Patterns of Physical Activity of Adolescents With ADHD in the School Context: A Cross-Sectional Study for Clinical Practice

Abstract

Objectives:

To describe the daily Physical Activity (PA) patterns of adolescents with Attention-deficit/hyperactivity disorder (ADHD), to analyze the differences in terms of PA patterns between adolescents with ADHD and those without ADHD, and to study the factors associated with achieving the daily PA recommendations.

Methods:

The sample was composed of 778 adolescents who provided complete information on their PA patterns through the Physical Activity Questionnaire for Adolescents (PAQ-A). Of these, 97 had ADHD according to DSM-5 criteria.

Results:

The results show that being a girl or being of foreign origin and having ADHD have an impact on the achievement of the recommended amount of daily PA.

Conclusions:

When promoting PA in adolescents with ADHD within the school environment, it is necessary to consider different domains and specific contexts of a school day, paying special attention to girls and adolescents with ADHD of immigrant origin.

Keywords

physical activity ADHD adolescence school context

Introduction

ADHD is a neurodevelopmental disorder (ND) that affects between 3% and 9.92% of the child and adolescent population, becoming one of the most frequent ND in school-age children (Bosch et al., 2021; Vysniauske et al., 2020). It is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning and social or school development. Symptoms of ADHD begin in childhood and are not explained by any other disorder (Faraone et al., 2021; Tamm et al., 2017; Tremblay et al., 2016). Children and teenagers with ADHD are at higher risk for school failure, behavioral problems, substance abuse, accidental injury, and premature death, as well as comorbidity with other organic or mental disorders, including anxiety, affective symptomatology, and/or Specific Learning Disorders (SLD; Faraone et al., 2021; Vysniauske et al., 2020). Individuals with ADHD often exhibit impairments in executive functions, including working memory deficits, response inhibition, cognitive flexibility, planning, and processing speed. These impairments impact in their academic performance and daily functioning (Chen et al., 2022; Daley & Birchwood, 2010; Engelhardt et al., 2008; Gilden & Marusich, 2009; Habsan Al-Saad et al., 2021; Marzocchi et al., 2008; Miller et al., 2012; Molavi et al., 2020; Zeeuw et al., 2012).

The American Academy of Pediatrics states that the current established evidence-based treatments to relieve ADHD symptoms are medication and behavioral treatment, preferably in combination (Aranas & Leighton, 2022; Chan et al., 2022; Christiansen et al., 2019; Ganjeh et al., 2021). However, there exists a significant proportion of individuals for whom these treatments are not effective. In this way, physical activity (PA) has been proposed as a promising form of adjunctive treatment for ADHD because it has a positive impact on symptoms of inattention, hyperactivity, and impulsivity in children and adolescents with ADHD (Chan et al., 2022; Christiansen et al., 2019; Ganjeh et al., 2021, 2022; Gapin & Etnier, 2014; Holton & Nigg, 2020; Jeyanthi et al., 2019; Koch et al., 2022; Mercurio et al., 2021; Xie et al., 2021). It should be considered that PA influences the same catecholaminergic systems as stimulant drugs commonly used in the treatment of ADHD (Ben-Amor, 2014; J. Johansson et al., 2011; Wilens, 2008; Wilens & Decker, 2007; Wilens et al., 2011). In this sense, the catecholaminergic system, especially dopamine, is crucial for motivation, attention, and reward processing, functions often impaired in individuals with ADHD. So, PA can regulate dopamine levels in the brain, leading to enhancements in attention and cognitive functions affected in ADHD. Furthermore, exercise has been associated with increased dopamine release, which can improve cognitive performance and alleviate symptoms of ADHD (Wilens & Decker, 2007). Additionally, PA has been associated with the regulation of norepinephrine, another essential neurotransmitter in the catecholaminergic system. Norepinephrine is involved in arousal, attention, and stress response, functions dysregulated in individuals with ADHD. By participating in PA, individuals with ADHD may experience elevated norepinephrine levels, resulting in enhancements in attention, focus, and cognitive control (Wilens & Decker, 2007). PA has also been found to increase heart rate, breathing, and the release of endorphins, which are associated with improved mood and reduced pain (Pouw et al., 2020; Tantimonaco et al., 2014). Overall, the impact of PA on brain health is positive, with potential benefits for cognitive function, memory, and mental well-being (Di Liegro et al., 2019; Stillman et al., 2016).

On the other hand, children who practice more PA show better performance in executive functions, including working memory, inhibition, and speed of information processing, and it also, improves academic performance, behavior, self-esteem, and relationships with peers (Chan et al., 2022; Christiansen et al., 2019; Cook et al., 2015; de Greeff et al., 2018; Głąbska et al., 2019).

These benefits have been observed in both young children and adolescents, indicating the potential of PA as a non-pharmacological intervention for managing ADHD symptoms (Smith et al., 2013).

On the other hand, PA has been associated with an improvement in socioemotional functioning and a reduction in symptoms of anxiety and depression, which are often observed in children and adolescents with ADHD (Aranas & Leighton, 2022; Bagwell et al., 2006; Holton & Nigg, 2020; Kita & Inoue, 2017; Koch et al., 2020, 2022; Lee & Rhyu, 2019; Murphy et al., 2020; Seymour et al., 2012; Whalen et al., 2002).

Nevertheless, although PA could have many benefits for youth with ADHD, it has been observed that adolescents with this disorder tend to have a higher risk of inactivity (Wiggs et al., 2023).

