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September 2, 2025
Background:
Children with ADHD often experience deficits in cognitive processes called executive functions. One of the main executive functions is working memory, which is crucial for learning and problem-solving. Issues related to working memory can impact not just academic performance, but also self-esteem, social interactions, and future career prospects. Daily challenges can include completing homework, remembering tasks, and maintaining focus in class, further complicating the learning and social experiences of those with ADHD.
Physical activity boosts blood flow to the brain. It also assists neural plasticity, meaning it enables networks of nerve cells to reorganize their connections and grow new connections. That helps improve physical skills and potentially academic performance. It is an engaging, easy-to-implement intervention that effectively and sustainably increases children’s participation, overcoming many limitations of other methods.
Study:
A Chinese study team set out to perform a systematic search of the published peer-reviewed medical literature to conduct a meta-analysis focusing specifically on the efficacy of physical activity for boosting working memory.
The inclusion criteria were fourfold. Studies had to:
Eleven studies with a combined total of 588 participants met the inclusion criteria. Five were rated high quality. None were rated low quality.
Results:
Meta-analysis of these eleven studies yielded a medium effect size improvement in working memory. Variability in study outcomes was acceptable (low heterogeneity). There was no indication of publication bias.
Combined cognitive and aerobic interventions were associated with more than double the effect size of simple aerobic interventions, reaching large effect size (4 studies, 233 participants).
Subgroup analysis favored a happy medium, suggesting there are points beyond which more is not better:
Take-Away:
Because this work focuses on working memory, not the symptoms of ADHD, one cannot conclude that physical activity could replace current therapies for ADHD. It does, however, provide strong evidence that physical activity interventions can meaningfully improve working memory in children with ADHD. The most consistent benefits were seen with structured programs of moderate duration and frequency. As with previous studies, the results seem to suggest that interventions excessively long in duration may have diminishing results, highlighting the importance of optimizing session length, frequency, and total intervention time. Before recommending very specific exercises and durations, however, further study is still needed. Future research should refine protocols and explore mechanisms that maximize effectiveness.
Gong Cheng, Ce Song, and XiaoQin Hong, “The impact of physical activity on working memory in children with ADHD: a meta-analysis,” Frontiers in Psychiatry (2025), 16:1578614, https://doi.org/10.3389/fpsyt.2025.1578614.
A team of Spanish researchers has published a systematic review of 16 studies with a total of 728 participants exploring the effects of physical exercise on children and adolescents with ADHD. Fourteen studies were judged to be of high quality, and two of medium quality.
Seven studies looked at the acute effects of exercise on eight to twelve-year-old youths with ADHD. Acute means that the effects were measured immediately after periods of exercise lasting up to 30 minutes. Five studies used treadmills and two used stationary bicycles, for periods of five to 30 minutes. Three studies "showed a significant increase in the speed of reaction and precision of response after an intervention of 20-30 min, but at moderate intensity (50-75%)." Another study, however, found no improvement in mathematical problem-solving after 25 minutes using a stationary bicycle at low (40-50%) or moderate intensity (65-75%). The three others found improvements in executive functioning, planning, and organization in children after 20- to 30-minute exercise sessions.
Nine studies examined longer-term effects, following regular exercise over many weeks. One reported that twenty consecutive weekly yoga sessions improved attention. Another found that moderate to vigorous physical activity (MVPA) led to improved behavior beginning in the third week, and improved motor, emotional and attentional control, by the end of five weeks. A third study reported that eight weeks of starting the school day with 30 minutes of physical activity led to improvement in Connor's ADHD scores, oppositional scores, and response inhibition. Another study found that twelve weeks of aerobic activity led to declines in bad mood and inattention. Yet another reported that thrice-weekly 45-minute sessions of MVPA over ten weeks improved not only muscle strength and motor skills, but also attention, response inhibition, and information processing.
Two seventy-minute table tennis per week over twelve weeks improved executive functioning and planning, in addition to locomotor and object control skills.
Two studies found a significant increase in brain activity. One involved two hour-long sessions of rowing per week for eight weeks, the other three 90-minute land-based sessions per week for six weeks. Both studies measured higher activation of the right frontal and right temporal lobes in children, and lower theta/alpha ratios in male adolescents.
All 16 studies found positive effects on cognition. Five of the nine longer-term studies found positive effects on behavior. No study found any negative effects. The authors of the review concluded that physical activity "improves executive functions, increases attention, contributes to greater planning capacity and processing speed and working memory, improves the behavior of students with ADHD in the learning context, and consequently improves academic performance." Although the data are limited by a lack of appropriate controls, they suggest that, in addition to the well-known positive effects of physical activity, one may expect to see improvements in ADHD symptoms and associated features, especially for periods of sustained exercise.
