RESEARCH ARTICLE
Motor Skills in Brazilian Children with Developmental Coordination Disorder versus Children with Motor Typical Development Ana Amélia Cardoso1*†, Livia Castro Magalhães2 & Marcia Bastos Rezende3 1
Occupational Therapy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, 31270–901, Brazil
2
Occupational Therapy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
3
Occupational Therapy, UFMG, Belo Horizonte, Minas Gerais, 30220-260, Brazil
Abstract The aims of the study were to compare the performance of children with probable developmental coordination disorder (DCD) and motor typically developing peers on items from the Assessment of Motor Coordination and Dexterity (AMCD), to determine whether age, gender and type of school had significant impact on the scores of the AMCD items, to estimate the frequency of DCD among Brazilian children ages 7 and 8 years and to investigate whether children with DCD exhibit more symptoms of attention deficit and hyperactivity disorder than children with motor typical development. A total of 793 children were screened by the Developmental Coordination Disorder Questionnaire – Brazilian version (DCDQ-Brazil); 90 were identified as at risk for DCD; 91 matched controls were selected from the remaining participants. Children in both groups were evaluated with the AMCD, the Movement Assessment Battery for Children (MABC-II) and Raven’s coloured progressive matrices. Thirty-four children were classified as probable DCD, as defined by a combination of the DCDQ-Brazil and MABC-II scores (fifth percentile). The final frequency of DCD among children ages 7 and 8 years was 4.3%. There were significant differences between children with and without DCD on the majority of AMCD items, indicating its potential for identifying DCD in Brazilian children. The use of a motor test (MABC-II) that is not validated for the Brazilian children is a limitation of the present study. Further studies should investigate whether the AMCD is useful for identifying DCD in other age groups and in children from different regions of Brazil. The application of the AMCD may potentially contribute in improving occupational therapy practice in Brazil and in identifying children that could benefit from occupational therapy services. Copyright © 2014 John Wiley & Sons, Ltd. Received 3 May 2013; Revised 13 June 2014; Accepted 6 August 2014
Keywords paediatric occupational therapy; developmental coordination disorder; Assessment of Motor Coordination and Dexterity Test *Correspondence Ana Amélia Cardoso, Occupational Therapy, Federal University of Minas Gerais, Av. Antônio Carlos, 6627, EEFFTO, Occupational Therapy Department, Belo Horizonte, Minas Gerais, 31270–901, †
Email: [email protected]; [email protected]
Published online 17 October 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1376
Introduction Developmental coordination disorder (DCD), as defined by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (APA, 2013), is characterized by motor 176
performance substantially below expected levels, considering the child’s chronologic age and previous opportunities for skill acquisition. The prevalence of DCD in the United States is estimated to be between 5% and 8% among school-age children (APA, 2000), but a more recent study Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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using longitudinal data conducted in the UK reported a prevalence of 1.8% with a predominance of boys (1.9:1; Lingam et al., 2009). Cousins and Smyth (2005) also reported a predominance of boys at a proportion of three to one. This disorder tends to persist into adulthood, and the severity of motor problems may be correlated with functional performance in important activities of daily living, such as handwriting and organizing/finding objects (Kirby et al., 2010). Besides motor issues, the co-occurrence of other developmental problems is common. It is estimated that 68% of children with DCD also have other diagnoses, including attention deficit and hyperactivity disorder (ADHD), learning disorders (Kaplan et al., 2006) and behavioural, emotional (Iversen et al., 2006) and speech and language (Gaines and Missiuna, 2006) problems. Moreover, children with motor difficulties tend to participate less in free or organized play activities (Cairney et al., 2005, 2006) and sports (Poulsen et al., 2008). Despite the importance of detecting DCD early (Clark et al., 2005; Van Waelvelde et al., 2010), there is no gold standard for the diagnosis of this disorder (Dewey and Wilson, 2001; Missiuna et al., 2006), and the most commonly employed motor tests are not standardized and validated for Brazilian children, the focus of this study (Magalhães et al., 2004). With the aim of developing a valid assessment tool for reliable detection of DCD in Brazil, Magalhães and Rezende (2001) created the Assessment of Motor Coordination and Dexterity (AMCD), a motor coordination test for children aged 4–8 years. The AMCD is an assessment of the final product or of what is observable (child’s actions) rather than an assessment of the underlying reason for the lack of coordination. The AMCD is intended to be both a descriptive tool and a discriminative tool, to determine if intervention is required and to be an evaluative tool to measure change over time as a result of intervention (Missiuna et al., 2006). The AMCD assesses motor skills in three categories: (a) hand coordination and dexterity; (b) body coordination; and (c) motor activities and participation at home and school (questionnaires for parents and teachers). AMCD’s development followed a four-step process (Benson and Clark, 1982), is recommended for test development and is currently in the final phase (validation stage) of the process. As part of the AMCD validation process, the present study had the following aims: (a) estimate the frequency of DCD in a sample of Brazilian children aged 7 and 8 years from a metropolitan city (Belo Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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Horizonte, Brazil); (b) investigate whether children with DCD exhibit more symptoms of ADHD than children with typical development do; (c) determine whether age, gender and type of school had significant impact on the scores of the AMCD items; and (d) determine whether the scores on the AMCD items of children with and without DCD were significantly different.
Methods Participants One hundred eighty-one children aged 7 and 8 years from a metropolitan city in Brazil participated in this study. In order to recruit the total sample of 181 children with and without motor problems, the DCDQ-Brazil was administered to 793 children. On the basis of parental and teacher reports, children with the following conditions were excluded from both groups: (a) physical handicap, altered neurological examination or diagnosis of known disorders, such as cerebral palsy, autism spectrum disorder and muscular dystrophy; (b) subnormal hearing or vision; (c) cognitive deficit; (d) orthopaedic problems or lower-limb fracture in the 6 months prior to the assessment; and (e) genetic diseases. Parents/guardians signed a term of informed consent, authorizing the participation of their child in the study. Children were divided into two groups: • DCD group: children at risk for DCD based on the score of the DCDQ-Brazil (Prado et al., 2009). Inclusion criterion: in the absence of Brazilian norms, the Canadian DCDQ cut-off score, ≤55 points (Wilson et al., 1998), was used to indicate risk for DCD. Fifteen 7-year-olds and twenty-two 8-year-olds were recruited from private schools, and twenty-seven 7-year-olds and twenty-seven 8-year-olds were recruited from public schools, totalling 91 children at risk for DCD. Children were recruited from both settings because there are major differences between schools in Brazil; private schools have more resources, and the students have higher socio-economic status. • Typically developing group (TD group): children with typical development, matched by gender and age with each child identified as at risk for DCD. The pairs were recruited among the classmates of the children in the DCD group, on the basis of the DCDQ-Brazil (Prado et al., 2009). The inclusion criterion was a score above 56, that is, the Canadian cut-off on the DCDQ-Brazil (Wilson et al., 1998). 177
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Fifteen 7-year-olds and twenty-three 8-year-olds were recruited from private schools, and twenty-eight 7-year-olds and twenty-four 8-year-olds were recruited from public schools, totalling 90 children without signs of motor problems. The exclusion criteria for the TD group are as follows: (a) history of prematurity (gestational age ≤ 36 weeks) and/or low birth weight (less than 2500 g); (b) school failure, as reported by the teacher; and (c) enrolment in any type of motor intervention programme (e.g. occupational therapy, physiotherapy and psychomotor therapy).
