Disability and Health Journal 16 (2023) 101377

Contents lists available at ScienceDirect

Disability and Health Journal

journal homepage: www.disabilityandhealthjnl.com

Original Article

The effect of physical activity on quality of life and parenting stress in

children with attention-deficit/hyperactivity disorder: A randomized
controlled trial
Zhenzhen Zhang, MEd a, Ru Li, PhD a, *, Ziwei Zhou, MEd a, Peng Wang, PhD b,
Binrang Yang, PhD c, Xiaodong Wang, PhD a
a
Faculty of Physical Education, Shenzhen University, Shenzhen, China
b
Cardiac Rehabilitation Center, Fuwai Hospital, CAMS&PUMC, Beijing, China
c
Children's Healthcare & Mental Health Center, Shenzhen Children's Hospital, Shenzhen, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Poorer quality of life (QoL) is commonly observed in children with Attention-deficit/
Received 10 March 2022 Hyperactivity Disorder (ADHD). Parents of children with ADHD also perceived elevated levels of
Received in revised form parenting stress. Previous research has documented the positive effects of physical activity (PA) on
3 September 2022
managing ADHD symptoms. It is critical to implement ADHD management with broader functioning
Accepted 7 September 2022
from both children's and parents' perspectives.
Objective: This study aimed to examine whether PA would exert an influence on the QoL of children with
Keywords:
ADHD and parenting stress of their parents.
ADHD
Physical activity
Methods: Forty-three children with ADHD (6e12 years) were randomly assigned to the PA intervention
Quality of life and waitlist control groups. Children in the intervention group participated in a 12-week PA program.
Parenting stress Parent-reported QoL and parenting stress were assessed before and immediately after the intervention.
Analysis of covariance with a mixed factorial design of 2 (time: before vs. after intervention)
2 (group:
PA intervention vs. waitlist control) was conducted to examine changes in QoL and parenting stress over
the 12 weeks.
Results: Compared to the control group, parents of children in the intervention group reported signifi-
cant reduced overall parenting stress (p ¼ .021, h2 ¼ 0.142) and child domain of parenting stress
(p ¼ .024, h2 ¼ 0.138) after the intervention. No significant improvement in QoL was documented in
either group.
Conclusions: The participation of PA intervention positively impacts parenting stress perceived by par-
ents of children with ADHD, which provides further evidence of the family-wide benefits of the PA
intervention.
© 2022 Elsevier Inc. All rights reserved.

Attention-deficit/hyperactivity disorder (ADHD) is a common frequently manifest a poorer health-related quality of life (QoL)
childhood-onset neurodevelopmental disorder, affecting approxi- compared with children without the disorder.2,4 QoL describes “an
mately 5.29% of children worldwide.1 ADHD is characterized by individual's subjective perception of the impact of his/her health
developmentally inappropriate degrees of inattention, hyperactiv- status of disease and treatment, on the physical, psychological, and
ity, and impulsivity, which impairs various aspects of daily life social function”.5 It is generally perceived as multidimensional,
emotionally, socially, and academically.2 These daily life functional which can be broadly categorized into physical and psychosocial
outcomes have increasingly been the focus of ADHD treatment aspects.6 The psychosocial functioning aspect of QoL is especially
trials in addition to symptom reduction.3 Children with ADHD impaired in children with ADHD.2 This disorder not only causes
functioning impairment in children themselves, but interferes
negatively with their family relationships.7e9
* Corresponding author. Shenzhen University, No. 3588 Nan Hai Da Dao, Nanshan Families of children with ADHD experience difficulties in
District, Shenzhen, China. several aspects of functioning including parenting, parent
E-mail address: [email protected] (R. Li).

https://doi.org/10.1016/j.dhjo.2022.101377
1936-6574/© 2022 Elsevier Inc. All rights reserved.
Z. Zhang, R. Li, Z. Zhou et al. Disability and Health Journal 16 (2023) 101377

