2013

http://informahealthcare.com/dreISSN 0963-8288 print/ISSN 1464-5165 online

Disabil Rehabil, 2013; 35(21): 1814–1820! 2013 Informa UK Ltd. DOI: 10.3109/09638288.2012.756943

RESEARCH PAPER

Social participation by children with developmental coordinationdisorder compared to their peers

Audette Sylvestre1,2, Line Nadeau1,2, Line Charron3, Nicole Larose3, and Celine Lepage2,3

1Department of Rehabilitation, Master’s Program in Speech-Language Pathology, Universite Laval, Quebec, QC, Canada, 2Centre for

Interdisciplinary Research in Rehabilitation and Social Integration, Universite Laval, Quebec, QC, Canada, and 3Research Institute for Physical

Rehabilitation of Quebec, Chemin St-Louis, Quebec, QC, Canada

Abstract

Purpose: Two objectives are being pursued: (1) to describe and compare the level of socialparticipation of children aged 5–13 with developmental coordination disorder (DCD) tochildren of the same age with typical development (TD) and (2) to describe and compare thelevel of social participation of two subgroups of youths with DCD, e.g. children with dyspraxiaaffecting both the motor sphere and the verbal sphere (mixed dyspraxia) and children withdevelopmental dyspraxia. Method: This cross-sectional study was conducted among 27youngsters with DCD: 9 having developmental dyspraxia and 18 having mixed dyspraxia,compared to 27 same-age peers with TD. Life habits (LIFE-H) for children was used to measuresocial participation. Results: Levels of lifestyle achievements among youngsters with DCD aresignificantly lower than those of TD youngsters in all categories. Noteworthy differences werefound between subgroups of youngsters with DCD in the categories of life habits related tocommunication and education. The group with mixed dyspraxia obtained the lowest scores.Conclusions: The achievement of a normal lifestyle by youngsters with DCD is upset in allspheres of life. The impact of DCD on the level of participation of these youngsters is quitesignificant and affects all lifestyles measured in this study. Children with mixed dyspraxia areparticularly affected. These facts must be taken into consideration by anyone involved in thelives of these youngsters.

� Implications for Rehabilitation

� It is necessary to encourage social participation of DCD sufferers aged 5–13 in all spheresof life.

� Special attention should be paid to those who have a speech disorder.� Life habits concerning communication and education may be related; greater efforts should

be made to limit the negative impact on other lifestyles.� Social participation of DCD sufferers should be measured periodically and appropriate

resources must be made available to promote training and support for clinicians.� It is important to provide tools to measure social participation for both stakeholders and

parents.

Keywords

Childhood apraxia of speech, developmentalcoordination disorder, developmental dys-praxia, life habits, social participation

History

Received 14 August 2012Revised 28 November 2012Accepted 5 December 2012Published online 19 April 2013

Introduction

There is an increasing recognition by physical rehabilitationservices concerning the importance of ensuring that children canactively participate in life domains that they and their parentsvalue, and of providing services that will ultimately enhance theirparticipation in everyday activities [1,2]. Thus, a consensus seemsto be well established that social participation is the ultimate goalof the rehabilitation process [1,3–5]. The concept of socialparticipation proposed by the International Classification of

Functioning, Disability and Health [6] refers to the fact oftaking part in a real life situation. Depending on the model of theDisability Creation Process (DCP), social participation is theresult of the interaction between the person and its environment.It is manifested in the achievement of a person’s lifestyle or in theexecution of daily activities and social roles that the personvalues [7,8].

