Research in Developmental Disabilities 32 (2011) 1253–1259

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Anxiety profiles in children with and without developmental

coordination disorder
Michelle L. Pratt a,*, Elisabeth L. Hill b
a
Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
b
Department of Psychology, Goldsmiths, University of London, UK

A R T I C L E I N F O A B S T R A C T

Article history: Previous work has highlighted that children diagnosed with DCD may be at risk of greater
Received 23 March 2010 problems related to emotional wellbeing. However, to date much work has relied on
Received in revised form 26 January 2011 population based samples, and anxiety has not been examined within a group of children
Accepted 5 February 2011 given a clinical diagnosis of DCD. Additionally, the profile of individual differences has
Available online 5 March 2011 generally not been considered within this group. Therefore, a group of parents (n = 27)
completed the parent version of the Spence Children’s Anxiety Scale (SCAS-P; Spence,
Keywords: 1998) in relation to their children with a diagnosis of DCD. Their responses on this measure
Developmental coordination disorder
were compared to those of parents with typically developing (TD) children (n = 35; both
Anxiety
groups 6–15 years of age). Children diagnosed with DCD were reported to experience
Individual differences
significantly greater levels of anxiety overall, as well as having significantly greater
difficulty than the TD group in the domains of panic/agoraphobic anxiety, social phobia,
and obsessive compulsive anxiety. In addition, the individual profiles of types of anxiety
reportedly experienced varied widely across the DCD group. These findings suggest that
anxiety is a major problem for a proportion of children diagnosed with DCD, and raises
questions regarding intervention, long term outcomes, and the nature of the disorder
itself.
ß 2011 Elsevier Ltd. All rights reserved.

1. Introduction

Suffering with an anxiety disorder can have a tremendous impact on a person’s quality of life. A recent study carried out
by Barrera and Norton (2009) investigated to what extent anxiety was linked to quality of life and found that adults suffering
from an anxiety disorder frequently reported that they were much less satisfied with their lives than those without anxiety
issues. Furthermore, the effect of having an anxiety disorder on reports of quality of life remained stable regardless of how
severe symptoms were reported to be; indicating that anxiety per se rather than severity of anxiety disorder mediates the
effect (Barrera & Norton, 2009).
While anxiety disorders, social phobia and generalised anxiety disorder are classified in DSM-IV (American Psychiatric
Association (APA), 1994) on their own axis (Anxiety – AXIS 1), they can also exist alongside other disorders. In recent years
there has been growing acknowledgement that anxiety disorders exist in childhood, and that those with a
neurodevelopmental disorder can show increased levels of anxiety in relation to their typical peers. These anxieties
may be integral to the diagnosed difficulties, or a secondary consequence of them. One such disorder is developmental
coordination disorder (DCD). DCD is diagnosed when motor difficulties (i) are out of keeping with chronological age and

* Corresponding author. Tel.: +44 20 7679 1691.

E-mail address: michelle.pratt@ucl.ac.uk (M.L. Pratt).

0891-4222/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2011.02.006
1254 M.L. Pratt, E.L. Hill / Research in Developmental Disabilities 32 (2011) 1253–1259

