Research Paper

British Journal of Occupational Therapy

1–9

Developmental coordination disorder is more ! The Author(s) 2017

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than a motor problem: Children describe the DOI: 10.1177/0308022617735046
http://journals.sagepub.com/home/bjot
impact of daily struggles on their quality of life

Jill G Zwicker1,2,3,4,5,6, Melinda Suto7, Susan R Harris8, Nikol Vlasakova9,10

and Cheryl Missiuna11,12

Abstract
Introduction: Affecting 5–6% of children, developmental coordination disorder is a neurodevelopmental disorder characterized by
poor motor coordination and difficulty learning motor skills. Although quantitative studies have suggested that children with
developmental coordination disorder experience reduced quality of life, no known qualitative studies have reported what daily life
is like from their perspective.
Method: Guided by an inductive realistic approach and using semi-structured, individual interviews, 13 children (8–12 years) were
asked to describe what life is like in their own words. Three researchers coded interviews manually to identify relevant content. An
experienced qualitative researcher conducted a second, in-depth thematic analysis using NVivo to identify patterns and themes.
Findings: Two themes – milestones as millstones and the perils of printing – illuminated participants’ challenges in completing
everyday activities at home and at school. The third theme – more than a motor problem – revealed the social and emotional impact
of these struggles and from being excluded from play. The fourth theme – coping strategies – described their efforts to be resilient.
Conclusion: Parents, educators, physicians, and therapists working with children with developmental coordination disorder must
recognize how their quality of life is affected by the physical and emotional toll of their efforts to participate successfully in daily
activities.

Keywords
Developmental coordination disorder, DCD, motor skills disorder, quality of life, school-aged children, thematic analysis

