Exploring parenting stress levels and its predicting factors in parents of children with

Developmental Coordination Disorder

Ana Maria Jijon Nemalceff

Submitted for the Degree of

Doctor of Psychology(Clinical Psychology)

School of PsychologyFaculty of Health and Medical Sciences

University of SurreyGuildford, SurreyUnited Kingdom

September 2019

© Ana M Jijon Nemalceff 2019

1

Abstract

Background: There is evidence that parents of children with neurodevelopmental

disorders report higher levels of parenting stress compared to parents of typically developing

(TD) children, with more than half of those parents experiencing levels of parenting stress within

the clinical range. However, there is very little research on whether parents of children with

Developmental Coordination Disorder (DCD) also experience high levels of parenting stress,

and, if so, the factors that contribute to this stress. Aim: The current study explored whether

parents of children with DCD experience higher levels of parenting stress compared to parents of

TD children, and the factors that predict parenting stress in parents of children with DCD.

Method: 174 parents of children (ages 5-12) with a diagnosis of DCD and 24 parents of TD

children participated in an online survey. Participants completed five questionnaires measuring

parenting stress, social support, parenting self-efficacy, the child’s emotional and behavioural

problems, and severity of the child’s motor coordination problems. Results: Parents of children

with DCD reported experiencing significantly higher levels of parenting stress than parents of

TD children. Two-thirds of parents of children with DCD reported experiencing levels of

parenting stress within the clinical range. The severity of the child’s emotional and behavioural

problems, the level of social support and parenting self-efficacy were found to be significant

predictors of parenting stress, but not the severity of the child’s motor difficulties. Discussion:

These findings are mostly consistent with research on other neurodevelopmental disorders. They

highlight that these parents may be a vulnerable group which requires support from professionals

to cope with the demands of caring for their children. The management of behavioural problems,

the parent’s self-efficacy, and increasing the level of social support should be considered in the

development of tailored interventions for these parents.

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Acknowledgements

Foremost, I would like to express my gratitude to my supervisor Dr Hayley Leonard. Her

guidance, encouragement and knowledge were invaluable to me in the last three years. Her

passion for DCD was inspiring and made me enjoy learning and conducting research in this

topic. It was a pleasure to work with her on these two papers.

I would like to thank the parents who participated in this study for all of their time and

effort. I am also grateful to the Dyspraxia Foundation for advertising study and helping with the

recruitment of participants.

I would also like to extend my thanks to my clinical tutor Dr Nan Holmes, my associate

tutor Dr Jennifer Mance, and all of my placement supervisors for all the advice and wisdom they

gave me during the Programme.

I am extremely grateful to my parents and siblings for their love and support. Their belief

in me helped me to persevere. I would not be here without them.

I am eternally grateful to my husband Leonardo. His endless support and encouragement

helped me to get through the challenging and stressful times of the Programme. Knowing that he

was there for me no matter what was indispensable for my well-being. I am very fortunate to

have him in my life, thank you for always believing in me.

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Presentations

Parts of this thesis have been presented in:

Jijon, A. M., (2019, June). Parenting stress of parents of children with Developmental Coordination

Disorder. Paper presented at the 13th International Conference on Developmental Coordination

Disorder, University of Jyväskylä, Finland.

Jijon, A. M., (2018, June). Parenting stress of parents of children with Developmental Coordination

Disorder. Paper presented at the UK’s 7th biennial academic and practitioner conference on

Developmental Coordination Disorder, Brunel University, London.

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Table of Contents

Abstract............................................................................................................................................2Acknowledgements..........................................................................................................................3Presentations....................................................................................................................................4Part 1: Major Research Project Empirical Paper.............................................................................7

Abstract................................................................................................................................8Introduction..........................................................................................................................9

Theoretical model of parenting stress......................................................................9Parenting stress in neurodevelopmental disorders.................................................10Developmental Coordination Disorder..................................................................16Current study and rationale....................................................................................17

Method...............................................................................................................................19Design....................................................................................................................19Participants............................................................................................................20Materials................................................................................................................22Procedure...............................................................................................................25Data analyses.........................................................................................................26

Results................................................................................................................................27Initial analyses and descriptive statistics...............................................................27Group comparison of parenting stress...................................................................29Factors predicting parenting stress in the DCD group...........................................31

Discussion..........................................................................................................................32Parenting stress between groups............................................................................33Factors predicting parenting stress in parents of children with DCD....................35Child factors...........................................................................................................35Parent characteristics.............................................................................................37Situational characteristics......................................................................................38Strengths and Limitations......................................................................................40Clinical implications..............................................................................................42Conclusion.............................................................................................................43

References..........................................................................................................................45Appendices........................................................................................................................62

List of appendices..................................................................................................62

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Part 2: Major Research Project Literature Review........................................................................88Abstract..............................................................................................................................89Introduction........................................................................................................................90Method...............................................................................................................................93

Database search strategy........................................................................................93Study selection.......................................................................................................94Data extraction, evaluation and synthesis..............................................................96

Results................................................................................................................................97Overview of studies...............................................................................................97Quality Appraisal.................................................................................................119

Discussion........................................................................................................................126Limitations...........................................................................................................132Conclusion...........................................................................................................133

References........................................................................................................................135Part 3: Summary of Clinical Experience.....................................................................................145Part 4: Table of Assessments Completed During Training.........................................................148

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Part 1: Major Research Project Empirical Paper

Exploring parenting stress levels and its predicting factors in parents of

children with Developmental Coordination Disorder

Word Count: 9950

7

Abstract

Background: There is evidence that parents of children with neurodevelopmental

disorders report higher levels of parenting stress compared to parents of typically developing

(TD) children, with more than half of those parents experiencing levels of parenting stress within

the clinical range. However, there is very little research on whether parents of children with

Developmental Coordination Disorder (DCD) also experience high levels of parenting stress,

and, if so, the factors that contribute to this stress. Aim: The current study explored whether

parents of children with DCD experience higher levels of parenting stress compared to parents of

TD children, and the factors that predict parenting stress in parents of children with DCD.

Method: 174 parents of children (ages 5-12) with a diagnosis of DCD and 24 parents of TD

children participated in an online survey. Participants completed five questionnaires measuring

parenting stress, social support, parenting self-efficacy, the child’s emotional and behavioural

problems, and severity of the child’s motor coordination problems. Results: Parents of children

with DCD reported experiencing significantly higher levels of parenting stress than parents of

TD children. Two-thirds of parents of children with DCD reported experiencing levels of

parenting stress within the clinical range. The severity of the child’s emotional and behavioural

problems, the level of social support and parenting self-efficacy were found to be significant

predictors of parenting stress, but not the severity of the child’s motor difficulties. Discussion:

These findings are mostly consistent with research on other neurodevelopmental disorders. They

highlight that these parents may be a vulnerable group which requires support from professionals

to cope with the demands of caring for their children. The management of behavioural problems,

the parent’s self-efficacy, and increasing the level of social support should be considered in the

development of tailored interventions for these parents.

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Introduction

Being a parent brings unique rewards and challenges. These challenges are magnified

when the parenting demands become difficult to cope with and may lead to parents experiencing

parenting stress. Parenting stress is defined as the psychological reaction to the demands of

parenthood when there is a mismatch between the perceptions of these demands and of the

resources available to the parent to meet them (Deater‐Deckard, 1998). Although parenting stress

is experienced by all parents to some extent (Crnic & Greenberg, 1990; Crnic, Gaze, & Hoffman,

2005), experiencing considerable amounts of stress has been associated with negative parenting

behaviours and parent-child interactions (Jarvis & Creasey, 1991; Östberg, 1998). Parenting

stress has also been associated with increased risk of poor child outcomes in areas such as

internalising symptoms, behavioural problems and executive functioning problems (de Cock, et

al., 2017; Neece, Green, & Baker, 2012; Rodriguez, 2011). In fact, Belsky’s (1984) model of

determinants of parenting suggests that the psychological well-being of the parent is a factor that

has an impact on parental functioning. Hence, it is important to consider parenting stress given

that it may affect the parent’s well-being and the child’s development.

Theoretical model of parenting stress

Parenting stress is a determinant of dysfunctional parenting in the model proposed by

Abidin (1976, as cited in Abidin, 1995). In this model, parenting stress could lead to parental

behaviours that are detrimental to the child’s development and outcomes. The model also

stipulates three main sources of parenting stress: child characteristics, parent characteristics and

situational variables. According to the model, child characteristics can be divided into

temperament-related variables such as adaptability, demandingness, mood and

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hyperactivity/distractibility, and variables of the impact that a child has on the parent such as

acceptability (child meets the expectations that the parent has of the child) and reinforcing for the

parent (“degree to which the parent-child interaction results in a positive affective response in the

parent”) (Abidin, 1995, p. 29). The parent characteristics in the model include the parent’s

emotional availability to the child, sense of competence in relation to the role as a parent, and the

parent’s investment in the role as a parent. The situational variables include support from the

spouse in relation to parenting, isolation/social support, parent’s physical health in relation to

being able to meet demands of being a parent, and the impact of being a parent on personal

freedom and other life roles.

Parenting stress in neurodevelopmental disorders

Weiss (1991) found that caregivers of children with developmental disorders are faced

with unique demands and stressors associated with the specific difficulties related to the

disability, including making special arrangements, getting professional help, and having

insufficient information about the disability. In addition, previous research suggests that parents

of children with developmental disabilities report higher levels of parenting stress compared to

parents of typically developing (TD) children (Oelofsen & Richardson, 2006; Woolfson & Grant,

2006). In fact, these studies reported that more than half of the parents of children with

developmental disabilities had levels of parenting stress within the clinical range, while this was

the case for only 5-10% of parents of TD children.

Similar results were found for parents of children with specific neurodevelopmental

disorders. Parents of children with Autism Spectrum Disorder (ASD) and Attention Deficit

Hyperactivity Disorder (ADHD) reported higher levels of parenting stress when compared to

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parents of TD children (Breen & Barkley, 1988; Hutchinson, Feder, Abar & Winsler, 2016;

Keenan, Newman, Gray & Rinehart, 2016; Lai, Goh, Oie & Sung, 2015). Meirsschaut, Roeyers

and Warreyn (2010) reported that this difference in parenting stress for those with and without

neurodevelopmental disorders is also manifested within the same household. Those mothers

reported experiencing higher levels of parenting stress for the children with ASD than for their

TD children. Hutchinson et al. (2016) found that parents of children with ASD and ADHD

reported experiencing similar levels of parenting stress to each other. While other

neurodevelopmental disorders have also been studied, the majority of research has focused on

ASD and ADHD. As such, the evidence on these disorders will be described in detail first before

moving on to the disorder of most relevance to the current study.

Child characteristics.

Previous studies on parents of children with ASD and ADHD have reported a number of

factors associated with parenting stress in line with the Abidin model (1976). One factor related

to child characteristics was the severity of the symptoms of the condition. Lyons, Leon, Roecker,

Phelps, and Dunleavy (2010) found that symptom severity of ASD was the strongest and most

consistent predictor of stress in parents. More specifically, Davies and Carter (2008) found that a

child’s deficits in social skills was the most consistent predictor of parental stress. Furthermore,

Firth and Dryer (2013) found that the severity of the child’s social impartments was a predictor

of parenting-related stress in parents of children with ASD.

Other studies also found a positive relationship between the severity of a child’s ASD

symptoms and parenting stress in that the more severe the symptoms, the higher the parenting

stress (Ingersoll & Hambrick, 2011; Benson, 2006; Zablotsky, Anderson & Law, 2013; Mak, Ho

11

& Law, 2007; Zamora, Harley, Green, Smith & Kipke, 2014). Several other studies assessed the

association of particular child difficulties and parenting stress. Increased levels of parenting

stress in parents of children with ASD was found to be associated with the child’s lower adaptive

functioning (Hall & Graff, 2011), higher severity of social impairments (Firth & Dryer, 2013;

Foody, James & Leader, 2014), and more severe cognitive impairment (Koegel et al., 1992).

Furthermore, the better a child’s social competence and school engagement, the lower the reports

of parental stress in parents of children with ASD (Hsiao, 2015). There were similar findings for

parents of children with ADHD, with Graziano, McMamara, Geffken and Reid (2011) reporting

an association between ADHD symptoms and parenting stress, wherein parents who rated their

child’s levels of hyperactivity/impulsivity and difficulties with executive functions as more

severe also reported higher levels of parenting stress. Li and Lansford (2018) also reported a

positive association between ADHD symptoms and parenting-related stress.

Another factor related to child characteristics was the child’s behavioural problems.

Several studies found the child’s behavioural problems to be statistically significant predictors of

parenting stress for parents of children with ASD (Huang et al., 2014; Krakovich, McGrew, Yu

& Ruble, 2016) and ADHD (Pimentel, Vieira-Santos, Santos, & Vale, 2011; Vitanza &

Guarnaccia, 1999). In fact, Krakovich et al. (2016) found that problem behaviours were the

strongest predictors of parenting stress for parents of children with ASD, and Vitanza and

Guarnaccia (1999) reported that a child’s challenging behaviour was the strongest predictor of

parenting stress in parents of children with ADHD.

Moreover, several studies found an association between the child’s behaviour and higher

levels of parental stress. For parents of children with ASD, these studies found that higher levels

of child behaviour problems were associated with higher levels of parental stress (Beer, Ward, &

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Moar, 2013; Rezendes & Scarpa, 2011). Parents of children with mild or moderate behavioural

problems reported lower levels of stress than parents of children with severe problems (Huang et

al., 2014). Similar findings were reported by Graziano et al. (2011) for parents of children with

ADHD, as they found that parents of children with ADHD with a higher rating of their children’s

levels of aggressive symptoms and emotional reactivity reported higher levels of parenting

stress. Pimentel et al. (2011) concluded that the greater prevalence of externalising and

internalising behavioural problems predicted higher levels of parental stress in parents of

children with ADHD.

Taken together, the literature supports the stipulations of the Abidin model that a child’s

symptom severity and their behavioural problems could be important sources of parenting stress

for parents of children with ASD and ADHD, which in turn could affect parenting functioning.

Parent characteristics.

The parents’ perceptions of their competence in relation to the role as a parent has been

associated with parenting stress and distress in line with Abidin’s model (1976, as cited in

Abidin, 1995). On parents’ perceptions of their competence as parents, studies have explored

parental self-efficacy, defined as the perception of how well a parent is able to function in the

role as a caregiver and effectively manage task and challenges associated with this role (Teti,

O’Connell, & Reiner, 1996). For parents of children with ASD, several studies have found that

there was a negative association between mother’s parenting self-efficacy and levels of overall

parent stress (Giallo, Wood, Jellett, & Porter, 2011), caregiver distress (Lindsey & Barry 2018)

and, more specifically, with parenting stress (Kuhn & Carter, 2006; May, Fletcher, Dempsey &

Newman, 2015). Furthermore, Mak et al. (2007) found a negative correlation between self-

13

reported level of confidence and parenting stress in parents of children with ASD. A similar

association was found for mothers of children with ADHD, as Williamson and Johnston (2019)

found that parental self-efficacy was negatively associated with parenting stress. Moreover,

Hastings and Symes (2002) reported a negative association between parenting stress and

mother’s perceived confidence in being able to support their children implement a behavioural

change. Primack et al. (2012) found that parents of children with ADHD reported lower level of

parenting self-efficacy compared to parents of children without ADHD.

Likewise, parental empowerment, defined as “a coping resource, including parents’

beliefs about their control, self-efficacy and perceived competence” (Minnes, Perry & Weiss,

2015, p. 552), has also been associated with parental distress. Weiss, Cappadocia, MacMullin,

Viecili and Lunsky (2012) found that greater empowerment was related with lower levels of

parental distress for parents of children with ASD. Similarly, lower parent empowerment was

found to be a predictor of parent distress for parents of children with ASD and other

developmental delays and disabilities (Minnes et al., 2015). Hence, the literature on parental

empowerment and self-efficacy supports Abidin’s model postulation that parents’ sense of

competence could play a role in parenting stress.

Situational variables

Finally, social support was found to be an important factor associated with parenting

stress. Social support was found to be a statistically significant predictor of stress in both mothers

and fathers of children with ASD (Falk, Norris & Quinn, 2014), and in parents of children with

ADHD (Theule, Wiener, Rogers & Marton, 2011). Zamora et al. (2014) found that less access to

services predicted higher parental stress for parents of girls with ASD.

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Family interactions were also found to impact the mental health of parents of children

with ASD, with lower co-parenting agreement, lower support (Thullen & Bonsal, 2017), and

lower parenting alliance (Hill-Chapman et al., 2013) being associated with higher levels of

parenting stress. Poor quality of interactions with the extended family was also associated with

higher parental stress scores (Derguy, Bailara, Michel, Roux & Bouvard, 2016).

Other studies found that support from different sources was associated with better

parental mental health for parents of children with ASD. Benson (2006) found that informal

support was associated with lower levels of depression in parents, while Moh and Magiati (2012)

found that lower levels of stress reported by parents during the diagnostic process was associated

with fewer number of professionals consulted and better perceived collaboration of those

professionals. Similarly, stronger alliance with teachers and receiving school interventions was

associated with lower levels of parental stress (Krakovich et al., 2016). The two studies on

parents with children with ADHD found that higher social support was associated with lower

parental stress (Vitanza & Guarnaccia, 1999, Theule et al., 2011). Again, the findings on the

relationship between parental support and parenting stress are in line with Abidin’s model for

parents of children with ASD and ADHD.

The literature suggests that there is some overlap between the difficulties experienced by

children with ASD and ADHD, and with a common neurodevelopmental disorder,

Developmental Coordination Disorder (DCD), which is diagnosed on the basis of motor

impairments. For example, one study reported that a significant percentage of children diagnosed

with ADHD also have motor problems that can be classed as DCD (Pitcher, Piek, & Hay, 2003),

while another study showed that there was some overlap on motor and social impairments

between children with ASD and those with DCD compared to TD children (Sumner, Leonard, &

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Hill, 2016). This suggests that the factors that have an impact on parenting stress identified in

studies involving parents of children with ASD or ADHD may also apply to parents of children

with DCD. This paper will therefore now focus on DCD.

Developmental Coordination Disorder

DCD, a relatively understudied neurodevelopmental disorder (Leonard, 2016) also

sometimes known as dyspraxia, is a condition characterised by an impairment of fine and gross

motor skills that has a negative impact on a child’s ability to learn and perform daily activities

that are necessary for the individual’s functioning (American Psychiatric Association, 2013). As

a result of their motor deficits, children with DCD experience difficulties in several areas

including self-care, and education and recreational activities (American Psychiatric Association,

2013). Children with DCD were also found to have worse outcomes in their psychological,

physical and social functioning compared to their peers (Zwicker, Harris, & Klassen, 2012). The

motor impairment is not associated with an intellectual disability, visual impairment, or

neurological condition that affects movement, and symptoms appear during the child’s

developmental period (American Psychiatric Association, 2013). Although the motor deficits and

associated difficulties start early in an individual’s life, research suggests that these difficulties

appear to persist into adulthood (Cousins & Smyth, 2003; Hill, Brown, & Sorgardt, 2011; Tal-

Saban, Zarka, Grotto, Ornoy, & Parush, 2012). While the estimated prevalence of DCD in

school-age children is between 5% and 6% (American Psychiatric Association, 2013), DCD is

often not identified by healthcare professionals (Harris, Mickelson, & Zwicker, 2015).

There is very little research on whether parents of children with DCD have higher levels

of parenting stress similar to other neurodevelopmental disorders, and, if so, the factors that

16

contribute to this stress. This limited research also means that there is no significant body of

evidence on whether the factors identified by Abidin (1976) in his model apply to this parent

group. There are only three studies on the experiences of parents of children with DCD. The first

study conducted an online survey of 228 parents about their experience of the process of their

children receiving a DCD diagnosis (Soriano, Hill, & Crane 2015). These researchers found that

four factors were predictive of overall satisfaction with the diagnostic processes: stress of the

process, the manner of the professional, satisfaction with post-diagnostic support, and the time

taken to receive a diagnosis. The study found that 76% of parents found the diagnosis process to

be stressful.

The second study interviewed 12 mothers of children with DCD to explore the long-term

impact of having the disorder, including the effect of having a child with DCD on the family

(Stephenson & Chesson, 2008). The researchers reported that the child’s emotional problems led

to mothers’ stress, distress, anger, and frustration. In the third study, although it was not specific

to parents of children with DCD, Takahashi et al. (2017) found that impairment of motor

coordination was a significant predictor of maternal stress. Taken together, the findings of these

studies suggest that parents of children with DCD may encounter several stressors associated

with their child’s condition which could lead to them experiencing stress. As such, it is important

to have a better understanding of the experiences of these parents.

Current study and rationale

The extensive literature on parents of children with ASD and ADHD can provide a

starting point when exploring the factors that may contribute to the parenting stress in parents of

children with DCD. This is because the factors that contribute to parenting stress in those

17

neurodevelopmental disorders may also affect parents of children with DCD given that children

with DCD and those with ASD and ADHD experience many common difficulties (Pitcher et al.,

2003; Sumner et al., 2016).

Nevertheless, while the extensive literature suggesting that these factors impact parenting

stress for parents of children with ASD and ADHD in line with Abidin’s model can provide a

helpful starting point, Ashworth, Palikara and Van Herwegen (2019) challenged whether these

findings are relevant for parents of children with all neurodevelopmental disorders. Their study

found that parents of children with very rare neurodevelopment disorders (such as Williams

syndrome) do not experience more stress than parents of children with more common disorders,

such as Down Syndrome and ASD, but they also found differences between the groups on the

factors that increase or reduce parenting stress. For example, they found that parenting stress was

associated with number of siblings for parents of children with Down’s Syndrome but not for

parents of children with Williams syndrome or ASD. This led the authors to stipulate that the

factors that affect parenting stress may be syndrome-specific. Therefore, these findings suggest

that while there is evidence to support that the child’s and parent’s characteristics and situational

variables do have an impact on parenting stress in ASD and ADHD, specific studies on DCD are

necessary to determine whether similar impacts can be observed in this parent group.

Closing this large unexplored gap in the literature on parenting stress in parents of

children with DCD is important as it would contribute to better understanding of the impact of

raising a child with DCD on their psychological well-being. This in turn will inform

professionals of potential areas for support and interventions for these parents, which could lead

to improving child outcomes. The high prevalence of DCD (up to 6%) amongst children suggests

that a large number of parents could potentially benefit from further research in this area

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(American Psychiatric Association, 2013). Given that DCD, as ASD and ADHD, is a

neurodevelopmental disorder and that it has been reported that there is an overlap between DCD

and the other disorders, the current study investigates whether the findings on parenting stress

and its contributing factors for parents of children with ASD and ADHD can be replicated in

parents of children with DCD.

The study therefore addressed the following research questions:

1. Are levels of parenting stress higher in parents of children with DCD compared to parents

of TD children?

2. What are the factors that predict parenting stress in parents of children with DCD?

It was expected that parents of children with DCD would experience higher levels of

parenting stress compared to parents of TD children. Furthermore, based on the literature in ASD

and ADHD, it was hypothesised that the following factors would predict parenting stress in

parents of children with DCD: severity of DCD and severity of the child’s behavioural problems

(child-related factors); parenting self-efficacy (parent-related factor); and social support

(situational factor).

Method

Design

The current study employed a non-experimental correlational cross-sectional design. The

variables measured were parent-reported parenting stress (dependent variable), social support,

parenting self-efficacy, a child’s behavioural problems, and severity of motor coordination

19

problems. The study also included a quasi-experimental element, with parenting stress compared

between parents of children with DCD and parents of TD children.

