Exercise is hugely beneficial to ADHD brains. It can also be pretty boring. And tiring. And inconvenient. And expensive.

All of which makes exercise a game-changing and seldom-used tool for ADHD management. In a recent ADDitude survey, 55% of respondents said they were dissatisfied with their exercise regimen and physical health. The most common obstacles cited by the 1,885 respondents include:

• Sticking to an exercise routine: 59%
• Just getting started: 43%
• Overcoming boredom with exercise: 21%
• Managing a disability that impacts physical activity: 17%
• Pushing myself to try something new: 9%
• Finding an affordable, accessible workout options: 7%

“The motivation to continue with exercise is a major challenge. Boredom is a total killer of any good intentions in this, as in other, life realms.” — Liv, Texas

“I struggle with fatigue and lack of motivation due to over-exertion of executive function demands.” — Tracey, California

[Read: The ADHD Exercise Solution]

Exercise Apps for ADHD Brains

Convenient, low-cost, and rated 2.82 (out of 5) on our helpfulness scale, exercise apps can kickstart and fuel an exercise routine. Whether you prefer yoga, running, or pumping iron, there’s an app that can support your workout goals. Here are our readers’ 10 top recommendations:

• Couch to 5K: a 9-week running program
• Yoga with Adriene: an inclusive yoga program for every body
• Silver Sneakers: Free for adults 65+ with some Medicare plans
• Nike Training Club: A network of at-home workouts from world-class trainers
• MapMyFitness: Find a place to exercise anywhere
• Nerd Fitness: Nutrition, fitness, and motivation
• My Fitness Pal: Convenient tracking of calories, movement, and goals
• Seven: A library of seven-minute workouts
• Strava: The social network for runners
• Bodi: On-demand fitness classes ranging from yoga to power lifting
• Curves: A women’s fitness club
• Classpass: A gateway to independent fitness and exercise classes
• Peloton: Thousands of exercise classes, many of which don’t require a bike

“Fitness Blender is super ADHD-friendly. It has a huge variety of free workout videos of varying length and style. You can search with lots of different filters to find exactly what you want or purchase multi-week courses. There are ‘fitness dice’ with different no-equipment exercises on each side. You roll the dice to discover your mini-workout for the day.” — Alice, Alaska

[Read: Exercise and the ADHD Brain – The Neuroscience of Movement]

“Ladder is an exercise app that offer short workouts with equipment I have at home. It creates a weekly workout plan that has kept me from getting bored and has a coach talking you through and motivating you during your workout.” — Alison, Colorado

How to Start Working Out: Helpful Supports

What motivates people with ADHD to start exercising, and to stick with it, despite boredom, fatigue and other hurdles? ADDitude readers chimed in by rating the supports they find most helpful (out of 5):

• Personal trainer: 3.66
• Accountability partner(s): 3.33
• Gym or fitness class membership: 3.06
• Race or event registration to apply deadline pressure: 3.02
• Spouse, family member, friend: 2.94
• Exercise app: 2.82
• ADHD coach: 2.79
• In-home exercise equipment: 2.72
• Online exercise class subscription: 2.51

“Exercise trainers were incredibly helpful to make me stick to an exercise routine, not to mention learning about proper exercise form, nutrition etc.” — Liv, Texas

“Taking up competitive sport for the thrill factor, accountability, training routine and social interaction was the most helpful.” — Tony, Australia

How to Start Working Out: Reader-Tested Techniques

Anyone with ADHD knows that the slogan “Just do it” doesn’t motivate neurodivergent people to lace up their Nikes. What does work? Here is the most popular advice from our readers:

Exercise Before Coffee

“By exercising first thing, I get it over with right away, and I can move on with my day without exercise looming over my head. It also helps me to eat healthier and have more energy during the day.” — Rachel, Minnesota

“Daily exercise is probably the thing that helps me most with ADHD management, physical and mental health. The first thing I do in the morning is a 30-minute, very low-intensity routine. The key here is to lower the bar, by keeping it simple and easy, and turning it into a daily habit.” — Joanna, France

Invest

“Giving myself permission to spend money on a personal trainer has been the single best thing I’ve done as an adult. It hits all my triggers: I’ve spent money on it, have a scheduled appointment, someone else has to come up with what we are doing, and I have an accountability partner — all in one.” — LN, Wisconsin

Prioritize Fun

“I do dancing because I love it, yoga for relaxation, white water rafting for the adrenaline and fun, and swimming in natural waters because I feel really joyful to mingle with Mother Nature!” — An ADDitude Reader

“I download books and podcasts to listen to while walking the dog. If I only allow myself to listen to the series or book while exercising, I look forward to the next exercise.” — Ellie, Virginia

Do It at Home

“I got an under-the-desk elliptical that I love, as it alleviates the anxious energy I have while I have to sit at my desk, and I can do something productive with my feet instead of having non-stop leg shaking going on.” — Laura, Arizona

Do It Anywhere But Home

“I have to do exercise outside the home because there are too many excuses (laundry, email, cleaning) at home.” — Valeria, Colorado

Incorporate It Into Your Daily Routine

“I take bathroom breaks at work at least one floor away so I use the stairs multiple times a day.” — An ADDitude reader in Washington

“Park 15 minutes away from work, or get off the bus five stops early. The quiet walking time is a very nice way to gear up for the work day.” — Francine, Canada

“Have a dog that demands walks.” — MC, Canada

Identify a Goal

“Start something that has short-term goals that progress to long-term goals as part of the program, like martial arts. That’s how I ended up earning black belts in two different arts.” — An ADDitude Reader

“When I was running, signing up to participate in 5k and 10k races helped.” — Keena, Wisconsin

“Have a Plan A (big workout or run) and a Plan B (small workout or run) if you have no energy for Plan A. That way, I still feel like I’ve achieved my goal, even if it’s just five minutes of exercise.” — Alex, New Zealand

Recruit an Accountability Partner

“I walk with a friend who has limited availability; knowing that encourages me to join her on the two afternoons a week she is available.” — Dianne, Massachusetts

“I enjoy Apple Watch sharing with friends. We can compete and that keeps me from skipping workouts.” — Cassie, South Carolina

“I started horseback riding in spring, and for the health of the horse I have to exercise. Doing it for the horse is extremely helpful.” — Veronika, Germany

How to Start Working Out: Next Steps

• Read: I Can’t Muster Workout Motivation!
• Read: The Best Workout Apps for Your ADHD Brain & Body
• Read: Sports for ADHD – The Activities That Activate Neurodivergent Brains

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Q: Do people with ADHD experience winter depression more often and more severely than do neurotypical individuals? Also, why is my quality of sleep affected in winter?