Two recent meta-analyses, one by an Asian team, and the other by a European team, have reported encouraging results on the efficacy of physical exercise in treating ADHD among children and adolescents.
One, a Hong Kong-based team (Liang et al. 2021) looked at the effect of exercise on executive functioning.
The team identified fifteen studies with a combined total, of 493 participants that met the criteria for inclusion. As the authors noted, "only a few studies successfully blinded participants and therapists, due to the challenges associated with executing double-blind procedures in non-pharmacological studies."
After adjusting for publication bias, the meta-analysis of the fifteen studies found a large improvement in overall executive functioning.
The studies varied in which aspects of executive functioning were addressed. A meta-analysis of a subset of eleven studies encompassing 406 participants found a large improvement in inhibitory control. A meta-analysis of another subset, of eight studies with a total of 311 participants, found a large improvement in cognitive flexibility. Finally, a meta-analysis of a subset of five studies encompassing 198 participants found a small-to-medium improvement in working memory.
Nine studies involved acute (singular) exercise interventions lasting 5 to 30 minutes, while twelve studies involved chronic (regular) exercise interventions ranging from 6 to 12 weeks, with a total duration of 12 to 75 hours. The chronic exercise was more than twice as effective as acute exercise. The former resulted in large improvements in overall executive functioning, the latter in small-to-medium improvements.
No significant differences were found between aerobic exercises (such as running and swimming) and cognitively engaging exercises(such as table tennis and other ball games, and exergaming ... video games that are also a form of exercise, relying on technology that tracks body movements).
The authors concluded that "Chronic sessions of exercise interventions with moderate intensity should be incorporated as a treatment for children with ADHD to promote executive functions."
Meanwhile, a German study team (Seiffer et al. 2021) looked at the effects of regular, moderate-to-vigorous physical activity on ADHD symptoms in children and adolescents.
They found eleven studies meeting their criteria, with a combined total of 448 participants. A meta-analysis of all eleven studies found a small-to-moderate decline in ADHD symptoms. However, the three studies with blinded outcome assessors found a large and statistically highly significant decline in symptoms, whereas the eight studies with blinded outcome evaluators found only a small decline that was not statistically significant.
When compared with active controls using pharmacotherapy in a subgroup of two studies with 146 participants, pharmacotherapy held a small-to-moderate advantage that fell just short of statistical significance, most likely because of the relatively small sample size.
The authors concluded that moderate to vigorous physical activity (MVPA) "could serve as an alternative treatment for ADHD," but that additional randomized controlled trials "are necessary to increase the understanding of the effect regarding frequency, intensity, type of MVPA interventions, and differential effects on age groups."
Noting that "Growing evidence shows that moderate physical activity (PA) can improve psychological health through enhancement of neurotransmitter systems," and "PA may play a physiological role similar to stimulant medications by increasing dopamine and norepinephrine neurotransmitters, thereby alleviating the symptoms of ADHD," a Chinese team of researchers performed a comprehensive search of the peer-reviewed journal literature for studies exploring the effects of physical activity on ADHD symptoms.
They found nine before-after studies with a total of 232 participants, and fourteen two-group control studies with a total of 303 participants, that met the criteria for meta-analysis.
The meta-analysis of before-after studies found moderate reductions in inattention and moderate-to-strong reductions in hyperactivity/impulsivity. It also reported moderate reductions in emotional problems and small-to-moderate reductions in behavioral problems.
The effect was even stronger among unmediated participants. There was a very strong reduction in inattention and a strong reduction in hyperactivity/impulsivity.
The meta-analysis of two-group control studies found strong reductions in inattention, but no effect on hyperactivity/impulsivity. It also found no significant effect on emotional and behavioral problems.
There was no sign of publication bias in any of the meta-analyses.
The authors concluded, "Our results suggest that PA intervention could improve ADHD-related symptoms, especially inattention symptoms. However, due to a lot of confounders, such as age, gender, ADHD subtypes, the lack of rigorous double-blinded randomized-control studies, and the inconsistency of the PA program, our results still need to be interpreted with caution."
Many studies have shown that ADHD is associated with increased risks of suicidal behavior, substance misuse, injuries, and criminality. As we often discuss in our blogs, treatments for ADHD include medication and non-medication options, such as CBT (Cognitive Behavioral Therapy). While non-drug approaches are often used for young children or mild cases of ADHD, medications – both stimulants and non-stimulants – are common for adolescents and adults.
