The combinations of basic movement patterns of two or more body segments may be categorized as stability, manipulative or locomotor skills. Stability motor skills incorporate dodging, dynamic or static balance, and turning; manipulative skills include catching, kicking, striking, and throwing; whilst examples of locomotor skills include sprinting, jumping, and leaping (Donnelly et al., 2009). However, it is known that there is progressive decay along the years in gross motor coordination of children (Roth et al., 2010) following insufficient and un-structured physical activity (PA). Motor development is a critical component of preschool and elementary school PE from ages two through six or seven. Early PA is an encouraging alternative for the improvement of gross motor skills and education for an active lifestyle in preschool children (Lubans et al., 2010). This type of educational area considers the sensory, emotional, motor, social, and cognitive development of children in accordance with a holistic pedagogic approach (Roth et al., 2010). It is, indeed, a very integrative way to support children in their development. Parents and peer support, PA preferences, behavioral intentions and program/facility access can affect participation in the PA. However, adequate motor skill competence in early childhood has been suggested to be a relevant prerequisite for children’s involvement in PA later in life (Lloyd et al., 2014; Loprinzi et al., 2015). Several authors showed that regular PE could stimulate the development of self-competence, social aptitude and ability in dealing with materials and contents of every-day life in childhood (Pentimonti et al., 2016). According to several studies, fundamental motor skills such as running, jumping, kicking, throwing and catching, lay the basis for success in cognitive (Vukovic et al., 2010; Diamond and Lee, 2011), physical and sport skills (Battaglia et al., 2014). Fundamental motor skills do not develop automatically. The psychophysical development alone may lead children to acquire basic gross motor skills but PE, encouragement, and instruction by the physical education teacher are needed to mature advanced gross motor skill patterns (Gallahue et al., 2003, 2012). Moreover, several authors found that a structured PE program is more efficient than free play activities (Logan et al., 2012). Unlike other European countries, Italian preschools do not include the PE teacher as part of the school’s core staff. This is frequently associated with a lack of opportunities to perform PE by preschool children without the intervention of local institutions such as municipalities, universities or volunteers’ associations.

Recent empirical evidence showed beneficial short- and long-term effects of PA programs not only on motor skill development but also on cognitive growth (Diamond, 2015; Alesi et al., 2016). In their systematic review on PA and cognitive development, Carson et al. (2015) argued that an increase in PA frequency, intensity and duration “…had significant beneficial effects on 67% of the cognitive development outcomes assessed in the executive function (EF) domain and 60% in the language domain” (Carson et al., 2015). This relationship is explained in light of PA effects such as the activation of the prefrontal cortex, the cerebellum and the basal ganglia, the increase in brain-derived neurotrophic factor (BDNF) and the triggering of inhibitor control, planning, and monitoring processes (van der Fels et al., 2015). As a consequence, cognitively engaging motor programs have been planned to improve cognitive development in childhood (Moreau et al., 2017). A range of studies have provided evidence that play-based situations and motor exercise programs improve cognitive development by acting positively on EFs from kindergarten (Lakes et al., 2013; Pesce et al., 2016). EF is defined as higher order cognitive processes, such as inhibition, shifting, updating, fluency, and planning, that are important prerequisites for school readiness. In detail, the ability to control and repress a response in favor of another response or no response, the ability to switch the attention from one task to another, the ability to manipulate mental representations and items stored in working memory, and the ability to plan learning actions, together contribute to enable children to be cognitively competent and able for later literacy and numeracy achievements in primary school (Moffitt et al., 2011; Miyake and Friedman, 2012; Alesi et al., 2018).

Beneficial effects of PA programs on pre-literacy skills have also been demonstrated in kindergarten age (Barnett et al., 2008; Callcott et al., 2018).

Pre-literacy is an umbrella term for a set of predictors of later literacy achievement. These skills are oral language abilities, such as vocabulary, comprehension and listening, alphabetic abilities such as phonological/phonemic awareness and knowledge/understanding about print and its use (Puranik and Lonigan, 2011; Pinto et al., 2016). In particular, phonological awareness and knowledge of the alphabet are two of the strongest predictors of reading and writing acquisition in Italian children because of the transparent nature of their mother language. Phonological awareness refers to the ability to understand that spoken words have a sound structure and involves word, syllable, onset/rhyme and phonemic awareness. As a consequence, the phonological awareness enables preschool children to identify, analyze, and manipulate the word and its sub-components (Gibbs, 2004). Alphabet knowledge refers to the ability for letter-naming and letter-sound knowledge. Letter-name knowledge enables pre-school children to reach letter-sound knowledge and, consequently, grapheme-phoneme conversion (Duncan and Seymour, 2000; Gallagher et al., 2000). Another important pre-literacy set involves visual and visuo-spatial skills, such as the ability for visual analysis and discrimination, spatial orientation and sequential eye movements. Rapid visual processing makes grapheme and phoneme identification easier, with positive consequences on later reading and writing acquisition (Cornoldi et al., 1994).

