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J Neural Transm (2017) 124 (Suppl 1):S3S26

DOI 10.1007/s00702-016-1593-7

PSYCHIATRY AND PRECLINICAL PSYCHIATRIC STUDIES - REVIEW ARTICLE

Sweat it out? The effects of physical exercise on cognition


and behavior in children and adults with ADHD: a systematic
literature review
Anne E. Den Heijer1 Yvonne Groen1 Lara Tucha1 Anselm B. M. Fuermaier1

Janneke Koerts1 Klaus W. Lange2 Johannes Thome3 Oliver Tucha1

Received: 20 April 2015 / Accepted: 1 July 2016 / Published online: 11 July 2016
 The Author(s) 2016. This article is published with open access at Springerlink.com

Abstract As attentiondeficit/hyperactivity disorder Research provides evidence that physical exercise repre-
(ADHD) is one of the most frequently diagnosed devel- sents a promising alternative or additional treatment option
opmental disorders in childhood, effective yet safe treat- for patients with ADHD. Acute and chronic beneficial
ment options are highly important. Recent research effects of especially cardio exercise were reported with
introduced physical exercise as a potential treatment regard to several cognitive, behavioral, and socio-emo-
option, particularly for children with ADHD. The aim of tional functions. Although physical exercise may therefore
this review was to systematically analyze potential acute represent an effective treatment option that could be
and chronic effects of cardio and non-cardio exercise on a combined with other treatment approaches of ADHD, more
broad range of functions in children with ADHD and to well-controlled studies on this topic, in both children and
explore this in adults as well. Literature on physical exer- adults, are needed.
cise in patients with ADHD was systematically reviewed
based on categorizations for exercise type (cardio versus Keywords Physical  Exercise  Children  Adults 
non-cardio), effect type (acute versus chronic), and out- ADHD  Cognition  Behavior
come measure (cognitive, behavioral/socio-emotional, and
physical/(neuro)physiological). Furthermore, the method-
ological quality of the reviewed papers was addressed. Introduction
Cardio exercise seems acutely beneficial regarding various
executive functions (e.g., impulsivity), response time and Attentiondeficit/hyperactivity disorder (ADHD) is one of
several physical measures. Beneficial chronic effects of the most common neurodevelopmental disorders diagnosed
cardio exercise were found on various functions as well, in childhood, with symptoms continuing into adolescence
including executive functions, attention and behavior. The and adulthood [American Psychiatric Association (APA)
acute and chronic effects of non-cardio exercise remain 2013]. The vast consequences of ADHD on individuals
more questionable but seem predominantly positive too. lives stress the importance of proper and scientifically
based treatment options. In the past decades, the prescrip-
& Anne E. Den Heijer
tion of stimulant medication has substantially increased
a.e.den.heijer@rug.nl and has become a matter of social debate (Cortese et al.
2013). In this literature review, we systematically reviewed
1
Department of Clinical and Developmental the potential benefits of an alternative or additional treat-
Neuropsychology, Faculty of Behavioural and Social
Sciences, University of Groningen, Grote Kruisstraat 2/1,
ment option for ADHD, namely, physical exercise.
9712 TS Groningen, The Netherlands
2 Symptoms and cognition of patients with ADHD
Department of Experimental Psychology, University of
Regensburg, Universitatssrae 31, 93053 Regensburg,
Germany The Diagnostic and Statistical Manual of Mental Disorders
3
Department of Psychiatry and Psychotherapy, University of (DSM-5) describes inattention, impulsivity, impaired
Rostock, Gehlsheimer Strae 20, 18147 Rostock, Germany inhibition, and hyperactivity as the most common ADHD

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S4 A. E. Den Heijer et al.

symptoms [American Psychiatric Association (APA) Owens et al. 2000; Sonuga-Barke et al. 2009; Stein et al.
2013], giving rise to problems in everyday life, social, 2003; Taylor et al. 2004; Van der Heijden et al. 2006;
academic, and occupational domains (Gapin et al. 2011; Wilens et al. 2008) and a relatively high non-response rate
Hoza et al. 2005; Loe and Feldman 2007; Uekerman et al. of 1025 % (Banaschewski et al. 2006; Taylor et al. 2004).
2010). Furthermore, more specific deficits in higher cog- Besides pharmacological approaches to ADHD treatment,
nitive functions (executive functions) have often been there are non-pharmacological treatment options, such as
demonstrated in ADHD (Barkley 2004). These functions cognitive trainings, neurofeedback, and behavioral therapy,
facilitate self-monitored and self-regulated goal-directed diets, and combined interventions. Studies on these alter-
behavior (Gioia et al. 2001). For example, deficits have native treatments are relatively scarce, but do show
frequently been reported in working memory, response improvements in ADHD symptoms with small to medium
inhibition, cognitive flexibility, risk taking, and planning effect sizes (see for a meta-analysis: Sonuga-Barke et al.
(Barkley, 1997; Groen et al. 2013; Pliszka et al. 2006; 2013). However, many of these studies are flawed with
Semrud-Clikeman et al. 2008; Toplak et al. 2009). methodological weaknesses, and the beneficial effects
Impairments of cognitive flexibility, in particular, may play often disappear when controlling for blinded assessment.
an important role in behavior regulation and may underlie
the often seen perseverative, non-adaptive, and dysregu- General effects of physical exercise in relation
lated behavior in children with ADHD (Lezak 2004). to ADHD

Advantages and disadvantages of pharmacological Recently, physical exercise has been proposed as an
treatment of ADHD alternative or additional treatment for ADHD. Particularly
for children, physical exercise has been raised as a safe and
For several decades, stimulant medication (mainly effective ADHD symptom management method, having
methylphenidate, MPH) has constituted the most fre- beneficial effects on both cognition and behavior (Gapin
quently applied treatment of ADHD (Huang and Tsai 2011; et al. 2011). Physical exercise can be subdivided into
Pliszka et al. 2000; Tucha et al. 2006). On a neurobio- several categories. First, cardio exercise raises the heart
logical level, MPH increases dopamine and norepinephrine rate, stimulates perspiration, and makes one out of breath.
levels in the prefrontal cortex (PFC) (Oades et al. 2005; This category comprises activities such as running, cycling,
Pliszka 2005) and generally enhances central nervous dancing and treadmill exercise. Cardio exercise has been
system (CNS) activity (Semrud-Clikeman et al. 2008). On associated with several ameliorations of physical and
a behavioral level, an increase in alertness and a decrease cognitive functions (e.g., executive functions) in healthy
in antisocial behaviors (e.g., aggression) and impulsivity children (Best 2010; Hill et al. 2011). The second category
have been reported following stimulant drug treatment is non-cardio exercise which is tranquil, e.g., yoga and tai
(Rhodes et al. 2006; Semrud-Clikeman et al. 2008; Wilson chi, and has also been linked to both physical and cognitive
et al. 2006). Stimulants have also been shown to positively gains in healthy children (Field 2012). Another catego-
affect various aspects of cognition, including domains of rization of exercise is based on the duration of effects,
attention (e.g., mental alertness), executive functioning, which can be classified as either acute (i.e., effect mea-
memory, and visuospatial functioning as well as cognition surable shortly after the physical activity) or chronic (i.e.,
related to self-regulation (Huang and Tsai 2011; Rhodes effects extending after a considerable period of rest).
et al. 2006; Semrud-Clikeman et al. 2008; Tucha et al. Well-known general positive effects of exercise include
2006; Wilson et al. 2006). Furthermore, MPH was found to the enhancement of overall physical fitness, growth and
improve quality of life and academic achievement (Huang density of bone minerals, and the reduction of obesity and
and Tsai 2011). inflammation (Field 2012). In addition, positive effects of
Despite the existence of well-elaborated evidence-based exercise on psychological and cognitive functions have
guidelines (NICE Guidelines on ADHD 2008) and the fact been described (Hill et al. 2011; Hillman et al. 2008).
that efficacy and safety of stimulants have been proved in a Sibley and Etnier (2003) observed acute as well as chronic
considerable number of studies and meta-analyses (e.g., effects of various cardio and non-cardio exercises on per-
Maia et al. 2014; Rubia et al. 2014; Thapar and Cooper ceptual skills, intelligence, academic achievement, devel-
2016), uncertainties still exist concerning stimulant drug opmental level and performance on verbal and mathematic
treatment for ADHD. These include sub-optimal treatment tests in children and adolescents (418 years). Further-
in clinical practice (Hodgkins et al. 2013), uncertainty more, improvements of executive functions of children
about the physical safety and potential long-term and side have been demonstrated following cardio exercise (Best
effects of stimulant medication (Biederman et al. 1991; 2010). These benefits in executive functions were strongest
Buitelaar and Medori 2010; Dela Pena and Cheong 2013; in exercise types that demand cognitive engagement,