Children with Developmental Coordination Disorder (DCD)are particularly susceptible to certain disruptions in their socialparticipation since their physical, psychological and socialfunctioning is compromised when compared to peers [9].DCD is defined as a unique and separate neurodevelopmentaldisorder [10]. The main element of DCD is a serious impairmentin the development of motor coordination that is not explicable interms of general intellectual disability or of any specific

Address for correspondence: Audette Sylvestre, PhD, Department ofRehabilitation, Master’s Program in Speech-Language Pathology, Uni-versite Laval, Quebec, QC, GIV 0A6, Canada. Tel: 418-656-2131, #8993.E-mail: audette.sylvestre@rea.ulaval.ca

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congenital or acquired neurological disorder [11]. DCD can affectthe motor sphere (Developmental Dyspraxia: DD), the verbalsphere (Childhood Apraxia of Speech: CAS) or both simulta-neously (CAS-DD). Current prevalence estimates of DCD are 5–6% more or less [12].

DD is a neurological problem that affects planning and motorprogramming. It can hinder all gestures and movements ofdifferent body parts (upper limbs, lower limbs, trunk) [13,14]. Fora child with DD, learning a task is characterized by the need formultiple repetitions. It is very difficult to transfer a motor skill itlearned in a given context to a different context. The difficulty ofcomplex tasks required in daily life increases the risk that childrenwith DD live in situations of disability. Marked disruption of thedevelopment of motor coordination interferes with the involve-ment of youth in leisure activities [15,16]. Children with DD arealso often marginalized and have significant difficulties in schoolintegration [13,17].

CAS is a neurological childhood speech sound disorder wherethe precision and consistency of movements that underlie speechare impaired in the absence of neuromuscular deficits (e.g.abnormal reflexes, abnormal tone). Identification of segmentaland suprasegmental features that are consistent with a deficit inthe planning and programming of movements for speech havegained some consensus among investigators in apraxia of speechin children [18]. These and other reported signs change in theirrelative frequencies of occurrence with task complexity, severityof involvement and age. The complex of behavioral featuresreportedly associated with CAS places a child at increased risk forearly and persistent problems in speech, expressive and receptivelanguage, pragmatics, as well as for the phonological foundationsfor literacy [18]. The persistence of phonological difficulties inchildren with CAS during the early school years, e.g. throughoutthe period of explicit reading and spelling instructions, placesthese children at risk for persistent written language difficulties[19]. A child with CAS lives with considerable limitations incommunication and often demonstrates significant unintelligibil-ity during early childhood, even for its family. Since commu-nication is the basis of learning and social development, CAS islikely to have repercussions in all spheres of a child’sdevelopment. In fact, it is relatively rare that CAS is isolated. Itis most often associated with DD, resulting in a mixed form ofCAS-DD.

A recent study demonstrated the negative impact of CAS andDD on social participation of these children at preschool age[20]. However, to date no study has been conducted amongschool-aged youths to document their participation in all sociallife contexts, including home, school and community. Studiesconducted among young people with Specific LanguageImpairment (SLI), a problem similar to CAS, confirm negativeconsequences of a spoken language disorder on the developmentof social skills [21,22]. According to Liiva and Cleave [22],young SLI sufferers are often inhibited, speak less in theclassroom and share less with their peers. Moreover, no studieshave been conducted in order to compare the level of socialparticipation of a youth with CAS or DD to that of a youth withtypical development (TD). However, it is important to be able toidentify the areas where social participation of youth does ordoes not differ from that of their peers, in order to better targetareas of vulnerability of those with CAS or DD and proposeappropriate interventions.

Given the fundamental importance of language skills in theestablishment of social relations and in academic learning, andtaking into account that more than half of the tasks performed inthe early grades require motor skills [14,23,24], youth with CASor DD are significantly more likely than youth without dyspraxia,to encounter a large number of handicaps in daily situations [13]

that affect their quality of life and well-being [9]. An increasedknowledge of the level of achievement of their lifestyles wouldprovide a portrait of the real difficulties experienced by theparticipants in their different environments and allow for betterrecognition of their needs. These data could contribute to thedevelopment of more appropriate interventions and, ultimately,promote greater social participation of youngsters.

