Does gross motor proficiency contribute to cognitive and social development in early childhood?

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Catherine M. Capio, Norman B. Mendoza, Rachel A. Jones, Rich S.W. Masters, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4472617/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Nov, 2024 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract With limited evidence from intervention studies, causal relationships between motor competence and cognitive and social development have yet to be clearly established. In this research, we investigated whether a targeted training programme to improve gross motor skills (i.e., object control, locomotor) in young children would also lead to improvements in cognitive (i.e., executive function) and social (i.e., socioemotional competence) domains. Using a two-arm group randomized intervention design, 185 children aged 36 to 60 months (mean 47.51, SD 8.11 months) were allocated to a motor skill intervention group or an active control group. The intervention was implemented over one school year, and outcomes were monitored across five time points. Longitudinal analysis was performed using hierarchical linear mixed-effects and latent growth curve models. Participation in motor skills training led to higher rates of development in object control skills (p < 0.001) and executive function (p < 0.001). A dose‒response relationship was found where those children who displayed greater development in object control skills over time also displayed greater development in executive function (p = 0.001). We found no significant effects of the intervention on locomotor skills, social behaviors, or socioemotional competence. These findings provide evidence of a causal relationship between motor and cognitive development. Biological sciences/Developmental biology Health sciences/Health care/Paediatrics object control executive function social competence behaviors early childhood Figures Figure 1 Figure 2 Figure 3 Introduction The ability to move proficiently enables a young child to interact with their physical and social environment, thereby contributing to optimal development in cognitive and social domains. The positive relationship between motor proficiency and other developmental domains is particularly strong in early childhood 1,2 . Some evidence has come from intervention studies (e.g., Draper et al. 3 , Hudson et al. 4 ); however, knowledge of causal mechanisms that could inform child development programs remains limited. Experimental studies can unravel the underlying processes of development and establish causal relationships 5 . This study, therefore, used an experimental design to examine whether improved movement proficiency leads to improvements in the cognitive and social domains of child development. Motor skills in early childhood, especially those requiring visuospatial processing, have been suggested to be directly involved in learning processes 6 . They have also been shown to contribute to later cognitive and academic functions 7,8 . Motor skill proficiency in early childhood has also been shown to affect children’s interactions with others and their consequent social skills 9 . Thus, one might ask whether motor proficiency is an antecedent to cognitive and social development in early childhood. Neuroscientific evidence also supports the relationship between motor and cognitive development based on the interactions of brain regions associated with motor coordination and executive function 10,11 . A review by Diamond and Ling 12 suggested that intervention programs that focus on movement activities, but not aerobic exercise alone, could generate gains in executive function. Executive function refers to higher-order cognitive processes that include inhibitory control, working memory, and cognitive flexibility 13 . Executive function develops during early childhood, particularly between the ages of three and five years 14 , which coincides with the period when gross motor skills, including locomotor and object control skills, emerge and develop 15 . A recent study involving five- to six-year-old children showed that movement proficiency is a significant predictor of executive function 16 , suggesting that training gross motor skills in the early years could also yield gains in executive function. A recent study examined eight weeks of motor skills training for three- to five-year-old children and revealed concurrent gains in executive function and numeracy skills 4 . However, this recent study is limited by the use of a waitlist control rather than an active control, and the relatively short duration of the training limits insights into child development. Such limitations need to be addressed by experimental studies to generate evidence on the causal relationship between motor proficiency and executive function. Motor skills training Motor skills training programs that are grounded in evidence and utilize strategies that are suitable for young children are important. Theoretically, the process of acquiring motor skills has been modeled to occur in stages in which the initial cognitive stage is reliant on cognitive resources and verbal ability to support successful movement performance 17 . Young children, however, have cognitive resources and language skills that are not fully developed, such that facilitating a cognitive stage of skill learning is probably not ideal 18 . Young children also tend to rely less on verbal labels and more on visual codes when performing tasks 19 . A strategy for motor skills training that has been found to be suitable for children is errorless motor learning. In this approach, errors during practice are minimized, and learning is thought to be less reliant on cognitive resources 20 . This approach has been shown to improve the motor skill proficiency of children without dependence on short-term memory capacity 21 and therefore is deemed suitable for young children. Success during movement practice can lead to sustained engagement and motivation, which mediates the positive effect on cognitive development 22 . Success can also enhance self-efficacy, which contributes to social development 23 . The current study Children who are able to move proficiently can explore the environment and express themselves. Motor development, however, has continued to be relatively overlooked in studies of childhood behaviors 24 . Due to limited evidence from experimental intervention studies, the potential causal relationships between motor skill proficiency and cognitive and social development have yet to be clearly established 1 . In this study, we examined whether enhanced motor skill proficiency leads to improvements in the cognitive and social domains of child development. Across one school year, we implemented a gross motor skill training program for young children using the errorless learning approach (i.e., intervention) and compared the outcomes with those from typical kindergarten activities (i.e., active control). We hypothesized that significant improvements in (a) gross motor skill proficiency, (b) executive function (cognitive), and (c) socioemotional competence and behaviors (social) would be observed over one school year, which may be attributed to typical development, but improvements would be greater among those in the intervention group than among those in the active control group. We further hypothesized that cognitive and social development would be significantly greater for those who displayed greater improvements in gross motor skill proficiency (i.e., dose‒response relationship). We noted that fine motor skill proficiency has been shown to mediate the correlation between gross motor skills and cognitive development 25 ; hence, it was employed as a covariate in testing the hypothesized relationships. Materials and Methods We utilized a two-arm (intervention vs. active control) randomized intervention design. The study was conducted in a kindergarten setting where the intervention was delivered by teachers. All local kindergartens in Hong Kong follow the same curriculum, which stipulates a learning area of physical fitness and health that specifically targets the development of locomotor, object control, and stability skills 26 . All procedures were reviewed and approved by the institutional review board of the Education University of Hong Kong (Ref. : A2-18-2019-0180) and were performed in accordance with the Declaration of Helsinki. Participants The participants were recruited from eight classes in a local kindergarten within the same territory as the researchers' affiliated university (i.e., New Territories, Hong Kong). The kindergarten is located in a middle-class area, and the students were considered to have a homogeneous socioeconomic background. Informed consent was obtained from the participants’ parents. The participants consisted of children (n = 185; 87 females) aged 36 to 60 months (mean 47.51, SD 8.11 months) who had no diagnosed neurodevelopmental, medical, or orthopedic conditions that were contraindicated for moderate-intensity physical activity or that required special educational needs support. We calculated that to achieve 80% power (two-tailed alpha at 0.05), with an effect size of 0.28 27 , accounting for between-group and within-group interactions, and adding 10% for potential attrition, a total sample of 158 participants was required to compare two groups at four testing points. Our sample size exceeded the target because a large number of parents consented to their children’s participation. The participants were randomly allocated as a group (i.e., one intact kindergarten class) to either training or active control because the intervention was delivered in the context of kindergarten classes. Four classes were allocated to the intervention (n = 95) and active control (n = 90) groups. Procedures Figure 1 shows the flow diagram of the study. The intervention group participated in a motor skill training program that was delivered within the regular three-hour kindergarten program, while the active control group participated in typical kindergarten program activities. We codesigned the training program with two teachers and one principal and considered the following: the local curriculum guide, evidence from research on errorless motor learning for children 21 , and evidence about teacher-led interventions for early childhood education settings 28 . The training program was designed for two levels: nursery (i.e., children aged 36 to 48 months) and junior kindergarten (i.e., children aged 49 to 60 months), and delivered by trained kindergarten teachers. (Insert Fig. 1 about here) The training program targeted the following gross motor skills: object control (i.e., throwing, catching, rolling), locomotor (i.e., crawling, running, jumping, hopping), and stability (i.e., stretching, rolling, balancing) 15 . To minimize errors, activities were structured such that the initial sessions were suitably easy to allow successful practice. Task difficulty was progressively increased by manipulating equipment (e.g., smaller targets) when each child in the class displayed successful performance ≥ 75% of the time. Each training session lasted for 20 minutes and was conducted three times per week. In previous research, movement skills improved significantly