Research in Developmental Disabilities 57 (2016) 1–10

Contents lists available at ScienceDirect

Research in Developmental Disabilities

A racket-sport intervention improves behavioral and

cognitive performance in children with
attention-deficit/hyperactivity disorder
Chien-Yu Pan a,∗ , Chia-Hua Chu a , Chia-Liang Tsai b , Shen-Yu Lo a , Yun-Wen
Cheng a , Yu-Jen Liu a
a
Department of Physical Education, National Kaohsiung Normal University, No. 116, He-Ping First Road, Kaohsiung 802, Taiwan
b
Institute of Physical Education, Health and Leisure Studies, National Cheng Kung University, Tainan 701, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: The present study assessed the effects of a 12-week table tennis exercise on motor skills,
Received 21 January 2016 social behaviors, and executive functions in children with attention deficit hyperactivity
Received in revised form 8 June 2016 disorder (ADHD). In the first 12-week phase, 16 children (group I) received the interven-
Accepted 11 June 2016
tion, whereas 16 children (group II) did not. A second 12-week phase immediately followed
Number of reviews completed is 2 with the treatments reversed. Improvements were observed in executive functions in both
groups after the intervention. After the first 12-week phase, some motor and behavioral
Keywords: functions improved in group I. After the second 12-week phase, similar improvements were
Attention deficit hyperactivity disorder noted for group II, and the intervention effects achieved in the first phase were persisted in
(ADHD)
group I. The racket-sport intervention is valuable in promoting motor skills, social behav-
Table tennis exercise
iors, and executive functions and should be included within the standard-of-care treatment
Motor skills
Social behaviors for children with ADHD.
Executive functions © 2016 Elsevier Ltd. All rights reserved.

1. Introduction

Attention deficit hyperactivity disorder (ADHD), one of the most common childhood psychological disorders, persists
until adolescence and adulthood in the majority of diagnosed patients (American Psychiatric Association [APA], 2013).
ADHD is characterized by inattention, impulsiveness, and hyperactivity; these symptoms have various cognitive, social, and
behavioral consequences (Barkley, 1997; Bohlin, Eninger, Brocki, & Thorell, 2012; Tseng & Gau, 2013; Wåhlstedt, Thorell, &
Bohlin, 2008). Impaired executive function is considered one of the central deficits in ADHD (Barkley, 1997). Deficits in inhi-
bition have been associated with ADHD and attention problems as well as internalizing (Karasinski, 2015) and externalizing
behavior problems (Karasinski, 2015; Riccio, Lockwood, & Blake, 2011). Furthermore, approximately 30%–50% of people with
ADHD were reported to experience a comorbid motor coordination problem (Sergeant, Piek, & Oosterlaan, 2006). Studies
have reported potential interrelationships between motor skill performance and executive functions in children with ADHD
(Hung et al., 2013; Piek et al., 2004) and other disabilities (Hartman, Houwen, Scherder, & Visscher, 2010; Schott & Holfelder,
2015); hence, poorer motor skill performance is associated with in poorer executive functions and vice versa. These execu-
tive dysfunctions, motor skill difficulties, and social behavior deficits may interfere with the daily functioning of a child with

∗ Corresponding author at: Department of Physical Education, National Kaohsiung Normal University, No. 116, He-Ping First Road, Kaohsiung 80201,
Taiwan.
E-mail address: chpan@nknucc.nknu.edu.tw (C.-Y. Pan).

http://dx.doi.org/10.1016/j.ridd.2016.06.009
0891-4222/© 2016 Elsevier Ltd. All rights reserved.
2 C.-Y. Pan et al. / Research in Developmental Disabilities 57 (2016) 1–10

