Abstract
Background Children with developmental coordination disorder (DCD) face evident motor difficulties in daily functioning. Little is known, however, about their difficulties in specific activities of daily living (ADL).
Objective The purposes of this study were: (1) to investigate differences between children with DCD and their peers with typical development for ADL performance, learning, and participation, and (2) to explore the predictive values of these aspects.
Design This was a cross-sectional study.
Methods In both a clinical sample of children diagnosed with DCD (n=25 [21 male, 4 female], age range=5–8 years) and a group of peers with typical development (25 matched controls), the children's parents completed the DCDDaily-Q. Differences in scores between the groups were investigated using t tests for performance and participation and Pearson chi-square analysis for learning. Multiple regression analyses were performed to explore the predictive values of performance, learning, and participation.
Results Compared with their peers, children with DCD showed poor performance of ADL and less frequent participation in some ADL. Children with DCD demonstrated heterogeneous patterns of performance (poor in 10%–80% of the items) and learning (delayed in 0%–100% of the items). In the DCD group, delays in learning of ADL were a predictor for poor performance of ADL, and poor performance of ADL was a predictor for less frequent participation in ADL compared with the control group.
Limitations A limited number of children with DCD were addressed in this study.
Conclusions This study highlights the impact of DCD on children's daily lives and the need for tailored intervention.
Developmental coordination disorder (DCD) is associated with impairments in the coordination of voluntary movements, timing, force control, and motor learning.1 These impairments will affect all kinds of motor activities, including activities of daily living (ADL), which are essential for children's daily functioning.2 Children with DCD face difficulties in a broad range of motor-based ADL (eg, mobility, personal hygiene, feeding, and dressing; handwriting and doing craftwork; ball skills and riding a bicycle).3–6 For children with DCD, compared with their peers with typical development, poor performance of ADL, delays in learning of ADL, and less frequent participation in ADL are widely suggested in the literature3–9 and form part of the diagnostic criteria for DCD.10
However, evidence is scarce: a recent systematic review concluded that little is known about children's specific difficulties in performance of ADL and participation in ADL.11 For learning of ADL, no studies were performed. It was emphasized in the systematic review that every effort should be made to report the impact of the disorder on children's daily functioning, and improved understanding of the disorder is needed.11 Both require standardized assessment of ADL for children with DCD.11–14 For this purpose, the DCDDaily-Q was recently introduced.15 This parental questionnaire enables investigation of specific ADL difficulties in children with DCD (ie, how well children perform ADL, whether they have taken longer to learn ADL compared with peers, and how often they perform ADL).15 The DCDDaily-Q addresses a broad range of crucial ADL (23 tasks) known to be difficult for children with DCD,15 covering the domains of ADL that are relevant for children: “self-care and self-maintenance,” “productivity and school,” and “leisure and play.”3,5,16–20 This comprehensive range of ADL is essential, as full insight into children's difficulties is needed to support diagnosis, assessment, and intervention.4,5,7,11,14,21,22
The current study investigated differences between a clinical sample of children diagnosed with DCD and their typically developing peers for the aspects of performance, learning, and participation. Thus, the DCDDaily-Q is used to specify the difficulties that children with DCD are faced with in daily functioning in order to investigate the impact of the disorder on the children's daily lives. In addition, the DCDDaily-Q is the first instrument to assess ADL performance, learning, and participation in parallel, which enables investigation of the predictive values of these aspects. We hypothesized that delayed learning of specific ADL precedes poor performance in these ADL, which, in turn, may lead to less frequent participation because children avoid these ADL to prevent failure.23–26 For example, Schmidt and Lee24 recently reported that children with DCD participate less frequently in ADL and play activities and that a lower level of motor performance was associated with less participation in active physical activities. Furthermore, we hypothesized that less frequent participation in specific ADL may cause performance to fall further behind, as children with DCD do not practice these ADL as often as their peers.23,24,26 This has been proposed in the developmental skill-learning gap hypothesis: low participation will impede skill development, which, in turn, will lead to avoidance of participation.22
Shedding light on children's difficulties in ADL performance, learning, and participation and the relationships among these aspects, the DCDDaily-Q may support diagnosis and intervention for individual children with DCD and facilitate improved understanding of the disorder.