general ability; (ii) interfere with activities of daily living and/or educational achievement; and (iii) cannot be accounted for
by learning disability or other medical condition (e.g., cerebral palsy). More males are believed to be affected than females
and prevalence is estimated at around 5% (APA, 1994). Day-to-day motor difficulties are apparent: difficulties with balance,
spatial awareness, manual dexterity and hand eye-coordination, for example, make even simple tasks such as getting
dressed and eating difficult. Furthermore, social-esteem issues have long been reported in the disorder (e.g., Gubbay, 1975)
and have been assumed to arise as a reaction to poor motor skill either through a failure to learn important skills or because
the social concomitants of clumsiness lead to avoidance tactics on the part of the child. Children and teenagers with motor
difficulties have been shown to have self-perceptions consistent with their motor abilities (Jongmans, Demetre, Dubowitz, &
Henderson, 1996), indicating awareness of their problems. The majority of children diagnosed with DCD do not grow out of it
(e.g., Losse et al., 1991) and the impact of this has been shown on mental health outcomes. Hellgren, Gillberg, Bagenholm,
and Gillberg (1994) reported increased levels of substance abuse and suicide attempts in a longitudinal study of children
diagnosed with DAMP (deficits in attention, motor control and perception, used in Scandinavia to include those with DCD) in
a follow-up study at 16 years of age.
Various population based studies have investigated links between motor skill and emotional wellbeing in samples that
have not been diagnosed with DCD. In 2001, Skinner and Piek reported that when assessing the emotional wellbeing of
children and adolescents (aged 10–14 years), those with poorer motor development reported lower perceived levels of
competence (both scholastic and athletic), self worth, and social support than their peers, and they also endorsed greater
levels of anxiety. Furthermore, each effect was more pronounced in the older children with poorer motor skills relative to
their peers (Skinner & Piek, 2001). Dewey, Kaplan, Crawford, and Wilson (2002) have also reported that children with poorer
motor skill show greater difficulties with psychosocial adjustment than their peers whose movement has developed
normally.
Others have investigated this issue within groups of children and adolescents with a clinical diagnosis of DCD. A study
carried out by Green, Baird, and Sugden (2006) investigated psychopathology in DCD, and reported that of a sample of 47
children, ratings of 29 parents (62%) identified a significant level of emotional and behavioral difficulties present in their
children when completing the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997).
Missiuna, Moll, King, King, and Law (2007) interviewed the parents of 13 children (aged 6–14 years) who were suspected
to have DCD. When looking retrospectively, worries of parents with a child with DCD moved from motor skill and play at the
youngest ages, into academic/peer related, self care and hygiene issues in middle childhood, and then finally onto emotional
wellbeing in adolescence. This suggests that mental health related worries are a concern in DCD, and that this worry may be
moderated by the age of the child. Using a similar method, Stephenson and Chesson (2008) reported that 10 of 12 (83.3%)
parents of a child with DCD who they interviewed endorsed worries for their child related to emotional difficulties and social
skills.
While we are now clear that there is an increased risk of high levels of anxiety in those with DCD, we are less clear on the
precise nature and extent of these anxieties, and of the nature of causation (if any) between motor difficulties and anxiety
symptoms.
To address these outstanding questions, the current study aimed to investigate levels of anxiety in two groups of children,
one diagnosed with DCD and the other typically developing. This is the first time that a study has considered the profile of
anxiety in a group of children with a clinical diagnosis of DCD, in order to establish whether specific types of anxiety may be
more pervasive than others. In addition, past studies have focused on group analysis. While this is valuable, it masks
individual differences in anxiety characteristics. Therefore, we report both group comparisons of performance as well as
individual difference data to evaluate the possibility that some children with DCD will show increased levels of anxiety while
others will not. This information will provide the basis for future studies investigating the links between motor difficulties
and symptoms of anxiety, as well as investigation of likely risk and protective factors in this relationship. For the current
study, it was predicted that children diagnosed with DCD would have higher anxiety levels on average than their typically
developing peers, but that the patterns of anxiety type would vary within the DCD group. It was also predicted that panic
anxiety, social phobia, and physical injury fears would be the most common types of anxiety observed within the clinical
group.

