Introduction
Symptoms and cognition of patients with ADHD
Advantages and disadvantages of pharmacological treatment of ADHD
General effects of physical exercise in relation to ADHD
Reviewing the effects of physical exercise in patients with ADHD
Methods
Literature search
Authors (year) | Group (n M:F) | Medication use in ADHD group (n dose; abstinence) | Age range (years) | Intervention type (duration) | Time of measurements relative to exercise | Outcomes (measures) [ES when reported] |
---|---|---|---|---|---|---|
Cardio exercise and acute effects in children | ||||||
Tantillo et al. (2002) | ADHD diagnosis (DSM-III; n = 18; 10M:8F) Healthy control group (n = 25; 11M:14F) | MPH (n = 18; dose 10–20 mg/2–4 times/day; no abstinence) | 8–12 | Exercise condition: treadmill exercise (personalized bouts; 5–25 min.) Control condition: rest (watching a video) Both groups underwent both conditions | Pre and directly post |
P/NP: Boys/girls ADHD vs. boys/girls control, post vs. pre: Boys with ADHD: improved motor impersistence; increased spontaneous blink rate; decreased Acoustic Startle Eye Blink Response (ASER) latency. Girls with ADHD: decreased latency and increased amplitude of ASER. Unchanged: motor impersistence |
Wigal et al. (2003) | ADHD diagnosis (Diagnostic interview schedule for children; n = 10; 10M:0F) Matched (gender and age) healthy control group (n = 8; 8M:0F) | Stimulant medication naïve | 7–12 | Cycle ergometer (varying intensity levels; 20–30 min.) No control condition | Pre and directly post |
P/NP: ADHD vs. control, post vs. pre: No DA increase; lower lactate response; lower AC response; blunted increase of EPI and NE after physical exercise |
Mahon et al. (2008) | ADHD diagnosis (parents reported previous diagnosis; n = 14; 14M:0F) No control group | MPH or amphetamine (n = 14; dose 12–42 mg/day; no abstinence) | 9–12 | Cycle ergometer (varying intensity levels; durations dependent on personal sub- maximal and peak effort) Within subjects: one exercise bout with and one bout without medication | During and directly post |
P/NP: MPH vs. No MPH during exercise: (1) Sub-maximal exercise: higher heart rate. Similar: oxygen uptake, respiratory exchange ratio and perceived exertion; effects limited to cardiovascular functions. (2) Peak exercise: higher heart rate, oxygen uptake and work rate. Similar: oxygen uptake, respiratory exchange ratio and perceived exertion |
Medina et al. (2010) | ADHD diagnosis (DSM-IV; n = 25; 25M:0F) MPH-users (n = 16) Non-MPH-users (n = 9) | MPH (n = 16; dose 5–30 mg/day; 48 h abstinence before exercise and tests) | 7−15 | Treadmill exercise (30 min.) Control condition: 1 min. stretching | Pre and directly post |
C: Post vs. pre: Immediate improvements in speed and sustained attention and normalizations in impulsivity and vigilance (Conners’ Continuous Performance Test; CPT). Exercise effects comparable in medication users and non-users Unchanged: executive functions (Digit Span, Coding B of WISC-R, Illinois Test of Psycholinguistic Abilities—Visual Sequential Memory) |
Chang et al. (2012) | ADHD diagnosis (DSM-IV; n = 40; 37M:3F), randomly assigned to Exercise group (n = 20; 19M:1F) Control group (n = 20; 18M:2F) | Stimulant medication (n = 20; information about type and dose not reported; no abstinence) | 8–13 | Exercise group: moderate intensity treadmill exercise (30 min.) Control group: watching running- related video (30 min.) | Pre and directly post |
C: Exercise vs. control, post vs. pre: Improved inhibition in both groups (Stroop Test; interference condition) [ES: Cohen’s d = 0.28–1.26] Post-test performances of flexibility improved in exercise group but not in control group (WCST; ‘non- perseverative errors’ and ‘categories completed’) [ES: Cohen’s d = 0.34–0.74] |
Pontifex et al. (2013) | ADHD diagnosis (suspected diagnosis, clinical status verified by a DSM-IV semi-structured interview; confirmed diagnosis verified by the ADHD Rating Scale IV; n = 20; 14M:6F) Matched (gender, age, pubertal status, SES) healthy control group (n = 20; 14M:6F) | Stimulant medication naïve | 8–10 | Exercise condition: treadmill exercise (20 min.) Control rest condition: seated reading Counter-balanced: both groups underwent both conditions | Directly post |