Participants

Parents of children with DCD were recruited through an advertisement placed by a UK

charitable organisation, and from other studies at the University. Furthermore, parents who

participated in the study were asked to encourage other parents of children with DCD or TD

children to participate. Parents of TD children were recruited from advertisements placed on

social media, local libraries, word of mouth and from other studies at the University. Several

primary schools in West London were contacted face to face, via email or phone to request their

support in advertising the study to the parents of their pupils.

The online survey was accessed 483 times with 224 participants (186 parents of children

with DCD and 38 parents of TD children) completing the entire survey, resulting in a dropout

rate of 54%. It was not possible to compare the demographic characteristics of those who did not

complete with those who did because the majority of the participants who dropped out of the

study did not provide their demographic information.

Only parents of children who had been diagnosed with DCD by a qualified clinical

professional (e.g. paediatrician), had parent-reported scores of the child’s motor ability at or

below the age-dependent cut-off scores on the motor skills questionnaire and were between 5 and

12 years of age were included in the study. The diagnosis was confirmed through parental report.

The age range of the child between 5 and 12 years old was selected because two of the measures

used in the study, the Parenting Stress Index (Abidin, 1995) and the Developmental Coordination

Disorder Questionnaire ‘07 (Wilson et al., 2009), were only suitable to be used with parents of

20

children between those ages. Parents were excluded from the study if they reported that the child

had a visual impairment, neurological condition or intellectual disability, as these conditions

could have an impact on the child’s motor ability and would not qualify for a diagnosis of DCD.

For the comparison group, parents of TD children between 5 and 12 years of age were included

in the study. Parents were excluded from the study if they reported that the child had a

neurodevelopmental disorder, intellectual disability, or any other medical condition. In total,

twelve parents of children with DCD who completed the survey were excluded for the following

reasons: seven were awaiting or did not have a DCD diagnosis and five had children that were

older than 12 years old. Eight parents of TD children who fully completed the survey were

excluded for the following reasons: three were awaiting a DCD diagnosis/assessment, three had a

child with a neurodevelopmental disorder such as ASD and ADHD, and two did not provide the

child’s date of birth to confirm the age.

The final sample therefore consisted of 174 parents of children with DCD and 24 parents

of TD children. For DCD, the age range for parents was from 31.17 to 53.50 years (M=42.25 and

SD=4.95), and for the children was from 5.17 to 12.92 years (M=9.46 and SD=1.99). For TD, the

age range for parents was from 33.83 to 48.42 years (M=40.26 and SD=3.97), and for the

children was from 5.17 to 12.58 years (M=8.35 and SD=2.12). For both groups the majority of

parents were White British (80.46% for DCD, and 70.83% for TD), had higher education

qualifications or above (78.74% for DCD, and 91.67% for TD), and were in part-time or full-

time employment (83.33% for DCD and 91.67% for TD). In terms of a comorbid diagnosis,

29.3% of children with DCD were reported to also have a diagnosis of ASD and/or ADHD.

Table 1 below describes the comorbidity present within the DCD group.

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Table 1. Comorbid neurodevelopmental disorders in the DCD group

Variable n Percentage

No comorbidity 123 70.7%

ASD 25 14.37%

ADHD 20 11.49%

ASD and ADHD 6 3.45%

ASD: Autism Spectrum Disorder; ADHD: Attention Deficit Hyperactivity Disorder

Materials

Child factors.

Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997). This questionnaire

measures emotional and behavioural difficulties and strengths experienced by children between 4

and 16 years of age. The questionnaire can be completed by parents or by the child if s/he is

older than 11 years old. It includes 25 items and each item describes a behaviour for which the

parent has to indicate whether the child has exhibited that behaviour over the past 6 months or

school year using a 3- point scale (“not true”, “somewhat true”, and “certainly true”). An

example of an item is “often has temper tantrums or hot tempers”. The items are divided in 5

subscales: conduct problems, peer problems, hyperactivity, prosocial behaviour and emotional

symptoms. A total score of difficulties is obtained by summing the items of all the subscales

except the prosocial behaviour subscale. A higher score suggests that the child experiences more

difficulties. The questionnaire demonstrated convergent, criterion and discriminative validity

(Kersten et al., 2016). Rezendes and Scarpa (2011) reported a Cronbach’s alpha of .72 for the

total score of difficulties in a sample of mothers of children with ASD. A similar Cronbach’s

alpha of .68 was obtained for the SDQ total score of difficulties in the current study.

22

Developmental Coordination Disorder Questionnaire ‘07 (DCDQ-07; Wilson et al.,

2009). This questionnaire is a parent report measure of a child’s motor coordination in everyday

activities. It is comprised of 15 items in which the parent is asked to compare the child’s motor

performance to the performance of the child’s peers. An example of an item is: “Your child runs

as fast and in a similar way to other children of the same gender and age”. The questionnaire

uses a 5-point Likert scale ranging from “Not at all like your child” to “Extremely like your

child”. A total score is obtained by adding all the items and lower scores suggest more severe

motor coordination problems. The authors provide age-dependent cut-off scores that indicate a

child is likely to have DCD (score of 46 or below for ages 5-7, 55 or below for ages 8-9, and 57

or below for ages 10-15). The authors suggest that this questionnaire is suitable to use for

children between the ages of 5 and 15 years of age. Wilson et al (2009) reported the DCDQ-07 to

have good ability to detect DCD (sensitivity: 88.5%; specificity: 75.6%), concurrent validity

with performance-based measures of motor ability (r = .55), and high internal consistency (α

= .94). A Cronbach’s alpha for the DCDQ-07 Total score in the current study was high (α = .94).

Parent factors.

Parenting Stress Index/Short Form (PSI/SF; Abidin, 1995). This questionnaire

measures the stress associated with a person’s role as a parent. It consists of 36 items that come

from the Parenting Stress Index full-length questionnaire. The items are written in the form of

statements and the majority require a response from 5 options: strongly agree, agree, not sure,

disagree or strongly disagree. A small number of items have an item-specific different set of 5

response options. For example, one statement is “My child doesn’t seem to learn as quickly as

most children”. The questionnaire is comprised of 3 subscales: Parental Distress, Parent-Child

Dysfunctional Interaction, and Difficult Child, and each scale has 12 items. A score for each

23

subscale is obtained by summing the scores within it, while total scores are obtained through

summing all items. Higher scores suggest higher levels of parenting stress. The total score was

used in this study. Abidin (1995) reported good test-retest reliability (r=.84) and validity of the

measure. Oelofsen and Richardson (2006) reported a Cronbach’s alpha of .94 for the total stress

score in a sample of parents of children with learning disabilities. Cronbach’s alpha for the

PSI/SF Total score in the current study was high (α = .95).

Parenting Sense of Competence Scale (PSOC; Gibaud-Wallston & Wandersman,

1978). This scale measures the level to which parents view themselves as adequate in the

parenting role. The scale consists of 17 items. Each item is written in the form of a statement and

the respondent rates the extent to which s/he agrees or disagrees with each statement using a 6-

point Likert scale that ranges from “strongly disagree” to “strongly agree”. An example of an

items is: “Being a parent is manageable, and any problems are easily resolved”. The total score is

obtained by adding all the items, nine of which are reversed coded. A higher total score suggests

a higher level of sense of competence. The PSOC has demonstrated good convergent and

construct validity (Bui et al., 2017; Karp, Lutenbacher &Wallston, 2015). Vitanza and

Guarnaccia (1999) reported a Cronbach’s alpha of .81 in a sample of mothers of children with

ADHD. Cronbach’s alpha for the PSOC total score in the current study was good (α = .80).

Situational factors.

Family Support Scale (FSS; Dunst, Jenkins & Trivette, 1984). This scale measures the

extent to which parents find helpful the difference sources of support around them when raising a

child. It is comprised of 18 items covering the following sources of support: spouse/partner,

social organisations, formal and informal relationships and professional services. The scale uses

24

a 5-point Likert scale that ranges from “not helpful at all” to extremely helpful” and includes an

additional option “not applicable”. A total score for support is obtained by adding all the items of

the scale. Higher scores demonstrate that the parent perceives that the level of support is helpful.

The FSS has been found to have good predictive validity (Dunst et al., 1984). Hall and Graff

(2011) reported a reliability coefficient of .72 in a sample of parents of children with ADHD. A

similar Cronbach’s alpha of .72 was obtained for the FSS Total score in the current study.

Other information.

Demographic information about the parents and the children. Details about the parent’s

age, gender and ethnicity, and about the child’s age, gender, age at the time of the DCD

diagnosis, and co-occurring diagnoses was obtained by asking a number of closed questions.

Procedure

The study obtained a favourable ethical opinion from the University of Surrey Faculty of

Health and Medical Sciences Ethics Committee (see Appendix B). The study, including the link

to the online survey, was advertised using several methods, such as social media, email, and

word of mouth. Participants were also recruited from other studies at the University. Contact

details were provided to the parents in case they had questions before and during the study.

Qualtrics software was used to build and distribute the online survey for the study. Prior to

completing the survey, participants were asked to read an information sheet containing details

about the study (see Appendix C) and then consent was obtained. The participants completed the

five questionnaires and provided demographic information about themselves and their children.

At the end of the survey, information about relevant support services was offered and they were

asked whether or not they wanted to receive a brief summary of the results of the study. The

25

survey was available for participants to access for a period of 11 months (February 2018 to

January 2019).

Data analyses

All statistical analyses were performed using IBM SPSS version 24. The total and

subscale scores were calculated for every measure. Demographic information about the parents

and their children were compared to establish whether these variables were comparable between

the two groups or whether they needed to be controlled for in subsequent analyses of the data. In

this way potential confounding variables were controlled for as the participants were not

matched on demographic characteristics during recruitment. The assumptions of normality and

homogeneity of variance were checked for all the demographic variables. An Independent t-test

was employed for the variables that met the assumptions of normality and homogeneity of

variance. For the variables that violated these assumptions, Mann-Whitney tests were used. For

categorical data, Pearson’s chi-square test was used to compare the groups.

To assess Hypothesis 1, a hierarchical multiple regression analysis was conducted to

examine whether parents of children with DCD experienced different levels of parenting stress

compared to parents of TD children after controlling for demographic variables that differed

between the groups. The test assumptions were examined. This analysis was conducted first with

and then without the parents of children with DCD who had comorbid ASD and/or ADHD

(N=51). This is because literature suggests higher parenting stress for parents of children with

ADHD and ASD compared to TD controls, so the current results could be confounded by those

comorbid conditions.

26

A linear multiple regression was conducted to explore the factors that predict parenting

stress in parents of children with DCD, assessing Hypothesis 2. The regression assumptions were

examined. Again, the analysis was conducted first with and then without the parents of children

with DCD who had comorbid ASD and/or ADHD.

Power calculations.

It was expected to detect a medium effect size for a multiple regression predicting

parenting stress based on previous studies (e.g. Theule et al., 2011; Mak et al., 2007). Power

calculations were conducted using G*Power v3.1 (Faul, Erdfelder, Buchner & Lang, 2009) and

indicated that a sample size of 92 parents would be required to detect an effect size of 0.5. The

sample size was calculated setting the power at 0.8, alpha at 0.05 and 5 predictors. As such, the

sample size of 174 was adequately powered to detect a medium effect size for Hypothesis 2.

Results

Initial analyses and descriptive statistics

Table 2 summarises the demographic variables of the sample. The data was screened for

the parametric assumptions of normality and homogeneity of variance (see Appendix D). The

distributions of the number of children in the family and DCDQ-07 scores were not found to be

normally-distributed in the DCD group. Comparisons of demographic variables were performed

between groups to identify variables to be included in the hierarchical regression comparing the

study variables between the groups. The age of parents of children with DCD did not differ

significantly from the age of parents of TD children, t (195) = -1.88; p = .06. There was no

significant difference in number of children in the family between the groups, U = 310.50, z = -

27

0.004, p = .997. The age of the children differed significantly between the DCD and TD groups,

with children being older in the DCD group, t (195) = -2.56; p = .01. There was a significant

association between the gender of the child and whether they had DCD, with a higher percentage

of males having DCD, χ2 (1) = 18.87, p < .001, Cramer’s V = 0.31. As the age and gender of the

child were significantly different between groups, these variables were included in the first step

of the hierarchical regression of the group comparisons. As expected, the children in the DCD

group had significantly lower total scores on the DCDQ-07 than those in the TD group, U =

1.50, z = -7.94, p < .001, r = .56.

Table 2. Summary of the demographic characteristics in the DCD and TD groups

Variable DCD(n = 174)

TD(n = 24)

Age of parent, M (SD) years 42.25 (4.95) 40.26 (3.97)

Age of child, M (SD) years 9.46 (1.99) 8.35 (2.12)

Gender of parent

Male, n (%) 9 (5.2%) 3 (12.5%)

Female, n (%) 165 (94.8%) 21 (87.5%)

Gender of child

Male, n (%) 142 (81.6%) 10 (41.7%)

Female, n (%) 32 (18.4%) 14 (58.3%)

Number of children, M (SD) 1.25 (1.22) 1.17 (0.87)

DCDQ-07 Total, M (SD) 26.19 (6.84) 64.25 (7.65)

DCD: Developmental Coordination Disorder; DCDQ-07: Developmental Coordination Disorder Questionnaire – 07; TD: Typically developing

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Group comparison of parenting stress

The parenting stress scores across the groups are summarised in Table 3 below. Three

parents of TD children (12.50%) had a score above the clinical threshold for parental stress

(PSI/SF>90), while 116 parents (66.67%) met the same threshold for the DCD group.

Table 3. Summary of the scores for study variables

Variable DCD(n = 174)

TD(n = 24)

PSI/SF Total, M (SD) 101.10 (24.09) 72.91 (16.73)

PSI/SF Parental Distress, M (SD) 33.78 (9.70) 27.08 (7.01)

PSI/SF Parent-Child Dysfunctional Interaction, M (SD) 29.93 (8.11) 20.33 (5.10)

PSI/SF Difficult Child, M (SD) 37.39 (9.80) 24.63 (7.35)

DCD: Developmental Coordination Disorder; FSS: Family Support Scale; PSI/SF: Parenting Stress Index – Short form; TD: Typically developing

To test Hypothesis 1, the scores of parenting stress were compared between the two

groups. A hierarchical multiple regression was conducted, with age and gender of the child

entered in the first step, and group (DCD vs TD) entered as a dummy variable in the second step.

The assumptions of the regression were checked to determine whether the analysis was valid

(Appendix E). As the assumption of homoscedasticity was not met, bootstrapping with 1,000

samples was used to generate BCa 95% confidence intervals (see Table 4). In Step1, when age

and gender of the child were used to predict parenting stress, the model did not significantly

account for the variance in PSI/SF scores, R2= .02, F (2,195) = 1.89, p = .15. Neither of the two

factors, age of child and gender of child, differed significantly from zero. In Step 2, when group

was added to the model, the model explained 14% of the variance in parenting stress, R2= .14, F

(3,194) = 10.86, p < .001, with an additional 13% of variance explained, R2 = .13,

29

F(1,194)=28.27, p<.001. In addition, the group variable had a statistically significant impact on

parenting stress (see Table 4). This suggests that parents of children with DCD tended to have

higher levels of parenting stress when compared with parents of TD children.

Table 4. Results of the regression analysis predicting parenting stress

Note: R2 = .02 for Step1, R2 = 0.14 for Step 2. BCa: Bias-corrected and accelerated; DCD: Developmental Coordination Disorder; Significant predictors are highlighted in bold.

A similar regression was performed with only parents of children with DCD with no

comorbid ASD and/or ADHD. Similarly, bootstrapping was used due to heteroscedasticity

(Appendix F). In Step1, the model also did not significantly account for the variance in PSI/SF

scores, R2= .02, F (2,144) = 1.38, p = .26, with both age and gender of the child not differing

significantly from zero. In Step 2, the model explained 17% of the variance in parenting stress,

R2= .17, F (3,143) = 9.78, p < .001, with an additional 15% of variance explained, R2 = .15,

F(1,143)=26.09, p<.001. As with the original analysis, the group variable had a statistically

significant impact on parenting stress (see Appendix G). Thus, results were not affected by

including parents of children with DCD and comorbid ASD/ADHD.

30

B SE   B p BCa bootstrap 95% Confidence

Interval

Step1

Constant 89.58 8.54 .001 [71.90, 107.22]

Child age 0.08 0.07 .25 [-0.06, 0.23]

Child gender -5.94 4.43 .18 [-14.21, 2.35]

Step 2

Constant 68.67 8.18 .001 [52.09, 84.32]

Child age 0.03 0.07 .68 [-0.10, 0.18]

Child gender 0.48 4.20 .93 [-8.62, 0.18]

Group 28.83 4.42 .001 [20.89, 37.58]

Factors predicting parenting stress in the DCD group

To address hypothesis 2, Pearson’s correlation coefficients were first calculated for all

the relevant variables in the study in the DCD group only. There was a statistically significant

positive correlation between PSI/SF scores and SDQ Difficulties Total scores (r= .58, p <.001),

i.e. more emotional and behavioural difficulties in children was associated with higher levels of

parenting stress, with this association being large in magnitude. PSI/SF scores were significantly

negatively correlated with DCDQ-07 scores (r= -.22, p= .002), and FSS scores (r= -.33, p <.001),

i.e. higher levels of motor skills in children and more social support to parents were also

associated with lower parenting stress. These relationships had a small to moderate effect. There

was a statistically significant negative correlation between PSI/SF scores and PSOC scores (r=

-.69, p <.001) i.e. higher levels of parental self-efficacy was associated with lower levels of

parenting stress, with this correlation being large in magnitude. These analyses indicate that all

the variables except age of the child (r= .05, p= .27), were correlated with parenting stress. As

such, age of the child was not included in the regression.

A multiple regression was next conducted on the data. The outcome variable was

parenting stress (PSI/SF). The predictor variables consisted of the severity of the motor

impairment (DCDQ-07), the child’s emotional and behavioural difficulties (SDQ), parental sense

of competence (PSOC), and parents’ perceived support (FSS). The regression assumptions met

the requirements (see Appendix H) to ensure results were unbiased and could be generalised.

The results of the regression are shown in Table 5. All the study variables were entered at the

same time. The regression indicated that the four factors explained 61% of the variance in

parenting stress, R2= .61, F (4,169) = 65.10, p < .001. In this analysis, three of the four variables

were uniquely significant predictors. These variables were behavioural and emotional

31

difficulties, parental sense of competence, and social support. These results indicated that parents

of children who displayed more behavioural and emotional difficulties, with lower levels of

sense of competence, and lower levels of perceived support tended to report more parenting

stress.

Table 5. Results of the regression analysis predicting parenting stress

Note: R2 = 0.61. DCDQ-07: Developmental Coordination Disorder Questionnaire – 07; FSS: Family Support Scale; PSOC: Parenting Sense of Competence Scale; SDQ Difficulties Total: Strengths and Difficulties Questionnaire. Significant predictors are highlighted in bold.

A similar regression was again performed with only parents of children with DCD with

no comorbid ASD and/or ADHD. Similarly, the assumptions on the regression performed met

the requirements for validity (Appendix I). As in the previous regression, the four factors

explained 61% of the variance in parenting stress, R2= .61, F (4,118) = 46.82, p < .001 (see

Appendix J). The same three variables, behavioural and emotional difficulties, parental sense of

competence and support, were uniquely significant. Similar to Hypothesis 1, the inclusion of

parents of children with DCD and ASD/ADHD did not affect the results from the full sample.

Discussion

The current study was the first to investigate levels of parenting stress and the factors that

predict this stress in parents of children with DCD. The findings provided evidence that parents

of children with DCD experience greater levels of self-reported parenting stress compared to

32

B SE   B β p

Constant 164.04 12.02 <.001

DCDQ-07 -.08 .18 -.02 .67

SDQ Total Difficulties 1.29 .21 .34 <.001

PSOC -1.20 .12 -.54 <.001

FSS -.26 .12 -.11 .03

parents of TD children. Specifically, two thirds of parents of children with DCD had scores that

were clinically significant compared to 13% of parents of TD children. The results demonstrated

that, together, the child’s motor coordination and behavioural and emotional difficulties, the

parent’s sense of competence, and the parent’s perceived social support predicted parenting

stress in parents of children with DCD, with the latter three factors being unique significant

predictors.

Parenting stress between groups

The findings supported the first hypothesis that parents of children with DCD would

experience a higher degree of parenting stress when compared to parents of TD children. This

finding was consistent with previous studies that have compared parenting stress between parents

of TD children and parents of children with developmental disabilities (Oelofsen & Richardson,

2006; Woolfson & Grant, 2006), and ADHD and ASD (Breen and Barkley, 1988; Hutchinson, et

al, 2016; Keenan, et al, 2016; Lai et al, 2015). This indicates that, similar to parents of children

with other neurodevelopmental disabilities, parents of children with DCD find meeting the

demands of caring for their child challenging, which leads them to experience high levels of

stress. Motor skills play an important role in how individuals interact with the world and children

with DCD have difficulty learning and executing these skills compared to children who are able

to master them effortlessly (Fox & Lent, 1996). Parents may therefore need to provide more

regular support for their children and their role as a parent may become more demanding, which

could lead to an increase in stress. Research has indicated that children with DCD experience

difficulties in several areas of their lives, including personal hygiene and dressing (Summers,

Larkin, & Dewey, 2008), academic performance (Pieters, Desoete, Van Waelvelde,

Vanderswalmen, & Roeyers, 2012; Alloway, 2007), mental health (Francis & Piek, 2003; Pratt

33

& Hill, 2011), participation in activities (Magalhaes, Cardoso, & Missiuna, 2011) and social

problems (Dewey, Kaplan, Crawford & Wilson, 2002). Given the widespread difficulties

experienced by the child, this may mean that there is a higher demand on parental resources in

the form of support to help the child cope with their difficulties, as well as being an advocate for

the child to get the appropriate support from the school and services.

The results also indicated that a high proportion, 66%, of parents of children with DCD

experienced a level of stress that was considered to be clinically significant, while a small

proportion of parents of TD children reported levels of parenting stress above the clinical cut-off.

This finding is consistent with previous studies that reported that 57% of the parents of children

with developmental disabilities scored within the clinically significant range for parenting stress

compared to 8% for parents of TD children (Woolfson & Grant, 2006). For parents of children

with ASD, between 62.7 - 85% had scores within the clinical range (Hall & Graff, 2011;

Ingersoll & Hambrick, 2011). Although it is difficult to establish whether these high scores of

parenting stress reported are indicative of a considerable mental health problem, this nevertheless

deserves attention as it suggests a potential negative impact on the parents’ mental health.

Parents of children with DCD who are experiencing high levels of stress associated with

parenthood may be more likely to behave in a less optimal manner towards their children when

faced with the high demands of being a parent. For example, higher levels of stress have been

associated with negative parenting behaviours such as more maternal insensitivity towards the

child (Gerstein & Poehlmann-Tynan, 2015), less optimal emotional availability (McMahon &

Meins, 2012), and power assertive parenting responses to transgression (Critchley & Sanson,

2006). These behaviours could have a negative impact on the parent-child relationship and lead

to a cycle in which the child’s and the parents’ well-being is negatively affected. Studies have

34

also found that stress has a detrimental impact on cognitive processes such as reflective thinking,

decision making and information processing abilities (Preston, Buchanan, Stansfield, & Bechara,

2007; Simonovic, Stupple, Gale, & Sheffield, 2017; Starcke, Wolf, Markowitsch, & Brand,

2008). As such, the stress the parents are experiencing may have a negative impact on their

ability to reflect on and understand the motivators driving their own and their child’s behaviours,

a cognitive process that Rosenblum, McDonough, Sameroff, and Muzik (2008) argue plays a

role in how a parent responds to the behaviours and emotional needs of their children.

