What type of exercise prescription is best for improving cognitive flexibility in children and adolescents? A network...

Cognitive flexibility is defined as the capacity to adjust thoughts and behaviors in accordance with goals and changing situational demands. Across all included studies, it was operationalized using neuropsychological tasks, such as the Wisconsin Card Sorting Test, Dimensional Change Card Sort, and Flanker/More-Odd Shifting Task. This study aims to investigate the distinct effects of different exercise prescription parameters (i.e., duration, frequency, period, intensity, and type) on cognitive flexibility in children and adolescents, with the ultimate goal of providing evidence to inform the development of targeted interventions for enhancing cognitive flexibility in this population.

This systematic review and network meta-analysis was prospectively registered in PROSPERO (CRD42024539167). Following the PICOS principle, we established inclusion and exclusion criteria and searched the EBSCO, PubMed, Web of Science, Embase, and Cochrane databases through November 15, 2025. Eligible studies enrolled children and adolescents aged 4-18 years, compared any exercise intervention with usual physical activity, and reported cognitive flexibility outcomes. Two reviewers independently screened titles and abstracts, extracted data, and assessed the risk of bias. Network meta-analysis was performed using Stata 17.0, and SUCRA values were used to rank the effect sizes of different exercise prescription parameters.

A total of 21 articles involving 3099 participants were included in the study. The network meta-analysis revealed that interventions lasting 31-50 min were significantly more effective than those lasting 10-30 min [SMD=-0.79, 95% CI (-1.55, -0.03)] and those lasting ≥ 71 min [SMD=-1.30, 95% CI (-2.35, -0.25)]. Single aerobic exercise [SMD = 0.67, 95% CI (0.09, 1.25)] and cognitive+exercise interventions [SMD = 0.64, 95% CI (0.09, 1.18)] were significantly more effective than the control group. Additionally, interventions lasting 5-8 weeks were significantly more effective than those lasting ≥ 20 weeks [SMD=-0.79, 95% CI (-1.55, -0.03)]. Among the various intervention characteristics examined, cumulative ranking probability analysis (SUCRA) suggested that sessions lasting 31-50 min (SUCRA = 98.3%), administered twice weekly (SUCRA = 98.4%), implemented over 5-8 weeks (SUCRA = 91.4%), at low intensity (SUCRA = 89.3%), and involving ball games (SUCRA = 98.4%) may hold the greatest probability of being the most effective approach for improving cognitive flexibility in children and adolescents.

SUCRA rankings suggest that exercise sessions of 31-50 min, delivered twice per week for 5-8 weeks at low intensity and incorporating ball games, are most likely to yield the greatest benefits for cognitive flexibility. However, this reflects ranking probability rather than effect size magnitude. Direct pairwise comparisons indicated only modest effect sizes, highlighting the need for additional randomized controlled trials to confirm both the relative superiority of these parameters and their clinical significance.