Instruments • Assessment of Motor Coordination and Dexterity (Avaliação da Coordenação e DestrezaMotora; Magalhães et al., 2008): a new instrument designed to identify children with DCD. The current version of the instrument is based on extensive item analysis, described elsewhere (Magalhães et al., 2004), with the inclusion of only those items that demonstrated adequate reliability (i.e. test–retest and interexaminer reliability) and that discriminated motor performance by age (Cury and Magalhães, 2006; Cardoso and Magalhães, 2009; Cardoso et al., 2010). In its current version, the test has 42 motor performance items, 16 items on manual coordination and dexterity and 26 items on bilateral coordination and motor planning. The administration of the AMCD takes approximately 60 minutes. • Developmental Coordination Questionnaire – Brazilian version (Prado et al., 2009): Brazilian version of the DCDQ (Wilson et al., 1998), a 15-item parents’ questionnaire developed in Canada and specific for the screening of DCD among children aged 5–15 years, which has been translated and adapted for Brazilian children (Prado et al., 2009). The DCDQ has been found to have satisfactory test– retest reliability and construct validity in different countries (Loh et al., 2009; Prado et al, 2009; Wilson et al., 2009). It provides a standard method to measure a child’s coordination in everyday, functional activities, such as “throws a ball in a controlled and accurate fashion” and “cuts out pictures and shapes accurately and easily” (Wilson et al., 2009). • Movement Assessment Battery for Children (MABC-II; Henderson et al., 2007): a standardized test used for the identification of motor impairments among children aged 3–17 years. It includes eight items of gross 178
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and fine motor skills grouped into three categories: hand dexterity, throwing and catching, and balance. The raw scores are converted into percentiles, where scores less than or equal to the fifth percentile denotes definite motor difficulty; scores equal to the 6th to 15th percentiles denote risk/suspect; and scores above the 16th percentile indicate normal performance (Henderson et al., 2007). The MABC-II can be administered in 20 minutes, and there is evidence of adequate validity and reliability (Henderson et al., 2007; Brown and Lalor, 2009). • Swanson, Nolan and Pelham IV Scale (SNAP-IV; Swanson et al., 1999): an 18-item questionnaire to screen signs of ADHD, which has been translated to Portuguese (Mattos et al., 2006). Bussing et al. (2008) report that the internal consistency, item selection and factorial structure of the SNAP-IV are considered acceptable and consistent with the constructs of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition; the authors conclude that SNAP-IV ratings from either parents or teachers can distinguish children with different levels of ADHD. In the present study, the SNAP-IV was completed by the teacher, and it was used only to determine the presence of signs of attention difficulties and hyperactivity rather than for diagnostic purposes. The criteria of at least six items scored as “enough” or “too much” in a section of the questionnaire were used to identify symptoms of inattention (items 1–9) or hyperactivity and impulsivity (items 10–18); children who scored above criteria on both sections were considered as presenting signs of combined ADHD (Swanson et al., 1999). • Raven’s Progressive Coloured Matrices – Brazilian version (Angelini et al., 1999): one of the most widely employed intelligence tests (Sisto et al., 2006), consisting of a booklet composed of three sets of items (A, AB and B). Each item is a drawing with a missing part, allowing only one correct answer among the six options presented to the child. One point is attributed to each correct answer. The total score is determined by the sum of correct answers. The cut-off point determines the following classification: (1) intellectually superior; (2) definitely above average; (3) intellectually average; (4) definitely below average; and (5) intellectually deficient. to Pasquali et al. (2002), the Raven has satisfactory psychometric properties and adequately measures the aptitude of analogical reasoning in children aged Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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5–11 years. In the present study, the Raven was used to exclude children with cognitive impairment (children who scored definitely below average – 6th to 25th percentiles – or on the intellectually deficient range – below 6th percentile). • Brazilian Economic Classification Criteria (ABEP, 2008): a Brazilian criterion established to define large economic classes, on the basis of the buying power of urban individuals and families. The point system is based on two categories: possession of items and degree of schooling of the head of the family. The total score yields economic classification into eight categories (A1, A2, B1, B2, C1, C2, D or E). A1 means higher economic class, and E means lower economic class.
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that did not interfere with important learning activities. In order not to tire the child, the assessment was divided into two sessions; the MABC-II was administered in the first session (30 minutes), and the AMCD was administered in the second session (60 minutes). Teachers were asked to respond to the SNAP-IV by considering the child’s behaviour in the classroom. As final diagnostic criteria, children who scored below the cut-off on the DCDQ-Brazil (Prado et al, 2009) and below the fifth percentile on the MABC-II (Henderson et al., 2007) were considered to have DCD (DCD group), and the remaining children were considered to present typical motor development (TD group).
Data analysis Procedures Six public and 56 private elementary schools in the metropolitan area of Belo Horizonte were contacted, among which six public (100%) and 21 private (37.5%) schools agreed to participate in the study. The study was approved by the Human Research Ethics Committee of the Universidade Federal de Minas Gerais (Brazil; ETIC 80/08). An informed consent letter containing information on the objectives of the study, along with the DCDQ-Brazil (Prado et al., 2009), a brief questionnaire concerning birth conditions and child development and the Brazilian Economic Classification Criteria, was sent to parents. In this phase of xrecruitment, 1,879 children received the package, but 793 (42.2%) returned the questionnaires completely filled out with the signed consent letter. A research assistant student analysed the questionnaires, calculated the DCDQ-Brazil scores and identified children at risk for DCD, in accordance with the Canadian norms (Wilson et al., 1998). For each child detected with signs of DCD, another child matched for age and gender but with no signs of motor problems was selected from the same classroom. The matching was performed by the research assistant to blind the examiner to the children’s motor performance group. Children from both groups selected by the DCDQ-Brazil were assessed with the Raven’s Progressive Coloured Matrices (Angelini et al., 1999); children with signs of cognitive impairments were replaced with peers from the same classroom. Following exclusions, children were tested on the AMCD (Magalhães et al., 2008) and the MABC-II (Henderson et al., 2007). The assessments were conducted at school according to a schedule defined by the teachers Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
The SPSS program, version 17.0 (Chicago, IL, USA), was used for the data analyses. As the Kolmogorov–Smirnov test did not indicate that scores exhibit normal distribution, non-parametric tests were employed. The Mann– Whitney test was used to determine whether there were significant differences between the groups with and without DCD as well as differences according to gender, age and type of school, significance level set at 5% (p ≤ 0.05). Pearson’s chi-square was used for categorical variables. The frequency of DCD was calculated by a simple count of the number of children with results below both the DCDQ-Brazil cut-off and the fifth percentile on the MABC-II (Henderson et al., 2007).
Results The characteristics of the groups are displayed in Table I. Among the 34 children characterized as having DCD, of the 7-year-olds, 10 (29.4%) were boys and five (14.7%) girls, and 11 (32.35%) of the 8-year-olds were girls and eight (23.5%) boys. Overall, 45.86% were girls and 54.14% boys (Table I) In regard to the frequency of DCD, considering that 793 children returned the DCDQ-Brazil (Prado et al., 2009) completely filled out in the first phase and 34 children scored below the cut-off points for the DCDQ-Brazil (Prado et al., 2009) and the MABC-II (Henderson et al., 2007), the frequency in the total sample was 4.3%. All children presented superior to average performance on Raven’s cognitive test, and regarding economic status, the majority of the sample, 55.9% of the DCD and 57.8% of the TD groups, was from middle inferior (B2) or higher lower (C1) classes. Pearson’s chi-square test did not detect significant 179
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differences between groups with regard to economic classification or performance on Raven’s cognitive test. Considering the frequency of ADHD, on the basis of teachers’ responses on the SNAP-IV, within the DCD group, 41.2% showed signs of ADHD: six children with DCD (17.6%) exhibited signs of attention deficit, one (2.9%) exhibited signs of hyperactivity/impulsivity, seven (20.7%) exhibited signs of combined ADHD, 18 (52.9%) exhibited no signs of ADHD and two (5.9%) did not return the questionnaires. Within the TD group, 14.1% showed signs of ADHD: five (3.4%) exhibited signs of attention deficit, 10 (6.8%) exhibited signs of hyperactivity/impulsivity, six (4.1%) exhibited signs of combined ADHD, 113 (76.9%) exhibited no signs of ADHD and 13 (8.8%) did not return the questionnaires. Pearson’s chi-square indicated significant differences in the performance on the SNAP-IV between the DCD and TD groups (p = 0.001), with more signs of ADHD in the DCD group.
Assessment of motor coordination and dexterity results Significant gender differences were found for 11 AMCD items (26.19%): place peg in board – dominant hand; move pegs between rows; touch thumbs – dominant hand; cut straight line; trace butterfly; copy alphabet – time in seconds; copy sentence – time in seconds; throw ball against wall; perform jumping jacks; solve a complex maze with the dominant hand; and solve a complex maze with the non-dominant hand. On all items, girls had better performance than boys, with the exception of “throw ball against wall”. Table I. Sample distribution according to groups 7 years Public school
Private school
8 years Public school
Private school
N 55 30 51 45 Girls, n (%) 21 (38.2) 10 (33.3) 32 (62.7) 20 (44.4) Boys, n (%) 34 (61.8) 20 (66.7) 19 (37.3) 25 (55.6) DCD group,a 8 (14.5) 7 (23.3) 10 (19.6) 9 (20) n (%) 23 (76.7) 41 (80.4) 36 (80) Typical group,a 47 (85.5) n (%) Age in months 86.93 ± 2.88 89.13 ± 2.86 99.94 ± 4.00 101.82 ± 3.29 a
Diagnosis defined by combining the Developmental Coordination
Disorder Questionnaire – Brazilian version and Movement Assessment Battery for Children II scores.
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By comparing 7- and 8-year-olds, significant differences were found for most of the items (34 items = 80.95%), with better performance for the 8-year-old children. By comparing the type of school (public or private), significant differences were found on 13 items (30.95%), with children from private schools achieving better performance: move pegs between rows; place coins in piggy bank – non-dominant hand; distribute cards; copy alphabet – time; copy sentence – time; drumming 2; drumming 4; throw ball against wall; catch tennis ball with both hands; catch tennis ball with dominant hand; hopscotch 2; perform jumping jacks; and maintain supine flexion – accuracy. In the comparison of the scores on the AMCD for children with and without DCD, considering the groups in the first phase of the study (children with and without signs of DCD based on the DCDQ-Brazil [Groups 1 and 2]), significant differences were found on 23 (54.77%) AMCD items (Tables II and III). In the comparison of the DCD and TD groups, significant differences were found on 39 (92.85%) AMCD items (Tables II and III).
