Research in Developmental Disabilities 38 (2015) 171–180

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Relationship between motor skills, participation in leisure

activities and quality of life of children with Developmental
Coordination Disorder: Temporal aspects
S. Raz-Silbiger a,b, N. Lifshitz c, N. Katz d, S. Steinhart b, S.A. Cermak e,
N. Weintraub a,*
a
Research and Diagnostic Lab of Writing Functions, School of Occupational Therapy of Hadassah and the Hebrew University Jerusalem, Mt.
Scopus, P.O. Box 24026, Jerusalem 9124001, Israel
b
Alyn Hospital, Pediatric & Adolescent Rehabilitation Center, P.O.B. 9117, Jerusalem 9109002, Israel
c
Department of Occupational Therapy, Faculty of Health Professions, Ono Academic College, 104 Tsahal St., Kiryat Ono 5545173, Israel
d
Research Institute for Health and Medical Professions, Ono Academic College, 32 HaHaroshet St, Or Yehud 6037598, Israel
e
Division of Occupational Science and Occupational Therapy, Ostrow School of Dentistry, University of Southern California, 1540 Alcazar
Street CHP 133, Los Angeles, USA

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

Article history: The study examined the relationship between motor skills, participation in leisure
Received 22 August 2014 activities and quality of life (QOL), within a temporal context (school year vs. summer
Received in revised form 7 December 2014 vacation and school days vs. weekends). Parents of 22 children with Developmental
Accepted 9 December 2014 Coordination Disorder (DCD) and of 55 typically developing children, aged 6–11, filled out
Available online 10 January 2015 two questionnaires relating to their children’s participation in leisure activities (vigorous,
moderate and sedentary) and QOL. The Movement Assessment Battery for Children-2
Keywords: (MABC-2) was administered to their children. Results showed that among the children
Motor skills
with DCD, balance scores positively correlated with participation in sedentary activities,
Leisure
and in both groups both balance and aiming and catching were related to the physical and
Quality of life
DCD
school aspects of QOL. Furthermore, participation in vigorous activities in the summer was
Temporal context positively correlated with social and school QOL. In contrast, among typically developing
children, participation in vigorous activities during the school year was negatively
correlated with school QOL. Finally, in both groups, participation in sedentary activities
during school days was negatively correlated with school QOL. These results suggest that
the parents’ perceptions of their children’s QOL may be related to the level of activeness of
the leisure activities but also to temporal aspects. Therefore, it is important that therapists
and educators consider the temporal aspects, when consulting with parents and their
children regarding participation in leisure activities.
ß 2014 Elsevier Ltd. All rights reserved.

1. Introduction

Children participate in various occupational areas such as self-care, play, education and leisure, within different contexts
(e.g. physical, social, and temporal; American Occupational Therapy Association [AOTA], 2008). Participation has been found

* Corresponding author. Tel.: +972 2 5845317; fax: +972 2 5325345.

E-mail addresses: shanimi1@gmail.com (S. Raz-Silbiger), niritlif@gmail.com (N. Lifshitz), noomi.katz@ono.ac.il (N. Katz), cermak@usc.edu (S.A. Cermak),
naomi.weintraub@mail.huji.ac.il (N. Weintraub).

http://dx.doi.org/10.1016/j.ridd.2014.12.012
0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
172 S. Raz-Silbiger et al. / Research in Developmental Disabilities 38 (2015) 171–180