psychopathology, and life stress.10,11 Given the increased caretaking Present and Lifetime (K-SADS-PL).29 The inclusion criteria include:
demands that children with ADHD impose on their parents, these (1) aged 6e12 years attending regular primary schools; (2) diag-
parents find themselves frequently dealing with a variety of school, nosed as ADHD based on the criteria of Diagnostic and Statistical
peer, and family difficulties throughout childhood.12 Research has Manual of Mental Disorders, 5th edition (DSM-5); (3) having a full
consistently demonstrated that parents of children with ADHD IQ of more than 70 on the Chinese Wechsler Intelligence Scale for
frequently perceive elevated levels of parenting stress.13 Parenting Children; (4) no medication use (medication-naive or medication
stress, conceptualized as “the aversive psychological reaction to the withdrawal for at least 6 months before the enrollment) or taking
demands of being a parent”,14 may stem from multiple sources in the medication with stabilized dosage in the past 3 months (dose
families of children with ADHD. Child-level (e.g., severity of ADHD adjustment 10%); (5) physically able to participate in the
symptoms, oppositional defiant behavior, internalizing and exter- requested PA intervention; (6) no prior regular participation in PA
nalizing behaviors), parent-level (e.g., parental ADHD, maternal other than school PE classes. We excluded children with comor-
depression), and contextual-level (e.g., social support, spousal bidities of major psychiatric conditions (e.g., bipolar disorder,
support, socioeconomic status) characteristics have been identified autism spectrum disorder, substance abuse), neurological abnor-
as factors that may affect parenting stress in this population.8,9,15 malities, and physical diseases.
Few studies focused on parenting stress within the context of
intervention for children with ADHD. A previous study found that Intervention
parent well-being could moderate the treatment effect in ADHD.16
Also considering that high parenting stress negatively affects their Children in the intervention group were required to participate
parenting practices which may further exacerbate the child's in 12 weeks of PA training for 36 sessions (three sessions per week,
symptoms, parenting stress should be identified as an intervention 60 min per session) in the gym of Shenzhen Children's Hospital. The
target in its own right. Beyond managing ADHD core symptoms, primary investigator supervised each intervention session, assisted
there is a pressing need to develop a comprehensive treatment by trained research staff and graduate research assistants. A trained
strategy for ADHD that focuses on broader functioning from both coach, who had 6 years of experience in teaching PE or physical
children's and parents' perspectives.2,3 fitness training to children with and without ADHD, conducted the
Research in the past decade has documented the potential value teaching and provided modeled behaviors with instructions based
of physical activity (PA) on alleviating ADHD symptomatology on the intervention protocol. All research staff and assistants maj-
(inattention, hyperactivity/impulsivity),17,18 and improving specific ored in PE, adapted to PE or psychology, and had experience
functional deficits in behavioral control, executive function, motor working with children with ADHD. The staff-to-participant ratio
skills, and emotional and social capabilities.19e24 As for the wide- ranged from 1:2 to 1:1 depending on the attendance.
reaching effect of PA on broader functioning beyond core ADHD The design of the intervention aimed to maximize children's
symptoms and specific impairments that characterized ADHD, participation in continuous moderate-to-vigorous PA (MVPA). Each
some cross-sectional evidence indicated that the participation in intervention session was organized in the following manner: (1)
PA of children with ADHD was positively associated with their warm-up group games (10 min); (2) main exercise (45min); (3)
QoL25 and negatively associated with parenting stress perceived by cool down (5 min). As high intensity of PA was conducive to the
their parents.26 A randomized controlled trial including 28 boys improvement of QoL,25 the main exercise was designed to maxi-
with ADHD found that those who received a 3-week multimodal mize children's participation in sustained MVPA. Children learned
therapy combining a section of high-intensity interval training various forms of motor skills (e.g., skipping, running, hopping,
(HIIT) scored greater improvement in social functioning of QoL cross-step, dribbling) through practice in groups and group games.
compared to those assigned to the standard multimodal therapy.27 Table 1 describes the PA intervention protocol. The intensity of
Overall, this small body of evidence not only supports the tentative MVPA is defined as a target heart rate (THR) ranging from 64% to
speculation that children's participation in PA may benefit their 93% of the maximum HR.30 We objectively measured the intensity
QoL, but raises the possibility of family-wide benefits on parenting of the main exercise section by asking the participants to wear a
stress through a children-focused PA intervention. Polar OH1 heart rate monitor during each intervention session. For
The present study aimed to conduct a randomized controlled the convenience of monitoring in the Polar system, PA with an HR
trial exploring the efficacy of a PA intervention on QoL in children ranging from 60% to 90% of the maximum HR was regarded as
with ADHD and parenting stress of their parents. This study also reaching the intensity of MVPA. The intervention was considered
considered some variables that might confound the effects of PA on successful if the participants can maintain their THR for 30 min or
QoL and parenting stress, including child characteristics (i.e., age, above throughout a single session. Participants were positively
gender) as well as clinically relevant characteristics (i.e., obesity, reinforced verbally with praise for their efforts in learning and
ADHD subtype, comorbidities, medication use).26,28 These potential practicing the skill. Participants were required to follow their daily
confounders were included as covariates in the analysis. It was routine without participating in any additional exercise or sports
hypothesized that PA intervention in general would show positive program except regular PE classes provided by schools during the
effects on QoL of children with ADHD and parenting stress of their intervention period.
parents. Participants in the waitlist control group did not receive any PA
intervention during the 12 weeks. They were required to maintain
Methods their normal daily routine without participating in any additional
exercise or sports program except regular PE classes provided by
Participants schools during this period.