Discussion The present study continues the validation process of the AMCD and had the following aims: (a) estimate the frequency of DCD in a sample of Brazilian children aged 7 and 8 years from a metropolitan city (Belo Horizonte, Brazil); (b) investigate whether children with DCD exhibit more symptoms of ADHD than do children with motor typical development; (c) determine whether age, gender and type of school had significant impact on the scores of the AMCD items; and (d) determine whether the scores on the AMCD items of children with and without DCD were significantly different. The frequency of DCD among Brazilian children aged 7 and 8 years (4.3%) is close to the prevalence estimated in the literature, which reports values of 5–8% (APA, 2000; Dewey and Wilson, 2001; Cairney et al., 2005), but is higher than the 1.8% reported for 7-year-old children from the UK (Lingam et al., 2009). The lower prevalence by Lingam et al. (2009) is probably due to a different approach to data collection, as they used fewer items to assess motor coordination; they also reported some dropout that might have influenced the prevalence. It should be stressed that the frequency of DCD was calculated on the basis of Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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Table II. Performance of DCD and TD groups on hand coordination and dexterity items of AMCD
Item Place peg in board – dominant hand Place peg in board – non-dominant hand Move pegs between rows Lacing Place coins in piggy bank – dominant hand Place coins in piggy bank – non-dominant hand Sort 20 cards Thumb to fingertips – dominant hand Thumb to fingertips – non-dominant hand Trace straight line Trace curved line Trace butterfly Copy pictures Cut straight line Cut out square Cut out circle Cut out cat Copy alphabet – time Copy sentence – time
DCD group (mean ± standard deviation)
TD group (mean ± standard deviation)
Mann–Whitney U
19.24 ± 5.09 21.91 ± 4.79 22.34 ± 4.72 40.56 ± 14.20 12.72 ± 3.59 14.97 ± 4.52 26.37 ± 7.94 11.12 ± 3.30 12.19 ± 4.33 2.00 ± 6.84 2.06 ± 2.67 8.73 ± 6.62 3.59 ± 1.50 2.32 ± 3.90 6.42 ± 4.40 7.24 ± 6.31 14.03 ± 7.87 111.55 ± 55.03 128.83 ± 113.55
15.72 ± 3.11 17.74 ± 3.20 18.71 ± 4.01 29.48 ± 9.48 10.92 ± 2.44 11.97 ± 2.62 20.99 ± 6.72 9.19 ± 2.48 9.83 ± 2.33 0.18 ± 0.53 1.03 ± 1.87 4.22 ± 4.24 5.10 ± 1.37 0.62 ± 1.37 2.91 ± 2.60 3.03 ± 3.55 7.23 ± 6.80 101.79 ± 38.89 82.22 ± 39.11
1,204.5* 1,095.5* 1,186.5* 1,033.5* 1,698.5*** 1,368.0* 1,321.0* 1,579.5* 1,537.5** 1,932.0** 1,747.5** 1,266.0* 1,187.5* 1,900.5** 1,168.5* 1,319.5* 1,111.5* 1,690.5 1,358.0***
DCD = developmental coordination disorder; TD = typically developing; AMCD = Assessment of Motor Coordination and Dexterity. *p < 0.001. **p < 0.01. ***p < 0.05.
the results of the DCDQ-Brazil (Prado et al., 2009) and the MABC-II (Henderson et al., 2007), for which there are no normative data for Brazilian children. In a study involving a sample of 240 children in the city of Manaus (northern Brazil), Souza et al. (2007) found that 11.8% of children in an urban area were classified as having motor problems using the MABC (Henderson and Sugden, 1992), whereas the frequency in rural areas was 4.4%. Considering the huge diversity of the Brazilian population, further studies are needed with measures that have been validated for Brazilian children in order to estimate the frequency of DCD with greater accuracy. In contrast with findings described in the literature (Cousins and Smyth, 2005; Lingam et al., 2009), there was a predominance of girls in the DCD group at 8 years of age (Table I). Cairney et al. (2005) also found more girls (57%) than boys (43%) with DCD, in a cross-sectional investigation of students in grades 4–8 from schools in Canada. Most studies that showed higher frequency of DCD among boys were performed with clinical samples. The present study and the one by Cairney et al. (2005) used non-clinical samples, which may explain the differences in gender prevalence. Additionally, Rivard et al. (2007), in a study on teachers’ perceptions of motor difficulties in children, suggested that the Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
detection of DCD may be influenced by gender stereotypes. Considering the discrepancies in prevalence and the suggestion that the identification of DCD might also be influenced by gender, further prevalence studies of the disorder should investigate distribution in non-clinical samples. On the basis of the teachers’ responses on the SNAP-IV, a high percentage of children with DCD exhibited signs of attention deficit (17.6%), hyperactivity/impulsivity (2.9%) or combined ADHD (20.6%). These findings are consistent with the literature (Kaplan et al., 2006), and the combination of DCD and ADHD deserves greater attention, as it appears to have important long-term implications. Rasmussen and Gillberg (2000) reported that, among 22-year-old individuals with combined ADHD and DCD, there was a greater frequency of alcohol and/or drug abuse, personality disorders and psychiatric disorders and fewer years of schooling in comparison with those with ADHD alone. In the present study, the SNAP-IV was used only to screen symptoms of ADHD and not for diagnostic purposes. However, the data reported herein lend support to the findings of previous studies (Rasmussen and Gillberg, 2000; Kaplan et al., 2006) and underscore the importance of performing a broaderscoped evaluation to identify the presence of attention difficulties and/or hyperactivity among children with DCD. 181
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Table III. Performance of DCD and TD groups on bilateral coordination and motor planning items of AMCD
Item Drumming 1 Drumming 2 Drumming 3 Drumming 4 Catch beanbag Bounce 20 cm ball on floor/catch with both hands Throw ball against wall/catch Bounce tennis ball on floor/catch with both hands Bounce tennis ball on floor/catch with dominant hand Catch tennis ball with both hands Catch tennis ball with dominant hand Hopscotch 1 Hopscotch 2 Hopscotch 3 Jumping jacks Square maze – dominant hand Square maze – non-dominant hand Complex maze – dominant hand Complex maze – non-dominant hand Prone extension – time Prone extension – accuracy Supine flexion – time Supine flexion – accuracy Balance – eyes open – right leg Balance – eyes open – left leg Balance – eyes closed – right leg Balance – eyes closed – left leg Circuit – time Tandem forward Bunny hops
DCD group (mean ± standard deviation)
TD group (mean ± standard deviation)
Mann–Whitney U
2.38 ± 0.74 1.59 ± 0.74 1.26 ± 0.57 1.24 ± 0.50 4.18 ± 1.17 4.26 ± 1.27 0.85 ± 1.44 3.85 ± 1.33 2.97 ± 1.57 3.56 ± 1.33 2.35 ± 1.54 1.76 ± 0.65 1.74 ± 0.67 2.12 ± 0.81 1.32 ± 0.59 4.85 ± 1.52 5.79 ± 7.10 11.39 ± 5.82 11.09 ± 3.95 11.53 ± 10.60 1.59 ± 0.50 11.47 ± 8.96 1.65 ± 0.60 12.76 ± 6.81 11.91 ± 66.61 4.76 ± 3.48 3.74 ± 2.87 32.12 ± 8.30 7.06 ± 3.88 3.74 ± 1.54
2.89 ± 0.35 1.84 ± 0.74 1.78 ± 0.81 1.71 ± 0.73 4.59 ± 0.66 4.78 ± 0.48 2.73 ± 1.91 4.46 ± 0.80 4.24 ± 1.11 4.48 ± 0.84 3.62 ± 1.34 2.46 ± 0.61 2.33 ± 0.69 2.80 ± 0.47 2.22 ± 0.97 4.12 ± 1.46 3.88 ± 1.32 9.71 ± 2.93 9.56 ± 2.60 18.24 ± 8.47 2.00 ± 0.50 16.64 ± 9.39 1.93 ± 0.53 17.02 ± 4.87 16.90 ± 4.69 7.56 ± 5.15 7.71 ± 5.62 26.44 ± 6.61 10.84 ± 4.18 4.52 ± 0.89
1,542.0* 2,028.0 1,611.0* 1,609.5* 2,117.0 1,957.5** 1,127.0* 1,798.0** 1,206.0* 1,360.0* 1,353.5* 1,210.0* 1,419.0* 1,322.5* 1,153.0* 1,729.0** 1,910.0*** 1,707.0** 1,763.5*** 1,615.0* 1,596.0* 1,682.0** 1,883.0** 1,551.0* 1,468.0* 1,648.5** 1,265.0* 1,403.0* 1,303.5* 1,743.5*
DCD = developmental coordination disorder; TD = typically developing; AMCD = Assessment of Motor Coordination and Dexterity. *p < 0.001. **p < 0.01. ***p < 0.05.
