Does Cognitively Enhanced Physical Activity Improve Executive Functions in Preschool Children? A Systematic Review and Meta-Analysis

Does Cognitively Enhanced Physical Activity Improve Executive Functions in Preschool Children? 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A Systematic Review and Meta-Analysis Nemanja Lakicevic, Marko Manojlovic, Ambra Gentile, Antonino Bianco, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6871020/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Executive functions (EFs) predict school readiness and academic achievement in young children. Cognitively enhanced physical activity (CEPA), defined as physical activity (PA) combined with concurrent cognitive tasks, may substantially enhance EFs in preschool-aged children. Given that EFs are crucial for children’s intellectual development and later achievements in life, we sought to systematically review the literature on the effects of CEPA on EFs in preschool children following the PRISMA 2020 guidelines. Web of Science, PubMed and APA PsycINFO were systematically searched from inception to June 2024 for the relevant literature using predetermined keywords. Only randomized controlled trials that had performed CEPA in healthy preschool children and evaluated EFs were included. Quality appraisal of the included studies was assessed via Cochrane RoB2 tool. Eight studies comprised of 838 participants met the inclusion criteria and were analysed. The most consistent improvements in EFs were found in exergaming studies, which fostered CEPA through interactive video games adjusted for preschool children. The meta-analysis revealed that CEPA programs led to significantly better EFs outcomes in children than control conditions, with longer program durations yielding the greatest improvements. Future research should compare the effect sizes of CEPA, standard PA, and isolated cognitive training in preschool populations. physical activity cognition working memory inhibition cognitive flexibility motor skills kindergarten Figures Figure 1 Introduction As the name implies, the role of preschool institutions such as kindergartens is to prepare children for school. Thus, the key at this age is to develop a set of valuable habits and skills that will provide children with the necessary tools to thrive in the classroom once they reach school age. Among the most important skills for children to achieve academic success and properly develop as pupils is cultivating executive functions (EFs) (Cowan, 2014). Executive functions are broadly defined as goal-oriented behavior that includes competencies such as goal setting, time management, project monitoring, and organizing and prioritizing materials, all of which are relevant for successful learning and are thus prerequisites for academic success (Paschen et al., 2019). The three components of EFs that are interrelated and in constant interplay with each other are working memory (WM), inhibition, and cognitive flexibility (CF) (Diamond, 2013). Working memory (also called updating) refers to the temporary maintenance and information handling and retrieval of task-pertinent information over a short time frame ( 3 ). Inhibition (also called inhibitory control) is characterized by an intentional suppression of distracting stimuli (either interoceptive or exteroceptive) to manage attention, behavior, thoughts, and emotions (Diamond, 2013). Cognitive flexibility (also called switching of shifting) pertains to changing the focus of attention to rapidly switch perspectives and promptly adapt to new task-determined needs such as demands, rules, or priorities (Diamond, 2013). Therefore, using EFs requires significant effort (Zakharova & Machinskaya, 2023), as resisting distractions and staying focused on goal-directed actions is inherently more difficult than succumbing to them. This type of behaviour might be particularly difficult for preschool children, given their young age and unawareness of the consequences of their behaviour. Well-developed EFs are crucial for predicting young children's school readiness (Blair & Diamond, 2008; Roebers et al., 2014; Shaul & Schwartz, 2014) and academic success (Best et al., 2011; A. Veraksa et al., 2023; A. N. Veraksa et al., 2018). Thus, although complex (due to the dynamic nature and inextricable links of WM, inhibition, and CF) (Isquith et al., 2005), assessing EFs in preschool children is needed to determine the quality of parental and kindergarten care concerning EFs (Silva et al., 2022), which enables the strategic development of EFs subsequently. Among others, an intervention that has been shown to be particularly effective in improving EFs in preschool children both immediately (single-bout) and chronically (repeated bouts) is physical activity (PA) (Donnelly et al., 2016; Li et al., 2020), with a dose-response relationship (Hsieh et al., 2018), likely through beneficial effects on brain structure and function, such as increased neural activation and microstructural plasticity (Zhou et al., 2024). In preschool children, supervised PA interventions can increase attention, inhibition, WM, CF, and vocabulary (Morales et al., 2024), while PA of moderate-to-vigorous intensity (MVPA) significantly improves inhibitory control and WM in preschoolers (Xue et al., 2019). Emerging evidence indicates that preschool children with better physical fitness (strength, speed/agility and cardiorespiratory fitness) and greater daily PA display significantly better EFs compared to their less fit counterparts (García-Alonso et al., 2025). In addition, another important tool to improve EFs in preschool children is cognitive training (CT) (Scionti et al., 2019; Y. Song et al., 2023), especially for developmentally at-risk children (attention-deficit hyperactivity disorder (ADHD) or low socio-economic status). In healthy preschool children and in those with ADHD and oppositional defiant disorder (ODD) symptoms, CT led to an improvement of EFs performance whereas in children with ADHD and ODD, CT were most effective in terms of reducing ADHD and ODD symptoms (Vandenbroucke et al., 2018). Cognitive training is particularly important with respect to teacher–child interactions given that numerous studies show that it is crucial to EFs, especially at the end of preschool and the beginning of elementary school (Vandenbroucke et al., 2018). Based on the existing evidence, scientists have argued that, when merged, PA and CT can produce a greater positive effect on EFs than either of these approaches alone (Li et al., 2020). Indeed, some evidence suggests that acute (Budde et al., 2008) and chronic bouts (Koutsandréou et al., 2016) of cognitively challenging PA can improve EF in children and adolescents, although current evidence regarding this issue in preschool-aged children remains limited and warrants further investigation. Thus, this review aimed to systematically search the existing literature on the impact of cognitively enhanced PA (CEPA) i.e. physical activity (PA) performed together with CT on EFs in preschool children. We hypothesized that CEPA will increase EFs significantly more when compared to control i.e., standard care groups that involved usual kindergarten activities. Materials and Methods To ensure complete and transparent reporting, this review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020) (Page et al., 2021). The review was registered in The International Prospective Register of Systematic Reviews (PROSPERO), registration number 102 CRD42024542292. The complete study protocol can be obtained by contacting the corresponding author upon request. Search Strategy and Study Selection A literature search was performed through three electronic databases, including Web of Science, PubMed, and APA PsycINFO. Databases were comprehensively searched from inception to June 31st, 2024, while literature search was limited only to the English language. The overall search strategy was developed by checking relevant systematic reviews and experts' opinions in the area of sports sciences as well as applied exercise psychology. One independent reviewer (MM) searched each database to identify studies referring to CEPA and EFs in preschool children. A Boolean search syntax was implemented employing the operators 'AND' and 'OR' with the following keywords: ("physical exercise" OR "exercise" OR "physical activity" OR "training" OR "training interventions" OR "physical education" OR "cognition" OR "cognitive interventions") AND ("executive function" OR "executive control" OR "working memory" OR "inhibition" OR "inhibitory control" OR "cognitive flexibility" OR "self-regulation" OR "attention") AND ("children" OR "preschool children" OR "kindergarten"). Medical Subject Headings (MeSH) terms were also searched to provide additional keywords. In addition, a thorough search of Google Scholar and reference lists of relevant studies was also carried out. Selection of potentially included studies comprised the following phases: (a) review of titles and abstracts; (b) evaluation of articles sought for retrieval; and (c) analysis of full-text records assessed for eligibility. The selection of available literature, including all highlighted screening phases, was performed independently by two reviewers (NL and MM). The bias during selecting relevant studies was reduced by blinding the involved reviewers. Potential reviewer disagreements were resolved via discussion until a consensus was reached. The reference lists of included studies were also reviewed to identify any studies that may have been overlooked. Eligibility Criteria To access the effects of CEPA on EFs in preschool children, included studies had to meet the following criteria based on the PICO process: (P-population) participants had to be healthy children of preschool age, i.e., kindergarten age (3–7 years old) without any neurological diseases, attention deficit disorders, or physical disabilities; (I-intervention) interventions had to apply some form of PA (aerobic or resistance training, individual or group, play and/or sports activities, etc.) in conjunction with CT; (C-comparison) CEPA vs. control group (standard care i.e., sedentary or non-CEPA physical activity); (O-outcome): changes in EFs (WM, inhibition and CF) as a result of a intervention had to be the main outcome of a study. Additionally, studies had to be published in English language. We placed no restrictions on publication dates for studies to be included in our review. Data Extraction Following information was extracted: (a) study characteristics (e.g., the first author’s last name, publication year); (b) participant characteristics (e.g., sample size, age of participants); c) study design, details of the intervention and control conditions (e.g., type, duration, session length, frequency, volume); and (d) measuring methods (tools that measured EFs); (e) outcomes (WM, inhibition, CF). Information pertaining to the design of included studies was depicted both tabularly and narratively (NL, MM, AG, EC and KT). Further, details of the effects sizes found through meta-analysis were presented in a separate table (AG). Risk of Bias Studies were accessed for quality by an experienced researcher (AG) via the Cochrane Risk of Bias Tool for Randomized-Controlled Trials (RoB2). This tool examines different domains of bias, particularly trial design, conduct, and reporting, that ultimately determine the quality of a given study. Within each domain, a set of questions aims to provide information about features of a specific study relevant to the risk of bias. Based on answers stemming from the signalling questions, a proposed judgment about the risk of bias arising from each domain is generated by an algorithm that further classifies studies into 'Low' or 'High' risk of bias or can express 'Some concerns.' This tool remains the most comprehensive to appraise the quality of randomized controlled trials (Minozzi et al., 2020). Statistical Analysis Meta-analysis was performed through the library metaphor of the R software with RStudio interface (version 2023.12.1 + 402), following the Hedges and Olkin approach (Hedges & Olkin, 2014), which proposes to express the effect size in Cohen's d, intended as the mean difference in standard units between experimental group and control group performance. We synthesized children’s performance on inhibition, WM and CF following the intervention. The presence of heterogeneity was assessed through Cochrane’s Q. If significant, a meta-regression was performed considering the number of weeks of each training. Results Search findings A thorough literature search yielded 717 studies, of which 381 duplicates were removed using the Zotero software (Digital Scholar, USA). Further, 246 studies were eliminated after reviewing titles and abstracts, leaving 90 full-text studies