ADHD Attention Deficit and Hyperactivity Disorders

https://doi.org/10.1007/s12402-018-0270-0

REVIEW ARTICLE

Effect of physical exercises on attention, motor skill and physical

fitness in children with attention deficit hyperactivity disorder:
a systematic review
Jeyanthi S1 · Narkeesh Arumugam2 · Raju K. Parasher1

Received: 20 February 2018 / Accepted: 17 September 2018

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Abstract
Children with attention deficit hyperactivity disorder (ADHD) are educated in classrooms along with typically developing
children. Those with ADHD, however, find it difficult to participate in routine educational and recreational activities as they
encounter problems associated with behaviour, attention, motor skills and physical endurance. Traditionally, the manage-
ment of children with ADHD has focussed primarily on problems with cognition and has been heavily dependent on phar-
maceutical interventions and, to a lesser extent, on non-pharmaceutical measures. More recently, experts have increasingly
advocated the use of exercises in alleviating symptoms associated with ADHD. The primary objective of this review was to
summarize research that examined the role of exercises on deficits related to attention, motor skills and fitness in children
with ADHD. A search of the available literature was conducted using a combination of relevant key words in the following
databases: PubMed, MEDLINE, Google Scholar, Embase and Cochrane review. The search filtered 3016 studies of potential
relevance, of which 2087 were excluded after screening titles and abstracts as per the inclusion criteria. Thirty-four (34)
studies were analysed in greater depth, and 16 were excluded after detailed consideration as they did not match the inclusion
(PEDro score > 4) and exclusion criteria. Three (3) additional studies were excluded as they lacked exercise prescription
details such as intensity, duration and frequency of exercise. Finally, 15 studies were analysed with a focus on the effects
of physical exercises on attention, hyperactive behaviour, motor skills and physical fitness in ADHD children. Overall, the
studies reviewed were of moderate-to-high quality and reported benefits of a variety of exercise programmes in improving
motor skills, physical fitness, attention and social behaviour in children with ADHD. However, there was limited informa-
tion regarding school-based programmes, the effects of structured exercise programmes independently or in combination
with cognitive-based therapies, and the long-term benefits of exercises in alleviating behavioural problems in these children.

Keywords  ADHD · Physical exercise · Motor skills · Physical fitness · Attention

Introduction adolescence and adulthood. Worldwide, the prevalence

Attention deficit hyperactive disorder (ADHD) is a neuro-
developmental disorder defined by developmentally inap-
propriate symptoms of inattention, impulsiveness and over-
activity (Millichap 2011). It is considered as predominantly
a childhood disorder but continues to manifest itself through
* Jeyanthi S
jeykrishnan1999@gmail.com
1
Amar Jyoti Institute of Physiotherapy, University of Delhi,
New Delhi, Delhi, India
2
Physiotherapy Department, Punjabi University, Patiala,
Punjab, India
of ADHD has been documented at 5.3–20% (Moffitt and
Melchior 2007; Polanczyk et al. 2007), while in India stud-
ies based on hospital or outpatient clinic populations with
some degree of referral bias have reported a prevalence of
5.2–29.5% (Bhatia et al. 1991; Mukhopadhyay et al. 2003;
Kaur et al. 2006).
It is well documented that children with ADHD have sig-
nificant problems in executive function such as controlling
impulsive behaviour, cognition and attention. Furthermore,
these children make careless mistakes while doing their
school work and have problems focussing their attention
during the performance of tasks or play, whether conversa-
tions, lectures or lengthy reading. They are forgetful while
doing their daily activities and have poor time management

