Psychological distress in children with developmental coordination disorder and attention-deficit hyperactivity disorder

Highlights

• Children with motor coordination difficulties identified through a comprehensive population-based screening process experience more psychological distress than do their peers.

• Children who have both motor coordination and attention difficulties are at particularly heightened risk for clinically significant levels of depression and anxiety.

• Findings are consistent with previous population-based and clinically referred samples of children.

Abstract

This study explored whether or not a population-based sample of children with developmental coordination disorder (DCD), with and without comorbid attention deficit/hyperactivity disorder (ADHD), experienced higher levels of psychological distress than their peers. A two-stage procedure was used to identify 244 children: 68 with DCD only, 54 with ADHD only, 31 with comorbid DCD and ADHD, and 91 randomly selected typically developing (TD) children. Symptoms of depression and anxiety were measured by child and parent report. Child sex and caregiver ethnicity differed across groups, with a higher ratio of boys to girls in the ADHD only group and a slightly higher proportion of non-Caucasian caregivers in the TD group. After controlling for age, sex, and caregiver ethnicity, there was significant variation across groups in both anxiety (by parent report, F(3,235) = 8.9, p < 0.001; by child report, F(3,236) = 5.6, p = 0.001) and depression (parent report, F(3,236) = 23.7, p < 0.001; child report, F(3,238) = 9.9, p < 0.001). In general, children in all three disorder groups had significantly higher levels of symptoms than TD children, but most pairwise differences among those three groups were not significant. The one exception was the higher level of depressive symptoms noted by parent report in the ADHD/DCD group. In conclusion, children identified on the basis of motor coordination problems through a population-based screen showed significantly more symptoms of depression and anxiety than typically developing children. Children who have both DCD and ADHD are particularly at heightened risk of psychological distress.

Introduction

Developmental coordination disorder (DCD) is a neuro-developmental condition that impacts a child's ability to perform everyday tasks in self-care and academics. Prevalence estimates of 2 to 5% suggest that it is a common condition (American Psychiatric Association, 2000, Kadesjo and Gillberg, 1999, Lingam et al., 2009). Children with DCD have trouble performing everyday activities such as printing, using scissors, doing up buttons or zippers, opening juice-boxes, putting things in their knapsack, and climbing stairs (Missiuna et al., 2007, Summers et al., 2008, Wang et al., 2009). Parents often notice that something is wrong when their child is young but children usually are not referred for help until they begin to struggle at school. Most of these children are never recognized or diagnosed as having DCD (Gaines et al., 2008, Missiuna et al., 2006b). There is now strong scientific evidence that DCD is a chronic physical health condition, with motor problems persisting through childhood (Cantell and Kooistra, 2002, Losse et al., 1991), adolescence (Cantell, Smyth, & Ahonen, 2003), and into adulthood (Cousins and Smyth, 2003, Drew, 2005, Fitzpatrick and Watkinson, 2003, Kirby et al., 2011, Missiuna et al., 2008). More importantly, studies in the last two decades have shown that motor difficulties are frequently associated with mental health concerns (Gaines et al., 2008, Missiuna et al., 2008).

Children with DCD are socially isolated (Poulsen, Ziviani, Johnson, & Cuskelly, 2008), sedentary children who are at increased risk of obesity (Cairney et al., 2005, Cairney et al., 2010a, Schott et al., 2007). They frequently have attentional difficulties (Dewey et al., 2002, Querne et al., 2008), and may be over-represented within high school dropouts (Cantell, Smyth, & Ahonen, 1994) and adult mental health clinics (Drew, 2005, Rasmussen and Gillberg, 2000). Empirical evidence directly examining the co-occurrence of motor co-ordination difficulties and depression is growing (Campbell et al., 2012, Gillberg and Gillberg, 1989, Pearsall-Jones et al., 2011, Piek et al., 2007b). Indeed, there is good reason to believe that by late childhood and adolescence these health conditions are quite likely to co-occur (Cairney et al., 2010b, Gillberg and Gillberg, 1989, Kashani et al., 1987, Piek et al., 1999, Piek et al., 2007b). For example, many of the social consequences associated with DCD are known risk factors for depression, including: withdrawal from participation in physical activity (Cairney et al., 2010c, Missiuna et al., 2008, Poulsen et al., 2007a, Poulsen et al., 2007b, Poulsen et al., 2008); inadequate motor performance and reduced social acceptance by peers (Dunford et al., 2005, Poulsen and Ziviani, 2004); fewer social contacts and friendships (Cairney et al., 2006, Causgrove Dunn and Dunn, 2006, Dewey et al., 2002, Pellegrini, 1995, Poulsen et al., 2008, Watkinson et al., 2001, Wrotniak et al., 2006); poor social skills (Tseng, Howe, Chuang, & Hsieh, 2007); increased social exclusion and risk of being bullied (Campbell et al., 2012, Chen and Cohn, 2003, Piek et al., 2005, Poulsen et al., 2007a, Poulsen and Ziviani, 2004, Schoemaker and Kalverboer, 1994, Smyth and Anderson, 2000); decreased self-esteem and perception of competence (Cairney et al., 2006, Cantell et al., 2003, Missiuna et al., 2007, Piek et al., 2005, Piek et al., 2006, Schoemaker and Kalverboer, 1994); and generalized vulnerability resulting from atypical brain development (Kaplan et al., 2006, Visser, 2003).

