2 X 2 (Group x Age x Condition) doubly-
multivariate repeated measures analysis was conducted on the total raw scores for the locomotor
skills and object control skills subtests. Finally, separate 2 X 2 X 6 (Group x Age x Condition)
120
doubly-multivariate repeated measures analyses were conducted on the 6 locomotor skills and
the 6 object control skills to explore any differences due to individual movement skills.
Results
Reliability. Interrater reliability was determined by Kappa (Cohen, 1960). The Kappa
statistic ranges from 1.0 (no disagreement) to -1 (less than chance agreement), with the
agreement calculated on data by taking chance into account (Cone, 1999). The formula for
Kappa is K = Po - Pc / 1 - Pc where K is Kappa, Po is the proportion of agreement between
raters, Pc is the proportion of chance agreements (Cone, 1999). Rater agreements on the total
criterion scores were used to calculate separate proportions of agreement (po) for each of the
subtests and the gross motor development quotient (GMDQ). Rater agreements and
dis agreements were used to calculate the proportion of chance agreements (pc) for the locomotor
skills (48), object control skills (48), and the GMDQ (96). Interrater reliability was strong for
locomotor skills (K = .99), object control skills (K = .99) and the GMDQ (K = .99).
The effects of stimulant medication. Table 4 provides the means, standard deviations and
effect sizes (See Appendix K). There were no significant differences between or within effects
on the two-way repeated measures ANOV A. Only age approached significance (P(l,20) = 3.09, P
= .09) as the older children with ADHD scored higher on the GMDQ than their younger peers.
Treatment effect size (ES) was calculated for each group to interpret the effects of stimulant
medication on the components of fundamental movement skills. The method of Thomas and
Nelson (2001) was used where the means of the treatment levels were subtracted (e.g., off
medication - on medication) and divided by the pooled standard deviation (Sp). Thus, ES = Ml -
M 2/ Sp where Sp equals the square root ofS21 (nl- 1) + S22(n2-1) / nl- n2 - 2. Thomas and
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Nelson (2001) suggested the following guidelines for ES interpretation: ~.2 (smalt), .5
(moderate) and 2: .8 (large). The effect sizes were small.
Similar results were found with the four subsequent analyses. A significant overall effect
of age (F(2, 19) = 8.22, p. = .003) was found on the second analysis, the 2 X 2 (Group x Treatment)
doubly-multivariate repeated measures MANDV A. The total raw scores for locomotor skills and
object control skills subtests for the older children with ADHD were consistently higher than
their younger peers. There were no other significant effects. The 2 X 2 (Group x Time) doubly-
multivariate analysis also revealed a significant effect of age (F(2, 19) = 8.36, P = .003), with no
significant order or interaction effects found on skill performance from the first to the second
movement skill assessment for the boys with ADHD.
The doubly-multivariate analysis for the 6 locomotor skilts revealed no significant
effects. However, the older children with ADHD scored higher on alilocomotor skills than their
younger peers with ADHD. Finally, the doubly-multivariate analysis on the 6 object control
skills revealed a significant overall effect of age as the older children with ADHD scored
significantly higher on aIl object control skills when compared with their younger peer group
(F(6, 15) = 3.06, p. = .0366). No other significant effects were revealed. Since there were no
significant differences for the within subjects factor on all four analyses, we did not accept the
hypothesis that the gross motor development quotient (GMDQ), the locomotor skill subtest
scores, and object control skill subtest scores on the TGMD-2 (Ulrich, 2000) would be
significantly higher for children with ADHD when they were receiving methylphenidate
(Ritalin) than when they were not receiving the medication ..
Children with and without ADHD. Ulrich (2000) created a descriptive scale to interpret
fundamental movement skill performance on the lGMD-2. The means for the movement skills
122
of children with ADHD can be described as "poor" to "very poor" while the same skills of
children without ADHD can be described as "average". Tables 5 and 6 provide the means,
standard deviations and effect sizes for locomotor skills and object control skills (See
Appendices L & M).
The first series of analyses revealed no significant effect of medication on the movement
skill performance of the boys with ADHD and no testing order effect on their skill performance
from the first to the second movement skiU assessment. The second set of analyses focused on
the movement skills of children with and without ADHD. The repeated factor, condition, for
these analyses was the movement skill assessment scores of children with ADHD when they
were receiving placebo or stimulant medication and the movement skill assessment scores of
children without ADHD on the two consecutive TGMD-2 trials. The 2 X 2 X 2 (Group x Age x
Condition) ANOVA with repeated measures on the last factor revealed significant effects of
group (F(l,40) = 63.61, p. = .0001) and age (F(l,40) = 4.10, p. = .05). Children with ADHD
consistently scored lower than their peers without ADHD. Generally, older children scored
higher on the GMDQ than their younger peers (See Figure 1, Appendix N). The results of the
univariate tests were similar (See Appendix 0).
Three subsequent analyses round similar results. An overall effect of group (F(2,39) =
28.09, p. = 0001) and an overall effect of age (F(2,39) = 14.4, p. = .0001) were revealed in the
doubly-multivariate repeated measures analysis for the total raw scores of the locomotor skills
and object control skills subtests. The results of the univariate tests were similar (See Appendix
P). The magnitude of the group differences on locomotor skills and object control skills were
also calculated by ES (See Table 5, Appendix L; Table 6, Appendix M). Group means (e.g.,
Mnoadhd - hladbd) and divided by the pooled standard deviation (Sp). Thus, ES = Mnoadhd - hladbJ
123
Sp. Again, Thomas and Nelson (2001) suggested the following guidelines for ES interpretation:
~ .2 (small), .5 (moderate) and ~ .8 (large). The effect sizes were large.
Next, there was an overall effect of group (F(6,35) = 12.1, p. = 0001) and age (F(6,35) =
3.53, p. = .0078) in the doubly-multivariate analysis for the 610comotor skills. The results of the
univariate tests were similar (See Appendix Q). Finally, the doubly-multivariate analysis on the 6
object control skills revealed an overall effect ofgroup (F(6,35) = 7.34, p. = .0001) and age (F(6,35)
= 5.53, p. = .0004). The results of the univariate tests were similar (See Appendix R). The
significant differences in locomotor skills and object control skills between children with and
without ADHD can be observed by the average number of performance criteria achieved by each
group in relation to the other and the maximum achievable skill performance criteria (See Figure
2, Appendix S; Figure 3, Appendix T). The average number ofperformance criteria attained for
each skill is presented in the parentheses (e.g., children with ADHD, children without ADHD,
maximum number of criteria per skill). The innermost curves for both locomotor skills and
object control skills illustrate the performance of children with ADHD which, for ail skiIls, fall
within the curves for children without ADHD. The children without ADHD do not meet full
criteria for each assessed movement skiIl, reaffrrming that movement skillievel was not a
criterion for inclusion in the control group. Clearly, the shape and depth of the movement skill
proftles for the two groups are quite different for both locomotor skills and object control skills.
Therefore, we accepted the hypothesis that significant performance differences in the qualitative
components of fundamental movement skills exist between children with and without ADHD
since these differences were found on aIl analyses.

124
Discussion
The effects of stimulant medication. The results ofthis study shed light on the movement
performance problems linked to children with ADHD. It was hypothesized that TGMD-2 scores
(e.g., GMDQ, individual and totallocomotor skills, individual and total object control skill
scores) would be significantly higher for children with ADHD when they were receiving
methylphenidate rather than not receiving it. The first hypothesis is not plausible since the results
indicated the stimulant medication had no significant effect on the fundamental movement skills
of children with ADHD.
These results suggest children with ADHD should be provided the opportunity to
participate in as many physical activities as possible in order to learn basic play skills like most
children oftheir age and gender. Thus, there should be few, if any, activity restrictions placed on
children with ADHD due to stimulant medication usage. The results also suggest that various
movement skill interventions, designed to improve the skilllearning and performance of children
with ADHD, may not be affected by stimulant medications. Thus, adapted physical activity
researchers need to explore the relationships between stimulant medication and different
intervention methods. For example, we concur with Pelham et al. (1990) who suggested the
study of sport performance with combined methods of nonpharmacological interventions and
stimulant medications. Yet, we also recommend the study of a number of factors, other than
stimulant medication, influencing the low skill proficiency levels of children with ADHD.
Children with ADHD often experience problems in relationship development and
prosocial behaviors (Litner, 1999) which may lead to few opportunities to engage in free play and
deliberate play contexts where many children spend large amounts of time developing specific
movement skills (Cote, Baker, & Abemathy, 2003; Cote & Hay, 2002). Thus, we suggest that the
125
children may lack necessary domain specifie practice time and instruction (Ericsson, 2003), with
various implications on movement skill acquisition and performance. For example, the children
may experience problems in sequencing various components of movement skills (Kowalski &
Sherrill, 1992; Wall, 1990). Furthermore, they may be unaware of the required need for shifting
levels of conscious control during various movement performance situations (Wall, McClements,
Bouffard" Findlay, & Taylor, 1985). Thus, there is most likely a mismatch between conceptual
knowledge about movement skills and performance ofmovement skills (Wall, 1990,2004), with
limited amounts of problem"'-solving capabilities (Bouffard & Wall, 1990). Similar to the typical
movement skill problems and limited self-regulated learning skills of children with developmental
coordination disorder (Reid, Harvey, Lloyd, & Bouffard, 2002), children with ADHD may be less
inclined to self-regulate their movement skilllearning and performance. Thus, we need to explore
how children with ADHD understand and learn to use their movement skills in the appropriate
play and sport situations.
However, the sensitivity of the measurement instrument and the sample size may have
been influential to our finding that stimulant medication had no effect on the movement skills of
the children with ADHD. Movement skill analysis with the TGMD-2 is conducted at a molar
level that may not be sensitive enough to pick up minute body segment changes that may occur
at an unobservable level of human action. Perhaps kinematical anal ysis of entire body segments
during movement skills may provide a finer grain of analysis and more insight to the effects of
stimulant medication on fundamental movement skills.
The sample size of 22 children with ADHD was small, with a 7-year age range. While the
sample size and age range are similar to the other process-oriented assessment of the movement
skills of children with ADHD (Harvey & Reid, 1997), we emphasize the results of the clinical
126
medication trials must be interpreted with caution due to the sample size. Statistical power was
considered in advance as part of the research design (Hall ahan & Rosenthal, 1996). In orderto
determine an appropriate number of participants, the researcher needs to estimate the parameters
of power, significance level, and effect size (Hall ahan & Rosenthal, 1996). The significance
level was set at .05 and the goal for power was .80. The estimation of an effect size was difficult
since no other research has presented effect size results about the effects of stimulant medication
on the qualitative components offundamental movement skills for children with ADHD.
However, the only available movement skill research (Wade, 1976), where effect size could be
calculated, suggested that there should be a medium effect of stimulant medication on specifie
movement skill performance. Since MANOV A procedures would be conducted for the
locomotor and object control skill total sub-test scores, a power analysis table was consulted
(Stevens, 1996) where it was estimated that a sample of 15 participants would provide adequate
power (.80) for a repeated measures analysis, with two repeated measures, a medium effect size
and alpha set at .05. Thus, we estimated that a sample size of 15 participants or more would be
necessary and our power would be adequate, given the use of repeated measures analyses where
each participant acts as her or his own control. The sample size of22 participants with ADHD
seemed reasonable, given the results of the previous research and the use ofrepeated measures
analyses.
The results of our study indicate that there was no effect of stimulant medication on the
components of the TGMD-2 movement skills since the actual effect sizes of the medication
treatment were small (e.g., .07, .16). The findings may be the result of the short time period in
which the movement skills were tested. For example, fundamental movement skills are
considered to be universal skills which most children develop (Burton & Miller, 1997), with an
127
understanding that tremendous amounts of deliberate practice time are required to develop highly
proficient movement skills (Cote et al., 2003; Cote & Hay, 2002). Thus, it may be beneficial to
assess the effects of stimulant medication on movement skilllearning and performance over an
increased time period. For example, a non-equivalent groups design (Creswell, 2003) could be
utilized where participants with and without ADHD are pre-tested on the TGMD-2 and then are
post-tested on the TGMD-2 periodically over the course oftime (e.g., 3, 6, and 9 months). AlI
children with ADHD would refrain from stimulant medication ingestion for a period of 48 hours
before the pretest, after which, they would resume taking their medication. This longitudinal
design would help to explore if the significant movement skill differences between children with
and without ADHD remain stable over time, with the medication factor taken into account.
Furthermore, there would be a high likelihood for increased power of the results due to larger
sample size or a longer assessment time frame (Kazdin, 1997; Stevens, 1996).
The power of the experiment was also small at 0.14. Since reduced power may lead to
making a type-II error, we suggest that future research should continue to examine the effects of
stimulant medication on the movement skills of children with ADHD in case a type-II error was
made. For example, if a similar study was to be conducted about the effects of stimulant
medication on other age-appropriate movement skills (e.g., baseball, hockey, football, golf, etc.),
we estimate that at least 80 participants would be required to achieve adequate power (.80), with
alpha set at .05 (Cohen, 1992; Stevens, 1996). However, it may be difficult to access such large
sampi es of children with ADHD (Harvey & Reid, 2003) and many years of data collection may
be needed to obtain large sample sizes. Other strategies to increase statistical power might be
required. Thus, it may be useful to collect data in multiple sites in order to increase sample size
(Harvey & Reid, in press).

