Research in Developmental Disabilities 32 (2011) 11541162

Contents lists available at ScienceDirect

Research in Developmental Disabilities

The relationship between sensory processing difculties and leisure

activity preference of children with different types of ADHD
Batya Engel-Yeger *, Daniella Ziv-On
Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Mount Carmel, Haifa 31905, Israel

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 3 January 2011
Received in revised form 9 January 2011
Accepted 9 January 2011
Available online 15 February 2011

Sensory processing difculties (SPD) are prevalent among children with ADHD. Yet, the
question whether different SPD characterize children with different types of ADHD has not
received enough attention in the literature. The current study characterized sensory
processing difculties (SPD) of children with different types of ADHD and explored the
relationship between SPD and leisure activity preference.
Participants were 58 boys aged 610 years: 29 boys with ADHD: 15 with hyperactive
impulsive type and 14 characterized as inattentive. The controls were 29 typical peers. SPD
were evaluated by The Short Sensory Prole (SSP) completed by the parents. Participants
answered the preference for activities of children (PAC).
According the results, SPD were manifested among children with both ADHD types.
Children with both ADHD types showed signicantly lower preference to participate in
leisure activities than the controls. Their lower preference correlated with SPD. The
ndings suggest that children with different ADHD types may share common SPD, which
may negatively impact their activity preference. In this study it seemed that children with
ADD were more vulnerable to these impacts. SPD and participation should be considered
in evaluation and intervention programs for children with ADHD in order to focus on
childs abilities, needs and preferences, and enhance intervention success, childs
relationships with peers and childs well-being.
2011 Elsevier Ltd. All rights reserved.

Keywords:
ADHD
Sensory processing
Participation
Leisure activities
Activity preference
Outcome measure

1. Introduction
Attention decit/hyperactive disorder (ADHD) is a neurobehavioral developmental disorder. This heterogeneous
diagnostic group is characterized by patterns of inattention and/or hyperactivity as well as poor impulse control and
distractibility (Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, TR, American Psychiatric Association, 2000).
One of the prevalent characteristics of children with ADHD is sensory processing difculties (SPD) (Raggio, 1999;
Yochman, Parush, & Ornoy, 2004).
1.1. Sensory processing difculties
Sensory processing involves the registration and modulation of sensory information and the internal organization of
sensory input in order to execute successful adaptive responses to situational demands and thus engage meaningfully in
daily occupations (Humphry, 2002; Miller, Anzalone, Lane, Cermak, & Osten, 2007). Sensory processing impairments can

* Corresponding author. Tel.: +972 4 8288389; fax: +972 4 8249753.

E-mail address: batya@research.haifa.ac.il (B. Engel-Yeger).
0891-4222/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2011.01.008

