Accepted Manuscript

The Effect of Physical Exercise Activity Interventions on Children’s Cognition and

Metacognition: A Systematic Review and Meta-Analysis

Celia Álvarez-Bueno, MSc, Caterina Pesce, PhD, Iván Cavero-Redondo, MSc,

Mairena Sánchez-López, PhD, José Alberto Martínez-Hortelano, MSc, Vicente
Martínez-Vizcaíno, MD
PII: S0890-8567(17)30318-0
DOI: 10.1016/j.jaac.2017.06.012
Reference: JAAC 1786

To appear in: Journal of the American Academy of Child & Adolescent

Psychiatry

Received Date: 31 January 2017

Revised Date: 19 May 2017
Accepted Date: 20 June 2017

Please cite this article as: Álvarez-Bueno C, Pesce C, Cavero-Redondo I, Sánchez-López M, Martínez-
Hortelano JA, Martínez-Vizcaíno V, The Effect of Physical Exercise Activity Interventions on Children’s
Cognition and Metacognition: A Systematic Review and Meta-Analysis, Journal of the American
Academy of Child & Adolescent Psychiatry (2017), doi: 10.1016/j.jaac.2017.06.012.

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 ACCEPTED MANUSCRIPT
The Effect of Physical Exercise Activity Interventions on Children’s Cognition and

Metacognition: A Systematic Review and Meta-Analysis

RH = Physical Exercise and Youth’s Cognition

Celia Álvarez-Bueno, MSc; Caterina Pesce, PhD; Iván Cavero-Redondo, MSc; Mairena

Sánchez-López, PhD; José Alberto Martínez-Hortelano, MSc; Vicente Martínez-

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Vizcaíno, MD

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Supplemental material cited in this article is available online.

Accepted June 29, 2017

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Mrs. Álvarez-Bueno, Mr. Cavero-Redondo, Dr. Sánchez-López, Mr. Martínez-

Hortelano, and Dr. Martínez-Vizcaíno are with Universidad de Castilla-La Mancha,

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Health and Social Research Center, Cuenca, Spain. Dr. Sánchez-López is also with
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Universidad de Castilla-La Mancha, School of Education, Ciudad Real, Spain. Dr.
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Martínez-Vizcaíno is also with Universidad Autónoma de Chile, Facultad de Ciencias

de la Salud, Talca, Chile. Dr. Pesce is with Human and Health Sciences, Italian
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University Sport and Movement "Foro Italico," Rome, Italy.

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Mrs. Álvarez-Bueno is supported by a grant from the Spanish Ministry of Education,

Culture and Sport (FPU13/03137). Mr. Cavero-Redondo and Mr. Martínez-Hortelano

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are

supported by grants from the University of Castilla-La Mancha (FPU13/01582 and

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PREDUCLM16/14, respectively).

Dr. Martínez-Vizcaíno and Mrs. Álvarez-Bueno designed the study. Dr. Martínez-

Vizcaíno was the Principal Investigator and Guarantor. Dr. Pesce, Mrs. Álvarez-

Bueno, and Dr. Martínez-Vizcaíno were the main coordinators of the study. Dr. Pesce,

Mrs. Álvarez-Bueno, Mr. Martínez-Hortelano, and Mr. Cavero-Redondo conducted the

study. Mr. Martínez-Hortelano, Mr. Cavero-Redondo, Dr. Sánchez-López, and Dr.

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Pesce provided statistical and epidemiological support. Dr. Martínez-Vizcaíno wrote the

article with the support of Dr. Sánchez-López, Dr. Pesce, Mrs. Álvarez-Bueno, Mr.

Cavero-Recondo, and Mr. Martínez-Hortelano and revised it critically. All of the

authors revised and approved the final version of the manuscript.

Disclosure: Drs. Pesce, Sánchez-López, Martínez-Vizcaíno, Mrs. Álvarez-Bueno, Mr.

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Cavero-Redondo, and Mr. Martínez-Hortelano report no biomedical financial interests

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or potential conflicts of interest.

Correspondence to Mairena Sánchez-López, PhD, Social and Health Care Research Center,

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Universidad de Castilla-La Mancha, Ciudad Real, Spain; email: Mairena.Sanchez@uclm.es

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ABSTRACT

Objective: The objective was two-fold: i) to assess the effect of physical activity (PA)

interventions on children’s and adolescents’ cognition and metacognition; and ii) to

determine the characteristics of individuals and PA programs that enhance the development

of cognitive and metacognitive functions.

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Method: We systematically searched MEDLINE, EMBASE, Cochrane Central Register of

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Controlled Trials, Web of Science and PsycINFO databases from their inception to October

16, 2016. Intervention studies aimed at examining the exercise–cognition interaction at a

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developmental age were included in this systematic review and meta-analysis. Random-

effects models were used to calculate pooled effect size (ES) values and their corresponding

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95% CIs. Subgroup analyses were conducted to examine the effect of participants’ and PA
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programs’ characteristics.
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Results: Thirty-six studies were included in this systematic review and meta-analysis. Pooled

ES estimations were: i) non-executive cognitive functions 0.23 (95% CI: 0.09 to 0.37); ii)
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core executive functions 0.20 (95% CI: 0.10 to 0.30), including working memory (0.14 [95%
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CI: 0.00 to 0.27]), selective attention-inhibition (0.26 [95% CI: 0.10 to 0.41]) and cognitive

flexibility (0.11 [95% CI: -0.10 to 0.32]); and iii) metacognition 0.23 (95% CI: 0.13 to 0.32),
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including higher-level executive functions (0.19 [95% CI: 0.06 to 0.31]) and cognitive life
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skills (0.30 [95% CI: 0.15 to 0.45])

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Conclusion: PA benefits several domains of cognition and metacognition in youth.

Curricular physical education interventions and programs aimed at increasing daily PA seem

to be the most effective.

Key words: child; cognition; metacognition; physical activity; exercise.