ADHD and negatively affect academic performance (Loe & Feldman, 2007). Therefore, early physical exercise interventions
targeting motor skill training may be particularly helpful in addressing the essential behaviors and executive functions in
children with ADHD.
The potential therapeutic effects of physical exercise on cognitive functions, specifically executive functions, are increas-
ingly investigated in typically developing children and young adults (Verburgh, Königs, Scherder, & Oosterlaan, 2014).
Although few studies have examined the effects of exercise on people with ADHD, the available data suggest that phys-
ical exercise of moderate to vigorous intensity and lasting 30–45 min per session for 8–10 weeks likely has beneficial effects
on motor skills, behavioral symptoms, and executive functions (Smith et al., 2013; Verret, Guay, Berthiaume, Gardiner, &
Beliveau, 2012). Smith et al. (2013) used a within-subjects experimental design to examine an 8-week school-based physical
activity program (30 min, 5 times a week) held prior to classes and included 14 young children (Grades K–3) with a risk
of ADHD who exhibited at least four symptoms of hyperactivity or impulsivity. The findings revealed significant improve-
ments in pre-post program measurements of gross and fine motor skill proficiency and inhibitory control, in addition to
teacher-reported improvements in weekly measurements of response inhibition and problem behaviors (i.e., inattention
or overactivity and oppositional defiant behavior). Verret et al. (2012) used a between-subjects experimental design to
compare elementary school-aged children diagnosed with ADHD who either did (n = 10) or did not (n = 11) participate in a
thrice weekly 45-min moderate- to high-intensity physical activity program at lunchtime, reporting positive effects of phys-
ical exercise. These results indicated that the exercising children experienced significant improvements in their muscular
capacity (i.e., push-ups), motor skill performance (i.e., locomotion and total gross motor skills), parent-reported behavior (i.e.,
social, thought, and attention problems), and neuropsychological tests (i.e., information processing and auditory sustained
attention).
In the present study, a racket-sport intervention, namely table tennis training, was applied as physical exercise program
for children with ADHD because table tennis is easy to learn and culturally well accepted. Despite limited evidence, table
tennis training is considered effective in improving focus and attention. Pilot studies using this exercise as treatment for
children with ADHD (Pan et al., 2015) and intellectual disabilities (Chen, Tsai, Wang, & Wuang, 2015) have reported positive
outcomes. Pan et al. (2015) examined the effect of a table tennis program involving physical and cognitive training and
observed positive effects of long-term physical exercise (70 min, twice a week for 12 weeks) on motor skills and executive
functions measured using the Stroop test and Wisconsin Card Sorting Test (WCST) in children diagnosed with ADHD. Com-
pared with the children in the ADHD nontraining group, those in the ADHD training group exhibited specific significant
improvements in locomotor and object-control skills, selective attention, and overall performance in cognitive flexibility.
Improvements were also noted in tendency toward perseveration and correct set shifting in the ADHD training group over
time. Chen et al. (2015) examined the effect of a 16-week (60 min, three times a week) table tennis training program and
standard occupational therapy on visual perception and executive functions in school-age children with mild intellectual
disabilities and borderline intellectual functioning. Children in the two intervention groups exhibited specific significant
improvements in performance compared with those in the control group on all measures of visual perception and executive
functions measured using the Stroop and WCST-64; and children in the table tennis training group showed significantly
greater improvements in all measures of visual perception and executive function tests compared with those in the stan-
dard occupational therapy and control groups. The authors concluded that table tennis training can be considered a therapy
option for treating cognitive or perceptual problems in children with mild intellectual disabilities and borderline intellectual
functioning.
Collectively, these preliminary studies provide evidence that physical exercise may be a viable strategy for improving
symptoms, behaviors, inhibitory control, and neurocognitive function in children with ADHD. However, the studies have
shortcomings, limiting their impact. Smith et al. (2013) did not use a control group, Verret et al. (2012) did not randomly
assign participants to either an exercise or a control group, and none of the physical exercise interventions used in these
studies aimed at achieving sustained and constant improvements in children with ADHD. Therefore, the primary aim of
the present study was to examine the effects of a racket-sport intervention on motor skills, social behaviors, and executive
functions by using a randomized controlled trial (RCT) design, and the secondary aim was to determine whether any training
effects persisted several weeks after the training was completed. We focused on cognitive inhibition because of its centrality
in current theories on executive dysfunction in ADHD (Barkley, 1997). Impaired motor skills and social behaviors, although
not considered a core deficit in ADHD, are often associated with the disorder (Karasinski, 2015; Sergeant et al., 2006). We
hypothesized, first, that a racket-sport intervention would improve motor skills, social behaviors, and executive functions
in two groups (groups I and II) of children with ADHD and, second, that the intervention effects would be sustained in group
I for 12 weeks of follow-up.

2. Methods

2.1. Study design

This study was an RCT investigating the effects of a 12-week racket-sport intervention on the motor skills, social behaviors,
and executive functions of two groups of boys with ADHD. All participants were screened for eligibility and matched for age,
severity, and medication usage prior to random assignment to one of the two groups, groups I (n = 16) and II (n = 16). Group
I received the intervention in the first 12 weeks, whereas group II did not receive any table tennis exercise during the 12
 C.-Y. Pan et al. / Research in Developmental Disabilities 57 (2016) 1–10 3

Table 1
Participant descriptive characteristics.

group I (n = 16) group II (n = 16) t p

M ± SD M ± SD

Age (years) 8.93 ± 1.49 8.87 ± 1.56 0.12 0.91

Height (cm) 132.86 ± 11.64 133.73 ± 9.69 −0.23 0.82
Weight (kg) 30.68 ± 8.71 32.62 ± 9.34 −0.61 0.55
BMI (kg/m2 ) 17.11 ± 2.87 18.07 ± 4.10 −0.76 0.45
ADHD Q (n, %)
131 0 (0%) 0 (0%)
121–130 1 (6%) 1 (6%)
111–120 1 (6%) 1 (6%)
90–110 7 (44%) 7 (44%)
80–89 5 (31%) 5 (31%)
70–79 1 (6%) 1 (6%)
69 1 (6%) 1 (6%)
Medicine Intake (n, %)
None 7 (44%) 7 (44%)
Yes 9 (56%) 9 (56%)

Note. BMI = body mass index; ADHD = attention deficit hyperactivity disorder; Q = quotient, the higher the quotient lead levels the more severe; M ± SD
(standard deviation).

weeks of intervention and was the control group. Participants in the control group were asked to keep their usual routines,
schedules, and levels of activity, without taking part to new sport activities during the study period. The arrangement of
the intervention was reversed in the following 12 weeks. All participants completed assessments for motor skills, social
behaviors, and executive functions prior to the intervention (baseline [time1]), at the end of the first 12 weeks of the
intervention (12 weeks from the baseline [time2]), and then 12 weeks following the second 12 weeks of intervention (24
weeks from the baseline [time3]). All participants received the 12-week intervention for the same number of sessions and
hours, two sessions per week and 70 min per session, respectively, regardless of group assignment. This enabled examining
the effects of the intervention in groups I and II, and the potential sustainment of intervention effects in group I.