We recruited participants from the outpatient of Children's Procedure

Healthcare & Mental Health Center at Shenzhen Children's Hospital
in Shenzhen, China between August 2020 and September 2020. A research assistant generated a randomization schedule us-
Participants and their parents underwent a standard structured ing a computerized random number sequence. Participants were
interview by an experienced psychiatrist using the Kiddie Schedule randomly assigned to an intervention or a waitlist control group,
for Affective Disorders and Schizophrenia for School-age Children- stratified by age and ADHD subtype. Block randomization with a
2
Z. Zhang, R. Li, Z. Zhou et al. Disability and Health Journal 16 (2023) 101377

Table 1
Protocol of the physical activity intervention.

Order Main exercise Period Intensity Time

Warm-up Stretching, 1e12 weeks THR: 50%e80% of the maximum heart rate 10 min
Joint exercises,
Balancing,
Group games (e.g., tagging or chasing, dodgeball)
Main exercise Rope skipping (e.g., non rope-jumping, rope-walking, 1e4 weeks THR: 60%e90% of the maximum heart rate 45 min
rope-jumping, bounce step, side swing, jumping jacks)
Group games (e.g., couple rope-jumping, group rope-jumping)
Kickboxing (e.g., Cross, Jab, Hook, front kick, back kick, cross-step kick, side kick) 5e8 weeks THR: 60%e90% of the maximum heart rate
Group games (e.g., rope ladder, obstacle course)
Basketball skills (e.g., dribbling, passing, shooting, sliding) 9e12 weeks THR: 60%e90% of the maximum heart rate
Group games (e.g., basketball games)
Cool-down Stretching 1e12 weeks e 5 min

Note. THR: target heart rate.

block size of 2 was used to ensure equal allocation ratios for both weeks of intervention or control. They were asked to complete
groups. In accordance with the Declaration of Helsinki, the legal questionnaires evaluating QoL and parenting stress under the in-
guardians of all participants provided written informed consent, struction of research staff. Fig. 1 shows the procedure of the pre-
and children provided assent to participate. We informed all sent study.
participants and their parents that withdrawal at any time would In view of the COVID-19 pandemic, all research staff, partici-
not result in any negative consequences. This study was pating children, and their parents had to adhere to the epidemic
approved by the ethics committee board of Shenzhen Children's prevention protocols regulated by Shenzhen Children's Hospital
Hospital (Approval ID: 202010302). The trial was registered with and the local government. The body temperature was measured
ChiCTR, https://www.chictr.org.cn/enindex.aspx (ChiCTR22000 each time when an intervention or evaluation was conducted. The
55765). child or parent was also required to undergo a nucleic acid test if
Parents of each participant attended one baseline assessment they had an elevated temperature or displayed any symptoms of
(T1) and one post-test assessment (T2) immediately after 12 illness.

Fig. 1. Participant flow diagram describing the progress through the enrollment, allocation, and data analysis.

3
Z. Zhang, R. Li, Z. Zhou et al. Disability and Health Journal 16 (2023) 101377

Measures Table 2
Participants’ characteristics.

