Effects of physical activity on motor, communication, social, and executive function in children with autism spectrum disorder: A meta-analysis of randomized controlled trials

Effects of physical activity on motor, communication, social, and executive function in children with autism spectrum disorder: A meta-analysis of randomized controlled trials | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of physical activity on motor, communication, social, and executive function in children with autism spectrum disorder: A meta-analysis of randomized controlled trials Chenmu Li, Wenlai Cui, Hongling Pan, Tong Zhou, Xuecheng Li, Dong Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6484664/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Dec, 2025 Read the published version in European Journal of Pediatrics → Version 1 posted 10 You are reading this latest preprint version Abstract Background Autism Spectrum Disorder is a neurodevelopmental disorder with characteristic impairments including social and communication deficits, restricted interests, and repetitive behaviors. Physical activity has shown promise as a non-pharmacological intervention to improve motor skills, executive function, and social interaction in children with Autism Spectrum Disorder. However, existing studies often overlook age-specific effects. This study aims to evaluate the impact of physical activity on key functional domains in children with Autism Spectrum Disorder through meta-analysis. Methods This study conducted searches across four databases up to March 2024, to identify pertinent RCTs. The systematic screening, data extraction, quality assessment, and data analysis were independently conducted by two reviewers. A total of 19 studies were included in the analysis. A total of 609 participants were involved. Results The findings indicated that physical activity interventions exhibit the potential to ameliorate relevant symptoms in children with ASD. Specifically, communication ability (SMD = 0.58, 95%CI: 0.28, 0.87, p>0.05) and social ability (SMD = 0.72, 95%CI: 0.43, 1.01, p<0.05) showed a moderate to large effect size. Large effect sizes were noted for motor ability (SMD = 2.06, 95%CI:1.15, 2.96, p0.05) exhibited a moderate effect size. Conclusions Our investigation demonstrates that physical activity exerts a constructive influence on augmenting communication, social, motor, and executive function capabilities in children with ASD. However, disparities in optimal effects observed across communication, social, motor, and executive functioning outcomes are contingent upon intervention duration, frequency, and period. physical activity exercise ASD children Meta-Analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 what is known The physical and psychological benefits of physical activity are well established. Previous meta-analyses have failed to demonstrate the impact of physical activity on the motor ability and characteristic impairments of children with ASD. what is new: Physical activity exerts a constructive influence on augmenting communication, social, motor, and executive function capabilities in children with ASD. Different differences determine different effects, disparities in optimal effects are contingent upon intervention duration, frequency, and period. 1 Introduction Autism Spectrum Disorder (ASD) is a neurobiological developmental disorder, characterized by a range of heterogeneous neurodevelopmental conditions[ 1 ]. Approximately 1 in 100 children worldwide is diagnosed with ASD[2; 3]. It is primarily diagnosed during childhood, with a relatively high prevalence[ 4 ]. ASD is characterized by a constellation of impairments primarily affecting four functional domains: social interaction, communication, motor coordination, and executive functioning. These characteristic impairments form the basis for clinical diagnosis and significantly impact the daily lives of children with ASD[5; 6]. Within the ASD population, the prevalence is higher in males compared to females, with an average male-to-female ratio of 4.3:1[ 7 ], and this gender difference is even more pronounced in childhood ASD cases, with a ratio of 4.7:1[ 8 ]. Furthermore, research indicates that children with ASD are more prone to obesity and overweight compared to typically developing peers[9; 10]. Research indicates that children with ASD often exhibit a range of challenges, ranging from mild to severe motor delays[ 11 ], difficulties in communication and social interaction[ 12 ], and impaired executive functioning[ 13 ]. These challenges persist into adolescence, representing obstacles in the developmental trajectory of Children with ASD, affecting their overall well-being, academic growth, and social integration. Autism begins in early childhood and continues throughout the lifespan, adding to the economic burden on families and society[ 14 ]. The primary symptomatic feature of children with ASD is impaired cognitive function, leading to difficulties in social communication and interaction. It is noteworthy that impaired facial recognition resulting from cognitive impairments can diminish the cooperative interaction abilities displayed by Children with ASD in games[ 15 ]. Given these circumstances, the treatment of children with ASD holds paramount significance. Conventional treatment approaches encompass pharmacotherapy, nutritional supplementation, special diets such as gluten-free diets, vitamin diets, and complementary and alternative methods like neurofeedback and acupuncture[ 16 ]. Among these, there is limited support for using medication to improve characteristic impairments of ASD[ 17 ], the efficacy of pharmacotherapy in improving social and communication difficulties in Children with ASD remains limited[ 18 ]. Physical activity as a fundamental element of development for children with autism has been widely studied[19; 20], As a non-pharmacological intervention, it has been proven to have a positive effect on improving functional impairments associated with ASD[ 21 ]. Physical activity (PA) is defined as any bodily movement that increases energy expenditure above resting levels, including occupational, sports, recreational, and other activities[ 22 ]. In some studies, physical activity interventions have been explored as an optional or adjunctive approach to ameliorate symptoms in Children with ASD[ 23 ]. Children can maintain their weight, promote bone health, increase cardiovascular activity, and prevent various chronic diseases (such as coronary heart disease and diabetes) through physical activity[ 12 ]. In contrast, as a non-pharmacological therapy for children with ASD, physical activity intervention has gained increasing recognition in recent years due to its relatively minimal side effects, economic feasibility, ease of implementation, and strong interactivity, effectively promoting both physical and mental well-being[11; 12]. Several studies have reported that physical activity is associated with improvements in social, psychological, and cognitive functioning in children with ASD[ 24 ]. Reinders et al. suggested that physical activity is a feasible intervention strategy for this population[ 25 ]. In a randomized controlled trial, Wang et al. found that a basketball-based program improved executive function and ASD-related impairments[ 26 ]. A recent meta-analysis indicated that programs lasting at least 12 weeks, conducted three or more times per week for 90 minutes or more, produced the greatest benefits[ 27 ]. Sánchez et al. demonstrated that various physical activities, such as games, swimming, yoga, and cycling, can enhance gait, balance, coordination, and motor skills[ 28 ]. Additional studies have also shown positive effects on social interaction, communication, and quality of life[ 29 ], as well as moderate improvements in executive functioning[ 30 – 32 ] and social behaviors[12; 25]. Previous meta-analyses have indicated that physical activity interventions demonstrate an overall moderate effect in individuals with ASD, with these interventions showing moderate to large positive impacts in areas related to health-related skills, social functioning, and endurance[ 33 ]. Furthermore, physical activity brings significant benefits to the motor and social abilities of individuals with ASD[ 34 ]. In early intervention programs, collaboration among pediatricians, child psychiatrists, speech therapists, and various therapeutic approaches is employed, with the inclusion of non-traditional methods such as equine-assisted therapy and music therapy[ 35 ], to broaden the scope of communication and social skill enhancement[ 16 ]. In summary, these research findings collectively suggest that physical activity can be an effective therapeutic option for individuals with ASD. However, most existing meta-analyses have combined data from both children and adults, potentially obscuring developmental stage-specific effects[34; 36]. Moreover, these reviews often focus on general outcomes rather than investigating the domain-specific effects of physical activity interventions, such as their impact on communication, social interaction, motor coordination, and executive functioning in children with ASD[ 33 ]. As a result, there remains a gap in understanding how physical activity affects different functional domains in pediatric ASD populations. Considering the rapid development and gradual maturation of children, as well as their unique physiological characteristics[ 37 ], there is a need for further exploration of the suitability of the timing, frequency, and duration of physical activity interventions targeting communication, social, motor, and executive function in children with ASD. This study aims to provide valuable insights into the selection of effective physical activity intervention measures to enhance these abilities in children with ASD by conducting a meta-analysis of randomized controlled trials involving physical activity interventions related to communication, social, motor, and executive function in Children with ASD. 2 Materials and methods 2.1 Protocol and Registration In accordance with the directives delineated in the Cochrane Handbook for Systematic Reviews, this Meta-analysis was undertaken. The outcomes were documented in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement[38; 39]. Additionally, the ongoing meta-analysis was preregistered in PROSPERO (CRD 42023434313). 2.2 Data Sources and Search Strategy An unrestricted search was conducted across four prominent databases, namely PubMed, Web of Science, Embase, and Cochrane Library, to comprehensively identify relevant studies. The search strategy was designed to encompass keywords related to physical activity interventions, age criteria, and outcomes pertinent to individuals with ASD, without any linguistic constraints. The selection of search terms for each core concept was informed by previous review methodologies and insights from experts in the field of exercise interventions[40; 41]. This systematic search endeavor persisted until November 2022 and underwent a second retrieval in March 2024. A comprehensive search strategy, as employed for PubMed, is outlined in Table 1 , while the retrieval strategies utilized for other databases can be accessed in Appendix A . Table 1 Search strategy on PubMed #1 " Autism Spectrum Disorders" #2 (((((((((((((((((Autistic Disorder) OR (Disorder, Autistic)) OR (Disorders, Autistic[Title/Abstract])) OR (Kanner's Syndrome[Title/Abstract])) OR (Kanner Syndrome[Title/Abstract])) OR (Kanners Syndrome[Title/Abstract])) OR (Autism, Infantile[Title/Abstract])) OR (Infantile Autism[Title/Abstract])) OR (Autism[Title/Abstract])) OR (Autism, Early Infantile[Title/Abstract])) OR (Early Infantile Autism[Title/Abstract])) OR (Infantile Autism, Early[Title/Abstract])) OR (Autism Spectrum Disorder[Title/Abstract])) OR (Autism Spectrum Disorders[Title/Abstract])) OR (Autistic Spectrum Disorder[Title/Abstract])) OR (Autistic Spectrum Disorders[Title/Abstract])) OR (Disorder, Autistic Spectrum[Title/Abstract]))) #3 #1 OR #2 #4 " Child " [MeSH] #5 ((Child[Title/Abstract]) OR (Children[Title/Abstract])) #6 #4 OR #5 #7 " Exercise " [MeSH] #8 ((((((((((((((((((((((((((Exercise[Title/Abstract]) OR (Exercises[Title/Abstract])) OR (Physical Activity[Title/Abstract])) OR (Activities, Physical[Title/Abstract])) OR (Activity, Physical[Title/Abstract])) OR (Physical Activities[Title/Abstract])) OR (Exercise, Physical[Title/Abstract])) OR (Exercises, Physical[Title/Abstract])) OR (Physical Exercise[Title/Abstract])) OR (Physical Exercises[Title/Abstract])) OR (Acute Exercise[Title/Abstract])) OR (Acute Exercises[Title/Abstract])) OR (Exercise, Acute[Title/Abstract])) OR (Exercises, Acute[Title/Abstract])) OR (Exercise, Isometric[Title/Abstract])) OR (Exercises, Isometric[Title/Abstract])) OR (Isometric Exercises[Title/Abstract])) OR (Isometric Exercise[Title/Abstract])) OR (Exercise, Aerobic[Title/Abstract])) OR (Aerobic Exercise[Title/Abstract])) OR (Aerobic Exercises[Title/Abstract])) OR (Exercises, Aerobic[Title/Abstract])) OR (Exercise Training[Title/Abstract])) OR (Exercise Trainings[Title/Abstract])) OR (Training, Exercise[Title/Abstract])) OR (Trainings, Exercise[Title/Abstract])))) #9 #7 OR #8 #10 #3 AND #6 AND #9 2.3 Study selection Two authors (CML and DL) autonomously evaluated the retrieved search outcomes and conducted a systematic screening of publications identified from the databases. The reference lists of the studies encompassed within this analysis were also examined. Initial screening involved evaluating the titles and abstracts of these studies to ascertain their pertinence. Following this, a comprehensive review of the full texts of the pertinent studies was conducted to ascertain their eligibility for inclusion. Any discrepancies that arose during the screening process were resolved through collaborative discussions within the research team. 2.4 Inclusion and exclusion criteria Studies were included if they met all of the following criteria: (1) The study design was a randomized controlled trial (RCT). (2) Participants were 18 years of age or younger. (3) All participants were formally diagnosed with ASD based on established diagnostic criteria, such as DSM-IV, DSM-5, ICD-10, or equivalent clinical assessments conducted by licensed professionals. (4) The intervention involved structured physical activity or exercise programs. (5) The study reported pre- and post-intervention outcomes relevant to communication, social interaction, motor skills, or executive function in children with ASD. (6) Sufficient raw or extractable data were available for effect size calculation. (7) The article was published in English. Studies were excluded if they met any of the following criteria: (1) The study design was observational (e.g., cross-sectional, case-control, or cohort studies). (2) Participants were older than 18 years of age. (3) Participants had comorbid conditions likely to confound the results, including severe intellectual disability, genetic syndromes (e.g., Rett syndrome), or uncontrolled medical/psychiatric conditions. (4) The intervention lacked detailed information on physical activity components or was combined with other interventions (e.g., pharmacological treatment or behavioral therapies) without isolating the effects of physical activity. (5) The study did not report relevant outcome measures or lacked sufficient data for quantitative synthesis. (6) The study presented ethical concerns such as lack of informed consent or inadequate participant protection. 2.5 Data Extraction The study included a total of 609 children with ASD, comprising 451 males (74%), 88 females (14%), and 70 individuals (11%) whose gender was not reported, aged between 3.5 and 15 years. All children in the intervention group received various forms of physical activity treatment, with each session lasting between 30 and 90 minutes, a frequency of 1 to 5 times per week, and a duration of 2 to 40 weeks. Children in the control group were placed on a waiting list or engaged in regular activities without participating in any physical activity or exercise. The study required outcome measures to include at least one of the following functional impairments associated with ASD: communication skills, social skills, motor skills, and executive function. It aimed to investigate the impact of physical activity interventions on these characteristic impairments in children with ASD. Studies without a control group or without reporting any intergroup comparison results were excluded. The data were entered into an Excel spreadsheet, and the included experimental data were independently extracted by two authors. Any discrepancies that emerged during the research procedure were resolved through collaborative discussions within the research team. The subsequent data were extracted from each of the studies: author(s), publication year, country, intervention specifics, participant characteristics, and relevant outcome indicators post-intervention. In cases where the post-intervention outcomes were presented graphically but lacked explicit numerical values, utilized engineering digitization software (Version4.5, https://automeris.io/WebPlotDigitizer/ ) was employed for data extraction. In the case of studies featuring multiple follow-up assessments, data were exclusively extracted immediately after the intervention. In cases where standard deviations were not furnished, they were computed from the 95% confidence interval for the average value within either the intervention or control group. To elucidate the impact of intervention dosages in terms of physical activity, we categorized intervention duration into "≥ 60 minutes" and "< 60 minutes", intervention frequency into "≥ 3 times per week" and " 10 weeks". 2.6 Quality Assessment Utilizing Review Manager 5.4 software and employing the Cochrane Risk of Bias tool, the quality of the studies incorporated in the analysis was evaluated through the examination of seven criteria: 1. Random sequence generation; 2. Allocation concealment; 3. Blinding of participants and personnel; 4. Blinding of outcome assessment; 5. Handling of incomplete outcome data; 6. Reporting of selective outcomes; and 7. Identification of other potential biases. 2.7 Statistical Analysis For both the title and abstract screening stages as well as the full-text screening stage, the agreement between raters was assessed using Cohen's kappa coefficient. The classification of agreement levels is as follows: fair agreement (0.40–0.59), moderate agreement (0.60–0.74), substantial agreement (> 0.75)[42; 43]. Given the included data, the standardized mean difference (SMD) along with its corresponding 95% confidence interval (CI) were computed. The interpretation of effect sizes followed conventional conventions, with SMD values falling into the small effect range (SMD = 0.2), medium effect range (SMD = 0.5), or large effect range (SMD = 0.8)[ 44 ]. We assessed the statistical heterogeneity between different trials using the Cochrane Q test and quantified it using the I 2 statistic. Levels of heterogeneity were categorized as low ( I 2 ≤ 25%), moderate (25%< I 2 ≤ 50%), substantial (50% 75%). Distinct effect models were chosen based on the degree of heterogeneity within the trial data. Considering the variations in the studies, a random effects model was used to minimize the heterogeneity in study design and outcome measures[ 45 ]. Subgroup analyses were conducted, stratified by categorical variables, encompassing the intervention duration, intervention frequency, and intervention period. This was undertaken to explore potential origins of heterogeneity. Symmetry testing was performed on funnel plots of outcome indicators to examine potential publication bias and the impact of small-study effects. The presence of publication bias was assessed using the Begg's rank correlation test and Egger's regression test, with a P-value threshold of p > 0.05 indicating no publication bias and p < 0.05 indicating the presence of publication bias. Additionally, we conducted trim-and-fill analysis (random-effects model) to assess publication bias and explore the need for additional studies to achieve a balanced funnel plot[46; 47]. Furthermore, sensitivity analyses were carried out through a stepwise exclusion of individual studies to evaluate the robustness of our study findings[ 48 ]. All analyses were performed using Stata 15.1 software with two-sided tests for all statistical analyses. 