2. Method

2.1. Participants

Participants were recruited through existing research being conducted at Goldsmiths (University of London, UK), support
groups for those with DCD, and schools within London and the south-east of England. A total of 27 parents (25 mothers and 2
fathers) responded to an advert or letter regarding their child with DCD, and 35 parents (34 mothers and 1 father) for their
typical child (total n = 62). Children were aged between 6 and 18 months, with a mean age of 120.9 months in the DCD group,
and 112.6 months in the typically developing group. The DCD group comprised 20 males and 7 females, while the typically
developing group was made up of 18 males and 17 females. Only those with a clinical diagnosis of DCD made according to the
DSM-IV criteria and without further overlapping conditions diagnosed such as attention deficit hyperactivity disorder
(ADHD) were included in the DCD group. Medical records of participants were provided, and all had been diagnosed by
experienced clinicians or occupational therapists, and were deemed to have DCD based on Movement ABC-2 scores being
 M.L. Pratt, E.L. Hill / Research in Developmental Disabilities 32 (2011) 1253–1259 1255

below the 5th percentile (Henderson and Sugden, 2007). Parents of typically developing participants also completed the
Strengths and Difficulties Questionnaire (Goodman, 1997) to ensure that this group did not include children who may have
had undiagnosed behavioral difficulties. Children were excluded from the typically developing group if they had received a
diagnosis of a neurodevelopmental disorder prior to participation in the study, with no children excluded on this basis. All
parents also completed the DCD-Q (see Section 2.2.2) to further confirm their child’s level of movement skill. All children in
the DCD group scored as having DCD, with none of the children in the typically developing group scoring as having DCD or
suspected DCD.

2.2. Measures

2.2.1. The Spence Children’s Anxiety Scale (parent checklist; SCAS-P; Spence, 1998)
The SCAS-P is a 38 item parent report measure of anxiety which measures total level of anxiety, as well as six anxiety
disorders which are all classified in DSM-IV, namely panic/agoraphobia; generalised anxiety disorder; social phobia;
separation anxiety disorder; obsessive compulsive disorder; and physical injury fears.
Responses are scored on a scale of 0–3 (0 = never, 1 = sometimes, 2 = often, 3 = always). The total score is the sum of all
items (maximum = 114), with a higher score indicating elevated anxiety.
The SCAS-P has excellent reliability, with Cronbach’s alpha values ranging from r = .81 to r = .90 in the normal population
and r = .83 to r = .92 in anxiety disordered groups. The scale’s discriminant validity is also high, both in terms of classifying
children as having an anxiety disorder, as well as being very effective in discriminating between different types of anxiety
disorder (with the exception of generalised anxiety which has been shown to be very closely related to the total score and
therefore does not appear to represent a separate construct; Nauta et al., 2004). Therefore, for the current study, subscale
scores will be reported, with the exception of the generalised anxiety subscale.
Data on the questionnaire measure were compared in two ways: First by conducting traditional between group
comparisons of total and subscale scores for each questionnaire, and secondly, by investigating individual differences. This
was achieved by comparing the number of individuals in each group who would be categorised as impaired/unimpaired on
the measure using the published cut-off scores.

2.2.2. Developmental Coordination Disorder Questionnaire (DCD-Q; Wilson, Kaplan, Crawford, Campbell, & Dewey, 2000)
All parents completed the DCD-Q, which is a 17 item scale used to assess motor skill and ability in childhood. This was to
ensure that no typically developing participants had an undetected movement difficulty. The DCD-Q has been shown to be
valid and reliable at detecting the existence of motor difficulty (Wilson et al., 2000).

2.2.3. Informed consent and ethics

Parents provided informed consent to participate. The study was approved by the Department of Psychology Ethics
Committee at Goldsmiths, University of London, according to the guidelines laid down by the BPS and the ESRC.

3. Results

3.1. Descriptive statistics

An independent samples t-test showed that there was no significant difference between the two groups with regards to
their age (t(65) = 1.71, p > .05). However, there was a significant effect of gender, with the typically developing group
including significantly more females (t(65) = 1.71, p < .005). The data were also checked for normality, and this process
revealed that the data were significantly skewed. As a result, a log transformation was applied to the anxiety data. Therefore,
in the resulting analyses log transformed scores were used and gender was also applied as a covariate. Analysis revealed that
there were no significant gender differences across any of the anxiety categories, and therefore the gender difference will not
be discussed further and the analyses reported below do not include gender as a covariate.
Descriptive statistics for the SCAS-P total and subscales are shown for the two groups in Table 1, while the number of
children whose parent reports placed them above the published cut-off for clinically significant impairment is shown in
Table 2. The combinations of categories of anxieties reported are displayed in Table 3.