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1155

occur in some or all sensory systems (Bundy, 2002) and can be expressed by extreme behaviors to sensory stimuli, ranging
from over responsitivity to under responsitivity and behaviors of sensory seeking (Miller et al., 2007). Individuals with over
responsivity tend to respond to sensation faster, with more intensity or for a longer duration than those with typical sensory
responsivity. They experience non-harmful stimuli as painful, unpleasant, and irritating and thus may exhibit negative,
impulsive or aggressive responses, or avoidance of sensation. Individuals with under responsitivity tend to disregard sensory
stimuli or not to detect incoming sensory information. This lack of initial awareness may lead them to apathy, lethargy and a
seeming lack of inner drive to initiate exploration. Sensory seekers crave to unusual amount or type of sensory input. They
energetically engage in actions that add more intense sensations to their bodies. Invasive seeking behaviors can inuence
social interactions with peers (Miller et al., 2007).
SPD may negatively affect the efciency of the persons ability to adapt to daily situations (Ahn, Miller, Milberger, &
McIntosh, 2004; Parham & Mailloux, 2001). Extreme sensory responsivity may be accompanied by exaggerated emotional
responses as anxiety and stress (Dunn, 2001; Hofmann & Bitran, 2007; Jerome & Liss, 2005; Parham & Mailloux, 2001). SPD
may decrease social skills, impair friendships and relationships, self-condence and self-esteem (Parham & Mailloux, 2001),
affect the interaction with the physical and human environments and cause the person to withdrawal from specic daily
activities (Ahn et al., 2004; Schaaf, MiUer, Seawell, & OKeefe, 2003). Thus, SPD may reduce quality of life, well being (Dunn,
2001) and meaningful participation (Engel-Yeger, 2008; Pohl, Dunn, & Brown, 2003). These negative impacts of SPD may
explain why SPD received a diagnostic code by the Interdisciplinary Council on Developmental and Learning Disorders
(2005) and why it is of most important to examine sensory processing abilities among populations with conditions known to
be often characterized by SPD, as children with ADHD.
1.2. ADHD and sensory processing difculties
SPD among children with ADHD were previously reported. Studies highlighted the association between the difculties
children with ADHD express in sensory processing and their limited performance in daily living situations (Ayres, 1979; BarShalita, Vatine, & Parush, 2008; Fisher, Murray, & Bundy, 1991; Raggio, 1999). Dunn and Bennett (2002) reported that
children with ADHD differed signicantly from children without disabilities in their sensory responsiveness in several
sensory modalities, based on the Sensory Prole Questionnaire (SP) (Dunn, 1994) which is a parental report about the childs
responsivity to sensory events in daily living. Yochman et al. (2004) who used the same questionnaire, conrmed these
results among Israeli children and reported that higher sensory responsivity exists among preschoolers with ADHD as
compared to peers with typical development. Differences between the groups were also expressed in behavioral and
emotional responses. Lane, Reynolds, and Thacker (2010) reported that the relationship between sensory over responsitivity
among children with ADHD and their emotional responses may be expressed in their anxiety level.
SPD among children with ADHD have also neurophysiology manifestations. Mangeot et al. (2001) reported signicantly
higher sensory responsivity among ADHD young school children as compared to age matched typical controls measured by
the Short Sensory Prole SSP (McIntosh, Miller, & Shyu, 1999) which is a short version of the parental report mentioned
above, as well as by electro dermal reactivity (EDR). Parush, Sohmer, Steinberg, and Kaitz (2007) found that children with
ADHD and tactile over responsivity had different central processing of somatosensory input, measured via EEG recordings, as
compared to children with ADHD without tactile over responsivity.
Researchers suggest that the physiological aspects of hypersensitivity to sensory stimuli may result from hyperarousability and un-modulation inhibition processes of the central nervous system (Davies & Gavin, 2007; Smith, 2005). This
may be linked with manifestations of ADHD, as impaired attention and impulsivity.
Some studies suggest that SPD might serve as a moderating variable for ADHD subgroups (Parush et al., 2007; Reynolds,
Lane, & Gennings, 2010). Schaughency (1986) argued that possible differences in sensory perception may exist between
children with the hyperactive type and children with the inattentive type and reported that children with ADHD
characterized with the inattentive type had more tactile and visual decits than children with hyperactivity.
However, a clear understanding of the relationship between SPD and ADHD has proven elusive (Dunn & Bennett, 2002;
Lane et al., 2010). Moreover, the question whether different sensory processing abilities characterize children with different
types of ADHD has not received enough attention in the literature. In addition, since SPD may reduce meaningful
participation, an additional question is raised Do sensory processing abilities of children with different types of ADHD
impact the childs participation in daily living including his/her preference to participate in specic activities and not in
others?
1.3. The importance of referring to the association between SPD and participation among children with ADHD
According to the, a disorder or disease may lead to changes in three different aspects, namely, body functions and
structures (physiological and psychological functions of body systems), activity (the execution of a task or action by an
individual), and participation (involvement in a life situation) (WHO, 2001).
The concept of participation is becoming increasingly important in the eld of childhood disability (King et al., 2006). The
International Classication of Functioning, Disability and Health (ICF) model endorsed by the World Health Organization
(WHO, 2001) denes participation as involvement in life situations resulting from the interaction of individuals with their
social and physical environments. Participation in the everyday occupations of life is a vital part of human development and

