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A pilot study of psychopathology in Developmental Coordination Disorder

A pilot study of psychopathology in Developmental Coordination Disorder
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  Original Article   doi:10.1111/j.1365-2214.2006.00684.x  © 2006 The AuthorsJournal compilation © 2006 Blackwell Publishing Ltd  741  Blackwell Publishing LtdOxford, UKCCHChild: Care, Health and Development0305-1862© 2006 The Authors; Journal compilation © 2006 Blackwell Pub-lishing Ltd  ? 2006  32  6741750  Original Article  A pilot study of psychopathologyD.Green et al.   Correspondence:Mrs Dido Green, Newcomen Centre, Guy’s Hospital, St  Thomas Street, London SE1 9RE, UK E-mail: dido.green@gstt.nhs.uk    Original Article  A pilot study of psychopathology in Developmental Coordination Disorder  D. Green,*† G. Baird* and D. Sugden†  *Newcomen Centre, Guy’s Hospital, London, and †School of Education, University of Leeds, Leeds, UKAccepted for publication 12 June 2006  Abstract   Background     This paper explores the prevalence of emotional and behavioural disorders in children referred to a Community Paediatric Occupational Therapy service for assessment and treatment of problems with development of motor skills.   Methods   Parents of 47 children from a clinical sample of children who had been identified with Developmental Coordination Disorder (DCD) returned the Strengths and Difficulties Questionnaire (SDQ) – a brief measure of the pro-social behaviour and psychopathology that can be completed by parents, teachers or youths.   Results   Significant emotional and behavioural problems were reported by 29 parents (62%) with a further six (13%) reporting problems in the borderline range. Seven children (15%) were without significant problems in one or more area although only four of these (9%) were outside the borderline range for all of the sub-domains of the SDQ.   Discussion   A significant proportion of children with DCD were reported by their parents to be at risk of psychopathology. Further research is needed to understand the relationship between motor difficulties and emotional and behavioural symptoms; however, it is recommended that interventions for children with DCD should support mental health and behavioural problems as well as motor development.   Keywords   assessment, comorbidity, Developmental Coordination Disorders, mental health, paediatric Introduction   The diagnostic manuals of the American Psychiat-ric Association and the World Health Organiza-tion recognize a group of children in whomclumsiness is a substantial and primary impair-ment (APA 1987, 1994; DSM-III, DSM-IV; WHO1992, ICD-10). Developmental Coordination Dis-order (DCD) and specific developmental disorderof motor function (SDD-MF), respectively, definea chronic, often permanent condition in which asignificant impairment in the acquisition of motorskills influences functional performance. Theseschemes contain exclusion criteria whereby thedegree of motor deficit cannot be explained by thechild’s intellect or other neurological or psychiat-ric disorder(s). Secondary characteristics, e.g.social acceptance, are mentioned as frequently co-occurring, but not defining features (Polatajko &Fox 1995).Although it had been assumed for a number of  years that children with motor problems wouldgrow out of their clumsiness, longitudinal studiesshow that many of these children continue to havemotor difficulties through adolescence (Hall 1988;Losse et al    . 1991; Geuze & Borger 1993). Also –although motor competence may improve –concomitant social and emotional difficulties may   742  D. Green et al   .  © 2006 The AuthorsJournal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development   , 32  , 6, 741–750   persist (Gillberg & Gillberg 1989; Cantell et al    .1994; Schoemaker & Kalverboer 1994; Skinner &Piek 2001). In particular, Hellgren and colleagues(1994) showed an increased risk of negative psychi-atric outcome at age 16 years in children who hadshown deficits of motor control and perception inearlier childhood. Other studies have shown thecoexistence of a number of developmental condi-tions with motor difficulties – notably specific lan-guage impairment (SLI), dyslexia, attention deficithyperactivity disorder (ADHD) and Asperger’ssyndrome (see Green & Baird 2005 for summary).Rasmussen and Gillberg (2000) and Sigurdssonand colleagues (2002) have suggested that impair-ments in motor skills during childhood are signif-icant risk factors for poor psychosocial outcomeand adolescent anxiety, respectively, a propositionthat has implications for services whether or notthe emotional and behavioural problems areviewed as primary, thus coexisting, or secondary and possibly consequential.Fewer studies have explored the emotional andbehavioural characteristics of younger childrenwith DCD (Schoemaker & Kalverboer 1994; Rose   et al    . 