INTRODUCTION

The relationship between physical activity (PA) and exercise with cognitive function
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(e.g., information processing, memory, attention) in children and adolescents has had a

growing interest during the past two decades.1,2 Both the PA, as any bodily movement

produced by skeletal muscles through energy expenditure, and exercise, understood as

repetitive, structured, and planned physical activity aimed to maintain or improve physical

fitness or health, have been related to cognitive function.3 Evidence consistently supports that

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PA positively impacts cognitive function through several mechanisms including

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angiogenesis, oxygen saturation, glucose delivery, cerebral blood flow and neurotransmitter

levels,4 structural changes in brain volumes,5 and improving brain functioning.6 Furthermore,

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in exercise and cognition research, a joint neuro-cognitive and social-cognitive approach has

been proposed7 to highlight relevant intersections between higher-level executive functions

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and life skills, including creativity, decision making, and goal setting, which are essential for
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healthy child development.8-10
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Beyond the neurobiological, social, and cognitive influences of exercise, focus has

been recently extended to examine the characteristics of PA interventions1,11,12 that could

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result in greater benefits in cognitive function because of their inherent cognitive and motor
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demands.13 Thus, currently, a challenge is to identify the characteristics of PA interventions

that are more efficient for promoting cognitive development, and also the pathways through
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which these influences are transmitted.6,14 Recent research has shown that PA interventions
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that jointly involve physical effort and emotional and social engagement challenge core

cognitive functions,15,16 as well as cognitive life skills, such as goal setting, problem solving,
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and self-regulation, a life skill relying on the efficiency of a core executive function such as

inhibition.9,11,17-20 Several pathways behind the relationship between physical activity and

cognitive domains have been suggested, including that PA influences executive function by

stimulating motor fitness or increasing the complexity of the PA programs in terms of

creativity, diversity, and successfulness.21,22

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Previous systematic reviews and meta-analyses have shown the effectiveness of PA

interventions on improving children’s and adolescents’ cognition. These reviews were mainly

focused on describing the characteristics of interventions in terms of intensity, frequency, and

session or intervention duration.23–27 Two previous meta-analyses have examined the role of

the qualitative characteristics of PA interventions in the relationship between exercise and

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children´s cognition,12,26 though they did not distinguish between the cognitive outcomes that

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improved and those that did not.

To our knowledge, no review has evaluated the independent PA effects on each core

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cognitive executive function (inhibition, working memory, and cognitive flexibility) and

metacognition, extending the later construct to encompass a neuroscience perspective on

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higher-level executive functions28 and a social-cognitive perspective on cognitive life
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skills.17,29 Tomporowski et al.30 proposed that the benefits of quantitatively and/or
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qualitatively different PA interventions in multiple cognitive subdomains might be

interrelated through mediation chains that link increased executive function to improvements
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in metacognition and academic achievement.30 However, current mediation evidence is only

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cross-sectional in nature and has not yet addressed the potential role of

metacognition,31,32 that is, the ability to supervise and manage cognitive processes and to use
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knowledge to regulate behaviours,30 and distinguish it from cognition, which is understood as

the set of mental processes that contribute to perception, memory, intellect, and action.27 In
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sum, scientific evidence on the relationship between PA and cognitive performance in

childhood and adolescence, particularly with regard to possible moderators and mediating

mechanisms, is clearly insufficient to explain how and why PA may impact academic

achievement.

Thus, the aims of this systematic review and meta-analysis were to: i) assess the effect

of PA interventions on children’s and adolescents’ cognition, distinguishing between core

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executive functions and metacognition; and ii) determine which individual and PA program

characteristics are most favorable to aid the development of cognitive and metacognitive

functions.

METHOD

This systematic review and meta-analysis was guided by the PRISMA Statement

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(Preferred Reporting Items for Systematic Reviews and Meta-Analyses)33 and the Cochrane

Collaboration Handbook.34 The protocol for this systematic review and meta-analysis was

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registered on PROSPERO (CRD42015029913) and published elsewhere.35

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Search Strategy

A literature search was independently performed by two reviewers (C.A. and C.P.),

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and studies were identified through a combination of resources. First, a systematic search was
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performed in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials,
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Cochrane Database of Systematic Reviews, Web of Science, and PsycINFO databases from

their inception to October 16, 2016. The search strategy combined the following relevant
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terms: (1) ‘physical activity,’ ‘physical education,’ ‘exercise,’ ‘fitness,’ and ‘sport’; (2)
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‘cognition,’ ‘executive,’ ‘executive function,’ ‘cognitive control,’ ‘intelligence,’ ‘memory,’

‘attention,’ and ‘metacognition’; (3) ‘life skills,’ ‘goal setting,’ ‘problem solving,’ and ‘self-
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regulation’; (4) ‘brain development,’ ‘brain health,’ ‘neural,’ ‘neuroelectric,’ ‘neurotrophic,’

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‘neurotrophin,’ and ‘hormone’; (5) ‘children,’ ‘childhood,’ ‘pre-schooler,’ ‘schoolchildren,’

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‘preadolescent,’ ‘adolescent,’ and ‘adolescence’ and (6) ‘trial’ and ‘effect*.’ Second, the

reference lists of the included articles in this review, and the list of those included in previous

systematic reviews and meta-analyses, were reviewed for any additional relevant study.

Eligibility

Studies concerning the relationship between PA interventions and children’s and

adolescents’ cognition were included in the meta-analysis. Inclusion criteria were: i)

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Participants, studies including healthy children from 4 to 18 years of age (whose target

population was not preterm children or with disorders that could limit the generalisation of

the data); ii) Intervention characteristics, PA programs aimed at enhancing (referring to an

increased amount of time devoted to PA) or enriching (referring to a deliberate increase in

non-physical—coordinative and/or cognitive—demands of PA tasks) PA sessions. We

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classified the interventions into school-time and after school-time PA. Among the former, we

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distinguished: curricular physical education, integrated PA (active breaks or teaching subjects

like math with physically active tasks), and extracurricular PA (active recess or lunch time

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PA); the latter included after-school PA or sports programs. iii) Outcomes, cognitive

performance assessments of non-executive cognitive functions, core executive functions,

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and/or metacognition. Finally, (iv) Study design, including randomized controlled trials
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(RCTs), non-RCTs, and controlled pre-post studies.
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Studies were excluded when they: i) included an adult population, ii) were based on

the acute measurement of the effect of PA on cognition (i.e. those measuring cognition
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immediately after the exertion of single bouts of physical activity), iii) included children with
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any physical or mental disorders that could impede or limit their participation in the

intervention program activities, and iv) were not published in English or Spanish.
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Search and Data Extraction

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Two researchers (C.A. and C.P.) independently screened all abstracts of the retrieved
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articles, excluding those studies that did not meet eligibility criteria. The full texts of selected

studies were retrieved, and the same two authors independently collected the following data

of each study meeting the previously defined criteria: (1) year of publication, (2) country of

the study, (3) number of participants (in control and intervention groups), (4) age of

participants, (5) control condition and PA intervention(s) duration, (6) school time when PA

interventions took place and task characteristics of the intervention, (7) intervention design,
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(8) length of intervention in weeks, and (9) main outcomes and instruments for their

measurement (Tables S1 and S2, available online). The authors of the included studies were

contacted when a lack of information was detected. Disagreements in data collection were

settled by consensus. Cohen´s36 kappa was used to assess agreement between reviewers.