following eight weeks of errorless motor learning 29 or six weeks of training provided by early childhood teachers 30 . However, eight weeks of motor skills training did not improve the cognitive functioning of early primary school children 31 . Therefore, we planned for a longer duration of the program. Working around the school terms of the local curriculum, we planned to implement 10 weeks of training in each of the two terms of one school year. We completed the 10-week training in the first term (i.e., 30 sessions from October to December 2021). However, implementation in the second term was delayed due to the suspension of schools during the COVID-19 pandemic. We eventually implemented second-term training, but for a shortened bout of six weeks (i.e., 18 sessions in May to June 2022), as was feasible following the schools’ resumption. Assessments were planned to be conducted prior to training (pretraining first term, M1), at the end of the first term (midtraining, M2), at the end of the second term (posttraining, M3), and four months after the end of training (follow-up, M4). However, a pandemic-related school suspension was imposed soon after M2, which lasted for four months. We opted to perform an additional assessment prior to the second-term training upon the resumption of schools. We eventually completed five assessment time points: baseline M1, posttraining first term M2, postschool suspension/pretraining second term M3, posttraining second term M4, and follow-up four months later M5. Outcomes Gross motor skills Gross motor skill proficiency was measured using the Test of Gross Motor Development – 3rd Edition (TGMD-3) 32, which has high levels of validity, internal consistency, and reliability 33 . It consists of two subscales: locomotor (run, gallop, skip, jump, hop, slide) and object control (two-hand strike, one-hand strike, dribble, catch, kick, overhand throw, underhand throw) skills. Trained examiners administered the tests, who first demonstrated each skill followed by one practice trial and two scored trials. Post hoc scoring was performed by two raters who were trained by an experienced rater with > 10 years of experience using the TGMD for research and clinical purposes. The two raters and the experienced rater independently scored 10% of the data sample and demonstrated high levels of interrater reliability (> 90% agreement). Each skill was scored based on the presence ( 1 ) or absence (0) of predetermined performance criteria in every trial. The highest possible raw scores for the locomotor (i.e., 46) and object control (i.e., 54) subscales were calculated based on the sum of skill scores. Consistent with previous studies, raw scores were analyzed because standardized scores are based on North American norms 34,35 . Executive function Executive function was measured using the Head-Toes-Knees Shoulders (HTKS) test, which measures both working memory and inhibitory control 36 . Working memory and inhibitory control are considered the two core components of executive function 37 . They have been shown to be relatively undifferentiated in children aged three to five years and are conceptualized as unitary constructs 14 . We therefore deemed the HTKS to be compatible with the undifferentiated nature of executive function in early childhood. The HTKS has excellent interrater reliability and internal consistency in studies of young children 38 . We administered the HTKS as a two-part game where children performed the opposite action to verbal commands. The first part of the game involved two commands (i.e., “touch your head”, “touch your toes”), and the second part of the game involved four commands (“touch your head”, “touch your toes”, “touch your knees”, “touch your shoulders”). With each verbal command (e.g., “touch your toes”), the child was expected to demonstrate the opposite response (e.g., the child touches their head) as quickly as possible. Four practice trials were given for each of the two parts, where the examiner demonstrated the correct response to each verbal command. Twenty test trials were administered, which were scored as 0 (incorrect action), 1 (initially incorrect but self-corrected and finished the correct action), or 2 (correct action). The HTKS score ranged from 0 to 40. Social competence Social competence was measured using the Social Competence and Behavior Evaluation Short Form (SCBE-30), which is a validated measure of children’s capacity for affect modulation 39 . The SCBE-30 was completed by the parents of the participants and included 30 items that were rated on a 6-point Likert-type scale (1 = never, 6 = always). Ten items contributed to each of three subscales: anger-aggression (e.g., easily frustrated), anxiety-withdrawal (e.g., uneasy in a group), and social competence (e.g., takes pleasure in one’s own accomplishment). The raw scores ranged from 10 to 60 for each subscale. The SCBE-30 has been shown to have good reliability and internal consistency in studies involving young children in Hong Kong 40,41 . Fine motor skill proficiency was assessed at baseline using the fine motor subscale of the Hong Kong Early Child Development Scale (HKECDS), which is a validated measure of child development that was specifically designed for young children in Hong Kong 42 . Data analysis Prior to the analyses, missing data were evaluated. The majority of the participants (n = 156, 84.32%) had less than 20% missing data. All missing data were imputed using multiple imputation by chained Eq. 4 3 using the mice package in R 44 . Hierarchical linear mixed-effects models (HLMMs) were employed to test the hypotheses that there would be significant improvements in (a) object control and locomotor skill proficiency, (b) executive function, and (c) socioemotional subscales over time, with improvements greater among those in the intervention group than among those in the active control group. These analyses utilized the Satterthwaite test method, with models being fitted via the restricted maximum likelihood approach. The analyses were controlled for sex and baseline fine motor skills. HLMMs were generated using the mixed-models package of JASP (version 0.18.1.0) 45 . Findings from the HLMMs were followed up by the use of latent growth curve models (LGCMs) to explore growth trajectories and interindividual variation over time, as well as dose‒response relationships between developmental domains 46 . LGCMs employ latent variables (i.e., variables that are not directly measured but are inferred from the observed manifest measures) to describe growth trajectories 47 . The LGCMs included two growth factors: an intercept (representing initial status or baseline), a slope (representing the rate of change over time), and a quadratic slope (accounting for varying gaps in measurement between the five time points) (see Muñez et al. 48 ). All growth factors were regressed to the dichotomous variable ‘condition’, which represents the control (‘0’) and intervention groups (‘1’). Time-invariant covariates (sex, fine motor skills at baseline) were also included in each of the models. The LGCM was generated using the growth function of the “lavaan” package (version 0.6.15) in R 44 . Maximum likelihood was used to account for potential nonnormality and nonindependence of the observations. Model fit was assessed using several fit indices, including the Comparative Fit Index (CFI), the Tucker‒Lewis index (TLI), the Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMR). Modification indices were examined to identify potential adjustments to improve the model fit. Results The HLMMs revealed that across all outcomes, there was a consistent positive and significant relationship with time, demonstrating that all the measured variables significantly changed over time (see Table 1 ). These results support our hypothesis that significant improvements in motor, cognitive and social outcomes would be observed over time. Significant interaction effects were observed between time and intervention only for object control skills (p < 0.001) and executive function (p < 0.001). These results suggest that even though object control (see Fig. 2 and Table 2 ) and executive function (see Fig. 3 and Table 3 ) demonstrated an upward trajectory as a function of time for both groups, the rate of increase was more pronounced for participants in the intervention group than for those in the control group. The interaction effect between time and intervention was not significant for locomotor skills, anxiety/withdrawal, anger/aggression, or social competence (all p values > 0.05). Thus, our hypothesis that the development of outcomes would be greater for those in the intervention group was only partially supported. Fine motor skill was a significant covariate of locomotor skills (p = 0.015), object control skills (p < 0.001), and anxiety withdrawal (p = 0.007). Table 1 Estimates from the hierarchical linear mixed effect model testing intervention effects Outcome Effect df F p Locomotor Intervention 1, 159 0.702 0.403 Time 4, 636 94.614 < .001* Sex 1, 159 0.229 0.633 Baseline FMS a 6, 159 2.742 0.015* Intervention x Time 4, 636 1.004 0.405 Object control Intervention 1, 159 2.581 0.11 Time 4, 636 134.371 < .001* Sex 1, 159 0.038 0.846 Baseline FMS a 6, 159 4.064 < .001* Intervention x Time 4, 636 4.659 0.001* Executive Function Intervention 1, 159 3.261 0.073 Time 4, 636 424.848 < .001* Sex 1, 159 0.272 0.603 Baseline FMS a 6, 159 1.825 0.097 Intervention x Time 4, 636 4.48 0.001* Anxiety/Withdrawal Intervention 1, 159 0.007 0.934 Time 4, 636 2.518 0.04* Sex 1, 159 0.336 0.563 Baseline FMS a 6, 159 3.063 0.007* Intervention x Time 4, 636 1.368 0.243 Anger/Aggression Intervention 1, 159 0.422 0.517 Time 4, 636 40.344 < .001* Sex 1, 159 0.345 0.558 Baseline FMS a 6, 159 1.164 0.328 Intervention x Time 4, 636 1.402 0.232 Social Competence Intervention 1, 159 0.004 0.952 Time 4, 636 13.179 < .001* Sex 1, 159 0.698 0.405 Baseline FMS a 6, 159 0.268 0.951 Intervention x Time 4, 636 1.472 0.209 Note. a Fine Motor Skills (FMS); * Statistically significant. Table 2 Estimated means for object control and their respective 95% confidence intervals for each group at different time points Time Mean (Group 0) Mean (Group 1) 95% CI (Group 0) 95% CI (Group 1) 1 8.00 7.15 6.67–9.33 5.55–8.74 2 11.83 11.11 10.50–13.16 9.52–12.71 3 14.08 14.05 12.75–15.41 12.45–15.64 4 16.94 18.53 15.62–18.27 16.94–20.13 5 16.49 18.98 15.17–17.82 17.39–20.58 Table 3 Estimated means for executive function and their respective 95% confidence intervals for each group at different time points Time Mean (Group 0) Mean (Group 1) 95% CI (Group 0) 95% CI (Group 1) 1 24.51 23.88 22.21–26.81 21.12–26.63 2 33.37 36.35 31.07–35.67 33.59–39.11 3 39.64 41.82 37.34–41.94 39.06–44.58 4 48.63 53.39 46.33–50.93 50.63–56.15 5 52.27 56.41 49.97–54.57 53.65–59.17 (Insert Table 1 about here) (Insert Fig. 2 and Table 2 about here) (Insert Fig. 3 and Table 3 about here) Rate of change over time LGCMs were performed for the outcomes that were found to have significant interactions between time and intervention in the HLMMs (i.e., object control skills, executive function). The models focused on the regression of the intercept and slope on the condition variable to explore whether the intervention significantly predicted the initial status (i.e., baseline comparison) or