Kids with ADHD can benefit from physical activity, research suggests

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Can physical activity impact symptoms of Attention Deficit Hyperactivity Disorder? We'll explore the answer from my guest, Dr. Stephen Faraone. He's a distinguished professor and vice chair of research of psychiatry and behavioral sciences at Upstate who has devoted most of his professional life to research of ADHD. Welcome back to "The Informed Patient," Dr. Faraone.

[00:00:37] Stephen Faraone, PhD: Thank you, Amber.

[00:00:39] Host Amber Smith: The symptom I think we're going to talk mostly about is disinhibition. Can you explain what that is?

[00:00:45] Stephen Faraone, PhD: Sure, sure. First, disinhibition is, in itself, a symptom in a sense that is not used to diagnose ADHD. There's a set of 18 symptoms that one can look up on the internet that are used for the diagnosis.

Disinhibition is a function of the brain, that we think is part of the cause of symptoms of ADHD. It's easier to talk -- so people understand, first, inhibition. A lot of what we do in life, and what's important for survival, is to inhibit our behavior. So, for example, a little boy's playing out in his yard, and he kicks the ball, and it goes into the street. He runs after the ball. Most little boys will inhibit the behavior of running into the street because they're concerned there might be a car, and they'll stop, and they'll look for cars. But if somebody's behavior's disinhibited, they just will run into the street and maybe get into an accident. That's one reason why kids with ADHD have more accidents.

Or take a little girl in the classroom who, maybe she hears a bird chirping outside, and instead of focusing on the work on the blackboard, she turns her head to look for that bird. Her brain is supposed to inhibit that behavior because it's off-task behavior. It's not on task. But because she has ADHD, she has a hard time doing that, and so she's distractible, which is actually one of the symptoms of ADHD.

[00:02:00] Host Amber Smith: So maybe I should ask you to explain ADHD, just briefly, for our listeners. You said there's 18 symptoms that go into the diagnosis?

[00:02:08] Stephen Faraone, PhD: There's 18 symptoms. They fall into three categories. One is hyperactivity, running around, climbing on furniture. Another is impulsivity, acting with out thinking, like running into the street to go after a ball. And inattention, which means being distractible, not being able to sustain your attention for long periods of time.

Those are the three symptom sets, which is very important for people to understand, because sometimes, especially on social media, people with ADHD will talk about lots of things in their life as if it's part of their ADHD when it's really something else, not ADHD.

So for example, I had a question once from a person: "I heard that gender dysphoria was part of ADHD." I said, "No, no. It's not a symptom of ADHD. Some people with ADHD might have gender dysphoria, but it's not part of the disorder."

[00:02:54] Host Amber Smith: So what issues might someone who has ADHD face if they have problems with inhibition? And do all people with ADHD have problems with inhibition?

[00:03:06] Stephen Faraone, PhD: First of all, there's nothing that all people with ADHD have. We have 18 symptoms. They only need to have six of those 18 symptoms. The disorder itself is very varied in how it manifests. For example, some people with ADHD are only inattentive. They're not hyperactive or impulsive. And they don't seem that disinhibited in their life, except, as I mentioned, the example of the little girl looking out the window to look for the bird as opposed to focusing.

But many people, I would say, do have problems, some problem with being disinhibited because their brain, the part of their brain that's supposed to stop them from doing things isn't working right. They end up doing things they shouldn't do.

[00:03:46] Host Amber Smith: So what would you expect to see in someone with ADHD who improves their inhibition? I mean, can you see progress?

[00:03:54] Stephen Faraone, PhD: Oh absolutely. If inhibition is improved, we would expect more impulse control. So we would see less impulsivity. We would expect to see improvements in their attention because the part of the brain that's keeping them focused on the task is working better because it's stopping them from doing other things. So yes, in a wide range of areas, we would expect to see improvements in symptoms of ADHD.

[00:04:19] Host Amber Smith: Well, I wanted to ask you to talk about an analysis you wrote recently on your blog at the website, ADHDevidence.org. It had to do with exercise. What can you tell us about it?

[00:04:32] Stephen Faraone, PhD: Well, you know, people have been studied exercise for a long time, and one thing I should say is exercise is good for everybody. So anybody listening, you should exercise regularly unless your healthcare professional tells you otherwise.