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B. Engel-Yeger, D. Ziv-On / Research in Developmental Disabilities 32 (2011) 11541162

life experience through which we acquire skills and competencies, connect with others and nd purpose and meaning in life
(Law, 2002). One of the major determinants of participation in leisure and recreation is individual preferences or interests
(Garton & Pratt, 1991; Searle & Jackson, 1985).
The inattention and hyperactivityimpulsivity that characterize children with attention-decit hyperactivity disorder
(ADHD) may cause these children to experience negative outcomes in personal, educational, and social domains. These
outcomes may impair their functional adaptation throughout their life (Barkley, Fischer, Smallish, & Fletcher, 2006). Indeed,
to identify whether a child meets ADHD criteria, professionals consider a combination of behavioral characteristics that
indicate function is severely limited across environments (McBurnett, Lahey, & Pffner, 1993) including home, school, day
care centers, and social settings. However, the knowledge about these negative impacts on participation of children with
ADHD in daily scenarios needs to be elaborated.
The existing information about participation of children with ADHD mostly refers to school environment and emphasized
difculties in academic achievement and in school adjustment (Frazier, Youngstrum, Glutting, & Watkinz, 2007; Rapport,
Koer, Alderson, Timko, & DuPaul, 2009; Rogers, Wiener, Marton, & Tannock, 2009).
Other studies describe difculties of children with ADHD in social adjustment: these children are characterized by poor
social skills and inadequate behavior affecting their participation in various social activities (Hurt, Hoza, & Pelham, 2007;
Murphy, 2007; Pallegrini & Bohn, 2005). Children with ADHD may elicit less social support, and more stress and negative
evaluations from both teachers and parents (Demaray & Elliot, 2001; DuPaul, McGoey, Eckert, & VanBrakle, 2001). Because of
the potential long-term consequences of social isolation and the pervasiveness of peer rejection, some researchers have
begun to describe ADHD as a social disability (Gentshel & McLaughlin, 2000).
Some reports describe the limited participation of children with ADHD in sports activities based on the motor difculties
that may be a comorbid condition of ADHD (e.g. Beyer, 1999; Kiluk, Weden, & Culotta, 2008; Piek, Pitcher, & Hay, 1999).
The knowledge about participation of children with ADHD in other activity types and in extra curricula activities is scarce.
Moreover, most information about participation of children with ADHD is based on parents and teachers reports. The
present study aimed to elucidate participation patterns of children with different types of ADHD by referring to their
preference to participate in activities performed outside mandatory school hours, based on the childs report. This study also
examines the association between these preferences and the childs sensory processing abilities.

2. Methods
2.1. Participants
Based on the higher prevalence of ADHD among boys, and the differences in participation expressed in both genders
(Biederman et al., 2002; Gaub & Carlson, 1997), the study was based on boys only.
The study included 58 children aged 610 years: 29 boys with ADHD 15 of the children were characterized mainly as
hyperactiveimpulsive and 14 children were characterized mainly as inattentive. Diagnosis of ADHD subtype was given by
neurologists according to the DSM-IV criteria, and supported by the Conners Parent and Teacher Rating Scales revised
CPRS-r (Conners, 1997). Participants in the study group were recruited from a clinic in the north of Israel. The children
participated in the study before receiving any therapeutic or medical intervention for ADHD. The controls were 29 children
with typical development, based on parents report. The controls were recruited as a convenient sample by an advertisement
published in the local newspaper/neighborhood from which the children with ADHD were recruited, calling to participate in
a study about sensory processing abilities and activity preference of children. All participants attended mainstream
elementary schools, were not under any medical treatment on a daily basis or under any medical treatment which impacted
their nervous system, and did not suffer from any other chronic health condition or uncorrected sensory loss (as glasses).
Table 1 depicts the participants socio-demographic data.
Table 1
Socio-demographic data of the participants.
Controls (N = 29)