1998). These children are commonly referredto community Occupational Therapy services inthe UK for assessment and management of theirmotor difficulties (NAPOT & COT 2003). Thisstudy reports on the presence of such problems ina group of young children identified with DCDfollowing referral to a community OccupationalTherapy service.  Methodology   The data for this study were collected as part of aresearch project investigating the efficacy of anOccupational Therapy programme for the remedi-ation of the major (motor) symptoms of DCD.  Subjects   The subjects aged 5 years to 10 years and 8 monthswere referred consecutively to a local ‘district’Occupational Therapy service over a period of 22 months for concerns regarding perceptual andmotor problems thus children were not included if they were known to have significant learning diffi-culty, autism, a neuromotor or significant medicalproblem.Referrals (   n   =   116) came from a variety of sources including medical, therapy and educa-tional professionals. No child was referred to orknown to a Child and Adolescent Mental HealthService (CAMHS) and all children were attendingmainstream schools. The diagnosis of DCD wasmade following medical review and OccupationalTherapy assessment which included a number of motor, perceptual, cognitive and performancemeasures.  Procedure   Seventy-eight children met DSM-IV criteria forDCD placing them below the 15th percentile onboth clinical measures and parental report of movement problems. Families were sent letters andinformation for the children explaining a treat-ment study to be undertaken over a 2-year period.A consent form for participation in the treatmentstudy was included along with the questionnairesused for this study regarding parents’ perceptionsof their child’s motor, emotional/behavioural andgeneral developmental attainments. Data were col-lected over a period of 3 months. All letters andquestionnaires to families were sent with stampedaddressed envelopes to encourage return of thequestionnaires. Ethical approval to undertake thisproject was granted by the Local Research andEthics Committee (Project number 631). Figure 1illustrates the process of data collection.   Figure 1.  Referrals. DCD, Developmental Coordination Disorder. Referrals n   =   116Referral Source:Doctor n   =   54 Therapists n   =   17 School n   =   31 Psychology n   =   14Excluded n   =   38Children without DCD andchildren with known significantlearning difficulty, autism,neuromotor or significantmedical problemIncluded n   =   78 Children with DCDFamilies sent questionnaires andinvited to participate intreatment studyOpted in n   =   47Opted out n   =   31   A pilot study of psychopathology  743  © 2006 The AuthorsJournal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development   , 32  , 6, 741–750  Measures   The diagnosis of DCD was supported by perfor-mance on the Movement Assessment Battery forChildren (M-ABC, Henderson & Sugden 1992).Criterion scores are computed on eight subtestsover three domains of motor performance: manualdexterity, ball skills and static and dynamic balancetasks. The sum of these subsections provides a totalimpairment score which can be converted to per-centile ranks. Total impairment scores from 10place a child on or below the 15th percentile. Scoresof 14 or more place a child on or below the 5thpercentile (Henderson & Sugden 1992). This testhas established reliability and validity information(Henderson & Sugden 1992; Croce et al    . 2001).The British Picture Vocabulary Scale (BPVS,Dunn & Dunn 1997) was used to provide an indi-cation of verbal cognitive capability and estimateof general learning potential. Although not a directmeasure of verbal intelligence, BPVS standardscores are highly correlated with measures of verbalintelligence (Wechsler Intelligence Scale for Chil-dren, Wechsler 1992; Dunn & Dunn 1997). Chil-dren with BPVS standard scores 69 or below wereexcluded from this study.  Parental questionnaires   The Developmental Coordination Disorder Ques-tionnaire (DCDQ) was completed by all parents toprovide an indication of functional impact of motor difficulties (Wilson et al    . 