Received: 27 January 2017; accepted: 12 September 2017

1
Assistant Professor, Department of Occupational Science and Occupational
Therapy and Associate Member, Department of Pediatrics (Division of
Introduction Developmental Pediatrics), University of British Columbia, Vancouver,
Developmental coordination disorder (DCD) is a neuro- Canada
2
Associate Member, Department of Pediatrics (Division of Developmental
developmental disorder characterized by marked impair-
Pediatrics), University of British Columbia, Vancouver, Canada
ment of motor coordination that significantly interferes 3
Investigator, Brain, Behaviour and Development, BC Children’s Hospital
with academic achievement, performance of activities of Research Institute, Vancouver, Canada
4
daily living, and engagement in play (American Clinician Scientist, Sunny Hill Health Centre for Children, Vancouver,
Psychiatric Association (APA), 2013). With a prevalence Canada
5
Research Associate, CanChild Centre for Childhood Disability Research,
of 5–6% (APA, 2013), DCD is one of the most common Hamilton, Canada
disorders affecting school-aged children. While the eti- 6
Affiliate Investigator, Kids Brain Health Network, Vancouver, Canada
ology of DCD is unknown, several brain imaging studies 7
Associate Professor Emerita, Department of Occupational Science and
have been conducted to suggest neurological underpin- Occupational Therapy, University of British Columbia, Vancouver, Canada
8
nings of the disorder, including under-activation of brain Professor Emerita, Department of Physical Therapy, University of British
Columbia, Vancouver, Canada
regions associated with motor learning and altered devel- 9
PhD student, Department of Occupational Science and Occupational
opment of motor and sensory pathways (Brown-Lum and Therapy, University of British Columbia, Vancouver, Canada
Zwicker, 2015). Children experience numerous functional 10
PhD student, Charles University in Prague, Czech Republic
11
difficulties related to their motor incoordination, including Professor, School of Rehabilitation Science, McMaster University,
difficulty with dressing, tying shoes, using utensils, riding a Hamilton, Canada
12
Scientist, CanChild Centre for Childhood Disability Research, Hamilton,
bike, catching a ball, handwriting, participating in phys-
Canada
ical play, and engaging in leisure activities (APA, 2013;
Corresponding author:
Zwicker et al., 2012). While it was once believed that chil- Dr. Jill Zwicker, BC Children’s Hospital, K3-180, 4480 Oak Street, Vancouver,
dren with DCD would outgrow their motor difficulties, BC, V6H 3V4, Canada.
evidence suggests that these difficulties persist into Email: jill.zwicker@ubc.ca
2 British Journal of Occupational Therapy 0(0)
adolescence and adulthood (Cantell et al., 2003; Cousins
and Smyth, 2003; Kirby et al., 2011).
Children with DCD tend to avoid social and physical
activities (Chen and Cohn, 2003; Missiuna et al., 2007)
and are at higher risk for obesity (Cairney et al., 2010)
and coronary vascular disease (Faught et al., 2005). In
addition to physical concerns, these children may experi-
ence secondary psychosocial issues, including difficulty
with social and peer relationships (Dewey et al., 2002;
Poulsen and Ziviani, 2004), lower self-worth and self-
esteem (Piek et al., 2006; Zwicker et al., 2013), anxiety
and depression (Missiuna et al., 2014; Piek et al., 2006),
loneliness (Poulsen et al., 2007), and emotional/behavioral
disorders (Green et al., 2006; Lingam et al., 2012).
Quantitative evidence suggests that children with DCD
may experience lower quality of life (QOL) compared to
peers (Zwicker et al., 2013), but few qualitative studies
have been conducted. Some studies have captured the per-
spectives of parents (Mandich et al., 2003; Missiuna et al.,
2006, 2007; Segal et al., 2002) and of adolescents/young
adults with DCD (Kirby et al., 2013; Lingam et al., 2014;
Missiuna et al., 2008), but no studies have documented
what life is like from the voices of school-aged children.
Thus, the purpose of this study was to interview school-
aged children with DCD to better understand the implica-
tions of the disorder on their daily life and to deepen our
understanding about their QOL.
Literature review
Although physical and psychosocial concerns related to
DCD have been well documented (Harris et al., 2015;
Zwicker et al., 2013), few studies have examined the
health-related QOL of children with DCD. Health-related
QOL is a multi-dimensional construct encompassing three
broad domains of functioning: physical, psychological,
and social (Rajmil et al., 2004). Health-related QOL ide-
ally reflects the individual’s perception of their subjective
experience of QOL, but proxy reports are also considered
(Eiser and Morse, 2001). Two qualitative studies based on
parental interviews suggest that DCD may be detrimental
to children’s QOL. Parents of children aged 7 to 12 years
with DCD reported QOL concerns such as their children
‘‘com[ing] home from school in tears’’ because they did
not have the motor skills needed to play physical games
with other children and their children’s low self-esteem in
trying to conduct simple motor activities such as tying
shoes (Mandich et al., 2003: 589). Missiuna et al. (2007)
interviewed parents of children with DCD and discovered
a developmental trajectory of QOL-related issues across
the childhood years: from motor and play concerns in
early childhood; to problems with self-care, school, and
peer interactions in middle childhood; and issues with
self-esteem and emotional health in later childhood.
Parents expressed great concern about the emotional
impact of DCD – from children’s repeated experiences
of failure to master everyday activities to negative experi-
ences at school (Mandich et al., 2003; Missiuna et al.,
2006). Adolescents (Lingam et al., 2014) and young
adults reflecting on their teen years (Missiuna et al.,
2008) described being bullied, laughed at, and teased by
their peers because of their poor motor skills. The emo-
tional impact of DCD extends into adulthood, with adults
reporting high levels of depressive symptoms and poor life
satisfaction (Kirby et al., 2013; Tal-Saban et al., 2014).
As no known qualitative studies of children with DCD
from their own perspectives have been published, little is
known about the QOL of younger children based on their
subjective experiences and in their own voices. A greater
understanding of what life is like for these children will
increase awareness of the significant impact of DCD and
may lead to greater ability to support them at home, at
school, and in the community.
Method
This qualitative research study used thematic analysis to
explore the QOL of children with DCD from their own
perspective (Braun and Clark, 2006). Using an inductive
realistic approach, we focused on accessing the children’s
personal experiences of their daily life. Children were
recruited from caseloads of occupational or physical ther-
apists and met the following inclusion criteria: (1) prob-
able DCD based on clinician judgment and level of motor
impairment (416th percentile on the Movement
Assessment Battery for Children – 2 (Henderson et al.,
2007)); (2) aged 8 years to 12 years; (3) able to speak
and understand English fluently; and (4) able to demon-
strate awareness of their condition and/or motor difficul-
ties in order to be information-rich cases for data
collection. Parents completed the DCD Questionnaire
(Wilson et al., 2007) to confirm that they had observed
their child’s motor difficulties during activities at home.
Children were excluded if they had other medical condi-
tions that might contribute to motor impairment (such as
cerebral palsy) or if parents reported that their child had a
condition that commonly co-occurs with DCD, such as
attention deficit hyperactivity disorder, learning disability,
or autism spectrum disorder. Comorbidities were excluded
so that we could better understand the personal experience
of children with DCD without confounding with other
disorders. This study received approval from the
University of British Columbia Behavioural Research
Ethics Board. Parents provided written consent and all
children assented to participate in the study.
Capitalizing on the relative verbal strength of children
with DCD (Alloway, 2007; Missiuna et al., 2004), individ-
ual semi-structured interviews were conducted. While it
was once believed that young children could not provide
accurate information in interviews, qualitative research
has demonstrated that children as young as 4 years old
can provide information regarding their daily lives and
health experiences (Irwin and Johnson, 2005). To facilitate
the interview, children received a disposable camera prior
to the interview and were asked to take photos of activities
they enjoyed doing and activities that they wished they
could do. While other researchers have asked children to
draw pictures to initiate conversation (Green et al., 2009;
Zwicker et al. 3