Studies were classified into three groups according to their measured outcomes: (1)

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non-executive cognitive functions; (2) core executive functions including: working memory,

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cognitive flexibility, and inhibition, with the latter including response inhibition and

interference control for selective attention28; and (3) metacognition, including higher-level

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executive functions (planning, fluid intelligence–abstract reasoning and problem solving)28

and cognitive life skills.7,30

Quality Assessment
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After concealing information about authors, affiliations, and date and source of each
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manuscript, two investigators (C.A. and I.C.) independently assessed their methodological

quality. Disagreements were solved by consensus.

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The Jadad Scale37 was used to assess the methodological quality of randomized
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controlled trials (RCTs). The scale included the evaluation of three domains: randomization,

double blinding, and description of withdrawals and dropouts. Each item could be scored as
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“1” or “0” if the study satisfied it or not. Randomization and double blinding could score one
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extra point if they were described in detail. Based on this, each study could score between 0
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and 5.

The Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for

Quantitative Studies38 was used to assess the quality of non-RCTs and controlled pre–post

studies. Studies were evaluated in seven domains: selection bias, study design, confounders,

blinding, data collection method, and withdrawals and drop-outs. Each domain could be

scored as strong, moderate, or weak, and studies could be classified as strong (with no weak
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domains), moderate (with one weak domain), and weak (with two or more weak domains).

Statistical Analysis

Detailed statistical procedures used in this meta-analysis have been reported

elsewhere.35 A standardized mean difference score was calculated for each specific variable

using Cohen’s d index,39 in which positive ES values indicate higher scores in outcomes in

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favor of the intervention group. The pooled ES was estimated using a random-effects model

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based on the Der Simonian and Laird method. Heterogeneity across studies was assessed

using the I2 statistic. Values of <25%, 25–50%, and >50% are considered to represent small,

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medium, and large amounts of inconsistency, respectively. The influence of each study in the

pooled ES estimates was examined using sensitivity analyses. For assessing publication bias,

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Egger’s regression asymmetry test40 was used. The trim-and-fill41 computation was used to
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assess the effect of publication bias on the interpretation of results. Only those studies
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providing complete data for pre- and post-intervention measurements and including a control

group were included in the meta-analysis.

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Some additional statistical aspects that should be detailed here were: i) when studies
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included two cohorts or two intervention groups, their data were analyzed as independent

samples; ii) when studies used two or more tests for measuring the same variable, the average
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effect size was calculated; iii) when studies reported two or more follow-up measurements,
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only the last measurement was considered; and iv) an interference outcome for Stroop-like
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test or Flanker-like test was calculated as follows: incongruent test-congruent test or

commission test-omission test.

A pooled ES was calculated for three groups of cognitive domains: (1) non-executive

cognitive functions, (2) core executive functions, and (3) metacognition. Additionally,

subgroup analyses were conducted considering individual tasks within each domain: i) core

executive function (working memory, cognitive flexibility, and selective attention-inhibition:

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for the last, an additional analysis was conducted by considering selective attention and

inhibition measurements separately) and ii) metacognition (higher-level executive functions

[including planning, fluid intelligence—reasoning and problem solving—and creativity] and

cognitive life skills [including self-awareness of goal setting, problem solving, and positive

thinking skills]).

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Subgroup analyses were performed based on different aspects of the intervention: i)

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the school time when PA intervention took place, distinguishing between: curricular physical

education, integrated or extracurricular PA, and after-school PA and sports programs, and ii)

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task characteristics, distinguishing between: quantitative and qualitative characteristics of the

PA intervention, considering if the interventions were designed as enhanced or enriched PA.

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Interventions could be both enhanced and enriched when the manipulation included
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additional physically active times, and deliberately increased coordinative and cognitive task
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requirements.

Other subgroup analyses were performed based on some variables that could act as
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confounders: i) children´s weight status, comparing the effectiveness of studies considering

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when studies provided the effectiveness of the interventions on overweight and obese

children, and ii) time and accuracy of cognitive test performance, considering the papers that
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reported the effect of the intervention on accuracy, time, or both separately.

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Additionally, random-effects meta-regression analyses were performed in order to

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determine whether the children´s age (in years), the length of the intervention (in weeks), and

the study quality could be related with the effectiveness of the intervention on each outcome.

Statistical analyses were performed using StataSE software, version 14 (StataCorp).

RESULTS

The search retrieved a total of 4,582 articles. Of those, 777 were removed as

duplicates and 3,805 were screened based on the title and the abstract (Figure S1, available
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online). The overall percentage of agreement between the reviewers on data extraction, as

assessed using Cohen’s kappa statistic, was 0.91.

A total of 36 papers were included in this systematic review,6,9,10,19,20,42-72 of which

only five were non-RCT designs.42,44,59,64,66 Characteristics of the included studies are

displayed in Table S1 (available online). Studies were conducted in 15 countries: United

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States (10 studies), India (5), Italy (5), Australia (2), Germany (2), Greece (2), the

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Netherlands (2), Denmark (1), Iran (1), South Africa (1), Spain (1), Switzerland (1), Taiwan

(1), Turkey (1), and the United Kingdom (1). The total sample included 5,527 children and

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adolescents (2,308 in control group) aged from 4 to 14 years. Three studies included only

overweight and obese children,48,49,57 and three addressed the moderating role of children´s

weight status.10,47,53
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The interventions, mostly performed during curricular school time, were aimed at

increasing the amount of PA or qualitatively enriching PA, 9,10,19,20 ,43,46,47,51,53,54,61,62,64-67,69 and

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at adding classroom-based PA during daily lessons targeted to learning various subjects

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through being physically active (integrated PA),50,60,63,68 unrelated to subject learning (active
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breaks),52,71 or PA during recess (e.g., active lunch).70 Further, studies developed after-school

PA programs,6,42,44,45,48,49,55-57,72 two of them during summer camp.58,59

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Overall, the interventions resulted in an increase of PA time from 15 to 120 minutes

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per day, except one intervention study that included 480 minutes per day, seven days a week,

but limited to the time of summer camp vacations.59 Only three studies included data from
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two cohorts,9,64,66 and 14 studies included more than one intervention group, four of them

without a control group.45,46,58,69 For those studies with more than one intervention group,

experimental groups differed in exercise intensity,43,45,48,49,65 duration,48,49 PA type,46,52,53,56,58-

61,65,69
or educators who delivered the intervention activities (generalist versus specialist

teachers).61 The length of interventions ranged broadly from four weeks9,58,60,71 to 54 weeks.54
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Systematic Review

Table S1 (available online) describes the relevant characteristics of the included

studies. Seven studies10,43,48,49,51,52,71 reported information regarding the efficacy of PA

interventions on cognitive domains that do not or only minimally rely on executive function.