to be assessed for eligibility. The most frequent reasons for reviewers (NL and MM) to exclude full-text studies were the inappropriate age of participants or interventions applied. Additionally, one investigation was found via a Google Scholar search, and one study was found through a bibliography search of studies that were deemed relevant. In total, eight studies met eligibility criteria and were included in the qualitative and quantitative analysis (Bai et al., 2022; Biino et al., 2023; Gao, Lee, et al., 2019; Mavilidi et al., 2023; Schmidt et al., 2020; Vazou & Mavilidi, 2021; Xiong et al., 2019; Zeng et al., 2023)(28–35). All details regarding the database search and phases of the study selection process are summarized in Figure 1 (PRISMA flow diagram). The studies were published within the last six years and included 838 children (4-6 years old) with boys and girls being equally represented (Table 1). More than half of the included studies have shown concerns regarding study quality, and one study showed a high risk of bias. The main issues related to quality were randomization, deviations from the intended intervention, missing outcome data, inappropriate measurement of the outcome, and selection of the reported result. A detailed description of the risk of bias assessment is outlined in Table 1 (Cochrane Risk of Bias 2 scale). CEPA and EFs Five studies have used CEPA (without exergaming) to elicit changes in EFs in preschool children (Bai et al., 2022; Biino et al., 2023; Mavilidi et al., 2023; Schmidt et al., 2020; Vazou & Mavilidi, 2021) (Table 2). Although these studies showed high heterogeneity concerning study design, similar features will be listed below. Intervention duration ranged from six (Mavilidi et al., 2023; Schmidt et al., 2020) and eight weeks (Bai et al., 2022; Vazou & Mavilidi, 2021) to twelve weeks (Biino et al., 2023), with frequencies being two (Biino et al., 2023; Mavilidi et al., 2023), three (Bai et al., 2022), four (Schmidt et al., 2020), while one study did not share any intervention details besides overall intervention duration (Vazou & Mavilidi, 2021). Duration per session was 15-20 (Mavilidi et al., 2023; Schmidt et al., 2020) to 45 minutes (Bai et al., 2022; Biino et al., 2023). One study employed group-play CEPA of moderate to vigorous intensity to affect EFs. It showed significant improvements in the accuracy and reaction time aspects of all three EFs compared to the control group (Bai et al., 2022). Another study looked at the effects of CEPA on EFs and found significant improvements in WM accuracy and no difference in CF or inhibition compared to the swimming and standard care group (Biino et al., 2023). Yet, the swimming group showed better inhibition accuracy when compared to the CEPA group and better WM accuracy when compared to the standard care group. A study that included a CEPA group, CT without PA group, and standard care group showed no difference in EFs after a week of intervention (Mavilidi et al., 2023). One study included CEPA group, CT only group, and no intervention group (Schmidt et al., 2020). Both experimental groups showed greater improvements in WM than the control group, while there were no differences in inhibition and CF. One study provided educational materials and offered webinars to teachers who performed CEPA with complete autonomy (Vazou & Mavilidi, 2021), meaning that intervention was performed at the time and place of their choosing, but they had to keep training log and report back to the researchers. No significant differences in EFs were seen between the groups, although both groups showed an increase in EFs over time (time effect). Exergaming CEPA and EFs Three studies have explored exergaming CEPA as a tool to enhance EFs in preschool children (Gao, Lee, et al., 2019; Xiong et al., 2019; Zeng et al., 2023) (Table 2). Intervention duration ranged from eight (Xiong et al., 2019) to twelve weeks (Gao, Lee, et al., 2019; Zeng et al., 2023), while frequency was five times per week (Gao, Lee, et al., 2019; Xiong et al., 2019; Zeng et al., 2023). One study had participants engaging in exergaming for 20 minutes per session (Xiong et al., 2019), while the other two were designed to provide 30 minutes per session (Gao, Lee, et al., 2019; Zeng et al., 2023). Two studies were home-based (Gao, Lee, et al., 2019; Zeng et al., 2023), while another one was performed in kindergarten (Xiong et al., 2019). These studies only measured CF. Both home-based studies showed that exergaming produced greater EF effects than control groups (usual PA) (Gao, Lee, et al., 2019; Zeng et al., 2023). However, one crossover study exhibited only a marginally greater increase in EF (vs. control group), likely due to a short (one-week) washout period and possible carryover effects (Zeng et al., 2023). Another study demonstrated that kindergarten children who engaged in teacher-led exergaming CEPA exhibited significantly greater gains in CF than the control group (Xiong et al., 2019). Table 1 (Study characteristics) depicts the essential characteristics of each of each included study. Meta-Analytic Results The meta-analyses found significant effects of CEPA on children’s EFs compared to control groups. The detailed effects are reported in Table 3. On the first meta-analysis performed on CF with k=10 effects, CEPA revealed to have a positive effect on CF (d= 0.59, SE=0.13, z=4.46, 95% CI 0.33 – 0.85, p<0.0001), meaning that the group performing CEPA also displayed higher CF than the control group (Table 3). Cochrane’s Q resulted significant (Qdf=9= 21.92, p<0.0001) indicating heterogeneity across the studies. Therefore, moderation analysis was performed including the duration in weeks of the program. The results highlighted a significant effect of CEPA program duration (z= 2.95, 95% CI 253 0.05 – 0.24, p<0.01), with an explained variance of 82.02%. Regarding WM, the meta-analysis was performed on k=7 effects and resulted significant (d= 0.50, SE=0.14, z=3.60, 95% CI 0.23 – 0.77, p<0.001), where the group performing CEPA reported higher WM capacity than the control group (Table 3). The heterogeneity resulted significant (Qdf=6=13.83, p=0.03) and the moderation analysis found that the length of the training explained the variability across the studies (z= 3.12, 95% CI 0.08, 0.33, p<0.01). Concerning inhibition, the meta-analysis was performed on k=10 effects and resulted in a significant difference between CEPA group and control group (d=0.62, SE=0.18, z=3.46, 95% CI 0.27 – 0.97, p<0.0001) (Table 3). The heterogeneity resulted significant (Qdf=9= 51.34, p<0.001) but the moderation analysis did not yield any significant result of the program length (z=1.85, 95% CI -0.01 – 0.32, p=0.06). Discussion Key findings This review sought to synthesize cutting-edge evidence on the effects of CEPA on EFs in preschool children. Despite substantial heterogeneity across studies, we identified consistent patterns warranting discussion. The results validated our initial hypothesis i.e., preschool children that engage in CEPA experience greater gains in EFs compared to preschool children in control groups. Furthermore, the meta-analytic syntheses highlighted the beneficial role of CEPA on preschoolers’ inhibition, WM and CF, with high effect sizes. The meta-analytic synthesis highlighted that the larger effect sizes were obtained with longer programs (8 or 12 weeks). This effect suggests the more time spent in PA, the greater gains in EFs performance. However, it seems that intervention fidelity decreases after about 10 weeks when CEPA intervention is implemented in young children (Egger et al., 2019), so researchers need to be cognizant of this when designing an intervention that aims aim to produce increases in EFs in preschool children. Both CEPA components, PA and CT, are deemed equally important in prompting improvements in EFs in preschool children (Li et al., 2020; Scionti et al., 2019). Thus, to ensure progression and continuous improvement in EFs across time, subsequent research designs should increase PA intensity and integrate innovative, increasingly demanding cognitive tasks (Gao, Lee, et al., 2019; Schmidt et al., 2020; H. Song et al., 2023). For this reason, scientists have advocated that when conducting CEPA, intervention qualities such as task novelty and complexity should be viewed as equally important as traditional training variables (frequency, volume, duration, etc.) (Mavilidi et al., 2023). Indeed, in terms of improving EFs, comprehensive interventions are more effective than interventions that tackle sedentary behavior alone (Diamond, 2010). Enjoyment in PA and EFs The enjoyment factor of developing EFs is important and needs to be assessed as enjoyable activities, in this case CEPA, will contribute to long-term adherence, even after cessation of the study (Barnett et al., 2019; Lakicevic et al., 2020). In our review, one study reported no difference in perceived enjoyment between CEPA (storytelling, cognitive activities, and motor tasks), cognition (storytelling and cognitive activities without motor tasks), or control (traditional storytelling) group (Mavilidi et al., 2023). In contrast, another study reported no difference between CEPA and cognition groups (Schmidt et al., 2020). Another study in preschool children showed that science classes combined with PA were perceived as more joyful in learning compared to children in the control (usual care) condition (Mavilidi et al., 2023). Although many factors affect PA enjoyment, research has shown that children's enjoyment in PA depends on perceived athletic competence. Essentially, the lower the perceived athletic competence, the lower the enjoyment of PA, especially among girls (Cairney et al., 2012). Consequently, perceived athletic competence is likely based on motor skills that children have developed prior to an assessment. Yet, evidence has indicated that actual (objectively measured) motor competence is more important than perceived motor competence in children as it predicts PA engagement more accurately (McIntyre et al., 2018; Slykerman et al., 2016). Our review indicated that CEPA is a viable tool to increase perceived motor competence (Biino et al., 2023). Other exergaming studies in preschool children showed improvements in both perceived motor competence and MVPA (Gao, Zeng, et al., 2019). Indeed, there is a positive relationship between preschoolers' perceived motor competence and fundamental motor skills (Robinson, 2011). However, despite no changes in perceived competence, EFs can still be markedly increased due to PA intervention in preschool children (Xiong et al., 2017). Motor skills development is essential for enabling continuous deliverance of increasingly challenging CEPA that will further trigger EF benefits (Sadri et al., 2021; Vanhala et al., 2024). Motor skills should really be perceived as a gateway into challenging PA (Škundrić et al., 2023). In our review, two studies assessed motor skills among their sample. The authors found that group-play CEPA increased motor skills to a greater degree than in children who had their usual PA activities (Bai et al., 2022) and that CEPA produced greater gains in motor skills than swimming (Biino et al., 2023). Recent publication on Chinese preschoolers indicates that motor skills and EFs are closely linked in preschool children, with locomotor skills being significant predictors of inhibition, WM, and CF. In contrast, object control skills are significant predictors of inhibition (Han et al., 2022). Similar findings come from a large-scale study from Australian kindergartens where researchers found that locomotor, object control, and total skill competence were significantly associated with visual-spatial WM and inhibition. In contrast, total skill competence was associated with CF (Veldman et al., 2023). Further, a recent study indicated that overweight/obese preschoolers showed that poor EFs are associated with worse gross motor skills in this population when compared to normal-weight children (Fernandes et al., 2022). Play, CEPA and EFs The importance of play in preschool children should be noticed. One study in our review incorporated group-play CEPA and showed better outcomes in EFs than in the usual PA group (Bai et al., 2022). Play is an additional variable of value that enhances children's creativity and emphasizes social skills if it is done in a group setting. It looks that all types of play, i.e., role play (free role play, adult-directed play, child-directed play), digital games, and games with rules (board games), increase overall EFs, but only digital games benefit all EFs (A. Veraksa et al., 2022). Whether implemented at home with parents (Metaferia et al., 2020) or in preschool as a part of the curriculum (Coelho et al., 2020), play in an effective way to promote EFs. A