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Mental Health Difficulties in Children With Developmental Coordination Disorder Raghu Lingam, Marian J.

Jongmans, Matthew Ellis, Linda P. Hunt, Jean Golding and Alan Emond Pediatrics 2012;129;e882; originally published online March 26, 2012; DOI: 10.1542/peds.2011-1556

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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associated developmental traits.Mental Health Difficulties in Children With Developmental Coordination Disorder WHAT ’S KNOWN ON THIS SUBJECT: Cross-sectional studies have shown an increased risk of mental health difficulties in children with developmental coordination disorder. MD. Utrecht University. abstract OBJECTIVE: To explore the associations between probable developmental coordination disorder (DCD) defined at age 7 years and mental health difficulties at age 9 to 10 years. Pediatrics 2012. Dr Lingam is funded by a Researcher Development Award from the UK National Institute for Health Research. MBChB. 2013 . Netherlands KEY WORDS developmental coordination disorder. mental health.1542/ peds.ac. Wilhelmina Children’s Hospital. University Medical Centre Utrecht.pediatrics. Jongmans. However. Online. child development. Protective factors for self-reported depression included high IQ. Text Revision criteria as those children below the 15th centile of the Avon Longitudinal Study of Parents and Children Coordination Test. there has been limited longitudinal research in this area controlling for confounding factors and assessing the role of potential mediators.70. FUNDING: The UK Medical Research Council. Faculty of Social Sciences. Bristol.uk PEDIATRICS (ISSN Numbers: Print. self-esteem.2011-1556 Accepted for publication Nov 29. Multiple logistic regression models. The odds of mental health difficulties significantly decreased after accounting for verbal IQ. and friendships.1542/peds.129:e882–e891 e882 LINGAM et al Downloaded from pediatrics.org/cgi/doi/10.pediatrics. child behavior. School of Social and Community Medicine and cSchool of Clinical Sciences. PhD. "Probable" DCD was defined by using Diagnostic and Statistical Manual of Mental Disorders. with the use of multiple imputation to account for missing data. Oakfield House. and the absence of bullying. depression. School of Social and Community Medicine. RESULTS: Children with probable DCD (N = 346) had an increased odds of self-reported depression. online at www. high self-esteem. Hunt. DCD.08 (95% confidence interval: 1. E-mail: raghu. Fourth Edition.2011-1556 doi:10. bullying. in part. MBChB. MRCPCH. METHODS: We analyzed of prospectively collected data (N = 6902) from the Avon Longitudinal Study of Parents and Children. developmental disabilities ABBREVIATIONS ALSPAC—Avon Longitudinal Study of Parents and Children ASD—autistic spectrum disorder CI—95% confidence interval DCD—developmental coordination disorder DSM IV-TR—Diagnostic and Statistical Manual of Mental Disorders.lingam@bristol. excluding children with neurologic difficulties or an IQ . and potential mediating factors such as verbal IQ.org at Indonesia:AAP Sponsored on August 5. MDa aCentre for Child and Adolescent Health. Prevention and treatment of mental health difficulties should be a key element of intervention for children with DCD. MSC. Text Revision EPDS—Edinburgh Postnatal Depression Scale MABC—Movement Assessment Battery for Children OR—odds ratio SDQ—Strengths and Difficulties Questionnaire SMFQ—Short Mood and Feelings Questionnaire This publication is the work of the authors and Dr Lingam will serve as guarantor for the contents of this article. United Kingdom. www. ALSPAC. good social communication skills. and bullying. MSC. Fourth Edition.b Matthew Ellis. PhD.2011-1237.23 (95% confidence interval: 3.36–3. with functional limitations in activities of daily living or handwriting. WHAT THIS STUDY ADDS: Children with "probable" developmental coordination disorder at 7 years had a significantly increased risk mental health difficulties at 10 years.a Linda P. Copyright © 2012 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. COMPANION PAPER: A companion to this article can be found on page e892. and Department of Special Education. 1098-4275). social communication. odds ratio: 2. and bDepartment of Neonatology. Utrecht.c Jean Golding.19) and parent-reported mental health difficulties odds ratio: 4. the Wellcome Trust. University of Bristol.77).10–5. poor self-esteem.1542/peds.a Marian J.org/cgi/doi/10. and self-esteem. bullying. AUTHORS: Raghu Lingam. low verbal IQ. Bristol BS8 2BN. Mental health was measured by using the child-reported Short Moods and Feelings Questionnaire and the parent-reported Strengths and Difficulties Questionnaire.aappublications. PhD. assessed the associations between probable DCD and mental health difficulties. and the University of Bristol currently provide core support for the Avon Longitudinal Study of Parents and Children. were mediated through associated developmental difficulties. Oakfield Rd. CONCLUSIONS: Children with probable DCD had an increased risk of mental health difficulties that.a and Alan Emond. PhD. UK. 2011 Address correspondence to Raghu Lingam. 0031-4005. Centre for Child and Adolescent Health. MRCPCH. Adjustments were made for environmental confounding factors.