In all of them, non-executive functions improved as a result of the intervention. Four of those

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studies included two experimental groups that differed in exercise intensity,43,48,49 duration,48

or PA type,52 and yielded controversial results. Two studies48,49 did not find dose-response

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relationships, however two43,52 others found that increases in the duration and intensity of the

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sessions was associated with greater improvements in non-executive functions.

A total of 29 studies6,10,19,20,42,44-51,53-57,59-62,65-70,72 reported improvements in core

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executive functions. Eleven studies included more than one intervention group: three did not
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find differences between intervention groups,46,48,49 and the remaining eight studies reported

differences in favor of aerobic exercise,56 yoga,59 coordinative or cognitively enriched PA

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carried out by specialists,53,61 integrated PA,60,69 or team games65 or the moderate intensity
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group.45
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The 15 studies9,10,19,43,46,48,49,51,52,58,61,63,64,67,70 in which metacognition was an outcome

reported post-intervention improvements in its domains. Studies including more than one
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intervention group43,46,48,49,52,58 failed to find significant differences in improvements.

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Study Quality
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From the 31 RCTs whose quality was assessed using the Jadad scale, only two scored

5 points,6,51 six scored 4 points,43,46,49,10,67,69 thirteen scored 3 points,19,47,48,50,53,57,61-63,65,68,70,71

nine scored 2 points,18,20,45,52,54-56,60,72 and one scored 1 point.58 All of the studies included

information regarding the randomization method, and only two did not provide information

about the withdrawals and dropouts. However, only four studies properly described the

double blinding method used (Table S3, available online).

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From the five non-RCTs in which quality was assessed using the EPHPP tool,

four42,44,59,66 scored as weak and one as moderate.64 The worst scored items were: i) data

collection, because the tools for primary outcomes were not described as reliable and valid;

and ii) the descriptions of the withdrawals and drop-outs, because the papers did not describe

the number and/or the reasons for the withdrawals and drop-outs (Table S3, available online).

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Meta-Analysis

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Non-Executive Cognitive Functions. The pooled ES estimation for PA intervention

effects on cognitive performances not—or only minimally—relying on executive functions

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was 0.23 (95% CI: 0.09 to 0.37). There was small heterogeneity among the studies

(I2=21.9%; p=.199; Figure 1A).

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Core executive functions. For core executive functions (including performance on
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selective attention tests requiring executive interference control), the pooled ES estimation
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was 0.20 (95% CI: 0.10 to 0.30). There was large heterogeneity between the studies

(I2=70.0%; p<.001; Figure 1B).

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Data for the working memory subgroup analysis showed a pooled ES of 0.14 (95%
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CI: 0.00 to 0.27). There was medium heterogeneity among the studies (I2=48.0%; p=.027).

The pooled ES for selective attention-inhibition subgroup analysis, including the

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outcomes of selective attention tests requiring executive interference control, was 0.26 (95%

CI: 0.10 to 0.41). There was large heterogeneity among the studies (I2=76.0%, p<.001).
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When a complementary analysis was performed for measures of inhibition process and

selective attention separately, the pooled ESs were 0.38 (95% CI: 0.13 to 0.63) and 0.13

(95% CI: -0.07 to 0.33), respectively. There was large heterogeneity in both groups of studies

(I2=86.2% and 66.8%; respectively).

Finally, for the cognitive flexibility subgroup, the pooled ES was 0.11 (95% CI: -0.10

to 0.32), with large heterogeneity across studies (I2=68.7%; p=.013).

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Metacognition. The pooled ES for PA programs on metacognition was 0.23 (95% CI:

0.13 to 0.32), with small heterogeneity between studies (I2=4.7%; p=.398; Figure 1C).

The pooled ES for the subgroup of higher-level executive functions was 0.19 (95%

CI: 0.06 to 0.31), and heterogeneity was small (I2=12.9%; p=.315).

For cognitive life skills, the pooled ES estimation was 0.30 (95% CI: 0.15 to 0.45)

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with no heterogeneity among the studies (I2=0.0%, p=.549).

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**Please insert Figure 1 about here**

Subgroup Analysis. Subgroup analysis by the school time when PA interventions took

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place (curricular physical education, integrated or extracurricular PA and after-school PA)

showed that curricular physical education programs broadly benefited: i) non-executive

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cognitive functions (ES=0.42; 95% CI: 0.14 to 0.70), ii) the selective attention-inhibition
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component of core executive functions (ES=0.41; 95% CI: 0.15 to 0.67), and iii) higher-level
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executive functions (ES=0.25; 95% CI: 0.06 to 0.43). On the other hand, no PA intervention

influenced working memory or cognitive flexibility. This subgroup comparison could not be
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performed for cognitive life skills, which were only measured in curricular physical
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education programs (ES=0.30; 95% CI: 0.15 to 0.45; Table S4, available online).

Subgroup analysis based on task characteristics of the intervention (quantitatively

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enhanced PA, qualitatively enriched PA, or both) (Table S4, available online) showed that
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non-executive cognitive functions were mostly improved in enhanced PA programs

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(ES=0.21; 95% CI: 0.07 to 0.35). With regards to core executive functions, working memory

benefited mostly from enhanced PA programs (ES= 0.28; 95% CI: 0.04 to 0.52), while

selective attention-inhibition benefited mostly from enriched PA programs (ES=0.49; 95%

CI: 0.05 to 0.93), and cognitive flexibility did not benefit from any type of intervention.

Finally, higher-level executive functions improved through enhanced PA (ES=0.21; 95% CI:

0.09 to 0.34), while cognitive life skills were only evaluated in enriched PA (ES=0.30; 95%
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CI: 0.15 to 0.45).

Subgroup analysis by children´s weight status could only be performed for the

selective attention-inhibition subdomain. Six overweight and/or obese children comparison

groups were extracted from four47-49,57 studies. The pooled ES estimation when considering

only overweight and/or obese children was -0.02 (95% CI: -0.22 to 0.17).

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When subgroup analyses were conducted based on the individual and joint effects on

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cognitive performance time and accuracy, only inhibition and cognitive flexibility could be

considered (Table S5, available online). The pooled ES for studies focused on accuracy

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outcomes was 0.15 (95% CI= 0.01 to 0.29), for those focused on performance time (i.e.,

reaction time, or time to test completion) -0.25 (95% CI= -0.45 to -0.04), and for those

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including both accuracy and performance time, the pooled ES for accuracy was 0.29 (95%
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CI= 0.04 to 0.54) while the pooled ES for time was -0.05 (95% CI: -0.20 to 0.11).
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Random-Effects Meta-Regression Model. The random-effects meta-regression model

showed that the effect of PA interventions on children´s non-executive functions was

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positively associated with children’s age (β=0.08; 95%: 0.00 to 0.15; p = .036), and
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negatively associated with working memory and the length of the intervention (β=-0.01;

95%: -0.02 to -0.01; p = .023; Table S6, available online).