Clinicians who treat ADHD had noticed for a while that some of their patients said if they exercise, it made them feel better. They thought maybe it actually helped their ADHD. For many of them, it certainly helped them get to sleep because some people with ADHD had difficulty sleeping, and some would exercise later in the day to help them sleep at night. And so, over the years, there've been many studies that have attempted to look at the effects of exercise on improving the symptoms of ADHD.

[00:05:13] Host Amber Smith: So who did the analysis that you wrote about, and what did they look at?

[00:05:19] Stephen Faraone, PhD: So this was a group of researchers in China and South Korea, and what they did was something called a meta-analysis. And what that is, they combined studies that other people did into one big giant study. And what they do is, when you do a meta-analysis, you go into the, you comb the entire research literature for relevant studies, and they found in their work, 11 relevant studies and had studied a total of 713 people. So it's a fairly big number of people. It's still not huge compared to, for example, we have thousands of people who have gone through medication trials or cognitive behavior therapy trials. So it's still a relatively small group of people that had been studied.

And what they did was they combined these studies with the goal of saying: Could you, when you put them all together, did they convert any conclusions about the effect of exercise on ADHD?

[00:06:09] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with psychologist Stephen Faraone about the impact of exercise on ADHD symptoms.

So let's talk about the findings, then.

[00:06:23] Stephen Faraone, PhD: What they did find was some consistent evidence that physical activity was helpful for people with ADHD in this area of, they were focusing on the area of disinhibition, becoming more, if you will, inhibited in your behavior.

Importantly, they showed that the physical activity had to be done at least twice a week. And each of the sessions had to be at least 45 minutes to an hour long. The idea was that longer, the more exercise, the better was the conclusion that they drew from these analyses.

It was also important that it was a consistent exercise, that if you did it for the longer term, it's going to help symptoms more than if it was done just every now and then. So consistent, frequent and enduring exercise was very important. It was important in the exercise program to at least have some vigorous exercise that could be combined with moderate exercise, but some vigorous exercise like jogging, lifting weights, breaking a sweat essentially. I think people know what that means. You're really working hard. You had to have some really intense exercise to make that work.

[00:07:26] Host Amber Smith: Was this conclusion -- that physical activity can significantly improve inhibition in children with ADHD -- was this new, or was this already suspected?

[00:07:37] Stephen Faraone, PhD: Well, it was suspected because you had, these 11 studies that had been done essentially had suspected that these symptoms would be improved. What was the surprise here, I think, was that when you combined all these studies, you had fairly consistent results.

One of the other, I thought, pretty interesting findings was they compared three different kinds of exercise activities, right? The one that had the most value, was most beneficial for affecting this inhibition was what they called open skill sports. And these were any sport that involved reacting to some kind of a changing environment, such as playing tennis, playing ping pong, martial arts, where you really had to kind of think on your feet while you're actually doing the sport.

A closed skill sport is something like running, jogging, swimming, where there's not a lot of, if you will, detailed thinking that goes into doing those sports. You're just kind of rote, going back and forth in the pool or running down a track. And then finally that using a video game to exercise also wasn't as good as having an open skill kind of sport.

So it's real important that there seems to be some connection between the cognitive part of the brain, the thinking part of our brain, and the part of our brain that's dealing with exercise, that connecting them together in one of these complex sports was much better for disinhibition.

[00:08:54] Host Amber Smith: So what age people are we looking at with this? Is it elementary school or even younger than that, or older than that?

[00:09:02] Stephen Faraone, PhD: It's been looked at at a variety of ages, mostly in children and adolescents and young adults. I don't think in older adults much work has been done there.

[00:09:10] Host Amber Smith: What would you say is the takeaway message for parents of kids with ADHD?

[00:09:15] Stephen Faraone, PhD: Well, I would say there's really two takeaway messages in a way. The one that's explicit is that exercise is good for your child, in general. And it will, to some degree, help them with certain aspects of their ADHD. But remember, this is only about disinhibition, and ADHD is a more complex, variable disorder. And so exercise is not recommended by any guidelines group as being the first and only treatment one does for ADHD.

Nothing that I've said today changes, the current guideline for treating ADHD, which is to start with a medication, and then to also use some kind of behavior therapy, family behavior therapy with kids, or cognitive behavior therapy for adults.

[00:09:58] Host Amber Smith: You talked about the types of activities, karate, maybe, or...

[00:10:02] Stephen Faraone, PhD: Mmm-hmm. Yep.

[00:10:03] Host Amber Smith: ...dance, or ping pong. But what if your child doesn't show an interest in those? If you try to force them into it, is it going to backfire?