Children who attended motor coordination testing at 7 years were more likely to have white mothers who were educated to a higher level and come from a higher social class.21 The assumed latent trait underlying the SMFQ is depression. The multistage definition used met DSM IV-TR criteria for DCD. ball skills (throwing bean bag into box). and social factors. which consisted of 3 subtests derived from the Movement Assessment Battery for Children (MABC).5–9 Our objective was. but also to consider factors that may mediate this relationship. Measures Exposure Variable: Probable DCD Children with probable DCD were defined by the use of the DSM IV-TR criteria. These motor subtests have been shown to have concurrent validity with other similar coordination tests and represent the 3 domains of coordination by using principal component analysis of original standardization data from the MABC. which have been described previously. by using the child-completed 13item Short Mood and Feelings Questionnaire (SMFQ).12 Those children with a known visual deficit or neurologic condition such as cerebral palsy were excluded. they either failed their National Curriculum Key Stage 1 writing test (a standardized assessment undertaken by all children in state education in England at aged 7).12. especially in association with attention deficit hyperactivity disorder. Number 4. which causes functional limitations in activities of daily living or academic achievement (criterion B). The study contains data on 14 062 live births. not caused by a general medical condition nor severe learning difficulties (exclusion criteria C and D).70 were excluded. in addition.10.aappublications.5 years.4 Recent work has highlighted the need for robust epidemiological analyses to assess not only the risk of mental health difficulties in children with developmental coordination disorder (DCD). Second. Fourth Edition. and balance (heel-to-toe walking). Children with an IQ .12 Data on a variety of parent. and who had data from a school-based handwriting test or an Activities of Daily Living scale. did not control for potential confounding factors.23. 2013 . these studies did not use standardized tools for the measurements of motor coordination or mental health difficulties.16. adapted for research by using the 2006 Leeds Consensus Statement. to assess the associations between children with probable DCD (defined by using criteria based on the Diagnostic and Statistical Manual of Mental Disorders.18.14. and linked education and health records. 1992 to take part.24 The SDQ is a standardized screening questionnaire used extensively in mental e883 METHODS Sample The Avon Longitudinal Study of Parents and Children (ALSPAC) is a prospective population-based birth cohort study designed to investigate the interaction of environment and genotype on the health and development of children.1–3 However.ARTICLE Previous longitudinal research has found an increased risk of anxiety and depression in teenagers with severe functional motor coordination difficulties.12 Motor skills of children were assessed between 7 and 8 years by using the ALSPAC Coordination Test. 1991 and December 31.70. April 2012 Downloaded from pediatrics. 6902 children who attended a research clinic for motor testing at 7 years.13 Children were defined as having probable DCD if they met all 4 DSM IV-TR criteria for DCD: poor motor coordination (criterion A). as we used the 15th centile. with an expected date of delivery between April 1.22 Parents were asked to complete the Strengths and Difficulties Questionnaire (SDQ) for their child at 9. Our sample consisted of PEDIATRICS Volume 129. and friendships as potential mediating factors in this relationship.17 Those children scoring below the 15th centile on motor testing were then considered to have functional limitations in motor skills if. and in the case of the Goteborg cohort. Ethical approval for the study was obtained from the ALSPAC Law and Ethics Committee and the Local Research Ethics Committees.21. or they scored below the 15th centile on a 23-item activity of daily living scale derived from parent-completed questionnaires.10. we aimed to explore the effect of associated developmental difficulties. Text Revision [DSM IV-TR]10) at age 7 years and parent and child– reported mental health difficulties at age 9 or 10 years. first. rather than the more conservative fifth centile of the motor coordination test.19 Outcome Variables: Measures of Mental Health and Child Behavior The primary outcome was depressive symptoms reported at the age of 10 years. self-esteem. which has been shown to have high levels of reliability and validity. from face-to-face assessments at special clinics. as were children with an IQ .org at Indonesia:AAP Sponsored on August 5.14 The subtests were selected to test the 3 realms of coordination: manual dexterity (placing pegs task). we described our population as having "probable" DCD in keeping with our previous work.11 The study invited all pregnant women in the geographically defined area of Avon. However.and childrelated confounding factors and developmental traits were collected by parent self-completion questionnaires. accounting for known confounding factors.15 We used the 15th centile of the ALSPAC Coordination Test to define children as having or being at risk for coordination difficulties in keeping with the MABC manual and previous literature.20.12. southwest England. specifically bullying.