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Moreover, this model showed that study quality was also not related to the
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heterogeneity observed across the studies.

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Sensitivity analyses. Sensitivity analyses suggested that the pooled ES estimation for

working memory was only modified when removing Fisher et al.,51 Kamijo et al.,55

Manjunath et al.,59 and Mavilidi et al60 (Table S7, available online).

Publication Bias. Funnel plots indicated significant publication bias for the pooled

subgroup analyses of working memory only (p< .10; Figure S2, available online).

Additionally, trim-and-fill computation showed that six studies were needed for removing
 ACCEPTED MANUSCRIPT
publication bias from working memory subgroup (p = .628).

DISCUSSION

To our knowledge, this is the first systematic review and meta-analysis that separately

summarizes evidence regarding the effectiveness of PA interventions on children’s and

adolescents’ non-executive cognitive functions, core executive functions, and metacognition.

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Overall, this review shows that PA programs benefit multiple facets of non-executive (ES:

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0.23), executive (ES: 0.20), and metacognitive (ES: 0.23) functions and skills in children and

adolescents. Additionally, our data found that curricular physical education and programs

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aimed at increasing the amount of exercise seem to be the most effective.

Subgroup analyses showed that the domains of cognition most sensitive to exercise

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were working memory (ES: 0.14), inhibition (ES: 0.26), higher-level executive functions
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(ES: 0.19) and cognitive life skills (ES: 0.30). However, individual and task characteristics,
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as well as the school time when the PA interventions took place have some influence on these

effects. Participants’ age seems to uniquely act as an amplifier of the size of intervention
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effects in non-executive functions. With regards to the context in which PA interventions

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were conducted, curricular physical education lessons seem to be the most appropriate

framework to improve children´s cognition. The influence that the nature of activities
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included in the PA programs seems to be greater on core and higher-level executive

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functions. However, while increasing the amount of PA appears to improve children´s

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working memory and higher-level executive functions, enriched PA programs with flexible

cognitive-oriented tasks implying greater coordinative and cognitive demands seem to

particularly improve inhibitory efficiency.

Developmental evidence concerning the beneficial effects of PA interventions on

cognition has been growing during the last decades. However, not all exercise produces the

same results, in such a way that animal studies have shown that complex and random
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activities result in greater neural growth in the hippocampus, cerebellum, and cerebral

cortices than simple and repetitive actions.73 Thus, at present, evidence consistently supports

that not all forms of exercise influence cognition equally,4,11,21 and that exercises requiring

complex, controlled, and adaptive cognition and movement have a greater impact on

executive functions.13 Our analyses also showed that classroom-based PA did not positively

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impact children´s cognition,23 at least when evidence on this in-school intervention type was

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merged with other non-curricular types of school time PA (e.g., recess time PA), and as

compared with the greater impact of curricular physical education.

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Previous research has reported an association between working memory and

cardiorespiratory and muscular fitness levels, and also between inhibition processes and some

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components of enriched PA games such as decision-making or tactical cooperation.22
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Although most of the activities included in the PA interventions were not deliberately
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designed to involve coordinative and cognitive demands, the interventions often included a

variety of activities that did not emphasize task repetition; rather, they imply a progressive
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increase in task complexity ensuring a cognitive effort that might help cognition
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development.21,74 In this meta-analysis, we classified as “enriched” only those PA

interventions in which the coordinative and cognitive demands were deliberately

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manipulated. Such kinds of deliberate cognitive enrichment of exercise programs seem to be

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essential for promoting the development of inhibitory functions, which plays a crucial role in
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the achievement of academic goals and life skills, which are essential to positive youth

development.75,76

Additionally, our meta-analysis shows that when speed and accuracy for developing

core executive functions are considered, only accuracy is improved by PA interventions.

Behind this finding could be the fact that children are not able to independently control their

speed and accuracy in response to an impulse, but they could be able to control the speed–
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accuracy trade-offs77; therefore, the sensory performance (accuracy) could be improved

without improving the motoric stage (reaction time).

There has been a growing concern about the worldwide alarming increase of

overweight and obesity prevalence rates in children. Physical inactivity and changes in eating

habits have been identified as key factors for this dramatic change in children’s body

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composition. Evidence suggests a negative complex relationship between weight status and

motor and cognitive development,78,79 although changes in the anatomy and function of the

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brain of overweight and obese children have also been highlighted.79 Mediation analyses

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suggest that motor development mediates the relationship between weight status and

cognitive performance,14 and therefore it seems important to elucidate whether it would be

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expected that overweight and/or obese children involved in PA programs achieve greater
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benefits in terms of cognitive development and academic achievement than their normal-
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weight peers. However, our results did not show a significantly higher ES in overweight

and/or obese children in the intervention groups than those overweight and/or obese children
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in the control groups. Nevertheless, these results should be considered with caution because
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most of the studies did not provide effect data by weight status, and only six presented

separate data for overweight and/or obese children.

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The main point of our findings is that they consistently support that curricular PA
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programs seem to be the most effective interventions for promoting the development of a
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broad range of cognitive and metacognitive functions and skills. Therefore, increasing

physical education curricular time does not negatively affect but also even promotes

cognitive development and academic achievement.1,2,23,63 Moreover, it should be taken into

account that although this review has exclusively focused on school-based structured PA

interventions, the benefits on health and cognition of any of these programs would

presumably be extended far beyond the school. Thus, scientific evidence of the effectiveness
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of interventions that jointly include motor and cognitive stimulation school-based activities,

and the promotion of complementary outdoor free-play experiences, are necessary in order to

amplify the benefits of school-based enriched PA programs.62

Nevertheless, it should also be noted that there is a lack of information regarding

school-based interventions design; therefore, studies should describe in more detail the

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methodologies, cognitive variables involved in the interventions, and the compliance and

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acceptability of the programs in order to make definitive conclusions regarding their

effectiveness.12 Furthermore, considering the importance of early brain development

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processes in the acquisition of core executive functions, metacognition, and life skills later in

life and their relation with academic achievement, it seems essential to gather information

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regarding the maintenance of the beneficial effects of PA interventions on children’s and
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adolescents’ cognition over time after intervention cessation. We have not been able to state
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how long the benefits of school-based PA programs could be maintained over time, since

there is a lack of follow-up studies measuring outcomes after intervention cessation.50,61

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The design of PA and motor learning interventions for children and adolescents with
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contents and delivery strategies tailored to specifically enhance their executive function is

emerging as a promising way to promote motor and cognitive development.14,80,81 However,