Global prescriptions for ADHD drugs have risen significantly in recent years, raising questions about their safety and effectiveness. Randomized controlled trials have demonstrated that medication can help reduce the core symptoms of ADHD. However, research from these trials still offers limited or inconclusive insights into wider and more significant clinical outcomes, such as suicidal behavior and substance use disorder.
An international study team conducted a nationwide population study using the Swedish national registers. Sweden has a single-payer national health insurance system, which covers nearly every resident, enabling such studies. The researchers examined all Swedish residents aged 6 to 64 who received their first ADHD diagnosis between 2007 and 2018. Analyses of criminal behavior and transport accidents focused on a subgroup aged 15 to 64, since individuals in Sweden must be at least 15 years old to be legally accountable for crimes or to drive.
The team controlled for confounding factors, including demographics (age at ADHD diagnosis, calendar year, sex, country of birth, highest education (using parental education for those under 25), psychiatric and physical diagnoses, dispensations of psychotropic drugs, and health care use (outpatient visits and hospital admissions for both psychiatric and non-psychiatric reasons).
Time-varying covariates from the previous month covered diagnoses, medication dispensations, and healthcare use. During the study, ADHD treatments licensed in Sweden included amphetamine, atomoxetine, dexamphetamine, guanfacine, lisdexamphetamine, and methylphenidate.
After accounting for covariates, individuals diagnosed with ADHD who received medication treatment showed better outcomes than those who did not. Specifically:
-Suicidal behaviors dropped by roughly 15% in both first-time and recurrent cases.
-Initial criminal activity decreased by 13%, with repeated offences falling by 25%.
-Substance abuse initiation declined by 15%, while recurring substance abuse was reduced
by 25%.
-First automotive crashes were down 12%, and subsequent crashes fell by 16%.
There was no notable reduction in first-time accidental injuries, and only a marginally significant 4% decrease in repeated injuries.
The team concluded, “Drug treatment for ADHD was associated with beneficial effects in reducing the risks of suicidal behaviours, substance misuse, transport accidents, and criminality, but not accidental injuries when considering first event rate. The risk reductions were more pronounced for recurrent events, with reduced rates for all five outcomes.”
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Background:
Pharmacotherapies, such as methylphenidate, are highly effective for short-term ADHD management, but issues remain with medication tolerability and adherence. Some patients experience unwanted side effects from stimulant medications, leaving them searching for alternative ADHD treatments. Alternative treatments such as cognitive training, behavioral therapies, psychological interventions, neurofeedback, and dietary changes have, so far, shown limited success. Thus, there is a critical need for non-pharmacological options that boost neurocognitive performance and address core ADHD symptoms.
First— What Are NIBS (Non-Invasive Brain Stimulation) Techniques?
Non-invasive brain stimulation (NIBS) techniques, including transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS), transcranial alternating current stimulation (tACS), and repetitive transcranial magnetic stimulation (rTMS) are generating growing attention within the scientific community.
NIBS techniques are methods that use external stimulation, such as magnets or electrical currents, to affect brain activity without any invasive procedures. In transcranial alternating current stimulation (tACS), for example, small electrodes are placed on the scalp of the patient, and a weak electrical current is administered.
The theory behind these techniques is that when a direct current is applied between two or more electrodes placed on specific areas of the head, it makes certain neurons more or less likely to fire. This technique has been successfully used to treat conditions like depression and anxiety, and to aid recovery from stroke or brain injury.
The Study:
Previous meta-analyses have produced conflicting indications of efficacy. A Chinese research team consisting of sports and rehabilitative medicine professionals has just published a network meta-analysis to explore this further, through direct comparison of five critical outcome domains: inhibitory control, working memory, cognitive flexibility, inattention, hyperactivity and impulsivity.
To be included, randomized controlled trials needed to have participants diagnosed with ADHD, use sham control groups, and assess ADHD symptoms and executive functions – such as inhibitory control, working memory, cognitive flexibility, inattention, hyperactivity, and impulsivity – using standardized tests.
A total of thirty-seven studies encompassing 1,615 participants satisfied the inclusion criteria. It is worth noting, however, that the authors did not specify the number of randomized controlled trials nor the number of participants included in each arm of the network meta-analysis.
Furthermore, the team stated, “We checked for potential small study effects and publication bias by conducting comparison-adjusted funnel plots,” but did not share their findings. They also did not provide information on outcome variation (heterogeneity) among the RCTs.