Age
Mothers years of education
Fathers years of education
Number of siblings

Children with ADHD (N = 29)

Mean

SD

Mean

SD

8.55
15.06
14.05
5.86

.87
2.18
3.68
2.57

8.61
14.34
7.96
6.24

.62
1.63
6.25
1.92

Controls (N = 29)

Residence
City
Village
Learning disabilities
SD: standard deviation.

Children with ADHD (N = 29)

Number

Percentage

Number

Percentage

24
5
0

83
17
0

0
29
3

0
100
10.35

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2.2. Instruments
2.2.1. Demographic questionnaire
This included data on family socio-demographic status; childs health status; medications, treatments and para-medical
therapies.
2.2.2. Short Sensory Prole (SSP) (McIntosh et al., 1999)
This is a shorter version of the Sensory Prole (Dunn, 1999), an instrument that provides a standard method to measure a
childs sensory processing patterns as expressed in daily life. The SSP is lled by the childs main caregiver. It contains 38
items that demonstrated the highest discriminative power of atypical sensory processing among all the items from the
longer version of the Sensory Prole. The seven sections of the SSP are: tactile sensitivity (7 items) (for example: Has
difculty standing in line or close to other people); taste/smell sensitivity (4 items) (for example: Avoids certain tastes or
food smells that are typically part of childrens diets); movement sensitivity (3 items) (for example: Fears falling or
heights); under-responsive/seeks sensation (7 items) (for example: Seeks all kinds of movement and this interferes with
daily routines); auditory ltering (6 items) (for example: Cant work with background noise); low energy/weak (6 items)
(for example: Poor endurance/tires easily); and visual/auditory sensitivity (5 items) (for example: Is bothered by bright
lights after others have adapted to the light)
Internal consistency of the sections within the scale ranged from .70 to .90 (Dunn, 1999). Internal validity correlations
for the sections ranged from .25 to .76 and were all signicant at p < .01. Initial studies of the validity of the SSP
demonstrated discriminate validity of >95% in identifying children with and without sensory processing difculties
(McIntosh et al., 1999).
Items are scored on a ve-point scale. Both section scores and a total score are recorded on the SSP. The possible
range of raw scores on the total scale is 38190, with higher scores (155190) reecting normal performance. A score of
142154 reects a probable difference in performance, while a score of 38141 reects a denite difference
in performance (Dunn, 1999). The Hebrew version of SSP was found to have good psychometric properties
(Engel-Yeger, 2010).
2.2.3. Preference for Activities of Children (PAC) (King et al., 2004)
This instrument is used for evaluating childrens preferred activities outside mandated school hours, with no relation to
whether the activities are actually performed. Each activity is presented on a card with a drawing of the activity and a phrase
(in words) describing the activity. The version used in this study contains 49 items. Scores are obtained for (1) ve activity
types, derived through factor analysis of participation preference data: recreational, active physical, social, skill-based, and
self-improvement/educational scales. (2) Two domains for formal and informal activities. The formal domain, which is
measured by 14 items, consists of structured activities that involve rules or goals and that have a formally designated coach,
leader, or instructor (e.g. taking art lessons, learning to dance, swimming, getting extra help for schoolwork from a tutor). The
informal domain, which is measured by 35 items, includes activities that require little or no planning and often are initiated
by oneself (e.g. reading, hanging out, going to a party) (Law et al., 2000). (3) Total PAC score.
The child/adolescent is asked to sort the cards into three piles according to how much he/she prefers to do the activity, as
follows: (1) really likes to do; (2) sort of likes to do; (3) does not like to do the activity. Mean scores are calculated for each
activity type, for each domain, and for the PAC total score, ranging from 1 to 3. Preliminary assessments of the PAC have
demonstrated sufcient internal consistency, testretest reliability, and validity (King et al., 2004).
2.3. Procedure
Participants were recruited after receiving ethical approval from the institutional review board (IRB) of the
University of Haifa and from the clinic in which the study group was recruited. Parents who agreed to participate with
their children in the study were invited with their children to the center for childs development in their living area,
signed a consent form and lled the demographic questionnaire. In case children answered the inclusion criteria, their
parents were asked to complete the SSP, while their children completed the PAC in the presence of the data collector in
another quiet room.
2.4. Data analysis
The signicance of differences between the groups was measured in two phases: (1) when comparing two groups: the
study group and the typical controls. (2) when comparing three groups: each group of children characterized by specic
ADHD type and the typical controls. The signicance of difference in regard to PAC total score between the study group and
the controls was examined by T-test. When comparing PAC total score of the three groups, ANOVA was used. MANOVA was
applied to examine the signicant of differences in PAC subscales between the study group and the controls, as well as
between both groups of ADHD and the controls. Among children with ADHD Pearson test was used to examine the
signicance of correlations between SSP scores and PAC scores.
The level of signicance was set at p  .05.