To address this inactivity and taking into account the benefits of PA in adolescents with ADHD, school has been identified as an important setting for promoting Moderate to Vigorous Physical Activity (MVPA) and limiting sedentary time (ST) as children and adolescents spend 40% of their waking time at school (Aubert et al., 2022; Borde et al., 2017; Bull et al., 2020; Escalante et al., 2014; Jones et al., 2020; Lonsdale et al., 2013; Mercurio et al., 2021; Owen et al., 2017). The daily recommendations for MVPA in children and adolescents are at least 60 minutes per day, as outlined in the Physical Activity Guidelines for Americans (Landry & Driscoll, 2012; Meriwether et al., 2008; Trost & Loprinzi, 2008). Despite these recommendations, a significant percentage of children and adolescents do not meet these guidelines (Trost & Loprinzi, 2008). Therefore, healthcare professionals need to encourage and support PA in this population (Trost & Loprinzi, 2008; Yang, 2019). School-based strategies to increase MVPA include adopting active recesses (indoor or outdoor), providing daily Physical Education (PE) compulsory to all school levels, offering extracurricular sports, implementing active learning lessons, delivering active travel to school initiatives, providing active homework and active assignments, or providing resources to improve the design of open spaces at schools for promoting active play (Aubert et al., 2022). If done efficiently, PA school-based strategies could be included as part of the MVPA-related treatment for ADHD as highlighted by several studies (Chan et al., 2022; Christiansen et al., 2019; Montalva-Valenzuela et al., 2022; Pagani et al., 2020; Suarez-Manzano et al., 2018). However, there is a lack of understanding regarding the PA patterns of children and teenagers with ADHD while being at school, which might limit the effectiveness of PA-related interventions. In this context, this study aimed to describe the daily PA patterns of boys and girls with ADHD, to analyze the differences in terms of PA patterns of boys and girls with ADHD and those without ADHD, and to study the factors associated with achieving the daily MVPA recommendations for health (i.e., at least 60 minutes/day) of adolescents.

Materials and Methods

Participants and Procedure

The present study is part of the project “Neurodevelopmental disorders, school failure, and behavioral alterations in adolescence: Prospective and territorial modeling study of two groups of secondary education students from Central Catalonia,” aiming to identify adolescents’ behavioral alterations, mental health problems and learning difficulties in the school setting of Catalonia. Before the start of data collection in 2017, the project was authorized by the ethics committee of the Vall d’Hebron University Hospital, in Barcelona (Catalonia, Spain).

First, 23 schools from four cities in Central Catalonia were contacted and invited to participate after explaining the procedures to the school staff. Twenty-two of them accepted, which resulted in 1,656 eligible subjects who were studying second grade of secondary education, with ages comprised between 12 and 14 years old. Informed consents were obtained from 1,211 adolescents and their parents or legal guardians (participation rate = 73.1%). The participants in this study did not receive any form of compensation for their time or participation. Parents of the enrolled students completed a questionnaire regarding sociodemographic data and adolescents provided information on PA through the Physical Activity Questionnaire for Adolescents (PAQ-A; Kowalski et al., 2004). To assess PA patterns, we removed those cases in which at least one of the PAQ-A items was missing (n = 260) and the cases that had been sick or something had prevented them from doing PA in the last week (n = 173). Thus, the final sample comprised 778 pupils with complete data from the PAQ-A. After a screening process, adolescents with suspected ADHD and their parents were interviewed by a psychiatrist of the research team for diagnostic confirmation based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria using the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS/PL-5; de la Peña et al., 2018). The sample was grouped into those who had a diagnosis of ADHD (n = 97) and those who had ruled out the presence of ADHD (n = 681).

Measures

Sociodemographic Variables. Parents completed a questionnaire on sociodemographic data, including adolescents’ gender, age, and country of birth. Parents also provided information about their educational level, occupation, and country of birth. Students who were not native Spanish were considered of foreign origin. Parents’ education and occupation were weighted to compute the Hollingshead Four-Factor Index, a measure of socioeconomic status (SES) ranging from 8 to 66, where higher scores reflect higher SES (Cirino et al., 2002).

Physical Activity. PA was measured using the Physical Activity Questionnaire for Adolescents (PAQ-A; Kowalski et al., 2004) in its Spanish version. The PAQ-A is a 9-item self-reported questionnaire that assesses adolescents’ PA levels performed in the last 7 days. The items report the frequency of PA performed at different times of the day (i.e., PE classes, at lunchtime, after school, in the evening, and at weekends). The last item reports if during the last week the adolescent was sick, or something prevented him or her from doing PA. Each item is scored using an ordinal scale from 1 (no, none, sitting, little PA) to 5 (seven times or more, always, running and playing intensely, five times or more in the last week, a lot). The overall result for PA levels is a score of 1 to 5 points, which is calculated from the average score of items 1 to 8. This score allows us to establish the level of PA performed by each adolescent from 1 to 5 (from low to high PA). Regarding the cut-off point of the PAQ-A for achieving the PA recommendations for health (60 minutes of MVPA), it was considered a score ≥ 2.75 (Kowalski et al., 2004).

ADHD

The diagnosis of ADHD was established using the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version-5 (K-SADS/PL-5; de la Peña et al., 2018), which is a semi-structured interview that assesses current and past psychopathology in school-age children according to the DSM-5 criteria (American Psychiatric Association, 2013). In this sense, the criteria for diagnosing ADHD according to the DSM-5 include a thorough assessment of the individual’s symptoms and their impact in multiple settings. To evaluate this, the K-SADS-PL-5 was administered to the family during the diagnostic phase, inquiring about the presence, onset, duration, and level of impairment of the symptoms. Family members were also asked to provide examples of the impact of the symptoms on familial and social areas. Additionally, an interview with the adolescent was conducted to assess the presence and negative impact of ADHD symptoms. Furthermore, communication with the school environment was essential, involving discussions with the teachers to confirm the presence of symptoms and their impairment in the school setting. Therefore, the impairment of ADHD was qualitatively assessed across various environments, including school, home, and social settings. The final diagnosis of ADHD was determined based on the fulfillment of criteria, including the presence of at least six symptoms in two different settings, their onset, and moderate impairment in any of the environments. To facilitate the differential diagnosis, criteria for other disorders evaluated by the K-SADS-PL-5 were also administered (i.e., depressive, and bipolar disorders; psychotic disorders; anxiety, stress, and obsessive-compulsive disorders; disruptive behavior and impulse control disorders; substance use disorders and feeding and eating disorders; and neurodevelopmental disorders). On the other hand, cognitive and Specific Learning Disorders (SLD) tests were administered to confirm that the symptoms presented were not caused by another disorder.