Factors predicting parenting stress in parents of children with DCD

The results of the current study supported the second hypothesis that child-related,

parent-related and situational factors would predict parenting stress in parents of children with

DCD. First, these factors accounted for a significant amount of the variance in parenting stress

for parents of children with DCD. This also provides evidence that supports Abidin’s (1976)

model of parenting stress as a useful framework that can help with understanding the factors that

are relevant for parents of children with DCD. The following sections explore the results of the

factors considered in the model.

Child factors

Two factors associated with the child’s characteristics were investigated in this study:

severity of motor difficulties, and behavioural and emotional problems. Only the behavioural

problems experienced by the child was a significant predictor in the model. Behavioural

problems being a statistically significant predictor of parenting stress is in line with previous

findings in both ASD (Huang et al., 2014; Krakovich, et al., 2016) and ADHD (Pimentel et al.,

2011; Vitanza & Guarnaccia, 1999). However, the severity of motor skills not being a

35

statistically significant predictor was more surprising given that motor skills were reported to be

a significant predictor of maternal stress in the general population (Takahashi et al., 2017).

Moreover, the literature on ASD (Lyons et al., 2010; Firth & Dryer, 2013) and ADHD (Graziano

et al., 2011; Li & Lansford, 2018) had suggested that the severity of the symptoms was a

statistically significant predictor or was positively associated, respectively, with higher levels of

parenting stress.

One factor that may explain motor skills not being a statistically significant predictor of

parenting stress is that children with DCD already have considerable deficits in motor skills to be

assessed as having DCD. As a result, the variability within the sample may not be sufficient to

have an impact on the levels of parenting stress experienced by parents. This would mean that

once a certain level of considerable motor impairment is reached, whether there is a slightly

higher or lower score is no longer relevant. However, when considering the general population of

parents, as in the Takahashi et al. (2017) study, greater impairment of motor skills was found to

impact parenting stress. This is again supported by the current study, wherein parents of children

with DCD have higher levels of parenting stress than parents of TD children. Therefore, it is

consistent that the impairment of motor skills was a significant predictor of maternal stress in the

general population, and the current study of children with DCD did not find similar evidence.

Another possibility is that the secondary difficulties associated with the motor difficulties in

DCD are capturing some of the variability related to the impact of a child’s motor skills on

parenting stress. Research has suggested that there are a number of secondary difficulties that are

experienced by children with DCD including academic, psychological and physical issues

(Zwicker et al, 2012). Further research will be required to better understand these potential

explanations. Nevertheless, the current study did find evidence that child-related factors were a

36

statistically significant predictor of parenting stress, in line with Abidin’s (1976) model of

parenting stress, again supporting the use of that framework when considering parenting stress

for parents of children with DCD.

Parent characteristics

Parental self-efficacy was the factor associated with parents’ characteristics assessed in

the current study as a potential predictor of parenting stress for parents of children with DCD.

The results suggest that parental self-efficacy is a statistically significant predictor of parenting

stress, with a negative association between the two variables, i.e. a higher level of parental self-

efficacy predicts a lower level of parenting stress. These findings provide support in DCD for

what several studies have identified in ASD (Kuhn & Carter, 2006; May et al., 2015; Mak et al,

2007) and ADHD (Williamson & Johnston, 2019; Hastings & Symes 2002). Moreover, changes

to parental self-efficacy had the greatest impact on the predicted parenting stress levels in the

model.

Conceptually, one potential explanation for these results is that parents with low self-

efficacy see themselves as less able in their role as a caregiver and less effective in managing

tasks related to parenting (Teti et al., 1996), which could lead to them considering themselves

more negatively as a resource to meet the demands of parenting when compared to parents with

higher self-efficacy. This could then increase their parenting stress. There is some evidence in

the literature to support this conceptual argument. Lavenda and Kessler-Peleg (2017) found in a

study of parents of TD children that, for parents with low self-efficacy, spouse contribution was

a more significant predictor of parenting stress than for parents with higher self-efficacy. This

could mean that those parents rely more on their spouse to meet the parenting demands, and

37

consequentially, their parenting stress is more dependent on that support. Conversely, parents

with higher self-efficacy may rely more on themselves to meet the demands of parenting, which

would lead to the amount of spouse support available having a lower impact on their parenting

stress. However, more research needs to be conducted on the mechanism behind the relationship

between self-efficacy and parenting stress to better understand whether this is the case.

Nevertheless, given that self-efficacy had the largest modelled impact on parenting stress, it

would be important that interventions support parents in becoming more confident in their

abilities to care for their children to help them decrease their parenting stress levels.

Situational characteristics

The level of social support was the predictor used in this study to capture situational

characteristics. Again, the study found social support to be a statistically significant predictor of

parenting stress, with a negative association between the two factors, i.e. lower levels of social

support predict a higher level of parenting stress. These findings were in line with studies on

ASD (Falk et al., 2014; Zamora et al., 2014; Thullen & Bonsal, 2017; Hill-Chapman et al., 2013;

Derguy et al., 2016; Krakovich et al., 2016) and ADHD (Theule et al., 2011; Vitanza &

Guarnaccia, 1999) that focused on the role that social support, family interactions, and other

sources of support had on parenting stress. This is also consistent with Soriano et al. (2015), who

identified that parents who were dissatisfied with the DCD diagnosis process also found it

stressful. As suggested in Abidin’s model, this result suggests that parenting stress is affected by

the support network available to them. In this case, parents of children with DCD who had

greater social support had a lower level of parenting stress. This could potentially mean that

where the parent feels less confident in his/her competence as a parent, having a wider social

38

network that supports them would lead to lower parenting stress than would otherwise be the

case.

Moreover, these findings reinforce the importance of strong support for parents of

children with DCD when engaging services. The literature suggests that DCD is poorly

understood among professionals (Gaines, Missiuna, Egan, & McLean, 2008; Wilson, Neil,

Kamps, & Babcock, 2013). Families often report difficulties obtaining support (Stephenson &

Chesson, 2008), and when they receive support, they are dissatisfied with it (Soriano et al.,

2015). This lack of knowledge and poor or no support could then lead to an increase in parenting

stress and ultimately to worse child outcomes.

Finally, there was no impact on the results of the analysis when parents of children that

had a comorbid neurodevelopmental disorder (i.e. ASD and/or ADHD) were included or

excluded. This suggests that similar factors may be contributing to the stress of these parents,

with the exception of severity of symptoms. This would be in line with the literature on ASD and

ADHD that has identified the factors assessed in this study as predictors of parenting stress in

those groups (e.g. Falk et al, 2014; Pimentel et al. 2011). This could be explained by the overlap

also identified in the literature between the difficulties experienced by children with these three

neurodevelopmental disorders (Pitcher et al., 2003; Sumner et al., 2016). This is contrary to the

findings of Ashworth et al. (2019) that suggested a difference in factors that contributed to stress,

in particular for disorders that are less prevalent. This contradiction may result from DCD being

a prevalent neurodevelopmental disorder, while that study’s main finding related to rare

disorders. Moreover, this finding implies that there are many parallels between the support and

interventions needed for parents of children with these neurodevelopmental disorders, and

39

synergies that can be leveraged by schools and services to improve the support for parents of

children with DCD.

Strengths and Limitations

This is the first study to focus on levels of parenting stress and the factors that predict this

stress in parents of children with DCD. One of the key strengths, therefore, is that it shines the

first light into whether the knowledge gained in more widely researched neurodevelopmental

disorders, such as ASD and ADHD, can be a good starting point for assessment of parenting

stress for parents of children with DCD. Given the high prevalence of DCD amongst children,

these findings can help improve the understanding and the well-being of a large group of parents

that have so far been understudied. In addition, it provides contributing evidence on the factors

that predict parenting stress for this group of parents that so far had not been studied, which can

now be taken into account in a clinical setting to better support them. Moreover, the study is

based on a strong theoretical basis, the Abidin’s model, and allows for specific factors to be

assessed for DCD that have been deemed significant in the literature for other

neurodevelopmental disorders. Another strength of this study was the large sample size of

parents of children with DCD, which ensured there was enough power to effectively interpret the

regression in Hypothesis 2.

Nevertheless, there were a number of limitations in this study that could be improved

upon in the future. First, all the measures in this study were self-reported and completed by one

informant. Studies have identified differences in reporting of a child’s emotional and behavioural

problems and symptomatology of neurodevelopmental disorders (ADHD) between informants

(i.e. parents vs teachers, mother vs fathers) (Crane, Sumner, & Hill, 2017; Nelson, O'brien,

40

Calkins, & Keane, 2013; Wolraich et al., 2004). This difference in reporting may have an impact

on the findings as a previous study found that child’s behavioural problems were a significant

predictor of parental stress when the parent-report instead of the teacher-report was included in

the model (Thuele et al., 2011). This means that bias could have been introduced by parents in

the different measures. Therefore, having more informants or objective measures of the level of

motor impairment or behavioural problems could help attest the robustness of these results.

Secondly, the study was cross-sectional and as a result data was collected at a particular

point in time. This means that a causal relationship cannot be established between parenting

stress and the variables measured. As such, longitudinal studies on the factors predicting

parenting stress for parents of children with DCD can be useful to better understand whether

changes to these factors does lead to a change in parenting stress, while controlling for potential

confounding variables. In the context of neurodevelopmental disorders, these longitudinal studies

can also lead to a better understanding of whether there are differences to parenting stress levels

and the factors that predict it as children age (Gray, 2002).

Finally, most of the sample was composed of White British, well-educated mothers,

which means we may not have captured the experience of fathers, and the wider population of

parents of children with DCD in the UK. Previous research has suggested that there are

similarities and differences in the factors that are associated with high parenting stress between

mothers and fathers of children with ASD (Pozo & Sarria, 2014; Rivard, Terroux, Parent-

Boursier, & Mercier, 2014; Hastings 2003). In particular, Foody, James, and Leader (2015)

reported that mothers of children with ASD had higher levels of parenting stress compared to

fathers and attributed this to higher level involvement of mothers in parenting in their study.

Therefore, developing a better understanding of the differences and similarities between the

41

experiences of mothers and fathers of children with DCD can help service providers to better

support their needs.

Clinical implications

The current study highlights that parents of children with DCD experience higher levels

of parenting stress, with two-thirds of the sample experiencing levels that are within the clinical

range. This finding suggests that parents of children with DCD may be a vulnerable group that

may require support from professionals to cope with the demands of being a parent. This is

important as studies have reported that higher levels of parenting stress were associated with

lower ratings of quality of life and well-being, and other mental health difficulties such as more

depressive symptoms and higher levels of anxiety (Hsiao, 2016; Phetrasuwan & Shador Miles,

2009; Wang et al., 2013). Providing a parenting intervention could also benefit children with

DCD, given that theory and literature indicate that parents’ experience of considerable amounts

of stress is associated with negative parenting behaviours and parent-child interactions (Jarvis &

Creasey, 1991; Östberg, 1998, Abidin 1976).

Furthermore, these parents may experience these high levels of stress for a prolonged

period of time, as the literature on parents of children with ASD suggests that parenting stress for

mothers remains high (McStay, Trembath and Dissanayake, 2014) and consistent across time

(Zaidman-Zait et al., 2014; McStay et al. 2014). Hence, it is important for professionals to

consider the well-being of the parents alongside the diagnosis of DCD in order to prevent high

levels of enduring parenting stress. In addition, as the diagnosis of DCD in itself has been found

to be stressful (Soriano et al., 2015), interventions at that time can help mitigate the additional

42

stress on parents undergoing this process. As suggested by Abidin’s model, interventions to help

reduce parenting stress would also translate to better child outcomes.

Another clinically relevant factor is the role that parental self-efficacy may play on

parenting stress. The current study suggests that parents’ confidence in their role as a parent may

have a substantial impact on parenting stress. This means that professionals who are supporting

children with DCD could help improve parenting stress by providing parents with the relevant

skills, information, and support in order to improve their confidence when caring for their

children.

The current study findings of factors predicting parenting stress suggest that interventions

for parents should focus on increasing parenting self-efficacy, management of the child’s

behavioural and emotional difficulties, and increasing the quantity and quality of the social

support. One such intervention is the Triple P – Positive Parenting Program (Sanders, 1999),

specifically, the Enhanced Triple P (Sanders, 1999), as it not only incorporates parenting skills

but also strategies for the parent to manage their stress and maximise the support from partners.

Studies have shown that the use of the Enhanced Triple P intervention with parents increased

parenting self-efficacy and lowered levels of child behaviour problems (Sanders, Kirby,

Tellegen, & Day, 2014; Sanders, Markie-Dadds, Tully, & Bor, 2000). Increasing the repertoire

of strategies available to parents might allow them to feel more confident when dealing with the

unique demands of supporting and caring for a child with DCD.

Conclusion

The current study identified that parents of children with DCD have higher levels of

parenting stress compared to parents of TD children, with a high proportion of these parents

43

scoring within the clinical range. Furthermore, parenting self-efficacy, the child’s behavioural

and emotional difficulties, and social support were found to be factors that may be contributing

to parenting stress in parents of children with DCD. This adds to the literature into parenting

stress in parents of children with ASD and ADHD. However, unlike the literature on ASD and

ADHD, this study did not find that severity of child DCD symptoms was a significant predictor

of parenting stress. Given that this was the first study to investigate the predictors of parenting

stress in DCD, future research should focus on replicating the results with both mothers and

fathers, exploring other measures of child, parental, and situational variables in line with

Abidin’s model, and assessing causality through longitudinal studies. The current study

highlights that raising a child with DCD is likely to lead parents to experience high levels of

parenting stress and professionals need to identify and address this stress in order to improve

parental well-being and child outcomes.

44

References

Abidin, R. R. (1995). Parenting Stress Index, Third Edition: Professional Manual. Odessa, FL:

Psychological Assessment Resources, Inc.

Alloway, T. P. (2007). Working memory, reading, and mathematical skills in children with

developmental coordination disorder. Journal of Experimental Child Psychology, 96(1),

20-36.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Washington, DC: American Psychiatric Publishing.

Ashworth M, Palikara O, & Van Herwegen J. (2019). Comparing parental stress of children with

neurodevelopmental disorders: The case of Williams syndrome, Down syndrome and

autism spectrum disorders. J Appl Res Intellect Disabil, 2019, 1–11.

Beer, M., Ward, L., & Moar, K. (2013). The relationship between mindful parenting and distress

in parents of children with an autism spectrum disorder. Mindfulness, 4(2), 102-112.

Belsky, J. (1984). The Determinants of Parenting: A Process Model. Child Development, 55(1),

83-96.

Benson, P. R. (2006). The impact of child symptom severity on depressed mood among parents

of children with ASD: The mediating role of stress proliferation. Journal of Autism and

Developmental Disorders, 36(5), 685-695. 

45

Breen, M. J., & Barkley, R. A. (1988). Child psychopathology and parenting stress in girls and

boys having attention deficit disorder with hyperactivity. Journal of Paediatric

Psychology, 13(2), 265-280.

Bui, E., Zakarian, R. J., Laifer, L. M., Sager, J. C., Chen, Y., Cohen, S., ... & Ohye, B. (2017).

Psychometric properties of the Parenting Sense of Competence Scale in treatment-

seeking post-9/11 veterans. Journal of Child and Family Studies, 26(2), 464-470.

Cousins, M., & Smyth, M. M. (2003). Developmental coordination impairments in adulthood.

Human Movement Science, 22, 433–459.

Crane, L., Sumner, E., & Hill, E. L. (2017). Emotional and behavioural problems in children

with Developmental Coordination Disorder: Exploring parent and teacher

reports. Research in Developmental Disabilities, 70, 67-74.

Critchley, C. R., & Sanson, A. V. (2006). Is parent disciplinary behavior enduring or situational?

A multilevel modeling investigation of individual and contextual influences on power

assertive and inductive reasoning behaviors. Journal of Applied Developmental

Psychology, 27(4), 370-388.

Crnic, K. A., & Greenberg, M. T. (1990). Minor parenting stresses with young children. Child

Development, 61(5), 1628-1637.

Crnic, K. A., Gaze, C., & Hoffman, C. (2005). Cumulative parenting stress across the preschool

period: Relations to maternal parenting and child behaviour at age 5. Infant and Child

Development: An International Journal of Research and Practice, 14(2), 117-132.

46

Davis, N. O., & Carter, A. S. (2008). Parenting stress in mothers and fathers of toddlers with

autism spectrum disorders: Associations with child characteristics. Journal of Autism and

Developmental Disorders, 38(7), 1278.

Deater‐Deckard, K. (1998). Parenting stress and child adjustment: Some old hypotheses and new

questions. Clinical Psychology: Science and Practice, 5(3), 314-332.

de Cock, E. S., Hendrics, J., Klimstra, T. A., Maas, A. J., Vreeswijk, C. M., Meeus, W. H., &

van Bakel, H. J. (2017). Longitudinal Associations Between Parental Bonding, Parenting

Stress, and Executive Functioning in Toddlerhood. Journal of Child and Family Studies,

26(6), 1723-1733.

Derguy, C., M’Bailara, K., Michel, G., Roux, S., & Bouvard, M. (2016). The need for an

ecological approach to parental stress in autism spectrum disorders: The combined role of

individual and environmental factors. Journal of Autism and Developmental

Disorders, 46(6), 1895-1905.

Dewey, D., Kaplan, B. J., Crawford, S. G., & Wilson, B. N. (2002). Developmental coordination

disorder: associated problems in attention, learning, and psychosocial adjustment. Human

Movement Science, 21(5-6), 905-918.

Dunst, C. J., Jenkins, V., & Trivette, C. (1984). Family Support Scale: Reliability and validity.

Journal of Individual, Family, and Community Wellness, 1(4), 45–52.

Durbin, J., & Watson, G. S. (1951). Testing for serial correlation in least squares regression.

II. Biometrika, 38(1/2), 159-177.

47

Falk, N. H., Norris, K., & Quinn, M. G. (2014). The factors predicting stress, anxiety and

depression in the parents of children with autism. Journal of Autism and Developmental

Disorders, 44(12), 3185-3203.

Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Statistical power analyses using

G*Power 3.1: Tests for correlation and regression analyses. Behavior Research

Methods, 41, 1149-1160.

Field, A. (2018). Discovering statistics using IBM SPSS statistics. London. England: Sage

Publications.

Firth, I., & Dryer, R. (2013). The predictors of distress in parents of children with autism

spectrum disorder. Journal of Intellectual & Developmental Disability, 38(2), 163-171.

Foody, C., James, J. E., & Leader, G. (2014). Parenting stress, salivary biomarkers, and

ambulatory blood pressure in mothers of children with autism spectrum

disorders. Research in Autism Spectrum Disorders, 8(2), 99-110.

Foody, C., James, J. E., & Leader, G. (2015). Parenting stress, salivary biomarkers, and

ambulatory blood pressure: A comparison between mothers and fathers of children with

autism spectrum disorders. Journal of Autism and Developmental Disorders, 45(4), 1084-

1095.

Fox, A. M., & Lent, B. (1996). Clumsy children. Primer on developmental coordination

disorder. Canadian Family Physician, 42, 1965.

Francis, M., & Piek, J. (2003). The effects of perceived social support and self-worth on

depressive symptomatology in children with and without developmental coordination

48

disorder (DCD). In Proceedings of the 38th APS annual conference (pp. 70-74). The

Australian Psychological Society Ltd.

Gaines, R., Missiuna, C., Egan, M., & McLean, J. (2008). Educational outreach and

collaborative care enhances physician’s perceived knowledge about Developmental

Coordination Disorder. BMC Health Services Research, 8, 21–21.

Gerstein, E. D., & Poehlmann-Tynan, J. (2015). Transactional processes in children born

preterm: Influences of mother–child interactions and parenting stress. Journal of Family

Psychology, 29(5), 777.

Giallo, R., Wood, C. E., Jellett, R., & Porter, R. (2011). Fatigue, wellbeing and parental self-

efficacy in mothers of children with an autism spectrum disorder. Autism, 17(4), 465-480.

Gibaud-Wallston J. & Wandersman L. P. (1978) Development and Utility of the Parenting Sense

of Competence Scale. Paper presented at the meeting of the American Psychological

Association, Toronto.

Goodman, R. (1997). The Strengths and Difficulties Questionnaire: a research note. Journal of

Child Psychology and Psychiatry, 38(5), 581-586.

Gray, D. E. (2002). Ten years on: A longitudinal study of families of children with

autism. Journal of Intellectual and Developmental Disability, 27(3), 215-222

Graziano, P. A., McNamara, J. P., Geffken, G. R., & Reid, A. (2011). Severity of children's

ADHD symptoms and parenting stress: A multiple mediation model of self-

regulation. Journal of Abnormal Child Psychology, 39(7), 1073-1083.

49

Hall, H. R., & Graff, J. C. (2011). The relationships among adaptive behaviors of children with

autism, family support, parenting stress, and coping. Issues in Comprehensive Pediatric

Nursing, 34(1), 4-25.

Harris, S. R., Mickelson, E. C., & Zwicker, J. G. (2015). Diagnosis and management of

developmental coordination disorder. CMAJ, 187(9), 659-665.

Hastings, R. P., & Symes, M. D. (2002). Early intensive behavioral intervention for children with

autism: Parental therapeutic self-efficacy. Research in developmental disabilities, 23(5),

332-341.

Hastings, R. P. (2003). Child behaviour problems and partner mental health as correlates of

stress in mothers and fathers of children with autism. Journal of Intellectual Disability

Research, 47(4-5), 231-237.

Hill, E. L., Brown, D., & Sorgardt, K. S. (2011). A preliminary investigation of quality of life

satisfaction reports in emerging adults with and without developmental coordination

disorder. Journal of Adult Development, 18(3), 130-134.

Hill-Chapman, C., Herzog, T. K., & Maduro, R. S. (2013). Aligning over the child: Parenting

alliance mediates the association of autism spectrum disorder atypicality with parenting

stress. Research in Developmental Disabilities, 34(5), 1498-1504.

Hsiao, Y. (2016). Pathways to mental health-related quality of life for parents of children with

autism spectrum disorder: Roles of parental stress, children's performance, medical

support, and neighbor support. Research in Autism Spectrum Disorders, 23, 122-130.

50

Huang, C., Yen, H., Tseng, M., Tung, L., Chen, Y., & Chen, K. (2014). Impacts of autistic

behaviors, emotional and behavioral problems on parenting stress in caregivers of

children with autism. Journal of Autism and Developmental Disorders, 44(6), 1383-1390.

Hutchison, L., Feder, M., Abar, B., & Winsler, A. (2016). Relations between parenting stress,

parenting style, and child executive functioning for children with ADHD or

autism. Journal of Child and Family Studies, 25(12), 3644-3656.

IBM Corp. Released 2017. IBM SPSS Statistics for Apple, Version 24.0. Armonk, NY: IBM

Corp.

Ingersoll, B., & Hambrick, D. Z. (2011). The relationship between the broader autism phenotype,

child severity, and stress and depression in parents of children with autism spectrum

disorders. Research in Autism Spectrum Disorders, 5(1), 337-344.

Jarvis, P. L., & Creasey, G. L. (1991). Parental stress, coping, and attachment in families with an

18-month-old infant. Infant Behavior and Development, 14(4), 383-395.

Karp, S. M., Lutenbacher, M., & Wallston, K. A. (2015). Evaluation of the parenting sense of

competence scale in mothers of infants. Journal of Child and Family Studies, 24(11),

3474-3481.

Keenan, B. M., Newman, L. K., Gray, K. M., & Rinehart, N. J. (2016). Parents of children with

ASD experience more psychological distress, parenting stress, and attachment-related

anxiety. Journal of Autism and Developmental Disorders, 46(9), 2979-2991.

