An intervention for children with ADHD using physical activity and exercise in Primary Schools.
Research by ‘The Mental Health Foundation’ (2016) has shown that Attention Deficit Hyperactivity Disorder (ADHD) is caused by an imbalance of brain chemicals which affect impulsivity, concentration and attention. This condition impacts 11% of 4-17-year-old children equating to 6.4 million in USA (Centres for Disease Control and Prevention, 2016) and 2% to 5% of children in the UK (NHS, 2016). Children in school who have been diagnosed with ADHD may display several characteristics including: being fidgety, impulsive or making careless errors in their work (NHS, 2016).
ADHD intervention.
Rationale
Children with ADHD are often in mainstream schools and form part of the normal classroom. These students are typically managed by teaching assistants or SEN trained staff. Their behaviours can not only impact on their own education but also that of their pupils. This impact is typically negative and therefore any interventions that can help to improve behaviour and learning are welcomed in the education system (Service Children’s Education, 2013). Therefore, using exercise as an intervention for ADHD is not only good for student’s physical health but also their mental health and education. A simple, yet powerful demonstration of the (Ratey, 2012) Hindu Squat to an adult group to highlight how the brain would be better ready to learn. Titled ‘Run, jump, learn! How exercise can transform our schools’, Ratey said.
“exercise is really for our brains; physical exercise turns our brains on. And all the wonderful side effects we get help our body be healthy”.
Ratey (2012) goes on to discuss a research study by California Department of Education Study (2001) that found 33% of freshmen in California were overweight/obese and after introducing 45 minute’s exercise per day this significantly reduced to 3% in 2003. Therefore, the current intervention could be used to help children learn better, increase academic self-efficacy and improve cognitive performance.
Recent research conducted by (Smith et al, 2014) in the USA, investigated whether exercise before school and reducing ADHD symptom severity. They conducted a 12-week intervention of physical activity (exercise to breath hard/expend energy) or sedentary classroom activity (art class). This consisted of a 31-minute activity and 94 at risk, randomly assigned children (108 typically developing). Overall, results showed that both parents and teachers reported a reduction in the symptoms of ADHD children after the intervention. This research was only 12-weeks so the findings should be viewed with caution in terms of any long-term effect. This is another reason for implementing an intervention, to improve the symptoms of ADHD in school.
One area that appears to be lacking in schools is the inclusion of exercise as part of the treatment plan or as a method of managing ADHD. Schools are not doing enough physical activity each week and exercise is not seen as a possible tool to use, despite numerous studies highlighting the benefits of exercise and physical activity on children with ADHD (Tomporowski, 2003). One report suggested primary schools do on average 2 hours of physical activity per week (Ofsted, 2013) which is less than the 60 minutes per day as recommended by the NHS (2011). Therefore, the current intervention may be able to increase this to 150 minutes per week.
Aims/Objectives:
1: to improve academic self-efficacy in children with ADHD through physical activity
2: to improve cognitive attention performance in visual/auditory processing in children with ADHD through physical activity.
Measures Completed at Baseline and weeks 6 and 12
(See Appendix 2)
The Intervention
The intervention will take place between June 5th to July 21st 2017 and is funded by Manchester city Council. The sample for this intervention are year five (N=15, 3 ADHD) and six (N=18, 4 ADHD) students from Armitage Primary School in Manchester, ranging from 8-11 years old (Total 33 students). Consideration would be taken for children with injuries, complex needs, medical needs and obesity. BPS Ethical guidelines will be followed including: Medical, School and Parental Consent and The Data Protection Act 1988. The school is providing all the equipment and has a container on the premises where this is all stored. Core Staff competencies such as good communication and organisational skills along with attended teacher training days on the CPT3, CATA, token economy, TTM and processes of change prior to the intervention and one PE trained teacher will be present in each session who is an appointed first aider (See Appendix 3). Children showing success will be rewarded for their effort/motivation/participation/attitude are assigned ‘buddy roles’ to help children who are potential at risk of dropping out or who are struggling. Token economy will be used to help motivate children who are struggling along with praise, extra break time and rewards given out (certificates/trophy’s) each week on Friday assembly, for example 1: best pupil in X 2: best effort given in X.
The intervention consists of 30 minute’s aerobic exercise split into 5 stations each lasting 6 minutes. Each station consists of a ball sport for example; 1x football, 1x rounders, 1x volleyball, 1x mini tennis and 1x netball. This will take place before school starts and 30 minutes after breakfast has been eaten. The physical activity intervention will take place each morning and run for five days, Monday to Friday and will be over the course of 12 weeks (total 150 minutes’ physical activity per week). As mentioned, the aim(s) are to help to improve academic self-efficacy and auditory/visual cognitive attentional factors. There will be an assembly open day 1 week before the intervention starts to discuss exercise and mental health from NHS professionals to the children and local sports coaches will come in give a taster session in the hall consisting of fun games and activities (linking to precontemplation stage of TTM).