Kortesluoma et al., 2003), we chose to use photographs to Table 1. Participant characteristics.

avoid taxing the children with DCD with drawing, given
Pseudonym Age (years) Sex DCDQ score (interpretation)
their poor motor skills. The film was developed prior to
the interview so that the photographs could be used solely Grant 8 Male 35 (indication of DCD)
to initiate discussion; photographs were not analyzed. Adam 9 Male 25 (indication of DCD)
Children were asked to describe their photographs and Cindy 9 Female 30 (indication of DCD)
were prompted to describe the thoughts and feelings that Jack 9 Male 19 (indication of DCD)
the pictures evoked. The interviewer (JZ) used follow-up Peter 9 Male 35 (indication of DCD)
probes and asked questions from the interview guide Sarah 9 Female 42 (suspect DCD)
(Appendix). The guide was comprised of 10 questions Thomas 9 Male 31 (indication of DCD)
developed by investigators (JZ, SH, CM) based on a Nicolas 10 Male 39 (suspect DCD)
review of pediatric QOL and DCD literature. Interviews Tristan 10 Male 32 (indication of DCD)
were 25 to 80 minutes long and occurred in a quiet room in Alison 11 Female 48 (suspect DCD)
a university setting, child health center, or participant’s Bill 12 Male 24 (indication of DCD)
home; occasionally a parent was present. Data were col- Jason 12 Male 25 (indication of DCD)
lected using a digital voice recorder and transcribed ver- Philip 12 Male 34 (indication of DCD)
batim by a professional transcriptionist who replaced DCDQ: Developmental Coordination Disorder Questionnaire.
participants’ names with pseudonyms.
Four researchers contributed to the inductive thematic
data analysis, following the process suggested by Braun and
Clarke (2006). We adopted a realistic approach that focuses
Findings
on the text itself, analyzing what was actually said.
Consistent with this, we first generated codes for the data, Three girls and 10 boys ranging in age from 8 to 12 years
and then conducted thematic analysis at the semantic level, were recruited and participated in this study. They lived in
with themes being identified based upon explicit or surface three different urban cities in British Columbia, Canada.
meanings, rather than interpretation. These methodo- Demographic information appears in Table 1. Four inter-
logical choices arose from the exploratory nature of the related themes provide insight about the experience of
research, the number and length of interviews, and the abil- living with DCD, from participants’ perspectives: (1) mile-
ity of young participants to articulate their experiences. stones as millstones: struggling to perform ordinary activ-
Initially, three team members (JZ, SH, NV) coded all ities; (2) the perils of printing: schooling as hard work; (3)
interviews manually to identify chunks of relevant content. more than a motor problem: left out of left field; and (4)
An experienced qualitative researcher (MS) conducted a coping strategies: thinking differently and emphasizing
second, more in-depth analysis using NVivo10 to aid with strengths. Consistent with the aim of understanding sub-
coding and finding patterns in the data. She identified 27 jective experiences, quotes remain unedited except where
codes that included fatigue, feelings, sports, and tricky clarity was needed. Further, the voices of participants are
things about eating, dressing, and grooming. An iterative emphasized, whereas the researchers’ interpretation
process of eliminating duplicate data and reading the appears in the Discussion section of this article.
interviews several times helped crystallize the study find-
ings into themes that were negotiated with team members. Milestones as millstones: struggling to perform
A reflexive process enabled team members to gauge the
influence that their assumptions, knowledge, and beliefs
ordinary activities
had on the data analysis. The first author (JZ) has extensive Developmental milestones mark progression through
experience as an occupational therapist working with chil- childhood and reflect skills that, once acquired, support
dren with DCD, as well as research training in rehabilita- independence. Participants’ descriptions of performing
tion and familiarity with literature on DCD and quality of ordinary activities (for example using utensils, getting
life. These experiences contributed to the first author dressed, riding a bicycle) are noteworthy because of the
developing astute interview questions. The second author early onset of the difficulties and the impact on their daily
(MS) has no experience with children with DCD but is lives. Describing tricky aspects of mealtime routines, 9-
aware of research that shows how environments affect chil- year-olds reported eating with spoons but struggling to
dren’s participation regardless of individual factors asso- manipulate knives and forks successfully. Cindy’s inability
ciated with diagnoses. The third author (SH) is a seasoned to coordinate a knife and fork was apparent from her