Kersten, P., Czuba, K., McPherson, K., Dudley, M., Elder, H., Tauroa, R., & Vandal, A. (2016).

A systematic review of evidence for the psychometric properties of the Strengths and

51

Difficulties Questionnaire. International Journal of Behavioral Development, 40(1), 64-

75.

Koegel, R. L., Schreibman, L., Loos, L. M., Dirlich-Wilhelm, H., Dunlap, G., Robbins, F. R., &

Plienis, A. J. (1992). Consistent stress profiles in mothers of children with

autism. Journal of Autism and Developmental Disorders, 22(2), 205-216.

Krakovich, T. M., McGrew, J. H., Yu, Y., & Ruble, L. A. (2016). Stress in parents of children

with autism spectrum disorder: An exploration of demands and resources. Journal of

Autism and Developmental Disorders, 46(6), 2042-2053.

Kuhn, J. C., & Carter, A. S. (2006). Maternal self‐efficacy and associated parenting cognitions

among mothers of children with autism. American Journal of Orthopsychiatry, 76(4),

564-575.

Lai, W. W., Goh, T. J., Oei, T. P. S., & Sung, M. (2015). Coping and well-being in parents of

children with autism spectrum disorders (ASD). Journal of Autism and Developmental

Disorders, 45(8), 2582-2593.

Lavenda, O., & Kestler-Peleg, M. (2017). Parental self-efficacy mitigates the association

between low spousal support and stress. Psychiatry research, 256, 228-230.

Leonard, H. C. (2016). The impact of poor motor skills on perceptual, social and cognitive

development: The case of developmental coordination disorder. Frontiers in

Psychology, 7, 311.

52

Li, J. J., & Lansford, J. E. (2018). A smartphone-based ecological momentary assessment of

parental behavioral consistency: Associations with parental stress and child ADHD

symptoms. Developmental Psychology, 54(6), 1086–1098.

Lindsey, R. A., & Barry, T. D. (2018). Protective factors against distress for caregivers of a child

with autism spectrum disorder. Journal of Autism and Developmental Disorders, 48(4),

1092-1107.

Lyons, A. M., Leon, S. C., Phelps, C. E. R., & Dunleavy, A. M. (2010). The impact of child

symptom severity on stress among parents of children with ASD: The moderating role of

coping styles. Journal of Child and Family Studies, 19(4), 516-524.

Magalhaes, L. C., Cardoso, A. A., & Missiuna, C. (2011). Activities and participation in children

with developmental coordination disorder: A systematic review. Research in

Developmental Disabilities, 32(4), 1309-1316.

Mak, W. W., Ho, A. H., & Law, R. W. (2007). Sense of coherence, parenting attitudes and stress

among mothers of children with autism in Hong Kong. Journal of Applied Research in

Intellectual Disabilities, 20(2), 157-167.

May, C., Fletcher, R., Dempsey, I., & Newman, L. (2015). Modeling relations among

coparenting quality, autism-specific parenting self-efficacy, and parenting stress in

mothers and fathers of children with ASD. Parenting: Science and Practice, 15(2), 119-

133.

McMahon, C. A., & Meins, E. (2012). Mind-mindedness, parenting stress, and emotional

availability in mothers of preschoolers. Early Childhood Research Quarterly, 27(2), 245-

252.

53

McStay, R. L., Trembath, D., & Dissanayake, C. (2014a). Maternal stress and family quality of

life in response to raising a child with autism: From preschool to adolescence. Research

in Developmental Disabilities, 35(11), 3119-3130.

Menard, S. (1995). An introduction to logistic regression diagnostics. Applied Logistic

Regression Analysis, 58-79.

Meirsschaut, M., Roeyers, H., & Warreyn, P. (2010). Parenting in families with a child with

autism spectrum disorder and a typically developing child: Mothers’ experiences and

cognitions. Research in Autism Spectrum Disorders, 4(4), 661-669.

Minnes, P., Perry, A., & Weiss, J. A. (2015). Predictors of distress and well‐being in parents of

young children with developmental delays and disabilities: the importance of parent

perceptions. Journal of Intellectual Disability Research, 59(6), 551-560.

Moh, T. A., & Magiati, I. (2012). Factors associated with parental stress and satisfaction during

the process of diagnosis of children with autism spectrum disorders. Research in Autism

Spectrum Disorders, 6(1), 293-303.

Myers, R. H., & Myers, R. H. (1990). Classical and modern regression with applications (Vol.

2). Belmont, CA: Duxbury press.

Neece, C. L., Green, S. A., & Baker, B. L. (2012). Parenting stress and child behavior problems:

A transactional relationship across time. American Journal on Intellectual and

Developmental Disabilities, 117(1), 48-66.

54

Nelson, J. A., O'brien, M., Calkins, S. D., & Keane, S. P. (2013). Mothers' and fathers' negative

responsibility attributions and perceptions of children's problem behavior. Personal

Relationships, 20(4), 719-727.

Oelofsen, N., & Richardson, P. (2006). Sense of coherence and parenting stress in mothers and

fathers of preschool children with developmental disability. Journal of Intellectual and

Developmental Disability, 31(1), 1-12.

Östberg, M. (1998). Parental stress, psychosocial problems and responsiveness in help-seeking

parents with small (2–45 months old) children. Acta Paediatrica, 87(1), 69-76.

Phetrasuwan, S., & Miles, M. S. (2009). Parenting stress in mothers of children with autism

spectrum disorders. Journal for Specialists in Pediatric Nursing, 14(3), 157-165.

Pieters, S., Desoete, A., Van Waelvelde, H., Vanderswalmen, R., & Roeyers, H. (2012).

Mathematical problems in children with developmental coordination disorder. Research

in Developmental Disabilities, 33(4), 1128-1135.

Pimentel, M. J., Vieira-Santos, S., Santos, V., & Vale, M. C. (2011). Mothers of children with

attention deficit/hyperactivity disorder: Relationship among parenting stress, parental

practices and child behaviour. Attention Deficit and Hyperactivity Disorders, 3(1), 61-68.

Pitcher, T.M., Piek, J.P. and Hay, D.A. (2003). Fine and gross motor ability in males with

ADHD. Dev Med Child Neurol, 45(8), 525–35.

Pozo, P., & Sarriá, E. (2014a). A global model of stress in parents of individuals with autism

spectrum disorders (ASD). Anales De Psicología, 30(1), 181-192. 

55

Pratt, M. L., & Hill, E. L. (2011). Anxiety profiles in children with and without developmental

coordination disorder. Research in Developmental Disabilities, 32(4), 1253-1259.

Preston, S. D., Buchanan, T. W., Stansfield, R. B., & Bechara, A. (2007). Effects of anticipatory

stress on decision making in a gambling task. Behavioral Neuroscience, 121(2), 257.

Primack, B. A., Hendricks, K. M., Longacre, M. R., Adachi-Mejia, A. M., Weiss, J. E., Titus, L.

J., ... & Dalton, M. A. (2012). Parental efficacy and child behavior in a community

sample of children with and without attention-deficit hyperactivity disorder

(ADHD). ADHD Attention Deficit and Hyperactivity Disorders, 4(4), 189-197.

Qualtrics, (2017). Provo, UT, USA. Accessed via http://www.qualtrics.com.

Rezendes, D. L., & Scarpa, A. (2011). Associations between parental anxiety/depression and

child behavior problems related to autism spectrum disorders: The roles of parenting

stress and parenting self-efficacy. Autism Research and Treatment, 2011.

Rivard, M., Terroux, A., Parent-Boursier, C., & Mercier, C. (2014). Determinants of stress in

parents of children with autism spectrum disorders. Journal of Autism and

Developmental Disorders, 44(7), 1609-1620.

Rodriguez, C. M. (2011). Association between independent reports of maternal parenting stress

and children’s internalizing symptomatology. Journal of Child and Family

Studies, 20(5), 631-639.

Rosenblum, K. L., McDonough, S. C., Sameroff, A. J., & Muzik, M. (2008). Reflection in

thought and action: Maternal parenting reflectivity predicts mind‐minded comments and

interactive behavior. Infant Mental Health Journal: Official Publication of The World

Association for Infant Mental Health, 29(4), 362-376.

56

Sanders, M. R., Kirby, J. N., Tellegen, C. L., & Day, J. J. (2014). The Triple P-Positive

Parenting Program: A systematic review and meta-analysis of a multi-level system of

parenting support. Clinical Psychology Review, 34(4), 337-357.

Sanders, M. R., Markie-Dadds, C., Tully, L. A., & Bor, W. (2000). The triple P-positive

parenting program: a comparison of enhanced, standard, and self-directed behavioral

family intervention for parents of children with early onset conduct problems. Journal of

Consulting and Clinical Psychology, 68(4), 624.

Sanders, M. R. (1999). The Triple P-Positive parenting program: Towards an empirically

validated multilevel parenting and fam- ily support strategy for the prevention of

behavior and emotional problems in children. Clinical Child and Family Psychology

Review, 2(2), 71–90.

Simonovic, B., Stupple, E. J., Gale, M., & Sheffield, D. (2017). Stress and risky decision

making: Cognitive reflection, emotional learning or both. Journal of Behavioral Decision

Making, 30(2), 658-665.

Soriano, C. A., Hill, E. L., & Crane, L. (2015). Surveying parental experiences of receiving a

diagnosis of developmental coordination disorder (DCD). Research in Developmental

Disabilities, 43, 11-20.

Starcke, K., Wolf, O. T., Markowitsch, H. J., & Brand, M. (2008). Anticipatory stress influences

decision making under explicit risk conditions. Behavioral Neuroscience, 122(6), 1352.

Stephenson, E. A., & Chesson, R. A. (2008). 'Always the guiding hand': Parents' accounts of the

long-term implications of developmental co-ordination disorder for their children and

families. Child: Care, Health and Development, 34(3), 335-343.

57

Summers, J., Larkin, D., & Dewey, D. (2008). Activities of daily living in children with

developmental coordination disorder: dressing, personal hygiene, and eating

skills. Human Movement Science, 27(2), 215-229.

Sumner, E., Leonard, H. C., & Hill, E. L. (2016). Overlapping phenotypes in autism spectrum

disorder and developmental coordination disorder: A cross-syndrome comparison of

motor and social skills. Journal of Autism and Developmental Disorders, 46(8), 2609-

2620.

Takahashi, M., Adachi, M., Takayanagi, N., Yasuda, S., Tanaka, M., Osato-Kaneda, A., ... &

Nakamura, K. (2017). Coordination difficulties in preschool-aged children are associated

with maternal parenting stress: A community-based cross-sectional study. Research in

Developmental Disabilities, 70, 11-21.

Tal-Saban, M., Zarka, S., Grotto, I., Ornoy, A., & Parush, S. (2012). The functional profile of

young adults with suspected developmental coordination disorder (DCD). Research in

Developmental Disabilities, 33(6), 2193-2202.

Teti, D. M., O’Connell, M. A., & Reiner, C. D. (1996). Parenting sensi- tivity, parental

depression and child health: The mediational role of parental self-efficacy. Early

Development & Parenting, 5(4), 237–250.

Theule, J., Wiener, J., Rogers, M. A., & Marton, I. (2011). Predicting parenting stress in families

of children with ADHD: Parent and contextual factors. Journal of Child and Family

Studies, 20(5), 640-647.

58

Thullen, M., & Bonsall, A. (2017). Co-parenting quality, parenting stress, and feeding challenges

in families with a child diagnosed with autism spectrum disorder. Journal of Autism and

Developmental Disorders, 47, 878–886.

Van der Linde, B. W., van Netten, J. J., Otten, B., Postema, K., Geuze, R. H., & Schoemaker, M.

M. (2015). Activities of Daily Living in Children With Developmental Coordination

Disorder: Performance, Learning, and Participation. Physical Therapy, 95(11), 1496-

1506.

Vitanza, S. A., & Guarnaccia, C. A. (1999). A model of psychological distress for mothers of

children with attention-deficit hyperactivity disorder. Journal of Child and Family

Studies, 8(1), 27-45.

Wang, J., Hu, Y., Wang, Y., Qin, X., Xia, W., Sun, C., . . . Wang, J. (2013). Parenting stress in

chinese mothers of children with autism spectrum disorders. Social Psychiatry and

Psychiatric Epidemiology, 48(4), 575-582.

Weiss, S. J. (1991). Stressors experienced by family caregivers of children with pervasive

developmental disorders. Child Psychiatry & Human Development, 21(3), 203-216.

Weiss, J. A., Cappadocia, M. C., MacMullin, J. A., Viecili, M., & Lunsky, Y. (2012). The impact

of child problem behaviors of children with ASD on parent mental health: The mediating

role of acceptance and empowerment. Autism, 16(3), 261-274.

Williamson, D., & Johnston, C. (2019). Maternal ADHD symptoms and parenting stress: The

roles of parenting self-efficacy beliefs and neuroticism. Journal of Attention

Disorders, 23(5), 493-505.

59

Wilson, B. N., Neil, K., Kamps, P. H., & Babcock, S. (2013). Awareness and knowledge of

developmental co‐ordination disorder among physicians, teachers and parents. Child:

Care, Health and Development, 39(2), 296–300.

Wilson, B. N., Crawford, S. G., Green, D., Roberts, G., Aylott, A., & Kaplan, B. (2009).

Psychometric Properties of the Revised Developmental Coordination Disorder

Questionnaire. Physical & Occupational Therapy in Pediatrics, 29(2), 182-202.

Wolraich, M. L., Lambert, E. W., Bickman, L., Simmons, T., Doffing, M. A., & Worley, K. A.

(2004). Assessing the impact of parent and teacher agreement on diagnosing attention-

deficit hyperactivity disorder. Journal of Developmental & Behavioral Pediatrics, 25(1),

41-47.

Woolfson, L., & Grant, E. (2006). Authoritative parenting and parental stress in parents of pre-

school and older children with developmental disabilities. Child: Care, Health and

Development, 32(2), 177-184.

Zablotsky, B., Anderson, C., & Law, P. (2013). The association between child autism

symptomatology, maternal quality of life, and risk for depression. Journal of Autism and

Developmental Disorders, 43(8), 1946-1955.

Zamora, I., Harley, E. K., Green, S. A., Smith, K., & Kipke, M. D. (2014). How sex of children

with autism spectrum disorders and access to treatment services relates to parental

stress. Autism Research and Treatment, 2014.

Zaidman-Zait, A., Mirenda, P., Duku, E., Szatmari, P., Georgiades, S., Volden, J., ... &

Fombonne, E. (2014). Examination of bidirectional relationships between parent stress

60

and two types of problem behavior in children with autism spectrum disorder. Journal of

Autism and Developmental Disorders, 44(8), 1908-1917.

Zwicker, J. G., Harris, S. R., & Klassen, A. F. (2012). Quality of life domains affected in

children with developmental coordination disorder: a systematic review. Child: Care,

Health and Development, 39(4), 562-580.

61

Appendices

List of appendices

Appendix A. Ethical Approval......................................................................................................63

Appendix B. Example of the online survey as seen by participants..............................................64

Appendix C. Assumptions for independent samples t-tests..........................................................65

Appendix D. Assumptions of the hierarchical multiple regression that includes parents of

children with comorbid ASD and/or ADHD (Hypothesis 1)........................................................70

Appendix E. Assumptions of multiple regression that does not include parents of children with

comorbid ASD and/or ADHD (Hypothesis 1)...............................................................................74

Appendix F. Results of multiple regression that does not include parents of children with

comorbid ASD and/or ADHD (Hypothesis 1)...............................................................................78

Appendix G. Assumptions of multiple regression predicting parenting stress including parents of

children with DCD and comorbid ASD and/or ADHD (Hypothesis 2)........................................79

Appendix H. Assumptions of multiple regression predicting parenting stress that does not

include parents of children with DCD and comorbid ASD and/or ADHD (Hypothesis 2)..........83

Appendix I. Results of multiple regression predicting parenting stress that does not include

parents of children with DCD and comorbid ASD and/or ADHD (Hypothesis 2).......................87

62

Appendix A. Ethical Approval

63

Appendix B. Example of the online survey as seen by participants

[Appendix removed for E-Thesis submission]

64

Appendix C. Assumptions for independent samples t-tests

Data plots

Histograms and Q-Q plots were created for each variable separated into groups to explore the

data for normality.

(i) Age of the child

DCD group TD group

65

(ii) Age of parents

DCD group TD group

66

(iii) Number of children

DCD group TD group

67

(iv) DCDQ-07

DCD group TD group

Normality

The histograms and Q-Q plots indicated that the data was skewed for number of children

and DCDQ-07 Total scores in the DCD group. Skewness and kurtosis scores were calculated for

each variable and divided by their standard error to obtain z-scores (see Table D1). All but the

number of children and DCDQ-07 in the DCD group were within the cut-off for significance

(2.58) suggesting the only those two distributions differed significantly from a normal

distribution. Taking into consideration all this information, the data for both the number of

68

children and DCDQ-07 were not considered to meet the assumption of normal distribution. As

such, non-parametric tests were used to compare the variables that violated this assumption

(Field, 2018).

Table C1. Normality statistics for demographic variables

Variable Skewness z-score Kurtosis z-score

TD DCD TD DCD

Age of child 0.04 -1.32 -0.96 -2.42

Age of parent 0.56 0.51 -0.57 -1.33

Number of children 1.11 19.35* -0.03 65.27*

DCDQ-07 Total -0.48 4.11* -1.02 1.82

*Significantly different from a normal distribution (p < .05)DCD: Developmental Coordination Disorder; DCDQ-07: Developmental Coordination Disorder Questionnaire – 07; TD: Typically developing

Homogeneity of variance

Levene’s tests were conducted to determine whether the assumption of homogeneity of

variance was met for the variables. Levene’s test were not significant for aged of the child, F (1,

195) = 0.002, p = .969, age of the parent, F (1, 195) = 2.042, p = .155, number of children, F (1,

195) = 0.180, p = .672, and DCDQ-07 Total, F (1, 195) = 1.281, p = .295. This suggests that the

variances were approximately equal and the assumption of homogeneity of variance was not

violated for any of the variables (Field, 2018).

69

Appendix D. Assumptions of the hierarchical multiple regression that includes parents of children with comorbid ASD and/or ADHD (Hypothesis 1)

Multicollinearity

The correlation matrix of all the predictor variables was observed and none of the

variables correlated highly (i.e. correlation above .80) (Field, 2018).

To assess the assumption of no multicollinearity, VIF and tolerance statistics were

checked. The tolerance values are all above 0.2 suggesting that there is not a serious problem

(Menard, 1995). The VIF values were not larger than 10 and the average of VIF was not

substantially greater than 1 suggesting that the regression is not likely to be biased and

collinearity is not a problem for this model (Myers, 1990).

Furthermore, when looking at the collinearity diagnostics, there was no evidence of

multicollinearity as none of the predictors had high proportions of variance on the same

eigenvalues (Field, 2018).

Table D1. Collinearity Statistics

Model Collinearity StatisticsTolerance VIF

1 Age of child .977 1.023Gender of child .977 1.023

2 Age of child .895 1.117Gender of child .958 1.044DCD/TD .887 1.128

70

Collinearity Diagnosticsa

Model Dimension Eigenvalue Condition IndexVariance Proportions

(Constant) Genderchild Agechild DCDTD1 1 2.305 1.000 .01 .07 .01

2 .673 1.851 .01 .89 .013 .022 10.293 .99 .05 .98

2 1 3.152 1.000 .00 .02 .00 .012 .754 2.045 .00 .80 .00 .013 .073 6.553 .04 .10 .16 .924 .021 12.310 .95 .08 .84 .06

a. Dependent Variable: PSI

Independent errors

Durbin Watson statistic was 1.807 which is not less than 1 or more than 3, suggesting that

the assumption of independent errors has been met. Meaning that the residuals in the model are

independent. (Durbin and Watson, 1951).

Linearity and homoscedasticity

The graph of regression standardised residuals and regression standardised predicted

values was used to determine if the assumptions of linearity and homoscedasticity were met.

While the residuals appeared to be linear, they were not evenly distributed throughout the plot

which suggested that the assumption of homoscedasticity was violated (Field, 2018).

Also, to check for normality of residuals, a histogram and normal probability plot was

used. Both the histogram and the plot suggested that the distribution of the residuals was normal

(Field, 2018).

71

72

Influential cases

Standardised residuals were calculated to check that there were no influential cases

within the data and model is accurate. More than 95% of the cases had a standardised residual

within about +/- 2 and more than 99% of the cases were within +/-2.5. As such, the diagnosis

does not raise any concern and it is expected that the current model is a fairly accurate model

(Field, 2018).

Casewise Diagnosticsa

Case Number Std. Residual PSI Predicted Value Residual

45 -2.446 44.00 101.3639 -57.36392

84 -2.196 50.00 101.4876 -51.48763

86 2.298 156.00 102.1062 53.89384

87 2.082 150.00 101.1784 48.82164

129 -2.325 47.00 101.5186 -54.51856

138 2.066 151.00 102.5528 48.44716

177 2.652 162.00 99.8176 62.18241

185 2.290 155.00 101.3021 53.69793

a. Dependent Variable: PSI

73

Appendix E. Assumptions of multiple regression that does not include parents of children with comorbid ASD and/or ADHD (Hypothesis 1)

Multicollinearity

The correlation matrix of all the predictor variables was observed and none of the

variables correlated highly (i.e. correlation above .80) (Field, 2018).

To assess the assumption of no multicollinearity, VIF and tolerance statistics were

checked. The tolerance values are all above 0.2 suggesting that there is not a serious problem

(Menard, 1995). The VIF values were not larger than 10 and the average of VIF was not

substantially greater than 1 suggesting that the regression is not likely to be biased and

collinearity is not a problem for this model (Myers, 1990).

Furthermore, when looking at the collinearity diagnostics, there was no evidence of

multicollinearity as none of the predictors had high proportions of variance on the same

eigenvalues (Field, 2018).

Table E1. Collinearity Statistics

Model Collinearity StatisticsTolerance VIF

1 Age of child .969 1.032Gender of child .969 1.032

2 Age of child .934 1.071Gender of child .893 1.120DCD/TD .872 1.147

74

Collinearity Diagnosticsa

Model Dimension Eigenvalue Condition Index

Variance Proportions(Constant) Agechild Genderchild DCDTD

1 1 2.349 1.000 .01 .01 .062 .630 1.931 .01 .01 .883 .021 10.637 .99 .98 .06

2 1 3.163 1.000 .00 .00 .02 .012 .724 2.090 .00 .00 .77 .023 .093 5.837 .05 .09 .13 .964 .021 12.395 .94 .90 .07 .01

a. Dependent Variable: PSI

Independent errors

Durbin Watson statistic was 1.769 which is not less than 1 or more than 3, suggesting that

the assumption of independent errors has been met. Meaning that the residuals in the model are

independent. (Durbin and Watson, 1951).

Linearity and homoscedasticity

The graph of regression standardised residuals and regression standardised predicted

values was used to determine if the assumptions of linearity and homoscedasticity were met.

While the residuals appeared to be linear, they were not evenly distributed throughout the plot

which suggested that the assumption of homoscedasticity was violated (Field, 2018).

Also, to check for normality of residuals, a histogram and normal probability plot was

used. Both the histogram and the plot suggested that the distribution of the residuals was normal

(Field, 2018).

75

76

Influential cases

Standardised residuals were calculated to check that there were no influential cases

within the data and model is accurate. More than 95% of the cases had a standardised residual

within about +/- 2 and more than 99% of the cases were within +/-2.5. As such, the diagnosis

does not raise any concern and it is expected that the current model is a fairly accurate model

(Field, 2018).