The Spanish version of the K-SADS/PL-5 demonstrates good construct validity and inter-rater reliability, as evidenced by de la Peña et al. (2018). The instrument’s factor structure aligns with the DSM-5 disorder organization, and it is reliable for assessing psychopathology in children and adolescents.

Statistical Analysis

All analyses were performed with SPSS 25.0 (IBM). Descriptive statistics were calculated to illustrate the sociodemographic characteristics, PA patterns, and the prevalence of ADHD in the total sample. The chi-square (χ²) test was used to compare the differences in PA intensity across various contexts and times of the day (e.g., PE classes, at lunch, or right after school) between students with and without ADHD.

To examine the impact of ADHD, foreign origin, SES, type of school (public vs. private), comorbidity between ADHD and SLD, and gender on meeting PA recommendations for health, a series of binary logistic regression analyses were conducted. All steps were incremental. First, to estimate the influence of socio-demographic variables on the practice of PA gender, SES, and type of school were entered in Step 1. Then foreign origin was included in Step 2. Subsequently, to assess the influence of ADHD on the practice of PA it was introduced in Step 3, and ADHD and SLD in Step 4 to estimate the influence of comorbidity between these disorders. Last, we included interaction terms (i.e., ADHD × Gender, ADHD × Foreign origin, Foreign origin × Gender) into the final model (Step 5) to examine the potential moderating role of foreign origin and gender. The Nagelkerke R2 was used to measure the global predictive capacity of each model. The odds ratio (OR) and their corresponding 95% confidence interval (CI) were reported. A two-sided p-value of .05 was set as the significance level in all tests.

Results

Sample Characteristics

All socio-demographic variables are described in Table 1. The study sample was composed of 379 boys (48.7%) and 399 girls (51.3%). The ADHD adolescents’ group was composed of 70 boys (72.2%) and 27 girls (27.8%). About half of the students (51.1%) attended public schools and the other half attended private schools. The sample was mainly composed of Caucasian students and of non-foreign origin (70.9%; Table 1).

Table 1.

Characteristics of the Study Samples.

	Non-ADHD		ADHD
	Boys	Girls	Boys	Girls
n (%)	309 (45.4)	372 (54.6)	70 (72.2)	27 (27.8)
Age, M (SD)	13.1 (0.38)	13.0 (0.38)	13.1 (0.39)	13.0 (0.42)
Type of school, n (%)
Public	158 (51.1)	177 (47.6)	35 (50.0)	11 (40.7)
Private	151 (48.9)	195 (52.4)	35 (50.0)	16 (59.3)
SES, M (SD)	38.9 (11.9)	37.7 (12.9)	35.2 (13.1)	35.3 (11.2)
Origin, n (%)
Spanish	219 (70.9)	250 (67.2)	42 (60.0)	19 (70.4)
Others	75 (24.3)	107 (28.8)	24 (34.3)	7 (25.9)
Unknown	15 (4.90)	15 (4.00)	4 (5.70)	1 (3.70)
Predominant ADHD Presentations, n (%)
ADHD-PI	N/A	N/A	24 (34.3)	17 (63.0)
ADHD-PH	N/A	N/A	2 (2.90)	2 (7.40)
ADHD-C	N/A	N/A	34 (48.6)	4 (14.8)
ADHD-NOS	N/A	N/A	3 (4.30)	1 (3.70)
ADHD-Uns	N/A	N/A	7 (10.0)	3 (11.1)

Note. M = mean; SD = standard deviation; SES = socioeconomic status; ADHD-PI = predominantly inattentive presentation; ADHD-PH = predominantly hyperactive-impulsive presentation; ADHD-C = combined presentation; ADHD-NOS, Not Otherwise Specified; ADHD-Uns = unspecified presentation.

Physical Activity Patterns in Adolescents With ADHD

Regarding the PA patterns of adolescents with ADHD, less than half of the boys (44.3%) achieved the PA recommendations for health and only 18.5% of the girls did. Regarding the amount of PA those students performed in the PE class, it should be noted that 11.4% of boys with ADHD never engaged in the PE classes. During lunchtime, 54.3% and 88.9% of boys and girls with ADHD respectively, sat down, stood down, or walked around. The group that carried out less PA right after school were girls with ADHD with 44.4% never doing PA, followed by boys with ADHD with 28.6% never doing PA. Regarding the PA performed in the evening, 48.2% of the girls with ADHD never did PA at that time of the day, while 34.3% and 22.2% of boys and girls with ADHD respectively did it two to three times last week. Girls with ADHD were the group who performed less PA at the weekend (33.3% did not do any PA), as well as, during the last week where 81.5% of the girls with ADHD did little PA during their free time (Table 2).

Table 2.

Characteristics of Physical Activity Patterns of Adolescents With ADHD and Adolescents Without ADHD.

