The Effects of VR-Based Multi-Task Sensorimotor Intervention on Motor Skill Learning in Children with ADHD and Developmental Coordination Disorder Comorbidity

The Effects of VR-Based Multi-Task Sensorimotor Intervention on Motor Skill Learning in Children with ADHD and Developmental Coordination Disorder Comorbidity | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Effects of VR-Based Multi-Task Sensorimotor Intervention on Motor Skill Learning in Children with ADHD and Developmental Coordination Disorder Comorbidity Yanwei Cai, Zongtao Li, Yanzhao Zhao, Lei Zhao, Jiaqi Wang, Yingjie Gao, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6153569/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Dec, 2025 Read the published version in Scientific Reports → Version 1 posted 12 You are reading this latest preprint version Abstract Attention-Deficit/Hyperactivity Disorder (ADHD) and Developmental Coordination Disorder (DCD) are two prevalent neurodevelopmental disorders and occur with a comorbidity rate of up to 50%. Both of the two conditions are associated with significant motor skill deficits. The existed interventions often emphasize the outcomes of learning while the learning process is often overlooked underlining the inconsistent results. This study evaluated the effectiveness of a 12-week Enhanced Multi-Task Sensorimotor Intervention (MTSI) in improving motor skill learning in children with ADHD, DCD, and their comorbidity. A total of 139 children (ADHD: n = 37, ADHD + DCD: n = 33, DCD: n = 34, Typically Developing [TD]: n = 35) participated in the MTSI, which involved five multi-sensory motor tasks integrating visual, auditory, and proprioceptive feedback. Motor skill learning provided MTSI system was assessed and changes in gross and fine motor skills were analyzed before and after intervention. All groups demonstrated significant improvements in motor skills ( p < 0.01, η² = 0.31–0.84), with ADHD children showed the most substantial gains in gross motor skills. Children with ADHD + DCD combidity demonstrated more improvement than DCD children but less than ADHD children. And further, motor skill retention was well-maintained for all the three groups of children. These findings highlight the potential role of VR-based sensorimotor interventions to enhance motor skill acquisition and retention in children with ADHD and DCD as well as for those with ADHD and DCD combidity, and offer a novel and promising strategy for the enhancement of their moter dificiency. Health sciences/Neurology/Neurological disorders Health sciences/Neurology/Neurological disorders/Movement disorders Health sciences/Neurology/Neurological disorders/Neurodevelopmental disorders Physical sciences/Mathematics and computing Health sciences/Medical research/Paediatric research Health sciences/Health care/Public health Health sciences/Health care/Paediatrics/Paediatric research Health sciences/Signs and symptoms/Comorbidities Motor Skill Development Children ADHD-DCD Comorbidity Virtual Reality Sensorimotor Training Neurodevelopmental Disorders Figures Figure 1 Figure 2 Introduction Neurodevelopmental disorders (NDDs) affect millions of children worldwide, typically manifesting early in life and encompassing a broad spectrum of symptoms across multiple functional domains. 1 Different types of NDD has its unique clinical features, but sometimes, they are often comorbid, presenting the same challenge in treatment and care. 2 Attention-deficit/hyperactivity disorder (ADHD) and developmental coordination disorder (DCD) are among the most common neurodevelopmental disorders, with ADHD affecting approximately 7% of school-age children and DCD having a prevalence of 6%. 3,4 ADHD is characterized by inattention, hyperactivity, and impulsivity, while DCD primarily manifests as clumsiness and poor coordination. 5 In addition, these children also face higher risks of anxiety, depression, academic underachievement, and social psychological issues. 6 , 7 Notably, the comorbidity rate of ADHD and DCD reaches up to 50%. 3,4,7 However, the motor difficulties of children with comorbid ADHD and DCD are often underrecognized clinically, attributing motor problems solely to attention deficits and behavioral regulation issues. 8 This has led to insufficient focus on the intersection of ADHD and DCD. In 1982, Gillberg et al. introduced the concept of "Attention, Motor Control, and Perceptual Deficits" (DAMP), which described the symptom overlap between ADHD and DCD, highlighting the intrinsic connection between perceptual and motor difficulties in these children. 9 Furthermore, ADHD and DCD share high comorbidity with other NDDs involving impairments in sensory processing. 10 Studies have found that children with ADHD and DCD perform worse across various domains compared to children with only one of the disorders, facing more significant challenges, especially in information processing speed, sensory integration, motor skill learning and control, as well as both gross and fine motor skills. 11 , 12 However, traditional cognitive and motor training approaches often fail to integrate sensory processing and motor skill development comprehensively. While pharmacological treatments can only partially improve motor performance in children with ADHD, 15 and still leaves motor difficulties after the tratment of medication, so the motor impairments are not solely attributed to attention deficits. Fortunately, more and more researches have shown that exercise-based interventions can effectively improve motor control and coordination in children with ADHD and DCD, 13 , 14 which be broadly classified into two categories: process-oriented interventions that correct motor defects and standardize movements, and task-oriented interventions that enhance engagement and function. 16 , 17 The 2019 International Clinical Practice Guidelines for DCD recommended task-oriented training as the first-choice intervention for children with DCD, 18 based on the experimental results that, these inteventions have shown more significant improvements. 17 In recent years, virtual reality (VR) technology has increasingly been applied in neurorehabilitation. Sensory interaction-based interventions could not only provide controllable multi-sensory stimuli, but also integrate task-oriented training with multi-features of interactivity, intelligence, contextualization and immersion. It is fo great help to create virtual environments that capture children's attention and provide real-time feedback. 20 , 21 Evidently, this active video games (AVG), as a task-oriented intervention, have been shown to positively improve both gross and fine motor skills in children by increasing the frequency and intensity of motor practice, 20 – 22 and the multi-task and variable practice training methods have been proven to be effective in enhancing memory and skill transfer. 24 Thus, this study conducted an exploratory randomized controlled trial study by using a self-designed VR-based enhanced multisensory motor intervention system (MSI), and aimed to investigate its effects on motor skill learning in children with ADHD, DCD, and ADHD + DCD childern aged 6–8 years. This study hypothesized Children in the ADHD, DCD, and ADHD + DCD groups would get improvement in motor skill learning retention in comparison to those of typically developing (TD) children, and eventually, their gross and fine motor skills would also be observed. Hopefully, this study would provide new evidence and intervention strategies for motor intervention in children with ADHD and DCD comorbidity. Methods Participants This study recruited participants from the Special Education Center and community primary schools in Hebei Province, China between May 2022 and September 2023. The participants included children with Attention-Deficit/Hyperactivity Disorder (ADHD) only (ADHD group), children with both ADHD and Developmental Coordination Disorder (DCD) (ADHD + DCD group), children with DCD only (DCD group), and typically developing (TD) children. The demographic characteristics of the participants in each group are shown in Table 1 . Inclusion criteria were as follows: (1) children aged 6–8 years, (2) ADHD group diagnosed based on the Conners Rating Scale and the Vanderbilt ADHD Diagnostic Parent Rating Scale, (3) DCD group assessed by trained physical therapists using the Developmental Coordination Disorder Questionnaire (DCDQ) and the Movement Assessment Battery for Children, Second Edition (MABC-2), (4) all participants with an IQ ≥ 70, (5) no medication use in the past three months or use of stable doses, (6) ADHD + DCD group meeting all the above criteria, and (7) confirmation of diagnosis based on the DSM-5 criteria through interviews and neurological examination by two experienced pediatric neurologists. Exclusion criteria included other developmental disorders or serious motor and neurological issues. Table 1 Participants’ characteristics. Characteristics (M ± SD) ADHD group (n = 37) ADHD་DCD group (n = 33) DCD group (n = 34) TD group (n = 35) F p Sex (boy/girl) 25/12 21/12 21/13 22/13 0.11 0.89 Age 6.97 ± 0.73 6.63 ± 0.82 6.88 ± 0.69 6.86 ± 0.68 0.33 0.72 Height (m) 33.81 ± 6.67 35.75 ± 5.97 33.61 ± 6.38 33.92 ± 6.27 0.21 0.98 Weight (kg) 1.41 ± 0.46 1.47 ± 0.52 1.37 ± 0.48 1.39 ± 0.47 0.12 0.81 BMI 18.23 ± 2.81 18.45 ± 2.86 17.97 ± 2.82 18.18 ± 2.65 0.10 0.91 Conners’ 35.7 ± 16.8 38.2 ± 16.4 —— —— 0.28 0.52 Locomotor Skills 30.89 ± 3.21 25.61 ± 3.94 24.91 ± 3.32 36.46 ± 3.592 197.68 .001 Ball Skills 28.3 ± 6.10 24.97 ± 4.51 23.76 ± 4.95 37.51 ± 5.452 163.01 .000 TGMD-3 total score 59.19 ± 8.05 51.58 ± 7.13 49.68 ± 7.37 73.97 ± 7.517 254.83 .000 Manual Dexterity 6.54 ± 1.10 4.62 ± 1.12 4.50 ± 1.11 8.66 ± 1.533 160.10 .000 Aiming and Catching 9.78 ± 1.51 7.42 ± 1.37 7.82 ± 