Casewise Diagnosticsa

Case Number Std. Residual PSI Predicted Value Residual

45 -2.378 44.00 100.0479 -56.04794

84 -2.129 50.00 100.1790 -50.17897

87 2.128 150.00 99.8514 50.14860

129 -2.258 47.00 100.2117 -53.21173

138 2.016 151.00 103.4969 47.50310

177 2.698 162.00 98.4101 63.58992

185 2.335 155.00 99.9824 55.01757

a. Dependent Variable: PSI

77

Appendix F. Results of multiple regression that does not include parents of children with comorbid ASD and/or ADHD (Hypothesis 1)

Table F1. Results of the regression analysis predicting parenting stress

Note: R2 = .02 for Step1, R2 = 0.17 for Step 2. BCa: Bias-corrected and accelerated; DCD: Developmental Coordination Disorder; Significant predictors are highlighted in bold.

78

B SE   B p BCa bootstrap 95% Confidence

Interval

Step1

Constant 83.90 11.59 .001 [60.52, 108.26]

Child age 0.11 0.10 .25 [-0.08, 0.31]

Child gender -3.91 5.08 .43 [-13.74, 5.36]

Step 2

Constant 67.19 10.49 .001 [45.38, 88.71]

Child age 0.03 0.09 .70 [-0.15, 0.21]

Child gender 2.70 4.60 .56 [-6.39, 11.40]

Group 28.77 4.40 .001 [20.66, 36.34]

Appendix G. Assumptions of multiple regression predicting parenting stress including parents of children with DCD and comorbid ASD and/or ADHD (Hypothesis 2)

Multicollinearity

The correlation matrix of all the predictor variables was observed and none of the

variables correlated highly (i.e. correlation above .80) (Field, 2018).

To assess the assumption of no multicollinearity, VIF and tolerance statistics were

checked. The tolerance values are all above 0.2 suggesting that there is not a serious problem

(Menard, 1995). The VIF values were not larger than 10 and the average of VIF was not

substantially greater than 1 suggesting that the regression is not likely to be biased and

collinearity is not a problem for this model (Myers, 1990).

Furthermore, when looking at the collinearity diagnostics, there was no evidence of

multicollinearity as none of the predictors had high proportions of variance on the same

eigenvalues (Field, 2018).

Table G1. Collinearity Statistics

Model Collinearity StatisticsTolerance VIF

1 DCD-Q .891 1.122SDQ- Difficulties .751 1.332PSOC .840 1.191FSS .901 1.110

a. Dependent Variable: Parenting Stress

79

Collinearity Diagnosticsa

Model Dimension Eigenvalue Condition Index

Variance Proportions(Constant) DCDQ SDQ PSOC FSS

1 1 4.755 1.000 .00 .00 .00 .00 .002 .128 6.083 .00 .01 .31 .00 .253 .077 7.836 .00 .36 .07 .01 .504 .032 12.203 .01 .45 .11 .38 .215 .007 26.288 .98 .17 .50 .61 .04

a. Dependent Variable: PSI

Independent errors

Durbin Watson statistic was 1.854 which is not less than 1 or more than 3, suggesting that

the assumption of independent errors has been met. Meaning that the residuals in the model are

independent. (Durbin and Watson, 1951).

Linearity and homoscedasticity

The graph of regression standardised residuals and regression standardised predicted

values was used to determine if the assumptions of linearity and homoscedasticity were met. As

the points were randomly and evenly distributed throughout the plot, this suggested that the two

assumptions were not violated (Field, 2018).

Also, to check for normality of residuals, a histogram and normal probability plot was

used. Both the histogram and the plot suggested that the distribution of the residuals was normal

(Field, 2018).

80

81

Influential cases

Standardised residuals were calculated to check that there were no influential cases

within the data and model is accurate. More than 95% of the cases had a standardised residual

within about +/- 2 but, less than 99% of the cases were within +/-2.5 as 3 out of the 174 cases

had a standardised residual more than +/-2.5. As such, further checks were conducted on cases

that had a standard residual above +/- 2.5. None of these cases had a Cook’s distance greater than

1, the centred leverage value two times as large as the average leverage, i.e. 2x[(4+1)/174]=0.06,

and the Mahalanobis distances was less than 9.49 for all the cases suggesting that these cases

were not influential within the data and were not having a large influence on the regression

parameters (Field, 2018).

Casewise Diagnosticsa

Case Number Std. Residual PSI Predicted Value Residual

71 2.021 98.00 67.0994 30.90056

87 2.459 150.00 112.4085 37.59152

93 2.987 131.00 85.3322 45.66775

122 -2.770 70.00 112.3479 -42.34790

143 -2.050 67.00 98.3334 -31.33337

157 -2.225 79.00 113.0223 -34.02235

177 2.674 162.00 121.1206 40.87941

a. Dependent Variable: PSI

82

Appendix H. Assumptions of multiple regression predicting parenting stress that does not include parents of children with DCD and comorbid ASD and/or ADHD (Hypothesis 2)

Multicollinearity

The correlation matrix of all the predictor variables was observed and none of the

variables correlated highly (i.e. correlation above .80).

To assess the assumption of no multicollinearity, VIF and tolerance statistics were

checked. The tolerance values are all above 0.2 suggesting that there is not a serious problem

(Menard, 1995). The IVF values were not larger than 10 and the average of VIF was not

substantially greater than 1 suggesting that the regression is not likely to be biased and

collinearity is not a problem for this model. (Myers, 1990)

Furthermore, when looking at the collinearity diagnostics, there was no evidence of

multicollinearity as none of the predictors had high proportions of variance on the same

eigenvalues.

Table H1. Collinearity Statistics

Model Collinearity StatisticsTolerance VIF

1 DCD-Q .880 1.137SDQ- Difficulties .710 1.409PSOC .821 1.218FSS .874 1.144

a. Dependent Variable: Parenting Stress

83

Collinearity Diagnosticsa

Model Dimension EigenvalueCondition

IndexVariance Proportions

(Constant) DCDQ SDQ PSOC FSS1 1 4.733 1.000 .00 .00 .00 .00 .00

2 .149 5.632 .00 .01 .29 .00 .223 .077 7.838 .00 .34 .08 .01 .554 .033 11.910 .01 .50 .10 .39 .175 .007 25.600 .98 .15 .53 .60 .06

a. Dependent Variable: PSI

Independent errors

Durbin Watson statistic was 1.737 which not less 1 or more than 3, suggesting that the

assumption of independent errors has been met. Meaning that the residuals in the model are

independent. (Durbin and Watson, 1951).

Linearity and homoscedasticity

The graph of regression standardised residuals and regression standardised predicted

values was used to determine if the assumptions of linearity and homoscedasticity were met. As

the points were randomly and evenly distributed throughout the plot, this suggested that the two

assumptions were not violated (Field, 2018).

Also, to check for normality of residuals, a histogram and normal probability plot was

used. Both the histogram and the plot suggested that the distribution of the residuals was normal

(Field, 2018).

Influential Cases

Standardised residuals were calculated to check that there were no influential cases

within the data and model is accurate. More than 95% of the cases had a standardised residual

within about +/- 2 but, less than 99% of the cases were within +/-2.5 as 3 out of the 123 cases

84

had a standardised residual more than +/-2.5. As such, further checks were conducted on cases

that had a standard residual above +/- 2.5. None of these cases had a Cook’s distance greater than

1, the centred leverage value two times as large as the average leverage, i.e. 2x[(4+1)/123]=0.08,

and the Mahalanobis distances was less than 9.49 for all the cases suggesting that these cases

were not influential within the data and were not having a large influence on the regression

parameters (Field, 2018).

Casewise Diagnosticsa

Case Number Std. Residual PSI Predicted Value Residual

87 2.462 150.00 111.8713 38.12873

93 2.980 131.00 84.8456 46.15442

122 -2.767 70.00 112.8472 -42.84722

177 2.654 162.00 120.8920 41.10796

a. Dependent Variable: PSI

85

86

Appendix I. Results of multiple regression predicting parenting stress that does not include parents of children with DCD and comorbid ASD and/or ADHD (Hypothesis 2)

Table I1. Results of the regression analysis predicting parenting stress

Note: R2 = 0.61. DCDQ-07: Developmental Coordination Disorder Questionnaire – 07; FSS: Family Support Scale; PSI/SF: Parenting Stress Index – Short form; PSOC: Parenting Sense of Competence Scale; SDQ Difficulties Total: Strengths and Difficulties Questionnaire. Significant predictors are highlighted in bold.

87

B SE   B β p

Constant 162.38 14.16 <.001

DCDQ .003 .21 .001 .99

SDQ Total Difficulties 1.22 .26 .33 <.001

PSOC -1.17 .14 -.54 <.001

FSS -.30 .15 -.13 .04

Part 2: Major Research Project Literature Review

Social problems in children with Developmental Coordination Disorder: A

review of the literature

Word Count: 7964

88

Abstract

There is growing evidence that Developmental Coordination Disorder (DCD) has an

impact on several aspects of a child’s life including their psychological, social and physical well-

being. According to the Elaborated Environmental Stress Hypothesis, having DCD leads

children to experience more negative social or interpersonal experiences that then affects their

mental health. The aim of this systematic review is to present the current evidence on the social

difficulties experienced by children with DCD as, to date, this has not been systematically

explored in the literature. A systematic search was conducted on three databases (PsychINFO,

MEDLINE and CINAHL), with search terms associated with the concepts of ‘DCD’ and ‘social

difficulties.’ A total of 21 quantitative and qualitative articles were identified as meeting the

inclusion criteria for the review and critically appraised. Five themes were identified:

participation in social activities; negative social experiences; parent-reported social problems;

children’s view of themselves with regard to interactions with others; and loneliness or isolation.

This review identified four main areas of social difficulties: poor self-concept in relation to peer

relations; negative social experiences with their peers; lower physical social activity

participation; and higher likelihood of being lonely or isolated. Given the known association

between these negative social interactions with poor mental health, this highlights the importance

for clinicians and professionals to consider this area when working with children with DCD and

tailor interventions accordingly.

89

Introduction

Developmental Coordination Disorder (DCD), also known as dyspraxia, is a

developmental condition that it is estimated to affect 5-6 % of children (American Psychiatric

Association, 2013). This condition is characterised by impairments in the coordination of gross

and/or fine motor skills that are necessary to perform daily activities (Barnhart, Davenport, Epps,

& Nordquist, 2003). For a diagnosis of DCD, the following four criteria need to be considered

according to the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5)

(American Psychiatric Association, 2013): 1. There is a deficit in a person’s ability to learn and

execute coordinated motor tasks compared to peers of the same age which are manifested in the

form of an inaccurate or slow performance of motor skills and ‘clumsiness’; 2. The motor

coordination impairments have a considerable and persistent impact on a person’s daily activities

and affects several areas of a person’s life including academic, work, play and leisure; 3. The

symptoms become apparent in early childhood, and; 4. The motor deficits are not explained by

other conditions such as intellectual disability, visual impairment or a neurological condition that

impacts movement.

Research suggests that parents notice that their children have motor difficulties from an

early age (Soriano, Hill, & Crane, 2015). However, these difficulties become more pronounced

when the child enters the school system (Rodger & Mandich, 2005), with children being

commonly diagnosed between the ages of five and seven (Novak, Lingam, Coad, & Emond,

2012). Although DCD primarily affects a child’s motor skills and their ability to perform daily

activities, there is growing evidence that it also has an impact on several aspects of a child’s life

including their psychological, social and physical well-being, quality of life, and academic

achievement (Crane, Sumner, & Hill, 2017; Zwicker, Harris, & Klassen, 2012). In fact, children

90

with DCD experience higher levels of internalising problems (i.e. symptoms of anxiety and

depression) compared to their typically developing (TD) peers (Francis & Piek, 2003; Pratt &

Hill; Skinner & Piek, 2001). Similar to the identification of DCD itself, this wider impact on the

child’s life becomes more apparent when the child starts attending school (Missiuna, Moll, Law,

King, & King, 2006). Therefore, early schooling may be a critical period where the difficulties

experienced by children with DCD intensify and, as a result, when they may need more support

from professionals.

The Elaborated Environmental Stress Hypothesis (EESH; Cairney, Rigoli, & Piek, 2013;

Cairney, Veldhuizen, & Szatmari, 2010) proposes a theoretical explanation to understand the

impact of having DCD on the child’s mental health (i.e. internalising problems) during

childhood. The EESH suggests that this impact is both directly and indirectly related to motor

coordination problems. One indirect impact that the framework stipulates are the negative social

or interpersonal experiences that children with DCD may experience. Therefore, a key

relationship of the framework is between what the authors refer to as the primary stressor (motor

coordination difficulties), with the secondary stressor (interpersonal conflicts) and, subsequently,

the relationship between that secondary stressor with internalising problems, such as anxiety and

depression.

The first key relationship in this framework is that the motor skills difficulties of children

with DCD leads to a higher level of interpersonal conflicts. The authors hypothesise that this is

because those around children with DCD notice the disruption in their functioning in everyday

activities associated with motor coordination problems. This then leads children to be more

susceptible to having negative social or interpersonal experiences in the form of isolation,

ridicule or stigmatisation from their peers, disrupting their social encounters with them. Research

91

suggests that motor skills have social significance among children as they value highly the ability

to play games and sport well (Vannatta, Gartstein, Zeller, & Noll, 2009). In fact, it is reported

that perceived popularity among children is determined by their physical ability and having a

large number of peer contacts (Chase & Dummer, 1992; LaFontana & Cillessen, 2002). Children

with lower motor performance had higher levels of peer exclusion and their peers were less

likely to want to interact with them in play compared to children with good motor performance

(Livesey, Lum Mow, Toshack & Zheng 2010). Therefore, it is possible that the motor

coordination difficulties experienced by children with DCD may place them at greater risk of

having interpersonal conflicts with their peers as is suggested by the EESH.

The second key relationship of the EESH then suggests that the social or interpersonal

conflict that is directly associated with the children’s motor difficulties becomes a source of

stress for them and has an impact on their mental health as it leads to the children experiencing

internalising problems such as anxiety or depression. This is again supported by research in

typical development that suggests that a child’s positive relations with their peers in the form of

reciprocal friendships and being liked by peers are associated with higher levels of self-reported

quality of life (Lezhnieva, Fredriksen, & Bekkhus, 2018). Similarly, positive experiences with

friends has been associated with higher levels of subjective well-being (Goswami, 2012). In

turn, this level of connection with peers has been found to be associated with fewer behavioural

problems (Merritt & Snyder, 2015). Moreover, the frequency of interaction with both familiar

and unfamiliar peers has been associated with better psychological adjustment (i.e. higher

perceived self-worth and lower levels of loneliness) and fewer psychological problems (Zhang,

et al., 2015). Therefore, the motor difficulties experienced by children with DCD would affect

their quality of life and subjective well-being through the interpersonal conflicts that those

92

difficulties create and by limiting these children’s opportunities to interact and learn from their

peers, with whom they spend significant amount of time when they start school, leading to more

isolation for this group of children.

Interpersonal conflicts in the form of peer difficulties, therefore, are central to how the

EESH explains the impact of DCD on children’s internalising problems. Moreover, given that

evidence suggests that physical ability and motor skills can impact social interactions amongst

children, and that positive social interactions can have a positive impact on children’s mental

health, it is important to understand the social difficulties experienced by children with DCD. To

date, the social difficulties experienced by children with DCD have not been systematically

explored in the literature. As such, the aim of this systematic review of the literature is to answer

the following question: What are the social problems experienced by children with DCD? By

answering this question, we will increase the understanding of the social impact of DCD and

help inform interventions that are tailored not only to the difficulties closely related to the motor

deficits but also other areas that are impacted by DCD. This is important because DCD is a

prevalent neurodevelopmental disorder, and research suggests that it is a condition that remains

relatively unknown (Wilson, Neil, Kamps, & Babcock, 2013) and potentially undiagnosed by

mental health professionals.

Method

Database search strategy

Terms that represented the concepts of ‘DCD’ and ‘social difficulties’ were identified by

performing a general search of relevant literature on these topics and extracting the terms which

are frequently used. The search terms used were:

93

social problems or social behaviour or social* or social play or social impact or peer

problems or social participation or peer relation or social competence or social development or

social identity or socialisation or socialization or social functioning or social difficulties

AND

DCD or developmental coordination disorder or dyspraxia or motor difficulties or motor

impairment or motor coordination problem or low motor competence or poor motor skill or poor

motor ability or clums*

The search for relevant literature was performed simultaneously in the following

databases: PsychINFO, MEDLINE and CINAHL on 7th July 2018.

Study selection

The selection process is shown in Figure 1. The search generated a total of 1832 titles. At

this stage, 521 titles were excluded if they were not published in the last 20 years, not available

in English and not a peer-reviewed journal article. This left 1331 articles of which duplicates

were removed (n=410) leaving a total of 921 articles. The remaining 921 articles were assessed

based on the title and abstract and 57 were selected as relevant. Then, these 57 articles were

screened by full-text to determine if they met the inclusion criteria and 21 articles were identified

to be included in this review. Articles were eligible if they: (i) included participants of primary

school age (5-12 years old) with a diagnosis of DCD or who were identified as having motor

coordination impairments consistent with DCD; (ii) measured levels of difficulties with peers

(i.e. peer acceptance, victimisation, participation in social activities ) using self-report, parent-

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report, or direct observation (for quantitative studies), or collected data about social difficulties

using interviews of children or their parents (for qualitative studies); (iii) presented primary data.

There were a number of reasons why papers were not included in the review: the article

was a review of the literature or a commentary; the sample was from the general population of

children and did not have a diagnosis of DCD; there was no measure of peer-related difficulties,

or the majority of the participants were not within the primary school age. Twenty-one papers

met the inclusion criteria and were included in the review.

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Figure 1. PRISMA Flow Diagram of Study Selection

Data extraction, evaluation and synthesis

All 21 papers were read in full and relevant information about the general characteristics

of each study was extracted and gathered in a database. Then, the relevant results of each paper

were extracted. The quality of the study was critically assessed using the ‘Standard Quality

Assessment Criteria for Evaluating Primary Research Papers from a Variety of

Fields’ (Kmet, Lee, & Cook, 2004). This tool was selected because the current review included

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Duplicates removed(n= 410)

Records excluded for not meeting criteria(n=521)

 223 = not published in the last 20 years

117= not available in English181= not a peer-reviewed journal article

Studies included in review (n = 21)

Full-text articles excluded (n = 36)

7= review of the literature or commentary 7= sample from the general population

13 = no measure of peer-related difficulties

9 = not within primary school age

Full-text articles assessed for eligibility(n = 57)

Articles excluded after screening(n = 864)

Titles/Abstracts screened(n = 921)

Records (n = 1331)

Records identified through database search

(n =1832)

studies with different designs and the quality criteria of the tool can be applied to all of the study

designs included. Furthermore, the tool has been previously used in systematic reviews in the

field of developmental conditions which have also included different designs (Melville et al.,

2017; McGarty & Melville, 2018). The tool has a comprehensive checklist and some items of the

checklist were excluded as they were not relevant for the study designs. For the current review,

the quality of the study was not used as an exclusion criterion. As several research designs were

included in this review, common themes of the findings were identified and synthesised to

provide an overview of the social difficulties experienced by children with DCD.

Results

Overview of studies

Twenty-one studies met the inclusion criteria and were incorporated in the systematic

review. The characteristics of each study were summarised in Table 1. Seventeen of these studies

employed a quantitative approach while four studies were qualitative. All studies used a cross-

sectional design. The majority of the studies (13) were conducted in Canada and Australia, with

the remainder in Europe and Asia. In 14 studies the data was collected directly from children,

and in seven studies from parents. Five studies included only males in the samples, with the

remaining studies containing both females and males. Fourteen of the studies had one or more

comparison groups, with TD children being the most common comparison group. Where

reported, the participants’ ages ranged from 5 to 14 years old, with the mean age ranging from

6.07 to 11.8 years. Two studies included participants above the cut-off age, but the average

participant age was between 5 and 12 years of age so the studies were retained. Ten studies used

a population-based sample in which participants were screened from schools, five studies

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recruited participants through purposive or convenience samples such as clinical settings,

community centres and charitable organisations, and six studies from a mix of population-based

and convenience samples. In terms of the sample size, for qualitative studies the size ranged

from 5 to 13 participants, and for quantitative studies it ranged from 10 to 318.

There was variation between studies in the way that DCD was operationalised. Five

studies categorised children as DCD or probable/at risk of DCD based on performance-based

tests of motor function or parent-report questionnaires of motor difficulties. However, 16 studies

either relied on a previous diagnosis of DCD by a professional or the researchers assessed that

the diagnostic criteria for DCD was met.

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Table 1. Summary of the characteristics of the studies

Author

(Year)

Country

Methodology and design

Informant DCD sample, n

DCD age, mean (SD) range

DCD gender, % male

Control sample, n

Control age, mean (SD) range

Control gender, % male

Controlled variables

Population DCD Assessment

Comorbidity considered

Cairney et al. (2005) Canada

Quantitative Questionnaire

Children DCD: 44 11.46 (SD=1.46) 9-14

43 Non-DCD: 542

11.46 (SD=1.46) 9-14

56 Age, height, weight

Students in grades 4th - 8th from 5 elementary schools

Probable DCD (performance-based test)

NR

Campbell et al. (2012) Canada

Quantitative Questionnaire

Children DCD:159 10.90 (SD=0.47) NR

48 TD:159 10.91 (SD=0.34) NR

48 Gender, age Students in 5th grade from a large public school

Probable DCD (screening questionnaire)

NR

Chung (2018) Hong Kong

Qualitative Interview

Children DCD: 5 NR NR N/A Students from 8 randomly selected mainstream public primary schools

Probable DCD (performance-based test)

NR

Cocks et al. (2009) Australia

Quantitative Questionnaire

Children DCD:30 9.5 (SD=1.4) NR

100 ADHD Children accessing services at the Occupational Therapy Department at a Hospital

Confirmed (researcher assessment)

Excluded if ASD. Not excluded if ADHD.

Dewey et al. (2002) Canada

Quantitative Questionnaire

Parents DCD:45 Probable DCD:51

DCD:11.8 (1.9)

NR Probable DCD:11.2 (1.7)

NR

DCD:58 Probable DCD:65

TD:78 TD:11.4 (2.00) NR

76 Age, gender, SES, intellectual functioning

Students from public and private schools

Confirmed (researcher assessment)

Excluded if ASD. Not excluded if ADHD.

Engel-Yegeret al. (2017) Israel

Quantitative Questionnaire

Children DCD: 25 DCD:7.12 (1.25)

NR

100 TD:25 TD: 6.9 (1.21) NR

100 Age, SES Children attending clinics and community centres

Confirmed (medical report and researcher assessment)

NR

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Author

(Year)

Country

Methodology and design

Informant DCD sample, n

DCD age, mean (SD) range

DCD gender, % male

Control sample, n

Control age, mean (SD) range

Control gender, % male

Controlled variables

Population DCD Assessment

Comorbidity considered

Jarus et al (2011) Israel

Quantitative Questionnaire

Children DCD:25 6.07

(0.61)

5-7

92 TD:25 6.07 (0.61) 5- 7

92 Age, gender, SES

DCD children recruited from clinical settings. TD recruited from the community.

