Developmental coordination disorder (DCD) is a specific motor delay characterized by significant difficulties with motor skills; it is typically associated with poor balance, coordination, and handwriting.1 According to the Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-5), the identification of DCD is composed of four criteria. These criteria are subsequently: (A) motor skills performance is substantially below the level which can be expected considering the chronological age of the child; (B) motor skills interfere with activities of daily living at home and at school; (C) the symptoms were present at an early age; (D) the motor problems are not explained by intellectual, medical, or neurological conditions.1 DCD is one of the most prevalent motor disorders, affecting about 6% of school-age children2–4 and persisting to adulthood.5

Significantly lower motor skills have been found to interfere with the individual activities of daily living,6 making the execution of movements significantly challenging.7,8 The gaps in motor skills possessed by children with DCD decrease their participation in sports and regular physical activities.9 In addition, children with DCD report more difficulties with self-care, which can interfere with their participation at school, on the playground, and at home,10 which in turn can cause social isolation that decreases their sense of self-worth.11

Low self-esteem is only one of the factors that can lead to increased symptoms of anxiety and depression.12 Anxiety is defined as “an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure”,1 while stressful life events predict periods of depression,13,14 of which – amongst others – symptoms of reduced interest or pleasure in activities previously enjoyed, and delayed psychomotor skills are presented. Considered a multifactorial disorder, the etiology is affected by the genetic and environmental context, which can influence the normal cycle of development in children.15 The present study aimed at analyzing data regarding symptoms of anxiety and depression from screening tests, which signal the presence of more anxious or depressed feelings that meet the clinical criteria of a disorder.16

Missiuna et al.12 studied children who had DCD combined with attention-deficit hyperactivity disorder (ADHD) and found that they had more symptoms of anxiety and depression than their peers who had typical development. Lingam et al.17 identified more risk for both physical and mental health problems in a population with DCD. Assuming that children with DCD widely present a profile of vulnerability due to these potential mediators combined with more exposure to contributory factors for increased symptoms of depression and anxiety, it was hypothesized that children with DCD or probable DCD have significantly more symptoms of anxiety/depression than their typically developing (TD) peers. Therefore, the present systematic review study aimed to find evidence of symptoms of anxiety/depression in children with DCD compared to their TD peers at both the group and individual level, and to identify how many different tools are used to measure anxiety and/or depression.

The methodology of this systematic review was developed using the guidelines of the Cochrane Handbook.18 The review's protocol was registered in the PROSPERO database using ID number CRD42018091859.

The initial database searches identified 581 studies, of which six studies met all eligibility criteria (Fig. 1).24 Five articles were cross-sectional studies, and one was a cohort study. The cumulative sample size of all the included studies was 7920 children (653 with DCD, 7213 TD peers, and 54 with ADHD – who were not considered in these analyses). The participants’ ages ranged from 4 years and 4 months to 11 years and 6 months (Table 1).

Figure 1.

Flowchart showing the steps in the systematic review.24

(0.31MB).

The body of evidence from the six studies indicated significantly more symptoms of anxiety and depression in children with DCD than in their TD peers. In five of the six studies, the effect sizes could be calculated for symptoms of anxiety12,25–28 and symptoms of depression.12,24,27,28 All included studies reported similar results of increased symptoms of anxiety and depression in children with DCD compared with their typical peers (Table 1).

In the included studies, the DSM 5 criteria A and B were the most commonly considered criteria, evaluating motor performance and interference of coordination difficulties in academic achievement or daily life activities, respectively.

To evaluate motor performance assessment (criteria A), 67% of the studies (n=4)12,26–28 included used the Movement Assessment Battery for Children (MABC) with ≤15th percentile, or the MABC-2 with ≤5th percentile to indicate DCD; one27 of them also used the Bruininks–Oseretsky Test of Motor Proficiency (BOTMP) with a cut-off standard score of <40 for DCD. One study17 used the Avon Longitudinal Study of Parents and Children (ALSPAC) Coordination Test with a score <15th percentile, and one study25 used the McCarron Assessment of Neuromuscular Development (MAND) with a score ≤85 indicating DCD.

To evaluate criteria B, three of the six studies12,26,27 included used the Developmental Coordination Disorder Questionnaire (DCDQ) and two studies17,28 analyzed the reported outcomes of a parent questionnaire.

The studies used ambiguous terminology to refer to the children with DCD. Of the six studies included, three used DCD, two at risk for DCD, and one probable DCD.