2000; Green et al    .2005). This is a 17-item survey which taps parentalperspectives of the extent of their children’s func-tional difficulties across environmental domainsarising as a consequence of poor motor skills. Atotal score is computed. Cut-off scores discriminat-ing between children with and without motorproblems or at risk of DCD are currently based onCanadian norms of children between the ages of 8–14.5 years. The resultant score can range between17 and 85 with a score of 48 or less indicatingsignificant motor difficulties and those above 57are considered to be within the normal range.These cut-offs show good sensitivity (93%) for usein clinical screening in the UK for ages 5–14 years(Green et al    . 2005).The Strengths and Difficulties Questionnaire(SDQ, Goodman 1997) incorporates questionscovering 25 emotional and behavioural attributesof the child: 10 of which are considered to bestrengths and 14 of which represent difficultiesand one neutral item. Scores are generated usinga 3-point Likert scale to indicate how far eachattribute applies to the child. Summed scores canbe obtained for total deviance, emotional symp-toms, conduct problems, hyperactivity, peer prob-lems and pro-social scales. Reliability and validity of the SDQ is satisfactory and this tool has beenidentified as a useful measure detecting emotionaland behavioural problems of children and adoles-cents (Goodman 2001; Mathai et al    . 2002). Cutoff scores for identifying risk of psychopathology havebeen obtained through studies of the mentalhealth of populations of British children (Meltzer   et al    . 2000). Total scores of 13 or less are withinthe normal band, scores of 14–16 place children asborderline and scores 17 or above represent theextreme 10% of the population and are associatedwith a substantial increase in psychiatric risk (Goodman 2001). Cut-offs represent atypicalscores for the emotion (   ≥   5), conduct (   ≥   4), activity (   ≥   8), peer relation (   ≥   4) and pro-social (   ≤   4) scales.The scores for the pro-social items are not incor-porated (in the reverse direction) into the totaldifficulties score, as the absence of pro-socialbehaviours is conceptually different from thepresence of psychological difficulties (Goodman1997).Townsend scores of social deprivation were usedto estimate socio-economic status in view of thepotential impact of experience and opportunity onmotor development and behaviour (Townsend   et al    . 1988; Hadders-Algra & Lindhahl 1999).Scores between 3 and +   3 represent the middlerankings. Scores below −   3 the least deprived andscores of 4 and above the most deprived.  Statistical procedures   The percentage of parents reporting emotional andbehavioural difficulties in their children wascalculated (Meltzer et al    . 2000; Goodman 2001).   MANOVA   was undertaken to investigate the rela-tionship of age and degree of motor impairment to   744  D. Green et al   .  © 2006 The AuthorsJournal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development   , 32  , 6, 741–750   SDQ scores for the DCD group.   1   Spearman rank correlations were performed to identify relation-ships between variables. Analyses were carried outusing the Statistical Package for Social Sciences(   SPSS   , Vol. 11, Chicago, IL, USA, SPSS Inc. 1999).  Results   Forty-seven families of children with DCD (motorimpairment scores placing them below the 15thpercentile and with BPVS scores >   69) returnedthe questionnaires with consent to participate inthe intervention study (60%). Table 1 sets out thesample characteristics. By design, all children hadM-ABC total impairment scores of 10 or more(mean =   18.8, SD =   6.68) and DCDQ total scoresof 57 or less (mean =   39.4, SD =   9.85). The meanage of this sample was 8 years and 1 month (range64–128 months). The group comprised 39 malesand eight females.The demographic data of those choosing to par-ticipate in the treatment study were contrasted tothose who did not. There were no differencesbetween the groups in the extent of motor impair-ment (by standardized testing and parent report),estimated verbal intelligence (BPVS standardscores), identified comorbidity, age or Townsendscores [t(d.f. 76) <   1.8, P    >   0.05 on these mea-sures]. Further details of families who did notrespond were not available.Six children had additional diagnoses (13%)which had been made by a consultant paediatricianand specialist speech and language therapist fol-lowing ICD-10 criteria but which would not nec-essarily rule out DCD (WHO 1992). Four childrenhad a diagnosis of ADHD and two had SLI; neithercondition exclusive of a diagnosis of DCD.The SDQ scores were analysed for the severity of the emotional and behavioural problems reportedby each child’s parent. The mean total SDQ scorefor this DCD group was 17.89 (SD =   6.34, range 3–30) placing the mean within the abnormal range(see Table 1). Removing the four children withADHD and two children with SLI who obtainedtotal SDQ scores between 19 and 30 did not