Table 1
SCAS-P mean (SD) scores and range for each group.

DCD Typical ANOVA

Total score* 23.04 (19.85) 3–90 11.66 (6.48) 3–29 F(1, 66) = 6.42, p < .005
Panic/agoraphobia** 2.70 (3.87) 0–17 .17 (.51) 0–2 F(1, 66) = 15.22, p < .001
Separation anxiety 3.85 (4.48) 0–17 2.86 (2.28) 0–8 F(1, 66) = .179, p > .05
Physical injury fears 3.67 (2.99) 0–10 3.0 (1.64) 0–6 F(1, 66) = .448, p > .05
Social phobia* 5.85 (4.43) 0–16 2.62 (2.31) 0–8 F(1, 66) = 5.46, p < .005
Obsessive compulsive** 2.63 (3.31) 0–13 .66 (.98) 0–3 F(1, 66) = 7.80, p < .001
*
p < .005.
**
p < .001.
1256 M.L. Pratt, E.L. Hill / Research in Developmental Disabilities 32 (2011) 1253–1259

Table 2
Number (percent of group) falling above cut-off (see SCAS-P manual) indicating clinically significant impairment.

DCD group n = 27 Typical group n = 35

Total score 7 0
25.9 –
Panic/agoraphobia 13 1
Score** 48.1 3
Separation anxiety 7 5
25.9 14
Physical injury fears 10 18
37 50
Social phobia 8 2
29.6 6
Obsessive compulsive disorder* 10 3
37 9
*
p < .005.
**
p < .001.

3.2. Overall group comparison results

In line with predictions, a oneway ANOVA showed that there was a significant between group difference in total score on
the SCAS-P [F(1, 65) = 6.42, p < .005]. Thus further analysis of specific subscales of the SCAS-P was conducted in order to
provide insight into the locus and profile of these anxiety problems (see Table 1 for SCAS-P and ANOVA scores). In sum,
significant group differences were identified on three of the five subscales (panic/agoraphobia; social phobia; obsessive
compulsive anxiety).Individual difference results
Strikingly, over a quarter of the group with DCD were reported to display symptoms consistent with clinically significant
levels of anxiety (see Table 2). However the actual patterns of anxiety which were evident and the extent to which anxiety
was pervasive across subscales of the SCAS-P differed throughout the DCD group, as shown in Table 3. There were no clear
patterns within the group with respect to the combination of types of anxieties reported. Chi-square tests were carried out to
investigate whether the instances of clinical levels of anxiety observed across the two groups differed. The only categories
that reached significance were panic anxiety (x2(9, N = 62) = 22.00, p = < .005) and obsessive compulsive anxiety (x2(9,
N = 62) = 14.78, p = < .005), with these two types of anxiety being observed at clinically levels significantly more often in the
DCD group.

4. Discussion

In line with predictions, parent reports demonstrated that children with DCD had elevated anxiety levels when compared
with a matched, typically developing group. These findings support previous reports by Skinner et al. (2001), Dewey et al.
(2002), and Green et al. (2006). Moreover, the findings of the current study extend these previous findings by focusing on
individual differences within the group; which showed that many– but by no means all – individual children with a

Table 3
Patterns of anxiety types within the DCD group.

