The effects of physical exercise interventions on executive function in children and adolescents with autism spectrum disorder: a three-level meta-analysis and systematic review

Physical exercise has been increasingly recognized as a potential non-pharmacological approach for improving executive function in children and adolescents with autism spectrum disorder (ASD). This study systematically examined the effects of physical exercise on executive function in this population. Randomized controlled trials (RCTs) were systematically retrieved from PubMed, Web of Science, and other electronic databases. The methodological quality of the included studies was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. Meta-analyses were conducted using the metafor package in R, with three-level and two-level random-effects models applied to account for dependent effect sizes. A total of 19 studies involving 714 participants were included. The three-level model showed that physical exercise significantly improved inhibitory control (g = 0.70, 95% CI [0.09, 1.31], p < 0.05) and cognitive flexibility (g = 0.59, 95% CI [0.29, 0.90], p < 0.001), with these findings supported by the two-level model. The effect on working memory was not statistically significant in the three-level model (g = 0.31, 95% CI [−0.40, 1.01], p > 0.05), although a significant positive effect was observed in the two-level model (g = 0.41, 95% CI [0.01, 0.85], p < 0.05). Subgroup analyses indicated significant improvements across executive function domains following interventions lasting >8 weeks, although between-subgroup differences were not statistically significant. Meta-regression further showed that total intervention duration significantly predicted improvements in cognitive flexibility. The certainty of evidence was rated as moderate according to the GRADE approach. Overall, physical exercise may be a promising adjunctive strategy for supporting executive function in children and adolescents with ASD, particularly inhibitory control and cognitive flexibility. However, the findings should be interpreted cautiously given the substantial heterogeneity, wide prediction intervals, and potential small-study effects. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251165448 , identifier (CRD420251165448).