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Sweat it out? The effects of physical exercise on cognition and behavior in children and S5

entailing cooperation awareness, anticipation, task-de- reviews describing the relation between intense cardio
mands and team-sport strategic thinking, compared with exercise treatment and enhancement of cognitive and
exercise types that do not require such cognitive involve- behavioral functioning of children with ADHD suggested
ment (Best 2010). positive influences on the structure, function, and growth of
It is assumed that the mechanisms by which physical the brain as underlying mechanisms (Berwid and Halperin
exercise provokes beneficial psychological and/or cogni- 2012; Halperin and Healey 2011). A review by Wigal and
tive effects are an increase in vagal activity, anti-pain, and others (2013) on the effect of physical exercise on the
anti-depression neurotransmitters (e.g., serotonin) as well physiology of childhood ADHD stressed that physical
as a decrease in stress hormones (Field 2012). On the one activity and stimulant medication both affect the
hand, acute exercise (i.e., cognitive examination shortly dopaminergic and noradrenergic systems. One recently
upon completing an exercise bout) is thought to enhance published review described ameliorated executive func-
cognitive functioning by immediate neurochemical tions and social functioning and decreased levels of ADHD
responses. For example, neurological effects of exercise as symptoms following the short-term aerobic exercise (Cer-
described by Lojovich (2010) and Knaepen et al. (2010) illo-Urbina et al. 2015). A final recently published review
include increases in brain-derived neurotrophic factor, paper stated that especially mixed exercise programs
levels of synaptic proteins, glutamate receptors, and the appear beneficial for ADHD symptomatology and fine
availability of insulin-like growth factor, which altogether motor skills (Neudecker et al. 2015).
seem to contribute to cell proliferation and neural plasticity Despite the high informative value of the existing
(Halperin et al. 2012). The cognitive enhancements are, reviews, they present with several shortcomings. First, not
furthermore, related to increased arousal and blood flow in all currently available studies on cognitive and behavioral
the PFC (Lambourne and Tomporowski 2010). On the gains of physical exercise in children with ADHD were
other hand, chronic exercise (i.e., cognitive examination considered so far as the field is rapidly expanding. Second,
after several weeks of regular physical exercise) could not all of the former reviews systematically categorized the
indirectly promote more permanently improved cognition specific types of exercise and outcome measures, pre-
and learning through morphological brain changes and venting clear conclusions with regard to effectiveness and
improved cardio-respiratory functioning (Best 2010). This implementation (concerning for instance exercise type and
cognitive enhancement and improvements in the PFC are frequency and expected advantages). Third, the value of
possibly cumulative and, therefore, lasting over time the available reviews is limited, since information con-
(Pesce 2009). Long-term cognitive benefits of regular cerning the cognitive and behavioral outcome measures has
cardio exercise are, furthermore, suggested to promote the not been considered sufficiently. Recently, the literature on
accelerated cerebellar development in children (Bishop this topic is growing, making frequent, critical and updated
2007) and the processes of healthier cerebrovascular aging, overviews necessary. The current literature review, there-
such as positive influences on blood flow, cell mainte- fore, aimed to provide a systematic, up-to-date overview on
nance, and circulating catecholamines (Bolduc et al. 2013). the effects of cardio and non-cardio exercise types on
cognitive, behavioral/socio-emotional, and physical/
Reviewing the effects of physical exercise in patients (neuro)physiological outcome measures in children with
with ADHD ADHD, thereby also addressing the duration of these
effects (acute or chronic). To better interpret and describe
Seven prior literature reviews addressing the effects of the existing literature, a quality screening of the included
physical exercise in children with ADHD have led to studies was performed. Furthermore, we described similar
promising conclusions. Gapin et al. (2011) concluded in literature in adults with ADHD in an exploratory way,
their review of six studies that physical exercise has both providing a more lifespan perspective on the effects of
acute and chronic positive effects on behavioral and cog- physical exercise in patients with ADHD.
nitive measures in children with ADHD. The authors
suggested physical exercise as a potential supplement to
medication. Archer and Kostrzewa (2012) reviewed three Methods
studies on this topic and reported a reduction of ADHD
symptoms following moderate intensity cardio exercise, Literature search
including impulse control, inattentiveness, stress, negative
affect (e.g., depression), anxiety, and bad conduct. These A literature search of scientific published literature in the
reductions were related to an increased level of brain- databases of PubMed, PsycINFO and Web of Knowledge
derived neurotrophic factor, which is typically reduced in revealed 25 research articles published before April 2016
patients with ADHD. Two biopsychologically oriented that described exercise in relation to cognition and

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S6 A. E. Den Heijer et al.

behavior in children with ADHD and 4 articles related to as non-cardio exercise, including yoga, walking, and
this topic in adults with ADHD. The keywords ADHD, playground activity.
children, adults, physical, and exercise were Outcome measures of the reviewed papers were classi-
combined with words related to physical exercise or out- fied into one of three categories, namely, cognitive out-
come measures, such as activity, sports, yoga, come measures [including intelligence scores and
neuropsychology, cognition, executive, function- (neuropsychological) tests for attention, planning, inhibi-
ing, and treatment. Only articles, including an ADHD tion and memory], behavioral and socio-emotional out-
group, describing some form of exercise and that were comes (comprising parent and/or teacher questionnaires
written in English, were included. In addition, relevant on the behavioral functioning of children, e.g., ADHD
articles cited in the included papers were added. Through a symptoms), and physical and (neuro)physiological out-
systematic categorization of these articles, the outcomes comes (e.g., sheer physical/physiological effects).
were organized within a descriptive table (see Table 1). To Finally, we screened the included papers for their
provide additional grounds for comparison, effects sizes methodological quality to weigh the descriptions of the
were calculated when possible (if not already presented in studies and the conclusions of this review. Two indepen-
the original paper) by using Cohens d and its interpretation dent raters classified the following four important quality
classification index (Cohen 1988), describing small effects determinants of treatment studies as adequate (A), inade-
(0.2 B d \ 0.5), medium effects (0.5 B d \ 0.8), and quate (IA), not applicable (NA) or not reported (NR). First,
large effects (d C 0.8). Effect sizes or ranges are shown in ADHD-diagnosis was assessed by standardized measures
Table 1. However, there was unfortunately a profound (e.g., DSM, ICD, ARS, Connors rating scale) to diagnose
variation in the characteristics of the study samples of the or operationally define behaviors and symptoms of partic-
reviewed articles (e.g., medication use and control condi- ipants. Second, sample size: for detecting a medium effect
tions), the type of functions assessed, the (un)availability of size (f = 0.25) in the most commonly employed design of
outcome statistics, the type of (neuropsychological) tests the studies included in this review (a within-between group
applied, and the comparisons performed (e.g., within or interaction in a repeated measures ANOVA with two
between subjects or mixed designs). We, therefore, deemed groups (e.g., ADHD versus control) and one within-sub-
it unjustified to reliably compare effect sizes across studies. jects variable (e.g., pre-measurement versus post-mea-
surement), 17 participants are needed per group (with a
Analysis power of 0.80 and an alpha of 0.05). When more within-
subjects variables are added, a fewer participants are nec-
To provide a systematic overview of the existing literature, essary (e.g., adding a low versus high intensity exercise
categorizations were made for three variables; exercise condition reduces the needed participants to 12 per group)
type (cardio versus non-cardio), duration of effects (acute but when a control group is omitted, more participants are
versus chronic), and outcome measures (cognitive, behav- necessary to demonstrate a prepost effect (34 participants
ioral/socio-emotional, and physical/(neuro) physiological). are needed). Third, control condition/group: either a
Acute effects of exercise were defined as the effects of between group or a within subject comparison was made
physical exercise immediately after the workout, with a comparing exercise to some other condition without exer-
maximum of 24 h; hence, the outcome measures stemmed cise. Last, control for medication use: either all participants
from the same full day as the exercise intervention. were on medication, nave for medication or off medication
Chronic effects of exercise were defined as outcomes during the treatment/control condition, or it was checked
lasting longer than 24 h after the exercise intervention, whether medication influenced the results (e.g., by com-
with assessments after one to 10 weeks, depending on the paring subgroups).
follow-up period of included studies. This classification
into acute and chronic effects was made, because physical
aftereffects of exercise were thought to last for the first full Results
day but to diminish after a resting period during the night.
Persisting effects after nocturnal rest and recovery are Cardio exercise: acute effects
considered to be long-lasting.
Cardio exercise included all types of workout that lead After cardio exercise (e.g., treadmill running, cycling),
to an increased heart rate and oxygen use and that are several positive effects on (higher) cognitive functioning of
performed for a relatively long duration, such as (treadmill) children with ADHD were found. Response inhibition,
running, (ergo meter) cycling, swimming, and jumping. cognitive control, attention allocation (based on event-re-
Any exercise type that is performed at a lower energy level lated brain potentials; Pontifex et al. 2013), cognitive
and does not intensely increase the heart rate was classified flexibility, processing speed, and vigilance were found to

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Table 1 Sample characteristics and results of reviewed studies (N = 29)
Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements
relative to
exercise

