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Cited by 88Attention Deficit Hyperactivity DisorderAutism Spectrum Disorder ResearchDevelopmental and Educational Neuropsychology

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

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Kofler, Michael J., Raiker, Joseph S., Sarver, Dustin E., Wells, Erica L., Soto, Elia F.·2016·Clinical Psychology Review
DOI 10.1016/j.cpr.2016.04.004PMC PMC4902796
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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 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.

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  • Under conditions requiring little cognitive effort, children with ADHD and children without ADHD cannot be reliably distinguished from each other.

    “In contrast, children with and without ADHD are largely indistinguishable from one another under low cognitive demand task conditions (Hudec et al., 2015; Kofler et al., 2016; Patros et al., 2017; Rapport et al., 2008; Sarver et al., 2015; cf. Soto et al., 2024)”

    From Ecological Validity of Clinic-Based Actigraphy for Assessing Hyperactivity in Clinically Evaluated Children with and without ADHD (2025) · cites this paper as Kofler et al., 2016

    The Discussion reports approximately 70% overlap between ADHD and non-ADHD activity levels under high-stimulation, low-cognitive-load conditions, supporting 'largely indistinguishable.' But the Results (Worst case estimation) find a statistically significant difference (d = 0.44), so the source does not support saying the groups cannot be reliably distinguished at all. (LLM, conf=0.88)

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  • Children with ADHD and typically developing children both move significantly more during tasks with high cognitive demands than during tasks with low cognitive demands.

    “Children with ADHD, as well as same age typically developing (TD) children, move significantly more when engaged in high relative to low cognitive demand tasks (for review see Kofler et al., 2016).”

    From Ecological Validity of Clinic-Based Actigraphy for Assessing Hyperactivity in Clinically Evaluated Children with and without ADHD (2025) · cites this paper as Kofler et al., 2016

    The Results section (Activity Level: ADHD vs. Typically Developing Group Comparisons; page unavailable) reports a significantly larger ADHD–TD activity difference during high- than low-cognitive-demand conditions. That supports a demand-related difference in relative activity, but it does not establish that movement increased significantly within each group; in particular, it does not show the claimed increase among TD children. (LLM, conf=0.84)

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  • The perception that clinic-based actigraphy has poor ecological validity likely partly reflects the common practice of measuring movement mainly during low cognitive demand tasks.

    “(c) the common practice of measuring children’s motor movement via actigraphy primarily during repetitive/monotonous activities or tasks with low cognitive demands that evoke comparatively lower levels of movement than those observed in educational settings (for review, see Kofler et al., 2016).”

    From Ecological Validity of Clinic-Based Actigraphy for Assessing Hyperactivity in Clinically Evaluated Children with and without ADHD (2025) · cites this paper as Kofler et al., 2016

    The Methods section (Coding of Moderators; page unavailable) distinguishes low-demand activities from classroom schoolwork, and the Results show that cognitive demands affect measured ADHD–control differences in activity. But those results do not establish that clinic-based actigraphy is commonly conducted mainly during low-demand tasks or that such tasks produce less movement than educational settings; the reported low-demand and classroom effect sizes did not differ significantly. The paper therefore supports the relevance of task demands, not the full explanation attributed to it. (LLM, conf=0.84)

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  • Most contemporary neurocognitive/behavioral models of ADHD make predictions regarding the role of executive dysfunction in the etiology, pathophysiology, and/or recovery from the disorder.

    “Thus, it is not surprising that most contemporary neurocognitive/behavioral models of ADHD make predictions regarding the role of executive dysfunction in the etiology, pathophysiology, and/or recovery from the disorder (3, 4).”

    From Working memory and inhibitory control deficits in children with ADHD: an experimental evaluation of competing model predictions (2024) · cites this paper as [4]

    The Discussion (page not provided) says that some ADHD etiological models explain hyperactivity through neurocognitive deficits, including demands on executive functioning. It does not establish that most contemporary models assign executive dysfunction a role in ADHD’s etiology, pathophysiology, or recovery; the models it describes make differing predictions about hyperactivity. (LLM, conf=0.85)

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  • In children with ADHD, working memory dysfunction predicts concurrent reading underachievement.

    “For children with ADHD, working memory dysfunction predicts concurrent reading underachievement (Kofler et al., 2016; Mayes & Calhoun, 2007; Rogers et al., 2011)”

    From Do Working Memory Deficits Underlie Reading Problems in Attention-Deficit/Hyperactivity Disorder (ADHD)? (2019) · cites this paper as Kofler et al., 2016

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Research works printed but not linked: 1

  1. Nevin ST 2003 Diagnostic efficiency of a battery of cognitive and activity measures for classification of childhood ADHD Dissertation Abstracts International: Section B: The Sciences and Engineering 64 1-B 427 UMI No. AAI3077225

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Authors
Kofler, M. J., Raiker, J. S., Sarver, D. E., Wells, E. L., & Soto, E. F.
Affiliations
  • Florida State University (US)
  • Florida International University (US)
  • University of Mississippi Medical Center (US)
Corresponding author
Kofler, Michael J.
ORCID
Venue
Clinical Psychology Review
Publisher
Elsevier BV
Published
2016-06
Volume
46
Pages
12-24
ISSN
0272-7358 (ISSN-L)
DOI
10.1016/j.cpr.2016.04.004
PMC
PMC4902796
OpenAlex
W2335803398
Cited by
88
References
126
Citations by year
2026: 10 · 2025: 9 · 2024: 11 · 2023: 10 · 2022: 7 · 2021: 7 · 2020: 11 · 2019: 8 · 2018: 8 · 2017: 5 · 2016: 2
FWCI
1.10
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Psychology Review (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (R34MH102499)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
  • Social Sciences › Psychology › Neuropsychology and Physiological Psychology › Developmental and Educational Neuropsychology
Keywords
attention deficit hyperactivity disorder, hyperactivity, gross motor activity, environmental demands, cognitive load, executive function, inattentive subtype, actigraphy, movement frequency, age differences, sex differences, DSM-5
MeSH terms
Adult, Age Factors, Attention Deficit Disorder with Hyperactivity, Child, Humans, Psychomotor Agitation, Sex Factors, Executive Function

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