C: Exercise vs. control: Improved in both groups: inhibitory control; allocation of attention resources; selective enhancement in stimulus classification; processing speed; reading comprehension; arithmetic. Unchanged: spelling (Eriksen Flanker Test; Wide Range Achievement Test; neuroelectric assessment)
P/NP: Exercise vs. control: Improved in both groups: accurate response production and neurocognitive function (measured by ERPs) |
Smith et al. (2013)* | At risk for ADHD (≥4 hyperactivity/impulsivity symptoms based on Disrupting Behavior Disorders Rating Scale; n = 14; 6M:8F) No control group | Stimulant medication naïve | 5–9 | Moderate-vigorous physical exercise such as moving around, hopping, running (30 min. daily; 8 weeks) No control condition | Pre and post (daily, weekly and after 9 weeks; assessment moment relative to physical exercise not reported) |
C: Post vs. pre: Improvements: response inhibition and flexibility (Shape School-set shifting) Unchanged: planning (Mazes subtest of the WPPSI-R), spatial working memory (Finger Windows), verbal working memory (Sentence Memory), working memory and planning (Numbers Reversed of the Woodcock- Johnson III Tests of Cognitive Abilities) [ES: Cohen’s d = −0.10 to 0.43] Weekly measures: Both improved and unchanged levels of response inhibition (respectively Red light/Green light and Simon Says) [ES: Cohen’s d = −0.18 to 0.60]
B/SE: post vs. pre: motor proficiency improved (Bruin-Oseretsky Test of Motor Proficiency; BOT-2); motor timing unchanged (Motor Timing Task) [ES: Cohen’s d = 0.96] Weekly measures: Behavior improvements based on teacher ratings (Pittsburgh Modified CTRS) [ES: Cohen’s d = 0.40–0.70] Daily measures: Behavior observations; improved ‘interrupting’ and ‘overall’ behavior; unchanged levels of ‘not speaking nicely’, ‘(un)intentional aggression’, ‘not following adult directions’ [ES: Cohen’s d = −0.18 to 0.78] |
Hartanto et al. (2015) | ADHD diagnosis (clinical interview and Connor’s Total ADHD score >65; n = 26; 14M:12F) Healthy control group (n = 18; 5M:13F) | Stimulant medication (n = 15; information about type and dose not reported 24 h abstinence before exercise and tests) | 10–17 | Physical activity: intensity and frequency were measured in all participants by an actometer | Simultaneous assessment of activity and task performance on a trial-by-trial basis |
C: ADHD group vs. control group: Between group: children with ADHD displayed better performance during intense physical activity on a cognitive control performance task (Eriksen Flanker Paradigm), which was not found in the control group.
C: Within ADHD-group: Higher intensity movements during correct trials and not during error trials; this difference did not exist in the control group A non-causal relation was described between cognitive control functioning and physical activity in children with ADHD specifically |
Ziereis and Jansen 2015* | ADHD diagnosis (ICD-10; n = 39; 18M:5F) Randomly assigned to: exercise group 1 (n = 12; 9M:3F) Exercise group 2 (n = 11; 9M:2F) Wait-list control group (n = 16; males and females were mixed) | Stimulant medication naïve | 7–12 | Exercise group 1: Specific, moderate-vigorous physical exercises; focus on ball handling, manual dexterity and balance (60 min. weekly) Exercise group 2: Non-specific, moderate-vigorous physical exercises; no specific focus (60 min. weekly) Wait-list control group: no intervention
Time period: 12 week intervention
| 1-week pre, immediately following and 1-week post program |
C: Post vs. pre in both exercise groups: Short-term effects (after first session): no support for improved executive functioning after any of the two types of physical exercise Long term positive effects (following 12 weeks of exercise): verbal working memory, digit span backward and letter-number-sequencing (HAWIK-IV), which were not found in the control group
P/NP: Post vs. pre in both exercise groups: Long-term positive effects: motor performance and catching and aiming (Movement-ABC)
Improvements were independent of exercise type and not seen in the control group |
Cardio exercise and chronic effects in children | ||||||
McKune et al. (2003) | ADHD diagnosis (DSM-III-R; n = 19; 13M:6F), not randomly assigned to: Exercise group (n = 13; 10M:3F) Non-exercise control group (n = 6; 3M:3F) | MPH (n = 19; dose 10–30 mg/day, 1-2 times/day; no abstinence) | 5–13 | Various high-intensity exercise sessions (e.g., forms of running and jumping; 60 min.; 5 days a week) No control condition Time period: 5 weeks
