Effects of Geography on Risk for Future Suicidal Ideation and Attempts Among Children and Youth.

Objective: Geography may influence the relationships of predictors for suicidal ideation (SI) and suicide attempts (SA) in children and youth. Method: This is a nationwide retrospective cohort study of 124,424 individuals less than 25 years of age using commercial claims data (2011-2015) from the Health Care Cost Institute. Outcomes were time to SI or SA within 3 months after the indexed mental health or substance use disorder (MH/SUD) outpatient visit. Predictors included sociodemographic and clinical characteristics up to 3 years before the index event. Results: At each follow-up time period, rates of SI and SA varied by the US geographic division (p < .001), and the Mountain Division consistently had the highest rates for both SI and SA (5.44%-10.26% for SI; 0.70%-2.82% for SA). Having MH emergency department (ED) visits in the past year increased the risk of SI by 28% to 65% for individuals residing in the New England, Mid-Atlantic, East North Central, West North Central, and East South Central Divisions. The main effects of geographic divisions were significant for SA (p<0.001). Risk of SA was lower in New England, Mid-Atlantic, South Atlantic, and Pacific (hazard ratios = 0.57, 0.51, 0.67, and 0.79, respectively) and higher in the Mountain Division (hazard ratio = 1.46). Conclusion: To understand the underlying mechanisms driving the high prevalence of SI and SA in the Mountain Division and the elevated risk of SI after having MH ED visits, future research examining regional differences in risks for SI and SA should include indicators of access to MH ED care and other social determinants of health.

Assessing Detection of Children With Suicide-Related Emergencies: Evaluation and Development of Computable Phenotyping Approaches.

BACKGROUND: Although suicide is a leading cause of death among children, the optimal approach for using health care data sets to detect suicide-related emergencies among children is not known. OBJECTIVE: This study aimed to assess the performance of suicide-related International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and suicide-related chief complaint in detecting self-injurious thoughts and behaviors (SITB) among children compared with clinician chart review. The study also aimed to examine variations in performance by child sociodemographics and type of self-injury, as well as develop machine learning models trained on codified health record data (features) and clinician chart review (gold standard) and test model detection performance. METHODS: A gold standard classification of suicide-related emergencies was determined through clinician manual review of clinical notes from 600 emergency department visits between 2015 and 2019 by children aged 10 to 17 years. Visits classified with nonfatal suicide attempt or intentional self-harm using the Centers for Disease Control and Prevention surveillance case definition list of ICD-10-CM codes and suicide-related chief complaint were compared with the gold standard classification. Machine learning classifiers (least absolute shrinkage and selection operator-penalized logistic regression and random forest) were then trained and tested using codified health record data (eg, child sociodemographics, medications, disposition, and laboratory testing) and the gold standard classification. The accuracy, sensitivity, and specificity of each detection approach and relative importance of features were examined. RESULTS: SITB accounted for 47.3% (284/600) of the visits. Suicide-related diagnostic codes missed nearly one-third (82/284, 28.9%) and suicide-related chief complaints missed more than half (153/284, 53.9%) of the children presenting to emergency departments with SITB. Sensitivity was significantly lower for male children than for female children (0.69, 95% CI 0.61-0.77 vs 0.84, 95% CI 0.78-0.90, respectively) and for preteens compared with adolescents (0.66, 95% CI 0.54-0.78 vs 0.86, 95% CI 0.80-0.92, respectively). Specificity was significantly lower for detecting preparatory acts (0.68, 95% CI 0.64-0.72) and attempts (0.67, 95% CI 0.63-0.71) than for detecting ideation (0.79, 95% CI 0.75-0.82). Machine learning-based models significantly improved the sensitivity of detection compared with suicide-related codes and chief complaint alone. Models considering all 84 features performed similarly to models considering only mental health-related ICD-10-CM codes and chief complaints (34 features) and models considering non-ICD-10-CM code indicators and mental health-related chief complaints (53 features). CONCLUSIONS: The capacity to detect children with SITB may be strengthened by applying a machine learning-based approach to codified health record data. To improve integration between clinical research informatics and child mental health care, future research is needed to evaluate the potential benefits of implementing detection approaches at the point of care and identifying precise targets for suicide prevention interventions in children.