the rate of change (i.e., growth trajectory) in the outcomes. The covariance between the intercept and slope was also evaluated to estimate the relationship between the initial status and rate of change while controlling for fine motor skills at baseline as a covariate. We incorporated a quadratic growth component to capture potential nonlinear patterns of change over time because of the variation in elapsed time between measurement points as a consequence of the pandemic-related school suspension. The model for object control skills (see Supplementary file, Fig. S1 ) showed that the intervention did not significantly predict the initial status of object control skills (intercept: β = 0.05, p = .618), indicating comparable baseline scores across the intervention and control groups. The intervention significantly influenced the linear rate of change in object control skills (slope: β = 0.22, p < .001), indicating a significant effect of the intervention on the growth trajectory of object control skills, with participants in the intervention group showing a faster rate of change over time. The covariance between the intercept and slope was significant in a negative direction (β = − .24, p < .001), suggesting that those who started at a higher initial status tended to experience a slower rate of change, possibly because they were already close to a developmental ceiling such that there was less room for improvement. The goodness-of-fit indices indicate that this model fit the data at an acceptable level (CFI = .945, TLI = .900, RMSEA = .13, SRMR = .076). The model for executive function (see Supplementary file, Fig. S2) revealed that the intervention did not significantly predict the initial status of executive function (intercept: β = 0.04, p = .618), suggesting comparable baseline executive function across the intervention and control groups. The intervention significantly influenced the linear rate of change in executive function (slope: β = 0.14, p < .001), indicating a significant effect of the intervention on the growth trajectory of executive function. The covariance between the intercept and slope was significant in the negative direction ( β = -0.38, p < 0.001), indicating a slower rate of change for those who started at a higher initial status of executive function. Additionally, fine motor skill proficiency at baseline was a significant predictor of baseline executive function (intercept: β = 0.17, p = .022). The goodness-of-fit indices indicate that this model fit the data at an acceptable level (CFI = .949, TLI = .907, RMSEA = .13, SRMR = .077). Dose‒response relationship For the dose‒response relationship, we ran an LGCM that incorporated an intercept and slope for object control skills (iOB, sOB) and executive function (iCO, sCO; see Supplementary file, Fig S3). The model tested the effect of the rate of change in object control skills (sOB) on both the initial status (iCO) and the rate of change (sCO) in executive function. The findings indicate that the rate of change in object control skills significantly predicted the initial status ( β = 0.35, SE = 0.979, p = .002) and the rate of change (β = .38, SE = 0.320, p = .001) in executive function. These results suggest a dose‒response relationship in which improvements in object control skills were associated with enhanced executive function initially and over time. The goodness-of-fit indices suggest an acceptable fit to the data: CFI = 0.939, TLI = 0.922, RMSEA = 0.121, and SRMR = 0.106. The specified model appears to adequately capture the developmental trajectories influenced by the intervention. Discussion We aimed to contribute to the understanding of causal relationships among child development domains. We examined the effects of a codesigned gross motor skills training program implemented in a kindergarten setting in the motor, cognitive, and social development domains. Our key findings showed that, compared to typical classroom activities, participation in the motor skills training program led to greater improvements over time in object control skills and executive function. A dose‒response relationship was also found, where greater improvements in object control skills were associated with greater gains in executive function. The results partially support our hypothesis that motor skills training would enhance motor, cognitive, and social outcomes. While object control proficiency and executive function increased at a faster rate in the intervention group, the between-group differences for locomotor skills and the social development outcomes were not significant. This finding suggests that a classroom-based motor skills program will be more likely to generate concurrent cognitive gains by targeting object control skills. While a review of correlational studies of the relationship between object control skills and executive functions in children previously found insufficient evidence 49 , our current findings provide evidence of a causal relationship. Object manipulation requires visuospatial processing, which contributes to learning processes 6 . For instance, enhanced visuospatial skills through object manipulation have been associated with gains in executive function 50 . Thus, it makes sense that when object control skills develop, concurrent gains in executive function also occur. A meta-analysis also showed that movement skill interventions in early childhood tend to have a greater impact on improving object control skills than locomotor skills 51 . Our current findings suggest that exposure to training did not enhance the development of locomotor skills. Compared to object control skills, locomotor skills tend to emerge earlier in childhood and develop with less reliance on targeted training 52 . Given the age of our participants, it is likely that their locomotor skills were more developed than their object control skills at the onset of the school year. Hence, the intervention did not have a substantial impact on the typical development of locomotor skills. The development of executive function evident in the intervention group aligns with our hypothesis and demonstrates that object control skill proficiency may facilitate cognitive development in early childhood. Our findings offer evidence of a causal mechanism that builds on our current understanding of child development in which motor and cognitive development are associated 10 and executive function is predicted by movement proficiency 16 . We hypothesized that there would be a dose‒response relationship in which cognitive development would be greater when children had similarly greater improvements in motor skill proficiency. Our findings partially support this hypothesis, as we found that the rate of development of object control skills contributed to the rate of improvement in executive function. This evidence of a dose‒response relationship suggests a causal mechanism in which motor skill proficiency may enable cognitive development. Physical activity programs have been shown to improve executive function in children 53 , possibly due to the stimulating effect of physical activity on frontal brain regions that are linked to executive function 25 . While this mechanism may offer some explanation for why a movement intervention leads to gains in executive function, the scope of this current study did not include an examination of brain activity. Future studies could explore cognitive processes and motor activities through direct measures of brain activity 54 . For instance, neuroimaging tools, such as functional near-infrared spectroscopy (fNIRS), which monitors brain activity through changes in cortical oxygenation 55 , may be suitable for studying dynamic movements in ecologically valid conditions 56 . We expected that improved motor skills would benefit social development because proficient motor skills are linked to social skills through peer interactions 9 . For instance, a child with poor movement skills may tend to avoid physical play, which may limit the development of age-appropriate social skills and lead to cascading negative effects on self-confidence 57 . Contrary to our expectation, the intervention did not contribute to the development of social behaviors or socioemotional competence. The lack of clear effects in the social domain may be explained by several factors. First, learning activities in the broader curriculum likely had a greater influence on social development than those in the supplementary motor skills program. The interactions during class hours in other learning areas would have provided many more opportunities for social interactions among the children. Second, our instruments for measuring social outcomes may have been insufficiently sensitive for detecting differences between two groups who both displayed typical development. While the SCBE-30 has been widely used for measuring the socioemotional competence of kindergarten children in Hong Kong 40,41 , further work should consider measuring alternative aspects of social development, such as prosocial behaviors and social functioning 58 . Based on our current findings, enhanced development of object control skills through targeted training does not seem to benefit the development of social behaviors and socioemotional competence. Our evidence does not support a causal mechanism in which motor skill proficiency might have an antecedent role in social development. Strengths and Limitations The experimental design that we adopted to test causal mechanisms was strengthened by a longitudinal approach. The motor skill intervention was implemented over one school year, and our analysis was based on five time points of outcome measurements. As such, we were able to apply longitudinal analyses that accounted for individual variation. We originally intended to measure four time points, but the implementation of this study was impacted by the COVID-19 pandemic, during which periods of school suspension were imposed in Hong Kong. There was a four-month disruption between the two bouts of our intervention, which prompted us to add an additional point of measurement. However, some limitations also occurred due to the pandemic, such as variations in the duration of the intervention bouts. Although we included a quadratic slope in our models to account for these, we acknowledge that this variation might have impacted the findings, along with other constraints that children experienced during the pandemic. For instance, a large-scale survey involving parents of young children in Hong Kong revealed notable difficulties during periods of school suspension 59 . In terms of translating the findings to practical use in kindergartens, the study’s generalizability may be limited by the specific socioeconomic and cultural context of Hong Kong. The experiences of children and the feasibility of implementing similar interventions might differ in other regions or contexts, particularly those with different educational systems and family support mechanisms. Finally, while the longitudinal design offers robust insights into developmental trajectories, the study could benefit from a more comprehensive assessment of confounding variables. These factors might include children’s home environment, parental involvement, and access to extracurricular activities, all of which could influence motor skill