2.8 Certainty assessment The credibility of the findings is evaluated employing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, which furnishes guidelines for assessment, creation, and evaluation[ 49 ]. 3 Results 3.1 Trial Selection To ensure the precision of the systematic retrieval process, the search was conducted by two researchers (CML and DL) who are well-versed in the fields of ASD and exercise science. These researchers independently screened titles, abstracts, and full-text articles. In the initial electronic database search, a total of 3,281 citations were obtained. After excluding duplicate studies (n = 1044), 2,237 relevant articles were retained. Subsequently, following title and abstract screening, a total of 2,010 articles were excluded, resulting in 227 articles remaining for full-text review. During this phase, the inter-rater reliability between the two reviewers was deemed substantial (Cohen's kappa = 0.63). After an extensive full-text review, an additional 208 articles were excluded, with 115 of them lacking relevant outcome reporting,55 had inconsistent experimental designs, 17 lacked full-text availability, and 21 had unavailable data. Finally, we included 19 studies[26; 31; 50–66]for quantitative synthesis (Fig. 1). At this stage, the inter-rater reliability between the two reviewers was characterized as substantial (Cohen's kappa = 0.71). 3.2 Trial Characteristics Table 2 summarizes the characteristics of the 19 studies included in the analysis, all of which employed randomized controlled trial designs. The majority of studies originated from Iran, accounting for 7 out of the 19 publications. A total of 609 children with ASD were included, comprising 451 males (74%), 88 females (14%), and 70 participants (11%) whose gender was not reported. The intervention subjects involved in this study all met the diagnostic criteria for ASD and were excluded if they had one or more concurrent psychiatric disorders, severe behavioral problems, visual or auditory impairments, uncontrolled epileptic seizures, used posture-assistive devices and were confirmed to have neurological or musculoskeletal issues, or had documented allergic reactions. Among them, in 5 articles, the intervention subjects had no intellectual disabilities[50; 54; 56; 62; 66], in 13 articles, the presence or absence of intellectual disabilities in the intervention subjects was not described[26; 31; 51–53; 55; 57–61; 63; 64], and in 1 article, the intervention subjects had mild intellectual disabilities[65], with a majority being male and aged between 3.5 and 15 years old. The sample sizes of intervention groups ranged from 7 to 42 participants, totaling 339 children with ASD; control group sample sizes ranged from 8 to 25 participants, comprising 272 children with ASD. The age span for both the intervention and control groups encompassed individuals under 18 years of age. participants being included across the studies. All research adhered to standardized diagnostic criteria, specifically the Diagnostic and Statistical Manual of Mental Disorders (DSM), 4th or 5th edition. All physical activity interventions were conducted with the informed consent of parents or guardians. The duration of a single intervention ranged from 30 to 90 minutes; intervention frequencies spanned from once a week to five times a week; and intervention periods varied from 2 to 40 weeks. Children in the control group were placed on a waiting list or engaged in regular activities without participating in any physical activity or exercise. Measurement of communication abilities, social skills, motor ability, and executive functions commonly employed assessment tools such as the Gilliam Autism Rating Scale (GARS), Autism Diagnostic Observation Schedule (ADOS), Autism Treatment Evaluation Checklist (ATEC), Movement Assessment Battery for Children (MABC), Brininx-Oresetsky Test (BOT), Wisconsin Card Sorting Test (WCST), and Vineland Adaptive Behavior Scales (VABS). 3.3 Risk of bias Out of the 19 studies, 11 investigations[31; 50; 53; 56; 57; 59; 60; 63–66] (58%) exhibited low risk of bias concerning random sequence generation. Allocation concealment bias was considered low risk in 10 studies[31; 52; 53; 57; 58; 60; 62; 63; 65; 66] (53%). Additionally, 12 studies[26; 52; 54–56; 59; 60; 62–66] (63%) demonstrated low risk in terms of blinding of participants and personnel. Regarding blinding of outcome assessment, 9 studies[52; 54; 56–60; 63; 65] (47%) indicated low risk of bias. Among the included studies, 16[26; 31; 50–55; 57–64] (84%) presented low risk of bias regarding incomplete outcome data. Furthermore, 13 studies[31; 51–53; 57–65] (68%) displayed low risk of selective reporting bias. The presence of other biases remains unclear. Detailed assessments of bias outcomes for the included literature can be found in Fig. 2A and 2B. 3.4 Meta-analysis 3.4.1 The effects of physical activity on motor ability A total of 10 studies (including two different types of physical activity interventions in the Hassani study) elucidated the impact of physical activity on motor abilities in children with ASD, encompassing 212 diagnosed Children with ASD. As shown in Fig. 3, the overall effect indicated a large effect size (SMD = 2.06, 95%CI:1.15, 2.96, p<0.05) for physical activity interventions when compared to the control groups. This effect was characterized by considerable heterogeneity ( I 2 = 85.9%, p < 0.05). Subgroup analyses were conducted, and the results are presented in Table 3. Table 3 The subgroup analysis of the effect of physical activity interventions on motor ability Subgroup Cut-off Inclusion of literature Heterogeneity test SMD (95% CI) P I 2 % P Time ≥ 60 min 6 86.1 0.000 2.46 (1.15, 3.78) < 0.001** <60 min 4 87.2 0.000 1.59 (0.25, 2.93) 0.020* Frequency ≥ 3 weekly 3 77.0 0.013 1.33 (0.32, 2.35) 0.010** <3 weekly 7 89.1 0.000 2.60 (1.19, 4.10) 10 weeks 4 51.1 0.105 1.15 (0.49, 1.82) 0.001** ≤ 10 weeks 6 91.1 0.000 3.01 (1.35, 4.68) < 0.001** *: P ≤ 0.05; **: P ≤ 0.01; NI: no intervention; N/A: not applicable. 3.4.2 The effects of physical activity on communication ability A total of 6 studies elucidated the impact of physical activity on communication abilities in children with ASD, encompassing 227 diagnosed Children with ASD. As depicted in Fig. 4, the overall effect indicated a moderate to large effect size (SMD = 0.58, 95%CI: 0.28, 0.87, p>0.05) for physical activity interventions when compared to the control groups. This effect was characterized by low heterogeneity ( I 2 = 17.8%, p>0.05). Subgroup analyses were conducted, and the results are presented in Table 4. Table 4 The subgroup analysis of the effect of physical activity interventions on communication ability Subgroup Cut-off Inclusion of literature Heterogeneity test SMD (95% CI) P I 2 % P Time ≥ 60 min 3 00.0 0.756 0.85 (0.48, 1.23) < 0.001** <60 min 3 00.0 0.553 0.28 (-0.11, 0.67) 0.155 Frequency ≥ 3 weekly 2 17.0 0.272 0.33 (-0.24, 0.90) 0.257 10 weeks 5 00.0 0.454 0.66 (0.37, 0.95) 0.000** ≤ 10 weeks 1 N/A N/A 0.04 (-0.69, 0.77) 0.914 *: P ≤ 0.05; **: P ≤ 0.01; NI: no intervention; N/A: not applicable. 3.4.3 The effects of physical activity on social ability A total of 12 studies elucidated the impact of physical activity on social ability in children with ASD, encompassing 370 diagnosed Children with ASD. As depicted in Fig. 5, the overall effect indicated a moderate to large effect size (SMD = 0.72, 95%CI: 0.43, 1.01, p0.05). Subgroup analyses were conducted, and the results are presented in Table 5. Table 5 The subgroup analysis of the effect of physical activity interventions on social ability Subgroup Cut-off Inclusion of literature Heterogeneity test SMD (95% CI) P I 2 % P Time ≥ 60 min 6 46.4 0.097 1.06 (0.61, 1.50) < 0.001** <60 min 6 0.00 0.783 0.41 (0.12, 0.71) 0.005** Frequency ≥ 3 weekly 4 13.4 0.326 0.71 (0.30, 1.11) < 0.001** <3 weekly 8 56.5 0.024 0.73 (0.32, 1.14) 10 weeks 7 0.00 0.528 0.65 (0.39, 0.91) < 0.001** ≤ 10 weeks 5 71.7 0.007 0.72 (0.43, 1.01) 0.019* *: P ≤ 0.05; **: P ≤ 0.01; NI: no intervention; N/A: not applicable. 3.4.4 The effects of physical activity on executive function A total of 13 studies (including two different types of physical activity interventions in the studies by TSE and Milajerdi) elucidated the impact of physical activity on executive function abilities in children with ASD, encompassing 204 diagnosed Children with ASD. As depicted in Fig. 6, the overall effect indicated a small to medium effect size (SMD = 0.46, 95%CI:0.23, 0.69, p>0.05) for physical activity interventions when compared to the control groups. This effect was characterized by moderate heterogeneity ( I 2 = 37.5%, p>0.05). Subgroup analyses were conducted, and the results are presented in Table 6. Table 6 The subgroup analysis of the effect of physical activity interventions on executive function Subgroup Cut-off Inclusion of literature Heterogeneity test SMD (95% CI) P I 2 % P Time ≥ 60 min 8 57.3 0.022 0.51 (0.14, 0.87) 0.006** <60 min 5 0.00 0.607 0.40 (0.12, 0.69) 0.006** Frequency ≥ 3 weekly 11 27.5 0.183 0.38 (0.15, 0.60) 0.001** <3 weekly 2 00.0 0.491 1.09 (0.49, 1.70) 10 weeks 3 00.0 0.548 0.92 (0.46, 1.38) < 0.001** ≤ 10 weeks 10 30.6 0.164 0.35 (0.11, 0.59) 0.004** *: P ≤ 0.05; **: P ≤ 0.01; NI: no intervention; N/A: not applicable. 3.5 Publication bias We employed funnel plots to assess potential publication bias. As depicted in Fig. 7, the funnel plot for the motor ability outcome exhibited some asymmetry, with certain studies dispersed towards the right upon visual inspection, while other outcomes displayed a generally symmetric pattern. This asymmetry suggested the possibility of publication bias in the motor ability outcome. Subsequently, we conducted Begg's rank correlation and Egger's regression tests to investigate publication bias. The results indicated statistically significant bias for the motor ability outcome (p = 0.016 and p = 0.013, respectively). Additionally, a trim and fill analysis (random-effects model) was conducted to assess publication bias for the motor ability outcome. The results indicated "no trimming," suggesting the absence of bias detection (see Supplementary Appendix B1). Furthermore, sensitivity analysis was performed by iteratively excluding individual studies, revealing no significant impact on the overall results (see Supplementary Appendix B2). 3.6 Certainty assessment results According to the grading approach, detailed results are presented in Table 7. Table 7 GRADE Certainty assessment № of patients Effect Importance № of studies Study design Risk of bias Inconsistency Indirectness Imprecision EG CG Absolute (95% CI) Communication ability 6 randomised trials not serious serious not serious not serious 79 87 SMD 0.58 (0.28 to 0.87) CRITICAL Social ability 12 randomised trials not serious serious not serious not serious 192 180 SMD 0.72 (0.43 to 1.01) CRITICAL Motor ability 9 randomised trials serious serious not serious not serious 111 101 SMD 2.06 (1.15 to 2.96) IMPORTANT Executive function 5 randomised trials not serious serious not serious not serious 124 79 SMD 0.46 (0.23 to 0.69) CRITICAL EG: experimental group; CG: control group; CI: confidence interval; SMD: standardised mean difference 4 Discussion 4.1 Main results We conducted a systematic review and meta-analysis of 19 randomized controlled trials to investigate the effects of physical activity interventions on communication ability, social ability, motor ability, and executive function in children with ASD. Our findings reveal a generally moderate to large positive impact of physical activity interventions on the aforementioned domains for Children with ASD. Specifically, the optimal forms of physical activity interventions for achieving the best intervention outcomes are as shown in Table 8 , it can be observed that the optimal single intervention duration for all four measures is 60 minutes or more. The intervention frequency is less than three times per week for all measures. Regarding the intervention period, except for motor skills (10 sessions or fewer), the optimal design for improving or enhancing motor skills, communication skills, social skills, and executive function in children with ASD involves a physical activity intervention lasting 10 weeks or more. Table 8 The optimal form of physical activity intervention for the best outcomes in each measure Indicator Time (min) Frequency (weekly) Duration (weeks) Motor ability ≥ 60 <3 ≤ 10 Communication ability ≥ 60 10 Social ability ≥ 60 10 Executive function ≥ 60 10 Time: single intervention time; Frequency: number of interventions per week; Duration: total intervention period 4.2 Comparison with existing literature We further explored the communication ability, social ability, motor ability, and executive function of children with ASD, extending the scope of previous research on physical activity interventions in ASD populations. In line with earlier studies, our investigation aligns with positive effects associated with physical activity interventions. Physical activity has been shown to contribute to the enhancement of participants' communication ability[ 67 ], social ability[ 68 ], motor ability[ 69 ], and executive function[ 70 ]. Stress, emotions, and social interactions are closely linked to executive function[71; 72], yielding in a multitude of advantageous outcomes across physiological, psychological, and neurocognitive domains. These include reductions in stress, alleviation of anxiety, mitigation of depression, and attenuation of negative emotions[ 73 – 76 ]. Furthermore, physical activity interventions exhibit a certain level of symptom improvement in ASD patients. Previous research has indicated that prolonged engagement in physical activity among individuals with ASD leads to improvements in core symptoms, including enhancement of mental and physical well-being[ 34 ], heightened health-related proficiency[ 77 ], augmented social skills[ 78 ], improved motor ability[ 79 – 81 ], and reduced occurrence of repetitive behaviors[ 82 ]. Some studies have reported that exercise or physical activity is beneficial for improving the physical condition and cognitive status of children with ASD[ 31 ]. Several studies have demonstrated the beneficial effects of physical activity on various functional domains in children with ASD. For example, Homa et al. (2021) reported improvements in motor abilities and executive function following movement-based interventions[ 64 ]. Harris et al. (2017) observed enhancements in social functioning through equine-assisted programs[ 55 ]. Similarly, Zhao et al. (2018) found that structured physical activity significantly improved communication and social interaction skills in children with ASD[ 61 ]. Siskova et al. also reported that a 12-session exercise program led to notable gains in motor coordination and object control, with potential long-term benefits[ 28 ]. Consequently, multiple studies suggest beneficial effects of physical activity on enhancing the communication ability, social ability, motor ability, and executive function of children with ASD. However, further research is warranted to explore potential benefits in other dimensions within this population. Our study conducted a subgroup analysis, which provided additional information and valuable contributions to this field by identifying the most appropriate single intervention duration, weekly intervention frequency, and total intervention period for improving or enhancing motor skills, communication skills, social skills, and executive function in children with ASD. However, the different outcome measurement tools for various indicators (motor skills, communication skills, social skills, and executive function) resulted in varying differences, which may be a contributing factor to the heterogeneity in the results of this meta-analysis. We chose the standardized mean difference (SMD) as the effect size to minimize the differences in measurement instruments and units[ 83 ]. Applying standardized assessment tools in future research can improve the reliability and consistency of the results. 