The effects of physical exercise on executive function, internalizing symptoms and externalizing symptoms in children and adolescents with attention-deficit/hyperactivity disorder: a systematic review and meta-analysis

Background The aim of this study is to comprehensively assess the potential effects of physical exercise on executive function, internalizing symptoms and externalizing symptoms in children and adolescents with attention-deficit/hyperactivity disorder (ADHD), and to explore the moderating factors influencing these effects. Methods We performed a systematic search of six databases (including Web of Science, PubMed, Embase, PsycNET, the Cochrane Library and SPORTDiscus). Data analysis was performed using R software, and a meta-analysis was conducted using a random-effects model to estimate the pooled effect size. In addition, subgroup analyses and meta-regression were conducted to explore potential moderating factors. Results A total of 25 randomised controlled trials involving 1,116 participants were included. With low certainty of evidence, the pooled effect of inhibitory control was statistically significant ( g = 0.45, p < 0.01). With very low certainty of evidence, the pooled effect of internalizing symptoms was statistically significant ( g = 0.97, p = 0.03). The pooled effects of cognitive flexibility ( g = 0.69, p = 0.054), working memory ( g = 0.28, p = 0.10), and externalizing symptoms ( g = 0.64, p = 0.29) did not reach statistical significance, all rated as very low certainty of evidence. Conclusion Physical exercise may be positively associated with inhibitory control in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). However, the effects of interventions show high heterogeneity, have wide confidence intervals, and exhibit limited stability. Systematic review registration PROSPERO CRD420261380631.