In the analysis of performance by gender, significant differences were found in 11 AMCD items (26%). Girls achieved better performance on items involving dexterity and handwriting, which is similar to the findings of Junaid and Fellowes (2006) using the MABC (Henderson and Sugden, 1992). Moreover, unlike the results of Cardoso and Magalhães (2009) with the previous version of the AMCD and those described by Causgrove-Dunn and Watkinson (1996) using the MABC, our results showed that the boys did not perform better than girls on ball tasks. The fact that most of the current AMCD ball items involve throwing/catching a small tennis ball may have made the tasks more difficult for Brazilian boys, who play sports that use larger balls and kicking. 182
It is important to identify factors that can influence motor skills. According to Causgrove-Dunn and Watkinson (1996), if there is evidence of gender differences, the normative tables of motor tests should reflect these differences. However, Barnett (2008) states that there are arguments against different norms for each gender, as this approach divides the sample and thus increases the likelihood of sampling errors. Before making any decisions regarding the AMCD, it is important to investigate the response pattern of children between 4 and 6 years of age as well as those from other regions of Brazil. If differences in performance are striking and consistent at different ages, the establishment of normative tables differentiated by gender should be considered. Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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As expected, significant differences were found between the 7- and 8-year-olds on most AMCD items. Therefore, norms differentiated by age should be used for the identification of motor delays, same as with other motor performance assessment tools, such as the MABC-II (Henderson et al., 2007). Regarding the type of school (public or private), significant differences were found on 31% of the AMCD items, with an advantage for children in private schools. The examiners perceived that the private schools offered a greater variety of physical as well as personnel resources, which likely provide greater stimuli than those received by children in public schools. Besides, parents who send their children to private schools can also provide additional resources at home. According to Pellegrini et al. (2005), motor development is the result of individual disposition for action as well as the physical, social and cultural contexts in which a child finds himself or herself. It is possible that children in private schools achieved better performance on some AMCD items because they received extra stimuli in both the physical and social environments. More in-depth studies should be conducted to determine the need for specific motor performance norms according to the type of school in Brazil. Significant differences between the groups initially selected by the DCDQ-Brazil (Prado et al., 2009) were found in a number of AMCD items, especially those involving ball skills and motor sequencing (Tables II and III). However, no significant differences were found on the AMCD balance and motor planning items. This finding was likely due to the fact that the DCDQ-Brazil (Prado et al., 2009) is a screening tool for DCD based on the parents’ perspective regarding the performance of their children in routine motor activities, which includes writing tasks and ball games, whereas the balance and motor planning items of the AMCD involve standardized situations not directly related to the functional activities that are common in children’s daily lives. The comparison between the DCD and TD groups, which were defined by the combined results of the DCDQ-Brazil (Prado et al., 2009) and the MABC-II (Henderson et al., 2007), is of greater interest to the AMCD validation process. A total of 39 of the 42 AMCD items discriminated between DCD and typical children (Tables II and III). This finding lends support to the AMCD’s good potential for detecting differences Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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in motor performance between children with and without coordination problems. One limitation of the present study is the fact that the MABC-II has not been validated for Brazilian children, and conclusions regarding the scores on this test should be made with caution. Another limitation regards the fact that the AMCD was designed to detect motor difficulties among Brazilian children aged 4–8 years, whereas the present study was limited to children aged 7 and 8 years. Therefore, further studies should investigate the quality of the AMCD items for the assessment of children aged 4–6 years. Moreover, the sample was restricted to children residing in a single metropolitan area, which limits the generalization to children from other regions of Brazil. Further studies with the AMCD should include children from metropolitan areas and the countryside.
Conclusion The most commonly used tests for the assessment of DCD, such as the MABC-II (Henderson et al., 2007), have not been standardized for Brazilian children and have limited clinical use because of their high cost, added to importation taxes. Therefore, children with DCD in Brazil may not receive the necessary support, which may increase the risk of school failure or associated problems. The creation of the AMCD is an attempt to establish standardized measures for the assessment of motor coordination in Brazilian children. The results lend support to the quality of most of the test items, which should be transformed into standardized scores in order to allow the determination of the most appropriate cut-off point for the detection of DCD in Brazilian children. Further validity studies, such as concurrent and predictive validity, should be conducted with standardized scores. Although the present study lends support to AMCD’s good potential for clinical use, the possibility of reducing the number of items should be considered in order to facilitate its clinical use. Normative data should be collected on a representative sample of the children population in Brazil.
Conflict of interest The authors declare no conflict of interest. 183
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Acknowledgements The authors are grateful to all the schools and parents/guardians who allowed the participation of the children in the study, to the student research assistants for their support in recruitment and data collection and to the Brazilian funding agencies Conselho Nacional de Pesquisa (CNPq) and Fundação de Auxílio a Pesquisa do Estado de Minas Gerais (FAPEMIG) for funding the AMCD project. REFERENCES American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorder (4th text revision ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM5). Arlington, VA: American Psychiatric Publishing. Angelini AL, Alves ICB, Custódio EM, Duarte WF, Duarte JL (1999). Matrizes Progressivas Coloridas de Raven: Manual [Raven Colored Progressive Matrices: Manual]. São Paulo, SP: Centro Editor de Testes e Pesquisas em Psicologia. Associação Brasileira de Empresas de Pesquisa (ABEP) (2008). Critério de Classificação Econômica Brasil [Economic Classification Criterion Brazil]. São Paulo: ABEP. Available at: http://www.abep.org/codigosguias/ criterio_Brasil_2008.pdf. Accessed on 5 March 2009, at 9:06 AM. Barnett AL (2008). Motor assessment in developmental coordination disorder: from identification to intervention. International Journal of Disability, Development and Education 55: 113–129. Benson J, Clark F (1982). A guide to instrument development and validation. American Journal of Occupational Therapy 36: 789–800. Brown T, Lalor A (2009). The Movement Assessment Battery for Children – second edition (MABC-2): a review and critique. Physical and Occupational Therapy in Pediatrics 29: 86–102. Bussing R, Fernandez M, Harwood M, How W, Garvan CW, Eyberg SM, Swanson JM (2008). Parent and teacher SNAP-IV ratings of attention deficit hyperactivity disorder symptoms: psychometric properties and normative ratings from a school district sample. Assessment 15: 317–328. Cairney J, Hay JA, Faught BE, Wade TJ, Corna LM, Flouris AD (2005). Developmental coordination disorder, generalized self efficacy toward physical activity and participation in organized and free play activities. Journal of Pediatrics 147: 515–520. 184
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Cairney J, Faught BE, Hay JA, Corna LM, Flouris AD (2006). Developmental coordination disorder, age and play: a test of the divergence in activity-deficit with age hypothesis. Adapted Physical Activity Quarterly 23: 261–276. Cardoso AA, Magalhães LC (2009). Bilateral coordination and motor sequencing in Brazilian Children: preliminary construct validity and reliability analysis. Occupational Therapy International 16: 107–121. Cardoso AA, Galvão BAP, Magalhães LC (2010). Fine motor coordination and manual dexterity of the Assessment of Motor Coordination and Dexterity (AMCD). Santiago: Congress 2010 Abstract – WFOT 2010, 1744-1744. Causgrove-Dunn J, Watkinson EJ (1996). Problems with identification of children who are physically awkward using the TOMI. Adapted Physical Activity Quarterly 13: 347–356. Clark JE, Getchell N, Smiley-Oyen AL, Whitall J (2005). Developmental coordination disorder: issues, identification and intervention. Journal of Physical Education, Recreation and Dance 76: 49–53. Cousins M, Smyth MM (2005). Progression and development in Developmental Coordination Disorder. In: Children with Developmental Coordination Disorder. London, UK: Whurr Publishers. Cury RLM, Magalhães LC (2006). Criação de um protocolo de avaliação do equilíbrio corporal em crianças de quatro, seis e oito anos de idade: uma perspectiva funcional. [Creating a protocol to assess body balance in children four, six and eight-years old: a functional perspective]. Revista Brasileira de Fisioterapia 10: 346–353. Dewey D, Wilson BN (2001). Developmental coordination disorder: what is it? Physical and Occupational Therapy in Pediatrics 20: 5–27. Gaines R, Missiuna C (2006). Early identification: are speech/language-impaired toddlers at increased risk for Developmental Coordination Disorder? Child: Care, Health and Development 33: 325–332. Henderson SE, Sugden DA (1992). Movement Assessment Battery for Children. London: The Psychological Corporation. Henderson SE, Sugden DA, Barnett AL (2007). Movement Assessment Battery for Children (2nd ed.). London: The Psychological Corporation. Iversen S, Knivsberg AM, Ellertsen B, Nodland M, Larsen TB (2006). Motor coordination in 5-6-yearold children with severe behavioral and emotional problems. Emotional and Behavioural Difficulties 11: 169–185. Junaid KA, Fellowes S (2006). Gender differences in the attainment of motor skills on the Movement Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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Assessment Battery for Children. Physical & Occupational Therapy in Pediatrics 26: 5–11. Kaplan BJ, Crawford SG, Cantell M, Kooistra L, Dewey D (2006). Comorbidity, co-occurrence, continuum: what’s in a name? Child: Care, Health and Development 32: 723–731. Kirby A, Edwards