Quality of life domains affected in children with developmental coordination disorder: a systematic review

Authors


Abstract

The quality of life (QOL) of children with developmental coordination disorder (DCD) is largely unknown, but evidence suggests that multiple QOL domains are affected by the disorder. While DCD is primarily considered a motor disorder, multiple studies have reported psychological and social concerns in children with this condition. Our primary aim was to present the current state of the evidence regarding the physical, psychological, and social QOL domains that can be affected in children with DCD. Systematic review of articles from seven databases through November 2010 (MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, CDSR, DARE) was conducted. Search terms included developmental coordination disorder, dyspraxia, quality of life, life satisfaction, well-being, activities of daily living, and participation. Two independent reviewers screened titles, abstracts, and full-text articles. Studies meeting the following criteria were selected: (1) sample comprised solely of individuals with coordination difficulties consistent with DCD; (2) outcome measures related to physical, psychological, or socials domains of QOL; and (3) articles published in English. Data were extracted by one author and verified by a second. Outcomes were categorized according to physical, psychological and social domains of QOL and study quality was rated by case definitions of DCD based on diagnostic criteria as per the Diagnostic and Statistical Manual – 4th edition. Forty-one articles were included. Most studies reported significantly poorer results in physical, psychological and social functioning in children with DCD compared with peers. Despite the impact of DCD on multiple domains, only one study used a QOL measure as an outcome. Although DCD impacts several QOL domains, the QOL of children with this disorder remains largely unknown. The next critical step is for clinicians and researchers to use QOL measures to gather information on how DCD may affect the QOL of children with this disorder.

Introduction

Developmental coordination disorder (DCD) is a condition characterized by marked impairment of motor coordination that substantially interferes with an individual's academic achievement and/or activities of daily living [American Psychiatric Association (APA) 2000]. With a prevalence of 5–6% of children aged 5–11 years (APA 2000), DCD is one of the most common disorders affecting school-aged children (Wann 2007). Children with DCD experience numerous functional difficulties related to their motor incoordination. These problems can include difficulty with dressing, tying shoes, using utensils, riding a bike, catching a ball, handwriting, physical education, play skills, and engagement in leisure activities (Polatajko & Cantin 2005; Missiuna et al. 2006). While it was once believed that children with DCD would outgrow their motor difficulties, evidence suggests that these difficulties persist into adolescence and adulthood (Cantell et al. 1994; Cousins & Smyth 2003).

Because DCD can have profound effects on a number of aspects of children's lives, there is good reason to suspect that the condition will also affect their quality of life (QOL). To date, only one study has examined QOL of children with DCD. This study showed that children with DCD and comorbid attention deficit hyperactivity disorder (ADHD) have significantly lower QOL than typically developing children (Flapper & Schoemaker 2008). While QOL is generally conceptualized as a multidimensional construct encompassing the three broad domains of physical, psychological and social health (Rajmil et al. 2004; PROMIS Health Ogranization & PROMIS Cooperative Group 2011), how these domains are affected in children with DCD has not been systematically explored.

Consequently, our team synthesized the existing literature in seeking to answer the following question: In children and youth with DCD, what aspects of QOL are compromised by their condition? Our primary aim was to present the current state of the evidence regarding the physical, psychological and social QOL domains that can be affected in children with DCD. By achieving this goal, we hope to increase awareness that DCD affects more than the motor domain and that there is a need to examine how QOL of children with this disorder may be impacted.

Methods

Literature search and data sources

We conducted an electronic search from the inception of each of the following nine databases to 2008: MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, CDSR, DARE, PEDro and OTDbase. We then updated the search to November 2010, excluding PEDro and OTDbase because these databases yielded few original articles in the first search. We developed an extensive list of search terms related to DCD and QOL domains for each database, resulting in a large number of titles identified (see Appendix I for search terms for MEDLINE; search terms for other databases are available upon request). We used the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) Statement to guide our methodology and reporting (Liberati et al. 2009).

Study selection

Titles of search results were independently reviewed by two authors (JGZ and SRH). If either reviewer deemed the title relevant to the systematic review, the citation proceeded to abstract review. The same two reviewers independently screened abstracts and resolved disagreements by consensus. Full-texts of all potentially relevant papers were obtained and examined independently: the first author (JGZ) reviewed all articles, with 75% and 25% reviewed by each of the co-authors (SRH and AFK respectively). Articles were selected using the following inclusion criteria: (1) the sample was comprised solely of children, adolescents or young adults with motor coordination difficulties consistent with DCD; (2) outcome measures were related to physical, psychological or social domains of QOL; and (3) article was published in English. We excluded articles that were not peer-reviewed (e.g. dissertations) or did not report primary data (e.g. review articles, commentaries).

Quality assessment

To be comprehensive in our review, we did not exclude any study designs, except for one case study. In particular, we sought to include both quantitative and qualitative data to answer our research question. As a result, we could not assess study quality by using the same quality assessment tool for each study. Given the nature of our review and the variability in how DCD was defined, we determined study quality by assessing how closely the cases of DCD were defined based on the four diagnostic criteria from the Diagnostic and Statistical Manual – 4th edition (APA 2000):

  • A Performance in daily activities that require motor coordination is substantially below that expected given the person's chronological age and measured intelligence. This may be manifested by marked delays in achieving motor milestones (e.g. walking, crawling, sitting), dropping things, ‘clumsiness’, poor performance in sports, or poor handwriting.
  • B The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living.
  • C The disturbance is not because of a general medical condition (e.g. cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet the criteria for a Pervasive Developmental Disorder.
  • D If mental retardation is present, the motor difficulties are in excess of those usually associated with it.

Studies received a score of 4 if all diagnostic criteria were met by: (1) reporting a measure a motor impairment; (2) documenting the impact of the motor problems on activities of daily living; (3) excluding children with other neurological conditions, such as cerebral palsy or autism spectrum disorder; and (4) considering the child's intelligence, by either obtaining an intelligence quotient or excluding children with developmental delay. A score of 3 was given if studies met three of these criteria, a score of 2 if two criteria were met, and a score of 1 if only a measure of motor impairment was used to define DCD (Table 1). Studies with scores of 4 were considered to be of high quality. A score of 3 represented studies of moderate quality, whereas studies rated with scores of 1 or 2 were considered low quality. Study results are presented by study quality ratings within each QOL domain and measure (Table 3).

