Rochel Boord
Based on the PICO from Rotation 7 Pico 1 (Psychiatry Rotation)
Children are typically given stimulants for ADHD. Can young people with ADHD use physical activity to improve symptoms (such as cognition, behavior, focus etc.) associated with ADHD?
PICO Search Elements:
| P | I | C | O |
| ADHD | Physical activity | Without ADHD | Cognition |
| Attention deficit hyperactivity disorder | exercise | Children without attention deficit hyperactivity disorder | Behavior |
| Young people with ADHD | Young people without ADHD | Focus | |
| Executive function | |||
| Attention | |||
| Working memory | |||
| Impulsivity |
Search Strategy:
Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on. This will likewise be a revision and refinement of what you have already done. A minimum of 3 search databases should be used.
I first looked for meta-analysis and systematic review. I then searched for randomized control trials. I used pubmed, science direct and google scholars. I also searched both within the last 5 years and last 10 years.
- Pubmed
Search terms: physical activity for ADHD
Filters: Meta-analysis and systematic review, last 5 years
9 results - Pubmed
Search terms: physical activity for ADHD
Filters: randomized control trial, last 5 years
15 results - Science Direct
Search term: Exercise to improve ADHD meta-analysis
Filter: last 5 years
1,321 results - Google Scholars
Search terms: physical activity for adhd symptoms meta-analysis and systematic review
Filter: since 2017
results: 17,800 - Jama
Search terms: ADHD and Physical Activity
Filter: Research, Review
Results: 127
Articles Chosen At least 6 articles for Inclusion (please copy and paste the abstract with link):
Please pay attention to whether the articles actually address your question and whether they are the highest level of evidence available. (Be aware that the instructor may also do a search and should not be able to find better articles that you overlooked).
If after reviewing you cannot find high quality articles, be prepared to explain the extensiveness of your search and why there aren’t any better sources available. If you are having trouble finding better sources, please reach out to the librarian or one of the instructors for help with this.
Article 1: The effect of physical activity interventions on executive functions in children with ADHD: A systematic review and meta-analysis
| Abstract |
| Abstract Background Attention-deficit hyperactivity disorder (ADHD) is a commonly diagnosed behavioral disorder in school-aged children. A core symptom of ADHD is difficulties with executive functions (EF). Physical activity (PA) interventions are proposed to be a valuable addition to traditional treatment approaches for ADHD. This systematic review examined the evidence for the effect of chronic PA on EF, specifically, inhibition, shifting, working memory, and attention in children with ADHD compared to no treatment. The moderating impact of PA cognitive demand and methylphenidate (MPH) treatment on the effect of PA interventions on EF was also examined. Methods A systematic review and meta-analyses were conducted following the Cochrane Guidelines for Systematic Reviews. A protocol was published with PROSPERO (CRD42018099617); seven databases were searched, and 3690 results screened by two independent researchers. Based on inclusion and exclusion criteria, 12 eligible studies were included, and separate meta-analyses were conducted for each EF domain, each including subgroups of high vs low cognitive demand, and MPH-intake vs. MPH-free. Results Results showed beneficial effects of PA for all EF, with 95%-CI compatible with positive effects for shifting (SMD = −1.58; 95%-CI [−3.12; −0.04]) and working memory (SMD = −0.99; 95%-CI [−1.80; −0.18])only. Cognitive demand of PA differed in its impact depending on the domain of EF. Benefits of PA were lesser in those taking MPH, though subgroup differences were statistically non-significant. Conclusion Children with ADHD benefit from PA leading to enhanced executive functioning performance. However, the cognitive demands of the PA need to be considered when contemplating PA as an adjunctive treatment option. |
Article 2: Impact of physical exercise on children with attention deficit hyperactivity disorders
| Abstract |
| Abstract Background: Attention deficit hyperactivity disorder (ADHD) which is characterized by developmentally inappropriate levels of attention, hyperactivity and impulsivity, is considered as the most common neurodevelopmental disorder in childhood. Physical exercise has shown to have several benefits in the improvement of children with ADHD. In this meta-analysis, we aimed to systematically show, with evidence, the impact of physical exercise on children with ADHD. Methods: Web of Science, MEDLINE, EMBASE, Google Scholar, Cochrane Central and http://www.ClinicalTrials.gov were the searched sources for studies which were based on the impact of physical exercise on children with ADHD. Relevant endpoints were assessed. This evidence based meta-analysis was carried out by the most relevant RevMan 5.3 software. Due to the involvement of continuous data (mean and standard deviation), weight mean difference (WMD) with 95% confidence intervals (CI) were used to represent the final analysis. A significant level of P ≤ .05 was set and a fixed statistical effect model was used throughout the analysis. Results: Fourteen studies with a total number of 574 participants with ADHD were