Effects of Physical Activity Interventions on Cognitive Flexibility in Children with ADHD: A Systematic Review

Abstract

Background: Attention Deficit Hyperactivity Disorder (ADHD) is associated with impairments in executive functions, particularly cognitive flexibility, which may negatively affect academic performance, behavioral regulation, and daily adaptation in children. Physical activity has emerged as a promising non-pharmacological strategy to support executive functioning; however, evidence regarding the effects of different exercise modalities on cognitive flexibility remains heterogeneous. Methods: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol was retrospectively registered in the PROSPERO database (CRD420261399699) before manuscript submission. Searches were conducted in PubMed, Scopus, MEDLINE, Web of Science, PsycInfo, and SPORTDiscus. Studies examining the effects of physical activity interventions on cognitive flexibility in Primary Education students with ADHD were included. Seventeen studies involving 634 participants aged 6–12 years met the eligibility criteria. Methodological quality was assessed using design-appropriate critical appraisal tools. Results: Overall, the included studies reported potentially beneficial effects of physical activity on cognitive flexibility, although findings varied according to study design, intervention characteristics, and outcome measures. Across the available studies, multi-session interventions tended to report more consistent improvements across cognitive flexibility outcomes than single-session protocols. Structured sports and interventions combining physical and cognitive demands, including football, table tennis, EXCIR, and BARAN, also reported improvements in several cognitive flexibility outcomes. However, substantial methodological heterogeneity and the absence of direct comparisons between intervention types or durations preclude conclusions regarding the superiority or comparative effectiveness of specific approaches. Conclusions: Physical activity may represent a promising complementary strategy for supporting cognitive flexibility in children with ADHD. The available evidence suggests potentially favorable findings for multi-session and cognitively engaging interventions; however, these patterns should be interpreted cautiously because of the heterogeneity of study designs, intervention protocols, and cognitive flexibility measures. Further well-designed studies directly comparing intervention characteristics and exercise modalities are needed before specific recommendations regarding optimal type or duration can be established.