Exercise as it relates to Disease/Can Table Tennis improve motor skills and executive functions in children with ADHD?
This article is a critical analysis of the paper: "Effects of Physical Exercise Intervention on Motor Skills and Executive Functions in Children With ADHD: A Pilot Study” (Pan et al, 2015). 
What is the background to this research?
- Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that causes attention issues, impulsive behaviour and hyperactivity.  ADHD can interrupt a person’s ability to demonstrate age appropriate behavioural, cognitive function and can cause life-long educational, social and emotional issues.  United States ADHD rates have increased in children between ages 12-17 according to data collected over 20 years by the National Health Interview Survey (NHIS). In 2016, the rate was 13.5% compared to 7.2% in 1997. 
- A 2011 study found children with ADHD had a higher risk of becoming obese  due to high anxiety levels  and poor social interactions contributing to poor cardiovascular function and physical inactivity.  Medication and behavioural interventions can be effective treatments in treating ADHD, however, not all individuals will respond to pharmacological and behavioural treatments. 
- The study aimed to establish if physical activity such as table tennis which combines both cognitive and physical functions has a role in helping cognitive and executive functions in ADHD children. Earlier studies have shown physical activity can improve motor/neuropsychological performances, muscular capabilities, and social and behavioural problems.  However, those studies mainly focused on aerobic exercise and the FITT principals (frequency, time and intensity) and not exercise based complex motor skills typical of an activity like table tennis.
Where is the research from?
- The study was published in 2015 in Taiwan. It focussed on male children with and without ADHD between 7 to 12 years of age, recruited through media announcements, from local primary schools and paediatric facilities.  No details about when the data collection was taken have been mentioned in the study.
- Chien – Yu Pan is one of the authors. He is a professor at the National Kaohsiung Normal University within the Department of Physical Education in Taiwan. Pan along with his co-authors have been involved in many studies specialising in physical activity in people with autistic and neurodevelopmental disorders. 
- According to its authors, there was no conflicts of interest associated with the study to benefit on their behalf. 
What kind of research was this?
- The research was conducted as a pilot study. Pilot studies are small-scale studies conducted before a main study is executed. It is used to refine research methods, and to identify errors or issues within the project, and whether it is even feasible. 
What did the research involve?
- The study involved 3 groups of all male participants: a training group with ADHD, ADHD non-training group and non-ADHD non-training group. The study involved a 12-week table tennis program, twice a week for 70 mins with each session focusing on motor skills and executive functions. 
- The study used the TGMD-2 Test to exam motor skills of 3 to 10-year old which were broken down into locomotor (e.g. run, hop, jump) and object control skills (e.g. catch, throw, bat). 
- The Stroop colour and word test: was used to assess executive function. The aim of the task: is to name the colour but to ignore what is written. The amount of correct answers was calculated in 45 seconds.
- To measure executive functions, a computerised version of the Wisconsin Card Sorting Test (WCST):
Limitations of the Study
- The study only included a small sample size of all male participants aged 7 to 12 years which limits the generalisability of the results. 
- The medication dose and type were not controlled and could have varied between the participants. Controlling the medication could have provided a more accurate representation of the benefits of exercise on ADHD children. 
- The tests used in this study only explored limited assessments of motor skills and executive functions which meant a participant’s full abilities were not assessed. 
- In a future main study, these limitations could be addressed in order to provide a more useful and accurate representation of the benefits of exercise based complex motor skills on ADHD children.
What were the basic results?
|Group||ADHD Training group||ADHD Non-Training||Non-ADHD-Non-Training|
*Pre and post-test = out of 48 marks 
- The ADHD training group significantly improved their locomotor and object-control baseline marks compared to the other groups, indicating exercise program had a positive effect on this population. The ADHD training group were able to increase their correct answers by 8.74 in 45 seconds in the Stroop test compared to marginal improvement in the non-training ADHD group. The ADHD training group improved significantly in total correct answers by 10.94 in the WCST test compared to 0.9 improvement achieved by other groups. In addition, it is possible at least some of the improvement in other groups may have been due to familiarity of test conditions.
What conclusions can we take from this research?