1.55 11.97 ± 1.543 164.36 .000 Balance 8.78 ± 1.53 8.45 ± 1.67 8.76 ± 1.60 10.97 ± 0.954 64.85 .000 MABC-2 total score 7.22 ± 1.78 5.81 ± 1.22 5.68 ± 1.55 10.8 ± 1.568 249.19 .000 Intervention The intervention took place at various sites within the participants' community schools to ensure focused attention. The 12-week intervention was conducted three times a week with 35 minutes per session. The intervention was divided into three stages, each stage lasting 4 weeks, with progressively increasing in difficulty. Children controlled a virtual character in the MSI system using their bodies. Before the formal intervention, two practice sessions were conducted to familiarize the children with the system. The intervention included five tasks in the MSI system: Task 1, Tennis Ball Strike; Task 2, Parkour; Task 3, Quick Reaction; Task 4, Skiing Over Obstacles; Task 5, Passing Through Human Shape Wall. Each task lasted 6 minutes, with 1 point awarded for each completed action, and the total scores were displayed and stored in real-time. The intensity of the participants' physical activity was monitored using a wearable fitness tracker. The entire intervention was supervised by multiple rehabilitation therapists and researchers. During the intervention, participants were required to maintain their usual routines and were instructed not to engage in any additional exercise or sports activities other than the regular physical education classes provided by the school. Figure 1 illustrates the research process. Experimental design This study utilized a self-designed MSI system, incorporating Kinect motion sensing technology with RGB cameras and depth sensors to capture both color images and depth information. This enabled skeletal tracking and motion recognition. The MSI system was developed on the Unity platform, utilizing Microsoft Kinect SDK, Maya, and Visual Studio technologies, and integrated with a user interface, 3D virtual environment, and backend services. The MSI system consists of two main modules: the motion task module and the data processing module. The motion task module was designed based on relevant theoretical concepts and expert consultations, encompassing five tasks that engage multiple sensory inputs and train skills from fine to gross motor tasks. Table 2 outlines the five tasks. The data processing module automatically records scores and provides real-time feedback on correct and incorrect actions. Validity and reliability tests indicated that the task scores significantly improved after 12 sessions (p 0.60, Cronbach's Alpha > 0.80), and further optimization was applied. All participants underwent baseline (T1) and post-intervention (T2) assessments using the Test of Gross Motor Development-Third Edition (TGMD-3) and Movement Assessment Battery for Children-Second Edition (MABC-2). A retention assessment was conducted one week post-intervention by using the difficult level at the third stage of intervention. The study adhered to the principles of the Declaration of Helsinki. Written informed consent was obtained from the legal guardians of all participants, and children also consented to participate. Participants were informed that they could withdraw from the study at any time without negative consequences. The study protocol was approved by the Medical Ethics Committee of Hebei Normal University (Approval No. 2023LLSC015). Measures Gross Motor Skill Assessment The children's gross motor development was assessed using the Test of Gross Motor Development, Third Edition (TGMD-3), which evaluates both locomotor skills and object control skills. Locomotor skills include tasks such as running, hopping, sliding, etc., with six specific items, while object control skills include tasks such as overhand throwing, kicking a stationary ball, dribbling, and catching with both hands, comprising seven items. Higher scores indicate better gross motor development. The TGMD-3 has demonstrated strong reliability and validity, and it is widely used to assess gross motor skills in Chinese children. In this study, the inter-rater reliability for locomotor skills, object control skills, and total gross motor scores were r = 0.981, 0.969, and 0.976, respectively. Fine Motor Skill Assessment The Movement Assessment Battery for Children, Second Edition (MABC-2) was used to assess children's motor coordination and fine motor skills. The MABC-2 is internationally recognized as the gold standard for motor coordination assessment and is divided into three age groups: 3–6 years, 7–10 years, and 11–16 years. In this study, children aged 7–10 years were assessed, and the standard scores for each test item were compared with the data norms for same-age children in China. The MABC-2 consists of three sections: manual dexterity, aiming and catching, and static and dynamic balance. The manual dexterity section includes tasks such as coin tossing, peg insertion, and bead threading. The results were compared with Chinese norms for children of the same age, and standard scores were calculated. The tool has shown good test-retest reliability (r = 0.73–0.84) and inter-rater reliability (r = 0.49–0.70). Statistical Methods All data were analyzed using IBM SPSS 27.0 software. Descriptive statistics (mean ± standard deviation) were used to summarize the performance in gross and fine motor skills before and after the intervention for each group. The normality of the data was assessed using the Shapiro-Wilk test (S-W test), and homogeneity of variance between groups was checked using Levene’s test. Repeated Measures ANOVA was used to compare changes in task performance scores across the three intervention phases. Paired sample t-tests and one-way ANOVA were performed to compare the within- and between- group differences in gross and fine motor skill scores between the ADHD, ADHD + DCD, DCD, and TD groups, respectively. Statistical significant difference was set at p < 0.05, and p < 0.01 for highly significant differences. Effect sizes in within- group difference were evaluated using Cohen’s d (d), categorized as small (0.20), medium (0.50), and large (0.80). Effect sizes in between- group difference were assessed using partial eta squared ( η² ), with categories small (0.01), medium (0.06), and large (0.14). Results Sample Characteristics and Protocol Adherence This study successfully implemented the intervention program, in which all the participants completed the required tasks in 12 weeks, an additional week was allocated before and after the intervention for baseline assessment and post-test data collection, and a skill retention test was conducted one week following the intervention, therefore, the total study duration was 15 weeks. Table 1 presents the demographic characteristics of the participants and the comparative differences in gender, age, motor skill levels, and other variables among the ADHD, ADHD + DCD, DCD, and TD groups. Significant differences were observed between the groups in TGMD-3 and MABC-2 scores ( p 0.05), suggesting that the groups were balanced at baseline according to the requirements for a randomized controlled trial. Data passed the Shapiro-Wilk test for normality ( p > 0.05) and Levene’s Test for homogeneity of variances ( p > 0.05). One participant from the ADHD group and one from the TD group withdrew during the study. The average attendance rate for all participants throughout the intervention was 91.98%, with an average heart rate of 120–150 beats per minute. Motor Skill Learning Score Data Analysis As shown in Table 4 and Fig. 2 , during the three intervention phases, the ADHD group exhibited significant improvements in all the tasks’ scores from the first to the last trial of each phase ( p < 0.001, η² = 0.41–0.85), and demonstated slightly lower values in baseline scores and overall trend than the TD group ( p < 0.001, η² = 0.55–0.73). The ADHD + DCD group showed a similar trend, with significant improvements in each phase from the first to the last trial ( p < 0.001, η ² = 0.44–0.71), but displayed greater variability in their overall scores. The DCD group had the lowest scores at all phases with slower but relative stable progressy, and their performance score was slightly worse than that of the ADHD and TD groups, though their within-group score improvements were still significant ( p < 0.001, η² = 0.31–0.76). During the retention test phase, the scores of most of the tasks for the ADHD group ( η² = 0.13–0.38), ADHD + DCD group ( η² = 0.06–0.26), and DCD group ( η² = 0.14–0.41) were maintained well above the baseline levels, which indicates they retain well for the learned motor skills. Pre- and Post-Intervention Comparison of Motor Skills effects As shown in Table 4 , in terms of gross motor skills, the ADHD group exhibited significant improvements in standing long jump, kicking a stationary ball, and other sub-items and total scores ( p 0.05). The ADHD + DCD group showed significant improvements in forward sliding, side sliding, overhand throwing, and other sub-items and total scores (p 0.05). The DCD group demonstrated significant improvements in forward sliding, overhand throwing, and other sub-items and total scores ( p 0.05). Moreover, significant differences were found between these three groups and the TD group in gross motor skills (F = 2.41–17.02, p < 0.05, η² = 0.04–0.21).In terms of fine motor skills, the ADHD group showed significant improvements in tasks like coin tossing, bead threading, and other sub-items and total scores ( p < 0.05, d = 1.52–4.09). The ADHD + DCD group showed similar significant improvements in coin tossing, bead threading, and other sub-items and total scores (p < 0.05, d = 1.68–4.21). Similarly, the DCD group showed significant improvements in fine motor tasks ( p < 0.05, d = 1.78–4.43). However, significant