| 1-week pre, during and post (after 3 and after 5 weeks) |
B/SE: Post vs. pre: Improved behavior; attention; emotional and motor skills, in both exercise and non-exercise groups; reportedly probably due to extra attention received (CPRS) Unchanged: task orientation and oppositional behavior |
Gapin and Etnier (2010) | ADHD diagnosis (diagnosed by medical professional; n = 18; 18M:0F) No control group | Stimulant medication (n = 18; information about type and dose not reported; no abstinence) | 9–12 | Moderate to vigorous physical exercise (e.g., biking, skateboarding; 30-60 min. daily) No control condition. Time period: 7 days
| Pre and post (after 7 days) |
C: Post vs. pre: Physical exercise was a significant predictor of planning performance (ToL) and a non- significant but trending predictor of other executive functions: inhibition, working memory, processing speed (CPT-II; Digit Span WISC-III;
Children’s Color Trial Test) |
Ahmed and Mohamed (2011) | ADHD diagnosis (recruited from special needs school; n = 84; 54M:30F), randomly and equally assigned to: Physical exercise group (n = 42; 27M:15F) Non-exercise control group n = 42; 27M:15F) | Information on medication intake not reported | 11–16 | Exercise group: aerobic, muscular and motor skills exercises (40 min. in first 4 weeks and 50 min. in last six weeks; 3 days a week) Control group: no physical exercise. Time period: 10 weeks Time period: 10 weeks | Pre and post |
B/SE: Post vs. pre: Behavioral-cognitive and psychological functioning improved after physical exercise: three of five domains of a teacher report Behavior Rating Scale (based on Connor’s Rating Scale) improved significantly in the exercise group and not the control group: attention, motor skills and academic and classroom behavior Unchanged: task orientation, emotional behavior and oppositional behavior |
Kang et al. (2011) | ADHD diagnosis (diagnosis instrument not specified; n = 28; 28M:0F), randomly assigned to Exercise group (n = 15; 15M:0F) Behavior education group (n = 13; 13M:0F) (n = 13; 13M:0F) | MPH (n = 28; dose 10–40 mg/day; no abstinence) | 7–9 | Exercise group: combination of running, goal- directed throwing, rope jumping and rest (90 min.; 2 days a week) Behavior education group: 12 education sessions on social behavior
Time period: 6 weeks
| Baseline and post (after 6 weeks) |
C: Post vs. pre: Improved in exercise and not in behavior education group: executive functions (e.g. flexibility); cognitive function and speed (TMT-B; Digit Symbol of the Korean Educational Development Institute-WISC) [ES: Cohen’s d = 0.18–0.49]
B/SE: Post vs. pre: Improved in exercise and not in behavior education group: attention and social competencies (cooperativeness) Unchanged: hyperactivity; assertiveness; self-control (ADHD Rating Scale; Social Skills Rating System). [ES: Cohen’s d = −0.27 to 0.22]. Suggested mechanism: CA/DA/NE increases in the prefrontal cortex, nucleus accumbens and basal ganglia |
Lufi and Parish-Plass (2011) | ADHD diagnosis (DSM-IV-TR; n = 15; 15M:0F) Other behavioral and emotional problems (n = 17; 17M:0F) | Stimulant medication naïve None of the participants used medication during the time of the study | 8–13 | Combined intervention of sports and behavioral techniques. The exercise intervention was comprised of vigorous physical exercise in individual sport such as relay races (30 min., weekly) and vigorous physical exercise in team sports such as soccer (40 min., weekly) No control condition
Time period: 1 academic year
| Pre, post (within 2 weeks following the intervention) and follow up (1 year after completion of the study) |
B/SE: Post vs. pre, acute post-test:
Following a sports and behavioral intervention, hyperactivity and behavior total scores as reported by participants and parents in both groups (ASQ-P, YSR, CBCL). Participants in both groups reported less anxiety, less somatic complaints, less internalizing behavior and less total problems. Parents of children in both groups reported less ADHD symptoms, aggression, anxiety, social problems, externalizing behavior and total problems. Unchanged: all other YSR and CBCL domains Sports + therapy = beneficial for both clinical groups, non-ADHD-specific.