Quality of life PA intervention Control group (n ¼ 21) p

Parents of the participants completed the Chinese version of the group (n ¼ 22)
Pediatric Quality of Life Inventory (PedsQL™ Generic Core M ± SD M ± SD
Scales),31,32 which was used to measure health-related QoL in
Age (years) 8.51 ± 1.54 9.09 ± 1.27 0.19
children and adolescents of 2e18 years old. This 23-item scale Height (cm) 1.31 ± 0.11 1.33 ± 0.09 0.53
comprises four functional dimensions, namely physical functioning Weight (kg) 29.76 ± 9.93 29.92 ± 9.51 0.96
(8 items), emotional functioning (5 items), social functioning (5 BMI (kg/m2) 16.98 ± 3.50 16.63 ± 2.98 0.73
BMI-for-age percentile (th) 50.64 ± 34.09 46.76 ± 34.36 0.71
items), and school functioning (5 items). The physical health
Gender (n)
summary score was computed by averaging 8 items of physical Boys 16 18 0.30
functioning and the psychological health summary score was Girls 6 3
computed by averaging 15 items of emotional, social, and school ADHD subtype (n)
functioning. The 5-point Likert response scale (‘0’ ¼ never; ADHD-I 13 10 0.74
ADHD-HI 1 1
‘4’ ¼ almost always) was converted to 0 to 100 scores, with higher
ADHD-C 8 10
scores representing higher levels of QoL. Cronbach's alphas suggest Medication use (n)
good internal consistency for each subscale (a ranged from 0.730 to None 19 21 0.08
0.856) and the general scale (a ¼ 0.870) in our sample. Yes 3 0
Comorbidities (n)
ODD 5 4 0.15
Parenting stress OCD 1 1
Tic 0 4
The Chinese version of the 15-item Parenting Stress Encopresis 0 1
IndexeShort Form (PSI-SF-15) was used.33 This 5-point Likert Note. BMI: body mass index; ADHD: attention-deficit hyperactivity disorder; M:
response scale (‘1’ ¼ strongly disagree; ‘5’ ¼ strongly agree) mea- mean; SD: standard deviation; ADHD-I: attention-deficit hyperactivity disorder-
sures parenting stress in three domains, including parent domain inattention; ADHD-HI: attention-deficit hyperactivity disorder-hyperactivity
impulsive; ADHD-C: attention-deficit hyperactivity disorder-combined; ODD:
(i.e., parental distress; 5 items), child domain (i.e., difficult child; 5
oppositional defiant disorder; OCD: obsessive compulsive disorder.
items), and parent-child relation (i.e., parent-child dysfunctional
interaction; 5 items). Internal consistency for each dimension (a
ranged from 0.623 to 0.827) and the general scale (a ¼ 0.850) was (n ¼ 41) on demographic data and outcome variables (all ps > .074).
acceptable in our sample. Of the 21 children who completed the PA intervention, the average
attendance rate and the percentage of reaching prescribed PA in-
Data analysis tensity throughout the whole intervention were 76.98% ± 19.57,
and 168.39% ± 21.54, respectively. For a 60-min intervention ses-
Analysis of covariance (ANCOVA) with a mixed factorial design sion, the average time within the target zone for each participant in
of 2 (time: T1 vs. T2)
2 (group: PA intervention vs. waitlist con- the intervention group was 50.52 min ±6.46.
trol) was conducted to examine changes in QoL in children with
ADHD and their parents’ perceived parenting stress over the 12
Primary outcomes
weeks. The potential confounding variables (i.e., age, gender, body
mass index (BMI)-for-age percentile, ADHD subtype, medication
The significant main effect of the Group showed that children in
use, and comorbidities) were considered as covariates in the
the intervention group had a higher level of school functioning
analysis. The BMI-for-age percentile, which was calculated based
(F ¼ 7.39, p ¼ .010, h2 ¼ 0.174), psychosocial functioning (F ¼ 5.52,
on the Centers for Disease Control and Prevention (CDC) growth
p ¼ .025, h2 ¼ 0.136), and total QoL (F ¼ 4.30, p ¼ .046, h2 ¼ 0.109).
charts, was used to represent obesity.34 A series of simple effects
The main effect of Time was found to be significant on the parental
analyses were further conducted if a significant interaction effect
distress subscale (F ¼ 8.57, p ¼ .006, h2 ¼ 0.197), showing that the
was identified. Intention-to-treat analysis was used with simple
parent domain of stress decreased over time. Importantly, we noted
imputation of the Last Observation Carried Forward. For those
significant Group
Time interaction effect on difficult child sub-
participants who dropped out during the intervention or control,
scale (F ¼ 5.01, p ¼ .032, h2 ¼ 0.125) and total score of parenting
the missing values of outcome variables at T2 were replaced by
stress (F ¼ 5.67, p ¼ .023, h2 ¼ 0.140), as well as a marginally sig-
those measured at T1. All statistical tests were performed in the R
nificant interaction effect on the subscale of parent-child dysfunc-
version 4.0.3, and the alpha level was set to p < .05.
tional interaction (F ¼ 3.36, p ¼ .075, h2 ¼ 0.088) (Table 4).
Follow-up simple main effect analyses showed that parents of
Results
children in the intervention group perceived similar levels of
parenting stress in relation to child domain and total score as those
Sample characteristics and protocol adherence
in the control group at baseline, but they perceived significantly
lower levels of them after the intervention (difficult child: p ¼ .043,
A total of 43 children met the inclusion criteria and participated
in this study. Table 2 demonstrates the baseline characteristics of
h2 ¼ 0.112; total score of parenting stress: p ¼ .033, h2 ¼ 0.123).
the sample. Most of the children were boys, were medication-naïve,
and were diagnosed as inattentive or combined subtype of ADHD. Discussion
We found no differences between groups at baseline (T1) on all
demographic data (all ps > .08, Table 2), QoL (all ps > .10, Table 3), The main purpose of the present study was to evaluate the
and parenting stress (all ps > .29, Table 3). effectiveness of a PA intervention program on the QoL of children
One participant in the intervention group and one in the control with ADHD and the parenting stress of their parents. The findings
group dropped out of the study. Participants who did not complete documented significant decreases in overall parenting stress
the study (n ¼ 2) were comparable to participating children following participation in the program. The use of PSI-SF-15
4
Z. Zhang, R. Li, Z. Zhou et al. Disability and Health Journal 16 (2023) 101377

Table 3
Quality of life and Parenting stress by the group at two assessments.