Recently, preschool-based programs including PA activities and aiming to improve pre-literacy skills have been developed. For example, Bedard et al. (2017) implemented a movement and pre-literacy program of 60 min per week over 10 weeks. This involved pre-school age children and consisted of fundamental movement skills tasks, free-play activities with balls, steps, bricks or puzzles, and a storybook reading activity shared among children and their parents. The authors found that this parent-oriented movement and pre-literacy program was able to improve motor proficiency as well as literacy skills concerning print-concept and alphabet knowledge (Bedard et al., 2017).

Kirk and Kirk (2016) developed a PA program to be carried out by classroom teachers to preschool children over 8 months. This comprised 60 min of moderate PA units (two times per day) combining motor and early literacy tasks aimed at training oral language, vocabulary and phonological awareness. For example, dedicated motor activities such as acting words, jumping, running, moving on lines, and marching were used to improve rhyming, alliteration and picture naming (Kirk and Kirk, 2016). However, in our knowledge, many studies lack of a structured and reproducible Physical Education Program (PEP) that includes specific activities, timing and duration. Based on these issues, the aim of this study was to explore the effects of a specific 16-week-long PEP on the development of gross motor and pre-literacy skills concerning visual analysis and spatial orientation skills in preschool children with a psychomotor, fun and enjoyable approach.

In agreement with McGee et al. (2016) a school-based non-randomized trial was conducted to evaluate the effect of a pilot PEP on preschool children’s gross motor skills (Gallahue et al., 2003, 2012; McGee et al., 2016). This study has been recently developed within the Training-to-Health Project financed by Municipality of Palermo. Due to funding requirements, PEP was carried out in several pilot preschools within the Palermo City Council administrative boundaries. A preschool with demographic characteristics (age, sex, socioeconomic characteristics) similar to the enrolled playschools was recruited in Palermo and used as the control. In particular, the catchment areas of these schools were predominately of middle socioeconomic status as judged by employment and education.

Insufficient funding or perceived benefits associated with participation in the study by children and parents at the control site made the number of control preschoolers very small. However, we used them as the control group because they showed similar demographic characteristics to the children enrolled in the intervention. Need for educational support or disability was considered an exclusion criterion. Once preschools had given written informed consent to participate in the study, all Year 3.5 preschool children were invited to take part in the experiment and were tested before and after the experimental period.

This study involved 119 children who were clustered in a control group [CG, n = 29, age: 52.1 ± 8.65 months; height: 1.10 ± 0.07 m, body weight: 19.20 ± 5.55 kg, body mass index (BMI): 16.90 ± 3.16] and an intervention group (IG, n = 90, age: 57.4 ± 9.42 months; height: 1.10 ± 0.06 m, body weight: 19.30 ± 3.65 kg, BMI: 16.00 ± 1.75). Moreover, 62.10% males and 37.90% females composed the CG. Similarly, 55.60% males and 44.40% females composed the IG. The study was approved by the Ethical Board of the University of Palermo (N. 2/2018) and conformed to criteria for the use of persons in research as defined in the Declaration of Helsinki (Trial Registration: NCT03454061 retrospectively registered 2 March 2018). Given that the participants were minors, parents or legal guardians provided their written informed consent to participate in this research. All children participated voluntarily and could withdraw from the study at any time.

Height and body weight were measured according to standard procedures (Lohman et al., 1988) using a stadiometer (maximum height recordable, 220 cm; resolution, 1 mm) and a Seca electronic scale (maximum weight recordable, 300 kg; resolution, 100 g; Seca Deutschland, Hamburg, Germany). Body mass index was calculated using the formula: weight in kilograms (kg) divided by height in squared meters (m²).

The PEP, based on the psychomotor approach, was done in a group setting and based on useful, goal-directed training, practicing activities of relevance for a preschool child. The program lasted 16 weeks and was applied twice a week by a physical education specialist (PES), who also had experience with preschool children. Teachers were involved in the goal-setting process and cooperated with PES to carry over the activities safely. Before intervention, PES and teachers have followed a training course concerning the aims, methodology and evaluation of PEP in order to make the intervention uniform for all children.