128
The only significant effect observed in the first series of statistical analyses was for the
age factor as older children with ADHD performed better at locomotor and object control skills
when compared to their younger peers with ADHD. These results suggest that children with
ADHD may demonstrate developmental progression in movement skill performance, an
encouraging finding.
Chi/dren with and without ADHD. There were significant differences in the qualitative
components of fundamental movement skills between children with and without ADHD.
Therefore, the second hypothesis was accepted as plausible since the results indicated
significantly lower scores (e.g., GMDQ, total and individuallocomotor skills, total and
individual object control skills) for children with ADHD in both the placebo and medication
conditions when compared to children without ADHD. AlI analyses demonstrated significant
group and age effects. Unlike the stimulant medication trials, the effect sizes between children
with and without ADHD were large (e.g., ES range = 1.4 to 2.6), resulting in adequate statistical
power (e.g., ~ .80). Thus, more confidence can be placed in these results.
The significant differences between the groups lend added support to suggest children
with ADHD demonstrate qualitative movement skill difficulties in comparison with their peers
without ADHD (Harvey & Reid, 1997). Additionally, the significant effect of age illustrates that
older children performed fundamental movement skills better than the younger children in both
groups, strongly suggesting intragroup developmental progressions for both children with and
without ADHD. Thus, longitudinal observations of the movement and sport skills for children
with ADHD are recommended.
The present study improved on a number of methodological weaknesses of previous
research. First, acceptable levels of 80010 or greater agreement were found for interrater reliability
129
in the CUITent study. Next, it was difficult to generalize the findings of past research because of
small sample sizes with wide age range variability (Harvey & Reid, 1997; Miyahara et al., 1995;
Wade, 1976). Although the present study employed a small sample size, it was larger than the
other process-oriented assessment performed about the movement skills of children with ADHD
(Harvey & Reid, 1997). Also, the CUITent results should be considered as more robust than the
previous movement investigations since power was considered a priori and repeated measures
analyses were conducted. Finally, there has been minimal experimental control over independent
variables, like stimulant medication, in past physical activity research about ADHD (Harvey &
Reid, in press). The present study addressed this concem by utilizing a placebo-controlled design,
with a control group matched by (a) individuals on gender and age and (b) group on family income
level. While the reliability, use of repeated measures designs, and control of independent variables
may be viewed as strengths, there are two limitations to consider. First, all children with ADHD
also had leaming problems that may have affected the results (Lazarus, 1990). We speculate there
will be more substantial movement skill problems for children with ADHD and comorbid
disorders. Since comorbidity seems to be the norm rather than the exception for children with
ADHD (Szatmari, Offord, & Boyle, 1989), adapted physical activity researchers should further
explore the relationship of movement skill performance to children with varying levels of
comorbid psychopathology. For example, a relationship between participation and depressive
symptoms may exist as physically inactive children without ADHD, 8 to 12 years-old, were found
to be at an increased risk for depression (Thomson, Pangrazi, Friedman, & Hutchison, 2003). Since
converging evidence suggests children with ADHD perform movement skills poorly and
movement skills underlie participation in various activities, the movement skill performance of
children with ADHD may also be related to depressive symptomatology. Perhaps future research
130
could use movement skill perfonnance as a predictor of various comorbid disorders. The second
limitation to the present study was the inclusion of five children with and without ADHD who
were older than 10 years old, the eut-off age for the IGMD- 2. Yet the older children, who scored
poorly on the GMDQ, could be considered as having significant movement skill problems given
their age.
The current study demonstrates that children with ADHD may be at risk for developmental
delays in fundamental movement skill perfonnance. Thus, they may be experiencing problems
associated with the developmental skill-Iearning gap hypothesis. Wall (2004) suggests that children
with less physica1 skill may be affected by a developmental skill-Iearning gap where the children
experience minimal success and few opportunities to participate in physical activity. Limited
amounts of declarative knowledge about action and minimal movement experiences may lead the
child with less physical skill to decreased perfonnance ability as the environmental and other
situational demands increase in various movement contexts. The skill proficiency gap between
children with more physical skill and their peers with less physical skill would increase over time.
For example, the more skilled person becomes a highly proficient moyer as a result of more
experience in more complex tasks while the less skilled person continually attempts to master the
basic components of specific tasks.
Furthermore, there is little empirical data available about specific patterns of recreational
and sport behavior for children with ADHD. For example, there is no information available to
suggest that children with ADHD attempt to regulate their own movement behaviors. Again, it is
simply not known ifthey possess factual information necessary to successfully complete
fundamental movements or sport specific skills, nor to know when to use these skills in the
appropriate movement contexts. Yet, sorne children with ADHD may excel in sport skills
131
(Harvey & Reid, 2003) and it will be important to explore relationships between sport
performance and ADHD. However, children with ADHD, who possess highly proficient
movement skills and take prescribed stimulant medications, will most likely come under
increasing levels of scrutiny with age and the level of competition. For example, Hickey and
Fricker (1999) state that athletes with ADHD may discontinue medication use within a short time
frame before competitions (e.g., 24-48 hours) so their blood tests would not test positive for
banned substances at sporting events. However, elite athletes with ADHD might still be
perceived as receiving an unfair competitive advantage. It may prove useful to develop a list of
sports that may be provided with a direct physiological benefit (e.g., performance time in 100 m.
run) rather than an indirect psychological benefit (e.g., improved attention while driving Grand
Prix race cars) with the use of stimulant medication. In tum, sorne athletes with ADHD may
argue that they are put at a disadvantage when disallowed their medication. Thus, there are many
opportunities to explore the construct of self-regulation in relation to varying levels of ADHD.
In conclusion, this study demonstrated no significant effects of stimulant medication on
the movement skill patterns of 22 children with ADHD. The findings provided support for the
growing body of evidence that suggests the movement skills of children with and without ADHD
are significantly different. Yet, more well-controlled research is clearly needed to compare the
movement skills of children with and without ADHD. For example, future research needs to
provide more-evidence of the process-oriented differences in skill performance and identify
explanations for the performance difficulties. An exploration of extraneous factors on skill
performance and the quaIity of physical activity patterns is aIso needed in order to develop a better
understanding of the movement skills of children with ADHD. Piecing together the puzzle of the
movement problems associated to persons with ADHD may lead to a greater understanding of
132
their learning processes and perfonnance abilities, in turn, leading to improvements in adapted
physical activity service delivery and professional perceptions of persons with ADHD and their
unique physical activity needs.

133
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Chapter four was a placebo controlled and double blind study that indicated stimulant
medication had no significant effect on the movement skill patterns of children with ADHD.
Repeated measures analyses revealed significant performance differences between children with
and without ADHD (p ~ .001). The next research study, chapter five, is the final manuscript of
four original papers that explore the relationship between ADHD and physical activity. It was also
designed on the basis of the information provided in the two preceding review papers. The study is
the first time that a mixed method research design was used to explore the physical activity
experiences ofboys with ADHD. There were seven co-authors and their relative contributions
were as follows. As first author, 1 was responsible for 80010 of the manuscript and involved in all
aspects of the research, data collection, interviewing, coding, analyses, writing and editing of the
manuscript. Dr. Greg Reid was responsible for 5% of the work involved by ensuring the reliability
of the research process, with multiple reads of the text, editing and suggestions for text
improvement. Dr. Gordon Bloom and Ms. Kerri Staples contributed 5% ofworkload by
providing theoretical understanding of qualitative paradigms and practical feedback on important
issues of coding, interpretation and trustworthiness. The remaining 100/0 of the work was shared
by Natalie Grizenko, Dr. Valentin Mbekou, Mrs. Marina Ter-Stepanian and Dr. Ridha Joober.
The contributions of aIl four co-authors were the same as stated in chapter fOUf. Again, they also
provided feedback on the text as part of this collaborative process.

142
Chapter Five
Physical activity experiences ofboys with and without ADEID
Co-authors: William J. Harvey, Greg Reid, Gordon Bloom, Kerri Staples (McGiU University),
Natalie Grizenko, Valentin Mbekou, Marina Ter-Stepanian, and Ridha Joober (Douglas
Hospital)
Abstract
Similarities and differences in physical activity experiences ofboys with and without attention-
deficit hyperactivity disorder (ADHD) were explored by converging information from movement
skill assessments on the Test of Gross Motor Development (Ulrich, 2000), semi-structured
interviews, and discussions with parents. Six boys with ADHD conveyed many different
experiences than age-matched peers without ADHD. The results indicated boys with ADHD
were not as proficient movers as their peers without ADHD. As weIl, qualitative analysis
resulted in the creation ofthree categories: (a) deliberate play, (b) knowing about doing, and (c)
personal feelings. Taken together, the findings revealed that boys with ADHD had inadequate
attention to detail, superficial knowledge about movement skiIls, and negative feelings about
physical activity. The findings enabled a deeper understanding of skill performance and ADHD.
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Physical activity experiences ofboys with and without ADHD
Excessive movement and persons with attention-deficit hyperactivity disorder (ADHD)
have a long-standing historicaI connection. The German author, Heinrich Hoffman, wrote one of
the earliest known references to ADHD in 1865 with his poem "Fidgety Phil" about a boy with
behavior and attention problems who could not stay still (Miyahara, Mobs, & Doll-Tepper, 1995).
Barkley (1998) stated that excessive activity was important to understand hyperactivity, the term
used for ADHD during the time period of 1960 to 1970, because a state of constant motion was a
key element of the accepted definition ofhyperactivity at that time (Chess, 1960). The definition
"emphasized activity as the defining feature of the disorder, as other scientists of the time would
aIso do" (Barkley, 1998, p. 9). However, greater emphasis has been placed on deficits in attention
and a lack of self-control to define ADHD overthe past few decades (Barkley, 1997, 1998;
Douglas, 1999).
Yet, excessive movement continues to be a haIlmark of the ADHD definition from the
Diagnostic and Statistical Manual ofMental Disorders, or DSM-IV-TR (APA, 2000). Six
hyperactive symptoms are currently used in the DSM diagnostic framework; often fidgets with
hands or feet or squirms in seat, often leaves seat in c1assroom or in other situations in which
remaining seated is expected, often runs about or c1imbs excessively in situations in which it is
inappropriate, often has difIiculty playing or engaging in leisure activities quietly, is often "on the
go" or often acts as if"driven by a motor", and often taIks excessively. While these symptoms are
related to behavior in generaI, they are not linked to specific movement skills in physical activity
contexts. Thus, for the purposes ofthis paper, we distinguish between movement-related behaviors
and movement skills. Movement-related behaviors have a personaI-social nature where there is
limited goaI-directed movement associated with performance (Keogh, 1978) while movement
144
skills are observable, goal-directed movements that can be described in quantitative or qualitative
terms (Burton & Miller, 1998). For example, there is a difference between standing up and moving
around the room while waiting for a tum in agame of monopoly (e.g., movement-related behavior)
and using an overhand throw to propel a baseball towards homeplate to strike out a batter (e.g.,
movement skill). Appropriate movement-related behaviors, as typified in the DSM-IV- IR, serve a
much needed social purpose that many children with ADHD may lack. However, these behaviors
are not the same as specifie movement skills. Thus, the traditional focus on excessive activity as a
core component of ADHD may have hampered the investigation of the movement skills of
children with ADHD (Harvey & Reid, 1997).
Converging evidence suggests a considerable number of children with ADHD demonstrate
difficulties when performing locomotor and object control skills (Harvey & Reid, 1997~ Harvey et
al., in review~ Hodge, Murata, & Porretta, 1999). They also may lack the ability to regulate their
skill performances in different movement contexts, especially in competitive situations (Harvey,
Fagan, & Kassis, 2003). Barkley (1997) developed the inhibitory model of executive functions to
describe relationships between the cognitive system and human behaviors vital for self-
regulation. For example, individuals usually take necessary and adequate reflection time when
planning and making decisions in relation to their behavior. However, Barkley suggested
children with ADHD have difficulties in self-regulation and, more specifically, they may
experience an inability to proceduralize (e.g., perform) their declarative knowledge (e.g.,
personal facts and acquired knowledge about performance). In other words, "ADHD is more a
problem of doing what one knows rather than ofknowing what to do" (Barkley, 1997, p. 335).
Starkes, Helsen and Jack (2001) suggested the combination ofpersonal knowledge and
movement skill development to better understand the performance of movement skills which, in
145
tum, underlie sport performance. Thus, personal knowledge is an important factor that facilitates
skill performance and expertise, with a strong emphasis placed on the individual's tlexibility of
linking performance and knowledge (Wall, Reid, & Harvey, in press). Yet, there is little
information available to suggest that children with ADHD possess the factual information
necessary to successfully complete movement skills, or when to proceduralize their declarative
knowledge about action in appropriate movement contexts (Harvey & Reid, 2005).
The knowledge-based approach (Wall, McClements, Bouffard, Findlay, & Taylor, 1985)
was used as the gui ding theory, or theoreticallens, for this study since it is a significant
conceptual framework in adapted physical activity (APA) research (Reid, 1992). It is a unique
theoretical blend of developmental, educational and sport psychology that emphasizes the
importance of developmental factors, theories of expertise, and self-regulation for the individual
acquisition ofmovement skills (Wall et al., in press). For example, expertise research suggests
the importance of an individual' s ability to identify salient cues from the physical environment
and their own movements in order to perform in a more proficient manner (Wall et al., in press).
In fact, it is this attention to detail that distinguishes novice and expert performers (Ericsson,
2003). The theory was linked with the inhibitory model of executive functions (Barkley, 1997)
by exploring a movement-based relationship between declarative knowledge and procedural
knowledge of children with and without ADHD. For example, taking the necessary time to
retlect on movement skills, which may be a difficulty for sorne children with ADHD, is a factor
related to an awareness of the important metacognitive skills of error deduction, planning, and
monitoring of actions (Bouffard & Wall, 1990). Since both theories are linked to subjective
feelings about action, or affective knowledge (Wall et al., 1985), feelings about physical activity
experiences were also explored in the current study. Furthermore, these theories share many
146
important commonalities such as the value of a developmental perspective, the role of language
in child development and cognitive functioning, and a sharing of much technicallanguage. Thus,
a deep understanding of the relationship between ADHD and physicai activity was sought in the
present study.
This exploratory study was aiso deemed necessary since there have been few attempts to
understand various influences on the movement skill performance of children with ADHD (Harvey
& Reid, 2003). For example, Harvey and colleagues (in review) found methylphenidate (Rital in)
had no significant effect on the movement skill patterns of 22 children with ADHD, between the
ages of 6.6 to 12.5 years, who were assessed on the Test of Gross Motor Development-2, or
TGMD-2 (Ulrich, 2000). However, several recent motor control studies suggested that stimulant
medication improved (a) fine motor skills and reaction times (Shephard, Bradshaw, Georgiou,
Bradshaw, & Lee, 2000) , (b) performance on lower leg response times (Pedersen, Surburg, Heath,
& Koceja, 2004), and (c) gaze frequency on a ping pong task (Vickers, Rodrigues, & Brown,
2002).
Parents and teachers of children with ADHD have aIso suggested that the children have
poor movement and sport skills (Harvey et al., 2003; Rasmussen & Gillberg, 1983; Szatmari,
Offord, & Boyle, 1989). Yet, children with ADHD have not spoken about their perceptions of
movement skill proficiency and involvement in play, physicai activity, and sports. Thus, it seems
that children with ADHD have not been given the opportunity to have their physical activity voices
heard. Consistent with a postmodern tradition, it was reasoned that a qualitative study would
enable a better understanding of the daily physical activity experiences of children with disabilities
and the contextual meanings associated with physical activity (Goodwin, Krohn, & Kuhnle,
2004). A qualitative research approach was considered beneficial since qualitative studies aIso
147
shed light on process-related questions or why something happens (Merriam, 1990). Therefore,
the purpose oftbis study was to explore the physical activity experiences of children with and
without ADHD. The central question posed in tbis study follows. What are the similarities and
differences in the physical activity experiences of children with and without ADHD?
Method
Participants
Twelve boys with and without ADHD, ages 9 to 12 years, participated. The six boys with
ADHD were part of a larger clinical investigation about the effects of stimulant medication on
various behaviors of children with ADHD at an urban Canadian psychiatrie hospital. Each child
with ADHD had a formaI DSM-IV diagnosis of ADHD made by a qualified child psychiatrist
(Labeyet al., 1994). Identification of each child with ADHD was also based on consensus
between two child psychiatrists on a variety of diagnostic information that included the parent
report of the Diagnostic Interview Schedule for Children, computerized version~ or DISC-IV,
(National Institute of Mental Health, or NIHM, 1998)~ the Child Behavior Checklist (Achenbach,
1991)~ the Conners Global Index Parent Questionnaire, or CGI-P (Conners, 1997a)~ and the
Conners Global Index Teacher Questionnaire, or CGI-T(Conners, 1997b). ). AlI boys with
ADHD were diagnosed with the combined subtype of ADHD. Thus, all the boys with ADHD
had behavioral problems. They were also identified as having generallearning problems as
indicated by reports of clinical psychologists. Thus, the sample is best described as purposive
and unique since children with ADHD were sought (Merriam, 1998). Ali children with ADHD
were medicated with methylphenidate during the study.
Each boy with ADHD was matched by age (+ 6 months) to a boy without ADHD from a
local elementary school. AlI boys were between the ages of9.7 and 12.5 years to improve the
148
reliability of verbal reports given their age (Schneider & Pressley, 1997). The average age for the
boys with ADHD was 10.9 years while the average age oftheir peers without ADHD was 11.1
years. There was an average age difference of 3.2 months ai the time of interviewing.
The six boys without ADHD were identified by the physical educator and classroom
teacher as having no major cognitive, behavioral, emotional, or learning difficulties and were
considered of average intelligence. One parent of each control participant was interviewed on the
DISe-IV (NIMH, 1998) and the CGI-P (Conners, 1997a) to provide more information and rule
outADHD.
To ensure individual understanding of the interview questions, the 12 children
demonstrated a total IQ score of 70 or greater on the Wechsler Intelligence Scale for Children, or
WISC-III, (Wechsler, 1991). The IQ scores ofboys without ADHD were calculated with a short
form version of the WISC-ID (Donders, 1997). The IQ scores for boys with ADIID ranged from
88 to 117 (M = 100.2) and the IQ scores for boys without ADHD ranged from 88 to 127 (M =
110.7). University, hospita~ and school board ethics approval was received, with informed
consent obtained from the participants and their parents, prior to data collection.
Movement Skill Assessment
AlI participants were tested on the TGMD-2 (Ulrich, 2000) which includes six locomotor
skills (e.g., run, gal10p, hop, leap, horizontaljump, and slide) and six object control skills (e.g.,
striking a stationary baIl, stationary dribble, catch, kick, overhand throw, and underhand roll).
The test is designed for children 3 to 10 years (Ulrich, 2000). There are three to four
performance criteria on each of the 12 movement skills. Two test trials were administered per
movement skill (Ulrich, 2000). A mark of 0 (absent) or 1 (present) was scored for each
performance criterion observed on each of the 2 trials. These marks were then added to obtain a
149
raw score for each individual skill. The raw scores were summed to obtain separate subtest
scores for locomotor skills and object control skills. The raw scores of all 12 movement skills
were then added to produce a total score which, in turn, is converted into the Gross Motor
Development Quotient or GMDQ (Ulrich, 2000). AlI TGMD-2 assessments were videotaped
with a SONY Mini DV Digital Handycam (DCR-TRVI8 NTSC) video recorder.
Interview
The initial plan was to use a completely open-ended interview approach and inductive
data analysis (Denzin & Lincoln, 2000; Sparkes, 2003). However, pilot interviews indicated that
children with and without ADHD, between the ages of9 and 12 years, could not articulate specific
examples when asked open-ended questions about their physical activity experiences. Thus, an
interview guide was created to assist children to talk about their physical activity experiences (See
Appendix U). The 17 questions in the guide were developed from both the Physical Activity
Monitor Questionnaire, or P AMQ (Craig, Cameron, Russell, & Beaulieu, 2000) and theories of
expertise (Wall et al., 1985). The PAMQ represented the most current information about the
physical activity experiences of Canadian children at the time of data collection. Theories of
expertise, underlying the knowledge-based approach (Wall et al., 1985), provided insights to the
physical activity experiences of the children. The complete interview guide was reviewed by three
experts in physical education (e.g., 3 university professors with doctoral degrees in physical
education [PE], with a minimum of 10 years PE teaching experience at the university level and
qualitative research experience). After full agreement was reached with the expert panel on the
final format of the interview guide, interviews were conducted with 2 of the original 4 pilot
participants to verify if the children would respond to the new interview format. They spoke in
detail about their individual physical activity experiences. The fIfst author verified the accuracy
150
of individual responses with one parent of each child in a telephone interview format and, since
the approach was deemed successful, the interview guide was then ready for use with the study
participants.
A sequential mixed methodology was used in the development and application of the
interview guide (CresweIl, 2003), with a mixture ofhighly structured questions (e.g., Likert
scale) and less structured questions. Schneider and Pressley (1997) suggested a successful two-
part strategy for interviewing children. The approach began with structured questions that were
designed to acquire descriptive information about a participant' s prior knowledge and was
followed by less-structured questions that were designed to acquire deeper levels ofknowledge.
Twelve highly-structured questions focused on individual participation in, and
preferences for, specifie individual and group activities as weIl as various aspects of play (e.g.,
the time spent in play, practice habits, observationallearning, etc.). Probes, or follow-up
questions, were created to provide clarity and more information about individual responses
(Merriam, 1998). Thus, the boys were probed for examples of games (question 2), targets
(question 10), domain-specifie vocabulary (question Il), modeling (question 12) and about the
rationale for their choices (e.g., why do you like tbis game, targe!, model, etc.).
A less-structured approach was used for the five other questions (See questions 7, 8, 15,
16, & 17). For example, open-ended questions inquired about methods of practicing games (See
questions 7 & 8) and personal feelings about PE (Questions 15 to 17). Questions 15 and 16
inquired about individu al positive and negative feelings about PB. The boys spoke about their
individual feelings towards activities and peers in PE c1ass. Furthermore, follow-up probes were
asked to c1arify individual responses to questions 15 and 16.