development 52 . These factors may also include time-varying confounding variables. A more detailed examination of these factors could provide a fuller understanding of the mechanisms driving the observed outcomes. Conclusion Overall, our research showed that in early childhood, a targeted kindergarten-based gross motor skills training program enhanced the development of object control skills and executive function but not locomotor skills, social behavior, or socioemotional competence. A greater rate of development in object control skills contributed to a greater rate of development in executive function. This dose‒response relationship provides evidence of a causal relationship between motor proficiency and cognitive development. It has been proposed that motor and cognitive skills codevelop in bidirectional and reciprocal patterns, and experimental intervention studies are crucially important sources of evidence 57 . This study reveals one direction of a causal relationship, and future research is warranted to explore reciprocal patterns. We did not find evidence of a causal relationship between motor and social development, and further work is needed to address the identified limitations. From an applied perspective, our study findings underscore the importance of integrating evidence-based motor skills programs into early childhood education curricula. Training that emphasizes object control skills could contribute to enhanced cognitive development in young learners. Considering that both executive function and motor skills have been shown to be crucial for children’s transition to primary school 60 , training early childhood educators to embed object control skills in their learning activities could be a sustainable approach for supporting transition outcomes. Declarations Declaration of interest The authors declare no conflicts of interest. Author Contribution CMC is the principal investigator of the study and was responsible for the original concept and study design. RAJ, RSWM, and KL collaborated and provided input to the design and analytical plan. NBM performed the data analysis and visualization. CMC drafted the manuscript, and all co-authors provided expert input, contributed to this paper, and approved the submission. Acknowledgement This study was funded by the General Research Fund of the Research Grants Council of Hong Kong (Grant number 18607020). Data Availability Data is available at https://osf.io/m5nqr/?view_only=7226c7d5338646e8b58831f54202edc2 References Libertus, K. & Hauf, P. Editorial: Motor skills and their foundational role for perceptual, social, and cognitive development. Frontiers in Psychology 8, (2017). Veldman, S. L. C., Santos, R., Jones, R. A., Sousa-Sá, E. & Okely, A. D. Associations between gross motor skills and cognitive development in toddlers. Early Human Development 132, 39–44 (2019). Draper, C. E., Achmat, M., Forbes, J. & Lambert, E. V. Impact of a community-based programme for motor development on gross motor skills and cognitive function in preschool children from disadvantaged settings. Early Child Development and Care 182, 137–152 (2012). 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An after-school intervention targeting executive function and visuospatial skills also improves classroom behavior. International Journal of Behavioral Development 42, 474–484 (2018). Van Capelle, A., Broderick, C. R., van Doorn, N., E.Ward, R. & Parmenter, B. J. Interventions to improve fundamental motor skills in preschool aged children: A systematic review and meta-analysis. Journal of Science and Medicine in Sport 20, 658–666 (2017). Goodway, J. D., Ozmun, J. C. & Gallahue, D. L. Understanding Motor Development: Infants, Children, Adolescents, Adults . (Jones & Bartlett Learning, LLC, Burlington, 2021). de Greeff, J. W., Bosker, R. J., Oosterlaan, J., Visscher, C. & Hartman, E. Effects of physical activity on executive functions, attention and academic performance in preadolescent children: a meta-analysis. Journal of Science and Medicine in Sport 21, 501–507 (2018). Nishiyori, R., Bisconti, S. & Ulrich, B. Motor cortex activity during functional motor skills: An fNIRS study. Brain Topography 29, 42–55 (2016). Ferrari, M. & Quaresima, V. A brief review on the history of human functional near-infrared spectroscopy (fNIRS) development and fields of application. NeuroImage 63, 921–935 (2012). Ayaz, H., Izzetoglu, M., Izzetoglu, K. & Onaral, B. Chapter 3 - The use of functional near-infrared spectroscopy in neuroergonomics. in Neuroergonomics (eds. Ayaz, H. & Dehais, F.) 17–25 (Academic Press, 2019). doi: 10.1016/B978-0-12-811926-6.00003-8 . McClelland, M. M. & Cameron, C. E. Developing together: The role of executive function and motor skills in children’s early academic lives. Early Childhood Research Quarterly 46, 142–151 (2019). Carson, V. & Kuzik, N. The association between parent–child technology interference and cognitive and social–emotional development in preschool-aged children. Child: Care, Health and Development 47, 477–483 (2021). Lau, E. Y. H. & Lee, K. Parents’ views on young children’s distance learning and screen time during COVID-19 class suspension in Hong Kong. Early Education and Development 32, 863–880 (2021). Cameron, C. E. A transactional model of effective teaching and learning in the early childhood classroom. in Handbook of Early Childhood Education (Guilford Press, 2012). Additional Declarations No competing interests reported. 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Capio","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYLCCBAabBAkwi42BwYCHOC1ppGphYDhMghb+9sPPHjyoOJ8nOe2MAcOHssMM5jwH8GuROJNmbpBw5naxtHSOAeOMc4cZLHsb8GsxkGAwk0hsu504D6iFmbftMIPBeQIOM5Bg/wbUcg6i5S9xWnhAthxInA3SwgjScpaAwyTO5JQD/ZKcOHN2WsHBnnPpPAZnDuDXwt9+fNvDHxV2iTNuJ2988KPMWs7gTAIBl4HjAgpAxhMVkWyElYyCUTAKRsHIBgDkykMoNABdxAAAAABJRU5ErkJggg==","orcid":"","institution":"Hong Kong Metropolitan University","correspondingAuthor":true,"prefix":"","firstName":"Catherine","middleName":"M.","lastName":"Capio","suffix":""},{"id":311404447,"identity":"27067b33-6f79-42c5-8745-154097a7e75f","order_by":1,"name":"Norman B. 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Masters","email":"","orcid":"","institution":"University of Waikato","correspondingAuthor":false,"prefix":"","firstName":"Rich","middleName":"S.W.","lastName":"Masters","suffix":""},{"id":311404450,"identity":"35026006-8ae2-4d8b-8e72-4bf69a6b1c8c","order_by":4,"name":"Kerry Lee","email":"","orcid":"","institution":"Education University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Kerry","middleName":"","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2024-05-24 12:59:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4472617/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4472617/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-79538-1","type":"published","date":"2024-11-14T15:58:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58152907,"identity":"48eb2057-8115-4e0a-bf7e-f72944065f3a","added_by":"auto","created_at":"2024-06-11 20:24:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":21733,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the study\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4472617/v1/b2030833194758035891ad6f.png"},{"id":58153747,"identity":"ed2ed77e-0a11-4e38-b821-9719eae544ba","added_by":"auto","created_at":"2024-06-11 20:32:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":319969,"visible":true,"origin":"","legend":"\u003cp\u003eObject control growth trajectory of the intervention and active control groups\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-4472617/v1/0b58bf864a985c859817f5af.png"},{"id":58152908,"identity":"1d561d67-76ca-4fa8-a40b-0aee2bb04460","added_by":"auto","created_at":"2024-06-11 20:24:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":313200,"visible":true,"origin":"","legend":"\u003cp\u003eExecutive function growth trajectory of the intervention and active control groups.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-4472617/v1/52c3b93dd0bfc8e93cbf31a1.png"},{"id":69285141,"identity":"e3e3a9aa-9a3c-47f5-ab11-e404f5956f7a","added_by":"auto","created_at":"2024-11-18 19:24:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1204307,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4472617/v1/9eb0a133-ede3-44d4-9305-6b2f8736d8c8.pdf"},{"id":58153748,"identity":"1b5e6025-c944-48d4-9c8d-df7c0b7bf475","added_by":"auto","created_at":"2024-06-11 20:32:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":367691,"visible":true,"origin":"","legend":"","description":"","filename":"SciRepsuppfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-4472617/v1/70679e800bcf3d32fec6da90.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does gross motor proficiency contribute to cognitive and social development in early childhood?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe ability to move proficiently enables a young child to interact with their physical and social environment, thereby contributing to optimal development in cognitive and social domains. The positive relationship between motor proficiency and other developmental domains is particularly strong in early childhood\u003csup\u003e1,2\u003c/sup\u003e. Some evidence has come from intervention studies (e.g., Draper et al.\u003csup\u003e3\u003c/sup\u003e, Hudson et al.\u003csup\u003e4\u003c/sup\u003e); however, knowledge of causal mechanisms that could inform child development programs remains limited. Experimental studies can unravel the underlying processes of development and establish causal relationships\u003csup\u003e5\u003c/sup\u003e. This study, therefore, used an experimental design to examine whether improved movement proficiency leads to improvements in the cognitive and social domains of child development.\u003c/p\u003e \u003cp\u003eMotor skills in early childhood, especially those requiring visuospatial processing, have been suggested to be directly involved in learning processes\u003csup\u003e6\u003c/sup\u003e. They have also been shown to contribute to later cognitive and academic functions\u003csup\u003e7,8\u003c/sup\u003e. Motor skill proficiency in early childhood has also been shown to affect children\u0026rsquo;s interactions with others and their consequent social skills\u003csup\u003e9\u003c/sup\u003e. Thus, one might ask whether motor proficiency is an antecedent to cognitive and social development in early childhood.\u003c/p\u003e \u003cp\u003eNeuroscientific evidence also supports the relationship between motor and cognitive development based on the interactions of brain regions associated with motor coordination and executive function\u003csup\u003e10,11\u003c/sup\u003e. A review by Diamond and Ling\u003csup\u003e12\u003c/sup\u003e suggested that intervention programs that focus on movement activities, but not aerobic exercise alone, could generate gains in executive function. Executive function refers to higher-order cognitive processes that include inhibitory control, working memory, and cognitive flexibility\u003csup\u003e13\u003c/sup\u003e. Executive function develops during early childhood, particularly between the ages of three and five years\u003csup\u003e14\u003c/sup\u003e, which coincides with the period when gross motor skills, including locomotor and object control skills, emerge and develop\u003csup\u003e15\u003c/sup\u003e. A recent study involving five- to six-year-old children showed that movement proficiency is a significant predictor of executive function\u003csup\u003e16\u003c/sup\u003e, suggesting that training gross motor skills in the early years could also yield gains in executive function. A recent study examined eight weeks of motor skills training for three- to five-year-old children and revealed concurrent gains in executive function and numeracy skills\u003csup\u003e4\u003c/sup\u003e. However, this recent study is limited by the use of a waitlist control rather than an active control, and the relatively short duration of the training limits insights into child development. Such limitations need to be addressed by experimental studies to generate evidence on the causal relationship between motor proficiency and executive function.