Number of subscales of clinically relevant anxiety Number of participants Combinations

5 3 All subscales

4 2
1 P, Sep, S, & OC
1 P, Sep, PIF & OC

3 5
2 P, PIF, & OC
1 P, Sep, & S
1 PIF, S, & OC
1 P, Sep, & PIF

2 3
1 P&S
1 P &OC
1 PIF & S

1 4
2 P
1 OC
1 PIF
0 10 No subscales

Key: P = panic; S = social phobia; Sep = separation anxiety; OC = obsessive compulsive disorder; PIF = physical injury fears.
 M.L. Pratt, E.L. Hill / Research in Developmental Disabilities 32 (2011) 1253–1259 1257

diagnosis of DCD had significantly elevated levels of anxiety. Skinner et al. (2001) reported that low perceptions of self worth
in children and teenagers diagnosed with DCD varied with age and was not a whole group phenomenon, with perceptions
changing as the child aged. While supporting the findings of Green et al. (2006), the percentage of clinically significant
anxiety reported in the current group is not as high as the behavioral difficulties reported by parents in the Green et al. study
on the SDQ (Goodman, 1997). While the aspects being measured (anxiety and behavioral difficulties) are two separate
constructs, this may support the notion of great variability with regards to behavioral and emotional difficulties of
individuals diagnosed with DCD. As predicted, the specific types of anxiety that these children were reported to experience
were not always the same. The fact that such an array of individual differences was apparent in a relatively small group of
participants with DCD has implications for the way in which emotional wellbeing should be viewed in this disorder, and how
much more work needs to be done in order to fully understand the occurrence of anxiety symptoms and their impact on
outcomes.
From an everyday life perspective, it is easy to visualise how having a motor disorder may lead to elevated levels of
anxiety. Given their difficulties, children and adults with DCD have to navigate an intensely complex world. While it should
be noted that the mechanism for any link between motor difficulties and anxiety is as yet unknown, very recent work
reported by Piek, Barrett, Smith, Rigoli, and Gasson (2010) suggests that motor skills in infancy may be predictive of later
symptoms of anxiety and depression at school age.
The most striking difference between the groups was seen on the panic anxiety subscale. Here, around half of the group
diagnosed with DCD were reported to have elevated levels of panic anxiety (vs. 3%, n = 1, of the TD group). Panic anxiety was
predicted to be prevalent within the group. Researchers such as Bandura (1988) and Casey, Oei, and Newcombe (2004) have
theorised that perceptions of self efficacy and control are linked to panic. Thus those with DCD might be expected to show
elevated levels of anxiety related to panic. If a person struggles each day to complete tasks which seem relatively easy for
peers, such as getting dressed, using a knife and fork, or participating in team games, this may lead to anxiety regarding
current and future situations, and a sense of panic when such tasks have to be attempted. Potentially, the avoidance of
certain situations may further contribute to this effect, with children then not having built up appropriate strategies for
times when their poor motor skill means that an activity is challenging. This is an aspect of anxiety that warrants further
investigation and may have implications for educational achievement and psychosocial development. Future studies could
investigate this construct alongside perceived efficacy, to establish whether this contributes to panic anxiety within this
group (see Bandura, 1988; Casey et al., 2004). Investigations could also focus on whether strategy training for the child with
DCD in relation to panic anxiety lessens clinically significant levels of this anxiety subtype.
Nearly 30% of the DCD group were reported to experience social phobia at a clinically significant level. Reduced
participation in activities may contribute to poor or slower development of social skills in DCD, which in turn could
contribute to lack of social skills, and the perception of poor quality friendships, which have been linked with social phobia in
other groups in the past (Rodebaugh, 2009). Furthermore, negative self image (which has been reported across many
domains in DCD by Skinner et al., 2001) and feelings of control of anxiety in social situations (of which the child with DCD
may have little due to their impairment) have both been linked to social phobia (Hirsch, Clark, Matthews, & Williams, 2003;
Hofmann, 2005). It is important to note that children with DCD may also experience exclusion by peers due to their
difficulties, and that in fact the anxieties they experience may be influenced by others in some cases rather than social skill
deficits per se. Future work should aim to establish whether those children diagnosed with DCD who do suffer social anxiety
also have problems with social interaction, or whether these children are often excluded despite having appropriate social
skills. Much as panic has been associated with perceived efficacy, social phobia has been linked with a negative self-image
(Hirsch et al., 2003). Differences in perceived self-image could be an important distinction between children diagnosed with
DCD who have comorbid panic and social anxieties and those who do not; more encouragingly, if this were the case, it is clear
to see how interventions within the mental health arena may help to lessen anxiety within this group, and ultimately
improve long term outcomes.
A proportion of the DCD group were reported to have issues with obsessive compulsive anxiety, which was not predicted.
Two possible explanations might account for this. Firstly, it may be that a quarter of the group are experiencing difficulties in
this area for neurological reasons. Obsessive Compulsive Disorder has been linked to deficits within the frontal lobe region of
the brain (Marsh, Maia, & Peterson, 2009). If the frontal lobes do develop atypically in people with DCD, then this atypical
brain pathology may lead to the presence of other underlying and more subtle difficulties, such as a proportion of the group
showing elevated obsessive compulsive behavior. Alternatively, it could be that this proportion of the group are displaying
obsessive compulsive based anxiety symptoms as a means of gaining control over their environment, but not for
neurological reasons. Many people diagnosed with DCD may feel that they are out of control in terms of the skill base that
they have. The feeling of control over an activity that is gleaned from the repetition of a particular behavior or a pattern of
similar behaviors that an individual is capable of may lead to a proportion of these children having, or showing symptoms of
obsessive compulsive anxiety. Furthermore, signs of obsessive compulsive anxiety may also be linked to a dislike of change
in routine, which again would provide an aspect of control.
Surprisingly, those individuals with DCD did not show a difference to their typical peers on the physical injury fears scale.
It might be expected given their diagnoses that the children with DCD would be more concerned about injury than children
who do not have difficulty with movement and are likely to experience fewer problems and potential injuries. A number of
factors could explain this finding. The children diagnosed with DCD may shy away from activities that they know they
struggle with. Alternatively, they may have poor risk perception. One point to note here is that while not a significant
1258 M.L. Pratt, E.L. Hill / Research in Developmental Disabilities 32 (2011) 1253–1259