Academic Self-Efficacy and Cognitive Attention Performance were chosen because ADHD can impact on these areas in a negative way and therefore improving these areas should be of a benefit to the students both inside and outside the classroom.
Self-Efficacy
Self-Efficacy Questionnaire for Children (SEQ-C) including social self-efficacy, academic self-efficacy, and emotional self-efficacy, Muris (2001) completed at baseline, week 6 and 12 consisting of 8 questions measure on a Likert scale (See Appendix 1).
Research by Tabassam and Grainger (2002) found that students with LD and ADHD differ in terms of self-efficacy, self-concept and attributional style. Students reported lower scores on academic self-concept, attributional style and self-efficacy beliefs compared to students without LD or ADHD. Therefore, this intervention can help raise these factors and potentially help student’s academic performance, due to the behaviour difficulties that ADHD children can display in class.
McAuley and Blissmer (2000) found that after interventions using physical activity to help self-efficacy, it resulted in a significant effect (ES 0.16). Further research by Luszczynska and Tryburcy (2008) found that six months after a physical activity intervention participants reported higher levels of self-efficacy and higher levels of exercise. This shows that exercise may have a long-term effect. Manley et al (2014) using a pedometer intervention program, looked at self-efficacy, physical activity, aerobic fitness, and body composition and found a weak positive correlation between self-efficacy and physical activity.
Any intervention using physical activity with ADHD participants could help them to improve their self-efficacy through self-regulated strategy development (Jacobson & Reid, 2010; Johnson, Reid & Mason, 2012). It was also found that having low self-efficacy for self-regulated learning, can lead to learned helplessness, especially in SEN students (Gaskill & Hoy, 2002). There is however, conflicting research by Owens et al (2007) who found a ‘positive illusory bias’, in children with ADHD, where they report extremely positively regarding their own competence. This may, however, be a protective mechanism known as the ‘self-protective hypothesis’ where children with ADHD try to cover up and stop feelings of incompetence (Diener and Milich, 1997). These elements need to be considered when investigating self-efficacy in ADHD samples. Fefer (2013) research the positive illusionary bias in ADHD symptoms and used a new measurement approach. This could be used to help reduce any confounding results.
The TTM model (the chosen model for the current intervention) can be used to identify any cognitive or behavioural aspects (by using processes of change and stage matching) which may indicate this, making the model very effective. A weakness of some research is that self-efficacy is looked at globally rather than in specific facets. In the current intervention, the component of self-efficacy is academic.
Cognitive Performance
The Conners CPT 3 and Conners Continuous Auditory Test of Attention™ (Conners CATA™) 1 week prior to intervention and again at the end of weeks 6 and 12.
Support for the use of exercise for improving cognitive performance in ADHD comes from Biddle (2015) who found that physical activity helped cognitive performance in a sample of ADHD students. Moreover, an intervention correlated with a reduction in disruptive behaviours along with improvements in more desirable behaviours (Tompporowski, 2003).
In 2006, Dickstein, carried out a meta-analysis of 16 neuroimaging studies looking at deficits in frontal lobe function. The fMRI showed that children with ADHD had less blood flow in the pre-frontal cortex and brain regions for behavioural control tasks (Konrad, 2006).
(See Appendix 3 for the whole exercise plan)
Models of Behaviour Change
Transtheoretical Model of Change
The behaviour change model chosen for this intervention is the Transtheorectical Model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992).
The TTM consists of distinct stages:
1: Pre-Contemplation 2: Contemplation 3: Preparation 4: Action 5: Maintenance.
Originally the model was developed to deal with addiction behaviours such as smoking and has been transferred to physical activity (Adams, 2003). J. Erskine (personal communication, October, 2016) argued that sedentary behaviour could be an addiction due to it being classed as an activity and therefore could apply. The TTM focuses is on the ‘when’ and ‘how’ parts of change, for example, the ‘when’ looks at the stages people go through and the ‘how’ looks at the constructs of self-efficacy, decisional blame, pros and cons along with the processes of change. These stages can be ‘cyclical’ in that people may move forward and back through them, which potentially may strengthen the behaviour change (Prochaska, 1992). This means that if children are identified as being at different stages the model can still be implemented as part of the intervention. This would be extremely effective to help identify where the children are in the model and to then implement the cognitive or behavioural processes of change to help them overcome potential barriers. Support for the stage matching was found in research (Kim, Hwang and Yoo, 2004) where stage matching was used in an exercise intervention on type II diabetes, where participants showed significant improvements in stages of change for exercise behaviour.