growing body of research demonstrates that play-based interventions have the largest effects on improving EFs in young children, while computerized training showed smaller, less consistent effects (Takacs & Kassai, 2019). Teacher-led CEPA interventions Although researchers or trainers might deliver overall better intervention (Bukhalenkova & Nechaeva, 2023; Panfilova et al., 2024), it is important to educate teachers and parents on how to perform CEPA autonomously so it can be delivered in any given setting outside the intervention. One study included in our review reported that when teachers who are previously educated on how to implement CEPA and are given full autonomy to perform it as they see appropriate, both teachers and children reported high levels of enjoyment and subsequently showed increased adherence to the protocol (Vazou & Mavilidi, 2021). This approach allows teachers to have the autonomy to select which, when, and how to integrate the PA (perhaps combined with CT) during the school day, based on their students’ needs and their own level of comfort which ultimately increases external and ecological validity by evaluating the real-world feasibility of the intervention. This study also underlined that the intervention group had significantly greater levels of attention post-intervention with no differences in behavior control, social skills, and perceived motor competence. Daily PA and EFs In our review, six studies have used accelerometers to track levels and intensity of PA during the intervention (Bai et al., 2022; Biino et al., 2023; Gao, Lee, et al., 2019; Mavilidi et al., 2023; Schmidt et al., 2020; Zeng et al., 2023). Still, none have reported the daily PA levels of children observed outside the intervention. This information would show whether the included children met the daily recommended PA levels in the first place or whether the intervention was the only PA they were undergoing. Indeed, a recently published systematic review of 55 studies comprising nearly 14000 preschool children reported low levels of PA (i.e., less than 10 min/hr of MVPA) and worrying levels of sedentary time (between 27 and 57 min/hr), although results were highly variable across different studies (O’Brien et al., 2018). According to the World Health Organization and other prominent health-oriented institutions worldwide, there is a consensus that preschool children should spend at least 180 minutes a day doing a variety of PA spread throughout the day, including active and outdoor play, of which at least 60 minutes of MVPA (Pate et al., 2019). However, preschool children spend around 73% of their waking hours in sedentary behavior (Salmon et al., 2011), while 48.4% of their time in childcare is spent sitting (Ellis et al., 2017). Given the considerable time preschool children spend in kindergartens, this setting appears highly suitable for implementing CEPA interventions to reap the benefits of both PA and CT in preschool children and foster EF development. Recent findings indicate that PA interventions effectively enhance cognitive performance in preschool-aged children, with measurable effects observed in classroom environments, even after as little as 12 minutes of PA (Preston et al., 2025). Within our review, only two studies have measured PA intensity, with one being carried out via palpation of the radial artery of randomly selected children ( 28 ), and the other one used a heart rate strap to assess the intensity (Gao, Lee, et al., 2019). Evidence indicates that preschool children with higher cardiorespiratory fitness and more time in MVPA had better scores in inhibition and WM but showed no difference in CF (Luo et al., 2023; A. Veraksa et al., 2021). Surprisingly, some studies have found that MVPA was inversely related to performance on EFs (Cook et al., 2019; Willoughby et al., 2018). Still, these results may arise from competing demands for energy expenditures associated with PA and brain development (Voss et al., 2014). Strengths and limitations Our findings should be interpreted in light of several limitations. Due to this study's narrow focus, we have included only CEPA studies conducted exclusively in preschool children. Hence, fewer studies were reviewed, including less than 1000 participants. Also, our review has taken in consideration only CEPA studies that measured EFs in preschool children, thus precluding our research team from comparing CEPA, PA only, and CT only on EFs in preschool children. Included studies had rather small sample sizes, lack of long-term follow-up and had inconsistent measurement of EFs. Also, majority of the studies did not measure the intensity of PA which might be a decisive factor influencing EFs. Likewise, we did not compare the effects of CEPA in preschool children vs. in school children. To our knowledge, this is the first systematic review and meta-analysis of the effects of CEPA on preschool children. Notably, a thorough literature review was performed using stringent eligibility criteria, and novel findings were offered to scientists and the public. This study advances understanding of CEPA and EFs in preschool children and points out the gaps in the literature and design flaws of the existing studies, thereby providing ample evidence on what type of studies could be conducted in the future. Also, given that all eligible studies were published in the last six years, this review represents the contemporary status quo regarding the relationship between CEPA and EFs in preschool children. Finally, yet importantly, our findings offer practical, ready-to-implement strategies for kindergartens, with significant potential benefits for children, educators, and parents. Knowing that the level of neuroplasticity peaks in early childhood (Erickson et al., 2015), science and society as a whole should capitalize on embracing PA and CT in preschool children to favor optimal development of EFs, ultimately enhancing children’s ability to learn and mature as successful members of the community. Conclusions Cognitively enhanced physical activity might be a potent way to increase executive functions in preschool children. Duration of the intervention seems to be the most important factor producing the effect of the greatest magnitude in improving executive functions. Future studies should elaborate on the effect sizes of cognitively enhanced physical activity, physical activity, and cognitive training applied separately. Declarations Funding This study is supported by the Russian Science Foundation: 23-78-30005. Author Contributions Conceptualization, N.L., M.M. and A.G; methodology, 447 N.L., M.M. and A.G.; software, A.G..; validation, A.B., P.D. and Y.Z.; formal analysis, A.G.; investigation, N.L., M.M. and A.G.; resources, A.G.; data curation, N.L., M.M. and A.G.; writing—original draft preparation, N.L., M.M. and A.G.; writing—review and editing, A.C. and K.T..; visualization, N.L..; supervision, A.C. and K.T.; project administration, A.B. and P.D..; funding acquisition, Y.Z. All authors have read and agreed to the published version of the manuscript. Data Availability Statement The authors confirm that the data supporting the findings of this study are available within the study and its supplementary materials. Conflicts of Interest The authors declare no conflicts of interest. References Cowan N. Working Memory Underpins Cognitive Development, Learning, and Education. Educ Psychol Rev. 2014 Jun;26(2):197–223. Paschen L, Lehmann T, Kehne M, Baumeister J. Effects of Acute Physical Exercise With Low and High Cognitive Demands on Executive Functions in Children: A Systematic Review. Pediatr Exerc Sci. 2019 Aug;31(3):267–81. Diamond A. Executive functions. Annu Rev Psychol. 2013;64:135–68. Zakharova MN, Machinskaya RI. Voluntary Control of Cognitive Activity in Preschool Children: Age-dependent Changes from Ages 3-4 to 4-5. Psychol Russ state art. 2023;16(3):122–31. Blair C, Diamond A. Biological processes in prevention and intervention: the promotion of self-regulation as a means of preventing school failure. Dev Psychopathol. 2008;20(3):899–911. Roebers CM, Röthlisberger M, Neuenschwander R, Cimeli P, Michel E, Jäger K. The relation between cognitive and motor performance and their relevance for children’s transition to school: a latent variable approach. Hum Mov Sci. 2014 Feb;33:284–97. Shaul S, Schwartz M. The role of the executive functions in school readiness among preschool-age children. Read Writ. 2014;27:749–68. Best JR, Miller PH, Naglieri JA. Relations between executive function and academic achievement from ages 5 to 17 in a large, representative national sample. Learn Individ Differ. 2011;21(4):327–36. Veraksa AN, Bukhalenkova DA, Kovyazina MS. Language proficiency in preschool children with different levels of executive function. Psychol Russ State art. 2018;11(4):115–29. Veraksa A, Gavrilova M, Karimova A, Solopova O, Yakushina A. Regularly Functions in Preschoolers Aged 4–7: the Impact of Kindergarten Attendance Span. Moscow Univ Psychol Bull. 2023 Jan 1;46:64–87. Isquith PK, Crawford JS, Espy KA, Gioia GA. Assessment of executive function in preschool-aged children. Ment Retard Dev Disabil Res Rev. 2005;11(3):209–15. Silva C, Sousa-Gomes V, Fávero M, Oliveira-Lopes S, Merendeiro CS, Oliveira J, et al. Assessment of preschool-age executive functions: A systematic review. Clin Psychol Psychother. 2022 Jul;29(4):1374–91. Li L, Zhang J, Cao M, Hu W, Zhou T, Huang T, et al. The effects of chronic physical activity interventions on executive functions in children aged 3-7 years: A meta-analysis. J Sci Med Sport. 2020 Oct;23(10):949–54. Donnelly JE, Hillman CH, Castelli D, Etnier JL, Lee S, Tomporowski P, et al. Physical Activity, Fitness, Cognitive Function, and Academic Achievement in Children: A Systematic Review. Med Sci Sports Exerc. 2016 Jun;48(6):1197–222. Hsieh S-S, Fung D, Tsai H, Chang Y-K, Huang C-J, Hung T-M. Differences in working memory as a function of physical activity in children. Vol. 32, Neuropsychology. Hung, Tsung-Min: Department of Physical Education and Institute for Research Excellence in Learning Science, National Taiwan Normal University, Number 162, Section 1, Heping East Road, Da’an District, Taipei, Taiwan, 10610, [email protected] : American Psychological Association; 2018. p. 797–808. Zhou W, Saiz-González P, Rodriguez Aragon R, Adams K, Gao Z. Effect of Physical Activity Interventions on Brain Structure and Function Changes in Healthy Children: A Systematic Review. Quest [Internet]. 2024 Jan 2;76(1):54–71. Available from: https://doi.org/10.1080/00336297.2023.2217361 Morales JS, Alberquilla Del Río E, Valenzuela PL, Martínez-de-Quel Ó. Physical Activity and Cognitive Performance in Early Childhood: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Sports medicine (Auckland, N.Z.). New Zealand; 2024. Xue Y, Yang Y, Huang T. Effects of chronic exercise interventions on executive function among children and adolescents: a systematic review with meta-analysis. Br J Sports Med. 2019 Nov;53(22):1397–404. García-Alonso Y, Ramírez-Vélez R, Legarra-Gorgoñon G, Izquierdo M, Alonso-Martínez AM. Associations between physical fitness, physical activity, sedentary behavior and executive function in preschoolers. Pediatr Res. 2025;1–8. Scionti N, Cavallero M, Zogmaister C, Marzocchi GM. Is Cognitive Training Effective for Improving Executive Functions in Preschoolers? A Systematic Review and Meta-Analysis. Front Psychol. 2019;10:2812. Song Y, Fan B, Wang C, Yu H. Meta-analysis of the effects of physical activity on executive function in children and adolescents with attention deficit hyperactivity disorder. PLoS One. 2023;18(8):e0289732. Vandenbroucke L, Spilt J, Verschueren K, Piccinin C, Baeyens D. The classroom as a developmental context for cognitive development: A meta-analysis on the importance of teacher–student interactions for children’s executive functions. Vol. 88, Review of Educational Research. Vandenbroucke, Loren: [email protected] : Sage Publications; 2018. p. 125–64. Budde H, Voelcker-Rehage C, Pietrabyk-Kendziorra S, Ribeiro P, Tidow G. Acute coordinative exercise improves attentional performance in adolescents. Neurosci Lett. 2008 Aug;441(2):219–23. Koutsandréou F, Wegner M, Niemann C, Budde H. Effects of Motor versus Cardiovascular Exercise Training on Children’s Working Memory. Med Sci Sports Exerc. 2016 Jun;48(6):1144–52. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ [Internet]. 2021 Mar 29;372:n71. Available from: http://www.bmj.com/content/372/bmj.n71.abstract Minozzi S, Cinquini M, Gianola S, Gonzalez-Lorenzo M, Banzi R. The revised Cochrane risk of bias tool for randomized trials (RoB 2) showed low interrater reliability and challenges in its application. J Clin Epidemiol [Internet]. 