L, Sugden D, Rosenblum S (2010). The development and standardization of the Adult Developmental Co-ordination Disorders/Dyspraxia Checklist (ADC). Research in Developmental Disabilities 31: 131–139. Lingam R, Hunt L, Golding J, Jongmans M, Emond A (2009). Prevalence of developmental coordination disorder using the DSM-IV at 7 years of age: a UK population based study. Pediatrics 123: e693–e700. Loh PR, Piek JP, Barrett NC (2009). The use of the Developmental Coordination Disorder Questionnaire in Australian children. Adapted Physical Activity Quarterly 26: 28–53. Magalhães LC, Rezende MB (2001). Avaliação da Coordenação e Destreza Motora – ACOORDEM [Assessment of Motor Coordination and Dexterity – AMCD] – Versão 1. Manuscrito não publicado. Belo Horizonte, MG: Departamento de Terapia Ocupacional, UFMG. Magalhães LC, Nascimento VCS, Rezende MB (2004). Avaliação da coordenação e destreza motora – ACOORDEM; Etapas de criação e perspectivas de validação [Assessment of Motor Coordination and Dexterity – AMCD; Creation steps and validation perspectives]Revista de Terapia Ocupacional da USP 15, 104–109. Magalhães LC, Rezende MB, Cardoso AA (2008). Avaliação da Coordenação e Destreza Motora – ACOORDEM [Assessment of Motor Coordination and Dexterity – AMCD] – Versão 2. Manuscrito não publicado. Belo Horizonte, MG: Departamento de Terapia Ocupacional, UFMG. Mattos P, Serra-Pinheiro MA, Rodhe LA, Pinto D (2006). Apresentação de uma versão em português para uso no Brasil do instrumento MTA-SNAP-IV de avaliação de sintomas de transtorno do déficit de atenção/hiperatividade e sintomas de transtorno desafiador e de oposição [A Brazilian version of the MTA-SNAP-IV for evaluation of symptoms of attention-deficit/hyperactivity disorder and oppositional-defiant disorder]. Revista Brasileira de Psiquiatria 28: 290–297. Missiuna C, Rivard L, Bartlett D (2006). Exploring assessment tools and the target of intervention for children with Developmental Coordination Disorder. Physical & Occupational Therapy in Pediatrics 26: 71–89. Pasquali L, Wechsler S, Bensusan E (2002). Matrizes Progressivas do Raven Infantil: um estudo de validação para o Brasil [Raven’s Progressive Matrices Children: a validation study for Brazil]. Avaliação Psicológica 2: 95–110. Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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Pellegrini AM, Neto SS, Bueno FCR, Alleoni BN, Motta AI (2005). Desenvolvendo a coordenação motora no ensino fundamental [Developing motor skills in elementary school]. In: Vários coordenadores (org). Núcleo de Ensino. vol. 1 (1st ed.) (pp. 177–190). São Paulo: Editora da Unesp. Poulsen AA, Ziviani JM, Johnson H, Cuskelly M (2008). Loneliness and life satisfaction of boys with developmental coordination disorder: the impact of leisure participation and perceived freedom in leisure. Human Movement Science 27: 325–343. Prado MS, Magalhães LC, Wilson BN (2009). Cross cultural adaptation of the Developmental Coordination Disorder Questionnaire for Brazilian Children. Revista Brasileira de Fisioterapia 13: 236–243. Rasmussen P, Gillberg C (2000). Natural outcome of ADHD with DCD at age 22 years: a controlled, longitudinal, community-based study. Journal of American Academy Child and Adolescent Psychiatry 39: 1424–1431. Rivard LM, Missiuna C, Hanna S, Wishart L (2007). Understanding teacher’s perceptions of the motor difficulties of children with developmental coordination disorder (DCD). British Journal of Educational Psychology 77: 633–648. Sisto FF, Rueda FJM, Bartholomeu D (2006). Estudo sobre a unidimensionalidade do Teste Matrizes Progressivas Coloridas de Raven [Study on the unidimensionality of the Raven Coloured Progressive Matrices]. Psicologia: Reflexão e Crítica 19: 66–73. Souza C, Ferreira L, Catuzzo MT, Corrêa UC (2007). O teste ABC do Movimento em crianças de ambientes diferentes [The movement ABC in children from different environments]. Revista Portuguesa de Ciências do Desporto 7: 36–47. Swanson J, Lerner M, March J, Gresham FM (1999). and intervention for attention-deficit/hyperactivity disorder in the schools. Lessons from the MTA study. Pediatrics Clinics of North America 46: 993–1009. Van Waelvelde H, Oostra A, Dewitte G, Van Den Broeck C, Jongmans MJ (2010). Stability of motor problems in young children with or at risk of autism spectrum disorders, ADHD, and or developmental coordination disorder. Developmental Medicine and Child Neurology 52: e174–e178. Wilson BN, Dewey D, Campbell A (1998). Developmental Coordination Disorder Questionnaire (DCDQ) Calgary. Alta, Canada: Alberta Children’s Hospital Research Center. Wilson BN, Crawford SG, Green D, Roberts G, Aylott A, Kaplan BJ (2009). Psychometric properties of the revised Developmental Coordination Disorder Questionnaire. Physical and Occupational Therapy in Pediatrics 29: 182–202. 185
Motor Skills in Brazilian Children with Developmental Coordination Disorder versus Children with Motor Typical Development Ana Amélia Cardoso1*†, Livia Castro Magalhães2 & Marcia Bastos Rezende3 1
Occupational Therapy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, 31270–901, Brazil
2
Occupational Therapy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
3
Occupational Therapy, UFMG, Belo Horizonte, Minas Gerais, 30220-260, Brazil
Abstract The aims of the study were to compare the performance of children with probable developmental coordination disorder (DCD) and motor typically developing peers on items from the Assessment of Motor Coordination and Dexterity (AMCD), to determine whether age, gender and type of school had significant impact on the scores of the AMCD items, to estimate the frequency of DCD among Brazilian children ages 7 and 8 years and to investigate whether children with DCD exhibit more symptoms of attention deficit and hyperactivity disorder than children with motor typical development. A total of 793 children were screened by the Developmental Coordination Disorder Questionnaire – Brazilian version (DCDQ-Brazil); 90 were identified as at risk for DCD; 91 matched controls were selected from the remaining participants. Children in both groups were evaluated with the AMCD, the Movement Assessment Battery for Children (MABC-II) and Raven’s coloured progressive matrices. Thirty-four children were classified as probable DCD, as defined by a combination of the DCDQ-Brazil and MABC-II scores (fifth percentile). The final frequency of DCD among children ages 7 and 8 years was 4.3%. There were significant differences between children with and without DCD on the majority of AMCD items, indicating its potential for identifying DCD in Brazilian children. The use of a motor test (MABC-II) that is not validated for the Brazilian children is a limitation of the present study. Further studies should investigate whether the AMCD is useful for identifying DCD in other age groups and in children from different regions of Brazil. The application of the AMCD may potentially contribute in improving occupational therapy practice in Brazil and in identifying children that could benefit from occupational therapy services. Copyright © 2014 John Wiley & Sons, Ltd. Received 3 May 2013; Revised 13 June 2014; Accepted 6 August 2014
Keywords paediatric occupational therapy; developmental coordination disorder; Assessment of Motor Coordination and Dexterity Test *Correspondence Ana Amélia Cardoso, Occupational Therapy, Federal University of Minas Gerais, Av. Antônio Carlos, 6627, EEFFTO, Occupational Therapy Department, Belo Horizonte, Minas Gerais, 31270–901, †
Email: [email protected]; [email protected]
Published online 17 October 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1376
Introduction Developmental coordination disorder (DCD), as defined by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (APA, 2013), is characterized by motor 176
performance substantially below expected levels, considering the child’s chronologic age and previous opportunities for skill acquisition. The prevalence of DCD in the United States is estimated to be between 5% and 8% among school-age children (APA, 2000), but a more recent study Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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using longitudinal data conducted in the UK reported a prevalence of 1.8% with a predominance of boys (1.9:1; Lingam et al., 2009). Cousins and Smyth (2005) also reported a predominance of boys at a proportion of three to one. This disorder tends to persist into adulthood, and the severity of motor problems may be correlated with functional performance in important activities of daily living, such as handwriting and organizing/finding objects (Kirby et al., 2010). Besides motor issues, the co-occurrence of other developmental problems is common. It is estimated that 68% of children with DCD also have other diagnoses, including attention deficit and hyperactivity disorder (ADHD), learning disorders (Kaplan et al., 2006) and behavioural, emotional (Iversen et al., 2006) and speech and language (Gaines and Missiuna, 2006) problems. Moreover, children with motor difficulties tend to participate less in free or organized play activities (Cairney et al., 2005, 2006) and sports (Poulsen et al., 2008). Despite the importance of detecting DCD early (Clark et al., 2005; Van Waelvelde et al., 2010), there is no gold standard for the diagnosis of this disorder (Dewey and Wilson, 2001; Missiuna et al., 2006), and the most commonly employed motor tests are not standardized and validated for Brazilian children, the focus of this study (Magalhães et al., 2004). With the aim of developing a valid assessment tool for reliable detection of DCD in Brazil, Magalhães and Rezende (2001) created the Assessment of Motor Coordination and Dexterity (AMCD), a motor coordination test for children aged 4–8 years. The AMCD is an assessment of the final product or of what is observable (child’s actions) rather than an assessment of the underlying reason for the lack of coordination. The AMCD is intended to be both a descriptive tool and a discriminative tool, to determine if intervention is required and to be an evaluative tool to measure change over time as a result of intervention (Missiuna et al., 2006). The AMCD assesses motor skills in three categories: (a) hand coordination and dexterity; (b) body coordination; and (c) motor activities and participation at home and school (questionnaires for parents and teachers). AMCD’s development followed a four-step process (Benson and Clark, 1982), is recommended for test development and is currently in the final phase (validation stage) of the process. As part of the AMCD validation process, the present study had the following aims: (a) estimate the frequency of DCD in a sample of Brazilian children aged 7 and 8 years from a metropolitan city (Belo Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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Horizonte, Brazil); (b) investigate whether children with DCD exhibit more symptoms of ADHD than children with typical development do; (c) determine whether age, gender and type of school had significant impact on the scores of the AMCD items; and (d) determine whether the scores on the AMCD items of children with and without DCD were significantly different.