Processes of change
Marcus (1992c) argued that people use all ten processes of change (5 behaviour and 5 cognitive) when modifying their behaviour. This would be effective because it helps to identify what stage children are in by how they are thinking and behaving. For example, when the children are moving from pre-contemplation to contemplation, then temptations to stop exercise become more tempting. Therefore, the model can be effective in identifying this and the cognitive and behavioural processes of change can be used to help keep the children on target. Another example would be it helps to prevent relapse where temptations may occur due to low self-efficacy and therefore can be used to help keep the children exercising (in the action stage – maintenance stage), making the model extremely useful.
5 x Cognitive Processes
Consciousness Raising | Teachers receive education on how to interact with all 10 processes of change. Children will recall information given to them in class on the benefits of exercise |
Dramatic Relief | Children are warned about health implications of inactivity |
Environmental re-evaluation | Children could feel better as a role model if they exercised |
Self-re-evaluation | Children start to consider the idea that regular exercise would make them happier, healthier and better person to be around |
Social Liberation | Children see things changing in ways that make it easier to exercise |
5 x Behavioural Processes
Counterconditioning | Children start to engage in activity instead of doing nothing |
Helping relationships | Children have a person they can count on when they don’t feel like exercising |
Reinforcement management | Children reward themselves for doing physical activity |
Self-liberation | Children tell themselves they can keep exercising if they want to |
Stimulus control | Children have things at home to remind them about exercise |
(See Appendix 3)
At the centre of the TTM is the decisional balance which covers the pros and cons of any physical activity. Research (Callaghan, Khalil & Morres, 2010) showed that increasing self-efficacy is linked with greater readiness for physical activity and this increased at each stage. This would be very effective and have a positive impact on the outcome because self-efficacy is a key component of the model. The TTM has the benefit of focusing on people’s readiness to change and with its staged-matched interventions are ideal for children as well as needing a supporting environment to result in behavioural changes, making it very effective (Prochaska, 1992). A challenge for this model is that physical activity is not one behaviour but rather multiple actions and questions have been raised over the long-term effects (Adams and White, 2005).
Questions have also been asked of whether stage progression equates to behavioural change, however, improving self-efficacy and motivation may eventually lead to a change in behaviour (Adams and White, 2005). This positive intention was supported by Sheeran (2002) who found that a lack of intention can lead to a lack of behaviour and highlights the importance of getting through the early stages. A potential pitfall of the TTM is the amount of time each stage takes, for example, the maintenance stage lasts from 6 months to 5 years (Pro-Change Behaviour Systems, 2016) and in the current intervention there is only 12 weeks. One solution is to tailor the TTM to the 12-week intervention which is supported by Noar et al (2007).
Due to the cyclic nature of the TTM, any children who are identified as being at a different stage can be accommodated. For example, if John is in the contemplation stage, the focus can be on motivational strategies rather than maintenance strategies. This is another reason the model was picked for the current intervention as its flexible and can be tailored to meet individual needs.
Figure 1: Cyclic patterns of TTM (including fictitious examples)
This model was also chosen because children may find themselves going backwards and forth between stages during the current intervention and having a model that can incorporate this element would be extremely useful. This means that the correct input from teachers can then be given to that child to help keep them on track, making the model very effective and potentially have a massive impact on the mental health and physical activity levels of school children.
Health belief Model
In terms of the Health Belief Model (Becker, 1974), it was originally developed to help with tuberculosis screening/diseases. This model was not chosen because primary aged children do not think the same as adults regarding illness. Piaget (1920) developed the cognitive theory where in concrete operational stage (7-12 years) showed that children find abstract thinking and hypothetical situations (becoming ill) very difficult. Research found (using drawings) that children tend to use a biomedical explanation of illness, whereas adults use a psychosocial model (Mouratidi, Bonoti & Leondari, 2016). Therefore, the TTM is better as it will raise the conscious thoughts of health in the children by using the processes of change and stage matching. There are modifying factors in the HBM like media, health professionals and personal relationships which are important, however the models components and perceived barriers are not that well defined. Another criticism of the HBM is that it does not include unconscious or social factors linked to behaviour, but focuses on cognitive factors. Children in the current intervention may be behaving unconsciously and therefore not aware of health risks. This makes the TTM more suitable because the children will be educated in precontemplation and then be more aware in the contemplation stage and finally act.