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eMotor skills training\u003c/h2\u003e \u003cp\u003eMotor skills training programs that are grounded in evidence and utilize strategies that are suitable for young children are important. Theoretically, the process of acquiring motor skills has been modeled to occur in stages in which the initial cognitive stage is reliant on cognitive resources and verbal ability to support successful movement performance\u003csup\u003e17\u003c/sup\u003e. Young children, however, have cognitive resources and language skills that are not fully developed, such that facilitating a cognitive stage of skill learning is probably not ideal\u003csup\u003e18\u003c/sup\u003e. Young children also tend to rely less on verbal labels and more on visual codes when performing tasks\u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA strategy for motor skills training that has been found to be suitable for children is errorless motor learning. In this approach, errors during practice are minimized, and learning is thought to be less reliant on cognitive resources\u003csup\u003e20\u003c/sup\u003e. This approach has been shown to improve the motor skill proficiency of children without dependence on short-term memory capacity\u003csup\u003e21\u003c/sup\u003e and therefore is deemed suitable for young children. Success during movement practice can lead to sustained engagement and motivation, which mediates the positive effect on cognitive development\u003csup\u003e22\u003c/sup\u003e. Success can also enhance self-efficacy, which contributes to social development \u003csup\u003e23\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe current study\u003c/h2\u003e \u003cp\u003eChildren who are able to move proficiently can explore the environment and express themselves. Motor development, however, has continued to be relatively overlooked in studies of childhood behaviors\u003csup\u003e24\u003c/sup\u003e. Due to limited evidence from experimental intervention studies, the potential causal relationships between motor skill proficiency and cognitive and social development have yet to be clearly established\u003csup\u003e1\u003c/sup\u003e. In this study, we examined whether enhanced motor skill proficiency leads to improvements in the cognitive and social domains of child development. Across one school year, we implemented a gross motor skill training program for young children using the errorless learning approach (i.e., intervention) and compared the outcomes with those from typical kindergarten activities (i.e., active control). We hypothesized that significant improvements in (a) gross motor skill proficiency, (b) executive function (cognitive), and (c) socioemotional competence and behaviors (social) would be observed over one school year, which may be attributed to typical development, but improvements would be greater among those in the intervention group than among those in the active control group. We further hypothesized that cognitive and social development would be significantly greater for those who displayed greater improvements in gross motor skill proficiency (i.e., dose‒response relationship). We noted that fine motor skill proficiency has been shown to mediate the correlation between gross motor skills and cognitive development\u003csup\u003e25\u003c/sup\u003e; hence, it was employed as a covariate in testing the hypothesized relationships.\u003c/p\u003e \u003c/div\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eWe utilized a two-arm (intervention vs. active control) randomized intervention design. The study was conducted in a kindergarten setting where the intervention was delivered by teachers. All local kindergartens in Hong Kong follow the same curriculum, which stipulates a learning area of physical fitness and health that specifically targets the development of locomotor, object control, and stability skills\u003csup\u003e26\u003c/sup\u003e. All procedures were reviewed and approved by the institutional review board of the Education University of Hong Kong (Ref. : A2-18-2019-0180) and were performed in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe participants were recruited from eight classes in a local kindergarten within the same territory as the researchers' affiliated university (i.e., New Territories, Hong Kong). The kindergarten is located in a middle-class area, and the students were considered to have a homogeneous socioeconomic background. Informed consent was obtained from the participants\u0026rsquo; parents. The participants consisted of children (n\u0026thinsp;=\u0026thinsp;185; 87 females) aged 36 to 60 months (mean 47.51, SD 8.11 months) who had no diagnosed neurodevelopmental, medical, or orthopedic conditions that were contraindicated for moderate-intensity physical activity or that required special educational needs support. We calculated that to achieve 80% power (two-tailed alpha at 0.05), with an effect size of 0.28\u003csup\u003e27\u003c/sup\u003e, accounting for between-group and within-group interactions, and adding 10% for potential attrition, a total sample of 158 participants was required to compare two groups at four testing points. Our sample size exceeded the target because a large number of parents consented to their children\u0026rsquo;s participation. The participants were randomly allocated as a group (i.e., one intact kindergarten class) to either training or active control because the intervention was delivered in the context of kindergarten classes. Four classes were allocated to the intervention (n\u0026thinsp;=\u0026thinsp;95) and active control (n\u0026thinsp;=\u0026thinsp;90) groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the flow diagram of the study. The intervention group participated in a motor skill training program that was delivered within the regular three-hour kindergarten program, while the active control group participated in typical kindergarten program activities. We codesigned the training program with two teachers and one principal and considered the following: the local curriculum guide, evidence from research on errorless motor learning for children\u003csup\u003e21\u003c/sup\u003e, and evidence about teacher-led interventions for early childhood education settings\u003csup\u003e28\u003c/sup\u003e. The training program was designed for two levels: nursery (i.e., children aged 36 to 48 months) and junior kindergarten (i.e., children aged 49 to 60 months), and delivered by trained kindergarten teachers.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here)\u003c/p\u003e \u003cp\u003eThe training program targeted the following gross motor skills: object control (i.e., throwing, catching, rolling), locomotor (i.e., crawling, running, jumping, hopping), and stability (i.e., stretching, rolling, balancing)\u003csup\u003e15\u003c/sup\u003e. To minimize errors, activities were structured such that the initial sessions were suitably easy to allow successful practice. Task difficulty was progressively increased by manipulating equipment (e.g., smaller targets) when each child in the class displayed successful performance\u0026thinsp;\u0026ge;\u0026thinsp;75% of the time. Each training session lasted for 20 minutes and was conducted three times per week. In previous research, movement skills improved significantly following eight weeks of errorless motor learning\u003csup\u003e29\u003c/sup\u003e or six weeks of training provided by early childhood teachers\u003csup\u003e30\u003c/sup\u003e. However, eight weeks of motor skills training did not improve the cognitive functioning of early primary school children\u003csup\u003e31\u003c/sup\u003e. Therefore, we planned for a longer duration of the program. Working around the school terms of the local curriculum, we planned to implement 10 weeks of training in each of the two terms of one school year. We completed the 10-week training in the first term (i.e., 30 sessions from October to December 2021). However, implementation in the second term was delayed due to the suspension of schools during the COVID-19 pandemic. We eventually implemented second-term training, but for a shortened bout of six weeks (i.e., 18 sessions in May to June 2022), as was feasible following the schools\u0026rsquo; resumption.\u003c/p\u003e \u003cp\u003eAssessments were planned to be conducted prior to training (pretraining first term, M1), at the end of the first term (midtraining, M2), at the end of the second term (posttraining, M3), and four months after the end of training (follow-up, M4). However, a pandemic-related school suspension was imposed soon after M2, which lasted for four months. We opted to perform an additional assessment prior to the second-term training upon the resumption of schools. We eventually completed five assessment time points: baseline M1, posttraining first term M2, postschool suspension/pretraining second term M3, posttraining second term M4, and follow-up four months later M5.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eGross motor skills\u003c/h2\u003e \u003cp\u003eGross motor skill proficiency was measured using the Test of Gross Motor Development \u0026ndash; 3rd Edition (TGMD-3)\u003csup\u003e32,\u003c/sup\u003e which has high levels of validity, internal consistency, and reliability\u003csup\u003e33\u003c/sup\u003e. It consists of two subscales: locomotor (run, gallop, skip, jump, hop, slide) and object control (two-hand strike, one-hand strike, dribble, catch, kick, overhand throw, underhand throw) skills. Trained examiners administered the tests, who first demonstrated each skill followed by one practice trial and two scored trials.