4.3 Mechanisms of physical activity in children with ASD Physical activity serves as a neuroenhancer, exerting acute and long-term effects on monoaminergic transmission, neural trophic signaling, and neuroplasticity mechanisms to enhance cognitive capacities[ 84 ]. Furthermore, physical exercise constitutes a cognitive demand, continuously challenging essential higher-order cognitive processes[70; 85], inducing changes in cognitive functionality[86; 87]. Evidence indicates that exercise interventions can successfully activate brain networks in children with ASD[ 88 – 91 ]. Previous research data have shown aberrations in the cerebellum of individuals with ASD, including impaired Purkinje and granule neurons, and deficits in the posterior hemisphere and vermis[ 92 ]. Appropriate physical activity, encompassing skill acquisition, motor control, and social engagement, can positively influence improvements in cortical, subcortical, and cerebellar functions. Brain-derived neurotrophic factor (BDNF) is considered a critical factor in various neurodevelopmental disorders (e.g., autism, Rett syndrome) and neurodegenerative diseases (e.g., Huntington's disease, Alzheimer's disease, and Parkinson's disease), with its levels closely associated with the severity of symptoms in Children with ASD[ 93 ]. In the context of physical activity interventions, prior research has indicated that exercise can modulate the regulation of BDNF[ 94 ]. Thus, physical activity exhibits a degree of enhancement in communication ability, social ability, motor ability, and executive function in children with ASD. 4.4 Discussion of subgroup analysis results Our subgroup analysis revealed that physical activity interventions timing, frequency, and duration of physical activity interventions for enhancing communication ability, social ability, motor ability, and executive function in children with ASD, our study uncovered a dose-response relationship between physical activity and executive function benefits. Notably, greater intervention duration, frequency, and cycle length do not necessarily yield more positive effects. There exists an optimal intervention range beyond which the positive effects of physical activity might diminish. This phenomenon aligns with the "Exercise is Medicine" (EIM) concept presented by the American College of Sports Medicine (ACSM), wherein the dose of exercise and its positive effects do not always exhibit a linear correlation, resembling the dose-response relationship seen in medication treatments[95; 96]. Our subgroup analysis reveals that for improvements in communication skills, social abilities, motor skills, and executive functions in children with ASD, intervention doses with a duration of 60 minutes or more per session and a frequency of three times or less per week are most suitable. Literature reports indicate that children and adolescents should engage in moderate to vigorous physical activity for most of the day, with each session lasting 60 minutes or more[ 97 ]. However, almost all studies focusing on the impact of physical activity on children's cognitive performance have been conducted at moderate to high intensities[ 40 ]. Therefore, considering the individual variations among ASD subtypes, gender differences, and comorbidities is essential when designing precise interventions tailored to achieve optimal therapeutic outcomes. In this study, there were only 88 girls, which can be explained by the lower participation rate of females in the intervention group due to the higher prevalence of autism in boys, where every 4 to 8 male participants correspond to 1 female participant[ 98 ]. In conclusion, physical activity exhibits a positive impact on enhancing communication ability, social ability, motor ability, and executive function in children with ASD. However, the efficacy of physical activity interventions varies based on intervention timing, frequency, and duration. In general, physical activity represents an effective non-pharmacological intervention measure for enhancing communication ability, social ability, motor ability, and executive function in children with ASD. 4.5 Strengths and limitations Our study has several strengths. Firstly, by including only randomized controlled trials and excluding observational and cross-sectional studies, we enhanced the reliability of our study outcomes. Secondly, our focus on the developmental stages of Children with ASD below 18 years allowed for more targeted and precise interventions. Lastly, our study provides valuable insights into the selection of physical activity therapies for enhancing communication ability, social ability, motor ability, and executive function in children with ASD. However, there are limitations to our meta-analysis that may influence the interpretation of our findings. Firstly, the relatively limited pool of studies meeting the statistical robustness and the vigor of our assertions. Secondly, the scarcity of data available for subgroup analyses could potentially influence the outcomes of the study. Thirdly, the preponderance of male participants in the analysis precludes an evaluation of potential gender disparities. Lastly, due to the limited number of studies included, caution is needed in interpreting our results, and additional research is imperative to furnish more robust evidence. 4.6 Implications and Future Research Taking into consideration the current body of research, prospective investigators can contemplate the following avenues within the scope of future endeavors. Firstly, precise interventions tailored to diverse age groups warrant exploration. Given the rapid developmental trajectory observed in children, it is imperative to acknowledge the influence of age-related disparities and select appropriate physical intervention strategies suited to distinct age brackets among ASD-afflicted juveniles. Secondly, a concerted effort towards efficacious interventions addressing comorbidity phenomena merits attention. Given the prevalent co-occurrence of comorbidities with ASD, encompassing conditions such as ADHD and depression, clinical populations of ASD commonly exhibit overlapping ailments. Notably, extant studies indicate a comorbidity prevalence ranging from 40–70% between ASD and ADHD[ 99 – 103 ]. This profusion of comorbid instances presents a formidable challenge in terms of diagnostic differentiation and treatment. Consequently, intervention strategies should consider latent comorbidities and encompass a spectrum of physical activities capable of addressing multifarious comorbid conditions. Thirdly, it is noteworthy that the majority of intervention samples in this Meta-analysis derive from male subjects, resulting in a skewed gender proportion. Acknowledging the influences of gender disparities, along with the effects of relative introversion and cultural milieu, the likelihood of underdiagnoses and inadequate treatment for females demands recognition[ 104 ]. Hence, future research endeavors should be attuned to gender variations, particularly focusing on physical activity interventions tailored for ASD-afflicted females. Fourthly, the diverse array of physical activities encompasses a wide spectrum of intervention outcomes, evincing substantial disparities in their efficacy. Subsequent investigations might involve comparative analyses across distinct physical activity modalities, elucidating differential therapeutic impacts therein. Lastly, there emerges the potential of network-based collaborative interventions. Leveraging the convenience and cost-effectiveness inherent to combined network interventions holds promise in circumventing spatial and economic constraints, thereby fostering enhanced participation among a broader demographic of individuals within the ASD population. 5 Conclusion Our investigation demonstrates that physical activity has a positive impact on improving communication, social interaction, motor skills, and executive functioning in children with ASD. These findings highlight the overall therapeutic value of physical activity as a non-pharmacological intervention for this population. While the specific effects may be influenced by factors such as intervention duration, frequency, and total period, this study did not compare different physical activity modalities. Therefore, future research is needed to explore the relative effectiveness of various activity types through direct comparisons. Prior to implementation, individual characteristics such as age, gender, and symptom profile should also be carefully evaluated to optimize intervention outcomes. Abbreviations ASD (Autism Spectrum Disorder) RCTs (randomized controlled trials) PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) SMD (Standardized Mean Difference) CI (confidence interval) Declarations Author Contributions All authors contributed to the study conception and design. CML and DL conceived and designed the study. CML and DL collected the data. CML, WLC, HLP, TZ and XCL analyzed and interpreted the data. CML, HLP and DL drafted the manuscript. CML, WLC and DL revised the manuscript. All authors have read and agreed to the published version of the manuscript. Data Availability Statement All datasets generated for this study are included in the article/supplementary material. Ethics approval Not applicable. Consent to participate Not applicable. Consent to publish Not applicable. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding This research was funded by the National Social Science Foundation of China (23BTY121) References Bandelow B, Schmahl C, Falkai P, Wedekind D, Crockett C, Sackett G, Sandman C, Chicz-DeMet A, Benson KJEoO, Behaviors GRPiRMES-I (2017) American Psychiatric Association. DSM-5 Task Force.(2013). Diagnostic and statistical manual of mental disorders: Dsm-5 . Washington, DC: American Psychiatric Association. Bachevalier, J., Meunier, M., Lu, MX, & Ungerleider, LG (1997). Thalamic and temporal cortex input to medial prefrontal cortex in rhesus monkeys. Exp Brain Res, 115 (3). 100:11 Ahmed F (2022) Delphi Consensus on Role of Physiotherapy Interventions in Autism Spectrum Disorder (ASD). Bangladesh Health Professions Institute, Faculty of Medicine, the University …, Zeidan J, Fombonne E, Scorah J, Ibrahim A, Durkin MS, Saxena S, Yusuf A, Shih A, Elsabbagh MJAr (2022) Global prevalence of autism: A systematic review update. 15:778-790 Teh EJ, Vijayakumar R, Tan TXJ, Yap MJJJoA, Disorders D (2021) Effects of physical exercise interventions on stereotyped motor behaviours in children with ASD: a meta-analysis.1-24 Levenson JL (2018) The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. American Psychiatric Pub Lord C, Elsabbagh M, Baird G, Veenstra-Vanderweele JJTl (2018) Autism spectrum disorder. 392:508-520 Lyall K, Croen L, Daniels J, Fallin MD, Ladd-Acosta C, Lee BK, Park BY, Snyder NW, Schendel D, Volk HJAroph (2017) The changing epidemiology of autism spectrum disorders. 38:81-102 Nordahl CWJAR (2023) Why do we need sex‐balanced studies of autism? 16:1662-1669 Kummer A, Barbosa IG, Rodrigues DH, Rocha NP, Rafael MdS, Pfeilsticker L, Silva ACS, Teixeira ALJRPdP (2016) Frequency of overweight and obesity in children and adolescents with autism and attention deficit/hyperactivity disorder. 34:71-77 McCoy SM, Jakicic JM, Gibbs BBJJoa, disorders d (2016) Comparison of obesity, physical activity, and sedentary behaviors between adolescents with autism spectrum disorders and without. 46:2317-2326 Reinders NJ, Branco A, Wright K, Fletcher PC, Bryden PJJFip (2019) Scoping review: Physical activity and social functioning in young people with autism spectrum disorder. 10:120 Chan JS, Deng K, Yan JHJA (2021) The effectiveness of physical activity interventions on communication and social functioning in autistic children and adolescents: A meta-analysis of controlled trials. 25:874-886 Craig F, Margari F, Legrottaglie AR, Palumbi R, De Giambattista C, Margari LJNd, treatment (2016) A review of executive function deficits in autism spectrum disorder and attention-deficit/hyperactivity disorder.1191-1202 Zheng Z, Zhang L, Li S, Zhao F, Wang Y, Huang L, Huang J, Zou R, Qu Y, Mu DJSR (2017) Association among obesity, overweight and autism spectrum disorder: a systematic review and meta-analysis. 7:11697 Ludyga S, Gerber M, Bruggisser F, Leuenberger R, Brotzmann M, Trescher S, Förster M, Zou L, Herbrecht E, Hanke MJAR (2023) A randomized cross‐over trial investigating the neurocognitive effects of acute exercise on face recognition in children with autism spectrum disorder. Sefen JAN, Al-Salmi S, Shaikh Z, AlMulhem JT, Rajab E, Fredericks SJFibn (2020) Beneficial use and potential effectiveness of physical activity in managing autism spectrum disorder. 14:587560 McPheeters ML, Warren Z, Sathe N, Bruzek JL, Krishnaswami S, Jerome RN, Veenstra-VanderWeele JJP (2011) A systematic review of medical treatments for children with autism spectrum disorders. 127:e1312-e1321 Kaplan G, McCracken JTJPc (2012) Psychopharmacology of autism spectrum disorders. 59:175-187 Srinivasan SM, Pescatello LS, Bhat ANJPt (2014) Current perspectives on physical activity and exercise recommendations for children and adolescents with autism spectrum disorders. 94:875-889 Pitetti KH, Rendoff AD, Grover T, Beets MWJJoa, disorders d (2007) The efficacy of a 9-month treadmill walking program on the exercise capacity and weight reduction for adolescents with severe autism. 37:997-1006 Toscano CV, Barros L, Lima AB, Nunes T, Carvalho HM, Gaspar JMJN, Reviews B (2021) Neuroinflammation in autism spectrum disorders: Exercise as a “pharmacological” tool. 129:63-74 Belcher BR, Zink J, Azad A, Campbell CE, Chakravartti SP, Herting MMJBpCn, neuroimaging (2021) The roles of physical activity, exercise, and fitness in promoting resilience during adolescence: effects on mental well-being and brain development. 6:225-237 Neely L, Rispoli M, Gerow S, Ninci JJBm (2015) Effects of antecedent exercise on academic engagement and stereotypy during instruction. 39:98-116 Poitras VJ, Gray CE, Borghese MM, Carson V, Chaput J-P, Janssen I, Katzmarzyk PT, Pate RR, Connor Gorber S, Kho MEJAp, nutrition,, metabolism (2016) Systematic review of the relationships between objectively measured physical activity and health indicators in school-aged children and youth. 41:S197-S239 Reinders NJ, Branco A, Wright K, Fletcher PC, Bryden PJJFip (2019) Scoping review: Physical activity and social functioning in young people with autism spectrum disorder. 10:412065 Wang J-G, Cai K-L, Liu Z-M, Herold F, Zou L, Zhu L-N, Xiong X, Chen A-GJBs (2020) Effects of mini-basketball training program on executive functions and core symptoms among preschool children with autism spectrum disorders. 10:263 Wang S, Chen D, Yang Y, Zhu L, Xiong X, Chen AJAR (2023) Effectiveness of physical activity interventions for core symptoms of autism spectrum disorder: A systematic review and meta‐analysis. 16:1811-1824 Castaño PRL, Suárez DPM, González ER, Robledo-Castro C, Hederich-Martínez C, Cadena HPG, Vargas PAS, Montenegro LCGJJoA, Disorders D (2023) Effects of physical exercise on gross motor skills in children with autism spectrum disorder.1-10 Iliadis I, Apteslis NJDiCN, Health M (2020) The role of physical education and exercise for children with Autism Spectrum Disorder and the effects on socialization, communication, behavior, fitness, and quality of life. 3:71-81 Phung JN, Goldberg WAJJoa, disorders d (2019) Promoting executive functioning in children with autism spectrum disorder through mixed martial arts training. 49:3669-3684 Pan C-Y, Chu C-H, Tsai C-L, Sung M-C, Huang C-Y, Ma W-YJA (2017) The impacts of physical activity intervention on physical and cognitive outcomes in children with autism spectrum disorder. 21:190-202 Sung M-C, Ku B, Leung W, MacDonald MJJoa, disorders d (2022) The effect of physical activity interventions on executive function among people with neurodevelopmental disorders: A meta-analysis. 52:1030-1050 Healy S, Nacario A, Braithwaite RE, Hopper CJAR (2018) The effect of physical activity interventions on youth with autism spectrum disorder: A meta‐analysis. 11:818-833 Sowa M, Meulenbroek RJRiasd (2012) Effects of physical exercise on autism spectrum disorders: A meta-analysis. 6:46-57 Wong C, Odom SL, Hume KA, Cox AW, Fettig A, Kucharczyk S, Brock ME, Plavnick JB, Fleury VP, Schultz TRJJoa, disorders d (2015) Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. 45:1951-1966 Lang R, Koegel LK, Ashbaugh K, Regester A, Ence W, Smith WJRiASD (2010) Physical exercise and individuals with autism spectrum disorders: A systematic review. 4:565-576 Janssen I, LeBlanc AGJIjobn, activity p (2010) Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. 7:1-16 Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (2019) Cochrane handbook for systematic reviews of interventions. John Wiley & Sons Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SEJIjos (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. 88:105906 De Greeff JW, Bosker RJ, Oosterlaan J, Visscher C, Hartman EJJos, sport mi (2018) Effects of physical activity on executive functions, attention and academic performance in preadolescent children: a meta-analysis. 21:501-507 Xue Y, Yang Y, Huang TJBjosm (2019) Effects of chronic exercise interventions on executive function among children and adolescents: a systematic review with meta-analysis. 53:1397-1404 Sim J, Wright CCJPt (2005) The kappa statistic in reliability studies: use, interpretation, and sample size requirements. 85:257-268 Vickers NJJCb (2017) Animal communication: when i’m calling you, will you answer too? 27:R713-R715 Higgins JP, Thompson SG, Deeks JJ, Altman DGJB (2003) Measuring inconsistency in meta-analyses. 327:557-560 Li D, Li L, Zang W, Wang D, Miao C, Li C, Zhou L, Yan J (2023) Effect of physical activity on attention in school-age children with ADHD: a systematic review and meta-analysis of randomized controlled trials. Frontiers in Physiology 14 Duval S, Tweedie R (2000) Trim and fill: a simple funnel‐plot–based method of testing and adjusting for publication bias in meta‐analysis. Biometrics 56:455-463 Egger M, Smith GD, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. Bmj 315:629-634 Khera R, Murad MH, Chandar AK, Dulai PS, Wang Z, Prokop LJ, Loomba R, Camilleri M, Singh SJJ (2016) Association of pharmacological treatments for obesity with weight loss and adverse events: a systematic review and meta-analysis. 315:2424-2434 Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris SJJoce (2011) GRADE guidelines: 3. Rating the quality of evidence. 64:401-406 Pan C-YJA (2010) Effects of water exercise swimming program on aquatic skills and social behaviors in children with autism spectrum disorders. 14:9-28 Pan C-YJRiASD (2011) The efficacy of an aquatic program on physical fitness and aquatic skills in children with and without autism spectrum disorders. 5:657-665 Lanning BA, Baier MEM, Ivey-Hatz J, Krenek N, Tubbs JDJJoa, disorders d (2014) Effects of equine assisted activities on autism spectrum disorder. 44:1897-1907 Bahrami F, Movahedi A, Marandi SM, Sorensen CJJoa, disorders d (2016) The effect of karate techniques training on communication deficit of children with autism spectrum disorders. 46:978-986 Borgi M, Loliva D, Cerino S, Chiarotti F, Venerosi A, Bramini M, Nonnis E, Marcelli M, Vinti C, De Santis CJJoa, disorders d (2016) Effectiveness of a standardized equine-assisted therapy program for children with autism spectrum disorder. 46:1-9 Harris A, Williams JMJIjoer, health p (2017) The impact of a horse riding intervention on the social functioning of children with autism spectrum disorder. 14:776 Sotoodeh MS, Arabameri E, Panahibakhsh M, Kheiroddin F, Mirdoozandeh H, Ghanizadeh AJCTiCP (2017) Effectiveness of yoga training program on the severity of autism. 28:47-53 Zachor DA, Vardi S, Baron‐Eitan S, Brodai‐Meir I, Ginossar N, Ben‐Itzchak EJDM, Neurology C (2017) The effectiveness of an outdoor adventure programme for young children with autism spectrum disorder: a controlled study. 59:550-556 Caputo G, Ippolito G, Mazzotta M, Sentenza L, Muzio MR, Salzano S, Conson MJJoa, disorders d (2018) Effectiveness of a multisystem aquatic therapy for children with autism spectrum disorders. 48:1945-1956 Coman DC, Bass MP, Alessandri M, Ghilain CS, Llabre MMJs, animals (2018) Effect of equine-assisted activities on social and sensory functioning of children with autism. 26:551-575 Najafabadi MG, Sheikh M, Hemayattalab R, Memari A-H, Aderyani MR, Hafizi SJP, Neonatology (2018) The effect of SPARK on social and motor skills of children with autism. 59:481-487 Zhao M, Chen SJBri (2018) The effects of structured physical activity program on social interaction and communication for children with autism. 2018 Arabi M, Kakhki AS, Sohrabi M, Kouhbanani SS, Nooghabi MJJND, Treatment (2019) Is visuomotor training an effective intervention for children with autism spectrum disorders? 15:3089 Sarabzadeh M, Azari BB, Helalizadeh MJJob, therapies m (2019) The effect of six weeks of Tai Chi Chuan training on the motor skills of children with Autism Spectrum Disorder. 23:284-290 Rafiei Milajerdi H, Sheikh M, Najafabadi MG, Saghaei B, Naghdi N, Dewey DJGfhj (2021) The effects of physical activity and exergaming on motor skills and executive functions in children with autism spectrum disorder. 10:33-42 TSE AC, Anderson DI, Liu VH, Tsui SSJM, Sports Si, Exercise (2021) Improving executive function of children with autism spectrum disorder through cycling skill acquisition. 53:1417-1424 Hassani F, Shahrbanian S, Shahidi SH, Sheikh MJIJoDD (2022) Playing games can improve physical performance in children with autism. 68:219-226 Brunner DL, Seung HJCDQ (2009) Evaluation of the efficacy of communication-based treatments for autism spectrum disorders: A literature review. 31:15-41 Ward SC, Whalon K, Rusnak K, Wendell K, Paschall NJJoa, disorders d (2013) The association between therapeutic horseback riding and the social communication and sensory reactions of children with autism. 