Winter depression is marked by two or more weeks of low mood, usually starting in the Northern Hemisphere’s fall or winter when there is less daylight, that resolves in the spring or summer when there is more light. There is an association between winter depression, also known as seasonal affective disorder, or SAD, and ADHD.

In the Netherlands, where I live, researchers asked 259 patients with ADHD about seasonal mood swings; 27% reported winter depression compared with 3% in neurotypical people.¹ Other researchers have confirmed this increased rate among people with ADHD.² What’s more, females are four times more likely than males to have winter depression.¹

Sleep problems are also common among people with ADHD: About 80% are late sleepers³ , which means they have a short sleep duration — they fall asleep at a later time and sleep less because they must wake up for work or school.

Q : How does winter depression relate to screen addiction in children with ADHD?

Children with ADHD who are late sleepers and who experience winter depression may turn to video games and the Internet. Screens emit blue light, and they’re often held close to the eye, so the effects are similar to light therapy if you’re staring at them for a while.

[Get This Free Download: How to Sleep Better with ADHD]

Screen use at night can induce delayed circadian rhythms, disrupting your sleep-wake cycle.⁴ Many children with ADHD are already late sleepers, so using screens after 9:30 pm will delay their rhythm even more; this is not recommended. Keep in mind that when sleep gets delayed, mood is affected.

The good news is that winter depression and sleep problems can be easily and quickly treated with artificial light therapy. A 10,000-lux light therapy lamp can be used for 30 minutes a day for 5 to 20 consecutive days. The lamp, or light box, should be used at a close distance to your eyes; the distance is very important for the intensity of the treatment. It’s best to do this every day at the same time, preferably between 7 and 8 am, to reset your biological clock and alter the sleep-wake cycle.

You may also consider using light therapy glasses, which work in the same way as lamps. You can wear these for 30 minutes a day while you’re dressing or eating breakfast; in other words, without disrupting your routine.

Light therapy is a serious antidepressant that often unlocks better mood, improved sleep, and more energy.

[Read: How to Fall Asleep with a Rowdy, Racing ADHD Brain]

Q:  Is vitamin D recommended for people with winter depression?

If your vitamin D is too low, then taking vitamin D is recommended. Vitamin D is generally low in people with ADHD, though we don’t know why.⁵ You get vitamin D from sunlight; in winter, when there is less light, you may need to take a supplement. Another way we can get vitamin D is by eating fatty fish, though many people don’t eat enough to affect levels.

Winter Depression: Next Steps

• Self-Test: Could You Have Delayed Sleep Phase Disorder?
• Read: 9 Sleep Deprivation Solutions for Adults with ADHD
• Read: 6 Tips to Overcoming Winter Depression
  

J.J. Sandra Kooij, M.D., Ph.D., is a psychiatrist and head of the Expertise Center Adult ADHD at PsyQ in the Netherlands.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹Amons, P. J., Kooij, J. J., Haffmans, P. M., Hoffman, T. O., & Hoencamp, E. (2006). Seasonality of mood disorders in adults with lifetime attention-deficit/hyperactivity disorder (ADHD). Journal of affective disorders, 91(2-3), 251–255. https://doi.org/10.1016/j.jad.2005.11.017

²Wynchank, D. S., Bijlenga, D., Lamers, F., Bron, T. I., Winthorst, W. H., Vogel, S. W., Penninx, B. W., Beekman, A. T., & Kooij, J. S. (2016). ADHD, circadian rhythms and seasonality. Journal of psychiatric research, 81, 87–94. https://doi.org/10.1016/j.jpsychires.2016.06.018

³Van Veen, M. M., Kooij, J. J., Boonstra, A. M., Gordijn, M. C., & Van Someren, E. J. (2010). Delayed circadian rhythm in adults with attention-deficit/hyperactivity disorder and chronic sleep-onset insomnia. Biological psychiatry, 67(11), 1091–1096. https://doi.org/10.1016/j.biopsych.2009.12.032

⁴Hartstein, L. E., Mathew, G. M., Reichenberger, D. A., Rodriguez, I., Allen, N., Chang, A. M., Chaput, J. P., Christakis, D. A., Garrison, M., Gooley, J. J., Koos, J. A., Van Den Bulck, J., Woods, H., Zeitzer, J. M., Dzierzewski, J. M., & Hale, L. (2024). The impact of screen use on sleep health across the lifespan: A National Sleep Foundation consensus statement. Sleep health, 10(4), 373–384. https://doi.org/10.1016/j.sleh.2024.05.001

⁵Khoshbakht, Y., Bidaki, R., & Salehi-abargouei, A. (2018). Vitamin D Status and Attention Deficit Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Observational Studies.. Advances in nutrition, 9 1, 9-20 . https://doi.org/10.1093/advances/nmx002.

In this final installment of ADDitude magazine’s two-part series, “The Future of ADHD” (the first part appeared in the Winter 2023 issue), I’ll explain each of the developments poised to revolutionize ADHD understanding and treatment.

New Pharmacologic Interventions for ADHD

Development of pharmacologic interventions for ADHD has mushroomed over the last two decades. Though researchers have made progress in developing non-stimulant treatment options (i.e., long-acting forms of clonidine and guanfacine, as well as atomoxetine and viloxazine), most of the FDA-approved agents are simply tweaks of methylphenidate and amphetamine compounds.

