The impact of exercise in improving executive function impairments among children and adolescents with ADHD, autism spectrum disorder, and fetal alcohol spectrum disorder: a systematic review and meta-analysis

Abstract Objective: he goal of this work was to perform a systematic review and meta-analysis evaluating and comparing exercise related improvements in various executive function (EF) domains among children and adolescents with attention-deficit hyperactivity disorder (ADHD), Autism Spectrum Disorders (ASD), and Fetal Alcohol Spectrum Disorders (FASD). Methods: A systematic literature research was conducted in PubMed, CENTRAL, and PsycInfo from October 1st, 2018 through January 30th, 2019 for original peer-reviewed articles investigating the relationship between exercise interventions and improvements in three domains of executive function (working memory, attention/set shifting, and response inhibition) among children and adolescents with ADHD, ASD, and FASD. Effect sizes (ES) were extracted and combined with random-effects meta-analytic methods. Covariates and moderators were then analyzed using meta-regression and subgroup analyses. Results: A total of 28 studies met inclusion criteria, containing information on 1,281 youth (N=1197 ADHD, N= 54 ASD, N=30 FASD). For ADHD, exercise interventions were associated with moderate improvements in attention/set-shifting (ES 0.38, 95% CI 0.01-0.75, k=14) and approached significance for working memory (ES 0.35, 95%CI −0.17-0.88, k=5) and response inhibition (ES 0.39, 95%CI −0.02-0.80, k=12). For ASD and FASD, exercise interventions were associated with large improvements in working memory (ES 1.36, 95%CI 1.08-1.64) and response inhibition (ES 0.78, 95%CI 0.21-1.35) and approached significance for attention/set-shifting (ES 0.69, 95% −0.28-1.66). There was evidence of substantial methodologic and substantive heterogeneity among studies. Sample size, mean age, study design, and the number or duration of intervention sessions did not significantly moderate the relationship between exercise and executive function. Conclusion: Exercise interventions among children and adolescents with neurodevelopmental disorders were associated with moderate improvements in executive function domains. Of note, studies of youth with ASD and FASD tended to report higher effect sizes compared to studies of youth with ADHD, albeit few existing studies. Exercise may be a potentially cost-effective and readily implementable intervention to improve executive function in these populations.

The Impact of Attachment-Disrupting Adverse Childhood Experiences on Child Behavioral Health.

OBJECTIVES: To describe patterns of overall, within-household, and community adverse childhood experiences (ACEs) among children in vulnerable neighborhoods and to identify which individual ACEs, over and above overall ACE level, predict need for behavioral health services. STUDY DESIGN: This was a cross-sectional study that used a sample of 257 children ages 3-16 years who were seeking primary care services with co-located mental healthcare services at 1 of 2 clinics in Chicago, Illinois. The outcome variable was need for behavioral health services (Pediatric Symptom Checklist score ≥28). The independent variables were ACEs, measured with an adapted, 28-item version of the Traumatic Events Screening Inventory. RESULTS: Six ACE items were individually predictive of a clinical-range Pediatric Symptom Checklist score after adjusting for sociodemographic covariates: emotional abuse or neglect (OR 2.93, 95% CI 1.32-6.52, P < .01), natural disaster (OR 3.89, 95% CI 1.18-12.76, P = .02), forced separation from a parent or caregiver (OR 2.95, 95% CI 1.50-5.83, P < .01), incarceration of a family member (OR 2.43, 95% CI 1.20-4.93, P = .01), physical attack (OR 2.84, 95% CI 1.32-6.11, P < .01), and community violence (OR 2.35, 95% CI 1.18-4.65, P = .01). After adjusting for overall ACE level, only 1 item remained statistically significant: forced separation from a parent or caregiver (OR 2.44, 95% CI 1.19-5.01, P = .02). CONCLUSIONS: ACEs that disrupt attachment relationships between children and their caregivers are a significant predictor of risk for child emotional or behavioral problems.

Postacute Care after Pediatric Hospitalizations for a Primary Mental Health Condition.

OBJECTIVES: To determine the proportion of US children hospitalized for a primary mental health condition who are discharged to postacute care (PAC); whether PAC discharge is associated with demographic, clinical, and hospital characteristics; and whether PAC use varies by state. STUDY DESIGN: Retrospective cohort study of a nationally representative sample of US acute care hospitalizations for children ages 2-20 years with a primary mental health diagnosis, using the 2009 and 2012 Kids' Inpatient Databases. Discharge to PAC was used as a proxy for transfer to an inpatient mental health facility. We derived adjusted logistic regression models to assess the association of patient and hospital characteristics with discharge to PAC. RESULTS: In 2012, 14.7% of hospitalized children (n = 248 359) had a primary mental health diagnosis. Among these, 72% (n = 178 214) had bipolar disorder, depression, or psychosis, of whom 4.9% (n = 8696) were discharged to PAC. The strongest predictors of PAC discharge were homicidal ideation (aOR, 24.9; 96% CI, 4.1-150.4), suicide and self-injury (aOR, 15.1; 95% CI, 11.7-19.4), and substance abuse-related medical illness (aOR, 5.0; 95% CI, 4.5-5.6). PAC use varied widely by state, ranging from 2.2% to 36.3%. CONCLUSIONS: The majority of children hospitalized primarily for a mood disorder or psychosis were not discharged to PAC, and safety-related conditions were the primary drivers of the relatively few PAC discharges. There was substantial state-to-state variation. Target areas for quality improvement include improving access to PAC for children hospitalized for mood disorders or psychosis and equitable allocation of appropriate PAC resources across states.