Timing of Mental Health Service Use After a Pediatric Firearm Injury.

OBJECTIVES: To examine how timing of the first outpatient mental health (MH) visit after a pediatric firearm injury varies by sociodemographic and clinical characteristics. METHODS: We retrospectively studied children aged 5 to 17 years with a nonfatal firearm injury from 2010 to 2018 using the IBM Watson MarketScan Medicaid database. Logistic regression estimated the odds of MH service use in the 6 months after injury, adjusted for sociodemographic and clinical characteristics. Cox proportional hazard models, stratified by previous MH service use, evaluated variation in timing of the first outpatient MH visit by sociodemographic and clinical characteristics. RESULTS: After a firearm injury, 958 of 2613 (36.7%) children used MH services within 6 months; of these, 378 of 958 (39.5%) had no previous MH service use. The adjusted odds of MH service use after injury were higher among children with previous MH service use (adjusted odds ratio, 10.41; 95% confidence interval [CI], 8.45-12.82) and among non-Hispanic white compared with non-Hispanic Black children (adjusted odds ratio, 1.29; 95% CI, 1.02-1.63). The first outpatient MH visit after injury occurred sooner among children with previous MH service use (adjusted hazard ratio, 6.32; 95% CI, 5.45-7.32). For children without previous MH service use, the first MH outpatient visit occurred sooner among children with an MH diagnosis made during the injury encounter (adjusted hazard ratio, 2.72; 95% CI, 2.04-3.65). CONCLUSIONS: More than 3 in 5 children do not receive MH services after firearm injury. Previous engagement with MH services and new detection of MH diagnoses during firearm injury encounters may facilitate timelier connection to MH services after injury.

Availability of LGBTQ Mental Health Services for US Youth, 2014 to 2020.

This survey study reports the variability of lesbian, gay, bisexual, transgender, queer (LGBTQ) youth­specific mental health care in the US from 2014 to 2020.

Editorial: Global Widening of the Inequitable Child and Adolescent Mental Health Care Chasm During COVID-19.

The long-standing and inequitable chasm between clinical need and child and adolescent mental health care has likely widened during the COVID-19 pandemic, especially for children and adolescents in developing low- and middle-income countries (LMICs). Internationally, the risk for suicidal behaviors among young people rose, while timely access to care worsened.1 People in LMICs are envisioned to be precariously positioned within a perfect storm characterized by greater exposure to life-threatening COVID-19-related social determinants of health that also pose higher risk of new and recurrent mental disorders.2 In this issue of the Journal, the study by Wong et al.3 is the first international study to report a substantial rise in emergency department (ED) visits for any psychiatric disorder and self-harm among children and adolescents after the onset of the COVID-19 pandemic. Using a retrospective cohort study design, ED visits for any psychiatric disorder and self-harm were compared between March-April of 2019 (prepandemic), 2020 (early pandemic), and 2021 (later pandemic), with the most recent time interval corresponding to the "third wave of the pandemic worldwide." The total sample included 8,174 psychiatric ED visits to 62 emergency units in 25 countries, including developing countries with lower-middle, upper-middle, and high incomes as well as developed countries with upper-middle and high incomes. Of these, 3,865 psychiatric ED visits in 13 countries had data for all time intervals. Using the complete data, compared with March-April 2019, the rate of ED visits for any psychiatric disorder was lower in March-April 2020, consistent with the abrupt drop reported in the United States that broadly aligns with statewide school closures and shelter in place orders.4,5 However, when comparing early pandemic with later pandemic time intervals matched by months, the rates for any psychiatric and self-harm ED visits were twice as high. Despite the sharp drop following the onset of the pandemic, when compared with the prepandemic time interval, the overall rates of ED visits for any psychiatric diagnosis and self-harm during the later pandemic were 50% and 70% higher, respectively. Girls were also at greater risk for self-harm ED visits following the onset of the COVID-19 pandemic. Compared with the prepandemic time interval matched by months, girls had almost twice the odds of a self-harm ED visit in March-April 2021. The international rise in self-harm ED visits likely driven by the increases among girls is also consistent with prior US studies.4,5.