Outcomes T1 PA intervention group (n ¼ 22) Waitlist control group (n ¼ 21)

t p T1 T2 T1 T2

QoL
PH 0.95 0.35 75.28 ± 16.48 81.25 ± 14.34 70.68 ± 15.23 77.68 ± 14.02
EF 0.61 0.55 69.32 ± 17.27 78.64 ± 15.13 65.95 ± 18.88 69.29 ± 16.30
SF 1.19 0.24 73.18 ± 19.49 78.86 ± 17.11 66.43 ± 17.76 69.05 ± 16.25
SCF 1.66 0.10 54.55 ± 15.42 65.45 ± 12.72 47.86 ± 10.32 51.19 ± 14.05
PSY 1.41 0.17 65.68 ± 14.48 74.32 ± 11.18 60.08 ± 11.29 63.17 ± 13.57
Total 1.43 0.16 68.08 ± 13.64 76.05 ± 10.91 62.73 ± 10.68 66.80 ± 12.58
PSI
PD 0.42 0.68 11.59 ± 3.22 10.55 ± 2.77 12.00 ± 3.16 12.48 ± 3.25
PCDI 0.28 0.78 11.09 ± 3.90 9.68 ± 3.20 11.38 ± 2.85 11.57 ± 3.27
DC 1.07 0.29 15.18 ± 4.65 13.73 ± 4.32 16.62 ± 4.17 16.57 ± 3.34
Total 0.78 0.44 37.86 ± 10.20 33.95 ± 8.87 40.00 ± 7.58 40.62 ± 7.65

Note. QoL: quality of life; PH: physical functioning; EF: emotional functioning; SF: social functioning; SCF: school functioning; PSY: psychological functioning; PSI: parenting
stress index; PD: parental distress; PCDI: parent-child dysfunctional interaction; DC: difficult child.

Table 4
Summary of the two-way (Group
Time) ANCOVA controlling for confounders.

Group (G) PA intervention Control Time (T) T1 T2 Group
Time

M ± SE M ± SE M ± SE M ± SE

QoL
PH 0.400 78.41 ± 3.11 74.04 ± 3.19 0.709 72.99 ± 2.45 79.46 ± 2.20 0.933
EF 0.172 73.89 ± 3.14 67.71 ± 3.22 0.281 67.65 ± 2.53 73.96 ± 2.54 0.273
SF 0.074 77.18 ± 3.60 66.53 ± 3.70 0.340 69.78 ± 2.86 73.93 ± 2.49 0.471
SCF 0.010* 59.83 ± 2.51 49.70 ± 2.58 0.614 51.20 ± 2.02 58.33 ± 2.00 0.198
PSY 0.025* 70.30 ± 2.55 61.31 ± 2.62 0.456 62.87 ± 1.93 68.74 ± 1.97 0.180
Total 0.046* 72.33 ± 2.49 64.50 ± 2.56 0.607 65.40 ± 1.86 71.42 ± 1.87 0.267
PSI
PD 0.266 11.22 ± 0.59 12.08 ± 0.60 0.006 ** 11.79 ± 0.40 11.51 ± 0.47 0.115
PCDI 0.405 10.52 ± 0.68 11.34 ± 0.70 0.290 11.23 ± 0.54 10.63 ± 0.51 0.075
DC 0.227 14.74 ± 0.87 16.30 ± 0.90 0.307 15.89 ± 0.66 15.15 ± 0.60 0.032*
Total 0.194 36.48 ± 1.73 39.71 ± 1.78 0.059 38.91 ± 1.29 37.28 ± 1.29 0.023*

Note. QoL: quality of life; PH: physical functioning; EF: emotional functioning; SF: social functioning; SCF: school functioning; PSY: psychological functioning; PSI: parenting
stress index; PD: parental distress; PCDI: parent-child dysfunctional interaction; DC: difficult child.
**p < .01; *p < .05.