Cardio exercise and acute effects in children


Tantillo et al. ADHD diagnosis (DSM-III; MPH (n = 18; dose 1020 mg/ 812 Exercise condition: Pre and directly P/NP: Boys/girls ADHD vs. boys/girls control,
(2002) n = 18; 10M:8F) 24 times/day; no abstinence) treadmill exercise post post vs. pre: Boys with ADHD: improved motor
Healthy control group (personalized bouts; impersistence; increased spontaneous blink rate;
(n = 25; 11M:14F) 525 min.) decreased Acoustic Startle Eye Blink Response
Control condition: rest (ASER) latency. Girls with ADHD: decreased
(watching a video) latency and increased amplitude of ASER.
Unchanged: motor impersistence
Both groups underwent
both conditions
Wigal et al. ADHD diagnosis Stimulant medication nave 712 Cycle ergometer (varying Pre and directly P/NP: ADHD vs. control, post vs. pre: No DA
(2003) (Diagnostic interview intensity levels; post increase; lower lactate response; lower AC
schedule for children; 2030 min.) response; blunted increase of EPI and NE after
n = 10; 10M:0F) No control condition physical exercise
Matched (gender and age)
healthy control group
(n = 8; 8M:0F)
Mahon et al. ADHD diagnosis (parents MPH or amphetamine (n = 14; 912 Cycle ergometer (varying During and P/NP: MPH vs. No MPH during exercise: (1)
(2008) reported previous dose 1242 mg/day; no intensity levels; directly post Sub-maximal exercise: higher heart rate.
diagnosis; n = 14; abstinence) durations dependent on Similar: oxygen uptake, respiratory exchange
14M:0F) personal sub- maximal ratio and perceived exertion; effects limited to
No control group and peak effort) cardiovascular functions. (2) Peak exercise:
Within subjects: one higher heart rate, oxygen uptake and work rate.
exercise bout with and Similar: oxygen uptake, respiratory exchange
one bout without ratio and perceived exertion
medication
Sweat it out? The effects of physical exercise on cognition and behavior in children and

Medina et al. ADHD diagnosis (DSM-IV; MPH (n = 16; dose 7-15 Treadmill exercise Pre and directly C: Post vs. pre: Immediate improvements in speed
(2010) n = 25; 25M:0F) 530 mg/day; 48 h (30 min.) post and sustained attention and normalizations in
MPH-users (n = 16) abstinence before exercise Control condition: 1 min. impulsivity and vigilance (Conners Continuous
and tests) stretching Performance Test; CPT). Exercise effects
Non-MPH-users comparable in medication users and non-users
(n = 9) Unchanged: executive functions (Digit Span,
Coding B of WISC-R, Illinois Test of
Psycholinguistic AbilitiesVisual Sequential
Memory)
Chang et al. ADHD diagnosis (DSM-IV; Stimulant medication (n = 20; 813 Exercise group: moderate Pre and directly C: Exercise vs. control, post vs. pre: Improved
(2012) n = 40; 37M:3F), information about type and intensity treadmill post inhibition in both groups (Stroop Test;
randomly assigned to dose not reported; no exercise (30 min.) interference condition) [ES: Cohens
Exercise group (n = 20; abstinence) Control group: watching d = 0.281.26]
19M:1F) running- related video Post-test performances of flexibility improved in
Control group (n = 20; (30 min.) exercise group but not in control group (WCST;
18M:2F) non- perseverative errors and categories
completed) [ES: Cohens d = 0.340.74]
S7

123
S8

Table 1 continued
Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements

123
relative to
exercise

Pontifex et al. ADHD diagnosis Stimulant medication nave 810 Exercise condition: Directly post C: Exercise vs. control: Improved in both groups:
(2013) (suspected diagnosis, treadmill exercise inhibitory control; allocation of attention
clinical status verified by (20 min.) resources; selective enhancement in stimulus
a DSM-IV semi- Control rest condition: classification; processing speed; reading
structured interview; seated reading comprehension; arithmetic. Unchanged: spelling
confirmed diagnosis (Eriksen Flanker Test; Wide Range Achievement
verified by the ADHD Counter-balanced: both Test; neuroelectric assessment)
Rating Scale IV; n = 20; groups underwent both
conditions P/NP: Exercise vs. control: Improved in both
14M:6F) groups: accurate response production and
Matched (gender, age, neurocognitive function (measured by ERPs)
pubertal status, SES)
healthy control group
(n = 20; 14M:6F)
Smith et al. At risk for ADHD (C4 Stimulant medication nave 59 Moderate-vigorous Pre and post C: Post vs. pre: Improvements: response
(2013)* hyperactivity/impulsivity physical exercise such (daily, weekly inhibition and flexibility (Shape School-set
symptoms based on as moving around, and after shifting)
Disrupting Behavior hopping, running 9 weeks; Unchanged: planning (Mazes subtest of the
Disorders Rating Scale; (30 min. daily; assessment WPPSI-R), spatial working memory (Finger
n = 14; 6M:8F) 8 weeks) moment relative Windows), verbal working memory (Sentence
No control group No control condition to physical Memory), working memory and planning
exercise not (Numbers Reversed of the Woodcock- Johnson
reported) III Tests of Cognitive Abilities) [ES: Cohens
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: Cohens
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: Cohens d = 0.96]
Weekly measures: Behavior improvements based
on teacher ratings (Pittsburgh Modified CTRS)
[ES: Cohens d = 0.400.70]
Daily measures: Behavior observations; improved
interrupting and overall behavior; unchanged
levels of not speaking nicely, (un)intentional
aggression, not following adult directions
[ES: Cohens d = -0.18 to 0.78]
A. E. Den Heijer et al.
Table 1 continued
Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements
relative to
exercise

Hartanto et al. ADHD diagnosis (clinical Stimulant medication (n = 15; 1017 Physical activity: Simultaneous C: ADHD group vs. control group: Between
(2015) interview and Connors information about type and intensity and frequency assessment of group: children with ADHD displayed better
Total ADHD score [65; dose not reported 24 h were measured in all activity and task performance during intense physical activity on
n = 26; 14M:12F) abstinence before exercise participants by an performance on a cognitive control performance task (Eriksen
Healthy control group and tests) actometer a trial-by-trial Flanker Paradigm), which was not found in the
basis control group.
(n = 18; 5M:13F)
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 ADHD diagnosis (ICD-10; Stimulant medication nave 712 Exercise group 1: 1-week pre, C: Post vs. pre in both exercise groups: Short-
Jansen 2015* n = 39; 18M:5F) Specific, moderate- immediately term effects (after first session): no support for
Randomly assigned to: vigorous physical following and improved executive functioning after any of the
exercise group 1 (n = 12; exercises; focus on ball 1-week post two types of physical exercise
9M:3F) handling, manual program Long term positive effects (following 12 weeks of
dexterity and balance exercise): verbal working memory, digit span
Exercise group 2 (n = 11; (60 min. weekly)
9M:2F) backward and letter-number-sequencing
Exercise group 2: Non- (HAWIK-IV), which were not found in the
Wait-list control group specific, moderate- control group
(n = 16; males and vigorous physical
females were mixed) P/NP: Post vs. pre in both exercise groups: Long-
exercises; no specific term positive effects: motor performance and
focus (60 min. weekly) catching and aiming (Movement-ABC)
Wait-list control group: Improvements were independent of exercise type
Sweat it out? The effects of physical exercise on cognition and behavior in children and

no intervention and not seen in the control group


Time period: 12 week
intervention
Cardio exercise and chronic effects in children
McKune et al. ADHD diagnosis (DSM-III- MPH (n = 19; dose 513 Various high-intensity 1-week pre, B/SE: Post vs. pre: Improved behavior; attention;
(2003) R; n = 19; 13M:6F), not 1030 mg/day, 1-2 exercise sessions (e.g., during and post emotional and motor skills, in both exercise and
randomly assigned to: times/day; no abstinence) forms of running and (after 3 and after non-exercise groups; reportedly probably due to
Exercise group (n = 13; jumping; 60 min.; 5 weeks) extra attention received (CPRS)
10M:3F) 5 days a week) Unchanged: task orientation and oppositional
Non-exercise control group No control condition behavior
(n = 6; 3M:3F) Time period: 5 weeks
S9

123
Table 1 continued
S10

Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements

123
relative to
exercise

Gapin and ADHD diagnosis Stimulant medication (n = 18; 912 Moderate to vigorous Pre and post (after C: Post vs. pre: Physical exercise was a significant
Etnier (2010) (diagnosed by medical information about type and physical exercise (e.g., 7 days) predictor of planning performance (ToL) and a
professional; n = 18; dose not reported; no biking, skateboarding; non- significant but trending predictor of other
18M:0F) abstinence) 30-60 min. daily) executive functions: inhibition, working
No control group No control condition. memory, processing speed (CPT-II; Digit Span
Time period: 7 days WISC-III; Childrens Color Trial Test)
Ahmed and ADHD diagnosis (recruited Information on medication 1116 Exercise group: aerobic, Pre and post B/SE: Post vs. pre: Behavioral-cognitive and
Mohamed from special needs intake not reported muscular and motor psychological functioning improved after
(2011) school; n = 84; skills exercises (40 min. physical exercise: three of five domains of a
54M:30F), randomly and in first 4 weeks and teacher report Behavior Rating Scale (based on
equally assigned to: 50 min. in last six Connors Rating Scale) improved significantly
Physical exercise group weeks; 3 days a week) in the exercise group and not the control group:
(n = 42; 27M:15F) Control group: no attention, motor skills and academic and
physical exercise. classroom behavior
Non-exercise control
group n = 42; 27M:15F) Time period: 10 weeks Unchanged: task orientation, emotional behavior
and oppositional behavior
Time period: 10 weeks
Kang et al. ADHD diagnosis (diagnosis MPH (n = 28; dose 79 Exercise group: Baseline and post C: Post vs. pre: Improved in exercise and not in
(2011) instrument not specified; 1040 mg/day; no combination of running, (after 6 weeks) behavior education group: executive functions
n = 28; 28M:0F), abstinence) goal- directed throwing, (e.g. flexibility); cognitive function and speed
randomly assigned to rope jumping and rest (TMT-B; Digit Symbol of the Korean
Exercise group (n = 15; (90 min.; 2 days a Educational Development Institute-WISC) [ES:
15M:0F) week) Cohens d = 0.180.49]
Behavior education group Behavior education B/SE: Post vs. pre: Improved in exercise and not
(n = 13; 13M:0F) group: 12 education in behavior education group: attention and social
(n = 13; 13M:0F) sessions on social competencies (cooperativeness)
behavior Unchanged: hyperactivity; assertiveness; self-
Time period: 6 weeks control (ADHD Rating Scale; Social Skills
Rating System). [ES: Cohens d = -0.27 to
0.22]. Suggested mechanism: CA/DA/NE
increases in the prefrontal cortex, nucleus
accumbens and basal ganglia
A. E. Den Heijer et al.
Table 1 continued
Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements
relative to
exercise

