Effects of School-Based Physical Training on Cognitive Function and Physical Fitness in Children with Developmental Coordination Disorder

Summary

This controlled intervention study evaluated the effects of a 12-week school-based exercise program on cognitive function and physical fitness in children with developmental coordination disorder. Significant improvements were observed in executive function, mental rotation performance, sprint ability, and lower-limb strength, particularly among children with probable developmental coordination disorder (pDCD).

Abstract

This controlled intervention study investigated the effects of a 12-week school-based physical training program on cognitive function and physical fitness in children with probable developmental coordination disorder (pDCD). A total of 116 children with pDCD and 60 typically developing (TD) children underwent pre- and post-intervention assessments. The training group (TG) and TD group participated in the exercise intervention, whereas the control group (CG) did not receive training. Cognitive outcomes included executive function and mental rotation performance, while physical fitness outcomes included standing broad jump (SBJ), 50 m sprint, and 50 m × 8 shuttle run performance. Baseline findings demonstrated significantly lower cognitive and motor performance among children with pDCD compared with TD children. Significant group-dependent improvements were observed following the intervention. Children with pDCD demonstrated significant gains in executive function, mental rotation performance, sprint ability, and lower-limb explosive strength, with greater cognitive improvements than TD children in several domains. These findings support the beneficial role of structured school-based physical activity programs in improving cognitive and physical performance in children with pDCD.

Introduction

Developmental coordination disorder (DCD) is a neurodevelopmental condition characterized by significant motor impairment in children, which negatively affects motor skill acquisition and broader developmental functioning¹. Globally, approximately 5–6% of school-aged children are affected by DCD². According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classification, DCD is associated with difficulties in performing a variety of daily tasks and functional activities, including participation in leisure activities, recreational events, and academic tasks within school settings³. This developmental disorder commonly manifests during childhood as impaired self-care abilities and reduced participation in physical activities⁴. Beyond motor difficulties, increasing evidence suggests that DCD is also associated with impairments in several cognitive domains that contribute to motor planning, learning, and everyday functioning.

Researchers have proposed that DCD involves a lack of predictive control and manifests in effector systems⁵. Previous studies suggest that children with DCD have significant cognitive deficits, especially in spatial cognition and executive function^6,7,8. These impairments may affect spatiotemporal integration, object localization, movement planning, and motor coordination compared with typically developing (TD) peers. Mental rotation is the ability of the human brain to manipulate objects in space; these objects change position in space and constitute an integral component of spatial cognition⁹. Mental rotation ability has additionally been recognized as a predictor of motor and sports performance¹⁰. Therefore, assessment of mental rotation performance may provide important insight into cognitive functioning and visuospatial processing deficits in children with probable developmental coordination disorder (pDCD). In addition to spatial cognition, executive function has emerged as another important area of cognitive functioning that may influence motor performance and adaptive behavior in children with DCD.

At the same time, studies have shown that children with DCD also have deficits in executive function¹¹. Executive functions are higher-order cognitive processes involved in attention regulation, inhibitory control, working memory, and cognitive flexibility. These functions are essential for academic achievement and daily functioning¹². However, despite increasing evidence regarding cognitive dysfunction in DCD, it remains unclear whether exercise intervention can similarly improve executive functioning and spatial cognition in children with pDCD compared with TD peers. Because cognitive and motor functions are closely interconnected, these impairments may also contribute to reduced participation in physical activity and lower physical fitness levels among children with DCD.

Children's physical fitness level is an important independent predictor of health outcomes¹³. Recent studies suggest that children who have been diagnosed with DCD generally exhibit lower levels of physical fitness when compared with their typically developing peers. A study by Farhat et al. observed that these children demonstrated diminished aerobic capacity, which appeared to be linked to reduced pulmonary function and altered muscular responses¹⁴. Previous studies also reported differences in muscle endurance and explosive whole-body movements among children with pDCD, although findings regarding upper-body strength remain inconsistent^15,16. Therefore, understanding the relationship between physical fitness deficits and exercise-related improvements in children with pDCD remains clinically important.

Although previous studies have separately examined cognitive impairments, motor deficits, and exercise-related benefits in children with DCD, there is limited evidence for simultaneously evaluating cognitive function and physical fitness outcomes following a structured school-based exercise intervention. In particular, the extent to which children with pDCD demonstrate responsiveness to exercise intervention compared with TD peers remains insufficiently understood. Therefore, the present controlled intervention study evaluated the effects of a 12-week school-based exercise intervention on executive function, spatial cognition, and physical fitness outcomes in children with pDCD compared with TD children. The study additionally compared intervention-related changes between children with pDCD and TD children. It was hypothesized that children with pDCD would demonstrate significant exercise-related improvements in cognitive and physical fitness outcomes following intervention, although the magnitude of improvement may differ from that observed in TD children.