Table 1. Study quality based on case definitions of developmental coordination disorder using DSM-IV diagnostic criteria
Reference Measure of motor impairment Impact on ADL Excluded other neurological diagnoses Consideration of IQ Study quality *
  • %ile, percentile; BAS, British Ability Scale; BOTMP, Bruininks-Oseretsky Test of Motor Proficiency; BOTMP-BC, Bruininks-Oseretsky Test of Motor Proficiency – Battery Composite; BOTMP-FM, Bruininks-Oseretsky Test of Motor Proficiency – Fine Motor Composite; BOTMP-GM, Bruininks-Oseretsky Test of Motor Proficiency – Gross Motor Composite; BOTMP-SF, Bruininks-Oseretsky Test of Motor Proficiency – Short Form; BPVS, British Picture Vocabulary Scale; C, clinical sample; CPM-C, Colored Progressive Matrices – Chinese version; DAMP, deficits in attention, motor control, and perception; DCDQ, Developmental Coordination Disorder Questionnaire; DCDQ-C, Developmental Coordination Disorder Questionnaire – Chinese version; DSM-IV, Diagnostic and Statistical Manual – 4th edition; DTVMI, Developmental Test of Visual Motor Integration; Dx, diagnosis; FSIQ, full-scale intelligence quotient; IQ, intelligence quotient; KBIT, Kaufman Brief Intelligence Test; LD, learning disability; MABC, Movement Assessment Battery for Children; MAND, McCarron Assessment of Neuromuscular Development; MR, mental retardation; NDPA, Neuro-developmental Physiotherapy Assessment; NR, not reported; P, population-based sample; PEGS, Perceived Efficacy and Goal-Setting; SIT-R3, Slosson Intelligence Screening Test – Revised 3; TOMI, Test of Motor Impairment; WASI, Wechsler Abbreviated Scale of Intelligence; WISC-III, Wechsler Intelligence Scale for Children – 3rd edition; WISC-R, Wechsler Intelligence Scale for Children – Revised, Dutch version; WPPSI-R, Wechsler Preschool and Primary Scale of Intelligence – Revised.

  • *

    Study quality is based case definitions of DCD using the 4 diagnostic criteria outlined in the Diagnostic and Statistical Manual – 4th edition. Studies received the highest score of 4 if all diagnostic criteria were met, a score of 3 if three criteria were met, and so on.

Cairney et al. (2005)BOTMP-SF ≤10th %ileNoYesLD excluded3
Cairney et al. (2010)BOTMP-SF ≤5th %ileNoYesLD excluded3
Chen et al. (2009)BOTMP <16th %ile or MABC ≤15th %ileDCDQ-C <10th %ileYesCPM-C >10th %ile4
Christiansen (2000)DAMP DxDAMP DxYesDAMP Dx4
Cocks et al. (2009)MABC ≤15th %ileParent & teacher questionnaireYesNone in special classes or schools for intellectual disability4
Dewey et al. (2002)DCD ≤10th %ile on ≥2 of 6 measures: BOTMP-GM, BOTMP-FM, BOTMP-BC, BOTMP-SF, MABC, DCDQ; sDCD ≥11th %ile but <25th %ile on ≥2 of 6 measures, or ≤10th %ile on 1/6 and ≥11th %ile but <25th %ile on 1/6 measuresDCDQ ≤10th %ile for only some of sampleYesFSIQ >753
Dunford et al. (2005)MABC <15th %ilePEGSYesVerbal IQ or cognitive ability within 1 SD of norm4
Engel-Yeger & Hanna Kasis (2010)DCD Dx; MABC <15th %ileDCD DxYesDCD Dx4
PEGS
Flapper & Schoemaker (2008)DCD Dx; MABC <5th %ileDCD DxYesWISC-R >704
Green et al. (2006)MABC <15th %ileDCDQ <15th %ileYesBPVS ≥704
Heath et al. (2005)MABC <15th %ileNoNoWASI (mean IQ in average range)2
Kanioglou et al. (2005)DCD: MABC <5th %ile; sDCD: MABC <15th %ileNoImplied: all were healthy and attended typical school and physical education classesImplied: all attended typical school classes3
Lingam et al. (2010)≤15th %ile on 3 subtests of MABCFailed National Curriculum Key Stage 1 writing test or ADL scale <15th %ileYesWISC-III >704
Losse et al. (1991)TOMINoNoWISC-R (mean verbal IQ for DCD group in average range)2
Mæland (1992)TOMINoNoNo1
Mandich et al. (2003)Met DSM-IV criteriaMet DSM-IV criteriaMet DSM-IV criteriaMet DSM-IV criteria4
McWilliams (2005)MABC ≤15th %ileNoNoNo1
Missiuna et al. (2007)MABC <15th %ileYesYesKBIT >854
Missiuna et al. (2008)NoDCDQ and client reportYes, as per client reportYes, as per client report3
Piek et al. (2000)MABC ≤15th %ileNoNoWISC-III ≥802
Piek et al. (2005)MAND <85NoYesWISC-III ≥803
Piek et al. (2007)NoDCDQ ≤63 (using calculated cut-offs from distribution of scores)NoNo1
Piek et al. (2008)MAND ≤85NoYesWPPSI-R >703
Pless et al. (2001)MABC ≤15th %ileMet DSM-IV criteriaYesNone in classes for children with MR4
Poulsen et al. (2006)Severe DCD: <5th %ile; Moderate DCD: MABC ≥5th %ile but <15th %ileParent reportYesSIT-R3 ≥804
Poulsen et al. (2007a)Severe DCD: <5th %ile; Moderate DCD: MABC ≥5th %ile but <15th %ileParent reportYesSIT-R3 ≥804
Poulsen et al. (2007b)Severe DCD: <5th %ile; Moderate DCD: MABC ≥5th %ile but <15th %ileParent reportYesSIT-R3 ≥804
Poulsen et al. (2008)Severe DCD: <5th %ile; Moderate DCD: MABC ≥5th %ile but <15th %ileParent reportYesSIT-R3 ≥804
Rodger et al. (2003)MABC ≤15th %ileNoNo known sensory, motor, or neurological impairmentNo known intellectual impairment3
Rodger et al. (2007)MABC ≤15th %ile; NDPAParent reportNo known sensory, motor, or neurological impairmentNo known intellectual impairment4
Schoemaker & Kalverboer (1994)TOMI ≤5th %ileNoYesAll from mainstream schools; IQ assumed to be in normal range3
Segal et al. (2002)DCD DxDCD DxDCD DxDCD Dx4
Skinner & Piek (2001)MABC <15th %ileNoNoWISC-III ≥802
Smyth & Anderson (2000)MABC ≤15th %ileNoExcluded global developmental delayBAS3
Stephenson & Chesson (2008)DCD DxDCD DxDCD DxDCD Dx4
Summers et al. (2008a)<1 SD on at least one of the following measures: MAND, DTVMI, BOTMP, MABCNot as part of inclusion criteriaYesNo2
Summers et al. (2008b)<1 SD on at least one of the following measures: MAND, DTVMI, BOTMP, MABCNot as part of inclusion criteriaYesNo2
Tsang et al. (2010)MABC <5th %ileNoNo known sensory, motor, or neurological impairmentNo known intellectual impairment3
Tseng et al. (2007)DCD: MABC ≤5th %ile or ≤4th %ile on one of BOTMP-GM, BOTMP-FM, or BOTMP-BC; sDCD: MABC ≤15th %ile or ≤22nd %ile on one of BOTMP-GM, BOTMP-FM, or BOTMP-BCDCDQ-C ≤10th %ileYesNo3
Wang et al. (2009)DCD: MABC ≤5th %ile or ≤4th %ile on one of BOTMP-GM, BOTMP-FM, or BOTMP-BC; sDCD: MABC ≤15th %ile or ≤22nd %ile on one of BOTMP-GM, BOTMP-FM, or BOTMP-BCDCD: DCDQ-C ≤10th %ileNoAverage to above average IQ on CPM-C3
sDCD: DCDQ-C ≤25th %ile
Watson & Knott (2006)DCD DxDCD Dx; school and parent questionnairesDCD DxDCD Dx; Excluded children with intellectual disability4
MABC

Data extraction and analysis

The first author (JGZ) extracted the following information from each article: study design, sample source (population-based or clinical sample), case definitions of DCD, mean age or age range of participants in DCD and control groups, outcome measures relevant to QOL, variables measured, and results by group. A co-author (SRH) verified the extracted data. Given the heterogeneity of research designs and outcomes (Tables 2 & 3), we did not complete a meta-analysis; rather, results were synthesized across QOL domains to provide an overview of how DCD might affect the QOL of children with this condition. Results of quantitative studies with a control group of typically developing children are presented in Table 3; outcomes of other quantitative studies and those qualitative in design are reported only in the text. We analysed inter-rater agreement for abstract and full-text screening using the kappa statistic (Cohen 1968).

