Enhancing effects of exercise and neurofeedback: A systematic review and meta-analysis of computer game-based...

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.

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.

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 (I²)=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], I²=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.

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.