13
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skills, leading to a failure in meeting deadlines, etc. (So and
Oh 2008).
Children with ADHD have known to have difficulties
with motor coordination and have difficulties performing
multiple motor tasks in a sequence or at the same time (Piek
et al. 1999; Boonstra et al. 2005). Poor fine motor coordi-
nation in children with ADHD is well known (Harvey and
Reid 2003), and a few studies have also reported motor skill
problems associated with the regulation of gross movements
such as synkinesis (Denckla and Rudel 1978), running,
climbing, hopping on one leg (Rasmussen et al. 1983) and
with activities that necessitate the stabilization of the trunk
(Stray et al. 2009). Furthermore, Cho et al. (2014) assessed
motor function in school-aged children with ADHD using
the Bruininks–Oseretsky test of motor proficiency (II edi-
tion) and found significantly lower motor function compared
to controls in gross and fine motor skills. Similar results have
also been reported by Jeyanthi et al. (2016) in elementary
school Indian children with ADHD. Geuze (2005) found
that ADHD children generally fall below the 25th percentile
on their ability to perform routine motor skills, which is the
clinically recognized cut-off, wherein these children need
special services to help overcome their deficits.
Tremblay and Williams (2000) have reported that the
proportion of children with ADHD who are overweight and
obese is higher compared to control subjects. In addition,
Harvey and Reid (2003) found that children with ADHD
scored well below average on most physical fitness param-
eters compared to standardized Canadian norms (Fitness
Canada 1985). Jeyanthi et al. (2016) compared children with
ADHD with typically developing children and found deficits
in muscle endurance, cardiovascular endurance, leg explo-
sive strength, flexibility and anaerobic capacity.
Traditionally, ADHD children have been primarily treated
with medications and to some degree with behavioural thera-
pies that focus only on improving cognition and their aber-
rant distractive behaviour (Wigal et al. 2013). However, up
to 30% of all children with ADHD do not respond favourably
to medication and/or are unable to tolerate frequently occur-
ring side effects, including insomnia, appetite suppression,
growth retardation and headaches (Wigal et al. 2013). More
importantly, medications do not yield the desired long-term
benefits, as their effectiveness is limited and time-bound
(Graham and Coghill 2008).
Non-pharmaceutical measures have mainly consisted of
counselling, parent management training, social skill train-
ing, neurofeedback and school-based contingency man-
agement. This multimodal approach has been shown to be
effective in reducing ADHD symptoms (MTA Cooperative
Group 1999; Oord et al. 2008); however, it is reported that
the beneficial results are not sustained beyond 24 months
(Jensen et al. 2007). Behavioural interventions also pose
a heavy burden on teachers and/or parents as they require
13
J. S et al.
long-term commitment with regards to levels of commit-
ment and intensity (Chronis et al. 2001). In addition, there
is a growing concern among parents and caregivers about
the unknown and long-term negative effects of medication
(Berger et al. 2008). Keeping in mind the chronic nature
of ADHD and limitations of traditional treatments that tar-
get primarily attention and hyperactive behaviour, there is
a growing demand for alternative approaches that can be
used independently or in combination with pharmacological
and traditional interventions in order to attenuate and reduce
the negative effects of the disorder.
The benefits of exercises in improving cognition and
physical fitness have been well established in typically devel-
oping children. This has led to a growing area of research
that is examining the effects of exercises that are increas-
ingly being used to address deficits in attention, motor skills
and physical fitness that children with ADHD exhibit.
The purpose of this paper is to review the literature rel-
evant to the effectiveness of various types of exercises on
attention, gross motor skills and fitness in children with
ADHD, and secondly to provide some practical recom-
mendations for further scientific enquiry and therapeutic
management.
Methods
Identification and selection of trial
Data source and search strategy
Studies in this systematic review were assessed using the
PEDro scale. Research articles were searched using search
engines such as PubMed, MEDLINE, Google Scholar,
Embase and Cochrane review. The following mesh terms:
‘ADHD’, ‘attention deficit/hyperactivity disorder’, ‘exercise’
along with the keywords, ‘physical activity’, ‘gross motor
skill’, ‘fine motor skill’, ‘attention’, ‘physical fitness’, ‘child’,
‘children’ and ‘boy’. In addition, we searched the lists of the
available literature manually for additional articles pertain-
ing to therapy of children with ADHD.
Study selection and eligibility criteria
Studies that pertained to gross motor skill, fine motor
skill, physical fitness and attention in ADHD children
were included in the review. In addition, only studies that
referred to exercise-based interventions in these children
were included. Only full-text articles were reviewed. Case
studies and retrospective studies were excluded as there
is uncertainty on generalization of results. The details of
inclusion and exclusion criteria are summarized in Table 1.
Finally, the selected studies, relevant to the purpose, were
Effect of physical exercises on attention, motor skill and physical fitness in children with…

Table 1  Criteria employed to include or exclude studies from the present analysis

Inclusion criteria Exclusion criteria

Peer reviewed Unpublished data

Full-text article Abstract
Participants < 16 years of age Participants > 16 years of age
Participants diagnosed with ADHD, both boys and girls Participants not diagnosed with ADHD
Studies focusing on comorbidities
Studies involving any kind of physical activity or exercise with children with ADHD Retrospective study
Case study
Physical fitness, motor skill and attention as primary outcome measures Other outcome measures
Publication not older than 15 years Publication older than 15 years
PEDro score of more than 3 PEDro score of 3 or less than 3

reviewed in detail and relevant information was extracted. assess motor skill and ADHD symptoms); and (4) results
The flow chart in Fig. 1 illustrates the search strategy and of outcomes.
the subsequent steps of exclusion based on the pre-defined
criteria. Quality assessment