Protocol

Ethical approval for the study was obtained from the Ethics Committee of Shanghai University of Medicine and Health Sciences (Approval No. 2021-NFC-10-150203198809). The study was prospectively registered on ClinicalTrials.gov (ID. NCT06544317).

Study population and recruitment

Participants were recruited from primary schools located in three different districts of Shanghai. Before initiating the recruitment process, the researchers distributed recruitment letters to the children's parents. The letters provided the objectives of the study, its significance, and methodology, along with a consent form. Parents who agreed to participate were asked to sign a consent form and complete an online questionnaire accessible via a QR code. The information included the Developmental Coordination Disorder Questionnaire (DCDQ), the ADHD Rating Scale-VI, and other demographic information about participants. Questionnaire responses were accessible only to the research team. The lead researcher's contact details were also provided in the form to address parents' inquiries.

A total of 2,761 children and their parents volunteered to be included in this study. The children were initially screened with the Developmental Coordination Disorder Questionnaire (DCDQ)^17,18. Based on teachers’ assessments, those identified as potentially having pDCD but showing no signs of intellectual or cognitive impairments were selected for further evaluation. These candidates subsequently underwent an assessment using the Movement Assessment Battery for Children, Second Edition¹⁹. A total of 194 children were identified as potential pDCD candidates during screening. After exclusion of 78 children who did not meet the eligibility criteria, 116 children met the study criteria for pDCD and were randomly allocated to either a training group (TG; n = 58) or a control group (CG; n = 58) using computer-generated random number allocation performed by an independent researcher not involved in outcome assessment. Allocation results were concealed from outcome assessors during baseline and post-intervention testing. In addition, a group of typically developing children (TD; mean age 10.35 ± 1.87 years; 48 boys and 12 girls) was included as a comparison group, matched for gender. Both the TG and TD groups participated in a 12-week physical training program, whereas the CG group did not undergo any training intervention. An overall schematic representation of the study design and experimental workflow is presented in Figure 1.

Eligibility criteria

The inclusion criteria used for the group of children who had pDCD were as follows: (1) DCDQ scores as follows: 8–9 years: < 56 points; 10–12 years: < 58 points; (2) identification of motor problems using Movement Assessment Battery for Children, Second Edition (MABC-2) (a percentile rank below 15% in at least one subitem of the MABC-2); (3) age 9 to 11 years old (elementary school age); (4) children with known intellectual disability, neurological disorders, or clinically diagnosed cognitive impairment reported by school records, parents, or teachers were excluded from participation; (5) no reports or history of other neurodevelopmental conditions (e.g., ADHD) by parents. Before testing, the researchers ensured that the parents filled out the Attention Deficit/Hyperactivity Disorder (ADHD) Rating Scale-VI²⁰. Children whose ADHD Rating Scale-VI scores exceeded the age- and sex-adjusted 98th percentile cutoff were excluded from participation, per established screening criteria for ADHD²¹. Children included in the TD group additionally met the same exclusion criteria applied to the pDCD group, including absence of ADHD, neurological disorders, intellectual disability, or other neurodevelopmental conditions.

The second edition of the Movement Assessment Battery for Children (MABC-2) is intended for use with children aged 3–16 years¹⁹. It comprises eight specific tasks that assess a range of abilities. This includes fine motor control, gross motor skills, balance, and related functions. Each task produced a raw score, which was standardized for the child’s age. These standardized scores are summed across three subcomponents to calculate a motion subdomain score. A higher score indicates better motor coordination. The MABC-2 has shown strong internal consistency (α = 0.90) and reliable test–retest total scores (ICC = 0.97)²², in addition to demonstrating discriminant validity for identifying motor disorders²³.

Randomization and group allocation

All the children were right-handed, as assessed using the Edinburgh Handedness Scale²⁴. A total of 116 children with pDCD (98 boys and 18 girls) and 60 TD children (48 boys and 12 girls) were included in the final analysis. Details regarding participant screening, eligibility assessment, randomization, and group allocation are provided in the Study Population and Recruitment subsection and summarized in Figure 1.