	Non-ADHD		ADHD
	Boys	Girls	Boys	Girls
Meet the recommendation of PA, n (%)
No	116 (37.5)	255 (68.5)	39 (55.7)	22 (81.5)
Yes	193 (62.5)	117 (31.5)	31 (44.3)	5 (18.5)
Physical Education (PE) classes, n (%)
I didn’t do PE	7 (2.30)	17 (4.60)	8 (11.4)	0 (0)
Hardly ever	11 (3.60)	23 (6.20)	3 (4.29)	3 (11.1)
Sometimes	50 (16.2)	77 (20.7)	17 (24.3)	6 (22.2)
Quite often	104 (33.7)	146 (39.2)	20 (28.6)	13 (48.2)
Always	137 (44.3)	109 (29.3)	22 (31.4)	5 (18.5)
At lunchtime, n (%)
Sat down	151 (48.9)	242 (65.1)	26 (37.1)	12 (44.4)
Stood around or walked around	39 (12.6)	79 (21.2)	12 (17.1)	12 (44.4)
Ran or played a little bit	51 (16.5)	33 (8.90)	21 (30)	1 (3.7)
Ran around and played quite a bit	52 (16.8)	14 (3.80)	10 (14.3)	2 (7.41)
Ran and played hard most of the time	16 (5.20)	4 (1.10)	1 (1.43)	0 (0)
Right after school, n (%)
None	57 (18.4)	91 (24.5)	20 (28.6)	12 (44.4)
One time last week	37 (12.0)	79 (21.2)	9 (12.9)	5 (18.5)
Two to three times last week	97 (31.4)	118 (31.7)	23 (32.9)	6 (22.2)
Four times last week	65 (21.0)	55 (14.8)	8 (11.4)	2 (7.41)
Five times last week	53 (17.2)	29 (7.80)	10 (14.3)	2 (7.41)
Evenings, n (%)
None	39 (12.6)	72 (19.4)	17 (24.3)	13 (48.2)
One time last week	30 (9.70)	61 (16.4)	9 (12.9)	4 (14.8)
Two to three times last week	104 (33.7)	142 (38.2)	24 (34.3)	6 (22.2)
Four to five last week	80 (25.9)	56 (15.1)	12 (17.1)	4 (14.8)
Six to seven times last week	56 (18.1)	41 (11.0)	8 (11.4)	0 (0)
Last weekend, n (%)
None	34 (1.01)	66 (17.7)	17 (24.3)	9 (33.3)
One time	66 (21.4)	127 (34.1)	12 (17.1)	5 (18.5)
Two to three times	128 (41.4)	136 (36.6)	23 (32.9)	7 (25.9)
Four to five times	42 (13.6)	27 (7.30)	10 (14.3)	3 (11.1)
Six or more times	39 (12.6)	16 (4.30)	8 (11.4)	3 (11.1)
Last week, n (%)
All or most of free time little physical effort	51 (16.5)	69 (18.5)	14 (20)	12 (44.4)
Sometimes	62 (20.1)	121 (32.5)	21 (30)	10 (37.0)
Often	95 (30.7)	116 (31.2)	15 (21.4)	3 (11.1)
Quite often	64 (20.7)	48 (12.9)	13 (18.6)	1 (3.70)
Very often	37 (12.0)	18 (4.80)	7 (10.0)	1 (3.70)

Considering the group of adolescents with ADHD, significant differences were observed between boys and girls in terms of the achievement of PA recommendations for health (p = .02) and the amount of PA performed at lunchtime (p = .005; Table 3).

Table 3.

Differences Between Groups in Terms of PA Patterns.

	Non-ADHD		ADHD
	χ²	p	Χ²	p
Meet the recommendation of PA
Gender	65.4	<.001	5.54	.02
Foreign origin	8.45	.004	0.15	.82
Type of school	0.48	.54	0.15	.83
Physical Education (PE) classes
Gender	18.7	.001	7.95	.08
Foreign origin	2.28	.69	4.73	.31
Type of school	2.61	.63	1.94	.74
At lunch
Gender	62.3	<.001	13.2	.005
Foreign origin	5.60	.23	3.71	.48
Type of school	4.28	.37	7.26	.103
Right after school, n (%)
Gender	27.3	<.001	3.71	.49
Foreign origin	3.40	.49	1.54	.802
Type of school	3.19	.52	2.30	.70
Evenings
Gender	27.2	<.001	7.71	.108
Foreign origin	52.8	<.001	3.09	.54
Type of school	10.5	.03	1.72	.804
Last weekend
Gender	37.1	<.001	1.07	.91
Foreign origin	15.5	.004	0.86	.94
Type of school	1.83	.77	8.22	.08

Physical Activity Patterns in Adolescents Without ADHD

Considering the group of adolescents without ADHD, significant differences were observed in terms of gender (p < .001), foreign origin (p < .001), and type of school (p = .033) regarding the amount of PA performed in the evening. If we consider the achievement of PA recommendations for health, significant differences were detected between boys and girls (p < .001), and between adolescents of foreign origin and those who are not (p = .004). As to the amount of PA performed at the weekend, significant differences were detected between boys and girls (p < .001), and between adolescents of foreign origin and those who are not (p = .004). In terms of gender, there are significant differences also for PA performed during PE classes (p = .001), at lunchtime (p < .001), and right after school (p < .001; Table 3).

Factors Influencing the Amount of Physical Activity Among Adolescents

Table 4 reports the significant p values and odd ratios (OR) of the binary logistic regression using the total sample. The results indicated that the female gender, being of foreign origin, and having a diagnosis of ADHD were significant risk factors for not achieving the recommended amount of daily PA for health (Table 4; Step 4). Specifically, adolescents who received a diagnosis of ADHD had ~2 times the odds of achieving less PA (OR = 1.877, 95% CI [1.168, 3.02], p = .009), while girls were over ~4 times more likely to perform less PA (OR = 3.614, 95% CI [2.64, 4.94], p < .001). On the other hand, adolescents of foreign origin performed less PA than those of non-foreign origin (OR = 1.516, 95% CI [1.08, 2.13], p = .017). In step 5, interactions were added between ADHD and gender, and between ADHD and foreign origin. In this way, there were significant differences in terms of interactions between ADHD and foreign origin (Table 4; Step 5). Therefore, being of foreign origin and having a diagnosis of ADHD have a negative impact on the achievement of the recommended amount of daily PA for health. On the other hand, it was observed that being a girl (regardless of whether or not you have ADHD, and whether or not you are of foreign origin) was related to not carrying out the recommended daily PA.

