Effects of VR interventions on pediatric ADHD: a systematic review, meta-analysis and exploratory machine-learning analysis.

Objective: To synthesize the effects of virtual reality (VR) interventions across clinically distinct ADHD-related outcome domains in children and adolescents, compare the pattern of effects across these domains, and examine the robustness, certainty, and potential sources of between-study heterogeneity. Methods: PubMed, Embase, Web of Science Core Collection, IEEE Xplore, CENTRAL, ScienceDirect, and CNKI were searched for randomized controlled trials and controlled quasi-experimental studies of VR interventions in children and adolescents with ADHD. Outcomes were grouped into four clinical domains: ADHD/behavioral symptoms, executive/cognitive function, social/emotional function, and motor/visual-perceptual function. Random-effects meta-analyses within these domains were treated as the primary efficacy analyses, while an all-domain study-level composite was retained as a secondary descriptive synthesis. Safety, adherence/retention, and cybersickness were summarized at study level. Meta-regression and exploratory machine-learning analyses were used to investigate heterogeneity and were conducted separately from the meta-analytic pooling. Results: Thirteen studies involving 928 participants were included, of which 11 contributed to the quantitative syntheses. In the primary outcome-domain analyses, pooled Hedges' g values were 0.49 (95% CI -0.59 to 1.57) for ADHD/behavioral symptoms, 1.15 (95% CI 0.38 to 1.92) for executive/cognitive function, 0.51 (95% CI 0.08 to 0.93) for social/emotional function, and 0.88 (95% CI 0.02 to 1.74) for motor/visual-perceptual function. The dependence-adjusted comparison did not identify differences among domains (p = 0.624), and under Hartung-Knapp inference only the executive/cognitive confidence interval remained above zero. The secondary all-domain synthesis yielded g = 0.98 (95% CI 0.47 to 1.50), with substantial heterogeneity (I² = 91.7%) and a prediction interval spanning the null (-0.69 to 2.65). Exploratory subgroup, meta-regression, and machine-learning analyses did not identify reliable explanations for heterogeneity. Safety and adherence reporting was heterogeneous; no serious intervention-related adverse event was reported among studies reporting safety, but event incidence could not be estimated. GRADE certainty was very low across all four outcome domains. Conclusion: Domain-specific syntheses identified positive signals for executive/cognitive, social/emotional, and motor/visual-perceptual outcomes, with the clearest support for executive/cognitive function, whereas the ADHD/behavioral estimate remained uncertain. These findings support further evaluation of VR as an adjunctive intervention, although the current evidence does not support domain superiority or consistent effects across settings. The small and heterogeneous evidence base, substantial risk of bias, and very low GRADE certainty limit confidence in the magnitude and reproducibility of the observed effects. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD420261405127.