Is hyperactivity ubiquitous in ADHD or dependent on environmental demands? Evidence from meta-analysis

Abstract

Hyperactivity, or excess gross motor activity, is considered a core and ubiquitous characteristic of ADHD. Alternate models question this premise, and propose that hyperactive behavior reflects, to a large extent, purposeful behavior to cope with environmental demands that interact with underlying neurobiological vulnerabilities. The present review critically evaluates the ubiquity and environmental modifiability of hyperactivity in ADHD through meta-analysis of 63 studies of mechanically measured activity level in children, adolescents, and adults with ADHD relative to typically developing (TD) groups. Random effects models corrected for publication bias confirmed elevated gross motor activity in ADHD (d = 0.86); surprisingly, neither participant age (child vs. adult) nor the proportion of each ADHD sample diagnosed with the Inattentive subtype/presentation moderated this effect. In contrast, activity level assessed during high cognitive load conditions in general (d = 1.14) and high executive functioning demands in particular (d = 1.39) revealed significantly higher effect sizes than activity level during low cognitive load (d = 0.36) and in-class schoolwork (d = 0.50) settings. Low stimulation environments, more rigorous diagnostic practices, actigraph measurement of movement frequency and intensity, and ADHD samples that included fewer females were also associated with larger effects. Overall, the results are inconsistent with DSM-5 and ADHD models that a) describe hyperactivity as ubiquitous behavior, b) predict a developmental decline in hyperactivity, or c) differentiate subtypes/presentations according to perceived differences in hyperactive behavior. Instead, results suggest that the presence and magnitude of hyperactive behavior in ADHD may be influenced to a considerable extent by environmental factors in general, and cognitive/executive functioning demands in particular.

Working memory and organizational skills problems in ADHD

“…Overall, the current findings are consistent with model‐driven predictions (Rapport et al., ), and suggest that organizational problems reflect, to a large extent, an outcome of impaired working memory processes that in turn negatively impact children's ability to sustain attention and maintain consistent task engagement (McBurnett et al., ). This hypothesis is consistent with the strong covariation between treatment‐related improvements (but not normalization) in ADHD symptoms and organizational behavior (Abikoff et al., ), as well as observations of children with ADHD at school; they often come to class unprepared, have disorganized desks/lockers, misplace materials, and require accommodations to manage deadlines and submit completed homework (Abikoff et al., ; Langberg, Epstein et al., ; Langberg, Molina et al., ; Power, Werba, Watkins, Angelucci, & Eiraldi, ). Working memory deficits would make it extraordinarily difficult to engage in the forethought and planning necessary to organize materials, anticipate deadlines, inhibit irrelevant internal and external stimuli, and simultaneously coordinate relevant, in vivo data with project goals and prior knowledge.…”

“…Organizational problems are a critical yet understudied area of impairment for children with ADHD (Abikoff et al., ). Organization is a multifaceted construct, and children with ADHD frequently show organizational impairments related to planning tasks, tracking assignments, recalling due dates, and managing supplies (Abikoff & Gallagher, ; Langberg, Epstein et al., ). As a result, these children frequently misplace materials, come to class unprepared (Pelham, Fabiano, & Massetti, ), and have messy and disorganized lockers, backpacks, and desks (Atkins, Pelham, & Licht, ; Zentall, Harper, & Stormont‐Spurgin, ).…”

“…Organizational problems begin in elementary school for many children with ADHD, and increase in severity as they progress in school (Booster, DuPaul, Eiraldi, & Power, ; Langberg, Molina, et al., ), experience higher workloads (Evans, Allen, Moore, & Strauss, ), and experience increased expectations for personal responsibility from teachers and parents (Meyer, Allison, & Le'Roy, ). These organization problems continue into adulthood (Bikic, Reichow, McCauley, Ibrahim, & Sukhodolsky, ), and portend academic underachievement (Kent et al., ) and lower school grades both concurrently (Langberg, Epstein et al., ) and longitudinally into high school (Langberg, Molina et al., ) – even for intellectually gifted children with ADHD (Leroux & Levitt‐Perlman, ). Psychostimulant medication appears to improve but not normalize these impairments (Abikoff et al., ).…”

“…To our knowledge, no study has investigated neurocognitive mechanisms associated with organizational problems in ADHD. Following conceptual models suggesting neurocognitive dysfunction as a plausible causal mechanism of the ADHD phenotype (for review, see Kofler, Raiker, Sarver, Wells, & Soto, 2016), we predicted direct effects of working memory on ecologically valid measures of organizational behavior (Figure 1, path c). We further predicted indirect effects ( Figure 1, path a*b) based on evidence that working memory deficits evoke ADHD-related inattentive and hyperactive behaviors (Rapport et al, 2009), which in turn predicts ADHD-related organizational problems (Langberg et al, 2012;McBurnett et al, 2014).…”

Perspectives of preschool children in England with speech and language needs in the development of evidence‐based activities

“…Although our study was a small group of diverse young children with varying speech and language ability, our observation of children's fidgeting, apparently supporting prolonged engagement, would support some of the findings of Sarver et al (). Kofler, Raiker, Sarver, Wells, and Soto's () meta‐analytic review suggests that gross motor activity is influenced by environmental factors in general and cognitive/executive functioning demands in particular, but the group of children under investigation in the current study requires more detailed study. In our activity groups, we built in a range of sitting and movement‐based activities; no efforts were directly made to stop children fidgeting during any activity.…”