included in this evidenced based meta-analysis. Two hundred and seventy six (276) participants were assigned to the physical activity group whereas 298 participants were assigned to the control group. Results of this analysis showed that anxiety and depression were significantly improved with physical activity in these children with ADHD (WMD: -1.84; 95% CI: [-2.65 – (-1.03)], P = .00001). Hyperactive/impulsive symptoms (WMD: -0.01; 95% CI: [-0.32 – 0.29], P = .93) and inattention symptoms (WMD: -0.22; 95% CI: [-0.51 – 0.08], P = .15) were also improved with physical exercise but the results were not statistically significant. This evidence based analysis showed thought problems (WMD: -3.49; 95% CI: [-5.51 – (-1.47)], P = .0007), social problems (WMD: -5.08; 95% CI: [-7.34 – (-2.82)], P = .0001), and aggressive behaviors (WMD: -3.90; 95% CI: [-7.10 – (-0.70)], P = .02) to have significantly been improved in participants with ADHD who were assigned to physical activity group. Conclusions: This current meta-analysis showed with evidence, that physical exercise has a major contribution owing to significant improvement in anxiety and depression, aggressive behaviors, thought and social problems among children suffering from ADHD. Therefore, physical exercise should be incorporated in the daily life of children with ADHD. Further future research should be able to confirm this hypothesis. |
Article 3: Acute and chronic effect of physical activity on cognition and behaviour in young people with ADHD: A systematic review of intervention studies
| Abstract |
| Abstract Background Young people with attention deficit hyperactivity disorder (ADHD) often have learning and behavioral control difficulties. Aim The aim of this review is analyze the acute and chronic effect of physical activity (PA) on the cognition and behavior of children and adolescents with ADHD. Methods Studies were identified in five databases (PubMed, SPORTDiscus, ProQuest, Web of Science, and SCOPUS), from January 2000 through to January 2017. A total of 16 interventional studies met the inclusion criteria. Results/conclusions PA practice of 20–30 min (intensity 40–75%) produces a positive acute effect on processing speed, working memory, planning and problem solving in young people with ADHD. However, these effects on behavior are contradictory and vary depending on age. Chronic PA practice (≥30 min per day, ≥40% intensity, ≥three days per week, ≥five weeks) further improves attention, inhibition, emotional control, behavior and motor control. The results must be treated with caution, because only 25% of the studies used confounders. Implication More research is needed to justify the causes of these effects. It is necessary to establish programs with regard to the duration, intensity, kind of exercise, and time of PA to improve cognition and behavior in young people with ADHD taking into account potential confounders. |
Article 4: Aerobic exercise and attention deficit hyperactivity disorder: brain research
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5504911/
| Abstract |
| Abstract Purpose: As adjuvant therapy for enhancing the effects of stimulants and thereby minimizing medication doses, we hypothesized that aerobic exercise might be an effective adjunctive therapy for enhancing the effects of methylphenidate on the clinical symptoms, cognitive function, and brain activity of adolescents with attention deficit hyperactivity disorder (ADHD). Methods: Thirty-five adolescents with ADHD were randomly assigned to one of two groups in a 1/1 ratio; methylphenidate treatment + 6-wk exercise (sports-ADHD) or methylphenidate treatment + 6-wk education (edu-ADHD). At baseline and after 6 wk of treatment, symptoms of ADHD, cognitive function, and brain activity were evaluated using the Dupaul attention deficit hyperactivity disorder rating scale–Korean version (K-ARS), the Wisconsin Card Sorting Test, and 3-T functional magnetic resonance imaging, respectively. Results: The K-ARS total score and perseverative errors in the sports-ADHD group decreased compared with those in the edu-ADHD group. After the 6-wk treatment period, the mean β value of the right frontal lobe in the sports-ADHD group increased compared with that in the edu-ADHD group. The mean β value of the right temporal lobe in the sports-ADHD group decreased. However, the mean β value of the right temporal lobe in the edu-ADHD group did not change. The change in activity within the right prefrontal cortex in all adolescents with ADHD was negatively correlated with the change in K-ARS scores and perseverative errors. Conclusions: The current results indicate that aerobic exercise increased the effectiveness of methylphenidate on clinical symptoms, perseverative errors, and brain activity within the right frontal and temporal cortices in response to the Wisconsin card sorting test stimulation. |
Article 5: Managing childhood and adolescent attention-deficit/hyperactivity disorder (ADHD) with exercise: A systematic review
| Abstract |