Various instruments were used to assess the children's mental-health outcomes, but the most commonly used was the Child Behavior Checklist (CBCL) (n=2).25,27 Furthermore, Children's Depression Inventory (CDI)12 and the Short Moods and Feelings Questionnaire (SMFQ)17 scored by children were used to measure depression. The Self-report for Childhood Anxiety and Related Disorders (SCARED)12 scored by children and the Spence Children's Anxiety Scale Parental version (SCAS-P)26 scored by parents were used to measure anxiety. The Teacher's Report Form (TRF)28 was used by teachers to score the emotional and behavioral problems of the children.

At an individual level, presented in Table 2, the results of the studies included in this review infer that a percentage of children with DCD have a higher probability of presenting symptoms of anxiety or depression in the clinical range when compared to children with typically development.

The methodological quality of the included studies was classified as high quality in five articles. Two of them reaching 90% of methodological criteria,25,27 one study reached, 88%,17 and two reached 70% of the criteria.12,28 One study was of moderate quality, reaching 60% of the criteria.26

None of the cross-sectional studies, evaluated by the NOS adapted for cross-sectional studies, scored two stars on outcome criterion 1 (independent blind evaluation or analysis by registry). However, the six studies (five cross-sectional and one cohort) scored on the criterion “controls the most important factor” (comparability A, one star). All details are displayed in Table 3.

The present review compiled evidence from six articles that assessed symptoms of anxiety and/or depression in children with DCD as compared with symptoms in TD peer controls. The results showed that in all studies evidence was found for increased presence of symptoms of anxiety and depression in children with DCD compared to TD children, supporting the hypothesis of this study.

Piek et al.,25 Chen et al.,27 and van den Heuvel et al.28 showed that anxiety and depression in DCD is significantly higher than in TD children. Children's motor coordination ability was negatively associated with reported anxious-depressed behavior, so when the children scored poorly in coordination, more anxiety/depression was reported by parents.25 However, of this group, no individual child was reported as scoring in the clinical range of anxious/depressive behavior.25,27 This is an important finding to report, since this means that there was no causality found for DCD resulting in clinical symptoms of anxiety and depression. It only brings forward that children with DCD have more vulnerability factors that may lead to increased symptoms of anxiety and depression in some of the children. In van den Heuvel et al.,28 anxiety and depression were part of an emotional and behavior problems scale that involves other emotional problems; 15% of the DCD children presented a clinical TRF in the DCD group compared to the TD children.

Missiuna et al.12 and Lingam et al.17 found similar results of significant differences between children with DCD compared to TD children regarding depression. Based on these results, similar percentages of individual children were observed who scored within the clinical range by both children with DCD and parents (11.8% and 11.9%, respectively) for children12,17 and 9.1% for parents,12 even though they were measured by different tools. Again, this only demonstrates that a minority of children with DCD would feel more depressed compared to their peers. More information is needed regarding self-esteem, social lifestyle, academic scores, and support of parents and/or teachers in order to understand more of the processes leading to symptoms of depression.

Missiuna et al.12 and Pratt and Hill26 showed significant differences between children with DCD compared to TD children regarding anxiety. But the mean of the SCARED responded to by parents and children did not reach the clinical range. However, 16.7% of parents and 33.8% of children from the DCD group scored positive for clinical symptoms of anxiety. Pratt and Hill26 showed similar percentages of individual children that scored within the clinical range; 25.9% DCD children reported symptoms of anxiety. It is of interest to gain more understanding regarding why parents score their children lower in symptoms of anxiety than the children themselves.

The effect size could be calculated for five out of six studies included in this review. Considering these studies (n=5 for symptoms of anxiety and n=4 for symptoms of depression, assuming that in two studies both outcomes were evaluated together) the mean of calculated effect size for symptoms of anxiety was d=0.61, while for symptoms of depression it was d=0.78, indicating a medium effect size for the clinical implications of both symptoms of anxiety and depression in children with DCD. This means that DCD is not a fully contributing factor to the presence of symptoms of anxiety or depression. In fact, a considerable number of children with DCD may not develop symptoms of anxiety or depression. Other factors, like the factors put forward in the study by Lingam et al.17 of low verbal IQ, poor social communication, being a victim, low self-esteem, and poor scholastic competence may contribute even more. Further research is needed to disentangle the relationship between the motor competence of children with DCD, the history of treatment and support, and the effects on self-esteem, social communication, and isolation, preferably in different cultures.

Given the current diagnostic criteria for identifying children with DCD based on DSM-5,1 it is possible to infer that each of the four criteria takes the child's daily life and his or her opportunities for practice into account. In addition, it can be inferred that, in addition to opportunities for practice, children should be surrounded by psychosocial protective factors, including positive social support from family, friends, and teachers. This support must be adequate to promote the encouragement that these children need to try to overcome their motor deficits and/or become socially more involved and minimize their risk for anxiety and depression. They can be clumsy, but can build up sufficient social relationships with their peers.