151
Data Analysis
There were two levels of data analysis (Merriam, 1998). First, each interview was treated
as part of a comprehensive within-case analysis where the researcher learned as much as possible
about the individuals at each site (e.g., hospital & school) to build a separate profile of
abstractions for each group ofboys. Second, a cross-case analysis was performed where the
researcher compared their experiences.
Verbatim transcriptions were performed on the open-ended questions and probes. A line-
by-line analysis was conducted where similar words and phrases were identified as data units
(Merri am, 1998). Similar data units were then labeled with tags to reflect their underlying
meaning (Côté, Salmela, & Russell, 1995~ Ryan & Russell Bernard, 2000). There were 17 tags
identified for the 2,188 data units. Similar tags were grouped together to form properties which,
in turn, formed dimensions ofhigher abstract categories (Côté et al., 1995). Thus, there is a
resultant increase in the magnitude of abstract conceptualization from data units to categories.
These categories were reflective of the expertise lens (Wall et al., 1985), guiding interpretations
in this study. The categories, properties, and sample data units are provided in Table 1 (See
Appendix V).
Trustworthiness
Various methodological procedures may be incorporated in qualitative research designs
to gain the reader's trust of the research findings (Brantlinger, Jimenez, Klingner, Pugach, &
Richardson, 2005). For example, the strategie use of triangulation, member checks, and explicit
statements of the researcher' s biases helped demonstrate the trustworthiness of the research
(Brantlinger et al., 2005~ Merriam, 1998~ Sparkes, 1998,2003).

152
The tirst component of trustworthiness was the triangulation of data, or the use of various
data sources, to help establish the internaI validity ofthis study and provide a holistic
understanding of the phenomenon ofinterest (Brantlinger et al., 2005; Merriam, 1998). More
specifically, three sources of information described the physical activity experiences of the boys
with and without ADHD. For example, the fundamental movement skillievei of each child was
identified by their performance on the TGMD-2 (Ulrich, 2000). Next, the 17-question interview
was coIiducted. The final source of information for data triangulation was parental input. Each
parent was asked to complete various questions based on the 2000 P AMQ (Craig et al., 2000) to
gain a more complete description of the physical activity experiences of children with and
without ADHD.
The second component oftrustworthiness was child and parent member checks, where
they confirmed the accuracy of the summary statements and interview, important for establishing
internaI validity (Brantlinger et al., 2005; Merriam, 1998). For example, the content of each
interview was summarized into a single page summary statement and read back to each child
within three to four days after the conclusion of the interview. Each individual was provided the
opportunity to verify the accuracy of the summary statement and to add·or deleteany
information they felt necessary. Furthermore, each child' s summary statement was made
available to a parent so she or he could verify the accuracy oftheir child's verbal reports.
The third and final component of trustworthiness for tbis study was a description of the
primary author' s life experiences and bis underlying assumptions about movement skill
performance and ADHD as they guided and molded the methods and interpretations ofthis
exploratory study. Biographical information was shared because his lived experience lends
credibility to the interpretations of the cbildren's interviews but the accuracy and trustwortbiness of
153
interpretation May be justifiably questioned (Sparkes, 1998, 2003). The openness, honesty and
credibility of the research May also be questioned due to the mixed methodological approach.
As the primary author, 1 am a Caucasian male, who has been a life-long resident of the
same working neighborhoods as the participants. My childhood background was similar to Many
of the participants. For example, 1 lived and went to elementary school and high school within an 8
city block radius ofboth data collection sites. In fact, some parents of the participants were in my
elementary and high school cohorts. Our family income level and social status would match Many
of the participants' families. There is little doubt that 1 am familiar with Many local mannerisms,
colloquial expressions and physical activity practices. 1 also performed three years ofPE teacher
training in this same geographical area. Thus, 1 possess extensive first-hand knowledge of the
specific culturally-normative skills and habits relative to this well-defioed area. As an adult, 1
continue to live in this same community. Moreover, 1 taught PE to children with ADHD for
approximately 12 years. This variety of experiences about children with ADHD leads to the
contention of a trustworthy research instrument.
Results
The results of the movement skill assessment and interview data were compiled
concurrently. The movement skill assessment was conducted to indicate individual and group
movement skill proficiency levels. First, information from the 12 interviews was gathered
individually and Likert scale responses were then averaged. Next, transcriptions were coded into
data units and developed into categories of physical activity experience. This sequential pro cess
led to a deeper understanding from a narrow focus on specific physical activity information (e.g.,
structured questions) to a general exploratory approach about personal physical activity

154
experiences (e.g., less-structured questions). The results are reported in a similar sequential
manner to remain consistent with the analytic process.
Movement Ski/l Assessment
The fundamental movement skills of the boys with and without ADHD were assessed on
the TGMD-2. Interrater reliability was established on the videotaped TGMD-2 skill
performances, with Kappa (Cohen, 1960) strong for locomotor skills, (K = .99), object control
skills (K = .99) and the Gross Motor Development Quotient (K = .99) as reported in a prior study
(Harvey et al., in review). The boys with ADHD were not as proficient movers as their peers
without ADHD (see Table 2, Appendix W). Note that an names used in the text and Table 2 are
fictional to ensure participant confidentiality. Common names for males were used to keep a
human touch to the boys' stories. According to the descriptors provided in the TGMD-2 (Ulrich,
2000), the overall fundamental movement skill performance of the boys with ADHD ranged
between poorto average (e.g., Gross Motor Development Quotient, or GMDQ), with below
average to poor locomotor skills and average to very poor object control skills. The overall
fundamental movement skills of the boys without ADHD ranged from average to above average,
with average to above average locomotor and object control skills.
Interview
Each Likert-scale question was averaged to compare responses between the boys with
and without ADHD. There were 2,188 data units for all of the transcribed interview data, with
1,044 data units forthe boys with ADHD and 1,154 data units for the boys without ADHD. The
complete transcriptions of four participants, two boys from each group, were randomly selected
. for peer review by a graduate student in adapted physical activity. Thus, 570 data units (26.1 % of
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total data units) were recoded for interrater reliab ility, with 81. 6% complete agreement reached
(e.g., 465 of570 data units).
Each category is described below with specifie references made to the appropriate
properties. The first category was named deliberate play to convey the importance of play in the
development ofmovement skill proficiency (Côté, Baker, & Abemathy, 2003; Côté & Hay, 2002)
and reflect the deliberately planned activities of the six boys without ADHD. Both groups spoke
about different types of play experiences. For example, the boys indicated who they played with
and where they played (e.g., solitary play, group play, no play and play settings). The second
category was labeled knowing about doing as the boys spoke about their skill performance and
learning (e.g., leisure skills, movement skills, modeling, game situations, personal theories, and
self-awareness). The third category was called personal feelings where the boys spoke about
their feelings related to physical activity skills and activities (e.g., positive, negative affective
responses and prosocial, asocial behaviors). AlI data units were summed to support the
observations and comparisons made in each categorical analysis (See Tables 3,4, & 5;
Appendices W & X). Responses on the 12 Likert scale questions were also noted for each
individual and averaged for each group.
Of interest, a fourth category was named "other" for data units and properties that did not
fit into the three categories named above. First, data units reflected the transition between
thoughts property if participants required additional interview time to gather their thoughts.
There were a similar number of data units for the groups (ADHD = 72, No-ADHD = 81). Next,
the clarifications property included data units where a participant asked a question during the
interview or responded with either a yes or no to the interviewer' s attempt to clarify a point. The
boys without ADHD sought more clarifications than their peers with the disorder (ADHD = 306,
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No-ADHD = 451). Finally, sorne data units indicated a person was not responding to the posed
question. This "off-task" property illustrated, to no surprise, the boys with ADHD were off-task
more often during the interviews (ADHD = 33, No-ADHD = 5). This category did not contribute
overall to the understanding of the boys' experiences but it was important to observe because
both groups of boys had approximately the same amount of total data units (ADHD = 1,044, No-
ADHD = 1,154). This might not have been expeeted, given excessive talking and off-task
behaviors are typical of children with ADHD (AP A, 2000). While the boys with ADHD were
more off-task during the interviews, they did not talk more than the boys without ADHD. In faet,
they spoke slightly less, indicating that excessive talking did not affect the results.
Deliberate Play. Questions one to nine explored the children' s perceptions of individual
aetivity preferences, participation in various activities, organizational aspects of play, and
participation time. There are three major similarities between boys with and without ADHD.
First, most of the boys did not consider their formaI and informaI physical aetivity time as
practice. Instead they referred to this time as play; a fin ding consistent with the retrospective
views of experts who recalled their childhood physical aetivity experiences (Côté et al., 2003).
Next, aIl boys were asked to indicate which individual activities and group activities they played,
at least once, within the last 12 months, and how much they liked playing this activity. Most of
the boys had participated in all of the activities in the past 12 months. However, the boys with
ADHD reported a greater preference for and participation in individual aetivities (e.g., swings
and slides, bicycling, swimming and roller-blading) than their peers without ADHD who, in turn,
preferred and participated in more group aetivities (e.g., hockey, football, and basebaIl). FinaIly,
both groups ofboys reported that they took part in PE class in school most of the time (ADHD
M = 5.0, No-ADHD M = 4.8).

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The Likert-scale questions revealed more differences between the groups. The boys with
ADHD spent approximately 30 minutes less time in daily physical activity than boys without
ADHD as indicated by both the child and parent questionnaires. The children with ADHD also
reported the organization offewer activities (ADHD avg. = 3.8; No-ADHD avg. = 4.3),
engagement in less spontaneous play (ADHD avg. = 3.5; No-ADHD avg. = 4.3), and
participation in fewer organized sports compared to the boys without ADHD (ADHD = 2/6; No-
ADHD=4/6).
In relation to the less-structured questions and probes, the boys spoke about times and
places where they played or practiced their movement skills alone, with friends, not at all or in
specifie physical activity settings. Table 3 illustrates the number of data units for the four
different properties of deliberate play (See Appendix W). The boys with ADHD made more
references to playing with peers. Yet they also indicated that they often play alone whereas the
children without ADHD made no such references. The boys without ADHD differed from their
peers with the disorder because they referred more to a variety of physical activity settings that,
in tum, linked their practice and play experiences with substantial involvement oftheir family or
friends. For example, Mike without ADHD mentioned, "WeIl, 1 don't usually practice by myself
1 take my sister or my mom. Because, for most of the sports you need more than one person to
practice" .
Knowing about Doing. The knowing about doing category is related to questions 10 to
12, where the children were asked about various dec1arative knowledge factors that may have
affected skiIl performance. Table 4 illustrates the number of data units for the knowing about
doing category and the interviews indicated many differences in dec1arative knowledge about
physical activity (See Appendix X).

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The boys with ADHD spoke about their lei sure skills, the first property of knowing about
doing, when they mentioned playing cards and creating make-believe games with their siblings
while the boys without ADHD did not refer to leisure participation. The second property of
knowing about doing was movement skills where data units reflected general descriptions of
movement skill performance, including examples and explanations about special practice targets
during play and specific vocabulary for particular actions (e.g., domain-specific terms). The boys
with ADHD reported that they often use targets to practice (M = 3.0) whereas boys without
ADHD responded that they do not use targets very often (M = 2.2). However, as specified during
the probes, the practice targets of the boys with ADHD were often associated with inappropriate
social behaviors like throwing objects at others in an aggressive manner. For example, Larry
with ADHD mentioned that his special target in football is to get someone to stand up so he
could throw a football to hit the person. On the other hand, the boys without ADHD used more
socially desirable and appropriate practice targets. For example, Jim without ADHD spoke about
his football experience. "WeIl. 1 take a bucket and 1 hang it to the fence and shoot a football
through it". When asked for clarification, he responded, "1 said 1 take a bucket, 1 shoot football in
it. Sometimes 1 run to shoot the football in it, cause just in case there' s somebody rushing you".
When the issue was probed further, he stated, "Like say if someone' s running after you and you
are like trying to shoot the baIl. You are going to have to run left if he is coming at you by that
way (points to his right), so you're gonna have to shoot it diagonaIly". Jim mentioned, after his
summary statement, that he tries to practice just like he plays in agame. Thus, while the
participants with ADHD reported the greater use of practice targets in play than their peers
without ADHD, our discussions indicated that the targets were often socially inappropriate.
159
The boys without ADHD used more domain-specifie vocabulary than their peers with
ADHD (No-ADHD M = 2.8, ADHD M = 2.0). The differences between the groups were
associated with the depth and use of the action tenns articulated. The boys with ADHD reported
knowing specifie action tenns but they either did not use them or forgot the words entirely. For
example, Bob with ADHD stated,
"WeIl like the meaning of slap shot. 1 know what it means, but yeah sometimes l'Il use
words like that, but that' s the only thing. Like in football people say dive and 1 know
what it means but 1 don't use it. When 1 try to tell somebody something 1 don't reaIly use
special words".
Furthermore, Randy mentioned, "WeIl sometimes 1 name sorne of my things like 1 give it a name
and afterwards 1 forget the name that 1 give it. So 1 have to give it a new name over and over and
over and over and over". Y et, the boys without ADHD knew and used many specific action
tenns in the appropriate contexts. For example, Chad without ADHD used the tenn Cross 34 and
after being asked what the word meant to him, he elaborated:
"Yeah. There's two running backs in the back (field) and the first goes tbis way (motions
across the table with his left hand) so the defence tbinks l'm going to go tbis way
(motions right hand in same direction as the left hand) but l'm going tbis way (motions
right hand across table and left arm in opposite direction)".
Jim without ADHD aIso used football-specific tenninology. He stated, "Only when l'm playing
with my mend Tom cause he tells me plays to do. And 1 just go down like, say in, it's like a
post pattern. It tells you to go up and turn right or on the left side, turn left".
The third property of knowing about doing was modeling. The boys without ADHD
reported watching someone play a game very often (M = 4.0) to learn how to play and improve
compared to boys with ADHD (M = 3.5). Data units reflected either a general observation of a
group of people playing agame to improve movement skills or a specific focus on the
performance of an individual person, or a particular group of people, to improve movement skill