\u003c/p\u003e \u003cp\u003ePost hoc scoring was performed by two raters who were trained by an experienced rater with \u0026gt;\u0026thinsp;10 years of experience using the TGMD for research and clinical purposes. The two raters and the experienced rater independently scored 10% of the data sample and demonstrated high levels of interrater reliability (\u0026gt;\u0026thinsp;90% agreement). Each skill was scored based on the presence (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) or absence (0) of predetermined performance criteria in every trial. The highest possible raw scores for the locomotor (i.e., 46) and object control (i.e., 54) subscales were calculated based on the sum of skill scores. Consistent with previous studies, raw scores were analyzed because standardized scores are based on North American norms\u003csup\u003e34,35\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eExecutive function\u003c/h2\u003e \u003cp\u003eExecutive function was measured using the Head-Toes-Knees Shoulders (HTKS) test, which measures both working memory and inhibitory control\u003csup\u003e36\u003c/sup\u003e. Working memory and inhibitory control are considered the two core components of executive function\u003csup\u003e37\u003c/sup\u003e. They have been shown to be relatively undifferentiated in children aged three to five years and are conceptualized as unitary constructs\u003csup\u003e14\u003c/sup\u003e. We therefore deemed the HTKS to be compatible with the undifferentiated nature of executive function in early childhood. The HTKS has excellent interrater reliability and internal consistency in studies of young children\u003csup\u003e38\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe administered the HTKS as a two-part game where children performed the opposite action to verbal commands. The first part of the game involved two commands (i.e., \u0026ldquo;touch your head\u0026rdquo;, \u0026ldquo;touch your toes\u0026rdquo;), and the second part of the game involved four commands (\u0026ldquo;touch your head\u0026rdquo;, \u0026ldquo;touch your toes\u0026rdquo;, \u0026ldquo;touch your knees\u0026rdquo;, \u0026ldquo;touch your shoulders\u0026rdquo;). With each verbal command (e.g., \u0026ldquo;touch your toes\u0026rdquo;), the child was expected to demonstrate the opposite response (e.g., the child touches their head) as quickly as possible. Four practice trials were given for each of the two parts, where the examiner demonstrated the correct response to each verbal command. Twenty test trials were administered, which were scored as 0 (incorrect action), 1 (initially incorrect but self-corrected and finished the correct action), or 2 (correct action). The HTKS score ranged from 0 to 40.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eSocial competence\u003c/h2\u003e \u003cp\u003eSocial competence was measured using the Social Competence and Behavior Evaluation Short Form (SCBE-30), which is a validated measure of children\u0026rsquo;s capacity for affect modulation\u003csup\u003e39\u003c/sup\u003e. The SCBE-30 was completed by the parents of the participants and included 30 items that were rated on a 6-point Likert-type scale (1\u0026thinsp;=\u0026thinsp;never, 6\u0026thinsp;=\u0026thinsp;always). Ten items contributed to each of three subscales: anger-aggression (e.g., easily frustrated), anxiety-withdrawal (e.g., uneasy in a group), and social competence (e.g., takes pleasure in one\u0026rsquo;s own accomplishment). The raw scores ranged from 10 to 60 for each subscale. The SCBE-30 has been shown to have good reliability and internal consistency in studies involving young children in Hong Kong\u003csup\u003e40,41\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFine motor skill proficiency was assessed at baseline using the fine motor subscale of the Hong Kong Early Child Development Scale (HKECDS), which is a validated measure of child development that was specifically designed for young children in Hong Kong\u003csup\u003e42\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003ePrior to the analyses, missing data were evaluated. The majority of the participants (n\u0026thinsp;=\u0026thinsp;156, 84.32%) had less than 20% missing data. All missing data were imputed using multiple imputation by chained Eq.\u0026nbsp;4\u003csup\u003e3\u003c/sup\u003e using the mice package in R\u003csup\u003e44\u003c/sup\u003e. Hierarchical linear mixed-effects models (HLMMs) were employed to test the hypotheses that there would be significant improvements in (a) object control and locomotor skill proficiency, (b) executive function, and (c) socioemotional subscales over time, with improvements greater among those in the intervention group than among those in the active control group. These analyses utilized the Satterthwaite test method, with models being fitted via the restricted maximum likelihood approach. The analyses were controlled for sex and baseline fine motor skills. HLMMs were generated using the mixed-models package of JASP (version 0.18.1.0)\u003csup\u003e45\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFindings from the HLMMs were followed up by the use of latent growth curve models (LGCMs) to explore growth trajectories and interindividual variation over time, as well as dose‒response relationships between developmental domains\u003csup\u003e46\u003c/sup\u003e. LGCMs employ latent variables (i.e., variables that are not directly measured but are inferred from the observed manifest measures) to describe growth trajectories\u003csup\u003e47\u003c/sup\u003e. The LGCMs included two growth factors: an intercept (representing initial status or baseline), a slope (representing the rate of change over time), and a quadratic slope (accounting for varying gaps in measurement between the five time points) (see Mu\u0026ntilde;ez et al.\u003csup\u003e48\u003c/sup\u003e). All growth factors were regressed to the dichotomous variable \u0026lsquo;condition\u0026rsquo;, which represents the control (\u0026lsquo;0\u0026rsquo;) and intervention groups (\u0026lsquo;1\u0026rsquo;). Time-invariant covariates (sex, fine motor skills at baseline) were also included in each of the models. The LGCM was generated using the growth function of the \u0026ldquo;lavaan\u0026rdquo; package (version 0.6.15) in R\u003csup\u003e44\u003c/sup\u003e. Maximum likelihood was used to account for potential nonnormality and nonindependence of the observations. Model fit was assessed using several fit indices, including the Comparative Fit Index (CFI), the Tucker‒Lewis index (TLI), the Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMR). Modification indices were examined to identify potential adjustments to improve the model fit.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe HLMMs revealed that across all outcomes, there was a consistent positive and significant relationship with time, demonstrating that all the measured variables significantly changed over time (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These results support our hypothesis that significant improvements in motor, cognitive and social outcomes would be observed over time. Significant interaction effects were observed between time and intervention only for object control skills (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and executive function (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These results suggest that even though object control (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and executive function (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) demonstrated an upward trajectory as a function of time for both groups, the rate of increase was more pronounced for participants in the intervention group than for those in the control group. The interaction effect between time and intervention was not significant for locomotor skills, anxiety/withdrawal, anger/aggression, or social competence (all p values\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Thus, our hypothesis that the development of outcomes would be greater for those in the intervention group was only partially supported. Fine motor skill was a significant covariate of locomotor skills (p\u0026thinsp;=\u0026thinsp;0.015), object control skills (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and anxiety withdrawal (p\u0026thinsp;=\u0026thinsp;0.007).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEstimates from the hierarchical linear mixed effect model testing intervention effects\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEffect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocomotor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e94.614\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.633\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline FMS\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.742\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.015*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention x Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.405\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObject control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.581\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e134.371\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.846\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline FMS\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention x Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.659\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExecutive Function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e424.848\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline FMS\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.825\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention x Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety/Withdrawal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.518\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.563\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline FMS\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.007*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention x Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.368\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnger/Aggression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.422\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.517\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40.344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.558\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline FMS\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.328\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention x Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.232\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Competence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.952\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.698\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.405\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline FMS\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.951\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention x Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.472\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote.\u003c/em\u003e \u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eFine Motor Skills (FMS);\u003c/em\u003e \u003csup\u003e\u003cem\u003e*\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eStatistically significant.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEstimated means for object control and their respective 95% confidence intervals for each group at different time points\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (Group 0)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (Group 1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI (Group 0)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI (Group 1)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.67\u0026ndash;9.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.55\u0026ndash;8.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.50\u0026ndash;13.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.52\u0026ndash;12.