Table 2. Characteristics of included studies
Reference Study design Sample DCD group Control group Comorbidities
n Mean age (SD) n Mean age (SD)
  • ADHD, attention deficit hyperactivity disorder; C, clinical sample; CS, cross-sectional; D, descriptive; DAMP, deficits in attention, motor control and perception; DBPC, double-blind placebo-controlled; DCD, developmental coordination disorder; EBD, emotional/behavioral difficulties; LD, learning disability; mo, months; nDCD, non-developmental coordination disorder; NR, not reported; P, population-based sample; Qual, qualitative; sDCD, suspect developmental coordination disorder; y, years.

  • *

    Age for total sample.

  • Medium coordination defined as greater than or equal to the 15th percentile but less than 50th percentile on the Movement Assessment Battery for Children.

  • High coordination is defined as greater than or equal to the 50th percentile on the Movement Assessment Battery for Children.

Cairney et al. (2005)CSP4411.46 y (1.46)*54211.46 y (1.46)*NR
Cairney et al. (2010)CohortP100–1039 y 11 mo (5 mo)–11 y 11 mo (4 mo)*19729 y 11 mo (5 mo)–11 y 11 mo (4 mo)*NR
Chen et al. (2009)CSP1447.74 y (0.81)*1267.74 y (0.81)*NR
Christiansen (2000)CohortC10 DAMP11.8 y (0.43)2011.37 y (0.37)10/10 had deficits in attention and perception
Cocks et al. (2009)CSC309.5 y (1.4)Normative data (n= 1971) 14/30 (47%) had ADHD
Dewey et al. (2002)CSP45 DCD11.8 y (1.9)7811.4 y (2.0)Attention and learning difficulties included
51 sDCD11.2 y (1.7)
Dunford et al. (2005)DC35 parents7 y 11 mo (1.68)NR
34 teachers
Engel-Yeger & Hanna Kasis (2010)DC377.57 y (1.05)*377.57 y (1.05)*NR
Flapper & Schoemaker (2008)DBPCC23 DCD + ADHD8 y 6 mo (3 mo)23Matched for age23/23 had ADHD
Green et al. (2006)CSC4796.5 mo (range 64–128 mo)NR
Heath et al. (2005)CSP15 DCD + EBD107.47 mo (21.67)15 EBD102.93 mo (18.96)Emotional and behavioural difficulties included
Kanioglou et al. (2005)CSP10 DCD10.9 y (0.7)*12810.9 y (0.7)*Attention difficulties included
16 sDCD
Lingam et al. (2010)CohortP346Range 7–9 y*6556Range 7–9 y*Attention, language, and learning difficulties included
Losse et al. (1991)CohortC15Range 15 y 1 mo–17 y 4 mo*15Range 15 y 1 mo–17 y 4 mo*NR
Mæland (1992)CSP1910 y*1910 y*NR
Mandich et al. (2003)QualC10 (12 parents)Range 7–12 yNR
McWilliams (2005)Mixed methodC12Range 6 y 3 mo–11 y 1 moNR
Missiuna et al. (2007)QualC13 parentsRange 6–14 yNR
Missiuna et al. (2008)QualP9Range 19–25 yNR
Piek et al. (2000)CSC36127.30 mo (8.81)36126.25 mo (10.88)NR
Piek et al. (2005)CSP20 girls; 23 boys9.15 y (0.82)20 girls; 23 boys9.17 y (0.80)NR
Piek et al. (2007)CSC92 DCD (twin A)12.26 y (3.65)145 Control A14.68 y (2.71)ADHD included
33 DCD + ADHD (A)12.85 y (3.45)   
100 DCD (twin B)12.12 y (3.55)134 Control B14.67 y (2.45) 
36 DCD + ADHD (B)13.28 y (3.76)   
24 DCD twins11.91 yr (3.57)24 nDCD twins11.91 y (3.57) 
Piek et al. (2008)CSP404 y 4 mo (0.33)Normative data NR
Pless et al. (2001)CS/RCTC375 y 11 mo (4.36 mo)605 y 8 mo (2.34 mo)NR
Poulsen et al. (2006)DP/C27 severe DCD10–13 y*41 medium coord10–13 y*No parent-reported ADHD
33 moderate DCD 72 high coord  
Poulsen et al. (2007a)DP/C27 severe DCD11 y 7 mo (9.7 mo)41 medium coord11 y 9 mo (9.3 mo)No parent-reported ADHD
33 moderate DCD72 high coord
Poulsen et al. (2007b)DP/C27 severe DCD11 y 7 mo (9.7 mo)41 medium coord11 y 9 mo (9.3 mo)No parent-reported ADHD
33 moderate DCD72 high coord
Poulsen et al. (2008)DP/C5911 y 7 mo (9.7 mo)10611 y 9 mo (9.3 mo)No parent-reported ADHD
Rodger et al. (2003)CSC2069 mo (12 mo)NR
Rodger et al. (2007)CSC6072.9 mo (11.7)NR
Schoemaker & Kalverboer (1994)CSP187 y 4 mo (Range 6.1–9.0 y)187 y 4 mo (Range 6.1–9.0 y)NR
Segal et al. (2002)QualC6 (8 parents)Range 9–11 y5/6 children had comorbid conditions
Skinner & Piek (2001)CSP58Range 8–10 y58Range 8–10 yNR
51Range 12–14 y51Range 12–14 y
Smyth & Anderson (2000)CSP55Range 6–10 y55Range 6–10 yAsperger's and ADHD excluded
Stephenson & Chesson (2008)Case studyC35 parents; 12 interviewsRange 10–20 y4/12 (33%) children had other primary diagnosis
Summers et al. (2008a)QualC38Range 5–9 y*49Range 5–9 y*Language and learning difficulties included; Asperger's and ADHD excluded
Summers et al. (2008b)QualC38Range 5–9 y*49Range 5–9 y*Language and learning difficulties included; Asperger's and ADHD excluded
Tsang et al. (2010)PsychometricP19Range 5–8 y*293Range 5–8 y*ADHD excluded
Tseng et al. (2007)CSP38 DCD8.2 y (1.0)827.8 y (0.71)NR
32 sDCD7.8 y (0.89)
Wang et al. (2009)CSP16 DCD8 y 0 mo (9 mo)637 y 10 mo (9 mo)NR
25 sDCD7 y 6 mo (10 mo)   
Watson & Knott (2006)CSC1510.2 y1510.2 yADHD and LD excluded
1510.3 y
Table 3. Study outcomes comparing children with DCD to TD children
QOL domains Study quality DCD significantly lower than TD No significant difference between DCD and TD DCD significantly higher than TD
  • ALRS, Activity Level Rating Scales for Parents; BASC, Behavior Assessment System for Children; BDM, Birleson Depression Measure; CAMP, Caregiver Assessment of Movement Participation; CBCL, Child Behavior Checklist; CSAPPA, Children's Self Perceptions of Adequacy in and Prediction for Physical Activity; CTQ, Conners' Teacher Questionnaire; DANA, Diagnostic Analysis of Nonverbal Accuracy; DAWBS, Development and Well-Being Assessment; DCD, developmental coordination disorder; DUX-25, Dutch-Child-AZL-TNO-Quality-of-Life Questionnaire; LSDS, Loneliness and Social Dissatisfaction Questionnaire; MPVS, Multidimensional Peer-Victimization Scale; mo, months; PAC, Preference for Activities of Children; PCSC, Perceived Competence Scale for Children; PDMS, Peabody Developmental Motor Scale; PEGS, Perceived Efficacy and Goal Setting; PMCS, Perceived Motor Competence Scale; PSQ, Perception of Success Questionnaire; SCDC, Social and Communication Disorders Checklist; SDQ, Self Description Questionnaire; SFA-C, School Function Assessment – Chinese version; SLSS, Students' Life Satisfaction Scale; SPPC, Self-Perception Profile for Children; SSS, Social Support Scale for Older Children and Adolescents; SSSC, Social Support Scale for Children; STAI, State-Trait Anxiety Inventory; TACQOL, TNO-AZL-Child-Quality-of-Life Questionnaire; TD, typically developing; UMESOL, Balloon- and Flag-Child Scale; VABS-C, Vineland Adaptive Behavior Scale – Chinese version; y, years.