Method
The data collected for this study were part of the DCDDaily-Q validation study.15
Participants
Twenty-five children with DCD were included (age [male:female ratio]: 5 years [4:0], 6 years [5:0], 7 years [7:2], 8 years [5:2]). All of them were referred to a rehabilitation center or physical therapy center in the Netherlands. They were diagnosed by a medical doctor according to the diagnostic criteria for DCD operationalized in the international clinical practice guideline for DCD.10,14 A control group of 25 children matched for age and sex was randomly selected from an accessible population of 5- to 8-year-old school children that served as a reference group for a previous study (see the DCDDaily-Q validation study15 for additional details). Children were excluded from the control group beforehand if they had a known clinical condition such as uncorrected visual problems or when they were at risk for DCD (a score equal to or lower than the 16th percentile on the Movement Assessment Battery for Children–2).27
Test and Measures
The development of the DCDDaily-Q was extensively described in an earlier study.15 The DCDDaily-Q is a parental 23-item questionnaire covering the domains of “self-care and self-maintenance,” “fine motor activities,” and “gross motor play activities,” in correspondence with the relevant ADL domains reported in the literature.15
For the aspect of performance of ADL, the DCDDaily-Q was found to be a valid and reliable parental questionnaire to address a comprehensive range of ADL in 5- to 8-year-old children with and without DCD.15 Compared with their peers with typical development, children with DCD demonstrated poor performance of all ADL included. In the current study, data on ADL performance are put into new perspective, as additional data are presented on children's delays in learning of ADL and frequency of participation in ADL, to fully inform professionals about children's daily functioning.
To evaluate any relevant difficulties in motor-based daily functioning, parents rate how well children perform each of the ADL included, whether they are taking or have taken longer to learn these ADL compared with peers, and how often they perform these ADL. An example of the directions given to parents when filling in the questionnaire and an example of one complete item are provided in the Appendix. An overview of the 23 items included in the DCDDaily-Q is provided in Table 1. For the aspects of performance, learning, and participation, DCDDaily-Q item and total scores are calculated as explained in Table 2. Furthermore, for the aspects of performance, learning, and participation, scores were calculated for the specific domains of “self-care and self-maintenance,” “fine motor activities,” and “gross motor play activities” (Tab. 3).
Items Included in the DCDDaily-Q
DCDDaily-Q Scores for Performance, Learning, and Participationa
DCDDaily-Q Domain and Total Scores for Performance, Learning, and Participationa
In order to compare individual children's scores on the 3 subscales, DCDDaily-Q total scores were converted to percentage scores, ranging from 0% (good performance in all ADL, no delays in learning any of the ADL, and frequent participation in all ADL) to 100% (poor performance and delayed learning in all ADL, and no participation in any of the ADL).
Procedure
The 38-item research version of the DCDDaily-Q was sent to parents, who returned it to the researchers after completion between September 2008 and March 2012. In the current study, data are shown for the 23 items included in the final version of the DCDDaily-Q.15
Data Analysis
Analyses were performed using IBM SPSS version 20.0 (IBM SPSS, Armonk, New York). Alpha was set at .05; no corrections were made for multiple testing due to the small sample size. The 95% confidence intervals (CI) were calculated using the Monte Carlo method.
Missing values were replaced with the mean item score of the child's group (reference or DCD). Per individual questionnaire, a maximum of 4 out of 23 questions were allowed to remain unanswered; for all questionnaires in total, fewer than 1% of all answers were missing. When participation was rated 4 (not yet performed/never performed), parents could not rate performance and learning for that particular item (4% of all answers in the DCD group; 2% in the control group). Again, for performance and learning, mean scores of the child's group were used for that item to replace the missing value. For further reliability analyses of the DCDDaily-Q subscales, internal consistency was calculated for the 3 subscales.
To explore whether the data were normally distributed, Kolmogorov-Smirnov tests were performed for the total scores of the 3 subscales (performance, learning, and participation). The Kolmogorov-Smirnov test was nonsignificant for the performance and participation subscales, implying that the distribution of these samples was not statistically different from a normal distribution. For investigation of the differences between children with DCD and their peers with typical development, item scores, domain scores, and total scores were analyzed for the 3 subscales of the DCDDaily-Q. Differences between mean scores in the DCD group and the control group were investigated using t tests for performance and participation. For learning, Pearson chi-square analysis was used, as this test considers nominal data.