| Abstract Background Attention deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders affecting some 8–10% of children worldwide. Increasing research has shed light on the life course of the disorder, suggesting that majority of children with ADHD will continue to have persistent symptoms into adulthood. The mainstay of ADHD management has been pharmacologic and behavioural/psychological interventions, with little attention paid to exercise as a potential management strategy. A systematic review, examining both the short-term and long-term effects of exercise on children with ADHD, is timely and necessary to guide further research in this area. Methods Using the keywords [exercise OR physical OR activity OR sport] AND [attention deficit hyperactivity disorder OR ADHD OR ADDH], a preliminary search on the PubMed and Ovid database yielded 613 papers published in English between 1-Jan-1980 and 1-July-2016. Full articles were also reviewed for references of interest. Results A total of 30 studies were included in this systematic review. Both short-term and long-term studies support the clinical benefits of physical activity for individuals with ADHD. Cognitive, behavioural and physical symptoms of ADHD were alleviated in most instances, and the largest intervention effects were reported for mixed exercise programs. No adverse effects arising from physical exercise were reported in any of the studies, suggesting that exercise is a well-tolerated intervention. Conclusion Physical activity, in particular moderate-to-intense aerobic exercise, is a beneficial and well-tolerated intervention for children and adolescents with ADHD. Future research should include more adequately-powered trials and investigate the ideal exercise prescription. |
Article 6
A Randomized Trial Examining the Effects of Aerobic Physical Activity on Attention-Deficit/Hyperactivity Disorder Symptoms in Young Children
https://link-springer-com.york.ezproxy.cuny.edu/article/10.1007/s10802-014-9929-y
| Abstract |
| Abstract The goal of this study was to compare the effects of before school physical activity (PA) and sedentary classroom-based (SC) interventions on the symptoms, behavior, moodiness, and peer functioning of young children (M age = 6.83) at risk for attention-deficit/hyperactivity disorder (ADHD-risk; n = 94) and typically developing children (TD; n = 108). Children were randomly assigned to either PA or SC and participated in the assigned intervention 31 min per day, each school day, over the course of 12 weeks. Parent and teacher ratings of ADHD symptoms (inattention, hyperactivity/impulsivity), oppositional behavior, moodiness, behavior toward peers, and reputation with peers, were used as dependent variables. Primary analyses indicate that the PA intervention was more effective than the SC intervention at reducing inattention and moodiness in the home context. Less conservative follow-up analyses within ADHD status and intervention groups suggest that a PA intervention may reduce impairment associated with ADHD-risk in both home and school domains; interpretive caution is warranted, however, given the liberal approach to these analyses. Unexpectedly, these findings also indicate the potential utility of a before school SC intervention as a tool for managing ADHD symptoms. Inclusion of a no treatment control group in future studies will enable further understanding of PA as an alternative management strategy for ADHD symptoms. |
For the DRAFT & Final CAT (Rotations 8 & 9) – YOU WILL INCLUDE THE PARTS ABOVE AND COMPLETE THE REMAINING PARTS BELOW:
Summary of the Evidence:
| Author (Date) | Level of Evidence | Sample/Setting (# of subjects/ studies, cohort definition etc. ) | Outcome(s) studied | Key Findings | Limitations and Biases |
| Livia Welsch, Olivia Alliott, Paul Kelly, Samantha Fawkner, Josie Booth, Ailsa Niven, The effect of physical activity interventions on executive functions in children with ADHD: A systematic review and meta-analysis, Mental Health and Physical Activity, Volume 20, 2021,100379 | Systematic Review and meta-anaysis | 12 Studies included. 186 participants aged 0-18. | Interventions: exercise, physical activity, aerobic exercise, anaerobic exercise, physical education, sport, fitness. Outcomes: Cognitive function, executive function, working memory, inhibition, cognitive flexibility, attention control, executive control. | This systematic review and meta-analysis included 12 eligible studies. This study aimed to study the effects of chronic physical activity on executive function on patients with ADHD. Physical activity has been shown to have a medium to large beneficial effect on the executive function for patients with ADHD. The effect varied by cognitive task. The effect of physical activity was independent on methylphenidate treatment status. Future research is needed to strengthen the scientific evidence and to increase generalizability and reliability of the findings to determine if physical activity can be used as a single treatment option for children with ADHD. | The gender distribution is unequal, which is expected since males have a higher prevalence of ADHD. Physical activity levels, age, gender, socioeconotic states and parental education level of participants were not studied as possible covariates. |
| Zang Y. Impact of physical exercise on children with attention deficit hyperactivity disorders: Evidence through a meta-analysis. Medicine (Baltimore). 2019;98(46):e17980. doi:10.1097/MD.0000000000017980 | Meta-analysis | 14 studies included, 574 participants with ADHD where included | Outcomes studied included: Hyperactive/impulsive symptoms, anxiety and depression, inattention symptoms, oppositional symptoms, thought problems, social problems, aggressive behavior, strength and agility, internalized problems, externalized problems, perseveration errors, non-perseveration errors, stroop color-word response | The study showed physical activity improved anxiety, depression, aggressive behaviors, thought, social problems and aggressive behavior among children suffering from ADHD. This study recommends the implementation of physical exercise into the daily life of children with ADHD. | The type of physical activity differed from one article to another, but they were all part of the subset of physical activity. One study involved adolescents with a mean age of 21, while the other studies were all conducted on children. |