43:2190-2198 Casey AF, Quenneville-Himbeault G, Normore A, Davis H, Martell SGJPPT (2015) A therapeutic skating intervention for children with autism spectrum disorder. 27:170-177 Best JRJDr (2010) Effects of physical activity on children’s executive function: Contributions of experimental research on aerobic exercise. 30:331-351 Moriguchi YJFip (2014) The early development of executive function and its relation to social interaction: a brief review. 5:388 Shields GS, Sazma MA, Yonelinas APJN, Reviews B (2016) The effects of acute stress on core executive functions: A meta-analysis and comparison with cortisol. 68:651-668 Tsatsoulis A, Fountoulakis SJAotNYAoS (2006) The protective role of exercise on stress system dysregulation and comorbidities. 1083:196-213 McKercher CM, Schmidt MD, Sanderson KA, Patton GC, Dwyer T, Venn AJJAjopm (2009) Physical activity and depression in young adults. 36:161-164 Garcia D, Archer T, Moradi S, Andersson-Arntén A-CJP (2012) Exercise frequency, high activation positive affect, and psychological well-being: beyond age, gender, and occupation. 3:328 Diamond A, Ling DSJDcn (2016) Conclusions about interventions, programs, and approaches for improving executive functions that appear justified and those that, despite much hype, do not. 18:34-48 Bremer E, Cairney JJJoA, Disorders D (2020) Adaptive behavior moderates health-related pathways in children with autism spectrum disorder. 50:491-499 Keino H, Funahashi A, Keino H, Miwa C, Hosokawa M, Hayashi Y, Kawakita KJJoes (2009) Psycho-educational horseback riding to facilitate communication ability of children with pervasive developmental disorders. 20:79-88 Wuang Y-P, Wang C-C, Huang M-H, Su C-YJAPAQ (2010) The effectiveness of simulated developmental horse-riding program in children with autism. 27:113-126 Lloyd M, MacDonald M, Lord CJA (2013) Motor skills of toddlers with autism spectrum disorders. 17:133-146 Bremer E, Balogh R, Lloyd MJA (2015) Effectiveness of a fundamental motor skill intervention for 4-year-old children with autism spectrum disorder: A pilot study. 19:980-991 Liu T, Fedak AT, Hamilton M (2016) Effect of physical activity on the stereotypic behaviors of children with autism spectrum disorder. Higgins JPJhwc-ho (2008) Cochrane handbook for systematic reviews of interventions version 5.0. 1. The Cochrane Collaboration. Hillman CH, Erickson KI, Kramer AFJNrn (2008) Be smart, exercise your heart: exercise effects on brain and cognition. 9:58-65 Pesce CJJoS, Psychology E (2012) Shifting the focus from quantitative to qualitative exercise characteristics in exercise and cognition research. 34:766-786 Diamond AJAosm, research (2015) Effects of physical exercise on executive functions: going beyond simply moving to moving with thought. 2:1011 Schmidt M, Jäger K, Egger F, Roebers CM, Conzelmann AJJoS, Psychology E (2015) Cognitively engaging chronic physical activity, but not aerobic exercise, affects executive functions in primary school children: a group-randomized controlled trial. 37:575-591 Srinivasan SM, Bhat ANJFiin (2013) A review of “music and movement” therapies for children with autism: embodied interventions for multisystem development. 7:22 Srinivasan SM, Kaur M, Park IK, Gifford TD, Marsh KL, Bhat ANJAr, treatment (2015) The effects of rhythm and robotic interventions on the imitation/praxis, interpersonal synchrony, and motor performance of children with autism spectrum disorder (ASD): a pilot randomized controlled trial. 2015 Srinivasan SM, Park IK, Neelly LB, Bhat ANJRiasd (2015) A comparison of the effects of rhythm and robotic interventions on repetitive behaviors and affective states of children with Autism Spectrum Disorder (ASD). 18:51-63 Srinivasan SM, Eigsti I-M, Gifford T, Bhat ANJRiasd (2016) The effects of embodied rhythm and robotic interventions on the spontaneous and responsive verbal communication skills of children with Autism Spectrum Disorder (ASD): A further outcome of a pilot randomized controlled trial. 27:73-87 Fournier KA, Hass CJ, Naik SK, Lodha N, Cauraugh JHJJoa, disorders d (2010) Motor coordination in autism spectrum disorders: a synthesis and meta-analysis. 40:1227-1240 Kasarpalkar NJ, Kothari ST, Dave UPJAon (2014) Brain-derived neurotrophic factor in children with autism spectrum disorder. 21:129 Langdon KD, Corbett DJN, repair n (2012) Improved working memory following novel combinations of physical and cognitive activity. 26:523-532 Lobelo F, Stoutenberg M, Hutber AJBjosm (2014) The exercise is medicine global health initiative: a 2014 update. 48:1627-1633 Thompson WR, Sallis R, Joy E, Jaworski CA, Stuhr RM, Trilk JLJAjolm (2020) Exercise is medicine. 14:511-523 Pan C-Y, Tsai C-L, Chu C-H, Sung M-C, Ma W-Y, Huang C-YJPt (2016) Objectively measured physical activity and health-related physical fitness in secondary school-aged male students with autism spectrum disorders. 96:511-520 Olin SS, McFadden BA, Golem DL, Pellegrino JK, Walker AJ, Sanders DJ, Arent SMJM, Sports Si, Exercise (2017) The effects of exercise dose on stereotypical behavior in children with autism. 49:983-990 Kaat AJ, Gadow KD, Lecavalier LJJoACP (2013) Psychiatric symptom impairment in children with autism spectrum disorders. 41:959-969 Joshi G, Faraone SV, Wozniak J, Petty C, Fried R, Galdo M, Furtak SL, McDermott K, Epstien C, Walker RJJoA, Disorders D (2014) Examining the clinical correlates of autism spectrum disorder in youth by ascertainment source. 44:2117-2126 Salazar F, Baird G, Chandler S, Tseng E, O’sullivan T, Howlin P, Pickles A, Simonoff EJJoa, disorders d (2015) Co-occurring psychiatric disorders in preschool and elementary school-aged children with autism spectrum disorder. 45:2283-2294 Joshi G, Faraone SV, Wozniak J, Tarko L, Fried R, Galdo M, Furtak SL, Biederman JJJoAD (2017) Symptom profile of ADHD in youth with high-functioning autism spectrum disorder: a comparative study in psychiatrically referred populations. 21:846-855 Antshel KM, Russo NJCpr (2019) Autism spectrum disorders and ADHD: Overlapping phenomenology, diagnostic issues, and treatment considerations. 21:1-11 Posserud MB, Skretting Solberg B, Engeland A, Haavik J, Klungsøyr KJAPS (2021) Male to female ratios in autism spectrum disorders by age, intellectual disability and attention‐deficit/hyperactivity disorder. 144:635-646 Table 2 Table 2 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Table2.docx Cite Share Download PDF Status: Published Journal Publication published 11 Dec, 2025 Read the published version in European Journal of Pediatrics → Version 1 posted Editorial decision: Revision requested 13 May, 2025 Reviews received at journal 13 May, 2025 Reviews received at journal 11 May, 2025 Reviewers agreed at journal 04 May, 2025 Reviewers agreed at journal 02 May, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviewers invited by journal 28 Apr, 2025 Editor assigned by journal 28 Apr, 2025 Submission checks completed at journal 28 Apr, 2025 First submitted to journal 19 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6484664","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449380140,"identity":"efba511a-3397-4bdf-a0f9-6a0ab4291460","order_by":0,"name":"Chenmu Li","email":"","orcid":"","institution":"Zhaoqing University","correspondingAuthor":false,"prefix":"","firstName":"Chenmu","middleName":"","lastName":"Li","suffix":""},{"id":449380141,"identity":"be4a4c30-8980-4e10-8cec-ffcdbfd06c15","order_by":1,"name":"Wenlai Cui","email":"","orcid":"","institution":"Capital University of Physical Education and Sports","correspondingAuthor":false,"prefix":"","firstName":"Wenlai","middleName":"","lastName":"Cui","suffix":""},{"id":449380142,"identity":"77442200-e044-4a6c-a095-d04b96f84d0c","order_by":2,"name":"Hongling Pan","email":"","orcid":"","institution":"Changsha University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Hongling","middleName":"","lastName":"Pan","suffix":""},{"id":449380143,"identity":"a320d8ce-29f5-4468-9776-668cfff3118c","order_by":3,"name":"Tong Zhou","email":"","orcid":"","institution":"Korea University","correspondingAuthor":false,"prefix":"","firstName":"Tong","middleName":"","lastName":"Zhou","suffix":""},{"id":449380144,"identity":"ad0ec80f-ca0d-437f-b569-f8468ef9fbbc","order_by":4,"name":"Xuecheng Li","email":"","orcid":"","institution":"South China Normal University","correspondingAuthor":false,"prefix":"","firstName":"Xuecheng","middleName":"","lastName":"Li","suffix":""},{"id":449380145,"identity":"727f415c-ee1a-47c1-957c-d2a656a17684","order_by":5,"name":"Dong Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYBACA2YGAyD1T46fvfngg4SKGqK1HDCW7DmWbPDgzDEitDBAtCRuuJFjJvmwhZkILezMGx8X/LpjbADUUpHYwMbA396dQMBhbMXGM/ueyUmeeVZ2I3GHDIPEmbMbCGjhMZPm7WE25juevO1G4hk2BgOJXOK0JDYcSDArSGxjJlILz4/DiRNOpJgxEKkF6BfehjRwIEsknDnGQ9Av9v2HNz7m+WMDjsqPPypq5Pjbe/FrAQPGNgSbh7ByMPhDpLpRMApGwSgYmQAAyUZK6h4xPO8AAAAASUVORK5CYII=","orcid":"","institution":"Zhaoqing University","correspondingAuthor":true,"prefix":"","firstName":"Dong","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-04-19 12:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6484664/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6484664/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00431-025-06636-1","type":"published","date":"2025-12-11T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82203749,"identity":"ea1376b5-95eb-4aca-a08c-9d7bb057583b","added_by":"auto","created_at":"2025-05-07 16:49:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":205937,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of the study process\u003c/p\u003e","description":"","filename":"Figure1PRISMAflowdiagramofthestudyprocess.png","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/62a001ab7484f48c56193744.png"},{"id":82203748,"identity":"c064f585-670d-47cc-8a44-70f4a84c416d","added_by":"auto","created_at":"2025-05-07 16:49:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":92182,"visible":true,"origin":"","legend":"\u003cp\u003eA: Methodological Quality of Included Studies. B: The Distribution of the Methodological Quality of Included Studies.\u003c/p\u003e","description":"","filename":"Figure2RiskofBias.png","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/3f6e3cac5373f299ad327e56.png"},{"id":82204881,"identity":"dee1e2a7-b619-468a-844b-cd9f8853816b","added_by":"auto","created_at":"2025-05-07 17:05:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":322325,"visible":true,"origin":"","legend":"\u003cp\u003eThe subgroup analysis of the effect of physical activity intervention type on motor ability\u003c/p\u003e","description":"","filename":"Figure3subgroupanalysisoftypeonmotorability.png","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/979640ece82cffd5b415831f.png"},{"id":82204697,"identity":"41e32fca-9d22-442f-a3d1-88f0ae56eb47","added_by":"auto","created_at":"2025-05-07 16:57:09","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":244945,"visible":true,"origin":"","legend":"\u003cp\u003eThe subgroup analysis of the effect of physical activity intervention type on communication ability\u003c/p\u003e","description":"","filename":"Figure4subgroupanalysisoftypeoncommunicationability.png","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/7916237d95cfe00f878c26bc.png"},{"id":82204883,"identity":"da9a8c4e-e0f2-49ed-a036-e54500ff9936","added_by":"auto","created_at":"2025-05-07 17:05:09","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":366375,"visible":true,"origin":"","legend":"\u003cp\u003eThe subgroup analysis of the effect of physical activity intervention type on social ability\u003c/p\u003e","description":"","filename":"Figure5Thesubgroupanalysisoftypeonsocialability.png","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/98f8b3e3fe917056ca08c31b.png"},{"id":82203758,"identity":"d359a0d6-4cb7-487a-bb1d-aa89b34a1a21","added_by":"auto","created_at":"2025-05-07 16:49:09","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":392256,"visible":true,"origin":"","legend":"\u003cp\u003eThe subgroup analysis of the effect of physical activity intervention type on executive function\u003c/p\u003e","description":"","filename":"Figure6Thesubgroupanalysisoftypeonexecutivefunction.png","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/9713523680b677ac31bef561.png"},{"id":82204699,"identity":"301d77cd-8a05-433a-8909-f6aa1acf3a29","added_by":"auto","created_at":"2025-05-07 16:57:09","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":232301,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot on publication bias\u003c/p\u003e","description":"","filename":"Figure7Funnelplotonpublicationbias..png","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/c8d7134e1391b03768efe71c.png"},{"id":98243521,"identity":"4c2ff56b-70ea-45dc-9314-97189c9cd978","added_by":"auto","created_at":"2025-12-15 16:08:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2893593,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/fcfcd3a2-161c-4e0d-ad55-d75ebf1247e1.pdf"},{"id":82203752,"identity":"f20b1b4c-9873-488e-adc7-2c01d600a308","added_by":"auto","created_at":"2025-05-07 16:49:09","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":931842,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/f96fff0b6a25ed0dc376af9e.docx"},{"id":82203747,"identity":"c149cd7a-f14d-416e-a95c-06d678eb2e89","added_by":"auto","created_at":"2025-05-07 16:49:09","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":42293,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6484664/v1/cd1232155071b82bb464d13d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of physical activity on motor, communication, social, and executive function in children with autism spectrum disorder: A meta-analysis of randomized controlled trials","fulltext":[{"header":"what is known","content":"\u003cul\u003e\n \u003cli\u003eThe physical and psychological benefits of physical activity are well established.\u003c/li\u003e\n \u003cli\u003ePrevious meta-analyses have failed to demonstrate the impact of physical activity on the motor ability and characteristic impairments of children with ASD.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003ewhat is new:\u003c/strong\u003e\u003c/p\u003e\n\u003cul start=\"50\"\u003e\n \u003cli\u003ePhysical activity exerts a constructive influence on augmenting communication, social, motor, and executive function capabilities in children with ASD.\u003c/li\u003e\n \u003cli\u003eDifferent differences determine different effects, disparities in optimal effects are contingent upon intervention duration, frequency, and period.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1 Introduction","content":"\u003cp\u003eAutism Spectrum Disorder (ASD) is a neurobiological developmental disorder, characterized by a range of heterogeneous neurodevelopmental conditions[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Approximately 1 in 100 children worldwide is diagnosed with ASD[2; 3]. It is primarily diagnosed during childhood, with a relatively high prevalence[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. ASD is characterized by a constellation of impairments primarily affecting four functional domains: social interaction, communication, motor coordination, and executive functioning. These characteristic impairments form the basis for clinical diagnosis and significantly impact the daily lives of children with ASD[5; 6]. Within the ASD population, the prevalence is higher in males compared to females, with an average male-to-female ratio of 4.3:1[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and this gender difference is even more pronounced in childhood ASD cases, with a ratio of 4.7:1[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, research indicates that children with ASD are more prone to obesity and overweight compared to typically developing peers[9; 10].\u003c/p\u003e \u003cp\u003eResearch indicates that children with ASD often exhibit a range of challenges, ranging from mild to severe motor delays[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], difficulties in communication and social interaction[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and impaired executive functioning[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These challenges persist into adolescence, representing obstacles in the developmental trajectory of Children with ASD, affecting their overall well-being, academic growth, and social integration. Autism begins in early childhood and continues throughout the lifespan, adding to the economic burden on families and society[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The primary symptomatic feature of children with ASD is impaired cognitive function, leading to difficulties in social communication and interaction. It is noteworthy that impaired facial recognition resulting from cognitive impairments can diminish the cooperative interaction abilities displayed by Children with ASD in games[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven these circumstances, the treatment of children with ASD holds paramount significance. Conventional treatment approaches encompass pharmacotherapy, nutritional supplementation, special diets such as gluten-free diets, vitamin diets, and complementary and alternative methods like neurofeedback and acupuncture[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Among these, there is limited support for using medication to improve characteristic impairments of ASD[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], the efficacy of pharmacotherapy in improving social and communication difficulties in Children with ASD remains limited[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Physical activity as a fundamental element of development for children with autism has been widely studied[19; 20], As a non-pharmacological intervention, it has been proven to have a positive effect on improving functional impairments associated with ASD[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Physical activity (PA) is defined as any bodily movement that increases energy expenditure above resting levels, including occupational, sports, recreational, and other activities[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn some studies, physical activity interventions have been explored as an optional or adjunctive approach to ameliorate symptoms in Children with ASD[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Children can maintain their weight, promote bone health, increase cardiovascular activity, and prevent various chronic diseases (such as coronary heart disease and diabetes) through physical activity[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In contrast, as a non-pharmacological therapy for children with ASD, physical activity intervention has gained increasing recognition in recent years due to its relatively minimal side effects, economic feasibility, ease of implementation, and strong interactivity, effectively promoting both physical and mental well-being[11; 12].