Backward stepwise multiple regression analyses were performed to explore the predictive values of performance, learning, and participation. We hypothesized that (1) learning of ADL would predict performance of ADL; (2) performance of ADL would predict participation in ADL; and (3) participation in ADL, in turn, would predict performance of ADL. To analyze hypotheses 1 and 3, learning and participation were used as predictor variables in model 1, with performance as the dependent variable. As a removal criterion for model 2, to check the predictive value of the separate subscales, the probability of F≥.100 was used. To analyze hypothesis 2, the analyses were repeated, with participation as the dependent variable and performance and learning as predictors. Finally, interaction effects were investigated by calculating standardized values and including the effects of performance × learning on participation and of learning × participation on performance. For all models, data are provided for DCDDaily-Q total scores for the DCD group and the control group separately.
Role of the Funding Source
Fonds NutsOhra provided financial support for the project.
Results
Internal consistency of the performance subscale was found to be good: Cronbach α was .84 for both the DCD group and the control group.15 For learning, Cronbach α was .95 for the DCD group and .59 for the control group, including items with zero variance. For participation, Cronbach α was .65 for the DCD group and .77 for the control group.
DCDDaily-Q Scores in the DCD Group and the Control Group
According to their parents, children with DCD showed poor performance of ADL compared with their matched controls. Significant differences were found between groups for DCDDaily-Q total performance scores (P<.001), domain scores (all: P<.001), and each of the 23 item scores (all: P≤.005; Tab. 3, Fig. 1).
DCDDaily-Q mean item scores on activities of daily living (ADL) performance, learning, and participation in children with and without developmental coordination disorder (DCD). The items are organized per domain and sequenced from good to poor for the mean DCDDaily-Q item scores in the control group (performance scores range from 1 [good] to 3 [poor], learning scores range from 0 [did not take long to learn compared with peers] to 1 [took long to learn the ADL compared with peers], and participation scores range from 1 [often performed] to 4 [never performed]). An explanation of the item numbers is provided in Table 1. *P<.05.
Parental rating demonstrated delays in learning of ADL in children with DCD compared with peers. Significant differences were found between groups for DCDDaily-Q total learning scores (P<.001), domain scores (all: P<.001), and each of the 23 item scores (all: P≤.002; Tab. 3, Fig. 1). In more detail, 5 children with DCD (20%) showed a delay in learning of all ADL included (total learning score=23, percentage score=100), and the majority of children in the DCD group (64%) showed a delay in learning more than half of the ADL included (total learning score ≥12, percentage score ≥50), whereas the maximum total learning score was 4 (percentage score ≤17) in the control group (eTable, Fig. 2). The majority of children in the control group (76%) showed no delay in learning in any of the ADL compared with one child in the DCD group (4%; total learning score=0, percentage score=0; eTable, Fig. 2).
Percentage scores for activities of daily living (ADL) performance, learning, and participation for all children in the developmental coordination disorder (DCD) group and the control group. Children's scores are sequenced from good to poor according to their performance scores. Percentage scores range from 0% (good performance, no delays in learning, and frequent participation) to 100% (poor performance and delayed learning in all ADL and no participation in any of the ADL).
Children with DCD participated in ADL less frequently than their matched controls. Significant differences were found between groups for total participation scores (P<.001) as well as for the domain scores of self-care and self-maintenance (P<.001) and fine motor activities (P=.021) but not for the domain of gross motor play activities (P=.056; Tab. 3). Considering the specific ADL, parents acknowledged that children with DCD participated less frequently in 7 out of 23 activities: cutting a sandwich with a knife (P=.002), pouring a drink (P=.047), opening a wrapper or package (P=.002), drying after a shower (P=.035), constructional play (P=.030), moving game pieces on a board game (P=.020), and kicking a football (P=.018; Fig. 1).