B/SE: Post vs. pre, acute post-test: Effects were maintained 1 year post-treatment. Especially anxiety consistently reduced from pretest, to posttest, to follow-up, reported by both children and parents |
Verret et al. (2012) | ADHD diagnosis (DSM-IV;
n = 21; 19M:2F) Physical exercise group (n = 10; 9M:1F; recruited from the same school) Control group (n = 11; 10M:1F; recruited from different areas) | Stimulant medication (n = 3 in physical exercise condition and n = 11 in control condition; information about type and dose not reported; no abstinence) | 7–12 | Exercise group: aerobic, muscular and motor skills exercises, cool down afterwards (45 min.; 3 days a week) Control group: no physical exercise. Time period: 10 weeks
| Pre and post (after 10 weeks) |
C: Exercise vs. control, post vs. pre: Improved level of information processing, speed of visual search, auditory and sustained attention (Test of Everyday Attention for Children)
B/SE: Exercise vs. control, post vs. pre: Parent- reported posttest improvements: total problems, social, thought and attention problems (CBCL; other scales unchanged). Teacher-reported posttest improvements: anxiety-depression; social problems (CBCL; other scales unchanged)
P/NP: Exercise vs. control, post vs. pre: Better motor performance (increased locomotion and total motor skill scores) |
Smith et al. (2013)* | At risk for ADHD (≥4 hyperactivity/impulsivity symptoms based on Disrupting Behavior Disorders Rating Scale; n = 14; 6M:8F) No control group | Stimulant medication naïve | 5–9 | Moderate-vigorous physical exercise such as moving around, hopping, running (30 min. daily; 8 weeks) No control condition | Pre and post (daily, weekly and after 9 weeks; assessment moment relative to physical exercise not reported) |
C: Post vs. pre: Improvements: response inhibition and flexibility (Shape School-set shifting) Unchanged: planning (Mazes subtest of the WPPSI-R), spatial working memory (Finger Windows), verbal working memory (Sentence Memory), working memory and planning (Numbers Reversed of the Woodcock- Johnson III Tests of Cognitive Abilities) [ES: Cohen’s d = −0.10 to 0.43] Weekly measures: Both improved and unchanged levels of response inhibition (respectively Red light/Green light and Simon Says) [ES: Cohen’s d = −0.18 to 0.60]
B/SE: Post vs. pre: Motor proficiency improved (Bruin-Oseretsky Test of Motor Proficiency; BOT-2); motor timing unchanged (Motor Timing Task) [ES: Cohen’s d = 0.96] Weekly measures: Behavior improvements based on teacher ratings (Pittsburgh Modified CTRS) [ES: Cohen’s d = 0.40–0.70] Daily measures: Behavior observations; improved ‘interrupting’ and ‘overall’ behavior; unchanged levels of ‘not speaking nicely’, ‘(un)intentional aggression’, ‘not following adult directions’ [ES: Cohen’s d = −0.18 to 0.78] |
Chang et al. (2014) | ADHD diagnosis (DSM-IV-TR; n = 27; 23M :4F), non-random assignment to: Physical exercise group (n = 14; 10M:4F) Wait-list control group (n = 13; 13M:0F) | MPH (n = 7 in physical exercise condition and n = 6 in control condition; information about dose not reported; 24 h abstinence before tests) | 5–10 | Exercise group: moderate intensity water aerobic exercise and perceptual-motor water exercise and cool down afterwards (90 min.; 2 days a week) Wait-list control group Time period: 8 weeks | Pre and post (within 1 week of completing the study) |
C: Post vs. pre by group/condition: Children with ADHD in the exercise group showed improved accuracy (Go/No-Go Task) with the no-go-stimulus (d = 0.9) as well as coordination of motor skills, whereas accuracy with the no-go-stimulus remained unchanged over time in the control group (d = −0.04). Physical exercise was therefore linked to increased levels of restraint/behavioral inhibition in children with ADHD Unchanged/reversed effect: go-stimuli scores were respectively longer and less accurate than in the control group, with no effect of time
P/NP: Post vs. pre: The physical exercise group and not the control group achieved increased levels of hand-eye-coordination in throwing and bilateral hand-eye-coordination and dexterity (as measured by target throwing scores and bead moving scores of the Basic Motor Ability Test-Revised) |