Methods Participants One hundred eighty-one children aged 7 and 8 years from a metropolitan city in Brazil participated in this study. In order to recruit the total sample of 181 children with and without motor problems, the DCDQ-Brazil was administered to 793 children. On the basis of parental and teacher reports, children with the following conditions were excluded from both groups: (a) physical handicap, altered neurological examination or diagnosis of known disorders, such as cerebral palsy, autism spectrum disorder and muscular dystrophy; (b) subnormal hearing or vision; (c) cognitive deficit; (d) orthopaedic problems or lower-limb fracture in the 6 months prior to the assessment; and (e) genetic diseases. Parents/guardians signed a term of informed consent, authorizing the participation of their child in the study. Children were divided into two groups: • DCD group: children at risk for DCD based on the score of the DCDQ-Brazil (Prado et al., 2009). Inclusion criterion: in the absence of Brazilian norms, the Canadian DCDQ cut-off score, ≤55 points (Wilson et al., 1998), was used to indicate risk for DCD. Fifteen 7-year-olds and twenty-two 8-year-olds were recruited from private schools, and twenty-seven 7-year-olds and twenty-seven 8-year-olds were recruited from public schools, totalling 91 children at risk for DCD. Children were recruited from both settings because there are major differences between schools in Brazil; private schools have more resources, and the students have higher socio-economic status. • Typically developing group (TD group): children with typical development, matched by gender and age with each child identified as at risk for DCD. The pairs were recruited among the classmates of the children in the DCD group, on the basis of the DCDQ-Brazil (Prado et al., 2009). The inclusion criterion was a score above 56, that is, the Canadian cut-off on the DCDQ-Brazil (Wilson et al., 1998). 177
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Fifteen 7-year-olds and twenty-three 8-year-olds were recruited from private schools, and twenty-eight 7-year-olds and twenty-four 8-year-olds were recruited from public schools, totalling 90 children without signs of motor problems. The exclusion criteria for the TD group are as follows: (a) history of prematurity (gestational age ≤ 36 weeks) and/or low birth weight (less than 2500 g); (b) school failure, as reported by the teacher; and (c) enrolment in any type of motor intervention programme (e.g. occupational therapy, physiotherapy and psychomotor therapy).
Instruments • Assessment of Motor Coordination and Dexterity (Avaliação da Coordenação e DestrezaMotora; Magalhães et al., 2008): a new instrument designed to identify children with DCD. The current version of the instrument is based on extensive item analysis, described elsewhere (Magalhães et al., 2004), with the inclusion of only those items that demonstrated adequate reliability (i.e. test–retest and interexaminer reliability) and that discriminated motor performance by age (Cury and Magalhães, 2006; Cardoso and Magalhães, 2009; Cardoso et al., 2010). In its current version, the test has 42 motor performance items, 16 items on manual coordination and dexterity and 26 items on bilateral coordination and motor planning. The administration of the AMCD takes approximately 60 minutes. • Developmental Coordination Questionnaire – Brazilian version (Prado et al., 2009): Brazilian version of the DCDQ (Wilson et al., 1998), a 15-item parents’ questionnaire developed in Canada and specific for the screening of DCD among children aged 5–15 years, which has been translated and adapted for Brazilian children (Prado et al., 2009). The DCDQ has been found to have satisfactory test– retest reliability and construct validity in different countries (Loh et al., 2009; Prado et al, 2009; Wilson et al., 2009). It provides a standard method to measure a child’s coordination in everyday, functional activities, such as “throws a ball in a controlled and accurate fashion” and “cuts out pictures and shapes accurately and easily” (Wilson et al., 2009). • Movement Assessment Battery for Children (MABC-II; Henderson et al., 2007): a standardized test used for the identification of motor impairments among children aged 3–17 years. It includes eight items of gross 178
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and fine motor skills grouped into three categories: hand dexterity, throwing and catching, and balance. The raw scores are converted into percentiles, where scores less than or equal to the fifth percentile denotes definite motor difficulty; scores equal to the 6th to 15th percentiles denote risk/suspect; and scores above the 16th percentile indicate normal performance (Henderson et al., 2007). The MABC-II can be administered in 20 minutes, and there is evidence of adequate validity and reliability (Henderson et al., 2007; Brown and Lalor, 2009). • Swanson, Nolan and Pelham IV Scale (SNAP-IV; Swanson et al., 1999): an 18-item questionnaire to screen signs of ADHD, which has been translated to Portuguese (Mattos et al., 2006). Bussing et al. (2008) report that the internal consistency, item selection and factorial structure of the SNAP-IV are considered acceptable and consistent with the constructs of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition; the authors conclude that SNAP-IV ratings from either parents or teachers can distinguish children with different levels of ADHD. In the present study, the SNAP-IV was completed by the teacher, and it was used only to determine the presence of signs of attention difficulties and hyperactivity rather than for diagnostic purposes. The criteria of at least six items scored as “enough” or “too much” in a section of the questionnaire were used to identify symptoms of inattention (items 1–9) or hyperactivity and impulsivity (items 10–18); children who scored above criteria on both sections were considered as presenting signs of combined ADHD (Swanson et al., 1999). • Raven’s Progressive Coloured Matrices – Brazilian version (Angelini et al., 1999): one of the most widely employed intelligence tests (Sisto et al., 2006), consisting of a booklet composed of three sets of items (A, AB and B). Each item is a drawing with a missing part, allowing only one correct answer among the six options presented to the child. One point is attributed to each correct answer. The total score is determined by the sum of correct answers. The cut-off point determines the following classification: (1) intellectually superior; (2) definitely above average; (3) intellectually average; (4) definitely below average; and (5) intellectually deficient. to Pasquali et al. (2002), the Raven has satisfactory psychometric properties and adequately measures the aptitude of analogical reasoning in children aged Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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5–11 years. In the present study, the Raven was used to exclude children with cognitive impairment (children who scored definitely below average – 6th to 25th percentiles – or on the intellectually deficient range – below 6th percentile). • Brazilian Economic Classification Criteria (ABEP, 2008): a Brazilian criterion established to define large economic classes, on the basis of the buying power of urban individuals and families. The point system is based on two categories: possession of items and degree of schooling of the head of the family. The total score yields economic classification into eight categories (A1, A2, B1, B2, C1, C2, D or E). A1 means higher economic class, and E means lower economic class.
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that did not interfere with important learning activities. In order not to tire the child, the assessment was divided into two sessions; the MABC-II was administered in the first session (30 minutes), and the AMCD was administered in the second session (60 minutes). Teachers were asked to respond to the SNAP-IV by considering the child’s behaviour in the classroom. As final diagnostic criteria, children who scored below the cut-off on the DCDQ-Brazil (Prado et al, 2009) and below the fifth percentile on the MABC-II (Henderson et al., 2007) were considered to have DCD (DCD group), and the remaining children were considered to present typical motor development (TD group).
Data analysis Procedures Six public and 56 private elementary schools in the metropolitan area of Belo Horizonte were contacted, among which six public (100%) and 21 private (37.5%) schools agreed to participate in the study. The study was approved by the Human Research Ethics Committee of the Universidade Federal de Minas Gerais (Brazil; ETIC 80/08). An informed consent letter containing information on the objectives of the study, along with the DCDQ-Brazil (Prado et al., 2009), a brief questionnaire concerning birth conditions and child development and the Brazilian Economic Classification Criteria, was sent to parents. In this phase of xrecruitment, 1,879 children received the package, but 793 (42.2%) returned the questionnaires completely filled out with the signed consent letter. A research assistant student analysed the questionnaires, calculated the DCDQ-Brazil scores and identified children at risk for DCD, in accordance with the Canadian norms (Wilson et al., 1998). For each child detected with signs of DCD, another child matched for age and gender but with no signs of motor problems was selected from the same classroom. The matching was performed by the research assistant to blind the examiner to the children’s motor performance group. Children from both groups selected by the DCDQ-Brazil were assessed with the Raven’s Progressive Coloured Matrices (Angelini et al., 1999); children with signs of cognitive impairments were replaced with peers from the same classroom. Following exclusions, children were tested on the AMCD (Magalhães et al., 2008) and the MABC-II (Henderson et al., 2007). The assessments were conducted at school according to a schedule defined by the teachers Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
The SPSS program, version 17.0 (Chicago, IL, USA), was used for the data analyses. As the Kolmogorov–Smirnov test did not indicate that scores exhibit normal distribution, non-parametric tests were employed. The Mann– Whitney test was used to determine whether there were significant differences between the groups with and without DCD as well as differences according to gender, age and type of school, significance level set at 5% (p ≤ 0.05). Pearson’s chi-square was used for categorical variables. The frequency of DCD was calculated by a simple count of the number of children with results below both the DCDQ-Brazil cut-off and the fifth percentile on the MABC-II (Henderson et al., 2007).