PEP included activities with specific aims developing body awareness, fundamental motor and perceptual-sensory skills of preschool children (see Figure 1). Each lesson (see Table 1) lasted about 60 min and included the following parts: a warm-up and social interaction phase (about 5 min), enhancing children’s fitness level and their motivation to participate; a central phase (about 50 min), including the scheduled activities; and a cool-down and feedback phase (about 5 min), to relax the children and explore their satisfaction levels. In the central phase the number of sets, repetitions and complexity of schedule-related exercises were gradually increased when children were able to perform them easily. Each lesson was structured in the form of scheduled play that emphasizes enjoyment and participation in several play actions (Pesce et al., 2016). Gross motor skill acquisition was focused by means of developmentally appropriate tasks (Giblin et al., 2014) in order to promote transfer effects between PA and spontaneous play. PES used hands-on discovery and problem-solving heuristic learning modalities in order to strengthen the effectiveness of such a program targeted on the preparation and the scheduled play. The CG participated in classroom activities for the same amount of time as the IG with teachers. Both groups performed the activities during the school period in a multi-activity area.

Participants were assessed for object control and locomotor skills by the Italian version of gross motor development test (Ulrich, 2003). This test examines two different sides of gross motor development, i.e., object control (bounce the ball, catch the ball, catch a ball with a tennis racket, and running while kicking a ball and throwing a ball) and locomotion (requiring subjects to run as fast as possible for 15 m, jump forward, gallop for 10 m, hop on one leg for 5 m, do a long jump, and take little jumps forward and laterally). Scores of two subtests were summed and converted to a combined quotient of gross motor development (QGMD). Children were tested individually and encouraged to produce their maximum effort (e.g., jump far). A digital video camera videotaped all their performances. Before observations, two observers were previously trained on videotapes of children in order to analyze movement sequences and to assign scores. To obtain a higher validity, according to the handbook, each child performed three trials of each skill and acquired a “1” mark, when a criterion performance was executed two out of three times, or a “0” grade, when a criterion was not observed or was used inappropriately two out of three times. The sum of the scores found for each item (maximum total score 48) was converted into standard scores according to the age level of the child. We assessed the gross motor development level based on QGMD scores suggested by the manual, i.e., 131–165 (very high motor ability, VH-MA), 121–130 (high motor ability, H-MA), 111–120 (over average motor ability, OA-MA), 90–110 (average motor ability, A-MA), 80–89 (below average motor ability, UA-MA), 70–79 (low motor ability, L-MA), and 35–69 (very low motor ability, VL-MA).

Pre-literacy skills were measured through the PRCR-2/2009 (Cornoldi et al., 2009). This is an Italian battery of standardized tasks aimed at measuring general and specific prerequisites to later reading and writing abilities in preschool children. Four tasks were derived from the PRCR-2/2009 Battery and used in the present study: (1) Printed letters identification; (2) object naming; (3) partially hidden object naming; and (4) pointed object naming. We selected only measures concerning visual analysis and spatial orientation skills because they were considered more closely related to movement activities included in PEP.

The printed letters identification task measured visual analysis ability and spatial orientation. It was composed of a sheet with 12 target letters printed on the left and four letters for each target (the target and three distractor letters) printed on the right. A child was required to identify and cross the target letter. The number of errors for the task was recorded. The final score was obtained by adding together the number of errors.

The object naming task measured linguistic proficiency, visual attention and the sequentiality of eye movements. It was composed of 30 objects in five sequences of six objects for each. The objects were for example animals (mouse, cat, chick), flowers, ice-cream, the sun, stars, etc. The partially hidden object naming task measured linguistic proficiency, visual attention and discrimination, and the sequentiality of eye movements. It was composed of the three sequences of objects that appeared in the objects naming task, but the objects were overlapping and smaller. The pointed object naming task measured the visuo-perceptual ability to identify a figure from the background, linguistic proficiency, visual attention and discrimination, and the sequentiality of eye movements. It was composed of the two sequences of overlapping objects that appeared in the partially hidden object naming task with four objects for each sequence marked by a dot at 15 mm. For measures relating to the last three tasks, a child was required to rapidly name the marked objects from left to right and from the top to bottom. The number of errors for the task was recorded. The final score was obtained by adding together the number of errors.

Means and standard deviations (SD) were calculated to describe the sample characteristics. Analysis of gain scores, also called change scores or difference scores, was used to test for the effect of treatment; unpaired Student’s t-tests were used to compare the post- and pre-test difference in scores between the control and intervention groups (Allison, 1990; Ragosa, 1995; Oakes and Feldman, 2001). Since baseline differences between groups existed at pre-test, analysis of covariance (ANCOVA) was applied as an alternative to analyze the scores. We used the post-test gross motor and pre-literacy scores as the dependent variable, the control/intervention group as independent variable and the pre-test score as covariate. ANCOVA focuses on differences between the groups at post-test while holding constant pre-test differences. In all the analyses, the level of significance was set at p < 0.05. Statistics were performed by using STATA/MP 12.1.