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3. Results
3.1. Conrmation of sensory processing differences among children with both types of ADHD
As presented in Table 2, differences in sensory processing performance were manifested among children with both ADHD
types in most SSP scales. However, sensory processing performance was similar in both groups of children with ADHD.
3.2. Comparison of PAC scores between children with ADHD and controls
Children with ADHD showed signicantly lower preference to participate in physical activities; social activities; skillbased activities and formal activities than the controls. Their total PAC score also indicated their lower preference to
participate in activities, as compared to the controls (see Table 3).
3.3. Comparison of PAC scores between both types of ADHD and controls
Children characterized with the inattentive type showed lower preference to participate in most activity types then
children characterized with hyperactive-impulsive type. However, these differences were not signicant, except for
recreational activities: children characterized with the inattentive type showed signicantly lower preference to participate
in these activities as compared to children with the hyperactive type and the typical controls(F58,2 = 3.92, p = .026).
3.4. Correlations between sensory processing abilities and preference to participate in activities among children with ADHD
Among all children with ADHD (hyperactive + inattentive type) lower preference to participate in social activities
positively correlated with more difculties in auditory ltering (lower scores) (r = .41, p = .027) and with general sensory
processing difculties, as measured by the total SSP score (r = .37, p = .05).
When referring to each of the ADHD groups, correlations were presented among children characterized with the
inattentive type: higher smell sensitivity positively correlated with lower preference to participate in social activities

Table 2
SSP scores of children with ADHD (lower scores represent lower preference).
Factors

The whole ADHD

group (N = 29)
Mean  SD

Inattentive type
(N = 14)
Mean  SD

SSP Typical
performance range

28.55  4.08
15.17  3.83
12.55  2.68
26.17  4.37
20.17  4.98
23.82  5.67
20.65  4.11

27.81  3.94
14.81  4.03
12.53  2.41
25.33  3.92
20.86  4.61
24.21  5.42
20.66  3.92

29.35  4.21
15.57  3.7
12.57  3.03
27.07  4.79
19.42  5.43
23.42  6.11
20.64  4.45

3035
1520
1315
2735
2330
2630
1925

147.11  20.09

146.2  16.82

148.07  23.72

155190

Tactile sensitivity
Taste/smell sensitivity
Movement sensitivity
Under-responsive/seeks sensation
Auditory ltering
Low energy/weak
Visual/auditory sensitivity
SSP total score

Hyperactive type
(N = 15)
Mean  SD

SD: standard deviation.

Bold values under typical performance range.

