Can Exercise Help Treat the Effects of ADHD?
Jason Bouwkamp, Graduate Student,
College of Health and Human Performance, University of Florida, Gainesville, FL

As the American lifestyle and lifestyles around the world become more sedentary, an increase in the number of cases of Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) seems to be occurring. While the exact cause of the disorder, and a complete list of how it presents is not quite agreed upon, ADHD displays a few definitive symptoms and frequent co-morbidities. Because an absolute understanding of the cause of the disease is lacking, treatment methods tend to focus their attacks on those symptoms and co-morbidities of the disorder that are maladaptive and dysfunctional for the affected individual.

That said, exercise may serve as a viable and suggested alternative to many of these treatments, and may help the affected individual cope with the disorder in a more beneficial and personally developmental manner. The best results will most likely be experienced by incorporating exercise into the existing methods of treatment.

What exactly is ADHD? While the NIH lists "the inability to direct attention" as part of the definition of a learning disorder (2007), Dr. Christine Stopka lists ADD and ADHD as a common type of learning disability (2005). The NJCLD also makes it a point to state that "Attention disorders, such as Attention Deficit/Hyperactivity Disorder (ADHD) and learning disabilities often occur at the same time, but the two disorders are not the same" (2008). This is a very frustrating example of "one hand not knowing what the other is doing" and a very likely source of much confusion associated with these disorders. For the purpose of this paper, attention deficit/hyperactivity disorder (ADD or ADHD) will be viewed and addressed as a type of learning disability.

With that designation, it is safe to state that ADHD is a learning disability that has received a good deal of attention from the public. Dr. Stopka defines ADHD as "difficulty in concentrating on a single task for a long period of time" (2005). The Center for Disease Control and Prevention (CDC) defines ADHD as a "neurobehavioral disorder characterized by pervasive inattention and/or hyperactivity-impulsivity and resulting in significant functional impairment" (2005). The National Resource Center (NRC) on AD/HD is supported by the CDC, and it states that ADHD is usually diagnosed in childhood and persists into adulthood and that this "chronic disorder can negatively impair many aspects of daily life, including home, school, work, and interpersonal relationships" (2008).

Such problems are elaborated by Barkley as poor time management, poor social skills, inability to control impulses, and many other problems (2004). In further explanation, Tantillo performed studies in the mid 1990s that claim children with ADHD possess "morphological asymmetry in the caudate nucleus of the corpus striatum" (2002). The caudate nucleus is mainly dopaminergic (2002) and the asymmetry weakens the reception of the dopamine signal by this structure (NIDA, 2006). Thus, ADHD is believed to be caused by a slight abnormality in the brain caused either genetically or by perinatal complications.

This abnormality causes many classic, and some controversial symptoms. There are many subtypes of ADHD: Inattention, Combined, etc. (Zentall) and the arguments can become rather mucky. So, only classic ADHD symptoms will be lumped and discussed in this paper. The most common subject of complaint is "children with ADHD often have trouble in school." According to Loe and Feldman, these problems occur as behavioral issues, poor academic performance, educational problems, and underachievement, as well as grade repetition (2007). However, the children also have trouble with social skills and becoming outcasts. In fact, Zentall claims that ADHD-I results in social unpopularity, which eventually contributes to social withdrawal and high rates of anxiety and depression (2005). Many see anxiety, depression, and disruptive behavior disorders as co-morbid conditions. Other co-morbid conditions seen with ADHD are tics, learning problems (Loe and Feldman 2007), obsessive compulsive disorder, Tourette's Syndrome, and, later, drug and alcohol abuse (Quinn, 1995). Perhaps some of these co-morbid conditions are caused by ADHD. Regardless of causation or correlation, diagnosis and treatment become more complex as these conditions mix and interact.

Adding to the confusion, professions and the general public have long believed that children with ADHD would eventually outgrow the condition. Barkley, however, proposes the idea that an individual does not outgrow the disorder, but that the elemental constructs of inattention and poor inhibition that comprise the condition merely manifest themselves differently relative to hormonal changes (Quinn, 1995), biological-developmental changes, social expectations, and responsibilities (Barkley, 2004). In the journal article, "The Role of the Physician and Medication in the Treatment of ADHD in Postsecondary Students," Dr. Quinn claims that symptoms of ADHD persist into adulthood in 40-60% of children with ADHD resulting in instability, lack of satisfaction in the workplace, underachievement, and impulsivity. In fact, Quinn believes that social gender differences cause women to be under-diagnosed because the symptoms are internalized as anxiety and depression (1995).