\u003c/p\u003e \u003cp\u003eSeveral studies have reported that physical activity is associated with improvements in social, psychological, and cognitive functioning in children with ASD[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Reinders et al. suggested that physical activity is a feasible intervention strategy for this population[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In a randomized controlled trial, Wang et al. found that a basketball-based program improved executive function and ASD-related impairments[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A recent meta-analysis indicated that programs lasting at least 12 weeks, conducted three or more times per week for 90 minutes or more, produced the greatest benefits[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. S\u0026aacute;nchez et al. demonstrated that various physical activities, such as games, swimming, yoga, and cycling, can enhance gait, balance, coordination, and motor skills[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Additional studies have also shown positive effects on social interaction, communication, and quality of life[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], as well as moderate improvements in executive functioning[\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and social behaviors[12; 25].\u003c/p\u003e \u003cp\u003ePrevious meta-analyses have indicated that physical activity interventions demonstrate an overall moderate effect in individuals with ASD, with these interventions showing moderate to large positive impacts in areas related to health-related skills, social functioning, and endurance[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Furthermore, physical activity brings significant benefits to the motor and social abilities of individuals with ASD[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In early intervention programs, collaboration among pediatricians, child psychiatrists, speech therapists, and various therapeutic approaches is employed, with the inclusion of non-traditional methods such as equine-assisted therapy and music therapy[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], to broaden the scope of communication and social skill enhancement[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn summary, these research findings collectively suggest that physical activity can be an effective therapeutic option for individuals with ASD. However, most existing meta-analyses have combined data from both children and adults, potentially obscuring developmental stage-specific effects[34; 36]. Moreover, these reviews often focus on general outcomes rather than investigating the domain-specific effects of physical activity interventions, such as their impact on communication, social interaction, motor coordination, and executive functioning in children with ASD[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. As a result, there remains a gap in understanding how physical activity affects different functional domains in pediatric ASD populations.\u003c/p\u003e \u003cp\u003eConsidering the rapid development and gradual maturation of children, as well as their unique physiological characteristics[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], there is a need for further exploration of the suitability of the timing, frequency, and duration of physical activity interventions targeting communication, social, motor, and executive function in children with ASD. This study aims to provide valuable insights into the selection of effective physical activity intervention measures to enhance these abilities in children with ASD by conducting a meta-analysis of randomized controlled trials involving physical activity interventions related to communication, social, motor, and executive function in Children with ASD.\u003c/p\u003e"},{"header":"2 Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Protocol and Registration\u003c/h2\u003e \u003cp\u003e In accordance with the directives delineated in the Cochrane Handbook for Systematic Reviews, this Meta-analysis was undertaken. The outcomes were documented in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement[38; 39]. Additionally, the ongoing meta-analysis was preregistered in PROSPERO (CRD 42023434313).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data Sources and Search Strategy\u003c/h2\u003e \u003cp\u003eAn unrestricted search was conducted across four prominent databases, namely PubMed, Web of Science, Embase, and Cochrane Library, to comprehensively identify relevant studies. The search strategy was designed to encompass keywords related to physical activity interventions, age criteria, and outcomes pertinent to individuals with ASD, without any linguistic constraints. The selection of search terms for each core concept was informed by previous review methodologies and insights from experts in the field of exercise interventions[40; 41]. This systematic search endeavor persisted until November 2022 and underwent a second retrieval in March 2024. A comprehensive search strategy, as employed for PubMed, is outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, while the retrieval strategies utilized for other databases can be accessed in \u003cb\u003eAppendix A\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSearch strategy on PubMed\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\" Autism Spectrum Disorders\"\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(((((((((((((((((Autistic Disorder) OR (Disorder, Autistic)) OR (Disorders, Autistic[Title/Abstract])) OR (Kanner's Syndrome[Title/Abstract])) OR (Kanner Syndrome[Title/Abstract])) OR (Kanners Syndrome[Title/Abstract])) OR (Autism, Infantile[Title/Abstract])) OR (Infantile Autism[Title/Abstract])) OR (Autism[Title/Abstract])) OR (Autism, Early Infantile[Title/Abstract])) OR (Early Infantile Autism[Title/Abstract])) OR (Infantile Autism, Early[Title/Abstract])) OR (Autism Spectrum Disorder[Title/Abstract])) OR (Autism Spectrum Disorders[Title/Abstract])) OR (Autistic Spectrum Disorder[Title/Abstract])) OR (Autistic Spectrum Disorders[Title/Abstract])) OR (Disorder, Autistic Spectrum[Title/Abstract])))\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#1 OR #2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\" Child \" [MeSH]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e((Child[Title/Abstract]) OR (Children[Title/Abstract]))\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#4 OR #5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\" Exercise \" [MeSH]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e((((((((((((((((((((((((((Exercise[Title/Abstract]) OR (Exercises[Title/Abstract])) OR (Physical Activity[Title/Abstract])) OR (Activities, Physical[Title/Abstract])) OR (Activity, Physical[Title/Abstract])) OR (Physical Activities[Title/Abstract])) OR (Exercise, Physical[Title/Abstract])) OR (Exercises, Physical[Title/Abstract])) OR (Physical Exercise[Title/Abstract])) OR (Physical Exercises[Title/Abstract])) OR (Acute Exercise[Title/Abstract])) OR (Acute Exercises[Title/Abstract])) OR (Exercise, Acute[Title/Abstract])) OR (Exercises, Acute[Title/Abstract])) OR (Exercise, Isometric[Title/Abstract])) OR (Exercises, Isometric[Title/Abstract])) OR (Isometric Exercises[Title/Abstract])) OR (Isometric Exercise[Title/Abstract])) OR (Exercise, Aerobic[Title/Abstract])) OR (Aerobic Exercise[Title/Abstract])) OR (Aerobic Exercises[Title/Abstract])) OR (Exercises, Aerobic[Title/Abstract])) OR (Exercise Training[Title/Abstract])) OR (Exercise Trainings[Title/Abstract])) OR (Training, Exercise[Title/Abstract])) OR (Trainings, Exercise[Title/Abstract]))))\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#7 OR #8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#3 AND #6 AND #9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study selection\u003c/h2\u003e \u003cp\u003eTwo authors (CML and DL) autonomously evaluated the retrieved search outcomes and conducted a systematic screening of publications identified from the databases. The reference lists of the studies encompassed within this analysis were also examined. Initial screening involved evaluating the titles and abstracts of these studies to ascertain their pertinence. Following this, a comprehensive review of the full texts of the pertinent studies was conducted to ascertain their eligibility for inclusion. Any discrepancies that arose during the screening process were resolved through collaborative discussions within the research team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Inclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eStudies were included if they met all of the following criteria:\u003c/p\u003e \u003cp\u003e(1) The study design was a randomized controlled trial (RCT).\u003c/p\u003e \u003cp\u003e(2) Participants were 18 years of age or younger.\u003c/p\u003e \u003cp\u003e(3) All participants were formally diagnosed with ASD based on established diagnostic criteria, such as DSM-IV, DSM-5, ICD-10, or equivalent clinical assessments conducted by licensed professionals.\u003c/p\u003e \u003cp\u003e(4) The intervention involved structured physical activity or exercise programs.\u003c/p\u003e \u003cp\u003e(5) The study reported pre- and post-intervention outcomes relevant to communication, social interaction, motor skills, or executive function in children with ASD.\u003c/p\u003e \u003cp\u003e(6) Sufficient raw or extractable data were available for effect size calculation.\u003c/p\u003e \u003cp\u003e(7) The article was published in English.\u003c/p\u003e \u003cp\u003eStudies were excluded if they met any of the following criteria:\u003c/p\u003e \u003cp\u003e(1) The study design was observational (e.g., cross-sectional, case-control, or cohort studies).\u003c/p\u003e \u003cp\u003e(2) Participants were older than 18 years of age.\u003c/p\u003e \u003cp\u003e(3) Participants had comorbid conditions likely to confound the results, including severe intellectual disability, genetic syndromes (e.g., Rett syndrome), or uncontrolled medical/psychiatric conditions.\u003c/p\u003e \u003cp\u003e(4) The intervention lacked detailed information on physical activity components or was combined with other interventions (e.g., pharmacological treatment or behavioral therapies) without isolating the effects of physical activity.\u003c/p\u003e \u003cp\u003e(5) The study did not report relevant outcome measures or lacked sufficient data for quantitative synthesis.\u003c/p\u003e \u003cp\u003e(6) The study presented ethical concerns such as lack of informed consent or inadequate participant protection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data Extraction\u003c/h2\u003e \u003cp\u003eThe study included a total of 609 children with ASD, comprising 451 males (74%), 88 females (14%), and 70 individuals (11%) whose gender was not reported, aged between 3.5 and 15 years. All children in the intervention group received various forms of physical activity treatment, with each session lasting between 30 and 90 minutes, a frequency of 1 to 5 times per week, and a duration of 2 to 40 weeks. Children in the control group were placed on a waiting list or engaged in regular activities without participating in any physical activity or exercise. The study required outcome measures to include at least one of the following functional impairments associated with ASD: communication skills, social skills, motor skills, and executive function. It aimed to investigate the impact of physical activity interventions on these characteristic impairments in children with ASD. Studies without a control group or without reporting any intergroup comparison results were excluded.\u003c/p\u003e \u003cp\u003eThe data were entered into an Excel spreadsheet, and the included experimental data were independently extracted by two authors. Any discrepancies that emerged during the research procedure were resolved through collaborative discussions within the research team. The subsequent data were extracted from each of the studies: author(s), publication year, country, intervention specifics, participant characteristics, and relevant outcome indicators post-intervention. In cases where the post-intervention outcomes were presented graphically but lacked explicit numerical values, utilized engineering digitization software (Version4.5,\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://automeris.io/WebPlotDigitizer/\u003c/span\u003e\u003cspan address=\"https://automeris.io/WebPlotDigitizer/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) was employed for data extraction. In the case of studies featuring multiple follow-up assessments, data were exclusively extracted immediately after the intervention. In cases where standard deviations were not furnished, they were computed from the 95% confidence interval for the average value within either the intervention or control group. To elucidate the impact of intervention dosages in terms of physical activity, we categorized intervention duration into \"\u0026ge; 60 minutes\" and \"\u0026lt; 60 minutes\", intervention frequency into \"\u0026ge; 3 times per week\" and \"\u0026lt; 3 times per week\", and intervention period into \"\u0026le; 10 weeks\" and \"\u0026gt; 10 weeks\".\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Quality Assessment\u003c/h2\u003e \u003cp\u003e Utilizing Review Manager 5.4 software and employing the Cochrane Risk of Bias tool, the quality of the studies incorporated in the analysis was evaluated through the examination of seven criteria: 1. Random sequence generation; 2. Allocation concealment; 3. Blinding of participants and personnel; 4. Blinding of outcome assessment; 5. Handling of incomplete outcome data; 6. Reporting of selective outcomes; and 7. Identification of other potential biases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Statistical Analysis\u003c/h2\u003e \u003cp\u003eFor both the title and abstract screening stages as well as the full-text screening stage, the agreement between raters was assessed using Cohen's kappa coefficient. The classification of agreement levels is as follows: fair agreement (0.40\u0026ndash;0.59), moderate agreement (0.60\u0026ndash;0.74), substantial agreement (\u0026gt;\u0026thinsp;0.75)[42; 43].\u003c/p\u003e \u003cp\u003eGiven the included data, the standardized mean difference (SMD) along with its corresponding 95% confidence interval (CI) were computed. The interpretation of effect sizes followed conventional conventions, with SMD values falling into the small effect range (SMD\u0026thinsp;=\u0026thinsp;0.2), medium effect range (SMD\u0026thinsp;=\u0026thinsp;0.5), or large effect range (SMD\u0026thinsp;=\u0026thinsp;0.8)[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. We assessed the statistical heterogeneity between different trials using the Cochrane Q test and quantified it using the \u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e statistic. Levels of heterogeneity were categorized as low (\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;\u0026le;\u0026thinsp;25%), moderate (25%\u0026lt;\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;\u0026le;\u0026thinsp;50%), substantial (50%\u0026lt;\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;\u0026le;\u0026thinsp;75%), or considerable (\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;\u0026gt;\u0026thinsp;75%). Distinct effect models were chosen based on the degree of heterogeneity within the trial data. Considering the variations in the studies, a random effects model was used to minimize the heterogeneity in study design and outcome measures[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Subgroup analyses were conducted, stratified by categorical variables, encompassing the intervention duration, intervention frequency, and intervention period. This was undertaken to explore potential origins of heterogeneity. Symmetry testing was performed on funnel plots of outcome indicators to examine potential publication bias and the impact of small-study effects. The presence of publication bias was assessed using the Begg's rank correlation test and Egger's regression test, with a P-value threshold of p\u0026thinsp;\u0026gt;\u0026thinsp;0.05 indicating no publication bias and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicating the presence of publication bias. Additionally, we conducted trim-and-fill analysis (random-effects model) to assess publication bias and explore the need for additional studies to achieve a balanced funnel plot[46; 47]. Furthermore, sensitivity analyses were carried out through a stepwise exclusion of individual studies to evaluate the robustness of our study findings[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. All analyses were performed using Stata 15.1 software with two-sided tests for all statistical analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Certainty assessment\u003c/h2\u003e \u003cp\u003eThe credibility of the findings is evaluated employing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, which furnishes guidelines for assessment, creation, and evaluation[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003e3.1 Trial Selection\u003c/h2\u003e\n \u003cp\u003eTo ensure the precision of the systematic retrieval process, the search was conducted by two researchers (CML and DL) who are well-versed in the fields of ASD and exercise science. These researchers independently screened titles, abstracts, and full-text articles.\u003c/p\u003e\n \u003cp\u003eIn the initial electronic database search, a total of 3,281 citations were obtained. After excluding duplicate studies (n = 1044), 2,237 relevant articles were retained. Subsequently, following title and abstract screening, a total of 2,010 articles were excluded, resulting in 227 articles remaining for full-text review. During this phase, the inter-rater reliability between the two reviewers was deemed substantial (Cohen's kappa = 0.63). After an extensive full-text review, an additional 208 articles were excluded, with 115 of them lacking relevant outcome reporting,55 had inconsistent experimental designs, 17 lacked full-text availability, and 21 had unavailable data. Finally, we included 19 studies[26; 31; 50–66]for quantitative synthesis (Fig.\u0026nbsp;1). At this stage, the inter-rater reliability between the two reviewers was characterized as substantial (Cohen's kappa = 0.71).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003e3.2 Trial Characteristics\u003c/h2\u003e\n \u003cp\u003eTable\u0026nbsp;2 summarizes the characteristics of the 19 studies included in the analysis, all of which employed randomized controlled trial designs. The majority of studies originated from Iran, accounting for 7 out of the 19 publications. A total of 609 children with ASD were included, comprising 451 males (74%), 88 females (14%), and 70 participants (11%) whose gender was not reported.\u003c/p\u003e\n \u003cdiv\u003e\n \u003c/div\u003e\n \u003cp\u003eThe intervention subjects involved in this study all met the diagnostic criteria for ASD and were excluded if they had one or more concurrent psychiatric disorders, severe behavioral problems, visual or auditory impairments, uncontrolled epileptic seizures, used posture-assistive devices and were confirmed to have neurological or musculoskeletal issues, or had documented allergic reactions. Among them, in 5 articles, the intervention subjects had no intellectual disabilities[50; 54; 56; 62; 66], in 13 articles, the presence or absence of intellectual disabilities in the intervention subjects was not described[26; 31; 51–53; 55; 57–61; 63; 64], and in 1 article, the intervention subjects had mild intellectual disabilities[65], with a majority being male and aged between 3.5 and 15 years old. The sample sizes of intervention groups ranged from 7 to 42 participants, totaling 339 children with ASD; control group sample sizes ranged from 8 to 25 participants, comprising 272 children with ASD. The age span for both the intervention and control groups encompassed individuals under 18 years of age. participants being included across the studies. All research adhered to standardized diagnostic criteria, specifically the Diagnostic and Statistical Manual of Mental Disorders (DSM), 4th or 5th edition. All physical activity interventions were conducted with the informed consent of parents or guardians. The duration of a single intervention ranged from 30 to 90 minutes; intervention frequencies spanned from once a week to five times a week; and intervention periods varied from 2 to 40 weeks. Children in the control group were placed on a waiting list or engaged in regular activities without participating in any physical activity or exercise.