Medications for Alcohol Use Disorder and Retention in Care in Medicaid-Enrolled Youth, 2014-2019.

PURPOSE: Alcohol use disorder (AUD) is a pediatric-onset condition needing timely, effective treatment. Medications for AUD are part of nationally recommended treatments for youth. This study measured receipt of medications and behavioral health services for AUD and subsequent retention in care. METHODS: This retrospective cohort study used claims data from > 4.7 million publicly insured youth aged 13-22 years in 15 states from 2014-2019. Timely treatment was defined as receipt of medication (naltrexone, acamprosate, or disulfiram) and/or behavioral health services within 30 days of incident AUD diagnosis. Associations of age and other characteristics with timely treatment were identified using modified Poisson regression. Retention in care (i.e., no period ≥ 60 days without claims) was studied using Cox regression. RESULTS: Among 14,194 youth with AUD, 10,851 (76.4%) received timely treatment. Only 2.1% of youth received medication (alone or in combination); nearly all (97.9%) received behavioral health services only. Older (aged 16-17 years) and younger adolescents (aged 13-15 years) were 0.13 (95% confidence interval [CI], 0.07-0.26) and 0.24 (95% CI, 0.11-0.51) times as likely, respectively, to receive medications than young adults aged ≥ 21 years. Median retention in care for youth receiving medications was 119 days (interquartile range, 54-321) compared with 108 days (interquartile range, 43-243) for behavioral health services alone (p = .126). Young adults aged ≥ 18 years were 1.12 (95% CI, 1.06-1.18) times as likely to discontinue treatment compared with adolescents aged < 18 years. DISCUSSION: This study found that more than seven in 10 youth received AUD treatment but only two in 100 received medications. Future studies should further characterize the effectiveness of medications and determine whether low rates of receipt represent underuse.

Study Preregistration: Measuring What Matters: Development and Dissemination of a Core Outcome Set for Pediatric Anxiety Disorders Clinical Trials.

Pediatric anxiety disorders (AD) are prevalent disorders with an impact on all aspects of a child's life and functioning.1 Although evidence supports commonly used treatments, there are notable concerns with the research to date.2 Heterogeneity in outcome selection, measurement, analysis, and reporting is a contributing factor to the hinderance of the translation of research into clinical practice.3 Recognition for outcome standardization in pediatric mental health disorders is evolving and there are several initiatives of importance, including the International Consortium for Health Outcomes Measurement (ICHOM), which has developed standardized outcome sets for use in the routine clinical mental health treatment of children and adolescents.4 Similarly, the International Alliance of Mental Health Research Funders5 advocate for use of 1 specific outcome measurement instrument (OMI) in the youth mental health research that they fund. Development of a Core Outcome Set (COS), a minimal set of outcomes that should be measured and reported in clinical trials, has been a solution in other areas of medicine to address heterogeneity in outcome selection and measurement across trials.6 The Core Outcomes and Measures in Pediatric Anxiety Clinical Trials (COMPACT) Initiative will develop a harmonized, evidence- and consensus-based COS that is meaningful to youth and families for use in future trials in pediatric AD.

Follow-up After Pediatric Mental Health Emergency Visits.

OBJECTIVES: To examine how outpatient mental health (MH) follow-up after a pediatric MH emergency department (ED) discharge varies by patient characteristics and to evaluate the association between timely follow-up and return encounters. METHODS: We conducted a retrospective study of 28 551 children aged 6 to 17 years with MH ED discharges from January 2018 to June 2019, using the IBM Watson MarketScan Medicaid database. Odds of nonemergent outpatient follow-up, adjusted for sociodemographic and clinical characteristics, were estimated using logistic regression. Cox proportional hazard models were used to evaluate the association between timely follow-up and risk of return MH acute care encounters (ED visits and hospitalizations). RESULTS: Following MH ED discharge, 31.2% and 55.8% of children had an outpatient MH visit within 7 and 30 days, respectively. The return rate was 26.5% within 6 months. Compared with children with no past-year outpatient MH visits, those with ≥14 past-year MH visits had 9.53 odds of accessing follow-up care within 30 days (95% confidence interval [CI], 8.75-10.38). Timely follow-up within 30 days was associated with a 26% decreased risk of return within 5 days of the index ED discharge (hazard ratio, 0.74; 95% CI, 0.63-0.91), followed by an increased risk of return thereafter. CONCLUSIONS: Connection to outpatient care within 7 and 30 days of a MH ED discharge remains poor, and children without prior MH outpatient care are at highest risk for poor access to care. Interventions to link to outpatient MH care should prioritize follow-up within 5 days of an MH ED discharge.