2.2. Participants

A total of 32 boys with ADHD, aged 6–12 years, participated in this study. The participants were recruited through
LISTSERV emails sent from the Taiwan ADHD association and the local clinical center and through word of mouth in a large
urban city. The medication status was not controlled in this study; however, the participants were advised to maintain their
current pharmacological treatment throughout the study. Inclusion criteria were (a) formal diagnosis made by a pediatrician
or psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria (APA,
2000), (b) an age of 6–12 years, and (c) current symptoms consistent with the diagnostic criteria for ADHD, as indicated by the
Chinese version of the Child Behavior Checklist (CBCL; Chen, Huang, & Chao, 2006), and meeting the clinical cutoff score of a
t value ≥70 on the DSM-IV subscales of the CBCL, originally developed by Achenback and Rescorla (2001). In addition, parent
ratings were collected using the traditional Chinese version of the ADHD test (ADHDT; Cheng, 2008), originally developed by
Gilliam (1995) to screen for the severity of ADHD symptoms. The ADHDT is an age- and gender-normed scale consisting of
DSM-IV symptoms of ADHD scaled from 0 (not a problem) to 2 (severe problem). The ADHDT consists of 36 items comprising
three subscales measuring hyperactivity, impulsivity, and inattentiveness. These three subscales are the categories related
to ADHD diagnosis according to the DSM-IV criteria and professional literature. Most raters require approximately 5 min
for completing the protocol, and scoring is easily accomplished. Exclusion criteria were a history of psychosis, pervasive
developmental disorder, brain injuries, severe neurological or medical problems, and motor or perceptual impairments that
would prevent participation in the physical exercise program or motor skill assessment.
Regarding prior table tennis skills, four children had participated in weekly table tennis instruction during inclusive
physical education classes (ranged from 8 to 10 sessions, 40 min each) prior to this study, and were evenly distributed
between the two groups. All participants had very limited table tennis technical skills (forehand and backhand counter-
stroke/serve/return), footwork movement, and ball- and racquet-handling drills based on the first assessment at study
entry.
Written informed consent was obtained from the participants and their parents. The protocol was approved by the
National Cheng Kung University Research Ethics Committee for Human Behavioral Sciences. Demographic and anthropo-
metric characteristics of the participants are presented in Table 1, and all the attributes were evenly distributed between
the two groups.

2.3. Physical exercise intervention

The intervention program was conducted on an individual basis at a table tennis center located at the university. The
program consisted of 24 sessions performed twice a week for 12 weeks, and it focused on improving motor skills, social
4 C.-Y. Pan et al. / Research in Developmental Disabilities 57 (2016) 1–10

behaviors, and cognitive functions. Each session lasted approximately 70 min and consisted of a warm-up (5 min), motor
skills practice (20 min), executive function training by using table tennis exercise (20 min), group games (20 min), and a
cooldown (5 min). The current intervention was mainly adopted from our previous protocol developed for children with
ADHD (Pan et al., 2015), and the two main parts of the training program, motor skills practice and executive function training,
were based on a constraints-led approach (Davids, Button, & Bennett, 2008). Dynamic interactions among the following three
key constraints were major influences on successful skill learning and development: the individual performer (e.g., age and
ADHD), environment (e.g., peers and coaches), and task (e.g., ball speed, direction, and color). The present intervention
focused primarily on the manipulation of the task and social environment because they are easy to manipulate. For example,
the interval, direction, and speed of the balls served either by the coach or by the automatic ball projection machine were
varied to provide various levels of complexity. In addition, the coach threw balls in two colors, orange and white, and asked
the participants to hit balls with the requested color in a random order. In addition to the manipulation of the task, the
participant and the coach were crucial for developing the motor and cognitive skills. The participant was taught to observe
and mentally rehearse the movements of the coach. The coach monitored, guided, and facilitated the learning process of
individual participants by manipulating the task constraints, and consistently provided verbal and physical feedback and
support to promote their learning. These two main parts of the intervention focused on learning table tennis ball skills and
motor skills that were expected to relate to executive functions in a structured manner.
To optimize the learning environment and challenge each participant, the instructor-to-participant ratio ranged from
1:2 to 1:1 for the intervention group, depending on attendance. One primary coach and eight research assistants conducted
the intervention; they were trained by the primary investigator and were provided a written treatment protocol for admin-
istering the intervention. The primary coach was an elite national table tennis player for 5 years, with 5 years of experience
in teaching table tennis exercise to children with and without disabilities. All research assistants, majoring in physical edu-
cation, special education, or adapted physical education, had experience with children with ADHD. To meet the competency
requirement in teaching techniques delivered to the children, the primary coach and all research assistants undertook an
one-hour training before each intervention session to focus on teaching new skills as well as integrating previously learned
skills for the children.