  • *

    DCD as defined by authors of original article.

  • suspected DCD as defined by authors of original article.

  • DCD + ADHD as defined by authors of original article.

Physical domain    
 Gross motor skills    
  SFA-C: Travel3 Wang et al. (2009)* Wang et al. (2009) 
  SFA-C: Maintaining/changing positions3 Wang et al. (2009)*  
  SFA-C: Up-down stairs3 Wang et al. (2009)* Wang et al. (2009) 
  VABS-C: Gross motor3 Wang et al. (2009)*  
 Fine motor skills    
  SFA-C: Manipulation with movements3 Wang et al. (2009) Wang et al. (2009)* 
  SFA-C: Using materials3 Wang et al. (2009)*  
  SFA-C: Written work3 Wang et al. (2009)*  
  VABS-C: Fine motor3 Wang et al. (2009)*  
 Daily living skills    
  SFA-C: Setup and clean-up3 Wang et al. (2009) Wang et al. (2009)* 
  SFA-C: Eating and drinking3 Wang et al. (2009) Wang et al. (2009)* 
  VABS-C: Personal living scale3 Wang et al. (2009)*  
 Leisure activities    
  PAC: Preference for recreational, active physical, & skill-based activities4 Engel-Yeger & Hanna Kasis (2010)  
  Spare-time activities: Team sports4 Christiansen (2000)  
  7-day leisure diary (parents): # of structured physical-social activities and % of total leisure time (e.g. team sports)4 Poulsen et al. (2007b)*  
  12-mo retrospective leisure survey (parents): Team sports – sessions/week and # of activities4 Poulsen et al. (2007b)*  
  Spare-time activities: Individual sports, two-person sports, boy scouts4  Christiansen (2000) 
  7-day leisure diary (parents): Unstructured physical-social activities (e.g. street ball) and % of leisure time4 Poulsen et al. (2007b)*  
  7-day leisure diary (parents): Structured (e.g. gymnastics) and unstructured physical-nonsocial (e.g. swimming) activities and % of leisure time4  Poulsen et al. (2007b)*; Poulsen et al. (2008)* 
  12-mo retrospective leisure survey (parents): Structured physical-nonsocial activities – sessions/week and # of activities4  Poulsen et al. (2007b)* 
  LDB: Perceived freedom in leisure – total score4 Poulsen et al. (2007a)*  
  Previous Day Physical Activity Recall measure: Low intensity activities4   Poulsen et al. (2008)*
  Previous Day Physical Activity Recall measure: Moderate to vigorous intensity4 Poulsen et al. (2008)*  
  Participation questionnaire: Organized activities3 Cairney et al. (2005)  
3 Cairney et al. (2010)  
  Participation questionnaire: Free play3 Cairney et al. (2005)  
3 Cairney et al. (2010)  
  Participation questionnaire: Total score3 Cairney et al. (2010)  
  SFA-C: Recreational movement3 Wang et al. (2009)*  
  CAMP: Movement participation3   Tsang et al. (2010) (poorer performance)
Psychological domain    
 Self-concept/self-efficacy/competence    
  PEGS: Leisure4 Engel-Yeger & Hanna Kasis (2010)  
  CSAPPA: Generalized self-efficacy toward physical activity3 Cairney et al. (2005)  
  SDQ: Physical abilities4 Cocks et al. (2009); Poulsen et al. (2006)*  
  PMCS: Motor competence4  Pless et al. (2001) 
  SPPC: Athletic competence4 Watson & Knott (2006)  
2 Piek et al. (2000); Skinner & Piek (2001) Heath et al. (2005) 
  PCSC: Physical competence2 Losse et al. (1991)  
1  Mæland (1992) 
  SDQ: Physical appearance4 Poulsen et al. (2006)* Cocks et al. (2009) 
  SPPC: Physical appearance4  Watson & Knott (2006) 
2 Skinner & Piek (2001) Heath et al. (2005); Piek et al. (2000) 
  UMESOL: Self-perceived competence – school & peer relations4  Pless et al. (2001) 
  SDQ: Peer relations4 Cocks et al. (2009); Poulsen et al. (2006)*  
  SPPC: Social acceptance4  Watson & Knott (2006) 
2 Skinner & Piek (2001) (12–14 y) Heath et al. (2005); Piek et al. (2000); Skinner & Piek (2001) (8–10 y) 
  PCSC: Social competence3 Schoemaker & Kalverboer (1994)  
2 Losse et al. (1991)  
1  Mæland (1992) 
  SPPC: Close friendships2  Skinner & Piek (2001) 
  SPPC: Romantic appeal2  Skinner & Piek (2001) 
  CBCL: Sex problems3  Dewey et al. (2002)* 
  SDQ: Parent relations4 Cocks et al. (2009); Poulsen et al. (2006)*  
  SDQ: Reading4  Cocks et al. (2009); Poulsen et al. (2006)* 
  SDQ: Mathematics4  Cocks et al. (2009); Poulsen et al. (2006)* 
  SDQ: General school4  Cocks et al. (2009); Poulsen et al. (2006)* 
  SDQ: Total academic4  Cocks et al. (2009) 
  PEGS: School/productivity4 Engel-Yeger & Hanna Kasis (2010)  
  SPPC: Scholastic competence4 Watson & Knott (2006)  
2 Skinner & Piek (2001) (8–10 y) Heath et al. (2005); Piek et al. (2000); Skinner & Piek (2001) (12–14 y) 
  PCSC: Cognitive competence3 Schoemaker & Kalverboer (1994)  
2  Losse et al. (1991) 
1 Mæland (1992)  
  SPPC: Job competence2  Skinner & Piek (2001) 
  SDQ: General self-concept4 Poulsen et al. (2006)* Cocks et al. (2009) 
  SDQ: Total non-academic4 Cocks et al. (2009)  
  SDQ: Total self4  Cocks et al. (2009) 
  SPPC: Global self-worth4  Watson & Knott (2006) 
3  Piek et al. (2005) 
2 Heath et al. (2005); Skinner & Piek (2001) Piek et al. (2000) 
  PCSC: General competence2  Losse et al. (1991) 
1  Mæland (1992) 
  PCSC: Overall competence2 Losse et al. (1991)  
  PSQ: Task orientation4 Poulsen et al. (2006)*  
  PSQ: Ego orientation4  Poulsen et al. (2006)* 
  PACS: Preference for self-improvement activities4 Engel-Yeger & Hanna Kasis (2010)  