- The study conclusions suggest sport specific physical exercise can be used as a beneficial intervention that provides a safe and positive change on motor skills and some functions in ADHD children. However, further research would be required to address the limitations of the study including the absence of females because it has been shown males and females have different strengths and weaknesses in cognitive functions. 
- A future area of study might identify if ADHD males and females react differently and if the benefits of exercise interventions are similar across genders. It also is not clear to what extent medication interfered with the results.
For people with ADHD:
- Undertaking moderate intensity aerobic exercise for 40 minutes three times a week has shown to improve behavioural and cognitive responses in patients with ADHD. 
- Adopting exercise into a daily routine should help those with ADHD, however, if this amount cannot be achieved, starting with some exercise is always better than no exercise. A good starting point would be to follow the Australian Physical Activity Guidelines.
For future researchers interested in the benefits of exercise among those with ADHD there are several areas that could be explored:
- For instance, determining if sport specific, aerobic or resistance training is more beneficial for ADHD children or whether such interventions could address other related issues such as obesity or high social anxiety.  Understanding whether various ages and genders benefit from certain exercise interventions could also be explored.
The following resources provide fact-sheets, further support, and research studies regarding the effects of exercise on ADHD:
- Exercise Improves Behavioural, Neurocognitive, and Scholastic Performance in Children with Attention-Deficit/Hyperactivity Disorder:
- Australia's Physical Activity and Sedentary Behaviour Guidelines and the Australian 24-Hour Movement Guidelines:
- Neuroelectric and Behavioural Effects of Acute Exercise on Task Switching in Children with Attention-Deficit/Hyperactivity Disorder:
- Pan C, Tsai C, Chu C, Sung M, Huang C, Ma W. Effects of Physical Exercise Intervention on Motor Skills and Executive Functions in Children With ADHD: A Pilot Study. Journal of Attention Disorders. 2015;23(4):384-397
- Coombes S. Attention Deficit Hyperactivity Disorder (ADHD) - Brain Foundation [Internet]. Brain Foundation. [cited 8 September 2019]. Available from: https://brainfoundation.org.au/disorders/attention-deficit-hyperactivity-disorder-adhd/
- General Prevalence of ADHD - CHADD [Internet]. CHADD. [cited 10 September 2019]. Available from: https://chadd.org/about-adhd/general-prevalence/
- Morano, M., Colella, D., Robazza, C., Bortoli, L., Capranica, L. (2011). Physical self-perception and motor performance in normal-weight, overweight and obese children. Scandinavian Journal of Medicine & Science in Sports, 21, 465-473
- Ayaz, A. B., Ayaz, M., Yazgan, Y., Akın, E. (2013). The relationship between motor coordination and social behaviour problems in adolescents with attention-deficit/hyperactivity disorder. Bulletin of Clinical Psychopharmacology, 23, 33-41.
- Pan, C. Y., Chang, Y. K., Tsai, C. L., Chu, C. H., Cheng, Y. W., Sung, M. C. (2017). Effects of physical activity intervention on motor proficiency and physical fitness in children with ADHD: An exploratory study. Journal of Attention Disorders, 21, 783-795. doi:10.1177/1087054714533192.
- Hoza, B., Gerdes, A. C., Mrug, S., Hinshaw, S. P., Bukowski, W. M., Gold, J. A., . . .Wells, K. C. (2005). Peer-assessed outcomes in the multimodal treatment study of children with attention deficit hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 34, 74-86
- Verret, C., Guay, M., Berthiaume, C., Gardiner, P., Beliveau, L. (2012). A physical activity program improves behavior and cognitive functions in children with ADHD: An exploratory study. Journal of Attention Disorders, 16, 71-80
- Crossman A. How a Pilot Study Can Improve Sociological Research [Internet]. ThoughtCo. 2019 [cited 6 September 2019]. Available from: https://www.thoughtco.com/pilot-study-3026449
- Upadhayay N. Comparison of Cognitive Functions Between Male and Female Medical Students: A Pilot Study. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. 2014.
- Ahmed G, Mohamed S. Effect of Regular Aerobic Exercises on Behavioural, Cognitive and Psychological Response in Patients with Attention Deficit-Hyperactivity Disorder. Life Science Journal. 2011;8(2).