2.4. Instruments

2.4.1. Motor skill proficiency

The long form of the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2; Bruininks & Bruininks, 2005)
was used. The BOT-2 measures an array of motor skills and uses a composite structure organized around the muscle groups
and limbs involved in movements of people aged 4–21 years. It has four motor area composites, namely fine manual control,
manual coordination, body coordination, and strength and agility. Each composite comprises two subscales with five to
nine items in each. The subscales are fine motor precision, integration, manual dexterity, upper-limb coordination, bilateral
coordination, balance, running speed and agility, and strength.
The BOT-2 was selected for this study because it is one of the most widely used, reliable, and valid performance-based
measures, and it provides norms for the age group of the participants included in this study (Bruininks & Bruininks, 2005).
The norm sample for the BOT-2 consisted of randomly selected participants who were stratified on the basis of gender,
race or ethnicity, socioeconomic status, and disability status including ADHD (Bruininks & Bruininks, 2005). Bruininks and
Bruininks (2005) established a strong internal subtest consistency reliability (r = 0.70–0.80), internal composite consistency
reliability (r = 0.80–0.90), test–retest reliability (r = 0.69–0.80), and interrater reliability (r = 0.92–0.99) for the BOT-2.

2.4.2. Social behavioral measure

The CBCL (Achenback & Rescorla, 2001) for the participants was completed by their parents for evaluating the behavioral
problems and social competences of the participants. This test has a satisfactory reliability coefficient (r = 0.85) and has been
used extensively in clinical and research settings. Scores in eight scales were calculated: anxiety-depression, withdrawn-
depression, somatic complaints, social problems, thought problems, attention problems, rule-breaking behaviors, and
aggressive behaviors. Their compilation enables scaled computation of internalized, externalized, and total problems. These
items were rated on a 3-point scale: 0 (not true), 1 (somewhat or sometimes true), and 2 (very true or often true). Percentile
scores calculated using the test manual are reported.

2.4.3. Neuropsychological measure

The children’s version of the Stroop Color and Word Test for ages 5–14 years was used for evaluating executive func-
tions (Golden, Freshwater, & Golden, 2003). The Stroop test version consisted of three subtasks, namely word, color, and
color–word. The stimulus material for each of these subtasks was shown on a white 8.5 × 11 sheet of paper. The 100 stimuli
used for each subtask were distributed evenly in a 5 (column) × 20 (row) matrix. In the first subtask, a page showed the
words “red,” “green,” and “blue” printed in black ink 100 times in random order. In the second subtask, 100 solid-color rect-
angles printed in red, green, and blue were displayed. The third subtask involved 100 color words printed in an incongruous
ink color, for example, the word “green” printed in red. The Stroop test has been confirmed to measure executive functions
and is sensitive to the effects of physical exercise on children with ADHD (Chang, Liu, Yu, & Lee, 2012; Pan et al., 2015) and
intellectual disabilities (Chen et al., 2015).
 C.-Y. Pan et al. / Research in Developmental Disabilities 57 (2016) 1–10 5

Table 2
Motor skill proficiency, social behaviors, and executive function by group at three assessments.

group I (n = 16) group II (n = 16)

time1 time2 time3 time1 time2 time3

BOT-2, standard scores (M = 50, SD = 10)

Fine manual control 50.56 ± 7.36 54.38 ± 14.56 51.19 ± 7.83 52.56 ± 9.86 50.19 ± 12.94 56.56 ± 9.64
Manual coordination 57.19 ± 8.46 60.44 ± 8.85 59.88 ± 8.99 55.19 ± 10.26 52.13 ± 11.53 54.25 ± 10.89
Body coordination 53.50 ± 9.38 57.00 ± 7.96 56.25 ± 7.51 50.13 ± 6.87 52.44 ± 9.26 55.81 ± 8.00
Strength and agility 61.63 ± 10.18 69.50 ± 6.86 67.88 ± 8.62 59.44 ± 8.21 61.25 ± 7.75 67.63 ± 8.58
Total motor composite 58.38 ± 9.26 64.13 ± 9.50 62.31 ± 9.32 55.75 ± 10.38 55.88 ± 10.74 61.63 ± 11.42
Behavior
Anxiety-depression 7.19 ± 4.68 5.63 ± 5.28 5.38 ± 5.25 7.13 ± 3.96 7.50 ± 3.65 5.50 ± 4.08
Withdrawn-depression 3.88 ± 1.86 3.00 ± 2.39 2.31 ± 1.78 3.65 ± 1.93 3.63 ± 2.31 3.06 ± 2.17
Somatic complaints 2.94 ± 2.91 2.63 ± 2.83 2.13 ± 2.09 3.19 ± 3.82 3.25 ± 3.62 2.88 ± 2.90
Social problems 9.38 ± 4.35 5.31 ± 4.05 5.88 ± 4.36 7.13 ± 4.18 6.94 ± 7.01 5.00 ± 3.27
Thought problems 5.25 ± 2.29 3.38 ± 3.16 3.56 ± 3.42 4.75 ± 2.74 4.50 ± 3.39 4.00 ± 2.73
Attention problems 13.44 ± 3.10 9.69 ± 3.00 10.94 ± 4.33 11.56 ± 4.07 11.50 ± 4.05 9.56 ± 3.98
Rule-breaking behaviors 5.31 ± 3.24 4.94 ± 4.45 4.19 ± 3.85 4.88 ± 3.12 5.06 ± 3.45 4.75 ± 3.07
Aggressive behaviors 14.31 ± 7.05 9.69 ± 7.45 10.81 ± 7.09 13.00 ± 6.01 13.00 ± 7.11 8.69 ± 6.17
Internalized problems 14.00 ± 7.68 11.25 ± 8.22 9.80 ± 8.09 13.88 ± 7.78 14.38 ± 6.96 11.44 ± 6.86
Externalized problems 19.63 ± 9.93 14.63 ± 11.28 15.00 ± 10.42 17.88 ± 8.66 18.06 ± 10.19 13.44 ± 8.83
Total problems 61.69 ± 21.65 44.25 ± 26.79 45.19 ± 27.27 55.19 ± 22.49 55.38 ± 22.51 43.44 ± 21.12
Stroop
Color-word 23.88 ± 3.98 32.13 ± 2.92 31.06 ± 6.12 24.25 ± 5.29 23.44 ± 2.97 29.81 ± 5.01

