Enhancing effects of exercise and neurofeedback: A systematic review and meta-analysis of computer game-based interventions for pediatric ADHD

Objective: While numerous reviews examine digital interventions, including computer game-based, evidence regarding their effectiveness for ADHD symptoms remains mixed. Focusing on computer game-based interventions, this study aims to identify specific intervention features and trial-related factors that influence outcomes in pediatric ADHD symptoms through a systematic review and meta-analysis of randomized controlled trials. Methods: Comprehensive literature searches were conducted in Web of Science, PubMed and PsycINFO. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Results: Seventeen studies were included. Beyond common game characteristics, some interventions incorporated additional elements-such as neurofeedback, physical exercise via virtual reality (VR) and social components-allowing subgroup analyses. The neurofeedback subgroup showed the largest effect size (standardized mean difference (SMD)=-0.51, 95 % confidence interval (CI) [-0.88, -0.15], heterogeneity index (I-2)=45.85 %, p < 0.05, very low certainty of evidence), followed by the physical exercise/VR subgroup (SMD=-0.40, 95 %CI [-0.76, -0.04], I-2=0.00 %, p < 0.05, very low certainty of evidence). Other subgroups, including those with social components or without additional elements, did not show significant effect sizes. The physical exercise/VR subgroup demonstrated small-to-medium effect sizes in both inattention and hyperactivity/impulsivity subscales, whereas the neurofeedback subgroup showed similar effects only in inattention. Trial-level factors, including participant demographics and intervention duration, showed no significant relationship with SMD in meta-regression. Conclusion: Although inconclusive, synergizing with game dynamics, neurofeedback and physical exercise/VR may enhance effectiveness of computer game-based interventions in addressing pediatric ADHD symptoms. Particularly, interventions with physical exercise/VR have potential to address both inattention and hyperactivity/impulsivity.