160
performance. There were a similar number of data units from both groups about the general
observation of models to learn movement skills. However, the boys without ADHD made
approximately 50% more references to the specific observation of particular models than the
boys with ADHD. For example, the boys with ADHD mentioned they would watch a sport on
television but not usually observe any one specifie person as frequently as the boys without
ADHD. The boys without ADHD observed specifie learning models (e.g., mother, siblings, sport
celebrity) and provided the reasons for selecting these people to watch. For example, Dale
watched his oIder brother play hockey because he was leaming how to perform body checks.
AIso, he mentioned the observation of a teenager, a 15 year-old elite hockey player, because that
person was good at stick-handling and checking. Bob without ADHD also provided sorne deep
insight about his observationallearning practices. "After 1 play, it's a lot ofgames, there's
another team that plays after me, an older team and 1 watch them play and 1 see how they use the
stick and shoot. They're older than me and better skilled". When asked for clarification, he
replied, "Yeah. 1 don't watch someone with lower skills than me because 1 won't learn that
much". Thus, the boys with ADHD seemed unaware of the benefits of observation to skill
improvement.
The question about observational learning sometimes led the participants to imagine
themselves in different game situations, the fourth property of knowing about doing, and
personal theories, the fifth property. The two groups ofboys made a similar number of
verbalizations about game situations and personal theories. For example, the boys with and
without ADHD recalled (a) play or game situations, with reference to the specifie movement
skills they used or were trying to learn and (b) causal attributions for practice effects on
performance.
161
The sixth and final property of knowing about doing was self-awareness where data units
reflected an awareness of individual skilllevels, game regulations and action strategies. There
were a similar number of data units for both groups about self-awareness. Overall, the self-
reflections accurately reflected the individual skiIllevels of the boys with and without ADHD on
the movement skill assessment. For example, the fundamental movement skills of boys with
ADHD ranged between poorto average on the GMDQ. Randy's performance on the TGMD-2
was described as below average in locomotor skills and average in object control skills (See
Table 2, Appendix W). He knew that he could not perform movement skills like many peers of
bis own age group. In fact, he stated, "1 know how to catch a baIl and throw a baIl, but
sometimes when 1 throw, it doesn't go far because, like in a baseball game, 1 have to throw the
ball to somebody. 1 can't throw it that far." Bob's performance on the TGMD-2 was described as
below average in locomotor skills and poor in object control skills (See Table 2, Appendix W).
He knew that he was less proficient in sport skills when compared to bis friends. "My friends
like soccer and 1 like playing soccer, but l'mjust not good at it. 1 like playing. l'Il play. It doesn't
bother me, but l' m not good at it."
The overall fundamental movement skills of the boys without ADHD on the TGMD-2
ranged between average to above average and their statements reflected their individual skill
levels. For example, Fred's performance on the TGMD-2 is described as above average in
locomotor skills and average in object control skills (See Table 2, Appendix W). He compared
bis movement skills to his peers in the following way. "It depends what l'm playing. Sometimes,
weIl the same or better". Furthermore, he also knew that parts of skill performance may be
automatized. For example, Fred remembered domain-specific terms for particular moves but
then forgot the terms after being accustomed to performing the related actions. While aIl of the
162
boys without ADHD referred to their movement skilllearning strategies, most of their peers with
ADHD (e.g., 5 of6 boys) did not do so during the open-ended interview questions. In contrast to
the boys with ADHD, the boys without ADHD deliberately planned specifie practice procedures
to improve their play skills. For example, Chad without ADHD spoke about throwing a football
at a black mark on a park fence and a basketball into plastic bins to deliberately improve his
throwing and shooting accuracy.
Another interesting difference between the boys with and without ADHD was
observed in question 14 where they were asked to compare their movement skills to other
children in their PE classes. The boys without ADHD reported their skills to be the same
or better when compared to their peers (M = 3.7) while the boys with ADHD reported
their movement and sport skills were better to much better when compared to other
children in PE class (M = 4.3), whether the comparison group was children with ADHD'
or not. Thus, in the context of peer comparisons in PE class, it seems that the boys with
ADHD either overrated their skill performance or provided socially desirable responses
while the boys without ADHD were fairly accurate about their movement skills.
Personal Feelings. Questions 15 to 17 explored feelings associated with movement skills
in PE. Table 5 illustrates the number of data units for the personal feelings category (See
Appendix X). Positive affective responses indicated enjoyable mental states while negative
affective responses indicated distressing mental states. There were a similar number of positive
affective statements related to specific activities and behaviors ofpeers in PE class. For example,
Claude with ADHD stated that he liked playing (a) basketball because "1 like bouncing it a lot. 1
like dribbling the baIl" and (b) volleyball "because it's fun". He mentioned that playing together
with other children was important to him because of "making new friends and its fun". Mike
163
without ADHD also focused on baIl sports and making mends. For example, he said, "1 really
like soccer because it's fun to play and it's a competitive sport, but ail other, like all friends can
play soccer. And it's a very calm game".
Both groups also made negative affective responses related to specifie activities and
behaviors oftheir peers in PE class. There were almost twice as many data units indicating
negative feelings about specific activities for the boys with ADHD than boys without the
disorder. For example, Randy with ADHD found many games to be boring and often his
negative feelings were related to a lack of skill, with children singling him out for his poor skill
proficiency. He mentioned that he would be picked last for football games and he did not like to
be "tackled and knocked down to the ground", "hit in the stomach by the football" and avoided
being passed to by the quarterback. Boys without ADHD also made negative affective responses
related to specific movement skills but they did not seem to get ridiculed. For example, Jim
without ADHD mentioned that he did not like gymnastics activities and when other children
were "picked on" in physical education class. Yet, he did not feel personally singled out for
ridicule.
Responses about prosocial behavior demonstrated an individual's positive social
behaviors related to movement skills and responses about asocial behavior indicated an
individual' s negative social behaviors related to movement skills. There were a similar number
of data units from both groups about prosocial behavior. For example, all of the boys spoke
about Ca) children who would encourage peers by cheering and clapping, Cb) having sorne choice
in activities, with fun games to play, and Cc) trying to behave in PE class in order to play as much
as possible. There were approximately 50% more data units about asocial behaviors related to
the movement skills of boys with ADHD than their peers without ADHD. The boys with ADHD
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would often refer to being reprimanded for their misbehavior. They also blamed other children
for behavior problems that would decrease their own personal enjoyment of physical activity and
time spent in PE. Yet, both groups spoke about children insulting each other, calling each other
names, talking over the teacher' s voice, fooling around in class, cheating, fighting and hurting
others. For example, Larry with ADHD mentioned that he liked to play agame called "British
BuIldog" because you get to run into people. This type of aggressive behavior was also
mentioned by the children without ADHD. For example, Mike without ADHD mentioned the
"Pirate Ship" game, "Because there's always the, weIl, people are sharks and they're ronning
after people and they don't care. They'Il run into them and they'Illike hurt them to get them.
They'lllike go smack into them".
Discussion
Distinct group profiles of physical activity experiences were developed from the
interview data of the boys with and without ADHD. Our results indicated more differences than
similarities between the two groups ofboys. Both groups spoke about playing with peers, a
pleasant surprise because children with ADHD are well-known for having difficulty with social
relationships (Litner, 1999). Since the accuracy of the boys' statements could be questioned, we
verified with the parents and guardians that the boys with ADHD participated in physical
activities with other children.
There were several differences between the boys with and without ADHD. For example,
the boys with ADHD rarely organized opportunities to play or be active with other children. In
fact, they seemed to enjoy being involved in a variety of different activities, especially
individually-oriented sports or lei sure activities. These may be areas of strength for children with
ADHD to successfully explore their unique interests. Furthermore, the boys with ADHD devoted
165
little time to acquire the specifie details of physical activities whereas their peers without ADHD
would purposely learn much about their activity of interest. Perhaps the boys' testimonials are
retlections of the nature of ADHD. As Barkley (1997) would suggest, the boys with ADHD lack
the necessary problem-solving abilities required of carefully planned behavior; namely attention
to detail, adequate retlection time, and the need to delay immediate gratification. For example, a
lack of attention to detail emerged in our interview data and most of the boys with ADHD
resemble novices in movement skill performance. We would hardly expect the boys to
demonstrate highly proficient movement skillieveis when it seems that they participated in many
different activities, spending minimal amounts of deliberate time in learning and practicing the
intricacies of basic physical movements, sport skills, and recreational activities.
Planning and monitoring movements are critical to ensuring skilled performance over
time (Wall et al., in press). If the boys are novice-like in their planning and monitoring of
physical activity because they did not prepare or plan activities as our data suggest, their
movement skills are likely to remain low. Ifthis is correct, many children with ADHD may be
affected by a developmental skill-learning gap where children with less physical skill may have
limited opportunities to become involved in physical activities and experience minimal success as
they grow oIder (Harvey & Reid, 2005). The skill proficiency gap between children with less and
more physical skiU would widen over time as environmental constraints and other situational
demands become more complex in various movement contexts (Wall, 2004). Other important
factors, identified by researchers as important in the context of skill proficiency and physical
activity, include: (a) practice methods in free play and deliberate play contexts (Côté et al., 2003;
Côté & Hay, 2002), (b) necessary domain-specifie practice time and instruction (Ericsson, 2003),
(c) problem-solving (Bouffard & Wall, 1990), (d) self-regulated learning (Reid, Harvey, Lloyd, &
166
Bouffard, 2002) and (e) high levels of motivation (Côté et al., 2003). These five areas may be
starting points to develop a thorough understanding of the relationship between ADHD and skiU
performance and learning. Thus, there are opportunities to design research about the influence of
these factors and devise practical application strategies for persons with ADHD.
Our interview discussions about domain-specific vocabulary also demonstrate substantial
differences between the two groups with regard to selective attention. The boys with ADHD
knew different action terms but clearly indicated that they would not use these terms with their
peers. The boys without ADHD, on the other hand, knew that they would use the action terms in
the appropriate contexts of play or sports and they would also stop using certain terms after a
skill had been automatized. The boys with ADHD are likely to experience communication
problems in play if they do not realize, as their peers without ADHD understand, that domain-
specific terminology is required for proficiency in both individual skill performance and team
game performance. It seems the boys with ADHD know many action terms but they possess a
superficial understanding ofboth movement skills and the purposes for the actions within
broader contexts. For example, the boys with ADHD spoke about practice targets which, in tum,
were often socially undesirable. A person with ADHD will have difficulty making new friends if
he tries to hit people with a football for the sake of fun and practice. Also, this same person will
not be able to fine-tune throwing skills to other people and will lack sufficient deliberate play
and practice time to become a highly proficient performer (Cote et al., 2003). Furthermore, the
boys with ADHD seemed unwilling to use their domain-specific knowledge about action in the
appropriate contexts.
Our interviews demonstrate substantial qualitative differences in the depth of declarative
knowledge between the boys with and without ADHD, leading to the contention that the boys
167
with ADHD leaned heavily on using superficial domain-specifie tenninology to convince others
that they know what to do in different sports and at a high level. For example, the boys with
ADHD thought that they were more proficient movers and learners than suggested by the data.
This behavior is hypothesized to be a "faking" phenomenon where a person is not highly
proficient at a skill but can provide a socially desirable response. The tenn is not meant to be
pejorative rather it reflects a distinct form of affective knowledge required when one may try to
detract others' attention away from a personallack of specifie skill or skills (e.g., a defense
mechanism).
Another example of the superficiality of acquired knowledge about action for the boys
with ADHD can be observed in the choice of observational learning models. Not surprisingly,
boys without ADHD were able to demonstrate their preference for particular observational
learning models. However, most of the boys with ADHD did not name a specifie person
observed in order to learn how to become a more proficient moyer or player. Even when probed
for more infonnation, the boys did not articulate why it would be important to watch others to
learn from. Yet, the boys without ADHD did mention the rationale for choosing specifie learning
models. Most likely, the boys with ADHD were unaware that proficient skill performance also
includes a depth ofskill acquisition knowledge. Clearly, they were unaware of the benefits of
observational learning to skill improvement. It would seem the typical symptom combinations of
impulsivity, inattention and overactivity present formidable impediments to the development of
the movement skill perfonnance and proficiency of children with ADHD.
The boys with ADHD also seemed to incorporate an external attributional response style
in physical activity. In fact, the boys expressed many negative aspects of physical activity and
were over-reliant on external causes for movement success and failure. For example, they
168
blamed other children for behavior problems that would decrease their own personal enjoyment
of physical activity and PE. Barkley (1997) suggested persons with ADHD may experience
difficulties when trying to gain emotional self-control and, in turn, negative affective thoughts
would likely lead to avoidance behaviors. Thus, physical awkwardness and leamed helplessness
are suitable constructs to explain the boys' expressions. For example, one of the boys with
ADHD said that he would feel embarrassed if he performed a skill incorrectly because the other
children might laugh or the teacher might get angry. He also mentioned that he gets hurt often
when attempting novel physical skills and activities. While knowing he could not throw a baIl in
a direct line or accurately at a target, he did not seek help to learn for fear ofbeing ridiculed.
When teaching sessions were offered on how to throw a baIl, the boy suggested that the first
author would not be able to make available the sufficient time to help. Thus, the effects of
physical awkwardness and learned helplessness or low skill proficiency and intense feelings of
inability seemed to be present. Interestingly enough, it took approximately 90 minutes to teach
this boy how to throw a ball (e.g., 3 sessions of30 minutes). He did not understand the ideas of
force regulation and point of release in the skill of overhand throwing. Perhaps it would be
beneficial to devise task-specific intervention programs (e.g., Hodge et al., 1999; Trocki-Ables,
French, & O'Connor, 2001) for children with ADHD to improve their movement skills and, in so
doing, they may participate more readily in physical activity.
However, this recommendation is grounded by the realization that the boys with ADHD
named few specifie learning models or other people from which to draw valuable information.
Highly skilled performers often have parents or significant others who exert a significant
influence on their skiU development (Côté et al., 2003). In fact, these adults often guide and lead
the child to become involved in a variety of activities, with a gradual withdrawal of direct
169
involvement as individual skill and sport proficiency increase (Côté et al., 2003). Since many
children with ADHD experience social problems at home (Grizenko & Pawliuk, 1994) and have
trouble establishing and maintaining social relationships (Litner, 1999), there may be minimal
guidance and support from significant others in order to learn important skills (e.g., play, social,
academic, etc.). Clearly, children with ADHD would benefit from the watchful and attentive eyes
of significant others like parents, friends, teachers, coaches, and volunteers. Participation in
ADHD-sensitive PE classes and after school or recreational programs may provide the opportunity
to participate in supportive learning and performance environments. Future research should
investigate the influence ofthese mentors and community-based programs on the functional skill
performance of children with ADHD. Renee, there may be positive and practical benefits ofusing
an expertise approach when understanding the skill development of children with ADHD.
Conclusions
The groups ofboys spoke about very different physical activity experiences and they did not
regulate their physical activityinvolvement in a similar manner. Contrary to the suggestion that
children with ADHD possess sufficient factual domain-specifie knowledge but cannot perform
what they know (Barkley, 1997), limited physical activity experiences and acquired knowledge
were apparent in the children with ADHD. They possessed a superficial understanding ofvarious
knowledge factors underlying both movement skills and sport skills. For example, the children
with ADHD knew the domain-specifie terms for different actions and games but they lacked a
deeper understanding of associated concepts. In other words, the children may indicate to their
peers and adults appropriate movement skill terminology but may not possess a complete
understanding of the factors underlying movement performance. Such superficial differences in
skiI~ procedural knowledge, and declarative knowledge have been found in soccer between adults
170
with physical disabilities who were experienced spectators of soccer and their peers without
disabilities who had 14 to 15 years of playing experience (Williams & Davids, 1995).
To our knowledge, this is the tirst qualitative study to provide a voice for children with
ADHD in relation to their movement skills. We should increase the range of qualitative methods
used to gain more insightful information about the skilllearning of children with ADHD. For
example, the use of the probes in our interview format was important since the quality of 8 to 16
year-old children's recall ofphysical activity improves with verbal prompting (McKenna, Foster,
& Page, 2004). Yet there is also the possibility ofusing a wide range of inductive qualitative
research methods in ADHD research (e.g., drawing, collage, art wode, etc.) to provide more
opportunity for the children' s physical activity experiences to be voiced from a hermeneutic
phenomenological approach (e.g, Goodwin et al., 2004). Our fmdings willlead to more in-depth
research about the self-regulatory behavior of children with and without ADHD in different
physical activity contexts. Most importantly, this exploratory study has led to a preliminary
understanding of the concomitant factors associated with the physical activity experiences of
children with ADHD. This research area promises to be an exciting avenue ofresearch inquiry.
171
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177
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178
Chapter 6
Summary
This doctoral dissertation is a series of manuscripts devoted to understanding the
movement skills ofpersons with attention-deficit hyperactivity disorder (ADHD). There are six
chapters. The first chapter was called theoretical perspectives and it provided a rationale for
combining the two main theoretical approaches that guided the research. Thus, the knowledge-
based approach to motor development (Wall et al., 1985) and the inhibitory model of executive
functioning (Barkley, 1997) were described. Chapters two and three are two manuscripts,
published in the Adapted Physical Activity Quarterly, which form a comprehensive review of the
literature. Chapter two, the first review paper, provided a discussion about important issues
related to ADHD that included a contemporary definition of the disorder, etiology,
nomenclature, classification, comorbidity, treatment, and developmental course (Harvey & Reid,
2003). This review of 49 movement behavior studies about ADHD, published between 1949 and
2002, indicated that children with ADHD may experience poor levels of physical fitness and
movement skiU difficulties when compared to children without ADHD, with a likelihood of
experiencing coinorbid developmental coordination disorder (DCD). While few intervention
studies on the movement performance and physical fitness of children with ADHD were
retrieved, future physical activity researchers and program planners in ADHD were referred to
numerous reference citations for seminal review articles on ADHD.
Chapter three, the second review paper, explored the research methods used in movement
performance studies about ADHD and provided useful information for adapted physical activity
(APA) researchers interested in ADHD research (Harvey & Reid, 2005). It is a unique
manuscript because approximately 20 new AP A research questions about ADHD were provided.
179
AIso, there was extensive discussion of the identification ofpersons with ADHD, the importance
of providing complete descriptions of research participants with ADHD as well as discussions and
recommendations about key data collection issues related to the organization of the research
environment, associated motivational concerns, and medication use. Strategies to improve AP A
research about ADHD were provided to strengthen research designs because substantial
methodological inconsistencies were identified in the CUITent ADHD physical activity literature.
The two review papers, when combined, are a substantial and original contribution to the ADHD
literature.
Chapter four was a study about the effects of stimulant medication on the qualitative
components of fundamental movement skill performance for 22 children with ADHD and a
comparison oftheir movement skills to age- and gender-matched peers without ADHD. This
investigation was based on the information from the two review manuscripts and a strict research
design resulted. It is one of the first AP A studies to explore the influence of an external factor,
methylphenidate, on the movement skills of children with ADHD. Furthermore, experimental
control was exerted over more independent variables than achieved in previous AP A research
(e.g., gender, age, and family income level). The use ofrepeated measures designs and
multivariate statistical analyses was also considered as an important aspect of the study. There
was no significant effect of methylphenidate on the performance criteria of the TGMD-2 (Ulrich,
2000). Again, the clinical trial component of the study would have benefited from a larger
sample size. However, there were significant differences between the children with and without
ADHD on both locomotor skills and object control skills. The development and presentation of
the movement skill profiles of children with and without ADHD is an original and unique
180
contribution to the movement skill performance literature. This manuscript is currently in the
peer review process.
Chapter five is a study that explores the perceptions of six boys with and without ADHD
about their physical activity experiences. This study is one of the first attempts to explore the
physical activity experiences of children with ADHD with the use of qualitative research
methodology. In fact, the children's physical activity voices were sought because the published
literature mentions only the concerns of parents and teachers, with no representation from the
children. The interpretation of the interviews was an important element of the study where a
mixed methodology was utilized to obtain a deeper understanding of the physical activity
experiences of the boys with and without ADHD. There were sorne similarities expressed by the
two groups about their physical activity experiences. However, differences were apparent on key
aspects of skiU proficiency (e.g., attention to detail, knowledge about action, and affective
knowledge) that may be problematic for the boys with ADHD. This manuscript is also in the
peer review process.
This sixth and final chapter provided a brief summary of the relevant findings and future
recommendations follow. The doctoral dissertation represents a new research li ne in AP A. For
example, the four manuscripts are a cohesive series of papers that build on each other. The two
review papers provide a comprehensive understanding of ADHD in relation to physical activity,
with the two subsequent studies building on the reviewed information as well as contributing to
the current physical activity knowledge base about ADHD.
The combination oftheories to guide the research project was unique as each theory
provided a needed link between sport expertise and psychology in order to explore the movement
skills of children with ADHD. The review manuscripts have already been cited in the ADHD
181
literature and form a comprehensive overview in relation to physical activity. They are original
contributions to the ADHD literature as we were able to gather together research findings that
compared children with and without ADHD and, in tum, gain a clearer understanding of the
movement skill performance of children with ADHD. The research challenge review manuscript
provided general guidelines for performing research studies for children with ADHD in physical
activity. Most of the methodological suggestions were borrowed from key psychology and
psychiatry researchers in ADHD. Thus, in combination, these review papers should guide the
research in this area of inquiry for many years to come.
Future research studies about persons with ADHD and movement skills will be created as
my research program will continue to develop and grow. There is a lifetime of research
opportunities in this relatively new and exciting APA area. For example, the series of20 new
research questions, generated in the review papers, could not be conducted over the lifetime of a
single researcher. It will be exciting and interesting to study particular constructs related to
ADHD. For example, can children with ADHD self-regulate their learning and performance in
physical activity? A mixed methods procedure emerged from this research experience that, in
tum, willlead to an in-depth understanding of the self-regulatory processes ofmovement skill
acquisition and proficiency of aU children, including persons with ADHD. Thus, future
investigations of movement skill proficiency and children with ADHD are anticipated by
combining the expertise approach with interviewing methods. However, a greater range of
qualitative research methods will be incorporated to gain much deeper insight to persons with
ADHD and movement-related phenomena. Therefore, we may be able to achieve greater
understanding of the metacognitive knowledge and metacognitive skills of children with ADHD
by further describing various degrees of procedural and declarative knowledge about action. We
182
may gain much insight about the skilllearning and physical activity experiences of more people
with ADHD. Thus, the CUITent study provides the reader with a greater range ofmethodological
tools to draw from. This fact is important and a valuable contribution to research in the area as
we demonstrate that different methodologies help to answer different questions and illuminate
the skill sets and specifie interests of children with ADHD. AIso, there may be a unique
opportunity to have a significant AP A treatment impact on a substantial number of people
affected by ADHD. For example, it may be possible to develop, use, or learn cognitive strategies
to meet physical activity task demands for persons with ADHD as this type of intervention
method has been successful for persons with learning disabilities (Kowalski & Sherrill, 1992) or
intellectual disabilities (Reid, 1980a, 1980b). While these intervention types need to be
developed, it is clear from our research data that clinical populations of children with ADHD are
"at-risk" for movement skill problems. Practitioners will benefit from reading the dissertation
manuscripts by understanding the skill performance based issues, the personal and environmental
constraints sUITounding people with ADHD, effective teaching and coping strategies, and
practical solutions for active and effective living.
There is much more to explore and learn about persons with ADHD and physical activity.
It may take many years for answers to surface in response to the research questions raised in the
dissertation. Isolated studies, indicating similar results, were drawn together in this doctoral
research project. Clearly, many people with ADHD experience movement skill difficulties. Since
overactivity has been an integral component of the ADHD definition for the past 40 years
(Barkley, 1998), perhaps APA researchers may help to better understand the nature of ADHD by
examining the influence ofkey constructs in physical activity contexts. For example, what type
of causal attribution response styles do people with ADHD employ in different physical activity
183
contexts and what are the associated impacts on specific physical activities and exercise
adherence? Also, we may be able to devise regression models for ADHD, with movement skill
performance as a predictor variable.
A lifespan perspective is also recommended as ADHD and its behavioral correlates may
continue to be present throughout a person's lifetime (Weiss & Hechtmann, 1993). Our data
suggest that there is sorne type of difficulty in the learning and performance of movement skills
for many cbildren with ADHD. Yet, the developmental course ofmovement skills and sport-
specifie skills for people with ADHD is not well understood because most AP A investigations
about ADHD have been cross-sectional research designs. Furthermore, we have a limited
understanding of the physical activity experiences of adolescents and adults with ADHD.
Perhaps we may find interesting activity patterns that other researchers have yet to discover and
explore. For example, we may observe the various types ofphysical activities and recreational
pursuits that adolescents and adults with ADHD prefer and perform. We may then inquire if
these people with ADHD feel empowered in the choice of activities. Moreover, we can ask about
the rationale for activity selection and observe if there are tendencies to adhere to specific
activities or participate sporadically in a variety of activities. Thus, cross-sectional and
longitudinal investigations about sport, exercise, and physical activity are recommended for
people with ADHD of all ages. Again, we re-emphasize the importance of conducting sound and
etbical research projects wbile also collaborating at a multidisciplinary team level. Thus, tbis line
of inquiry has much to offer scholars and field professionals if they choose to study or work in
the area. We believe tbis work will be cited in much of the ADHD and physical education
literature circles due to the complexity of the research designs and the robust findings which
emerged.
184
In summary, this dissertation is a cohesive series of original papers that have led to a
better understanding of the movement skills of children with ADHD. However, there is a need
and ample opportunity for more in-depth AP A research about people with ADHD.
185
References
Barkley, R.A. (1997). ADHD and the nature ofself-control. New York: Guilford Press.
Barkley, R.A. (1998). Attention-deficit hyperactivity disorder: A handhook for diagnosis
and treatment (r ed.). New York: Guilford Press.