allowed for analysis of three aspects of parenting stress and of change in parenting stress across domains. This may suggest that
addressed that decreases in parenting stress were mainly specific to the PA intervention in our study can target overall parenting stress,
the child domain (i.e., difficult child). PA intervention was found to as well as a particular area of need for these parents.
be associated with a tendency of improved QoL, but was not sta- Participation in PA intervention did not elicit significant
tistically significant. The present study represents an extension of improvement in QoL of children with ADHD, which is partially
previous work by providing insights into the family-wide benefits inconsistent with the results of another randomized controlled
of children-focused PA intervention. trial evaluating a 3-week multimodal therapy including HIIT on
Consistent with our hypothesis, the results showed that QoL of boys with ADHD.27 In that study, the multimodal therapy
participation in the PA intervention had a general impact on with HIIT was shown to be superior to standard multimodal
parenting stress. It is reasonable to expect that the specific impact therapy with regard to the increased overall QoL reported by
on parenting stress was stronger in the child domain compared to guardians, but not to the overall QoL rated by children themselves.
the parent domain and parent-child relation. The child domain of Parents appear to have a less critical view of QoL compared with
parenting stress measures the child's self-regulatory abilities self-ratings of their children.38 It is therefore possible that the
perceived by the parents. The potential benefits of PA on improving inconsistent findings may be attributed to parents’ perception
ADHD symptoms and behavioral control associated with ADHD bias in evaluating QoL of their children. Additionally, another
have been addressed by past work.35 Though ADHD symptoms and observational study revealed a weak relationship between PA and
behavioral problems were not measured in this study, changes in QoL in children with ADHD.28 PA dose-response effect on out-
these may contribute to decreases in parenting stress in that comes of QoL proposes that PA elevated by over 2 h/day could
domain. Of note, the child domain of parenting stress (i.e., difficult achieve a clinically meaningful change in QoL.39 The insufficient
child) was relatively elevated at baseline in this sample. Since the volume of PA prescribed by our intervention may also explain the
intervention simply focused on children and did not involve par- nonsignificant changes of QoL in this study.
ents, it may be less likely to directly influence the domains of The present study had limitations that warrant mention. First,
parents and parent-child relations. Previous interventions focusing the absence of children's self-rating of QoL precludes a conclusion
on parents of children with ADHD mainly involve consultations or that PA intervention is associated with improved QoL. It is recom-
training targeting parents themselves36 or the whole family.9 In mended that children's self-report should be assessed in conjunc-
contrast, Corona et al.37 found that the demands on parents to tion with parents' proxy reports in future studies for a complete
attend or assist in intervention may also contribute to the absence picture of QoL. Second, the relatively small sample size with PA