2020;126:37–44. Available from: https://www.sciencedirect.com/science/article/pii/S0895435620301815 Hedges L V, Olkin I. Statistical methods for meta-analysis. Academic press; 2014. Bai J, Huang H, Ouyang H. Effects of Group-Play Moderate to Vigorous Intensity Physical Activity Intervention on Executive Function and Motor Skills in 4- to 5-Year-Old Preschoolers: A Pilot Cluster Randomized Controlled Trial. Front Psychol. 2022;13:847785. Biino V, Tinagli V, Borioni F, Pesce C. Cognitively enriched physical activity may foster motor competence and executive function as early as preschool age: a pilot trial. Phys Educ Sport Pedagog. 2023;28(4):425–43. Gao Z, Lee JE, Zeng N, Pope ZC, Zhang Y, Li X. Home-Based Exergaming on Preschoolers’ Energy Expenditure, Cardiovascular Fitness, Body Mass Index and Cognitive Flexibility: A Randomized Controlled Trial. J Clin Med. 2019 Oct;8(10). Mavilidi M, Okely AD, Chandler P, Paas F. Effects of integrating physical activities into a science lesson on preschool children’s learning and enjoyment. Appl Cogn Psychol. 2017;31(3):281–90. Schmidt M, Mavilidi MF, Singh A, Englert C. Combining physical and cognitive training to improve kindergarten children’s executive functions: A cluster randomized controlled trial. Contemp Educ Psychol [Internet]. 2020;63:101908. Available from: https://www.sciencedirect.com/science/article/pii/S0361476X20300734 547 Xiong S, Zhang P, Gao Z. Effects of Exergaming on Preschoolers’ Executive Functions and Perceived Competence: A Pilot Randomized Trial. J Clin Med. 2019 Apr;8(4). Zeng N, Lee JE, Gao Z. Effects of home-based exergaming on preschool children’s cognition, sedentary behavior, and physical activity: A randomized crossover trial. Brain Behav Immun Integr [Internet]. 551 2023;1:100002. Available from: https://www.sciencedirect.com/science/article/pii/S2949834123000016 553 Vazou S, Mavilidi MF. Cognitively Engaging Physical Activity for Targeting Motor, Cognitive, Social, and Emotional Skills in the Preschool Classroom: The Move for Thought preK-K Program. Front Psychol. 2021;12:729272. Mavilidi MF, Pesce C, Mazzoli E, Bennett S, Paas F, Okely AD, et al. Effects of Cognitively Engaging Physical Activity on Preschool Children’s Cognitive Outcomes. Res Q Exerc Sport. 2023 Sep;94(3):839–52. Egger F, Benzing V, Conzelmann A, Schmidt M. Boost your brain, while having a break! The effects of long-term cognitively engaging physical activity breaks on children’s executive functions and academic achievement. PLoS One. 2019;14(3):e0212482. Song H, Wang J-J, Zhang B, Shi L, Lau PWC. Do acute and chronic physical activity interventions affect the cognitive function of preschool children? A meta-analysis. Psychol Sport Exerc [Internet]. 2023;67:102419. Available from: https://www.sciencedirect.com/science/article/pii/S1469029223000432 Diamond A. The evidence base for improving school outcomes by addressing the whole child and by addressing skills and attitudes, not just content. Early Educ Dev. 2010;21(5):780–93. Barnett EY, Ridker PM, Okechukwu CA, Gortmaker SL. Integrating children’s physical activity enjoyment into public health dialogue (United States). Health Promot Int. 2019;34(1):144–53. Lakicevic N, Gentile A, Mehrabi S, Cassar S, Parker K, Roklicer R, et al. Make Fitness Fun: Could Novelty Be the Key Determinant for Physical Activity Adherence? Front Psychol. 2020;11. Cairney J, Kwan MY, Velduizen S, Hay J, Bray SR, Faught BE. Gender, perceived competence and the enjoyment of physical education in children: a longitudinal examination. Int J Behav Nutr Phys Act. 2012 Mar;9:26. McIntyre F, Parker H, Chivers P, Hands B. Actual competence, rather than perceived competence, is a better predictor of physical activity in children aged 6-9 years. J Sports Sci. 2018 Jul;36(13):1433–577 40. Slykerman S, Ridgers ND, Stevenson C, Barnett LM. How important is young children’s actual and perceived movement skill competence to their physical activity? J Sci Med Sport. 2016 Jun;19(6):488–92. Gao Z, Zeng N, Pope ZC, Wang R, Yu F. Effects of exergaming on motor skill competence, perceived competence, and physical activity in preschool children. J Sport Heal Sci. 2019 Mar;8(2):106–13. Robinson LE. The relationship between perceived physical competence and fundamental motor skills in preschool children. Child Care Health Dev. 2011 Jul;37(4):589–96. Xiong S, Li X, Tao K. Effects of structured physical activity program on Chinese young children’s executive functions and perceived physical competence in a day care center. Biomed Res Int. 2017;2017. Sadri F, Sadri I, Krneta Z, Trbojević Jocić J, Batez M. Relationship between cognitive abilities and manual coordination and balance in preschool children. Exerc Qual Life. 2021 Jun 15;13:31–8. Vanhala A, Widlund A, Korhonen J, Haapala EA, Sääkslahti A, Aunio P. Developmental associations of fundamental motor skills and executive functions in preschoolers — The role of the physical activity and the effects on early numeracy. Trends Neurosci Educ [Internet]. 2024;34:100220. Available from: https://www.sciencedirect.com/science/article/pii/S2211949324000012 Škundrić G, Macak D, Damjanović S, Popović B. Motor competence of children with different levels of physical activity. 2023 Jun 21;15:37–43. Han X, Zhao M, Kong Z, Xie J. Association between fundamental motor skills and executive function in preschool children: A cross-sectional study. Front Psychol. 2022;13(August):1–9. Veldman SLC, Hammersley ML, Howard SJ, Stanley RM, Okely AD, Jones RA. Associations of gross motor skills with self-regulation and executive function in preschool-aged children. Australas J Early Child [Internet]. 2023 May 11;48(3):234–46. Available from: https://doi.org/10.1177/18369391231175524 Fernandes AC, Viegas ÂA, Lacerda ACR, Nobre JNP, Morais RLDS, Figueiredo PHS, et al. Association between executive functions and gross motor skills in overweight/obese and eutrophic preschoolers: cross-sectional study. BMC Pediatr. 2022 Aug;22(1):498. Veraksa A, Sukhikh V, Veresov N, Almazova O. Which play is better? Different play types and development of executive functions in early childhood. Int J Early Years Educ. 2022;30(3):560–76. Metaferia BK, Futo J, Drew R, Takacs ZK. Parents’ Beliefs About Play and the Purpose of Preschool Education, Preschoolers’ Home Activity and Executive Functions. Front Psychol. 2020;11:1104. Coelho LA, Amatto AN, Gonzalez CLR, Gibb RL. Building executive function in pre-school children through play: a curriculum. Int J Play. 2020;9(1):128–42. Takacs ZK, Kassai R. The efficacy of different interventions to foster children’s executive function skills: A series of meta-analyses. Psychol Bull. 2019 Jul;145(7):653–97. Panfilova E, Aslanova M, Leonov S, Sukhochev P, Sedogin E, Polikanova I. The Application of Eye Movement Registration Systems in the Assessment of Visuospatial Memory in Preschool Children. Natl Psychol J. 2024 Jan 1;19:58–77. Bukhalenkova DA, Nechaeva DM. Development of Inhibition Control in Children during the Transition from Kindergarten to School during the COVID-19 Pandemic: Longitudinal Study. Lomonosov Psychol J [Internet]. 2023; Available from: https://msupsyj.ru/en/articles/article/9968/ O’Brien KT, Vanderloo LM, Bruijns BA, Truelove S, Tucker P. Physical activity and sedentary time among preschoolers in centre-based childcare: a systematic review. Int J Behav Nutr Phys Act. 2018 Nov;15(1):117. Pate RR, Hillman CH, Janz KF, Katzmarzyk PT, Powell KE, Torres A, et al. Physical Activity and Health in Children Younger than 6 Years: A Systematic Review. Med Sci Sports Exerc. 2019 Jun;51(6):1282–91. Salmon J, Tremblay MS, Marshall SJ, Hume C. Health risks, correlates, and interventions to reduce sedentary behavior in young people. Am J Prev Med. 2011 Aug;41(2):197–206. Ellis YG, Cliff DP, Janssen X, Jones RA, Reilly JJ, Okely AD. Sedentary time, physical activity and compliance with IOM recommendations in young children at childcare. Prev Med reports. 2017 Sep;7:221–6. Preston ML, McClelland M, Craig J, Herbst E, Golinkoff RM. Cognitively engaging physical activity has an immediate impact on preschool children’s executive function. Early Child Res Q [Internet]. 2025;72:91–101. Available from: https://www.sciencedirect.com/science/article/pii/S0885200625000201 634 Luo X, Herold F, Ludyga S, Gerber M, Kamijo K, Pontifex MB, et al. Association of physical activity and fitness with executive function among preschoolers. Int J Clin Heal Psychol [Internet]. 2023;23(4). Available from: https://www.elsevier.es/en-revista-international-journal-clinical-health-psychology-355-articulo-association-physical-activity-fitness-with-S1697260023000364 638 Veraksa A, Tvardovskaya A, Gavrilova M, Yakupova V, Musálek M. Associations Between Executive Functions and Physical Fitness in Preschool Children. Front Psychol. 2021;12:674746. Cook CJ, Howard SJ, Scerif G, Twine R, Kahn K, Norris SA, et al. Associations of physical activity and gross motor skills with executive function in preschool children from low-income South African settings. Dev Sci. 2019 Sep;22(5):e12820. Willoughby MT, Wylie AC, Catellier DJ. Testing the association between physical activity and executive function skills in early childhood. Early Child Res Q [Internet]. 2018;44:82–9. Available from: https://www.sciencedirect.com/science/article/pii/S0885200618300243 Voss MW, Carr LJ, Clark R, Weng T. Revenge of the “sit” II: Does lifestyle impact neuronal and cognitive health through distinct mechanisms associated with sedentary behavior and physical activity? Ment Health Phys Act [Internet]. 2014;7(1):9–24. Available from: https://www.sciencedirect.com/science/article/pii/S1755296614000027 Erickson KI, Hillman CH, Kramer AF. Physical activity, brain, and cognition. Curr Opin Behav Sci [Internet]. 2015;4:27–32. Available from: https://www.sciencedirect.com/science/article/pii/S2352154615000157 Tables Tables 1 to 3 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files PRISMAchecklist.docx Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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A Systematic Review and Meta-Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs the name implies, the role of preschool institutions such as kindergartens is to prepare children for school. Thus, the key at this age is to develop a set of valuable habits and skills that will provide children with the necessary tools to thrive in the classroom once they reach school age. Among the most important skills for children to achieve academic success and properly develop as pupils is cultivating executive functions (EFs) (Cowan, 2014). Executive functions are broadly defined as goal-oriented behavior that includes competencies such as goal setting, time management, project monitoring, and organizing and prioritizing materials, all of which are relevant for successful learning and are thus prerequisites for academic success (Paschen et al., 2019). The three components of EFs that are interrelated and in constant interplay with each other are working memory (WM), inhibition, and cognitive flexibility (CF) (Diamond, 2013). Working memory (also called updating) refers to the temporary maintenance and information handling and retrieval of task-pertinent information over a short time frame (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Inhibition (also called inhibitory control) is characterized by an intentional suppression of distracting stimuli (either interoceptive or exteroceptive) to manage attention, behavior, thoughts, and emotions (Diamond, 2013). Cognitive flexibility (also called switching of shifting) pertains to changing the focus of attention to rapidly switch perspectives and promptly adapt to new task-determined needs such as demands, rules, or priorities (Diamond, 2013). Therefore, using EFs requires significant effort (Zakharova \u0026amp; Machinskaya, 2023), as resisting distractions and staying focused on goal-directed actions is inherently more difficult than succumbing to them. This type of behaviour might be particularly difficult for preschool children, given their young age and unawareness of the consequences of their behaviour. Well-developed EFs are crucial for predicting young children's school readiness (Blair \u0026amp; Diamond, 2008; Roebers et al., 2014; Shaul \u0026amp; Schwartz, 2014) and academic success (Best et al., 2011; A. Veraksa et al., 2023; A. N. Veraksa et al., 2018). Thus, although complex (due to the dynamic nature and inextricable links of WM, inhibition, and CF) (Isquith et al., 2005), assessing EFs in preschool children is needed to determine the quality of parental and kindergarten care concerning EFs (Silva et al., 2022), which enables the strategic development of EFs subsequently.