Harvey, W.l, & Reid, G. (2003). A review offundamental movement skill performance
20, 1-25.
Harvey, W.l, & Reid, G. (2005). Attention-Deficit Hyperactivity Disorder: Ways to
improve AP A research. Adapted Physical Activity Quarterly, 22, 1-20.
Kowalski, E.M., & Sherrill, C. (1992). Motor sequencing ofboys with learning
disabilities: Modeling and verbal rehearsal strategies. Adapted Physical Activity
Quarterly, 9,261-272.
Reid, G. (1980a). The effects ofmemory strategy instruction in the short-term memory of
the mentally retarded. Journal ofMotor Behavior, 12,221-227.
Reid, G. (1980b). Overt and covert rehearsal in short-term motor memory ofmentally
retarded and nonretarded pesrons. American Journal ofMental Deficiency, 85, 69-75.
Ulrich, D.A. (2000). Test of Gross Motor Development (rd ed). Austin, TX: PRO-ED, Inc.
Wall, A.E., McClements, l, Bouffard, M., Findlay, H., & Taylor, M.l (1985). A
Weiss, G., & Hechtman, L. (1993). Hyperactive Children Grown Up, (2nd ed) New York:
The Guilford Press.

186
Appendices
189
Appendix C
HÔPIT.uDOUGLAS HOSPITAL
6875, boulevard Lasalle, Verdun (Québec!. Canada H4H 1 R3 Tél. : (514) i61·6131 Téléc.: (514) 8.88-1067
September, 2002
Dear Parent or Guardian,
My name is Billy Harvey and 1 am a doctoral srudent at the Depamnent of Kinesiology and Physical
Education of McGill Univer;ity. This lener requests the permission for both you and your sonldaughter to panicipare
in a physical acrivity research srudy to be conducted at the hospital. 1 believe that the cmldren will find the
experiencc to be enjoyable.
My research has been designed to describe the fundamental movement skills used by childreD with
anention-deficit hyperactivity disorder (ADHD) in everyday play activities such as running and throwing. There are
rwo main purposes of my research. Fir;!, 1 will ask children with ADHD to perform a 10 minute movement skills
test. Second, 1 wou Id also Iike 10 interview some of the chilciren so that they can describe their unique experiences in
everyday play and sport senings.
Vour sonidaughter is currently part of a research srudy at the hospital where heishe performs a series of tests
when he/she is on and offmedication. 1 will administer the movement skills test once per week durine their rwo week
testing period. The test is commonly used by physical education teachers to assess locomotor skills ai;d object
control skills. The locomotor skills evaluaied are: run. gallop. hop, leap. horizontal jump. and slide. The object
control skills evaluated are: striking a stationary bail (base baIl batting), basketball dribble. catching, kicking,
overhand throw. and underhand roll. The chilciren will be able to perform the rasks at their own pace because we are
observing the quali~ of the children's movement ski Ils not their speed and accuracy. 1 will videotape cach
performance in order to accurately evaluate the movement skills.
1 will also conduct an interview with your child ifheishe is berween 9 and 12 years old 50 that he/she may
describe his/her ph~'sical activity experiences. The interview will last approximately 45 minutes to 1 hour and each
interview will be videotaped. About 1 week afrer the interview has been conducted. 1 will read a summary of the
interview to both you and your child for your feedback and input. Children berween 6 to 8 years will participate in
the movement skills test but they are not decmed old enough for the interview.
1 will not show the videotapes to anyone without your wrinen permission. Please be assured that no child's
name will be associated with any presentation or publication that might cmerge from this research. Vour child's
identity is secured. 1 have 12 years of teaching experience in physical education and 1 am currently the department
head ofrecreation and leisure services at the hospÎtal. 1 am weil aware of the importance ofconiidentiality. respect
for each participant. and the right of each chi Id to witheiraw at any time from the study without any reservation
whatsoever. Even ifyou sign the form below, your child is !Tee to witheiraw at any point later on \vithout question. In
fact. 1 have also arrached a place on the form for your child to agree to and sign.
io43ou~.1 "·C".JC1rncmcm "1n:;iJlL",.~ry Ccntn Ile cDila~IOft dE l'O~tS )CDI'Urcu'" H..O C.,./aocJl'un; Ccnrn:
.:c11':nu~III·~MI Tcac!'II"! HcaPicU Oc ~lonft21 pow' 13 l'II:'~ jOtiù:::tarr.l.and7~"r
ri la ionnaUCMI en IoIIIlIIt nwncaJc "'~c"Q.lHalUI
191
AppendixD
~ McG1ll
e
~/
Depertment of Klnesiology and Phys1cal Education Département ~f kmfs1olog1e et d'éducation physique (514) 398-4184
McGill University Université McGl1i (514)398-4186 Fax
475 Pi ne Avenue West 475 avenue des Pins Ques1
Montreal. PO. Canada H2W 154 Montréal IOuébec) Canada H2W 1$4
April, 2003
Dear Parent or Guardian,
My narne is Bi1Iy Harvey and 1 am a doctoral student at the Department of Kinesiology and
Physical Education of McGiIl University. This lener requests the permission for both you and your
sonldaughter to participate in a physical activity research study to be conducted at the school. 1 believe
that the children will find the experience to be enjoyable.
The main purpose of my research is to describe the movement skills used by children with
anention-deficit hyperactivity disorder (ADIID). In order to do this, 1 need to compare the movement
skill performance of children with and without ADI-ID. Your sonldaughter has been identified as a person
without a disability by the school principal and hislher teacher. Therefore, your child would be a part of
the important comparison group.
Three different tests will he administered to your child: a) a standard intelligence test which will
require 1 to 2 hours, b) a 20 minute academic achievement test, and c) a 20-30 minute movement skiIls
test. The movement skills test is commonly used by physical education teachers to assess locomotor
skills and object control skiIIs_ The locomotor skiIIs evaluated are: run, gaIlop, hop, leap, horizontal
jump, and slide. The object control skills evaluated are: striking a stationary baIl (baseball baning),
basketball dribble, catching, kicking, overhand throw, and underhand roll. The children will perform the
tasks at their own pace. These performances wiII be videotaped hecause we are observing the quality of
the children's movement skills not their speed and accuracy. Please rest assured that we will notif)' the
school principal immediately if the test scores indicate any major problems. 1 do not believe this will he
the case since your child has been identified as a person without problems. In fact, your child should he a
good candidate to be in our important comparison group.
1 will also conduct an interview with your child ifhelshe is between 9 and 12 years old so that
he/she may describe hislher physical activity experiences~ The interview williast approximately 45
minutes to 1 hour and it will be videotaped. About 1 week after the interview, 1 will read a summary of it
to both you and your child for your feedback and input.
1 will not show the videotapes to anyone without your wrinen permission. Please be assured that
no child's narne will be associated with any presentation or publication that might emerge from this
research. Your child's identity is secured. 1 have 12 years ofteaching experience in physical education
and! am current1y the department head ofrecreation and leisure services at a hospital in Montreal. 1 am
weil aware of the importance of confidentiality, respect for each participant, and the right of each child to
withdraw at any time from the study without any reservation whatsoever. Even ifyou sign the form
below, your child is free to withdraw at any point later on without question. ln fact, 1 have also anached a
place on the fonn for your child to agree to and sign.
193
AppendixE
Table 1 Historical Review ofDSM Nomenclature
Manual Classification Terms Major Subtypes
DSM-I (1952) None None
DSM-ll (1968) Hyperkinetic Syndrome None

of Childhood
DSM-ID (1980) Attention Deficit Disorder ADDH,ADD-H
DSM-ID-R (1987) Attention-Deficit pervasive, situational

