Child development is a dynamic and multidimensional process involving physical, motor, cognitive, social, emotional, and behavioral domains. Preschool age, particularly between 4 and 6 years, represents an important developmental period during which children experience substantial changes in cognitive and motor abilities, behavioral regulation, and social functioning (Santrock et al., 2002). Appropriate stimulation and developmental monitoring during this period are therefore important for supporting children's developmental potential and identifying possible developmental difficulties.

Early childhood development reflects the interaction between biological maturation and environmental influences. During this period, children undergo rapid changes in cognitive, motor, emotional, and behavioral functioning that require continuous stimulation and monitoring (Mingkala, 2021; Sarver et al., 2015). The development of attention regulation, impulse control, and behavioral adaptation is particularly important as children increasingly interact with structured social and learning environments. However, developmental trajectories vary among children, and some may exhibit symptoms associated with neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD). ADHD is characterized by persistent patterns of inattention and/or hyperactivity–impulsivity that can interfere with functioning and development (Kurniawan et al., 2021; Rahmani, Kusumawicitra, & Karyani, 2022). These symptoms may affect learning, social interaction, and behavioral regulation during the preschool years.

ADHD symptoms can be assessed systematically using standardized instruments such as the ADHD Rating Scale-5, which was developed in accordance with the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (DuPaul et al., 2016). The instrument consists of 18 items representing two domains: Inattention and Hyperactivity–Impulsivity. Ratings can be completed by parents or teachers based on observations of children's behavior in everyday settings. The ADHD Rating Scale-5 has demonstrated good psychometric properties and provides quantitative scores reflecting the severity of ADHD-related symptoms, supporting its use in clinical and research settings involving children.

ADHD symptoms are relatively common among children. Globally, the prevalence of ADHD among children aged 3–12 years has been estimated at 7.6% (Salari et al., 2023). In Indonesia, national epidemiological data remain limited, although local studies have reported indications of ADHD symptoms among preschool-aged children. For example, a study conducted in Gonilan Village reported that 21.9% of children aged 4–6 years exhibited ADHD symptoms (Naufal et al., 2023), while another study identified 15 children with indications of ADHD symptoms at Saymara Kartasura Kindergarten (Taqfani et al., 2023). Although these local findings should not be interpreted as estimates of national prevalence, they highlight the relevance of examining ADHD-related symptoms among preschool children in the local context.

Hyperactivity–impulsivity is one of the core symptom domains of ADHD and may manifest behaviorally as restlessness, excessive movement, difficulty remaining seated, and difficulties with impulse control (Dekkers et al., 2020; DuPaul et al., 2016). Previous research has indicated that children with ADHD may demonstrate higher levels of objectively measured motor activity than typically developing children (Lin et al., 2013). Such motor activity represents an observable behavioral characteristic that may provide complementary information to symptom assessments based on parent or teacher reports. Nevertheless, motor activity itself should not be considered equivalent to pathological hyperactivity, particularly in young children for whom movement is a normal component of development and play.

Objective activity-monitoring devices provide an opportunity to quantify children's movement in natural settings. Pedometers and accelerometers, for example, can provide quantitative indicators of physical movement and have been used to characterize activity patterns in children (Villalba-Heredia et al., 2023). Step count provides a simple measure of locomotor activity and may therefore offer an objective indicator that complements behavioral ratings of ADHD symptoms. However, evidence directly linking standardized ADHD symptom scores with objectively measured step counts remains limited, particularly among preschool-aged children. Evidence is even more limited in the Indonesian context, where studies integrating parent-reported ADHD symptom assessments with objective measures of motor activity are scarce.

Children aged 4–6 years represent a particularly relevant population for examining this relationship because attention regulation, inhibitory control, and other executive functions continue to develop substantially during the preschool period (Best & Miller, 2010; Tanoyo, 2013). Understanding whether variation in ADHD symptom scores is associated with objectively measured motor activity may provide additional insight into the behavioral characteristics accompanying ADHD-related symptoms during early childhood (Figure 1). Therefore, this study aimed to examine the association between ADHD symptom severity, as assessed using the ADHD Rating Scale-5, and motor activity, as represented by step counts measured during school recess, among children aged 4–6 years.

Based on these considerations, this study aimed to examine the association between ADHD symptom severity, as assessed using the ADHD Rating Scale-5, and motor activity, as represented by step counts, among children aged 4–6 years using a cross-sectional design. The findings are expected to provide further evidence on the relationship between parent-reported ADHD symptoms and objectively measured motor activity in preschool children and to inform future research on complementary approaches to developmental assessment and monitoring.