Table 4.

Factors Associated With Carrying Out the Recommended Amount of PA Among Adolescents (n = 778).

Variable	Nagelkerke R²	OR [95% CI]	p value
Step 1	.107
Gender (ref. Boys)		0.44	<.001
Type of school (ref. Public)		NS	NS
SES		NS	NS
Step 2	.120
Gender (ref. Boys)		3.33	<.001
Foreign origin (ref. No)		1.55	.012
Type of school (ref. Public)		NS	NS
SES		NS	NS
Step 3	0.132
Gender (ref. Boys)		3.61	<.001
Foreign origin (ref. No)		1.52	.017
ADHD (ref. No)		1.88	.009
Type of school (ref. Public)		NS	NS
SES		NS	NS
Step 4	.132
Gender (ref. Boys)		3.61	<.001
Foreign origin (ref. No)		1.52	.017
ADHD (ref. No)		1.88	.009
Type of school (ref. Public)		NS	NS
SES		NS	NS
Comorbidity with SLD (ref. No)		NS	NS
Step 5	.132
Gender (ref. Boys)		3.49	<.001
ADHD × foreign origin		1.82	<.001
Type of school (ref. Public)		NS	NS
SES		NS	NS
Foreign origin (ref. No)		NS	NS
ADHD (ref. No)		NS	NS
Comorbidity with SLD (ref. No)		NS	NS
ADHD × gender		NS	NS
Gender × foreign origin		NS	NS

Note. All steps are incremental. First, demographic predictors and type of school were entered in Step 1. Foreign origin (Step 2), ADHD (Step 3), and ADHD and SLD (Step 4). Last, we included interaction terms (i.e., ADHD × Gender, ADHD × Foreign origin, Foreign origin × Gender) into the final model (Step 5) to examine the potential moderating role of foreign origin and gender. CI = confidence interval; NS = non-significant; OR = odds ratio; SES = socioeconomic status; SLD = specific learning disorders.

Discussion

The purposes of this study were to describe the daily PA patterns of boys and girls with ADHD, to analyze the differences in terms of PA patterns between adolescents with ADHD and those without ADHD, as well as to study the factors associated with higher achievement of the PA recommendations for health in this population group. The findings of this formative research will allow the development of effective school-based interventions through PA to improve the symptoms of ADHD.

To begin with, it should be noted that although the current practice of categorizing disorders based on presentations is widely criticized, we differentiated it to gain a better understanding of the sample (Nigg et al., 2010).

Regarding the first main result of this study, adolescents with ADHD tended to have different daily PA patterns than those without ADHD. About this, we observed that less than half of boys and girls with ADHD achieved the PA recommendations for health. This finding is consistent with the literature since children with ADHD between 6 and 17 years of age tend to participate less in PA and organized sports than their peers (Aranas & Leighton, 2022; Głąbska et al., 2019; Rommel et al., 2015). Regarding the amount of PA those students performed in the PE class, it should be noted that 11.4% of boys with ADHD never engaged in the PE classes. It is important to consider this fact because a systematic review showed positive effects on executive function through the development of programs and interventions of PA, exercise, or sport, which could be used as programs and/or interventions complementary in the PE classes (Montalva-Valenzuela et al., 2022). In this way, previous studies indicate that children with ADHD who did high-intensity exercise in PE class were able to reduce their intake of stimulant medications due to an increase in norepinephrine and dopamine levels in the brain and a biological adaptive response of brain function to the stimulus generated by exercise (Suarez-Manzano et al., 2018). According to our results, the need to promote PA in the school environment is clear to increase the amount of PA carried out by boys and girls with ADHD. Thus, schools are important settings for promoting MVPA and limiting sedentary time (ST) as children spend 40% of their waking time at school, and PE is the main vehicle associated with this goal in schools as PE-based interventions can increase students’ MVPA during classes by 24% compared to usual practice, and this increase could have a substantial positive influence on the total amount of PA they accumulate (Lonsdale et al., 2013). However, PE is taught infrequently in Spanish schools (typically 1–2 hours/week) and only accounts for a very small percentage of weekly waking hours, so its impact on total daily MVPA is limited (Owen et al., 2017). In the same sense, it is important to highlight that PA practice in the school setting can significantly improve ADHD symptomatology. So, PA can be a multifaceted, low-cost approach that, if deliberately designed and delivered, could be used together with traditional pharmacological, psychological, and pedagogical intervention strategies to promote cognitive performance in children and adolescents with ADHD (Christiansen et al., 2019). In this regard, systematic and planned moderate-high PA programs should be administered as soon as possible since these interventions can help alleviate inattention, symptoms of hyperactivity/impulsivity, and problems in interpersonal interactions to improve students’ adaptability in learning (Chan et al., 2022). In line with this, the school environment has the potential to provide a cost-effective site for a PA intervention as it is not necessary to transport the teenagers anywhere, resources are available and school professionals may be ready to receive training to become involved in a PA intervention (Mears & Jago, 2016).

In the same line, it is considered that promoting PA among adolescents with ADHD is very necessary and has many benefits, and PA prescription is one strategy to do this, although it involves collaboration in the community (Lydell et al., 2022). The small amount of PA that students with ADHD carry out in their free time is also very relevant since we identified that almost half of girls with ADHD never did PA right after school or in the evening and are the group who performed less PA at the weekend. In this sense, extracurricular programs provided by schools must also be considered when promoting PA in adolescents (Mears & Jago, 2016; Telford et al., 2016). Pagani et al. (2020), showed in a study of 758 girls and 733 boys that participation in an after-school sports program between ages 6 and 10 years was a significant predictor of lower ADHD symptoms at age 12 years in girls, but not in boys.