Choi et al. (2014) | ADHD diagnosis (DSM-IV; n = 30; 30M:0F), randomly assigned to: Physical exercise group (n = 17; 17M:0F) Education ADHD group (n = 13; 13M:0F) Age-matched healthy control group (n = 15; 15M:0F) | MPH (n = 35; dose 10–40 mg/day, 1 time/day; no abstinence as examining the relation of MPH with respectively physical exercise and behavioral education was one of the study aims | 13–18 | Exercise group: Aerobics exercises such as running and jumping rope (90 min.; several days a week) Education ADHD group: education sessions for behavior and control such as good behavior and bad behavior and interaction with family (50 min.; several days a week) Control group: no physical exercise Time period: 6 weeks | Pre and post (after 6 weeks of treatment) |
C: Post vs. pre: Decreased scores on ADHD rating scale (Dupaul ADHD rating scale, Korean version) and decreased perseverative errors (Wisconsin Card Sorting Test) in the exercise group and not in the education group
P/NP: Sports ADHD group vs. education ADHD group: Increased brain activity (fMRI) within the right frontal and temporal cortices during a Wisconsin Card Sorting Test stimulation Unchanged: activity within left parietal (trend), right middle temporal, right occipital, right parietal, right cerebellum and left middle temporal cortices The observed improvements in ADHD symptoms, perseverative errors and brain activity following physical exercise are proposed to be related to a higher MPH effectivity when medication is combined with sports |
Pan et al. (2014) | ADHD diagnosis (DSM-IV; n = 24; 24M:0F), randomly assigned to: Training group (n = 12; 12M:0F) Non-training control group (n = 12; 12M:0F) Age and gender matched healthy control group (n = 24; 24M:0F) | Stimulant medication (n = 15; information about type and dose not reported; no abstinence) | 7–14 | Simulated developmental horse riding program in combination with moderate-vigorous fitness training (90 min., weekly) Control group: no physical exercise
Time period: 12 weeks
| Pre and directly post |
P/NP: Post vs. pre by group comparison: Both ADHD groups showed worse total motor proficiency scores than TD children; but the ADHD training group performed better than the ADHD non-training group at total motor proficiency, fine manual control, manual coordination, body coordination, strength and agility, manual dexterity and bilateral coordination (Bruininks-Oseretsky Test of Motor Proficiency, second edition) Non-significant: fine motor precision and integration, upper-limb coordination, balance, running speed and agility and strength
P/NP: Post vs. pre, within-group: The ADHD training group showed improvements in all motor and fitness measures. The ADHD and TD non-training groups improved in some but not all motor skills or fitness measures In conclusion: children with ADHD thus exhibit low motor proficiency, cardiovascular fitness and flexibility at baseline, and these functions benefit from physical activity |
Ziereis and Jansen (2015)* | ADHD diagnosis (ICD-10; n = 39; 18M:5F) Randomly assigned to: Exercise group 1 (n = 12; 9M:3F) Exercise group 2 (n = 11; 9M:2F) Wait-list control group (n = 16; males and females were mixed) | Stimulant medication naïve | 7–12 | Exercise group 1: Specific, moderate-vigorous physical exercises; focus on ball handling, manual dexterity and balance (60 min. weekly) Exercise group 2: Non-specific, moderate-vigorous physical exercises; no specific focus (60 min. weekly) Wait-list control group: no intervention Time period: 12 week intervention Time period: 12 weeks | 1-week pre, immediately following and 1-week post program |
C: Post vs. pre in both exercise groups: Short-term effects (after first session): no support for improved executive functioning after any of the two types of physical exercise Long term positive effects (following 12 weeks of exercise): verbal working memory, digit span backward and letter-number-sequencing (HAWIK-IV), which were not found in the control group.
