Developmental Coordination Disorder and Physical Activity

Original Editor ­ Irene Leahy

Top Contributors - Stacy Zousmer, Irene Leahy, Kim Jackson, Admin, Adam Vallely Farrell, 127.0.0.1 and Michelle Lee

What is Developmental Coordination Disorder?[edit | edit source]

Developmental coordination disorder (DCD) is a diagnosis given to children who have marked impairment in motor coordination that significantly impacts on their academic achievement and activities of daily living and is not due to any known medical or mental condition as stated in the DSM-5.[1]

According to the DSM-5, the diagnostic criteria for DCD includes the following[1]:

A. The acquisition and execution of coordinated motor skills is substantially below that expected given the individual’s chronological age and opportunity for skill learning and use. Difficulties are manifested as clumsiness (e.g., dropping or bumping into objects) as well as slowness and inaccuracy of performance of motor skills (e.g., catching an object, using scissors or cutlery, handwriting, riding a bike, or participating in sports).

B. The motor skills deficit in Criterion A significantly and persistently interferes with activities of daily living appropriate to chronological age (e.g., self-care and self-maintenance) and impacts academic/school productivity, prevocational and vocational activities, leisure, and play.

C. Onset of symptoms is in the early developmental period.

D. The motor skills deficits are not better explained by intellectual disability (intellectual developmental disorder) or visual impairment and are not attributable to a neurological condition affecting movement (e.g., cerebral palsy, muscular dystrophy, degenerative disorders).

DCD should not be confused with dyspraxia in which there is no formal diagnostic criteria and is not recognised by many paediatricians and school authorities as a diagnosis.

Prevalence[edit | edit source]

Developmental coordination disorder is identified as a common disorder of childhood and is usually identified in children between 5 and 11 years of age.[1] In the 1990s researchers estimated that DCD occurred in 10% to 19% of school-aged children.[2] Following a more precise diagnostic criteria and definition, the current prevalence is estimated to be 5%- 8% of all school-aged children.[3] It is more prevalent in boys than in girls (2:1).[4] This difference is often associated with a higher referral rate for boys, because the behaviour of boys with motor incoordination may be more difficult to manage at home and in the classroom.

Etiology[edit | edit source]

Motor control processes depend on the integrated functioning of the sensory, perceptual, cognitive and motor systems. It is, therefore, difficult to determine the location and nature of this neural deficiency.[5] The heterogenous presentation of DCD also makes it to challenging to identify the pathophsiology. It has been hypothesized that reduced activation of the parietal cortex and cerebellum may contribute to signs and symptoms of DCD, including compromised manual dexterity. [6] In addition, current evidence reports a significantly higher risk in premature and/low birth weight children, those with delayed walking after 15 months and abnormalities in neurotransmission. [7]

Characteristics of DCD[edit | edit source]

Gross Motor Fine Motor Perceptual/Sensory Psychosocial
Hypotonia Handwriting Poor awareness of body position in space Learning disabilities
Immature balance reactions Drawing Poor sense of direction Reading difficulties
Awkward running patterns Confused about which hand to use Sensitive to touch Speech problems
Poor posture Gripping Find some fabrics uncomfortable Class clown
Frequent falls Dressing Few friends
Dropping items Buttons Lower self-esteem
Difficulty imitating body positions Zipping Increased anxiety
Difficulty following 2-3 stage motor commands Shoelaces
Reduced ability to throw/catch ball
Difficulty hopping, skipping, riding a bike
Slow to dress

[8][9]

Measurement of DCD[edit | edit source]

There is currently no gold standard for the measurement of DCD. Common outcome measures that can be used by a physiotherapist to measure its severity and impact include;

  • Developmental Coordination Disorder Questionnaire (DCD-Q)
  • Movement Assessment Battery for Children (MABC-2) most widely used
  • Bruininks-Oseretsky Test of Motor Proficiency (BOTMP)
  • BOT-SF (Short Form)
International Classification of Function, Disability and Health (ICF model)

Why is Participation in Physical Activity Important?[edit | edit source]

The International Classification of Function, Disability and Health (ICF model) considers not only the impairment of a condition, but the impact of activity limitations and participation restrictions on disability. [10] Studies investigating participation of children with DCD have indicated decreased physical activity (PA) and fitness. [11] This may negatively influence not only physical health, [11] but also mental health and social development in children with DCD. [12]

Outcome Measures[edit | edit source]