Regarding differences in terms of PA patterns in adolescents with ADHD, the second most important result of this study is that there were significant differences between boys and girls in terms of the achievement of PA recommendations for health and the amount of PA performed at lunchtime. This finding coincides with the existing literature since girls are less active than boys (Béghin et al., 2019; Camacho-Miñano et al., 2011; Kallio et al., 2020; Lago-Ballesteros et al., 2021; Mercurio et al., 2021; Moreno-Llamas et al., 2021; Owen et al., 2017; Rosselli et al., 2020). On the other hand, our data reflects that during lunchtime, 88.9% of girls with ADHD, sat down, stood down, or walked around. So, taking into account the amount of free time students have at lunchtime in our country, to improve the amount of PA carried out by adolescents during leisure time, it is important that this is included in the school’s PA schedule and policy and that the recreation environment encourages young people to make physically active decisions (Ridgers et al., 2012).

Finally, the third result of this study is that being of foreign origin and having a diagnosis of ADHD have an impact on the achievement of the recommended amount of daily PA for health. On the other hand, it was observed that being a girl (regardless of whether you have ADHD, and whether you are of foreign origin) was related to not carrying out the recommended daily PA. This statement agrees with Cook et al. (2015) who claim that youth with ADHD are significantly less likely than their peers to meet recommendations for vigorous PA (3 days per week or month). As mentioned, in terms of gender, according to literature girls are less active than boys (Béghin et al., 2019; Camacho-Miñano et al., 2011; Kallio et al., 2020; Lago-Ballesteros et al., 2021; Mercurio et al., 2021; Moreno-Llamas et al., 2021; Owen et al., 2017; Rosselli et al., 2020). Worryingly, in this sense, MVPA declines by approximately 4.2% to 7% per year between ages 12 and 18 years, and more recent studies indicate that girls’ PA levels decline at a greater rate than boys (Borde et al., 2017; Jones et al., 2020; Owen et al., 2017; Pearson et al., 2015; Spencer et al., 2015). In this sense, there is previous research indicating that girls and boys may behave differently in terms of PA during school lunch breaks and during PE classes (Telford et al., 2016) A plausible explanation is that some schools offer more opportunities for students to be physically active during these times but are more accessible or desirable for boys than for girls. These differences make it clear that teachers, parents, and coaches need to consider gender differences in PE and sports settings because activities that focus on physical performance are likely to benefit boys more than girls (Telford et al., 2016). It should also be taken into account that in this study, another risk factor was found for not carrying out the recommended PA since girls of foreign origin carry out less PA than those who were not. This fact agrees with the data obtained by the Centers for Disease Control and Prevention in which white girls followed PA recommendations more than those of black origin (Stephens et al., 2009).

To enhance PA engagement among adolescents with ADHD, it is crucial to acknowledge the increased risk of obesity and physical inactivity in this population (Khalife et al., 2014). Incorporating PA into their routine has been shown to lead to improvements in executive functions (Montalva-Valenzuela et al., 2022). While PA in Spanish schools is reported to be infrequent (Aibar et al., 2014), promoting PA among adolescents with ADHD is vital for their overall well-being.

One effective strategy to boost PA engagement could involve implementing school-based interventions that encourage active commuting to school. Research indicates that adolescents who actively commute to school are generally more physically active (Martínez-Gómez et al., 2012). Additionally, a randomized controlled trial focusing on promoting cycling to school could offer valuable insights into enhancing PA levels among Spanish adolescents (Chillón et al., 2021).

Considering the reluctance of adolescents with ADHD to engage in vigorous PA and organized sports (van Egmond-Fröhlich et al., 2012), it is essential to provide alternative options that align with their preferences and needs. Tailoring PA programs to match individual interests and abilities can help increase participation. Moreover, involving adolescents in decision-making regarding the type of PA they engage in can boost their motivation and adherence to exercise routines (Charach et al., 2014).

Practical strategies to boost PA engagement in adolescents with ADHD may involve implementing structured exercise programs tailored to their needs and preferences. These programs could encompass a variety of activities such as team sports, dance, or martial arts to maintain engagement and include adopting active recesses (indoor or outdoor), providing daily PE compulsory to all school levels, offering extracurricular sports, implementing active learning lessons, delivering active travel to school initiatives, providing active homework and active assignments, or providing resources to improve the design of open spaces at schools for promoting active play (Aubert et al., 2022; Schoenfelder et al., 2017). Additionally, incorporating technology like wearable activity trackers and social media platforms, as demonstrated in a pilot study (Schoenfelder et al., 2017), can offer motivation and a sense of community support. Moreover, promoting extracurricular activities beyond physical exercise can be advantageous. Adolescents with ADHD might benefit from engaging in activities that foster a sense of mastery, pleasure, and social connection, akin to strategies utilized for depression (Wiggs et al., 2023). Encouraging participation in after-school activities targeting academic and social functioning has been associated with enhanced school performance and reduced hyperactivity (Lax et al., 2020). Addressing barriers to engagement in care and treatment for adolescents with ADHD is crucial. Effectively using technology and ADHD information sources can enhance engagement (Zolli et al., 2020). Furthermore, focusing on the therapeutic relationship and implementing population-specific engagement strategies can further support adolescents with ADHD (M. Johansson et al., 2023).

Addressing the unique challenges faced by adolescents with ADHD during PA is crucial. While they may exhibit higher rates of disqualification, aggression, and emotional reactivity in sports (Seiffer et al., 2021), providing structured and supportive environments for PA can help mitigate these challenges. Implementing strategies to manage impulsivity and enhance focus during exercise sessions can further enhance their experience and outcomes.