Confirmed (researcher assessment)

NR

Kanioglou et al. (2005) Greece

Quantitative Questionnaire

Children Severe motor difficulties: 10 Moderate motor difficulties: 16

10.9

(0.70)

NR

NR TD: 128 10.9 (0.70) NR

NR None Students from primary school

Probable DCD (performance-based test)

NR

Klein & Magill-Evans (1998) Canada

Quantitative Questionnaire

Children DCD: 10 DCD:89.5 (5.7) NR

60 LD: 13 NS: NR

LD:92.3 (8.3) NR

LD:54 Age Students in 1st and 2nd grades accessing an outpatient

Confirmed (researcher assessment)

NR

Mandich et al. (2003) Canada

Qualitative Interview

Parents DCD:10 NR 7-12 90 N/A Children attending a university-based clinic that specialises in treating children with motor-based performance problems

Confirmed (researcher assessment)

NR

Missiuna et al. (2007) Canada

Qualitative Interview

Parents DCD:13 NR 6-14 77 N/A Children accessing a paediatric orthopaedic surgeon, private therapy services and publicly funded school health support services

Confirmed (researcher assessment)

NR

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Author

(Year)

Country

Methodology and design

Informant DCD sample, n

DCD age, mean (SD) range

DCD gender, % male

Control sample, n

Control age, mean (SD) range

Control gender, % male

Controlled variables

Population DCD Assessment

Comorbidity considered

Piek et al. (2000) Australia

Quantitative Questionnaire

Children DCD:36 127.30 months (8.81) 8-12

53 TD:36 126.25 months (10.88) 8-12

53 Age, gender, intellectual functioning

DCD: children attending schools or accessing individual practitioners. TD: recruited from primary schools.

Probable DCD (performance-based test)

NR

Poulsen et al. (2008) Australia

Quantitative Questionnaire

Children DCD:60 DCD: 11 years, 7 months (9.7 months) 10-12

100 TD:113 TD:11 years, 9 months (9.3 months) 10-13

100 Age, SES, school year

DCD: children accessing a school screening program at 2 independent boy's schools, therapy clinics and media releases. TD: 2 independent boy's schools.

Confirmed (researcher assessment)

NR

Poulsen et al. (2011a) Australia

Quantitative Questionnaire

Children DCD:59 DCD: 11 years, 7 months (9.7 months) 10-12

100 None Children recruited from a school screening program at two independent boy's schools, therapy clinics and media releases.

Confirmed (researcher assessment)

NR

Poulsen et al. (2011b) Australia

Quantitative Questionnaire and Interview

Children DCD:60 DCD: 11 years, 7 months (9.7 months) 10-12

100 TD:113 TD:11 years, 9 months (9.3 months) 10-13

Age, SES, school year

DCD: children accessing a school screening program at 2 independent boy's schools, therapy clinics and media releases. TD: 2 independent boy's schools.

Confirmed (researcher assessment)

NR

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Author

(Year)

Country

Methodology and design

Informant DCD sample, n

DCD age, mean (SD) range

DCD gender, % male

Control sample, n

Control age, mean (SD) range

Control gender, % male

Controlled variables

Population DCD Assessment

Comorbidity considered

Segal et al. (2002) Canada

Qualitative Interview

Parents DCD:6 NR 9 -11 83 N/A Children accessing an occupational therapy clinic that specialises in children with motor difficulties

Confirmed (medical report)

NR

Smyth & Anderson (2000) United Kingdom

Quantitative Observation

Children DCD:55 NR 6-10 69 TD:55 NR 6-10 69 Age, gender, verbal ability

Students from in year 2 to 5 from 6 primary schools

Confirmed (researcher assessment)

Excluded if ASD and ADHD

Sumner et al. (2016) United Kingdom

Quantitative Questionnaire

Parents DCD:30 8.61 (1.16) 7-10

70 ASD:30 TD:35

ASD: 8.65 (1.18) 7-10 TD: 9.11 (0.95) 7-10

ASD:83 TD:74

Age and intellectual functioning

DCD: via a charitable foundation, ASD: via a charitable foundation and local schools in with specialist units or provision for students with ASD. TD: students from primary schools

Confirmed (researcher assessment)

Excluded if ASD and ADHD

Sylvestre et al. (2013) Canada

Quantitative Questionnaire

Parents DCD:27 DCD:7.7 (1.70) 5-13

81 TD:27 TD:7.7 (1.80) 5-13

63 Age, gender, parent's education

DCD: children accessing Child Development and Language Impairment programmes. TD: students from the same school as those who were in the DCD group.

Confirmed (researcher assessment)

NR

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Author

(Year)

Country

Methodology and design

Informant DCD sample, n

DCD age, mean (SD) range

DCD gender, % male

Control sample, n

Control age, mean (SD) range

Control gender, % male

Controlled variables

Population DCD Assessment

Comorbidity considered

Tseng et al. (2007) Taiwan

Quantitative Questionnaire

Parents DCD: 38 Probable DCD: 32

DCD:8.2 (1.00) 6-10 Probable DCD: 7.8 (0.89) 6-10

DCD:42 Probable DCD:69

TD:82 TD:7.8 (0.71) 6-10

58 Age, gender, SES

Students in 1st to 3rd grades from 13 public elementary schools

Confirmed (researcher assessment)

Excluded if ASD

Wagner et al (2012) Germany

Quantitative Questionnaire

Parents DCD:35 DCD:7.69 (1.55) 5-11

77 TD:35 TD:7.69 (1.55) 5-11

77 Age, gender Children accessing occupational therapy practice and students from elementary schools

Confirmed (researcher assessment)

Excluded if ASD

ADHD: Attention Deficit Hyperactivity Disorder; ASD: Autism Spectrum Disorder; DCD: Developmental Coordination Disorder; LD: Learning Disability; NR: not reported; NS: Normative sample, SES: Socio-economic status; TD: Typically developing.

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For the synthesis of the findings, the results were first extracted from each study and then

summarised in Table 2 for quantitative studies and

for qualitative studies. Findings were then clustered together into themes based on

similar content. Five main themes were identified: participation in social activities, negative

social experiences, parent-reported social problems, children’s view of themselves with regard to

interactions with others, and loneliness or isolation. Some themes include findings solely from

quantitative studies, while others are comprised of findings from both qualitative and

quantitative studies.

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Table 2. Summary Quantitative Studies Findings

Author (year)

Aim(s) relevant to this review

Measure Analysis Finding 1 Findings 2 Findings 3 Findings 4 Findings 5

Cairney et al. (2005)

To ascertain if children with DCD report lower levels of participation in free play and organised activities than do children without movement problems. To ascertain if gender influence the relationship between DCD and lower levels of participation in free play and organizes activities.

Participation Questionnaire

ANCOVA Children with p-DCD participated significantly less in organised activities than children without DCD. F(1,574)=7.57, p<.01. No main effect for gender.

Children with p-DCD participated significantly less in free play than children without DCD. F(1,574)=9.58, p<.01.No main effect for gender.

     

Campbell et al. (2012)

To examine the mental health implications of DCD by investigating the risk of peer victimization in children with and without poor motor coordination.

Peer victimization screening measure

ANOVA Regression

Children with p-DCD reported experiencing significantly more verbal, F(1,314)=17.05, p<.001) and relational victimization bullying F(1,314)=4.25, p<.05) compared to children in the control group.

No significant difference in physical bullying between children with p-DCD and the control group.

Group membership (p-DCD/control) but not gender accounted for 5% of the variance in depression scores F(2,315)=9.35, p<.001, R2=.05.

The 3 types of victimisation jointly explained 32% of the variance in depression scores F(3,312)=53.81, p<.001, R2=.32.

Relational victimisation accounted for the largest proportion (11%) of unique variance in depression scores.

Cocks et al. (2009)

To examine the relationship between motor difficulties and self-concept. To examine the relationship with self-concept domains

Self-Description Questionnaire - peer relations subscale

t-test; Pearson’s correlations

Boys with DCD had significantly lower scores of self-concept in peer relations compared to the normative sample t(29)=-3.35, p=.002.

43% of boys with DCD had low self-concept for peer relations.

76% of the boys who had low self-concept for peer relations had motor coordination scores below the 5th percentile.

Motor coordination and peer relations self-concept scores were not significantly correlated r=-.11, p=.57.

 A positive significant correlation between self-concept for physical abilities and peer relations scores r=.46, p=.01.

Author (year)

Aim(s) relevant to this review

Measure Analysis Finding 1 Findings 2 Findings 3 Findings 4 Findings 5

Dewey et al. (2002)

To determine whether children with DCD experience more difficulties in psychosocial adjustment compared to TD children. To determine whether children with DCD and probable DCD display a similar level of difficulty.

Child Behaviour Checklist - social problem subscale

MANOVA Children with DCD and probable DCD had significantly higher scores on social problems compared to TD children F(2,68)=21.98, p<.001.

       

Engel-Yegeret al. (2017)

To compare reports of self-confidence in social domain between children with DCD and TD.

Pictorial Scale of Perceived Competence and Social Acceptance for young children - peer acceptance subscale

MANOVA and stepwise regression

No significant difference was found on the scores of the peer acceptance subscale between children with DCD and TD children F(1,45)=0.13.

       

Jarus et al (2011)

To examine the multidimensional aspects of participation of children with and without DCD in a variety of out-of-school time activities. To examine the relationship between the children’s motor ability and their participation patterns.

Children's Assessment of Participation and Enjoyment -social subscale

MANOVA, Chi Square, Pearson’s correlation

No significant difference on number of social activities the children participated on between children with DCD and TD F(6,43)=1.78.

No significant difference on intensity of the participation in social activities between children with DCD and TD F(6,43)=.86.

No significant difference on how much the children enjoyed the social activities between children with DCD and TD F(6,43)=.21.

Greater number of children with DCD (64%) played mostly along as compared to children without DCD χ2= 3.92, p=.046.

The better the child's motor performance, the higher the levels of participation diversity r=-.29, p≤.05. and intensity. r=-.29, p≤.05.

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Author (year)

Aim(s) relevant to this review

Measure Analysis Finding 1 Findings 2 Findings 3 Findings 4 Findings 5

Kanioglou et al. (2005)

To examine the role of DCD on children's socialization

Peer nomination method

Kruskal Wallis test and Mann-Whitney

Most children in the rejected category had motor coordination problems while most children in the popular category did not have motor difficulties.

Children with moderate coordination problems had significant lower scores on social acceptance than children without motor problems U = 623.50, p = .01.

 No difference in social acceptance scores between children with severe coordination problems and children without motor problems U = 456, p = NR.

 No difference in social acceptance scores between children with severe coordination problems and children with moderate coordination problems U =74, p = NR.

 

Klein & Magill-Evans (1998)

To compare the perceived peer acceptance of children with DCD, with a learning disability and a normative sample.

Pictorial Scale of Perceived Competence and Social Acceptance - peer acceptance subscale

MANOVA, ANOVA,

No significant difference in peer acceptance scores between children with DCD and with learning disability F=NR.

Peer acceptance was significantly positively associated with perceptions of physical competence for both children with DCD and learning disability r=.41, p<.05.

     

Piek et al. (2000)

To explore how self-perception, influence a child's self-worth.

Self-Perception Profile for Children and Social Support Scale for Children – peer acceptance subscale

MANOVA, multiple regression

No significant difference in peer acceptance scores between children with DCD and TD children F=NR.

       

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Author (year)

Aim(s) relevant to this review

Measure Analysis Finding 1 Findings 2 Findings 3 Findings 4 Findings 5

Poulsen et al. (2008)

To investigate the leisure time participation of boys with DCD.

Self-Description Questionnaire, 7 day leisure time diary

ANOVA There was a significant difference in peer relations self-concept scores between boys with DCD and TD, with boys with DCD scoring lower than TD boys F(3,161)=22, p<.001.

Boys with DCD spent statistically significantly more time doing unstructured non-social non-physical activities than TD boys F=NR.

 Boys with DCD spent statistically significantly less time doing unstructured F(3,161)=12.44, p<.001and structured social physical activities F(3,161)=13.74, p<.001than TD boys

   

Poulsen et al. (2011a)

To identify relationships between participation, psycho-social adjustment and motor performance in boys with DCD.

Self Description Questionnaire, 7 day leisure time diary

Classification and Tree Analysis

There were five distinct groups identified, one of them being boys who had low participation in unstructured group physical out of school activities and who also scored low on peer relations self-concept.

 One other distinct group was boys who had high participation in structured group activities with low physical activity and who had low scores on all motor areas.

     

Poulsen et al. (2011b)

To explore the differences in number and context (Social and environmental) of leisure-time personal projects reported by children with and without DCD. To describe the types of personal projects elicited by boys with DCD.

Personal Project Analysis

Chi-square Boys with DCD had fewer total number of friends across all projects χ2(4,173)= 60.32, p<.001 compared to boys without DCD.

Boys with DCD had higher participation in solitary social personal projects χ2(3,173)=27.67, p<.001 compared to boys without DCD.

Boys with DCD reported participating in fewer team sports than boys without DCD χ2(3,173)=65.68, p<.001.

   

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Author (year)

Aim(s) relevant to this review

Measure Analysis Finding 1 Findings 2 Findings 3 Findings 4 Findings 5

Smyth & Anderson (2000)

To determine if children with poor coordination are involved in play activity or spend time by themselves or very small groups. To explore whether children with DCD engaged in social, but not physical play.

Observation coding scheme

ANOVA, Chi-Square

16 children with DCD and 1 child in the TD group were alone more than 20% of their time. Children with DCD group spent statistically significant more time alone (F(1,102)=7.34, p<.01) and there was no effect of age or gender.

Children in DCD group spent more time with one other child and less time in groups of 8+ than boys in control group.

Informal team games were played more often by girls than boys. Girls in the DCD group played these games less often than girls in the control group F(1,32)=4.89, p<.05.

Boys in the DCD group played formal team games less frequently than boys in the control group F(1,54)=5.49, p<.05.

No significant difference between groups in relation to negative social contact χ2=NR.

Sumner et al. (2016)

To explore whether school-aged children with ASD and DCD are impaired in both motor and social skills in comparison to TD group. Does the relationship between motor and social skills differ between all three groups?

Vineland Adaptive Behaviour Scales -socialisation subscale

 ANCOVAMultiple Regression

Children with DCD were significantly more impaired in social functioning compared to TD children F(2,88)=43.74, p<.001.

17% of the variance in social skill scores was explained by motor skills in the DCD group.

     

Sylvestre et al. (2013)

To describe and compare social participation levels of between children with DCD and TD children.

LIFE-H - Interpersonal relationships

ANOVA Children with DCD had significantly lower scores of achievement in interpersonal relationships compared to TD group F=NR, .023≤p<.0001.

Children in the DCD group reported no problems in terms of social relationships with family members

 Children in the DCD group reported difficulties associated with relationships with friends and social relationship with peers.

   

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Author (year)

Aim(s) relevant to this review

Measure Analysis Finding 1 Findings 2 Findings 3 Findings 4 Findings 5

Tseng et al. (2007)

To investigate problems in psychosocial adjustment in children with DCD.

Child Behaviour Checklist (Chinese) - social problems subscale

MANOVA, Chi-square

Scores of social problems of children with DCD were statistically significantly higher than the score of the non-DCD children t=NR, p<.001.

Scores of social problems of children with suspected-DCD were statistically significantly higher than the score of the non-DCD children t=NR, p<.05

 No significant difference between the scores of children with DCD and suspected-DCD t=NR.

 65.9% of children with DCD and 61.3% of children with suspected-DCD had social problems scores within the clinical range, compared to 6% of children in the non-DCD group.

Wagner et al (2012)

To explore the relationship between DCD, peer problems and behavioural problems in school-aged children.

Intelligence and Development Scales - peer problems subscale

Path Analysis

The children with DCD had higher scores of peer problems than those of TD children (statistical significance NR).

Relationship between DCD and internalising and externalising problems is partly mediated by peer problems

   

DCD: Developmental Coordination Disorder; NR: not reported; TD: Typically developing.

Table 3. Summary of Qualitative Studies Findings

Author (year)

Aim(s) relevant to this review Analysis Theme 1 Theme 2 Theme 3

Chung (2018)

To examine the effects of motor coordination problems on self-efficacy and activity participation.

Content analysis Commonly reported difficulties regarding social self-efficacy were: 1. working in harmony with classmates, 2. expressing opinions and 3. being assertive enough to tell other children that they were doing something he/she did not like.

Limitation in social, play and recreational activities reported by 1 out of 5 children

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Mandich et al. (2003)

To gain an understanding of the performance deficits and competencies on the lives of children with DCD

Grounded Theory Approach

When ordinary becomes extraordinary

-Being left out, teased, bullied

- Sense of failure

Turning points:

-Willingness to try

- Opening doors

Missiuna et al. (2007)

To explore parent's perspectives regarding the life experiences of children with DCD

Phenomenological Approach

Limited participation Peer problems Altered self-perceptions

Segal et al. (2002)

To explore parental perceptions of the social lives of children with DCD

Grounded Theory Approach

Stigma situations Shaping participation: avoiding stigma situations

DCD: Developmental Coordination Disorder

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Participation in social activities.

One theme found in five quantitative and two qualitative studies was the participation

patterns of children with DCD in social activities. Four of these studies compared participation

patterns between children with and without DCD. Cairney, Hay, Faught, Mandingo and Flouris

(2005) found that children with probable DCD reported participating significantly less in free

play and organised physical activities such as team sports and lessons compared to children

without a motor impairment, after controlling for age, height, and weight, and with no difference

between genders.

A similar pattern of participation was identified through observations in the school

playground. Smyth and Anderson (2000) reported that boys with DCD engaged significantly less

frequently and spent less time in an active role while playing formal team games (e.g. football,

netball) than TD boys. At the same time, girls with DCD played informal team games (e.g. hide

and seek) significantly less often than TD girls. Moreover, children with DCD spent more time

watching other children play compared to the control group. There was no difference between

children with and without DCD in the frequency of rough and tumble play.

However, Jarus, Lourie-Gelberg, Engle-Yeger and Bart (2011) in their investigation of

participation patterns in activities outside of school in children with and without DCD, found no

significant difference between the groups for the number or the frequency of participation in

social activities. However, they reported significant positive correlations between motor skills

and number of activities and participation frequency of social activities, i.e. the better the motor

performance of the child, the higher the number of social activities.

Poulsen, Ziviani and Cuskelly (2008) explored the distinction between non-physical and

physical social activities. They found that boys with and without DCD spent most of their time

engaging in non-physical unstructured activities and that both groups did not differ on the

amount of time spent on non-physical social activities. However, boys with DCD spent

significantly less time on structured and unstructured physical social activities when compared to

boys without DCD.

Three studies provided an insight on the possible reasons for the participation patterns of

children with DCD. Poulsen, Johnson and Ziviani (2011a) found that, for a group of boys with

DCD, there was a link between poor motor performance on all motor areas and high levels of

participation in organised group activities with low physical activity energy expenditure.

Furthermore, they reported a link between these motor difficulties, low levels of participation in

unstructured group physical activities, and low scores on peer relations self-concept for a group

of boys with ball skills and manual dexterity difficulties. These findings suggest that specific

motor difficulties may be associated with different patterns of participation in group activities.

Two qualitative studies considered the role of self-efficacy in children with DCD on their

participation in physical activities with their peers. They identified that children refrained from

participating in physical activities if they believed they could not perform well in them (Segal,

Mandich, Polatajko, & Cook, 2002; Missiuna, Moll, King, King, & Law, 2007). For example,

one mother reported that her son would not participate in any physical games, even if they were

not competitive, and that he would stay on the side-lines.

Taken together, the studies suggested that children with DCD participate in fewer social

activities that require physical activity (i.e. free play and team games) compared with TD

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children, but there was no difference in non-physical social activities participation. Moreover,

there was evidence that the perception of poorer performance by children with DCD compared to

peers in physical activities combined with the type of motor difficulties experienced by them

may be barriers to their participation in some activities.

Negative social experiences.

Six studies considered the negative social experiences of children with DCD. Three of

them addressed the topic of children with DCD being bullied and teased. Campbell, Missiuna,

and Vaillancourt (2012) found that children with probable DCD experienced significantly more

verbal and social bullying compared to children without DCD, but there was no significant

difference between the two groups for physical bullying. The researchers also found that being

bullied was more predictive of depression than motor coordination status, with social bullying

being the strongest predictor of depression. These findings are consistent with other research

with parents who reported that their children were often left out, teased or bullied (Missiuna et

al., 2007; Mandich, Polatajko, & Rodger, 2003). However, Mandich et al. (2003) also noted that

parents reported that after having treatment and improving competence on the skills, their

children fit in as they were no longer singled out for their motor difficulties and peers noticed the

improvement.

Kanioglou, Tsorbatzodoudis and Barkoukis (2005) compared the social status of children

with moderate and severe difficulties with children without DCD and found that of the children

who were categorised as ‘rejected’ by their peers, most of them had moderate or severe motor

difficulties, while those who were in the ‘popular’ category did not have a motor difficulty.

Furthermore, children with moderate motor difficulties had significantly higher scores on social

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rejection than children without difficulties. Similarly, Segal et al. (2002) found from interviews

with parents about the social life of their children that children with DCD experienced ‘stigma

situations’ in which their motor difficulties interfered with the child’s participation in social

interaction and led to rejection or not being accepted by others. For example, two parents

reported that their children were excluded by classmates from activities such as skipping and

group sports on the basis of not being able to do it.

In contrast, Smyth and Anderson (2000) did not observe a similar pattern of negative

social contact (i.e. physical violence, fighting, verbal abuse) for children with DCD compared to

children without DCD in the playground. They reported a small number of observations of

negative social contact between children. Only seven out of the 110 children observed were

categorised as a victim of negative social contact, with three of these belonging to the DCD

group and four to the control group. Overall, most studies identified that children with DCD

experienced negative social experiences, either bullying or teasing or facing stigma situations,

while one study found no difference between children with DCD and TD children on

experiencing negative social contact.

Parent-reported social problems.

Five quantitative studies measured social problems in children with DCD through

parental report. In two of them, researchers found that the children with DCD and suspected-

DCD had significantly higher social problem scores from the Child Behavioural Checklist

(CBCL; Achenbach, 1991) compared to TD children in samples of elementary school children

screened for motor difficulties (Dewey, Kaplan, Crawford, & Wilson, 2002; Tseng, Howe,

Chuang, & Hsieh, 2007). In both studies, the authors controlled for potential confounding

115

variables, including age, gender and socio-economic status (SES). Tseng et al. (2007) also

reported no significant difference in social problems between the DCD and suspected-DCD

scores. They also noted that more than half of the children in the DCD and suspected-DCD

group had social problem scores within the clinical range, while only 6% of the children in the

TD group had scores within this range. These studies highlight that children with DCD may be at

a higher risk of experiencing social problems compared to their peers.

Consistent with the previous findings, Sumner, Leonard, and Hill (2016) found that, after

controlling for intellectual ability, children with DCD scored significantly lower than TD

children but higher than children with Autism Spectrum Disorder (ASD) using the socialisation

scores of the parent report Vineland Adaptive Behaviour Scales (Sparrow, Cicchetti & Balla,

2006). This suggests that children with DCD experience more difficulties with socialisation than

their TD peers. Moreover, they found that children with DCD scored significantly lower on

social skills tasks compared to TD children, but this was not significantly different from children

with ASD. Additionally, they found that motor skill was a significant predictor of socialisation,

accounting for 47 percent of the variance when comparing the DCD and the TD group.

While the previous studies highlight that children with DCD seem to experience more

social difficulties compared to their peers, Sylvestre, Nadeau, Charron, Larose and Lepage

(2013) focused on the accomplishments of children with DCD in several areas including

interpersonal relationships. They found that children with DCD had a significantly lower level of

accomplishment in interpersonal relationships compared to a TD group on the Life-H

questionnaire (Noreau, Fougeyrollas, & Vincent, 2002).