Objectives and hypotheses

The objectives of this study were (1) to describe and compare thelevel of social participation of youngsters aged 5–13 with DCD tothose of the same age with TD and (2) to describe and comparethe level of social participation of two subgroups of DCD, e.g.youngsters with mixed dyspraxia (CAS-DD) and others with DD.

The hypotheses were that youngsters with DCD would have alower level of social participation than TD youngsters in areasrelated to communication, interpersonal relationships, responsi-bilities, education and leisure, and that a significant differencebetween the two subgroups of youngsters with DCD would beevident at the communication level to the advantage of DDyoungsters.

Methods

This cross-sectional study was conducted among 27 youngsterswith DCD (mean age¼ 7.7, SD¼ 1.7), 9 of whom exhibit DD and18 have CAS-DD. These children were compared to 27 childrenwith TD (mean age¼ 7.7, SD¼ 1.8). All youths were aged 5–13at the time of data collection and spoke Quebec French. Theywere matched based on age and sex, variables on which they werenot significantly different (age: p¼ 0.79; sex: p¼ 0.32). The studywas approved by the Ethics Committee of the Research Institutefor Physical Rehabilitation of Quebec (IRDPQ). All parentssigned the consent form prior to the start of the study.

Participants

Children with DCD were recruited for the ‘‘Child Development’’and ‘‘Language Impairment’’ programs of the IRDPQ. Toparticipate in the study, the children had to be (1) free fromintellectual or sensory impairments, (2) show no severe impair-ment of verbal comprehension as identified in the document‘‘Students with handicaps or adaptation and learning difficulties;definitions’’ [25] and (3) meet one or more of the followingselection criteria available at the time of completion of the datacollection (2006):� CAS: (a) difficulty in achieving and maintaining articulatory

positions, (b) presence of transformations of vowels and (c)difficulty in achieving articulatory movement of a phonemein a complex syllable while this phoneme is grasped withmore ease in a single syllable [26]. These characteristics wereidentified by a speech-language pathologist after theexamination of spontaneous phonological productions andsituation assessment production as well as the examination oforal-motor praxis.

� DD: (a) presence of a motility disorder as evidenced byscores below the 15th percentile of the ‘‘Movement ABC’’test [27] or subtests such as upper limb coordination, visual-motor control or upper limb speed and dexterity of theBruininks–Oseretsky test [28], or an interval of one year ormore on the scale of gross motor or fine motor assessmentbattery Talbot [29] and (b) problem of upper limb praxishighlighted by a score below the 15th percentile in imitationof the posture test ‘‘MAP’’ [30] or a score less than thechronological age for the imitation of the gesture test‘‘PEEX-2’’ [31].

DOI: 10.3109/09638288.2012.756943 Social participation by children with DCD 1815

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The comparison group was composed of 27 children. Theseyoungsters were selected from the same school as those who werepart of the DCD group. The recruitment of the former was carriedout by the teaching staff. Participants were selected based onmatching criteria (age and sex). These children had no impair-ments or disabilities, as confirmed by the parents.

Materials

The following sociodemographic variables were documented:age and sex of participants, family type, parental age and theparents’ level of education. The measure of life habits (LIFE-H)adapted to children aged 5–13 [32] was used to determine thesocial participation of these children. This tool is designed togather information on the lifestyle that the child experiences athome, in school or in the community. It is in the form of aquestionnaire with 196 items in its detailed version and 64 itemsin its abridged version, all divided into 12 categories. Thesecover all the common activities such as nutrition, bodycondition, personal care, communication, housing, transportationand social roles, i.e. responsibilities, interpersonal relationships,community life, education, work, leisure, usually attributed tochildren according to their sociocultural context. For the purposeof this study, the subscales ‘‘community life’’ and ‘‘work’’ wereremoved according to the age and activities of the participants.As seen in Table 1, a total of 113 items in either the detailed orthe abridged version was retained. The choice of long or shortform version of the instrument was guided by hypothesis. The10-point rating scale (0–9) takes into account the level ofdifficulty and the type of assistance required to accomplisha particular life habit (Table 2). A score of 0 indicates thatthe individual is experiencing a disabling situation, such as theinability to accomplish a particular life habit as the resultof individual–environmental interaction, whereas a score of9 points indicates an optimal level of social participation,i.e. life habits accomplished without difficulty or assistance.