Assessment personnel and blinding

The experimental setup of this study was carefully designed according to the standard assessment tool, MABC-2, and the experimenters were trained and licensed researchers. The entire study was conducted in consultation and collaboration with sports rehabilitation experts with pDCD training experience. The coaches and trainers in the study were physical education teachers with more than 5 years of teaching experience. Each group had ten children, with one coach explaining the movements and two caring for the children during training. Five undergraduate physical therapy students were present for all the tests to ensure that the participants in the two tests were identical. Outcome assessors responsible for cognitive and physical fitness testing were blinded to participant group allocation. Due to the nature of the exercise intervention, coaches supervising training sessions could not be blinded.

Testing schedule

All pretests were completed within three days before the children started the exercise intervention, while post-tests were completed within three days after the last training session (depending on the group's training time). This study used a prospective controlled intervention design.

Procedure

The study evaluated 176 participants (116 children with pDCD and 60 TD children) on cognitive and physical fitness assessments before and after the intervention. Refer to Table 1 for the motor skills training program. A series of 90 min after-school physical training sessions, three times a week for 12 weeks, was administered. Each session began with a 20 min warm-up, followed by 60 min of three or four tasks targeting the specific skill to be developed (aerobic training, resistance training, motor skills and balance activities, stretching and flexibility exercises, and core strength and posture exercises), and concluded with a 10 min cool-down. The children were divided into six groups, each consisting of eight to twelve participants. The intervention program was standardized across sessions and progressively adjusted according to participant tolerance and motor performance. Exercise intensity was monitored by supervising physical education teachers using session completion and participation monitoring. Attendance was recorded throughout the intervention period.

Testing procedures and instrumentation

Physical fitness and anthropometric measures

Three physical fitness tests were conducted, including the standing broad jump (SBJ), the 50 m sprint, and the 50 m × 8 shuttle run²⁵. Students were instructed to start in a standing position and complete the 50 m sprint with maximum effort. The test was performed twice, and the fastest result was recorded. The SBJ test was administered on a flat surface to test the explosive strength of the lower limbs. The shuttle run was used to assess children’s speed, agility, and endurance²⁶; children were instructed to run back and forth between two points as quickly as possible. The participants' heights were measured to the nearest 0.1 cm with a stadiometer, and their weights were measured to the nearest 0.1 kg with the same device. Children were weighed in light school uniforms without shoes, and all anthropometric measurements were performed by the same trained assessor.

Cognitive function

Cognitive tasks were computerized and administered in a standardized laboratory setting. Reaction time and response accuracy were recorded for each trial. Participants completed familiarization trials before formal testing. Stimulus presentation order was randomized across trials.

Mental rotation tasks

Children were instructed to use object-based mental rotation strategies by keeping their bodies still and mentally manipulating visual stimuli from a stationary perspective to apply object-based transformations²⁷. Two pictures of “giraffes” were presented simultaneously, with the left image fixed as the main focus while the right image displays angular or mirror differences. Set angular disparities at 0°, 60°, 120°, or 180°. Children were asked to determine, as quickly and accurately as possible, if the two images were identical.

Modified Stroop task

A computerized modified Stroop task, with two conditions: naming (non-execution) and execution, was used²⁸. In the naming condition, display a colored “XXX” on the screen and instruct children to press the key corresponding to the displayed color. In the execution condition, present a distracting-colored Chinese character in blue or red, and instruct children to press the key matching the color of the word rather than its meaning. Define the condition as congruent when the color and meaning are consistent, and incongruent when they are inconsistent.

Statistical analysis

Physical fitness analyses

A mixed-design analysis of variance (ANOVA) was conducted for each variable, with three groups (TG, CG, and TD) completing pre- and post-test measurements to determine the efficacy of the school-based exercise intervention. In physical fitness tests, a 3 × 2 (Group [TG, CG, and TD] × Time [baseline and post-intervention]) mixed-design repeated-measures ANOVA was used to analyze the results. Paired t-tests were also used to assess each group's results before and after the intervention. Post-hoc pairwise group comparisons were conducted following significant ANOVA effects.

Statistical assumptions

Normality of data distribution was assessed using the Shapiro–Wilk test, while homogeneity of variance was evaluated using Levene’s test. Sphericity assumptions for repeated-measures factors were examined using Mauchly’s test, and Greenhouse–Geisser corrections were applied when violations of sphericity were detected.