116

Finally, Wagner, Bos, Jascenoka, Jekauc and Petermann (2012) provide an insight into

the relationship between motor difficulties, peer problems, and internalising and externalising

behavioural problems for children with DCD. Using the peer problems, internalising and

externalising problems scores of the Intelligence and Development Scales (Grob, Meyer, &

Hagmann-von Arx, 2009), they found that the relationship between motor difficulties and

internalising and externalising problems was partly mediated by peer problems. That is, the

greater the motor impairment, the greater the level of peer problems, and thus the greater the

level of internalising and externalising problems. Nevertheless, they did not state whether the

difference in peer problems scores of children with DCD compared to those of the TD children

was statistically significant.

Overall, these studies suggest that children with DCD and suspected-DCD experience

more social problems, have more difficulties with socialization and lower levels of

accomplishment in interpersonal relationships compared to their TD counterparts. Social

problems may be a mediator between motor difficulties and externalising and internalising

behaviour.

Children’s view of themselves with regard to interactions with others.

Two studies investigated how boys with DCD view themselves using the Self-

Description Questionnaire (SDQ-I; Marsh, 1992). This questionnaire measures self-concept in

several areas such as peer relations, physical ability, school and self. Both studies found that

boys with DCD scored significantly lower in peer relations self-concept compared to boys

without DCD when matched for school year, age, and SES (Poulsen et al., 2008) and the

normative sample of the SDQ-I (Cocks, Barton, & Donelly, 2009). Furthermore, Cocks et al.

117

(2009) reported that 43% of the boys with DCD had peer relations self-concept scores below the

15th percentile, and that there was a significant positive correlation between peer relations self-

concept and physical ability self-concept.

Four studies investigated how children with DCD believe others see them through a

comparison of peer acceptance between them and a comparison group. In two of them,

researchers did not find that perceived peer acceptance, measured using the Pictorial Scale of

Perceived Competence and Social Acceptance for Young Children (PCSA; Harter & Pike, 1984),

differed significantly between children with DCD and those with learning disability or the

normative sample of the PCSA (Klein & Magill-Evans, 1998) and between boys with DCD and

TD boys (Engel-Yeger, Sido, Mimouni-Bloch, & Weiss, 2017). Engel-Yeger et al. (2017) also

found that motor performance was not a significant predictor of peer acceptance.

On the other hand, Piek, Dworcan, Barrett and Coleman (2000) found that there was no

significant difference between the social acceptance scores of children with DCD compared to

those of children without DCD using the Self Perception Profile for Children (Harter, 1985).

They also found that both groups rated social acceptance as the third most important factor for

them after scholastic competence and behavioural conduct.

Kanioglou et al. (2005) instead divided children with DCD into two groups (severe and

moderate coordination difficulties) and compared social acceptance between them and children

without motor difficulties using the peer nomination method. They found that children with

moderate motor difficulties had significantly lower social acceptance scores compared to

children without motor difficulties, while no significant difference was found between children

with severe difficulties and children without motor difficulties or with moderate difficulties. This

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suggests that while the moderate levels of difficulty can have a negative impact on social

acceptance, the impact of more severe levels of difficulty is more uncertain, as this and the other

two groups did not differ significantly.

Finally, Chung (2018) explored social self-efficacy in interviews with a small group of

children with DCD. They found that many of these children reported social self-efficacy as a

considerable concern and the most common difficulties associated with self-efficacy were

working in harmony with their classmates.

Taken together, the findings of these studies suggest that children with DCD perceive that

they have poorer relationships with their peers and have a lower level of accomplishment in

interpersonal relationships compared to TD children. Additionally, social self-efficacy is a

concern for children with DCD. However, studies consistently reported that children with DCD

did not believe they were less socially accepted compared to the comparison group, suggesting

that children with DCD may be attributing these difficulties to themselves rather than others.

Loneliness or isolation.

Four studies, three quantitative and one qualitative, included themes of loneliness and

isolation. Jarus et al. (2011) found that a significantly greater number of children with DCD

(64%) played mostly alone during out of school activities compared to children without DCD

(36%). Furthermore, they found a significant negative correlation between motor skills and

social activities carried out alone, in that children with lower motor performance carried out

more social activities alone. Poulsen, Barker and Zivianni (2011b) investigated how boys with

and without DCD spend and would like to spend their time outside of school. They found that in

terms of social personal projects (activities, goals and pursuits), boys with DCD reported having

119

significantly fewer friends with whom to complete personal projects compared to boys without

DCD. Boys with DCD had significantly higher rates of participation in solitary social projects

compared to boys without DCD.

In terms of school time, Smyth and Anderson (2000) reported that children with DCD

spent significantly more time alone in the playground compared to children without DCD. They

found that 16 out of 55 children in the DCD group and one child out of 55 children in the control

group were alone more than 20% of the time. When time was spent with other peers, children

with DCD spent significantly more time with one other child and significantly less time in

groups of 8+ compared to the control group.

Missiuna et al. (2007) found that several parents of children with DCD reported that, due

to motor difficulties, their children found it hard to keep up with their peers who engaged in

physical activities such as playing sports or skipping rope on the school playground. As a result,

they often spent time alone on the playground or played with children who were much younger

than them. Overall, the findings of these studies indicate that children with DCD carried out

more social activities alone outside the school and spent more time alone in the school

playground compared to children without DCD. Moreover, they had fewer friends with whom to

engage in activities and spent more time with smaller groups of people compared to children

without DCD.

Quality Appraisal

The quality total scores for the quantitative studies ranged from 0.68 to 1 (1 being the

highest quality), see Table 4 and Table 5 for the scores for each study. Most studies explicitly

stated and clearly defined the question or objective of the study in the introduction section, while

120

three studies (Jarus et al., 2011; Piek et al., 2000; Tseng et al, 2007) provided a more vague or

insufficient description. One of the main limitations of a considerable number of studies (Cocks

et al., 2009; Engel-Yeger et al., 2017; Jarus et al., 2011; Klein & Magill-Evans, 1998; Piek et al.,

2000; Sumner et al., 2016; Sylvestre et al., 2013; Wagner et al., 2012) was the use of

convenience sampling wherein participants were recruited from clinical settings, community

centres or charitable foundations. This method for the selection of participants is likely to

introduce bias because it may overrepresent children with DCD who are accessing some form of

support for their difficulties. These children may require support due to the severity or

complexity of their difficulties, which may lead to the sample not being representative of all

children. This in turn could potentially jeopardise the external validity of the findings. Kanioglou

et al. (2005) recruited participants from schools; however, no clear description of their sampling

strategy was provided, and therefore it was not possible to assess its adequacy.

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Table 4. Quality Appraisal of Quantitative Studies

Aut

hor

(yea

r)

Que

stio

n/ob

ject

ive

suff

icie

ntly

de

scri

bed? D

esig

n ev

iden

t and

app

ropr

iate

to

answ

er th

e qu

estio

n?

Met

hod

of su

bjec

t sel

ectio

n is

de

scri

bed

and

appr

opri

ate

Subj

ect c

hara

cter

istic

s suf

ficie

ntly

de

scri

bed? O

utco

me

mea

sure

s wel

l def

ined

and

ro

bust

to m

easu

rem

ent/m

iscl

assi

ficat

ion

bias

? M

eans

of a

sses

smen

t rep

orte

d?

Sam

ple

size

app

ropr

iate

?

Ana

lysi

s des

crib

ed a

nd a

ppro

pria

te?

Are

som

e es

timat

es o

f var

ianc

e re

port

ed fo

r th

e m

ain

resu

lts/o

utco

mes

?

Con

trol

led

for

conf

ound

ing?

Res

ults

rep

orte

d in

suff

icie

nt d

etai

l?

Do

the

resu

lts su

ppor

t the

con

clus

ions

?

Tot

al sc

ore

Cairney et al. (2005) 2 2 2 2 2 1 2 2 1 2 1 0.86

Campbell et al. (2012) 2 2 2 2 2 2 2 2 1 2 2 0.95

Cocks et al. (2009) 2 2 1 2 2 2 2 2 1 2 2 0.91Dewey et al. (2002) 2 2 2 2 1 2 1 2 2 2 2 0.91Engel-Yegeret al. (2017) 2 2 1 2 2 2 2 2 1 2 1 0.86

Jarus et al (2011) 1 2 1 2 1 1 2 2 1 1 1 0.68Kanioglou et al. (2005) 2 1 1 1 1 1 2 2 1 1 2 0.68

Klein & Magill-Evans (1998) 2 2 1 1 2 1 2 2 1 2 2 0.82

Piek et al. (2000) 1 1 1 2 1 2 2 2 1 2 2 0.77Poulsen et al. (2008) 2 2 2 2 1 2 2 2 2 2 2 0.95

Aut

hor

(yea

r)

Que

stio

n/ob

ject

ive

suff

icie

ntly

de

scri

bed? D

esig

n ev

iden

t and

app

ropr

iate

to

answ

er th

e qu

estio

n?

Met

hod

of su

bjec

t sel

ectio

n is

de

scri

bed

and

appr

opri

ate

Subj

ect c

hara

cter

istic

s suf

ficie

ntly

de

scri

bed? O

utco

me

mea

sure

s wel

l def

ined

and

ro

bust

to m

easu

rem

ent/m

iscl

assi

ficat

ion

bias

? M

eans

of a

sses

smen

t rep

orte

d?

Sam

ple

size

app

ropr

iate

?

Ana

lysi

s des

crib

ed a

nd a

ppro

pria

te?

Are

som

e es

timat

es o

f var

ianc

e re

port

ed fo

r th

e m

ain

resu

lts/o

utco

mes

?

Con

trol

led

for

conf

ound

ing?

Res

ults

rep

orte

d in

suff

icie

nt d

etai

l?

Do

the

resu

lts su

ppor

t the

con

clus

ions

?

Tot

al sc

ore

Poulsen et al. (2011a) 2 2 2 2 1 2 2 2 1 2 2 0.91

Poulsen et al. (2011b) 2 2 2 2 2 2 2 N/A 2 2 2 1.00

Smyth & Anderson (2000) 2 2 2 2 2 2 2 2 2 2 2 1.00

Sumner et al. (2016) 2 2 1 2 2 2 2 2 2 2 2 0.95

Sylvestre et al. (2013) 2 2 1 1 2 2 2 2 2 1 1 0.82

Tseng et al. (2007) 1 2 2 2 1 1 2 2 1 2 2 0.82Wagner et al (2012) 2 1 1 1 1 2 1 2 1 1 2 0.68

N/A: Not applicable; 0=criterion not met; 1=criterion partially met; 2=criterion met.

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Table 5. Quality Appraisal of Qualitative Studies

Aut

hor

(yea

r)

Que

stio

n/ob

ject

ive

suff

icie

ntly

des

crib

ed?

Des

ign

evid

ent a

nd a

ppro

pria

te to

ans

wer

the

ques

tion? C

onte

xt fo

r th

e st

udy

is c

lear

?

Con

nect

ion

to a

theo

retic

al fr

amew

ork/

wid

er

body

of k

now

ledg

e?

Sam

plin

g st

rate

gy d

escr

ibed

, rel

evan

t and

ju

stifi

ed? D

ata

colle

ctio

n m

etho

ds c

lear

ly d

escr

ibed

and

sy

stem

atic

?

Dat

a an

alys

is c

lear

ly d

escr

ibed

and

syst

emat

ic?

Use

of v

erifi

catio

n pr

oced

ure(

s) to

est

ablis

h cr

edib

ility

?

Con

clus

ion

supp

orte

d by

res

ults

?

Ref

lexi

bilit

y of

the

acco

unt?

Tot

al sc

ore

Chung (2018) 1 1 0 1 1 1 1 0 0 0 0.3

Mandichet al. (2003) 2 2 1 2 1 2 1 2 2 0 0.75

Missiuna et al. (2007) 2 2 2 2 2 1 2 2 2 1 0.9

Segal et al. (2002) 1 2 1 2 1 2 2 1 2 0 0.7

0=criterion not met; 1=criterion partially met; 2=criterion met.

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All but four of the quantitative studies (Kanioglou et al., 2005; Klein & Magill-Evans,

1998; Sylvestre et al., 2013; Wagner et al., 2012) provided an adequate description of

participants’ characteristics and demographic information. This enabled a good understanding of

the characteristics of the sample and its representativeness of the population. However, there

needs to be caution when attributing findings of these studies to DCD due to the considerable

variability in the rigour with which the diagnostic criteria were assessed. In seven studies the

participants had either a diagnosis of DCD by a suitable professional (Engel-Yeger et al., 2017)

or met all important criteria (Jarus et al., 2011; Klein & Magill-Evans, 1998; Poulsen et al.,

2008; Poulsen et al., 2011a; Poulsen et al., 2011b, Wagner et al., 2012). One study (Kanioglou et

al., 2005) only used a performance-based test of motor function and another (Campbell et al.,

2012) a parent-report of motor difficulties to assess the DCD status of the participants.

Nonetheless, the latter study did state that those children were at risk of DCD and highlighted

that as a limitation of the study.

All but one (Campbell et al., 2012) of the 14 quantitative studies that utilised

self-report/parent questionnaires or scales used measures that were established and had good

validity and reliability properties, which was a strength of these studies. One study (Smyth &

Anderson, 2000) collected data through robust observation methods with a clear procedure and a

detailed and specific coding scheme with good reliability. Two studies had limitations as they

did not provide information to assess the validity and reliability of tools that were adapted for the

study, one on leisure-time activity participation which was adapted to be used for children

(Poulsen et al., 2011b), and one on estimation of a child’s social status (Kanioglou et al., 2005).

A strength of several quantitative studies that compared children with DCD with a

comparison group was the use of appropriate methods to control for important confounding

variables such as age, gender, SES and IQ, by matching participants on these variables

(Campbell et at., 2012; Engel-Yeger et al., 2017; Jarus et al., 2011; Piek et al., 2000; Poulsen et

al., 2008; Poulsen et al., 2011b; Smyth & Anderson, 2000; Sylvestre et al., 2013; Tseng et al.,

2007; Wagner et al., 2012), including them as covariates in the statistical analyses (Cairney et al.,

2005; Sumner et al., 2016) or determining whether there was statistically-significant differences

or correlations between the groups in regard to these variables (Dewey et al., 2002; Klein &

Magill-Evans, 1998; Sumner et al., 2016; Sylvestre et al., 2013). Two studies (Cocks et al., 2009;

Kanioglou et al., 2005) did not use any method to control for counfounding variables, which was

a limitation. However, only a few studies excluded participants with comorbidities to address

potential counfounding variables (Cocks et al., 2009; Dewey et al., 2002; Smyth & Anderson,

2000; Sumner et al., 2016; Tseng et al., 2007; Wagner et al., 2012). Given that conditions such as

Autism Spectrum Disorder or Attention Deficit Hyperactivity Disorder can have an impact on a

child’s social functioning (Knott, Dunlop, & Mackay, 2006; Hoza, 2007) and therefore may

influence how the findings are interpreted, this is a limitation of those studies which did not take

comorbidities into account.

For the qualitative studies, the quality total scores ranged from 0.30 to 0.90. A main

limitation of most of the qualitative studies (Chung, 2018; Mandich et al., 2003; Segal et al.,

2002) was the sampling strategy because a clear justification was not provided for their selection

of participants. It is unlikely that the sample included a range of relevant cases because

participants were selected from one clinic/service. Given that studies included only a

convinience sample, the findings may not represent the views and experiences of all children

with DCD. In addition, these studies did not acknowledge this limitation and how it may affect

interpretations of the findings. Another limitation of all the qualitative studies was the lack of

126

explicit consideration or assessment of the impact that the researcher’s characteristics and role

may have had on the data collected. This is important because researchers may influence the data

through the use of questions and opinions while collecting data, or affect the analysis when

coding or deciding what is reported (Jootun, McGhee, & Marland, 2009).

One of the strengths of the majority of the qualitative studies (Mandich et al., 2003;

Missiuna et al., 2007; Segal et al., 2002) was the appropriate approach to answer research

questions and the sound rationale given for using this approach. Another strength of two studies

(Mandich et al., 2003; Missiuna et al., 2007) was the use of methods to make the data analysis

more reliable, such as having two researchers compare coding consistency of transcripts and

participants checking the findings to ensure they were accurate representations of their

interviews.

Discussion

The aim of this paper was to systemically review the literature to better understand the

social difficulties experienced by children with DCD. A number of these studies suggest that

children with DCD are at a higher risk of having social difficulties and are less able to socialise

compared to their peers without motor difficulties (Dewey et al., 2002; Sumner et al., 2016;

Tseng et al., 2007). These social difficulties may be significant given that more than half of the

children with DCD in one study had scores within the clinical range for social problems (Tseng

et al., 2007) and these difficulties do not seem to differ between children with moderate or severe

motor difficulties. Taken together, these findings highlight that it is important that social

difficulties are considered when assessing and carrying out interventions for all children with

DCD. Furthermore, it is important to consider the long-term implications of these motor skills

127

impairments on social difficulties given that studies have found that adolescents with DCD also

experience social difficulties (Payne, Ward, Turner, Taylor, & Bank, 2013; Stepheson &

Chesson, 2008). Potentially, these difficulties experienced by adolescents have started during

childhood and persisted into adolescence. Given that all these studies were cross-sectional,

further studies could employ a longitudinal approach to contribute to the understanding of the

progression and impact of the social difficulties experienced by individuals with DCD

throughout their lifespan.

On the question of what are the social difficulties of children with DCD, this review

identified four main areas of social difficulties. One area identified is that children with DCD

may have a poor self-concept in relation to peer relations. However, studies have only focused

on boys with DCD, in which they reported having a significantly poorer self-concept for peer

relations than boys without DCD. There was an association between self-concept for peer

relations and for physical ability, wherein the lower the peer relations, the lower the physical

ability (Poulsen et al., 2008; Cocks et al., 2009). Therefore, it remains unclear whether similar

views are held by girls with DCD, which is a gap in the current literature. In addition, children

with DCD reported social self-efficacy as a considerable concern and the most common

difficulties associated with self-efficacy were working harmony with their classmates (Chung,

2018). Overall, this research would suggest that children with DCD are aware of their higher risk

of social difficulties in their evaluation of themselves and their abilities to interact with peers.

Further research could investigate whether this self-perception is having an impact on these

children’s mental health.

Despite the findings on self-concept and self-efficacy discussed above, the perception of

social acceptance of children with DCD was not found to be different compared to children

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without motor difficulties or with a learning disability in several studies (Engel-Yeger et al.,

2017; Klein & Magill-Evans, 1998; Piek et al., 2000). This would then suggest that while

children with DCD believe they have greater difficulties making friends and working with

others, they perceive that they are accepted by their peers in a similar way to children without

DCD. This may indicate that children with DCD attribute their difficulties with their peers to

their behaviour and skills rather than how others see and behave around them. It would be useful

for further studies to explore within the same sample this relationship between children’s

perception of themselves and how others see them.

However, one study had mixed results on the social acceptance of children with DCD as

it identified children with moderate motor difficulties reported having a lower social acceptance

than TD children, but there was no such difference between children with severe motor

difficulties and either TD children and those with moderate difficulties (Kanioglou et al., 2005).

This could mean that children are more accepting of children with severe difficulties as they see

clearer differences between them, which is not the case when difficulties are more moderate.

Further studies should explore this difference in acceptance.

The current review also highlighted that children with DCD may encounter negative

social experiences with their peers which include being bullied, teased, rejected and excluded

from activities and games (Missiuna et al., 2007; Mandich et al., 2003, Segal et al., 2002). In

fact, these children may be at a higher risk of social and verbal bullying, and of being rejected by

their peers compared to children without DCD (Campbell et al., 2012, Kanioglou et al., 2005).

The higher risk of experiencing bullying behaviour is consistent with other studies that have

reported that children with learning disabilities and those who stutter, and thus have a noticeable

difficulty which leads to being perceived as different from their peers, are more likely to be

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victims of bullying (Blood & Blood, 2007; Nabuzoka, 2003). This is not consistent with the

findings on the children’s perception of social acceptance discussed above. This difference may

result from the fact that most of the studies on negative social experiences were based on

parents’ perceptions of negative experiences of their children rather than the perspectives of the

children themselves. This discrepancy is an area that future studies could further explore.

However, some studies did not find differences in negative interactions with their peers in

terms of physical bullying and in the school playground (Smyth & Anderson, 2000, Campbell et

al., 2012). This would suggest that when trying to understand the negative interactions of

children with DCD, it is important to consider the specific type and context of the negative

interaction. Nonetheless, being bullied, in particular social bullying, was found to be a predictor

of depression for children with DCD (Campbell et al., 2012) suggesting that bullying may have a

negative impact on their psychological wellbeing. This is consistent with studies reporting an

association between children that are victims of bullying and higher levels of internalising

symptoms such as depression and anxiety (Reijntjes, Kamphuis, Prinzie, & Telch, 2010).

Children with DCD that have these negative experiences may require access to mental health

services, as research suggests children who have been bullied are more likely to access mental

health services in childhood and later in adolescence (Evans-Lacko et al., 2017; Kumpulainen,

Räsänen, & Puura, 2001). As such, further research should focus on better understanding the link

between having negative social experiences and overall mental health throughout development in

DCD.

Another social difficulty identified in the review concerns the lower participation in

physical social activities of children with DCD compared to children without DCD. The

evidence suggests that children with DCD participate less in social activities compared to their

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peers without DCD when the activities involve physical activity, such as free play, team games

or sport and lessons, both in the school playground and outside of school (Cairney et al., 2005;

Smyth & Anderson, 2000). However, there is no difference in patterns of participation in social

activities when physical activity is not required (Jarus et al., 2011). These findings were expected

considering that physical activities are likely to be challenging for children with DCD due to

their motor difficulties and low levels of participation in overall physical activities have been

reported in the literature (Noordstar et al., 2014; Tsang, Guo, Fong, Mak, & Pang, 2012). At the

same time, children with DCD were found to spend more time watching others play compared to

their counterparts without motor difficulties (Smyth & Anderson, 2000), which suggests that

children may be demonstrating interest in these activities but not engaging in them and taking the

role of outsiders. By participating less in physical activities with their peers, children with DCD

are missing out on the positive impact that participation can have on their overall wellbeing.

Participation in sports has been associated with positive psychosocial adjustment and positive

youth development indicators such as social well-being, self-concepts, and positive behaviours

(Findlay & Coplan, 2008; Linver, Roth, & Brooks-Gunn, 2009). Furthermore, this may have a

negative impact on their social status in front of their peers, given that physical ability and

having a large number of peer contacts were found to be important determinants of perceived

popularity among children (LaFontana & Cillessen, 2002).

The studies in the current review suggest a variety of factors that could explain the link

between the child’s motor impairment and participation in social physical activities. One factor

may be children’s lack of confidence in their performance in front of others. Children with

probable DCD reported that they viewed themselves as less able to perform physical activities

than children without motor difficulties (Cairney et al., 2005). This was supported by parents’

131

reports that the child’s awareness of their poor physical performance and not being able to keep

up with their peers were factors that contributed to their children not wanting to participate in

physical activities or team sports (Missiuna et al., 2007; Segal et al., 2002). This impact may be

dependent on the severity of motor difficulties and the type of motor difficulties which has been

found to influence the participations patterns and the types of activities in which a child with

DCD chooses to participate (Poulsen et al., 2011a; Jarus et al., 2011). Hence, when working with

children with DCD, it is important to consider the type of motor difficulties and the factors that

discourage participation in social activities to tailor interventions.

Alongside lower participation in physical social activities, children with DCD are more

likely to be lonely or isolated. Children with DCD were more likely to play or spend time alone,

participate in solitary activities, and reported having fewer friends to do activities or spend time

with compared to children without DCD in the school playground and activities and projects

outside of school (Jarus et al., 2011; Missiuna et al., 2007; Poulsen et al., 2011b; Smyth &

Anderson, 2000). Furthermore, parents reported that as their children found it hard to keep up

with their peers, they often spent time alone on the playground or played with children who were

much younger than them (Missiuna et al., 2007). There was also evidence of a link between

motor skills and social activities carried out alone, in that children with lower motor performance

carried out more social activities alone (Jarus et al., 2011). While this may be a way of these

children coping with their perceived social difficulties, this could mean they lose opportunities to

develop social skills and have positive interactions with their peers that are associated with better

psychological wellbeing (Goswami, 2012).