Hyperactivity Disorder
DSM-N (1994) Attention-Deficit Inattentive,

Hyperactivity Disorder Hyperactive-Impulsive,
& Combined Types
DSM-N-TR (2000) Attention-Deficit Inattentive,

Hyperactivity Disorder Hyperactive-Impulsive,
& Combined Types
Note. DSM = Diagnostic and Statistical Manual of Mental Disorders publi shed by the American
Psychiatric Association, Washington, D.C., ADDH = Attention Deficit Disorder with
Hyperactivity, ADD-H = Attention Deficit Disorder without Hyperactivity, Situational subtype =
only symptomatic at one setting or another (APA, 1987, p. 50), Pervasive subtype = symptomatic
in at least two or more settings (APA, 1987, p. 50). See Hechtman (2000) for thorough review of
diagnostic practices.
Table 2
Movement Performance
Study Purpose Sample Statistical Findings

Analysis
Intergroup Comparison
Beyer Compared movement skills of 112 boys MANOVA, Significant multivariate age (p < .001) and
(1999) boys with ADHD and boys with ADHD = 56, taking Ritalin ANOVA condition (p < .001) main effects were found on
LD LD = 56, no medication the BOTMP-LF. ANOVAs revealed boys with
7-12 years ADHD performed bilateral coordination (p <
DSM-IV .001), strength (p < .001), visuaI motor
coordination (p < .001), and upper limb speed ~
"CS
and dexterity (p < .001) significantly worse than g
their peers with LD. &.
~
ITJ
Doyle et al. (1995) Exarnined movement skills of 38 children multiple 82% of children with ADHD performed gross
children with ADHD and 33 boys, 5 girls independent motor skills above the norms of the BOTMP-SF.
parental perceptions about their 7-12 years t tests Parents underrated the movement skill
children' s skills DSM-III-R performance oftheir children with the use of 5-
stimulant medication use was point Likert scaIe.
variable
Wade (1976) Described differences on 24 children descriptive Cbildren witbout a disability spent, on the
stabilometer task between 12=ND statistics average, more time on the static balancing task
children with and without 12 = hyperactive and performed more consistently tban children
ADHD and examined the effects 7.7-11.8 years withADHD.
ofRitalin on children with genders not reported
ADHD performing a diagnostic framework not reported
stabilometer task stimulant medication taken Table continues
-
\0
.j::o.
î
Harvey & Reid Described fundamental 19 children Descriptive Children with ADHD performed locomotor
(1997) movement skills and fitness 17 boys, 2 girls statistics, skills (22.3 percentile) and object control skills
conditions of children with 5-12 years graphs (33.4 percentile) below the 35th percentile when
ADHD DSM-III-R compared to the age-matched norms of the
89% of sample took stimulant TGMD.
medication
Intragroup Comparison
Piek et al. Investigated movement skills and 48 boys MANOVA, Boys with ADHD (ADHD-PI, ADHD-C)
(1999) kinaesthetic processes ofboys 16 = ADHD-PI ANOVA performed significantly poorer (p < .002) on the
with and without ADHD 16 = ADHD-C MABC than boys without disabiIities. In
16=ND comparison with the other groups, boys with
matched on age & verbal IQ ADHD-PI demonstrated significantly worse
8.7-11. 7 years manual dexterity skills (p < .01) while boys with
DSM-IV ADHD-C demonstrated significantly worse
8 children from (ADHD-C) balance skills (p < .01).
received stimulant medication
Miyahara et al. Identified movement and 23 children Cluster Significant univariate results were found
(1995) behavioral subtypes ofHKS 21 boys, 2 girls analyses, between the free-from-severe motor impairment
while estimating the comorbidity 4-12 years ANOVA and mannal incoordination motor c1usters on
ofHKS with DCD diagnostic framework for HKS manual dexterity (p < .01) and balance (p < .01)
from a German psychiatric subtests of the MABC. 52% of the sample, or 12
textbook out of 23 participants, fell in the manual
stimulant medications taken incoordination subtype and were thus
considered as having DCD.
Table Continues
....
\0
Ul
Kaplan et al. Described comorbidity between 162 children Descriptive Assessment instruments were the BOTMP,
(1998) DCD, ADHD, and RD Specific age and gender statistics, MABC, and an initial version of the DCDQ. Of
information was not provided. Pearson the 162 participants with comorbidity, 47
However, the participants were correlation children had no disabilities. There were pure
selected because complete data coefficients, cases of ADHD (N = 8), DCD (N = 26), and RD
were available from an initial ,l, (N = 19). Comorbidity was identified for
sample of379 children ANOVA ADHDIRD (N = 7), ADHDIDCD (N = 10),
169 boys, 55 girls = ADHD + LD DCDIRD (N= 22), and ADHDIDCDIRD (N =
105 boys, 50 girls = ND 23).
8-18 years
DSM-III-R
Medication not reported
Miyahara et al. Examined the severity of HKS 47 children ANOVA Children with HKS, attending a school, were
(2001) behaviors and comorbidity 38 boys, 9 girls rated with significantly greater conduct
between HKS and DCD from average age = 8.4 years problems (p < .02) than their hospitalized peers
school, support group, and diagnostic framework for HKS with HKS and greater hyperactive behaviors (p
hospital sample sources from a German psychiatric < .09) when compared to other peers with RKS
textbook from a support group. No significant differences
stimulant medications were not were found between the groups on the MABC'
reported Substantial amounts of overlap between HKS
and DCD were found at the school (35%),
support group (54%), and hospital (55%).
Intervention Effectiveness
Hodge et al. Examined the effects of warm-up 46 children Two-way Children with ADHD (visual imagery warm-up
(1999) activities on fundamental 36 males factorial condition) demonstrated significantly better
movement skill performance of 10 females ANOVAs throwing accuracy (p < .001) than their peers
children with LD + ADHD 9-11 years (group skill who participated in task-specific warm-up or no
diagnostic framework not reported x gender) warm-up conditions. No performance
medications were not reported differences were found between the groups on a
timed 40 yd-dash and a bail catching task. No
main effects for gender or interaction effects
werefound.
......
Table Continues ~
24 children ANOVA The static balance of children with ADHD on
Wade (1976) Described differences on
12=ND the stabilometer improved significantly (p <
stabilometer task between
12 = hyperactive .01) when methylphenidate was being used.
children with and without
ADIID and examined the effects 7.7-11.8 years
of Ritalin on children with genders not reported
ADHD performing a diagnostic framework not reported
stabilometer task stimulant medication taken
17 boys MANOVA The attention of boys with ADHD, when

Pelham et al. Examined the effects of
7.8-9.9 years medicated with methylphenidate, improved
(1990) methylphenidate on the attention
DSM-III-R significantly during baseball games (p < .001).
and baseball skills of boys with
Stimulant medications taken However, their baseball skills did not improve.
ADHD
Note. ADHO = attention-deficit/hyperactivity disorder, ADHO -PI

= attention-deficit/hyperactivity disorder-predominantly inattentive
subtype, DCD = developmental coordination disorder, DCDQ =
subtype, ADHO-C = attention-deficit/hyperactivity disorder-combined
, Crawford, Campbell, & Dewey, 2000), HKS = hyperkinetic
Developmental Coordination Disorder Questionnaire (Wilson, Kaplan
disability, MABC = Movement Assessment Batter y for Children
disorders, RD = reading disability, LD = learning disability, ND = no
of Motor Proficiency (Bruininks, 1978), TGMD = Test of Gross
(Henderson & Sugden, 1992), BOTM P = Bruininks-Oseretsky Test
Motor Development (Ulrich, 1985)
....
\0
.......
Table 3
Physical Fitness
Study Purpose N Statistical Findings

~~---:--_ _ _ _ _--:------:-~----=-_--:---:---:-_ _ _-:-:-:-:--_ _ _ _ _ _ _ _ _ _ _::-::Anc-:-alysis
Ballard Examined the effects of Ritalin on 50 children MANOVA, No differences in weight, height, and
(1977) the health-related fitness of 27 = ADIID ANOVA lean body mass between children
children with ADIID under rest, a 24 boys, 3 girls with ADIID and contraIs. Children
submaximal treadmill walk, and 23 = ND with ADIID had significantly more
recovery conditions 19 boys, 4 girls body fat (p < .02) and demonstrated
7-13 years increased heart rates and mean blood
diagnostic framework not pressure at rest (p < .01, .01)*,
reported exercise (p < .01, .03)*, and recovery
stimulant medication (p < .01, .003)* conditions. ~
"0
Boileau et al. Examined the effect of Ritalin on 20 children ANOVA Heart rates of children with ADIID [
(1977) the heart rates and oxygen 17 boys, 3 girls were significantly higher during rest x·
consumption (V02) of children 4-12 years (p < .01) and exercise (p < .01) when Q
with ADIID during rest and a diagnostic framework not reported compared to placebo conditions. V02
submaximal treadmill walk stimulant medication during exercise was significantly
condition for children with ADIID lower (p < .01) for the children in the
medication condition.
Harvey & Reid Described fundamental movement 19 children descriptive statistics, Children with ADIID performed
(1997) skills and fitness conditions of 17 boys, 2 girls graphs below the 25 th percentile compared to
children with ADIID 5-12 years the norms of a V02 Max test (Leger
DSM-III-R et al., 1984), shuttle fUn test
89% of sample took stimulant (CAHPER, 1980), and sit-up test
medication (Fitness Canada, 1985). Flexibility
and push-ups scores (Fitness Canada,
1985) were below the 40th percentile
of the respective nonns. Excess body
fat was found (75 th percentile) on a
skinfold test (Fitness Canada, 1985)
....
\0
Table Continues 00
Trocki-Ables, Described the effects of 3 different 5 boys single subject Visual inspection of the individual
French, & types of reinforcement on the ADHD methodology graphs (Time in seconds x Trials)
O'Connor (2001) amount of time spent to complete a 8-10 years descriptive, graphs revealed that boys with ADHD
1 mile/1.6 km walk/run test diagnostic framework not reported perfonned the walk/run test in less
medications were not reported time when provided bath tokens and
verbal praise rather than when
provided just tokens or verbal praise
alone.
Note. ADHD = attention-deficit/hyperactivity disorder, ND = no disability, * = (p < heart rate, mean blood pressure)
-
\0
\0
200
AppendixH
Table 1 Assessment Instruments for Movement Behavior ofPersons with ADHD
Movement Performance Test Movement Performance Study
Movement Assessment Battery for Children Christiansen, 2000~ Kaplan et al., 1998~
(Henderson & Sugden, 1992) Miyahara et al., 1995, 2001~ Piek et al., 1999
Bruininks-Oseretsky Test of Motor Proficiency Beyer, 1999~ Doyle et al., 1995~ Kaplan et al.,
(Bruininks, 1978) 1998
Stabilometer Wade, 1976

(Wade & Newell, 1972)
Test of Gross Motor Development Harvey & Reid, 1997

(Ulrich, 1985)
Submaximal treadmill walk Ballard, 1977~ Boileau et al., 1977

(Ballard, 1977~ Boileau et al., 1977)
1 mile Il.6 km walk/run test Trocki-Ables et al., 2001

(Cooper Institute For Aerobies
Research, 1992)
201
AppendixI
Table 1
Perrormance criteria for TGMD-210comotor skills (Adapted from Ulrich, 2000)
Skill Perrormance Criteria
Run 1. Arms move in opposition to legs, elbows bent

2. Briefperiod where both feet are off the ground
3. Narrow foot placement landing on heel or toe (i.e., not flat footed)
Gallop 1. Arms bent and lifted to waist level at takeoff
2. A step forward with the lead foot followed by a step with the
trailing foot to a position adjacent to or behind the lead foot
3. Brief period when both feet are off the floor
4. Maintains a rhythmic pattern for four consecutive gallops
Hop 1. Nonsupport leg swings forward in a pendular fashion to
produce force
2. Foot ofnonsupport leg remains behind body
3. Arms flexed and swing forward to produce force
4. Takes off and lands three consecutive times on preferred foot
5. Takes off and lands three consecutive times on nonpreferred
foot
Leap 1. Take off on one foot and land on the opposite foot
2. A period where both feet are off the ground longer than
running
3. Forward reach with the arm opposite the lead foot
Horizontal lump 1. Preparatory movement includes flexion ofboth knees with
arms extended behind body
2. Arms extend forcefully forward and upward reaching full
extension above the head
3. Take offand land on both feet simultaneously
4. Arms are thrust downward during landing
Slide 1. Body turned sideways so shoulders are aligned with the line
on the floor
2. A step sideways with lead foot followed by a slide of the
trailing foot to a point next to the lead foot
3. A minimum of four continuous step-slide cycles to the right
4. A minimum offour continuous step-slide cycles to the left
202
Appendix J
Table 2
Performance criteria for TGMD-2 object control skills (Adapted from Ulrich, 2000)
Skill Performance Criteria
Striking a 1. Dominant hand grips bat ab ove nondominant hand

stationary baIl 2. Nonpreferred side ofbody faces the imaginary tosser with
feet parallel
3. Hip and shoulder rotation during swing
4. Transfers body weight to front foot
5. Bat contacts baIl
Stationary dribble 1. Contacts baIl with one hand at about belt level
2. Pushes baIl with fingertips (not a slap)
3. BalI contacts surface in front of or to the outside of foot on
preferred side
4. Maintains control of baIl for four consecutive bounces
without having to move the feet to retrieve it
Catch 1. Preparation phase where hands are in front of the body and
elbows are flexed
2. Arms extend while reaching for the baIl as it arrives
3. BalI is caught by hands only
Kick 1. Rapid continuous approach to the baIl
2. An elongated stride or leap immediately prior to baIl contact
3. Nonkicking foot placed even with or slightly in back of the
baIl
4. Kicks baIl with instep of preferred foot (shoelaces) or toe
Overhand throw 1. Windup is initiated with downward movement ofhand/arm
2. Rotates hip and shoulders to a point where the nonthrowing
side faces the wall
3. Weight is transferred by stepping with the foot opposite the
throwing hand
4. Follow-through beyond ball release diagonally across the
body toward the nonpreferred side
Underhand roll 1. Preferred hand swings down and back, reaching behind the
trunk while chest faces cones
2. Strides forward with foot opposite the preferred hand
towards the cones
3. Bends knees to lower body
4. Releases ball close to the floor sa baIl does not bounce more
than 4 inches high
203
Appendix K
Table 3
Reliability of the TGMD-2 (from Ulrich, 2000)
TGMD -2 Scores InternaI Consistency Stability Reliability Interrater Reliability
Locomotor Subtest .85 .88 .98
Object Control Subtest .88 .93 .98
Gross Motor .91 .96 .98

Development Quotient
Table 4
Means, standard deviations and effect sizes: GMDQ scores for participants with ADHD
Age (years) Medication Mean Standard deviation Effect size
6-9 off 66.1 13.0
on 67.0 14.8 .07
10-12 off 77.0 14.0
on 79.2 16.9 .16

204
Appendix L
Table 5
Means, standard deviations and effect sizes for the locomotor skills of participants with and
without ADHD
Age (years) Group Mean Standard deviation Effect size
6-9 ADHD (off med) 28.2 7.3