A standardized score between 0 and 10 can be established forthe overall tool (total score), and for each life habit category,taking into account only the items relevant to the child’s life.The tool also has a second scale of five levels, rangingfrom ‘‘very dissatisfied’’ (1) to ‘‘very satisfied’’ (5) that can beused to assess the level of satisfaction of respondents, in thiscase parents, with regard to their children’s accomplishmentof life habits.

The estimate of internal consistency (a� 0.90), of intra-raterreliability (0.82� ICC� 0.96) and inter-rater precision(0.70� ICC� 0.91) of the different categories of lifestylemeasured by the instrument is considered to be excellent [33].The psychometric properties of LIFE-H for children arecomparable to several tools used in pediatric rehabilitation andmeet usual methodological standards. Its content allows for acomplete description of the person-perceived participationapplied to children with disabilities. Moreover, the tool candepict variations across dimensions and across diagnoses [34].The use of this instrument is recommended to thoroughly assessmultiple domains of social participation [35–37].

Procedures

Interviews for data collection lasted 60 minutes. They were allcarried out with the parents. Two experienced evaluators trainedin the use of LIFE-H conducted the interviews; one for the DCDgroup and one for the TD group. A suitable reference guide wasavailable to the evaluators in order to standardize the use of thequestionnaire.

Data analysis

First, we computed descriptive statistics of the demographiccharacteristics of the participants. The next step was to verifypotential differences in the groups of participants using Chi-square test or the Fisher exact test. Levels of LIFE-Haccomplishment scores were drawn using graphic methods inorder to illustrate variations between categories of LIFE-H andamong different groups. Significant differences were determinedby a one way analysis of variance (ANOVA) and tests of multiplecomparisons (Tukey). A statistical threshold of 0.05 was used toidentify those differences.

Results

The sociodemographic characteristics of the participants arepresented in Table 3. As previously mentioned, groups do notdiffer based on age and sex. A higher proportion of males thanfemales made up the DCD group which corresponds to thestatistical data already known for this subgroup.

With regard to objective 1, the results showed that childrenwith DCD have significantly lower levels of lifestyle achievement(0.023� p50.0001) than youngsters of TD in all categories oflife habits (Figures 1 and 2). The categories presenting majordisturbances were related to communication, education andnutrition, while categories concerning housing, interpersonalrelations and body condition produced the best results.

A detailed analysis of the categories showing the greatestdisturbances indicates that the less successful items in thecommunication category were related to (1) the inability ofholding a conversation with a peer or an adult or with a groupof peers or adults at home or in the community, (2) expressingneeds to family members or other persons at home or in thecommunity, (3) understanding oral information in a group, and(4) communicating in writing. In the education category, scoresof all items related to learning activities and school work at

Table 2. Accomplishment scale of LIFE-H of children.

Score Level of difficulty Type of assistance

9 Accomplished with no difficulty No assistance8 Accomplished without difficulty Technical aid (or adaptation)7 Accomplished with difficulty No assistance6 Accomplished with difficulty Technical aid (or adaptation)5 Accomplished without difficulty Additional human assistance4 Accomplished without difficulty Technical aid (or adaptation)

and additional humanassistance

3 Accomplished with difficulty Additional human assistance2 Accomplished with difficulty Technical aid (or adaptation)

and additional humanassistance

1 Accomplished by a proxy0 Not accomplishedN/A Not applicable

Table 1. Nomenclature of life habits and the number of items of LIFE-Hof children based on the short and long version.