Quinn states that problems for young adults with ADHD exist in the areas of sustained attention, impulse control, decision making, distractibility, and hyperactivity, but that the hyperactivity tends to manifest as "fidgety restlessness or the inability to sit still" (1995). Obviously, such disturbances can cause problems for the individual that can poorly affect them academically and socially (1995). Loe and Feldman agree that, though the severity of certain symptoms decrease with age, the overall effect of the disorder is not transient and persists through adulthood (2007). With detrimental effects on academic performance, motor performance, and social interaction, ADHD is a very important and real threat to the happiness and well-being of the individuals, and this needs to be addressed.

Obviously, with so many theories about the cause of ADHD, the fact that ADHD is a complex disorder with a somewhat idiopathic origin is apparent. With no real understanding of cause or long-term effects, diagnosis and treatment for ADHD can be complex and tends to focus on symptoms and co-morbidities of the disorder. Before parents and physicians decide on a treatment, the disorder must first be diagnosed. Unfortunately, a true consensus on either goal does not exist. Of course, parents should be vigilant in looking for inattentiveness, problems in school, and problems with inhibition, but the real diagnosis should be performed by a professional (Quinn, 1995). The NRC states that, since the symptoms exist in all people and children to some degree, the symptoms must be more frequent or severe than those present in children of the same age, and the symptoms for adults must persist from childhood and interfere with the ability of the individual to function in daily life (2008).

Quinn argues that hearing and vision screenings should be performed with blood testing to rule out potential causes of symptoms, and to discover if other conditions exist (1995). Some causes for symptoms mimicking ADHD include the inability to see or hear directions, hypoglycemia, drug abuse, and frontal-lobe epilepsy. Blood tests can also verify the individual's general resistance to thyroid hormone, which is common in those with attention deficit disorder (1995). The NRC adds that a clinical assessment of the individual's academic, social, and emotional functioning and developmental level, a complete history from parents and teachers, checklists for rating the ADHD symptoms, and ruling out other problems should be completed as part of a comprehensive evaluation (2008). Such procedures are outlined in the Diagnostic and Statistical Manual IV (2008).

After diagnoses by a physician or other qualified professional, a few treatment options are currently being employed. In 1995, Quinn listed counseling and behavior management, cognitive therapies, supportive therapies and tutoring, exercise and diet, medication, and multimodal treatment programs (which are combinations of the other treatments) as accepted treatments for ADHD. Currently, the NRC applauds the effectiveness of multimodal treatment programs. This new gold standard has 4 elements: 1) parents and child education (through programs and designated centers) about the diagnosis and treatments, 2) behavior management techniques, 3) stimulant medication, and 4) appropriate educational programs and supports (2008).

An epidemiological study by the National Center on Birth Defects and Developmental Disabilities states that 4.3 % of children are medicated for ADHD. Some argue this number implies overmedication and others claim the opposite. While a search on drugs.com yields a plethora of drugs used to combat ADHD, a quick Google search for medications for the treatment of ADHD yields 4 top names: Strattera, Adderall, Concerta, and the widely recognized Ritalin. All of these are stimulants except Strattera. The NRC states the generic name for Strattera is Atomoxetine which is a norepinphrine reuptake inhibitor. Adderall is an amphetamine, which is a central nervous system stimulant. The generic name for both Concerta and Ritalin is Methylphenidate, which is also a central nervous system stimulant (drugs.com).