to be vital for children’s social and academic development as well as for their sense of competence and self-identity (Cairney,
Hay, Veldhuizen, Missiuna, & Faught, 2010). Therefore, it is considered one of the most important outcome measures of
health intervention (Weintraub, Rot, Shoshani, Pe’er, & Weintraub, 2011). Children’s participation is most successful and
meaningful when there is a balance between the ‘just right challenge’, the required skills and body functions to perform the
activities, a supportive environment and a sense of satisfaction (Law, Baum, & Dunn, 2005). Participation in activities is
commonly evaluated using various measures such as duration, diversity, independence level, enjoyment and satisfaction
(Bart, Rosenberg, Erez, & Jarus, 2009).
Leisure is one of the important occupational areas in which children participate. Studies have shown that children spend
30% of their day in leisure activities (Jarus, Anaby, Bart, Engel-Yeger, & Law, 2010). These activities are defined as non-
obligatory, intrinsically motivating and performed during discretionary time (AOTA, 2008). Participation in leisure activities
may vary according to the type of activities and the level of physical activeness the activity requires, i.e. vigorous, moderate
or sedentary (Lifshitz et al., 2011; Ziviani, Scott, & Wadley, 2004). Vigorous-level activities (that entail high levels of
activeness) may include ball games or swimming, which require gross motor skills such as balance and coordination
(Kioumourtzoglou, Derri, Tzetzis, & Theodorakis, 1998). Moderate-level activities, such as art work or playing musical
instruments, require mostly fine motor skills. Sedentary activities, such as playing on the computer or watching television,
require little physical exercise and are normally performed while sitting. These activities may vary with respect to the type of
motor skills they entail, mostly fine-motor skills (Biddle, Marshall, Gorely, & Cameron, 2009).
Children’s participation in everyday activities is thought to be related to their motor competence (Polatajko & Mandich,
2004; Summers, Larkin, & Dewey, 2008). Yet, studies examining the relationship between motor abilities and participation in
leisure activities are limited (Engel-Yeger & Kasis, 2010). These studies focused mostly on children with Developmental
Coordination Disorder (DCD), a developmental deficit in motor coordination. Individuals with DCD may be impaired
predominantly in gross motor skills, in fine motor skills, or in both. DCD affects 5–6% of school aged children (American
Psychiatric Association [APA], 2013).
The difficulties of children with DCD often evoke a negative cycle. The motor impairments may affect their physical
health, and cause secondary emotional and psycho-social problems (Engel-Yeger & Kasis, 2010; Mandich, Polatajko, &
Rodger, 2003). These impairments may also limit their performance in different occupational areas such as activities of daily
living (ADL), play, leisure and academic skills (Cermak & Larkin, 2002; Dunford, Missiuna, Street, & Sibert, 2005). This, in turn,
may result in further delay in acquisition of new skills. Engel-Yeger and Kasis (2010) found that 5–9-year-old children with
DCD showed less preference to participate in leisure activities (requiring various levels of activeness) compared to typical
children. The authors also reported a moderately significant correlation between the children’s motor skills and their
preference to participate in leisure activities. Yet, they did not examine this relationship in children without DCD. Similarly,
Cairney et al. (2005) showed that children in Grades 4–8, with probable DCD (pDCD) participated less frequently in sports
and in other physical play activities. In a later 3-year longitudinal study, Cairney et al. (2010) followed 2083 children (ages
9.11–11.11 years), of which 111 were with pDCD. The children with pDCD reported participating less in organized and free-
play activities compared to their typically developing peers. These differences persisted over time.
The limited performance and participation in daily activities may affect the quality of life (QOL) of children with DCD.
Individuals’ participation in activities is believed to influence their QOL. Quality of life relates to individuals’ dynamic
appraisal of their life satisfaction, hope, self-concept and well-being, in relation to their goals, expectations, culture, values
and beliefs (Skevington, Lofty, & O’Connell, 2004; World Health Organization Quality of Life Group [WHOQOL] Group, 1995).
It reflects their functional and health status, independence level and ability to participate in meaningful, motivating and
empowering occupations (Christiansen, Baum, & Bass-Haugen, 2005; Eiser & Morse, 2001). QOL may be measured by
objective factors or subjective perspectives (Cummins, 2005). Subjective QOL may be obtained from the individuals
themselves or from proxies. Often parents serve as the proxies (Connoly & Johnson, 1999; Weintraub et al., 2011), since they
have been found to be sensitive to their children’s perception of their well-being and provide reliable data (Morrow, Quine,
Heaton, & Craig, 2010).
Only a few studies examined the QOL of children with DCD (Zwicker, Harris, & Klassen, 2012). A review of the literature
indicated that even fewer studies have explored the relationship between their QOL and participation in leisure activities, in
general, and specifically within a temporal context. As early as preschool years, children with DCD have been found to
experience less pleasure and satisfaction from daily functions (Bart et al., 2009). As they grow older, Flapper and Schoemaker
(2008, 2013) found that school-aged children with co-occurrence of attention deficits, DCD and with specific language
impairment-DCD as well as their parents, perceived the motor, autonomic, cognitive, psychosocial and overall QOL of the
children to be significantly lower than perceived by their typical peers and their parents. Similar results were noted by
Wuang, Wang, & Mao-Hsiung (2012), who studied the perceptions of parents of children with DCD and of typically
developing children, regarding their children’s and their own QOL. They found that the children with DCD and their parents
had significantly lower psychosocial QOL, compared to typically developing children and their parents.
From the review above it is clear that the studies examining the underlying assumption of the bio-psychosocial model
with respect to children with DCD are limited. The few studies that did examine this issue (e.g. Cairney et al., 2010) did not
differentiate between the children’s motor deficits (i.e. fine or gross motor), nor did they examine the relationship between
the child’s specific motor skills and participation in leisure activities, requiring varying levels of activeness (i.e. sedentary,
moderate or vigorous). Finally, they did not relate to the temporal aspect of participation (i.e. during the school year or school
days versus the summer or weekends). Tucker and Gilliland (2007), based on an extensive review, noted that the season of
 S. Raz-Silbiger et al. / Research in Developmental Disabilities 38 (2015) 171–180 173