differences between these three groups and the TD group were observed in gross motor skill comparisons (F = 0.74–76.12, p < 0.05, η² = 0.01–0.54). Discussion The primary objective of this study was to assess the impact of a Virtual Reality (VR)-based Enhanced Multi-Task Sensorimotor Intervention (MSI) on the motor skill learning processes and outcomes in children with Attention-Deficit/Hyperactivity Disorder (ADHD), Developmental Coordination Disorder (DCD), and ADHD + DCD comorbidity. The results of the study aligned with our hypothesis that, children with ADHD, ADHD + DCD comorbidity, and DCD demonstrated motor skill learning rates that approached or reached the levels of Typically Developing (TD) children over 12 weeks of intervention. Motor skills significantly were improved across all groups, including the substantial enhancement of both gross and fine motor skills, and the well retention of the learned motor skills in intervention. This finding certifys the effectiveness of VR-based, task-oriented, and multi-sensory feedback-driven interventions, and further confirms the critical role of sensory input in facilitating motor skill acquisition. . In motor skill learning, children in the TD group consistently outperformed all other groups in the tasks across three stages. Firstly, The learning rate and final scores of the children with ADHD approached the levelf of those of TD children, though their baseline scores were significantly lower than the TD children. In contrast, children in the DCD group exhibited the slowest performance and were at a distinct disadvantage compared with other groups in motor learrning. Motor skill learning relies on the synergistic interaction of sensory feedback, motor control, and neural plasticity. 28 The sydrome of ADHD is primarily associated with dysfunctions in the prefrontal-striatal pathway, and some executive functions are not affected, while the disease of DCD is linked to impairments in cerebellar-motor cortex connectivity, which leads to difficulties in forming internal motor models. 29 , 30 The cerebellum is responsible for motor execution, and the prefrontal cortex plays a role in motor planning, with children with DCD potentially rely more on visual feedback to compensate for deficits in proprioceptive integration. 31 The hyperactivity/impulsivity traits of ADHD may partially counterbalance motor deficits by enhancing task engagement, though attention fluctuations can interfere with skill consolidation, as their baseline scores were high and no significant improvement was observed after intervention in the TGMD-3 running task,. Secondly, considerable evidence have accumulated over the past two decades indicating the significant impact of sensory input on motor skill learning, as sensory signals can serve as substitutes or supplements to physical practice by modifying and improving motor performance. 26 MSI integrates visual (virtual character motion correction), auditory (task rhythm cues), and proprioceptive (skiing/human wall tasks) feedback to enable online modulation of multi-modal sensory input, generating a supra-additive effect that enhances motor learning outcomes. The ADHD + DCD group outperformed than the DCD group on most of the tasks, but perform worse than the ADHD and TD groups, which suggested that attention regulation mechanisms associated with ADHD and hyperactivity/impulsivity factors may partially compensate for motor deficits associated with DCD. And further, skill retention was another evidence to investigate motor learnign, and both of the three groups for children showed rapid skill recovery and some retention. These results are consistent with the findings of Gheysen et al. (2011) and Chen et al. (2011), demonstrating that children with ADHD and DCD can achieve full skill acquisition through practice. 32 , 33 In gross and fine motor skills, Our study found that baseline scores in the ADHD + DCD group on TGMD-3 and MABC-2 were significantly lower than those of ADHD and TD groups but higher than those of the DCD group And after the intervention, the ADHD + DCD group’s performance had been improved above the level of the DCD group. This finding aligns with Miyahara et al.’s discovery that motor performance in children with ADHD is not declined even with increased attention demands. 37 But does not cohere with the finding of Gillberg and Pitcher’s research, which suggests that ADHD and DCD comorbidity results in more severe outcomes compared to the isolated disorders. 9 , 36 However, baseline scores on the MABC-2 fine motor tasks were poorest in the ADHD + DCD group, highlighting a synergistic effect between ADHD and DCD traits. 38 According to the results, this study agrees with Pitcher’s finding that children with ADHD + DCD have common & genuine motor disorders independent of attention deficits, which challenges the DSM-IV view that “ADHD-related motor problems arise from distractibility.” 36 And further, this study also coincides with Harris et al’s and Straker et al’s findings that sensory input’s therapeutic benefits for different neurodevelopmental disorders (NDDs). 34 , 35 In addition, The higher variance in performance befreo and after the MTSI intervention suggests that the ADHD + DCD comorbidity should not be viewed merely as a symptom overlap. This study proposes that the interaction between attention fluctuations (core ADHD symptoms) and noise in sensory-motor processing (DCD traits) contributes to the formation of a "double-risk effect" during the skill consolidation phase. MSI may mitigate this variance through externally guided attention control via gamified multi-task constraints and enhanced learning outcomes by incorporating various sensory modalities. Limitations and Future Work Despite this study’s systematic evaluation of long-term motor skill learning processes and effects in children with ADHD, DCD, and their comorbidities, certain limitations remain. First, the differences observed could stem from task complexity, training duration, participant age, or baseline abilities. However, this study minimized confounding factors by rigorously matching participant age and excluding other comorbidities. Future research could expand the participant pool and include different subtypes to increase the generalizability of the findings. Second, this study did not include a long-term follow-up post-intervention, suggesting the need for future studies to assess the long-term impact of MSI on skill retention. Finally, this study primarily relied on behavioral measurements, and future research could integrate fMRI or EEG to explore neuroadaptive changes in ADHD and DCD children during motor learning. Conclusion This study introduces a novel VR-based, multi-modal sensory input, and task-oriented intervention strategy for children with ADHD and DCD, which provides preliminary evidence that MTSI intervention could positively affect the motor skill learning process and developmental outcomes in children with ADHD, DCD, and ADHD + DCD comorbidity, and could improve both their gross and fine motor skills together with good retention. These findings will be of help in clinical setting and curriculum in adapted physical aducation by offering a new feasible intervention strategy for addressing motor issues in children with ADHD and DCD comorbidity. Declarations Acknowledgments We sincerely thank all the participants and their parents for their invaluable contributions to this study. Special thanks are due to the leaders and teachers at the Education Bureau of Qiaoxi District in Shijiazhuang, the Special Education School, and Zhonglu Primary School in Shijiazhuang, for their support in participant recruitment and throughout the course of the experiment. Author’s Contributions All authors contributed to the study conception and design. Material preparation, data collectioiand analysis were performed by L.Z., and Z.Z.. L.Z., and J.W. were responsible for recruiting and data collection. Y.G. were responsible for patient selection. K.W., Y.Z., and Z.Z. contributed advice during the study in their specific fields. The first draft ofthemanuscript was written by Z.L. and all authors commented on previousversions ofthemanuscript. All authors read and approved the final manuscript. Declaration of competing interest The authors declare no competing interests. Funding This study was supported by the National Key Research and Development Program of the Ministry of Health and Family Planning, China [grant numbers No. 2024YFC2707903], the National Social Science Fund of China [grant numbers No. 19BTY045], and the Hebei Province Overseas Returnee Talent Program [grant numbers No. C2023034]. Ethical Approval This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was granted by the Ethics Committee of Hebei Normal University (Approval No. 2023LLSC015). Data availability More information is available on the hyperlink as Data Availability statement page. References Thapar, A., Cooper, M., & Rutter, M. Neurodevelopmental disorders. The lancet. 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Ossmy, O., & Mukamel, R. Activity in superior parietal cortex during training by observation predicts asymmetric learning levels across hands. Scientific reports. 6, 32133 (2016). Lee, J., Mayall, L. A., Bates, K. E., Hill, E. L., Leonard, H. C., & Farran, E. K. The relationship between motor milestone achievement and childhood motor deficits in children with Attention Deficit Hyperactivity Disorder (ADHD) and children with Developmental Coordination Disorder. Research in developmental disabilities. 113, 103920 (2021). Wilson, P. H., Maruff, P., Butson, M., Williams, J., Lum, J., & Thomas, P. R. (2004). Internal representation of movement in children with developmental coordination disorder: a mental rotation task. Developmental medicine and child neurology. 