There are now more choices available to prescribers and patients, offering stimulant preparations of varying durations, delivery formats (patch, liquid, tablet, capsule), and pharmacokinetic profiles. It should be noted that both older and newer preparations are exceptionally effective for most patients and, when comparing them to non-stimulants in head-to-head trials and in clinical practice, the psychostimulants generally win hands-down. However, the various forms of psychostimulants differ in their rate of onset, duration of coverage, convenience (once daily vs. multiple doses daily), and cost.

Psychostimulants, however, are not effective for everyone; about 30% of patients may not have a satisfactory response.¹ As a result, researchers are increasingly exploring the benefits of combining psychostimulant treatment with other compounds (e.g., methylphenidate paired with atomoxetine, or a dextroamphetamine compound plus guanfacine).

[Get This Free Download: 2024 Scorecard of ADHD Treatments]

The robust effectiveness of psychostimulants in treating ADHD has somewhat slowed the development of alternatives. However, researchers are exploring newer agents that target different neurotransmitter systems, including:

• Solriamfetol (used to treat excessive daytime drowsiness)
• Tipepidine (used as a cough suppressant)
• Amantadine (used to treat Parkinson’s disease)
• Dasotraline (used to treat depression and other disorders)

Not yet FDA-approved for ADHD, these compounds face two main challenges: matching the effectiveness of psychostimulants and effectively targeting symptoms not currently treated by psychostimulants.

ADHD and the Gut-Brain Axis

Emerging research suggests a significant, but underappreciated, relationship between the gut biome — a diverse community of microorganisms living in the digestive tract — and behavior and emotions. The gut and the brain communicate through the gut-brain axis, allowing gut microbiota to influence brain function and vice versa.

Multiple studies have now shown that abnormalities in the gut microbiome can affect mood, anxiety, and stress levels.² Certain gut bacteria can even produce neurotransmitters like serotonin and gamma-aminobutyric acid (GABA), which play a crucial role in regulating emotions.³ Other gut bacteria can produce toxins, inflammatory molecules, and other metabolites that can cross the blood-brain barrier to adversely impact brain health and cognitive function.⁴

[Get This Free Download: Lifestyle Changes for Adults with ADHD]

Imbalances in the gut microbiome can be caused by diet, stress, and even antibiotic use during the prenatal period or during infancy.^{5 6} Longitudinal studies have shown that these gut factors can be linked to mental health disorders, including ADHD, in later childhood.⁷ Multiple studies also suggest that restoring a healthy gut balance through probiotics, prebiotics, or dietary changes might improve emotional wellbeing.⁸ Research involving the microbiome’s impact on human behavior and emotions is still emerging.

ADHD and Gene-Environment Interactions

ADHD is highly heritable; however, environmental influences are exceptionally important in determining whether, when, and how a set of genes will manifest in ADHD symptoms. Environments determine whether a particular illness or disease manifests. This area of research — how certain genes are differentially expressed due to differences in environments — is in its infancy.

A major challenge: Because there are so many genes and possible environmental factors unfolding over time, there are literally trillions of possible gene-environment interactions that could affect the timing, severity, and persistence of ADHD. Due to the likely number and complexity of these interactions, multiple replications across independent studies will be essential.

Several studies have already shown that the severity and persistence of ADHD can be a function of parent-child interactions and supervision across different settings.⁹ This is not a “blame the parents” finding, but, instead, suggests that certain interventions from caregivers (and possibly teachers, coaches, and other adults) may mitigate a child’s symptom severity and persistence. For example, teaching parents how to remain neutral, or even express warmth in the face of difficult behaviors, is likely an important area of intervention. Related findings indicate that parental rejection¹⁰ can affect a child’s outcomes, as can the level of household disorganization¹¹, overall life stress¹², and other factors. Attention to such challenges offers an opportunity for targeted interventions.

Many different factors contribute to ADHD’s etiology, timing of onset, and severity, as well as possibilities for prevention and person-specific treatment. Our research to date, and our research programs unfolding over the next decades, will continue to lead to advances in the way we diagnose and treat ADHD in childhood and in adults.

ADHD Research: Next Steps

• Read: The Evolution of ADHD — Examining the Last 25 Years and the Future
• Read: Prenatal and Early Life Risk Factors of ADHD
• Watch: Epigenetics — Understanding Its Role in ADHD and Future Applications
• Hub: ADHD News & Research

Peter S. Jensen, M.D., is the founder of The REACH Institute, which trains providers in interventions for children’s mental health care.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹ Spencer, T., Biederman, J., & Wilens, T. (2004). Nonstimulant treatment of adult attention-deficit/hyperactivity disorder. The Psychiatric clinics of North America, 27(2), 373–383. https://doi.org/10.1016/j.psc.2003.12.001

² Xiong, R. G., Li, J., Cheng, J., Zhou, D. D., Wu, S. X., Huang, S. Y., Saimaiti, A., Yang, Z. J., Gan, R. Y., & Li, H. B. (2023). The Role of Gut Microbiota in Anxiety, Depression, and Other Mental Disorders as Well as the Protective Effects of Dietary Components. Nutrients, 15(14), 3258. https://doi.org/10.3390/nu15143258

³ Chen, Y., Xu, J., & Chen, Y. (2021). Regulation of Neurotransmitters by the Gut Microbiota and Effects on Cognition in Neurological Disorders. Nutrients, 13(6), 2099. https://doi.org/10.3390/nu13062099

⁴ Parker, A., Fonseca, S., & Carding, S. R. (2020). Gut microbes and metabolites as modulators of blood-brain barrier integrity and brain health. Gut microbes, 11(2), 135–157. https://doi.org/10.1080/19490976.2019.1638722

⁵ Madison, A., & Kiecolt-Glaser, J. K. (2019). Stress, depression, diet, and the gut microbiota: human-bacteria interactions at the core of psychoneuroimmunology and nutrition. Current opinion in behavioral sciences, 28, 105–110. https://doi.org/10.1016/j.cobeha.2019.01.011