Data extraction and analysis
The authors extracted the following data from each selected
article: (1) characteristics of trial participants (number,
sex and age); (2) intervention features (type, duration, fre-
quency, intensity of physical exercise, adherence, dropouts
and adverse effect); (3) outcome measure (physical fitness
test measures such as muscle strength, muscular endurance,
flexibility, aerobic capacity; questionnaires and scales to
The quality of clinical trials was assessed using the PEDro
scale. This scale consists of a checklist of ten (10) criteria,
scored yes or no, that pertain to the internal validity and sta-
tistical analysis provided in the study that is being assessed.
If the scores were equal or more than 6, the study was rated
as high-quality article. If the scores were between 4 and 5,
the study was rated as moderate quality, and if the score was
equal to or less than 3, it was considered as a low-quality
study.

Studies of potential relevance (n = 3016)

Studies excluded by screening titles and abstracts

for inclusion criteria (n = 2987)

Studies retrieved for more detailed information (n =

34)

Studies excluded after detailed consideration of the

methods of our inclusion criteria and PEDro score
4 or more than 4 were included (n = 16)
Studies analysed in greater depth (n = 18)

Studies excluded for lack of any detailed exclusion

criteria (i.e., duration, frequency, intensity of
exercise) (n = 3)

Critical appraisal of the Studies included (n= 15),

involving athletic training, HIIT,aerobic program or
walks

Fig. 1  Process of study selection

13

Participants in the reviewed studies
The review included studies that had ADHD boys and girls
as participants between the ages of 4 and 16 years. The par-
ticipants in these studies were diagnosed with ADHD by
psychiatrists or clinical psychologists using standardized
instruments such as DSM III-R and DSM IV.
Results
Flow of studies through the review
Overall, the review of the literature suggests that different
types of exercises have been used successfully as interven-
tional strategies in children with ADHD. The search using
the key words filtered 3016 studies of potential relevance,
of which 2087 were excluded after screening titles and
abstracts as per the inclusion criteria. Thirty-four (34) stud-
ies were analysed in greater depth, and 16 were excluded
after detailed consideration as they did not match the inclu-
sion (PEDro score > 4) and the exclusion criteria. Three (3)
additional studies were excluded as they lacked exercise pre-
scription details such as intensity, duration and frequency
of exercise.
Thus, relevant characteristics of the fifteen (15) studies
were included in this review. The articles were reviewed for
the following data: background characteristics of the partici-
pants, characteristics of the exercise interventions employed,
type, intensity, duration and frequency of exercise, primary
outcomes (Tables 2, 3, 4 and 5).
Study characteristics
The background characteristics of the participants involved
in the studies were analysed, and the age range of partici-
pants in all articles was between 4 and 16 with mean age of
9.52 year. Only 3 authors (McKune et al. 2003; Taylor and
Kuo 2009; Verret et al. 2012) included both boys and girls,
while all other authors included only boys in their study.
Recruitment was through random sampling method. Eight
of these studies (Tantillo et al. 2002; Ahmed and Mohamed
2011; Verret et al. 2012; Chang et al. 2012; Mahon et al.
2013; Pontifex et  al. 2013; Silva et  al. 2015; Memar-
moghaddam et al. 2016) included a control group, while in
another case the participants served as their own controls.
Blinding in all the studies was unclear except for one study
which was a single-blinded study (Taylor and Kuo 2009).
Characteristics of exercise programmes
It was observed that the average duration of interventions
was around five (5) weeks; the duration of each session
13
J. S et al.
was approximately 50 min, and the frequency ranged from
two to three times (2–3) per week (Lee et al. 2015; Memar-
moghaddam et al. 2016; Verret et al. 2012; Kang et al. 2011;
Tantillo et al. 2002). The types of exercises included walk-
ing, running, jumping rope, ball throwing, one-leg hopping,
relay and high-intensity interval training (Tantillo et al.
2002; McKune et al. 2003; Ahmed and Mohamed 2011;
Kang et al. 2011; Verret et al. 2012; Pontifex et al. 2013; Lee
et al. 2015; Silva et al. 2015; Mebler et al. 2016; Memar-
moghaddam et al. 2016). In most studies, exercise intensity
was monitored by a heart rate monitor (McKune et al. 2003;
Chang et al. 2012; Verret et al. 2012; Mahon et al. 2013;
Pontifex et al. 2013; Lee et al. 2015) and by V ­ O2 max in
two studies (Tantillo et al. 2002; Mebler et al. 2016). The
intensity of exercise programmes ranged from 50 to 75% of
the maximum heart rate, while peak V ­ O2 ranged from 65
to 75%. One study did not report exercise intensity (Kang
et al. 2011).
Adherence, dropouts and adverse effect
The adherence rate was high in all studies (> 70%). Most
studies reported no dropouts, and two reported some prob-
lems in the participating children (e.g. nausea and headache)
(Kang et al. 2011).
Outcome measures
As given in Tables 2, 3, 4 and 5, there was a range of out-
comes measured and symptoms evaluated in the studies
reviewed. Physical fitness measurements included muscle
strength (Verret et al. 2012; Lee et al. 2015), muscle endur-
ance (Verret et al. 2012; Lee et al. 2015), flexibility (Verret
et al. 2012; Lee et al. 2015) and aerobic capacity (Hoza et al.
2015; Mebler et al. 2016; Lee et al. 2015). Motor skills were
assessed using the Movement Assessment Battery of Chil-
dren-II (Mebler et al. 2016) and the Bruininks–Oseretsky
test of motor proficiency (Kosari et al. 2013). Attention was
measured using the digit span backwards (Taylor and Kuo
2009) and the Stroop colour word test (Taylor and Kuo 2009;
Memarmoghaddam et al. 2016), the behaviour rating scale
(Ahmed and Mohamed 2011), the modified Conner’s parent
(McKune et al. 2003; Hoza et al. 2015) and the teacher rat-
ing scale (Hoza et al. 2015). Hyperactivity and impulsivity
were assessed using the DuPaul’s ADHD rating scale (Kang
et al. 2011), while executive function was measured using
the KEDI-WISC (Kang et al. 2011) and the Wisconsin Card
Sorting Test (Chang et al. 2012). Social disorder, behaviour
inhibition and anxiety were measured by the social skill
rating system (Kang et al. 2011), Go–No–Go test (Memar-
moghaddam et al. 2016) and the Child Behaviour Checklist
(Verret et al. 2012), respectively.
 Table 2  Effect of exercise on physical fitness in children with ADHD
References PEDro score No. of subjects and gender Grade or age range Type of intervention Frequency and duration of inter- Outcome and outcome variables
vention