Note. M ± SD (standard deviation).

The participants were taken individually to a quiet place for the examination. They were given the first page (all words)
of the Stroop test and were instructed to read the words out loud as fast as they could from top to bottom within 20 trials,
and from left to right (comprising five columns). The number of items completed within 45 s was the “word score.” After
completing the first task, they were given the second page (colored ink in the rectangle pattern) and asked to name the
colors out loud as fast as they could from the top to the bottom of the column. The number of items completed within 45 s
was the “color score.” Finally, they were given the third page (color words written in nonmatching colored ink) and asked
to name the ink color of the printed words as quickly and as accurately as possible. The number of items completed within
45 s was the “color–word score.” Upon encountering a mistake, the participants were asked to stop and proceed only after
correcting the mistake. Because the word and color subtask scores are not measures of executive functions, we used the raw
color–word scores for the subsequent data analysis.

2.5. Statistical analysis

All statistical analyses were performed using SPSS (Version 18.0) for Windows (SPSS Inc., Chicago, IL, USA). Independent
t-tests were conducted to examine differences in group characteristics between the groups. A series of 2 (within-subjects
factor: time1 vs time2) × 2 (between-subjects factor: group I vs group II) mixed-model analyses of variance (ANOVAs) was
applied to determine the effects of the physical exercise intervention. An 2 (eta square) value for the ANOVAs was used as
an index of the effect size. Simple main effects were determined following observation of any significant interaction effects.
Comparisons of results between time2 and time3 were performed using paired t tests to evaluate the maintenance of effects
in group I and the physical exercise intervention effects in group II. Cohen’s d was computed and reported as an index of the
effect size for paired t tests. Results were considered to be statistically significant at an alpha level of p < 0.01 to control for
possible type I error inflation caused by multiple comparisons in repeated-measures ANOVAs and paired t tests.

3. Results

3.1. Participation rates

The overall mean participation rate for the physical exercise intervention was 89%. The participation rate did not differ
significantly for the first (90%) and second (88%) 12-week phases in groups I and II, respectively (t = 0.42, p = 0.42). The results
for motor skill proficiency, social behavior, and executive function performance are listed in Table 2.

3.2. Analysis I: motor skill proficiency effects

No significant main effect of time on all indices of the BOT-2 was noted after performing the two-way mixed-model
ANOVA (Table 3). No main effect of group allocation on any of the BOT-2 composite scores was observed. Significant group-
by-time interaction effects for manual coordination (F = 11.50, p < 0.01, 2 = 0.28), strength and agility (F = 15.20, p < 0.01,
2 = 0.18), and the total motor composite (F = 10.45, p < 0.01, 2 = 0.20) were observed.
6 C.-Y. Pan et al. / Research in Developmental Disabilities 57 (2016) 1–10

Table 3
Summary of analyses from two-way ANOVA (group x time) with repeated measures on one factor (time).

Group (G) group I group II Time (T) time1 time2 Statistically Significant
Interactions (p < 0.01)

BOT-2
Fine motor control NS 52.47 ± 2.35 51.38 ± 2.35 NS 51.56 ± 1.54 52.28 ± 2.43 NS
Manual coordination NS 58.81 ± 2.37 53.66 ± 2.37 NS 56.19 ± 1.66 56.28 ± 1.82 p < 0.01
Body coordination NS 55.25 ± 1.93 51.28 ± 1.93 NS 51.81 ± 1.45 54.72 ± 1.53 NS
Strength and agility NS 65.56 ± 2.01 60.34 ± 2.01 p < 0.01 60.53 ± 1.64 65.38 ± 1.29 p < 0.01
Total motor composite NS 61.25 ± 2.42 55.81 ± 2.42 p < 0.01 57.06 ± 1.74 60.00 ± 1.79 p < 0.01
Behavior
Anxiety-depression NS 6.41 ± 0.99 7.31 ± 0.99 NS 7.16 ± 0.77 6.56 ± 0.80 NS
Withdrawn-depression NS 3.44 ± 0.46 3.59 ± 0.46 NS 3.72 ± 0.34 3.31 ± 0.42 NS
Somatic complaints NS 2.78 ± 0.77 3.22 ± 0.77 NS 3.06 ± 0.60 2.94 ± 0.57 NS
Social problems NS 7.34 ± 0.99 7.03 ± 0.99 p < 0.01 8.25 ± 0.75 6.13 ± 0.71 p < 0.01
Thought problems NS 4.31 ± 0.67 4.63 ± 0.67 NS 5.00 ± 0.45 3.94 ± 0.58 NS
Attention problems NS 11.56 ± 0.85 11.53 ± 0.85 p < 0.01 12.50 ± 0.64 10.59 ± 0.63 p < 0.01
Rule-breaking behaviors NS 5.13 ± 0.84 4.97 ± 0.84 NS 5.09 ± 0.56 5.00 ± 0.70 NS
Aggressive behaviors NS 12.00 ± 1.67 13.00 ± 1.67 p < 0.01 13.66 ± 1.16 11.34 ± 1.29 p < 0.01
Internalized problems NS 12.63 ± 1.77 14.13 ± 1.77 NS 13.94 ± 1.37 12.81 ± 1.35 NS
Externalized problems NS 17.13 ± 2.42 17.97 ± 2.42 NS 18.75 ± 1.65 16.34 ± 1.90 NS
Total problems NS 52.97 ± 5.61 55.28 ± 5.61 p < 0.01 58.44 ± 3.90 49.81 ± 4.37 p < 0.01
Stroop
Color-word p < 0.01 28.00 ± 0.90 23.84 ± 0.90 p < 0.01 24.06 ± 0.83 27.78 ± 0.52 p < 0.01