[00:10:13] Stephen Faraone, PhD: I wouldn't recommend forcing your child into it. It likely could backfire, and you really put your finger on one of the problems with exercise as a treatment is that for it to work, the person has to do it. And as I think many of your listeners know, exercise is frequently a difficult thing for us to do. It's easy to make excuses -- I don't feel like it today. I'm too busy. I'm not interested -- and it goes to the side.

Whereas, for example, taking a medicine is much easier. If you just remember every morning to take your pill, you're going to be OK. So if your child isn't interested in any kind of activity, one recommendation is to try to get them interested. I mean, you wouldn't want to necessarily force them, but you can say to them, "Hey, why don't you just try taekwondo, and see if you like it. You don't have to do it. Just try it for a week. See what it's like." And if you've tried different sports of that sort, eventually they might like something, because kids don't always know what they like until they have a chance to try it out.

[00:11:08] Host Amber Smith: Are there any precautions or any things to look out for if you're trying to help your child become more active? Any red flags to be on the lookout for?

[00:11:17] Stephen Faraone, PhD: Well, certainly there are some people who can't exercise because of health conditions, so obviously you want your healthcare provider to approve that exercise is OK. You want exercise to be something that's safe to do, all of the standard things that a parent would care about for their child would be important there.

[00:11:36] Host Amber Smith: I know this study looked at children, but do you think based on this that exercise could help adults with ADHD?

[00:11:45] Stephen Faraone, PhD: Oh, I think so. Yeah. There's no reason not. We know, for example, in the area of medication treatment, any medication that works for kids also works for adults. And even in the area of psychological treatments, they're a little bit different just because kids are younger, and their brains aren't as well developed. But we know that behavioral treatments work well for kids and adults as well. So I would suspect, and there are some data that do show similar signs of exercise being good for adults.

The other thing I want your listeners to understand is that although there are a lot of studies, this is still a relatively weak evidence base, compared to what we know from the evidence for, say, medications for ADHD, both in terms of numbers of studies and the quality of the studies.

Some of these exercise studies didn't do such a great job with some of the technical parts of the study, which I can't really get into, and that's why these people who did the meta-analysis said we need more studies to be essentially sure about these findings. But, at this stage we feel pretty confident that there's good evidence that point us to say exercise is helpful.

And given that we know exercise is helpful for many, many things, including, by the way, obesity -- and we know there's an epidemic of obesity in the United States in kids, and obesity is associated with ADHD -- it's really a very good idea to get your kids exercising for all sorts of reasons. And if it helps their ADHD, that's going to be fantastic.

[00:13:11] Host Amber Smith: Well, before we wrap up, I wanted to ask you how you think pediatricians are doing these days with recognizing ADHD early in children?

[00:13:20] Stephen Faraone, PhD: Most pediatricians are very well qualified to diagnose and treat ADHD. Recognition usually occurs not because the doctor sees something in the office when he is examining the patient on his own or her own. It usually happens because the parent comes in with a complaint that says, my child is really causing trouble at home by running around and climbing on furniture, or the teacher told me he or she's not paying attention in class. That's typically how kids are identified. And the problem with that is the kids that get identified are mostly the kids that are disruptive. I like to say that when you're a child, the behaviors that bother other people bring you to the doctor. When you're an adult, things that bother you bring you to the doctor.

So, in kids the girls with ADHD tend to be more inattentive and less hyperactive and disruptive, and so they're less likely to be identified early, or identified at all. And in fact, we know that the diagnostic rates, if you compare girls versus boys, diagnostic rates for boys are much higher in childhood, and they only even out when you get to adulthood. This is the latest data from the CDC (Centers for Disease Control and Prevention.). And we think that happens because when the girls grow up and they're adults, they refer themselves. They realize "I have a problem," and they go talk to their doctor about it. So I would really like it if both pediatricians and primary care doctors would actually screen for ADHD without waiting for the parent to complain about it. Because then we would actually get people being treated much earlier in life, which is going to be better for their disorder.

[00:14:53] Host Amber Smith: Dr. Farone, I really appreciate you making time for this interview. Thank you.

[00:14:56] Stephen Faraone, PhD: Always happy to be here with you, Amber. You're welcome.

[00:14:59] Host Amber Smith: My guest has been Dr. Stephen Faraone. He's a distinguished professor and vice chair of research of psychiatry and behavioral sciences at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.