  PEGS: Self-care4 Engel-Yeger & Hanna Kasis (2010)  
 Anxiety/depression    
  BDM: Depressed mood4   Watson & Knott (2006)
  Depressive symptoms: ‘sad affect’3   Piek et al. (2005)*
  CBCL: Withdrawn4   Chen et al. (2009)
3   Dewey et al. (2002)*
3  Piek et al. (2008) Tseng et al. (2007)*
  CBCL: Somatic complaints4  Chen et al. (2009) 
3   Dewey et al. (2002)*
3  Tseng et al. (2007)* Tseng et al. (2007)
  CBCL: Anxious/depressed4   Chen et al. (2009)
3   Dewey et al. (2002)*
3  Piek et al. (2008) Tseng et al. (2007)*
  CTQ: Tension-anxiety3  Kanioglou et al. (2005) Kanioglou et al. (2005)*
  STAI: State anxiety3   Schoemaker & Kalverboer (1994)
2   Skinner & Piek (2001)
  STAI: Trait anxiety3   Schoemaker & Kalverboer (1994)
2   Skinner & Piek (2001)
  CBCL: Internalizing behaviour3   Dewey et al. (2002)*
3   Tseng et al. (2007)*
  BASC (parent): Internalizing behaviour2  Heath et al. (2005) 
  BASC (teacher): Internalizing behaviour2   Heath et al. (2005)
 Cognitive function    
  CBCL: Thought problems4   Chen et al. (2009)
3  Dewey et al. (2002)* 
3   Tseng et al. (2007)*
  CBCL: Attention problems4   Chen et al. (2009)
3   Dewey et al. (2002)*
3   Tseng et al. (2007)*
  CTQ: Inattentive-passive3   Kanioglou et al. (2005)*
 Behaviour    
  CBCL: Delinquent behaviour4   Chen et al. (2009)
3  Dewey et al. (2002)* 
3   Tseng et al. (2007)*
  CTQ: Conduct problems3  Kanioglou et al. (2005) Kanioglou et al. (2005)*
  CBCL: Aggressive behaviour4   Chen et al. (2009)
3   Dewey et al. (2002)*
3   Tseng et al. (2007)*
  CBCL: Externalizing behaviour3   Dewey et al. (2002)*
3   Tseng et al. (2007)*
  BASC (parent & teacher): Externalizing behaviour2  Heath et al. (2005) 
  DAWBS: Inattention or hyperactivity4   Lingam et al. (2010)
  ASQ: Hyperactivity questionnaire3   Dewey et al. (2002)*
  CTQ: Hyperactivity3  Kanioglou et al. (2005) Kanioglou et al. (2005)*
  ALRS: Activity level/hyperactivity3   Tseng et al. (2007)*
  SPPC: Behavioural conduct4  Watson & Knott (2006) 
2  Heath et al. (2005); Piek et al. (2000); Skinner & Piek (2001) 
  SPPC (parent & teacher): Behavioural symptoms2  Heath et al. (2005) 
  CBCL: Total score3   Tseng et al. (2007)*
 Miscellaneous    
  BASC (self): Clinical, school, or personal maladjustment2  Heath et al. (2005) 
  BASC (parent & teacher): School problems2  Heath et al. (2005) 
  BASC (parent): Adaptive skills2  Heath et al. (2005) 
  BASC (teacher): Adaptive skills2 Heath et al. (2005)  
Social domain    
 CBCL: Social problems4   Chen et al. (2009)
3   Dewey et al. (2002)*
3   Tseng et al. (2007)*
 Sociogram: Social acceptance3 Kanioglou et al. (2005) Kanioglou et al. (2005)* 
 Sociogram: Social rejection3  Kanioglou et al. (2005)* Kanioglou et al. (2005)
 Sociogram: Social preference3 Kanioglou et al. (2005) Kanioglou et al. (2005)* 
 Sociogram: Social impact3  Kanioglou et al. (2005)* 
 SSS: Approval, emotional & instrumental support2 Skinner & Piek (2001)  
 SSSC: Classmate, friend, parent & teacher support4  Watson & Knott (2006) 
2  Piek et al. (2000) 
 LSDS: Total loneliness score4   Poulsen et al. (2007b)*
 MPVS: Physical or verbal victimization, social manipulation, property attacks, total victim score3  Piek et al. (2005) 
 PAC: Preference for social activities4 Engel-Yeger & Hanna Kasis (2010)  
 7-day leisure diary (parents): # of structured (e.g. choir, chess club) & unstructured (e.g. computer with peers) social-nonphysical activities and % of total leisure time4  Poulsen et al. (2007b)*; Poulsen et al. (2008)* 
 12-mo retrospective leisure survey (parents): Structured social-nonphysical sessions/week4   Poulsen et al. (2007b)*
 12-mo retrospective leisure survey (parents): # of structured social-nonphysical activities4  Poulsen et al. (2007b)* 
 Playground observations: Time alone3   Smyth & Anderson (2000)
 Playground observations: Time in groups3 Smyth & Anderson (2000)  
 DANA: Non-verbal skills4   Lingam et al. (2010) (risk of difficulty)
 SCDC: Social and communication skills4   Lingam et al. (2010) (risk of difficulty)
Quality of life/life satisfaction    
 SLSS: Life satisfaction4 Poulsen et al. (2007a)*  
 DUX-25: Physical (child)4  Flapper & Schoemaker (2008) 
 DUX-25: Physical (parent)4 Flapper & Schoemaker (2008)  
 DUX-25: Home (child)4  Flapper & Schoemaker (2008) 
 DUX-25: Home (parent)4 Flapper & Schoemaker (2008)  
 DUX25: Emotional (child & parent)4 Flapper & Schoemaker (2008)  
 DUX25: Social (child & parent)4 Flapper & Schoemaker (2008)  
 DUX25: Total score4 Flapper & Schoemaker (2008)  
 TACQOL: Bodily (child & parent)4  Flapper & Schoemaker (2008) 
 TACQOL: Motor (child & parent)4 Flapper & Schoemaker (2008)  
 TACQOL: Autonomy (child & parent)4 Flapper & Schoemaker (2008)  
 TACQOL: Cognitive (child & parent)4 Flapper & Schoemaker (2008)  
 TACQOL: Social (child & parent)4 Flapper & Schoemaker (2008)  
 TACQOL: Positive moods (child & parent)4 Flapper & Schoemaker (2008)  
 TACQOL: Negative moods (child)4  Flapper & Schoemaker (2008) 
 TACQOL: Negative moods (parent)4 Flapper & Schoemaker (2008)  
 TACQOL: Total score (child & parent)4 Flapper & Schoemaker (2008)  