Lufi and ADHD diagnosis (DSM-IV- Stimulant medication nave 813 Combined intervention of Pre, post (within B/SE: Post vs. pre, acute post-test:
Parish-Plass TR; n = 15; 15M:0F) None of the participants used sports and behavioral 2 weeks Following a sports and behavioral intervention,
(2011) Other behavioral and medication during the time of techniques. The following the hyperactivity and behavior total scores as
emotional problems the study exercise intervention intervention) reported by participants and parents in both
(n = 17; 17M:0F) was comprised of and follow up groups (ASQ-P, YSR, CBCL). Participants in
vigorous physical (1 year after both groups reported less anxiety, less somatic
exercise in individual completion of complaints, less internalizing behavior and less
sport such as relay races the study) total problems. Parents of children in both
(30 min., weekly) and groups reported less ADHD symptoms,
vigorous physical aggression, anxiety, social problems,
exercise in team sports externalizing behavior and total problems.
such as soccer (40 min., Unchanged: all other YSR and CBCL domains
weekly)
Sports ? therapy = beneficial for both clinical
No control condition groups, non-ADHD-specific.
Time period: 1 academic B/SE: Post vs. pre, acute post-test: Effects were
year 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. ADHD diagnosis (DSM-IV; Stimulant medication (n = 3 in 712 Exercise group: aerobic, Pre and post (after C: Exercise vs. control, post vs. pre: Improved
(2012) n = 21; 19M:2F) physical exercise condition muscular and motor 10 weeks) level of information processing, speed of visual
Physical exercise group and n = 11 in control skills exercises, cool search, auditory and sustained attention (Test of
(n = 10; 9M:1F; condition; information about down afterwards Everyday Attention for Children)
recruited from the same type and dose not reported; (45 min.; 3 days a B/SE: Exercise vs. control, post vs. pre: Parent-
school) no abstinence) week) reported posttest improvements: total problems,
Control group (n = 11; Control group: no social, thought and attention problems (CBCL;
Sweat it out? The effects of physical exercise on cognition and behavior in children and

10M:1F; recruited from physical exercise. Time other scales unchanged). Teacher-reported
different areas) period: 10 weeks 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)
S11

123
Table 1 continued
S12

Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements

123
relative to
exercise

Smith et al. At risk for ADHD (C4 Stimulant medication nave 59 Moderate-vigorous Pre and post C: Post vs. pre: Improvements: response
(2013)* hyperactivity/impulsivity physical exercise such (daily, weekly inhibition and flexibility (Shape School-set
symptoms based on as moving around, and after shifting)
Disrupting Behavior hopping, running 9 weeks; Unchanged: planning (Mazes subtest of the
Disorders Rating Scale; (30 min. daily; assessment WPPSI-R), spatial working memory (Finger
n = 14; 6M:8F) 8 weeks) moment relative Windows), verbal working memory (Sentence
No control group No control condition to physical Memory), working memory and planning
exercise not (Numbers Reversed of the Woodcock- Johnson
reported) III Tests of Cognitive Abilities) [ES: Cohens
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: Cohens
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: Cohens d = 0.96]
Weekly measures: Behavior improvements based
on teacher ratings (Pittsburgh Modified CTRS)
[ES: Cohens d = 0.400.70]
Daily measures: Behavior observations; improved
interrupting and overall behavior; unchanged
levels of not speaking nicely, (un)intentional
aggression, not following adult directions
[ES: Cohens d = -0.18 to 0.78]
Chang et al. ADHD diagnosis (DSM-IV- MPH (n = 7 in physical 510 Exercise group: moderate Pre and post C: Post vs. pre by group/condition: Children with
(2014) TR; n = 27; 23M :4F), exercise condition and n = 6 intensity water aerobic (within 1 week ADHD in the exercise group showed improved
non-random assignment in control condition; exercise and perceptual- of completing accuracy (Go/No-Go Task) with the no-go-
to: information about dose not motor water exercise the study) stimulus (d = 0.9) as well as coordination of
Physical exercise group reported; 24 h abstinence and cool down motor skills, whereas accuracy with the no-go-
(n = 14; 10M:4F) before tests) afterwards (90 min.; stimulus remained unchanged over time in the
2 days a week) control group (d = -0.04). Physical exercise was
Wait-list control group therefore linked to increased levels of restraint/
(n = 13; 13M:0F) Wait-list control group
behavioral inhibition in children with ADHD
Time period: 8 weeks
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)
A. E. Den Heijer et al.
Table 1 continued
Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements
relative to
exercise

Choi et al. ADHD diagnosis (DSM-IV; MPH (n = 35; dose 1318 Exercise group: Pre and post (after C: Post vs. pre: Decreased scores on ADHD rating
(2014) n = 30; 30M:0F), 1040 mg/day, 1 time/day; Aerobics exercises such 6 weeks of scale (Dupaul ADHD rating scale, Korean
randomly assigned to: no abstinence as examining as running and jumping treatment) version) and decreased perseverative errors
Physical exercise group the relation of MPH with rope (90 min.; several (Wisconsin Card Sorting Test) in the exercise
(n = 17; 17M:0F) respectively physical exercise days a week) group and not in the education group
and behavioral education was P/NP: Sports ADHD group vs. education ADHD
Education ADHD group one of the study aims Education ADHD group:
(n = 13; 13M:0F) education sessions for group: Increased brain activity (fMRI) within
behavior and control the right frontal and temporal cortices during a
Age-matched healthy Wisconsin Card Sorting Test stimulation
control group (n = 15; such as good behavior
15M:0F) and bad behavior and Unchanged: activity within left parietal (trend),
interaction with family right middle temporal, right occipital, right
(50 min.; several days a parietal, right cerebellum and left middle
week) temporal cortices
Control group: no The observed improvements in ADHD symptoms,
physical exercise perseverative errors and brain activity following
Time period: 6 weeks 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; Stimulant medication (n = 15; 714 Simulated developmental Pre and directly P/NP: Post vs. pre by group comparison: Both
n = 24; 24M:0F), information about type and horse riding program in post ADHD groups showed worse total motor
randomly assigned to: dose not reported; no combination with proficiency scores than TD children; but the
Training group (n = 12; abstinence) moderate-vigorous ADHD training group performed better than the
12M:0F) fitness training ADHD non-training group at total motor
(90 min., weekly) proficiency, fine manual control, manual
Non-training control group coordination, body coordination, strength and
(n = 12; 12M:0F) Control group: no
physical exercise agility, manual dexterity and bilateral
Age and gender matched coordination (Bruininks-Oseretsky Test of Motor
Sweat it out? The effects of physical exercise on cognition and behavior in children and

healthy control group Time period: 12 weeks Proficiency, second edition)


(n = 24; 24M:0F) 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
S13

123
Table 1 continued
S14

Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements

123
relative to
exercise

Ziereis and ADHD diagnosis (ICD-10; Stimulant medication nave 712 Exercise group 1: 1-week pre, C: Post vs. pre in both exercise groups: Short-
Jansen n = 39; 18M:5F) Specific, moderate- immediately term effects (after first session): no support for
(2015)* Randomly assigned to: vigorous physical following and improved executive functioning after any of the
exercises; focus on ball 1-week post two types of physical exercise
Exercise group 1 handling, manual program Long term positive effects (following 12 weeks of
(n = 12; 9M:3F) dexterity and balance exercise): verbal working memory, digit span
Exercise group (60 min. weekly) backward and letter-number-sequencing
2 (n = 11; 9M:2F) Exercise group 2: Non- (HAWIK-IV), which were not found in the
specific, moderate- control group.
Wait-list control group vigorous physical
(n = 16; males and P/NP: Post vs. pre in both exercise groups: Long-
exercises; no specific term positive effects: motor performance and
females were mixed)
focus (60 min. weekly) catching and aiming (Movement-ABC)
Wait-list control group: Improvements were independent of exercise type
no intervention and not seen in the control group
Time period: 12 week
intervention
Time period: 12 weeks
Janssen et al. ADHD diagnosis (DSM-IV- Stimulant medication nave (all 713 Exercise group: Moderate 1 week pre and P/NP: Group comparison, post vs. pre: Children
(2016a) TR; n = 81), randomly patients had been stimulant -vigorous physical ~1 week post with ADHD (often showing increased slow
assigned to: medication free for at least activity (not specified). wave activity theta and decreased fast wave
Physical exercise group 1 month before the beginning The maximum heart activity beta in EEG studies which is linked to
(n = 27; 21M:6F) of the study) rate (HRmax) was ADHD symptoms) displayed reduced theta
Medication group: assessed. The aim was power waves after neurofeedback and
Neurofeedback group to first elevate the heart medication interventions but not after physical
(n = 29; 21M:8F) MPH (n = 25; doses rate to 70-80 % of activity on an EEG-analysis. The medication
Medication group (n = 25; 515 mg/day) HRmax (5 9 2 min.) and neurofeedback groups showed reduced theta
19M:6F) and then to 80-100 % of power post-treatment during a resting condition.
HRmax. (45 min. with Solely the medication group displayed this
20 min. of effective reduction in an effortful task condition
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
A. E. Den Heijer et al.
Table 1 continued
Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements
relative to
exercise