From this review, it is clear that anxiety and/or depression are measured inconsistently by different tools, i.e., six different tools were used and were completed by different respondents. So far, it is unclear whether parental or teacher scores of mental health items correspond with the experienced feelings of the children. Some issues should be noted regarding the differences between the symptoms of anxiety and depression. For example, whereas anxiety includes excessive worry about future actions combined with tension or stress, depression is characterized by low self-esteem, mood disturbance or dysregulation, and sadness.1 Often, both conditions frequently co-occur12 in the same period or sequentially and, overtime, an increase of the presence of both conditions is seen29; therefore, assessments for both conditions are often conducted together, particularly in non-clinical studies. Given this, four of the six studies included in the present review assessed both anxiety and depression in children with DCD and peer control groups.12,25,27,28 One study26 assessed only anxiety, and another one17 assessed only depression. Taking into consideration that symptoms of anxiety and depression are composed of different characteristics,29 it is possible to induce a bias when both assessments are performed by the same instrument. On the other hand, for research purposes the researchers can save time and resources using only one standardized questionnaire for screening symptoms of both anxiety and depression. However, more additional detailed information is needed when a child scores ‘at risk.’

It is important to realize that deprivation, in this case children who are not exposed to practice motor skills or have an active lifestyle in early childhood, may lead to neurodevelopmental problems, which can be related to symptoms of depression in adolescence.30 Therefore, besides motor performance level, the context of the child regarding parenthood, environment, and social economic status can give a better overview regarding factors that may predict symptoms of anxiety and/or depression. Further research is needed to determine which factors play the most important role to become ‘at risk’ for psychological problems.

All cross-sectional studies scored on the selection criterion 4 (validated assessments), thus it can be concluded that the studies included in this review strictly followed the recommended criteria for studies with this design, avoiding possible biases. This is also appropriate for criterion 2, which refers to statistical tests used for analysis, reinforcing that those were appropriate to demonstrate the relevance of the results. Besides the NOS cross-sectional, none of the selected studies scored two stars on the outcome criterion 1, corresponding to independent blind evaluation or analysis by registry. This lack of fulfilling independent blind evaluation or analysis by registry (also criterion 1 for cohort studies) infers that for this outcome of anxiety and/or depression symptoms, the use of self-completed questionnaires seemed to be a questionable choice, since the evaluation is done by an interviewer who may have had a direct influence on the respondent's response. To avoid the tendency to give overly positive self-descriptions, self-report questionnaires without the influence of an interviewer could be used to minimize socially desirable responses (SDR),31 or self-report questionnaires answered by parents or teachers.

The findings of the present review both support the importance of investigating the psychosocial aspects of children with DCD and reinforce the recommendations of the European Academy for Childhood Disability (EACD) regarding clinical practice in children with DCD.32 The entire process of evaluation and intervention must involve not only the motor aspects, but also personal and individual factors, and should include a review of all items present in the International Classification of Functioning, Disability, and Health (ICF).33 In fact, evaluations and interventions that focus on the indicative symptoms of anxiety and depression in children with DCD correspond to the personal and environmental factors of the ICF. In addition, considering the multifactorial aspects, improvements in these psychosocial cues can improve the structure and function of the body and participation in daily activities. Thus, the results of the present review support the importance of considering the indicative symptoms of anxiety and depression in children with DCD.

To avoid confusion when studies are compared, researchers and therapists must be aware of the terms in the current literature. The authors encourage researchers to follow the classification based on Smits-Engelsman et al.,34 which consider the DSM-5 criteria to be described and observed using standardized assessments, and also the children's age.

This systematic review has some limitations. The various designs adopted by the included studies resulted in various interpretations of their findings. Notably, the cohort study was capable of evaluating the relationships between causes and effects, and the cross-sectional studies were not. Furthermore, the variety of sample sizes, instruments used to assess motor performance, and the psychosocial outcomes of interest (anxiety and depression) may have affected interpretation of the studies’ results. However, regarding the outcomes of interest, higher risks of symptoms of anxiety and depression in children with DCD were found in all studies included in the review.

Children with DCD appear to be at increased risk of presenting symptoms of anxiety and/or depression than children with typical development. This implies that the effect of motor problems may be facilitating an increased risk for symptoms of anxiety and/or depression, even though this is not the case for all children. Clinicians have to be aware of these risks and may consider extending their assessments to questionnaires aimed to measure symptoms of anxiety or depression. If more attention is paid to these symptoms and children are measured more consistently, more knowledge will be gained regarding the mediating effects of motor problems on symptoms of anxiety and depression.

The authors would like to thank the financial support from Coordination for the Improvement of Higher Education Personnel(CAPES).

The authors declare no conflicts of interest.