Motor Skills

The Infant Development Group compiled a list of the most well-established psychometric tools to measure neurodevelopment outcomes, including (but not limited to) cognition, language skills, motor skills and behavior, at 24 months in an international sample. This age was selected as it was found to be the earliest at which: (i) neurodevelopment is not confounded by transient neurological syndromes of prematurity and (ii) conventionally used developmental instruments, such as the Bayley Scales of Infant Development, have been found to possess an acceptable level of medium and long term predictive validity [18] . The list was compiled in two phases.
Phase 1 involved a search of online databases (PubMed, PsycINFO and Embase) using search terms for cognition, language, motor skills and behavior. These are listed in Table S1 in File S1.
During Phase 2, the Infant Development Group contacted a number of child development experts and authors of child psychometric measures from Bangladesh, Brazil, India, Italy, Kenya, the Netherlands, UK and USA. The experts were asked to list the available measures they were familiar with to assess cognition, language, motor skills and behavior at 24 months.
Phases 1 and 2 (Figure S1 in File S1) resulted in a list of 47 tools (Table S2 in File S1). Their purpose, the age ranges at which they may be used, the domains assessed and the languages the tools are currently available in are summarized in Table S2 in File S1. The Infant Development Group critically analyzed these tools against the criteria listed in Table 3. Thirteen fulfilled some of the Project's criteria. Information on the characteristics, purpose, and strengths and weaknesses (in to the context of the INTERGROWTH-21^st Project) of each tool is presented in Table S3 in File S1.
The 13 tools were critically analyzed against the Project's criteria by a scientific advisory panel of independent international experts in the fields of neurodevelopment, pediatric neurology, child psychiatry, child psychology, vision, neuroscience, ophthalmology, sleep research, perinatal medicine and epidemiology at a meeting organized by the Infant Development Group.
Results of Approach 1: The findings of Phases 1 and 2, as reviewed by the scientific advisory panel, resulted in four key conclusions. First, the panel acknowledged that no one tool fulfilled all the Project's criteria. Second, the panel found 5 of the 13 tools to individually fulfill most of the Project's criteria and recommended the use of these tools in their most sensitive and reliable domains of neurodevelopment (Table 5). These were the Bayley Scales of Infant Development – Third Edition (BSID) [19] , [20] , the Rapid Neurodevelopment Assessment (RNDA) [21] (link), the Malawi Development Assessment Tool (MDAT) [22] , the Griffiths Mental Development Scale [23] , [24] and the Child Behaviour Checklist (CBCL) [25] (link), [26] (link). Third, the panel recommended that while it is almost impossible for any psychometric instrument measuring ECD to be free from cultural biases, it is possible to undertake a decentering approach by selecting items that are suitable for middle- and upper-class families in high-, middle- and low-income contexts [27] . In this approach, no single cultural group provides the initial items sets. Instead the test development process sets out to select items that are equally familiar to the different target groups and excludes any materials or content that seems unfamiliar to any of the target groups. The rationale for this approach was that in the current global situation, children from most middle- and upper-class families across settings are exposed to a set of similar resources (such as cups, spoons, dolls, crayons, shoes, stacking blocks) and therefore it is possible to pool this common set of exposures to select a set of items that most middle- and upper-class children across high-, middle- and low-income settings can perform. Finally, the panel suggested a package-based approach combining the use of psychometric tools with neurophysiological measures. The panel recommended that the methodology, scope and sensitivity of such a package must be tailored to the needs of the INTERGROWTH-21^st Project.

After receiving human subjects IRB approval, the following procedures will occur regarding participant recruitment and the informed consent process. Parent(s)/guardian(s) will receive an information letter from the Principal Investigator notifying them of the PATH-SR Study at the beginning of the school year. The letter will provide a brief description of the study along with a statement from the school administrators indicating that parent(s) are not obligated to participate. Members of the research team will be present during morning drop-offs and afternoon pick-ups to answer any questions from parents/guardians. All parents/guardians who return a consent form, regardless of whether they agreed to participate in the PATH-SR Study, will receive a one-time cash incentive of $5.00. In addition to parental consent, verbal assent will be obtained from each preschooler. Parents will receive reminder letters for each upcoming PATH-SR assessment and a developmental report of their child’s findings from each assessment (i.e., motor skills, physical activity, health outcomes, SR outcomes). Each center will be provided with aggregated data of the findings.

CHAMP is grounded in Achievement Goal Theory. This theory originates from educational psychology and focuses on the learners’ motivation to learn [41 , 43 , 44 ], since goals for learning influence intrinsic motivation. Achievement Goal Theory refers to the beliefs, attributions, and affect that contribute to one’s behaviors and represents how an individual approaches, engages, and responds to various activities [42 , 43 ]. Individuals can take either a mastery- (task-) or performance- (ego-) orientation [42 , 71 ]. Performance- (ego-) individuals focus on ensuring that their performance is successful and superior to others while mastery- (task-) individuals engage in learning for the sake of learning and are less threatened by failure. Mastery- (task-) oriented individuals often have higher intrinsic motivation [42 , 43 ] exhibit an intrinsic interest in learning [44 , 72 ] and have positive attitudes towards learning [72 , 73 ].
Learning environments can be intentionally and purposefully structured to encourage learners to adopt a mastery- (task-) orientation to learning. These environment are called mastery-motivational climates and are created using Epstein’s TARGET structures [46 ] (see Table 1). Applying the TARGET structures to the learning environment redistributes the ownership to the learner and allows them to autonomy to navigate the intervention climate, make their own choices on how, where, and in what level of difficulty they engage in and practice new skills. In the case of CHAMP, allowing the child the autonomy to navigate the mastery-motivational climate fosters self-navigated engagement, self-selections of learning groups, and self-paced learning. These activities and expectations require a child to demonstrate and continually practice the cognitive, emotional and behavioral regulation skills that are hallmarks of effective SR (see Table 1). Therefore, even while the primary learning outcomes of CHAMP are motor skills and health behaviors, the theoretical principles (i.e., achievement-goal theory) and implementation (i.e., TARGET structures) applied during the program are likely to promote SR in children.