Children with DCD also have been shown to have higher levels of anxiety than children without the disorder (Hellgren et al., 1994, Kristensen and Torgersen, 2008, Rasmussen and Gillberg, 2000). Links have been demonstrated between children's perceptions of physical competence and low self-worth (Cairney et al., 2006, Schoemaker and Kalverboer, 1994, Sigurdsson et al., 2002). In turn, a connection between these perceptions and anxiety has been suggested with anxiety shown to increase with age (McCarty et al., 2007, Sigurdsson et al., 2002, Skinner and Piek, 2001). Retrospectively, adults with DCD have described the anxiousness that they felt about their movement problems in settings such as physical education and recess (Fitzpatrick & Watkinson, 2003). In particular, adults with DCD and parents of children with DCD describe school anxiety, social anxiety, and physical symptoms of anxiety such as heart palpitations (Fitzpatrick and Watkinson, 2003, Missiuna et al., 2007). Fear of failure, ridicule, and embarrassment among children with DCD are beginning to be studied (Grills and Ollendick, 2002, Piek et al., 2005), but age effects and the manner in which this impacts on their mental health is unknown.

The co-morbidity between DCD and ADHD is very high (Cruddace and Riddell, 2006, Iwanaga et al., 2006, Kaplan et al., 2006, Piek et al., 2007b, Piek et al., 2007a, Tseng et al., 2007). Indeed, multiple authors have concluded that “pure” ADHD is the exception rather than the rule (Dewey et al., 2002, Hamilton, 2002, Missiuna et al., 2006a). They urge practitioners to evaluate all children who present with attention problems for signs of motor impairment because the motor difficulties are often overlooked. Studies of population-based and clinically referred samples of children with ADHD have established prevalence estimates as high as 50% for DCD (Dewey et al., 2002, Fliers et al., 2008, Fliers et al., 2009a, Martin et al., 2006). Thus, it is of great concern that the presence of both ADHD and DCD has been found to be an early predictor of poor mental health outcomes in adulthood (Rasmussen & Gillberg, 2000). Specifically, children who have both ADHD and DCD have more mental health problems than children with ADHD only (Martin et al., 2006, Rasmussen and Gillberg, 2000). This includes more cases of depression (Piek, Rigoli, et al., 2007), depression as a comorbidity in children with ADHD (Biederman et al., 2008, Daviss, 2008, Daviss et al., 2009), other psychiatric disorders (Hellgren et al., 1994) and an increased requirement for services (Tervo et al., 2002, Tseng et al., 2007).

Yet even though the overlap between ADHD and DCD is significant, it is far from complete (Dewey et al., 2002, Fliers et al., 2008, Fliers et al., 2009b, Kadesjo and Gillberg, 1998, Piek et al., 2007b). Moreover, unlike ADHD, most children with DCD are never diagnosed (Gaines et al., 2008, Missiuna et al., 2006a). Consequently, it is a significant concern that large numbers of children with motor coordination impairments may be struggling with mental health issues and/or psychological distress without any recognition of their difficulties. Indeed, we know of no study in the published literature that has simultaneously examined depression and anxiety in children with DCD only, ADHD only, and comorbid DCD and ADHD using a large, population-based sample in which motor coordination difficulties were assessed comprehensively. Therefore, the primary objective of this study was to determine if symptoms of depression and anxiety, referred to collectively as psychological distress, were greater among a population-based sample of children with motor and/or attentional difficulties. We hypothesized that children with DCD are at greater risk for psychological distress than their peers. Further, we predicted that the presence of ADHD would increase the risk of psychological distress in children with DCD, and that this pattern would differ from that of children with ADHD only and from typically developing children.