46(11), 754–759 (2004). Wilson, P. H., Ruddock, S., Smits-Engelsman, B., Polatajko, H., & Blank, R. Understanding performance deficits in developmental coordination disorder: a meta-analysis of recent research. Developmental medicine and child neurology. 55(3), 217–228 (2013). Gheysen, F., Van Waelvelde, H., & Fias, W. Impaired visuo-motor sequence learning in Developmental Coordination Disorder. Research in developmental disabilities. 32(2), 749–756 (2011). Chen, Y. Y., Liaw, L. J., Liang, J. M., Hung, W. T., Guo, L. Y., & Wu, W. L. Timing perception and motor coordination on rope jumping in children with attention deficit hyperactivity disorder. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 14(2), 105–109 (2013). Harris E, Cox L, Auld M, et al. Visual perception and upper limb function in children with Developmental Coordination Disorder[J]. Physiotherapy. 101, e535-e535 (2015). Straker, L., Howie, E., Smith, A., Jensen, L., Piek, J., & Campbell, A. A crossover randomised and controlled trial of the impact of active video games on motor coordination and perceptions of physical ability in children at risk of Developmental Coordination Disorder. Human movement science. 42, 146–160 (2015). Pitcher, T. M., Piek, J. P., & Hay, D. A. Fine and gross motor ability in males with ADHD. Developmental medicine and child neurology. 45(8), 525–535 (2003). Miyahara, M., Piek, J., & Barrett, N. Accuracy of drawing in a dual-task and resistance-to-distraction study: motor or attention deficit?. Human movement science. 25(1), 100–109 (2006). Adams, I. L., Lust, J. M., Wilson, P. H., & Steenbergen, B. Compromised motor control in children with DCD: a deficit in the internal model?—A systematic review. Neuroscience and biobehavioral reviews. 47, 225–244 (2014). Table 2 To 4 Table 2 To 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBACPmYYi5mx8cGHCgk5fkJa2CBaDBgY2JkPG844Y2Es2UBICwNMCz9bmjRnW0XiBoJa2NkfPi749Ueen5nHQJpxngTjBgbmh49u4HdYsvHMPgPDmc08BsaF2ySYzRnYjI1z8Gs5Js3bY8C44TCPQfLMbRJslg08bNL4tTC2gbTYg7Qc5p0jwWNwgKAWZjZpnh8GiRsOsyU28zZISBChhY3ZmLfBOHlmM/NhxhnHJAwkmwn4hZ//+MPHPH/kbPv5D7b/+FBTV9/P3vzwMT4tYMDYhsxjxqUMBfwhStUoGAWjYBSMVAAAZ3pA4inbR3EAAAAASUVORK5CYII=","orcid":"","institution":"Hebei Normal University","correspondingAuthor":true,"prefix":"","firstName":"Zongtao","middleName":"","lastName":"Li","suffix":""},{"id":440751852,"identity":"a39a4a7b-81dd-41b5-9a13-ebb960e629fe","order_by":2,"name":"Yanzhao Zhao","email":"","orcid":"","institution":"Hebei Normal University","correspondingAuthor":false,"prefix":"","firstName":"Yanzhao","middleName":"","lastName":"Zhao","suffix":""},{"id":440751853,"identity":"8d30cc28-bca6-4533-9046-09ee6e97aaa3","order_by":3,"name":"Lei Zhao","email":"","orcid":"","institution":"Hebei Normal University","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Zhao","suffix":""},{"id":440751854,"identity":"c7424904-3ee4-4ba5-9a49-d2260d328d60","order_by":4,"name":"Jiaqi Wang","email":"","orcid":"","institution":"Hebei Normal University","correspondingAuthor":false,"prefix":"","firstName":"Jiaqi","middleName":"","lastName":"Wang","suffix":""},{"id":440751855,"identity":"d1f4b39a-90f6-4567-ab06-883d9610d731","order_by":5,"name":"Yingjie Gao","email":"","orcid":"","institution":"Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yingjie","middleName":"","lastName":"Gao","suffix":""},{"id":440751856,"identity":"88e8576f-fde6-4474-9e0a-fa134a45d27d","order_by":6,"name":"Keshan Wang","email":"","orcid":"","institution":"Hebei Normal University","correspondingAuthor":false,"prefix":"","firstName":"Keshan","middleName":"","lastName":"Wang","suffix":""},{"id":440751857,"identity":"d3f8bf44-ab2d-471c-9c30-d8c46ce6965d","order_by":7,"name":"Yajie Zheng","email":"","orcid":"","institution":"Hebei Normal University","correspondingAuthor":false,"prefix":"","firstName":"Yajie","middleName":"","lastName":"Zheng","suffix":""}],"badges":[],"createdAt":"2025-03-04 10:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6153569/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6153569/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-27613-6","type":"published","date":"2025-12-17T15:57:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80580652,"identity":"091448dd-918e-4406-95d4-41bce949db1b","added_by":"auto","created_at":"2025-04-14 23:16:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":322553,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart illustrating the complete experimental design and data analysis process of this study.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6153569/v1/b1179297b3c60720f28d4514.png"},{"id":80582502,"identity":"680efd1d-4bae-4760-af70-898f2af732d3","added_by":"auto","created_at":"2025-04-14 23:32:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":428907,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of intervention and retention phase scores among ADHD+DCD, ADHD, DCD, and TD groups. a: Task 1 performance across groups. b: Task 2 performance across groups. c: Task 3 performance across groups. d: Task 4 performance across groups. e: Task 5 performance across groups.\u003c/p\u003e","description":"","filename":"floatimage12.png","url":"https://assets-eu.researchsquare.com/files/rs-6153569/v1/6fd5aacd75e78c7258c4d52a.png"},{"id":98813993,"identity":"fd5bed04-808a-4b40-bdca-fc7d8f5ac192","added_by":"auto","created_at":"2025-12-22 16:09:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1505068,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6153569/v1/0fceb941-859c-43e8-a1b6-55ecd509f6a8.pdf"},{"id":80580654,"identity":"03cc1581-5778-4bf1-80a9-65932c714f53","added_by":"auto","created_at":"2025-04-14 23:16:11","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":664091,"visible":true,"origin":"","legend":"","description":"","filename":"Table2to4.docx","url":"https://assets-eu.researchsquare.com/files/rs-6153569/v1/7bbed09309a75b3dd0a4c815.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effects of VR-Based Multi-Task Sensorimotor Intervention on Motor Skill Learning in Children with ADHD and Developmental Coordination Disorder Comorbidity","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNeurodevelopmental disorders (NDDs) affect millions of children worldwide, typically manifesting early in life and encompassing a broad spectrum of symptoms across multiple functional domains.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e Different types of NDD has its unique clinical features, but sometimes, they are often comorbid, presenting the same challenge in treatment and care.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e Attention-deficit/hyperactivity disorder (ADHD) and developmental coordination disorder (DCD) are among the most common neurodevelopmental disorders, with ADHD affecting approximately 7% of school-age children and DCD having a prevalence of 6%.\u003csup\u003e\u003cb\u003e3,4\u003c/b\u003e\u003c/sup\u003e ADHD is characterized by inattention, hyperactivity, and impulsivity, while DCD primarily manifests as clumsiness and poor coordination.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e In addition, these children also face higher risks of anxiety, depression, academic underachievement, and social psychological issues.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNotably, the comorbidity rate of ADHD and DCD reaches up to 50%.\u003csup\u003e\u003cb\u003e3,4,7\u003c/b\u003e\u003c/sup\u003e However, the motor difficulties of children with comorbid ADHD and DCD are often underrecognized clinically, attributing motor problems solely to attention deficits and behavioral regulation issues.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e This has led to insufficient focus on the intersection of ADHD and DCD. In 1982, Gillberg et al. introduced the concept of \"Attention, Motor Control, and Perceptual Deficits\" (DAMP), which described the symptom overlap between ADHD and DCD, highlighting the intrinsic connection between perceptual and motor difficulties in these children.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e Furthermore, ADHD and DCD share high comorbidity with other NDDs involving impairments in sensory processing.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStudies have found that children with ADHD and DCD perform worse across various domains compared to children with only one of the disorders, facing more significant challenges, especially in information processing speed, sensory integration, motor skill learning and control, as well as both gross and fine motor skills.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/b\u003e,\u003cb\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e However, traditional cognitive and motor training approaches often fail to integrate sensory processing and motor skill development comprehensively. While pharmacological treatments can only partially improve motor performance in children with ADHD,\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e and still leaves motor difficulties after the tratment of medication, so the motor impairments are not solely attributed to attention deficits. Fortunately, more and more researches have shown that exercise-based interventions can effectively improve motor control and coordination in children with ADHD and DCD,\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e which be broadly classified into two categories: process-oriented interventions that correct motor defects and standardize movements, and task-oriented interventions that enhance engagement and function.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e The 2019 International Clinical Practice Guidelines for DCD recommended task-oriented training as the first-choice intervention for children with DCD,\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e based on the experimental results that, these inteventions have shown more significant improvements.