Mental Health Care Following Firearm and Motor Vehicle-related Injuries: Differences Impacting Our Treatment Strategies.

OBJECTIVE: To compare new mental health diagnoses (NMHD) in children after a firearm injury versus following a motor vehicle collision (MVC). BACKGROUND: A knowledge gap exists regarding childhood mental health diagnoses following firearm injuries, notably in comparison to other forms of traumatic injury. METHODS: We utilized Medicaid MarketScan claims (2010-2016) to conduct a matched case-control study of children ages 3 to 17 years. Children with firearm injuries were matched with up to 3 children with MVC injuries. Severity was determined by injury severity score and emergency department disposition. We used multivariable logistic regression to measure the association of acquiring a NMHD diagnosis in the year postinjury after firearm and MVC mechanisms. RESULTS: We matched 1450 children with firearm injuries to 3691 children with MVC injuries. Compared to MVC injuries, children with firearm injuries were more likely to be black, have higher injury severity score, and receive hospital admission from the emergency department ( P <0.001). The adjusted odds ratio (aOR) of NMHD diagnosis was 1.55 [95% confidence interval (95% CI): 1.33-1.80] greater after firearm injuries compared to MVC injuries. The odds of a NMHD were higher among children admitted to the hospital compared to those discharged. The increased odds of NMHD after firearm injuries was driven by increases in substance-related and addictive disorders (aOR: 2.08; 95% CI: 1.63-2.64) and trauma and stressor-related disorders (aOR: 2.07; 95% CI: 1.55-2.76). CONCLUSIONS: Children were found to have 50% increased odds of having a NMHD in the year following a firearm injury as compared to MVC. Programmatic interventions are needed to address children's mental health following firearm injuries.

Mental Health-Related Emergency Department Visits Among Children During The Early COVID-19 Pandemic.

Objective: To measure univariate and covariate-adjusted trends in children's mental health-related emergency department (MH-ED) use across geographically diverse areas of the U.S. during the first wave of the Coronavirus-2019 (COVID-19) pandemic. Method: This is a retrospective, cross-sectional cohort study using electronic health records from four academic health systems, comparing percent volume change and adjusted risk of child MH-ED visits among children aged 3-17 years, matched on 36-week (3/18/19-11/25/19 vs. 3/16/20-11/22/20) and 12-week seasonal time intervals. Adjusted incidence rate ratios (IRR) were calculated using multivariate Poisson regression. Results: Visits declined during spring-fall 2020 (n = 3892 vs. n = 5228, -25.5%) and during spring (n = 1051 vs. n = 1839, -42.8%), summer (n = 1430 vs. n = 1469, -2.6%), and fall (n = 1411 vs. n = 1920, -26.5%), compared with 2019. There were greater declines among males (28.2% vs. females -22.9%), children 6-12-year (-28.6% vs. -25.9% for 3-5 years and -22.9% for 13-17 years), and Black children (-34.8% vs. -17.7% to -24.9%). Visits also declined for developmental disorders (-17.0%) and childhood-onset disorders (e.g., attention deficit and hyperactivity disorders; -18.0%). During summer-fall 2020, suicide-related visits rose (summer +29.8%, fall +20.4%), but were not significantly elevated from 2019 when controlling for demographic shifts. In contrast, MH-ED use during spring-fall 2020 was significantly reduced for intellectual disabilities (IRR 0.62 [95% CI 0.47-0.86]), developmental disorders (IRR 0.71 [0.54-0.92]), and childhood-onset disorders (IRR 0.74 [0.56-0.97]). Conclusions: The early pandemic brought overall declines in child MH-ED use alongside co-occurring demographic and diagnostic shifts. Children vulnerable to missed detection during instructional disruptions experienced disproportionate declines, suggesting need for future longitudinal research in this population.