shiftthe overall mean significantly (mean =   17.12,SD =   6.29, range 3–28). Subsequently, these six children are included in the remaining analyses.Table 2 sets out the percentage of parents whoreported significant behavioural problems in theirchildren, 62% of whom reported severe difficultiesin their children. A further 13% reported overallproblems in the borderline range. The greatest dif-ficulties were reported for showing emotionalsymptoms (59% significant, 11% borderline) andhyperactivity/inattention (57% significant, 21%borderline). Peer problems were also evident for anumber of children (40% significant, 13% border-line). Fewer parents reported conduct problems intheir children (30% significant, 13% borderline).Seven children (15%) were without significantproblems in one or more areas – only four of whom were outside the borderline range in allsub-domains. Children were more likely to haveabnormal scores in two or more domains (   n   =   32/40, 80%). The majority of parents felt that their   Table 1.  Sample characteristics – means (ranges)   Age (months)TownsendscoreBPVSscoreM-ABCscoreDCDQscoresSDQ totalscores   DCD participating group(   n   =   47)96.5(64–128)   −   0.5(   −   5 to +   7)98.85(71–132)18.8(10–34)39.4(21–57)17.89(3–30)DCD not participating group(   n   =   31)98.9(72–127)   −   0.8(   −   5 to +   6)100(74–131)17.7(10–33.5)41.4(24–57)Not availableBPVS, British Picture Vocabulary Scale; DCD, Developmental Coordination Disorder; DCDQ, Developmental Coordination Disorder Questionnaire; M-ABC, Movement Assessment Battery for Children; SDQ, Strengths and Difficulties Questionnaire.   1  Parametric analyses were repeated using non-parametric techniques. There were no differences in outcome and therefore parametric results are reported except Spearman rho correlations because of the ordinal nature of the scales and different scale dimensions.   A pilot study of psychopathology  745  © 2006 The AuthorsJournal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development   , 32  , 6, 741–750   child’s problems had a significant impact withrespect to distress to the child, burden to othersand interference with daily life (62%). (referTable 2).Although the absence of pro-social behaviours isqualitatively distinct from the presence of behav-iours representing social difficulties, problems inboth areas undeniably represent poor socialbehaviour (Fombonne et al    . 2001). Fifteen childrenshowed reduced social responses (32%). Only fiveof these children had problems with peer relationsthat outweighed their sociability when their overallsocial rating score was calculated with a furthersix being at risk of more social problems thanstrengths. When the more positive pro-social scoreis subtracted from the score for poor peer relations,a zero-to-positive value suggests difficulties ininstigating and sustaining appropriate socialbehaviour.Exploration of the effect of age (classifying by M-ABC age band) and/or extent of motor impair-ment on SDQ scores was undertaken. MANOVA   of the SDQ scores by degree of motor impairmentwith children classified as being below the 1st per-centile (severe), between the 1st and 5th percentiles(definite) and between the 5th and 15th percentiles(borderline) was inconclusive with no main effectof motor impairment on total SDQ scores. Therewas no interaction between age and/or degree of motor impairment on SDQ scores (see Fig. 2).Gabriel’s post hoc procedure was used because of unequal group sizes and equal variance. Confir-matory ANOVA   of SDQ subtest scores contrastingage groups found 7–8-year-olds to be moreoveractive/inattentive than the younger children[   F    (2,44) =   3.91, P    =   0.029, eta   2   =   0.18] and 9–10- year-olds demonstrated more positive socialbehaviours [   F    (2,44) =   3.49, P    <   0.05, eta   2   =   0.16].Analyses were rerun excluding the six children withADHD and SLI with no significant differences onthe results. Comparison of gender showed parentsto report more problems with peer relations   Table 2.  Strengths and difficulties scores   DCD group (   n    =    47)TotalEmotionalConductActivityPeer relationsPro-socialImpact   Mean17.894.–300–100–70–100–83–100–10Percentage*75704378531762*Percentage of parents reporting moderate to severe behavioural and emotional problems on the SDQ.   Figure 2.  Comparison of total SDQ scores by age and degree of motor impairment. SDQ, Strengths and Difficulties Questionnaire. Age Band (1   =   5-6 years; 2   =   7-8 years; 3   =   9-10 years) 00.300.200.1    M  e  a  n   t  o   t  a   l   S   D   Q  s  c  o  r  e 220281614121 Motor impairment borderlinedefinitesevere
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