year may have significant effects on the type and duration of children’s participation in physical activities. Therefore, in studying
children’s participation behaviors, such temporal aspects need to be considered. Similarly, the research on the QOL of children
with DCD is scarce, and the studies that do exist did not examine the relationship between specific motor skills and children’s
QOL, nor did they examine the participation in leisure activities requiring varying levels of activeness, and QOL.
The purpose of this study was to examine the relationship between motor skills, participation in leisure activities and QOL
among children with and without DCD. These relationships were examined within a temporal context (school year vs.
summer vacation and school days vs. weekends). However, in order to determine whether the relationships among these
factors are unique to children with DCD, the relationships among these factors were also examined within a group of
typically developing children. We expected to find a relationship between the children’s motor skills and the duration and
type of leisure activities in which children participated (i.e. children with better motor skills will participate more in vigorous
activities and children with poorer motor skills will participate more in sedentary activities). We also expected that the
children’s motor skills and participation in the various activities would be related to their QOL. Finally, we hypothesized that
these correlation patterns among three factors will differ during the school days versus weekends or during the school year
versus the summer vacation. For example, we expected to find a correlation between motor skills and participation in
vigorous activities during the week, but not during the weekends, because during the weekends, all children spend more
time engaging in sedentary activities. The results of this study may expand the understanding of the impact of DCD on
children’s participation in leisure activities and their QOL, and shed light on the importance of addressing the temporal
context, while working with these children.

2. Method

2.1. Study design and participants

The design of this study is correlative. Using a convenience sampling method, the children with DCD were recruited from
an out-patient clinic for children with mild motor and sensory disabilities and from a workout facility for children with
special needs. The typically developing children were recruited using a convenient and snowball sampling method. The
study sample included 77 children and their parents; 22 with DCD or probable DCD (72.7% boys; Mage = 8.6 years, SD = 1.4)
and 55 typically developing children (69.1% boys; Mage = 8.8 years, SD = 1.5). Power analysis was calculated based on a study
by Wuang et al. (2012), who compared the QOL of children with and without DCD between the ages of 7 and 15 years. Using
power of 80% and one-tailed assumptions (a=0.05), the required sample size was N = 20 per group.
The DCD group met the following criteria: (a) a total score at, or below, the 16th percentile on the movement assessment
battery for children 2 (MABC-2; Henderson, Sugden, & Barnett, 2007), and (b) the motor skills interfered with at least two
functions in school and/or ADL, based on the parents’ reports. The children were classified as typical if they scored above the
16th percentile in the MABC-2 (see Table 1). Children were excluded if: (a) they had a chronic illness or a developmental
disability (e.g. cerebral palsy, autistic spectrum disorder, etc.), other than DCD; or (b) were receiving any medication on a
regular basis, that may have affected their activity level, growth or appetite (e.g. steroids or stimulants). The children in both
groups studied in regular education elementary schools in a city in central Israel and were not receiving any special
education services. The mean years of education of the parents of the children with DCD did not significantly differ from that
of the typical children (mothers: DCD, M = 15.7, SD = 2.6; typical, M = 16.4, SD = 2.5, t = 0.90, p > 0.05; fathers: DCD,
M = 15.0, SD = 3.2; typical, M = 16.6, SD = 3.7, t = 0.90, p > 0.05).

2.2. Instruments

2.2.1. Participant selection

2.2.1.1. Demographic, Medical and Motor Questionnaire (Cermak, 2007a). This is a parent-report questionnaire, developed
with the purpose of collecting demographic information (e.g. age, gender, parental education, etc.), the child’s medical

Table 1
Means and standard deviations of motor skills and functional difficulties by study group.