Use of Acute Mental Health Care in U.S. Children's Hospitals Before and After Statewide COVID-19 School Closure Orders.

Objective: This study aimed to examine changes in child emergency department (ED) discharges and hospitalizations for primary general medical (GM) and primary psychiatric disorders; prevalence of psychiatric disorders among acute care encounters; and change in acute mental health (MH) care encounters by disorder type and, within these categories, by child sociodemographic characteristics before and after statewide COVID-19­related school closure orders. Methods: This retrospective, cross-sectional cohort study used the Pediatric Health Information System database to assess percent changes in ED discharges and hospitalizations (N=2,658,474 total encounters) among children ages 3­17 years in 44 U.S. children's hospitals in 2020 compared with 2019, by using matched data for 36- and 12-calendar-week intervals. Results: Decline in MH ED discharges accounted for about half of the decline in ED discharges and hospitalizations for primary GM disorders (−24.8% vs. −49.1%), and MH hospitalizations declined 3.4 times less (−8.0% vs. −26.8%) in 2020. Suicide attempt or self-injury and depressive disorders accounted for >50% of acute MH care encounters before and after the statewide school closures. The increase in both ED discharges and hospitalizations for suicide attempt or self-injury was 5.1 percentage points (p<0.001). By fall 2020, MH hospitalizations for suicide attempt or self-injury rose by 41.7%, with a 43.8% and 49.2% rise among adolescents and girls, respectively. Conclusions: Suicide or self-injury and depressive disorders drove acute MH care encounters in 44 U.S. children's hospitals after COVID-19­related school closures. Research is needed to identify continuing risk indicators (e.g., sociodemographic characteristics, psychiatric disorder types, and social determinants of health) of acute child MH care.

Overview of Ten Child Mental Health Clinical Outcome Measures: Testing of Psychometric Properties with Diverse Client Populations in the U.S.

While many standardized assessment measures exist to track child mental health treatment outcomes, the degree to which such tools have been adequately tested for reliability and validity across race, ethnicity, and class is uneven. This paper examines the corpus of published tests of psychometric properties for the ten standardized measures used in U.S. child outpatient care, with focus on breadth of testing across these domains. Our goal is to assist care providers, researchers, and legislators in understanding how cultural mismatch impacts measurement accuracy and how to select tools appropriate to the characteristics of their client populations. We also highlight avenues of needed research for measures that are in common use. The list of measures was compiled from (1) U.S. state Department of Mental Health websites; (2) a survey of California county behavioral health agency directors; and (3) exploratory literature scans of published research. Ten measures met inclusion criteria; for each one a systematic review of psychometrics literature was conducted. Diversity of participant research samples was examined as well as differences in reliability and validity by gender, race or ethnicity, and socio-economic class. All measures showed adequate reliability and validity, however half lacked diverse testing across all three domains and all lacked testing with Asian American/Pacific Islander and Native American children. ASEBA, PSC, and SDQ had the broadest testing.

Prolonged Emergency Department Length of Stay for US Pediatric Mental Health Visits (2005-2015).

BACKGROUND AND OBJECTIVES: Children seeking care in the emergency department (ED) for mental health conditions are at risk for prolonged length of stay (LOS). A more contemporary description of trends and visit characteristics associated with prolonged ED LOS at the national level is lacking in the literature. Our objectives were to (1) compare LOS trends for pediatric mental health versus non-mental health ED visits and (2) explore patient-level characteristics associated with prolonged LOS for mental health ED visits. METHODS: We conducted an observational analysis of ED visits among children 6 to 17 years of age using the National Hospital Ambulatory Medical Care Survey (2005-2015). We assessed trends in rates of prolonged LOS and the association between prolonged LOS and demographic and clinical characteristics (race and ethnicity, payer type, and presence of a concurrent physical health diagnosis) using descriptive statistics and survey-weighted logistic regression. RESULTS: From 2005 to 2015, rates of prolonged LOS for pediatric mental health ED visits increased over time from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours), in contrast to non-mental health visits for which LOS remained stable. For mental health visits, Hispanic ethnicity was associated with an almost threefold odds of LOS >12 hours (odds ratio 2.74; 95% confidence interval 1.69-4.44); there was no difference in LOS by payer type. CONCLUSIONS: The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care. Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.