difference, a larger percentage of the typical group scored as having heightened levels of physical injury anxiety. This may
suggest that many typically developing children are wary of physical injury as society increasingly becomes more sedentary.
Another issue here may be that typically developing children undertake less physical activity as parents have become
increasingly aware of safety, giving children less freedom, and less active experience (Valentine & McKendrick, 1997).

4.1. Future directions

While parent reports are extremely useful, they may not reflect the perceptions of the child, and future studies should
endeavour to cover this perspective. In addition, future work could focus on the underlying mechanisms of anxiety in DCD,
and should attempt to document the prevalence and types of anxiety that exist in DCD in larger groups using a variety of
measures (other report, self report, objective measures). By doing this, a clearer understanding will be gained of why certain
individuals with DCD have greater difficulties with emotional wellbeing than others, how this impacts on their progress in
life, and whether suitable interventions could be introduced to improve long term physical and mental health outcomes. It
will be interesting to note whether a certain level of anxiety is related to poor outcomes, or alternatively whether the
presence of any anxiety is enough to have an obvious impact on long term outcomes. Finally, it may be informative to use
structural equation modelling, and other such techniques, to consider the nature and direction of the relationship between
anxiety and recorded level of motor skill across different motor domains.

5. Conclusions

The current study adds to the body of evidence which suggests that many children diagnosed with DCD experience low
levels of emotional wellbeing. In addition to this, it is the first study which not only documents reported levels of anxiety on a
group level and individually, but also investigated the specific nature of parent reported anxiety. The investigation of
individual patterns and the specific forms that they take offer a real opportunity to move the field forward, in terms of
understanding why some children and adults diagnosed with DCD do relatively well, while others have much poorer long
term outcomes with regards to their quality of life (Hill, Brown, & Sorgärdt, in press).

Acknowledgements

We gratefully acknowledge the willing participation of all parents in this study. This research was facilitated by an ESRC
PhD studentship awarded to the first author and the data were collected while she was at the Department of Psychology,
Goldsmiths, University of London, UK.

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