⁶ Fish-Williamson, A., Hahn-Holbrook, J., Hobbs, M., Wallander, J., & Morton, S. M. B. (2022). Prenatal antibiotic exposure in pregnancy and early childhood socioemotional development. JCPP advances, 2(2), e12066. https://doi.org/10.1002/jcv2.12066

⁷ Cassidy-Bushrow, A. E., Sitarik, A. R., Johnson, C. C., Johnson-Hooper, T. M., Kassem, Z., Levin, A. M., Lynch, S. V., Ownby, D. R., Phillips, J. M., Yong, G. J. M., Wegienka, G., & Straughen, J. K. (2023). Early-life gut microbiota and attention deficit hyperactivity disorder in preadolescents. Pediatric research, 93(7), 2051–2060. https://doi.org/10.1038/s41390-022-02051-6

⁸ Bistas, K. G., & Tabet, J. P. (2023). The Benefits of Prebiotics and Probiotics on Mental Health. Cureus, 15(8), e43217. https://doi.org/10.7759/cureus.43217

⁹Haack, L. M., Villodas, M. T., McBurnett, K., Hinshaw, S., & Pfiffner, L. J. (2016). Parenting Mediates Symptoms and Impairment in Children With ADHD-Inattentive Type. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 45(2), 155–166. https://doi.org/10.1080/15374416.2014.958840

¹⁰ Brinksma, D. M., Hoekstra, P. J., de Bildt, A., Buitelaar, J. K., van den Hoofdakker, B. J., Hartman, C. A., & Dietrich, A. (2023). Parental rejection in early adolescence predicts a persistent ADHD symptom trajectory across adolescence. European child & adolescent psychiatry, 32(1), 139–153. https://doi.org/10.1007/s00787-021-01844-0

¹¹ Agnew-Blais, J. C., Wertz, J., Arseneault, L., Belsky, D. W., Danese, A., Pingault, J. B., Polanczyk, G. V., Sugden, K., Williams, B., & Moffitt, T. E. (2022). Mother’s and children’s ADHD genetic risk, household chaos and children’s ADHD symptoms: A gene-environment correlation study. Journal of child psychology and psychiatry, and allied disciplines, 63(10), 1153–1163. https://doi.org/10.1111/jcpp.13659

¹² Hartman, C. A., Rommelse, N., van der Klugt, C. L., Wanders, R. B. K., & Timmerman, M. E. (2019). Stress Exposure and the Course of ADHD from Childhood to Young Adulthood: Comorbid Severe Emotion Dysregulation or Mood and Anxiety Problems. Journal of clinical medicine, 8(11), 1824. https://doi.org/10.3390/jcm8111824

That study, published in the Journal of the American Medical Association, did not show a causal relationship. Patients in that study may have had conditions like diabetes or obesity, in addition to ADHD, that raised their risk of cardiovascular disease.

This is what I say to parents of my patients: ADHD causes all kinds of problems if it’s untreated. School failure, substance use, and, as an adult, poor job performance or getting fired, breakups in marriages — these are known risks when ADHD is not well managed.

In older populations, the risk for cardiovascular disease generally increases, but even then, I say to patients, “How are your diet, exercise, sleep, and other health habits?” These are the predictors of cardiovascular disease as best as we know. The study didn’t look at these factors.

Q: Does research show that nutrition plays a role in ADHD symptoms or symptom management?

We have every reason to think that healthy diets may lead to general benefits in mood and behavior. Large population-based studies suggest that food additives may have a relatively small negative effect on behavior. However, many parents report that children have hyperactive responses to sugar.

[Free Guide to ADHD Brain Food: What to Eat, What to Avoid]

New research is beginning to teach us more about the importance of a healthy diet and healthy gut biome. We know that too much processed food leads to the generation of unhealthy bacteria in the gut, which can create chemicals that pass through the blood-brain barrier and lead to problems, such as depression, anxiety, and possibly even ADHD. So, a healthy diet (along with adequate sleep and regular exercise) is likely to benefit people with ADHD.

Q: Does screen addiction over a period of several years affect a young adult’s brain development?

Very good studies have shown that screen time can lead to brain changes. A number of neuroimaging studies have proven this even in randomized controlled trials. Specifically, violent video games, such as first-person shooter games, have been found to lead to decreased empathy and social connections, increased negative and hostile thoughts, and possibly harmful actions.

ADHD Symptom Management: Next Steps

• Download: Lifestyle Changes for Adults with ADHD
• Read: 5 Smart Screen Rules for Teens with ADHD
• Read: Your ADHD Treatment Options — Medication, Diet, Therapy & More
• Find: ADHD Specialists and Clinics Near You

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

EndeavorOTC is an over-the-counter digital therapeutic authorized by the Food and Drug Administration (FDA) for the treatment of adults 18 and older with primarily inattentive or combined-type ADHD. In the U.S., it is indicated to improve attention and functioning as measured by computer-based testing. It is available without a prescription.

EndeavorOTC is not intended to be used as a stand-alone therapeutic and is not a substitution for ADHD medication.

Developed by Akili Interactive, EndeavorOTC is the first FDA-authorized over-the-counter digital therapeutic treatment for adult ADHD. It uses the same proprietary technology as EndeavorRx, an FDA-approved digital therapeutic for the treatment of children ages 8 to 12 with primarily inattentive or combined-type ADHD.

EndeavorOTC is available in the U.S. in the Apple App Store for iOS and the Google Play Store for Android mobile devices.

How Does EndeavorOTC Work?

Through its immersive video game experience, EndeavorOTC presents specific sensory stimuli and simultaneous motor challenges designed to alter pathways in the brain related to focus.

Adults typically interact with EndeavorOTC on mobile devices for 25 minutes daily, five days a week.

The EndeavorOTC games, which challenge players to simultaneously target and navigate through a series of obstacles, are designed to boost cognitive functions related to attention, focus, multitasking, and prioritization.

How Long Does EndeavorOTC Take to Work?