Tantillo et al. (2002) 6 18 ADHD and 25 control 10.02 Motor-driven treadmill running 2/week; 1 week Inability to sustain a posture or
motor activity, e.g. sitting in a
position for long period, or mak-
ing prolonged ‘ah’ sound
Verret et al. (2012) 4 10 ADHD and 11 control 9.1 Aerobic training of muscular 3/week; 10 weeks; 45 min Improved muscular endurance,
strength and motor skill (multi- aerobic capacity and flexibility
sports—soccer, basketball, ball
games)
Hoza et al. (2015) 6 94 ADHD 4–9 years Physical activity—tracing and 31 min daily for 12 weeks Aerobic capacity improved
cutting frog, assembling a frog,
etc
Effect of physical exercises on attention, motor skill and physical fitness in children with…

Lee et al. (2015) 6 12 ADHD boys Grade 1–4 Jump rope and ball exercises 3 times/week for 12 weeks; Improved cardiorespiratory endur-
60 min ance, muscle strength, muscle
endurance and flexibility
Mebler et al. (2016) 6 28 ADHD 8–13 years One group received high-inten- 24-min session for HIIT; Aerobic capacity (peak power) was
sity interval training (HIIT) 60-min session for TRAD; found to be improved
and the other traditional low- to 3 times/week for 3 weeks
moderate-intensity exercises
(TRAD)