Antenatal depression was measured by using the Edinburgh Postnatal Depression Scale (EPDS) at 32 weeks’ gestation by using a binary cutoff of $13 as used previously. Responses were scored by using a 3-point Likert scale.58 (1. accommodation. the SDQ also provides 5 questions that measure prosocial behavior.to 15-year-olds and their parents. measured by using validated tests and subtest within ALSPAC.25. N = 6422 (n = 371) Spelling.44 A child was classified as an overt victim if they had been bullied frequently (several times a month) or very frequently (several times a week). Details of these tests have been reported previously. N = 5913 (n = 338) Short-term memory. which assessed the association between IQ and later psychosis and depression. and items for the baby).76–5.46 All 3 of these measures were completed by the child and have been reported in ALSPAC.health research with young people.59–2.001 .18 Bullying was assessed by using a modified version of the Bullying and Friendship Schedule.. which has been validated in a survey of ..org at Indonesia:AAP Sponsored on August 5. assessed by using the Basic Reading subtest of the Wechsler Objective Reading Dimensions42 and spelling. and peer relationship difficulties). LINGAM et al Downloaded from pediatrics.04–2. age when the SDQ or SMFQ were performed. hyperactivity and inattention.aappublications. N = 5817 (n = 336) Social communication.48–4.29. and family income at age 8 years.27 The test consists of 20 questions arranged to create 4 difficulty subscales (measuring emotional symptoms. and extremely stressful events in the child’s life.90) 2.24. to give a “total difficulty score” out of 40.18) 2. N = 5884 (n = 337) Reading. financial difficulties in pregnancy (with the use of a 5-point scale derived from maternal report of ability to afford food. The SMFQ was dichotomized in line with the TABLE 1 ORs of Child-Reported Depression (SMFQ) at 10 y in Children With Developmental Difficulties. highest parent social class (3 categories). heating.03 .5 years.. and academic ability.37 We have previously shown a strong association between probable DCD and difficulties in attention and hyperactivity.30 Child-related confounding factors selected were: gender. SDQ scores above the 10th centile from parental report were associated with a 15-fold increased odds of the young person having an independently diagnosed psychiatric disorder.33 Maternal depression at 9 years was taken from maternal self-report.45 Finally.32 Maternal anxiety was measured at 32 weeks’ gestation by using the anxiety items from the Crown-Crisp Index.25) P . N = 6308 (n = 362) Nonverbal skills. and the indicators of mental health. N = 6353 (n = 356) a Odds of Low Mood at 10 y by Using SMF Q and a Binary Cutoff of 11 OR (95% CI) 3.22) 3.43 All test results were dichotomized by using the fifth centile to define significant difficulties. Confounding Factors Potential confounding factors were selected after appraisal of the relevant literature and additional univariable analyses against both the exposure (probable DCD) and primary outcome (child-reported depression). Measures of parent mental health shown in univariable analysis to be associated with both probable DCD and child-reported depression at 10 years were antenatal depression and e884 anxiety.reported depression at 10 years (Table 1). between 7.36. clothing. conduct.41 Measures of academic ability consisted of reading.38 (1. short-term memory. probable DCD.73 (2.18 Univariable analysis showed all of these factors to be associated with child.35 Verbal IQ was considered to be a potential mediating factor in keeping with recent research. each of the 4 difficulty subscales were summed and prorated. Peer relationships and peer support were assessed by using 5 questions from the Cambridge Hormones and Moods project Friendship questionnaire.49 (2.38) 3. short-term memory was assessed by using a shortened version of the Children’s Test of Nonword Repetition39. a validated self-rating inventory.001 .26 Within this validation dataset. nonverbal skills.74–3.001 .96) 1.31. housing tenure of the family in pregnancy (owned or rented). 2013 .40.17 (1.28 In addition. taken from parent report at age 7.5 and 9 years. nonverbal skills were assessed by using the Faces subtest of the Diagnostic Analysis of Nonverbal Accuracy.79 (2.001 ..001 N is the number for analysis (n is the total number children $11 y in the SMFQ).18 Inattention and hyperactivity were assessed by using the Development and Well-Being Assessment38.34.. social communication. Defined as the Fifth Centile of Each Trait in Turn Associated Developmental Difficulties as Fifth Centilea Inattention or hyperactivity. in keeping with the author’s instructions.47 Analysis Logistic regression models were used to assess the associations between the exposure variable. and social communication was measured by the Social and Communication Disorders Checklist. Mediating Factors IQ was measured at age 7 by using a short version of Wechsler Intelligence Scale for Children III. self-esteem was measured by using a 12-item shortened form of Harter’s Self Perception Profile for Children comprising the global selfworth and scholastic competence subscales. Parent and environmental confounding factors were highest maternal educational attainment (3 categories). assessed by using 15 age-appropriate words developed by Nunes et al.10 000 British 5.68–5.

