Effects of Exercise on Cognitive Performance in Children and Adolescents with ADHD: Potential Mechanisms and Evidence-based Recommendations

Lasse Christiansen, Mikkel M Beck, Niels Bilenberg, Jacob Wienecke, Arne Astrup, Jesper Lundbye-Jensen, Lasse Christiansen, Mikkel M Beck, Niels Bilenberg, Jacob Wienecke, Arne Astrup, Jesper Lundbye-Jensen

Abstract

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with a complex symptomatology, and core symptoms as well as functional impairment often persist into adulthood. Recent investigations estimate the worldwide prevalence of ADHD in children and adolescents to be ~7%, which is a substantial increase compared to a decade ago. Conventional treatment most often includes pharmacotherapy with central nervous stimulants, but the number of non-responders and adverse effects call for treatment alternatives. Exercise has been suggested as a safe and low-cost adjunctive therapy for ADHD and is reported to be accompanied by positive effects on several aspects of cognitive functions in the general child population. Here we review existing evidence that exercise affects cognitive functions in children with and without ADHD and present likely neurophysiological mechanisms of action. We find well-described associations between physical activity and ADHD, as well as causal evidence in the form of small to moderate beneficial effects following acute aerobic exercise on executive functions in children with ADHD. Despite large heterogeneity, meta-analyses find small positive effects of exercise in population-based control (PBC) children, and our extracted effect sizes from long-term interventions suggest consistent positive effects in children and adolescents with ADHD. Paucity of studies probing the effect of different exercise parameters impedes finite conclusions in this regard. Large-scale clinical trials with appropriately timed exercise are needed. In summary, the existing preliminary evidence suggests that exercise can improve cognitive performance intimately linked to ADHD presentations in children with and without an ADHD diagnosis. Based on the findings from both PBC and ADHD children, we cautiously provide recommendations for parameters of exercise.

Keywords: ADHD; cognition; executive functions; exercise; physical activity.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure A1
Figure A1
Flow-chart of the study selection process.
Figure 1
Figure 1
Neurophysiological differences between PBC and children with ADHD and the potential counteractive effects of exercise. (A) Identified neurophysiological and anatomical differences between children and adolescent with ADHD and their PBC peers divided into analysis level (‘neurochemical’, ‘functional’ and ‘structural’) in colour-coded boxes. Due to the substantial amount of experimental work conducted on differences in task-related activation between indiviudals with ADHD and PBC peers, the citations all refer to meta-analyses. (B) Potential counteracting effects of ‘acute’ and ‘chronic’ exercise are listed in representative colours. Please note that ‘chronic exercise’ encompasses both long-term intervention and associations. Delta and Nabla denote the sign of the physiological change. Abbreviations are listed below. Abbreviations: ACC (anterior cingulate cortex), BDNF (brain-derived neurotrophic factor), BG (basal ganglia), CB (cerebellum), CC (corpus callosum), CR (corona radiata), CrB (cerebral), DA (dopamine), DAN (dorsal attention network), DRD2 (dopamine receptor D2), DS (dorsal striatum), EN (executive networks), FAc (frontoaccumbal) FC (functional connectivity), FP (frontoparietal), FrC (frontal cotex), FT (frontotemporal), GM (grey matter), NE (norepinephrine), NET (norepinephrine transporter), PC (parietal cortex), PFC (prefrontal cortex), PPC (posterior parietal cortex), RN (reward networks), SLF (superior longitudinal fasciculus), STR (striatum), TBR (theta/beta ratio), TC (temporal cortex), TH (tyrosine hydroxylase), TR (task-related), UF (uncinate fasciculus), VAN (ventral attention network), WM (white matter).
Figure 2
Figure 2
The effects of acute exercise on cognitive performance for children with ADHD. The three parts of the figure depict effect sizes extracted from studies systematically identified and categorized by cognitive domain (inhibitory Control (INH, purple); Cognitive Flexibility (CF, red); Working Memory (WM; orange), Sustained Attention (SA, green) and Psychomotor Speed (PS, blue) as a function of exercise intensity (A), duration (B) and volume (intensity x duration, (C)). The size of the circles denotes the number children with ADHD (within subject design) allocated to the active group or groups (between subject design) that completed the study.
Figure 3
Figure 3
The effects of long-term exercise on cognitive performance for children with ADHD. The multi-plot illustrates extracted effect sizes color-coded by cognitive domain and plotted against exercise intensity (A), session duration (B), study duration (C) and volume (session-duration x session frequency x study duration, (D)).
Figure 4
Figure 4
The effects exercise on cognitive performance for children with and without ADHD. Dual-plot presenting extracted effect sizes for acute (A) and long-term (B) exercise interventions color-coded by cognitive domain and plotted next to effects sizes derived from published meta-analyses in children with (circles) and without (triangles) ADHD. Effects sizes across executive functions are depicted in grey. Please, note that scale of the ordinate differ between the two plots.

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