13

Table 3  Effect of exercise on motor skills in children with ADHD
References
13
McKune et al. (2003)
Ahmed and Mohamed (2011) 6
Kosari et al. (2013)
Mebler et al. (2016)
PEDro score No. of subjects and gender
5 13 ADHD; 10 boys and 3
girls
42 ADHD and 42 control
6 20 ADHD male; 10 in
experimental group and 10
in control group
6 28 ADHD
Grade or age range Type of intervention
5–13 years Plyometrics (one-leg hops,
tuck jumps), aerobic
exercises (running, obstacle
running skipping, relay
race)
11–16 Aerobic Exercise for upper
limb, lower limb, neck and
trunk
Free running
8.8 years Motor displacement activity
such as ball throw, ball
kicking. Manipulative
motor skill activities
8–13 years One group received high-
intensity interval training
(HIIT) and the other tra-
ditional low- to moderate-
intensity exercises (TRAD)
Frequency and duration of
intervention
5 times/week for 5 weeks;
60 min
10 weeks; first 4 weeks, 30
min, and last 6 weeks, 50
min; 3 session/week
18 sessions, 45 min
24-min session for HIIT;
60-min session for TRAD;
3 times/week for 3 weeks
Outcome and outcome vari-
ables
Motor skill components
improved as measured on
the modified Conner’s parent
rating scale
Motor skill improved as
assessed on the behaviour
rating scale
Improvement in gross motor
skill such as running speed
and agility, balance, bilateral
coordination and strength
Motor skills assessed by move-
ment assessment battery of
children-II
Significantly improved in the
HIIT group
J. S et al.
 Table 4  Effect of exercise on attention in children with ADHD
References
McKune et al. (2003)
Taylor and Kuo (2009)
Ahmed and Mohamed (2011) 6
Kang et al. (2011)
Chang et al. (2012)
Verret et al. (2012)
Mahon et al. (2013)
Pontifex et al. (2013)
Hoza et al. (2015)
Silva et al. (2015)
Mebler et al. (2016)
13
PEDro score No. of subjects and gender
5 13 ADHD; 10 boys and 3
girls
8 17 ADHD; 15 boys and 2
girls
42 ADHD and 42 control
6 32 ADHD
Assigned randomly into 2
groups
6 20 ADHD and 20 control
4 10 ADHD and 11 control
4 21 ADHD and 21 control
5 20 ADHD and 20 control
6 94 ADHD
5 28 ADHD and 28 control
6 28 ADHD
Grade or age range Type of intervention
5–13 years Plyometrics (one-leg hops,
tuck jumps), aerobic exer-
cise (running, obstacle run-
ning, skipping, relay race)
7–12 years Walking in urban park, down- 1/day; 30 days; 20 min
town or residential area
11–16 Aerobic exercise for upper
limb, lower limb, neck and
trunk; free running
8.4 years Running, goal-directed
exercises, skipping versus
education
8–13 Treadmill running
9.1 Aerobic training and motor
skill training (playing
multi-sports—soccer, bas-
ketball, ball games, etc.)
8–14 years Cycle ergometer at 90% of
peak aerobic work rate
9.46 Treadmill running
4–9 years Motor skill activities (tracing 31 min daily for 12 weeks
and cutting frog, assemble
frog, etc.)
10–16 years Relay race
8–13 years High-intensity interval train- 24-min session for HIIT;
ing (HIIT) versus tradi-
tional low- to moderate-
intensity exercises (TRAD)
Frequency and duration of
intervention
5 times/week for 5 weeks;
60 min
10 weeks; first 4 weeks, 30
min, and last 6 weeks, 50
min; 3 session/week
2/week; 6 weeks; 90 min
1/week; 1 week; 30 min
3/week; 10 weeks; 45 min
20 min of intermittent exer-
cise (30 s exercise/30 s rest) behaviour as assessed by the
1/week; 1 week; 20 min
Pre–post (immediately after Attention as measured by a
5-min relay race)
60-min session for TRAD;
3 times/week for 3 weeks
Outcome and outcome vari-
ables
Attention
improved when measured on
the modified Conner’s parent
rating scale
Attention in park walk group
improved when measured
using the digit span back-
wards and Stroop colour
word test
Attention improved when
assessed by the behaviour
rating scale
Attention as measured by Du
Paul’s ADHD rating scale,
trail making part II, signifi-
cantly improved in aerobics
group
Attention as measured by the
Stroop test improved signifi-
cantly
Attention as assessed by the
child behaviour checklist
improved significantly
Effect of physical exercises on attention, motor skill and physical fitness in children with…
Attention and hyperactive
behaviour assessment system
improved significantly
Attention assessed by DSM IV
improved significantly
Attention and hyperactive
behaviour improved as meas-
ured by R-Conner’s parent
and teacher rating scale
computer game (raiders of
the lost treasure) improved
Attention assessed by DSM IV
improved significantly in the
HIIT group
 J. S et al.