Several methodological limitations should be considered when interpreting the results. First, the cross-sectional design of the study precludes establishing causal relationships between variables or defining the objective PA patterns of adolescents. However, it provides contextual information on the domains where PA is performed, offering valuable information to inform the design of school-based interventions to address ADHD symptomatology. On the other hand, the cut-off points of the questionnaire used do not differentiate by gender. The samples included voluntary participants, a fact that may have underrepresented some groups. Moreover, individuals had to be removed from the sample for not having completed the questionnaire or because they were ill the week before answering it. Accelerometers are currently the most used devices for collecting objective data related to PA, as they also allow ST to be measured. In this sense, in the present study accelerometers were not available. On the other hand, we had the advantage of being able to find out through the PAQ-A questionnaire the amount of PA perceived by adolescents throughout the day. In future research, it would be interesting to be able to use accelerometers accompanied by a written record of PA to be able to establish 24-hour movement patterns.

Conclusions

In conclusion, when promoting PA in adolescents with ADHD within the school environment, it is necessary to take into account different domains and specific contexts of a school day in addition to leisure time, PE classes within the school, and after-school programs. Special attention must also be paid to girls and adolescents with ADHD of immigrant origin to propose policies that promote PA in these groups since they are the ones who least follow the daily recommendations of PA. PA that is done at school can be part of the treatment of adolescents with ADHD considering that in Spain, there are health teams (nurses) in schools that should make these recommendations in coordination with pediatricians.

Footnotes

Acknowledgements

We are grateful to the students, families, and staff of the public secondary schools (i.e., Antoni Pous i Argila, Cal Gravat, Guillem Catà, Institut de Vic, Institut del Ter, Jaume Callís, Lacetània, La Plana, Lluís de Peguera, and Pius Font i Quer), and private schools (i.e., L’Ave Maria, Casals-Gràcia, FEDAC Manresa, FEDAC Vic, Joviat, La Salle Manlleu, La Salle Manresa, Oms i de Prat, Sagrat Cor Vic, Sagrats Cors Centelles, Sant Miquel dels Sants, and Vedruna Escorial Vic), who kindly participated in this study, as well as to the Ministry of Education of Generalitat de Catalunya.

Authors’ Note

Gemma Español-Martín is also affiliated to Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.

Miquel Casas is also affiliated to Fundació d’Investigació Sant Pau, Barcelona, Spain and Instituto para el Desarrollo de Terapias Avanzadas en Neurociencias (IDETAN). Barcelona, Spain.

Rosa Bosch is also affiliated to Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.

Author Contributions

Conceptualization, R.P., A.P.-R., and R.B.; investigation, R.P., G.E.-M, C.R., A.A., P.T., and A.C.M.; data curation, R.P., M.P., and R.B.; writing—original draft preparation, R.P., A.P-R., and R.B.; writing—review and editing, A.P.-R., M.P., and R.B.; project administration, M.C. and R.B.; funding acquisition, M.C. All authors have read and agreed to the published version of the manuscript.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: G.E.-M. has received travel grants from Angelini Pharma, Laboratorios Rubió, Lundbeck, and Takeda for participating in psychiatric meetings. M.C. has received fees to give talks for TAKEDA and Laboratorios RUBIO. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by “la Caixa” Banking Foundation (LCR/PR/PR20/51150021), Diputació de Barcelona (PR(AG)72-2012 (2016/011627)), Health Research and Innovation Strategic Plan (SLT006/17/00285) the Ministry of Health of Generalitat de Catalunya and Fundacio Privada d’Investigacio Sant Pau (FISP).

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Vall d’Hebron Hospital Universitari, in Barcelona (SLT006/17/00285).

Informed Consent Statement

Informed consent was obtained from the parents or guardians of all participants and from adolescents in study.

ORCID iD

Raquel Prat

Author Biographies

Raquel Prat, BSc, is a Psychologist Specialized in the Neuropsychological Evaluation of Neurodevelopmental disorders and the development of school interventions. She is also a predoctoral researcher at the Centre for Health and Social Care Research of the University of Vic-Central University of Catalonia (UVic-UCC), where she investigates the relationship between physical exercise and emotional well-being in adolescents. She completed a Master’s degree in Educational Psychology at the Universitat Oberta de Catalunya (UOC) in 2019 and a Master’s degree in Clinical Neuropsychology at ISEP Barcelona from 2015 to 2017. She earned her Bachelor’s degree in Psychology from the UVic-UCC in 2015. In her professional experience, she has served as a clinical neuropsychologist at various institutions, including Hospital de Sant Joan de Déu de Barcelona and Vall d’Hebron Institut de Recerca (VHIR). She has published scientific articles and has been awarded diferent grants.

Anna Puig-Ribera, BSc, PhD, is a Lecturer and Researcher in Physical Activity and Health Sciences at the University of Vic-Central University of Catalonia and coordinates the Research Group in Sport and Physical Activity (GREAF) at this university. She earned her PhD in Exercise in Health Sciences from the University of Bristol, United Kingdom. With an H-index of 19 in Scopus, she specializes in promoting health through physical activity and reducing sedentary behavior.

Mireia Pagerols, BSc, PhD, is a Pharmacist and Biomedical Scientist with a broad background in the study of the genetic and epidemiology of neurodevelopmental disorders. She initially focused her research on the pharmacogenetic and molecular mechanisms implicated in psychiatric disorders through candidate-gene, GWAS, transcriptomic and methylomic analyses. As a member of the SJD MIND Schools Program, she is currently involved in the design and development of different research projects that aim to identify children and adolescents’ mental health problems in a school setting in order to improve their psychological well-being and functioning. Over the last five years, she has actively participated in 10 national and international projects and has published 12 articles, mostly in the field of Psychiatry, Pharmacology and Neurosciences, in high impact journals (e.g., Molecular Psychiatry, Neuropsychopharmacology, Psychological Medicine, Translational Psychiatry). Overall, she has an accumulated impact factor of 85.107 and an H-index of 10, with a total of 227 citations. She is also Associate Lecturer in Psychometrics and Pharmacology at the Universitat Oberta de Catalunya and Universitat de Barcelona, respectively.