DCD1 Typical F(1,75) p

n = 22 n = 55
M (SD) M (SD)
2
MABC-2 (%)
Manual dexterity 5.0 (5.6) 39.5 (26.2) 37.3 0.001
Ball aiming and catching 25.3 (21.7) 41.2 (32.2) 4.5 0.037
Static and dynamic balance 12.5 (14.5) 48.2 (28.8) 30.5 0.001
Total 4.5 (4.8) 39.5 (23.0) 49.5 0.001
DMMQ3 5.2 (3.1) 1.8 (2.7) 23.0 0.001

Notes: 1DCD - Developmental Coordination Disorder; 2

M-ABC-2 - Movement ABC-2–standard scoredss; 3
DMMQ -
Demographic, Medical and Motor Questionnaire
174 S. Raz-Silbiger et al. / Research in Developmental Disabilities 38 (2015) 171–180

history and current status, and information about the child’s motor coordination skills, as well as his/her past and present
daily life abilities, as reflected in 24 functional activities. The parents also rated the gross and fine motor skills of their child,
on a scale of 1 (much better than others) to 5 (much worse than others). The questionnaire was translated into Hebrew
following the author’s approval.

2.2.1.2. Movement Assessment Battery for Children-2 (MABC-2; Henderson et al., 2007). The MABC-2 is a valid and reliable norm-
referenced performance test, designed to screen and identify children with DCD aged 3–16, and includes eight items that evaluate
manual dexterity, aiming and catching as well as balance skills. Each item receives a raw score. Standard scores and percentiles
may be calculated for each motor component and for the total score. These scores are used to categorize the child’s functioning as
having a significant movement difficulty (<5%); ‘at risk’ for having movement difficulty (5–15%); no movement difficulty detected
(>15%). Intra-rater (ICC = 0.79) and test–retest reliability (r = 0.77) for manual dexterity, for aiming and catching (r = 0.84), for
balance (r = 0.73) and for total test score (r = 0.80), respectively, were found to be high (Henderson et al., 2007).

2.2.2. Participation and QOL measures

2.2.2.1. Participation in Physical Activity and Sedentary Behavior Questionnaire (PQ; Cermak, 2007b). The PQ is a parent
questionnaire which identifies children’s participation in well-defined physical and sedentary activities. The questionnaire
contains 35 recreational activities that, based on a panel of five therapists who work with children with DCD (i.e. face validity),
were divided into three levels of activeness: (a) vigorous (22 activities)—basketball, dance, swimming, etc.; (b) moderate (7
activities)—drama, choir, youth movement, etc.; and (c) sedentary (6 activities)—reading, screen related activities, board games,
etc. Parents were asked to state with regards to each of the vigorous and moderate activities, the participation duration of their
children, during the school year and during the summer vacation. As opposed to the vigorous and moderate activities that may
be influenced by seasonal changes, sedentary activities can be done all year round and therefore, the parents were asked to
report the participation duration separately for school days and for the weekends. Two measures were obtained from the PQ: (a)
the number of activities in each level of activeness and (b) the duration—that is calculated by summing the amount of time spent
in the activities in each level of activeness. The questionnaire was translated into Hebrew following the author’s approval. To
establish content validity a table of specification was developed. Five pediatric occupational therapists were asked to classify
each of the activities as vigorous, moderate of sedentary. Only items that had an above 80% agreement were included in the PQ.
In addition, we found a moderate internal consistency of the total score of the PQ a = 0.491)

2.2.2.2. Pediatric Quality of Life Inventory (PedsQL 4.0 Generic Core Scales; Varni, 2005) - Parent Proxy Report. The PedsQL is a
health related QOL questionnaire. It was developed for children aged 2–18 and includes 23 items tapping four functional
dimensions: physical (8), emotional (5), social (5) and school (5). Each item is rated on a five-point Likert type scale from 0
(Never) to 4 (Almost always). The total scale score as well as the scores of each dimension were calculated. Higher scores
indicate higher perceptions of QOL. The PedsQL is reported to have high internal consistency, especially the Total score
(92. = a parent). In addition, construct validity has been found to be good (Varni, Burwinkle, Seid, & Skarr, 2003).

2.3. Procedure

This study was approved by the IRB Committee. A list of candidates for the study (i.e. children who were previously
treated for DCD or possible DCD) was obtained from the clinic’s database and by referral of other participants. Initially, a
phone screening interview was conducted with the family, to explain the study’s objectives, determine the children’s
suitability for the research, and to examine the family’s interest in participating in the study. Next, the families (parents and
their children) who were willing to participate were invited to come to the clinic and were asked to sign a written consent.
The parents filled out the Participation and QOL questionnaires, while the MABC-2 was administered to the children by
certified pediatric occupational therapists who had at least 5 years of experience, had training and experience administering
the MABC-2 and assessing children with DCD and other neurodevelopmental disorders routinely.