The clinical study supporting EndeavorOTC’s FDA clearance found that, after six weeks of EndeavorOTC use, 83% of participants saw clinical improvements in their ability to focus as measured by the TOVA attentional control score. Nearly three-quarters (72.5%) of participants reported some quality-of-life improvements as measured by the Adult ADHD Quality of Life Scale (AAQoL), and roughly half (45.8%) of adults met a prespecified threshold for clinically meaningful improvement.¹

What are the Side Effects of EndeavorOTC?

The clinical trial for EndeavorOTC reported no lasting or serious side effects. Of the 221 adults who received EndeavorOTC for six weeks in the trial, 11 (5%) reported a treatment-emergent adverse device event, most commonly nausea (1.8%) and headache (1.4%).¹

What Precautions are Associated with EndeavorOTC?

EndeavorRx may not be appropriate for patients with photosensitive epilepsy, color blindness, or physical limitations that stop a patient from comfortably holding a device.

To learn more about EndeavorOTC, visit EndeavorOTC.com.

What is EndeavorRX?

EndeavorRx, a version of EndeavorOTC designed for children ages 8 to 12 with ADHD, was approved by the FDA in June 2020. Through its immersive video game experience, EndeavorRx presents specific sensory stimuli and simultaneous motor challenges designed to target neural systems in the brain related to attentional control. Children interact with EndeavorRx on mobile devices and typically play for 25 minutes per day, five days a week. It is available by prescription from a licensed healthcare provider.

Learn more about EndeavorRx at www.endeavorrx.com/

Source

¹ Stamatis, C.A., Mercaldi, C., Kollins, S.H. (2023). A Single-Arm Pivotal Trial to Assess the Efficacy of Akl-T01, a Novel Digital Intervention for Attention, in Adults Diagnosed With ADHD. Journal of the American Academy of Child & Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2023.09.510

Most people who do this exercise will describe a place in the natural environment – not a place behind a screen. It might be a sandy beach with the waves rolling in, a mountain meadow, or a forest of towering trees. It’s almost never an app or video game.

Humans are deeply connected to nature and we have been for as long as we’ve walked the Earth. We thrive when we spend time outdoors. But today that connection is hanging by a frayed thread, due largely to our overreliance on technology.

Today’s youth spend more time than ever before in front of screens. Even kids realize they are spending too much time on technology. A recent Pew study reports that 54% of young people say they are spending too much time on their phones. Then there’s the fact that excessive screen time has been linked to health issues from anxiety and depression to poor sleep, a cluster of issues that award-winning journalist Richard Louv dubs “nature-deficit disorder.”

The Power of No Power

The happiest teens use their phones less than one hour a day, according to a study. It might be difficult to convince a kid of that, but it’s clear that the happier kids are the ones finding ways to engage with the world rather than just looking at it online.

[Get This Free Download: Too Much Screen Time? How to Regulate Your Teen’s Devices]

Studies show that time in nature improves children’s school performance, behavior, self-discipline, creativity, and problem-solving abilities. It also helps them feel more connected with nature, making them more likely to help protect the natural world.

For kids with ADHD and related conditions, the benefits of spending time outdoors are profound. While increased screen time is linked to more severe symptoms in these kids, exercise and time outdoors have been shown to reduce symptoms. One study found that even looking at natural greenery significantly decreased stress levels for kids with ADHD, and that they could focus better after being outside.

Being out and about and taking in fresh air helps us sleep better. A study found that a weekend camping trip can reset circadian rhythms. Spending time in nature has even been shown to improve eyesight. Another benefit of family green time? A better relationship with your child.

How to Help Your Child Plug Into Nature

I’m not suggesting we try to eliminate all screen time. I am advocating for the benefits of unplugging, or as I call it, “the power of no power.”

[Read: “Why We’re Drawn to Beaches, Gardens, and Forests”]

As parents, you have the opportunity to give your kids real-life experiences to help them break free from their digital trance. Here are a few suggestions, many of which cost little yet provide priceless benefits:

• Go for a hike. There are state and local parks everywhere. If not a hike, a stroll through your neighborhood’s greenest parts.
• Ride bikes along a greenway path.
• Go fishing.
• Visit a waterfall.
• Take your kids swimming in a lake or swimming hole to cool off on a hot summer day.
• Rent canoes or inner tubes and float a river or paddle a lake.
• Picnic at a spring, lake, or river.
• Create a scavenger hunt or try geocaching, a real-life treasure hunt that gives kids a connection to nature and the people who left those treasures behind.

Your best memories probably don’t start with “There I was, at the computer.” So don’t just read about life online — get outside and live it with your kids.

Nature Deficit Disorder: Next Steps

• Free Download: Activity Ideas for ADHD Families
• Read: Go Take a Hike! (No, Really, It Helps.)
• Read: Never Underestimate the Healing Power of Mother Nature

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

High-intensity exercise treats depression as effectively as do cognitive behavior therapy (CBT) and medication, according to a new study that found combining SSRIs, a type of antidepressant, with exercise improved depressive symptoms more than medication alone.¹

The systematic review and meta-analysis led by a research team from the University of Queensland, Australia, found that the more intense the physical activity, the more effective it was at managing depression. More specifically, vigorous exercises (e.g., running, interval training, strength training, mixed aerobic exercise) reduced depression symptoms in participants more than light physical activity (e.g., walking and hatha yoga), although the latter did provide some benefit.

These findings emerged from examinations of 218 randomized controlled trials, including 14,170 participants diagnosed with depression, to determine the effectiveness of exercise, psychotherapy, and antidepressants in treating depression.

When the researchers narrowed their analysis by demographics, they discovered that strength training and cycling positively impacted more women than men, and yoga or qigong provided more benefits to men than women. Yoga appeared more effective among older adults, and younger adults received better results from strength training. The duration and frequency of exercise did not affect the results.

The study also suggested that men appeared to benefit more than women from combining yoga, Tai Chi, or aerobic exercise with psychotherapy. Yoga and aerobic exercise combined with psychotherapy seemed more effective among older adults.