Performance, Learning, and Participation
Percentage scores on performance, learning, and participation were below the 40th percentile for all children in the control group, indicating good performance in most ADL, no delays in learning in most of the ADL, and frequent participation in most of the ADL; for the majority of children in the DCD group, percentile scores were above the 40th percentile for performance and learning of ADL (Figs. 1 and 2).
For children with DCD, percentage scores on performance, learning, and participation ranged from 0% to 100%, reflecting heterogeneous patterns in their scores on the 3 subscales (Fig. 2). Heterogeneity in performance and learning is shown in Figures 1 and 2. Difficulties were observed in each of the ADL included. Some children with DCD showed difficulties in only some ADL, and others showed difficulties in all ADL.
Relationships Among Performance, Learning, and Participation
In the DCD group, regression analyses of the DCDDaily-Q total scores demonstrated that delays in learning were predictive of poor performance and that poor performance was predictive of less frequent participation, but less frequent participation did not predict poor performance (Tab. 4). In the control group, regression analyses of DCDDaily-Q total scores did not demonstrate delays in learning to predict poor performance but did demonstrate performance to predict participation and participation to predict performance (Tab. 4).
Backward Regression Analyses for Mean DCDDaily-Q Total Performance and Participation Scoresa
No interaction effects were found (DCD group: P=.713 for effect of learning × participation interaction on performance, P=.899 for effect of performance × learning interaction on participation; control group: P=.468 for effect of learning × participation interaction on performance, and P=.170 for effect of performance × learning interaction on participation).
Discussion
The first aim of this study was to investigate difficulties in daily functioning in children with DCD. The DCDDaily-Q was used to assess children's performance, learning, and participation in a broad range of crucial ADL in order to elucidate the consequences of DCD for the individual child. This study is the first to quantify what has been suggested in the literature: children with DCD show poor performance of ADL, delays in learning of ADL, and less frequent participation in some ADL compared with their peers with typical development.3–7,10,25,28
Interestingly, for the majority of the specific ADL included in the DCDDaily-Q (16 out of 23), parents rated children with DCD to participate as often as peers. Children with DCD were found to participate less frequently in those ADL that can be avoided (eg, the domain of gross motor play activities and, at item level, kicking a ball, constructional play, and moving game pieces on a board game) and in ADL that can be “taken over” by parents, such as cutting bread, pouring a drink, unwrapping packages, and drying after a shower. The moderate reliability of this subscale for the DCD group must be taken into account when interpreting these findings. However, it was demonstrated earlier that children with DCD avoid certain ADL when their poor performance disturbs other children (eg, in playing games).7–9,26 Furthermore, as the poor performance in children with DCD puts pressure on the entire family, parents may “take over” activities such as preparing food in order to prevent the mess of spilled juice or dangerous situations involving use of a knife or purchase supportive materials such as shoes with self-adhesive fasteners to prevent endless attempts of getting dressed during the morning rush to get to school.7–9 For all other ADL included in the DCDDaily-Q, parents rated children with DCD to participate as often as peers. Apparently, avoidance or adaptations are uncommon for these ADL (eg, children have to wash their own hands and participate in school activities such as writing and tinkering, and children participate as often as peers in play activities such as catching balls and hopping in squares). Given their poor performance in these ADL, this must be a frustrating experience.
A second important result of this study considers the heterogeneity of DCD. It is well known that children with DCD show heterogeneous performance.6 Some children face difficulties in handwriting only; others lack specific skills, such as ball skills; and others may experience severe “clumsiness” in multiple motor domains.3,10 The current study is the first to assess children's difficulties in a broad range of crucial ADL with a valid and reliable instrument. The heterogeneity in ADL performance and learning in children with DCD, as revealed with the DCDDaily-Q, stresses the range of differences among children with DCD and, with that, the need for tailored intervention. Moreover, the DCDDaily-Q may support the investigation of possible subtypes of DCD.29 In future studies demonstrating comparable patterns of difficulties in ADL performance, learning, or participation in larger groups of children with DCD, the specific impairments of children in these subgroups may be explored.
Third, the relationship among the aspects of performance, learning, and participation was explored. Delays in learning of ADL were hypothesized to predict poor performance of ADL. In children with DCD, delays in learning were found to be a predictor of poor performance. This is an excellent starting point for assessment, as early recognition of delays in learning may support intervention to prevent performance difficulties. This finding is important, as children's further motor development is challenged when their performance lags behind because of delays in learning of ADL.4,23 In the control group, learning was not found to predict performance, likely due to the small variation in total learning scores.