P/NP: Post vs. pre in both exercise groups: Long-term positive effects: motor performance and catching and aiming (Movement-ABC)
Improvements were independent of exercise type and not seen in the control group |
Janssen et al. (2016a) | ADHD diagnosis (DSM-IV-TR;
n = 81), randomly assigned to: Physical exercise group (n = 27; 21M:6F) Neurofeedback group (n = 29; 21M:8F) Medication group (n = 25; 19M:6F) | Stimulant medication naïve (all patients had been stimulant medication free for at least 1 month before the beginning of the study) Medication group: MPH (n = 25; doses 5–15 mg/day) | 7–13 | Exercise group: Moderate -vigorous physical activity (not specified). The maximum heart rate (HRmax) was assessed. The aim was to first elevate the heart rate to 70-80 % of HRmax (5 × 2 min.) and then to 80-100 % of HRmax. (45 min. with 20 min. of effective training; 3 days a week) Neurofeedback group: Participants received theta/beta training with the aim of inhibiting theta (4-8 Hz) and strengthening beta (13-20 Hz) at Cz. (45 min. with 20 min. of effective training; 3 days a week) Medication group Time period: ~10 weeks | 1 week pre and ~1 week post |
P/NP: Group comparison, post vs. pre: Children with ADHD (often showing increased slow wave activity –theta– and decreased fast wave activity –beta– in EEG studies which is linked to ADHD symptoms) displayed reduced theta power waves after neurofeedback and medication interventions but not after physical activity on an EEG-analysis. The medication and neurofeedback groups showed reduced theta power post-treatment during a resting condition. Solely the medication group displayed this reduction in an effortful task condition |
Janssen et al. (2016b) | ADHD diagnosis (DSM-IV-TR;
n = 81), randomly assigned to: Physical exercise group (n = 27; 21M:6F) Neurofeedback group (n = 29; 21M:8F) Medication group (n = 25; 19M:6F) | Stimulant medication naïve (all patients had been stimulant medication free for at least 1 month before the beginning of the study) Medication group: MPH (n = 25; doses 5–15 mg/day) | 7–13 | Exercise group: Moderate -vigorous physical activity (not specified). The maximum heart rate (HRmax) was assessed. The aim was to first elevate the heart rate to 70-80 % of HRmax (5 × 2 min.) and then to 80–100 % of HRmax. (45 min. with 20 min. of effective training; 3 days a week) Neurofeedback group: participants received theta/beta training with the aim of inhibiting theta (4–8 Hz) and strengthening beta (13–20 Hz) at Cz. (45 min. with 20 min. of effective training; 3 days a week) Medication group Time period: ~10 weeks | 1 week pre and ~ 1 week post |
P/NP: Group comparison, post vs. pre: The medication group displayed a specific post-intervention P3 amplitude increase, related to response inhibition. Across all groups, N2 amplitude increased from pre to post intervention. Thus, medication but not neurofeedback or physical exercise, was related to improved response inhibition |
Non-cardio exercise and acute effects in children | ||||||
Hernandez-Reif et al. (2001)* | ADHD diagnosis (DSM-IV; n = 13; 11M:2F) No control group | Information on medication intake not reported | 13–16 | Physical exercise: Tai Chi, training of postures (30 min.; 2 days a week) for 5 weeks; then a non-exercise follow-up phase without Tai Chi (2 weeks) No control condition Time period: 5 weeks | Two weeks pre (baseline), directly post (after 5 weeks) and follow-up (after 7 weeks) |
B/SE: Post vs. pre: Both acute (directly post) and chronic (2 weeks after intervention) effects were found; less anxiety, improved conduct, less daydreaming, less inappropriate emotions and less hyperactivity (CTRS) Unchanged: asocial behavior |
Azrin et al. (2006) | ADHD diagnosis (diagnosis instrument not described;
n = 1; M) No control group | Stimulant medication naïve | 4 | Gymnastic playground activities (i.e. sliding, climbing, swinging; 1 min.; recurring over 5 days) No control condition | Pre and directly post |
B/SE: Post vs. pre: Improved observed attentive sitting in the classroom (observed by 2 school assistants) Physical exercise was however suggested to be a reinforcement. Substantial limitations were reported |