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well-designed PA programs joining motor and cognitive stimulation should be complemented

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with the great variety of outdoor free play experiences that seem to amplify the benefits of

school-based enriched PE programs.62

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The limitations of this study are those common to systematic reviews and meta-

analyses. In addition, we should highlight the following aspects that could limit the

robustness of our results: i) we only found significant publication bias for working memory;

however, we cannot affirm that publication bias did not affect other variables due to poor

results being un published because we did not search for unpublished studies or included grey
 ACCEPTED MANUSCRIPT
literature; ii) the results of this meta-analysis were obtained after some data manipulation,

which could generate some bias; iii) less than the 50% of the studies included in the

systematic review scored a good quality; conversely, meta-regression models showed that

study quality was not related to heterogeneity among studies; iv) cognitive performance was

measured across the studies using a wide variety of tools, but measurements were

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standardized by calculating the ES; and v) participants’ age and the length or type of

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interventions could influence our estimations, thus subgroup analysis and meta-regressions

were performed in order to minimize this possible source of bias and heterogeneity.

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In conclusion, this systematic review and meta-analysis supports that PA interventions

are useful strategies to foster the development of children´s cognition (non-executive

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cognitive functions, core executive functions, and higher-level executive functions).
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Moreover, this study shows that curricular exercise and programs aimed at increasing the
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time dedicated to PA are more likely to produce an effect on children’s and adolescents’

cognition. This information should be jointly considered with previous research that has
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highlighted the positive effects of physical activity on children’s health.82,83 It also might be
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relevant for policy and decision makers in order to design new strategies not only for

promoting children´s cognitive development, and as a consequence better academic

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performance, but also for improving mental health (reducing anxiety/depressive disorders,

improving self-esteem)82 and preventing cardiovascular disease.84 Including this evidence

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AC

into good practice guidelines in education and public health might lead to counteracting the

current school trend of PA reduction. For this purpose, qualified professionals71 are essential

in designing PA strategies tailored to enhance children’s and adolescents’ executive

functions, and therefore motor and cognitive development promotion.14,80,81 Future reviews

should address the efficacy, for children’s cognitive development, of environment-based

programs tailored to create favorable surroundings for playground games and PA.
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REFERENCES

1. Tomporowski PD, Lambourne K, Okumura MS. Physical activity interventions and

children’s mental function: an introduction and overview. Prev Med. 2011;52:S3-9.

2 Donnelly JE, Hillman CH, Castelli D, et al. Physical activity, fitness, cognitive

function, and academic achievement in children: a systematic review. Med Sci Sports Exerc.

PT
2016;48:1197–222.

RI
3 Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise effects

on brain and cognition. Nat Rev Neurosci. 2008;9:58-65.

SC
4. Diamond AB. The cognitive benefits of exercise in youth. Curr Sports Med Rep.

2015;14:320–6.

5.
U
Chaddock-Heyman L, Hillman CH, Cohen NJ, et al. the Importance of physical
AN
activity and aerobic fitness for cognitive control and memory in children. Monogr Soc Res
M

Child Dev. 2014;79:25–50.

6. Hillman CH, Pontifex MB, Castelli DM, et al. Effects of the FITKids randomized
D

controlled trial on executive control and brain function. Pediatrics. 2014;134:e1063-1071.

TE

7. Pesce C. Shifting the focus from quantitative to qualitative exercise characteristics in

exercise and cognition research. J Sport Exerc Psychol. 2012;34:766–86.

EP

8. WHO. Life skills education for children and adolescents in schools. 2nd ed. Geneva:
C

World Health Organization; 1994.

AC

9. Goudas M, Dermitzaki I, Leondari A, et al. The Effectiveness of teaching a life skills

program in a sport context. European journal of psychology of education, 2006;21:429-438.

10. Pesce C, Marchetti R, Forte R, et al. Youth life skills training: exploring outcomes

and mediating mechanisms of a group-randomized trial in physical education. Sport Exerc

Perform Psychol. 2016;5:1–16.

11. Pesce C, Ben-soussan TD. ‘Cogito ergo sum’ or ‘ambulo ergo sum’? New
 ACCEPTED MANUSCRIPT
perspectives in developmental exercise and cognition research. In: Mc Morris, eds. Exercise-

Cognition interaction: a neuroscience perspective. Amsterdam: Elsevier Inc; 2014: 251-282.

12. Vazou S, Caterina P, Lakes K, et al. More than one road leads to Rome: A narrative

review and meta-analysis of physical activity intervention effects on children’s cognition. Int

J Sport Exerc Psychol. 2016;0:1–26.

PT
13. Best JR. Effects of physical activity on children’s executive function: Contributions of

RI
experimental research on aerobic exercise. Dev Rev. 2010;30:331-51.

14. Pesce C, Croce R, Ben-Soussan TD, et al. Variability of practice as an interface

SC
between motor and cognitive development. Int J Sport Exerc Psychol. 2016: 1-20.

15. Diamond A, Ling DS. Conclusions about interventions, programs, and approaches for

U
improving executive functions that appear justified and those that, despite much hype, do not.
AN
Dev Cogn Neurosci. 2016;18:34–48.
M

16. Diamond A. Effects of physical exercise on executive functions: going beyond simply

moving to moving with thought. Ann Sport Med Res. 2015;2:1011.

D

17. Goudas M. Prologue: A review of life skills teaching in sport and physical education.
TE

Hell J Psychol. 2010;7:241–58.

18. Papacarisis V, Goudas M, Danish SJ, et al. The Effectiveness of teaching a life skills
EP

program in a sport context. J Appl Sport Psychol. 2005;17:247–54.

C

19. Lakes KD, Hoyt WT. Promoting self-regulation through school-based martial arts
AC

training. J Appl Dev Psychol. 2004;25:283–302.

20. Lakes KD, Bryars T, Sirisinahal S, et al. The healthy for life taekwondo pilot study: a

preliminary evaluation of effects on executive function and BMI, feasibility, and

acceptability. Ment Health Phy Act. 2013;6:181-188.

21. Diamond A, Lee A. Intervention shown to aid executive function development in

children 4-12 years old. Science. 2011;333:959–64.

 ACCEPTED MANUSCRIPT
22. Marchetti R, Forte R, Borzacchini M, et al. Physical and motor fitness, sport skills and

executive function in adolescents: a moderated prediction model. Psychology. 2015;6:1915-29.

23. Donnelly JE, Lambourne K. Classroom-based physical activity, cognition, and

academic achievement. Prev Med. 2011;52:S36–42.

24. Centers for Disease Control and Prevention. The association between school based

PT
physical activity, including physical education, and academic performance. Atlanta, GA: US

RI
Department of Health and Human Services; 2010.