Results

Description of studies

A total of 41 studies were included in this systematic review (Fig. 1 & Table 2) (Losse et al. 1991; Mæland 1992; Schoemaker & Kalverboer 1994; Christiansen 2000; Piek et al. 2000, 2005, 2007, 2008; Smyth & Anderson 2000; Pless et al. 2001; Skinner & Piek 2001; Dewey et al. 2002; Segal et al. 2002; Mandich et al. 2003; Rodger et al. 2003, 2007; Cairney et al. 2005, 2010; Dunford et al. 2005; Heath et al. 2005; Kanioglou et al. 2005; McWilliams 2005; Green et al. 2006; Poulsen et al. 2006, 2007a,b, 2008; Watson & Knott 2006; Missiuna et al. 2007, 2008; Tseng et al. 2007; Flapper & Schoemaker 2008; Stephenson & Chesson 2008; Summers et al. 2008a,b; Chen et al. 2009; Cocks et al. 2009; Wang et al. 2009; Engel-Yeger & Hanna Kasis 2010; Lingam et al. 2010; Tsang et al. 2010). Inter-rater reliability for abstract screening was k= 0.71 (‘good’ agreement). Full-text inter-rater reliability ranged from k= 0.64 (‘good’ agreement between JGZ and AFK) and k= 0.81 (‘very good’ agreement between JGZ and SRH). Study designs included: cross-sectional (n= 21), descriptive (n= 6), qualitative (n= 6), cohort (n= 4), mixed methods (n= 1), psychometric (n= 1), case series (n= 1), and double-blind placebo-controlled trial (n= 1). Seventeen studies used a population-based sample, 20 used a clinical sample, and four were from a mixed (population-based/clinical) sample. Sample sizes varied greatly, from n= 6 in a qualitative study (Segal et al. 2002) to n= 346 children with DCD in a population-based cohort study (Lingam et al. 2010); most studies had a sample size between 20 and 50. The age of participants ranged from 4 years and 4 months to 20 years, with the majority of participants in the school-aged years.

Figure 1.

Flow of information through different phases of the systematic review. *Reviews, commentaries, letters to the editor, critically appraised papers, dissertations. †Duplicate data, no means reported. DCD, developmental coordination disorder; QOL, quality of life.

Results by quality of life domains

Physical domain

Given the nature of DCD, it is not surprising that children with this disorder experience substantial differences in the physical domain compared with typically developing children. As shown in Table 3, a population-based sample of children with DCD scored significantly lower on measures of gross motor skills compared with similar-aged peers; children with suspected DCD were also significantly different from control children on 2 of 4 gross motor measures in this moderate-quality study (Wang et al. 2009). Similarly, children with DCD and suspected DCD had significantly poorer fine motor skills than typically developing children on the majority of fine motor scores (Wang et al. 2009). In other studies of clinical samples of children with DCD, fine motor scores were not significantly different from test norms (Rodger et al. 2003) and were within the average range (Rodger et al. 2007). These studies were of moderate and high quality respectively.

Several high-quality qualitative studies (Mandich et al. 2003; Dunford et al. 2005; Missiuna et al. 2007; Stephenson &Chesson 2008) and one low-quality study (Summers et al. 2008a) of parents of children with DCD indicated that their child had difficulty with many daily activities because of their poor motor skills. Activities included difficulty with self-care, such as washing or combing hair, brushing teeth, wiping after toileting, manipulating clothes, managing buttons or zippers, and tying shoelaces. Children with DCD are also reported to have difficulty using a knife and fork in a coordinated manner, to be messy and slow at eating, and to prefer to eat with their fingers (Summers et al. 2008a). Interestingly, when compared with typically developing children, children with suspected DCD seemed to have more difficulty with eating and drinking than children with DCD (Wang et al. 2009).

Parents are also concerned about their child's lack of participation in sports and leisure pursuits, reporting that their child often avoids physical activities (Mandich et al. 2003; Dunford et al. 2005; Missiuna et al. 2007; Stephenson & Chesson 2008). Findings from these qualitative studies have been confirmed in several high-quality quantitative studies comparing leisure preferences and behaviour of children with and without DCD. Children with DCD show significantly less preference for recreational, active physical, and skill-based activities (Engel-Yeger & Hanna Kasis 2010) and spend significantly less time engaged in team sports compared with peers (Christiansen 2000; Poulsen et al. 2007b). Additional moderate-quality studies reported that children with DCD participate significantly less in organized activities, free play, and recreational activities (Cairney et al. 2005, 2010; Wang et al. 2009). However, children with DCD are similar to their peers in participation in individual sports and physical-nonsocial activities, such asgymnastics and swimming (Christiansen 2000; Poulsen et al. 2007b, 2008).

Psychological domain

A wealth of studies have explored the impact of DCD on psychological domains, including self-concept, self-efficacy, emotional health, cognitive function, and behaviour. Compared with typically developing children, studies consistently show that children with DCD have significantly lower self-efficacy in leisure and physical activities and significantly lower self-perceived competence in motor, physical and athletic skills (Losse et al. 1991; Piek et al. 2000; Skinner & Piek 2001; Cairney et al. 2005; Poulsen et al. 2006; Watson & Knott 2006; Cocks et al. 2009; Engel-Yeger & Hanna Kasis 2010); two exceptions are a study of preschool children (Pless et al. 2001) and two low-quality studies (Mæland 1992; Heath et al. 2005) that found no significant differences between children with and without DCD. Similarly, several studies reported significantly lower self-perceived competence in peer and social relations for children with DCD (Losse et al. 1991; Schoemaker & Kalverboer 1994; Poulsen et al. 2006; Cocks et al. 2009), except for a study of young children (Pless et al. 2001) and one that used only a measure of motor impairment to define their sample (Mæland 1992). Other than a population-based sample of teenaged children with DCD who perceived significantly less social acceptance than their peers (Skinner & Piek 2001), children with DCD generally do not differ from peers in terms of their perception of being socially accepted, having close friendships, or displaying romantic appeal (Piek et al. 2000; Skinner & Piek 2001; Heath et al. 2005). Two high-quality studies reported that, compared with typically developing children, children with DCD perceive significantly poorer relations with their parents (Poulsen et al. 2006; Cocks et al. 2009).

Perceived competence in school-related domains is variable across studies. While some studies suggest that children with DCD rate their scholastic and cognitive competence as significantly lower than control children (Schoemaker & Kalverboer 1994; Watson & Knott 2006; Engel-Yeger & Hanna Kasis 2010), other studies of lower quality report no differences between groups (Losse et al. 1991; Piek et al. 2000; Heath et al. 2005). Another study showed differences between age groups when compared with peers, with the younger group (8–10-year-olds) perceiving lower scholastic competence than older children with DCD. Although general school competence was inconsistent across studies, two high-quality studies found no differences between children with and without DCD in their perceived competence in specific school subjects, such as reading and math (Poulsen et al. 2006; Cocks et al. 2009).

In terms of overall self-worth, most studies found no significant difference between children with and without DCD (Piek et al. 2000, 2005; Watson & Knott 2006; Cocks et al. 2009); two lower-quality studies, one of which had children with comorbid emotional and behavioural difficulties, reported significantly lower self-worth in the DCD group (Skinner & Piek 2001; Heath et al. 2005). Mixed results were noted for general self-concept, with Cocks and colleagues (2009) reporting no difference between groups and Poulsen and colleagues (2006) indicating lower self-concept compared with peers for both moderate and severe DCD groups. Parents of children with DCD report concerns about their child's poor self-esteem (Mandich et al. 2003; Dunford et al. 2005; McWilliams 2005), likely because of a sense of failure in mastering everyday activities (Mandich et al. 2003).