Janssen et al. ADHD diagnosis (DSM-IV- Stimulant medication nave (all 713 Exercise group: Moderate 1 week pre and ~ P/NP: Group comparison, post vs. pre: The
(2016b) TR; n = 81), randomly patients had been stimulant -vigorous physical 1 week post medication group displayed a specific post-
assigned to: medication free for at least activity (not specified). intervention P3 amplitude increase, related to
Physical exercise group 1 month before the beginning The maximum heart response inhibition. Across all groups, N2
(n = 27; 21M:6F) of the study) rate (HRmax) was amplitude increased from pre to post
Medication group: MPH assessed. The aim was intervention. Thus, medication but not
Neurofeedback group to first elevate the heart neurofeedback or physical exercise, was related
(n = 29; 21M:8F) (n = 25; doses 515 mg/day)
rate to 70-80 % of to improved response inhibition
Medication group (n = 25; HRmax (5 9 2 min.)
19M:6F) and then to 80100 %
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 (48 Hz) and
strengthening beta
(1320 Hz) at Cz.
(45 min. with 20 min.
of effective training;
3 days a week)
Medication group
Time period: *10 weeks
Non-cardio exercise and acute effects in children
Sweat it out? The effects of physical exercise on cognition and behavior in children and

Hernandez-Reif ADHD diagnosis (DSM-IV; Information on medication 1316 Physical exercise: Tai Two weeks pre B/SE: Post vs. pre: Both acute (directly post) and
et al. (2001)* n = 13; 11M:2F) intake not reported Chi, training of postures (baseline), chronic (2 weeks after intervention) effects were
No control group (30 min.; 2 days a directly post found; less anxiety, improved conduct, less
week) for 5 weeks; then (after 5 weeks) daydreaming, less inappropriate emotions and
a non-exercise follow- and follow-up less hyperactivity (CTRS)
up phase without Tai (after 7 weeks) Unchanged: asocial behavior
Chi (2 weeks)
No control condition
Time period: 5 weeks
Azrin et al. ADHD diagnosis (diagnosis Stimulant medication nave 4 Gymnastic playground Pre and directly B/SE: Post vs. pre: Improved observed attentive
(2006) instrument not described; activities (i.e. sliding, post sitting in the classroom (observed by 2 school
n = 1; M) climbing, swinging; assistants)
No control group 1 min.; recurring over Physical exercise was however suggested to be a
5 days) reinforcement. Substantial limitations were
No control condition reported
S15

123
Table 1 continued
S16

Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements

123
relative to
exercise

Taylor and Kuo ADHD diagnosis Information on medication 712 Walking, alternatingly in Directly post C: Walk in park vs. walk in urban settings:
(2009) (professionally diagnosed intake not reported; children a park and 2 urban Improved concentration (Digit Span
by a physician, normally taking stimulant settings (respectively a Backwards); suggested greater influence of
psychologist or medication were asked to downtown and a environment than physical exercise [ES park
psychiatrist; n = 17; postpone intake to after the residential area; 20 min. urban settings: Cohens d = 0.520.77]
15M:2F) intervention per walk). Test Substantial limitations were reported
No control group administrators were
blind to the walking
condition
No control condition
Non-cardio exercise and chronic effects in children
Hernandez-Reif ADHD diagnosis (DSM-IV; Information on medication 1316 Physical exercise: Tai Two weeks pre B/SE: Post vs. pre: Both acute (directly post) and
et al. (2001)* n = 13; 11M:2F) intake not reported Chi, training of postures (baseline), chronic (2 weeks after intervention) effects were
No control group (30 min.; 2 days a directly post found; less anxiety, improved conduct, less
week) for 5 weeks; then (after 5 weeks) daydreaming, less inappropriate emotions and
a non-exercise follow- and follow-up less hyperactivity (CTRS)
up phase without Tai (after 7 weeks) Unchanged: asocial behavior
Chi (2 weeks)
No control condition
Time period: 5 weeks
Maddigan et al. ADHD diagnosis (DSM-IV; Stabilized on medication School-age Exercise group: sessions Pre, during and C & B/SE: Post vs. pre in exercise group:
(2003) n = 10; gender not (information about type and (details not of yoga exercise (6- post (after 0, 6 Improved ability to do homework; to cope in
reported), randomly dose not reported) reported) 20 min.; once a week and a follow up stressful situations; balancing; flexibility and
assigned to: for 6 weeks) at 12 weeks) concentration (observations and CPRS). Positive
Yoga/exercise group Massage group: massages overall responses in both exercise and massage
(n = 3) (6-20 min.; once a week groups. Substantial limitations were reported
Massage group (n = 3) for 6 weeks)
Control group (n = 4) Control group: no
intervention
Time period: 12 weeks
Jensen and ADHD diagnosis (DSM-IV MPH (n = 17; dose 813 Yoga group (60 min.; 20 Pre and post (after B/SE: Post vs. pre: Improvements in both groups:
Kenny and CPRS; n = 19; 1540 mg/day; no sessions) 20 weeks) perfectionism; DSM-IV hyperactive/impulsive;
(2004) 19M:0F) abstinence) Control group: DSM-IV total. Yoga group improved scales
Yoga group (n = 11; cooperative games (CPRS): oppositional; emotional liability; total;
11M:0F) (social activities) Time restless/impulsive; ADHD behavior
Control group (n = 8; period: 20 weeks Control group improved scales (CPRS):
8M:0F) hyperactivity; anxious/shy; social problems. No
significant differences according to teachers
Randomly allocated to yoga (CTRS)
group with the option to
crossover after the first 20 Substantial limitations were reported
sessions
A. E. Den Heijer et al.
Table 1 continued
Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements
relative to
exercise

Preliminary findings on the effects of physical exercise on cognitive and behavioral functioning in adults
Fritz and ADHD screening diagnosis Stimulant medication nave 1833 Exercise condition: Baseline, Post 1, C/NP: Exercise condition vs. resting condition by
OConnor (symptoms of adult Cycling at 65 % VO2 Post 2 (both time: No significant improvements in sustained
(2016) ADHD assessed by the peak (20 min.) immediately attention (Continuous Performance Task and the
Cardio exercise Adult ADHD Self- Report Non-exercise control after the Bakan Vigilance Task for sustained attention;
Scale; n = 36; 36M:0F) condition: intervention) Simple Reaction Time Task for psychomotor
Acute effects speed)
Seated rest (20 min.)
B/SE: Exercise condition vs. resting condition by
Within study design: all time: Enhanced motivation to complete mental
participants underwent work in the exercise group over time (as
both conditions 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 ADHD diagnosis (DSM-IV; Stimulant medication nave Mean Physical exercise was Correlational B/SE: High physical activity group vs. low
et al. (2013) n = 30;30M:0F) age = 27.29, assessed by a physical study, no physical activity group:
Cardio exercise High physical activity SD = 5.87 exercise subscale of a intervention ADHD patients who frequently engage in physical
group (n = 10; 10M:0F) (Infor-mation leisure time activity exercise showed a healthier psychological well-
Chronic effects
Sweat it out? The effects of physical exercise on cognition and behavior in children and

on age range questionnaire, being than ADHD patients who do not often
Low physical activity group measuring exercises
(n = 20; 20M:0F) not reported) exercise actively. They reported less meta-
with a strong aerobic worrying, less problems with intrusive thoughts
component (e.g., (i.e. difficulty removing them; thoughts of
jogging; competitive sadness and fear) and less behavioral
sports; C 30 min.) impulsivity (as measured by the Anxious
Based on the Thoughts Inventory; Eysenks Impulsivity-
questionnaire, Venturesomeness-Empathy Questionnaire;
participants were Distressive Thoughts Questionnaire)
divided into 2 groups: Similar across groups: social and health worrying,
high physical activity venturesomeness, frequency of thoughts,
and low physical thoughts of disapproval
activity
S17

123
Table 1 continued
S18

Authors (year) Group (n M:F) Medication use in ADHD Age range Intervention type Time of Outcomes (measures) [ES when reported]
group (n dose; abstinence) (years) (duration) measurements