The most commonly used drug in research is Ritalin. The effectiveness of methylphenidate in controlling symptoms of ADHD in children is undeniable. In fact, the National Institute of Drug Abuse (NIDA) states that the drug has a "notably calming and focusing effect on those with ADHD" (2006). How does methylphenidate achieve this? Tantillo et al. site 2 sources claiming that methylphenidate is a dopamine agonist with a high binding affinity for the corpus striatum to make up for the asymmetry of the caudate nucleus (2002). The NIDA concurs that the drug amplifies the release of the neurotransmitter dopamine (2006). While methylphenidate helps children deal with the symptoms of ADHD, many children experience side effects (2002). Some research suggests that the side effects of Ritalin and other stimulant medications are relatively minor. Tantillo et al. say that 20% of children experience side effects such as high blood pressure, sleep problems, or mood disturbances (2002). Barkley's overview of stimulant treatment-related side effects includes insomnia, loss of appetite, inability to gain weight and related growth stunting, head aches, stomach aches, and the development or worsening of motor and vocal tics (2004). It may also be addictive.

On one side of the argument, some research indicates that stimulants like methylphenidate are not only not addiction forming, but a childhood stimulant therapy regiment is correlated with reduced risk of drug and alcohol abuse later in life (Biederman, 2003). On the other hand, one might argue that any substance that changes brain chemistry in a noticeable and pleasurable manner must be addictive on at least a psychological level. Robbins and Everitt argue drug dependence and addiction can be understood as the brain's gradual adaptation to chronic exposure to drugs. They also argue all drugs of addiction act through the dopamine channels of the brain (1999), the same pathway utilized by methylphenidate and other stimulant therapies. Further, Lambert provides data that children treated with stimulant therapy have higher incidences of abuse of substances like tobacco, cocaine, marijuana, and other drugs later in life (2002).

This implies that stimulants used in stimulant therapy of ADHD may be "gateway" drugs. Lambert explains that the results are related to the self-medication and sensitization hypotheses, and the fact that the disorder predisposes the individual to seek novel and pleasurable stimuli, as well as make impulsive, uninhibited decisions (2002). However, such findings seem only common sense because the child is not only being chronically exposed to a brain-altering drug, but they learn from an early age to "pop pills" in order to solve their problems and regulate their feelings. It seems that they also learn that such behavior is not only ok, but encouraged by their family and very acceptable to the rest of society.

Other side effects of ADHD therapy employing stimulants like Ritalin are somewhat numerous. Other side effects of methylphenidate provided by WebMD include: irritability, nervousness, blurred vision, dry mouth, constipation, fast-pounding and irregular heartbeat, mental changes, mood changes, and behavior changes like agitation, aggression, mood swings, depression, and abnormal thoughts. Methylphenidate may also affect the immune and inflammatory system increasing risk of infection and occurrence of bruising. Sometimes methylphenidate can cause trouble breathing, angina, seizures, weakness, swelling, and other symptoms (2008). Some of these side effects appear to be life-threatening if a proper response does not occur. Even though, the more serious side effects of stimulant treatment are not very common, the fact that they can occur coupled with the risk of dependency and future drug abuse make a cogent argument for the use of alternative methods of controlling the symptoms of ADHD. Research has shown that various types of physical activity "fit the bill."

Studies on rats have demonstrated that exercise is just as addictive as morphine, cocaine, or methylphenidate because it also elevates the levels of dopamine in the brain (Rhodes et al., 2005). Noted previously, the methylphenidate employed in stimulant medication therapies for ADHD also amplifies the dopamine signal by increasing the concentration of this neurotransmitter. By extrapolation, one might deduce that adequate physical activity may lead to benefits similar to those witnessed with methylphenidate. Evidence of this can be seen in the study by Tantillo et al. where they studied the effects of varying levels of exercise on the spontaneous eye blink, Acoustic Startle Eye Response (ASER), and motor impersistence of children with ADHD.

The ASER is a test that is sensitive to dopamine agonists where the eye reflexively blinks in response to a noise. Motor impersistence is a measure of the inability to inhibit perceptual motor reflexes which is related to behavioral disinhibition (Tantillo, 2002). So, the spontaneous blink test and the ASER measure if there is an increase in dopamine or dopamine agonists in the brain, and the motor impersistence test measures weather exercise has an effect of behavioral disinhibition. The study discovered that maximal exercise increased performance on all 3 measures of inattention in boys only (Tantillo, 2002).