N (%) Maternal age at delivery years .8) n = 6257 108. N (%) Maternal antenatal depression at 32 wk EPDS $13: depressed. and self-esteem in this association by adding these factors to the previous factors (model 4).3) n = 5912 689 (13.7) n = 6556 316 (5.001a z = 23.1) n = 6321 1247 (20.53 The unadjusted associations between probable DCD and the binary SMFQ and the SDQ scores were first analyzed. N (%) Verbal IQ. Of the 346 children defined as having probable DCD at 7 years.06a .036. N (%) Gestation .8) n = 240 4 (2 to 6) 93 (39. Gender was considered as a potential effect modifier for the SMFQ and total SDQ score in model 3 and assessed by using the likelihood ratio test..55 Further details of the multiple imputation models and missing data are reported in Appendix 1.3) n = 324 98. Number 4.27.001a . c Wilcoxon Mann-Whitney test.7) n = 320 52 (17.52 Analysis of an imputed dataset reduces the potential bias introduced by missing data and was thus chosen as the definitive analysis to meet our study aims.32) n = 6109 944 (15.27) n = 319 47 (14.48.01a .1) n = 286 28 (9. N (%) Maternal antenatal anxiety at 32 wk (Crown Crisp Experimental index 15th centile cutoff): anxious.001a .7) n = 310 12 (3. RESULTS Of our total sample of 6902 children.37 wk. inattention and activity were not controlled for when considering total SDQ and the hyperactivity SDQ subscale as outcome variables.6) n = 295 46 (16. a Probable DCD N = 346 max 217 (62. April 2012 Downloaded from pediatrics..6) n = 6092 198 (3.9) n = 291 33 (15.0) n = 6321 301 (4.org at Indonesia:AAP Sponsored on August 5.5) n = 5761 489 (8. N (%) Friendship difficulties at 8 y.c N = 5291 z = 4.52. starting with verbal IQ (model 2) and subsequently adding developmental traits (model 3). All statistical analyses used Stata version 10. N (%) Parental and environmental factors Highest parental social class: IV.7) n = 5918 660 (11.00) .02a .001.03a z = 3.3) n = 5414 238 (4. N (%) Maternal alcohol in pregnancy (18 wk gestation): .52 (17. V. whereas 5499 children had data on both DCD status and SDQ. Data for both DCD status and SMFQ were available for 5475 children.c N = 5459 .1) n = 5977 1313 (21. 2013 e885 .2) n = 5218 3 (2 to 5) 1726 (33. mean IQ (SD) Stressful life event for child: Yes.9) n = 4751 900 (15.2) n = 329 30 (9.0%) met criteria for probable DCD.1.1 glass/wk.7) n = 346 27 (8. Because hyperactivity was one of the subscales making up the SDQ. b Student t test.91) n = 233 19 (16–21) 16 (14–19) P 3255 (49.c N = 5301 PEDIATRICS Volume 129.3) n = 6167 752 (12. N (%) Birth weight #2500g.£200 per week. N (%) Maternal depression 8 wk postdelivery EPDS $13: depressed.1) n = 5826 469 (9.ARTICLE test author’s guidelines by using a cutoff of 11 or more to define depression.21. and have been subject to more stressful life events (Table 2).50 (15. N (%) Maternal Parity: 3 or more.001.0) n = 6242 264 (4. in line with the standardization literature.98 (7.4) n = 297 38(15. Potential mediating factors were then added to the model.12) n = 5211 20 (17–22) 17 (15–20) . #. Our final model assessed the role of bullying. .148. Multiple Imputation by Chained Equations was used to impute missing data in the confounding factors.001a .51 The 10th centile was used to define difficulties in each of the SDQ subscales in turn.01a . N (%) Housing tenure at 8 wk gestation: rented. N (%) Global self-esteem at 8 y: median (interquartile range) Scholastic competence at 8 y: median (interquartile range) x 2 test. median (interquartile range) Bullying child is an overt victim at 8 y: yes.007a .44a .0) n = 220 74 (23..3) n = 325 20 (6.7) n = 329 79 (24.002.001a .9) n = 5390 666 (12.0) n = 256 23 (7.. come from a more deprived social background. The children with probable DCD were more likely to be male. N (%) Maternal reported depression in the last 3 y from age 9: yes often.001a Mean difference 9..01a .001b . friendship.6) n = 247 46 (18.54.94–12. . 235 attended for testing at 10 TABLE 2 Characteristics of Children With Probable DCD Compared With Controls Controls N = 6556 max Child factors Gender: males.5a .. A “variable focused model” of resilience was used to consider the factors that decreased the risk of psychological morbidity in young people with probable DCD compared with normally developing controls. N (%) Average weekly income at 8 y .31a .49 The 10th centile of the SDQ score measured in the cohort was used to define mental health difficulties. Adjustment was then made for all child and parent confounding factors (model 1). N (%) Ever smoked in pregnancy: ever.348.60a . 346 children (5.50.aappublications.7) n = 312 95 (30. N (%) Maternal education highest qualification: certificate of secondary education/vocational.