Participants gained the most benefits from group classes or scheduled exercises. The more autonomy participants had over their exercise programs, the weaker the outcome. “When provided with more freedom, the low self-efficacy that is symptomatic of depression may stop patients from setting an appropriate level of challenge (e.g., they may be less likely to choose vigorous exercise),” the study’s authors wrote.

The researchers cautioned that definitive conclusions are impossible to draw, and more studies are needed. “Our review did not uncover clear causal mechanisms, but the trends in the data are useful for generating hypotheses,” they wrote. “It is unlikely that any single causal mechanism explains all the findings in the review.”

“Exercise should be considered alongside traditional interventions as a core treatment for depression,” report author Michael Noetel, Ph.D., said in a press release. “No matter how often people exercised, whether they had other health issues or how severe their depression was, in all scenarios, exercise had a meaningful impact on their depression. Of course, anyone getting treatment for depression should talk to their doctor before changing what they are doing, but most people can start walking without many barriers.”

Exercise and Depression

Members of ADDitude’s reader panel confirm several findings from the study published in The BMJ (British Medical Journal).

“Strenuous full-body aerobic activities like boxing, karate, swimming, or boulder climbing help me get my thoughts in the right place and boost my mood and energy,” one panelist wrote. “Physical activity also helps me fall asleep and feel less stressed overall.”

“Running helps with my anxiety and depression,” another reader said. “It’s like a vacation for my overstimulated brain.”

A recent retiree who goes to the gym six days a week for group fitness classes and strength training sessions with a personal trainer shares that physical activity helps him feel calmer and more focused. “Exercise gives me a sense of accomplishment and community,” he says. “It is truly my second medication.”

Exercise Benefits Children and Teens with ADHD

The benefits of physical activity are not limited to adults; exercise improves the mental health of children and adolescents with neurodevelopmental disorders (NDDs), including ADHD, learning and motor disorders, autism spectrum disorder (ASD), and intellectual disability, according to a recent systematic review and meta-analysis published in JAMA Pediatrics.²

The researchers found that high-frequency (more than 27) 40-minute sessions of physical activity significantly benefited cognitive function, psychological well-being (e.g., self-esteem, quality of life), internalizing (e.g., anxiety and depression), and externalizing (e.g., aggression and disruptive behavior disorders) behaviors in children and adolescents aged 5-17 years with NDDs. They examined 59 studies with more than 3,000 participants.

ADDitude caregivers recognized similar results from their children after participating in physical activities.

One reader takes their son to the YMCA at least three times per week. “Depression can really take hold of my 10-year-old son,” the parent said. “We see great improvements after physical activity. He enjoys the elliptical, rower, spin bikes, automatic stepper, and treadmill.”

“My daughter has been playing hockey since she was young,” a reader said. “She says she can slow her brain down when she’s on the ice and think more clearly, and it’s as if her ‘ADHD evaporates.’”

“Intense cardio activities, like cross-country skiing and soccer, help my son burn off some of his boundless energy, and he gains self-confidence by being good at something nonacademic,” a reader said.

Another reader said, “My oldest is a distance runner. He is committed and gets up early to run his miles or workout. Running gives him that needed dopamine hit to keep his ADHD symptoms under control at the start of the school day.”

Incorporating Exercise in Depression Treatment Plans

A 2023 treatment survey of 11,000 ADDitude readers reaffirms both studies’ findings. Roughly half of the respondents who use this treatment rated exercise as “extremely” or “very” effective. A staggering 94% of caregivers and 95% of adults recommend exercise to treat ADHD symptoms. Yet only 13 % of these respondents said a doctor had recommended exercise to reduce symptoms, and only 37% of all respondents said physical activity was part of their treatment plan.

The BMJ study encourages clinicians to consider exercise a viable alternative to drug treatment or adjuvant for those already taking medication. “The findings support the inclusion of exercise, particularly vigorous exercise, in clinical practice guidelines for depression,” they wrote. “This may help bridge the gap in treatment coverage by increasing the range of first-line options for patients and health systems.”

Sources

¹Noetel, M., Sanders, T., Gallardo-Gómez, D., Taylor, P., del Pozo Cruz, B., van den Hoek, D. et al. (2024). Effect of Exercise for Depression: Systematic Review and Network Meta-Analysis of Randomised Controlled Trials. BMJ. doi:10.1136/bmj-2023-075847.

²Liu C, Liang X, Sit CHP. (2024). Physical Activity and Mental Health in Children and Adolescents with Neurodevelopmental Disorders: A Systematic Review and Meta-Analysis. JAMA Pediatr. doi:10.1001/jamapediatrics.2023.6251.

Immersive virtual reality-based interventions (VR) can improve cognitive deficits associated with ADHD in children, according to a study published in 2023 in the journal Virtual Reality. Compared to active and passive control groups, children with ADHD experienced positive outcomes with large effect sizes global cognitive functioning, attention, and memory when using immersive VR therapies.¹

In a meta-analysis of seven randomized controlled trials (RCTs), 149 participants were assigned to the immersive VR group and 172 participants to the control group. The study found a significant difference in performance outcomes for attention (g = 0.94) and global cognition (g = 1.06) in favor of the immersive VR group. Only one RCT assessed for memory outcomes, but as with attention and global cognition, the VR group showed a significant advantage (g = 1.81). Improvements were greater for children who were not otherwise treated for ADHD.

Efficacy of Immersive VR

Virtual reality is increasingly used in healthcare, and evaluations by clinicians have been positive. ^{2, 3} Patients say that brain training — an umbrella term used to describe cognitive tools like VR — is effective at improving ADHD symptoms. In a 2024 treatment survey conducted by ADDitude, brain training ranked in the top three most effective ADHD treatment options according to caregivers and adults with ADHD.

XRHealth is the maker of one commercially available VR therapy for ADHD. “Applications for kids with ADHD include a boxing-like game in which players choose which stimuli to punch, which to avoid, and what distractions to ignore,” said Randy Kulman, Ph.D., in “A User’s Guide to Digital Therapeutics for ADHD.”