More focused on behavior, a meta-analysis by Allison et al. demonstrated that "regular, noncontingent behavior" correlated with decreases in disruptive behavior especially in hyperactive children (1995). While demonstrating no real effect on academic performance, another study by Flohr et al. claims that children with ADHD, in an exercise condition, showed a marked improvement in behavior in the classroom over those in the non-exercise condition (2004). Additionally, a case study of a 4-year-old child with ADHD, by Azrin et al, showed an increase in mean attentive calmness from 3 seconds to 60 seconds when a scheduled period of physical activity was used as reinforcement for attentive calmness (2006).

In a 6 week study, Dr. Wendt said that running yielded significant behavioral improvement in children with ADHD. Wendt states that not only does exercise increase blood flow to the brain (waking it up), but it causes the release of neurotransmitters like dopamine, epinephrine, and other body chemicals that increase communication between nerve cells and have a positive impact on learning. Wendt states the study shows exercising 5-7 times/week for 20-40 minutes at a heart rate of 135-175 beats/minute causes the optimal effect for positive change in body chemistry (2001). Obviously, the data shows behavior and calmness can be positively influenced by exercise.

While improving behavior in those with ADHD is good, people with this disorder also suffer from motor deficits, poor social skills, poor self-confidence, and even depression. Physical activity may be able to help in these areas as well. In their study MacMahon and Gross found an association between aerobic exercise and increased self-concept and physical fitness (1987). Another study found children with learning disabilities in an exercise group experienced improved motor and social skills over children in the non-exercise group, and this seemed to contribute to increased feelings of self-worth (Bluechardt & Shephard, 1995). Furthermore, Dr. John Ratey states in his website (and in multiple interviews) that rat studies suggest exercise reduces the phenomenon of learned helplessness (2007).

Watching children with ADHD play in elementary school, a noted difference in productivity, concentration, and socialization is noticeable after an organized game of tag. Playing organized games also seems to help such children develop strategy and a respect for the consequences of their actions (Bouwkamp, 2008). Also, playing in a challenging environment not only seems to help with motor deficits, but the children also seem to have an increased capacity for visual-spatial awareness after being active. Playing with other children is when children with learning disabilities seem the most challenged; incidentally it also appears to be when they grow the most, develop the fastest, learn social skill, and learn their own limitations and capabilities (Bouwkamp, 2008). Obviously, evidence suggests that exercise benefits psychological development and social development.

The benefits of exercise to mind and body are rather evident. Exercise is always a good thing. Rhodes noted that exercise increased the blood to the brain and aided in development. He also found that exercise helped both rats bred to simulate ADHD and control rats (2005). Ratey claims that complex movements required for various sports work the attention system of the mind, and the neurotransmitters produced due to exercise increase alertness, and decrease the desire to seek novel stimuli; thus, this decreases acting-out behavior (2007). In addition to the behavioral, developmental, and cognitive benefits, exercise increases quality of life and just makes people feel better.

With so many benefits of exercise listed for those with ADHD, it is important to note that exercise does not solve everything. People with ADHD have a very real, documented learning disability with associated deficits, and regardless of what some claim, exercise is not a cure-all. For example, the Dore Programme, which uses motor-based exercises, claims to cure learning disabilities like ADHD. However, a study by Bishop shows there are many qualifiers for this claim, and that current scientific data supports the program's benefits for motor development, but not that it "cures" learning disabilities (Bishop, 2007).

That said, the current programs do a good job of treating the symptoms of ADHD, but they seem to neglect physical activity. The research on exercise and ADHD seems to suggest that the current multimodal method of treatment should be tweaked to incorporate exercise. Perhaps medication could be excluded from the program while the child adjusts to an exercise regimen, and then a joint decision as to whether to medicate, and how much medication a person with ADHD should receive, can be made by the individual, the physician, and the parents as necessary.

The treatment program put forth by the NRC on ADHD which prescribes the utilization of appropriate education about the disorder, behavioral management, appropriate education programs and medication could be manipulated so that an exercise regiment is a precursor to medication prescription. This could be done with the hopes of using as little medication as possible and only as needed. Such a multimodal program would have great promise for optimal results in the development and functioning of a person with ADHD throughout their life. ADHD is a potentially serious disorder that may be kept under control using very simple methods of physical activity.

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