Editors' Note and Special Communication: Research Priorities in Child and Adolescent Mental Health Emerging From the COVID-19 Pandemic.

Over the last year, the coronavirus disease 2019 (COVID-19) pandemic has resulted in profound disruptions across the globe, with school closures, social isolation, job loss, illness, and death affecting the lives of children and families in myriad ways. In an Editors' Note in our June 2020 issue,1 our senior editorial team described this Journal's role in advancing knowledge in child and adolescent mental health during the pandemic and outlined areas we identified as important for science and practice in our field. Since then, the Journal has published articles on the impacts of the pandemic on child and adolescent mental health and service systems,2-5 which are available in a special collection accessible through the Journal's website.6 Alongside many opinion papers, the pace of publication of empirical research in this area is rapidly expanding, covering important issues such as increased frequency of mental health symptoms among children and adolescents3,5,7-10 and changes in patterns of clinical service use such as emergency department visits.11-14 As the Senior Editors prepared that Editors' Note, they were acutely aware that the priorities that they identified were broad and generated by only a small group of scientists and clinicians. Although this had the advantage of enabling us to get this information out to readers quickly, we decided that a more systematic approach to developing recommendations for research priorities would be of greater long-term value. We were particularly influenced by the efforts of the partnership between the UK Academy of Medical Scientists and a UK mental health research charity (MQ: Transforming Mental Health) to detail COVID-19-related research priorities for "Mental Health Science" that was published online by Holmes et al. in The Lancet Psychiatry in April 2020.15 Consistent with its focus on mental health research across the lifespan, several recommendations highlighted child development and children's mental health. However, a more detailed assessment of research priorities related to child and adolescent mental health was beyond the scope of that paper. Furthermore, the publication of that position paper preceded the death of George Floyd at the hands of Minneapolis police on May 25, 2020, which re-energized efforts to acknowledge and to address racism and healthcare disparities in the United States and many other countries. To build upon the JAACAP Editors' Note1 and the work of Holmes et al.,15 we conducted an international survey of professionals-practitioners and researchers-working on child and adolescent development and pediatric mental health to identify concerns about the impact of the pandemic on children, adolescents, and their families, as well as what is helping families navigate these impacts, and the specific research topics that are of greatest importance.

Editorial: The Cost of Comorbid Child Psychiatric Disorders: A National Call to Achieve the Triple Aim for Child Mental Health Care.

The National Quality Strategy to transform the US health care system is predicated upon Donald Berwick et al.'s "Triple Aim" envisioning the simultaneous pursuit of improved care, better population health, and reduced costs.1 More recently, emphasis has been placed on improving the value of health care as defined by "achieving the best patient health outcomes (quality + experience) at the lowest cost."2 US health care expenditures are projected to grow at an average annual rate of 5.4% during this decade, reaching 19.7% of the gross domestic product or an estimated 6.1 billion dollars by 2028.3 Compared with 36 high-income countries, including Canada, the US spends nearly twice as much on health care yet has the lowest life expectancy and highest suicide rate.4 However, solely targeting reduction in mental health care costs is not a solution, because the mental and general health care systems are inextricably linked5 and for children span multiple care sectors (eg, schools, child welfare, juvenile justice). In this issue of the Journal, Ansari et al.6 validates the complexity of physically ill children with a comorbid psychiatric disorder among more than 50,000 admissions to an acute-care pediatric specialty hospital within Canada's publicly funded health care system. Almost one out of 10 admissions for a physical illness had a documented comorbid psychiatric disorder, which is consistent with US pediatric hospital discharges.7 Children who were older, more clinically complex, and with prior hospitalizations were more likely to be among inpatient admissions with a comorbid psychiatric disorder. With outstanding methodologic rigor, the data suggest that pediatric inpatient admissions with comorbid psychiatric disorders had a nearly 10% longer length of stay and higher costs per admission compared with inpatient admissions without a comorbid psychiatric disorder---a difference in total cumulative costs of more than CAN$11.3 million (equivalent of about US$8.4 million).

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.