Table 3
Comparison of PAC scores between groups (higher scores represent lower preference).
PAC scales

Typical controls (N = 29)

Mean  SD

ADHD group (N = 29)

Hyperactive type
(N = 15)
Mean  SD

Inattentive type
(N = 14)
Mean  SD

Signicance of difference
between ADHD and typical controls
F57,2, t

Recreational
Physical
Social
Skill based
Self-improvement
Formal
Informal

1.41  .27
1.35  .24
1.33  .23
1.53  .21
1.81  .35
1.55  .24
1.46  .19

1.42  .23
1.46  .25
1.45  .25
1.67  .26
1.87  .37
1.68  .25
1.52  .23

1.64  .26
1.51  .27
1.47  .24
1.71  .28
1.81  .34
1.72  .27
1.59  .23

3.04
3.55*
4.32*
4.41*
0.57
4.96*
2.84

Total PAC score

1.48  .17

1.57  .21

1.62  .21

t = 2.19*

SD: standard deviation.

*
p  .05.

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1159

(r = .54, p = .045); more difculties in auditory ltering positively correlated with lower preference to participate in
recreational activities (r = .71, p = .005); social activities (r = .83, p < .0001); informal activities (r = .76, p = .002); and general
preference to participate in activities, as measured by total PAC score (r = .59, p = .028).
Lower energy level positively correlated with lower preference to participate in social activities (r = .57, p = .034). Higher
auditory/visual sensitivity positively correlated with lower preference to participate in recreational activities (r = .58,
p = .03); social activities (r = .62, p = .019) and in informal activities (r = .55, p = .042).
Higher sensory seeking tendency (higher scores) was correlated with higher preference to participate in physical
activities (lower scores) (r = .61, p = 0.21).
General sensory processing difculties, as measured by the total SSP score positively correlated with lower preference to
participate in social activities (r = .75, p = .002).
4. Discussion
The present study characterized the sensory processing abilities and leisure activity preference of children with different
types of ADHD. This study also examined the association between these preferences and the childs sensory processing
abilities, as expressed in daily living scenarios.
4.1. Sensory processing difculties among children with both types of ADHD
The study conrmed previous reports according to which children with ADHD may show difculties in sensory
processing (e.g. Cheung & Siu, 2009; Dunn & Bennett, 2002; Raggio, 1999; Yochman et al., 2004). Recent studies have tried to
describe neural mechanisms for these atypical patterns. For example, Dockstader, Gaetz, Cheyne, and Tannock (2009) related
cortical response associated with basic somatosensory functions to possible impairment in the perception-to-action system
in ADHD resulting in impaired sensorimotor function and attention decits. While some of the recent studies try to describe
neural mechanisms of SPD among children with ADHD, others highlight that the difculties of children with ADHD to
perceive sensory information properly, may affect their performance and participation at school, home, and in the
community (Dunn & Bennett, 2002).
Although previous reports suggested that children with hyperactive type may show more difculties in sensory
processing (Hem & Hynd, 1992; Reeves & Werry, 1987; Schaughency, 1986), the present study did not nd signicant
differences between children with ADHD with either inattention or hyperactivity. Additional studies, on larger sample sizes
should further examine whether each ADHD type has unique SPD expressions.
The Short Sensory Prole was found to be sensitive in manifesting SPD among children with ADHD. Thus, it may be used
in the evaluation and intervention of children with ADHD. Since this tool is based on parents report, it may raise the parents
awareness to the childs behaviors related to sensory events in daily scenarios.
By referring to the childs sensory processing abilities we can contribute to diagnostic and program planning processes
and increase understanding of the nature of the disorder of ADHD (Dunn & Bennett, 2002). Yet, intervention should not refer
to the sensory difculties only, but deeply understand their impacts on childs participation in activities.
4.2. Activity preference of children with ADHD
Children with ADHD showed lower preference to participate in different types of leisure activities as compared to typical
controls. This supports recent studies in this area. For example, Leung, Chan, Chung, and Pang (2010) who examined activity
and participation in preschoolers with developmental delay found that limited participation may be signicantly impacted
by inattention/hyperactivity.
The present study elucidated this point by showing an elaborated prole of participation in leisure activities and found
that children with ADHD preferred less to participate in physical activities, as well as in social, skill based and formal
activities.
In regard to physical activities, studies highlight that children diagnosed with ADHD often struggle in sports and play
settings and show lower abilities compared to their peers (Pelham et al., 1990). Interestingly, in the present study, children
with higher tendency to sensation seeking, showed higher preference to participate in physical activities. This point should
be taken into account in intervention settings and used to encourage physical activity. This is especially important since
children with ADHD do not only miss opportunities for healthy recreation and play. They may miss the chance to develop
lasting and meaningful friendships essential to proper socialization (Reitman, OCallaghan, & Mitchell, 2005). This may also
explain their lower preference to participate in social activities. Support to this point may be found in the study of Shimoni,
Engel-Yeger, and Tirosh (2010) about participation patterns in leisure activities performed on another group of children with
ADHD. However, while the study of Shimoni et al. examined actual participation, the present study examined preference to
participate in activities whether actually performed or not. Shimoni et al. (2010) reported that boys with ADHD were
signicantly less intensively involved in social activities than typical peers. The authors supported their results by other
studies according to which children with ADHD may express unacceptable social behavior and social difculties causing
rejection and isolation (e.g. Barkley, 1990; De-boo & Prins, 2007; Paulson, Buermeyer, & Nelson-Gray, 2005). Children with
ADHD may have difculties in controlling temper during conicts with others (Lane, Stanton-Chapman, Jamison, & Phillips,