Cognitive task analyses

Computerized cognitive testing software was used to collect reaction time and correct rate data in children's cognitive tasks. All incorrect trials and trials with more than three standard deviations were removed as outliers. A 3 × 2 × 2 mixed-design ANOVA (Group [TG, CG, and TD] × Time [baseline and post-intervention] × 2 Conditions [non-executive conditions, and execution conditions]) mixed-design analysis was conducted to examine the RT and correct rate in the Stroop task for each group. In the mental rotation tasks, a 3 × 2 × 4 mixed-design ANOVA (Group [TG, CG, and TD] × Time [baseline and post-intervention] × Angular disparity [0°, 60°, 120°, or 180°]) was conducted to assess reaction time and error rate variables. Post hoc pairwise comparisons were performed, where appropriate, following significant interactions or group effects. Before the formal experiment, children were made familiar with the testing procedures and were asked to practice them a certain number of times. When the accuracy reached 75%, the test began; across all conditions, the study did not observe a notable difference in accuracy between the two groups. Finally, the researchers set the significance threshold to p < 0.05.  Effect sizes were reported using partial eta squared (η²). The researchers analyzed and statistically compared all data using statistical analysis software.

Results

Participant characteristics

The study demonstrated significant differences in the MABC-2 and DCDQ scores between the pDCD and TD groups. As expected, post-hoc least significant difference (LSD) comparisons revealed a significant difference between TG and TD, but no significant differences between TG and CG (Table 2).

Intervention adherence and compliance

Attendance and participation were monitored throughout the 12-week intervention period. Participants in the training group demonstrated high adherence to the intervention protocol, with a mean attendance rate of 92.3%. A total of 53 participants (91.4%) completed more than 90% of the scheduled training sessions. No intervention-related adverse events were reported.

Executive function outcomes

Table 3 summarizes reaction time (RT, ms) outcomes for executive function task conditions, with lower RT values indicating better task performance. The results of the executive function analysis showed that the interactions of time × condition × group (F_{(4, 346)} = 12.49, p < .001, η² = 0.13), time × group (F_{(2, 173)} = 16.26, p < .001, η² = 0.16), time × condition (F_(2,346) = 38.06, p < .001, η² = 0.18) and condition × group (F_(4,346) = 62.02, p < .001, η² = 0.42) were significant. The main effects of time (F_{(1, 173)} = 50.67, η² = 0.23), condition (F_(2,346) = 1824.61, p < .001, η² =0.91), and group (F_{(2, 173)} = 100.64, p < .001, η² = 0.54) were significant (Table 3). Accuracy rates exceeded 95% across all executive function conditions and did not demonstrate significant between-group differences; therefore, only RT outcomes are presented. Overall, reaction times decreased following the intervention, indicating improved executive function performance, with children in the pDCD training group demonstrating greater gains than those who did not receive training.

Mental rotation outcomes

Table 4 presents reaction time (RT, ms) outcomes across four angular disparity conditions (0°, 60°, 120°, and 180°), with lower RT values indicating faster mental rotation performance. The results of the mental rotation analysis showed that the interactions of time × angular disparity × group (F_{(6, 519)} = 14.10, p < .001, η² = 0.14), time × group (F_(2,173) = 43.09, p < .001, η² = 0.33), time × angular disparity (F_{(3, 519)} = 45.75, p < .001, η² = 0.21) and angular disparity × group (F_(6,519) = 32.91, p < .001, η² = 0.28) were significant. The main effects of time (F_{(1, 173)} = 151.68, p < .001, η² = 0.47), angular disparity (F_(3,519) = 695.63, p < .001, η² =0.80), and group (F_{(2, 173)} = 486.34, p < .001, η² = 0.85) were significant (Table 4). Accuracy rates remained high across all angular-disparity conditions and did not show significant group differences; therefore, RTs are reported as the primary indicator of mental rotation performance. Children with pDCD demonstrated significant improvements in mental rotation performance across all angular disparity conditions following the intervention, with the greatest improvements observed at 120° and 180°. Despite these improvements, their post-intervention performance remained below that of TD children.

Physical fitness outcomes

Regarding physical fitness tests, the results of the 50 m sprint showed that the main effects of group (F(2, 173) = 96.71, p < .001) and time (F_{(1, 173)} = 9.54, p = .002) were significant. However, the time × group interaction (F_{(2, 173)} = 1.37, p = .257) was not significant. These findings indicate that sprint performance improved over time across participants, although the magnitude of improvement did not differ significantly between groups.

The results of the SBJ test showed that the main effects of time (F_{(1, 173)} = 63.81, p < .001) and group (F_{(2, 173)} = 84.12, p < 0.001), together with a significant time × group interaction (F_{(2, 173)} = 20.20, p < .001, η² = 0.19), were significant. The significant time × group interaction indicates that changes in lower-limb explosive strength differed across groups, with greater improvements observed among participants receiving the exercise intervention.