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.75\u0026ndash;15.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.45\u0026ndash;15.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.62\u0026ndash;18.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.94\u0026ndash;20.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.17\u0026ndash;17.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17.39\u0026ndash;20.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEstimated means for executive function and their respective 95% confidence intervals for each group at different time points\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (Group 0)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (Group 1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI (Group 0)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI (Group 1)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.21\u0026ndash;26.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.12\u0026ndash;26.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.07\u0026ndash;35.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33.59\u0026ndash;39.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37.34\u0026ndash;41.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e39.06\u0026ndash;44.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46.33\u0026ndash;50.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50.63\u0026ndash;56.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49.97\u0026ndash;54.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e53.65\u0026ndash;59.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here)\u003c/p\u003e \u003cp\u003e(Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e about here)\u003c/p\u003e \u003cp\u003e(Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e about here)\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRate of change over time\u003c/h2\u003e \u003cp\u003eLGCMs were performed for the outcomes that were found to have significant interactions between time and intervention in the HLMMs (i.e., object control skills, executive function). The models focused on the regression of the intercept and slope on the condition variable to explore whether the intervention significantly predicted the initial status (i.e., baseline comparison) or the rate of change (i.e., growth trajectory) in the outcomes. The covariance between the intercept and slope was also evaluated to estimate the relationship between the initial status and rate of change while controlling for fine motor skills at baseline as a covariate. We incorporated a quadratic growth component to capture potential nonlinear patterns of change over time because of the variation in elapsed time between measurement points as a consequence of the pandemic-related school suspension.\u003c/p\u003e \u003cp\u003eThe model for object control skills (see Supplementary file, Fig. \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e) showed that the intervention did not significantly predict the initial status of object control skills (intercept: \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05, p\u0026thinsp;=\u0026thinsp;.618), indicating comparable baseline scores across the intervention and control groups. The intervention significantly influenced the linear rate of change in object control skills (slope: \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.22, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), indicating a significant effect of the intervention on the growth trajectory of object control skills, with participants in the intervention group showing a faster rate of change over time. The covariance between the intercept and slope was significant in a negative direction (β = \u0026minus;\u0026thinsp;.24, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), suggesting that those who started at a higher initial status tended to experience a slower rate of change, possibly because they were already close to a developmental ceiling such that there was less room for improvement. The goodness-of-fit indices indicate that this model fit the data at an acceptable level (CFI\u0026thinsp;=\u0026thinsp;.945, TLI\u0026thinsp;=\u0026thinsp;.900, RMSEA\u0026thinsp;=\u0026thinsp;.13, SRMR\u0026thinsp;=\u0026thinsp;.076).\u003c/p\u003e \u003cp\u003eThe model for executive function (see Supplementary file, Fig. S2) revealed that the intervention did not significantly predict the initial status of executive function (intercept: \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.618), suggesting comparable baseline executive function across the intervention and control groups. The intervention significantly influenced the linear rate of change in executive function (slope: \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.14, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), indicating a significant effect of the intervention on the growth trajectory of executive function. The covariance between the intercept and slope was significant in the negative direction (\u003cem\u003eβ\u003c/em\u003e = -0.38, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a slower rate of change for those who started at a higher initial status of executive function. Additionally, fine motor skill proficiency at baseline was a significant predictor of baseline executive function (intercept: \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.022). The goodness-of-fit indices indicate that this model fit the data at an acceptable level (CFI\u0026thinsp;=\u0026thinsp;.949, TLI\u0026thinsp;=\u0026thinsp;.907, RMSEA\u0026thinsp;=\u0026thinsp;.13, SRMR\u0026thinsp;=\u0026thinsp;.077).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDose‒response relationship\u003c/h2\u003e \u003cp\u003eFor the dose‒response relationship, we ran an LGCM that incorporated an intercept and slope for object control skills (iOB, sOB) and executive function (iCO, sCO; see Supplementary file, Fig S3). The model tested the effect of the rate of change in object control skills (sOB) on both the initial status (iCO) and the rate of change (sCO) in executive function. The findings indicate that the rate of change in object control skills significantly predicted the initial status (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.35, SE\u0026thinsp;=\u0026thinsp;0.979, p\u0026thinsp;=\u0026thinsp;.002) and the rate of change (β\u0026thinsp;=\u0026thinsp;.38, SE\u0026thinsp;=\u0026thinsp;0.320, p\u0026thinsp;=\u0026thinsp;.001) in executive function. These results suggest a dose‒response relationship in which improvements in object control skills were associated with enhanced executive function initially and over time. The goodness-of-fit indices suggest an acceptable fit to the data: CFI\u0026thinsp;=\u0026thinsp;0.939, TLI\u0026thinsp;=\u0026thinsp;0.922, RMSEA\u0026thinsp;=\u0026thinsp;0.121, and SRMR\u0026thinsp;=\u0026thinsp;0.106. The specified model appears to adequately capture the developmental trajectories influenced by the intervention.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe aimed to contribute to the understanding of causal relationships among child development domains. We examined the effects of a codesigned gross motor skills training program implemented in a kindergarten setting in the motor, cognitive, and social development domains. Our key findings showed that, compared to typical classroom activities, participation in the motor skills training program led to greater improvements over time in object control skills and executive function. A dose‒response relationship was also found, where greater improvements in object control skills were associated with greater gains in executive function.\u003c/p\u003e \u003cp\u003eThe results partially support our hypothesis that motor skills training would enhance motor, cognitive, and social outcomes. While object control proficiency and executive function increased at a faster rate in the intervention group, the between-group differences for locomotor skills and the social development outcomes were not significant. This finding suggests that a classroom-based motor skills program will be more likely to generate concurrent cognitive gains by targeting object control skills. While a review of correlational studies of the relationship between object control skills and executive functions in children previously found insufficient evidence\u003csup\u003e49\u003c/sup\u003e, our current findings provide evidence of a causal relationship. Object manipulation requires visuospatial processing, which contributes to learning processes\u003csup\u003e6\u003c/sup\u003e. For instance, enhanced visuospatial skills through object manipulation have been associated with gains in executive function\u003csup\u003e50\u003c/sup\u003e. Thus, it makes sense that when object control skills develop, concurrent gains in executive function also occur.\u003c/p\u003e \u003cp\u003eA meta-analysis also showed that movement skill interventions in early childhood tend to have a greater impact on improving object control skills than locomotor skills\u003csup\u003e51\u003c/sup\u003e. Our current findings suggest that exposure to training did not enhance the development of locomotor skills. Compared to object control skills, locomotor skills tend to emerge earlier in childhood and develop with less reliance on targeted training\u003csup\u003e52\u003c/sup\u003e. Given the age of our participants, it is likely that their locomotor skills were more developed than their object control skills at the onset of the school year. Hence, the intervention did not have a substantial impact on the typical development of locomotor skills.\u003c/p\u003e \u003cp\u003eThe development of executive function evident in the intervention group aligns with our hypothesis and demonstrates that object control skill proficiency may facilitate cognitive development in early childhood. Our findings offer evidence of a causal mechanism that builds on our current understanding of child development in which motor and cognitive development are associated\u003csup\u003e10\u003c/sup\u003e and executive function is predicted by movement proficiency\u003csup\u003e16\u003c/sup\u003e. We hypothesized that there would be a dose‒response relationship in which cognitive development would be greater when children had similarly greater improvements in motor skill proficiency. Our findings partially support this hypothesis, as we found that the rate of development of object control skills contributed to the rate of improvement in executive function. This evidence of a dose‒response relationship suggests a causal mechanism in which motor skill proficiency may enable cognitive development.