Lifestyle factors, physical activity, and exercise for school-aged children with Attention Deficit Hyperactivity Disorder

Children with attention deficit hyperactivity disorder (ADHD) comprise 7 % of the population and present the most frequent neurodevelopmental disorder. While pharmaceutical treatment has been predominant, such treatments have concerning side effects. Research into the impact of daily lifestyle factors, such as dietary patterns, physical activity (PA), sleep behaviour, and screen time, has attracted growing research interest. Furthermore, a large body of literature suggested positive effects of PA and exercise on ADHD symptoms through intervention programs. However, children with ADHD experience more challenges than their neurotypical peers during their participation in PA and exercise, due to their various symptoms. Little research has explored variables that are associated with these children's participation patterns in PA and exercise programs. Cultural variances in these challenges and needs that children with ADHD may have concerning exercise interventions, are not understood despite the global prevalence of the disorder. The present PhD project aimed to identify significant lifestyle factors and to understand needs and challenges to participation in PA and exercise among school-aged children with ADHD. In addition, this thesis presents a  randomised controlled trial protocol to apply an 8-week cricket program with evaluating the behavioural effects on childhood ADHD by using a mixed methods design. Study 1 (Chapter 3) engaged participant caregivers in an online survey regarding their children's sleep, diet, screen time, and physical activity. Potential mediation paths were examined among the lifestyle variables to understand the mechanisms of the impact on one another. A total of 309 parents/caregivers of children aged 8 to 12 years participated from English speaking countries. Multiple regression analyses showed that sleep issues were the most significantly different factor between children with ADHD (n = 54) and without ADHD (n = 255).  Furthermore, structural equation modelling (SEM) showed that having ADHD directly predicted more sleep problems while diet, physical activity, and screen time mediated the impact of ADHD upon sleep problems when demographic variables such as age and parental income were controlled. In Study 2 (Chapter 4) semi-structured in-depth interviews were conducted with 21 Australian caregivers of children with ADHD. The same interview protocol was used in Study 3 (Chapter 5) with a cross-culture approach interviewing 10 Taiwanese caregivers of children with ADHD. Both interview studies explored the patterns, challenges, and needs concerning children's participation in PA and exercise programs in relation to their ADHD symptoms and difficulties. Qualitative content analysis derived meaning units (n = 2,623 in Study 2, n = 1,823 in Study 3) of all verbatim transcripts within themed categories and subcategories such as Coaching Style and Challenges in PA and Exercise. The socioecological model was used as a theoretical framework to explain variables and factors on participating in PA and exercise programs, concerning psychosocial and environmental levels. Australian (Western) and Taiwanese (Eastern) caregivers reported their children with ADHD preferred individual exercises to group sports, experiencing social and physical coordination difficulties. Notably, the importance of coaches' influence and their role of empowerment and encouragement were emphasised for group exercise programs in both cultures. Professional training for coaches and teachers in understanding ADHD and appropriate skills appeared important to improve these children's engagement and participation. Furthermore, cross-cultural data yielded Taiwanese children and families appeared to require further support with more PA and exercise programs that are publicly available with quality coaching support. Study 4 (Chapter 6) proposes a protocol for a randomised controlled trial to examine the effects of an 8-week community-based exercise intervention program for children with ADHD. Preliminary data from two child participants suggested some limited effects of the cricket program on sleep measures, physical activity, and behavioural symptoms. While the protocolled interviews both with caregivers and coaches as a follow-up evaluation were disrupted by the COVID-19 pandemic, methodological challenges and future directions for research and interventions are discussed. The present thesis highlights the impact of poor diet, physical activity and screen time on sleep problems in children with ADHD. Furthermore, this thesis has attended to parents' voice and individual children's preferences and challenges in engaging physical activity and exercise programs. From this, suggestions have been made regarding: a) the promotion of self-efficacy and social skills of ADHD children by coaches on the field, b) organisational components at the institutional level such as local sport clubs and coach training, and c) social and political levels of community and public policy with social campaigning and raising public awareness about childhood ADHD and other disabilities. This framework could be used to guide the development of more inclusive exercise programs for children with ADHD.