2.4. Statistical analysis

Descriptive statistics were utilized to describe the study population (demographic data and basic skills). The study
sample was tested for normal distribution using the Kolmogorov-Smirnov (K-S) test. Due to the fact that the sample was
normally distributed, parametric statistics were used. The Pearson correlation tests were employed to examine the
relationship between motor skills, participation and the QOL measures, separately for the children with and without DCD.
Significance level of all statistical analysis was set at 0.05.

3. Results

The two groups’ motor skills and functional difficulties are described in Table 1. As can be seen, compared to the typical
group, the motor skills (MABC-2) of the children with DCD were significantly lower and children with DCD had more
functional difficulties.
 S. Raz-Silbiger et al. / Research in Developmental Disabilities 38 (2015) 171–180 175

Table 2a
Means and standard deviation of the participation measures (duration and number of activities) by levels of activeness.

Participation patterns1

Vigorous Moderate

School year Summer vacation School year Summer vacation

M (SD) M (SD) M (SD) M (SD)

Duration2
DCD3 (n = 22) 8.4 (5.5) 9.7 (9.0) 1.3 (1.5) 0.7 (2.4)
Typical (n = 55) 10.6 (7.7) 12.8 (12.2) 2.4 (2.7) 1.3 (2.8)
Number4
DCD3 (n = 22) 4.4 (2.0) 2.6 (2.0) 1.0 (1.0) 0.1 (0.5)
Typical (n = 55) 4.8 (1.8) 3.7 (2.4) 1.2 (1.2) 0.4 (0.7)

Notes: 1Participation patterns—participation in physical activity and sedentary behavior questionnaire; 2Duration—average
hours per week; 3DCD - Developmental Coordination Disorder; 4number of activities per week.

Both groups’ participation patterns during school year/summer as well as during school days/weekends, are described in
Tables 2a and 2b. As can be seen in Table 2a, children in both groups had participated for a longer duration in vigorous
activities during the summer, compared to during the school year. In addition, it may be noted from Tables 2a and 2b that
both groups spent many more hours (over three times as many) participating in sedentary activities, as compared to
vigorous and moderate activities.
The correlations between motor skills and participation using Pearson correlation coefficients were examined first. These
analyses were done for each group (DCD and typical), separately. The results yielded a negative moderate and significant
correlation between balance skills and the number of sedentary activities that children with DCD participated in during the
schooldays (r = 0.46, p = 0.03). In other words, the lower the balance skills of children with DCD, the more sedentary
activities they participated in during the week. No such correlation was found during the weekend. Moreover, no other
correlations were found between other motor skills and participation among the children with DCD or among the typical
group, both during school days, weekends or the summer vacation.
Next, we examined the correlation between motor skills and the children’s QOL, as reported by their parents (see Table 3).
Only few significant correlations were noted, and a few others approached significance. In both groups, no significant
correlations were noted between manual dexterity (fine motor skills) and QOL. In contrast, in both groups, gross motor skills,
namely, aiming and catching skills, and among the DCD group also balance, and the total motors skills score, were
significantly correlated with the physical dimension of QOL (0.28 < r < 0.49, p < 0.05). In addition, in the DCD group,
correlations approaching significance, were found between balance skills and the school dimension of QOL (r = 0.36,
p = 0.09). In the typical group, aiming and catching was also correlated with the social dimension of QOL (r = 0.29, p = 0.03)
and approached significance with the total score of QOL (r = 0.25, p = 0.07).
Finally, we examined the correlation between participation in activities and QOL. In both groups, no significant
correlations were found between participation in moderate activities and QOL. With respect to the sedentary activities (see
Table 4), among the DCD group, moderate negative correlations were noted between the number of activities during the
school days and the School QOL dimension (r = 0.41, p = 0.05). The correlation between the duration of participation in the
weekend and the emotional dimension of QOL approached significance (r = 0.38, p = 0.08). As for the typical children,
duration of participation during school days negatively correlated with the physical and school dimensions of QOL as well as
the total score (r = 0.37, p = 0.00; r = 0.27, p = 0.05 and r = 0.36, p = 0.00, respectively).

Table 2b
Means and standard deviation of the participation in sedentary activities (duration and number of activities).