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn recent years, virtual reality (VR) technology has increasingly been applied in neurorehabilitation. Sensory interaction-based interventions could not only provide controllable multi-sensory stimuli, but also integrate task-oriented training with multi-features of interactivity, intelligence, contextualization and immersion. It is fo great help to create virtual environments that capture children's attention and provide real-time feedback.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e Evidently, this active video games (AVG), as a task-oriented intervention, have been shown to positively improve both gross and fine motor skills in children by increasing the frequency and intensity of motor practice,\u003csup\u003e\u003cb\u003e\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e and the multi-task and variable practice training methods have been proven to be effective in enhancing memory and skill transfer.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThus, this study conducted an exploratory randomized controlled trial study by using a self-designed VR-based enhanced multisensory motor intervention system (MSI), and aimed to investigate its effects on motor skill learning in children with ADHD, DCD, and ADHD\u0026thinsp;+\u0026thinsp;DCD childern aged 6\u0026ndash;8 years. This study hypothesized Children in the ADHD, DCD, and ADHD\u0026thinsp;+\u0026thinsp;DCD groups would get improvement in motor skill learning retention in comparison to those of typically developing (TD) children, and eventually, their gross and fine motor skills would also be observed. Hopefully, this study would provide new evidence and intervention strategies for motor intervention in children with ADHD and DCD comorbidity.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants\u003c/h2\u003e\n \u003cp\u003eThis study recruited participants from the Special Education Center and community primary schools in Hebei Province, China between May 2022 and September 2023. The participants included children with Attention-Deficit/Hyperactivity Disorder (ADHD) only (ADHD group), children with both ADHD and Developmental Coordination Disorder (DCD) (ADHD\u0026thinsp;+\u0026thinsp;DCD group), children with DCD only (DCD group), and typically developing (TD) children. The demographic characteristics of the participants in each group are shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Inclusion criteria were as follows: (1) children aged 6\u0026ndash;8 years, (2) ADHD group diagnosed based on the Conners Rating Scale and the Vanderbilt ADHD Diagnostic Parent Rating Scale, (3) DCD group assessed by trained physical therapists using the Developmental Coordination Disorder Questionnaire (DCDQ) and the Movement Assessment Battery for Children, Second Edition (MABC-2), (4) all participants with an IQ\u0026thinsp;\u0026ge;\u0026thinsp;70, (5) no medication use in the past three months or use of stable doses, (6) ADHD\u0026thinsp;+\u0026thinsp;DCD group meeting all the above criteria, and (7) confirmation of diagnosis based on the \u003cem\u003eDSM-5\u003c/em\u003e criteria through interviews and neurological examination by two experienced pediatric neurologists. Exclusion criteria included other developmental disorders or serious motor and neurological issues.\u003c/p\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eParticipants\u0026rsquo; characteristics.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003cp\u003e(M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eADHD group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eADHD་DCD group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDCD group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTD group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex (boy/girl)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25/12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21/12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21/13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22/13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeight (m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.81\u0026thinsp;\u0026plusmn;\u0026thinsp;6.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.75\u0026thinsp;\u0026plusmn;\u0026thinsp;5.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.61\u0026thinsp;\u0026plusmn;\u0026thinsp;6.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.92\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.23\u0026thinsp;\u0026plusmn;\u0026thinsp;2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.97\u0026thinsp;\u0026plusmn;\u0026thinsp;2.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConners\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.2\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026mdash;\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026mdash;\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocomotor Skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.89\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.61\u0026thinsp;\u0026plusmn;\u0026thinsp;3.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.91\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.592\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e197.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBall Skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.97\u0026thinsp;\u0026plusmn;\u0026thinsp;4.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.76\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.51\u0026thinsp;\u0026plusmn;\u0026thinsp;5.452\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e163.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTGMD-3 total score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.19\u0026thinsp;\u0026plusmn;\u0026thinsp;8.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.58\u0026thinsp;\u0026plusmn;\u0026thinsp;7.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.68\u0026thinsp;\u0026plusmn;\u0026thinsp;7.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73.97\u0026thinsp;\u0026plusmn;\u0026thinsp;7.517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e254.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eManual Dexterity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.66\u0026thinsp;\u0026plusmn;\u0026thinsp;1.533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e160.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAiming and Catching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.543\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e164.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBalance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.45\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.954\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMABC-2 total score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.22\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.568\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e249.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe intervention took place at various sites within the participants\u0026apos; community schools to ensure focused attention. The 12-week intervention was conducted three times a week with 35 minutes per session. The intervention was divided into three stages, each stage lasting 4 weeks, with progressively increasing in difficulty. Children controlled a virtual character in the MSI system using their bodies. Before the formal intervention, two practice sessions were conducted to familiarize the children with the system. The intervention included five tasks in the MSI system: Task 1, Tennis Ball Strike; Task 2, Parkour; Task 3, Quick Reaction; Task 4, Skiing Over Obstacles; Task 5, Passing Through Human Shape Wall. Each task lasted 6 minutes, with 1 point awarded for each completed action, and the total scores were displayed and stored in real-time. The intensity of the participants\u0026apos; physical activity was monitored using a wearable fitness tracker. The entire intervention was supervised by multiple rehabilitation therapists and researchers. During the intervention, participants were required to maintain their usual routines and were instructed not to engage in any additional exercise or sports activities other than the regular physical education classes provided by the school. Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the research process.\u003c/p\u003e\n\u003ch3\u003eExperimental design\u003c/h3\u003e\n\u003cp\u003eThis study utilized a self-designed MSI system, incorporating Kinect motion sensing technology with RGB cameras and depth sensors to capture both color images and depth information. This enabled skeletal tracking and motion recognition. The MSI system was developed on the Unity platform, utilizing Microsoft Kinect SDK, Maya, and Visual Studio technologies, and integrated with a user interface, 3D virtual environment, and backend services. The MSI system consists of two main modules: the motion task module and the data processing module. The motion task module was designed based on relevant theoretical concepts and expert consultations, encompassing five tasks that engage multiple sensory inputs and train skills from fine to gross motor tasks. Table\u0026nbsp;2 outlines the five tasks. The data processing module automatically records scores and provides real-time feedback on correct and incorrect actions. Validity and reliability tests indicated that the task scores significantly improved after 12 sessions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with high internal consistency (ICC\u0026thinsp;\u0026gt;\u0026thinsp;0.60, Cronbach\u0026apos;s Alpha\u0026thinsp;\u0026gt;\u0026thinsp;0.80), and further optimization was applied.