For the 50 m × 8 shuttle run, a significant main effect of time was observed (F_{(1, 173)} = 5.70, p = 0.018), indicating modest improvement across participants. However, neither the main effect of group (F_{(2, 173)} = 2.52, p = 0.083) nor the time × group interaction (F_{(2, 173)} = 1.72, p = 0.183) reached statistical significance (Table 5). Although modest improvements were observed over time, the intervention did not result in significant between-group differences in cardiorespiratory endurance.

Overall, the findings demonstrated that children with pDCD exhibited significantly lower baseline cognitive and physical fitness performance than TD children. Following the 12-week school-based exercise intervention, significant improvements were observed in executive function, mental rotation performance, sprint ability, and lower-limb explosive strength. The training group demonstrated greater improvements in several cognitive outcomes than the control group, supporting the potential benefits of structured exercise programs for this population.

DATA AVAILABILITY:

The anonymized participant-level data supporting the findings of this study, including demographic information, screening and motor assessment data, cognitive task outcomes, physical fitness measures, group allocation variables, and post-intervention outcomes used in the reported analyses, are available from the corresponding author upon reasonable request.

Figure 1. Overall schematic representation of participant recruitment, eligibility screening, group allocation, the 12-week exercise intervention, cognitive and physical fitness assessments, and the pre-/post-intervention evaluation workflow. Please click here to view a larger version of this figure.

Domain	Examples of Activities
Locomotor skills	a) Run back and forth between cone barrels, run with a backward kick and run with high legs.
	b) "Throwing handkerchiefs" (children form a circle and chase each other)
	c) Run over obstacles, continuous bunny hops.
Balance skills	d) Walk along the marked line
	e) Walk on a balance beam, walk on plum blossom piles
	f) Walk backwards
Manipulative skills	g) Hit different balls in place (basketball, soft volleyball, tennis)
	h) Throw three different balls (basketball, soft volleyball, tennis) into the designated area
	i) Run back and forth with the football with your feet or hit the basketball with your hands or run with the ball with a racket

Table 1: Overview of the 12-week school-based motor skills training program, including exercise categories, session structure, and representative physical activities performed during the intervention.

Group (n)	TG (58)	TD (60)	CG (58)	p-value	F
MABC-2 Score	55.81 ± 9.26	77.48 ± 8.49**	55.78 ± 8.21	＜.00	126.52
DCDQ	49.31 ± 5.36	63.52 ± 7.31**	49.12 ± 5.76	＜.00	312.4
Height（cm）	139.81 ± 12.64	138.19 ± 9.78*	136.82 ± 8.72	0.06	2.78
Weight（kg）	31.21 ± 9.74	29.77 ± 9.41	30.14 ± 4.72	0.18	1.74
BMI (kg/m2)	17.73 ± 2.93	16.35 ± 3.30	16.87 ± 2.41	0.91	0.09
Note: Values are mean ± standard deviation unless specified otherwise. Height is reported in centimeters (cm), weight in kilograms (kg), and BMI in kg/m². TG = training group; CG =  control group; TD = typically developing; d = Cohen's d; DCDQ  = developmental coordination disorder questionnaire; BMI = body mass index.
* = p < .05; ** = p < .001 a significant difference compared with the TG group.

Table 2: Baseline demographic and clinical characteristics of the training group (TG), control group (CG), and typically developing (TD) group participants.

Condition		Pre-test	Post-test	p-value	t statistic
Naming	TG	565.42 ± 35.72	544.51 ± 33.84	< 0.001	3.05
	TD	545.52 ± 32.84**	536.95 ± 40.57	0.27	1.12
	CG	559.91 ± 49.52	562.25 ± 41.96*	0.16	-1.43
Incongruent	TG	1860.87 ± 390.31	1505.80 ± 271.45	< 0.001	4.54
	TD	1442.83 ± 383.33**	1178.13 ± 383.33**	< 0.001	6.54
	CG	1904.61 ± 420.06	1919.83 ± 420.72**	0.38	-0.87
Congruent	TG	1734.47 ± 392.08	1303.35 ± 381.13	< 0.001	5.48
	TD	1159.97 ± 271.13**	938.83 ± 163.98**	< 0.001	5.49
	CG	1712.46 ± 411.18	1718.60 ± 401.11**	0.85	-0.19
Note: Values represent reaction time (RT, milliseconds) and are presented as mean ± standard deviation (SD). Lower RT values indicate better executive function task performance. TG = training group; CG =  control group; TD = typically developing; d = Cohen's d; CI = confidence interval;  pre = pre-intervention; post = post-intervention.
* = p < .05; ** = p < .001 a significant difference compared with the TG group.

