The ADHD Exercise Solution
A renowned ADHD expert explains how physical activity changes your brain for the better and how exercise can act as a supplemental treatment for patients managing their symptoms with medication, therapy, and/or nutrition.
If you were to run into Jackson, my former patient, you would meet a compact 21-year-old in jeans and an untucked shirt, who speaks articulately about his plans for the future — a typical American college kid, if not a little smarter. What stands out about him isn’t so much where he is today, but how far he has come to get here and how he did it with an alternative ADHD treatment.
Jackson, who has attention deficit hyperactivity disorder (ADHD or ADD), runs nearly every day — three miles on days that he also does resistance training, six miles on the others. “If I don’t do it, it’s not like I feel guilty,” he says. “I feel like I’ve missed something in my day, and I want to go do it. Because I figured out that, while I’m exercising, I don’t have trouble concentrating on anything.”
Jackson was diagnosed with ADHD early on, after his third-grade teacher picked up on his disruptive behavior and inability to complete class work. He began taking Ritalin and stayed on some form of stimulant throughout his school years.
As a day student at a top-ranked private academy, he simply had more work than he could get through. At one point, I had him taking Adderall, Paxil, and clonazepam, a long-acting anxiety drug.
Jackson squeaked through with a 1.8 GPA, far too low to go to the college he hoped to attend, despite family connections. A small junior college accepted him, though, and that was just fine. The triumph of completing school, along with the comfort of having a destination the next fall, put him on top of the world. In fact, he felt so good that summer that he decided to go off his medication-all of it. (Needless to say, I wasn’t in the loop at the time.) “I noticed that a lot of small things that bothered me went away,” he reports.
The real turning point of the summer happened in Spain, on a trip with his girlfriend. Walking around shirtless on the beach, with all the “Spanish dudes,” he was inspired to do something about his Buddha belly. “I just started to run,” he says. “And I started feeling great.”
Jackson’s story appeals to me, partly because he got into exercise for his body image but stuck with it for the therapeutic effect. At first, the running didn’t make a dent in his physique (thanks to pizza and beer), but he stuck with it because it helped him focus. In his first semester at the junior college, he earned a 3.9 GPA, and, after a year, he was accepted as a transfer student at the college he had originally wanted to attend.
Jackson is clearly tuned in to his own state of mind. If he falls off his exercise regimen, his concentration wavers. He knows how it makes him feel, and that knowledge itself keeps him going. “When I started exercising, I suddenly was able to concentrate on things that were important to me,” he says. “There’s never been any question in my mind that exercise is related to concentration. Once I made this huge life change, and committed to exercise, it was very clear to me that things started to change in my life.”
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Not everyone with ADHD will experience the sweeping effect of exercise that Jackson did. And I would have never suggested he abruptly quit taking his medication, especially the antidepressant. His experience begs the question of whether exercise can replace Ritalin or Adderall or Wellbutrin, and, for the vast majority of cases, I would say the answer is no. At least not in the way James Blumenthal, Ph.D., and his colleagues at Duke University showed that exercise can stand in for Zoloft in treating those with a mood disorder.
Yet there is something instructive in Jackson’s motivation for discontinuing his medication. I think he felt out of control, knowing that he was smart enough to succeed but unable to make it happen. Constant frustration can lead to feelings of demoralization, and, in Jackson’s case, this fed his mood disorder. For him, taking medication created a sense of dependency, exacerbating those feelings. Conversely, getting into a running routine provided a sense of control over his inner self-his mood, his anxiety, his focus. For the first time in his life, he felt like he could steer his own future. He used running as his medicine.
Engage the Brain
According to the broad science, exercise tempers ADHD by increasing the neurotransmitters dopamine and norepinephrine-both of which play leading roles in regulating the attention system. With regular physical activity, we can raise the baseline levels of dopamine and norepinephrine by spurring the growth of new receptors in certain brain areas.
Exercise also helps balance norepinephrine in the brain stem’s arousal center. “Chronic exercise improves the tone of the locus coeruleus,” says Amelia Russo-Neustadt, M.D., Ph.D., a neuroscientist and psychiatrist at California State University. “The result is that we are less prone to startle or to react out of proportion to any given situation. We also feel less irritable.”
Similarly, I think of exercise as administering the transmission fluid for the basal ganglia, which is responsible for the smooth shifting of the attention system. This area is the key binding site for stimulants, and brain scans show it to be abnormal in children with ADHD.
One group of researchers, including the University of Georgia’s Rodney Dishman, Ph.D., examined the effects of exercise in ADHD kids by using motor-function tests that provide indirect measures of dopamine activity. The results threw Dishman for a loop because boys and girls responded differently. In boys, rigorous exercise improved their ability to stare straight ahead and stick out their tongue, for example, indicating better motor reflex inhibition.
