Some parents who start their children in martial arts are concerned with their children's ability to concentrate. Some of the students have been diagnosed with Attention Deficit Disorder (ADD) or Attention Deficit Hyperactive Disorder (ADHD). These disorders are characterized by a child's inability to focus or concentrate for a normal amount of time.

The following information is adapted from an article in the September/October 1990 edition of Your Patient & Fitness magazine (Use sports in treating hyperactive children, by Jeffery L. Alexander, MD) in which Taekwondo is mentioned as a known aid to children with ADD/ADHD. Although the two are not precisely the same, in this article, the terms "attention deficit disorder" and "hyperactivity” are used interchangeably for convenience.

Most of us can remember having been the 'goat' in a childhood ball game because a grounder scooted between our legs or we struck out in a crucial game. For hyperactive children, such early experiences in organized sports happen too often and, as a result, they quickly learn to dislike sports and games.

This is unfortunate, because sports and recreation can and should be one of the cornerstones of treatment for children with attention deficit hyperactive disorder. I cannot cite a stack of articles to back this assertion, because the role of sports and recreation in hyperactive children's lives has received little formal study. However, my experience has convinced me that helping a child to succeed in sports and recreation programs can make an important contribution to therapy. Carefully chosen activities, perhaps combined with the use of appropriate medications, can help enhance the child's confidence, self-esteem, fitness, and social adjustment.

Prevalence and Symptoms

Attention deficit disorder, with or without hyperactivity, is the most common reason for referral of children to child guidance clinics and specialists in child behavior and developmental medicine. The precise incidence of this disorder is not clear, but most experts agree that between 2% and 5% of children have it. Many children, particularly girls, who have attention deficit disorder without hyperactivity, are diagnosed either late or incorrectly.

For most children, the core symptoms of attention deficit hyperactivity disorder are hyperactivity, short attention span, distractibility, and impulsiveness. Most parents are aware of these problem behaviors by toddler hood or preschool, but they often become more apparent, and sometimes are greatly exaggerated, once the child enters school. Teachers complain that these children do not listen, disturb other children, cannot concentrate, cannot sit still, and have a short attention span.

As the years go by, the problems mount. The disorder sabotage academic performance; grades substantially understate the child's potential in most cases. In addition, the impulsive behavior ruins relationships with other young people and adults. If left untreated, the child may exhibit chronic school underachievement, behavioral problems, conduct disorders, and, not infrequently, depression and/or anxiety.

Conventional treatment

Most experts now agree that the most effective treatment for hyperactivity is medication, such as methylphenidate (Ritalin), dextroamphetamine sulfate (Dexedrine), pemoline (Cylert), or one of several antidepressant medications. These medications may produce nuisance side effects and sometimes problems that are more serious, but the great benefits they provide may be worth the risks. Obviously, the question of benefits versus risks is difficult.

Family counseling can also be helpful for a child with attention deficit disorder; especially in teaching parents which behaviors are attributable to the disorder and which are not. The thrust is to help the family structure the child's activities, learn to identify the child's special skills or gifts, and provide consequences to use for inappropriate behavior.

Much is made of educational treatment. In fact, the American Academy of Pediatrics Committee on Children with Disabilities has stated that behavioral and educational treatment should be tried before medication. However, only one state and Washington, DC provide for academic and behavioral assistance for hyperactive children. Although some teachers are very good with these children, many teachers have little training in dealing with them. Too often, children are incorrectly labeled as emotionally and behaviorally disturbed and are unnecessarily transferred to special settings.

Physical Education (PE) offers an opportunity for therapy, but it is seldom exploited properly. Hyperactive children typically have a rough time in PE because of their poor listening skills, distractibility, and impulsiveness. PE teachers should receive in-service training in the proper management of these children, as should playground monitors and school bus drivers.

For the present, however, most pediatricians cannot count on successful educational modifications and must rely on family therapy and medication. Sports participation can serve as an important adjunct to these modalities.

Choosing an activity

To integrate recreation and sports into treatment, the activities must be planned thoughtfully. Parents are familiar with "individual education plans," based on careful consideration about which sports or recreation programs are suitable.

Through short interviews with children and parents, a pediatrician usually may help the family select activities most likely to bring success. The pediatrician attempts to find out why certain athletic and recreational activities have failed in the past. How does the child spend free time? What activity does the child usually do when asked what he or she would like to do? What assets do the parents see in the child in the way of eye-hand coordination, running skills, speed, endurance, and strength? How mature is the child physically and emotionally? If the pediatrician knows about local opportunities for sports and recreation, he or she can greatly assist the parents in choosing an activity or activities to fit the child. For children with motor coordination problems or other special problems, the pediatrician might want to consult an adaptive PE instructor for advice about the best activity.