Gemma Español-Martín, MD, PhD, is a Specialist in Adult and Child Psychiatry and holds expertise in diagnosing and treating neurodevelopmental disorders in pediatric patients. After graduating from the University of Barcelona (UB) with a degree in Medicine and completing her psychiatry residency at the Autonomous University of Barcelona (UAB), she possesses dual specialization in adult psychiatry and child and adolescent psychiatry. Since 2015, she has served as an adjunct psychiatrist at Vall d’Hebron University Hospital’s Psychiatry Department, focusing on psychiatric comorbidities in pediatric patients within hospital and outpatient settings, including liaison programs. Dr. Español-Martín is actively engaged in research, particularly studying the biological underpinnings of neurodevelopmental disorders such as ADHD and learning disorders, collaborating with the Vall d’Hebron Institute of Research (VHIR) on various genetic and neurodevelopmental research studies and clinical trials. Additionally, she contributes to medical education as an associate professor of psychiatry at the Vall d’Hebron Teaching Unit at UAB.

Cristina Rivas, BSc, is a Psychologist Specialized in the neuropsychological evaluation of neurodevelopmental disorders and the development of school interventions.

Áurea Autet, MD, is a Psychiatrist with expertise in the clinical assessment of neurodevelopmental disorders and currently serves as the Director of Mental Health at the Althaia Foundation. Additionally, she is a predoctoral researcher at the Centre for Health and Social Care Research of the University of Vic-Central University of Catalonia (UVic-UCC), focusing on Neurodevelopmental Disorders. In academia, Dr. Autet serves as the Coordinator of the Postgraduate Program in Mental Illness and Behavior Disorders in Intellectual Disability at UVic-UCC, as well as a collaborating professor in the Human Behavior subject of the Medicine Degree at UVic-UCC, and she also lectures in other master’s programs. She has been a member of the Board of the Catalan Society of Child and Adolescent Psychiatry for the last eight years, currently holding the position of vice president. Dr. Autet has participated in various working groups of the Mental Health Advisory Council and was recently appointed as an expert advisor for the Mental Health and Addictions Master Plan.

Pere Tàpies, MD, is a Specialist in Psychiatry, and holds expertise in diagnosing and treating neurodevelopmental disorders in pediatric patients. He has been serving at the Consorci Hospitalari de Vic since 2007.

Ana C. Martín, MD, is a Psychiatrist with extensive academic and professional credentials. She obtained her medical degree from Universitat Rovira i Virgili (URV) in 2013 and completed her specialization in psychiatry at Consorci Hospitalari de Vic in 2018. She has pursued further training in various areas, including completing a course in ADI-R in 2020 and earning a Master’s degree in “Updates on Psychiatric Treatments in Pediatric Patients” from Universidad Cardenal Herrera in 2021. She also holds several University Expert certifications in different aspects of child and adolescent psychiatry from the same institution. Her professional experience includes serving as a psychiatrist at the Hospital de Dia Infantojuvenil and outpatient consultations at the Unit of Eating Disorders at Hospital Sant Joan de Déu de Barcelona in 2018. Since then, she has been working as a psychiatrist at the Hospital de Dia Infantojuvenil and outpatient consultations at Osona Salut Mental, as well as coordinating the First Psychotic Episode Program at Consorci Hospitalari de Vic. Dr. Martín has also been involved in teaching, being a guest lecturer in psychology programs at UVic-UCC, and participating in numerous courses and presentations as both an author and a speaker.

Miquel Casas, MD, PhD, is the Head of the SJD MIND Schools Program at the Hospital Sant Joan de Déu, Emeritus Professor of Psychiatry at the Universitat Autònoma de Barcelona, Honorary President of the Spanish Society of Dual Pathology and Head of the PAIMM-PAIME Program at the Clínica Galatea. He is also a member of the Advisory Council on Public Health and on Mental Health and Addictions of the Catalan Ministry of Health. From 1983 to 2000, he was Head of the Department of Psychiatry at the Hospital de la Santa Creu i Sant Pau, where he created and developed the Laboratory of Experimental Psychiatry and Psychopharmacology (1982), the Drug Addiction (1985) and Addictive Behaviors Unit (1987), and the Psychiatric Emergency Service (1996). In 2000, he became Head of the Department of Psychiatry at the Hospital Universitari Vall d’Hebron and since 2004 he was also responsible for the Psychiatry, Mental Health and Addictions Group at the Vall d’Hebron Research Institute. In 2015 he joined as a principal investigator the group 27 at the Mental Health Networking Biomedical Centre (CIBERSAM, ISCIII) and from 2016 to 2021 he was Head of the “Neurodevelopmental and learning disorders through lifespan” Program of the Catalan Institute of Health. Over his 48 years of professional experience, he has obtained grants and funds for more than 45 research projects, has published 34 books in the field of Psychiatry as editor, and has generated 374 articles in peer-reviewed journals (53 of them in the last five years) with an accumulated impact factor of 1,291.146, an H-index of 57 and a total of 14,237 citations. He has also participated in numerous clinical studies, pharmacological trials, and genetic studies, in addition to more than 250 national and international congresses.

Rosa Bosch, BSc, PhD, is a Renowned Psychologist with in-depth knowledge on clinical diagnosis, epidemiological and genetic studies of neurodevelopmental disorders. She has worked at the Department of Psychiatry of Hospital de la Santa Creu i Sant Pau and Hospital Universitari Vall d’Hebron, and she currently coordinates the program of “Neurodevelopmental disorders and school failure” at the Hospital Sant Joan de Déu. She is also a member of the group 11 at the Mental Health Networking Biomedical Research Centre (CIBERSAM, ISCIII) and has published 71 articles with an H-index of 32 and around 3,274 citations.

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