Another reason the TTM was chosen over the HBM was because research shows that the HBM has weak predictive power and only predicts about 10% of variance (low) in behaviour (Harrison et al. 1992) compared to the TTM which showed moderate too high in predicting dietary fat intake between 92-95% and in smoking 77-85%, (Wright, Velicer and Prochaska, 2009). A further reason the HBM model was not chosen was because to change people must feel vulnerable to a health problem and view the potential consequences as bad enough to act. Primary school children don’t really fall into this category (Natapoff, 1982). Natapoff (1982) does argue though that children can be made aware of how their own exercise can impact on disease. Some children may not even be aware of health concerns and therefore the TTM helps to educate them first, making the TTM very effective and potentially have a greater impact.
Theory of Planned Behaviour
Another model of change is the theory of planned behaviour (Ajzen, 1985) which succeeded the theory of reasoned action (Fishbein and Ajzen, 1975). This focuses on individual behaviour, attitudes (subjective norms) and beliefs. Intention to act is a key component and having a positive and negative evaluation of their behaviour in terms of social perceptions and what people think about that person. This model could be good at changing the children’s subjective norms and making other people influence the child’s behaviours by the children feeling compelled to do what others think you should be doing. However, the TPB model is best suited at predicting behaviour rather than planning and designing a physical activity intervention that results in a change. This model could be useful to predict behaviour, but it doesn’t suggest how to change behaviour or how to get people to act. Participant intentions are only one component of whether they will exercise because if they don’t have the ability or the opportunity then they probably won’t. This model is better suited to identifying cognitive targets to change rather than changing them (Hardeman, 2002). For the above reasons, this model was not selected for the current intervention and the preference was to encompass the TTM.
Overall, the TTM allows children to move back and forth through the stages of change and allows for an intervention that accommodates every individual by implementing the TTM.
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Appendix 1
Academic Self-Efficacy subscale for from Self-Efficacy questionnaire for Children (SEQ-C)
Murtis (2001)
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Appendix 2
CPT 3 (example)
During the 14-minute, 360-trial administration, respondents are required to push the spacebar when any letter, except “X”, appears. The Conners CPT 3 is available as an unlimited use program or pay-per-use for one computer. The number of computers that can use the program is limited to the number of installations purchased.
New scores and scoring algorithm have been developed to help assessors pinpoint the exact nature of the respondent’s attention problems. The Conners CPT 3 uses both standardised and raw scores to determine not only the respondent’s performance overall but also in four different aspects of attention: Inattentiveness, Impulsivity, Sustained Attention and Vigilance.
The Most Representative CPT Normative Samples Collected
The new normative sample consists of 1,400 cases and is representative of the United States (U.S.) population in terms of key demographic variables such as gender, race, geographical region, and parental education level.
During the 14-minute, 200-trial administration, respondents are presented with high-tone sounds that are either preceded by a low-tone warning sound (warned trials) or played alone (unwarned trials). Respondents are instructed to respond only to high-tone sounds on warned trials, and to ignore those on unwarned trials. On most trials, the low-tone and the high-tone sounds are played in the same ear (non-switch trials). On switch trials, the low-tone warning sound and the high-tone target sound are played in different ears, requiring the respondent to shift auditory attention from one ear to the other.
The Conners CATA is available as an unlimited use program or pay-per-use for one computer. The number of computers that can use the program is limited to the number of installations purchased.
The normative sample consists of 1,080 cases and is representative of the United States (U.S.) population in terms of key demographic variables such as gender, race, geographical region, and parental education level.
Conners CATA Age and Gender Normative Data
Conners CATA Race and Education Normative Data
(Full exercise plan is below in Appendix 3)
Appendix 3
Week 1 (unaware)
Pre-Contemplation Stage
Training and education prior to start date for teachers |
IN CLASS
|
Week 1 Processes of change:
|
Week 2 (aware)
Contemplation Stage | IN CLASS
| Week 2 Processes of change:
Dramatic relief (pay attention to feelings)
|
Week 3
Preparation Stage | IN CLASS
| Week 3 Processes of change:
Self-liberation (make a commitment)
|
Week 4
Action Stage | PHYSICAL ACTIVITY
| Week 4 Processes of change:
Environmental re-evaluation (notice their effect on others)
Counter Conditioning (using substitutes)
Reinforcement management (getting rewards)
|
Week 5
Action Stage |
PHYSICAL ACTIVITY
|
Processes of Change
Reinforcement Management |
Week 6
Action Stage | PHYSICAL ACTIVITY
|
|
Weeks 7-10
Action Stage |
Physical Activity
|
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Week 11
Physical Activity
Maintenance Stage |
Physical Activity
|
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Week 12
Maintenance Stage/Relapse | Physical Activity
|
Appendix 3 (Above)