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2007), to show difculties to adapt to school settings that require a high level of positive interaction and behavioral
regulation as regular classroom and playground settings (Egilson & Coster, 2004; Leung et al., 2010; Mancini & Coster, 2004).
It should be mentioned that many children with ADHD study in regular education system and that social incompetence may
lead to low self-condence (Hwang, 2008; Kuo, Lin, Yang, Soong, & Chen, 2004). Successful participation in the school setting
requires social competence, effective communication and compliance with rules (especially in the regular classroom)
(Mancini & Coster, 2004). The results of the present study which reect the childs own perspective, highlight the need to
refer to participation in social activities in intervention, based on a vast perspective which will consider social interaction
with peers, childs ability to cooperate with teachers, to communicate with family, etc.
The present study also found that children with ADHD preferred less to participate in skill based activities. This result is
also supported by Shimoni et al. (2010). The authors suggested that in skill based activities (as: learning to dance; playing a
musical instrument) a long period of participation experience is needed until the child accomplishes rewards and positive
results, whereas for children with ADHD the ability to accept delay of reward and maintenance of motivation are impaired
(Marco et al., 2009; Sergeant, Geurts, & Huijbregts, 2003). Hence, the lower preference to participate in skill based activities
may also result from the motor, cognitive and other emotional difculties children with ADHD may experience, and are
required for adaptive performance of these activities (as: doing gymnastics; dancing; participating in community
organizations).
These difculties mentioned above may also explain the lower preference of children with ADHD to participate in formal
activities, which are structured and require the ability to follow rules and involve the interaction with a coach or instructor.
Interestingly, Shimoni et al. (2010) found that boys with ADHD tended to participate in signicantly more formal activities
than typical children. The authors related it to specic activities included in the formal domain as getting extra help for
schoolwork from a tutor and explained that this may be associated with the higher frequency of learning difculties
reported in children with ADHD (Frazier et al., 2007). It may be also suggested that parents encourage children with ADHD to
participate in after school activities guided by a supervisor, as swimming lessons, gymnastics, art lessons. Moreover, the
formal domain also includes activities such as participating in school clubs, doing team sports, which may be less preferred
by children with ADHD also because of their social difculties. Interestingly, Shimoni et al. (2010) found that children with
ADHD expressed lower enjoyment when participating in formal activities. Thus, although children with ADHD might
actually participate in a larger number of formal activities than children with typical development, they report lower
preference to take part in this activity domain. This point should also receive attention in intervention programs, including
the parents supervision about optimal after-curricular activities that will also t the childs preference. If the childs voice is
heard in therapy, the child will be more involved, and intervention outcomes may be more efcient (Missiuna, 1998).
When referring to activity preference of children characterized with hyperactivity versus children with inattention,
although children with ADD showed lower preference to participate in most PAC activity types than children with ADHD,
these differences were not signicant. Additional studies with larger samples should examine this issue. Yet, children with
the inattentive type showed the lowest preference to participate in recreational activities, compared to children
characterized with the hyperactive type and to the controls. Recreation activities include unstructured free-time activities