Effect of exercises on physical fitness (Table 2)

Attention as assessed by Stroop

Outcome and outcome vari-

test was observed in the

Table  2 enumerates five (5) studies that have examined
the effects of exercises on fitness in children with ADHD.
experimental group Improvements were found in strength, flexibility, muscle
endurance and cardiorespiratory fitness using exercises such
as jump rope, ball exercises and high-intensity training. Lee
et al. (2015) in their study found that the fitness of ADHD
ables

children improved compared to a no-exercise group after

12 weeks of general exercises. Improvement was reported in
hamstring muscle flexibility, handgrip strength, abdominal
Frequency and duration of

24 sessions, 90 min per

3 days/week for 8 weeks;

muscle endurance and cardiovascular endurance. Jump rope

exercises, in particular, were seen to promote cardiovascu-
lar health significantly. Furthermore, children with ADHD
who underwent high-intensity interval training (HIIT) for
intervention

session

3 weeks improved peak power output and work economy

compared to children who received traditional low- to mod-
erate-intensity exercises and found incremental effect in
aerobic capacity. Importantly, they did not report any harm-
Walking, treadmill running,

ful effects of HIIT training (Mebler et al. 2016).

jumping and ball games
Grade or age range Type of intervention

Effect of exercises on motor skill (Table 3)

As given in Table 3, the evidence reviewed suggests that

exercises such as running on a treadmill (Tantillo et al.
2002), rope jumping, running, mini-obstacle crossing, one-
leg hopping exercises improved motor skills and conse-
quently activities of daily living in children with ADHD
(McKune et al. 2003). Additionally, exercise programmes
that included gross motor activities and manipulative motor
tasks improved performance on gross and fine motor skills
7–11

(Kosari et al. 2013). It is important to note that the weak

fine motor skills in children with ADHD were reported to
to experimental and control
40 ADHD assigned equally

be related to attentional deficits that were exhibited while

PEDro score No. of subjects and gender

doing effortful activities. Verret et al. (2012) and Mebler

et al. (2016) found that moderate- to high-intensity aerobic
training for 3 weeks improved fine as well as gross motor
skills in ADHD children. It was reported that manual dexter-
ity and ball skill improved after high-intensity aerobic train-
ing but not with traditional ball team games or court sports.
Ahmed and Mohamed (2011) demonstrated improvements
in gross motor skill and fine motor skill after ten (10) weeks
of aerobic exercises that included free running and exercises
for the upper limb, lower limb, neck and trunk.
6

Effect of exercises on attention (Table 4)

Memarmoghaddam et al.

In 2009, Taylor and Kuo demonstrated that guided walks in

Table 4  (continued)

the park improved attention spans in children with ADHD

and also noted that the effect of such walks in the park on
References

attention was roughly equal to the maximal effect of two

(2016)

doses of typical ADHD medications. Similarly, other studies

have also reported beneficial effects of moderate-to-vigorous

13
 Table 5  Effect of exercise on other variables in children with ADHD
References
McKune et al. (2003)
Ahmed and Mohamed (2011) 6
Kang et al. (2011)
Chang et al. (2012)
Verret et al. (2012)
Pontifex et al. (2013)
Mebler et al. (2016)
Memarmoghaddam et al.
(2016)
13
PEDro score No. of subjects and gender
5 13 ADHD; 10 ADHD boys
and 3 ADHD girls
42 ADHD and 42 control
6 32 ADHD
Assigned randomly into 2
groups
6 20 ADHD and 20 control
4 10 ADHD and 11 control
5 20 ADHD and 20 control
6 28 ADHD
6 40 ADHD assigned equally
to experimental and control
Grade or age range Type of intervention
5–13 years Plyometrics (one-leg hops,
tuck jumps), activities
such as running, running a
mini-obstacles, skipping,
relay race
11–16 Aerobic exercise for upper
limb, lower limb, neck and
trunk; free running
8.4 years Running, goal-directed exer-
cises, skipping rope versus
education
8–13 Treadmill running
9.1 Multi-sport activities—soc-
cer, basketball, ball games
9.46 Treadmill running
8–13 years High-intensity interval train-
ing (HIIT) versus tradi-
tional low- to moderate-
intensity exercises (TRAD).
7–11 Walking, treadmill running,
jumping and ball games
Frequency and duration of
intervention
5 times/week for 5 weeks;
60 min
10 weeks; first 4 weeks, 30
min, and last 6 weeks, 50
min; 3 session/week
2/week; 6 weeks; 90 min
1/week; 1 week; 30 min
3/week; 10 weeks; 45 min
1/week; 1 week; 20 min
24-min session for HIIT;
60-min session for TRAD;
3 times/week for 3 weeks
3 days/week for 8 weeks;
24 sessions, 90 min per
session
Outcome and outcome vari-
ables
Behaviour and emotional
components improved when
measured by the modified
Conner’s parent rating scale
Improvement is found in aca-
demic, classroom concentra-
tion and behaviour assessed
by behaviour rating scale
Hyperactivity and impulsiv-
ity assessed by Du Paul’s
ADHD rating scale and
executive function measured
by KEDI-WISC, and social
disorder measured by the
SSRS improved significantly
after exercises
Executive function as
measured by the Wisconsin
Card Sorting Test improved
significantly
Anxiety and social disorder
Effect of physical exercises on attention, motor skill and physical fitness in children with…
problems as assessed by the
Child Behaviour Checklist
improved
Inhibitory aspects of cogni-
tive control as measured by
the modified version of the
Eriksen flanker task showed
improvement
Academic performance also
improved significantly
Quality of life and competence
improved in the HIIT group
Behaviour inhibition assessed
by Go–No–Go tests
improved in experimental
group