123
relative to
exercise

Fuermaier et al. ADHD diagnosis (clinical MPH (n = 4; dose 1831 Passive exercise group: Directly post C : Vibration vs. resting: WBV significantly
(2014a) interview based on DSM- 1072 mg/day, 1 time/day; Passive Whole Body improved attention performance (Stroop Color
Non-cardio IV; n = 17; 8M; 9F) no abstinence) Vibration (WBV) was Word Interference Test) in both groups, with a
exercise Healthy adults (n = 83; implemented, small effect size in the healthy control group
Acute effects 40M:43F) participants were sitting (d = 0.44) and a medium effect size in the
on a chair that was ADHD group (d = 0.68). Passive physical
ascended on a vibrating exercise was thus related to improved cognitive
platform (Vibe 300, functioning in healthy adults and adults with
Tonic Vibes, Nantes, ADHD
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
Fuermaier et al. ADHD diagnosis (DSM-IV; MPH (dose 10 mg, 4 2025 Passive exerciseADHD 1 day pre, 16 h C: Post vs. pre: Descriptive performance data
(2014b) n = 1; M) times/day; no abstinence) patient: Passive WBV post and follow- showed 1) in healthy participants: improved
Non-cardio Control group (n = 6; was applied (15 min.; 3 up (after vigilance, flexibility, working memory and
exercise 3M:3F) times a day on 10 12 days and inhibition after repeated assessments; 2) in the
Acute and consecutive days), the after 25 days- ADHD patient: improved alertness, divided
chronic participant was sitting treatment started attention, vigilance, flexibility, inhibition,
effects on a chair that was on day 2) divergent thinking, verbal fluency and self-
mounted on a vibrating reported impairments of attention (especially
platform (Vibe 300, from first to second assessment). WBV-
Tonic Vibes, Nantes, treatment was therefore related to acute
France) cognitive gains
Control group: assessed Unchanged: alertness reaction times,
with the same test distractibility and working memory
battery to control for Follow-up: most of the assessed cognitive
practice effects; no functions returned to their pre-experiment-level
WBV (e.g. flexibility, inhibition, vigilance and self-
Time period: 10 days reported impairments of attention)

AC, acetylcholine; ADHD, attentiondeficit/hyperactivity disorder; AVL, ADHD Vragenlijst; ASRS, Adult ADHD Self-Report Scale; B/SE, behavioral/socio-emotional; CA, catecholamines;
C, cognitive; CBCL, Child Behavior Checklist; CPRS, Connors Parents Rating Scale; CPT-II, Connors Continuous Performance Test; CTRS, Connors Teacher Rating Scale; DA, dopamine;
EPI, epinephrine; ES, effect size(s); F, female; HRmax, maximum heart rate; ICD-10, International Statistical Classification of Diseases and Related Health Problems; M, male; MPH,
methylphenidate; NE, norepinephrine; P/NP, physical/(neuro)physiological; post, measurement after exercise; pre, measurement prior to exercise treatment; SES, social economic status; TMT,
Trail Making Test; ToL, Tower of London; WBV, whole body vibration; WCST, Wisconsin Card Sorting Test; WISC-R, WISC-III, Wechsler Intelligence Scale for Children; WPPSI-R,
A. E. Den Heijer et al.

Wechsler Preschool and Preliminary Scale of IntelligenceRevised; *, study also mentioned in another section
Sweat it out? The effects of physical exercise on cognition and behavior in children and S19

be improved in children with ADHD when assessed auditory sustained attention and selective attention/infor-
immediately after physical exercise (Chang et al. 2012; mation processing), executive functioning (including set
Hartanto et al. 2015; Medina et al. 2010; Pontifex et al. shifting, (accuracy of) response inhibition and planning),
2013; Smith et al. 2013). Academic performance was also verbal working memory, and cognitive speed (Chang et al.
found to be improved in both children with ADHD and 2014; Choi et al. 2014; Gapin and Etnier 2010; Kang et al.
healthy children following physical exercise, including 2011; Smith et al. 2013; Verret et al. 2012; Ziereis and
enhanced levels of reading comprehension and arithmetics Jansen 2015). However, a lack of robustness of chronic
(Pontifex et al. 2013). However, not all assessed aspects of effects on cognition after cardio exercise is shown by some
academic and cognitive functioning were sensitive to the studies not reporting affected functions [e.g., (working)
effects of physical exercise, with unchanged performance memory], and by studies not confirming significant bene-
levels of verbal short-term and working memory, sub-in- ficial long-term effects in the areas of inhibition, processing
dexes of executive function performances (e.g., persever- speed, planning, memory span, and continuous motor
ative responses), spelling, reading, and color naming timing (Gapin and Etnier 2010; Smith et al. 2013). The lack
(Chang et al. 2012; Medina et al. 2010; Pontifex et al. of agreement in findings might partly be explained by the
2013; Smith et al. 2013; Ziereis and Jansen 2015). small sample sizes examined in the latter two studies
With respect to behavioral and school-day functioning, (n = 14 and n = 18, respectively, which is less than the
parents and teachers reported children with ADHD to requested n = 34 for a one-factorial within subject design)
display overall improvements after physical activity (e.g., and their consequential low statistical power.
diminished interruption and unintentional aggression). No A number of studies provided ample evidence for
effects, however, were found concerning intentional chronic effects of cardio exercise on parent or teacher
aggression, language use and following directions (Smith ratings and observations of a broad range of behavioral and
et al. 2013). The authors did not report whether the raters socio-emotional outcomes. Overall functioning, general
were blind to the treatment of the child. ADHD symptomatology, attention, the childs self-esteem,
Finally, regarding physical/(neuro)physiological acute anxiety, depression, somatic complaints, academic and
effects of cardio exercise, improved motor impersistence classroom behavior, and social behavior were reported to
(defined as the inability to sustain motor acts, such as be improved after cardio exercise, extending beyond the
keeping the mouth open, protruding the eyes, centrally day on which the physical exercise took place (Ahmed and
fixing the eyes or shutting the eyelids) was reported in boys Mohamed 2011; Choi et al. 2014; Kang et al. 2011; Lufi
with ADHD. This effect was, however, not found in girls, and Parish-Plass 2011; Smith et al. 2013; Verret et al.
lacking a clear explanation (Tantillo et al. 2002). Pontifex 2012). Social behavior in this regard refers to general
et al. (2013) described physical exercise-induced social skills, social competency, cooperativeness, per-
improvements in neurocognitive function and response ceived social, thought and attention problems, interrupting
production as measured by event-related potentials (ERPs), behavior and (unintentional) aggression. No consistent
cautiously linking this to behavioral and academic gains. evidence was found in these studies, however, for long-
Wigal et al. (2013) demonstrated abnormal physiological term improvements of hyperactivity, assertiveness, task-
after effects of physical exercise in children with ADHD orientation, self-control, emotional behavior, and opposi-
(including more blunted (nor)epinephrine responses and no tional/defiant social behavior (e.g., language use, inten-
dopamine increase) which are in contrast to the effects tional aggression, not following adult directions, and
found in healthy controls. Another study stressed that teasing). The fact that effects were not significant is pre-
children with ADHD off MPH showed different, attenuated sumably (partly) explained by design limitations (e.g., lack
physiological responses to exercise compared to children of a control group or small sample size; Kang et al. 2011;
with ADHD on MPH, with the latter having a higher sub- Smith et al. 2013). In line with this lack of robustness,
maximal heart rate during exercise (Mahon et al. 2008). McKune et al. (2003) presented comparable improvements
However, other cardiorespiratory measures and perceived in both the physical exercise and the control group with
exertion were found to be unaffected by the use of MPH regard to attention, behavior, and emotional skills. These
(presumably due to the small sample size (n = 14); Mahon effects were thought to be (partly) explained by the extra
et al. 2008). attention children received in both conditions.
Last, motor performance scores, including locomotion,
Cardio exercise: chronic effects handeye coordination, and general motor skills (e.g., fine
motor skills, strength, and agility) were found to benefit
Cardio exercise (e.g., running and jumping) has also been from physical exercise (Chang et al. 2014; McKune et al.
linked to longer lasting effects on cognition in children 2003; Pan et al. 2014; Verret et al. 2012; Ziereis and Jansen
with ADHD, resulting in improved attention (including 2015). Although Pan and colleagues (2014) described

123
S20 A. E. Den Heijer et al.

overall improvement in motor skills and coordination, as methodological limitations related to the study execution
performance of some motor skills (e.g., balance and run- (e.g., unstable attendance to experimental sessions).
ning speed) improved comparably in children with ADHD Another study also reported improvements of behavior and
who performed physical exercise and a control group emotions following yoga (e.g., in terms of ADHD symp-
without exercise, which points to testretest effects (Pan tomatology and social behavior; Jensen and Kenny 2004).
et al. 2014). Regarding neurophysiological improvements, The underlying behavior observation ratings were, how-
Choi et al. (2014) found in a functional magnetic resonance ever, ambiguous, with more positive ratings of teachers
imaging study that brain activity enhanced within the right than parents, possibly due to the fact that teachers were
frontal and temporal cortices during a set-shifting task, but observing the children, while they were under the influence
that brain activity within several other cortices remained of stimulant medication. Furthermore, as shown by
unchanged. An EEG/ERP study showed inconsistent find- behavioral improvements in the social intervention control
ings, with an increased No-Go N2 amplitude but no group, positive effects were not limited to the yoga group.
increased No-Go P3 amplitude (which are linked to Finally, the sample size included in this study was too
improved executive function) in a physical activity group small for sufficient power (N = 19, Jensen and Kenny
after 10 weeks of exercise, and no reduction in EEG theta 2004).
power (which is often increased in children in ADHD, and
are associated with more ADHD symptoms; Janssen et al. Preliminary findings on the effect of physical
2016a, b). exercise on adults with ADHD