Short version items N Long version N items

Nutrition 4 Responsibility 15Fitness 4 Interpersonal Relationships 10Personal Care 8 Education 14Housing 6 Recreation 24Mobility 4 Communication 21

1816 A. Sylvestre et al. Disabil Rehabil, 2013; 35(21): 1814–1820

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school or at home were lower in children with DCD comparedto children with TD. In the nutrition category, the items relatedto meals at home or in restaurants as well as participation inthe preparation of meals received the lowest scores inyoungsters with DCD.

In the interpersonal relationships category, the results highlighttwo distinct clusters. Emotional and social relationships withfamily members exhibited no or few difficulties for youngsterswith DCD while the relationships with friends or social relation-ships with peers or adults exposed disturbances.

In relation to objective 2, significant differences were observed(0.021� p50.0001) between the two subgroups of children withDD and CAS-DD, respectively, in both categories of life habitsrelated to communication and to education. As seen in Figure 3,the group of children with CAS-DD showed the lowest level oflifestyle achievement. The main items that significantly differ-entiate the two groups of children were linked to (1) holding aconversation with a peer at home or with an adult, (2) holding aconversation with a peer or peer group in the community, (3)taking a course or activity in the classroom, (4) completingschool work, and (5) participating in workshops or group work(0.040� p� 0.002).

Discussion

The initial purpose of this study was to describe and compare thelevel of social participation of youngsters with DCD and childrenof the same age and sex with TD. The hypothesis stated thatchildren with DCD have a lower level of social participation inareas related to communication, interpersonal relationships,responsibilities, education and recreation than children with TD.Our data not only support this hypothesis but also showdifferences in other lifestyle categories that were measured.Thus, the impact of DCD extends beyond spheres of everyday lifeclinically alleged on the basis of the nature of the disabilitiesexhibited by these youngsters.

The most affected categories among all lifestyles are educationand communication. In the case of education, the results can beexplained by way of organizational difficulties presented bychildren with DCD, skills sought in school work, e.g. writing,numbers aligned with mathematics. These difficulties mayintroduce a delay in achieving the tasks, lead to only partialcompletion of tasks or a tendency to give up. It can be difficult forthese youngsters to follow their peers and be as efficient in a teamwork context, particularly because of the speed of the tasks andlimitations in verbal exchanges.

Figure 1. Distribution of the assessment of life habits for children (LIFE-H). Accomplishment scores for the long version categories of participation(a–e) based on children with developmental coordination disorders (DCD, n¼ 27) or typical development (TD, n¼ 27). p Values for the differencesbetween the two groups are50.0001. OP: Optimal Participation; MR: Maximal Restriction.

Table 3. Socio-demographic data (N¼ 54).

M(SD) Frequency

DD (n¼ 9) CAS-DD (n¼ 18) TD (n¼ 27) DD (n¼ 9) CAS-DD (n¼ 18) TD (n¼ 27) p

VariablesAge (years) 8.0 (2.0) 7.5 (1.6) 7.7 (1.6) 0.79Boys 7 (78%) 15 (83%) 17 (63%) 0.32Adapted education 4 (44%) 7 (39%) 0 (100%) 50.0001Mother’s education (� high school) 3 (38%) 7 (39%) 4 (15%) 0.14Father’s education (� high school) 4 (44%) 4 (22%) 6 (26%) 0.55Two-parent family 6 (67%) 15 (83%) 23 (85%) 0.46

DD: Developmental Dyspraxia, CAS-DD: Childhood Apraxia of Speech and Developmental Dyspraxia.

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Disruption of social participation in the field of commu-nication can be due to the strong unintelligibility of childrenwith speech problems. As a result, these children are less likelyto express themselves. They participate less in conversation inthe school setting, thus reducing the opportunity to improve.Their major difficulties and their repeated failures lead theseyoungsters to avoid certain motor and verbal activities that are

essential for socialization, both at school and in leisureactivities.