physical activity on attention span and executive function-
ing (Hoza et al. 2015; Mebler et al. 2016). Aerobic exer-
cises such as walking, running (Silva et al. 2015), tread-
mill running, static cycle (Mahon et al. 2013), jumping
and ball games have also shown to improve selective atten-
tion (Memarmoghaddam et al. 2016). Mebler et al. (2016)
reported significant improvements in quality of life, self-
esteem and competency after high-intensity exercises. Also,
it is reported that parents of children with ADHD reported
perceptible improvements in attention following the exer-
cises (Kang et al. 2011).
Physical exercises to improve ADHD core symptoms
(Table 5)
Several studies (Table 5) highlighted the efficacy of exer-
cises in positively influencing the core behavioural symp-
toms experienced by children with ADHD. The studies
reviewed reported improvements in cognitive function
(Memarmoghaddam et al. 2016), executive function (Kang
et al. 2011; Chang et al. 2012), socially aberrant behav-
iour (McKune et al. 2003; Pontifex et al. 2013; Memar-
moghaddam et al. 2016) and anxiety (Verret et al. 2012).
Interestingly, most of these studies used generalized aerobic
exercises (McKune et al. 2003; Ahmed and Mohamed 2011),
such as running (Kang et al. 2011; Chang et al., 2012; Pon-
tifex et al. 2013; Memarmoghaddam et al. 2016) or multi-
sports activities (Verret et  al. 2012), and high-intensity
interval training (Mebler et al. 2016) as interventions for
30–60 min per day, three times per week, for an average of
3–5 weeks. Physical exercise has also been reported to facili-
tate neurotransmitter production (Lee et al. 2015), which sig-
nificantly promotes brain function. As such, physical exer-
cise, both directly and indirectly, affects the catecholamine
systems, which is purported to play a key role in improving
symptoms associated with the pathophysiology of ADHD.
Discussion
School-going children with ADHD face many challenges,
such as the avoidance of physical activity, obesity, lack of
concentration, low self-esteem, deficiencies in school per-
formance and reduced efficacy in social relationships (So
and Oh 2008; Rich et al. 2009). In addition, and importantly,
the literature suggests that these children have significant
deficits in physical fitness (Harvey and Reid 2003; Verret
et al. 2010; Lee et al. 2015; Jeyanthi et al. 2016), motor
skills (Harvey and Reid 2003; Verret et al. 2010; Jeyanthi
et al. 2016) and attention (Sagvolden et al. 2005; So and Oh
2008). The preponderance of these impairments in ADHD
children suggests that these domains should be assessed and,
if required, addressed as early as possible so as to prevent
13
J. S et al.
feelings of physical incompetency, inadequacy, depression,
frustration and anxiety in these children and consequently
prevent long-term negative effects on their social develop-
ment and academic achievement (So and Oh 2008; Rich
et al. 2009).
In this highly focused review of moderate- to high-qual-
ity published reports, it was observed that studies varied
significantly with regards to study design (sample size, age
and gender) and the exercise parameters used (type, duration
and frequency of exercise intervention). Regardless, they
all reported an attenuation/reduction in negative symptoms
associated with ADHD using a variety of exercise interven-
tions, such as aerobic exercises and high-intensity interval
training. Significant improvements were reported in the per-
formance of motor skills, physical fitness, attention, social
behaviour and neuropsychological measures (Tantillo et al.
2002; McKune et al. 2003; Ahmed and Mohamed 2011;
Kang et al. 2011; Verret et al. 2012; Pontifex et al. 2013; Lee
et al. 2015; Hoza et al. 2015; Mebler et al. 2016; Memar-
moghaddam et al. 2016). Furthermore, and most signifi-
cantly, no negative effects of exercises were reported.
The beneficial effects of physical activity in children are
also supported with evidence from several neuroanatomical
studies. It is reported that participation in aerobic activity
leads to an increase in tissue volume in the basal ganglia
(Chaddock et al. 2010a) and hippocampus (Chaddock et al.
2010b), as well as a greater ability to recruit neural resources
in the frontal and parietal regions (Chaddock et al. 2012).
In addition, there are functional enhancements in neural
processes related to the allocation of attentional resources.
These changes in neuronal structures and functions if suf-
ficiently enhanced may alter the underlying neuroanatomical
aetiology of ADHD and, thus, lead to benefits in managing
these children.
Limitation
Overall, the evidence from this review provides substantial
moderate- to high-quality evidence for the beneficial effects