\u003c/p\u003e\n\u003cp\u003eAll participants underwent baseline (T1) and post-intervention (T2) assessments using the Test of Gross Motor Development-Third Edition (TGMD-3) and Movement Assessment Battery for Children-Second Edition (MABC-2). A retention assessment was conducted one week post-intervention by using the difficult level at the third stage of intervention. The study adhered to the principles of the Declaration of Helsinki. Written informed consent was obtained from the legal guardians of all participants, and children also consented to participate. Participants were informed that they could withdraw from the study at any time without negative consequences. The study protocol was approved by the Medical Ethics Committee of Hebei Normal University (Approval No. 2023LLSC015).\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eGross Motor Skill Assessment\u003c/h2\u003e\n \u003cp\u003eThe children\u0026apos;s gross motor development was assessed using the Test of Gross Motor Development, Third Edition (TGMD-3), which evaluates both locomotor skills and object control skills. Locomotor skills include tasks such as running, hopping, sliding, etc., with six specific items, while object control skills include tasks such as overhand throwing, kicking a stationary ball, dribbling, and catching with both hands, comprising seven items. Higher scores indicate better gross motor development. The TGMD-3 has demonstrated strong reliability and validity, and it is widely used to assess gross motor skills in Chinese children. In this study, the inter-rater reliability for locomotor skills, object control skills, and total gross motor scores were r\u0026thinsp;=\u0026thinsp;0.981, 0.969, and 0.976, respectively.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eFine Motor Skill Assessment\u003c/h2\u003e\n \u003cp\u003eThe Movement Assessment Battery for Children, Second Edition (MABC-2) was used to assess children\u0026apos;s motor coordination and fine motor skills. The MABC-2 is internationally recognized as the gold standard for motor coordination assessment and is divided into three age groups: 3\u0026ndash;6 years, 7\u0026ndash;10 years, and 11\u0026ndash;16 years. In this study, children aged 7\u0026ndash;10 years were assessed, and the standard scores for each test item were compared with the data norms for same-age children in China. The MABC-2 consists of three sections: manual dexterity, aiming and catching, and static and dynamic balance. The manual dexterity section includes tasks such as coin tossing, peg insertion, and bead threading. The results were compared with Chinese norms for children of the same age, and standard scores were calculated. The tool has shown good test-retest reliability (r\u0026thinsp;=\u0026thinsp;0.73\u0026ndash;0.84) and inter-rater reliability (r\u0026thinsp;=\u0026thinsp;0.49\u0026ndash;0.70).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eStatistical Methods\u003c/h3\u003e\n\u003cp\u003eAll data were analyzed using IBM SPSS 27.0 software. Descriptive statistics (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation) were used to summarize the performance in gross and fine motor skills before and after the intervention for each group. The normality of the data was assessed using the Shapiro-Wilk test (S-W test), and homogeneity of variance between groups was checked using Levene\u0026rsquo;s test. Repeated Measures ANOVA was used to compare changes in task performance scores across the three intervention phases. Paired sample t-tests and one-way ANOVA were performed to compare the within- and between- group differences in gross and fine motor skill scores between the ADHD, ADHD\u0026thinsp;+\u0026thinsp;DCD, DCD, and TD groups, respectively. Statistical significant difference was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01 for highly significant differences. Effect sizes in within- group difference were evaluated using Cohen\u0026rsquo;s d (d), categorized as small (0.20), medium (0.50), and large (0.80). Effect sizes in between- group difference were assessed using partial eta squared (\u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003e), with categories small (0.01), medium (0.06), and large (0.14).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eSample Characteristics and Protocol Adherence\u003c/h2\u003e\n \u003cp\u003eThis study successfully implemented the intervention program, in which all the participants completed the required tasks in 12 weeks, an additional week was allocated before and after the intervention for baseline assessment and post-test data collection, and a skill retention test was conducted one week following the intervention, therefore, the total study duration was 15 weeks. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic characteristics of the participants and the comparative differences in gender, age, motor skill levels, and other variables among the ADHD, ADHD\u0026thinsp;+\u0026thinsp;DCD, DCD, and TD groups. Significant differences were observed between the groups in TGMD-3 and MABC-2 scores (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but no significant differences were found for other variables (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), suggesting that the groups were balanced at baseline according to the requirements for a randomized controlled trial. Data passed the Shapiro-Wilk test for normality (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) and Levene\u0026rsquo;s Test for homogeneity of variances (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). One participant from the ADHD group and one from the TD group withdrew during the study. The average attendance rate for all participants throughout the intervention was 91.98%, with an average heart rate of 120\u0026ndash;150 beats per minute.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eMotor Skill Learning Score Data Analysis\u003c/h2\u003e\n \u003cp\u003eAs shown in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, during the three intervention phases, the ADHD group exhibited significant improvements in all the tasks\u0026rsquo; scores from the first to the last trial of each phase (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003e = 0.41\u0026ndash;0.85), and demonstated slightly lower values in baseline scores and overall trend than the TD group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003e = 0.55\u0026ndash;0.73). The ADHD\u0026thinsp;+\u0026thinsp;DCD group showed a similar trend, with significant improvements in each phase from the first to the last trial (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003e\u0026eta;\u003c/em\u003e\u0026sup2; = 0.44\u0026ndash;0.71), but displayed greater variability in their overall scores. The DCD group had the lowest scores at all phases with slower but relative stable progressy, and their performance score was slightly worse than that of the ADHD and TD groups, though their within-group score improvements were still significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003e = 0.31\u0026ndash;0.76). During the retention test phase, the scores of most of the tasks for the ADHD group (\u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003e = 0.13\u0026ndash;0.38), ADHD\u0026thinsp;+\u0026thinsp;DCD group (\u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003e = 0.06\u0026ndash;0.26), and DCD group (\u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003e = 0.14\u0026ndash;0.41) were maintained well above the baseline levels, which indicates they retain well for the learned motor skills.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003ePre- and Post-Intervention Comparison of Motor Skills effects\u003c/h2\u003e\n \u003cp\u003eAs shown in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, in terms of gross motor skills, the ADHD group exhibited significant improvements in standing long jump, kicking a stationary ball, and other sub-items and total scores (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.52\u0026ndash;16.60), though no significant improvements were seen in running or side-sliding steps (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The ADHD\u0026thinsp;+\u0026thinsp;DCD group showed significant improvements in forward sliding, side sliding, overhand throwing, and other sub-items and total scores \u003cem\u003e(p\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.20\u0026ndash;15.96), but no significant improvements were found in running (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The DCD group demonstrated significant improvements in forward sliding, overhand throwing, and other sub-items and total scores (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.52\u0026ndash;14.10), but no significant improvements in running or underhand throwing (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Moreover, significant differences were found between these three groups and the TD group in gross motor skills (F\u0026thinsp;=\u0026thinsp;2.41\u0026ndash;17.02, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003e = 0.04\u0026ndash;0.21).In terms of fine motor skills, the ADHD group showed significant improvements in tasks like coin tossing, bead threading, and other sub-items and total scores (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.52\u0026ndash;4.09). The ADHD\u0026thinsp;+\u0026thinsp;DCD group showed similar significant improvements in coin tossing, bead threading, and other sub-items and total scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, d\u0026thinsp;=\u0026thinsp;1.68\u0026ndash;4.21). Similarly, the DCD group showed significant improvements in fine motor tasks (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.78\u0026ndash;4.43). However, significant differences between these three groups and the TD group were observed in gross motor skill comparisons (F\u0026thinsp;=\u0026thinsp;0.74\u0026ndash;76.