\u003c/p\u003e \u003cp\u003eAmong others, an intervention that has been shown to be particularly effective in improving EFs in preschool children both immediately (single-bout) and chronically (repeated bouts) is physical activity (PA) (Donnelly et al., 2016; Li et al., 2020), with a dose-response relationship (Hsieh et al., 2018), likely through beneficial effects on brain structure and function, such as increased neural activation and microstructural plasticity (Zhou et al., 2024). In preschool children, supervised PA interventions can increase attention, inhibition, WM, CF, and vocabulary (Morales et al., 2024), while PA of moderate-to-vigorous intensity (MVPA) significantly improves inhibitory control and WM in preschoolers (Xue et al., 2019). Emerging evidence indicates that preschool children with better physical fitness (strength, speed/agility and cardiorespiratory fitness) and greater daily PA display significantly better EFs compared to their less fit counterparts (Garc\u0026iacute;a-Alonso et al., 2025).\u003c/p\u003e \u003cp\u003eIn addition, another important tool to improve EFs in preschool children is cognitive training (CT) (Scionti et al., 2019; Y. Song et al., 2023), especially for developmentally at-risk children (attention-deficit hyperactivity disorder (ADHD) or low socio-economic status). In healthy preschool children and in those with ADHD and oppositional defiant disorder (ODD) symptoms, CT led to an improvement of EFs performance whereas in children with ADHD and ODD, CT were most effective in terms of reducing ADHD and ODD symptoms (Vandenbroucke et al., 2018). Cognitive training is particularly important with respect to teacher\u0026ndash;child interactions given that numerous studies show that it is crucial to EFs, especially at the end of preschool and the beginning of elementary school (Vandenbroucke et al., 2018).\u003c/p\u003e \u003cp\u003eBased on the existing evidence, scientists have argued that, when merged, PA and CT can produce a greater positive effect on EFs than either of these approaches alone (Li et al., 2020). Indeed, some evidence suggests that acute (Budde et al., 2008) and chronic bouts (Koutsandr\u0026eacute;ou et al., 2016) of cognitively challenging PA can improve EF in children and adolescents, although current evidence regarding this issue in preschool-aged children remains limited and warrants further investigation.\u003c/p\u003e \u003cp\u003eThus, this review aimed to systematically search the existing literature on the impact of cognitively enhanced PA (CEPA) i.e. physical activity (PA) performed together with CT on EFs in preschool children. We hypothesized that CEPA will increase EFs significantly more when compared to control i.e., standard care groups that involved usual kindergarten activities.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eTo ensure complete and transparent reporting, this review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020) (Page et al., 2021). The review was registered in The International Prospective Register of Systematic Reviews (PROSPERO), registration number 102 CRD42024542292. The complete study protocol can be obtained by contacting the corresponding author upon request.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch Strategy and Study Selection\u003c/h2\u003e \u003cp\u003eA literature search was performed through three electronic databases, including Web of Science, PubMed, and APA PsycINFO. Databases were comprehensively searched from inception to June 31st, 2024, while literature search was limited only to the English language. The overall search strategy was developed by checking relevant systematic reviews and experts' opinions in the area of sports sciences as well as applied exercise psychology. One independent reviewer (MM) searched each database to identify studies referring to CEPA and EFs in preschool children. A Boolean search syntax was implemented employing the operators 'AND' and 'OR' with the following keywords: (\"physical exercise\" OR \"exercise\" OR \"physical activity\" OR \"training\" OR \"training interventions\" OR \"physical education\" OR \"cognition\" OR \"cognitive interventions\") AND (\"executive function\" OR \"executive control\" OR \"working memory\" OR \"inhibition\" OR \"inhibitory control\" OR \"cognitive flexibility\" OR \"self-regulation\" OR \"attention\") AND (\"children\" OR \"preschool children\" OR \"kindergarten\").\u003c/p\u003e \u003cp\u003eMedical Subject Headings (MeSH) terms were also searched to provide additional keywords. In addition, a thorough search of Google Scholar and reference lists of relevant studies was also carried out. Selection of potentially included studies comprised the following phases: (a) review of titles and abstracts; (b) evaluation of articles sought for retrieval; and (c) analysis of full-text records assessed for eligibility. The selection of available literature, including all highlighted screening phases, was performed independently by two reviewers (NL and MM). The bias during selecting relevant studies was reduced by blinding the involved reviewers. Potential reviewer disagreements were resolved via discussion until a consensus was reached. The reference lists of included studies were also reviewed to identify any studies that may have been overlooked.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eTo access the effects of CEPA on EFs in preschool children, included studies had to meet the following criteria based on the PICO process: (P-population) participants had to be healthy children of preschool age, i.e., kindergarten age (3\u0026ndash;7 years old) without any neurological diseases, attention deficit disorders, or physical disabilities; (I-intervention) interventions had to apply some form of PA (aerobic or resistance training, individual or group, play and/or sports activities, etc.) in conjunction with CT; (C-comparison) CEPA vs. control group (standard care i.e., sedentary or non-CEPA physical activity); (O-outcome): changes in EFs (WM, inhibition and CF) as a result of a intervention had to be the main outcome of a study. Additionally, studies had to be published in English language. We placed no restrictions on publication dates for studies to be included in our review.\u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eFollowing information was extracted: (a) study characteristics (e.g., the first author\u0026rsquo;s last name, publication year); (b) participant characteristics (e.g., sample size, age of participants); c) study design, details of the intervention and control conditions (e.g., type, duration, session length, frequency, volume); and (d) measuring methods (tools that measured EFs); (e) outcomes (WM, inhibition, CF). Information pertaining to the design of included studies was depicted both tabularly and narratively (NL, MM, AG, EC and KT). Further, details of the effects sizes found through meta-analysis were presented in a separate table (AG).\u003c/p\u003e\n\u003ch3\u003eRisk of Bias\u003c/h3\u003e\n\u003cp\u003eStudies were accessed for quality by an experienced researcher (AG) via the Cochrane Risk of Bias Tool for Randomized-Controlled Trials (RoB2). This tool examines different domains of bias, particularly trial design, conduct, and reporting, that ultimately determine the quality of a given study. Within each domain, a set of questions aims to provide information about features of a specific study relevant to the risk of bias. Based on answers stemming from the signalling questions, a proposed judgment about the risk of bias arising from each domain is generated by an algorithm that further classifies studies into 'Low' or 'High' risk of bias or can express 'Some concerns.' This tool remains the most comprehensive to appraise the quality of randomized controlled trials (Minozzi et al., 2020).\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eMeta-analysis was performed through the library metaphor of the R software with RStudio interface (version 2023.12.1\u0026thinsp;+\u0026thinsp;402), following the Hedges and Olkin approach (Hedges \u0026amp; Olkin, 2014), which proposes to express the effect size in Cohen's d, intended as the mean difference in standard units between experimental group and control group performance. We synthesized children\u0026rsquo;s performance on inhibition, WM and CF following the intervention. The presence of heterogeneity was assessed through Cochrane\u0026rsquo;s Q. If significant, a meta-regression was performed considering the number of weeks of each training.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eSearch findings\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA thorough literature search yielded 717 studies, of which 381 duplicates were removed using the Zotero software (Digital Scholar, USA). Further, 246 studies were eliminated after reviewing titles and abstracts, leaving 90 full-text studies to be assessed for eligibility. The most frequent reasons for reviewers (NL and MM) to exclude full-text studies were the inappropriate age of participants or interventions applied. Additionally, one investigation was found via a Google Scholar search, and one study was found through a bibliography search of studies that were deemed relevant. In total, eight studies met eligibility criteria and were included in the qualitative and quantitative analysis (Bai et al., 2022; Biino et al., 2023; Gao, Lee, et al., 2019; Mavilidi et al., 2023; Schmidt et al., 2020; Vazou \u0026amp; Mavilidi, 2021; Xiong et al., 2019; Zeng et al., 2023)(28\u0026ndash;35). All details regarding the database search and phases of the study selection process are summarized in Figure 1 (PRISMA flow diagram). The studies were published within the last six years and included 838 children (4-6 years old) with boys and girls being equally represented (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMore than half of the included studies have shown concerns regarding study quality, and one study showed a high risk of bias. The main issues related to quality were randomization, deviations from the intended intervention, missing outcome data, inappropriate measurement of the outcome, and selection of the reported result. A detailed description of the risk of bias assessment is outlined in Table 1 (Cochrane Risk of Bias 2 scale).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCEPA and EFs\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFive studies have used CEPA (without exergaming) to elicit changes in EFs in preschool children (Bai et al., 2022; Biino et al., 2023; Mavilidi et al., 2023; Schmidt et al., 2020; Vazou \u0026amp; Mavilidi, 2021) (Table 2). Although these studies showed high heterogeneity concerning study design, similar features will be listed below. Intervention duration ranged from six (Mavilidi et al., 2023; Schmidt et al., 2020) and eight weeks (Bai et al., 2022; Vazou \u0026amp; Mavilidi, 2021) to twelve weeks (Biino et al., 2023), with frequencies being two (Biino et al., 2023; Mavilidi et al., 2023), three (Bai et al., 2022), four (Schmidt et al., 2020), while one study did not share any intervention details besides overall intervention duration (Vazou \u0026amp; Mavilidi, 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuration per session was 15-20 (Mavilidi et al., 2023; Schmidt et al., 2020) to 45 minutes (Bai et al., 2022; Biino et al., 2023). One study employed group-play CEPA of moderate to vigorous intensity to affect EFs. It showed significant improvements in the accuracy and reaction time aspects of all three EFs compared to the control group (Bai et al., 2022). Another study looked at the effects of CEPA on EFs and found significant improvements in WM accuracy and no difference in CF or inhibition compared to the swimming and standard care group (Biino et al., 2023). Yet, the swimming group showed better inhibition accuracy when compared to the CEPA group and better WM accuracy when compared to the standard care group. A study that included a CEPA group, CT without PA group, and standard care group showed no difference in EFs after a week of intervention (Mavilidi et al., 2023). One study included CEPA group, CT only group, and no intervention group (Schmidt et al., 2020). Both experimental groups showed greater improvements in WM than the control group, while there were no differences in inhibition and CF. One study provided educational materials and offered webinars to teachers who performed CEPA with complete autonomy (Vazou \u0026amp; Mavilidi, 2021), meaning that intervention was performed at the time and place of their choosing, but they had to keep training log and report back to the researchers. No significant differences in EFs were seen between the groups, although both groups showed an increase in EFs over time (time effect).