5
Z. Zhang, R. Li, Z. Zhou et al. Disability and Health Journal 16 (2023) 101377

intervention administered in the setting of hospital may provide 4. Lee Y-c, Yang H-J, Chen VC-H, et al. Meta-analysis of quality of life in children
and adolescents with ADHD: by both parent proxy-report and child self-report
limited ecological validity. Future studies are encouraged to take
using PedsQL. Res Dev Disabil. 2016;51e52:160e172. https://doi.org/10.1016/
the next step in the translation pathway to test whether these j.ridd.2015.11.009.
benefits can be replicated when the PA intervention is imple- 5. Leidy NK, Revicki DA, Geneste
B. Recommendations for evaluating the validity
mented in the settings where children live their daily lives. Third, of quality of life claims for labeling and promotion. Value Health. 1999;2(2):
113e127.
future research considering parental and family factors (e.g., parent 6. Coghill D, Danckaerts M, Sonuga-Barke E, Sergeant J. Practitioner review:
education level, parent mental health, socioeconomic status, family quality of life in child mental health–conceptual challenges and practical
income) as covariates may be helpful in adjusting their potential choices. JCPP (J Child Psychol Psychiatry). May 2009;50(5):544e561. https://
doi.org/10.1111/j.1469-7610.2009.02008.x.
confounding effects on parenting stress. Finally, the sustained ef- 7. Cussen A, Sciberras E, Ukoumunne OC, Efron D. Relationship between symp-
fects on parenting stress should be examined. toms of attention-deficit/hyperactivity disorder and family functioning: a
community-based study. Eur J Pediatr. 2012;171(2):271e280. https://doi.org/
10.1007/s00431-011-1524-4.
Conclusions 8. Theule J, Wiener J, Rogers MA, Marton I. Predicting parenting stress in
families of children with ADHD: parent and contextual factors. J Child
The present study provides preliminary evidence that partici- Fam Stud. 2011/10/01 2011;20(5):640e647. https://doi.org/10.1007/s10826-
010-9439-7.
pation in PA intervention positively impacts on parenting stress, 9. Theule J, Wiener J, Tannock R, Jenkins JM. Parenting stress in families of chil-
and with a particular influence on stress in relation to the child dren with ADHD: a meta-analysis. J Emot Behav Disord. 2013;21(1):3e17.
domain. Continued research may help to clarify whether nonsig- 10. Breaux RP, Harvey EA. A longitudinal study of the relation between family
functioning and preschool ADHD symptoms. J Clin Child Adolesc Psychol.
nificant changes on QoL are linked to perception bias of parents or 2019;48(5):749e764. https://doi.org/10.1080/15374416.2018.1437737.
inadequate PA volumes. This study sets the scene for future 11. Margari F, Craig F, Petruzzelli MG, Lamanna A, Matera E, Margari L.
research to investigate the wide-reaching effects of PA intervention Parents psychopathology of children with attention deficit hyperactivity dis-
order. Res Dev Disabil. 2013;34(3):1036e1043. https://doi.org/10.1016/
for parents and families of children with ADHD. Additionally, the
j.ridd.2012.12.001.
findings have direct implications for clinical practice as they may 12. Barkley RA. Attention-deficit Hyperactivity Disorder: A Handbook for Diagnosis
help inform child-centered interventions that address the family- and Treatment. fourth ed. New York: Guilford Press; 2014.
13. Johnston C, Mash EJ. Families of children with attention-deficit/hyperactivity
wide perspectives of children with ADHD.
disorder: review and recommendations for future research. Clin Child Fam
Psychol Rev. 2001;4(3):183e207.
Acknowledgments 14. Deater-Deckard K. Parenting stress and child adjustment: some old hypotheses
and new questions. Clin Psychol Sci Pract. 1998;5(3):314. https://doi.org/
10.1111/j.1468-2850.1998.tb00152.x.
We thank for all participants and their parents for their great 15. Anastopoulos AD, Guevremont DC, Shelton TL, DuPaul GJ. Parenting stress
contribution to this study. We also appreciate the research staff and among families of children with attention deficit hyperactivity disorder.
graduate research assistants, including Dr. Xiao Liang, Ms. Fang Liu, J Abnorm Child Psychol. Oct 1992;20(5):503e520. https://doi.org/10.1007/
bf00916812.
Ms. Rongsang Fu, Ms. Yiman Yu, Ms. Qingqing Jiang, Ms. Siyi Yan, 16. Langberg JM, Evans SW, Schultz BK, Becker SP, Altaye M, Girio-Herrera E.
Ms. Zhuo Wang, Ms. Danping Li, Mr. Jian Lin, Mr. Henian Li, Mr. Trajectories and predictors of response to the challenging horizons program for
Yongshen Lu, Mr. Peng Wang, for their great help in the interven- adolescents with ADHD. Behav Ther. 2016;47(3):339e354. https://doi.org/
10.1016/j.beth.2016.01.001.
tion. The authors declared no conflicts of interest. 17. Hoza B, Smith AL, Shoulberg EK, et al. A randomized trial examining the effects
of aerobic physical activity on attention-deficit/hyperactivity disorder symp-
Presentation toms in young children. J Abnorm Child Psychol. 2015/05/01 2015;43(4):
655e667. https://doi.org/10.1007/s10802-014-9929-y.
18. Smith AL, Hoza B, Linnea K, et al. Pilot physical activity intervention reduces
This study was presented as a poster at the International Sym- severity of ADHD symptoms in young children. J Atten Disord. 2013;17(1):
posium of Behavioral Nutrition and Physical Activity (ISBNPA) 70e82. https://doi.org/10.1177/1087054711417395.
19. Cornelius C, Fedewa AL, Ahn S. The effect of physical activity on children
Annual Meeting in May 2022. with ADHD: a quantitative review of the literature. J Appl Sch Psychol. 2017/04/
03 2017;33(2):136e170. https://doi.org/10.1080/15377903.2016.1265622.
Funding 20. Den Heijer AE, Groen Y, Tucha L, et al. Sweat it out? The effects of physical
exercise on cognition and behavior in children and adults with ADHD: a sys-
tematic literature review. J Neural Transm. 2017;124(suppl 1). https://doi.org/
This work was supported by the Philosophy and Social Science 10.1007/s00702-016-1593-7.
Program of Guangdong Province of China (Number: GD19YTY02) 21. Seiffer B, Hautzinger M, Ulrich R, Wolf S. The efficacy of physical activity for
children with attention deficit hyperactivity disorder: a meta-analysis of ran-
and Sanming Project of Medicine in Shenzhen “The ADHD research domized controlled trials. J Atten Disord. 2022;26(5):656e673. https://doi.org/
group from Peking University Sixth hospital” (Number: 10.1177/10870547211017982.
SZSM201612036). 22. Suarez-Manzano S, Ruiz-Ariza A, De La Torre-Cruz M, Martínez-Lo
pez EJ. Acute
and chronic effect of physical activity on cognition and behaviour in young
people with ADHD: a systematic review of intervention studies. Res Dev Disabil.
Conflicts of interest 2018;77:12e23. https://doi.org/10.1016/j.ridd.2018.03.015.
23. Vysniauske R, Verburgh L, Oosterlaan J, Molendijk ML. The effects of
physical exercise on functional outcomes in the treatment of ADHD: a meta-
The authors declared no potential conflicts of interest with analysis. J Atten Disord. 2020;24(5):644e654. https://doi.org/10.1177/
respect to the research, authorship, and/or publication of this 1087054715627489.
article. 24. Welsch L, Alliott O, Kelly P, Fawkner S, Booth J, Niven A. The effect of physical
activity interventions on executive functions in children with ADHD: a sys-
tematic review and meta-analysis. Ment Health Phys. Act. 2021/03/01/2021;20,
References 100379. https://doi.org/10.1016/j.mhpa.2020.100379.
25. Gallego-Me
ndez J, Perez-Gomez J, Calzada-Rodríguez JI, et al. Relationship
1. Posner J, Polanczyk GV, Sonuga-Barke E. Attention-deficit hyperactivity disor- between health-related quality of life and physical activity in children with
der. Lancet. 2020;395(10222):450e462. https://doi.org/10.1016/S0140- hyperactivity. Int J Environ Res Publ Health. 2020;17(8). https://doi.org/10.3390/
6736(19)33004-1. ijerph17082804.
2. Coghill D, Hodgkins P. Health-related quality of life of children with attention- 26. Walton K, Simpson JR, Darlington G, Haines J. Parenting stress: a cross-
deficit/hyperactivity disorder versus children with diabetes and healthy con- sectional analysis of associations with childhood obesity, physical activity,
trols. Eur Child Adolesc Psychiatr. 2016;25(3):261e271. https://doi.org/10.1007/ and TV viewing. BMC Pediatr. 2014;14:244. https://doi.org/10.1186/1471-
s00787-015-0728-y. 2431-14-244.
3. Kollins SH. Moving beyond symptom remission to optimize long-term treat- 27. Meßler CF, Holmberg H-C, Sperlich B. Multimodal therapy involving high-
ment of attention-deficit/hyperactivity disorder. JAMA Pediatr. 2018;172(10): intensity interval training improves the physical fitness, motor skills,
901e902. https://doi.org/10.1001/jamapediatrics.2018.1642. social behavior, and quality of life of boys with ADHD: a randomized

