Relationship be characterized and classified as inappropriate/ impairing











Relationship of Exercise and Amount/
Intensity of Attention Deficit Hyperactivity Disorder (ADHD) Symptoms in Adults
Diagnosed with ADHD.


Synthesis of Literature

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            Attention-deficit/ hyperactivity
disorder (ADHD) is a very common neurodevelopmental disorder that is often
first diagnosed in childhood, but can continue and persist into adulthood
(Centers for Disease Control and Prevention CDC, 2017). Symptoms of ADHD
include inattention to detail, difficulty paying attention or performing tasks,
poor planning, following through on instructions, easily distractible,
hyperactive, talks in excess or interrupts others, impulsive, anxiety,
intrusive thoughts, etc. (CDC, 2017). ADHD can then be characterized and
classified as inappropriate/ impairing hyperactivity, impulsivity, and/or
inattention based on presenting symptoms (Rommel, 2015). Typically, ADHD is
diagnosed during childhood, but it can be diagnosed during adulthood. Symptoms
of ADHD in an adult may differ from those seen in childhood, and require only
five symptoms that are present for six months or more, as compared to children
whose diagnosis requires six symptoms present for six months or more. (CDC, 2017).

Neurobiology of ADHD

As stated previously ADHD is a
neurodevelopmental disorder, which is also thought to have some genetic and
environmental component. (Curatolo, 2010). However, there is not one specific
pathologic or physiologic cause for ADHD, and may vary from person to person,
depending on the presenting symptoms (Curatolo, 2010). Based on neuroimaging,
individuals with ADHD were found to have decreased “total cerebral
volume, prefrontal cortex, basal ganglia (striatum), dorsal anterior cingulate
cortex, corpus callosum and the cerebellum” (Curatolo, 2010). The development of the
brain in individuals with ADHD was delayed, peaking about 3 years later than
healthy controls, along with decreased white matter in these areas. The delay
was greatest in the prefrontal region of the brain, which is critical for “control of
cognitive processes, attention and motor planning”, correlating with many of the symptoms
seen in individuals with ADHD (Curatolo, 2010). Along with decreased volume,
adults with ADHD also have a decreased cortical thickness in the frontal and
parietal lobes, which are largely associated with attention (ADHD Institute,
2017). All of the aforementioned brain structures also have some level of under
or over activation, contributing to the neurological basis of the ADHD symptoms
(ADHD Institute, 2017).

On a more chemical level, ADHD has been
associated with dopamine (DA) and norepinephrine (NE).  The levels of DA in adults with ADHD seems to
be decreased in a number of brain structures impacting impulsivity, attentional
accuracy, and response control (ADHD Institute, 2017). Current treatment with
stimulant medication is targeted at the neurotransmitters of DA and NE, which
increase the levels of these neurotransmitters in the brain, allowing for
improvement and control of ADHD symptoms.

Brain-derived neurotrophic factor (BNDF)
is also a significant factor associated with ADHD. BNDF is necessary for
maintaining and differentiating between neurons and synapses within the brain,
allowing for normal brain development. ADHD has been associated with decreased
levels of BNDF causing difficulty in neuron and synapse differentiation in
areas of the brain that are related to memory and learning, and is a
contributing factor to the impairments seen with ADHD. (Berger, 2014).

Background of Adult ADHD

ADHD affects about 2-4% of the general
adult population (Berger, 2014). Adults with ADHD may have problems related to
attention, task completion, time management and higher-level cognitive
functions, which can lead to difficulty and frustration in one’s occupation and
daily life (Adler, 2008) Along with the functional impairments that adults with
ADHD suffer on a day to day basis, adults with ADHD are also at an increased
risk for development of comorbid psychiatric disorders (Berger, 2014). Finding
a way to manage ADHD symptoms in adults is of critical importance to ensure
that they are reaching their maximal capabilities within their everyday life,
without the frustration and stress that ADHD can produce.

Treatment of ADHD

ADHD and its associated symptoms can
cause impairments to individuals’ daily life such as, academic, occupational,
home and social activities. (CDC, 2017). There are multiple treatment methods
available for those diagnosed with ADHD which include, behavioral therapy,
pharmacotherapy of stimulant and nonstimulant drugs, and school accommodations
(for those still enrolled). Although ADHD symptoms and behavior are treated and
controlled during childhood, not all individuals with ADHD grow out of these
behaviors, and the behavior can continue to linger into adulthood (CDC, 2017).

ADHD can lead to functional impairment and difficulty in one’s work, home and
social life, which can lead to frustration, anxiety, and a number of other
problems in these individuals, requiring the need for continued management.

Currently, pharmacotherapy with stimulant
or non-stimulant medications is the treatment of choice for adults with
ADHD.  Many individuals manage their ADHD
symptoms with the use of stimulant medication (methylphenidate-based or
amphetamine-based) or nonstimulant medication (alpha-2 adrenergic agonists)
(Children and Adults with Attention-Deficit/Hyperactivity Disorder CHADD,
2017). However, these medications, stimulants in particular, can have a
multitude of adverse side effects such as “headache, decreased appetite, trouble
sleeping, sudden death in those with cardiac problems, increased blood
pressure, and a number of psychiatric problems” (CHADD, 2017). Therefore, finding an
alternative way to manage the symptoms of ADHD alone, or in combination with
psychosocial behavioral therapy, can greatly improve these individuals’ quality of
life, increase work and academic performance, attentiveness and motivation,
without the potentially harmful side effects seen with current stimulant and
nonstimulant medications available.