It is important for parents to talk to the coach or recreation leader about their child's skills and problems before a program begins, but parents worry that this will create a negative attitude in the coach or teacher. On the contrary, most coaches want and need to know about potential problems in advance. If not made aware of the problem, the coach probably will interpret some of the child's behaviors as deliberate and possibly directed at the coach, which will leave a particularly bad impression.

Best sports

From 15 years of using recreation and sports in the treatment of hyperactive children, it is my impression that certain activities are much better than others. Baseball, for a negative example, can be a nightmare for these children because of its slow pace and the need for well-developed motor skills and hand-eye coordination skills. However, other activities help children learn to enjoy athletics and, in fact, often awaken in them a passion for sports.

Soccer is one of the most attractive sports for young children with attention deficit disorder. Currently it is the second largest sport for children in the United States, quite remarkable for a country without a soccer tradition. For young hyperactive children it is often ideal because it entails ample participation for all, lots of running, and kicking a relatively large ball. Position play is not terribly important at younger age levels, and the natural impulsiveness of hyperactive children does not interfere with their performance. In addition, since most coaches of youngsters in this sport are parents who do not particularly know the nuances of soccer, they usually allow the children to go out and have a good time.

Soccer is a good building block for other sports because it enhances speed, endurance, and leg strength, and is very safe. In addition, the hyperactive child does not look that much different from other kids on the field. Most communities have summer and fall soccer programs, and warmer climates provide for soccer year-round. Older children may find soccer enjoyable if they can be coached, i.e., if they listen well, follow instructions, and learn to play positions.

Taekwondo and karate are, in my experience, the most enjoyable sports for hyperactive children after soccer. Parents often do a double take when these sports are mentioned, fearing that a martial art will lead to serious social problems for their children because of their impulsiveness and aggressiveness. However, to me, Taekwondo and karate are two of the most therapeutic programs for children with this syndrome, and children can start as early as 4 or 5 years of age.

These sports are beneficial because they involve structure, rules, rituals, a stop-and-think attitude, and absolute obedience. No techniques are taught until the children have learned to stop, listen, and think. Classes usually are small. The techniques are monitored carefully, emphasizing over and over that these are sports and are not to be used for any aggressive play. Students who disobey the rules usually are expelled from the class.

Swimming usually is well suited to children with attention deficit disorder. Swimming tends to be a fairly explosive activity in which impulsiveness may be an advantage. In general, swimming is highly recommended for children with motor coordination problems.

Wrestling programs for hyperactive children also have been quite successful. In wrestling, the coach usually teaches the athlete one-on-one, which enhances listening and works better than group teaching. As in swimming and soccer, endurance and stamina are improved, as is strength of all muscle groups.

Other activities in which hyperactive children have been particularly successful are diving, weight lifting, track and field, gymnastics, and, in some cases, tennis and golf. Tennis and golf, however, are difficult to learn and often end in frustration, which may bring out more of the attention deficit symptoms. Weight lifting is a fairly explosive sport which does not require sustained concentration, but it should be done under the guidance of a coach and should be reserved for children who are physically mature enough to avoid injury.

Role of medication

Often one of the most successful ways to enhance sports participation is to use methylphenidate or other medications. Hyperactive kids battle with the same problems on the athletic field as they do in the classroom. Methylphenidate and other medications are used primarily to improve the efficiency of learning by increasing attention span and decreasing hyperactive behavior, distractibility, and impulsiveness. Medication will not make children smarter, but they may very well study more effectively. There is also evidence that methylphenidate and other stimulant medications improve social skills.

If one of the purposes of medication is to increase attention and thereby improve academic achievement, it also makes sense to consider the benefits of medication to improve athletic and other recreational skills. The reason for using medications in these children, after all, is to help them succeed in general-not just in sports or academics. However, when their confidence and self-esteem are improved by helping them perform better in sports, other benefits may multiply. Many physicians now recommend that medication doses be adjusted so they will be effective during athletic practices and events. The fact is that medication makes many children more amenable to coaching.

For example, one boy was asked what sport he was playing. "Hockey," he replied. "What position do you play?" "E.O.B." "What's E.O.B.?" "End of the bench," answered the boy. His father then said, "What makes this particularly sad is that I'm the coach, but no one wants to play on his line. He skates well, handles the puck well, and shoots very well. The problem is that he doesn't listen to his coach or teammates, he's possessive of the puck and rarely passes, and has no concept of team play."

This boy was taking 10mg of methylphenidate in the morning and at noon. He was then instructed to take another 10mg of methylphenidate later in the afternoon, about 30 minutes before hockey practices and games. At a follow-up visit 2 months later, the father said the boy had improved so much in team play that he was selected for the all-star team at the end of the season. This suggests that many children have all ingredients for success, but they are sabotaged by the attention deficit symptoms.

