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Categories: 2012, June
by Michael Lara, MD
AS MANY PARENTS AND ADULTS WITH ADHD KNOW, making
treatment decisions can be difficult. On one hand, prescription
medications may help improve symptoms like hyperactivity,
inattentiveness, and impulsivity. Unlike antibiotics taken for an
infection, however, these medications will not suddenly fix all of your
or your child’s issues.
Even when the medicine is working, your child might still struggle with
forgetfulness, emotional problems, and social awkwardness, or you might
find yourself dealing with disorganization, distractibility, and
relationship difficulties. It is important to know, though, that ADHD
medications are not the only treatment option. There is now a consensus
among experts that regular exercise is one of best things you can do to
ADHD starts in the brain
ADHD stems from a glitch in the brain's attention system, which is
made up of an interconnected web of neurons that are spread throughout
various areas of the brain, from areas that control arousal, motivation,
and reward, to those involved in executive function and movement. These
attention circuits are regulated by neurotransmitters such as
norepinephrine and dopamine, which help usher messages from one part of
the system to another.
Broadly speaking, the problem for people with ADHD is that communication
within their attention system is often patchy and disconnected
(Mazaheri, 2010, and Pliska, 1996). Therefore, the goal of ADHD
treatment is to fill these gaps in order to decrease distractibility and
any other symptoms that might be present. And this is just what exercise
A recent study published in the Journal of Attention
Disorders (Verret, 2012) showed that doing moderate to vigorous
intensity exercise forty-five minutes a day, three times a week, for ten
weeks improved cognitive function and behavior in children with ADHD.
Specifically, it seemed that the children who followed the exercise
program were more efficient at processing information, as demonstrated
by faster speeds of visual research and better sustained auditory
Exercise has similar effects as medications
Although most of us equate exercise to changes in our waistline,
physical activity also has a profound effect on the brain. Early brain
and exercise research has indicated that exercise results in the growth
of new nerve cells (neurogenesis), increases in the levels of several
different neurotransmitters, and vascular (new blood vessel) adaptations
(van Prag, 2009). In fact, scientists have found that moderate to
intense exercise actually provokes changes in many of the same
neurochemicals and brain structures as popular prescription ADHD
As mentioned previously, the neurotransmitters norepinephrine and
dopamine play a major role in regulating the attention system. As a
result, they are the most common chemicals targeted by ADHD medications.
However, increasing norepinephrine and dopamine is also the broad
scientific explanation for exercise's profound effect on the ADHD
Whenever you walk, run, bike or swim, your brain releases lots of these
neurotransmitters, which increases the attention system’s ability
to be regular and consistent by spurring the growth of new receptors in
certain areas of the brain. This has many good effects like reducing the
need for new stimuli and increasing alertness. For example, John J.
Ratey says in his book Spark: The Revolutionary New Science of
Exercise and the Brain (2008), that exercise increases dopamine
levels in the rat equivalent of the basal ganglia (which is responsible
for the smooth shifting of the attention system and the key binding site
for methylphenidate) by creating new dopamine receptors.
That's all well and good for the rats, but what sort of effect can this
have in humans? In Spark, Ratey described the results of one
study that examined the effects of exercise in kids with ADHD by using
motor-function tests, which provide indirect measures of dopamine
activity. In boys, rigorous exercise improved their ability to stare
straight ahead and stick out their tongue, indicating better motor
reflex inhibition. Girls, on the other hand, didn’t show any
improvement, which may be because of a lower incidence of hyperactivity
in girls. However, both the boys and the girls improved according to
another measure related to the sensitivity of dopamine synapses,
although boys fared better after vigorous exercise and girls after
Another common symptom in children with ADHD, fidgetiness, has been
linked to an overactive cerebellum. While recent studies have shown that
ADHD drugs that elevate dopamine and norepinephrine bring this area back
into balance, exercise has also been shown to be effective, and the more
complex the exercise, the better.
Obviously researchers can't teach lab rats to do martial arts or
ballet,but they did look at the neurochemical changes in their brains
after periods of acrobatic exercise, the closest parallel to these sorts
of activities that you can replicate in a lab. Compared to rats running
on a treadmill, the rats that practiced complex motor skills had more
dramatic improvements in levels of brain-derived neurotrophic factor
(BDNF), which suggests that growth is happening in the cerebellum.
But what about adults with ADHD? Unfortunately, less research has been
done in this group of patients. However, research into cognitive decline
has shown that exercise continues to positively affect the brain well
into old age.
What type of exercise is best?
While most clinical studies researching the effects of exercise on
ADHD have utilized running on treadmills, you don't have to be a
marathoner, or even a jogger, to benefit from exercise. In fact,
challenging the body as well as the brain with complex activities like
martial arts, ballet, ice skating, gymnastics, rock climbing, and
mountain biking seems to have a greater positive impact on children with
ADHD than aerobic exercise alone.
One small, unpublished study by a graduate student at Hofstra University
(Morand) found that boys with ADHD who participated in martial arts
twice a week had greater improvements in behavior and performance on a
number of different measures than those who participated in a typical
aerobic exercise program (although exercise in general led to dramatic
improvements compared to nonactive controls). The kids involved in
martial arts finished more of their homework, were better prepared for
class, showed greater improvement in their grades, broke fewer rules,
and jumped out of their seats less often.