\u003c/p\u003e\n \u003cp\u003eMeasurement of communication abilities, social skills, motor ability, and executive functions commonly employed assessment tools such as the Gilliam Autism Rating Scale (GARS), Autism Diagnostic Observation Schedule (ADOS), Autism Treatment Evaluation Checklist (ATEC), Movement Assessment Battery for Children (MABC), Brininx-Oresetsky Test (BOT), Wisconsin Card Sorting Test (WCST), and Vineland Adaptive Behavior Scales (VABS).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003e3.3 Risk of bias\u003c/h2\u003e\n \u003cp\u003eOut of the 19 studies, 11 investigations[31; 50; 53; 56; 57; 59; 60; 63–66] (58%) exhibited low risk of bias concerning random sequence generation. Allocation concealment bias was considered low risk in 10 studies[31; 52; 53; 57; 58; 60; 62; 63; 65; 66] (53%). Additionally, 12 studies[26; 52; 54–56; 59; 60; 62–66] (63%) demonstrated low risk in terms of blinding of participants and personnel. Regarding blinding of outcome assessment, 9 studies[52; 54; 56–60; 63; 65] (47%) indicated low risk of bias. Among the included studies, 16[26; 31; 50–55; 57–64] (84%) presented low risk of bias regarding incomplete outcome data. Furthermore, 13 studies[31; 51–53; 57–65] (68%) displayed low risk of selective reporting bias. The presence of other biases remains unclear. Detailed assessments of bias outcomes for the included literature can be found in Fig.\u0026nbsp;2A and 2B.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003e3.4 Meta-analysis\u003c/h2\u003e\n \u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003e3.4.1 The effects of physical activity on motor ability\u003c/h2\u003e\n \u003cp\u003eA total of 10 studies (including two different types of physical activity interventions in the Hassani study) elucidated the impact of physical activity on motor abilities in children with ASD, encompassing 212 diagnosed Children with ASD. As shown in Fig.\u0026nbsp;3, the overall effect indicated a large effect size (SMD = 2.06, 95%CI:1.15, 2.96, p\u0026lt;0.05) for physical activity interventions when compared to the control groups. This effect was characterized by considerable heterogeneity (\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e = 85.9%, p \u0026lt; 0.05). Subgroup analyses were conducted, and the results are presented in Table\u0026nbsp;3.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe subgroup analysis of the effect of physical activity interventions on motor ability\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSubgroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCut-off\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eInclusion of literature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHeterogeneity test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSMD (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.46 (1.15, 3.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.59 (0.25, 2.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.020*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 3 weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.33 (0.32, 2.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.010**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;3 weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.60 (1.19, 4.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDuration period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15 (0.49, 1.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≤ 10 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.01 (1.35, 4.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*: P ≤ 0.05; **: P ≤ 0.01; NI: no intervention; N/A: not applicable.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003e3.4.2 The effects of physical activity on communication ability\u003c/h2\u003e\n \u003cp\u003eA total of 6 studies elucidated the impact of physical activity on communication abilities in children with ASD, encompassing 227 diagnosed Children with ASD. As depicted in Fig.\u0026nbsp;4, the overall effect indicated a moderate to large effect size (SMD = 0.58, 95%CI: 0.28, 0.87, p\u0026gt;0.05) for physical activity interventions when compared to the control groups. This effect was characterized by low heterogeneity (\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e = 17.8%, p\u0026gt;0.05). Subgroup analyses were conducted, and the results are presented in Table\u0026nbsp;4.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe subgroup analysis of the effect of physical activity interventions on communication ability\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSubgroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCut-off\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eInclusion of literature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHeterogeneity test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSMD (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e00.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.756\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85 (0.48, 1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e00.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.553\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.28 (-0.11, 0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 3 weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33 (-0.24, 0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.257\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;3 weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.67 (0.33, 1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDuration period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e00.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.66 (0.37, 0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≤ 10 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04 (-0.69, 0.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.914\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*: P ≤ 0.05; **: P ≤ 0.01; NI: no intervention; N/A: not applicable.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec18\"\u003e\n \u003ch2\u003e3.4.3 The effects of physical activity on social ability\u003c/h2\u003e\n \u003cp\u003eA total of 12 studies elucidated the impact of physical activity on social ability in children with ASD, encompassing 370 diagnosed Children with ASD. As depicted in Fig.\u0026nbsp;5, the overall effect indicated a moderate to large effect size (SMD = 0.72, 95%CI: 0.43, 1.01, p\u0026lt;0.05) for physical activity interventions when compared to the control groups. This effect was characterized by moderate heterogeneity (\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e = 43.7%, p\u0026gt;0.05). Subgroup analyses were conducted, and the results are presented in Table\u0026nbsp;5.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe subgroup analysis of the effect of physical activity interventions on social ability\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSubgroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCut-off\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eInclusion of literature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHeterogeneity test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSMD (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.097\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06 (0.61, 1.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.783\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41 (0.12, 0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.005**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 3 weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71 (0.30, 1.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;3 weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73 (0.32, 1.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDuration period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.528\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.65 (0.39, 0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≤ 10 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72 (0.43, 1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.019*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*: P ≤ 0.05; **: P ≤ 0.01; NI: no intervention; N/A: not applicable.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec19\"\u003e\n \u003ch2\u003e3.4.4 The effects of physical activity on executive function\u003c/h2\u003e\n \u003cp\u003eA total of 13 studies (including two different types of physical activity interventions in the studies by TSE and Milajerdi) elucidated the impact of physical activity on executive function abilities in children with ASD, encompassing 204 diagnosed Children with ASD. As depicted in Fig.\u0026nbsp;6, the overall effect indicated a small to medium effect size (SMD = 0.46, 95%CI:0.23, 0.69, p\u0026gt;0.05) for physical activity interventions when compared to the control groups. This effect was characterized by moderate heterogeneity (\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e = 37.5%, p\u0026gt;0.05). Subgroup analyses were conducted, and the results are presented in Table\u0026nbsp;6.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 6\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe subgroup analysis of the effect of physical activity interventions on executive function\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSubgroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCut-off\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eInclusion of literature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHeterogeneity test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSMD (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51 (0.14, 0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.607\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.40 (0.12, 0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 3 weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38 (0.15, 0.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;3 weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e00.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.491\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.09 (0.49, 1.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDuration period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e00.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.548\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92 (0.46, 1.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≤ 10 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.35 (0.11, 0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*: P ≤ 0.05; **: P ≤ 0.01; NI: no intervention; N/A: not applicable.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\"\u003e\n \u003ch2\u003e3.5 Publication bias\u003c/h2\u003e\n \u003cp\u003eWe employed funnel plots to assess potential publication bias. As depicted in Fig.\u0026nbsp;7, the funnel plot for the motor ability outcome exhibited some asymmetry, with certain studies dispersed towards the right upon visual inspection, while other outcomes displayed a generally symmetric pattern. This asymmetry suggested the possibility of publication bias in the motor ability outcome. Subsequently, we conducted Begg's rank correlation and Egger's regression tests to investigate publication bias. The results indicated statistically significant bias for the motor ability outcome (p = 0.016 and p = 0.013, respectively). Additionally, a trim and fill analysis (random-effects model) was conducted to assess publication bias for the motor ability outcome. The results indicated \"no trimming,\" suggesting the absence of bias detection (see Supplementary Appendix B1). Furthermore, sensitivity analysis was performed by iteratively excluding individual studies, revealing no significant impact on the overall results (see Supplementary Appendix B2).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\"\u003e\n \u003ch2\u003e3.6 Certainty assessment results\u003c/h2\u003e\n \u003cp\u003eAccording to the grading approach, detailed results are presented in Table\u0026nbsp;7.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab7\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 7\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eGRADE\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"10\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eCertainty assessment\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e№ of patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eImportance\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e№ of studies\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy design\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRisk of bias\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInconsistency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIndirectness\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eImprecision\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAbsolute\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"10\"\u003e\n \u003cp\u003eCommunication ability\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003erandomised trials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eserious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSMD 0.58\u003c/p\u003e\n \u003cp\u003e(0.28 to 0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCRITICAL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial ability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003erandomised trials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eserious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSMD 0.72\u003c/p\u003e\n \u003cp\u003e(0.43 to 1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCRITICAL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003eMotor ability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003erandomised trials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eserious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eserious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSMD 2.06\u003c/p\u003e\n \u003cp\u003e(1.15 to 2.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIMPORTANT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003eExecutive function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003erandomised trials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eserious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSMD 0.46\u003c/p\u003e\n \u003cp\u003e(0.23 to 0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCRITICAL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003eEG: experimental group; CG: control group; CI: confidence interval; SMD: standardised mean difference\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Main results\u003c/h2\u003e \u003cp\u003eWe conducted a systematic review and meta-analysis of 19 randomized controlled trials to investigate the effects of physical activity interventions on communication ability, social ability, motor ability, and executive function in children with ASD. Our findings reveal a generally moderate to large positive impact of physical activity interventions on the aforementioned domains for Children with ASD. Specifically, the optimal forms of physical activity interventions for achieving the best intervention outcomes are as shown in Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e, it can be observed that the optimal single intervention duration for all four measures is 60 minutes or more. The intervention frequency is less than three times per week for all measures. Regarding the intervention period, except for motor skills (10 sessions or fewer), the optimal design for improving or enhancing motor skills, communication skills, social skills, and executive function in children with ASD involves a physical activity intervention lasting 10 weeks or more.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe optimal form of physical activity intervention for the best outcomes in each measure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003cp\u003e(min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003cp\u003e(weekly)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDuration\u003c/p\u003e \u003cp\u003e(weeks)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotor ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunication ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExecutive function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eTime: single intervention time; Frequency: number of interventions per week; Duration: total intervention period\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Comparison with existing literature\u003c/h2\u003e \u003cp\u003eWe further explored the communication ability, social ability, motor ability, and executive function of children with ASD, extending the scope of previous research on physical activity interventions in ASD populations. In line with earlier studies, our investigation aligns with positive effects associated with physical activity interventions. Physical activity has been shown to contribute to the enhancement of participants' communication ability[\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], social ability[\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e], motor ability[\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e], and executive function[\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. Stress, emotions, and social interactions are closely linked to executive function[71; 72], yielding in a multitude of advantageous outcomes across physiological, psychological, and neurocognitive domains. These include reductions in stress, alleviation of anxiety, mitigation of depression, and attenuation of negative emotions[\u003cspan additionalcitationids=\"CR74 CR75\" citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. Furthermore, physical activity interventions exhibit a certain level of symptom improvement in ASD patients. Previous research has indicated that prolonged engagement in physical activity among individuals with ASD leads to improvements in core symptoms, including enhancement of mental and physical well-being[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], heightened health-related proficiency[\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e], augmented social skills[\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e], improved motor ability[\u003cspan additionalcitationids=\"CR80\" citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e], and reduced occurrence of repetitive behaviors[\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. Some studies have reported that exercise or physical activity is beneficial for improving the physical condition and cognitive status of children with ASD[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Several studies have demonstrated the beneficial effects of physical activity on various functional domains in children with ASD. For example, Homa et al. (2021) reported improvements in motor abilities and executive function following movement-based interventions[\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Harris et al. (2017) observed enhancements in social functioning through equine-assisted programs[\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Similarly, Zhao et al. (2018) found that structured physical activity significantly improved communication and social interaction skills in children with ASD[\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Siskova et al. also reported that a 12-session exercise program led to notable gains in motor coordination and object control, with potential long-term benefits[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Consequently, multiple studies suggest beneficial effects of physical activity on enhancing the communication ability, social ability, motor ability, and executive function of children with ASD. However, further research is warranted to explore potential benefits in other dimensions within this population.