Table 3: Pre- and post-intervention executive function task outcomes among the training group (TG), control group (CG), and typically developing (TD) group.

Condition	Group	Pre-test	Post-test	P value	T
0°	TG	2524.24 ± 677.43	2255.19 ± 624.69	0.03	2.26
	TD	1849.32 ± 390.75**	1817.57 ± 449.13**	0.71	0.38
	CG	2604.74 ± 669.40	2590.95 ± 604.21**	0.71	0.37
60°	TG	3416.48 ± 748.34	3150.31 ± 492.06	0.03	2.29
	TD	2477.35 ± 410.01**	2325.48 ± 342.86**	0.03	2.3
	CG	3416.31 ± 721.14	3392.17 ± 706.17**	0.22	1.25
120°	TG	5020.02 ± 759.27	4035.16 ± 503.58	<0.001	7.72
	TD	2926.47 ± 519.12**	2804.63 ± 448.48**	0.03	2.17
	CG	4898.71 ± 658.68	4867.28 ± 625.63**	0.42	0.82
180°	TG	5708.78 ± 905.23	4449.52 ± 549.37	<0.001	9.31
	TD	3847.85 ± 618.87**	2797.72 ± 438.22**	<0.001	1.68
	CG	5693.24 ± 999.67	5624.28 ± 934.70**	0.1	1.66
NOTE: Values represent reaction time (RT, milliseconds) during the mental rotation task and are presented as mean ± standard deviation (SD). Lower RT values indicate faster mental rotation performance. TG = training group; CG = control group; TD = typically developing.
* = p < 0.05; ** = p < 0.001 versus the TG group (post hoc comparison).

Table 4: Mental rotation task performance outcomes before and after intervention across different angular disparity conditions in the training group (TG), control group (CG), and typically developing (TD) group.

Condition		Pre-test	Post-test	p-value	T
50 m sprint	TG	11.14 ± 1.08	10.96 ± 0.94	0.03	2.21
	TD	9.32 ± 0.59**	9.11 ± 0.58**	0.02	2.32
	CG	11.17 ± 1.15	11.15 ± 0.98*	0.57	0.57
Standing broad jump test	TG	0.91 ± 0.16	1.34 ± 0.31	＜.001	-7.49
	TD	1.26 ± 0.28**	1.42 ± 0.26**	＜.001	-3.78
	CG	0.91 ± 0.15	0.91 ± 0.16**	0.4	-0.85
50 m × 8 shuttle run	TG	2.08 ± 0.25	2.05 ± 0.19	0.49	0.69
	TD	2.03 ± 0.25	1.98 ± 0.24	＜.001	4.23
	CG	2.11 ± 0.23	2.10 ± 0.23	0.32	-0.19
Note: Values are presented as mean ± standard deviation (SD). 50 m sprint is reported in seconds (s), standing broad jump in meters (m), and 50 m × 8 shuttle run in minutes (min). Lower values indicate better performance for sprint and shuttle-run tests, whereas higher values indicate better performance for standing broad jump.. TG = training group; CG =  control group; TD = typically developing; d = Cohen's d; CI = confidence interval;  pre = pre-intervention; post = post-intervention.
* = p < 0.05; ** = p < 0.001 versus the TG group (post hoc comparison).

Table 5: Physical fitness assessment outcomes, including standing broad jump, 50 m sprint, and 50 m × 8 shuttle run, before and after the intervention among the study groups.

Discussion

This study compared the inhibitory function, mental rotation, and motor skills between pDCD and TD children. Simultaneously, this study compared changes in performance across the two groups of children in each function after participating in the same 12-week school-based exercise intervention. The study found that, before the exercise intervention, the cognitive functions of children with pDCD were lower than those of TD children, especially on high mental rotation angles and high-inhibition tasks. In the exercise test, in addition to long-distance running, there were also significant differences between children with pDCD and TD on other items before the intervention. After the 12-week school-based exercise intervention, improvements were observed in both groups, with children with pDCD demonstrating greater improvements in selected cognitive outcomes.

Consistent with other studies, the baseline data showed that children with pDCD had poorer cognitive function and performed worse in tasks. Maziero's research showed that children with DCD have difficulties with their visuospatial working memory²⁹. In their study, Sartori reported that children with DCD tend to perform significantly worse than TD children on inhibitory control tasks (Go/No-Go App and Hayling Part B test), especially those that require both motor and verbal responses. Previous studies have suggested that the poorer inhibitory control observed in children with DCD may be associated with functional differences in neural networks involved in language and motor processing; however, these mechanisms were not directly assessed in the present study³⁰. Previous neuroimaging and behavioral studies have reported associations between DCD and impairments in visuospatial integration, inhibitory control, and motor automation, which may partially explain the poorer cognitive and motor task performance observed in the present study^31,32,33,34.