such as collecting things, playing with pets, watching TV, and other activities which may be performed more solitarily and do
not necessarily require social interactions, including computer or video games. Indeed, previous studies support this result
and even stress that children with ADHD are at risk in developing addiction to the internet and spend more time playing
computer games than typical children (Bioulac, Ar, & Bouvard, 2008; Chan & Rabinowitz, 2006).
It is recommended to further elucidate participation pattern of children with ADHD in practice and research, especially
since the literature highlight that participation in extracurricular activities among children at risk for developing violent
behavior (often found among children with ADHD) decreased incidences of expressed behavioral and emotional difculties
(Rutter, 1990; Stewart, Reid, & Mengham, 1997).
4.3. Correlations between sensory processing abilities and preference to participate in activities among children with ADHD
Interestingly, correlations between sensory processing abilities and preference to participate in leisure activities were
manifested among children characterized with the inattentive type. The most common activity type that was related to
sensory processing difculties was social activities. Specically, smell, auditory and visual sensitivity, difculties in auditory
ltering and low energy level were found to correlate with lower preference to participate in social activities. These sensory
processing aspects may add another explanation to the difculties in social relationship that children with ADHD may
experience. The result according to which sensory processing difculties correlate with lower preference to participate in
recreational activities and in informal activities, also raises the need to refer to the specic characteristics of these activities
may be impacted by SPD. Clinicians should examine how to create a better platform for the child to participate in these
activities by environmental accommodations that will t the childs sensory needs (for example, reduce stimuli as toys in the
room when performing informal activities as doing puzzles, doing crafts), supervise parents how to assist the child with
guidelines when performing informal activities as doing water sport, gardening, making food) and provide the child with
strategies that will enhance the optimal performance of these activities (for example, when visiting a friend; when going to a
party; dong individual physical activities).
In summary, children with different types of ADHD may exhibit SPD, which may negatively impact their leisure activities
preference and thus limit their participation in activities that children with typical development perform. Children

B. Engel-Yeger, D. Ziv-On / Research in Developmental Disabilities 32 (2011) 11541162

1161

characterized with the inattentive type seem to be more prone to lower preference to participate in activities due to SPD.
Considering that none of the questionnaires currently in use assess behaviors related to sensory processing of children with
ADHD (e.g. Dunn & Bennett, 2002; Lane et al., 2010; Mangeot et al., 2001), this issue should receive growing attention in
research and practice.
In line with previous studies, the SSP was found to identify sensory processing difculties among children with ADHD.
PAC was found to be sensitive in differing activity preference of children with ADHD from those of typical peers. By using
evaluation tools as the SSP, which is based on parents report, and the PAC, which provides information collected directly
from the child, therapists may incorporate a better client-centered and family centered evidence-based practice. This may
contribute to intervention goals setting. Being aware of the different types of activities that the child prefers to do, enables
the service provider to suggest suitable alternative activities that t the childs abilities, preferences and increases the
likelihood of success and enjoyment (King et al., 2002). This may optimize collaboration with children and families (Law
et al., 2006) as well as the intervention outcomes focusing on enhancing childs participation, self esteem and well being.

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