Despite the fact that the establishment of interpersonalrelationships are quantitatively lower than those of typicallydeveloping children, they are not part of the most disconcertingcategories of children with DCD. Interpersonal skills beingclosely linked to communication skills, it was expected that

Figure 3. Distribution of the Assessment of Life Habits for Children (LIFE-H). Accomplishment scores for the Education and Communicationcategories of participation based on children with Developmental Dyspraxia (DD, n¼ 9), with Childhood Apraxia of Speech and DevelopmentalDyspraxia (CAS-DD, n¼ 18) or Typical Development (TD, n¼ 27). p Values for the differences between the groups are50.0001, except for the twogroups of DCD in Communication (p¼ 0.021). OP: Optimal Participation; MR: Maximal Restriction.

Figure 2. Distribution of the assessment of life habits for children (LIFE-H). Accomplishment scores for the short version categories of participation(a–e) based on children with developmental coordination disorder (DCD, n¼ 27) or typical development (TD, n¼ 27). p Values for the differencesbetween the two groups are50.0001 except for fitness (p¼ 0.023). OP: Optimal Participation; MR: Maximal Restriction.

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similar results for these two lifestyle categories would emerge.This result may be partly explained by the greater proportion ofitems related to interpersonal relationships with a family member(60% on a comparative scale of measurement) to the number ofitems associated with social relations outside family (40%). Giventhat the family provides a much safer environment and parentsoften compensate for the difficulties of their child, the latterenjoys greater success despite its disabilities.

The second objective of the study was to describe and comparethe level of social participation of two subgroups: children withmixed dyspraxia (CAS-DD) and those with DD. The resultssupport the hypothesis that youngsters with DD deliver sig-nificantly better results in the communication category thanyouths with CAS-DD. The two subgroups also differ in theeducation category. This may be explained by the fact thatcommunication is an important requirement in education. Sinceisolated CAS is very rare, we have not been able to specificallystudy the social participation of those children. This should attractthe attention of researchers so as to identify potential needs of thissubgroup of DCD children.

Conclusion

Although the size of the sample is relatively limited and is aconvenience sample, which calls for caution in generalizing theresults, our results show with a respectable degree of confidencethat youngsters with DCD exhibit disturbances in achieving theirlifestyles both at home, at school and in the community. Theirlevel of social participation is lower than that of children with TD.This knowledge must be considered by parents, teachers and allinterveners who work with these youngsters, and their problemsshould be addressed in all areas of social participation.

Moreover, the categories that significantly distinguish childrenwith DD from children with CAS-DD (communication andeducation) must receive special surveillance by clinicians andspecific attention must be paid to children who have majordifficulties. More specifically, the need to intervene regardingaspects related to communication remains essential, given thesignificant impact of this matter on several areas of socialparticipation. Rehabilitation programs should include interven-tions aimed at the development of conversational skills and socialinteractions to improve contacts outside the family, the creationand the maintenance of friendships and social relations.

Furthermore, it is important that several strategies are used toencourage greater participation in school learning, such asproviding more time to accomplish a task, improve the organiza-tion of the task, e.g. pursuit of the goal, keeping the work pace byusing a logical work-step sequence, autocorrections, problemsolving and adapting the work environment. In addition, childrenwith CAS-DD would benefit from interventions that combinecommunication skills in an educational context within a schoolenvironment, interactions with teachers, classmates and schoolstaff. All these strategies can help reduce situations of failureexperienced by children and create a greater sense of confidence.

Acknowledgements

The authors gratefully acknowledge the research assistance provided byFrancine Morin, speech-language pathologist, and Annie Vallieres,physical therapist. Special thanks to Ann-Julie Gauthier for her helpfultechnical support. We also greatly appreciate the children and theirparents who generously gave of their time to participate in this study.

Declaration of interest

The authors report no conflicts of interest. The authors alone areresponsible for the content and writing of this article.

This project was supported by the Fondation Elan of the IRDPQ.

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