001 .19) to 1. friendship. maternal antenatal anxiety and depression at 32 wk gestation.73) 2..838 .97(1.23(3.51(2.08(1.41–2. and maternal depression at 9 y.001 .57) 2.87) 2.54(1.78–3. bullying.aappublications.025 .001 .40) 3.001 .. family income at 8 y of age.48–6.001 .31(3.06–4.25).80(1.67(1.001 ..09) 2.61–1..19) 4.98) 2..59(1. n = 5509 SDQ conduct subscale..51–3.19(0.36–3.91–4. and parental factors: highest maternal or paternal social class.23) 1. For comparison. n = 5521 Downloaded from pediatrics..001 .476 . The final addition of markers of bullying.10(2.e886 years for the SMFQ and 245 had available data for the parent-completed SDQ at 9 years.0%) children with probable DCD were at risk for mental health and behavioral difficulties (SDQ) compared with 423 of 5254 (8.1%) controls (unadjusted OR 4. P (95% CI) (95% CI) LINGAM et al Model 1a OR P .001 .06) 2..41) 1.85(2.58) 2.001 .. c Model 3 plus difficulties in attention and hyperactivity.59–3.81–2. n = 5475 Total SDQ difficulty score at 9 y (with a 10th centile cutoff).001 .86–3.74–3..17(1. short-term memory.00–4.00(0.. low self-esteem.001 SMFQ at 10 y (with binary cutoff of 11 to define depression).68) 0. the same analyses with the use of a nonimputed data set with all available data are presented (Table 4).89–3. n = 5499 SDQ hyperactivity subscale.001 .282 . developmental traits (model 3).99–5.45(1.53(1. n = 5511 SDQ prosocial subscale. peer relationship difficulties.3%). after controlling for confounding factors.64–4.62–5.91(1.22) 3.33) 1. age when SDQ/SMFQ performed.48–6.001 . and self-esteem (model 4) further decreased the association between probable DCD and childreported depression.25) 4. financial difficulties measured at 32 wk gestation. Cross-tabulation showed that 28 children with probable DCD (11. and friendship difficulties measured at 8 y...95(0. Children with probable DCD had increased odds of hyperactivity and inattention.24) 1. and SDQ subtest scores with the use of the multiple imputed data set are presented in Table 3.13(1.66.001 1.31) 2.79–5.9%) reported symptoms of depression (SMFQ) compared with 279 of 5240 controls (5.74–1.67–3.001 . Model 1 showed a twofold increased odds of child-reported symptoms of depression for children with probable DCD compared with controls.63) 4...44) 1.79) 2.63) 2.022 .10–5.45–3. emotional problems.87) 4. equating to an unadjusted OR of 2..64(2.10) 2. friendship. . The addition of verbal IQ (model 2).31–2.77) 3.06). n = 5514 SDQ peer subscale.37 (1.81–2. The addition of verbal IQ (model 2) and associated developmental traits (model 3) to the original model decreased the OR of depression in children with probable DCD from 2.001 .59) 3.61(1.66(3.36–2.58–1. nonverbal skills.29(0.59–3.5 and 9 y were also controlled for as binary variables by using the fifth centile of each trait (note: difficulties in attention and hyperactivity not controlled for in SDQ analysis).63) 2.94(1.001 .. Similar cross-tabulation for the total SDQ showed that 71 (23.76) 1.. b Model 2 plus verbal IQ measured at 8 y as a continuous variable.06) 2. social communication.90(2.org at Indonesia:AAP Sponsored on August 5.001 .06–2.001 . housing tenure during pregnancy. and academic ability assessed between 7.63).001 .07 .29 (0.16–5. with a significantly better fitting model.92) 2.. n = 5516 SDQ emotional subscale.001 . stressful life event.41–3.97– 2..41(1.51–4.91(2.45–3.49(1. 95% CI 3.001 Model 4d OR (95% CI) OR of: 2. 2013 a Model 1 controlled for child factors: gender. and fewer prosocial skills compared with their peers after adjustment for confounding factors.80–3.70(1. d Model 4 plus being subject to overt bullying..08–2. highest maternal educational qualification.22) 2..26) .47(0.36–3.85) .41 (95% confidence interval [CI] 1.001 Unadjusted OR (95%CI) P 1... The odds ratios (OR) of having significant difficulties according to the SMFQ score.62(2.90) 2.001 .17(1..99 .001 ..24(1.73–3.58(1.21) .001 .001 Model 3c OR (95% CI) TABLE 3 OR (95% CI) of Significant Mental Health Difficulties by Using the SDQ at 9 y and SMFQ at 10 y for Children With Probable DCD Compared With Controls by Using Multiple Imputation Data P 1.08 (1.001 .89–3. total SDQ score.58) Model 2b OR P .