Current Research on ADHD and

            Exercise as an alternative or
adjunctive therapy for those diagnosed with ADHD shows some promise in the
little research that has been done. A review done by Anne Den Heijer, although
the review and studies cited were on children, showed that both cardio
(running, cycling, etc.) and non-cardio (tai chi, yoga) had both short and long
term effects on ADHD symptoms. This study found that cardio exercises had
several short term benefits for executive function, impulsivity, response time,
cognitive control, attention, while decreasing interruptive and aggressive
behaviors. Long term effects of cardio exercise improved “attention,
executive function, planning, self-esteem, anxiety, depression and somatic
complaints”, which lasted longer than just the day that the exercise
took place. The non-cardio exercises had a short term effect of improved “attention,
anxiety and conduct, less hyperactivity, inappropriate emotions and daydreaming”. Long term
effects of non-cardio exercise showed improvements in “attention,
ability to cope with stress, flexibility, and behavior”. Although not
specific for adults, this study shows that exercise could be of benefit to help
control many of the symptoms associated with ADHD (Den Heijer, 2017).

            In a study conducted by Amitai
Abramovitch adults with ADHD reported their physical activity with a
questionnaire. Adults who participated in frequent aerobic exercise (biking,
jogging, walking, etc.) for at least thirty minutes, reported less behavioral
impulsivity, intrusive and worrisome thoughts. While not only improving
symptoms of ADHD such as impulsivity, this study suggests that exercise could
also help improve other potential comorbid psychiatric problems such as anxiety
and depression (Abramovitch, 2013). These findings were supported in another
study, in which adult males, after twenty minutes of moderate exercise,
reported “enhanced motivation for metal work, increased energy, and
decreased feelings of depression” (Fritz, 2016). However, this study did
not show that exercise was of benefit to cognitive performance or hyperactivity
(Fritz, 2016).

            Exercise was also found to have a
beneficial effect on the neurobiological mechanism of ADHD, specifically BDNF.

While BDNF is reduced in those with ADHD, physical exercise was shown to “markedly
BDNF within the brain improving this deficit (Archer, 2011). Physical exercise
was found to have effects on stress, anxiety, depression, improving executive
functioning, working memory and impulse control. Even short periods of exercise
(5-15 minutes) were found to help decrease hyperactivity, negative behavior, and
impulsivity. While exercise has been show to help the symptoms of ADHD, this
study shows that exercise may be of direct benefit to help enhance brain
chemicals that are decreased in individuals with ADHD, thus resulting in
symptom improvement (Archer, 2011).

            Other studies showed that physical
activity during adolescence may help decrease the frequency, intensity, and
duration of ADHD symptoms in early adulthood (Rommel, 2015). Thus
implementation of regular exercise in childhood and adolescents may help to
decrease the severity of ADHD symptoms experienced as adults. Implementation of
regular exercise during childhood and adolescents can also help to prevent body
mass index (BMI) changes seen with aging. Adults with ADHD reported a change in
BMI from adolescents to adulthood, and the “relationship among ADHD symptoms and
obesity was largely linear, with more ADHD symptoms being associated with an
increased BMI and obesity” (Fuemmeler, 2016). Thus, if reduction of symptoms during
adolescents can be achieved through physical exercise, this will not only
decrease ADHD symptoms, but could also help individuals have an exercise regimen
ingrained into their daily routine to help maintain a steady BMI and healthy
lifestyle into adulthood.

Questions that Remain

majority of research currently being done surrounding ADHD and exercise is
mostly focused on children. While many of the studies mentioned above showed
positive results from exercise on ADHD symptoms, further investigation is
needed because many of these studies had a multitude of limitations surrounding
adequate control groups, controlling for confounding variables such as comorbid
conditions, small sample size, etc.

Research is currently lacking a
longitudinal type study that shows both short and long term benefits of
exercise on ADHD, and if certain personal factors such as age, fitness level,
and severity of symptoms has an impact on who is more likely to respond to
physical exercise (Rommel, 2015). Research on lifestyle habits should be
conducted to determine if diet, activity, or family has any influence on ADHD
symptoms experienced (Weissenberger, 2017). This may help identify
environmental and social factors that could contribute to ADHD symptoms

Areas that should be further explored
include non-cardio exercises, such as yoga, meditation, tai chi, etc., and how
these exercises affect the symptoms of ADHD. Future studies should be focused
on determining if a certain type of exercise improves some aspects of ADHD more
than others, and which type of physical exercise has the best outcome for
certain cognitive, behavioral and social dysfunctions of ADHD (Den Heijer,
2017) (Weissenberger, 2017). Defining the type, intensity, duration and
frequency of exercise that is most beneficial for different dysfunctions and
symptoms of ADHD could help practitioners recommend specific exercise regimens
based on an individual’s most problematic symptoms.

Research Plan

proposed research question is focused on the effect of yoga practice on the
cognitive, behavioral and social dysfunctions and symptoms of adults (age 18
years or older) with ADHD. Particularly, if one type of yoga practice is of
more benefit for adults with ADHD than other yoga practices, and which ADHD
dysfunction or symptom is most responsive to yoga practice. Since there is
currently limited data about the effects of non-cardio exercise, it is of great
importance to explore this dimension of exercise to bring awareness to other potential
treatment modalities that may enhance functioning and reduce the symptoms of
ADHD. Current treatment with stimulant medication, carries a large number of
adverse side effects, which could be fatal, and exploration into other
alternative and adjunctive treatments can help to decrease the risk associated
with these drugs. Treatment of adult ADHD with exercise has the potential to
not only decrease the symptoms, but also decrease potential comorbid conditions
of anxiety and depression, while improving daily cognitive, behavioral and
social function in adults with ADHD.









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