There is evidence to suggest that the motor difficulties experienced by children with

DCD may be linked with difficulties in socialisation as the former was found to be a significant

132

predictor of the latter (Sumner et al., 2016). In addition, peer problems have been found to partly

mediate the relationship between motor difficulties and internalising and externalising problems

(Wagner et al., 2012). These findings are in line with the EESH (Cairney et al., 2013) as it

suggests that social problems, which are considered to be secondary to having DCD, may be one

of the core factors linking DCD to mental health problems. Moreover, a number of the studies

assessed in this review also have findings that support the EESH model. In particular, they

support the first relationship in the model that suggests that the motor skills impairment of

children with DCD impacts their socialisation and creates a number of social difficulties. Given

the research described above and the more general literature on the impact that social difficulties

may have on internalising problems, it is possible that these social difficulties are contributing to

mental health problems in this group.

Limitations

The current review only included primary research articles published in peer reviewed

journals in order to systematically review them. However, this might have introduced bias by not

including findings on the experiences of children documented in the grey literature, un-published

articles and dissertations. This is because research suggests that positive outcomes are more

likely to be published (Dwan et al., 2008). Furthermore, studies were excluded if they were not

written in English which may lead to having predominantly studies from cultures where English

is spoken and therefore the findings of this review may not be generalised.

Several studies included in this review used subscales specific to peer/social problems

that are part of a more general measure such as the CBCL or PCSA. There may be more studies

that used those measures that would not be identified with the search terms and therefore it may

133

be difficult to have obtained an exhaustive list of studies measuring for peer/social problems in

children with DCD. However, this review obtained a broad spectrum of studies where peer

relationships were a specific focus to inform understanding and future research. Finally, in order

to retain as much research as possible as part of this review, some studies that did not confirm

motor abilities with a medical report or by the researchers were also included.

One third of the studies relied solely on the perspectives of parents; given that the

participants are quite young, this is understandable. However, the perceptions of their difficulties

might be different from that of their children or other informants. Previous research has found

only modest agreement between children’s and parents report on a measure of children’s

strengths and difficulties for TD children, and between parents and teachers for children with

DCD (Van der Meer, Dixon, & Rose, 2008; Crane, Sumner, & Hill, 2017). Further research

should aim to gather the perspectives of the young people and of others around them, such as

siblings or teachers, to get a broader perspective of their difficulties. There would also be a

benefit in future research exploring the social experiences of adults with DCD to better

understand the long-term effect of motor difficulties on social outcomes.

Conclusion

Overall, the current systematic review identified a number of common themes amongst

studies in the literature on the social difficulties experienced by children with DCD. It does

suggest, in line with the EESH, that children with DCD experience a number of difficulties in

their interactions with their peers. Given the previous research associating these negative social

interactions with poor mental health, it is important for clinicians and professionals to consider

this area when working with children with DCD. In addition, the systematic review should help

134

these professionals to identify the type of social difficulties faced and tailor interventions

accordingly.

135

References

Achenbach, T.M.(1991). Manual for the Child Behavior Cheklist / 4-18 and 1991 profile.

Burlington VT: University of Vermont. Department of psychiatry.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders. Washington: APA.

Barnhart, R. C., Davenport, M. J., Epps, S. B., & Nordquist, V. M. (2003). Developmental

coordination disorder. Physical Therapy, 83(8), 722-31.

Blood, G. W., & Blood, I. M. (2007). Preliminary study of self-reported experience of physical

aggression and bullying of boys who stutter: Relation to increased anxiety. Perceptual

and Motor Skills, 104, 1060-1066.

Cairney, J., Hay, J., Faught, B., Mandigo, J., & Flouris, A. (2005). Developmental Coordination

Disorder, Self-efficacy Towards Physical ACtivity and Play: Does Gender Matter?

Adapted Physical Activity Quarterly, 22(1), 67-82.

Cairney, J., Rigoli, D., & Piek, J. (2013). Developmental coordination disorder and internalizing

problems in children: The environmental stress hypothesis elaborated. Developmental

Review, 33, 224–238.

Cairney, J., Veldhuizen, S., & Szatmari, P. (2010). Motor coordination and emotional–behavioral

problems in children. Current Opinion in Psychiatry, 23(4), 324–329.

Campbell, W. N., Missiuna, C., & Vaillancourt, T. (2012). Peer victimization and depression in

children with and without motor coordination difficulties. Psychology in the Schools,

49(4), 328-341.

Chase, M. A., & Dummer, G. M. (1992). The role of sports as a social status determinant for

children. Research Quarterly for Exercise and Sport, 63, 418–424.

136

Chung, E. Y.-H. (2018). Unveiling Issues Limiting Participation of Children with Developmental

Coordination Disorder: From Early Identification to Insights for Intervention. Journal of

Developmental and Physical Disabilities, 30, 373-389.

Cocks, N., Barton, B., & Donelly, M. (2009). Self-concept of boys with developmental

coordination disorder. Physical & Occupational Therapy in Pediatrics, 29(1), 6-22.

Crane, L., Sumner, E., & Hill, E. L. (2017). Emotional and behavioural problems in children

with Developmental Coordination Disorder: Exploring parent and teacher reports.

Research in Developmental Disabilities, 70, 67-74.

Dewey, D., Kaplan, B. J., Crawford, S. G., & Wilson, B. N. (2002). Developmental coordination

disorder: associated problems in attention, learning, and psychosocial adjustment. Human

Movement Science, 21(5-6), 905-918.

Dwan, K., Altman, D. G., Arnaiz, J. A., Bloom, J., Chan, A. W., Cronin, E., ... & Ghersi, D.

(2008). Systematic review of the empirical evidence of study publication bias and

outcome reporting bias. PloS one, 3(8), e3081.

Engel-Yeger, B., Sido, R., Mimouni-Bloch, A., & Weiss, P. L. (2017). Relationship between

perceived competence and performance during real and virtual motor tasks by children

with developmental coordination disorder. Disability and Rehabilitation: Assistive

Technology, 12(7), 752-757.

Evans-Lacko, S., Takizawa, R., Brimblecombe, N., King, D., Knapp, M., Maughan, B., &

Arseneault, L. (2017). Childhood bullying victimization is associated with use of mental

health services over five decades: a longitudinal nationally representative cohort

study. Psychological Medicine, 47(1), 127-135.

137

Findlay, L. C., & Coplan, R. J. (2008). Come out and play: Shyness in childhood and the benefits

of organized sports participation. Canadian Journal of Behavioural Science, 40(3), 153–

161.

Francis, M., & Piek, J. (2003). The effects of perceived social support and self-worth on

depressive symptomatology in children with and without developmental coordination

disorder (DCD). In Proceedings of the 38th APS annual conference (pp. 70-74). The

Australian Psychological Society Ltd.

Goswami, H. (2012). Social Relationships and Children’s Subjective Well-Being. Social

Indicators Research, 107(3), 575–588.

Grob, A., Meyer, C. S., & Hagmann-von Arx, P., (2009). Intelligence and development scales:

IDS. [Intelligenz-und Entwicklungsskalen für Kinder von 5-10 Jahren]. Bern: Huber.

Harter, S. (1985). Manual for the self-perception profile for children: Revision of the perceived

competence scale for children. Denver, CO: University of Denver.

Harter, S., & Pike, R. (1984). The pictorial scale of perceived competence and social acceptance

for young children. Child Development, 1969-1982.

Hoza, B. (2007). Peer functioning in children with ADHD. Journal of Pediatric

Psychology, 32(6), 655-663.

Jarus, T., Lourie-Gelberg, Y., Engel-Yeger, B., & Bart, O. (2011). Participation patterns of

school-aged children with and without DCD. Research in Developmental Disabilities,

32(4), 1323-1331.

Jootun, D., McGhee, G., & Marland, G. R. (2009). Reflexivity: promoting rigour in qualitative

research. Nursing Standard, 23 (23), 42-46.

138

Kanioglou, A., Tsorbatzoudis, H., & Barkoukis, V. (2005). Socialization and behavioral

problems of elementary school pupils with developmental coordination disorder.

Perceptual and Motor Skills, 101(1), 163-173.

Klein, S., & Magill-Evans, J. (1998). Perceptions of competence and peer acceptance in young

children with motor and learning difficulties. Physical & Occupational Therapy in

Pediatrics, 18(3/4), 39-52.

Kmet, L. M., Cook, L. S., & Lee, R. C. (2004). Standard quality assessment criteria for

evaluating primary research papers from a variety of fields. Alberta Heritage Foundation

for Medical Research. Retrieved from http://www.ihe.ca/documents/HTA-FR13.pdf.

Accessed on 01.09.2018.

Knott, F., Dunlop, A. W., & Mackay, T. (2006). Living with ASD: How do children and their

parents assess their difficulties with social interaction and understanding? Autism, 10(6),

609-617.

Kumpulainen, K., Räsänen, E., & Puura, K. (2001). Psychiatric disorders and the use of mental

health services among children involved in bullying. Aggressive Behavior: Official

Journal of the International Society for Research on Aggression, 27(2), 102-110.

LaFontana, K. M., & Cillessen, A. H. (2002). Children's perceptions of popular and unpopular

peers: A multimethod assessment. Developmental Psychology, 38(5), 635–647.

Lezhnieva, N., Fredriksen, P. M., & Bekkhus, M. (2018). Peer relationships and quality of life in

11–12-year-old children: The Health Oriented Pedagogical Project (HOPP).

Scandinavian Journal of Public Health, 46, 74–81.

139

Linver, M. R., Roth, J. L., & Brooks-Gunn, J. (2009). Patterns of Adolescents’ Participation in

Organized Activities: Are Sports Best When Combined With Other Activities?

Developmental Psychology, 45(2), 354–367.

Livesey, D., Lum Mow, M., Toshack, T., & Zheng, Y. (2011). The relationship between motor

performance and peer relations in 9‐to 12‐year‐old children. Child: Care, Health and

Development, 37(4), 581-588.

Mandich, A. D., Polatajko, H. J., & Rodger, S. (2003). Rites of passage: Understanding

participation of children with developmental coordination disorder. Human Movement

Science, 22(4-5), 583-595.

Marsh, H. W. (1992). Self-description questionnaire II: Manual. New South Wales, Australia:

University of Western Sydney, Macarthur, Faculty of Education, Publication Unit.

McGarty, A. M., & Melville, C. A. (2018). Parental perceptions of facilitators and barriers to

physical activity for children with intellectual disabilities: A mixed methods systematic

review. Research in Developmental Disabilities, 73, 40-57.

Melville, C. A., Oppewal, A., Elinder, L. S., Freiberger, E., Guerra-Balic, M., Hilgenkamp, T.

I., ... & Cuesta-Vargas, A. (2017). Definitions, measurement and prevalence of sedentary

behaviour in adults with intellectual disabilities—A systematic review. Preventive

Medicine, 97, 62-71.

Merritt, D. H., & Snyder, S. M. (2015). Correlates of Optimal Behavior Among Child Welfare-

Involved Children: Perceived School Peer Connectedness, Activity Participation, Social

Skills, and Peer Affiliation. American Journal of Orthopsychiatry, 85(5), 483–494.

140

Missiuna, C., Moll, S., King, S., King, G., & Law, M. (2007). A trajectory of troubles: parents'

impressions of the impact of developmental coordination disorder. Physical &

Occupational Therapy in Pediatrics, 27(1), 81-102.

Missiuna, C., Moll, S., Law, M., King, S., & King, G. (2006). Mysteries and mazes: Parents'

experiences of children with developmental coordination disorder. The Canadian Journal

of Occupational Therapy, 73(1), 7-17.

Nabuzoka, D. (2003). Teacher ratings and peer nominations of bullying and other behaviour of

children with and without learning difficulties. Educational Psychology, 23, 307–321.

Noordstar, J. J., Stuive, I., Herweijer, H., Holty, L., Oudenampsen, C., Schoemaker, M. M., &

Reinders-Messelink, H. A. (2014). Perceived athletic competence and physical activity in

children with developmental coordination disorder who are clinically referred, and

control children. Research in Developmental Disabilities, 35(12), 3591-3597.

Noreau, L., Fougeyrollas, P., & Vincent, C. (2002). The LIFE-H: Assessment of the quality of

social participation. Technology and Disability, 14(3), 113-118.

Novak, C., Lingam, R., Coad, J., & Emond, A. (2012). ‘Providing more scaffolding’: Parenting a

child with developmental co-ordination disorder, a hidden disability. Child: Care, Health

and Development, 38(6), 829–835.

Payne, S., Ward, G., Turner, A., Taylor, M., & Bank, C. (2013). The social impact of living with

developmental coordination disorder as a 13-year-old. British Journal of Occupational

Therapy, 76(6), 362-369.

Piek, J. P., Dworcan, M., Barrett, N. C., & Coleman, R. (2000). Determinants of self-worth in

children with and without developmental coordination disorder. International Journal of

Disability, Development and Education, 47(3), 259-272.

141

Poulsen, A. A., Barker, F. M., & Ziviani, J. (2011b). Personal projects of boys with

developmental coordination disorder. OTJR: Occupation, Participation and Health,

31(3), 108-117.

Poulsen, A. A., Johnson, H., & Ziviani, J. M. (2011a). Participation, self‐concept and motor

performance of boys with developmental coordination disorder: A classification and

regression tree analysis approach. Australian Occupational Therapy Journal, 58(2), 95-

102.

Poulsen, A. A., Ziviani, J. M., & Cuskelly, M. (2008). Leisure time physical activity energy

expenditure in boys with developmental coordination disorder: The role of peer relations

self-concept perceptions. OTJR: Occupation, Participation and Health, 28(1), 30-39.

Reijntjes, A., Kamphuis, J. H., Prinzie, P., & Telch, M. J. (2010). Peer victimization and

internalizing problems in children: A meta-analysis of longitudinal studies. Child Abuse

& Neglect, 34(4), 244-252.

Rodger, S., & Mandich, A. (2005). Getting the run around: Accessing services for children with

developmental co-ordination disorder. Child: Care, Health and Development, 31(4),

449–457.

Segal, R., Mandich, A., Polatajko, H., & Cook, J. V. (2002). Stigma and its management: A pilot

study of parental perceptions of the experiences of children with developmental

coordination disorder. he American Journal of Occupational Therapy, 56(4), 422-428.

Skinner, R. A., & Piek, J. P. (2001). Psychosocial implications of poor motor coordination in

children and adolescents. Human Movement Science, 20, 73–94.

142

Smyth, M. M., & Anderson, H. I. (2000). Coping with clumsiness in the school playground:

Social and physical play in children with coordination impairments. British Journal of

Developmental Psychology, 18(3), 389-413.

Soriano, C. A., Hill, E. L., & Crane, L. (2015). Surveying parental experiences of receiving a

diagnosis of developmental coordination disorder (DCD). Research in Developmental

Disabilities, 43, 11-20.

Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2006). Vineland adaptive behavior scales.

Oxford: NCS Pearson Inc.

Stephenson, E. A., & Chesson, R. A. (2008). ‘Always the guiding hand’: parents' accounts of the

long‐term implications of developmental co‐ordination disorder for their children and

families. Child: Care, Health and Development, 34(3), 335-343.

Sumner, E., Leonard, H. C., & Hill, E. L. (2016). Overlapping phenotypes in autism spectrum

disorder and developmental coordination disorder: A cross-syndrome comparison of

motor and social skills. Journal of Autism and Developmental Disorders, 46(8), 2609-

2620.

Sylvestre, A., Nadeau, L., Charron, L., Larose, N., & Lepage, C. (2013). Social participation by

children with developmental coordination disorder compared to their peers. Disability

and Rehabilitation, 35(21), 1814-1820.

Tsang, W. W., Guo, X., Fong, S. S., Mak, K. K., & Pang, M. Y. (2012). Activity participation

intensity is associated with skeletal development in pre-pubertal children with

developmental coordination disorder. Research in Developmental Disabilities, 33(6),

1898-1904.

143

Tseng, M.-H., Howe, T.-H., Chuang, I.-C., & Hsieh, C.-L. (2007). Cooccurrence of problems in

activity level, attention, psychosocial adjustment, reading and writing in children with

developmental coordination disorder. International Journal of Rehabilitation Research,

30(4), 327-332.

Van der Meer, M., Dixon, A., & Rose, D. (2008). Parent and child agreement on reports of

problem behaviour obtained from a screening questionnaire, the SDQ. European Child &

Adolescent Psychiatry, 17(8), 491-497.

Vannatta, K., Gartstein, M. A., Zeller, M., & Noll, R. B. (2009). Peer acceptance and social

behavior during childhood and adolescence: How important are appearance, athleticism,

and academic competence?. International Journal of Behavioral Development, 33(4),

303-311.

Wagner, M. O., Bös, K., Jascenoka, J., Petermann, F., & Jekauc, D. (2012). Peer problems

mediate the relationship between developmental coordination disorder and behavioral

problems in school-aged children. Research in Developmental Disabilities, 33(6), 2072-

2079.

Wilson, B. N., Neil, K., Kamps, P. H., & Babcock, S. (2013). Awareness and knowledge of

developmental co‐ordination disorder among physicians, teachers and parents. Child:

Care, Health and Development, 39(2), 296–300.

Zhang, G., Zhao, S., Liang, Z., Li, D., Chen, H., & Chen, X. (2015). Social Interactions With

Familiar and Unfamiliar Peers in Chinese Children: Relations With Social, School, and

Psychological Adjustment. International Perspectives in Psychology: Research,

Practice, Consultation, 4(4), 239–253.

144

Zwicker, J. G., Harris, S. R., & Klassen, A. F. (2012). Quality of life domains affected in

children with developmental coordination disorder: a systematic review. Child: Care,

Health and Development, 39(4), 562–580.

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Part 3: Summary of Clinical Experience

Adult Placement

Service: Adult Community Mental Health Team

Dates: October 2016 – September 2017

I conducted assessments and psychological interventions with working age adults (18-65 years)

presenting with a range of mental health difficulties, including depression, generalised anxiety

disorder, psychosis, personality disorder, and social anxiety. The interventions were mostly on

one-to-one basis and using a Cognitive Behavioural Therapy (CBT) approach. Furthermore, I co-

facilitated a CBT group for people diagnosed with Attention Deficit Hyperactivity Disorder, and

performed an evaluation of the effectiveness of this group. In addition, I gained experience

administering neuropsychological test, and delivered a presentation on the role of Clinical

Psychology and the Clinical Psychologist in the treatment mental health difficulties for family

members of service users. Also, I delivered a 4-session training on CBT techniques and

therapeutic skills for Recovery Support Workers at the service.

People with Learning Disabilities Placement

Service: Community Mental Health Learning Disability Team

Dates: October 2017 – March 2018

I worked with adults (18-65 years) with mild to severe learning disabilities, some of whom also

had a comorbid diagnosis of Autism Spectrum Disorder (ASD). The presenting difficulties

included anger, anxiety, low self-esteem and behaviours that challenge. The interventions were

carried out using a CBT and Behavioural models, which were also informed by systemic ideas.

The direct work was predominately carried out on an individual basis, but some session included

family members or carers, and the interventions were adapted to match the client’s intellectual

functioning. Part of the work was carried out indirectly with staff in residential homes and social

services. I conducted neuropsychological assessments for learning disability, and also for

dementia with clients with Down Syndrome.

Older Adult Placement

Service: Older People Community Mental Health Team and Memory Assessment Service

Dates: April 2018 – September 2018

I worked with older adults (75+ years) with a range of difficulties including depression,

generalized anxiety disorder, social anxiety, and fear of falling, and adjustment difficulties

associated with a Parkinson’s Disease diagnosis. I worked with clients predominantly on an

individual basis using CBT and Acceptance and Commitment Therapy (ACT) models.

Moreover, I conducted comprehensive neuropsychological assessments with adults presenting

with symptoms of dementia or mild cognitive impairment to assist with diagnosis or with

cognitive impairments following a stroke to assess its impact on the client’s functioning. I gained

experience in the administration, scoring and interpretation of a range of cognitive tests. I also

delivered training sessions for service users on fear of falling.

Child and Adolescent Placement

Service: Community Child and Adolescent Mental Health Team

Dates: October 2018 – March 2019

I worked with children and adolescents with a range of presenting mental health difficulties

including anxiety, depression, obsessive compulsive disorder, trauma, and behavioural problems.

147

I gained experience working with young people with ASD and ADHD. I conducted assessments

and delivered interventions both individually and with their parents predominantly using the

CBT model while incorporating systemic ideas. I co-facilitated a CBT group for depression for

adolescents. I conducted neuropsychological tests to ascertain the strengths and weakness of the

young person’s cognitive abilities in order to inform the support required. I also gained

experience conducting ASD assessments, and delivered a presentation on anxiety and strategies

to manage it for parents of children with ASD. I had the opportunity to supervise assistant

psychologists.

Specialist Placement: Neuropsychology

Service: Community Neuro Rehabilitation Service

Dates: April 2019 – September 2019

I conducted comprehensive neuropsychological assessments with adults presenting with

cognitive difficulties following a stroke or a traumatic brain injury. I gained experience

administering scoring and interpreting a range of neuropsychological tests. I conducted

assessments and psychological interventions with adults presenting with a range of difficulties

associated with the impact of having the stroke, traumatic brain injury or Functional

Neurological Disorder including depression, generalised anxiety disorder, fear of falling and

adjustment difficulties. I also gained experience delivering cognitive rehabilitation interventions.

I worked jointly with other healthcare professionals such as physiotherapists, occupational

therapists, and speech and language therapists. I took on a leadership role in piloting

psychological input to the Stroke Supported Discharge pathway. I also delivered a teaching

session on psychological input for stroke patients for staff in an in-patient stroke unit.

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Part 4: Table of Assessments Completed During Training

Year I AssessmentsASSESSMENT TITLE

WAIS WAIS Interpretation (online assessment)Practice Report of Clinical Activity

Assessment and formulation of Mr. Oliver, a man in his 60’s experiencing problems with urinary retention.

Audio Recording of Clinical Activity with Critical Appraisal

Audio recording with critical appraisal of a CBT session.

Report of Clinical Activity N=1

Assessment and Cognitive Behavioural Therapy for depression with a man in his 50’s.

Major Research Project Literature Survey

What is the impact of having children with developmental disorders on parental mental health?

Major Research Project Proposal

Parenting stress of parents of children with Developmental Coordination Disorder: Comparison with parents of typically developing children and factors that predict parenting stress.

Service-Related Project A service evaluation of a Cognitive Behavioural Therapy group for ADHD.

Year II AssessmentsASSESSMENT TITLE

Report of Clinical Activity/Report of Clinical Activity – Formal Assessment

A learning disability assessment for Charlie, a man in his 20’s.

PPD Process Account My experiences within the PPD group.

Year III Assessments ASSESSMENT TITLE

Presentation of Clinical Activity

Rauf: A 75-year-old man experiencing social anxiety.

Major Research Project Literature Review

Social problems in children with Developmental Coordination Disorder: A review of the literature.

Major Research Project Empirical Paper

Exploring parenting stress levels and its predicting factors in parents of children with Developmental Coordination Disorder.

Report of Clinical Activity/Report of Clinical Activity – Formal Assessment

A systemically informed CBT intervention: Robert, a 10-year old male presenting with obsessive compulsive disorder symptoms.

149