Emotional health is an important aspect of concern within the psychological domain for children with DCD. In three studies that gathered information from parents of children with DCD, a very high proportion of parents reported that they were worried about aspects of their child's emotional health, including feelings of unhappiness, anxiety, frustration and anger (Green et al. 2006; Missiuna et al. 2007; Stephenson & Chesson 2008). With the exception of one study of preschool-aged children with DCD (Piek et al. 2008), studies consistently reported significantly higher levels of depression, withdrawn behaviour, and anxiety in children with DCD (Dewey et al. 2002; Piek et al. 2005; Watson & Knott 2006; Tseng et al. 2007; Chen et al. 2009). Kanioglou and colleagues (2005) indicated that children with DCD, rather than suspected DCD, show higher levels of tension–anxiety compared with typically developing children. Both state and trait anxiety are significantly higher in children with DCD (Schoemaker & Kalverboer 1994; Skinner & Piek 2001).

Compared with peers, children with DCD not only have significantly higher internalizing behaviours, but also externalizing behaviours (Dewey et al. 2002; Tseng et al. 2007). Studies consistently show higher levels of hyperactivity in children with DCD (Dewey et al. 2002; Kanioglou et al. 2005; Tseng et al. 2007; Lingam et al. 2010). Greater aggressive behaviour is consistently reported for children with DCD (Dewey et al. 2002; Tseng et al. 2007; Chen et al. 2009), but the degree of delinquent behaviour is mixed across studies (Dewey et al. 2002; Kanioglou et al. 2005; Tseng et al. 2007; Chen et al. 2009). Kanioglou and colleagues (2005) noted higher conduct problems in children with DCD, but not in those with suspected DCD, whereas other studies found no differences in behavioural conduct between children with or without DCD (Piek et al. 2000; Skinner & Piek 2001; Heath et al. 2005; Watson & Knott 2006).

Cognitive issues may also be apparent in children with DCD. Thought problems, as measured by the Child Behavior Checklist (CBCL), are reported to be significantly higher in children with DCD compared with control children in two studies using the Chinese version of the checklist (Tseng et al. 2007; Chen et al. 2009), but not in a third study using the original version of the CBCL (Dewey et al. 2002). Parents of children with DCD reported that their children need more structure and assistance to complete tasks in a timely manner than do typical children, and that they have difficulty adjusting to changes in routine (Summers et al. 2008b). Parents and teachers also reported that children with DCD have difficulty with attention and concentration (Dunford et al. 2005), a finding confirmed in several studies showing significantly greater attentional difficulties in children with DCD compared with peers (Dewey et al. 2002; Kanioglou et al. 2005; Tseng et al. 2007; Chen et al. 2009; Lingam et al. 2010).

Social domain

Several aspects of the social domain have been investigated in children with DCD. While no differences exist between children with and without DCD in terms of maternal or parent support (Piek et al. 2000; Rodger et al. 2003, 2007; Watson & Knott 2006), adolescent and young adults with DCD reported that they perceived parental frustration and disappointment with them when they were younger (Missiuna et al. 2008). Some children with DCD felt accepted and supported by their friends and classmates (Piek et al. 2000; Rodger et al. 2003, 2007; Watson & Knott 2006), but others experienced social rejection (Skinner & Piek 2001; Segal et al. 2002; Kanioglou et al. 2005) or fell victim to being teased or bullied (Mandich et al. 2003; Missiuna et al. 2007). Compared with typically developing children, children with DCD experience significantly more social problems (Dewey et al. 2002; Tseng et al. 2007; Chen et al. 2009), perhaps in part because of poorer non-verbal and communication skills (Dunford et al. 2005; Lingam et al. 2010). Although children with DCD tend to prefer social activities to physical ones (Poulsen et al. 2007b; Engel-Yeger & Hanna Kasis 2010), they spend more time alone than control children (Smyth & Anderson 2000) and report significantly higher levels of loneliness (Poulsen et al. 2007b).

School/work domain

While school or work is not always conceptualized as a domain of QOL, individuals with DCD experience numerous difficulties in school, which undoubtedly affects their well-being. The majority of parents of children with DCD report concern about academics and school-related activities (Dunford et al. 2005; Stephenson & Chesson 2008), most notably in handwriting and written work (Dunford et al. 2005; Missiuna et al. 2007, 2008; Stephenson & Chesson 2008). Parents report their children with DCD experience frustration with fine motor tasks and have difficulty demonstrating knowledge through written work, despite average to above average intelligence (Missiuna et al. 2007). In addition to parent (and teacher) concerns, children with DCD perform significantly lower than their peers in written work, as measured by the School Function Assessment (Wang et al. 2009). Adolescents and young adults with DCD also reported difficulty with handwriting, as well as keeping up with the demands of physical education. In the work environment, they reported being teased by co-workers about poor motor performance and experiencing anxiety or injury on the job (Missiuna et al. 2008).

Quality of life

Only one study employed QOL questionnaires (Dutch-Child-AZL-TNO-Quality-of-Life Questionnaire and TNO-AZL-Child-Quality-of-Life Questionnaire) to assess a broad range of outcomes in children with DCD with co-occurring ADHD (Flapper & Schoemaker 2008). While it is difficult to determine what aspects of QOL may be attributed to DCD, children with motor and attentional problems have significantly lower QOL compared with age-matched control children according to both child and parent perspectives. Essentially all domains – motor, cognitive, emotional and social – were significantly lower in children with DCD compared with peers. Using a QOL-related concept of life satisfaction and comparing with typically developing children, Poulsen and colleagues (2007a) reported significantly lower life satisfaction in boys with DCD, regardless whether they had a moderate or severe form of the disorder.

Discussion

This systematic review synthesized evidence from 41 studies of children with DCD as to what aspects of QOL are compromised by their disorder. While typically considered a ‘motor’ disorder with issues in the physical domain, our review highlights the accumulating evidence that psychological and social domains are also significantly impacted in individuals with DCD. Overall, children with DCD report lower self-efficacy and competence in physical and social domains, experience greater symptoms of depression and anxiety, and display more externalizing behaviours compared with typically developing children. They are also more likely to experience social problems than their peers. However, the evidence also suggests that children with DCD are not significantly different from typically developing children in feeling socially accepted and in their general self-worth. Differing results in physical, psychological and social domains may be related to a number of factors, including the presence or absence of comorbid conditions, age differences in the samples, whether the sample was population-based or clinical, the assessment tools used to measure similar subdomains, how DCD was defined, and what cut-off score for motor impairment was used. No clear pattern emerged to explain differing results across studies, but age does appear to be a factor: preschool children do not experience or perceive any significant difference in their competence across domains compared with peers (Pless et al. 2001), but differences begin to emerge between 8–10-year-olds and 12–14-year-olds (Skinner & Piek 2001). Adolescence seems to be a particularly vulnerable time for children with DCD (Missiuna et al. 2007). While some differences between children with DCD and suspected DCD [generally differentiated by cut-off scores on the Movement Assessment Battery for Children (Henderson & Sugden 1992) as <5th percentile and <15th percentile respectively] emerged on some measures, most results were similar for both groups (Dewey et al. 2002; Kanioglou et al. 2005; Poulsen et al. 2006, 2007a,b, 2008; Tseng et al. 2007; Wang et al. 2009). These results, in combination with eight studies that used ≤15th percentile as the MABC cut-off score to indicate DCD (Piek et al. 2000; Skinner & Piek 2001; Pless et al. 2001; Heath et al. 2005; Chen et al. 2009; Cocks et al. 2009; Lingam et al. 2010; Engel-Yeger & Hanna Kasis 2010), suggest that children in the ‘borderline’ range for motor impairment still show significant differences in QOL domains compared with peers. The more liberal cut-off for DCD was also employed in several studies without a control group where QOL-related concerns were identified (Smyth & Anderson 2000; Dunford et al. 2005; McWilliams 2005; Green et al. 2006; Missiuna et al. 2007; Summers et al. 2008a,b). Overall, the ‘severity’ of DCD does not appear to be a critical factor for poorer physical, psychological or social health. Comorbidities may be an important consideration for QOL, especially for psychological and social domains. Although we recorded whether the samples of children with DCD had comorbid conditions, such as ADHD, Asperger's, or learning disabilities, over half of the studies (22/41) did not report the presence or exclusion of comorbidities in their sample; as such, it was difficult to ascertain how co-occurring conditions influence QOL domains.