25. Fedewa AL, Ahn S. The effects of physical activity and physical fitness on children’s

SC
achievement and cognitive outcomes. Res Q Exerc Sport. 2011;82:521–35.

26. Lees C, Hopkins J. Effect of aerobic exercise on cognition, academic achievement,

U
and psychosocial function in children: a systematic review of randomized control trials. Prev
AN
Chronic Dis. 2013;10:E174.
M

27. Donnelly JE, Hillman CH, Castelli D, et al. Physical activity, fitness, cognitive

function, and academic achievement in children: A systematic review. Med Sci Sports Exerc.
D

2016;48:1197-222.
TE

28. Diamond A. Executive functions. Annu Rev sychology. 2013;64:135–68.

29. Danish S, Forneris T, Hodge K, et al. Enhancing youth development through Sport.
EP

World Leis J. 2004;46:38–49.

C

30. Tomporowski PD, McCullick B, Pendleton DM, et al. Exercise and children’s
AC

cognition: the role of exercise characteristics and a place for metacognition. J Sport Heal Sci.

2014;4:47–55.

31. Rigoli D, Piek JP, Kane R, et al. Motor coordination, working memory, and academic

achievement in a normative adolescent sample: testing a mediation model. Arch Clin

Neuropsychol. 2012;27:766–80.

32. Van der Niet AG, Hartman E, Smith J, et al. Modeling relationships between physical
 ACCEPTED MANUSCRIPT
fitness, executive functioning, and academic achievement in primary school children. Psychol

Sport Exerc. 2014;15:319–25.

33. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews

and meta-analyses: the PRISMA statement. Int J Surg. 2010;8:336–41.

34. Higgins JP, Green S, editors. Cochrane Handbook for Systematic Reviews of

PT
Interventions. Chichester, UK: Wiley-Blackwell; 2008.

RI
35. Álvarez-Bueno C, Pesce C, Cavero-Redondo I, et al. Association of physical activity

with cognition, metacognition and academic performance in children and adolescents: a

SC
protocol for systematic review and meta-analysis. BMJ Open. 2016;6:e011065.

36. Landis JR, Koch GG. The measurement of observer agreement for categorical data.

Biometrics. 1977;33:159-74.
U
AN
37. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized
M

clinical trials: Is blinding necessary? Control Clin Trials. 1996;17:1–12.

38. Armijo-Olivo S, Stiles CR, Hagen NA, et al. Assessment of study quality for
D

systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the
TE

Effective Public Health Practice Project Quality Assessment Tool: Methodological research.

J Eval Clin Pract. 2012;18:12–8.

EP

39. Cohen J. Statistical power analysis for the behavioral sciences. Rev. ed. New York,
C

NY: Academic Press; 1977.

AC

40. Sterne JA, Egger M, Smith GD. Investigating and dealing with publication and other

biases in meta-analysis. BMJ. 2001;323:101–5.

41. Duval S, Tweedie R. Trim and Fill: a simple funnel-plot-based method. Biometrics.

2000;56:455-463.

42. Adsiz E, Dorak F, Ozsaker M, et al. The influence of physical activity on attention in

Turkish children. Health MED. 2012;6:1384–9.

 ACCEPTED MANUSCRIPT
43. Ardoy DN, Fernández-Rodríguez JM, Jiménez-Pavón D, et al. A physical education

trial improves adolescents’ cognitive performance and academic achievement: The EDUFIT

study. Scand J Med Sci Sport. 2014;24:52–61.

44. Castelli DM, Hillman CH, Hirsch J, et al. FIT Kids: time in target heart zone and

cognitive performance. Prev Med. 2011;52:S55–9.

PT
45. Chang YK, Tsai YJ, Chen TT, et al. The impacts of coordinative exercise on

RI
executive function in kindergarten children: An ERP study. Exp Brain Res. 2013;225:187–

96.

SC
46. Chaya MS, Nagendra H, Selvam S, et al. Effect of yoga on cognitive abilities in

schoolchildren from a socioeconomically disadvantaged background: a randomized

U
controlled study. J Altern Complement Med. 2012;18:1161-1167.
AN
47. Crova C, Struzzolino I, Marchetti R, et al. Cognitively challenging physical activity
M

benefits executive function in overweight children. J Sport Sci. 2014;32:201-211.

48. Davis CL, Tomporowski PD, Boyle CA, et al. Effects of aerobic exercise on
D

overweight children’s cognitive functioning: a randomized controlled trial. Res Q Exerc

TE

Sport. 2007;78:510–9.

49. Davis CL, Tomporowski PD, Mcdowell JE, et al. Exercise improves executive
EP

function and achievement and alters brain activation in overweight children: a randomized
C

controlled trial. Health Psychl. 2011;30:91.

AC

50. De Greeff JW, Hartman E, Mullender-Wijnsma MJ, et al. Long-term effects of

physically active academic lessons on physical fitness and executive functions in primary

school children. Health Educ Res. 2016;31:185–94.

51. Fisher A, Boyle JM, Paton JY, et al. Effects of a physical education intervention on

cognitive function in young children: randomized controlled pilot study. BMC Pediatr.

2011;11:97.
 ACCEPTED MANUSCRIPT
52. Fredericks CR, Kokot SJ, Krog S. Using a developmental movement programme to

enhance academic skills in grade 1 learners. South African J Res Sport Phys Educ Recreat.

2006;28:29–42.

53. Gallotta MC, Emerenziani GP, Iazzoni S, et al. Impacts of coordinative training on

normal weight and overweight/obese children’s attentional performance. Front Hum

PT
Neurosci. 2015;9:9.

RI
54. Ghahramani M, Sohrabi M, Kakhki A, et al. The effects of physical activity on

impulse control, attention, decision-making and motor functions in students with high and

SC
low impulsivity. Biosci Biotechnol Res Asia. 2016;13:1689–96.

55. Kamijo K, Pontifex MB, O’Leary KC, et al. The effects of an afterschool physical

U
activity program on working memory in preadolescent children. Dev Sci. 2011;14:1046–58.
AN
56. Koutsandréou F, Wegner M, Niemann C, et al. Effects of motor versus cardiovascular
M

exercise training on children´s working memory. Med Sci Sports Exerc. 2016;48:1144–52.

57. Krafft CE, Schwarz NF, Chi L, et al. An 8-month randomized controlled exercise trial
D

alters brain activation during cognitive tasks in overweight children. Obesity. 2014;22:232–
TE

42.

58. Manjunath NK, Telles S. Improved performance in the Tower of London test
EP

following yoga. Indian J Physiol Pharmacol. 2001;45:351–4.

