Exercise prescription to improve executive functioning in children and adolescents with attention deficit hyperactivity disorder: a network meta-analysis

Objective: This study employs a network meta-analysis to investigate the potential effects of exercise type, duration, frequency, intensity, and cycle on executive functions (inhibitory control, working memory, cognitive flexibility) in children and adolescents with ADHD, thereby providing directional insights for future research. Methods: Five databases were systematically searched up to February 1, 2025, yielding 21 RCTs (n = 1,491) involving participants aged 7-18 years. The risk of bias was assessed using Cochrane tools. Standardised mean differences (SMDs) were used as effect measures, while SUCRA was used for probability ranking and GRADE for evidence quality grading. Results: Skill-based exercise outperformed isolated aerobic exercise in inhibitory control (SMD = 0.73, 95% CI 0.31-1.41) and cognitive flexibility (SMD = 3.08, 95% CI 0.52-5.63). Combined exercise outperformed controls in working memory (SMD = 0.73, 95% CI 0.35-1.12). SUCRA ranking indicated the highest cumulative probability for skill-based exercise in inhibitory control (95.8) and cognitive flexibility (95.5), while aerobic exercise had the highest probability for working memory (87.1). Sensitivity analyses indicated that estimates for cognitive flexibility were significantly influenced by individual studies, demonstrating limited robustness. Conclusion: Preliminary evidence suggests that moderate-intensity, skill-based exercise may improve inhibitory control and cognitive flexibility within 6-10 weeks. Aerobic exercise may enhance working memory within 4-5 weeks. However, factors such as ADHD subtypes, age, and dose-response relationships remain unclear. Clinical implementation should be individualised and await high-quality validation.