Notes. M ± SE (standard error); NS = not significant.

Fig. 1. The BOT-2 standard score of two groups of children with ADHD before (time1) and after the intervention (time2); **p < 0.01.

A follow-up of the simple main effects revealed that strength and agility improved in group I compared with group II at
time2 (F = 10.17; p < 0.01; 2 = 0.25; Fig. 1). Improvements in manual coordination were observed in group I compared with
group II after the intervention (F = 5.23; p = 0.02); however, the difference was not significant (p < 0.01). The scores of group I
in strength and agility (F = 34.00, p < 0.01, 2 = 0.18) and the total motor composite (F = 16.50, p < 0.01, 2 = 0.09) were higher
at time2 than at time1, whereas group II showed no significant differences in any of the BOT-2 composite scores between
the time1 and time2 measurements.
Comparison between time2 and time3 measurements for group I did not reveal a significant difference in any of the
BOT-2 composite scores, whereas the scores of strength and agility (t = 4.70, p < 0.01, Cohen’s d = 0.78) and the total motor
composite (t = 5.02, p < 0.01, Cohen’s d = 0.52) in group II were significantly higher at time3 than at time2.

3.3. Analysis II: social behavior effects

The two-way mixed-model ANOVA revealed no significant time effect on all indices of the parent-reported behavioral
problems (Table 3). None of the behavioral items exhibited significant main effects of group. A significant difference was
noted in the group-by-time interaction for social problems (F = 23.19, p < 0.01, 2 = 0.29), attention problems (F = 18.76,
p < 0.01, 2 = 0.27), aggressive behaviors (F = 12.84, p < 0.01, 2 = 0.23), and total problems (F = 13.36, p < 0.01, 2 = 0.24).
Fig. 2 illustrates the group-by-time interaction for behavioral problems. Post hoc analyses showed significantly lower
scores for social problems (F = 33.30, p < 0.01, 2 = 0.20), attention problems (F = 41.67, p < 0.01, 2 = 0.29), aggressive behav-
 C.-Y. Pan et al. / Research in Developmental Disabilities 57 (2016) 1–10 7

Fig. 2. The CBCL raw score of two groups of children with ADHD before (time1) and after the intervention (time2); **p < 0.01.

Fig. 3. Stroop color-word raw score of two groups of children with ADHD before (time1) and after the intervention (time2); **p < 0.01.

iors (F = 18.75, p < 0.01, 2 = 0.10), and total problems (F = 19.14, p < 0.01, 2 = 0.12) in group I at time2, whereas the scores
in group II were similar at time1 and time2. No intergroup differences were observed in any of the behavioral problems
between time1 and time2.
Parent-reported behavioral problems in group II significantly decreased from time2 to time3 (social problems: t = 5.23,
p < 0.01, Cohen’s d = 0.35; attention problems: t = 3.42, p < 0.01, Cohen’s d = 0.48; aggressive behaviors: t = 6.01, p < 0.01,
Cohen’s d = 0.65; externalized problems: t = 4.55, p < 0.01, Cohen’s d = 0.48; total problems: t = 4.70, p < 0.01, Cohen’s d = 0.55).
No significant change was observed in any of the parent-reported behavioral problems for group I.