Taylor and Kuo (2009) | ADHD diagnosis (professionally diagnosed by a physician, psychologist or psychiatrist; n = 17; 15M:2F) No control group | Information on medication intake not reported; children normally taking stimulant medication were asked to postpone intake to after the intervention | 7–12 | Walking, alternatingly in a park and 2 urban settings (respectively a downtown and a residential area; 20 min. per walk). Test administrators were blind to the walking condition No control condition | Directly post |
C: Walk in park vs. walk in urban
settings: Improved concentration (Digit Span Backwards); suggested greater influence of environment than physical exercise [ES park–urban settings: Cohen’s d = 0.52–0.77] Substantial limitations were reported |
Non-cardio exercise and chronic effects in children | ||||||
Hernandez-Reif et al. (2001)* | ADHD diagnosis (DSM-IV; n = 13; 11M:2F) No control group | Information on medication intake not reported | 13–16 | Physical exercise: Tai Chi, training of postures (30 min.; 2 days a week) for 5 weeks; then a non-exercise follow-up phase without Tai Chi (2 weeks) No control condition Time period: 5 weeks | Two weeks pre (baseline), directly post (after 5 weeks) and follow-up (after 7 weeks) |
B/SE: Post vs. pre: Both acute (directly post) and chronic (2 weeks after intervention) effects were found; less anxiety, improved conduct, less daydreaming, less inappropriate emotions and less hyperactivity (CTRS) Unchanged: asocial behavior |
Maddigan et al. (2003) | ADHD diagnosis (DSM-IV; n = 10; gender not reported), randomly assigned to: Yoga/exercise group (n = 3) Massage group (n = 3) Control group (n = 4) | Stabilized on medication (information about type and dose not reported) | School-age (details not reported) | Exercise group: sessions of yoga exercise (6-20 min.; once a week for 6 weeks) Massage group: massages (6-20 min.; once a week for 6 weeks) Control group: no intervention
Time period: 12 weeks
| Pre, during and post (after 0, 6 and a follow up at 12 weeks) |
C & B/SE: Post vs. pre in exercise group: Improved ability to do homework; to cope in stressful situations; balancing; flexibility and concentration (observations and CPRS). Positive overall responses in both exercise and massage groups. Substantial limitations were reported |
Jensen and Kenny (2004) | ADHD diagnosis (DSM-IV and CPRS; n = 19; 19M:0F) Yoga group (n = 11; 11M:0F) Control group (n = 8; 8M:0F) Randomly allocated to yoga group with the option to crossover after the first 20 sessions | MPH (n = 17; dose 15–40 mg/day; no abstinence) | 8–13 | Yoga group (60 min.; 20 sessions) Control group: cooperative games (social activities) Time period: 20 weeks | Pre and post (after 20 weeks) |
B/SE: Post vs. pre: Improvements in both groups: perfectionism; DSM-IV hyperactive/impulsive; DSM-IV total. Yoga group improved scales (CPRS): oppositional; emotional liability; total; restless/impulsive; ADHD behavior Control group improved scales (CPRS): hyperactivity; anxious/shy; social problems. No significant differences according to teachers (CTRS) Substantial limitations were reported |
Preliminary findings on the effects of physical exercise on cognitive and behavioral functioning in adults | ||||||
Fritz and O’Connor (2016)
Cardio exercise
Acute effects
| ADHD screening diagnosis (symptoms of
adult ADHD
assessed by the
Adult ADHD Self- Report Scale;
n = 36; 36M:0F) | Stimulant medication naïve | 18–33 | Exercise condition: Cycling at 65 % VO2 peak (20 min.) Non-exercise control condition: Seated rest (20 min.) Within study design: all participants underwent both conditions | Baseline, Post 1, Post 2 (both immediately after the intervention) |
C/NP: Exercise condition vs. resting condition by time: No significant improvements in sustained attention (Continuous Performance Task and the Bakan Vigilance Task for sustained attention; Simple Reaction Time Task for psychomotor speed)
B/SE: Exercise condition vs. resting condition by time: Enhanced motivation to complete mental work in the exercise group over time (as assessed with a Visual Analog Scale with motivation indicators); significantly higher self-reported vigor, lower confusion scores, lower fatigue and lower depression scores in the exercise condition (Profile of Mood States-Brief Form) Unchanged: hyperactivity (in the legs; Bakan test), tension and anger Authors proposed that the increased vigor after physical exercise may be due to a similar working mechanism as described in stimulant medication, i.e. a DA-increase |