for a diverse set of non-structured, aerobic exercises in chil-
dren with ADHD. However, there are several shortcomings
of the evidence reviewed.
First, it was observed that there were no studies that had
explicitly evaluated potential gender differences in chil-
dren with ADHD. Gender differences in attention, motor
skills and fitness, if present, may be important as ADHD is
four times more common in boys (7.9%) than girls (1.8%)
(Schlack et al. 2007). While three of the studies reviewed
actively recruited girls (McKune et al. 2003; Taylor and Kuo
2009; Verret et al. 2012), none, however, considered gender
and or hormonal influences into consideration.
Second, in the reviewed studies, measurements carried
out by researchers were not blinded and, thus, could have
Effect of physical exercises on attention, motor skill and physical fitness in children with…
influenced the magnitude of the effect (Sonuga-Barke et al.
2013). Third, most studies did not document or control for
exercises performed outside of the study setting. Addition-
ally, the studies did not distinguish and/or control for the
use of medication for symptoms related to ADHD. Fourth,
the studies did not have any short- or long-term follow-up,
and thus it is difficult to predict the long-term impact of
exercise on ADHD. Finally, aerobic exercises’ interventions
were very heterogeneous regarding type, duration, frequency
and intensity.
Conclusion
The present analysis of the studies reviewed reveals that var-
ious types of either moderate- and/or high-intensity exercise
improve physical and several behavioural parameters related
to children with ADHD, with no undesirable side effects
being reported. However, it is not known which exercise
was most beneficial, as the interventions used were diverse
and were not differentially evaluated. It was observed that
interventions lasting 1–10 weeks and involving at least two
sessions of moderate exercise per week, which consisted
of walking, running, jumping and ball activity games, all
attenuated the characteristic symptoms of ADHD. In addi-
tion, high-intensity physical activity may also represent an
interesting alternative to pharmaceutical treatment of ADHD
for the following reasons: first, high-intensity exercise is less
time-consuming than submaximal exercise and is of particu-
larly interest to groups of individuals who are concerned
with fitness and good health (Sartor et al. 2010; Guiraud
et al. 2012; Shiraev and Barclay 2012; Sijie et al. 2012).
Secondly, movement in children is naturally characterized
by spontaneous, short-term high-intensity activity, such as
repetitive bouts of sprints with short periods of rest (Mas-
sicotte and Macnab 1974). Furthermore, repetitive move-
ment at high speeds, separated by short periods of recovery,
improves endurance in children (Williams et al. 2001; Faw-
kner et al. 2002; Sperlich et al. 2010). Although continuous
aerobic activity has been more extensively characterized and
is a more established mode of training, high-intensity inter-
mittent training may enhance both aerobic and anaerobic
performance in children even more effectively.
Clearly, the evidence reviewed suggests that unstruc-
tured aerobic exercises have an important role to play in
reducing deficits of attention, skills and fitness in children
with ADHD. In contrast to more traditional means of using
medication to treat these children, exercises reduce ADHD
symptoms and are a healthier option. Additionally, they help
improve social and psychological behaviour without any
undesirable side effects.
It is important to point out that the applied relevance
of the results of the present review is limited to a specific
population and the interventional strategies used. In addi-
tion, the studies selected for this review had small sample
sizes and, thus, the applied applicability and or generaliz-
ability is limited. Furthermore, the available studies did
not evaluate the efficacy of any structured programmes
with defined and detailed exercise prescriptions that reveal
details on procedure, intensity, duration of exercise, etc. In
this respect, future research focusing on this question and
evaluating the long-term benefits of these interventions in
children with ADHD is warranted.
Acknowledgements  I would like to thank Dr. Narkeesh arumugam and
Dr. Raju K. Parasher for their valuable suggestions and guiding me in
preparing this systematic review.
Compliance with ethical standards 
Conflict of interest  The authors declare they have no conflict of inter-
est.
Human and animal rights  It is a systematic review and does not involve
human and/or animal participants.
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