Studies of PA use subjective methods, such as questionnaires and diaries or objective measures, such as accelerometers. Objective measures tend to be more reliable, but typically only measure frequency and intensity of activity. [13] Subjective methods are less reliable and error in reporting occurs. [14] However, they can address numerous aspects of PA participation such as diversity, intensity, frequency, enjoyment and whether they participate in group activities or choose solitary activities. [15] There is a bias toward parent and teacher-reported PA participation in children with DCD in the literature. [16] It is important to consider children's perspectives and priorities, as they do not mirror that reported by adults. [17][18]. Therefore, it may be beneficial to focus research on the perceptive of children with DCD, rather than relying only on caregiver and teacher report. [19]

Frequency of Participation in PA[edit | edit source]

Frequency of participation in PA is reduced in this population of children. Children with DCD between the age of 9 and 14 years report lower frequency of participation in free-and organised-play. [20] [21] Fong et al. and Jarus et al. agreed with this finding for children aged between 6 and 12 years and 5 and 7 years, respectively.[21][15] Cairney et al. and Jarus et al. both used small sample sizes of children that were not randomly selected. [20] [15] Fong et al. had a larger sample based on statistical power calculations.[21] This was the only study to calculate sample size based on statistical power, but the sample was still a convenience sample. Therefore there is a risk of selection bias in these studies. While Jarus et al. [15] and Fong et al. [21] had a sample of children with a diagnosis of DCD, those included in Cairney et al. [20] were not given a formal diagnosis. Only one other study used a sample of children with a formal diagnosis of DCD. [22] None of the studies blinded the investigators, which may lead to detection bias. Frequency of PA participation was consistently reduced in all studies of children with DCD.

Intensity of Participation in PA[edit | edit source]

Poulsen et al. reported that adolescent boys with DCD spent decreased time in high-intensity PA and had a preference for low-intensity PA compared to boys without DCD.[23] This was estimated from a one-week diary log of PA which has a high risk of reporting error as it relies on recall abilities of participants. [24] Jarus et al. and Fong et al. included both genders and reported decreased intensity of PA in children with DCD.[15] [21] These results can be considered more reliable, as they were calculated using the Child Assessment of Participation and Enjoyment (CAPE) questionnaire.[25] Both studies matched controls and participants for age, gender and socio-economic class, but like the other studies in this review, they did not account for other confounding variables such as birth weight, gestational age or maternal PA levels during pregnancy in the statistical analyses, which have been shown to influence PA in childhood. [26] Differences in PA may, therefore, be due to factors other than DCD.

Diversity of Participation in PA[edit | edit source]

Fong et al. reported that children aged 6-12 years participate in a smaller variety of activities. Analysis of results shows that participation is less in informal, physical, social, skill-based and self-improvement activities than their peers without DCD.[21] However, participation in formal and recreational activities did not differ between groups. The majority of recreational activities in the CAPE questionnaire are sedentary and do not require motor coordination. Jarus et al. also used the CAPE questionnaire and found that children aged 5-7 years with DCD engage in less physical, skill-based and informal activities.[15] In contrast, no statistical significant difference was found in social and self-improvement activities. This may be due to the small sample size, as mentioned before. Poulsen et al. measured diversity of activities in boys with DCD over a week.[23] This may not be a reliable measure, due to the short time span. The CAPE questionnaire used by the previous studies considers the diversity of participation over the previous 4 months. Taking this into account, results once again show that boys with DCD participated in less diverse activities and the majority of time was spent in sedentary activities. Participation in team sports and unstructured social physical activities were significantly lower than their peers without DCD. Unstructured social PA included street ball games or running games. Interestingly, there was no difference between groups in individual sports. This may be due to these activities not requiring the evaluative skills needed for team sports.[23] According to a review of the literature, it may be concluded that children with DCD demonstrate a narrower diversity of PA compared to typical children.

Effect of Age on Participation Patterns[edit | edit source]

It has been suggested that the activity-deficit in children with DCD may increase with age.[27] This was not seen in children between the age of 9 and 14 years in free- and organised-play. [20] Appropriate ANCOVA tests were used to analyse this difference, but results should be interpreted with caution, as this study was cross-sectional. More accurate results would be obtained from a longitudinal study following the same group of children, rather than comparing results from different individuals at different ages. The only longitudinal study in this review used mixed-effects modelling analysis, which showed a difference over a 3 year period.[20] Boys showed an increase in the frequency of PA, while girls exhibited a consistent decrease. The increasing expectations and complexity of PA in adolescence were cited as a challenge.[28] The sample used in this qualitative study was a group of university students which is not representative of the wider heterogeneous population of children with DCD. However, it is important to consider qualitative research as it gives a deeper meaning to the reduced participation in this population.