Results The characteristics of the groups are displayed in Table I. Among the 34 children characterized as having DCD, of the 7-year-olds, 10 (29.4%) were boys and five (14.7%) girls, and 11 (32.35%) of the 8-year-olds were girls and eight (23.5%) boys. Overall, 45.86% were girls and 54.14% boys (Table I) In regard to the frequency of DCD, considering that 793 children returned the DCDQ-Brazil (Prado et al., 2009) completely filled out in the first phase and 34 children scored below the cut-off points for the DCDQ-Brazil (Prado et al., 2009) and the MABC-II (Henderson et al., 2007), the frequency in the total sample was 4.3%. All children presented superior to average performance on Raven’s cognitive test, and regarding economic status, the majority of the sample, 55.9% of the DCD and 57.8% of the TD groups, was from middle inferior (B2) or higher lower (C1) classes. Pearson’s chi-square test did not detect significant 179
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differences between groups with regard to economic classification or performance on Raven’s cognitive test. Considering the frequency of ADHD, on the basis of teachers’ responses on the SNAP-IV, within the DCD group, 41.2% showed signs of ADHD: six children with DCD (17.6%) exhibited signs of attention deficit, one (2.9%) exhibited signs of hyperactivity/impulsivity, seven (20.7%) exhibited signs of combined ADHD, 18 (52.9%) exhibited no signs of ADHD and two (5.9%) did not return the questionnaires. Within the TD group, 14.1% showed signs of ADHD: five (3.4%) exhibited signs of attention deficit, 10 (6.8%) exhibited signs of hyperactivity/impulsivity, six (4.1%) exhibited signs of combined ADHD, 113 (76.9%) exhibited no signs of ADHD and 13 (8.8%) did not return the questionnaires. Pearson’s chi-square indicated significant differences in the performance on the SNAP-IV between the DCD and TD groups (p = 0.001), with more signs of ADHD in the DCD group.
Assessment of motor coordination and dexterity results Significant gender differences were found for 11 AMCD items (26.19%): place peg in board – dominant hand; move pegs between rows; touch thumbs – dominant hand; cut straight line; trace butterfly; copy alphabet – time in seconds; copy sentence – time in seconds; throw ball against wall; perform jumping jacks; solve a complex maze with the dominant hand; and solve a complex maze with the non-dominant hand. On all items, girls had better performance than boys, with the exception of “throw ball against wall”. Table I. Sample distribution according to groups 7 years Public school
Private school
8 years Public school
Private school
N 55 30 51 45 Girls, n (%) 21 (38.2) 10 (33.3) 32 (62.7) 20 (44.4) Boys, n (%) 34 (61.8) 20 (66.7) 19 (37.3) 25 (55.6) DCD group,a 8 (14.5) 7 (23.3) 10 (19.6) 9 (20) n (%) 23 (76.7) 41 (80.4) 36 (80) Typical group,a 47 (85.5) n (%) Age in months 86.93 ± 2.88 89.13 ± 2.86 99.94 ± 4.00 101.82 ± 3.29 a
Diagnosis defined by combining the Developmental Coordination
Disorder Questionnaire – Brazilian version and Movement Assessment Battery for Children II scores.
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By comparing 7- and 8-year-olds, significant differences were found for most of the items (34 items = 80.95%), with better performance for the 8-year-old children. By comparing the type of school (public or private), significant differences were found on 13 items (30.95%), with children from private schools achieving better performance: move pegs between rows; place coins in piggy bank – non-dominant hand; distribute cards; copy alphabet – time; copy sentence – time; drumming 2; drumming 4; throw ball against wall; catch tennis ball with both hands; catch tennis ball with dominant hand; hopscotch 2; perform jumping jacks; and maintain supine flexion – accuracy. In the comparison of the scores on the AMCD for children with and without DCD, considering the groups in the first phase of the study (children with and without signs of DCD based on the DCDQ-Brazil [Groups 1 and 2]), significant differences were found on 23 (54.77%) AMCD items (Tables II and III). In the comparison of the DCD and TD groups, significant differences were found on 39 (92.85%) AMCD items (Tables II and III).
Discussion The present study continues the validation process of the AMCD and had the following aims: (a) estimate the frequency of DCD in a sample of Brazilian children aged 7 and 8 years from a metropolitan city (Belo Horizonte, Brazil); (b) investigate whether children with DCD exhibit more symptoms of ADHD than do children with motor typical development; (c) determine whether age, gender and type of school had significant impact on the scores of the AMCD items; and (d) determine whether the scores on the AMCD items of children with and without DCD were significantly different. The frequency of DCD among Brazilian children aged 7 and 8 years (4.3%) is close to the prevalence estimated in the literature, which reports values of 5–8% (APA, 2000; Dewey and Wilson, 2001; Cairney et al., 2005), but is higher than the 1.8% reported for 7-year-old children from the UK (Lingam et al., 2009). The lower prevalence by Lingam et al. (2009) is probably due to a different approach to data collection, as they used fewer items to assess motor coordination; they also reported some dropout that might have influenced the prevalence. It should be stressed that the frequency of DCD was calculated on the basis of Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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Table II. Performance of DCD and TD groups on hand coordination and dexterity items of AMCD
Item Place peg in board – dominant hand Place peg in board – non-dominant hand Move pegs between rows Lacing Place coins in piggy bank – dominant hand Place coins in piggy bank – non-dominant hand Sort 20 cards Thumb to fingertips – dominant hand Thumb to fingertips – non-dominant hand Trace straight line Trace curved line Trace butterfly Copy pictures Cut straight line Cut out square Cut out circle Cut out cat Copy alphabet – time Copy sentence – time
DCD group (mean ± standard deviation)
TD group (mean ± standard deviation)
Mann–Whitney U
19.24 ± 5.09 21.91 ± 4.79 22.34 ± 4.72 40.56 ± 14.20 12.72 ± 3.59 14.97 ± 4.52 26.37 ± 7.94 11.12 ± 3.30 12.19 ± 4.33 2.00 ± 6.84 2.06 ± 2.67 8.73 ± 6.62 3.59 ± 1.50 2.32 ± 3.90 6.42 ± 4.40 7.24 ± 6.31 14.03 ± 7.87 111.55 ± 55.03 128.83 ± 113.55
15.72 ± 3.11 17.74 ± 3.20 18.71 ± 4.01 29.48 ± 9.48 10.92 ± 2.44 11.97 ± 2.62 20.99 ± 6.72 9.19 ± 2.48 9.83 ± 2.33 0.18 ± 0.53 1.03 ± 1.87 4.22 ± 4.24 5.10 ± 1.37 0.62 ± 1.37 2.91 ± 2.60 3.03 ± 3.55 7.23 ± 6.80 101.79 ± 38.89 82.22 ± 39.11
1,204.5* 1,095.5* 1,186.5* 1,033.5* 1,698.5*** 1,368.0* 1,321.0* 1,579.5* 1,537.5** 1,932.0** 1,747.5** 1,266.0* 1,187.5* 1,900.5** 1,168.5* 1,319.5* 1,111.5* 1,690.5 1,358.0***
DCD = developmental coordination disorder; TD = typically developing; AMCD = Assessment of Motor Coordination and Dexterity. *p < 0.001. **p < 0.01. ***p < 0.05.
the results of the DCDQ-Brazil (Prado et al., 2009) and the MABC-II (Henderson et al., 2007), for which there are no normative data for Brazilian children. In a study involving a sample of 240 children in the city of Manaus (northern Brazil), Souza et al. (2007) found that 11.8% of children in an urban area were classified as having motor problems using the MABC (Henderson and Sugden, 1992), whereas the frequency in rural areas was 4.4%. Considering the huge diversity of the Brazilian population, further studies are needed with measures that have been validated for Brazilian children in order to estimate the frequency of DCD with greater accuracy. In contrast with findings described in the literature (Cousins and Smyth, 2005; Lingam et al., 2009), there was a predominance of girls in the DCD group at 8 years of age (Table I). Cairney et al. (2005) also found more girls (57%) than boys (43%) with DCD, in a cross-sectional investigation of students in grades 4–8 from schools in Canada. Most studies that showed higher frequency of DCD among boys were performed with clinical samples. The present study and the one by Cairney et al. (2005) used non-clinical samples, which may explain the differences in gender prevalence. Additionally, Rivard et al. (2007), in a study on teachers’ perceptions of motor difficulties in children, suggested that the Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
detection of DCD may be influenced by gender stereotypes. Considering the discrepancies in prevalence and the suggestion that the identification of DCD might also be influenced by gender, further prevalence studies of the disorder should investigate distribution in non-clinical samples. On the basis of the teachers’ responses on the SNAP-IV, a high percentage of children with DCD exhibited signs of attention deficit (17.6%), hyperactivity/impulsivity (2.9%) or combined ADHD (20.6%). These findings are consistent with the literature (Kaplan et al., 2006), and the combination of DCD and ADHD deserves greater attention, as it appears to have important long-term implications. Rasmussen and Gillberg (2000) reported that, among 22-year-old individuals with combined ADHD and DCD, there was a greater frequency of alcohol and/or drug abuse, personality disorders and psychiatric disorders and fewer years of schooling in comparison with those with ADHD alone. In the present study, the SNAP-IV was used only to screen symptoms of ADHD and not for diagnostic purposes. However, the data reported herein lend support to the findings of previous studies (Rasmussen and Gillberg, 2000; Kaplan et al., 2006) and underscore the importance of performing a broaderscoped evaluation to identify the presence of attention difficulties and/or hyperactivity among children with DCD. 181
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Table III. Performance of DCD and TD groups on bilateral coordination and motor planning items of AMCD
