Unlocking exercise compliance in children with ADHD: A comprehensive analysis of influencing factors

Despite documented benefits of exercise for children with attention deficit hyperactivity disorder (ADHD), poor adherence to exercise programs limits therapeutic effectiveness. While existing research focuses on symptom outcomes, the behavioral processes and contextual factors influencing sustained exercise participation remain underexplored.

This study systematically explored facilitators and barriers to exercise compliance-operationally defined as the degree to which a child's actual exercise behavior (frequency, intensity, duration) aligns with prescribed recommendations-in children with ADHD from parental perspectives, using the Capability-Opportunity-Motivation-Behavior (COM-B) model.

A qualitative descriptive study was conducted with 16 parents (13 mothers, 3 fathers; child age range: 6-12 years) of children diagnosed with ADHD, purposively sampled from a home-based exercise intervention program at a tertiary hospital in China (June-September 2024). Sampling considered child characteristics (age, ADHD subtype) and family socioeconomic status to ensure diverse perspectives. Semi-structured interviews (20-40 min) explored parents' experiences with their children's exercise participation. Data were analyzed using directed content analysis, whereby transcripts were systematically coded line-by-line within the COM-B framework while remaining open to inductive subtheme emergence. Data saturation was achieved at 16 interviews.

Analysis identified 12 distinct subthemes across three COM-B domains. Capability barriers included motor skill deficits, attention difficulties, emotional dysregulation, and limited self-management, collectively undermining children's confidence and willingness to exercise. Opportunity factors functioned bidirectionally: parental knowledge, companionship, peer support, and facility accessibility enhanced adherence; financial constraints, lack of parental time, and excessive academic workload-particularly salient in China's high-pressure educational context-significantly impeded participation. Motivation evolved dynamically, with external rewards initially driving engagement but intrinsic interest and perceived symptom improvement sustaining long-term adherence.

This study provides the first theoretically grounded, qualitative examination of exercise adherence processes (rather than solely outcomes) in pediatric ADHD. Findings reveal culture-specific barriers and the dynamic interplay among capability, opportunity, and motivation. Clinicians should conduct individualized capability assessments before prescribing exercise and tailor programs to children's motor abilities. Educators can adjust homework loads and integrate movement breaks. Parents should prioritize exercise companionship and employ structured reinforcement. These exploratory findings from a single-center Chinese sample require validation in diverse populations.