There are several limitations to this systematic review that warrant consideration. As the purpose of this paper was to comprehensively review the evidence of QOL domains impacted by DCD, we did not exclude research on the basis of poor methodological quality. Because there was no one quality assessment tool that could address the experimental, observational and qualitative study designs included in our systematic review, we opted to assess study quality in a novel manner by documenting the largest source of potential bias – how DCD was defined by each study. Studies that used the diagnostic criteria from the Diagnostic and Statistical Manual – 4th edition (APA 2000) and included measures of motor impairment, intelligence, and impact on activities of daily living were scored higher than studies that met fewer of the diagnostic criteria. However, cut-off scores for motor impairment varied between <5th percentile and <15th percentile, with some studies analysing potential differences using the stricter cut-off compared with the ‘at risk’ group. Because this is the first paper to systematically explore factors that may affect QOL in children with DCD, we opted to include all studies where authors described their sample as DCD in an effort to be more, rather than less, inclusive. Children who have poor motor skills but do not meet the diagnostic criteria for DCD also experience significant issues in physical, psychological and social domains and are worthy of attention. Last, our inclusion criteria were limited to articles published in English, but we found no articles published in a foreign language that required exclusion.

Using a wide range of study designs and domain-specific questionnaires, our review identified a range of QOL domains that are compromised in children with DCD. Despite the growing popularity of using QOL questionnaires in research involving children and adolescents with a range of health concerns (Klassen et al. 2008), our review identified only one study that had used a QOL questionnaire with children with DCD (Flapper & Schoemaker 2008). Because this study included a sample of children with DCD and comorbid ADHD, it is not possible to determine if the significantly lower QOL in these children was related to DCD, ADHD, or the combination of both disorders. While our review suggests that QOL may be affected in children with DCD, future research is needed to explore the QOL of a large sample of children with DCD using QOL measures (see Eiser & Morse 2001 and Solans et al. 2008 for reviews of QOL measures). From this work, we may be able to determine what aspects of QOL are most affected and explore ways to improve the QOL of children with DCD.

Conclusion

In summary, children and youth with DCD are at risk for lower QOL than their typically developing peers. Although DCD has an impact across several QOL domains – physical, psychological and social – only one study at the time of this review had measured the multidimensional construct of QOL. Clinicians and researchers are encouraged to incorporate QOL measures into their protocols so that we may better understand the impact of DCD on the QOL of children with this disorder.

Key messages

  • • Children with developmental coordination disorder (DCD) not only display poorer motor functioning compared with typically developing children, but also experience significantly greater symptoms of depression and anxiety, lower self-efficacy, and more social problems than their peers.
  • • Poorer scores across a range of physical, psychological and social domains may reflect poorer quality of life (QOL) in children with DCD.
  • • As only one study has measured the QOL of children with DCD, more research is needed to specifically examine the QOL of children with this disorder.

Acknowledgements

Dr JGZ was funded by the Canadian Institutes for Health Research (CIHR) Quality of Life Training Program in Rehabilitation Research and the Michael Smith Foundation for Health Research (MSFHR) at the start this project. She now holds a postdoctoral fellowship award from the CIHR Canadian Child Health Clinician Scientist Program, as well as funding from MSFHR and NeuroDevNet. Dr AFK is recipient of a CIHR career award.

Appendix

Appendix I

Search strategy for MEDLINE

  • 1‘developmental co?ordination disorder’.mp.
  • 2exp developmental coordination disorder/
  • 3DCD.mp.
  • 4clums*.mp.
  • 5‘clumsy child syndrome’.mp.
  • 6inco?ordinat*.mp.
  • 7‘perceptuomotor dysfunction*’.mp.
  • 8dyspraxia.mp.
  • 9dysgraphia.mp.
  • 10‘development* dyspraxia’.mp.
  • 11‘deficits in attention, motor control, and perception’.mp.
  • 12‘specific development* disorder* of motor function*’.mp.
  • 13‘psychomotor disorder*’.mp.
  • 14‘sensorimotor difficult’.mp.
  • 15‘sensory integrat* dysfunction*’.mp.
  • 16‘sensory integration’.mp.
  • 17‘nonverbal learn* disability*’.mp.
  • 18‘mov* disorder*’.mp.
  • 19‘developmental right hemisphere syndrome’.mp.
  • 20‘minor neuro* dysfunction*’.mp.
  • 21‘minimal brain dysfunction*’.mp.
  • 22‘development* apraxia’.mp.
  • 23‘development* apractic’.mp.
  • 24‘physical* awkward’.mp.
  • 25‘motor delay*’.mp.
  • 26‘motor skill* disorder*’.mp.
  • 27‘motor* awkward’.mp.
  • 28‘motor impair*’.mp.
  • 29‘perceptual motor difficult*’.mp.
  • 30‘motor-perceptual dysfunction*’.mp.
  • 31‘motor learn* disabilit*’.mp.
  • 32exp Motor Skills Disorders/
  • 33exp Motor Skills/
  • 34exp Developmental Disabilities/
  • 3533 and 34
  • 361 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 35
  • 37exp ‘quality of life’/
  • 38quality of life.mp
  • 39QOL.mp.
  • 40HRQ?L.mp.
  • 41health?related quality of life.mp.
  • 42health status
  • 43functional status.mp.
  • 44well?being.mp.
  • 45self?esteem.mp.
  • 46self?worth.mp.
  • 47self concept
  • 48exp Activities of Daily Living/
  • 49activit* of daily living.mp.
  • 50ADL.mp.
  • 51exp leisure activities/
  • 52leisure.mp.
  • 53recreation.mp.
  • 54sport*.mp.
  • 55play*.mp.
  • 56interpersonal relations
  • 57exp friends/
  • 58friend*.mp.
  • 59participation.mp.
  • 60exp social support/
  • 61exp social isolation/
  • 62loneliness.mp.
  • 63exp personal satisfaction/
  • 64life satisfaction.mp.
  • 65motor activity
  • 66exp psychomotor performance/
  • 67depression.mp.
  • 68anxiety.mp.
  • 69exp learning disorders/
  • 70occupational performance.mp.
  • 71parent* perspective*.mp.
  • 72child* perspective*.mp.
  • 73qualitative.mp.
  • 7437 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74
  • 7536 and 74

Ancillary