VR-based interventions may also be useful in the classroom, according to the researchers. “Given the positive association between global cognitive functioning and academic performance, and social functioning, VR-based interventions may benefit the daily life of children with ADHD in terms of school performance and peer relations.”

Yet, brain training was also one of the least utilized treatment options used by ADDitude survey respondents. Out of more than 12,000 respondents, only 6% of caregivers and adults reported having used it to treat ADHD for their child or personally. Lack of personalization to patient needs, treatment goals, and knowledge on the added value of VR have been cited as barriers to implementation.³Access to providers who have experience treating ADHD was the biggest overall barrier to care, according to survey respondents.

Potential Moderators

Researchers performed a second meta-analysis to identify potential moderators of the effect size of global cognitive functioning, for which there was significant substantial heterogeneity (I² = 71.23%). Improvements in global cognition were observed across all participant ages and intervention durations, regardless of diagnostic status (formal vs. informal), novelty of headsets (new vs. old), or control group intervention (passive vs. active). The study did not assess for moderators of attention alone, for which heterogeneity was also significant (I² = 68.26%).

The significance of moderators on immersive VR-based outcomes are mixed. Research has shown that longer interventions, younger participants, and passive control groups may lead to different outcomes, the researchers noted. Follow-up measurements could help “assess the long-term effects of VR interventions and whether improvements made on cognitive functioning outcomes from baseline to post-intervention are maintained after the intervention has ceased.”

Limitations and Future Research

The systematic review and meta-analysis was the first to address treatment adherence and safety of immersive VR in improving cognitive deficits in children with ADHD. Compared to control groups, drop-out rates were similar across groups, and there were no adverse effects. Researchers concluded that immersive VR “is feasible in terms of treatment adherence and a safe cognitive rehabilitation tool.”

A rigorous literature search was conducted for the current study according to PRISMA guidelines and the Cochrane Handbook, and improvements were observed even after correcting for publication bias. However, of the limited studies that were included, all were judged to have an unclear risk of bias based on randomization and selective reporting. Results should be interpreted cautiously.

Control group interventions included non-immersive VR, medication, psychotherapy, cognitive training, neurofeedback, hemoencephalographic biofeedback, being placed on a waiting list, or no treatment. Head-mounted displays were required to be considered an immersive VR-based intervention.

Learn about the current state of affairs in implementing VR technology in healthcare here.

Sources

¹Corrigan, N., Păsărelu, C.R., & Voinescu, A. (2023). Immersive virtual reality for improving cognitive deficits in children with ADHD: a systematic review and meta-analysis. Virtual Reality, 1-20. doi:10.1007/s10055-023-00768-1.

²Zangiacomi, A., Flori, V., Greci, L., Scaglione, A., Arlati, S., & Bernardelli, G. (2022). an immersive virtual reality-based application for treating ADHD: A remote evaluation of acceptance and usability. Digital Health, 8. doi:10.1177/20552076221143242

³Kouijzer, M., Kip, H., Bouman, Y., Kelders, S. (2023). Implementation of virtual reality in healthcare: a scoping review on the implementation process of virtual reality in various healthcare settings. Implement Sci Commun, 4(1):67. doi: 10.1186/s43058-023-00442-2.

Amphetamine and methylphenidate have been used to treat ADHD for at least 80 years, and their safety and efficacy have been studied relentlessly. But according to a recent ADDitude survey, less than half (42%) of parents opt to medicate their children in the months after a diagnosis, largely due to the fear of real or perceived side effects like appetite suppression or sleep disruption — both possible impediments to growth.

In the end, 85%  of all people with ADHD end up taking medication and they rate its efficacy higher than any other treatment approach included in the survey, ADDitude’s largest to date. More than 11,000 adults with ADHD and caregivers of children with the condition participated in the survey from July to December 2023.

“We hesitated for a long time and tried diet changes first in an attempt to avoid medication,” said one respondent. “Although diet is very important, medication has given our child the opportunity to enjoy life by having more emotional control, better friendships, and the ability to complete work and think things through. Greater self-confidence flows from all of this.”

Most Popular ADHD Medications

To be clear, ADHD medication is not a quick fix. On average, children try 2.75 different medications and adults try 2.56 prescriptions before finding one that works for them. Survey respondents also said that 17% of children and 14% of adults cease treatment with medication for one reason or another — cessation rates lower than reported in other studies.¹

Biggest Impediments to ADHD Treatment

Access to treatment professionals with experience in ADHD is the biggest impediment to effective treatment, according to both caregivers and adults. Other barriers include side effects, long wait times, poor access to diagnosing clinicians, and comorbid conditions that complicate evaluation and treatment (82% of children and 92% of adults with ADHD report comorbid diagnoses).

ADHD’s Most Common Comorbid Conditions

The average age of ADHD diagnosis in children is 8 for boys and 9 for girls, according to survey respondents. On average, adults not diagnosed as children learn of their ADHD around age 39. Most of these late diagnoses are among women, who report years of struggle preceding their diagnosis.

“I wish I had been diagnosed and treated sooner,” wrote one survey respondent. “The struggle is so profound and deep. And the longer you go through it without help or knowing what you’re really struggling with, the harder it feels to get others to hear and see you. You feel alone.”

Persistence, flexibility, and self-advocacy are vitally important when working to find the right medication. Though the trial-and-error phase was described as frustrating by most survey respondents, research tells us the benefits of ADHD medication use — reduced risks of automobile accidents, substance abuse, unwanted pregnancy, sexually transmitted diseases, and self harm in teens — are worthwhile and meaningful.²

“I wish I had known that ADHD medication helps prevent addictions to dangerous substances,” wrote one survey respondent, “and car accidents for people with ADHD.”