3.4. Analysis III: executive function effects

The ANOVA results revealed a significant main effect of time on the Stroop color–word score from time1 to time2
(F = 49.64; p < 0.01; 2 = 0.32), where the score was significantly higher at time2 as compared with time1. A significant main
effect of group allocation was observed (F = 10.59; p < 0.01; 2 = 0.40), where the scores were significantly higher in group
I than in group II. Furthermore, a group-by-time interaction effect was observed (F = 73.70, p < 0.01, 2 = 0.48). Follow-up
of the simple main effects revealed that the Stroop color–word score improved in group I compared with that in group II
at time2 (F = 69.75, p < 0.01, 2 = 0.70; Fig. 3). Regarding the within-group differences between time1 and time2, the Stroop
color–word score in group I was significantly higher at time2 (F = 161.73, p < 0.01, 2 = 0.60), whereas the score in group II
was similar at time1 and time2.
Changes in the Stroop color–word score for group I remained stable, with differences between time2 and time3 being
nonsignificant. However, the Stroop color–word score at time3 differed significantly in group II compared with that at time2
(t = 5.70; p < 0.01; Cohen’s d = 1.55).
8 C.-Y. Pan et al. / Research in Developmental Disabilities 57 (2016) 1–10

4. Discussion

The objectives of this study were to assess the usefulness of a long-term racket-sport intervention for enhancing motor
skills, social behaviors, and executive functions in two groups of children with ADHD and to examine whether the effects
were sustained in group I. Our previous pilot study suggested that 12 weeks of table tennis training improved fundamental
movement skills, namely locomotor and object control skills, and executive functions, namely selective attention and overall
performance in cognitive flexibility, in children with ADHD (Pan et al., 2015). In the current study, we replicated our previous
study and extended it to two samples of children with ADHD. The current study was conducted in two phases to assess
whether our earlier results for motor skills and executive functions in addition to social behaviors were improved and
sustained in the absence of direct external resources.
First we, confirmed that the implemented racket-sport intervention effectively improved motor skills, as indicated by
an increase in the strength and agility and total motor composite scores in both groups, and the intervention effects were
sustained in group I for 12 weeks of follow-up. The group-by-time interaction effect suggested that the participants in
group I that underwent the intervention showed improved scores, whereas the control group (group II) did not show any
improvement. Subsequent analysis of motor skill proficiency scores after the intervention in group II indicated positive
changes in the strength and agility and the total motor composite scores. The absence of significant findings for the BOT-2
submeasures suggested that the hypothesis that a racket-sport intervention would improve motor skills in children with
ADHD was partially supported. Previous studies on similar interventions have shown similar findings in children with ADHD,
indicating that long-term physical exercise improves motor skill performance (Ahmed & Mohamed, 2011; Pan et al., 2015;
Smith et al., 2013; Verret et al., 2012). For example, a physical activity training program involving progressive aerobic,
muscular, and motor skills exercises increased locomotion and total motor skills in children with ADHD (Verret et al., 2012).
Furthermore, a program involving 26 min of continuous, moderate to vigorous physical activity consisting of games and
activities that require participants to employ various motor skills yielded a high score in total motor skill proficiency in
children with ADHD (Smith et al., 2013). Similarly, a long-term, moderate-intensity exercise program including upper-limb,
lower-limb, trunk, and neck aerobic exercises and free running yielded considerable improvements in motor skills in children
with ADHD (Ahmed & Mohamed, 2011). Moreover, physical exercise training involving various types of table tennis ball,
locomotion, and object-control skills led to improvements in locomotor and object-control skills in an experimental group
compared with a control group that did not receive the training (Pan et al., 2015). Our findings are consistent with the
aforementioned studies and support the efficacy of physical exercise intervention in children with ADHD. This present study
suggests that targeting improvements in motor skills likely results in increases in strength and agility and the total motor
composite in children with ADHD throughout the training period.
We hypothesized that a racket-sport intervention would have an effect on social behaviors in children with ADHD,
and the effect would last for 12 weeks after the intervention. The CBCL results, specifically, showed significant group-by-
time interaction effects concerning social problems, attention problems, aggressive behaviors, and total problems. Further
analysis showed that such effects were significant only for group I in the first phase. However, group II exhibited significant
reductions in social problems, attention problems, aggressive behaviors, externalized problems, and total problems when it
underwent the intervention in the second phase. Hence, our hypothesis was partially supported concerning social behaviors.
These results are consistent with a causal hypothesis indicating that long-term physical exercise programs have a positive
effect on behavior functions, namely academic and classroom behaviors, and reduces attention, social, and thought problems
in children with ADHD (Ahmed & Mohamed, 2011; Verret et al., 2012). A possible explanation for improved behaviors is that
participating in an exercise intervention increases the level of physical activity in children with ADHD (Rommel et al., 2015).
Rommel et al. (2015) examined the effect of physical activity levels (i.e., weekly energy expenditure) during late adolescence
on ADHD symptoms (i.e., inattention and hyperactivity/impulsivity) in early adulthood by using a longitudinal study design
and demonstrated that higher levels of physical activity in late adolescence were associated with lower ADHD symptoms in
early adulthood. Another possible explanation for improved social behaviors is that the exercise sessions encouraged social
interactions with peers and coaches. Studies (Becker, Fite, Luebbe, Stoppelbein, & Greening, 2013; Hoza, Mrug, Pelham,
Greiner, & Gnagy, 2003) have indicated that friendship forming among children with ADHD is associated with improved
behaviors and reduced symptoms and social problems. In the present study, each participant was paired with the same
peer and coach throughout the intervention. The 1:2 instructor-to-participant ratio for the intervention group provided
an opportunity for establishing dyadic, mutual, and close friendships among the participants. In addition, the interaction
between the primary coach and each participant in various sessions, formation of small (e.g., motor skill training) and large
groups (e.g., group games), adequate supervision from other coaches, and use of an effective behavior management system
may have reduced social problems. This speculation was not confirmed because of a lack of relevant data; however, it is a
promising area for future research.
In this study, the Stroop color–word score significantly improved after the intervention in both groups, and the effects
persisted for 12 weeks of follow-up in group I. These findings support our hypothesis concerning executive functions and
suggest that neuronal structures and functions in children with ADHD may be enhanced through participation in a long-term
physical exercise program (Pontifex et al., 2011). Consonant with this assertion, two initial investigations (Smith et al., 2013;
Verret et al., 2012) on the effects of long-term physical exercise revealed significant improvements in cognitive functions in
children with ADHD. Verret et al. (2012) observed enhanced information processing, visual search, and sustained attention
in 10 children with ADHD compared with a similar-sized control group after participation in a 10-week physical exercise
 C.-Y. Pan et al. / Research in Developmental Disabilities 57 (2016) 1–10 9