\u003c/p\u003e \u003cp\u003ePhysical activity programs have been shown to improve executive function in children\u003csup\u003e53\u003c/sup\u003e, possibly due to the stimulating effect of physical activity on frontal brain regions that are linked to executive function\u003csup\u003e25\u003c/sup\u003e. While this mechanism may offer some explanation for why a movement intervention leads to gains in executive function, the scope of this current study did not include an examination of brain activity. Future studies could explore cognitive processes and motor activities through direct measures of brain activity\u003csup\u003e54\u003c/sup\u003e. For instance, neuroimaging tools, such as functional near-infrared spectroscopy (fNIRS), which monitors brain activity through changes in cortical oxygenation\u003csup\u003e55\u003c/sup\u003e, may be suitable for studying dynamic movements in ecologically valid conditions\u003csup\u003e56\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe expected that improved motor skills would benefit social development because proficient motor skills are linked to social skills through peer interactions\u003csup\u003e9\u003c/sup\u003e. For instance, a child with poor movement skills may tend to avoid physical play, which may limit the development of age-appropriate social skills and lead to cascading negative effects on self-confidence\u003csup\u003e57\u003c/sup\u003e. Contrary to our expectation, the intervention did not contribute to the development of social behaviors or socioemotional competence. The lack of clear effects in the social domain may be explained by several factors. First, learning activities in the broader curriculum likely had a greater influence on social development than those in the supplementary motor skills program. The interactions during class hours in other learning areas would have provided many more opportunities for social interactions among the children. Second, our instruments for measuring social outcomes may have been insufficiently sensitive for detecting differences between two groups who both displayed typical development. While the SCBE-30 has been widely used for measuring the socioemotional competence of kindergarten children in Hong Kong\u003csup\u003e40,41\u003c/sup\u003e, further work should consider measuring alternative aspects of social development, such as prosocial behaviors and social functioning\u003csup\u003e58\u003c/sup\u003e. Based on our current findings, enhanced development of object control skills through targeted training does not seem to benefit the development of social behaviors and socioemotional competence. Our evidence does not support a causal mechanism in which motor skill proficiency might have an antecedent role in social development.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThe experimental design that we adopted to test causal mechanisms was strengthened by a longitudinal approach. The motor skill intervention was implemented over one school year, and our analysis was based on five time points of outcome measurements. As such, we were able to apply longitudinal analyses that accounted for individual variation. We originally intended to measure four time points, but the implementation of this study was impacted by the COVID-19 pandemic, during which periods of school suspension were imposed in Hong Kong. There was a four-month disruption between the two bouts of our intervention, which prompted us to add an additional point of measurement. However, some limitations also occurred due to the pandemic, such as variations in the duration of the intervention bouts. Although we included a quadratic slope in our models to account for these, we acknowledge that this variation might have impacted the findings, along with other constraints that children experienced during the pandemic. For instance, a large-scale survey involving parents of young children in Hong Kong revealed notable difficulties during periods of school suspension\u003csup\u003e59\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn terms of translating the findings to practical use in kindergartens, the study\u0026rsquo;s generalizability may be limited by the specific socioeconomic and cultural context of Hong Kong. The experiences of children and the feasibility of implementing similar interventions might differ in other regions or contexts, particularly those with different educational systems and family support mechanisms. Finally, while the longitudinal design offers robust insights into developmental trajectories, the study could benefit from a more comprehensive assessment of confounding variables. These factors might include children\u0026rsquo;s home environment, parental involvement, and access to extracurricular activities, all of which could influence motor skill development\u003csup\u003e52\u003c/sup\u003e. These factors may also include time-varying confounding variables. A more detailed examination of these factors could provide a fuller understanding of the mechanisms driving the observed outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOverall, our research showed that in early childhood, a targeted kindergarten-based gross motor skills training program enhanced the development of object control skills and executive function but not locomotor skills, social behavior, or socioemotional competence. A greater rate of development in object control skills contributed to a greater rate of development in executive function. This dose‒response relationship provides evidence of a causal relationship between motor proficiency and cognitive development. It has been proposed that motor and cognitive skills codevelop in bidirectional and reciprocal patterns, and experimental intervention studies are crucially important sources of evidence\u003csup\u003e57\u003c/sup\u003e. This study reveals one direction of a causal relationship, and future research is warranted to explore reciprocal patterns. We did not find evidence of a causal relationship between motor and social development, and further work is needed to address the identified limitations.\u003c/p\u003e \u003cp\u003eFrom an applied perspective, our study findings underscore the importance of integrating evidence-based motor skills programs into early childhood education curricula. Training that emphasizes object control skills could contribute to enhanced cognitive development in young learners. Considering that both executive function and motor skills have been shown to be crucial for children\u0026rsquo;s transition to primary school\u003csup\u003e60\u003c/sup\u003e, training early childhood educators to embed object control skills in their learning activities could be a sustainable approach for supporting transition outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDeclaration of interest\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCMC is the principal investigator of the study and was responsible for the original concept and study design. RAJ, RSWM, and KL collaborated and provided input to the design and analytical plan. NBM performed the data analysis and visualization. CMC drafted the manuscript, and all co-authors provided expert input, contributed to this paper, and approved the submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis study was funded by the General Research Fund of the Research Grants Council of Hong Kong (Grant number 18607020).\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is available at https://osf.io/m5nqr/?view_only=7226c7d5338646e8b58831f54202edc2\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLibertus, K. \u0026amp; Hauf, P. Editorial: Motor skills and their foundational role for perceptual, social, and cognitive development. Frontiers in Psychology 8, (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeldman, S. L. C., Santos, R., Jones, R. A., Sousa-S\u0026aacute;, E. \u0026amp; Okely, A. D. Associations between gross motor skills and cognitive development in toddlers. 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A transactional model of effective teaching and learning in the early childhood classroom. in \u003cem\u003eHandbook of Early Childhood Education\u003c/em\u003e (Guilford Press, 2012).\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"object control, executive function, social competence, behaviors, early childhood","lastPublishedDoi":"10.21203/rs.3.rs-4472617/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4472617/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWith limited evidence from intervention studies, causal relationships between motor competence and cognitive and social development have yet to be clearly established. In this research, we investigated whether a targeted training programme to improve gross motor skills (i.e., object control, locomotor) in young children would also lead to improvements in cognitive (i.e., executive function) and social (i.e., socioemotional competence) domains. Using a two-arm group randomized intervention design, 185 children aged 36 to 60 months (mean 47.51, SD 8.11 months) were allocated to a motor skill intervention group or an active control group. The intervention was implemented over one school year, and outcomes were monitored across five time points. Longitudinal analysis was performed using hierarchical linear mixed-effects and latent growth curve models. Participation in motor skills training led to higher rates of development in object control skills (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and executive function (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A dose‒response relationship was found where those children who displayed greater development in object control skills over time also displayed greater development in executive function (p\u0026thinsp;=\u0026thinsp;0.001). We found no significant effects of the intervention on locomotor skills, social behaviors, or socioemotional competence. These findings provide evidence of a causal relationship between motor and cognitive development.\u003c/p\u003e","manuscriptTitle":"Does gross motor proficiency contribute to cognitive and social development in early childhood?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 20:24:27","doi":"10.21203/rs.3.rs-4472617/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-25T13:53:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-25T11:19:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314749134426151414174252577883586557558","date":"2024-08-22T07:27:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-21T13:12:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82558442774553557477021085807632104712","date":"2024-07-11T02:13:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138416436727239155265826734153983275156","date":"2024-07-10T14:42:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-05T12:33:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-05T12:30:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-29T11:36:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-27T05:05:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-05-24T12:58:04+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":"0adef4e0-81da-4b08-b76e-c26e37ac7b2e","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":32913671,"name":"Biological sciences/Developmental biology"},{"id":32913672,"name":"Health sciences/Health care/Paediatrics"}],"tags":[],"updatedAt":"2024-11-18T19:17:21+00:00","versionOfRecord":{"articleIdentity":"rs-4472617","link":"https://doi.org/10.1038/s41598-024-79538-1","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-11-14 15:58:03","publishedOnDateReadable":"November 14th, 2024"},"versionCreatedAt":"2024-06-11 20:24:27","video":"","vorDoi":"10.1038/s41598-024-79538-1","vorDoiUrl":"https://doi.org/10.1038/s41598-024-79538-1","workflowStages":[]},"version":"v1","identity":"rs-4472617","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4472617","identity":"rs-4472617","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}