ADHD Medication Formulation, Duration & Satisfaction

Barely half of patients taking a long-acting medication are satisfied with its duration of coverage, which is 9.5 hours for children and 10 hours for adults, on average. This is a flunking grade, but it’s far superior to the satisfaction ratings for short-acting formulations. So why do up to 23 percent of children and 30 percent of adults take short-acting stimulants? Perhaps because clinicians are more likely to prescribe them, and some adults like the medications’ relative flexibility.

“Sometimes, in a social setting, I quite like taking only 5 mg of short-release (rather than my prescribed 10 mg),” wrote one survey respondent. “Other times, when working on something that I find really dull, I often take 15 mg (3 x 5 mg tablets).”

In the end, adults are more likely than children to take short-acting formulations, to be dissatisfied with their medications, and to be considering a switch, according to the survey data.

ADHD Medication Side Effects

Caregivers are likely to try fish oil, eliminate food dyes, and sign up for karate before considering a prescription for their child. Once they decide to try medication, caregivers prioritize finding the one with the fewest side effects.

At the same time, 53% of children who end up taking medication try methylphenidate, 36% take amphetamine, and just 11% take a non-stimulant. So given its popularity, methylphenidate must deliver the fewest side effects, right?

No. According to caregiver reports, slightly more children reported side effects from methylphenidate than amphetamine, and those side effects were nearly identical, with appetite suppression being the most common by far; it impacted 61% of children taking any stimulant.

Adults use amphetamine for what they cite as their top priority in choosing a medication: symptom control. Yet they gave it an efficacy rating that was only slightly better than methylphenidate, which is associated with fewer side effects.

So should more adults consider trying Concerta, Ritalin, or a newcomer like Azstarys? One-quarter to one-third of adults said they are now considering some kind of medication switch.

ADHD Treatments Scorecard

Most Highly Recommended ADHD Treatment Approaches

ADHD Treatment Approaches with Highest Efficacy Ratings

Rated According to Effectiveness on ADHD Symptoms, Specifically

What Readers Say vs. What They Do

The most highly recommended approach to managing ADHD symptoms (exercise) has been used by less than half of ADDitude survey respondents. The second most recommended approach among adults (ADHD coaching) has been adopted by only 17 percent of people. And the vitamins, minerals, and supplements used by 49 percent of people surveyed don’t even earn a passing grade. All of this hints at problems with availability, cost, and medical advice in the world of ADHD treatment.

Diet and Nutrition Approaches for ADHD

What dietary changes move the needle?

At least half of caregivers and adults reported that the following dietary changes have a positive impact on ADHD symptoms:

• Decreasing or eliminating artificial colors/preservatives/sweeteners³
• Decreasing or eliminating sugar⁴
• Increasing protein

Research generally supports these observations and reader efficacy ratings are high. So why are fewer than 30% of caregivers and adults making dietary changes to address ADHD? For one, 61% of children using stimulant medication to treat their ADHD experience appetite suppression as a side effect, according to their caregivers. Dietitians generally advise that children should focus on eating first and eating heathy second.

“We struggle to get enough calories into our child due to decreased appetite,” wrote one parent. “We are happy to have her eat, regardless of what or when, to keep energy levels up.”

Psychotherapy More Prevalent Than ADHD Coaching

Though the recommendation rates are nearly identical, far more people engage in psychotherapy than work with an ADHD coach. Therapy generally helps clients work through comorbid conditions like anxiety and depression, and negative beliefs or self-defeating behaviors. Coaching helps to strengthen skills to mitigate ADHD deficits and reach goals, but its benefits are short-lived, readers say.

“ADHD coaching helped me to narrow down my biggest challenges and work on practical solutions for the day-to-day things I struggle with,” said one survey respondent.

Parent Training or Behavioral Therapy for ADHD

This first-line treatment is used by less than 6 out of 10 study participants.

The American Academy of Pediatrics recommends parent training in behavior management as a first-line ADHD treatment for children diagnosed before age 7, and a complementary treatment approach thereafter. Despite this recommendation, and a high rate of reported satisfaction, just more than half of parents say they’ve ever used it. Possible reasons for this: Clinicians aren’t recommending parent training nearly enough; behavioral therapists versed in ADHD are difficult to find; and/or therapy is expensive and time-consuming. Likely, all of these reasons are true.

“Changing the way we parented was a game changer,” wrote one survey respondent. “It brought the stress in the house down significantly and meant we could focus on the lagging skills and promoting the behaviors we wanted to see versus punishing behaviors we didn’t want to see.”

Exercise Is Invaluable and Infrequent

Does exercise eradicate ADHD symptoms? Hardly. Readers rated its efficacy on ADHD just 2.4 out of 5, but they also called it invaluable — especially vigorous cardiovascular morning exercise. It aids sleep, mood, and hyperactivity, our readers say. So why isn’t exercise a universal component of treatment plans? As we know, the ADHD brain is easily bored and resists routine.

“When I get into a good stride with routine exercise, it almost always goes hand-in-hand with better eating habits, better focus, energy levels, mental clarity, and stronger relationships and productivity,” said one adult with ADHD. “Exercise is undoubtedly a crucial piece of the (treatment) puzzle.”

Most Impairing Symptoms of ADHD

ADHD Treatment Options: Next Steps

• Download: Share This Report with Your Doctor
• Read: ADHD Medication Reviews
• Get: The ADHD Treatment Guide for Adults

Sources

¹ Brikell I, Yao H, Li L, Astrup A, Gao L, Gillies MB, Xie T, Zhang-James Y, Dalsgaard S, Engeland A, Faraone SV, Haavik J, Hartman C, Ip P, Jakobsdóttir Smári U, Larsson H, Man KK, de Oliveira Costa J, Pearson SA, Hostrup Nielsen NP, Snieder H, Wimberley T, Wong IC, Zhang L, Zoega H, Klungsøyr K, Chang Z. ADHD medication discontinuation and persistence across the lifespan: a retrospective observational study using population-based databases. Lancet Psychiatry. 2024 Jan;11(1):16-26. doi: 10.1016/S2215-0366(23)00332-2. Epub 2023 Nov 27. PMID: 38035876.