No-ADHD (trial 1) 41.1 2.5 2.36
ADHD (on med) 28.1 9.7

No-ADHD (trial 2) 43.9 2.0 2.26
10-12 ADHD (off med) 37.4 5.5

No-ADHD (trial 1) 44.8 2.1 1.60

No-ADHD (trial 2) 46.0 1.7 1.70
205
AppendixM
Table 6
Means, standard deviations and effect sizes for the object control skills of participants with and
without ADHD
Age (years) Group Mean Standard deviation Effect size
6-9 ADHD (off med) 24.6 7.1

No-ADHD (trial 1) 39.4 4.2 2.54

No-ADHD (trial 2) 38.6 4.5 2.17
10-12 ADHD (off med) 36.5 6.6

No-ADHD (trial 1) 44.3 2.5 1.56

No-ADHD (trial 2) 44.9 2.5 1.43
206
AppendixN
1 ADHD (6- 9 years)
IADHD (10-12 years)

120
ëI No- ADHD (6- 9 years)
105.4
100 (!] No- ADHD (10-12 years)

en
•
~
0
()
en
CI
80
c
~
C)
60
40
1 Trials
2
Figure 1 GMDQ scores of children with and without ADHD

207
Appendix 0
Univariate results for GMDQ
Dependent Variable: condl (otTmedication)
Sumof
Source DF Squares Mean Square F Value Pr > F
Model 3 9238.29156 3079.43052 23.95 <.0001
Error 40 5142.68571 128.56714
COITected Total 43 14380.97727
R-Square CoeffVar Root MSE condl Mean
0.642397 12.95520 11.33875 87.52273
Source DF Type 1 SS Mean Square F Value Pr > F
gpid 1 8596.022727 8596.022727 66.86 <.0001

age 1 532.848701 532.848701 4.14 0.0484
gpid *age 1 109.420130 109.420130 0.85 0.3618
Source DF Type ID SS Mean Square F Value Pr > F
gpid 1 8130.874675 8130.874675 63.24 <.0001

age 1 532.848701 532.848701 4.14 0.0484
gpid*age 1 109.420130 109.420130 0.85 0.3618
Dependent Variable: cond2 (on medication)
Sumof
Model 3 10041.02922 3347.00974 18.53 <.0001
EITor 40 7224.85714 180.62143
COITected Total 43 17265.88636

208
R-Square CoeffVar Root MSE cond2 Mean
0.581553 14.95927 13.43955 89.84091
Source DF TypeI SS Mean Square F Value Pr>F
gpid 1 9280.022727 9280.022727 51.38 <.0001

age 1 570.157792 570.157792 3.16 0.0832
gpid*age 1 190.848701 190.848701 1.06 0.3102
Source DF Typeill SS Mean Square F Value Pr>F
gpid 1 8979.757792 8979.757792 49.72 <.0001

age 1 570.157792 570.157792 3.16 0.0832
gpid*age 1 190.848701 190.848701 1.06 0.3102
209
AppendixP
Univariate results for locomotor and object control skills
Dependent Variable: locomotor slulls (off medication)
Sumof
Model 3 1400.194805 466.731602 22.13 <.0001
Error 40 843.714286 21.092857
Corrected Total 43 2243.909091
R-Square CoeffVar Root MSE locoffMean
0.623998 11.76243 4.592696 39.04545
gpid 1 927.3636364 927.3636364 43.97 <.0001

age 1 397.9948052 397.9948052 18.87 <.0001
gpid*age 1 74.8363636 74.8363636 3.55 0.0669
gpid 1 993.1090909 993.1090909 47.08 <.0001

age 1 397.9948052 397.9948052 18.87 <.0001
gpid*age 1 74.8363636 74.8363636 3.55 0.0669
Dependent Variable: locomotor slUlIs (on medication)
Sumof
Model 3 1755.079654 585.026551 17.27 <.0001
Error 40 1354.647619 33.866190
R-Square CoeffVar Root MSE locon Mean
0.564384 14.63180 5.819467 39.77273

210
Source DF Type I SS Mean Square F Value Pr>F
gpid 1 13 53.090909 1353.090909 39.95 <.0001

age 1 292.260606 292.260606 8.63 0.0055
gpid*age 1 109.728139 109.728139 3.24 0.0794
gpid 1 1449.728139 1449.728139 42.81 <.0001

age 1 292.260606 292.260606 8.63 0.0055
gpid*age 1 109.728139 109.728139 3.24 0.0794
Dependent Variable: object control skills (otT medication)
Sumof
Source DF Squares Mean Square F Value Pr>F
Model 3 1894.632035 631.544012 23.05 <.0001
Error 40 1096.095238 27.402381
R-Square CoeffVar RootMSE objcoffMean
0.633502 13.87518 5.234728 37.72727
gpid 1 1100.000000 11 00. 000000 40.14 <.0001

age 1 673.527273 673.527273 24.58 <.0001
gpid*age 1 121.104762 121.104762 4.42 0.0419
gpid 1 1217.832035 1217.832035 44.44 <.0001

age 1 673.527273 673.527273 24.58 <.0001
gpid*age 1 121.104762 121.104762 4.42 0.0419
211
Dependent Variable: object control siriUs (on medication)
Sumof
Model 3 2242.985931 747.661977 22.06 <.0001
Error 40 1355.809524 33.895238
R-Square CoeffVar RootMSE objconMean
0.623260 15.34849 5.821962 37.93182
Source DF Type 1 SS Mean Square F Value Pr>F
gpid 1 1090.022727 1090.022727 32.16 <.0001

age 1 1007.066883 1007.066883 29.71 <.0001
gpid*age 1 145.896320 145.896320 4.30 0.0445
gpid 1 1235.350866 1235.350866 36.45 <.0001

age 1 1007.066883 1007.066883 29.71 <.0001
gpid*age 1 145.896320 145.896320 4.30 0.0445
212
Appendix Q
Univariate results for individual locomotor skills
Dependent Variable: ron (off medication)
Sumof
Mode} 3 21.52619048 7.17539683 4.89 0.0055
Error 40 58.72380952 1.46809524
R-Square CoeffVar RootMSE runoffMean
0.268239 16.71241 1.211650 7.250000
gpid 1 14.20454545 14.20454545 9.68 0.0034

age 1 2.12142857 2.12142857 1.45 0.2364
gpid *age 1 5.20021645 5.20021645 3.54 0.0671
Source DF Type ID SS Mean Square F Value Pr>F
gpid 1 18.83658009 18.83658009 12.83 0.0009

age 1 2.12142857 2.12142857 1.45 0.2364
gpid*age 1 5.20021645 5.20021645 3.54 0.0671
Dependent Variable: ron (on medication)
Sumof
Model 3 15.37207792 5.12402597 5.06 0.0046
Error 40 40.51428571 1.01285714
R-Square CoeffVar Root MSE runon Mean
0.275060 13.70958 1.006408 7.340909

213
gpid 1 10.02272727 10.02272727 9.90 0.0031

age 1 2.38636364 2.38636364 2.36 0.1327
gpid*age 1 2.96298701 2.96298701 2.93 0.0949
Source DF TypeIDSS Mean Square F Value Pr>F
gpid 1 12.78116883 12.78116883 12.62 0.0010

age 1 2.38636364 2.38636364 2.36 0.1327
gpid*age 1 2.96298701 2.96298701 2.93 0.0949
Dependent Variable: gallop (off medication)
Sumof
Model 3 52.0329004 17.3443001 II.78 <.0001
Error 40 58.8761905 1.4719048
R-Square CoeffVar RootMSE gallopofMean
0.469149 18.79638 1.213221 6.454545
gpid 1 40.09090909 40.09090909 27.24 <.0001

age 1 7.32813853 7.32813853 4.98 0.0313
gpid*age 1 4.61385281 4.61385281 3.13 0.0843

gpid 1 44.61385281 44.61385281 30.31 <.0001
age 1 7.32813853 7.32813853 4.98 0.0313
gpid*age 1 4.61385281 4.61385281 3.13 0.0843
214
Dependent Variable: gallop (on medication)
Sumof
Modet 3 82.4077922 27.4692641 16.10 <.0001
Error 40 68.2285714 1.7057143
R-Square CoeffVar RootMSE gallopon Mean
0.547064 19.81563 1.306030 6.590909
gpid 1 71.27272727 71.27272727 41.78 <.0001

age 1 4.12207792 4.12207792 2.42 0.1279
gpid*age 1 7.01298701 7.01298701 4.11 0.0493
gpid 1 77.92207792 77.92207792 45.68 <.0001

age 1 4.12207792 4.12207792 2.42 0.1279
gpid*age 1 7.01298701 7.01298701 4.11 0.0493
Dependent Variable: hop (otT medication)
Sumof
Modet 3 128.6829004 42.8943001 20.80 <.0001
Error 40 82.4761905 2.0619048
R-Square CoeffVar Root MSE hopoffMean
0.609412 18.42014 l.435933 7.795455

215
gpid 1 79.11363636 79.11363636 38.37 <.0001

age 1 42.47813853 42.47813853 20.60 <.0001
gpid*age 1 7.09112554 7.09112554 3.44 0.0711
gpid 1 85.63658009 85.63658009 41.53 <.0001

age 1 42.47813853 42.47813853 20.60 <.0001
gpid*age 1 7.09112554 7.09112554 3.44 0.0711
Dependent Variable: hop (on Medication)
Sumof
Model 3 97.7186147 32.5728716 11.82 <.0001
Error 40 110.1904762 2.7547619
R-Square CoeffVar RootMSE hoponMean
0.470006 20.62963 1.659748 8.045455
gpid 1 71.27272727 71.27272727 25.87 <.0001

age 1 22.44242424 22.44242424 8.15 0.0068
gpid*age 1 4.00346320 4.00346320 1.45 0.2351
gpid 1 73.82164502 73.82164502 26.80 <.0001

age 1 22.44242424 22.44242424 8.15 0.0068
gpid*age 1 4.00346320 4.00346320 1.45 0.2351
216
Dependent Variable: leap (otT medication)
Sumof
Source DF Squares Mean Square FValue Pr>F
Model 3 10.34632035 3.44877345 4.26 0.0106
Error 40 32.38095238 0.80952381
R-Square CoeffVar Root MSE leapoffMean
gpid 1 9.09090909 9.09090909 11.23 0.0018

age 1 1.06060606 1.06060606 1.31 0.2592
gpid*age 1 0.19480519 0.19480519 0.24 0.6264
Source DF Type ID SS Mean Square F Value Pr> F
gpid 1 7.01298701 7.01298701 8.66 0.0054

age 1 1.06060606 1.06060606 1.31 0.2592
gpid*age 1 0.19480519 0.19480519 0.24 0.6264
Dependent Variable: leap (on medication)
Sumof
Model 3 13.06385281 4.35461760 5.11 0.0044
Error 40 34.09523810 0.85238095
R-Square CoeffVar Root MSE leapon Mean
0.277017 19.62453 0.923245 4.704545
Source DF Type 1 SS Mean Square F Value Pr> F
gpid 1 10.02272727 10.02272727 11.76 0.0014

age 1 2.47813853 2.47813853 2.91 0.0959
gpid*age 1 0.56298701 0.56298701 0.66 0.4212
217
Source DF Type ID SS Mean Square F Value Pr> F
gpid 1 10.38116883 10.38116883 12.18 0.0012

age 1 2.47813853 2.47813853 2.91 0.0959
gpid *age 1 0.56298701 0.56298701 0.66 0.4212
Dependent Variable: jump (otTmedication)
Sumof
Model 3 59.1937229 19.7312410 8.46 0.0002
Error 40 93.2380952 2.3309524
R-Square CoeffVar Root MSE jumpoffMean
0.388329 27.19709 l.526746 5.613636
gpid 1 38.20454545 38.20454545 16.39 0.0002

age 1 19.35086580 19.35086580 8.30 0.0063
gpid*age 1 l.63831169 l.63831169 0.70 0.4068
gpid 1 38.72922078 38.72922078 16.62 0.0002

age 1 19.35086580 19.35086580 8.30 0.0063
gpid*age 1 l.63831169 l.63831169 0.70 0.4068
Dependent Variable: jump (on medication)
Sumof
Model 3 80.0508658 26.6836219 7.00 0.0007
Error 40 152.3809524 3.8095238

218
R-Square CoetrVar RootMSE jumponMean
0.344406 33.15799 1.951800 5.886364
gpid 1 63.84090909 63.84090909 16.76 0.0002

age 1 16.13181818 16.13181818 4.23 0.0462
gpid*age 1 0.07813853 0.07813853 0.02 0.8868
gpid 1 53.89632035 53.89632035 14.15 0.0005

age 1 16.13181818 16.13181818 4.23 0.0462
gpid*age 1 0.07813853 0.07813853 0.02 0.8868
Dependent Variable: slide (off medication)
Sumof
Model 3 23.19307359 7.73102453 9.27 <.0001
Error 40 33.35238095 0.83380952
R-Square CoetrVar RootMSE slideoffMean
0.410167 12.71449 0.913132 7.181818
gpid 1 5.81818182 5.81818182 6.98 0.0117

age 1 16.48831169 16.48831169 19.77 <.0001
gpid *age 1 0.88658009 0.88658009 1.06 0.3087
gpid 1 6.70476190 6.70476190 8.04 0.0071

age 1 16.48831169 16.48831169 19.77 <.0001
gpid*age 1 0.88658009 0.88658009 1.06 0.3087
219
Dependent Variable: slide (on medication)
Sumof
Model 3 26.3816017 8.7938672 2.60 0.0657
Error 40 135.5047619 3.3876190
R-Square CoeffVar RootMSE slideon Mean
0.162964 25.70925 1.840549 7.159091
gpid 1 21.84090909 21.84090909 6.45 0.0151

age 1 . 4.06255411 4.06255411 1.20 0.2800
gpid*age 1 0.47813853 0.47813853 0.14 0.7091
gpid 1 21.20541126 21.20541126 6.26 0.0165

age 1 4.06255411 4.06255411 1.20 0.2800
gpid*age 1 0.47813853 0.47813853 0.14 0.7091
220
AppendixR
Univariate results for individual object control skills
Dependent Variable: bat (otT medication)
Sumof
Model 3 32.3556277 10.7852092 4.79 0.0061
Error 40 90.0761905 2.2519048
R-Square CoeffVar RootMSE batoffMean
0.264275 18.49522 1.500635 8.113636
age 1 Il.75086580 11.75086580 5.22 0.0277

gpid 1 19.11363636 19.11363636 8.49 0.0058
gpid*age 1 1.49112554 1.49112554 0.66 0.4206
age 1 11.75086580 11.75086580 5.22 0.0277

gpid 1 20.40021645 20.40021645 9.06 0.0045
gpid*age 1 1.49112554 1.49112554 0.66 0.4206
Dependent Variable: bat (on medication)
Sumof
Model 3 37.6199134 12.5399711 5.48 0.0030
Error 40 91.5619048 2.2890476
R-Square CoeffVar Root MSE baton Mean

0.291217 19.23995 1.512960 7.863636
221
-- Source DF Type 1 SS Mean Square F Value Pr>F
age 1 20.80086580 20.80086580 9.09 0.0045

gpid 1 15.36363636 15.36363636 6.71 0.0133
gpid*age 1 1.45541126 1.45541126 0.64 0.4299
Source DF TypeIDSS Mean Square F Value Pr>F
age 1 20.80086580 20.80086580 9.09 0.0045

gpid 1 16.72813853 16.72813853 7.31 0.0100
gpid*age 1 1.45541126 1.45541126 0.64 0.4299
Dependent Variable: dribble (otT medication)
Sumof
Model 3 108.0820346 36.0273449 18.27 <.0001
Error 40 78.8952381 1.9723810
R-Square CoeffVar RootMSE driboffMean
0.578049 23.31859 1.404415 6.022727
age 1 56.96298701 56.96298701 28.88 <.0001

gpid 1 42.02272727 42.02272727 21.31 <.0001
gpid*age 1 9.09632035 9.09632035 4.61 0.0379
age 1 56.96298701 56.96298701 28.88 <.0001

gpid 1 50.91450216 50.91450216 25.81 <.0001
gpid*age 1 9.09632035 9.09632035 4.61 0.0379
222
Dependent Variable: dribon
Sumof
Model 3 114.3627706 38.1209235 13.76 <.0001
Error 40 110.8190476 2.7704762
R-Square CoeffVar RootMSE dribonMean
0.507869 27.12477 l.664475 6.136364
age 1 59.88658009 59.88658009 2l.62 <.0001

gpid 1 44.00000000 44.00000000 15.88 0.0003
gpid*age 1 10.47619048 10.47619048 3.78 0.0589
Source DF Typeffi SS Mean Square F Value Pr>F
age 1 59.88658009 59.88658009 21.62 <.0001

gpid 1 54.11255411 54.11255411 19.53 <.0001
gpid*age 1 10.47619048 10.47619048 3.78 0.0589
Dependent Variable: catch otT
Sumof
Model 3 19.40670996 6.46890332 6.85 0.0008
Error 40 37.75238095 0.94380952
R-Square CoeffVar Root MSE catchoffMean
0.339521 18.66635 0.971499 5.204545