This study also examined the spatial abilities of children with pDCD, and the results were consistent with our expectations. Children with pDCD performed poorly on mental rotation tasks at all angles; although there was a significant improvement after the intervention, their performance remained lower than that of TD children, especially at large angles. The study also demonstrated that mental rotation performance varied with angular disparity, with larger disparities associated with longer reaction times in both groups. Although the exercise intervention improved performance across all angular disparities, the greatest reductions in reaction time were observed at 120° and 180° in children with pDCD. Consistent with a previous study³⁵, reaction times increased with increasing angular disparity in both groups. Following the intervention, children with pDCD demonstrated significant reductions in reaction time across all angular disparities, with the largest improvements occurring at 120° and 180°, although their performance remained inferior to that of TD children. These findings may suggest differences in spatial processing strategies between children with pDCD and TD children; however, the underlying mechanisms cannot be determined from the present data. Spatial ability, which is closely related to motor performance in studies of adults, plays a vital role in motor skills¹⁰. Previous studies have proposed that difficulties in closed-loop feedback processing and visuospatial information integration may contribute to motor and cognitive challenges in children with DCD; however, these processes were not directly evaluated in the present study. Children with DCD have deficiencies in spatiotemporal integration, often making incorrect judgments about the spatial orientation and velocity of objects; their spatial representation abilities are often not as good as those of their peers³⁶. Similarly, Jouira et al. demonstrated that cognitive task demands significantly influence postural control and motor performance, emphasizing the close interaction between cognitive processing and motor function in neurodevelopmental populations³⁷.

Previous neuroimaging studies have reported altered activation in premotor, parietal, and cerebellar regions among children with DCD during motor imagery and predictive control tasks^38,39. Although such findings may provide potential explanations for the cognitive differences observed in the present study, neurophysiological mechanisms were not directly assessed. Therefore, the mechanisms underlying exercise-related cognitive improvements in children with pDCD require further investigation.

Previous studies on exercise interventions for children with DCD have shown that exercise positively affects them. Ludyga points out that exercise was originally thought to promote, rather than normalize, executive functions. This being said, a growing body of research suggests that individuals with lower executive function can normalize it by exercising regularly⁴⁰_. It is therefore thought that only children and adolescents with below-average cognitive performance will show improved executive functioning after this type of intervention. Similar research shows that children with ADHD experience greater benefits from exercise in comparison to their peers⁴¹. Previous studies have reported that children with executive dysfunction may derive greater cognitive benefits from exercise interventions. In this study, after intervention, it was hypothesized that performance levels across all children would approach those of TD children. Several meta-analyses provide evidence of improved executive and other cognitive functions following regular exercise⁴². Regarding executive function, there was no difference between the two groups in low-difficulty executive tasks, but the TD group performed significantly better than the pDCD group in high-difficulty tasks. These results are consistent with others' research findings. The effects of the intervention seemed to differ between the two groups. Children in the pDCD group showed intervention effects only on executive tasks, whereas those in the TD group showed effects across all tasks. Based on evidence from healthy children, behavioral interventions provide an effective opportunity to enhance executive function⁴³. Recent evidence further supports the beneficial effects of coordination-based exercise interventions on motor competence, physical fitness, and inhibitory control in children. Başarır et al. reported significant improvements in motor competence, physical fitness, and executive function following coordination-based training programs in preschool children, highlighting the broader cognitive benefits of structured physical activity interventions⁴⁴.

The present findings suggest that structured school-based exercise intervention may be particularly beneficial for selected cognitive outcomes in children with pDCD. Previous studies have reported associations between DCD and impairments in interference control, motor automation, and predictive motor processing^45,46,47. These findings may provide possible explanations for the present results, although such mechanisms were not directly evaluated in this study. The mechanisms underlying these exercise-related cognitive improvements were not directly investigated in the present study. Future studies incorporating neurophysiological or neuroimaging assessments may help clarify the biological mechanisms underlying exercise-related cognitive changes in children with pDCD.

Consistent with previous studies^16,48,49,50, children with pDCD demonstrated lower baseline physical fitness than TD children^16,49,50. Cardiopulmonary function was assessed using the 50 m × 8 shuttle run. Although descriptive differences were observed between groups, the overall group effect was not statistically significant. It is clear that children can still benefit from exercise; for a more significant difference, children need to engage in more outdoor activities in open fields or playgrounds. The SBJ test is commonly used in many international fitness batteries for measuring muscle strength⁵¹ and is a useful tool for assessing lower-body muscle strength in children⁵².