Participation patterns1

Sedentary

Whole week School days Weekend

M (SD) M (SD) M (SD)

Duration2
DCD4 (n = 22) 31.63 (13.8) 4.5 (2.1) 4.6 (3.5)
Typical (n = 55) 30.73 (18.2) 4.4 (2.8) 4.4 (3.1)
Number5
DCD4 (n = 22) 4.36 (1.3) 0.7 (0.2) 2.7 (1.9)
Typical (n = 55) 4.26 (1.3) 0.6 (0.2) 2.8 (1.8)

Notes: 1Participation Patterns - Participation in Physical Activity and Sedentary Behavior Questionnaire; 2Duration—Average
hours per day (see exception in whole week); 3average hours per week;
4
DCD - Developmental Coordination Disorder; 5number of activities per day (see exception in whole week); 6activities that
were performed both during the school days and during the weekends were counted once.
176 S. Raz-Silbiger et al. / Research in Developmental Disabilities 38 (2015) 171–180

Table 3
Correlations between motor skills and quality of life.

PedsQL1

DCD (n = 22) Typical (n = 55)

Physical Emotional Social School Total Physical Emotional Social School Total

MABC-22
Manual Dexterity 0.06 0.20 0.21 0.10 0.04 0.09 0.06 0.13 0.11 0.06
Aiming & Catching 0.45* 0.13 0.28 0.25 0.40 0.28* 0.11 0.29* 0.07 0.25
Balance 0.43* 0.10 0.15 0.36 0.33 0.03 0.18 0.07 0.07 0.09
Total 0.49* 0.18 0.31 0.39 0.40 0.03 0.07 0.12 0.09 0.09

Note. 1 PedsQL - Pediatric Quality of Life Inventory (4.0 Generic Core Scales); 2M-ABC-2 - Movement ABC-2–standard scores.
p < .05*, p  .09.

With regards to vigorous activities (see Table 4), in the DCD group, positive moderate and significant (or approaching
significance) correlations were found during the summer; between the number of activities and the social dimension of QOL
(r = 0.41, p = 0.05), and between the duration of participation and the number of activities and the school dimension of QOL
(r = 0.44, p = 0.04; r = 0.40, p = 0.07, respectively). As for the typical group, negative low but significant correlations were
noted only during the school year; between the number and duration of activities and the school dimension of QOL
(r = 0.31, p = 0.02 and r = 0.30, p = 0.03, respectively). In addition, the duration of participation negatively correlated with
the emotional dimension of QOL (r = 0.32, p = 0.02). The typical children’s participation in vigorous activities (duration in
the summer and number of activities in the school year) also negatively correlated (approaching significance) with the
emotional dimension (r = 0.25, p = 0.07; r = 0.23, p = 0.09, respectively).

4. Discussion

Based on the bio-psychosocial model (WHO, 2001), it is presumed that motor skills are necessary for children’s
participation in daily activities (Mandich et al., 2003). It is further suggested that children with DCD participate less in
activities, thus affecting their QOL (Heah, Case, McGuire, & Law, 2007). The goal of this study was to examine the relationship
between motor skills, participation in leisure activities and QOL among children with and without DCD. These relationships
were studied with respect to temporal aspects of participation, namely the school year/summer vacation versus the school
days/weekends.
First, the correlations between motor skills and participation in leisure activities, which required varied levels of
activeness, were examined. Contrary to the basic assumptions (Law, 2002; WHO, 2001), overall, the results indicated that the
different motor skills were not related to participation in leisure activities, regardless of the time of year or week, both among
the children with and without DCD. These findings support previous studies, indicating that motor skills only account for a
small percentage of children’s participation in physical activities (Fisher et al., 2005; Okely, Booth, & Patterson, 2001), thus
implying that aside from motor skills there may be other important factors (e.g. familial or environmental) that better
explain children’s participation in physical and other activities (Law, Petrenchik, King, & Hurley, 2007; Sallis, Prochaska, &
Taylor, 2000), including activities related to leisure (King et al., 2003).

Table 4
Correlations between participation patterns and quality of life by study group.

Participation Patterns1

Vigorous Sedentary

Duration Number Duration Number

School year Summer School year Summer School days Weekends School days Weekends
2
PedsQL
DCD3 (n = 22)
Physical 0.15 0.04 0.30 0.08 0.20 0.06 0.18 0.20
Emotional 0.08 0.17 0.22 0.00 0.05 0.38 0.23 0.13
Social 0.06 0.31 0.30 0.41* 0.11 0.37 0.30 0.33
School 0.04 0.44* 0.11 0.40 0.08 0.03 0.41* 0.19
Total 0.06 0.23 0.28 0.28 0.07 0.12 0.35 0.27
Typical (n = 55)
Physical 0.03 0.03 0.07 0.06 0.37** 0.11 0.15 0.03
Emotional 0.32* 0.25 0.23 0.20 0.21 0.07 0.05 0.10
Social 0.13 0.19 0.14 0.11 0.21 0.00 0.07 0.10
School 0.30* 0.17 0.31* 0.17 0.27* 0.12 0.07 0.17
Total 0.14 0.08 0.15 0.11 0.36** 0.10 0.08 0.12

