Abstract: Exergaming-a form of interactive digital game requiring physical movement—has emerged as a promising tool for improving executive functions (EFs) in children and adolescents. While previous meta-analyses have quantitatively synthesized the overall effectiveness of exergaming interventions, they have paid limited attention to how exergaming works (i.e., underlying mechanisms), for whom it works best, and under what conditions (i.e., moderators). This paper provides a comprehensive review and proposes a novel integrative framework to address these gaps.
A key innovation of this review is the proposal of a Triple‑Path Synergistic Hypothesis Model, which posits that exergaming enhances EFs through the dynamic interaction of three mechanistic pathways: (1) physiological arousal (e.g., increased heart rate, cerebral blood flow, and release of brain‑derived neurotrophic factor), (2) cognitive engagement (e.g., dual‑task demands, rule switching, and adaptive cognitive load), and (3) neural plasticity (e.g., enhanced prefrontal connectivity and experience‑dependent structural reorganization). Unlike prior work that has treated these mechanisms in isolation, our model explicitly integrates them and explains previously inconsistent findings. For example, the model resolves the apparent contradiction between studies showing that acute EF improvements depend primarily on exercise intensity versus those showing a primary role of cognitive engagement: in acute interventions, neural plasticity has not yet developed and stable cognitive strategies are absent, so benefits rely largely on physiological arousal; in contrast, improvements in higher‑order functions such as cognitive flexibility require activation of specific frontoparietal networks, making cognitive engagement indispensable.
A second major contribution is the systematic articulation of a multi‑level moderator framework spanning individual characteristics (age, baseline EF, body mass index), game attributes (cognitive load, exercise intensity, difficulty adaptation, interaction mode), intervention parameters (duration, frequency, period), and environmental settings (school, home, laboratory). This framework provides a unified explanation for the substantial heterogeneity observed across studies. For instance, intervention effects are larger in children with lower baseline EF (“low‑baseline, high‑gain” pattern), competitive game formats outperform cooperative ones, and younger children may benefit more from physiological arousal whereas adolescents gain more from cognitive challenge.
The review also identifies critical evidence gaps that shape future research priorities. First, most existing exergames are commercially developed for entertainment and lack systematic, adaptive cognitive loading targeting specific EF components. Second, dose-response relationships remain poorly understood; current studies vary widely in intervention parameters (1-12 weeks, 1-5 sessions/week, 10-60 min/session), and no consensus exists on optimal intensity, duration, or frequency for different age groups or EF subdomains. Third, external validity is limited due to small sample sizes, restricted sampling (mostly from specific schools or regions), and a near‑absence of studies in naturalistic home environments. Fourth, mechanistic evidence is fragmented; few studies include both pure cognitive training and pure physical exercise control groups, making it difficult to disentangle the unique contributions of cognitive versus physical components. Finally, longitudinal follow‑ups are rare, leaving the long‑term sustainability of EF gains unknown.
To advance the field, we propose five future directions: (1) developing personalized, adaptive exergames based on real‑time assessment of individual cognitive and physical states; (2) establishing dose-response models for acute, short‑term, and long-term interventions; (3) integrating immersive virtual reality technologies to enhance engagement and ecological validity; (4) conducting large‑scale, multi‑site, and home-based trials with representative samples; and (5) testing the Triple‑Path Synergistic Hypothesis Model using multi‑modal neuroimaging (e.g., fMRI, fNIRS, EEG) and rigorous experimental designs (including pure cognitive and pure physical control groups). By shifting the research question from “whether exergaming works” to “how, for whom, and under what conditions it works”, this framework aims to guide the development of scientifically grounded, precisely targeted exergaming interventions for cognitive health promotion in children and adolescents.

Key words: exergaming, intervention, executive function, children and adolescents