Why is this? Experts don't know for sure, but it is probably due to a
number of different factors. According to Ratey, "The technical
movements inherent in any of these activities activate a vast array of
brain areas that control balance, timing, sequencing, evaluation
consequences, switching, error correction, fine motor adjustments,
inhibition and of course intense focus and concentration." And, of
course, these activities also generally take place the aerobic range,
which would boost cognitive abilities and attention in a similar manner
The most important thing to consider when starting an exercise program
is to find something you enjoy doing or that your child enjoys doing.
That way you or your child will stick with it. Team activities or
exercise with a social component can be especially beneficial.
Developing a successful prescriptive exercise program
The general guidelines for using exercise to treating ADHD are to do
moderate-intensity cardiovascular activity (65-75 percent of maximal
oxygen consumption—VO2 max) for thirty to forty minutes day at
least four to five times a week. However, there are a few gaping holes
in these guidelines, as few recommendations include resistance training
or translate how adults can use exercise for ADHD. However, the general
consensus is that exercising for ADHD must be done frequently, with
occasional bursts of intensity.
In my practice I frequently recommend exercise therapy for my patients
that incorporates cardiovascular training and strength training within a
structured program. The program also includes a variety of functional
movements that require coordination, balance, and flexibility to boost
behavior and performance even more.
However, like medication, exercise only works if you take it. As a
result, it is important to work with the ADHD brain (rather than against
it) when designing an exercise routine.
The program I recommend to my patients
is modeled after Crossfit (crossfit.com)
and includes circuit training, strength training, and endurance training
on a three-day cycle, followed by one day of rest. See the sidebar on
page ____, "An Example of a Successful Exercise Program for
It is important,
however, to build an aerobic-based program before starting a structured
exercise program like the one I describe here. One of the most common
reasons why patients quit an exercise prescription is that they get
injured because they try to do too much too soon. Therefore, I recommend
that patients walk for thirty minutes a day four times a week for a
minimum of one month before they begin to add variety.
All of these
exercises should be done outdoors whenever possible. At least two
studies have suggested that physical activity done in nature reduces
ADHD symptoms significantly more than activities done in other settings
(Kuo, 2004, and Taylor, 2009).
What about medication?
For a very small handful of people with ADHD, exercise may serve as
a viable replacement for prescription medications. For most, however, it
is complementary to their treatment—something you or your child
should absolutely do, along with taking meds, to help increase attention
and improve mood.
I typically tell
my patients to exercise in the morning, before they have taken their
medication, to benefit from the increased amounts of neurotransmitters
that are produced in response to exercise. If one of my patients needs a
quick energy boost before their workout, I will sometimes recommend they
take one to two grams of the amino acid L-Tyrosine before they start
exercising. I also advise my patients to take their stimulant medication
about two hours after they finish their workout to take advantage of the
cognitive boost provided by exercise.
find that they can eventually lower their dose of stimulant medication
as long as they stick to their exercise program. However, this is
definitely something you need to discuss with your doctor.
Day 1: Circuit
Day 2: Strength training
Day 3: Cardiovascular
Day 4: Rest
Day 1: Body
Weight Circuit Training
As many rounds as possible (AMRAP) in 15 minutes of:
Air squats 8 reps
Sit-ups 6 reps
Push-ups 4 reps
Score is total number of rounds in 20 minutes
Strength Training Ladders
Choose ONE of the following:
1 rep, rest. Take as much rest as you need before progressing to:
2 reps, rest.
3 reps, rest.
4 reps, rest.
5 reps, rest.
Continue until you no longer can progress. Score is total number of
(running, cycling, walking, swimming, rowing)
30-40 minute walk. Track distance. Try to walk farther each time within
the same time frame. Score is distance covered within the same time
Day 4: Rest or leisurely walk
Day 5: Repeat cycle using different exercises or movements
For example, you may wish to incorporate pull-ups or lunges into
your circuit training. On strength days, alternate between upper and
lower body exercises. On cardiovascular days, you may wish to use
swimming, biking or rowing rather than walking.
All of these exercises should be done outdoors whenever possible. At
least two studies have suggested that physical activity done in nature
reduces ADHD symptoms significantly more than activities done in other
settings. For more information on Crossfit, visit crossfit.com; for demonstrations of exercises mentioned
here, visit crossfit.com/cf-info/excercise.html.
Kuo FE, Taylor
AF. A Potential Natural Treatment for Attention-Deficit/Hyperactivity
Disorder: Evidence From a National Study. American Journal of Public
Mazaheri A, Coffey-Corina S, Mangun GR, Bekker EM, Berry AS, Corbett BA.
Functional disconnection of frontal cortex and visual cortex in
attention-deficit/hyperactivity disorder. Biological Psychiatry.
Morand M. Research Study Indicates Martial Arts Have a Positive Effect
on Boys with Attention Deficit Hyperactivity Disorder (AD/HD). Available
Pliszka SR, McCracken JT, Maas JW. Catecholamines in
attention-deficit hyperactivity disorder: current perspectives.
Journal of the American Academy of Child and Adolescent
Ratey JJ. Spark: The Revolutionary New Science of Exercise and the
Brain. New York, NY: Little, Brown and Company, 2008.
Taylor AF, Kuo FE. Children With Attention Deficits Concentrate Better
After Walk in the Park. Journal of Attention Disorders.
van Prag, H. Exercise and the brain: something to chew on. Trends in
Verret C, Guay MC, Berthiaume C, Gardiner P, Béliveau L. A physical
activity program improves behavior and cognitive functions in children
with ADHD: an exploratory study. Journal of Attention Disorders.
Anthony Rostain, MD, MA, on the years of transition to adulthood
interview by Susan Buningh, MRE
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