A total of 110 children aged 4–6 years were included in the analysis. Of these, 60 (54.5%) were male and 50 (45.5%) were female. The mean age was 5.06 years (SD = 0.79), with the largest proportion of participants aged 5 years (37.3%)

Based on Table 3, the ADHD Rating Scale-5 scores among the 110 respondents ranged from 0 to 33. The mean score was 12.42, with a median of 11. The standard deviation was 8.92, indicating variability in ADHD symptom scores among participants. The mean step count was 325.54 (SD = 116.73), with a median of 315 and values ranging from 120 to 700 steps, indicating substantial variability in step counts among participants.

Note. Normality was assessed using the Kolmogorov–Smirnov test.

The Kolmogorov-Smirnov test was used to assess the normality of the data at a significance level of 0.05 (Table 4). The ADHD Rating Scale-5 total score had a p-value of 0.055, while the step count variable had a p-value of 0.693; both values were greater than 0.05, indicating normal distributions. In contrast, the Inattention and Hyperactivity-Impulsivity scores were not normally distributed, with p-values of < .001 and 0.001, respectively. Therefore, the Pearson product-moment correlation test was used to examine the relationship between the total ADHD Rating Scale-5 score and step count. In contrast, Spearman's rank correlation test was used for the domain-level analyses.

Note. r = Pearson's correlation coefficient; ρ = Spearman's rank correlation coefficient. All correlations were calculated with step counts.

Pearson's correlation analysis showed a very strong positive correlation between the total ADHD Rating Scale-5 score and step counts (r = .865, p < .001; Table 5). At the domain level, Spearman's rank correlation analysis showed a strong positive correlation between the Inattention domain score and step counts (ρ = .756, p < .001), whereas the Hyperactivity–Impulsivity domain score showed a very strong positive correlation with step counts (ρ = .818, p < .001). All analyses included 110 participants.

As illustrated in Figure 2, the scatterplot shows a clear positive linear pattern between total ADHD Rating Scale-5 scores and step counts. Children with higher ADHD symptom scores generally recorded higher numbers of steps during the 15-minute school recess. The relatively close distribution of observations around the fitted regression line is consistent with the very strong positive correlation observed between the two variables (r = .865, p < .001). The coefficient of determination (R² = .748) further indicates that approximately 74.8% of the variation in step counts was statistically associated with variation in total ADHD Rating Scale-5 scores within this sample. These findings indicate a strong statistical association but should not be interpreted as evidence of a causal relationship.

This study demonstrated a very strong positive association between total ADHD symptom scores and objectively measured step counts in preschool children. Domain-level analyses also showed significant positive associations between step counts and both Inattention and Hyperactivity–Impulsivity scores. The association was strong for Inattention (ρ = .756, p < .001) and very strong for Hyperactivity–Impulsivity (ρ = .818, p < .001), while the total ADHD Rating Scale-5 score showed a very strong positive association with step counts (r = .865, p < .001). These findings indicate that higher ADHD symptom scores were associated with greater ambulatory activity during the measurement period. The numerically higher correlation coefficient for Hyperactivity–Impulsivity may reflect a closer relationship between step counts and the motor-behavioral characteristics represented by this symptom domain. However, because the correlations between the two domains were not formally compared, this difference should be interpreted cautiously.

The association between Hyperactivity–Impulsivity and step counts is consistent with the behavioral characteristics represented by this domain, including excessive movement, restlessness, difficulty remaining seated, and frequent changes in activity or position (Feng et al., 2025). Such behavioral characteristics could contribute to a greater number of steps during periods of unrestricted activity. Previous studies have similarly reported elevated motor activity among children with ADHD symptoms. Sarver et al. (2015) described motor behaviors associated with hyperactive symptoms, including frequent movement and changes in position, while Reetzke et al. (2022) reported higher levels of motor activity among young children at risk for ADHD. Fitriyani et al. (2023) also described motor and behavioral characteristics among children with ADHD symptoms, whereas Rahmani et al. (2022) reported associations between manifestations of hyperactivity–impulsivity and difficulties in behavioral regulation. Collectively, these findings provide a plausible behavioral context for the positive association observed between Hyperactivity–Impulsivity scores and step counts in the present study.

