To Örebro University

BACKGROUND: Adults with attention deficit/hyperactivity disorder (ADHD) often experience difficulties regulating emotions and balancing activity and rest. Impairments such as motor skills challenges and reduced body awareness, including interpretation of sensory signals and attitudes toward the body, often receive little clinical attention despite their potential negative impact on daily functioning and health. The START intervention is a 12-week structured exercise program that combines regular physical exercise with mindful attention to the body during movement. This study aimed to evaluate the effect of the START intervention on body awareness and movement quality in adults with ADHD.

METHODS: In this randomized controlled trial, 63 adults with ADHD were assessed for body awareness and movement quality before and after a 12-week intervention or treatment-as-usual control period using the Body Awareness Scale - Movement Quality and Experience.

RESULTS: Thirty-nine participants completed the study (26 intervention/13 control). Participants in the intervention group showed significantly greater improvement in body awareness compared to the control group, both in total score and in subscales for muscular tension and physical activity. Movement quality improved significantly within the intervention group, although no significant between-group differences were observed.

CONCLUSIONS: Structured physical exercise with mindful attention to the body enhanced body awareness in adults with ADHD compared to standard care. Effects on movement quality were not statistically different between groups and therefore remain uncertain. These findings suggest that such exercise may be a useful complement to conventional treatments and may support a healthier relationship with the body.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by inattention and hyperactivity that impair everyday functioning. While pharmacotherapy remains the mainstay of treatment, clinical guidelines recommend a multimodal approach. However, evidence for physical exercise as an adjunctive treatment option remains scarce. Consequently, there is a large unmet need for the development and evaluation of non-pharmacological treatment options. START is a novel intervention for adults with ADHD that consists of a structured physical exercise programme. The overall aim of this thesis is to evaluate the START intervention as a treatment for adults with ADHD using an interdisciplinary approach. By integrating quantitative assessments of feasibility and clinical outcomes with qualitative analyses of lived experience, the thesis aims to provide a comprehensive understanding of the intervention’s feasibility, relevance and impact. The thesis is based on four papers. Paper I is a randomised pilot study evaluating the feasibility and tolerability of the START intervention; it shows that the intervention was feasible and indicated beneficial trends. Papers II and III are based on a randomised controlled trial of 63 participants. Paper II investigates the effects of the START intervention on core ADHD symptoms, sleep problems and quality of life; its results demonstrate moderate to large effects on all assessed outcomes. Paper III evaluates the effect of START on body awareness and movement quality; the findings show that body awareness was improved by the intervention. Paper IV is a qualitative study exploring participant experiences with the START intervention; its findings reveal multifaceted meanings of exercise and an increased sense of agency through participation. In conclusion, the findings of this thesis suggest that physical exercise in a health care context is a potent treatment option for adults with ADHD.

Adult ADHD is associated with various health challenges and reduced quality of life. Current guidelines recommend multimodal treatment, and physical exercise has emerged as a promising non-pharmacological alternative, although evidence from randomized controlled trials remains limited. In this randomized controlled trial, we aimed to assess the clinical effectiveness of physical exercise as an add-on treatment for adults with ADHD compared to treatment as usual. The trial included adults with a clinically confirmed diagnosis of ADHD was conducted at one Psychiatric clinic in Sweden. Participants were randomly assigned (2:1, no stratification) using an electronic case-report platform, to either physical exercise (the protocolized 12-week intervention START) or treatment as usual (local community care). Primary outcome was the ASRS-v1.1 Symptom checklist at 12 weeks after inclusion. The analysis followed a modified intention-to-treat principle, excluding participants who provided no data beyond baseline. Of the 63 participants enrolled, 43 were randomly assigned to START physical exercise intervention and 20 to treatment as usual. After accounting for withdrawals (n = 11) and loss to follow up (n = 11), the primary analysis included data from 41 participants (30 assigned to START intervention and 11 to treatment as usual). The START intervention resulted in improved ADHD symptoms after 12 weeks, as measured by ASRS-v1.1. Symptom improvement differed significantly between groups (mean difference -6.98, 95% CI: -12.30 to -1.65; p = 0.012) with an effect size of 0.93 favoring the intervention group. No serious adverse events were reported. The results suggest that physical exercise may be a feasible, safe and clinically meaningful complement to standard care for adults with ADHD. However, the findings should be interpreted in the light of potential confounders and methodological limitations. This trial is registered with the ClinicalTrials.gov. Date of registration: 2021-05-14.

CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/study/NCT05049239, identifier NCT05049239.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is associated with sedentary lifestyle, low quality of life and low physical fitness. Studies in children with ADHD have shown that regular physical exercise can help reduce core ADHD symptoms, but evidence for this is lacking in adults. Although guidelines recommend multi-modal treatment, central stimulants (CS) remain the mainstay of treatment. CS are effective in the short-term, but their long-term efficacy remains to be established. There is thus huge unmet need for developing non-pharmacological treatment options, and for well-designed randomized controlled trials (RCTs).

OBJECTIVE: The study aimed to test the feasibility and tolerability of structured moderate-intensity 12-week physical exercise program for adults with ADHD, as a prelude to an adequately powered RCT which includes long-term follow-up.

MATERIALS AND METHODS: Fourteen adults with ADHD were recruited, 9 randomized to an intervention group and 5 to a control group. The intervention group received physiotherapist-led 50-minute mixed exercise program, three times a week for 12 weeks, and the control group treatment as usual. Participants were assessed at baseline and after 6 and 12 weeks using clinical and physical evaluations, self-rating questionnaires, and functional magnetic resonance imaging (fMRI) together with paradigms that tested attention, impulsivity and emotion regulation.

RESULTS: Three participants (21%) dropped out shortly after inclusion before receiving any intervention, while roughly 80% completed the intervention according to protocol. One participant from the intervention group participated in less than 60% of treatment sessions, and one who had done baseline fMRI was unwilling to do post-intervention imaging. Four participants in the intervention group (67%) reported increased stress in prioritizing the intervention due to time-management difficulties. Overall, consistent trends were observed that indicated the feasibility and potential benefits of the intervention on core ADHD symptoms, quality of life, body awareness, sleep and cognitive functioning.

CONCLUSION: Physiotherapist-led twelve-week regular physical exercise is a feasible and potentially beneficial intervention for adults with ADHD. There was a 20% drop-out initially and 67% of those who completed the intervention reported stress with time management difficulties due to participation. A third arm was thus added to the planned RCT where cognitive intervention administered by an occupational therapist will be given together with physical exercise. Clinical Trial Registration: https://clinicaltrials.gov, identifier NCT05049239.

Background: Core symptoms in attention deficit hyperactivity disorder (ADHD) are inattention, impulsivity and hyperactivity. Many individuals with this disorder also have a sedentary lifestyle, co-morbid mental illness such as depressive and anxiety disorders, and reduced quality of life. People with ADHD often have impaired executive function, which among other things may include difficulty in time management and structuring of everyday life. Pharmacological treatment is often the first-line option, but non-pharmacological treatment is also available and is used in clinical settings. In children and adolescents with ADHD, physical exercise is used as a non-pharmacological treatment. However, the evidence for the effectiveness of exercise in adults is sparse.

Objective: To implement the START intervention (START = Stöd i Aktivitet, Rörelse och Träning [Support in activity, movement and exercise]) consisting of a 12-week, structured mixed exercise programme with or without a cognitive intervention, in adults with ADHD, and study whether it has an effect on core symptoms of ADHD as well as physical, cognitive, mental and everyday functioning compared with usual treatment. A secondary aim is to investigate the participants' experiences of the intervention and its possible benefits, and to evaluate the cost-effectiveness of START compared with usual treatment.

Methods: This is a randomized controlled trial planned to be conducted in 120 adults with ADHD, aged 18-65. The intervention will be given as an add-on to standard care. Participants will be randomized to three groups. Group 1 will be given a physiotherapist-led mixed exercise programme for 12 weeks. Group 2 will receive the same intervention as group 1 with the addition of occupational therapist-led cognitive skills training. Group 3 will be the control group who will receive standard care only. The primary outcome will be reduction of ADHD symptoms measured using the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS-v1.1), Clinical Global Impression-Severity scale (CGI-S) and CGI-Improvement scale (CGI-I). The effect will be measured within 1 week after the end of the intervention and 6 and 12 months later.

Discussion: Data collection began in March 2021. The final 12-month follow-up is anticipated to be completed by autumn 2024.

Trial registration: ClinicalTrials.gov (Identifier: NCT05049239). Registered on 20 September 2021 (last verified: May 2021).