| Suarez-Manzano, S., Ruiz-Ariza, A., De La Torre-Cruz, M., & Martínez-López, E. J. (2018). Acute and chronic effect of physical activity on cognition and behavior in young people with ADHD: A systematic review of intervention studies. Research in Developmental Disabilities, 77, 12–23. https://doi.org/10.1016/j.ridd.2018.03.015 | Systematic Review | 16 studies and 728 participants were included. | This study aimed to determine the acute and chronic effects on physical activity on cognition and behavior in young people with ADHD. | 20-30 minutes of high physical activity improves short-term cognition in young people with ADHD. Improvements in executive functions, increased attention, greater planning capacity, processing speed, working memory and behavior improvements were seen in students with ADHD in terms of the learning context following physical activity interventions. After 5 weeks of physical activity participants had chronic improvements in cognition and behavior. There are no negative effects from physical activity on the cognition for ADHD people. However, the immediate effects on behavior are controversial. | One of the limitations of this systematic review is that only 25% of the analyzed studied used confounders. |
| Choi JW, Han DH, Kang KD, Jung HY, Renshaw PF. Aerobic exercise and attention deficit hyperactivity disorder: brain research. Med Sci Sports Exerc. 2015;47(1):33-39. doi:10.1249/MSS.0000000000000373 | Randomized Control Trial | 45 participants | This study aimed to look at exercise as an adjuvant therapy for enhancing the effects of stimulants, in order to decrease the dose of medication required to treat ADHD. Both cognitive function and brain activity of adolescents with ADHD were evaluated. | Aerobic exercise increases the effectiveness of methylphenidate to reduce symptoms from ADHD as well as increasing brain activity. After 6 weeks of treatment improvements were seen in the ADHD group on the K-ARS scores, and perseverative errors and cognitive function. | This study is limited since it included a small sample size consisting of 45 patients, and all of the patients were male. |
| Qin Xiang Ng, Collin Yih Xian Ho, Hwei Wuen Chan, Bob Zheng Jie Yong, Wee-Song Yeo, Managing childhood and adolescent attention-deficit/hyperactivity disorder (ADHD) with exercise: A systematic review, Complementary Therapies in Medicine, Volume 34, 2017, Pages 123-128 | Systematic review | 30 studies, 1,335 participants | Short term and long term benefits of exercise for ADHD were examined. Cognitive performance, stroop color-word and Wisconsin card test performance, academic performance, impulsivity, concentration, motor skills, attention, body coordination, executive function, and behavioral problems. | This systematic review examined exercise as a method for managing ADHD symptoms. Both short-term and long-term studies were included. Children and adolescents with ADHD tolerate moderate to intense aerobic exercise well and it has been found to be beneficial. The research shows there are positive neurocognitive effects and benefits to inhibitory control in children with ADHD. | There are some limitations to this article. Some of the studies didn’t perform the experiments blindly, and some didn’t had inadequate control groups. Additionally meta-analysis was not possible due to the variability in the design and measurement among the studies. Additionally most of the participants were school aged males. |
| Hoza, B., Smith, A.L., Shoulberg, E.K. et al. A Randomized Trial Examining the Effects of Aerobic Physical Activity on Attention-Deficit/Hyperactivity Disorder Symptoms in Young Children. J Abnorm Child Psychol 43, 655–667 (2015). | Randomized Control Trial | 202 participants | This study aimed to study the intervention of moderate-to-vigorous physical activity compared to sedentary classroom for reducing ADHD and oppositional symptoms, moodiness, and peer difficulties in young children (Kindergarten, 1st and 2nd graders). “Our first hypothesis was that chronic aerobic PA would reduce dysfunction for both children in the ADHD-risk and TD groups more than a sedentary classroom-based program. Our second hypothesis was that the benefit of PA vs. SC would be more apparent for the ADHD-risk group than TD children.” | Parents, but not teachers observed improvements in ADHD symptoms. This may be due to the fact that parents can better focus on their children compared to teachers who have a large amount of students, and may be able to notice it more easily. Parents of ADHD and typically developing children who had the physical activity intervention reported improvements in mood and peer function. Analysis showed improvements in mood and peer function were larger, but not statistically significant in the ADHD group compared to the typically developing group. | This study is limited by its small sample size. |
Conclusion(s):
Briefly summarize the conclusions of each article, then provide an overarching conclusion.
