Objective measurement of weekly physical activity and sensory modulation problems in children with attention deficit hyperactivity disorder
Introduction
Attention-deficit hyperactivity disorder (ADHD) is a developmental disorder with high prevalence worldwide, 3–10% (Graetz et al., 2001, Wolraich et al., 1996), and around 50% of referrals to pediatric psychiatric clinics are for the assessment and treatment of ADHD (McGee, Clark, & Symons, 2000). One of its core symptoms, hyperactivity (American Psychological Association, 2000), often causes substantial disturbances for children with ADHD and for their parents (Barkley, 1998, Lin and Chung, 2002, Taylor, 1998). For example, hyperactivity may cause children with ADHD to run in a class that requires sitting quietly, and may interrupt their learning, result in rejection by their peers, and increase pressure for their parents (Lin & Chung, 2002).
To better understand hyperactivity in children with ADHD, prior studies have measured the children's physical activity (PA) (e.g., Dane et al., 2000, Halperin et al., 1992, Porrino et al., 1983). Although these studies consistently confirmed that children with ADHD have a higher level of PA than typically developing children, some important questions remain unclear about the characteristics of PA, such as its intensity and frequency in children with ADHD. Some prior studies used subjective measures (Edwards et al., 2005, Luk, 1985), which could be biased by observers’ perspectives (Edwards et al., 2005). Some used objective measures to decrease the observers’ bias in laboratory situations on one particular day (Dane et al., 2000, Halperin et al., 1992, Halperin et al., 1993, Teicher et al., 1996), which would have worse reliability than recording PA for a week and would limit the understanding of children's general PA in daily life (Trost, Pate, Freedson, Sallis, & Taylor, 2000). Recording PA for an entire week would be more representative of daily life because school life is normally considered to recur in weeks per semester. Therefore, some studies (Imeraj et al., 2011, Porrino et al., 1983, Tsujii et al., 2007) assessed the PA of the children with ADHD in their daily life, including their time at school, for 7 days by asking the children to wear an objective activity monitor that recorded data as the number of movements the child made. However, using these units as an assessment of PA may limit the interpretation of the findings; that is, the connection between the number of movements and the intensity of PA may not be as clear as other units, such as metabolic equivalents (METs) per minute. For example, it may not be applicable to use number counts to understand whether a sufficient amount of PA is reached or to interpret the meaning of the differences between various levels of PA.
Activity monitors that can record PA using METs should be more helpful than using number counts for a better interpretation of the collected data. PA measured using METs can be classified into 4 levels of intensity: light (<3.00), moderate (3.00–5.99), vigorous (6.00–8.99), and very vigorous (>9.00) (Ekelund et al., 2001). Of these four levels, it is often suggested that time spent on moderate-to-vigorous physical activity (MVPA; 3.00–8.99 METs) be used to estimate a person's PA (Guerra et al., 2003, Lin et al., 2012). At least 420 min of MVPA per week is recommended (Cavill, Biddle, & Sallis, 2001). Average PA in daily life can also be presented as total METs divided by time (METs/min). Sufficient or more than recommended PA in children with ADHD has been assumed because of their hyperactivity (Holtkamp et al., 2004). However, this assumption has not been fully investigated. Information about MVPA might prompt new strategies for treating children with ADHD (Tsujii et al., 2007).
Sensory processing could influence PA (Parham & Mailloux, 2005), and the problems of sensory processing in children with ADHD have already raised concerns (Ahn et al., 2004, Cheung and Siu, 2009, Engel-Yeger and Ziv-On, 2011, Miller et al., 2012, Mulligan, 1996, Parush et al., 1997, Roid and Miller, 1997, Wang et al., 2003, Yochman et al., 2006, Yochman et al., 2004). One primary pattern of sensory processing problems is difficulty in sensory modulation, which causes problems in responding to sensory input relative to its degree, nature, or intensity (Miller, Anzalone, Lane, Cermak, & Osten, 2007). Some children with ADHD have also been identified with sensory modulation problems, measured by behavioral (e.g., Cheung and Siu, 2009, Engel-Yeger and Ziv-On, 2011, Miller et al., 2012) and physiological assessments (e.g., Mangeot et al., 2001, Miller et al., 2012).
Several studies (Herpertz et al., 2003, Mangeot et al., 2001, Miller et al., 2012, Rosenthal and Allen, 1978, Shibagaki and Yamanaka, 1990, Spring et al., 1974, Zahn et al., 1975) used electrodermal response (EDR) to assess the physiological reaction to sensory stimuli in children with ADHD. The EDR, which is regulated by the cholinergic fibers of the sympathetic nervous system, has been used to characterize the problems of sensory modulation (Mangeot et al., 2001, McIntosh et al., 1999, Miller et al., 1999). In contrast to the consistent results of those studies in the 1970s (Rosenthal and Allen, 1978, Spring et al., 1974, Zahn et al., 1975), which showed smaller phasic reactivity to stimuli in children with ADHD than in typically developing children, recent research has reported inconsistent results. For example, the physiological reactions in children with ADHD were reported as smaller than (Shibagaki & Yamanaka, 1990), larger than (Mangeot et al., 2001), and the same as (Herpertz et al., 2003, Miller et al., 2012) those in typically developing children. Thus, additional studies are needed to better understand this issue.
Additionally, to the best of our knowledge, few studies have examined the association between PA and sensory modulation problems in children with ADHD. A better understanding of their association may help clinicians develop better treatment strategies.
This appears to be the first study to record the PA in children with ADHD in METs for 7 consecutive days in natural settings, and to examine the association between PA and problems in sensory modulation. Specifically, we aimed to (1) examine the general difference in objective PA during one week between children with ADHD and their peers; (2) improve our understanding of the frequency and intensity of hyperactivity in children with ADHD in daily life, separately on weekdays and weekends; (3) examine the sufficiency of PA in children with ADHD; (4) use behavioral and physiological reports to understand reactions to sensory stimuli; (5) examine the relationship between PA and sensory modulation problems in children with ADHD.
Section snippets
Participants
Forty Taiwanese boys were recruited for this study: 20 boys diagnosed with attention deficit hyperactivity disorder (ADHD group) and 20 typically developing boys (control group).
Children in the ADHD group were referred by a local clinic specialized in the diagnosis and treatment of children with mental illness, including ADHD. An experienced child psychiatrist had diagnosed all the ADHD group children based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria (
Results
There were no significant differences in age, height, weight, or body mass index between the ADHD and control groups (Table 1).
Discussion
The current study appears to be the first to objectively record the PA in METs for 7 consecutive days in natural settings for children with ADHD. It examined the association between PA and sensory modulation problems. We found that children with ADHD tended to have a higher average level of PA than did typically developing children. However, this tendency was significant only during certain hours of daily life, such as 12:00–17:00 on the weekend. Also, the frequency and intensity of
Conclusion
In summary, we found that children with ADHD had a higher level of PA in daily life than did typically developing children, but that the group differences were not constant in daily life and that the degree of difference was not large as indicated by METs. The findings implied that the disturbance caused by hyperactive behaviors cannot be explained solely by the data of objectively measured PA. The distribution of hyperactivity seemed to be influenced by social and temporal contexts, which
Acknowledgments
We thank all the children and their parents for actively participating in our study, and we thank all the teachers, therapists, and physicians who helped us recruit the study participants.
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