Notes: 1participation patterns—participation in physical activity and sedentary behavior questionnaire; 2PedsQL - Pediatric Quality of Life Inventory (4.0
Generic Core Scales); 3DCD - Developmental Coordination Disorder; p < .05*, p  .09p < 0.05*, p  0.09.
 S. Raz-Silbiger et al. / Research in Developmental Disabilities 38 (2015) 171–180 177

This study’s results, however, did show a significant, negative moderate correlation between balance skills and the
number of sedentary activities (e.g. screen related) in which children with DCD participated in during the school days. This
finding contradicts Fisher et al.’s (2005) results, showing no correlation between motor skills and light intensity activity,
both among children with good and with poor motor skills. A possible explanation for this difference is that Fisher et al.
measured motor skills using an accelerometer whereas in this study, the focus was well-defined activities. It is apparent that
these two measures tap different types of engagement in physical activities. In contrast, the correlation found between
balance skills and sedentary activities supports earlier studies showing a relationship between children’s motor abilities and
their engagement in physical activities (Wrontiak, Epstein, Dorn, Jones, & Kondilis, 2006). This may reflect the noted negative
cycle among children with DCD, namely that their motor impairments may limit their performance in different occupational
areas (Dunford et al., 2005; Poulsen, Ziviani, & Cuskelly, 2008), which, consequently, may further delay development of
motor skills (Cermak & Larkin, 2002). This, in turn, may limit their participation in typical childhood activities (Mandich
et al., 2003).
It should be noted, however, that the negative correlation between balance skills and participation in sedentary activities
was only noted during the school days. This may be due to the fact that during the weekends there was a greater variance in
children’s participation in sedentary activities. These findings support the premise that the season of the year (Rifas-Shiman
et al., 2001; Tucker & Gilliland, 2007) or time of week (Biddle et al., 2009) may determine children’s engagement in leisure
activities.
The correlations between the children’s motor skills and QOL, as perceived by their parents showed that in both groups,
fine motor skills (manual dexterity) were not related to children’s participation, which may indicate that with respect to
leisure activities, parents were more concerned with their children’s gross motor skills. This was noted in the low but
significant correlation between the ball skills (aiming and catching) and the physical QOL noted in both groups. In the typical
group, these skills were also associated with their social QOL. In contrast, among the DCD group, the parents perceived their
children’s balance skills as related to the physical, and school dimensions of QOL (the latter only approached significance).
Perhaps the parents of the children with DCD believed that having poor motor skills was associated with their children’s
feeling of fatigue and pain (i.e. components of physical QOL), thus affecting their school QOL (missing school and having
difficulty concentrating on their school-work).
Given the results of previous studies (Flapper & Schoemaker, 2008; Wuang et al., 2012), it is somewhat surprising that the
association between motor skills and the parents’ perceptions of their children’s psychosocial QOL among the children with
DCD was not stronger. This may be due to our small sample size. However, it may also be because DCD is predominantly a
motor deficit, and the parents were more tuned into the physical dimension of QOL. Furthermore, due to the fact that
currently much of children’s social interactions happen through screen related activities (He, Piché, Beynon, & Harris, 2010;
Marques, Sallis, Martins, Diniz, & Carreiro Da Costa, 2014), their motor skills may be less related to the psychosocial aspects
of their QOL. Additional explanations of the difference in the studies’ results may be the different measures used for assessing
motor skills and QOL, and that most studies did not examine the various dimensions of QOL. Clearly, the few studies in this
area, and the contradicting results, suggest that this important issue warrants further examination, using similar measures,
and studying the different aspects of QOL.
In examining the relationship between the children’s participation in leisure activities and their parents’ perception of
their QOL, no correlations between children’s participation in moderate activities and QOL were noted. In other words,
children’s participation in activities such as art, drama, music, etc. was not associated with the parents’ perception of their
children’s QOL. In contrast, among the typical children, their participation in sedentary (screen-related) activities during
school days (but not weekends) was negatively correlated with the physical and school dimensions of QOL. Among the
children with DCD, a similar trend was noted, but a significant correlation was only found with respect to school QOL during
the school days (perhaps because of the small sample size). These findings are similar to previous results relating to typically
developing children (Iannotti, Kogan, Janssen, & Boyce, 2009; Tremblay et al., 2011). This may reflect the parents’ concern
regarding their children’s participating in sedentary activities, due to their possible negative ramification on their children’s
health and QOL.
This brings to question, however, why this association was mostly noted during the school days but not the weekends. A
possible explanation for this temporal difference is that there was a greater variance both in the number of activities and the
duration of participation during the weekends (even though the means were similar). This may have affected the strength of
relationship in the different periods of the week. Thus, here too, the temporal context may have affected the participation
patterns, and in turn, the relationship between children’s participation and their QOL.
The seasonal effect of participation and its relationship to QOL was also noted with respect to vigorous activities.
Participation of children with DCD in vigorous activities was positively associated with the parents’ rating of their children’s
school and social QOL, but only during the summer and not during the school year. These results may reflect the parents’
belief that engaging in physical activities is important for their children’s QOL (as was also seen in the relationship between
motor skills and QOL). Yet perhaps, this positive association was not noted during the school year because the parents
considered the possible negative effects of engagement in vigorous activities during the school year on children’s school QOL,
such as pressure and stress due to tight and overloaded schedules in addition to school work (Rodger & Ziviani, 2006).
Support for this premise may be found in the results among the typical group, in which participation in vigorous activities
was negatively related to the parents’ perception of their children’s School QOL during the school year. This premise is
further supported by the fact that during the summer, engagement in vigorous activities was not significantly related to
178 S. Raz-Silbiger et al. / Research in Developmental Disabilities 38 (2015) 171–180