Results:
Ultimately, none of the interventions produced significant improvements in ADHD symptoms, whether in inattention symptoms or hyperactivity/impulsivity symptoms. Likewise, none of the interventions produced significant improvements in inhibitory control. Some tDCS interventions enhanced working memory and cognitive flexibility, but details about trial numbers and participants were missing. The team concluded, “none of the NIBS interventions significantly improved inhibitory control compared to sham controls. … In terms of working memory, anodal tDCS over the left DLPFC plus cathodal tDCS over the right DLPFC … and anodal tDCS over the right inferior frontal cortex (rIFC) plus cathodal tDCS over the right supraorbital area ... were associated with significant improvements compared to sham stimulation. For cognitive flexibility, only anodal tDCS over the left DLPFC plus cathodal tDCS over the right supraorbital area demonstrated a statistically significant benefit relative to sham. ... Compared to the sham controls, none of the NIBS interventions significantly improved inattention. ... Compared to the sham controls, none of the NIBS interventions significantly improved hyperactivity and impulsivity.”
How Should We Interpret These Results?
In a word, skeptically.
If one were to read just the study’s abstract, which states, “The dual-tDCS and a-tDCS may be considered among the preferred NIBS interventions for improving cognitive function in ADHD”, it might seem that the takeaway from this study is that this combination of brain stimulation techniques might be a viable treatment option for those with ADHD. Upon closer inspection, however, the results do not suggest that any of these methods significantly improve ADHD symptoms. Additionally, this study suffers from quite a few methodological flaws, so any results should be viewed critically.
Background:
Despite recommendations for combined pharmacological and behavioral treatment in childhood ADHD, caregivers may avoid these options due to concerns about side effects or the stigma that still surrounds stimulant medications. Alternatives like psychosocial interventions and environmental changes are limited by questionable effectiveness for many patients. Increasingly, patients and caregivers are seeking other therapies, such as neuromodulation – particularly transcranial direct current stimulation (tDCS).
tDCS seeks to enhance neurocognitive function by modulating cognitive control circuits with low-intensity scalp currents. There is also evidence that tDCS can induce neuroplasticity. However, results for ADHD symptom improvement in children and adolescents are inconsistent.
The Method:
To examine the evidence more rigorously, a Taiwanese research team conducted a systematic search focusing exclusively on randomized controlled trials (RCTs) that tested tDCS in children and adolescents diagnosed with ADHD. They included only studies that used sham-tDCS as a control condition – an essential design feature that prevents participants from knowing whether they received the active treatment, thereby controlling for placebo effects.
The Results:
Meta-analysis of five studies combining 141 participants found no improvement in ADHD symptoms for tDCS over sham-TDCS. That held true for both the right and left prefrontal cortex. There was no sign of publication bias, nor of variation (heterogeneity) in outcomes among the RCTs.
Meta-analysis of six studies totaling 171 participants likewise found no improvement in inattention symptoms, hyperactivity symptoms, or impulsivity symptoms for tDCS over sham-TDCS. Again, this held true for both the right and left prefrontal cortex, and there was no sign of either publication bias or heterogeneity.
Most of the RCTs also performed follow-ups roughly a month after treatment, on the theory that induced neuroplasticity could lead to later improvements.
Meta-analysis of four RCTs combining 118 participants found no significant improvement in ADHD symptoms for tDCS over sham-TDCS at follow-up. This held true for both the right and left prefrontal cortex, with no sign of either publication bias or heterogeneity.
Meta-analysis of five studies totaling 148 participants likewise found no improvement in inattention symptoms or hyperactivity symptoms for tDCS over sham-TDCS at follow-up. AS before, this was true for both the right and left prefrontal cortex, with no sign of either publication bias or heterogeneity.
The only positive results came from meta-analysis of the same five studies, which reported a medium effect size improvement in impulsivity symptoms at follow-up. Closer examination showed no improvement from stimulation of the right prefrontal cortex, but a large effect size improvement from stimulation of the left prefrontal cortex.
Interpretation:
It is important to note that the one positive result was from three RCTs combining only 90 children and adolescents, a small sample size. Moreover, when only one of sixteen combinations yields a positive outcome, that begins to look like p-hacking for a positive result.
In research, scientists use something called a “p-value” to determine if their findings are real or just due to chance. A p-value below 0.05 (or 5%) is considered “statistically significant,” meaning there's less than a 5% chance the result happened by pure luck.
When testing twenty outcomes by this standard, one would expect one to test positive by chance even if there is no underlying association. In this case, one in 16 comes awfully close to that.
To be sure, the research team straightforwardly reported all sixteen outcomes, but offered an arguably over-positive spin in their conclusion: “Our study only showed tDCS-associated impulsivity improvement in children/adolescents with ADHD during follow-ups and anode placement on the left PFC. ... our findings based on a limited number of available trials warrant further verification from large-scale clinical investigations.”
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