This is not to say that medication should be given solely for the sake of sports performance. If an afternoon dose of medication is really needed for a sports event, it should be given regularly at that time to help the youngster cope with other afternoon and evening situations that otherwise would cause frustration.

Researchers studying hyperactive children in group settings have often reported beneficial effects of medications. One recent study looked at the effects of methylphenidate on baseball performance by boys with this disorder. Doses of 0.3 and 0.6 mg/kg of body weight were used in the double-blind placebo-controlled study, which involved 17 boys aged 7.8 to 9.9 years. Measures of attention improved dramatically, though there was no significant difference between the two doses. The players were more often able to tell the score and the number of outs, they were in a ready position more often when out on the field, and they were less likely to swing impulsively at balls well out of the strike zone. The researchers said the actual athletic skills of the children did not improve; what improved was their ability to stay focused on the game, and this enhanced their performance.

Stimulant medications are banned in Olympic and NCAA competition. That may not be a problem for athletes with attention deficit, because by the end of high school most children have compensated for most of their symptoms, and if they are candidates for high-level competition, they have probably learned to concentrate and are able to be coached. On the other hand, there is really no evidence that the medications used to treat attention deficit disorder in and of themselves enhance strength, speed, or stamina. Of course, the ban exists because these medications are controlled substances and can be easily abused. However, no one in good conscience could recommend that an athlete discontinue the phenobarbitol he or she takes for epilepsy, even though it is also a narcotic. Similarly, athletes with exercise-induced asthma commonly use albuterol inhalers, which allow them to breathe normally so they can compete to the best of their ability. Likewise, when wisely used, medications for hyperactivity may allow young athletes to do their best.

One final note: A bonus of athletic activity is that, if parents participate with their child, barriers are let down and more meaningful communication can occur. For example, although attempts at dinner conversation may be futile, dialog may flow freely if parent and child go outside to shoot baskets together.

Conclusion

Many hyperactive children have been turned off to sports because of poor early experiences in organized sports and PE classes. The negative attitudes engendered early must be turned around because of the benefits of fitness and the enjoyment that comes from participating in sports and recreation. Carefully chosen activities can be therapeutic as well as enjoyable. The judicious use of medication before these activities can enhance successful participation, particularly by improving the ability to be coached and team play.

Some tips to help manage the behavior of ADD or ADHD students:

• Objectively identify what problems are the biggest impediments to the child’s learning. These may not be the most annoying behaviors or the ones you would most like to correct. Make a chart. List the behavior, when it most frequently occurs, what triggers it, and how disruptive it is on a scale of one to ten, and, for each problem, list at least one strategy for eliminating or changing the behavior.
• Look at the way you and other instructors treat the child. By looking at the way you teach and the class environment, you may be able to eliminate some undesirable behaviors quickly.
• Demonstrate behaviors that you want the child to follow like not speaking when others are speaking, putting equipment away after using it, talking in a polite quiet voice, and not being overly critical.
• If a child is struggling with learning or remembering a skill, partner him or her with a responsible older child or an assistant instructor. Remind the older child that his or her job is to be a role model and a helper.
• Try keeping track of the amount of positive and negative feedback you are giving the child in class. Look for areas to praise so you do not come across as mean or nagging.
• Give an ADD child specific action messages and instructions. The child does not grasp the subtlety of a statement like “Hanging on the stretching bar is dangerous.” The child also does not translate “Pay attention” into “Stop hanging on the stretching bar and get back in line.” If you want the child off the stretching bar, tell him or her exactly that.
• There is a temptation to “bribe” children with ADD into good behavior by lavishing them with material rewards for every good behavior. Simple rewards are best, such as praise in front of the class or the child’s parents, a simple “thank you” or “good job” that is well timed, or the opportunity to hold a special position in class.
• If a child is not performing a specific behavior such as sitting still, try using a “when…then” sentence like “When you sit down and stop talking, then I’ll explain the rules of the game we’re going to play.” Always use when, not if, because when implies that child will do something while if implies that he or she has a choice.
• Resist the urge to use ADD as an excuse for the child’s behavior. If you exempt a child from punishment, responsibilities, and expectations because of ADD, you are doing the child a disservice.
• If you want an ADD child to listen to you, try speaking slowly, quietly, and briefly. It also helps to make eye contact before beginning to speak so you know you have the child’s attention.

Sources

Kim, S. H. (2002). Martial Arts Instructor's Desk Reference: A Complete Guide to Martial Arts Administration. Wethersfield Connecticut: Turtle Press.