school QOL. Results of other studies examining the relationship between participation in physical activities and school
performance were not conclusive (Strong et al., 2005; Taras, 2005). Yet most studies did not find a negative correlation
between engagement in physical activities and school performance. These studies, however, did not distinguish between
periods of the year, nor did they examine school QOL measures, but rather mostly focused on achievement or conduct.
Therefore, perhaps, the results of this study add a new perspective to the relationship between participating in vigorous
activities and school related QOL.
In contrast, regardless of the season, the parents of the typical children negatively associated engagement in vigorous
activities with emotional aspects of QOL (i.e. anxiety, anger and sleep disorders). Perhaps they felt that the strain related to
vigorous activities is inherent to these activities, and are not related to the time of year. Various studies, however, found that
engaging in vigorous activities is positively related to children’s emotional well-being (Henning Brodersen, Steptoe, Phil,
Williamson, & Wardle, 2005; Moksnes, Lillefjell, & Espnes, 2013). Yet, based on an extensive literature review, showing
contradicting results, Strong et al. (2005) concluded that there is insufficient evidence to conclude whether vigorous
activities have positive or negative ramifications on children’s psychosocial factors.
Finally, it is interesting to note that among the typical group, participating in vigorous activities was not significantly
related to the parents’ perceptions of their children’ social QOL. In contrast, such positive associations were noted among the
DCD group, yet, a significant correlation was found only for the summer. These results are incongruent with the relationships
noted between the children’s motor skills and parents’ perceptions of their QOL, and support earlier findings, showing that
parents of children with DCD viewed their psychosocial aspects of QOL as lower than that of their peers (Chen & Cohn, 2003;
Wuang et al., 2012). However, as in the other aspects of QOL, these associations varied at the different periods of the year,
perhaps reflecting the important role that the temporal context may have in the relationship between participation in
activities and children’s QOL.

4.1. Study limitations

This study employed a convenience sampling method and focused on elementary school children. Given the fact that both
participation patterns and QOL may vary in the different age groups, external validity of these results may be limited to this
age group. Therefore, generalization should be treated with caution. Furthermore, the small sample size may have weakened
the correlations within each of the groups. Finally, with respect to the measures, the PQ’s reliability needs to be further
established, yet it did provide extensive information on children’s participation patterns.

5. Conclusions

Overall, motor skills were not found do not appear to be related to children’s participation in leisure activities, with the
exception of poor balance skills among children with DCD, which were found to be related to participation in sedentary
activities. In contrast, gross motor skills of children with DCD do appear to be somewhat related to the physical and school
dimensions of their QOL. The association between participation in both sedentary and vigorous activities and QOL seems to
be influenced by the temporal context (i.e. school year/school days vs. summer vacation/weekends). Therefore it appears
that the relationship between participation in leisure activities and QOL may not only be affected by the varying levels of
activeness (sedentary, moderate or vigorous) but also by the time of year or week. These results partially support the bio-
psychosocial model, but further exploration of this issue among children with DCD is warranted. From a practical point of
view, it is important that therapists and educators take into consideration the temporal aspects when guiding parents and
their children on the topic of participation in leisure activities.

Acknowledgement

We thank all the children and parents who participated in the study; the Alyn hospital for their financial support.

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