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExergaming CEPA and EFs\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThree studies have explored exergaming CEPA as a tool to enhance EFs in preschool children (Gao, Lee, et al., 2019; Xiong et al., 2019; Zeng et al., 2023) (Table 2). Intervention duration ranged from eight (Xiong et al., 2019) to twelve weeks (Gao, Lee, et al., 2019; Zeng et al., 2023), while frequency was five times per week (Gao, Lee, et al., 2019; Xiong et al., 2019; Zeng et al., 2023). One study had participants engaging in exergaming for 20 minutes per session (Xiong et al., 2019), while the other two were designed to provide 30 minutes per session (Gao, Lee, et al., 2019; Zeng et al., 2023). Two studies were home-based (Gao, Lee, et al., 2019; Zeng et al., 2023), while another one was performed in kindergarten (Xiong et al., 2019). These studies only measured CF.\u003c/p\u003e\n\u003cp\u003eBoth home-based studies showed that exergaming produced greater EF effects than control groups (usual PA) (Gao, Lee, et al., 2019; Zeng et al., 2023). However, one crossover study exhibited only a marginally greater increase in EF (vs. control group), likely due to a short (one-week) washout period and possible carryover effects (Zeng et al., 2023). Another study demonstrated that kindergarten children who engaged in teacher-led exergaming CEPA exhibited significantly greater gains in CF than the control group (Xiong et al., 2019). Table 1 (Study characteristics) depicts the essential characteristics of each of each included study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMeta-Analytic Results\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe meta-analyses found significant effects of CEPA on children\u0026rsquo;s EFs compared to control groups. The detailed effects are reported in Table 3.\u003c/p\u003e\n\u003cp\u003eOn the first meta-analysis performed on CF with k=10 effects, CEPA revealed to have a positive effect on CF (d= 0.59, SE=0.13, z=4.46, 95% CI 0.33 \u0026ndash; 0.85, p\u0026lt;0.0001), meaning that the group performing CEPA also displayed higher CF than the control group (Table 3). Cochrane\u0026rsquo;s Q resulted significant (Qdf=9= 21.92, p\u0026lt;0.0001) indicating heterogeneity across the studies. Therefore, moderation analysis was performed including the duration in weeks of the program. The results highlighted a significant effect of CEPA program duration (z= 2.95, 95% CI 253 0.05 \u0026ndash; 0.24, p\u0026lt;0.01), with an explained variance of 82.02%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding WM, the meta-analysis was performed on k=7 effects and resulted significant (d= 0.50, SE=0.14, z=3.60, 95% CI 0.23 \u0026ndash; 0.77, p\u0026lt;0.001), where the group performing CEPA reported higher WM capacity than the control group (Table 3). The heterogeneity resulted significant (Qdf=6=13.83, p=0.03) and the moderation analysis found that the length of the training explained the variability across the studies (z= 3.12, 95% CI 0.08, 0.33, p\u0026lt;0.01).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConcerning inhibition, the meta-analysis was performed on k=10 effects and resulted in a significant difference between CEPA group and control group (d=0.62, SE=0.18, z=3.46, 95% CI 0.27 \u0026ndash; 0.97, p\u0026lt;0.0001) (Table 3). The heterogeneity resulted significant (Qdf=9= 51.34, p\u0026lt;0.001) but the moderation analysis did not yield any significant result of the program length (z=1.85, 95% CI -0.01 \u0026ndash; 0.32, p=0.06).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eKey findings\u003c/h2\u003e \u003cp\u003eThis review sought to synthesize cutting-edge evidence on the effects of CEPA on EFs in preschool children. Despite substantial heterogeneity across studies, we identified consistent patterns warranting discussion. The results validated our initial hypothesis i.e., preschool children that engage in CEPA experience greater gains in EFs compared to preschool children in control groups. Furthermore, the meta-analytic syntheses highlighted the beneficial role of CEPA on preschoolers\u0026rsquo; inhibition, WM and CF, with high effect sizes. The meta-analytic synthesis highlighted that the larger effect sizes were obtained with longer programs (8 or 12 weeks). This effect suggests the more time spent in PA, the greater gains in EFs performance. However, it seems that intervention fidelity decreases after about 10 weeks when CEPA intervention is implemented in young children (Egger et al., 2019), so researchers need to be cognizant of this when designing an intervention that aims aim to produce increases in EFs in preschool children. Both CEPA components, PA and CT, are deemed equally important in prompting improvements in EFs in preschool children (Li et al., 2020; Scionti et al., 2019). Thus, to ensure progression and continuous improvement in EFs across time, subsequent research designs should increase PA intensity and integrate innovative, increasingly demanding cognitive tasks (Gao, Lee, et al., 2019; Schmidt et al., 2020; H. Song et al., 2023). For this reason, scientists have advocated that when conducting CEPA, intervention qualities such as task novelty and complexity should be viewed as equally important as traditional training variables (frequency, volume, duration, etc.) (Mavilidi et al., 2023). Indeed, in terms of improving EFs, comprehensive interventions are more effective than interventions that tackle sedentary behavior alone (Diamond, 2010).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEnjoyment in PA and EFs\u003c/h2\u003e \u003cp\u003eThe enjoyment factor of developing EFs is important and needs to be assessed as enjoyable activities, in this case CEPA, will contribute to long-term adherence, even after cessation of the study (Barnett et al., 2019; Lakicevic et al., 2020). In our review, one study reported no difference in perceived enjoyment between CEPA (storytelling, cognitive activities, and motor tasks), cognition (storytelling and cognitive activities without motor tasks), or control (traditional storytelling) group (Mavilidi et al., 2023). In contrast, another study reported no difference between CEPA and cognition groups (Schmidt et al., 2020). Another study in preschool children showed that science classes combined with PA were perceived as more joyful in learning compared to children in the control (usual care) condition (Mavilidi et al., 2023). Although many factors affect PA enjoyment, research has shown that children's enjoyment in PA depends on perceived athletic competence. Essentially, the lower the perceived athletic competence, the lower the enjoyment of PA, especially among girls (Cairney et al., 2012). Consequently, perceived athletic competence is likely based on motor skills that children have developed prior to an assessment. Yet, evidence has indicated that actual (objectively measured) motor competence is more important than perceived motor competence in children as it predicts PA engagement more accurately (McIntyre et al., 2018; Slykerman et al., 2016). Our review indicated that CEPA is a viable tool to increase perceived motor competence (Biino et al., 2023). Other exergaming studies in preschool children showed improvements in both perceived motor competence and MVPA (Gao, Zeng, et al., 2019). Indeed, there is a positive relationship between preschoolers' perceived motor competence and fundamental motor skills (Robinson, 2011). However, despite no changes in perceived competence, EFs can still be markedly increased due to PA intervention in preschool children (Xiong et al., 2017). Motor skills development is essential for enabling continuous deliverance of increasingly challenging CEPA that will further trigger EF benefits (Sadri et al., 2021; Vanhala et al., 2024). Motor skills should really be perceived as a gateway into challenging PA (Škundrić et al., 2023). In our review, two studies assessed motor skills among their sample. The authors found that group-play CEPA increased motor skills to a greater degree than in children who had their usual PA activities (Bai et al., 2022) and that CEPA produced greater gains in motor skills than swimming (Biino et al., 2023). Recent publication on Chinese preschoolers indicates that motor skills and EFs are closely linked in preschool children, with locomotor skills being significant predictors of inhibition, WM, and CF. In contrast, object control skills are significant predictors of inhibition (Han et al., 2022). Similar findings come from a large-scale study from Australian kindergartens where researchers found that locomotor, object control, and total skill competence were significantly associated with visual-spatial WM and inhibition. In contrast, total skill competence was associated with CF (Veldman et al., 2023). Further, a recent study indicated that overweight/obese preschoolers showed that poor EFs are associated with worse gross motor skills in this population when compared to normal-weight children (Fernandes et al., 2022).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePlay, CEPA and EFs\u003c/h2\u003e \u003cp\u003eThe importance of play in preschool children should be noticed. One study in our review incorporated group-play CEPA and showed better outcomes in EFs than in the usual PA group (Bai et al., 2022). Play is an additional variable of value that enhances children's creativity and emphasizes social skills if it is done in a group setting. It looks that all types of play, i.e., role play (free role play, adult-directed play, child-directed play), digital games, and games with rules (board games), increase overall EFs, but only digital games benefit all EFs (A. Veraksa et al., 2022). Whether implemented at home with parents (Metaferia et al., 2020) or in preschool as a part of the curriculum (Coelho et al., 2020), play in an effective way to promote EFs. A growing body of research demonstrates that play-based interventions have the largest effects on improving EFs in young children, while computerized training showed smaller, less consistent effects (Takacs \u0026amp; Kassai, 2019).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTeacher-led CEPA interventions\u003c/h2\u003e \u003cp\u003eAlthough researchers or trainers might deliver overall better intervention (Bukhalenkova \u0026amp; Nechaeva, 2023; Panfilova et al., 2024), it is important to educate teachers and parents on how to perform CEPA autonomously so it can be delivered in any given setting outside the intervention. One study included in our review reported that when teachers who are previously educated on how to implement CEPA and are given full autonomy to perform it as they see appropriate, both teachers and children reported high levels of enjoyment and subsequently showed increased adherence to the protocol (Vazou \u0026amp; Mavilidi, 2021). This approach allows teachers to have the autonomy to select which, when, and how to integrate the PA (perhaps combined with CT) during the school day, based on their students\u0026rsquo; needs and their own level of comfort which ultimately increases external and ecological validity by evaluating the real-world feasibility of the intervention. This study also underlined that the intervention group had significantly greater levels of attention post-intervention with no differences in behavior control, social skills, and perceived motor competence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eDaily PA and EFs\u003c/h2\u003e \u003cp\u003eIn our review, six studies have used accelerometers to track levels and intensity of PA during the intervention (Bai et al., 2022; Biino et al., 2023; Gao, Lee, et al., 2019; Mavilidi et al., 2023; Schmidt et al., 2020; Zeng et al., 2023). Still, none have reported the daily PA levels of children observed outside the intervention. This information would show whether the included children met the daily recommended PA levels in the first place or whether the intervention was the only PA they were undergoing. Indeed, a recently published systematic review of 55 studies comprising nearly 14000 preschool children reported low levels of PA (i.e., less than 10 min/hr of MVPA) and worrying levels of sedentary time (between 27 and 57 min/hr), although results were highly variable across different studies (O\u0026rsquo;Brien et al., 2018). According to the World Health Organization and other prominent health-oriented institutions worldwide, there is a consensus that preschool children should spend at least 180 minutes a day doing a variety of PA spread throughout the day, including active and outdoor play, of which at least 60 minutes of MVPA (Pate et al., 2019). However, preschool children spend around 73% of their waking hours in sedentary behavior (Salmon et al., 2011), while 48.4% of their time in childcare is spent sitting (Ellis et al., 2017). Given the considerable time preschool children spend in kindergartens, this setting appears highly suitable for implementing CEPA interventions to reap the benefits of both PA and CT in preschool children and foster EF development. Recent findings indicate that PA interventions effectively enhance cognitive performance in preschool-aged children, with measurable effects observed in classroom environments, even after as little as 12 minutes of PA (Preston et al., 2025).