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. 2023 Mar 24:11:1133727.
doi: 10.3389/fpubh.2023.1133727. eCollection 2023.

Comparative effectiveness of various physical exercise interventions on executive functions and related symptoms in children and adolescents with attention deficit hyperactivity disorder: A systematic review and network meta-analysis

Feilong Zhu  1 , Xiaotong Zhu  1 , Xiaoyu Bi  1 , Dongqing Kuang  1 , Boya Liu  2 , Jingyi Zhou  1 , Yiming Yang  1 , Yuanchun Ren  1
Affiliations

Comparative effectiveness of various physical exercise interventions on executive functions and related symptoms in children and adolescents with attention deficit hyperactivity disorder: A systematic review and network meta-analysis

Feilong Zhu et al. Front Public Health. .

Abstract

Background: Physical exercise has been recommended as an important nonpharmacological therapeutic strategy for managing attention deficit hyperactivity disorder (ADHD). We conducted a network meta-analysis (NMA) to assess the comparative impact of different physical exercise modalities on enhancing executive functions (EFs) and alleviating symptoms in children and adolescents with ADHD.

Methods: We searched Web of Science, PubMed, Embase, Cochrane Central Register of Controlled Trials, SPORTDiscus, PsycINFO, CNKI, and clinical trials databases from inception to October 20, 2022. Randomized controlled trials (RCTs) and quasi-experimental studies investigating physical exercise for ADHD-related symptoms of hyperactivity/impulsivity and inattention, and executive functions were included. The frequentist random-effect NMA method was applied to pool the results.

Results: A total of 59 studies (including 39 RCTs, 5 quasi-RCTs, and 15 self-controlled trials) published between 1983 and 2022 were incorporated into the systematic review, of which 44 studies with 1757 participants were eligible for meta-analysis. All types of physical exercise were effective in improving EFs (SMD = 1.15, 95% CI: 0.83 to 1.46), and open-skill activities which require participants to react in a dynamically changing and externally paced environment induced the most incredible benefits for executive functions (SUCRA = 98.0%, SMD = 1.96, and 95% CI: 1.15 to 2.77). Subgroup analyses for EFs revealed varied findings that open-skill activities were the most promising physical exercise type for improving inhibitory control (SUCRA = 99.1%, SMD = 1.94, and 95% CI: 1.24 to 2.64), and closed-skill activities dominated by aerobic exercises had a slightly higher probability of being the most promising physical exercise intervention for working memory (SUCRA = 75.9%, SMD = 1.21, and 95% CI: -0.22 to 2.65), and multicomponent physical exercise tended to be the most effective in cognitive flexibility (SUCRA = 70.3%, SMD = 1.44, and 95% CI: -0.19 to 3.07). Regarding ADHD-related symptoms, closed-skill activities dominated by aerobic exercises might be more advantageous for hyperactivity/impulsivity (SUCRA = 72.5%, SMD = -1.60, and 95% CI: -3.02 to -0.19) and inattention (SUCRA = 96.3%, SMD = -1.51, and 95% CI: -2.33 to -0.69) improvement.

Conclusion: Physical exercise can significantly help to alleviate the symptoms of ADHD and improve executive functions in children and adolescents with ADHD. Most of all, to promote adherence to treatment, they should be encouraged to perform the physical exercises that they enjoy most.

Keywords: attention-deficit/hyperactivity disorder; children and adolescents; network meta-analysis; physical exercise; public health.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
PRISMA flow diagram of the search process for studies.
Figure 2
Figure 2
Network plot of comparisons and the efficacy of varied treatments compared with the control group for executive functions. Each node represents an intervention and its size depends on the number of participants. The connecting lines between 2 nodes represents 1 or more trials in which the 2 interventions have been compared directly. The thickness of the lines connecting 2 nodes is weighted according to the number of trials that directly compared the interventions it connected. PA, physical activity; SMD, standardized mean difference; SUCRA, the surface under the cumulative ranking curve.
Figure 3
Figure 3
League table of outcome analyses for executive functions. PA, physical activity; SUCRA, the surface under the cumulative ranking curve.
Figure 4
Figure 4
Network plot of comparisons and the efficacy of various treatments compared with the control group for hyperactivity/impulsivity. Each node represents an intervention and its size depends on the number of participants. The connecting lines between 2 nodes represents 1 or more trials in which the 2 interventions have been compared directly. The thickness of the lines connecting 2 nodes is weighted according to the number of trials that directly compared the interventions it connected. PA, physical activity; SMD, standardized mean difference; SUCRA, the surface under the cumulative ranking curve.
Figure 5
Figure 5
Network plot of comparisons and the efficacy of varied treatments compared with the control group for inattention. Each node represents an intervention and its size depends on the number of participants. The connecting lines between 2 nodes represents 1 or more trials in which the 2 interventions have been compared directly. The thickness of the lines connecting 2 nodes is weighted according to the number of trials that directly compared the interventions it connected. PA, physical activity; SMD, standardized mean difference; SUCRA, the surface under the cumulative ranking curve.
Figure 6
Figure 6
League table of outcome analyses for hyperactivity/impulsivity. PA, physical activity; SUCRA, the surface under the cumulative ranking curve.
Figure 7
Figure 7
League table of outcome analyses for inattention. PA, physical activity; SUCRA, the surface under the cumulative ranking curve.
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