57–4.68).36–8.001 .48–6.64). poor social communication (5th centile).10–3. n = 2768 Model 1a OR (95%CI) P P P Model 2b OR (95%CI) Model 3c OR (95%CI) Model 4d OR (95%CI) 2.001 .65–4.38 (0. family income at 8 y of age.31–3.33 (1.52 (1.77–6..54 (1.15–4.. SMFQ..org at Indonesia:AAP Sponsored on August 5.34–11. 2013 Interpretation of these models is that for each of the main outcome variables..57 There was no interaction detected for gender in either the model by using the SMFQ or total SDQ. n = 5499 SMFQ at 10 y(with binary cutoff of 11 to define depression) Total SDQ difficulty score at 9 y (with a 10th centile cutoff) SDQ hyperactivity subscale SDQ emotional subscale SDQ conduct subscale SDQ peer subscale SDQ prosocial subscale 4. social communication.14). n = 2865 1. n = 3537 4. ARTICLE e887 . n = 3533 .25). n = 2868 3. n = 2862 .63).001 .001 ..34–6.85).8.001 .70 (1..41). n = 2863 2.52).70–6. nonverbal skills.91–4.84–8. DISCUSSION Downloaded from pediatrics.001 .87).40). and maternal depression at 9 y.003 .001 5. maternal antenatal anxiety and depression at 32 wk gestation. and and self-esteem (model 4) decreased the odds of parent-reported total SDQ difficulties by 34%. n = 5475 PEDIATRICS Volume 129.89–3.79–11... n = 2869 . stressful life event.019 4.60–3.64 (1.001 2.08 (3.22).99–5.98 (1.27 (2.. The unique aspect of this study is the longitudinal nature of the dataset that has allowed us to consider potential mediating factors in this relationship. n = 5514 4. financial difficulties measured at 32 wk gestation. n = 5511 2.59–3... c Model 3 plus difficulties in attention and hyperactivity.78). April 2012 .035 . accounting for important confounding factors. n = 2866 2.88 (1. and are presented in Appendix Table 5.41 (1..001 . These factors can thus be thought of as potential mediating factors in this relationship.10 (2. d Model 4 plus being subject to overt bullying.. b Model 2 plus verbal IQ measured at 8 y as a continuous variable.71).001 3.82).92).22 (1.. n = 2585 2.125 .001 3.86).58–61 This is supported by longitudinal work from the United States.22)..56).50 (3.50–5. housing tenure during pregnancy.57 (0. being an overt victim.67–2.001 .22 (3..05–3. and academic ability assessed between 7.50–4.34–4.68).88–2.02). defined by using the DSM IV-TR criteria at 7 years.77 (1. n = 3537 1.001 2. United Kingdom.13 (2. n = 2583 1.12). low self-esteem.31 (3.22 .001 .64 (1. n = 5509 1.024 3. children with probable DCD still had significantly increased odds of difficulties: OR 2.09 (1.93).06).89–3.03–4. and lower global self-esteem and scholastic competence all significantly increased the risk of mental health difficulties in children with probable DCD (P .001 ..31–2. n = 3267 . have a 2-fold increased risk of self-reported depression and a 4-fold increased risk of parent-reported mental health and behavioral difficulties at 9 or 10 years by the use of prospectively collected data from a large United Kingdom birth cohort.20–4.72).042 OR of: Unadjusted OR (95%CI) 2. However. n = 3262 3.20 (1.80 (95% CI 1. highest maternal educational qualification.99). n = 3535 2.48 (0.33 (1.87).66 (3. n = 3263 1.16–5.5 and 9 y were also controlled for as binary variables by using the fifth centile of each trait (note: difficulties in attention and hyperactivity not controlled for in SDQ analysis).001 .001 6.aappublications.74 (3.001 3. n = 3258 . n = 2582 2.25).05).33 (1. Number 4.96 (1.21 (2. n = 3540 .95–5.03–4.36–4.96)..20 (1. n = 2586 .41).003 3..001 . n = 3144 1.25 (1. n = 3541 .10). decreased verbal IQ. n = 5516 2.001 . and total SDQ.84).94 (1. n = 3266 .37 (0.75).001 .05 . n = 5521 a Model 1 controlled for child factors: gender.98–5. n = 2580 P .003 .001 .85).87 (2.00–3.75 (2. n = 2509 6.53–5. Previous cross-sectional studies (varying in size from n = 40 to n = 270) have also found children with poor motor coordination to have an increased risk of mental health difficulties.08). and parental factors: highest maternal or paternal social class.381 . and friendship difficulties measured at 8 y..56.63).452 . n = 3261 2. Sensitivity analyses excluding children with a clinical diagnosis of ASD (n = 29 for the SDQ analysis and n = 19 in the SMFQ analysis) were similar.79–2.09). This study has shown that children with probable DCD. age when SDQ/SMFQ performed. .001 5.TABLE 4 OR (95% CI) of Significant Mental Health Difficulties by Using the SDQ at 9 y and SMFQ at 10 y for Children With Probable DCD Compared With Controls Using All Available Data P . short-term memory. n = 2586 2. n = 3314 1.