Girls didn’t show this improvement, which may be because of a lower incidence of hyperactivity in girls. Both boys and girls improved by another measure related to the sensitivity of dopamine synapses, although boys fared better after maximal (vigorous) exercise and girls after submaximal (moderate) exercise.
Exercise has beneficial effects on other areas of the brain. An overactive cerebellum, for instance, contributes to fidgetiness in ADHD kids, and recent studies have shown that ADHD drugs that elevate dopamine and norepinephrine bring this area back in balance. When it comes to elevating norepinephrine levels, the more complex the exercise, the better. Rats haven’t learned to do judo in the lab-at least not yet-but scientists have looked at neurochemical changes in their brains after periods of acrobatic exercise, the closest parallel to martial arts for rats. Compared to rats who ran on a treadmill, their cohorts who practiced complex motor skills improved levels of brain-derived neurotrophic factor (BDNF) more dramatically, which suggests growth in the cerebellum.
Any of the martial arts, ballet, ice skating, gymnastics, rock climbing, mountain biking, whitewater paddling, and-sorry to tell you, Mom-skateboarding are especially good for adults and children with ADHD. Why, exactly? The technical movement inherent in these types of sports activate a vast array of brain areas that control balance, timing, sequencing, evaluating consequences, switching, error correction, fine motor adjustments, inhibition, and, of course, intense focus and concentration.
In the extreme, engaging in these activities is a matter of survival-avoiding a karate chop, or breaking your neck on the balance beam, or drowning in a swirling pool of whitewater-and, thus, taps into the focusing power of the fight-or-flight response. When the mind is on high alert, there is plenty of motivation to learn the skills necessary for these activities. As far as the brain is concerned, it’s do or die. And, of course, we will be in the aerobic range most of the time we’re involved in these activities, which boosts our cognitive abilities and makes it easier to absorb new moves and strategies.
Exercise also has a positive effect on the limbic system, because it helps regulate the amygdala. In the context of ADHD, the amygdala blunts the hair-trigger responsiveness a lot of people experience, and evens out the reaction to a new source of stimulus, so we don’t go overboard and scream at another driver in a fit of road rage, for example.
To the extent that ADHD is a lack of control-of impulses and attention-the performance of the prefrontal cortex is critical. The seminal 2006 study, from Arthur Kramer, Ph.D., of the University of Illinois, used MRI scans to show that walking as few as three days a week for six months increased the volume of the prefrontal cortex in older adults.
And when Kramer tested aspects of their executive function, the subjects showed improvement in working memory, smoothly switching between tasks and screening out irrelevant stimuli. Kramer wasn’t on the trail of ADHD, but his findings illustrate another way exercise might help.
Everyone agrees that exercise boosts levels of dopamine and norepinephrine. One of the intracellular effects of these neurotransmitters, according to Yale University neurobiologist Amy Arnsten, Ph.D., is to improve the prefrontal cortex’s signal-to-noise ratio. Arnsten has found that norepinephrine improves the signal quality of synaptic transmission, while dopamine decreases the noise, or static, of undirected neuron chatter. This prevents the receiving cell from processing irrelevant signals.
Arnsten also suggests that neurotransmitter levels follow an upside-down U pattern, meaning that increasing them helps to a point, after which there’s a negative effect. As with every other part of the brain, the neurological soup needs to stay at optimum levels. Exercise is the best recipe.
For most of my patients, I suggest exercise as a tool to help them manage their symptoms, along with their medication. The best strategy is to exercise in the morning, and take the medication about an hour later, when the immediate focusing effects of exercise begin to wear off. For a number of patients, I find that, if they exercise daily, they need a lower dose of stimulant.
I try to do my workout first thing in the morning, both for the structure it affords and to set the right tone for the day. A lot of times, that keeps me going. Researchers haven’t quantified how long the spike in dopamine and norepinephrine lasts after an exercise session, but anecdotal evidence suggests an hour, or maybe 90 minutes, of calm and clarity. I tell people who need medication to take it at the point when the effects of exercise are wearing off, to get the most benefit from both approaches.
The truth is, everyone has a different level of attention deficit, and they should experiment to see what regimen works. My hope is that knowing how it works will allow one to find the best solution for himself. I would say 30 minutes of aerobic exercise a day should be the minimum. It’s not a lot of time, especially considering that it will help one focus enough to make the most of the rest of their day.
Excerpted from SPARK: The Revolutionary New Science of Exercise and the Brain by John J. Ratey, M.D. and Eric Hagerman. Copyright (c) 2008 by John J. Ratey, M.D. Reprinted by permission of Little, Brown and Company, New York, NY. All rights reserved.
John Ratey, M.D., is a member of the ADDitude ADHD Specialist Panel.