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003e = 0.01\u0026ndash;0.54).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary objective of this study was to assess the impact of a Virtual Reality (VR)-based Enhanced Multi-Task Sensorimotor Intervention (MSI) on the motor skill learning processes and outcomes in children with Attention-Deficit/Hyperactivity Disorder (ADHD), Developmental Coordination Disorder (DCD), and ADHD\u0026thinsp;+\u0026thinsp;DCD comorbidity. The results of the study aligned with our hypothesis that, children with ADHD, ADHD\u0026thinsp;+\u0026thinsp;DCD comorbidity, and DCD demonstrated motor skill learning rates that approached or reached the levels of Typically Developing (TD) children over 12 weeks of intervention. Motor skills significantly were improved across all groups, including the substantial enhancement of both gross and fine motor skills, and the well retention of the learned motor skills in intervention. This finding certifys the effectiveness of VR-based, task-oriented, and multi-sensory feedback-driven interventions, and further confirms the critical role of sensory input in facilitating motor skill acquisition. .\u003c/p\u003e \u003cp\u003eIn motor skill learning, children in the TD group consistently outperformed all other groups in the tasks across three stages. Firstly, The learning rate and final scores of the children with ADHD approached the levelf of those of TD children, though their baseline scores were significantly lower than the TD children. In contrast, children in the DCD group exhibited the slowest performance and were at a distinct disadvantage compared with other groups in motor learrning. Motor skill learning relies on the synergistic interaction of sensory feedback, motor control, and neural plasticity.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e The sydrome of ADHD is primarily associated with dysfunctions in the prefrontal-striatal pathway, and some executive functions are not affected, while the disease of DCD is linked to impairments in cerebellar-motor cortex connectivity, which leads to difficulties in forming internal motor models.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e The cerebellum is responsible for motor execution, and the prefrontal cortex plays a role in motor planning, with children with DCD potentially rely more on visual feedback to compensate for deficits in proprioceptive integration.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e The hyperactivity/impulsivity traits of ADHD may partially counterbalance motor deficits by enhancing task engagement, though attention fluctuations can interfere with skill consolidation, as their baseline scores were high and no significant improvement was observed after intervention in the TGMD-3 running task,. Secondly, considerable evidence have accumulated over the past two decades indicating the significant impact of sensory input on motor skill learning, as sensory signals can serve as substitutes or supplements to physical practice by modifying and improving motor performance.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e MSI integrates visual (virtual character motion correction), auditory (task rhythm cues), and proprioceptive (skiing/human wall tasks) feedback to enable online modulation of multi-modal sensory input, generating a supra-additive effect that enhances motor learning outcomes. The ADHD\u0026thinsp;+\u0026thinsp;DCD group outperformed than the DCD group on most of the tasks, but perform worse than the ADHD and TD groups, which suggested that attention regulation mechanisms associated with ADHD and hyperactivity/impulsivity factors may partially compensate for motor deficits associated with DCD. And further, skill retention was another evidence to investigate motor learnign, and both of the three groups for children showed rapid skill recovery and some retention. These results are consistent with the findings of Gheysen et al. (2011) and Chen et al. (2011), demonstrating that children with ADHD and DCD can achieve full skill acquisition through practice.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn gross and fine motor skills, Our study found that baseline scores in the ADHD\u0026thinsp;+\u0026thinsp;DCD group on TGMD-3 and MABC-2 were significantly lower than those of ADHD and TD groups but higher than those of the DCD group And after the intervention, the ADHD\u0026thinsp;+\u0026thinsp;DCD group\u0026rsquo;s performance had been improved above the level of the DCD group. This finding aligns with Miyahara et al.\u0026rsquo;s discovery that motor performance in children with ADHD is not declined even with increased attention demands.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e But does not cohere with the finding of Gillberg and Pitcher\u0026rsquo;s research, which suggests that ADHD and DCD comorbidity results in more severe outcomes compared to the isolated disorders.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e However, baseline scores on the MABC-2 fine motor tasks were poorest in the ADHD\u0026thinsp;+\u0026thinsp;DCD group, highlighting a synergistic effect between ADHD and DCD traits.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e According to the results, this study agrees with Pitcher\u0026rsquo;s finding that children with ADHD\u0026thinsp;+\u0026thinsp;DCD have common \u0026amp; genuine motor disorders independent of attention deficits, which challenges the DSM-IV view that \u0026ldquo;ADHD-related motor problems arise from distractibility.\u0026rdquo;\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e And further, this study also coincides with Harris et al\u0026rsquo;s and Straker et al\u0026rsquo;s findings that sensory input\u0026rsquo;s therapeutic benefits for different neurodevelopmental disorders (NDDs).\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn addition, The higher variance in performance befreo and after the MTSI intervention suggests that the ADHD\u0026thinsp;+\u0026thinsp;DCD comorbidity should not be viewed merely as a symptom overlap. This study proposes that the interaction between attention fluctuations (core ADHD symptoms) and noise in sensory-motor processing (DCD traits) contributes to the formation of a \"double-risk effect\" during the skill consolidation phase. MSI may mitigate this variance through externally guided attention control via gamified multi-task constraints and enhanced learning outcomes by incorporating various sensory modalities.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Work\u003c/h2\u003e \u003cp\u003eDespite this study\u0026rsquo;s systematic evaluation of long-term motor skill learning processes and effects in children with ADHD, DCD, and their comorbidities, certain limitations remain. First, the differences observed could stem from task complexity, training duration, participant age, or baseline abilities. However, this study minimized confounding factors by rigorously matching participant age and excluding other comorbidities. Future research could expand the participant pool and include different subtypes to increase the generalizability of the findings. Second, this study did not include a long-term follow-up post-intervention, suggesting the need for future studies to assess the long-term impact of MSI on skill retention. Finally, this study primarily relied on behavioral measurements, and future research could integrate fMRI or EEG to explore neuroadaptive changes in ADHD and DCD children during motor learning.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study introduces a novel VR-based, multi-modal sensory input, and task-oriented intervention strategy for children with ADHD and DCD, which provides preliminary evidence that MTSI intervention could positively affect the motor skill learning process and developmental outcomes in children with ADHD, DCD, and ADHD\u0026thinsp;+\u0026thinsp;DCD comorbidity, and could improve both their gross and fine motor skills together with good retention. These findings will be of help in clinical setting and curriculum in adapted physical aducation by offering a new feasible intervention strategy for addressing motor issues in children with ADHD and DCD comorbidity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank all the participants and their parents for their invaluable contributions to this study. Special thanks are due to the leaders and teachers at the Education Bureau of Qiaoxi District in Shijiazhuang, the Special Education School, and Zhonglu Primary School in Shijiazhuang, for their support in participant recruitment and throughout the course of the experiment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collectioiand analysis were performed by L.Z., and Z.Z.. L.Z., and J.W. were responsible for recruiting and data collection. Y.G. were responsible for patient selection. K.W., Y.Z., and Z.Z. contributed advice during the study in their specific fields. The first draft ofthemanuscript was written by Z.L. and all authors commented on previousversions ofthemanuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Key Research and Development Program of the Ministry of Health and Family Planning, China [grant numbers No. 2024YFC2707903], the National Social Science Fund of China [grant numbers No. 19BTY045], and the Hebei Province Overseas Returnee Talent Program [grant numbers No. C2023034].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was granted by the Ethics Committee of Hebei Normal University (Approval No. 2023LLSC015).