1–4.159(6):1044–1046 3.6. and lower global self-esteem and scholastic competence all significantly increased the risk of mental health difficulties in children with probable DCD (P .5th centile). showed that twin children with poor motor coordination difficulties had an increased risk of depressive symptoms compared with their non-DCD co-twin.52 Another limitation. Natural outcome of ADHD with developmental coordination disorder at age 22 years: a controlled. Piek et al. good social communication skills.39(11): 1424–1431 4. J Am Acad Child Adolesc Psychiatry. scholastic competence. as with all large cohort studies. Because the cotwin had decreased depression scores but similar home environment and genetic characteristics. depression. Skinner and Piek8 showed decreased levels of self-worth in children with DCD compared with controls matched on age.64. Some child psychiatric aspects. although they questioned the causal relationship of these findings. Rasmussen P. The odds of self-reported depression were attenuated after the addition of confounding and mediating factors. and enhancing social interaction may alleviate some of the risk of depression and behavioral difficulties in children with DCD. motor control and perception (DAMP) almost grown up: psychiatric and personality disorders at age 16 years. The differences seen between the parent and child-reported measures of mental health may relate to the differences between the parent ’s and child’s perception of the young person’s wellbeing. managers.35(7):1255–1271 2. The complex interaction between environmental and genetic components in the lives of children with DCD has been highlighted by recent twin studies. motor and attentional deficits in Swedish primary school children.aappublications. in contrast. Within a resilience framework.05). 1994. an increasingly used statistical technique to account for missing data. Decreased verbal IQ.7 with the use of data from an Australian cohort.K. ACKNOWLEDGMENTS We are extremely grateful to all the families who took part in this study. The work also demonstrates the importance of high IQ. To minimize this bias. have an increased risk of anxiety and depression as young adults. which includes interviewers. Gillberg C. 2002. but discrepant cases were still considered to reflect clinically meaningful impairment. Szatmari P. tackling bullying. Fombonne E.65 or may reflect the fact that the SDQ and the SMFQ are measuring different components of mental health. showing that children with poor motor coordination. J Child Psychol Psychiatry. poor social communication (. Van Os J. factors such as having a high IQ and high self-esteem can therefore be thought of as factors that engender resilience in this population of children. . Cairney J. 2013 . Am J Psychiatry.62 More recent work with a smaller cohort of children (n = 50) showed that early motor development was a strong predictor of parentreported anxiety and depression at 6 to 12 years. because of the size of the sample tested. Gillberg IC.24(3):377–403 5. REFERENCES 1. longitudinal. the authors stated that this observed difference may be due to the unique environment of a child with motor difficulties in school and home. and peer and parental relationships. defined by nonstandardized clinical examination or parental report. receptionists and nurses. 1983. was the use of subtests for measures such as self-esteem and friendship. appearance. and the absence of bullying as protective factors in the associations between DCD.Sweden. Gillberg C. clerical workers.org at Indonesia:AAP Sponsored on August 5. 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PEDIATRICS Volume 129. we know that socioeconomic factors affect loss to follow-up.51) . Number 4.27 (1.85) . IQ was normally distributed and incorporated by using linear regression in the imputation model.ARTICLE APPENDIX 1: DETAILS OF MISSING DATA AND MULTIPLE IMPUTATION USED Missing data are a problem in all longitudinal birth cohort studies.82–5.17) .01–2.22 (0.12 Variables that predicted missingness in the confounding factors were assessed by using logistic regression.47–3.10–4.aappublications. along with all variables from the final logistic regression model.00) . Twenty separate stacked data sets were created for the final analysis. nonverbal skills. index of crowding (ordered categorical variable). never). Binary variables and categorical variables used logistic. highest maternal educational qualification. specified in the ICE command. use of a car. especially when data relating to confounding factors are collected at different time points and from different sources (eg. marital status.34 Of these factors.47 (1. In total.003 1. in this case.001 1. family income. well-educated families.34 (0. The following factors were selected to explore if they were associated with missingness: maternal age. parity.83–2. Multiple imputation by using chained equations was employed with the use of the “ICE” command in STATA version 10. and 5475 had data from the SMFQ at 10 years. These variables.45–4. Within ALSPAC.001 Total SDQ score at 9 y (with a 10th centile cutoff). maternal anxiety at 9 years. and friendship difficulties measured at 8 y. thus supporting the “missing at random” assumption.. APPENDIX TABLE 5 OR (95% CI) of Significant Difficulties in Mental Health Difficulties by Using the SDQ (Total Score and Subscale Scores) at 9 y and SMFQ at 10 y (by Using the 10th Centile Cutoff) for Children With Probable DCD Compared With Controls by Using Multiple Imputation Data OR of: Unadjusted OR (95%CI) P Model 1a OR (95% CI) P Model 2b OR (95% CI) P Model 3c OR (95% CI) P Model 4d OR (95% CI) P SMFQ at 10 y (with binary cutoff 2.07) .88 (2.19) ..047 1. which used the MIM command in STATA.. It has been shown that children from lower socioeconomic groups were less likely to attend for assessment than children from more affluent. 