Abramovitch et al. (2013)
Cardio exercise
Chronic effects
| ADHD diagnosis (DSM-IV; n = 30;30M:0F) High physical activity group (n = 10; 10M:0F) Low physical activity group (n = 20; 20M:0F) | Stimulant medication naïve | Mean age = 27.29, SD = 5.87 (Infor-mation on age range not reported) | Physical exercise was assessed by a physical exercise subscale of a leisure time activity questionnaire, measuring exercises with a strong aerobic component (e.g., jogging; competitive sports; ≥ 30 min.) Based on the questionnaire, participants were divided into 2 groups: “high physical activity” and “low physical activity” | Correlational study, no intervention |
B/SE: High physical activity group vs. low physical activity group:
ADHD patients who frequently engage in physical exercise showed a healthier psychological well-being than ADHD patients who do not often exercise actively. They reported less meta-worrying, less problems with intrusive thoughts (i.e. difficulty removing them; thoughts of sadness and fear) and less behavioral impulsivity (as measured by the Anxious Thoughts Inventory; Eysenk’s Impulsivity-Venturesomeness-Empathy Questionnaire; Distressive Thoughts Questionnaire) Similar across groups: social and health worrying, venturesomeness, frequency of thoughts, thoughts of disapproval |
Fuermaier et al. (2014a)
Non-cardio exercise Acute effects | ADHD diagnosis (clinical interview based on DSM-IV; n = 17; 8M; 9F) Healthy adults (n = 83; 40M:43F) | MPH (n = 4; dose 10–72 mg/day, 1 time/day; no abstinence) | 18–31 | Passive exercise group: Passive Whole Body Vibration (WBV) was implemented, participants were sitting on a chair that was ascended on a vibrating platform (Vibe 300, Tonic Vibes, Nantes, France) Control condition: Resting period without vibration Procedure: The intervention consisted of four 2-min treatments of vibration (vibration condition) and four 2-min trials of resting (control condition) for each participant | Directly post |
C : Vibration vs. resting: WBV significantly improved attention performance (Stroop Color Word Interference Test) in both groups, with a small effect size in the healthy control group (d = 0.44) and a medium effect size in the ADHD group (d = 0.68). Passive physical exercise was thus related to improved cognitive functioning in healthy adults and adults with ADHD |
Fuermaier et al. (2014b) Non-cardio exercise Acute and chronic effects | ADHD diagnosis (DSM-IV; n = 1; M) Control group (n = 6; 3M:3F) | MPH (dose 10 mg, 4 times/day; no abstinence) | 20–25 | Passive exercise—ADHD patient: Passive WBV was applied (15 min.; 3 times a day on 10 consecutive days), the participant was sitting on a chair that was mounted on a vibrating platform (Vibe 300, Tonic Vibes, Nantes, France) Control group: assessed with the same test battery to control for practice effects; no WBV Time period: 10 days | 1 day pre, 16 h post and follow-up (after 12 days and after 25 days-treatment started on day 2) |
C: Post vs. pre: Descriptive performance data showed 1) in healthy participants: improved vigilance, flexibility, working memory and inhibition after repeated assessments; 2) in the ADHD patient: improved alertness, divided attention, vigilance, flexibility, inhibition, divergent thinking, verbal fluency and self-reported impairments of attention (especially from first to second assessment). WBV-treatment was therefore related to acute cognitive gains Unchanged: alertness reaction times, distractibility and working memory Follow-up: most of the assessed cognitive functions returned to their pre-experiment-level (e.g. flexibility, inhibition, vigilance and self-reported impairments of attention) |
Analysis
Results
Cardio exercise: acute effects
Cardio exercise: chronic effects
Non-cardio exercise: acute effects
Non-cardio exercise: chronic effects
Preliminary findings on the effect of physical exercise on adults with ADHD
Methodological quality screening of the included studies
Quality indicators | Adequate | Inadequate | Not reported | Not applicable |
---|---|---|---|---|
1. Diagnosis assessed by standardized measures | 23 | 1 | 5 | 0 |
2. Sample size | 14 | 13 | 0 | 2 |
3. Control condition/group | 18 | 11 | 0 | 0 |
4. Control for medication use | 22 | 5 | 2 | 0 |