\u003c/p\u003e \u003cp\u003eWithin our review, only two studies have measured PA intensity, with one being carried out via palpation of the radial artery of randomly selected children (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and the other one used a heart rate strap to assess the intensity (Gao, Lee, et al., 2019). Evidence indicates that preschool children with higher cardiorespiratory fitness and more time in MVPA had better scores in inhibition and WM but showed no difference in CF (Luo et al., 2023; A. Veraksa et al., 2021). Surprisingly, some studies have found that MVPA was inversely related to performance on EFs (Cook et al., 2019; Willoughby et al., 2018). Still, these results may arise from competing demands for energy expenditures associated with PA and brain development (Voss et al., 2014).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eOur findings should be interpreted in light of several limitations. Due to this study's narrow focus, we have included only CEPA studies conducted exclusively in preschool children. Hence, fewer studies were reviewed, including less than 1000 participants. Also, our review has taken in consideration only CEPA studies that measured EFs in preschool children, thus precluding our research team from comparing CEPA, PA only, and CT only on EFs in preschool children. Included studies had rather small sample sizes, lack of long-term follow-up and had inconsistent measurement of EFs. Also, majority of the studies did not measure the intensity of PA which might be a decisive factor influencing EFs. Likewise, we did not compare the effects of CEPA in preschool children vs. in school children.\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first systematic review and meta-analysis of the effects of CEPA on preschool children. Notably, a thorough literature review was performed using stringent eligibility criteria, and novel findings were offered to scientists and the public. This study advances understanding of CEPA and EFs in preschool children and points out the gaps in the literature and design flaws of the existing studies, thereby providing ample evidence on what type of studies could be conducted in the future. Also, given that all eligible studies were published in the last six years, this review represents the contemporary status quo regarding the relationship between CEPA and EFs in preschool children. Finally, yet importantly, our findings offer practical, ready-to-implement strategies for kindergartens, with significant potential benefits for children, educators, and parents.\u003c/p\u003e \u003cp\u003eKnowing that the level of neuroplasticity peaks in early childhood (Erickson et al., 2015), science and society as a whole should capitalize on embracing PA and CT in preschool children to favor optimal development of EFs, ultimately enhancing children\u0026rsquo;s ability to learn and mature as successful members of the community.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eCognitively enhanced physical activity might be a potent way to increase executive functions in preschool children. Duration of the intervention seems to be the most important factor producing the effect of the greatest magnitude in improving executive functions. Future studies should elaborate on the effect sizes of cognitively enhanced physical activity, physical activity, and cognitive training applied separately.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study is supported by the Russian Science Foundation: 23-78-30005.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, N.L., M.M. and A.G; methodology, 447 N.L., M.M. and A.G.; software, A.G..; validation, A.B., P.D. and Y.Z.; formal analysis, A.G.; investigation, N.L., M.M. and A.G.; resources, A.G.; data curation, N.L., M.M. and A.G.; writing\u0026mdash;original draft preparation, N.L., M.M. and A.G.; writing\u0026mdash;review and editing, A.C. and K.T..; visualization, N.L..; supervision, A.C. and K.T.; project administration, A.B. and P.D..; funding acquisition, Y.Z. All authors have read and agreed to the published version of the manuscript. \u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003cem\u003eData Availability Statement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the study and its supplementary materials.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConflicts of Interest\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCowan N. Working Memory Underpins Cognitive Development, Learning, and Education. Educ Psychol Rev. 2014 Jun;26(2):197\u0026ndash;223.\u003c/li\u003e\n \u003cli\u003ePaschen L, Lehmann T, Kehne M, Baumeister J. Effects of Acute Physical Exercise With Low and High Cognitive Demands on Executive Functions in Children: A Systematic Review. Pediatr Exerc Sci. 2019 Aug;31(3):267\u0026ndash;81.\u003c/li\u003e\n \u003cli\u003eDiamond A. Executive functions. Annu Rev Psychol. 2013;64:135\u0026ndash;68.\u003c/li\u003e\n \u003cli\u003eZakharova MN, Machinskaya RI. Voluntary Control of Cognitive Activity in Preschool Children: Age-dependent Changes from Ages 3-4 to 4-5. Psychol Russ state art. 2023;16(3):122\u0026ndash;31.\u003c/li\u003e\n \u003cli\u003eBlair C, Diamond A. Biological processes in prevention and intervention: the promotion of self-regulation as a means of preventing school failure. Dev Psychopathol. 2008;20(3):899\u0026ndash;911.\u003c/li\u003e\n \u003cli\u003eRoebers CM, R\u0026ouml;thlisberger M, Neuenschwander R, Cimeli P, Michel E, J\u0026auml;ger K. The relation between cognitive and motor performance and their relevance for children\u0026rsquo;s transition to school: a latent variable approach. Hum Mov Sci. 2014 Feb;33:284\u0026ndash;97.\u003c/li\u003e\n \u003cli\u003eShaul S, Schwartz M. The role of the executive functions in school readiness among preschool-age children. Read Writ. 2014;27:749\u0026ndash;68.\u003c/li\u003e\n \u003cli\u003eBest JR, Miller PH, Naglieri JA. Relations between executive function and academic achievement from ages 5 to 17 in a large, representative national sample. Learn Individ Differ. 2011;21(4):327\u0026ndash;36.\u003c/li\u003e\n \u003cli\u003eVeraksa AN, Bukhalenkova DA, Kovyazina MS. Language proficiency in preschool children with different levels of executive function. Psychol Russ State art. 2018;11(4):115\u0026ndash;29.\u003c/li\u003e\n \u003cli\u003eVeraksa A, Gavrilova M, Karimova A, Solopova O, Yakushina A. Regularly Functions in Preschoolers Aged 4\u0026ndash;7: the Impact of Kindergarten Attendance Span. Moscow Univ Psychol Bull. 2023 Jan 1;46:64\u0026ndash;87.\u003c/li\u003e\n \u003cli\u003eIsquith PK, Crawford JS, Espy KA, Gioia GA. Assessment of executive function in preschool-aged children. Ment Retard Dev Disabil Res Rev. 2005;11(3):209\u0026ndash;15.\u003c/li\u003e\n \u003cli\u003eSilva C, Sousa-Gomes V, F\u0026aacute;vero M, Oliveira-Lopes S, Merendeiro CS, Oliveira J, et al. Assessment of preschool-age executive functions: A systematic review. Clin Psychol Psychother. 2022 Jul;29(4):1374\u0026ndash;91.\u003c/li\u003e\n \u003cli\u003eLi L, Zhang J, Cao M, Hu W, Zhou T, Huang T, et al. The effects of chronic physical activity interventions on executive functions in children aged 3-7 years: A meta-analysis. J Sci Med Sport. 2020 Oct;23(10):949\u0026ndash;54.\u003c/li\u003e\n \u003cli\u003eDonnelly JE, Hillman CH, Castelli D, Etnier JL, Lee S, Tomporowski P, et al. Physical Activity, Fitness, Cognitive Function, and Academic Achievement in Children: A Systematic Review. Med Sci Sports Exerc. 2016 Jun;48(6):1197\u0026ndash;222.\u003c/li\u003e\n \u003cli\u003eHsieh S-S, Fung D, Tsai H, Chang Y-K, Huang C-J, Hung T-M. Differences in working memory as a function of physical activity in children. Vol. 32, Neuropsychology. Hung, Tsung-Min: Department of Physical Education and Institute for Research Excellence in Learning Science, National Taiwan Normal University, Number 162, Section 1, Heping East Road, Da\u0026rsquo;an District, Taipei, Taiwan, 10610, [email protected]: American Psychological Association; 2018. p. 797\u0026ndash;808.\u003c/li\u003e\n \u003cli\u003eZhou W, Saiz-Gonz\u0026aacute;lez P, Rodriguez Aragon R, Adams K, Gao Z. Effect of Physical Activity Interventions on Brain Structure and Function Changes in Healthy Children: A Systematic Review. Quest [Internet]. 2024 Jan 2;76(1):54\u0026ndash;71. Available from: https://doi.org/10.1080/00336297.2023.2217361\u003c/li\u003e\n \u003cli\u003eMorales JS, Alberquilla Del R\u0026iacute;o E, Valenzuela PL, Mart\u0026iacute;nez-de-Quel \u0026Oacute;. Physical Activity and Cognitive Performance in Early Childhood: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Sports medicine (Auckland, N.Z.). New Zealand; 2024.\u003c/li\u003e\n \u003cli\u003eXue Y, Yang Y, Huang T. Effects of chronic exercise interventions on executive function among children and adolescents: a systematic review with meta-analysis. Br J Sports Med. 2019 Nov;53(22):1397\u0026ndash;404.\u003c/li\u003e\n \u003cli\u003eGarc\u0026iacute;a-Alonso Y, Ram\u0026iacute;rez-V\u0026eacute;lez R, Legarra-Gorgo\u0026ntilde;on G, Izquierdo M, Alonso-Mart\u0026iacute;nez AM. Associations between physical fitness, physical activity, sedentary behavior and executive function in preschoolers. Pediatr Res. 2025;1\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eScionti N, Cavallero M, Zogmaister C, Marzocchi GM. Is Cognitive Training Effective for Improving Executive Functions in Preschoolers? A Systematic Review and Meta-Analysis. Front Psychol. 2019;10:2812.\u003c/li\u003e\n \u003cli\u003eSong Y, Fan B, Wang C, Yu H. Meta-analysis of the effects of physical activity on executive function in children and adolescents with attention deficit hyperactivity disorder. PLoS One. 2023;18(8):e0289732.\u003c/li\u003e\n \u003cli\u003eVandenbroucke L, Spilt J, Verschueren K, Piccinin C, Baeyens D. The classroom as a developmental context for cognitive development: A meta-analysis on the importance of teacher\u0026ndash;student interactions for children\u0026rsquo;s executive functions. Vol. 88, Review of Educational Research. Vandenbroucke, Loren: [email protected]: Sage Publications; 2018. p. 125\u0026ndash;64.\u003c/li\u003e\n \u003cli\u003eBudde H, Voelcker-Rehage C, Pietrabyk-Kendziorra S, Ribeiro P, Tidow G. Acute coordinative exercise improves attentional performance in adolescents. Neurosci Lett. 2008 Aug;441(2):219\u0026ndash;23.\u003c/li\u003e\n \u003cli\u003eKoutsandr\u0026eacute;ou F, Wegner M, Niemann C, Budde H. Effects of Motor versus Cardiovascular Exercise Training on Children\u0026rsquo;s Working Memory. Med Sci Sports Exerc. 2016 Jun;48(6):1144\u0026ndash;52.\u003c/li\u003e\n \u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ [Internet]. 2021 Mar 29;372:n71. Available from: http://www.bmj.com/content/372/bmj.n71.abstract\u003c/li\u003e\n \u003cli\u003eMinozzi S, Cinquini M, Gianola S, Gonzalez-Lorenzo M, Banzi R. The revised Cochrane risk of bias tool for randomized trials (RoB 2) showed low interrater reliability and challenges in its application. J Clin Epidemiol [Internet]. 2020;126:37\u0026ndash;44. Available from: https://www.sciencedirect.com/science/article/pii/S0895435620301815\u003c/li\u003e\n \u003cli\u003eHedges L V, Olkin I. Statistical methods for meta-analysis. Academic press; 2014.\u003c/li\u003e\n \u003cli\u003eBai J, Huang H, Ouyang H. Effects of Group-Play Moderate to Vigorous Intensity Physical Activity Intervention on Executive Function and Motor Skills in 4- to 5-Year-Old Preschoolers: A Pilot Cluster Randomized Controlled Trial. Front Psychol. 2022;13:847785.\u003c/li\u003e\n \u003cli\u003eBiino V, Tinagli V, Borioni F, Pesce C. Cognitively enriched physical activity may foster motor competence and executive function as early as preschool age: a pilot trial. Phys Educ Sport Pedagog. 2023;28(4):425\u0026ndash;43.\u003c/li\u003e\n \u003cli\u003eGao Z, Lee JE, Zeng N, Pope ZC, Zhang Y, Li X. Home-Based Exergaming on Preschoolers\u0026rsquo; Energy Expenditure, Cardiovascular Fitness, Body Mass Index and Cognitive Flexibility: A Randomized Controlled Trial. J Clin Med. 2019 Oct;8(10).\u003c/li\u003e\n \u003cli\u003eMavilidi M, Okely AD, Chandler P, Paas F. Effects of integrating physical activities into a science lesson on preschool children\u0026rsquo;s learning and enjoyment. Appl Cogn Psychol. 2017;31(3):281\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003eSchmidt M, Mavilidi MF, Singh A, Englert C. Combining physical and cognitive training to improve kindergarten children\u0026rsquo;s executive functions: A cluster randomized controlled trial. Contemp Educ Psychol [Internet]. 