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore information is available on the hyperlink as Data Availability statement page.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThapar, A., Cooper, M., \u0026amp; Rutter, M. Neurodevelopmental disorders. The lancet. Psychiatry. 4(4), 339\u0026ndash;346 (2017).\u003c/li\u003e\n\u003cli\u003eFirst M. B. Diagnostic and statistical manual of mental disorders, 5th edition, and clinical utility. The Journal of nervous and mental disease. 201(9), 727\u0026ndash;729 (2013).\u003c/li\u003e\n\u003cli\u003eSayal, K., Prasad, V., Daley, D., Ford, T., \u0026amp; Coghill, D. ADHD in children and young people: prevalence, care pathways, and service provision. The lancet. Psychiatry, 2018;5(2):175\u0026ndash;186 (2018).\u003c/li\u003e\n\u003cli\u003eZwicker, J. G., Missiuna, C., Harris, S. R., \u0026amp; Boyd, L. A. Developmental coordination disorder: a review and update. European journal of paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society. 16(6), 573\u0026ndash;581 (2012).\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. International statistical classification of diseases and related health problems (11th ed.) (2019).\u003c/li\u003e\n\u003cli\u003eBiotteau, M., Danna, J., Baudou, \u0026Eacute;., Puyjarinet, F., Velay, J. L., Albaret, J. M., \u0026amp; Chaix, Y. Developmental coordination disorder and dysgraphia: signs and symptoms, diagnosis, and rehabilitation. Neuropsychiatric disease and treatment. 15, 1873\u0026ndash;1885 (2019).\u003c/li\u003e\n\u003cli\u003eBlank, R., Smits-Engelsman, B., Polatajko, H., Wilson, P., \u0026amp; European Academy for Childhood Disability. European Academy for Childhood Disability (EACD): recommendations on the definition, diagnosis and intervention of developmental coordination disorder (long version). Developmental medicine and child neurology. 54(1), 54\u0026ndash;93 (2012).\u003c/li\u003e\n\u003cli\u003eSergeant, J. A., Piek, J. P., \u0026amp; Oosterlaan, J. ADHD and DCD: a relationship in need of research. Human movement science. 25(1), 76\u0026ndash;89 (2006).\u003c/li\u003e\n\u003cli\u003eGillberg C. Deficits in attention, motor control, and perception: a brief review. Archives of disease in childhood. 88(10), 904\u0026ndash;910 (2003).\u003c/li\u003e\n\u003cli\u003eTervo, R. C., Azuma, S., Fogas, B., \u0026amp; Fiechtner, H. Children with ADHD and motor dysfunction compared with children with ADHD only. Developmental medicine and child neurology. 44(6), 383\u0026ndash;390 (2002).\u003c/li\u003e\n\u003cli\u003eAlloway, T. P., Rajendran, G., \u0026amp; Archibald, L. M.Working memory in children with developmental disorders. Journal of learning disabilities. 42(4), 372\u0026ndash;382 (2009).\u003c/li\u003e\n\u003cli\u003eAlloway, T. P., \u0026amp; Temple, K. J. A comparison of working memory skills and learning in children with developmental coordination disorder and moderate learning difficulties. Applied Cognitive Psychology. 21(4), 473\u0026ndash;487 (2007).\u003c/li\u003e\n\u003cli\u003eKanevski, M., Booth, J. N., Stewart, T. M., \u0026amp; Rhodes, S. M. Cognition and maths in children with Attention-Deficit/Hyperactivity disorder with and without co-occurring movement difficulties. Research in developmental disabilities. 136, 104471 (2023).\u003c/li\u003e\n\u003cli\u003ePranjić, M., Rahman, N., Kamenetskiy, A., Mulligan, K., Pihl, S., \u0026amp; Arnett, A. B. A systematic review of behavioral and neurobiological profiles associated with coexisting attention-deficit/hyperactivity disorder and developmental coordination disorder. 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Physiotherapy. 101, e535-e535 (2015).\u003c/li\u003e\n\u003cli\u003eStraker, L., Howie, E., Smith, A., Jensen, L., Piek, J., \u0026amp; Campbell, A. A crossover randomised and controlled trial of the impact of active video games on motor coordination and perceptions of physical ability in children at risk of Developmental Coordination Disorder. Human movement science. 42, 146\u0026ndash;160 (2015).\u003c/li\u003e\n\u003cli\u003ePitcher, T. M., Piek, J. P., \u0026amp; Hay, D. A. Fine and gross motor ability in males with ADHD. Developmental medicine and child neurology. 45(8), 525\u0026ndash;535 (2003).\u003c/li\u003e\n\u003cli\u003eMiyahara, M., Piek, J., \u0026amp; Barrett, N. Accuracy of drawing in a dual-task and resistance-to-distraction study: motor or attention deficit?. Human movement science. 25(1), 100\u0026ndash;109 (2006).\u003c/li\u003e\n\u003cli\u003eAdams, I. L., Lust, J. M., Wilson, P. H., \u0026amp; Steenbergen, B. Compromised motor control in children with DCD: a deficit in the internal model?\u0026mdash;A systematic review. Neuroscience and biobehavioral reviews. 47, 225\u0026ndash;244 (2014).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 2 To 4","content":"\u003cp\u003eTable 2 To 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Motor Skill Development, Children, ADHD-DCD Comorbidity, Virtual Reality, Sensorimotor Training, Neurodevelopmental Disorders","lastPublishedDoi":"10.21203/rs.3.rs-6153569/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6153569/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAttention-Deficit/Hyperactivity Disorder (ADHD) and Developmental Coordination Disorder (DCD) are two prevalent neurodevelopmental disorders and occur with a comorbidity rate of up to 50%. Both of the two conditions are associated with significant motor skill deficits. The existed interventions often emphasize the outcomes of learning while the learning process is often overlooked underlining the inconsistent results. This study evaluated the effectiveness of a 12-week Enhanced Multi-Task Sensorimotor Intervention (MTSI) in improving motor skill learning in children with ADHD, DCD, and their comorbidity. A total of 139 children (ADHD: n\u0026thinsp;=\u0026thinsp;37, ADHD\u0026thinsp;+\u0026thinsp;DCD: n\u0026thinsp;=\u0026thinsp;33, DCD: n\u0026thinsp;=\u0026thinsp;34, Typically Developing [TD]: n\u0026thinsp;=\u0026thinsp;35) participated in the MTSI, which involved five multi-sensory motor tasks integrating visual, auditory, and proprioceptive feedback. Motor skill learning provided MTSI system was assessed and changes in gross and fine motor skills were analyzed before and after intervention. All groups demonstrated significant improvements in motor skills (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, \u003cem\u003eη\u0026sup2;\u003c/em\u003e = 0.31\u0026ndash;0.84), with ADHD children showed the most substantial gains in gross motor skills. Children with ADHD\u0026thinsp;+\u0026thinsp;DCD combidity demonstrated more improvement than DCD children but less than ADHD children. And further, motor skill retention was well-maintained for all the three groups of children. These findings highlight the potential role of VR-based sensorimotor interventions to enhance motor skill acquisition and retention in children with ADHD and DCD as well as for those with ADHD and DCD combidity, and offer a novel and promising strategy for the enhancement of their moter dificiency.\u003c/p\u003e","manuscriptTitle":"The Effects of VR-Based Multi-Task Sensorimotor Intervention on Motor Skill Learning in Children with ADHD and Developmental Coordination Disorder Comorbidity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-14 23:16:06","doi":"10.21203/rs.3.rs-6153569/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-02T11:44:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T07:35:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-27T18:03:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320279900557257868873360602442795865812","date":"2025-06-19T14:30:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169269833071072868567985656731084415152","date":"2025-06-19T06:04:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-28T15:34:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85863721722385855772323568879920711727","date":"2025-05-05T08:55:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307801476445740950044004053285902456753","date":"2025-04-21T07:57:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-09T14:43:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-08T07:17:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-06T09:39:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-04-06T09:37:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"32cce6a9-b43b-49e3-9199-574a3efab808","owner":[],"postedDate":"April 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":46928029,"name":"Health sciences/Neurology/Neurological disorders"},{"id":46928030,"name":"Health sciences/Neurology/Neurological disorders/Movement disorders"},{"id":46928031,"name":"Health sciences/Neurology/Neurological disorders/Neurodevelopmental disorders"},{"id":46928032,"name":"Physical sciences/Mathematics and computing"},{"id":46928033,"name":"Health sciences/Medical research/Paediatric research"},{"id":46928034,"name":"Health sciences/Health care/Public health"},{"id":46928035,"name":"Health sciences/Health care/Paediatrics/Paediatric research"},{"id":46928036,"name":"Health sciences/Signs and symptoms/Comorbidities"}],"tags":[],"updatedAt":"2025-12-22T16:02:23+00:00","versionOfRecord":{"articleIdentity":"rs-6153569","link":"https://doi.org/10.1038/s41598-025-27613-6","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-12-17 15:57:18","publishedOnDateReadable":"December 17th, 2025"},"versionCreatedAt":"2025-04-14 23:16:06","video":"","vorDoi":"10.1038/s41598-025-27613-6","vorDoiUrl":"https://doi.org/10.1038/s41598-025-27613-6","workflowStages":[]},"version":"v1","identity":"rs-6153569","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6153569","identity":"rs-6153569","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}