Effects of exercise on anxiety and psychiatric comorbidities in children with autism spectrum disorder: a systematic review and meta-analysis

Background Anxiety disorders affect nearly 40%–50% of children with autism spectrum disorder (ASD). While exercise benefits motor skills, its efficacy in modulating affective symptoms remains under-synthesized. This meta-analysis evaluated the effects of exercise on anxiety and co-occurring symptoms in pediatric ASD. Methods We analyzed data from 12 randomized controlled trials (RCTs) involving 482 participants. A three-level random effects model was utilized to account for effect size dependencies. Subgroup analyses examined the exercise modality and intensity. Results Exercise significantly reduced comorbid anxiety (Hedges’ g = −0.68, p < 0.001). Notably, aerobic exercise demonstrated the most substantial anxiolytic effect ( g = −1.18), outperforming other modalities. Improvements were also observed in the core ASD symptoms ( g = −0.56) and attention-deficit/hyperactivity disorder (ADHD)-related attention deficits ( g = −0.48). The effects on sleep were inconclusive due to heterogeneity. Conclusions Exercise, particularly aerobic interventions, serves as a potent non-pharmacological strategy for the management of anxiety and affective dysregulation in children with ASD. These findings support the integration of aerobic exercise into clinical treatment plans to improve emotional wellbeing. Systematic review registration https://www.crd.york.ac.uk/prospero/ , identifier CRD420251157119.