The significant association between Inattention scores and step counts is also noteworthy. Although inattention is not primarily characterized by excessive motor behavior, children with higher levels of inattentive symptoms may experience difficulties sustaining attention, maintaining engagement with tasks, and regulating their behavior during structured activities (Adamou et al., 2025). One possible explanation is that difficulties in sustained engagement may coincide with more frequent transitions between activities or locations, potentially contributing to greater ambulatory activity. Previous studies have also described relationships among ADHD symptoms, behavioral regulation, and activity patterns in children (Fitriyani et al., 2023; Rahmani et al., 2022). Nevertheless, step count should not be interpreted as a direct measure of inattention. The observed association may instead reflect the complex relationship between attention regulation and patterns of activity during early childhood. Accordingly, the present findings do not indicate that inattention causes greater step counts but rather that higher inattentive symptom scores were associated with greater ambulatory activity within the context examined.

The present findings are broadly consistent with previous research using objective measures of physical activity. Villalba-Heredia et al. (2023), using accelerometry to assess physical activity among school-aged children with ADHD, reported differences in step counts and physical activity according to ADHD characteristics. Similarly, Kofler et al. (2025) reported associations between objectively measured activity and ADHD symptom ratings, including hyperactivity–impulsivity symptoms. Curzon et al. (2024), studying children aged 4–7 years, also reported differences in daily step counts between children with and without ADHD and variation in activity associated with hyperactive symptoms. Taken together, these studies support the use of objective activity monitoring to characterize movement patterns associated with ADHD symptoms. However, because the present study identified significant associations for both ADHD symptom domains, step counts should not be interpreted as a specific indicator of Hyperactivity–Impulsivity.

The findings also suggest that step counts may provide a simple objective measure that complements behavioral assessments in preschool children (Fang et al., 2020). Pedometers offer a relatively simple method for quantifying ambulatory activity without relying exclusively on subjective observation. In the context of ADHD symptom assessment, such measurements may provide additional information about children's movement patterns in natural settings. However, step counts represent only one dimension of motor activity and primarily capture locomotor or ambulatory movement (Blanco-Martínez et al., 2025). They do not capture other manifestations of motor behavior, such as fidgeting, upper-limb movements, postural changes without locomotion, or the qualitative characteristics of movement. Therefore, the associations observed in this study should be interpreted specifically as relationships between ADHD symptom scores and ambulatory activity rather than as evidence that step counts comprehensively measure hyperactivity.

Overall, this study demonstrated that higher Inattention and Hyperactivity–Impulsivity scores were positively associated with greater step counts among preschool children, with a numerically higher correlation coefficient observed for the Hyperactivity–Impulsivity domain. These findings indicate that step counts may provide complementary information about ambulatory activity associated with ADHD symptom severity, particularly behaviors related to hyperactivity–impulsivity. Nevertheless, step counts should not be considered a diagnostic measure of ADHD or a stand-alone indicator of hyperactivity. Rather, objective measures of ambulatory activity may complement standardized behavioral assessments when characterizing activity patterns associated with ADHD symptoms.

Higher ADHD symptom severity was significantly associated with greater motor activity, as represented by step counts, among preschool children aged 4–6 years. Significant positive associations were observed for both the Inattention and Hyperactivity–Impulsivity domains, with a numerically stronger correlation observed for Hyperactivity–Impulsivity. These findings indicate that objectively measured step counts may provide complementary information about ambulatory activity associated with ADHD symptoms in preschool children. However, step counts reflect only one aspect of motor activity and should not be interpreted as a diagnostic measure of ADHD or a stand-alone indicator of hyperactivity.

Future studies should employ longer or repeated monitoring periods across different daily settings to better characterize children's habitual motor activity. The use of validated objective measures, such as accelerometers, together with behavioral assessments and direct observation, may provide a more comprehensive assessment of activity patterns. Future research should also consider potential contributing or confounding factors, including sleep patterns, habitual physical activity, play environments, and family or contextual characteristics.

The authors would like to thank Universitas Muhammadiyah Surakarta, the Faculty of Health Sciences, and the Physiotherapy Study Program for their institutional support and for facilitating the conduct of this study. The authors also sincerely appreciate the administrators and teachers of the participating schools for their assistance during data collection, as well as the parents and children who participated in the study. The authors extend their appreciation to all individuals who contributed to the successful completion of this research.

The data supporting the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to participant privacy and confidentiality considerations.

This research does not receive external funding.

The authors declare no conflict of interest.