In this study, the pDCD group consistently performed worse than the TD group, suggesting that children with pDCD may have lower muscle strength than TD children. On the other hand, since the SBJ test also requires whole-body coordination, this may explain why children with pDCD do not perform better. In addition, children with pDCD achieved the greatest gains in the 50-meter dash test, a measure of athletic ability. This is consistent with Denysschen's study, which found that children with poor motor skills were more likely to have lower aerobic and anaerobic capacities and lower muscle strength than TD children⁵³. It can be observed that children with DCD can significantly improve their strength and coordination through school-based exercise intervention, but with little effect on cardiorespiratory endurance. All health and fitness levels improved in TD children. In Denysschen’s study, children with DCD and their TD peers significantly improved in both aerobic and anaerobic fitness, agility, and balance⁵³. However, the cardiorespiratory endurance of children with pDCD in our study did not significantly improve. Several factors may have contributed to the limited improvement in cardiorespiratory endurance, including differences in exercise familiarity, exercise intensity, or responsiveness to the intervention; however, the present study was not designed to determine the specific causes of this finding.

The present study advances the current understanding of DCD by simultaneously examining executive function, mental rotation performance, and physical fitness outcomes following a structured school-based exercise intervention within the same cohort. Unlike many previous studies that focused primarily on isolated motor or cognitive outcomes, the present findings demonstrate that school-based exercise programs may positively influence both cognitive and physical domains in children with pDCD.

This study also has its limitations. In-depth quantification of children's daily physical activity was not conducted, which may have affected the evaluation of their physical fitness and ability development. An additional untrained TD control group was not included, which limits the ability to fully distinguish intervention effects from normal developmental changes. However, this experimental design was chosen to explore the differences in the changes between the two groups following school-based exercise training. Future studies may include a control group to better determine the benefits of exercise. Furthermore, this study did not include follow-up after the intervention; longer follow-ups may be useful in future studies to determine the intervention's long-term effects. Alternative approaches, including randomized controlled trials, neuroimaging-based studies, longitudinal follow-up designs, and individualized exercise intervention protocols, may further improve understanding of the mechanisms underlying cognitive and motor improvements in children with pDCD. Overall, the present findings highlight the potential clinical and educational value of structured school-based exercise programs for improving cognitive performance and physical fitness in children with pDCD. These findings may support the integration of targeted exercise interventions within school rehabilitation and physical education programs. Future studies incorporating larger multicenter cohorts, long-term follow-up assessments, neurophysiological measurements, and individualized intervention protocols may further clarify the mechanisms and sustainability of intervention-related improvements.

Following the 12-week school-based exercise intervention, both groups demonstrated improvements in cognitive and physical performance, with children with pDCD showing notable gains in several cognitive outcomes. Improvements in cardiorespiratory endurance outcomes were comparatively limited. The present findings highlight the potential clinical and educational value of structured school-based exercise programs for improving cognitive and physical performance in children with pDCD. Due to limitations in exercise duration, intervention settings, and the absence of DCD-specific training protocols, future studies should investigate individualized exercise programs, longer intervention periods, and additional outcome measures to better understand the factors associated with intervention-related improvements in children with pDCD.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
ADHD Rating Scale-VI	Guilford Press	9781609180751	Behavioral screening
Computerized cognitive testing software (E-Prime v1.1)	Psychology Software Tools	E-Prime 1.1	Reaction time assessment
Cones/markers	Decathlon	Training Marker Cone Set	Shuttle run setup
Desktop/laptop computer	Lenovo/Dell/HP	N/A	Cognitive task administration
Developmental Coordination Disorder Questionnaire (DCDQ)	CanChild Centre for Childhood Disability Research	DCDQ’07	Screening questionnaire
Digital weighing scale	Seca GmbH	Seca 813	Weight measurement
Edinburgh Handedness Inventory	N/A	N/A	Handedness assessment
Measuring tape	Stanley Tools	33-425	Standing broad jump measurement
Movement Assessment Battery for Children, Second Edition (MABC-2)	Pearson Assessment	9780749136086	Motor assessment
Stadiometer	Seca GmbH	Seca 213	Height measurement
Statistical analysis software	IBM	SPSS Statistics v27	Statistical analyses
Stopwatch	Casio	HS-80TW-1DF	Sprint timing