2020;63:101908. Available from: https://www.sciencedirect.com/science/article/pii/S0361476X20300734 547\u003c/li\u003e\n \u003cli\u003eXiong S, Zhang P, Gao Z. Effects of Exergaming on Preschoolers\u0026rsquo; Executive Functions and Perceived Competence: A Pilot Randomized Trial. J Clin Med. 2019 Apr;8(4).\u003c/li\u003e\n \u003cli\u003eZeng N, Lee JE, Gao Z. Effects of home-based exergaming on preschool children\u0026rsquo;s cognition, sedentary behavior, and physical activity: A randomized crossover trial. Brain Behav Immun Integr [Internet]. 551 2023;1:100002. Available from: https://www.sciencedirect.com/science/article/pii/S2949834123000016 553\u003c/li\u003e\n \u003cli\u003eVazou S, Mavilidi MF. Cognitively Engaging Physical Activity for Targeting Motor, Cognitive, Social, and Emotional Skills in the Preschool Classroom: The Move for Thought preK-K Program. Front Psychol. 2021;12:729272.\u003c/li\u003e\n \u003cli\u003eMavilidi MF, Pesce C, Mazzoli E, Bennett S, Paas F, Okely AD, et al. Effects of Cognitively Engaging Physical Activity on Preschool Children\u0026rsquo;s Cognitive Outcomes. Res Q Exerc Sport. 2023 Sep;94(3):839\u0026ndash;52.\u003c/li\u003e\n \u003cli\u003eEgger F, Benzing V, Conzelmann A, Schmidt M. Boost your brain, while having a break! The effects of long-term cognitively engaging physical activity breaks on children\u0026rsquo;s executive functions and academic achievement. PLoS One. 2019;14(3):e0212482.\u003c/li\u003e\n \u003cli\u003eSong H, Wang J-J, Zhang B, Shi L, Lau PWC. Do acute and chronic physical activity interventions affect the cognitive function of preschool children? A meta-analysis. Psychol Sport Exerc [Internet]. 2023;67:102419. Available from: https://www.sciencedirect.com/science/article/pii/S1469029223000432\u003c/li\u003e\n \u003cli\u003eDiamond A. The evidence base for improving school outcomes by addressing the whole child and by addressing skills and attitudes, not just content. Early Educ Dev. 2010;21(5):780\u0026ndash;93.\u003c/li\u003e\n \u003cli\u003eBarnett EY, Ridker PM, Okechukwu CA, Gortmaker SL. Integrating children\u0026rsquo;s physical activity enjoyment into public health dialogue (United States). Health Promot Int. 2019;34(1):144\u0026ndash;53.\u003c/li\u003e\n \u003cli\u003eLakicevic N, Gentile A, Mehrabi S, Cassar S, Parker K, Roklicer R, et al. Make Fitness Fun: Could Novelty Be the Key Determinant for Physical Activity Adherence? Front Psychol. 2020;11.\u003c/li\u003e\n \u003cli\u003eCairney J, Kwan MY, Velduizen S, Hay J, Bray SR, Faught BE. Gender, perceived competence and the enjoyment of physical education in children: a longitudinal examination. Int J Behav Nutr Phys Act. 2012 Mar;9:26.\u003c/li\u003e\n \u003cli\u003eMcIntyre F, Parker H, Chivers P, Hands B. Actual competence, rather than perceived competence, is a better predictor of physical activity in children aged 6-9 years. J Sports Sci. 2018 Jul;36(13):1433\u0026ndash;577 40.\u003c/li\u003e\n \u003cli\u003eSlykerman S, Ridgers ND, Stevenson C, Barnett LM. How important is young children\u0026rsquo;s actual and perceived movement skill competence to their physical activity? J Sci Med Sport. 2016 Jun;19(6):488\u0026ndash;92.\u003c/li\u003e\n \u003cli\u003eGao Z, Zeng N, Pope ZC, Wang R, Yu F. Effects of exergaming on motor skill competence, perceived competence, and physical activity in preschool children. J Sport Heal Sci. 2019 Mar;8(2):106\u0026ndash;13.\u003c/li\u003e\n \u003cli\u003eRobinson LE. The relationship between perceived physical competence and fundamental motor skills in preschool children. Child Care Health Dev. 2011 Jul;37(4):589\u0026ndash;96.\u003c/li\u003e\n \u003cli\u003eXiong S, Li X, Tao K. Effects of structured physical activity program on Chinese young children\u0026rsquo;s executive functions and perceived physical competence in a day care center. Biomed Res Int. 2017;2017.\u003c/li\u003e\n \u003cli\u003eSadri F, Sadri I, Krneta Z, Trbojević Jocić J, Batez M. Relationship between cognitive abilities and manual coordination and balance in preschool children. Exerc Qual Life. 2021 Jun 15;13:31\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eVanhala A, Widlund A, Korhonen J, Haapala EA, S\u0026auml;\u0026auml;kslahti A, Aunio P. Developmental associations of fundamental motor skills and executive functions in preschoolers \u0026mdash; The role of the physical activity and the effects on early numeracy. Trends Neurosci Educ [Internet]. 2024;34:100220. Available from: https://www.sciencedirect.com/science/article/pii/S2211949324000012\u003c/li\u003e\n \u003cli\u003e\u0026Scaron;kundrić G, Macak D, Damjanović S, Popović B. Motor competence of children with different levels of physical activity. 2023 Jun 21;15:37\u0026ndash;43.\u003c/li\u003e\n \u003cli\u003eHan X, Zhao M, Kong Z, Xie J. Association between fundamental motor skills and executive function in preschool children: A cross-sectional study. Front Psychol. 2022;13(August):1\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eVeldman SLC, Hammersley ML, Howard SJ, Stanley RM, Okely AD, Jones RA. Associations of gross motor skills with self-regulation and executive function in preschool-aged children. Australas J Early Child [Internet]. 2023 May 11;48(3):234\u0026ndash;46. Available from: https://doi.org/10.1177/18369391231175524\u003c/li\u003e\n \u003cli\u003eFernandes AC, Viegas \u0026Acirc;A, Lacerda ACR, Nobre JNP, Morais RLDS, Figueiredo PHS, et al. Association between executive functions and gross motor skills in overweight/obese and eutrophic preschoolers: cross-sectional study. BMC Pediatr. 2022 Aug;22(1):498.\u003c/li\u003e\n \u003cli\u003eVeraksa A, Sukhikh V, Veresov N, Almazova O. Which play is better? Different play types and development of executive functions in early childhood. Int J Early Years Educ. 2022;30(3):560\u0026ndash;76.\u003c/li\u003e\n \u003cli\u003eMetaferia BK, Futo J, Drew R, Takacs ZK. Parents\u0026rsquo; Beliefs About Play and the Purpose of Preschool Education, Preschoolers\u0026rsquo; Home Activity and Executive Functions. Front Psychol. 2020;11:1104.\u003c/li\u003e\n \u003cli\u003eCoelho LA, Amatto AN, Gonzalez CLR, Gibb RL. Building executive function in pre-school children through play: a curriculum. Int J Play. 2020;9(1):128\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eTakacs ZK, Kassai R. The efficacy of different interventions to foster children\u0026rsquo;s executive function skills: A series of meta-analyses. Psychol Bull. 2019 Jul;145(7):653\u0026ndash;97.\u003c/li\u003e\n \u003cli\u003ePanfilova E, Aslanova M, Leonov S, Sukhochev P, Sedogin E, Polikanova I. The Application of Eye Movement Registration Systems in the Assessment of Visuospatial Memory in Preschool Children. Natl Psychol J. 2024 Jan 1;19:58\u0026ndash;77.\u003c/li\u003e\n \u003cli\u003eBukhalenkova DA, Nechaeva DM. Development of Inhibition Control in Children during the Transition from Kindergarten to School during the COVID-19 Pandemic: Longitudinal Study. Lomonosov Psychol J [Internet]. 2023; Available from: https://msupsyj.ru/en/articles/article/9968/\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Brien KT, Vanderloo LM, Bruijns BA, Truelove S, Tucker P. Physical activity and sedentary time among preschoolers in centre-based childcare: a systematic review. Int J Behav Nutr Phys Act. 2018 Nov;15(1):117.\u003c/li\u003e\n \u003cli\u003ePate RR, Hillman CH, Janz KF, Katzmarzyk PT, Powell KE, Torres A, et al. Physical Activity and Health in Children Younger than 6 Years: A Systematic Review. Med Sci Sports Exerc. 2019 Jun;51(6):1282\u0026ndash;91.\u003c/li\u003e\n \u003cli\u003eSalmon J, Tremblay MS, Marshall SJ, Hume C. Health risks, correlates, and interventions to reduce sedentary behavior in young people. Am J Prev Med. 2011 Aug;41(2):197\u0026ndash;206.\u003c/li\u003e\n \u003cli\u003eEllis YG, Cliff DP, Janssen X, Jones RA, Reilly JJ, Okely AD. Sedentary time, physical activity and compliance with IOM recommendations in young children at childcare. Prev Med reports. 2017 Sep;7:221\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003ePreston ML, McClelland M, Craig J, Herbst E, Golinkoff RM. Cognitively engaging physical activity has an immediate impact on preschool children\u0026rsquo;s executive function. Early Child Res Q [Internet]. 2025;72:91\u0026ndash;101. Available from: https://www.sciencedirect.com/science/article/pii/S0885200625000201 634\u003c/li\u003e\n \u003cli\u003eLuo X, Herold F, Ludyga S, Gerber M, Kamijo K, Pontifex MB, et al. Association of physical activity and fitness with executive function among preschoolers. Int J Clin Heal Psychol [Internet]. 2023;23(4). Available from: https://www.elsevier.es/en-revista-international-journal-clinical-health-psychology-355-articulo-association-physical-activity-fitness-with-S1697260023000364 638\u003c/li\u003e\n \u003cli\u003eVeraksa A, Tvardovskaya A, Gavrilova M, Yakupova V, Mus\u0026aacute;lek M. Associations Between Executive Functions and Physical Fitness in Preschool Children. Front Psychol. 2021;12:674746.\u003c/li\u003e\n \u003cli\u003eCook CJ, Howard SJ, Scerif G, Twine R, Kahn K, Norris SA, et al. Associations of physical activity and gross motor skills with executive function in preschool children from low-income South African settings. Dev Sci. 2019 Sep;22(5):e12820.\u003c/li\u003e\n \u003cli\u003eWilloughby MT, Wylie AC, Catellier DJ. Testing the association between physical activity and executive function skills in early childhood. Early Child Res Q [Internet]. 2018;44:82\u0026ndash;9. Available from: https://www.sciencedirect.com/science/article/pii/S0885200618300243\u003c/li\u003e\n \u003cli\u003eVoss MW, Carr LJ, Clark R, Weng T. Revenge of the \u0026ldquo;sit\u0026rdquo; II: Does lifestyle impact neuronal and cognitive health through distinct mechanisms associated with sedentary behavior and physical activity? Ment Health Phys Act [Internet]. 2014;7(1):9\u0026ndash;24. Available from: https://www.sciencedirect.com/science/article/pii/S1755296614000027\u003c/li\u003e\n \u003cli\u003eErickson KI, Hillman CH, Kramer AF. Physical activity, brain, and cognition. Curr Opin Behav Sci [Internet]. 2015;4:27\u0026ndash;32. Available from: https://www.sciencedirect.com/science/article/pii/S2352154615000157\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"physical activity, cognition, working memory, inhibition, cognitive flexibility, motor skills, kindergarten","lastPublishedDoi":"10.21203/rs.3.rs-6871020/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6871020/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eExecutive functions (EFs) predict school readiness and academic achievement in young children. Cognitively enhanced physical activity (CEPA), defined as physical activity (PA) combined with concurrent cognitive tasks, may substantially enhance EFs in preschool-aged children. Given that EFs are crucial for children\u0026rsquo;s intellectual development and later achievements in life, we sought to systematically review the literature on the effects of CEPA on EFs in preschool children following the PRISMA 2020 guidelines. Web of Science, PubMed and APA PsycINFO were systematically searched from inception to June 2024 for the relevant literature using predetermined keywords. Only randomized controlled trials that had performed CEPA in healthy preschool children and evaluated EFs were included. Quality appraisal of the included studies was assessed via Cochrane RoB2 tool. Eight studies comprised of 838 participants met the inclusion criteria and were analysed. The most consistent improvements in EFs were found in exergaming studies, which fostered CEPA through interactive video games adjusted for preschool children. The meta-analysis revealed that CEPA programs led to significantly better EFs outcomes in children than control conditions, with longer program durations yielding the greatest improvements. Future research should compare the effect sizes of CEPA, standard PA, and isolated cognitive training in preschool populations.\u003c/p\u003e","manuscriptTitle":"Does Cognitively Enhanced Physical Activity Improve Executive Functions in Preschool Children? A Systematic Review and Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 10:55:46","doi":"10.21203/rs.3.rs-6871020/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81091f08-8765-447e-97dc-d59badba9edc","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T14:23:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-01 10:55:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6871020","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6871020","identity":"rs-6871020","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}