\u003c/p\u003e \u003cp\u003eOur study conducted a subgroup analysis, which provided additional information and valuable contributions to this field by identifying the most appropriate single intervention duration, weekly intervention frequency, and total intervention period for improving or enhancing motor skills, communication skills, social skills, and executive function in children with ASD. However, the different outcome measurement tools for various indicators (motor skills, communication skills, social skills, and executive function) resulted in varying differences, which may be a contributing factor to the heterogeneity in the results of this meta-analysis. We chose the standardized mean difference (SMD) as the effect size to minimize the differences in measurement instruments and units[\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. Applying standardized assessment tools in future research can improve the reliability and consistency of the results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Mechanisms of physical activity in children with ASD\u003c/h2\u003e \u003cp\u003ePhysical activity serves as a neuroenhancer, exerting acute and long-term effects on monoaminergic transmission, neural trophic signaling, and neuroplasticity mechanisms to enhance cognitive capacities[\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. Furthermore, physical exercise constitutes a cognitive demand, continuously challenging essential higher-order cognitive processes[70; 85], inducing changes in cognitive functionality[86; 87]. Evidence indicates that exercise interventions can successfully activate brain networks in children with ASD[\u003cspan additionalcitationids=\"CR89 CR90\" citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e]. Previous research data have shown aberrations in the cerebellum of individuals with ASD, including impaired Purkinje and granule neurons, and deficits in the posterior hemisphere and vermis[\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e]. Appropriate physical activity, encompassing skill acquisition, motor control, and social engagement, can positively influence improvements in cortical, subcortical, and cerebellar functions. Brain-derived neurotrophic factor (BDNF) is considered a critical factor in various neurodevelopmental disorders (e.g., autism, Rett syndrome) and neurodegenerative diseases (e.g., Huntington's disease, Alzheimer's disease, and Parkinson's disease), with its levels closely associated with the severity of symptoms in Children with ASD[\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e]. In the context of physical activity interventions, prior research has indicated that exercise can modulate the regulation of BDNF[\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e]. Thus, physical activity exhibits a degree of enhancement in communication ability, social ability, motor ability, and executive function in children with ASD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Discussion of subgroup analysis results\u003c/h2\u003e \u003cp\u003eOur subgroup analysis revealed that physical activity interventions timing, frequency, and duration of physical activity interventions for enhancing communication ability, social ability, motor ability, and executive function in children with ASD, our study uncovered a dose-response relationship between physical activity and executive function benefits. Notably, greater intervention duration, frequency, and cycle length do not necessarily yield more positive effects. There exists an optimal intervention range beyond which the positive effects of physical activity might diminish. This phenomenon aligns with the \"Exercise is Medicine\" (EIM) concept presented by the American College of Sports Medicine (ACSM), wherein the dose of exercise and its positive effects do not always exhibit a linear correlation, resembling the dose-response relationship seen in medication treatments[95; 96].\u003c/p\u003e \u003cp\u003eOur subgroup analysis reveals that for improvements in communication skills, social abilities, motor skills, and executive functions in children with ASD, intervention doses with a duration of 60 minutes or more per session and a frequency of three times or less per week are most suitable. Literature reports indicate that children and adolescents should engage in moderate to vigorous physical activity for most of the day, with each session lasting 60 minutes or more[\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e]. However, almost all studies focusing on the impact of physical activity on children's cognitive performance have been conducted at moderate to high intensities[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, considering the individual variations among ASD subtypes, gender differences, and comorbidities is essential when designing precise interventions tailored to achieve optimal therapeutic outcomes. In this study, there were only 88 girls, which can be explained by the lower participation rate of females in the intervention group due to the higher prevalence of autism in boys, where every 4 to 8 male participants correspond to 1 female participant[\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn conclusion, physical activity exhibits a positive impact on enhancing communication ability, social ability, motor ability, and executive function in children with ASD. However, the efficacy of physical activity interventions varies based on intervention timing, frequency, and duration. In general, physical activity represents an effective non-pharmacological intervention measure for enhancing communication ability, social ability, motor ability, and executive function in children with ASD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Strengths and limitations\u003c/h2\u003e \u003cp\u003eOur study has several strengths. Firstly, by including only randomized controlled trials and excluding observational and cross-sectional studies, we enhanced the reliability of our study outcomes. Secondly, our focus on the developmental stages of Children with ASD below 18 years allowed for more targeted and precise interventions. Lastly, our study provides valuable insights into the selection of physical activity therapies for enhancing communication ability, social ability, motor ability, and executive function in children with ASD.\u003c/p\u003e \u003cp\u003eHowever, there are limitations to our meta-analysis that may influence the interpretation of our findings. Firstly, the relatively limited pool of studies meeting the statistical robustness and the vigor of our assertions. Secondly, the scarcity of data available for subgroup analyses could potentially influence the outcomes of the study. Thirdly, the preponderance of male participants in the analysis precludes an evaluation of potential gender disparities. Lastly, due to the limited number of studies included, caution is needed in interpreting our results, and additional research is imperative to furnish more robust evidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Implications and Future Research\u003c/h2\u003e \u003cp\u003eTaking into consideration the current body of research, prospective investigators can contemplate the following avenues within the scope of future endeavors. Firstly, precise interventions tailored to diverse age groups warrant exploration. Given the rapid developmental trajectory observed in children, it is imperative to acknowledge the influence of age-related disparities and select appropriate physical intervention strategies suited to distinct age brackets among ASD-afflicted juveniles. Secondly, a concerted effort towards efficacious interventions addressing comorbidity phenomena merits attention. Given the prevalent co-occurrence of comorbidities with ASD, encompassing conditions such as ADHD and depression, clinical populations of ASD commonly exhibit overlapping ailments. Notably, extant studies indicate a comorbidity prevalence ranging from 40\u0026ndash;70% between ASD and ADHD[\u003cspan additionalcitationids=\"CR100 CR101 CR102\" citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e]. This profusion of comorbid instances presents a formidable challenge in terms of diagnostic differentiation and treatment. Consequently, intervention strategies should consider latent comorbidities and encompass a spectrum of physical activities capable of addressing multifarious comorbid conditions. Thirdly, it is noteworthy that the majority of intervention samples in this Meta-analysis derive from male subjects, resulting in a skewed gender proportion. Acknowledging the influences of gender disparities, along with the effects of relative introversion and cultural milieu, the likelihood of underdiagnoses and inadequate treatment for females demands recognition[\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e104\u003c/span\u003e]. Hence, future research endeavors should be attuned to gender variations, particularly focusing on physical activity interventions tailored for ASD-afflicted females. Fourthly, the diverse array of physical activities encompasses a wide spectrum of intervention outcomes, evincing substantial disparities in their efficacy. Subsequent investigations might involve comparative analyses across distinct physical activity modalities, elucidating differential therapeutic impacts therein. Lastly, there emerges the potential of network-based collaborative interventions. Leveraging the convenience and cost-effectiveness inherent to combined network interventions holds promise in circumventing spatial and economic constraints, thereby fostering enhanced participation among a broader demographic of individuals within the ASD population.\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eOur investigation demonstrates that physical activity has a positive impact on improving communication, social interaction, motor skills, and executive functioning in children with ASD. These findings highlight the overall therapeutic value of physical activity as a non-pharmacological intervention for this population. While the specific effects may be influenced by factors such as intervention duration, frequency, and total period, this study did not compare different physical activity modalities. Therefore, future research is needed to explore the relative effectiveness of various activity types through direct comparisons. Prior to implementation, individual characteristics such as age, gender, and symptom profile should also be carefully evaluated to optimize intervention outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASD (Autism Spectrum Disorder)\u003c/p\u003e\n\u003cp\u003eRCTs (randomized controlled trials)\u003c/p\u003e\n\u003cp\u003ePRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)\u003c/p\u003e\n\u003cp\u003eSMD (Standardized Mean Difference)\u003c/p\u003e\n\u003cp\u003eCI (confidence interval)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. CML and DL conceived and designed the study. CML and DL collected the data. CML, WLC, HLP, TZ and XCL analyzed and interpreted the data. CML, HLP and DL drafted the manuscript. CML, WLC and DL revised the manuscript. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll datasets generated for this study are included in the article/supplementary material.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the National Social Science Foundation of China (23BTY121)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBandelow B, Schmahl C, Falkai P, Wedekind D, Crockett C, Sackett G, Sandman C, Chicz-DeMet A, Benson KJEoO, Behaviors GRPiRMES-I (2017) American Psychiatric Association. DSM-5 Task Force.(2013). Diagnostic and statistical manual of mental disorders: Dsm-5 . Washington, DC: American Psychiatric Association. Bachevalier, J., Meunier, M., Lu, MX, \u0026amp; Ungerleider, LG (1997). Thalamic and temporal cortex input to medial prefrontal cortex in rhesus monkeys. Exp Brain Res, 115 (3). 100:11\u003c/li\u003e\n\u003cli\u003eAhmed F (2022) Delphi Consensus on Role of Physiotherapy Interventions in Autism Spectrum Disorder (ASD). Bangladesh Health Professions Institute, Faculty of Medicine, the University \u0026hellip;, \u003c/li\u003e\n\u003cli\u003eZeidan J, Fombonne E, Scorah J, Ibrahim A, Durkin MS, Saxena S, Yusuf A, Shih A, Elsabbagh MJAr (2022) Global prevalence of autism: A systematic review update. 15:778-790\u003c/li\u003e\n\u003cli\u003eTeh EJ, Vijayakumar R, Tan TXJ, Yap MJJJoA, Disorders D (2021) Effects of physical exercise interventions on stereotyped motor behaviours in children with ASD: a meta-analysis.1-24\u003c/li\u003e\n\u003cli\u003eLevenson JL (2018) The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. American Psychiatric Pub\u003c/li\u003e\n\u003cli\u003eLord C, Elsabbagh M, Baird G, Veenstra-Vanderweele JJTl (2018) Autism spectrum disorder. 392:508-520\u003c/li\u003e\n\u003cli\u003eLyall K, Croen L, Daniels J, Fallin MD, Ladd-Acosta C, Lee BK, Park BY, Snyder NW, Schendel D, Volk HJAroph (2017) The changing epidemiology of autism spectrum disorders. 38:81-102\u003c/li\u003e\n\u003cli\u003eNordahl CWJAR (2023) Why do we need sex‐balanced studies of autism? 16:1662-1669\u003c/li\u003e\n\u003cli\u003eKummer A, Barbosa IG, Rodrigues DH, Rocha NP, Rafael MdS, Pfeilsticker L, Silva ACS, Teixeira ALJRPdP (2016) Frequency of overweight and obesity in children and adolescents with autism and attention deficit/hyperactivity disorder. 34:71-77\u003c/li\u003e\n\u003cli\u003eMcCoy SM, Jakicic JM, Gibbs BBJJoa, disorders d (2016) Comparison of obesity, physical activity, and sedentary behaviors between adolescents with autism spectrum disorders and without. 46:2317-2326\u003c/li\u003e\n\u003cli\u003eReinders NJ, Branco A, Wright K, Fletcher PC, Bryden PJJFip (2019) Scoping review: Physical activity and social functioning in young people with autism spectrum disorder. 10:120\u003c/li\u003e\n\u003cli\u003eChan JS, Deng K, Yan JHJA (2021) The effectiveness of physical activity interventions on communication and social functioning in autistic children and adolescents: A meta-analysis of controlled trials. 25:874-886\u003c/li\u003e\n\u003cli\u003eCraig F, Margari F, Legrottaglie AR, Palumbi R, De Giambattista C, Margari LJNd, treatment (2016) A review of executive function deficits in autism spectrum disorder and attention-deficit/hyperactivity disorder.1191-1202\u003c/li\u003e\n\u003cli\u003eZheng Z, Zhang L, Li S, Zhao F, Wang Y, Huang L, Huang J, Zou R, Qu Y, Mu DJSR (2017) Association among obesity, overweight and autism spectrum disorder: a systematic review and meta-analysis. 7:11697\u003c/li\u003e\n\u003cli\u003eLudyga S, Gerber M, Bruggisser F, Leuenberger R, Brotzmann M, Trescher S, F\u0026ouml;rster M, Zou L, Herbrecht E, Hanke MJAR (2023) A randomized cross‐over trial investigating the neurocognitive effects of acute exercise on face recognition in children with autism spectrum disorder. \u003c/li\u003e\n\u003cli\u003eSefen JAN, Al-Salmi S, Shaikh Z, AlMulhem JT, Rajab E, Fredericks SJFibn (2020) Beneficial use and potential effectiveness of physical activity in managing autism spectrum disorder. 14:587560\u003c/li\u003e\n\u003cli\u003eMcPheeters ML, Warren Z, Sathe N, Bruzek JL, Krishnaswami S, Jerome RN, Veenstra-VanderWeele JJP (2011) A systematic review of medical treatments for children with autism spectrum disorders. 127:e1312-e1321\u003c/li\u003e\n\u003cli\u003eKaplan G, McCracken JTJPc (2012) Psychopharmacology of autism spectrum disorders. 59:175-187\u003c/li\u003e\n\u003cli\u003eSrinivasan SM, Pescatello LS, Bhat ANJPt (2014) Current perspectives on physical activity and exercise recommendations for children and adolescents with autism spectrum disorders. 94:875-889\u003c/li\u003e\n\u003cli\u003ePitetti KH, Rendoff AD, Grover T, Beets MWJJoa, disorders d (2007) The efficacy of a 9-month treadmill walking program on the exercise capacity and weight reduction for adolescents with severe autism. 37:997-1006\u003c/li\u003e\n\u003cli\u003eToscano CV, Barros L, Lima AB, Nunes T, Carvalho HM, Gaspar JMJN, Reviews B (2021) Neuroinflammation in autism spectrum disorders: Exercise as a \u0026ldquo;pharmacological\u0026rdquo; tool. 129:63-74\u003c/li\u003e\n\u003cli\u003eBelcher BR, Zink J, Azad A, Campbell CE, Chakravartti SP, Herting MMJBpCn, neuroimaging (2021) The roles of physical activity, exercise, and fitness in promoting resilience during adolescence: effects on mental well-being and brain development. 6:225-237\u003c/li\u003e\n\u003cli\u003eNeely L, Rispoli M, Gerow S, Ninci JJBm (2015) Effects of antecedent exercise on academic engagement and stereotypy during instruction. 39:98-116\u003c/li\u003e\n\u003cli\u003ePoitras VJ, Gray CE, Borghese MM, Carson V, Chaput J-P, Janssen I, Katzmarzyk PT, Pate RR, Connor Gorber S, Kho MEJAp, nutrition,, metabolism (2016) Systematic review of the relationships between objectively measured physical activity and health indicators in school-aged children and youth. 41:S197-S239\u003c/li\u003e\n\u003cli\u003eReinders NJ, Branco A, Wright K, Fletcher PC, Bryden PJJFip (2019) Scoping review: Physical activity and social functioning in young people with autism spectrum disorder. 10:412065\u003c/li\u003e\n\u003cli\u003eWang J-G, Cai K-L, Liu Z-M, Herold F, Zou L, Zhu L-N, Xiong X, Chen A-GJBs (2020) Effects of mini-basketball training program on executive functions and core symptoms among preschool children with autism spectrum disorders. 10:263\u003c/li\u003e\n\u003cli\u003eWang S, Chen D, Yang Y, Zhu L, Xiong X, Chen AJAR (2023) Effectiveness of physical activity interventions for core symptoms of autism spectrum disorder: A systematic review and meta‐analysis. 16:1811-1824\u003c/li\u003e\n\u003cli\u003eCasta\u0026ntilde;o PRL, Su\u0026aacute;rez DPM, Gonz\u0026aacute;lez ER, Robledo-Castro C, Hederich-Mart\u0026iacute;nez C, Cadena HPG, Vargas PAS, Montenegro LCGJJoA, Disorders D (2023) Effects of physical exercise on gross motor skills in children with autism spectrum disorder.1-10\u003c/li\u003e\n\u003cli\u003eIliadis I, Apteslis NJDiCN, Health M (2020) The role of physical education and exercise for children with Autism Spectrum Disorder and the effects on socialization, communication, behavior, fitness, and quality of life. 3:71-81\u003c/li\u003e\n\u003cli\u003ePhung JN, Goldberg WAJJoa, disorders d (2019) Promoting executive functioning in children with autism spectrum disorder through mixed martial arts training. 