1961 children (69% of those with missing data) had missing data in between 1 and 4 confounding factors with 1002 children (34%) having a single missing value from the final model. Multiple imputation models were used to create data sets to allow for missing data only in the confounding factors. and maternal depression at 9 y. n = 5470 a Model 1 controlled for child factors: gender. the oral expression and language comprehension subtests of the Wechsler Objective Language Dimensions67 and the performance IQ measured by using alternate items of the Wechsler Intelligence Scale for Children III at a mean age of 8. Variables included in the multiple imputation model included all those variables in the final regression model plus variables that predicted missingness in the confounders.32) .. b Model 2 plus verbal IQ measured at 8 y as a continuous variable. friendship score at 10 years.81) . housing tenure during pregnancy. We also assessed other factors that may add to our knowledge of the confounding factors themselves.233 1.96 (2. ordinal and multinomial regression as appropriate.65–3.75–3. but also to account for factors that help to explain missingness. temperature of the house in winter. ethnicity. age when outcome test performed. 2580 had no missing data in the confounding factors.001 2. d Model 4 plus being subject to overt bullying.75–2.org at Indonesia:AAP Sponsored on August 5..59 (1. short-term memory.5 and 9 y were also controlled for as binary variables by using the fifth centile of each trait (note: difficulties in attention and hyperactivity not controlled for in SDQ analysis).60 (1. and academic ability assessed between 7. Taking the SDQ analysis. financial difficulties measured at 32 wk gestation.7 years. self-esteem.1.05. maternal alcohol usage in pregnancy (ever. and temperature of the house in winter all predicted missingness in the model with a P value of . n = 5456 3. The model for the SDQ and SMFQ analyses were the same. family income at 8 y of age. these included the child’s birth weight and gestational age.. model 4 were included in the final multiple imputation model. postnatal depression or anxiety.52) .96 (1.. April 2012 Downloaded from pediatrics. 5499 had data for the total SDQ score.69) . different parental reported questionnaires and face-to-face assessments). of the 5499 children with both SDQ and DCD variables. and maternal anxiety at 9 years. social communication. stressful life event. use of hot water in the household. The wealth of prospectively collected data in ALSPAC allows the analysis to not only account for confounding factors. and parental factors: highest maternal or paternal social class. maternal antenatal anxiety and depression at 32 wk gestation.001 2.26–3. ever used drugs.44 (2. 2013 e891 . friendship at 10 years. Of those children with probable DCD.001 2.001 3.426 of 11 to define depression). c Model 3 plus difficulties in attention and hyperactivity.

DOI: 10. and trademarked by the American Academy of Pediatrics. along with others on similar topics. can be found at: http://pediatrics. it has been published continuously since 1948.org/content/129/4/e882.org/site/misc/Permissions. Jean Golding and Alan Emond Pediatrics 2012. Illinois.org at Indonesia:AAP Sponsored on August 5.xhtml Subspecialty Collections Permissions & Licensing Reprints PEDIATRICS is the official journal of the American Academy of Pediatrics. 141 Northwest Point Boulevard.Mental Health Difficulties in Children With Developmental Coordination Disorder Raghu Lingam. Hunt. Matthew Ellis.h tml This article cites 55 articles.org/content/129/4/e882. Marian J. 60007.aappublications. Linda P. appears in the following collection(s): Development/Behavioral Issues http://pediatrics.xh tml Information about ordering reprints can be found online: http://pediatrics. All rights reserved.e882.org/site/misc/reprints.aappublications. Jongmans.org/cgi/collection/developme nt:behavioral_issues_sub Information about reproducing this article in parts (figures. 11 of which can be accessed free at: http://pediatrics.aappublications.full. Downloaded from pediatrics. A monthly publication.h tml#ref-list-1 This article. published. 2013 . Elk Grove Village. Online ISSN: 1098-4275.aappublications.129.aappublications. originally published online March 26.aappublications.2011-1556 Updated Information & Services References including high resolution figures. PEDIATRICS is owned.1542/peds. Copyright © 2012 by the American Academy of Pediatrics. Print ISSN: 0031-4005. 2012.full. tables) or in its entirety can be found online at: http://pediatrics.