6
Z. Zhang, R. Li, Z. Zhou et al. Disability and Health Journal 16 (2023) 101377

controlled study. J Atten Disord. 2018;22(8):806e812. https://doi.org/10.1177/ 34. Centers for Disease Control and Prevention. BMI Percentile Calculator for Child
1087054716636936. and Teen. Available from: https://www.cdc.gov/healthyweight/bmi/calculator.
28. Li R, Liang X, Liu F, et al. Mediating effect of motor competence on the rela- html.
tionship between physical activity and quality of life in children with attention 35. Hoza B, Martin CP, Pirog A, Shoulberg EK. Using physical activity to manage
deficit hyperactivity disorder. BioMed Res Int. 2021;2021, 4814250. https:// ADHD symptoms:the state of the evidence. Curr Psychiatr Rep. 2016;18(12):
doi.org/10.1155/2021/4814250. 113.
29. Kaufman J, Birmaher B, Brent D, et al. Schedule for affective disorders and 36. Hiscock H, Sciberras E, Mensah F, et al. Impact of a behavioural sleep inter-
Schizophrenia for school-age children-present and Lifetime version (K-SADS- vention on symptoms and sleep in children with attention deficit hyperactivity
PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry. disorder, and parental mental health: randomised controlled trial. BMJ (Clinical
1997;36(7):980e988. research ed). 2015;350:h68. https://doi.org/10.1136/bmj.h68.
30. Centers of Disease Control and Prevention. Target heart rate and estimated 37. Corona LL, Janicki C, Milgramm A, Christodulu KV. Brief report:
maximum heart rate. Available from: https://www.cdc.gov/physicalactivity/ reductions in parenting stress in the context of PEERSda social skills inter-
basics/measuring/heartrate.htm. vention for adolescents with autism spectrum disorder. J Autism Dev Disord.
31. Hao Y, Tian Q, Lu Y, Chai Y, Rao S. Psychometric properties of the Chinese 2019/12/01 2019;49(12):5073e5077. https://doi.org/10.1007/s10803-019-
version of the Pediatric Quality of Life Inventory 4.0 generic core scales. Qual 04201-y.
Life Res. 2010;19(8):1229e1233. https://doi.org/10.1007/s11136-010-9672-y. 38. Becker A, Roessner V, Breuer D, Do €pfner M, Rothenberger A. Relationship be-
32. Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric tween quality of life and psychopathological profile: data from an observa-
Quality of Life Inventory version 4.0 generic core scales in healthy and patient tional study in children with ADHD. Eur Child Adolesc Psychiatr. 2011;20(Suppl
populations. Med Care. Aug. 2001;39(8):800e812. https://doi.org/10.1097/ 2):S267eS275. https://doi.org/10.1007/s00787-011-0204-2.
00005650-200108000-00006. 39. Marker AM, Steele RG, Noser AE. Physical activity and health-related quality of
33. Luo J, Wang M-C, Gao Y, et al. Refining the parenting stress index-short form life in children and adolescents: a systematic review and meta-analysis. Health
(PSI-SF) in Chinese parents. Assessment. 2021;28(2):551e566. https://doi.org/ Psychol. 2018;37(10):893e903. https://doi.org/10.1037/hea0000653.
10.1177/1073191119847757.