49:3669-3684\u003c/li\u003e\n\u003cli\u003ePan C-Y, Chu C-H, Tsai C-L, Sung M-C, Huang C-Y, Ma W-YJA (2017) The impacts of physical activity intervention on physical and cognitive outcomes in children with autism spectrum disorder. 21:190-202\u003c/li\u003e\n\u003cli\u003eSung M-C, Ku B, Leung W, MacDonald MJJoa, disorders d (2022) The effect of physical activity interventions on executive function among people with neurodevelopmental disorders: A meta-analysis. 52:1030-1050\u003c/li\u003e\n\u003cli\u003eHealy S, Nacario A, Braithwaite RE, Hopper CJAR (2018) The effect of physical activity interventions on youth with autism spectrum disorder: A meta‐analysis. 11:818-833\u003c/li\u003e\n\u003cli\u003eSowa M, Meulenbroek RJRiasd (2012) Effects of physical exercise on autism spectrum disorders: A meta-analysis. 6:46-57\u003c/li\u003e\n\u003cli\u003eWong C, Odom SL, Hume KA, Cox AW, Fettig A, Kucharczyk S, Brock ME, Plavnick JB, Fleury VP, Schultz TRJJoa, disorders d (2015) Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. 45:1951-1966\u003c/li\u003e\n\u003cli\u003eLang R, Koegel LK, Ashbaugh K, Regester A, Ence W, Smith WJRiASD (2010) Physical exercise and individuals with autism spectrum disorders: A systematic review. 4:565-576\u003c/li\u003e\n\u003cli\u003eJanssen I, LeBlanc AGJIjobn, activity p (2010) Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. 7:1-16\u003c/li\u003e\n\u003cli\u003eHiggins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (2019) Cochrane handbook for systematic reviews of interventions. John Wiley \u0026amp; Sons\u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SEJIjos (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. 88:105906\u003c/li\u003e\n\u003cli\u003eDe Greeff JW, Bosker RJ, Oosterlaan J, Visscher C, Hartman EJJos, sport mi (2018) Effects of physical activity on executive functions, attention and academic performance in preadolescent children: a meta-analysis. 21:501-507\u003c/li\u003e\n\u003cli\u003eXue Y, Yang Y, Huang TJBjosm (2019) Effects of chronic exercise interventions on executive function among children and adolescents: a systematic review with meta-analysis. 53:1397-1404\u003c/li\u003e\n\u003cli\u003eSim J, Wright CCJPt (2005) The kappa statistic in reliability studies: use, interpretation, and sample size requirements. 85:257-268\u003c/li\u003e\n\u003cli\u003eVickers NJJCb (2017) Animal communication: when i\u0026rsquo;m calling you, will you answer too? 27:R713-R715\u003c/li\u003e\n\u003cli\u003eHiggins JP, Thompson SG, Deeks JJ, Altman DGJB (2003) Measuring inconsistency in meta-analyses. 327:557-560\u003c/li\u003e\n\u003cli\u003eLi D, Li L, Zang W, Wang D, Miao C, Li C, Zhou L, Yan J (2023) Effect of physical activity on attention in school-age children with ADHD: a systematic review and meta-analysis of randomized controlled trials. Frontiers in Physiology 14\u003c/li\u003e\n\u003cli\u003eDuval S, Tweedie R (2000) Trim and fill: a simple funnel‐plot\u0026ndash;based method of testing and adjusting for publication bias in meta‐analysis. Biometrics 56:455-463\u003c/li\u003e\n\u003cli\u003eEgger M, Smith GD, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. Bmj 315:629-634\u003c/li\u003e\n\u003cli\u003eKhera R, Murad MH, Chandar AK, Dulai PS, Wang Z, Prokop LJ, Loomba R, Camilleri M, Singh SJJ (2016) Association of pharmacological treatments for obesity with weight loss and adverse events: a systematic review and meta-analysis. 315:2424-2434\u003c/li\u003e\n\u003cli\u003eBalshem H, Helfand M, Sch\u0026uuml;nemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris SJJoce (2011) GRADE guidelines: 3. Rating the quality of evidence. 64:401-406\u003c/li\u003e\n\u003cli\u003ePan C-YJA (2010) Effects of water exercise swimming program on aquatic skills and social behaviors in children with autism spectrum disorders. 14:9-28\u003c/li\u003e\n\u003cli\u003ePan C-YJRiASD (2011) The efficacy of an aquatic program on physical fitness and aquatic skills in children with and without autism spectrum disorders. 5:657-665\u003c/li\u003e\n\u003cli\u003eLanning BA, Baier MEM, Ivey-Hatz J, Krenek N, Tubbs JDJJoa, disorders d (2014) Effects of equine assisted activities on autism spectrum disorder. 44:1897-1907\u003c/li\u003e\n\u003cli\u003eBahrami F, Movahedi A, Marandi SM, Sorensen CJJoa, disorders d (2016) The effect of karate techniques training on communication deficit of children with autism spectrum disorders. 46:978-986\u003c/li\u003e\n\u003cli\u003eBorgi M, Loliva D, Cerino S, Chiarotti F, Venerosi A, Bramini M, Nonnis E, Marcelli M, Vinti C, De Santis CJJoa, disorders d (2016) Effectiveness of a standardized equine-assisted therapy program for children with autism spectrum disorder. 46:1-9\u003c/li\u003e\n\u003cli\u003eHarris A, Williams JMJIjoer, health p (2017) The impact of a horse riding intervention on the social functioning of children with autism spectrum disorder. 14:776\u003c/li\u003e\n\u003cli\u003eSotoodeh MS, Arabameri E, Panahibakhsh M, Kheiroddin F, Mirdoozandeh H, Ghanizadeh AJCTiCP (2017) Effectiveness of yoga training program on the severity of autism. 28:47-53\u003c/li\u003e\n\u003cli\u003eZachor DA, Vardi S, Baron‐Eitan S, Brodai‐Meir I, Ginossar N, Ben‐Itzchak EJDM, Neurology C (2017) The effectiveness of an outdoor adventure programme for young children with autism spectrum disorder: a controlled study. 59:550-556\u003c/li\u003e\n\u003cli\u003eCaputo G, Ippolito G, Mazzotta M, Sentenza L, Muzio MR, Salzano S, Conson MJJoa, disorders d (2018) Effectiveness of a multisystem aquatic therapy for children with autism spectrum disorders. 48:1945-1956\u003c/li\u003e\n\u003cli\u003eComan DC, Bass MP, Alessandri M, Ghilain CS, Llabre MMJs, animals (2018) Effect of equine-assisted activities on social and sensory functioning of children with autism. 26:551-575\u003c/li\u003e\n\u003cli\u003eNajafabadi MG, Sheikh M, Hemayattalab R, Memari A-H, Aderyani MR, Hafizi SJP, Neonatology (2018) The effect of SPARK on social and motor skills of children with autism. 59:481-487\u003c/li\u003e\n\u003cli\u003eZhao M, Chen SJBri (2018) The effects of structured physical activity program on social interaction and communication for children with autism. 2018\u003c/li\u003e\n\u003cli\u003eArabi M, Kakhki AS, Sohrabi M, Kouhbanani SS, Nooghabi MJJND, Treatment (2019) Is visuomotor training an effective intervention for children with autism spectrum disorders? 15:3089\u003c/li\u003e\n\u003cli\u003eSarabzadeh M, Azari BB, Helalizadeh MJJob, therapies m (2019) The effect of six weeks of Tai Chi Chuan training on the motor skills of children with Autism Spectrum Disorder. 23:284-290\u003c/li\u003e\n\u003cli\u003eRafiei Milajerdi H, Sheikh M, Najafabadi MG, Saghaei B, Naghdi N, Dewey DJGfhj (2021) The effects of physical activity and exergaming on motor skills and executive functions in children with autism spectrum disorder. 10:33-42\u003c/li\u003e\n\u003cli\u003eTSE AC, Anderson DI, Liu VH, Tsui SSJM, Sports Si, Exercise (2021) Improving executive function of children with autism spectrum disorder through cycling skill acquisition. 53:1417-1424\u003c/li\u003e\n\u003cli\u003eHassani F, Shahrbanian S, Shahidi SH, Sheikh MJIJoDD (2022) Playing games can improve physical performance in children with autism. 68:219-226\u003c/li\u003e\n\u003cli\u003eBrunner DL, Seung HJCDQ (2009) Evaluation of the efficacy of communication-based treatments for autism spectrum disorders: A literature review. 31:15-41\u003c/li\u003e\n\u003cli\u003eWard SC, Whalon K, Rusnak K, Wendell K, Paschall NJJoa, disorders d (2013) The association between therapeutic horseback riding and the social communication and sensory reactions of children with autism. 43:2190-2198\u003c/li\u003e\n\u003cli\u003eCasey AF, Quenneville-Himbeault G, Normore A, Davis H, Martell SGJPPT (2015) A therapeutic skating intervention for children with autism spectrum disorder. 27:170-177\u003c/li\u003e\n\u003cli\u003eBest JRJDr (2010) Effects of physical activity on children\u0026rsquo;s executive function: Contributions of experimental research on aerobic exercise. 30:331-351\u003c/li\u003e\n\u003cli\u003eMoriguchi YJFip (2014) The early development of executive function and its relation to social interaction: a brief review. 5:388\u003c/li\u003e\n\u003cli\u003eShields GS, Sazma MA, Yonelinas APJN, Reviews B (2016) The effects of acute stress on core executive functions: A meta-analysis and comparison with cortisol. 68:651-668\u003c/li\u003e\n\u003cli\u003eTsatsoulis A, Fountoulakis SJAotNYAoS (2006) The protective role of exercise on stress system dysregulation and comorbidities. 1083:196-213\u003c/li\u003e\n\u003cli\u003eMcKercher CM, Schmidt MD, Sanderson KA, Patton GC, Dwyer T, Venn AJJAjopm (2009) Physical activity and depression in young adults. 36:161-164\u003c/li\u003e\n\u003cli\u003eGarcia D, Archer T, Moradi S, Andersson-Arnt\u0026eacute;n A-CJP (2012) Exercise frequency, high activation positive affect, and psychological well-being: beyond age, gender, and occupation. 3:328\u003c/li\u003e\n\u003cli\u003eDiamond A, Ling DSJDcn (2016) Conclusions about interventions, programs, and approaches for improving executive functions that appear justified and those that, despite much hype, do not. 18:34-48\u003c/li\u003e\n\u003cli\u003eBremer E, Cairney JJJoA, Disorders D (2020) Adaptive behavior moderates health-related pathways in children with autism spectrum disorder. 50:491-499\u003c/li\u003e\n\u003cli\u003eKeino H, Funahashi A, Keino H, Miwa C, Hosokawa M, Hayashi Y, Kawakita KJJoes (2009) Psycho-educational horseback riding to facilitate communication ability of children with pervasive developmental disorders. 20:79-88\u003c/li\u003e\n\u003cli\u003eWuang Y-P, Wang C-C, Huang M-H, Su C-YJAPAQ (2010) The effectiveness of simulated developmental horse-riding program in children with autism. 27:113-126\u003c/li\u003e\n\u003cli\u003eLloyd M, MacDonald M, Lord CJA (2013) Motor skills of toddlers with autism spectrum disorders. 17:133-146\u003c/li\u003e\n\u003cli\u003eBremer E, Balogh R, Lloyd MJA (2015) Effectiveness of a fundamental motor skill intervention for 4-year-old children with autism spectrum disorder: A pilot study. 19:980-991\u003c/li\u003e\n\u003cli\u003eLiu T, Fedak AT, Hamilton M (2016) Effect of physical activity on the stereotypic behaviors of children with autism spectrum disorder. \u003c/li\u003e\n\u003cli\u003eHiggins JPJhwc-ho (2008) Cochrane handbook for systematic reviews of interventions version 5.0. 1. The Cochrane Collaboration. \u003c/li\u003e\n\u003cli\u003eHillman CH, Erickson KI, Kramer AFJNrn (2008) Be smart, exercise your heart: exercise effects on brain and cognition. 9:58-65\u003c/li\u003e\n\u003cli\u003ePesce CJJoS, Psychology E (2012) Shifting the focus from quantitative to qualitative exercise characteristics in exercise and cognition research. 34:766-786\u003c/li\u003e\n\u003cli\u003eDiamond AJAosm, research (2015) Effects of physical exercise on executive functions: going beyond simply moving to moving with thought. 2:1011\u003c/li\u003e\n\u003cli\u003eSchmidt M, J\u0026auml;ger K, Egger F, Roebers CM, Conzelmann AJJoS, Psychology E (2015) Cognitively engaging chronic physical activity, but not aerobic exercise, affects executive functions in primary school children: a group-randomized controlled trial. 37:575-591\u003c/li\u003e\n\u003cli\u003eSrinivasan SM, Bhat ANJFiin (2013) A review of \u0026ldquo;music and movement\u0026rdquo; therapies for children with autism: embodied interventions for multisystem development. 7:22\u003c/li\u003e\n\u003cli\u003eSrinivasan SM, Kaur M, Park IK, Gifford TD, Marsh KL, Bhat ANJAr, treatment (2015) The effects of rhythm and robotic interventions on the imitation/praxis, interpersonal synchrony, and motor performance of children with autism spectrum disorder (ASD): a pilot randomized controlled trial. 2015\u003c/li\u003e\n\u003cli\u003eSrinivasan SM, Park IK, Neelly LB, Bhat ANJRiasd (2015) A comparison of the effects of rhythm and robotic interventions on repetitive behaviors and affective states of children with Autism Spectrum Disorder (ASD). 18:51-63\u003c/li\u003e\n\u003cli\u003eSrinivasan SM, Eigsti I-M, Gifford T, Bhat ANJRiasd (2016) The effects of embodied rhythm and robotic interventions on the spontaneous and responsive verbal communication skills of children with Autism Spectrum Disorder (ASD): A further outcome of a pilot randomized controlled trial. 27:73-87\u003c/li\u003e\n\u003cli\u003eFournier KA, Hass CJ, Naik SK, Lodha N, Cauraugh JHJJoa, disorders d (2010) Motor coordination in autism spectrum disorders: a synthesis and meta-analysis. 40:1227-1240\u003c/li\u003e\n\u003cli\u003eKasarpalkar NJ, Kothari ST, Dave UPJAon (2014) Brain-derived neurotrophic factor in children with autism spectrum disorder. 21:129\u003c/li\u003e\n\u003cli\u003eLangdon KD, Corbett DJN, repair n (2012) Improved working memory following novel combinations of physical and cognitive activity. 26:523-532\u003c/li\u003e\n\u003cli\u003eLobelo F, Stoutenberg M, Hutber AJBjosm (2014) The exercise is medicine global health initiative: a 2014 update. 48:1627-1633\u003c/li\u003e\n\u003cli\u003eThompson WR, Sallis R, Joy E, Jaworski CA, Stuhr RM, Trilk JLJAjolm (2020) Exercise is medicine. 14:511-523\u003c/li\u003e\n\u003cli\u003ePan C-Y, Tsai C-L, Chu C-H, Sung M-C, Ma W-Y, Huang C-YJPt (2016) Objectively measured physical activity and health-related physical fitness in secondary school-aged male students with autism spectrum disorders. 96:511-520\u003c/li\u003e\n\u003cli\u003eOlin SS, McFadden BA, Golem DL, Pellegrino JK, Walker AJ, Sanders DJ, Arent SMJM, Sports Si, Exercise (2017) The effects of exercise dose on stereotypical behavior in children with autism. 49:983-990\u003c/li\u003e\n\u003cli\u003eKaat AJ, Gadow KD, Lecavalier LJJoACP (2013) Psychiatric symptom impairment in children with autism spectrum disorders. 41:959-969\u003c/li\u003e\n\u003cli\u003eJoshi G, Faraone SV, Wozniak J, Petty C, Fried R, Galdo M, Furtak SL, McDermott K, Epstien C, Walker RJJoA, Disorders D (2014) Examining the clinical correlates of autism spectrum disorder in youth by ascertainment source. 44:2117-2126\u003c/li\u003e\n\u003cli\u003eSalazar F, Baird G, Chandler S, Tseng E, O\u0026rsquo;sullivan T, Howlin P, Pickles A, Simonoff EJJoa, disorders d (2015) Co-occurring psychiatric disorders in preschool and elementary school-aged children with autism spectrum disorder. 45:2283-2294\u003c/li\u003e\n\u003cli\u003eJoshi G, Faraone SV, Wozniak J, Tarko L, Fried R, Galdo M, Furtak SL, Biederman JJJoAD (2017) Symptom profile of ADHD in youth with high-functioning autism spectrum disorder: a comparative study in psychiatrically referred populations. 21:846-855\u003c/li\u003e\n\u003cli\u003eAntshel KM, Russo NJCpr (2019) Autism spectrum disorders and ADHD: Overlapping phenomenology, diagnostic issues, and treatment considerations. 21:1-11\u003c/li\u003e\n\u003cli\u003ePosserud MB, Skretting Solberg B, Engeland A, Haavik J, Klungs\u0026oslash;yr KJAPS (2021) Male to female ratios in autism spectrum disorders by age, intellectual disability and attention‐deficit/hyperactivity disorder. 144:635-646\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 2","content":"\u003cp\u003eTable 2 is available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"physical activity, exercise, ASD, children, Meta-Analysis","lastPublishedDoi":"10.21203/rs.3.rs-6484664/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6484664/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAutism Spectrum Disorder is a neurodevelopmental disorder with characteristic impairments including social and communication deficits, restricted interests, and repetitive behaviors. Physical activity has shown promise as a non-pharmacological intervention to improve motor skills, executive function, and social interaction in children with Autism Spectrum Disorder. However, existing studies often overlook age-specific effects. This study aims to evaluate the impact of physical activity on key functional domains in children with Autism Spectrum Disorder through meta-analysis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study conducted searches across four databases up to March 2024, to identify pertinent RCTs. The systematic screening, data extraction, quality assessment, and data analysis were independently conducted by two reviewers. A total of 19 studies were included in the analysis. A total of 609 participants were involved.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe findings indicated that physical activity interventions exhibit the potential to ameliorate relevant symptoms in children with ASD. Specifically, communication ability (SMD\u0026thinsp;=\u0026thinsp;0.58, 95%CI: 0.28, 0.87, p\u0026gt;0.05) and social ability (SMD\u0026thinsp;=\u0026thinsp;0.72, 95%CI: 0.43, 1.01, p\u0026lt;0.05) showed a moderate to large effect size. Large effect sizes were noted for motor ability (SMD\u0026thinsp;=\u0026thinsp;2.06, 95%CI:1.15, 2.96, p\u0026lt;0.05), whereas executive function (SMD\u0026thinsp;=\u0026thinsp;0.46, 95%CI:0.23, 0.69, p\u0026gt;0.05) exhibited a moderate effect size.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur investigation demonstrates that physical activity exerts a constructive influence on augmenting communication, social, motor, and executive function capabilities in children with ASD. However, disparities in optimal effects observed across communication, social, motor, and executive functioning outcomes are contingent upon intervention duration, frequency, and period.\u003c/p\u003e","manuscriptTitle":"Effects of physical activity on motor, communication, social, and executive function in children with autism spectrum disorder: A meta-analysis of randomized controlled trials","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 16:49:04","doi":"10.21203/rs.3.rs-6484664/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-13T19:01:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-13T18:28:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-11T16:43:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219361202441377019338737412402325171915","date":"2025-05-04T13:07:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57483491405030397213598478240935716443","date":"2025-05-02T08:45:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59692650396442782863285117226269514756","date":"2025-04-28T23:13:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-28T20:12:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-28T07:55:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-28T07:48:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Pediatrics","date":"2025-04-19T12:10:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"57c608f0-a7b6-494a-baeb-2dd4cd2b9ec0","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:01:17+00:00","versionOfRecord":{"articleIdentity":"rs-6484664","link":"https://doi.org/10.1007/s00431-025-06636-1","journal":{"identity":"european-journal-of-pediatrics","isVorOnly":false,"title":"European Journal of Pediatrics"},"publishedOn":"2025-12-11 15:57:30","publishedOnDateReadable":"December 11th, 2025"},"versionCreatedAt":"2025-05-07 16:49:04","video":"","vorDoi":"10.1007/s00431-025-06636-1","vorDoiUrl":"https://doi.org/10.1007/s00431-025-06636-1","workflowStages":[]},"version":"v1","identity":"rs-6484664","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6484664","identity":"rs-6484664","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}