Effect of Gender on Participation[edit | edit source]

There are less societal expectations for females to be physically active.[29] It is, therefore, suggested that girls with DCD will be less active than boys with DCD. Cairney et al. found no statistical difference in PA frequency between genders. Despite this, there is a trend towards lower participation in free-and organized-play in girls, but it does not reach statistical significance, which may be due to the smaller sample size. [20] Cairney et al. used a larger sample size and showed that there was increased frequency of PA in boys with DCD compared with girls as they got older. [20] It is important to remember that both these studies used a Participation Questionnaire (PQ) which only accounts for organised- and free-play and not other forms of PA such as chores and active transport. Additionally, Engel-Yeger and Hanna Kasis showed there were differences between genders as far as preference for certain activities.[30] Girls with DCD favoured skill-based activities, whereas boys favoured active PA, which was similar to their peers without DCD. This study, unlike the others, included parent education, as well as age and gender as confounding factors in the analysis. One limitation of this study is the use of Preference for Activities of Children (PAC), as it just measures preference and gives no indication of whether these activities are performed. Therefore, it does not indicate actual participation patterns.

Effect of Motor Ability on Participation[edit | edit source]

Limited studies considered the effect of motor ability on participation. Motor ability was shown to positively correlate to PA. [15] Fong et al. used multiple regression analysis and concluded that after motor ability was added to regression with age and gender it accounted for 7.6% of the variance in PA diversity.[21] In contrast, Jarus et al. only used Pearson’s correlation coefficient to analyse this relationship, only considering two factors in isolation. [15] Preference to participate in active PA was also positively correlated with motor ability.[15] These findings suggest that children with higher motor ability have an increased ability to activate and sequence motor movements, which provides more opportunities for participation.[31] However, it is important to remember the cross-sectional design of these studies, making it impossible to demonstrate causal pathways for the relationship between these factors.

Effect of Reduced Participation on Social Development[edit | edit source]

Reduced PA may have a detrimental effect on social development.[12] A greater number of children with DCD play alone during out of school activities compared to their peers.[15] This was reiterated in qualitative studies, where individual activities were preferred as they avoid ridicule and pressure from peers. [28] [32] Fong et al. concluded that a large number of children in their sample with and without DCD participated in activities with family, demonstrating no difference between groups.[21] This may be due to cultural influence with more emphasis on family in this Asian sample. [33] Boys with DCD had a lower perception of their social competence which had a negative impact on the intensity of participation[23]. Poulsen et al. found that motor ability affected loneliness negatively and life satisfaction positively in the same group of boys.[23] They discovered that team sport participation increased life satisfaction and decreased loneliness, which is probably due to the social nature of these sports. However, there may be other factors that were not taken into consideration in this study, such as social-environmental influences, because only partial mediation effects were demonstrated. All the participants were males from a high socio-economic background, which may place social value on participation in sports, which may which affect generalizability of results. Additionally, there seems to be a paucity in the literature to support these results, making it difficult to draw causality.

Effect of Reduced Participation on Self-Efficacy Towards PA[edit | edit source]

Cairney et al. and Engel-Yeger and Hanna Kasis concluded that self-efficacy in children with DCD was significantly lower compared to their peers. [20][30] However, Cairney et al. had a low response rate to the PQ, which may bias results, as there is a lack of data on non-participants.[20] An additional limitation of these studies is that the outcome measures used do not measure efficacy in activities outside of school. Children’s Self-perception of Adequacy in and Predilection for Physical Activity (CSAPPA) measures self-efficacy in physical education class and the Perceived Efficacy and Goal Setting System (PEGS) include school and self-care activities as well as leisure activities.[20] [30] Therefore, it is difficult to draw conclusions about self-efficacy in activities outside of school.

Enjoyment of PA and Participation[edit | edit source]

Studies investigating enjoyment of PA report no difference between children with and without DCD. [15] [21] This may be due to the likelihood of children choosing to participate in activities that they enjoyed.[15] These children had not yet reached adolescence, which may have biased the results, as younger children are less likely to compare themselves to peers, and are less likely to be frustrated by their inability to perform.[34] Missiuna et al. indicated that adolescents also chose activities in which they excel and enjoy. [28] Additionally, Fitzpatrick and Watkinson reported avoidance of activities that caused humiliation.[32] Exposure of their awkwardness was likely to have resulted in decreased enjoyment during activities, rather than the lack of coordination. Similar to the research conducted by Missuina et al., this study used a phenomenological approach and considered the retrospective viewpoint of adults through interview. [28] Credibility of thematic analysis was established using member checks for verification of accuracy. Neither study considered the author's role and the bias that this may cause in the data. Participants were not diagnosed with DCD but had significant coordination difficulties that affected daily activities. These studies relied on the recall ability of adults rather than interviewing children. Both studies have limitations, but provide information regarding the children' selection of enjoyable activities. Ultimately, further qualitative research is needed of children with DCD.

References[edit | edit source]

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