Non-cardio exercise: acute effects Although the literature on the effect of physical activity on
(cognitive) functioning in adults remains particularly
The number of studies on acute effects of non-cardio scarce to date, a number of studies presented promising
exercise is scarce, and their conclusions are all limited by results. Two studies described a positive relation between
inadequate study designs that were justly addressed by the engaging in physical exercise and behavioral/socio-emo-
authors of these studies (e.g., small sample sizes, absence tional outcomes, including enhanced levels of self-reported
of a control group/condition). One study reported improved motivation and vigor, and lower levels of impulsivity,
anxiety and conduct as well as less hyperactivity, inap- worrying, intrusive and worrisome thoughts, confusion,
propriate emotions and daydreaming in children with fatigue and depression (Abramovitch et al. 2013; Fritz and
ADHD following tai chi sessions, but asocial behavior OConnor 2016). The findings were not robust for all
remained unchanged (Hernandez-Reif et al. 2001). Another measures, as Fritz and OConnor (2016) failed to find
study showed that although the attention of children with improvements of hyperactivity or cognition despite exam-
ADHD significantly improved after a walk in the park, it ining a sample of adequate size (N = 36).
remained unclear whether this effect could be attributed to With regard to non-cardio physical activity, Fuermaier
the physical activity or the natural environment (Taylor and et al. (2014a, b) reported promising effects of Whole Body
Kuo 2009). A case study stated that playground activity Vibration (WBV) on cognitive functioning in adults with
appeared to diminish hyperactive behavior, but this ADHD. WBV is a passive exercise method in which people
improvement might (partly) be due to the reinforcing and are physically activated by exposure to environmental
appraising character of the situation rather than the physi- vibration by sitting or standing on a vibrating plate. In a
cal activity itself (Azrin et al. 2006). group study, acute effects of WBV treatment on attention
performance were found, with larger beneficial effects in
Non-cardio exercise: chronic effects adults with ADHD (medium effect size) than healthy adults
(small effect size; Fuermaier et al. 2014a). It seems note-
Similar to the acute effects of non-cardio exercise, infor- worthy to point out that these effects could be observed
mation about the chronic effects of non-cardio exercise is after a WBV treatment of only a few minutes. A case study
scarce. The enhanced behavioral/socio-emotional measures about a young male adult with ADHD who underwent
as described by Hernandez-Reif et al. (2001) remained on a WBV treatment during 2 weeks, described long-lasting
long-term basis as well. Maddigan et al. (2003) described acute effects (assessed after nocturnal rest, within 24 h
positive effects of yoga on several general cognitive and following the two-week intervention) on cognition (e.g.,
neuropsychological functions (i.e., the ability to do inhibition, flexibility, self-reported levels of attention).
homework and to cope with stressful situations, balancing, However, since most of the cognitive measures returned to
flexibility, and attention). This study, however, claimed their baselines levels after 2 weeks of no WBV, chronic
that solid conclusions cannot be drawn from the results, effects were not found. The acute effect of WBV was
because of the small sample size included (N = 10) as well substantially larger than the testretest effect in a healthy

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Sweat it out? The effects of physical exercise on cognition and behavior in children and S21

control group receiving no treatment (N = 6). Reaction physical activity as indicated by significant improvements
times, distractibility, and working memory were unaffected with effect sizes (when reported) up to 0.96 (Cohens d).
by WBV treatment. Selective effects were observed here as well by some
measures not showing improvements. It should be consid-
Methodological quality screening of the included ered that some null findings may have been caused by
studies inadequate research designs (see Results section). Several
reported differences that did not reach significance were in
Table 2 displays the classification of four important the expected direction. Although most studies on cardio
methodological quality determinants of the reviewed exercise generally found improvements on cognitive func-
studies. As shown in Tables 1 and 2, most studies ade- tions that are often impaired in ADHD, such as speed of
quately described the diagnosis of the included patients information processing, attention, inhibition, and flexibility
with ADHD (23 out of 29 studies). Almost half of the (Ahmed and Mohamed 2011; Chang et al. 2012; Chang
studies were, however, underpowered because of too small et al. 2014; Choi et al. 2014; Gapin and Etnier 2010; Har-
sample sizes (13 out of 27 studies; 2 studies were case tanto et al. 2015; Kang et al. 2011; McKune et al. 2003;
reports). Although the majority of the studies adequately Medina et al. 2010; Pontifex et al. 2013; Smith et al. 2013;
included and described a control condition/group (18 out of Verret et al. 2012; Ziereis and Jansen 2015), some studies
29 studies), a substantial share of the papers did not include pointed to a lack of robustness by not (consistently)
an adequate control condition/group without exercise. Most revealing comparable improvements across studies (Chang
of the papers reported stimulant medication use of the et al. 2014; Gapin and Etnier 2010; Medina et al. 2010;
included patients, and sufficiently described whether Pontifex et al. 2014; Smith et al. 2013; Ziereis and Jansen
patients took their regular medication, were medication 2015). For example, working memory and memory func-
nave, whether medication use was abstained during the tions were found to be improved on the long term by
experiment, or whether medication influences were con- exercise in one study (Ziereis and Jansen 2015) but not in
trolled for in the analysis (22 out of 27 studies). Overall, it others (Gapin and Etnier 2010; Medina et al. 2010; Smith
can be concluded that especially small sample sizes and the et al. 2013). This inconsistency in findings may be related to
absence of adequate control conditions/groups were often differing methodological study qualities, which will be fur-
limiting the reviewed studies. ther discussed under limitations. Overall, it can be stated
that the reviewed studies describe acute as well as chronic
beneficial effects of cardio exercise on a wide variety of
Discussion cognitive and behavioral functions in children with ADHD,
but that cardio exercise does not necessarily result in func-
In this paper, the literature on the potential acute as well as tional improvement in all areas.
chronic effects of both cardio and non-cardio physical With regard to non-cardio exercise and acute effects,
exercise on cognitive, behavioral/socio-emotional, and studies suggested cognitive, behavioral and motor
physical/(neuro)physiological outcome measures in improvements in children with ADHD, with effect sizes
patients with ADHD was reviewed. (when reported) up to 0.77. Drawing firm conclusions
First, cardio exercise in children with ADHD appeared to seems, however, premature, because of the third variables
be related to acute positive changes in a wide variety of potentially explaining or moderating these effects (e.g.,
these outcome measures with effect sizes (when reported) up environmental factors, reinforcement and motivation) and
to 1.26 (Cohens d). However, findings were selective, with because of the limited number of studies performed.
some outcome measures showing an improvement following Moreover, most studies were characterized by method-
exercise and with other measures showing no improvement. ological weaknesses (e.g., small and heterogeneous groups,
Second, studies on chronic effects following cardio exercise lacking control group/condition and logistical problems
implied that children with ADHD also benefit on a longer with study execution in home settings). Although some
term (i.e., after a substantial period of rest) from cardio chronic beneficial effects were demonstrated for non-

Table 2 Number of studies


Quality indicators Adequate Inadequate Not reported Not applicable
(k) screened for adequate and
inadequate quality of four 1. Diagnosis assessed by standardized measures 23 1 5 0
relevant methodological quality
indicators 2. Sample size 14 13 0 2
3. Control condition/group 18 11 0 0
4. Control for medication use 22 5 2 0

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S22 A. E. Den Heijer et al.

