Exploring the Additive Effect of Combined Exercise and Cognitive Training for Attention Deficit-Hyperactivity Disorder: A Systematic review and Meta-Analysis

Introduction: ADHD is characterised by inattention and/or hyperactivity-impulsivity. Exercise combined with cognitive training (CT) has emerged as a non-pharmacological option for managing symptoms. This systematic review and meta-analysis examined whether integrating exercise with CT offer additive benefits in improving ADHD symptoms and executive functions (EF).Methods: OVID databases and Web of Science were searched to January 2025 for peer-reviewed studies in English administering CT alone, exercise alone, or both combined. Where possible, random-effects meta-analyses were conducted. Morris’s d estimated effect sizes across outcomes, stratified by intervention type. Risk of bias was assessed with the Cochrane ROB 2.0 tool.Results: Combined interventions tended to outperform controls on cognitive EF measures and ADHD symptom ratings. Meta-analysis showed that combined interventions significantly improved set-shifting with a moderate effect (SMD = -0.46, 95% CI -0.75 to -0.17; I² = 0%), but not inhibition. Risk of bias was generally high or raised some concerns, largely due to lack of blinding, reliance on subjective outcomes, limited preregistration, and handling of missing data; trials using objective, computerised tasks or blinded assessors more often fell into some concerns rather than high risk.Conclusion: Cognitively engaging exercise, such as interactive sports and exergames, may offer added benefits over exercise or CT alone through simultaneous engagement of cognitive and motor systems. However, the small number of available combined trials means that larger, high-quality RCTs are needed to confirm additive effects on EF and ADHD symptom outcomes.