Item Drumming 1 Drumming 2 Drumming 3 Drumming 4 Catch beanbag Bounce 20 cm ball on floor/catch with both hands Throw ball against wall/catch Bounce tennis ball on floor/catch with both hands Bounce tennis ball on floor/catch with dominant hand Catch tennis ball with both hands Catch tennis ball with dominant hand Hopscotch 1 Hopscotch 2 Hopscotch 3 Jumping jacks Square maze – dominant hand Square maze – non-dominant hand Complex maze – dominant hand Complex maze – non-dominant hand Prone extension – time Prone extension – accuracy Supine flexion – time Supine flexion – accuracy Balance – eyes open – right leg Balance – eyes open – left leg Balance – eyes closed – right leg Balance – eyes closed – left leg Circuit – time Tandem forward Bunny hops
DCD group (mean ± standard deviation)
TD group (mean ± standard deviation)
Mann–Whitney U
2.38 ± 0.74 1.59 ± 0.74 1.26 ± 0.57 1.24 ± 0.50 4.18 ± 1.17 4.26 ± 1.27 0.85 ± 1.44 3.85 ± 1.33 2.97 ± 1.57 3.56 ± 1.33 2.35 ± 1.54 1.76 ± 0.65 1.74 ± 0.67 2.12 ± 0.81 1.32 ± 0.59 4.85 ± 1.52 5.79 ± 7.10 11.39 ± 5.82 11.09 ± 3.95 11.53 ± 10.60 1.59 ± 0.50 11.47 ± 8.96 1.65 ± 0.60 12.76 ± 6.81 11.91 ± 66.61 4.76 ± 3.48 3.74 ± 2.87 32.12 ± 8.30 7.06 ± 3.88 3.74 ± 1.54
2.89 ± 0.35 1.84 ± 0.74 1.78 ± 0.81 1.71 ± 0.73 4.59 ± 0.66 4.78 ± 0.48 2.73 ± 1.91 4.46 ± 0.80 4.24 ± 1.11 4.48 ± 0.84 3.62 ± 1.34 2.46 ± 0.61 2.33 ± 0.69 2.80 ± 0.47 2.22 ± 0.97 4.12 ± 1.46 3.88 ± 1.32 9.71 ± 2.93 9.56 ± 2.60 18.24 ± 8.47 2.00 ± 0.50 16.64 ± 9.39 1.93 ± 0.53 17.02 ± 4.87 16.90 ± 4.69 7.56 ± 5.15 7.71 ± 5.62 26.44 ± 6.61 10.84 ± 4.18 4.52 ± 0.89
1,542.0* 2,028.0 1,611.0* 1,609.5* 2,117.0 1,957.5** 1,127.0* 1,798.0** 1,206.0* 1,360.0* 1,353.5* 1,210.0* 1,419.0* 1,322.5* 1,153.0* 1,729.0** 1,910.0*** 1,707.0** 1,763.5*** 1,615.0* 1,596.0* 1,682.0** 1,883.0** 1,551.0* 1,468.0* 1,648.5** 1,265.0* 1,403.0* 1,303.5* 1,743.5*
DCD = developmental coordination disorder; TD = typically developing; AMCD = Assessment of Motor Coordination and Dexterity. *p < 0.001. **p < 0.01. ***p < 0.05.
In the analysis of performance by gender, significant differences were found in 11 AMCD items (26%). Girls achieved better performance on items involving dexterity and handwriting, which is similar to the findings of Junaid and Fellowes (2006) using the MABC (Henderson and Sugden, 1992). Moreover, unlike the results of Cardoso and Magalhães (2009) with the previous version of the AMCD and those described by Causgrove-Dunn and Watkinson (1996) using the MABC, our results showed that the boys did not perform better than girls on ball tasks. The fact that most of the current AMCD ball items involve throwing/catching a small tennis ball may have made the tasks more difficult for Brazilian boys, who play sports that use larger balls and kicking. 182
It is important to identify factors that can influence motor skills. According to Causgrove-Dunn and Watkinson (1996), if there is evidence of gender differences, the normative tables of motor tests should reflect these differences. However, Barnett (2008) states that there are arguments against different norms for each gender, as this approach divides the sample and thus increases the likelihood of sampling errors. Before making any decisions regarding the AMCD, it is important to investigate the response pattern of children between 4 and 6 years of age as well as those from other regions of Brazil. If differences in performance are striking and consistent at different ages, the establishment of normative tables differentiated by gender should be considered. Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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As expected, significant differences were found between the 7- and 8-year-olds on most AMCD items. Therefore, norms differentiated by age should be used for the identification of motor delays, same as with other motor performance assessment tools, such as the MABC-II (Henderson et al., 2007). Regarding the type of school (public or private), significant differences were found on 31% of the AMCD items, with an advantage for children in private schools. The examiners perceived that the private schools offered a greater variety of physical as well as personnel resources, which likely provide greater stimuli than those received by children in public schools. Besides, parents who send their children to private schools can also provide additional resources at home. According to Pellegrini et al. (2005), motor development is the result of individual disposition for action as well as the physical, social and cultural contexts in which a child finds himself or herself. It is possible that children in private schools achieved better performance on some AMCD items because they received extra stimuli in both the physical and social environments. More in-depth studies should be conducted to determine the need for specific motor performance norms according to the type of school in Brazil. Significant differences between the groups initially selected by the DCDQ-Brazil (Prado et al., 2009) were found in a number of AMCD items, especially those involving ball skills and motor sequencing (Tables II and III). However, no significant differences were found on the AMCD balance and motor planning items. This finding was likely due to the fact that the DCDQ-Brazil (Prado et al., 2009) is a screening tool for DCD based on the parents’ perspective regarding the performance of their children in routine motor activities, which includes writing tasks and ball games, whereas the balance and motor planning items of the AMCD involve standardized situations not directly related to the functional activities that are common in children’s daily lives. The comparison between the DCD and TD groups, which were defined by the combined results of the DCDQ-Brazil (Prado et al., 2009) and the MABC-II (Henderson et al., 2007), is of greater interest to the AMCD validation process. A total of 39 of the 42 AMCD items discriminated between DCD and typical children (Tables II and III). This finding lends support to the AMCD’s good potential for detecting differences Occup. Ther. Int. 21 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.
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in motor performance between children with and without coordination problems. One limitation of the present study is the fact that the MABC-II has not been validated for Brazilian children, and conclusions regarding the scores on this test should be made with caution. Another limitation regards the fact that the AMCD was designed to detect motor difficulties among Brazilian children aged 4–8 years, whereas the present study was limited to children aged 7 and 8 years. Therefore, further studies should investigate the quality of the AMCD items for the assessment of children aged 4–6 years. Moreover, the sample was restricted to children residing in a single metropolitan area, which limits the generalization to children from other regions of Brazil. Further studies with the AMCD should include children from metropolitan areas and the countryside.
Conclusion The most commonly used tests for the assessment of DCD, such as the MABC-II (Henderson et al., 2007), have not been standardized for Brazilian children and have limited clinical use because of their high cost, added to importation taxes. Therefore, children with DCD in Brazil may not receive the necessary support, which may increase the risk of school failure or associated problems. The creation of the AMCD is an attempt to establish standardized measures for the assessment of motor coordination in Brazilian children. The results lend support to the quality of most of the test items, which should be transformed into standardized scores in order to allow the determination of the most appropriate cut-off point for the detection of DCD in Brazilian children. Further validity studies, such as concurrent and predictive validity, should be conducted with standardized scores. Although the present study lends support to AMCD’s good potential for clinical use, the possibility of reducing the number of items should be considered in order to facilitate its clinical use. Normative data should be collected on a representative sample of the children population in Brazil.
Conflict of interest The authors declare no conflict of interest. 183
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Acknowledgements The authors are grateful to all the schools and parents/guardians who allowed the participation of the children in the study, to the student research assistants for their support in recruitment and data collection and to the Brazilian funding agencies Conselho Nacional de Pesquisa (CNPq) and Fundação de Auxílio a Pesquisa do Estado de Minas Gerais (FAPEMIG) for funding the AMCD project. REFERENCES American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorder (4th text revision ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM5). Arlington, VA: American Psychiatric Publishing. Angelini AL, Alves ICB, Custódio EM, Duarte WF, Duarte JL (1999). Matrizes Progressivas Coloridas de Raven: Manual [Raven Colored Progressive Matrices: Manual]. São Paulo, SP: Centro Editor de Testes e Pesquisas em Psicologia. Associação Brasileira de Empresas de Pesquisa (ABEP) (2008). Critério de Classificação Econômica Brasil [Economic Classification Criterion Brazil]. São Paulo: ABEP. Available at: http://www.abep.org/codigosguias/ criterio_Brasil_2008.pdf. Accessed on 5 March 2009, at 9:06 AM. Barnett AL (2008). Motor assessment in developmental coordination disorder: from identification to intervention. International Journal of Disability, Development and Education 55: 113–129. Benson J, Clark F (1982). A guide to instrument development and validation. American Journal of Occupational Therapy 36: 789–800. Brown T, Lalor A (2009). The Movement Assessment Battery for Children – second edition (MABC-2): a review and critique. Physical and Occupational Therapy in Pediatrics 29: 86–102. Bussing R, Fernandez M, Harwood M, How W, Garvan CW, Eyberg SM, Swanson JM (2008). Parent and teacher SNAP-IV ratings of attention deficit hyperactivity disorder symptoms: psychometric properties and normative ratings from a school district sample. Assessment 15: 317–328. Cairney J, Hay JA, Faught BE, Wade TJ, Corna LM, Flouris AD (2005). Developmental coordination disorder, generalized self efficacy toward physical activity and participation in organized and free play activities. Journal of Pediatrics 147: 515–520. 184
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