cardio exercise on general cognitive and behavioral func- It is assumed that physical exercise entails similar
tions, valid conclusions cannot be drawn either because of neurobiological effects as stimulants (e.g., increased
weak study designs or the absence of theoretical support availability of monoaminergic catecholamines in the brain,
provided for the findings. In the light of the limitations Fritz and OConnor 2016; Wigal et al. 2013) and that these
discussed, clear conclusions of the acute and chronic effects result in improved functioning in overlapping areas
effects of non-cardio exercise on children with ADHD of cognition. A number of studies even showed (cognitive)
remain elusive to date. Based on our current knowledge, gains of physical exercise on top of medication treatment
cardio exercise appears to be a more promising treatment (i.e., when children were on stimulant medication during
method for children with ADHD than non-cardio exercise the exercise bouts and tests; Choi et al. 2014; Gapin and
with regard to both acute and chronic cognitive and Etnier 2010; Jensen and Kenny 2004; Kang et al. 2011;
behavioral effects, but more well-designed studies are Maddigan et al. 2003; Mahon et al. 2008; McKune et al.
needed. 2003; Tantillo et al. 2002; Verret et al. 2012). Regular
The literature on the effects of physical exercise in physical exercise could, therefore, be an effective (addi-
adults with ADHD also remains relatively scarce. In the tional) treatment option for children with ADHD (in this
available studies, beneficial effects (of medium size) of review, exercise bouts of 30 min were most common with
both active (leisure time sports activities with a strong a range of 190 min). This would especially be beneficial
aerobic component) and passive physical activity (WBV) in the following cases: (1) when deficits are not normalized
were described to be related to improved cognitive and by pharmacological treatment (e.g., see Tucha et al. 2006),
behavioral functions including attention, inhibition, moti- (2) when pharmacological treatment is not the first choice
vation and impulsivity (Abramovitch et al. 2013; Fritz and treatment, (3) when effects of pharmacological treatment
OConnor 2016; Fuermaier et al. 2014a, b). Not all asses- on a childs problem behaviors are inconsistent (Swanson
sed functions improved and the duration of the effects of et al. 2011) or (4) when children suffer from milder dis-
passive physical remains to be elucidated, but the fact that turbances which might benefit from physical exercise, thus
positive findings were shown in these studies is promising possibly eliminating the need for pharmacological treat-
when considering physical exercise interventions for adults ment. The advantages of physical exercise are broad:
with ADHD. exercise can be combined with all treatment approaches
In view of the findings of this literature review, the currently applied in ADHD (including pharmacological
question arises as to why physical exercise could improve treatment), it is cheap, non-invasive, and easy to imple-
cognitive and/or behavioral functioning in ADHD. As men- ment, it has additional health benefits (e.g., potential pre-
tioned in the introduction, the underlying working mecha- vention of chronic diseases and obesity), and can improve
nism of chronic exercise likely entails enhanced neural psychological well-being (e.g., Warburton et al. 2006).
growth and development which may have long-term impli- However, exercise programs should at all times be indi-
cations (Best 2010; Bishop 2007; Bolduc et al. 2013; Hal- vidually adapted and potential risks as well as physical and
perin et al. 2012; Pesce 2009). Especially when physical health issues have to be taken into consideration. Based on
exercise is performed at young age, long-term positive the demonstrated effectiveness and the practical imple-
responses of cell-proliferation might take place (as demon- mentation in everyday life, daily exercise bouts of 30 min
strated in animal research; Halperin et al. 2012; Kim et al. appear reasonable.
2004). Regular physical exercise may, therefore, be espe-
cially beneficial for children with ADHD, because cardio Limitations
exercise increases specific catecholamines and proteins/en-
zymes that are typically reduced in ADHD (e.g., dopamine, Despite the existing evidence for effectiveness, the present
tyrosine hydroxylase and brain-derived neurotrophic factor; findings ought to be interpreted with caution as the
Chang et al. 2012; Hattori et al. 1994; Kim et al. 2011). In majority of described studies suffered from one or several
addition, cognitive functions that have often been found methodological shortcomings. The methodological quality
impaired in patients with ADHD, such as executive func- of the included papers was screened by classifying four
tions, improved after acute exercise in the majority of the important quality determinants for each paper (see
reviewed studies. According to Chang and colleagues (2012), Table 2). Although the majority of the studies adequately
this can be explained by an exercise-induced improved assessed the ADHD symptoms by means of standardized
allocation of attention resources and by positive influences measures and controlled for the use of medication, almost
on the dorsolateral PFC. Interestingly, memory improve- half of the studies were underpowered, and one-third of the
ments after acute cardio exercise in healthy adults appear to studies did not include an adequate control group/condition
be related to better-facilitated molecular mechanisms of without exercise. We weighed these limitations in this
memory encoding and consolidation (Roig et al. 2013). review, and are therefore reluctant to draw conclusions

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Sweat it out? The effects of physical exercise on cognition and behavior in children and S23

about the beneficial effects of non-cardio exercise. How- Future perspectives


ever, a substantial amount of studies on the effects of
aerobic exercise that did adopt rigorous methodological Given the promising current body of evidence regarding
designs point to beneficial short- and long-term effects for the cognitive, behavioral/socio-emotional, and physical/
patients with ADHD. This finding stresses the importance (neuro)physiological effects of physical exercise in the
of developing exercise programs for children and adults treatment of ADHD symptoms, further research is neces-
with ADHD and of rigorously evaluating their effects by sary to substantialize these findings. It is of importance to
means of randomized controlled trials. By including ade- clearly distinguish between, on the one hand, the exercise
quate control groups/conditions, potential confounding type (cardio versus non-cardio) and, on the other hand, the
variables can be ruled out, such as received attention, duration of the effects (acute versus chronic). This dis-
environmental effects as well as possible testing/learning tinction could help establish the type of exercise that is
effects of repeated administration of the same tests. Fur- most effective for treating ADHD symptoms in clinical
thermore, none of the studies examining behavioral/socio- practice. Even though especially cardio exercise appears
emotional outcomes reported whether raters were blind to promising, both cardio and non-cardio exercise should be
the treatment condition of the participants. To overcome further examined in well-controlled studies to allow more
bias or a placebo effect, it is important for future studies definite conclusions, e.g., by means of randomized-con-
that either raters are blind to the treatment conditions or trolled trials. Future studies should further explore the
that more objective assessments are used. Another factor potential treatment effects and implementation possibilities
influencing the results of the studies may be an unequal of physical exercise in patients with ADHD and would be
gender distribution in favor of boys. This, however, is not advised to take the following issues into account. First,
necessarily a weakness, since ADHD prevalence rates are studies should consider multiple assessment moments by
higher in boys relative to girls (Gapin and Etnier 2010), but applying designs which allow the measurement of both
articles reporting gender differences in physical exercise acute and longitudinal effects. Second, studies should
effectiveness point to the need of equal numbers of boys include adequate control groups/conditions without exer-
and girls with ADHD in studies (e.g., Tantillo et al. 2002). cise to capture the true effect of exercise, and to control for
Last, exercise bouts were generally not standardized but confounding variables, such as the attention received or
rather varying with regard to type, intensity, and duration. testretest effects. In addition, more general aspects with
Although this is on the one hand a strength, since it shows regard to the methodological quality should be considered,
effectiveness at varying and personalized intensities, it is including larger sample sizes, the use of a wide variety of
on the other hand a weakness as it is not well controlled, cognitive, behavioral/socio-emotional and physical/
making clear conclusions difficult. (neuro)physiological outcome measures, the use of raters
In addition to these study-specific problems, there were who are blind for the treatment condition, and controlled
some limitations on the review level as well. Reliably intensity and duration of the bouts of exercise. Control
comparing studies and drawing general conclusions was groups of healthy children or adults should be included to
complex, since studies differed considerably in many assess whether exercise induced improvements are (1)
aspects (i.e., study designs, type of cognitive tests used, normalizing functioning of patients with ADHD and (2)
measurement outcomes, exercise types and duration and whether improvements are comparable to the improve-
sample sizes), making direct comparison difficult. Fur- ments described in healthy people. Finally, future studies
thermore, studies examined samples of children and ado- should address the interaction of physical exercise and
lescents with an age ranging from 5 to 18 years. Since stimulant medication in a controlled design, examining
symptomatology of ADHD and cognitive functions change possible complementary and/or differing effects.
with age and individual development (e.g., Schmidt and Due to the promising findings and other advantages of
Petermann 2009), it would have been desirable to analyze physical exercise implementation (e.g., inexpensive, easy
whether specific age groups benefit more from certain to apply, additional health benefits), future studies should
forms of exercise (cardio versus non-cardio). However, this focus on questions like Are there responders and non-
was not possible because of the small number of studies. responders?, Do certain dysfunctions improve more by
This difficulty is even complicated by the fact that children exercise than others?, What physical activity (e.g., run-
of different age groups were pooled in the same samples ning, yoga, etc.) has the best outcome for certain behaviors
(e.g., Medina et al. 2010: age range 715 years) which (e.g., cognition, social behavior)?, What is a realistic
might even have reduced the impact of exercise on func- exercise plan (e.g., with regard to intensity, frequency,
tioning. A final limitation on the review level is that, duration, etc.)?, and Does regular physical exercise have
despite the growing research focus on alternative ADHD an additional effect to other treatments (e.g., stimulant drug
treatments, only a small number of studies are available. treatment) on symptoms of ADHD?. A reasonable

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S24 A. E. Den Heijer et al.

method for daily implementation should be addressed by Bolduc V, Thorin-Trescases N, Thorin E (2013) Endothelium-
considering potential practical difficulties of physical dependent control of cerebrovascular functions through age:
exercise for healthy cerebrovascular ageing. Am J Physiol
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days. In this light, passive exercise (e.g., whole body Brown RT, Amler RW, Freeman WS, Perrin JM, Stein MT, Feldman
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Open Access This article is distributed under the terms of the Guijarro MJ, Santos Gomez JL, Martinez-Vizcaino V (2015)
Creative Commons Attribution 4.0 International License (http://crea The effects of physical exercise in children with attention
tivecommons.org/licenses/by/4.0/), which permits unrestricted use, deficit/hyperactivity disorder: a systematic review and meta-
distribution, and reproduction in any medium, provided you give analysis of randomized control trials. Child Care Health Dev
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made. executive function in children with attentiondeficit/hyperactiv-
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