C

59. Manjunath NK, Telles S. Spatial and verbal memory test scores following yoga and
AC

fine arts camps for school children. Indian J Physiol Pharmacol. 2004;48:353–6.

60. Mavilidi MF, Okely AD, Chandler P, et al. Effects of integrated physical exercises

and gestures on preschool children’s foreign language vocabulary learning. Educ Psychol

Rev. 2015;27:413–26.

61. Pesce C, Crova C, Marchetti R, et al. Searching for cognitively optimal challenge

point in physical activity for children with typical and atypical motor development. Ment
 ACCEPTED MANUSCRIPT
Health Phys Act. 2013;6:172–80.

62. Pesce C, Masci I, Marchetti R, et al. Deliberate play and preparation jointly benefit

motor and cognitive development: mediated and moderated effects. Front Psychol. 2016;7:1-18.

63. Reed J, Einstein G, Hahn E. Examining the impact of integrating physical activity on

fluid intelligence and academic performance in an elementary school setting: a preliminary

PT
investigation. J Phys Act Health. 2010;7:343.

RI
64. Reed J a, Maslow AL, Long S, et al. Examining the impact of 45 minutes of daily

physical education on cognitive ability, fitness performance, and body composition of

SC
African American youth. J Phys Act Health. 2013;10:185–97.

65. Schmidt M, Jaeger K, Egger F, et al. Cognitively engaging chronic physical activity,

U
but not aerobic exercise, affects executive functions in primary school children: a group-
AN
randomized controlled trial. J Sport Exerc Psychol. 2015;37:575–91.
M

66. Spitzer US, Hollmann W. Experimental observations of the effects of physical

exercise on attention, academic and prosocial performance in school settings. Trends

D

Neurosci Educ. 2013;2:1–6.

TE

67. Subramanian SK, Sharma VK, Arunachalam V, et al. Effect of structured and

unstructured physical activity training on cognitive functions in adolescents - a randomized

EP

control trial. J Clin Diagn Res. 2015;9:CC04-9.

C

68. Tarp J, Domazet SL, Froberg K, et al. Effectiveness of a school-based physical

AC

activity intervention on cognitive performance in Danish adolescents: LCoMotion—

Learning, Cognition and Motion – a cluster randomized controlled trial. PLoS One.

2016;11:e0158087.

69. Telles S, Singh N, Bhardwaj AK, et al. Effect of yoga or physical exercise on

physical, cognitive and emotional measures in children: a randomized controlled trial. Child

Adolesc Psychiatry Ment Health. 2013;7:37.

 ACCEPTED MANUSCRIPT
70. van der Niet AG, Smith J, Oosterlaan J, et al. Effects of a cognitively demanding

aerobic intervention during recess on children’s physical fitness and executive functioning.

Pediatr Exerc Sci. 2016;28:64–70.

71. Wilson AN, Olds T, Lushington K, et al. The impact of 10-minute activity breaks

outside the classroom on male students’ on-task behaviour and sustained attention: a

PT
randomised crossover design. Acta Paediatr Int J Paediatr. 2016;105:e181–8.

RI
72. Zervas Y, Danis A, Klissouras V. Influence of physical exertion on mental

performance with reference to training. Percept Mot Skills. 1991;72:1215–21.

SC
73. Carey JR, Bhatt E, Nagpal A. Neuroplasticity promoted by task complexity. Exerc

Sport Sci Rev. 2005;33:24–31.

74.
U
Tomporowski PD, Davis CL, Miller PH, et al. Exercise and children’s intelligence,
AN
cognition, and academic achievement. Educ Psychol Rev. 2008;20:111–31.
M

75. Danish SJ, Forneris T. Promoting positive development and competency across the

lifespan. 4th ed. In Brown SD, Lent RW, eds. Handbook of counseling psychology Hoboken,
D

NJ: Wiley; 2008: 500-517

TE

76. Theokas C, Danish SJ, Hodge K, Heke I, Forneris T. Enhancing life skills through

sport for children and youths. In Holt NL, eds. Positive youth development through sport.
EP

New York: Routledge; 2008:49-60

C

77. Rinkenauer G, Osman A, Ulrich R, et al. On the locus of speed-accuracy trade-off in

AC

reaction time: inferences from the lateralized readiness potential. J Exp Psychol Gen.

2004;133:261–82.

78. D’Hondt E, Deforche B, Gentier I, et al. A longitudinal analysis of gross motor

coordination in overweight and obese children versus normal-weight peers. Int J Obes.

2013;37:61–7.

79. Reinert KR, Po’e EK, Barkin SL, et al. The relationship between executive function
 ACCEPTED MANUSCRIPT
and obesity in children and adolescents: a systematic literature review. J Obes.

2013;2013:820956.

80. Moreau D. Brains and Brawn: Complex motor activities to maximize cognitive

enhancement. Educ Psychol Rev. 2015;27:475–82.

81. Tomporowski PD, McCullick B, Pesce C. Enhancing children’s cognition with

PT
physical activity games. Champaign, IL: Human Kinetics; 2015.

RI
82. Sibold J, Edwards E, Close DM, Hudziak JJ. Physical activity, sadness, and

suicidality in bullied US adolescents. J Am Acad Child Adolesc Psychiatry. 2015;54:808–

SC
815.

83. Larun L, Nordheim L, Ekeland E, Hagen K, Heian F. Exercise in prevention and

U
treatment of anxiety and depression among children and young people. Cochrane Database
AN
Syst Rev. 2006;(3):CD004691.
M

84. Ruiz JR, Cavero-Redondo I, Ortega FB, et al. Cardiorespiratory fitness cut points to

avoid cardiovascular disease risk in children and adolescents; what level of fitness should
D

raise a red flag? a systematic review and meta-analysis. Br J Sports Med. 2016;50:1451-1458.
TE
EP

Titles and captions for figures

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Figure 1. Pooled estimated effect size for non-executive cognitive functions (a), core
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executive functions (b), and metacognition (c). Note: Positive effect size (ES) values indicate

higher score in outcomes in favor of the intervention group. BART = Ballon Analogue Risk

Task; CANTAB = Cambridge Neuropsychological Test Battery; CAS = Cognitive

Assessment System; IGF-M = Spanish Overall and Factorial Intelligence Test; M-WCST =
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modified version of Wisconsin Card Sorting Test; RFFT = Ruff Figural Fluency Test; RNG =

Random number generation; WISC = Wechsler Intelligence Scale.

Titles and captions for supplementary figures

Figure S1. Literature search Preferred Reporting Items for Systematic Reviews and Meta-

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Analyses (PRISMA) consort diagram. Note: WOS = Web of Science.

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Figure S2. Assessment of potential publication bias by Egger test.

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