program (45 min, three times a week). Smith et al. (2013) reported improved inhibitory control in 14 children at risk for ADHD
after they engaged in an 8-week physical exercise program (30 min, five times a week). Our findings were not surprising
because the exercise sessions were designed to foster participants’ attention and concentration. Completing each exercise
session required that the participant be focused, attentive to instructions and feedback from the coach, and on task. Over the
training period, the participants with ADHD may have improved attention and inhibitory control; this could have contributed
to the improved overall motor skill performance observed in the group receiving training. Studies have indicated a strong
association between executive functions and motor skills (Hung et al., 2013; Piek et al., 2004). Piek et al. (2004) demonstrated
a strong positive association between motor skills and executive functions (i.e., working memory and behavioral inhibition)
in children with ADHD. Hung et al. (2013) demonstrated that motor skills in children with ADHD were positively associated
with their behavioral (i.e., faster reaction time and higher accuracy) and event-related potential (i.e., shorter N2 and P3
latencies and a larger P3 amplitude) measurements and suggested possible roles that motor skills may play in promoting
executive functions (i.e., attentional resource allocation and efficiency of neuroprocessing) in children with ADHD. Our results
are in accordance with those of a few studies using a racket-sport intervention for children with intellectual disabilities and
borderline intellectual functioning (Chen et al., 2015). The noted improvements in executive functions following a relatively
short-term (12 week long) intervention program with sustained effects for 12 weeks postintervention were encouraging.
However, further research is required to comprehensively understand how participating in long-term physical activity may
affect inhibitory control processes in children with ADHD and determine the specific components of physical activity that
may optimize its influencing on cognition in children with ADHD.
The absence of evidence of dose-dependent effects of training suggests that the observed changes in motor skills, social
behaviors, and executive functions may not be directly attributable to the intervention itself. We speculate whether other
factors might have contributed to overall improvement. For instance, the current intervention provided instructions at an
individual level. Immediate positive reinforcement and feedback on the accuracy of every movement from coaches and
participants’ self-reinforcement after completing each training session were crucial. In addition, the excellent program
adherence (88%–90%) and no dropout from the intervention confirmed that it was feasible for children with ADHD to com-
plete. Furthermore, some parents wrote thank-you notes indicating that their children enjoyed the sessions and always
looked forward to meeting with the coaches and other participants every week. They also stated that they and their chil-
dren had the opportunity to develop social networks with other family members through the program. These secondary
benefits might have increased effort and motivation to perform throughout the training period and during the posttraining
assessments, contributing to the effectiveness of and adherence to the program.
The limitations of this study that may limit the generalizability of our findings must be considered. First, the age range
and gender of participants (all male) limit generalization. Future research is warranted to establish the applicability of the
current findings to individuals of both gender and at different stages of the life cycle through replication studies. Second, the
use of stimulant medication was not well-controlled in the current study. It would have been preferable to have a sample
of children who were not on medication. Researchers need to explore the relationships between stimulant medications and
various physical activities or contexts without any influences on other aspects of these children’s daily routine because of this
personal intrusion. Third, the participants were recruited from economically advantaged community settings. Children who
participated in this study may differ from other children who did not participate because of a lack of ability and motivation
to undergo such a physical exercise intervention. Fourth, relying only on parent-reported social behavior assessment (e.g.,
lack of teacher reports) may be a limitation. Fifth, we were unable to distinguish potential maturation or coincidental
classroom-based training from intervention effects. Therefore, additional studies are required to replicate our findings by
using independent samples, to extend these findings by considering older participants, and to investigate other types of and
approaches to intervention. Furthermore, a systematic examination of how varying amounts of physical activity influence
improvements can yield valuable information on the intensity, frequency, and duration of physical activity required for
achieving benefits in children with ADHD.
This study supports the possibility that a long-term racket-sport intervention is an effective strategy for improving some
motor, cognitive, and behavioral functions in children with ADHD. Almost half of the measures in our study showed a
significant positive change after the intervention, with effect sizes of mostly small to medium magnitude. Therefore, this
intervention can be implemented immediately by appropriate professionals in an outpatient setting or community health
center at little cost. Moreover, although we focused on children with ADHD, this intervention paradigm can easily be extended
to other populations of children at risk for motor skill difficulties, behavioral problems, and executive dysfunctions.

Acknowledgements

This research was supported by MOST 103-2410-H-017-026-MY3. The authors would like to express their gratitude to all
the adolescents who participated in this study, teachers and parents of adolescents for their supports and research assistants
who helped with data collection and other contributions.

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