Summary of conclusions:
Article 1:
The effect of physical activity on executive function in children with ADHD was studied. The results showed varying findings for various executive function processes. Overall physical activity is beneficial on executive function for children with ADHD. Further research is required before physical activity can be recommended as a sole treatment for ADHD. At this time physical activity is recommended as an adjunctive therapy for children with ADHD.
Article 2:
This meta-analysis showed physical activity leads to significant improvement in children with ADHD. Improvements were seen in terms of anxiety, depression, aggressive behaviors, thought and social problems. It is recommended that physical activity is added to the daily life of children suffering with ADHD.
Article 3
This systematic review showed there are both acute and chronic benefits of adding physical activity to the lives of young people with ADHD. 20-30 minute sessions of physical activity has been shown to make improvements in executive functions, attention, planning, processing speed, working memory and behavior were seen.
Article 4
This randomized control trials demonstrates aerobic exercise increased the effectiveness of methylphenidate on clinical symptoms, perseverative errors, and brain activity.
Article 5
This systematic review included 30 studies and 1,335 participants. The article showed moderate to intense aerobic exercise benefited children and adolescents with ADHD. After physical activity improvements were seen in neurocognitive function and inhibitory control.
Article 6
This randomized control trial compared physical activity versus sedentary classroom intervention for children with ADHD and typically developing children. There were ADHD symptom improvement observed. Mood and peer function benefits were observed in both the ADHD and typically developing group following physical activity. The benefit was larger in the ADHD group, but it was not statistically significant.
Weight of evidence/magnitude of any effects/clinical significance:
The following is a list of my articles that I weighed from greatest weight to lowest.
Article 2: This article was weighted the highest due to is level of evidence, being a meta-analysis and systematic review. This article also has a large sample size consisting of 574 participants and 14 studies. This study has some limitations since all of the articles used different modalities of physical activity. However, since my question wasn’t specific about what type of physical activity is used, and the studies overall showed physical activity to be helpful, regardless of type of physical activity, I rank this article highly and it has a high clinical significance to me.
Article 1: This article ranked second on my list. Like article 2 it was a meta-analysis and systematic review. However, this article had a smaller sample size than article 2. This article included 186 participants and 12 studies. The gender distribution was unequal, but this is expected since males have a higher prevalence of ADHD. Physical activity levels, age, gender, socioeconomic states and parental education level of participants were not studied as possible covariates.
Article 3: This systematic review included 728 participants and 16 studies. Although it has a large sample size the research is somewhat limited due to the fact that 25% of the studies didn’t include confounders.
Article 5: This article I ranked equally to article 3. Like article 3 is a systematic review and had a large sample size, consisting of 1,335 participants and 30 studies. However, it was limited due to the fact that some of the experiments were not performed blindly, and some didn’t have adequate control groups. Additionally, most of the participants were school aged males.
Article 6: This article was a randomized control trial with 202 participants. This article was limited by its small sample size.
Article 4: Like article 6 this was a randomized control trial. However, this article is ranked lower due to having a small sample size consisting of 45 participants. Additionally, this study is limited by having all male participants. Clinically this is significant, because it only gives me information for my male patients.
Clinical Bottom Line:
Most of my articles suggest physical activity is more beneficial for ADHD children compared to children without ADHD to improve ADHD symptoms such as cognition, behavior, and impulsivity. Although one of my articles didn’t show physical activity to be statistically more beneficial for ADHD children compared to non-ADHD children, it still showed physical activity to benefit ADHD children. Overall the articles had a larger sample of male participants than female participants. This doesn’t concern me much, since it is representative of the ADHD population, which has a higher prevalence in males compared to females. All of the articles said further research is needed. There is no harm in doing physical activity. I would suggest adding physical activity into the lives of young people who suffer from ADHD. Although it is promising, more research is still needed on the topic. Research needs to be done to determine if physical activity should supplement ADHD medications, if it can lower the dose needed, or if it can even eliminate the need for medication.