Participation was hypothesized to predict performance because performance may fall behind when children do not practice certain ADL as often as their peers.23,24,26 In the control group, more frequent participation was associated with better performance of ADL. In the DCD group, however, this was not the case. Apparently, the relatively poor performance of children with DCD was not due to less frequent participation in these ADL compared with peers. Indeed, for 17 out of the 23 ADL included, parents rated their children to participate as often as peers. For these children, a lack of practice does not explain their poor ADL performance. Thus, in order to improve their ADL performance, more is needed than practice alone (ie, task-specific interventions, which were found effective in improving children's performance).6,30 During task-specific interventions, poor muscle strength, coordination, and balance are trained as part of the daily tasks with which children experience problems.
Performance of ADL was hypothesized to predict participation in ADL, as poor performance in specific ADL might lead to avoidance or adaptations as described above.4,23,24,26 This hypothesis was confirmed in both children with DCD and their peers with typical development and suggests that intervention aimed to improve performance of ADL also reinforces children's participation in ADL. It is worthwhile to evaluate this hypothesis in future research, as more frequent participation may support prevention or limitation of secondary consequences such as low self-esteem and social exclusion.4,23,26
A final interesting difference was found between the DCD and the control group in the performance difficulty per item. For example, compared with children in the control group, children with DCD showed relatively good performance on pouring a drink and putting on socks and relatively poor performance on handling a key or cutting paper with scissors. Further investigation of these differences in item difficulty is recommended to gain more insight into the impact of DCD on children's daily functioning.
Limitations
One limitation of this study was the use of a questionnaire, which is a subjective form of assessment. However, parental questionnaires do provide a valuable source of information,31 as they provide a long-term perspective instead of results of specific moments of testing. Second, although the clinical sample used in the study is promising, it must be noted that this study comprises data on performance, learning, and participation of only 25 children with DCD. Furthermore, only 4 girls were included, but this represents the male:female ratio in the DCD population.32 In future studies, we recommend assessing a larger sample in order to investigate possible differences between groups of age and sex. Finally, considering this small sample size, no Bonferroni correction was applied to the large number of comparisons of the DCDDaily-Q mean item scores (ie, 3 subscales × 23 questions).
Children with DCD in this study demonstrated poor performance of ADL, delays in learning of ADL, and less frequent participation in some ADL compared with peers with typical development. These difficulties in daily functioning clearly indicate the impact of the disorder on these children's daily lives. Furthermore, heterogeneous patterns were found in children with DCD for performance and learning of ADL, which stresses the need for tailored intervention. Finally, in children with DCD, learning was found to predict performance of ADL, and performance was found to predict participation in ADL. It is of worth to evaluate these findings in future research, as these findings suggest that early recognition of delays in learning might help clinicians in preventing or limiting performance difficulties in children with DCD.
Appendix.
Example and General Explanation for the Questions in the DCDDaily-Qa
a The complete DCDDaily-Q (in Dutch or English) is available on request from the authors.
Footnotes
Dr Van der Linde, Dr van Netten, and Dr Shoemaker provided concept/idea/research design and writing. Dr Van der Linde provided data collection. Dr Van der Linde, Dr van Netten, Dr Geuze, and Dr Shoemaker provided data analysis. Dr Van der Linde, Professor Otten, Professor Postema, and Dr Shoemaker provided project management. Professor Postema and Dr Shoemaker provided fund procurement. Dr Shoemaker provided facilities/equipment. Professor Otten, Professor Postema, Dr Geuze, and Dr Shoemaker provided consultation (including review of manuscript before submission).
The authors gratefully acknowledge the valuable contribution of children and parents who participated in the study; teachers, clinicians, and students involved in the data collection; and Fonds NutsOhra for financial support of the project.
This study was approved by the Medical Ethics Committee of the University Medical Center Groningen, the Netherlands.
- Received May 12, 2014.
- Accepted May 21, 2015.
- © 2015 American Physical Therapy Association
References
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