223
age 1 8.23051948 8.23051948 8.72 0.0052

gpid 1 10.02272727 10.02272727 10.62 0.0023
gpid*age 1 1.15346320 1.15346320 1.22 0.2755
age 1 8.23051948 8.23051948 8.72 0.0052

gpid 1 11.15346320 11.15346320 11.82 0.0014
gpid*age 1 1.15346320 1.15346320 1.22 0.2755
Dependent Variable: catchon
Sumof
Source DF Squares Mean Square F VaIue Pr > F
Model 3 18.68809524 6.22936508 9.04 0.0001
Error 40 27.56190476 0.68904762
R-Square CoeffVar Root MSE catchon Mean
0.404067 15.81122 0.830089 5.250000
Source DF Type 1 SS Mean Square F VaIue Pr > F
age 1 16.36904762 16.36904762 23.76 <.0001

gpid 1 1.84090909 1.84090909 2.67 0.1100
gpid*age 1 0.47813853 0.47813853 0.69 0.4098
Source DF Type ID SS Mean Square F VaIue Pr>F

age 1 16.36904762 16.36904762 23.76 <.0001
gpid 1 2.29632035 2.29632035 3.33 0.0754
gpid*age 1 0.47813853 0.47813853 0.69 0.4098
224
Dependent Variable: kick (otT medication)
Sumof
Model 3 35.65259740 11.88419913 8.62 0.0002
Error 40 55.14285714 1.37857143
R-Square CoeffVar RootMSE kickoff Mean
0.392669 18.25496 1.174126 6.431818
age 1 12.78116883 12.78116883 9.27 0.0041

gpid 1 21.84090909 21.84090909 15.84 0.0003
gpid*age 1 1.03051948 1.03051948 0.75 0.3924
age 1 12.78116883 12.78116883 9.27 0.0041

gpid 1 22.30324675 22.30324675 16.18 0.0002
gpid*age 1 1.03051948 1.03051948 0.75 0.3924
Dependent Variable: kick (on medication)
Sumof
Model 3 26.7125541 8.9041847 4.82 0.0059
Error 40 73.9238095 1.8480952
R-Square CoeffVar RootMSE kickonMean
0.265436 20.62609 1.359447 6.590909

225
age 1 9.00779221 9.00779221 4.87 0.0331

gpid 1 15.36363636 15.36363636 8.31 0.0063
gpid*age 1 2.34112554 2.34112554 1.27 0.2671
Source OF Type ID SS Mean Square FValue Pr>F

age 1 9.00779221 9.00779221 4.87 0.0331
gpid 1 17.70476190 17.70476190 9.58 0.0036
gpid*age 1 2.34112554 2.34112554 1.27 0.2671
Dependent Variable: throw (off medication)
Sumof
Source OF Squares Mean Square F Value Pr > F
Model 3 97.9573593 32.6524531 12.00 <.0001
Error 40 108.8380952 2.7209524
R-Square Coeff Var Root MSE throwoffMean
0.4 73692 27.18328 1. 649531 6.068182
age 1 37.63831169 37.63831169 13.83 0.0006

gpid 1 46.02272727 46.02272727 16.91 0.0002
gpid*age 1 14.29632035 14.29632035 5.25 0.0272
Source OF Type ID SS Mean Square F Value Pr> F
age 1 37.63831169 37.63831169 13.83 0.0006

gpid 1 59.20541126 59.20541126 21. 76 <.0001
gpid*age 1 14.29632035 14.29632035 5.25 0.0272
226
Dependent Variable: throw (on medication)
Sumof
Model 3 96.4352814 32.1450938 13.29 <.0001
Error 40 96.7238095 2.4180952
R-Square CoeffVar Root MSE throwon Mean
0.499253 24.70072 1.555023 6.295455
age 1 34.45909091 34.45909091 14.25 0.0005

gpid 1 54.56818182 54.56818182 22.57 <.0001
gpid*age 1 7.40800866 7.40800866 3.06 0.0877
age 1 34.45909091 34.45909091 14.25 0.0005

gpid 1 6l.95346320 6l.95346320 25.62 <.0001
gpid*age 1 7.40800866 7.40800866 3.06 0.0877
Dependent Variable: roll (off medication)
Sumof
Model 3 92.6309524 30.8769841 8.72 0.0001
Error 40 14l.6190476 3.5404762
R-Square CoeffVar Root MSE rolloffMean
0.395436 32.72374 l.881615 5.750000

227
Source DF Type 1 SS Mean Square F Value Pr> F
age 1 13.85476190 13.85476190 3.910.0548

gpid 1 73.84090909 73.84090909 20.86 <.0001
gpid*age 1 4.93528139 4.93528139 1.39 0.2447
age 1 13.85476190 13.85476190 3.91 0.0548

gpid 1 77.66255411 77.66255411 21.94 <.0001
gpid*age 1 4.93528139 4.93528139 1.39 0.2447
Dependent Variable: rollon
Sumof
Model 3 116.2138528 38.7379509 11.77 <.0001
Error 40 131.6952381 3.2923810
R-Square CoeffVar Root MSE roUon Mean
0.468776 30.47238 1.814492 5.954545

age 1 24.72813853 24.72813853 7.51 0.0091
gpid 1 87.36363636 87.36363636 26.54 <.0001
gpid*age 1 4.12207792 4.12207792 1.25 0.2698
age 1 24.72813853 24.72813853 7.51 0.0091

gpid 1 89.21298701 89.21298701 27.10 <.0001
gpid*age 1 4.12207792 4.12207792 1.25 0.2698
228
Appendix S
Run
-+--ADHD (6-12 yrs.)
(6.7, 7.8, 8.0)
___ No-ADHD (6-12 yrs.)
-i:r- Maximum Skill Crierion
10
Slide
(6.7,7.8,8.0) Gallop
(5.4, 7.6, 8.0)
Hop
Jump (6.7,9.2,10.0)
(4.7,6.7,8.0)
Leap
(4.3, 5.2, 6.0)
Figure 2 Locomotor skill profiles
Note. The numerals in the brackets indicate (avg. skill criteria for children with ADHD, avg.
skill criteria for children without ADHD, maximum skill criterion per skill)
229
Appendix T
-+--ADHD (6-12 yrs.)

Bat ---- No-ADHD (6-12 yrs.)
(7.4,8.6,10.0) ~ Maximum Skill Cr~erion
Dribble
(5.1, 7.4, 8.0)
Roll
(4.6, 7.3, 8.0)
Throw Catch
(5.2,7.3,8.0) (4.9, 5.6,6.0)
Kick
(5.9,7.2,8.0)
Figure 3 Object control skill profiles
Note. The numerals in the brackets indicate (avg. skill criteria for children with ADHD, avg.
skill criteria for children without ADHD, maximum skill criterion per skill)
230
AppendixU
Interview Guide
1 am now going to ask you about the times when you are playing alone or with your friends.
1. Which of the following activities have you played, at least once, within the last 12
months? (a check indicates a positive response) How mu ch do you like playing this
activity?
Q
"Really don't like it"
g
"It's okay"
g
Really like it a lot"
"Don 't Iike it" "Like it"
( ) Swings, slides, teeter-totters 1 2 3 4 5
( ) Bicycling 1 2 3 4 5
( ) Swimming 1 2 3 4 5
( ) Roller-blading 1 2 3 4 5
( ) Running or jogging 1 2 3 4 5
( ) Skateboarding 1 2 3 4 5
( ) Skating 1 2 3 4 5
( ) Hockey 1 2 3 4 5
( ) Football 1 2 3 4 5
( ) Basketball 1 2 3 4 5
( ) Soccer 1 2 3 4 5
( ) Baseball 1 2 3 4 5
231
( ) What other physical activity games have yOll played in the past 12 months?
1 2 3 4 5
2. Do yOll ever set IIp any ofthese games to play or practice with other children?
Not at aIl Not very often Often Very often Most of the time
1 2 3 4 5
2a. Have you ever tried to set up a game of physical activity?
(a) no (b) yes
2b. Ifyes, what games do you like to set up?
3. Do you like to play pick-up games with your friends?
Not at aIl Not very often Often Very often Most of the time
1 2 3 4 5
4. Do you playon any teams or in any organized sports?
(a) no (b) yes, which sports? List here:
Learning Context
1 am now going to ask you a few questions about how you have learned to play.
5. How much time do you spend in play each day from Monday to Friday?
( a) more than 1 hour (b) 1 hour (c) 30 minutes (d) 15 minutes (e) none
6. How much time do you spend in playon each day during the weekend?
(a) more than 1 hour (b) 1 hour (c) 30 minutes (d) 15 minutes (e) none
7. What is your special way of practicing activities or games on your own?
8. Which activity or games do you practice?
9. For each time that you play, how long do you practice each activity or game?
(a) more than 1 hour (b) 1 hour (c) 30 minutes (d) 15 minutes (e) none
232
10. Do you ever set up special targets to practice? For example, 1 sometimes set up a
glass on my office floor and try to putt a golf ball into it.
Not at all Not very often Often Very often Most of the time
1 2 3 4 5
Il. Do you ever use special words to remember how to practice any skills or moves?
For example, a special play in football is the "Dive 32" or the "switch" is a special
way of moving your hand in swimming the front crawl.
1 2 3 4 5
12. Do you ever watch someone else play agame so that you can learn how to play
that game better?
1 2 3 4 5
13. Do you take part in physical education class in school?
1 2 3 4 5
14. Ifyou compare yourselfto the other children in physical education class, are your
movement and sport skills:
(a) Much worse (b) Not as good (c) Same (d) Better (e) Much better
Affective Questions
1 am now going to ask you a few questions about how you feel when you play.
15. What do you like the most about physical education class?
16. What do you like the least about physical education class?
17. How do you feel if the physical education teacher asks you to show a skill or move in front
ofto the whole class?
233
AppendixV
Table 1 Physical Activity Categories
Categories Properties Sample data units
Deliberate Play Solitary Play "1 play basketball myself'

Group Play "My friend plays with me"
No Play "1 don't play games"
Play Settings "1 bring my sister to the park to play"
Knowing About Doing Leisure Sk.ills "We take a spin on my brother' s bike"
Movement Sk.ills "We hit a ball with racquets"
Modeling "1 watch my brother play hockey"
Game Situations "1 throw to the left when 1 play quarterback
in a real game"
Personal Theories "The more you practice, the better you get"
"The puck goes over the net when 1 aim at
Self-Awareness that spot"
Personal Feelings Positive Affect "You always have fun during gym"
Negative Affect "1 really don't like that game"
Prosocial Behavior "They'll cheer you on"
Asocial Behavior "They always pick on me"
234
AppendixW
Table 2 TGMD-2 scores ofboys with and without ADHD
Participants Locomotor Scores Object Control Scores GMDO Scores
Raw Standard Descriptor Raw Standard Descriptor Total Descriptor
ADHD
Larry 42 9 A 32 3 VP 76 P
Gord 31 4 P 30 3 VP 61 VP
Claude 43 9 A 41 7 BA 88 BA
Randy 39 7 BA 47 12 A 97 A
Bob 38 7 BA 36 5 P 76 P
Billy 43 9 A 45 10 A 97 A
No-ADHD
Dale 47 13 AA 46 11 A 112 AA
Mike 48 13 AA 48 13 AA 118 AA
Fred 47 13 AA 44 10 A 109 A
Jim 40 8 A 47 12 A 100 A
Ted 45 11 A 44 10 A 103 A
Chad 47 13 AA 46 11 A 112 AA
Note. VP = Very Poor, P = Poor, BA = Below Average, A = Average,

AA = Above Average
Table 3 Deliberate Play
Property ADHD No-ADHD
Solitary Play 12 o
Group Play 59 47
No Play 3 4
Play Settings 77 94
235
AppendixX
Table 4 Knowing about Doing
Leisure Skills 8 0
Movement Skills 128 159
General Models 14 10
Specifie Models 20 47
Game Situation 9 14
Personal Theories 14 15
Strategies & Self-Awareness 107 100
Table 5 Personal Feelings
Positive Affect 57 52
Negative Affect 70 40
Prosocial Behavior 12 7
Asocial Behavior 43 28

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Fundamental movement skills and associated physical activity

experiences of children with ADHD

Department of Kinesiology and Physical Education

McGill University, Montreal

ofDoctor ofPhilosophy in Kinesiology and Physical Education

©William J. Harvey, 2006

Published Heritage Direction du

395 Wellington Street 395, rue Wellington

Your file Votre référence

The author retains copyright L'auteur conserve la propriété du droit d'auteur

ln compliance with the Canadian Conformément à la loi canadienne

While these forms may be included Bien que ces formulaires

Excessive activity has been a prominent feature in the symptomatology of attention-deficit

and gender-matched peers without ADHD. Multivariate statistical analyses revealed no

unique physical activity needs.

L'activité excessive est une caractéristique marquante dans la symptomatologie du trouble

d'attention avec hyperactivité (TDAH) depuis plus de quatre décennies. Si toutefois

l'hyperactivité a aidé à identifier les personnes atteintes de TDAH, la capacité motrice et

l'activité physique adaptée (APA) et le TDAH. Le premier manuscrit, un article de révision,

des médicaments stimulants sur la performance fondamentale de la capacité motrice pour 22

chaque groupe et ils sont une contribution unique à la littérature de la performance du

compréhension des besoins uniques de l'activité physique chez les enfants.

Chapter 1 Theoretical Perspectives 16

Rationale for themy selection 16

Chapter 2 Attention-DeficitIHyperactivity Disorder: A Review of 33

Table of Contents, Conf d

Chapter Three Attention-DeficitIHyperactivity Disorder:

Chapter Four Fundamental movement slrills and children with

Table of Contents, Cont' d

Chapter Six Summary 178

List of Figures, Appendices and Tables

Chapter 1 Theoretical Perspectives

Figure 1.0. Knowledge About Action 18

Chapter 2 Attention-DeficitIHyperactivity Disorder: A Review of

AppendixE: Table 1 Historical Review ofDSM nomenclature 193

Chapter Three Attention-DeficitIHyperactivity Disorder: APA

Appendix H: Table 1 Assessment Instruments for Movement Behavior of 200

Chapter Four Fundamental movement skills and children with

Appendix 1: Table 1 Performance criteria for TGMD-2locomotor skills 201

List of Figures, Tables and Appendices, Cont'd

Appendix S: Figure 2 Locomotor skill profiles 228

Chapter Five Physical activity experiences of boys with and without

Appendix U: Interview Guide 230

Attention-deficit hyperactivity disorder (ADHD) is a problem of considerable importance,

for a lifetime of disability-related impairments. It affects a substantial number of school-aged

(e.g., throwing, catching, kicking, etc.).

framework. The hybrid model of executive functions (Barkley, 1997) is described as an

Rationa/e for theory selection

of ADHD, created a hybrid model of executive functioning to describe relationships between

response inhibition, cognitive functions, and behavioral actions, hypothesized to be responsible

understanding of the relationship between ADHD and physical activity.

The knawledge-based approach

Metacognitive Knowledge Metacognitive Skills

Figure 1.0 Knowledge About Action

movement includes both information-processing and a resultant behavioral response. Thus,

procedural knowledge involves both a cognitive component about

knowledge is influenced by morphological, biomechanical, and environmental constraints while

declarative components of movement skill acquisition and performance. Thus, declarative

the human physiological system, and the performance environment.

metacognitive knowledge in proficient movements based on previous successful and

reflecting metacognitive knowledge and metacognitive skills.

of children with disabilities. According to the knowledge-based model of information

processing, Wall (2001) hypothesized that relevant environmental information is identified,