pediatric physiotherapist who has worked extensively with photo, in which she described positioning her elbow awk-
children with many types of disabilities. The fourth author wardly and gripping her fork hard. Sarah’s mealtime
(NV) is a graduate student interested in DCD. The fifth description shows how her coordination difficulties con-
author (CM), a DCD expert, was involved in study tribute to messes at the table:
design and question creation but not data analysis.
Recognition of the lenses through which we analyzed the When I eat breakfast, like say – cereal this morning – I
data helped to assure that the findings reflected partici- sometimes, um. I describe something [using her hands]
pants’ experiences rather than our biases or expectations. for her [mother] and then I spilled my, um, cup over
4 British Journal of Occupational Therapy 0(0)
so . . . And when and also when, when I just took a
cereal and I ate it then it missed my mouth.
The children aged 10 to 12 years reported better fork use
but struggled to cut food with a knife. They persisted in
mastering this skill despite limited success and seemed
perplexed by their difficulties. Nicolas shared this
experience:
Well, I don’t really know how to hold them very well.
Like the fork is fine but like the knife. This is my,
I can’t do very much with this hand. My right
hand or I can only use this one. And I usually use
that for the knife but then the fork, it’s kind of hard
if I use this one with the knife and this one with the
fork. And I’ve been trying to get it right but I haven’t
quite yet.
Bill, Philip, and Jason identified knife use as a problem
and, like younger participants, still accepted their parents’
help. Whereas Nicolas and Tristan felt ‘sort of bad’
that they could not use a knife, 9-year-olds like Sarah
described being pleased to have parental assistance.
Parents helped their children further by supplying lunch
foods, such as sandwiches and cheese and crackers, that
fitted the child’s skills and containers with large tabs for
easier opening.
Not surprisingly, poor coordination and body aware-
ness impeded participants’ ability to dress. Their descrip-
tions of dressing reveal bewildering experiences. Jack
explained:
Um, it’s sort of hard for me to get dressed . . . My pants,
um, are quite hard because my feet get stuck inside
because they’re always inside, they’re always inside
out and sometimes they get stuck inside the legs.
Bill’s dressing difficulty is atypical for his age and evokes
the disconnection between intention and results:
Well, like when I pull on my pants like I put the leg and
it goes into the wrong socket like when I put on my
shorts. My right leg goes into the left socket and it just
really annoys me.
Similarly, Jack described confusion: ‘‘Um, like here it’s
hard because I can’t see what I’m doing outside my body-
. . . it’s sort of dark and I don’t know where my hands are.’’
Participants of all ages reported difficulty in tying shoe-
laces, whereas younger children also described problems
buttoning shirts and managing zippers. Some participants
who were still learning to tie wore shoes with Velcro clos-
ures. Adam’s description of shoe-tying typified children’s
perseverance:
I keep trying to learn knots and I try and I try and I try
and I just keep forgetting and still doing it quite, I, and
this hand thing is one of the problems that stops me
from tying a perfect knot.
Learning to ride a two-wheeled bicycle is a rite of pas-
sage for most children, offering physical freedom and
opportunities to socialize with friends. Some participants
described bike-riding as easy and some recalled learning to
ride by about age 6 years. However, many children, such
as Cindy and Sarah, learned or were still learning to ride a
bicycle at 9 years old and they communicated ambivalence
and fear of bicycling. This differed from Thomas’ enthu-
siasm and pride: ‘‘Well, I always really want to do it
mostly. I felt pretty good because it was hard for me to
learn how to ride it.’’
Few participants described biking with friends, riding
to school, or having two-wheeled adventures. Participants
were afraid of falling, sometimes banged into parked cars,
and used training wheels longer than their peers. Nicolas
was unable to bike with friends yet, explaining: ‘‘My dad is
trying to teach me how to ride a bike . . . And it’s a bit hard
because I never know if I’ll fall or not . . . But I’ve been
doing okay but it’s hard.’’
Falling off a bicycle happens to most children when
they learn to ride, but these participants described their
efforts to overcome bike-riding fears, and seemed to spend
longer and work harder to master this typically enjoyable
childhood activity.
Overall, this theme reflects the efforts and difficulties
that children experienced with everyday activities, such
as dressing, eating, and tying shoes, and highlights how
children perceive their physical functioning QOL domain
to be affected by DCD.
The perils of printing: schooling as hard work
Difficulty with printing/handwriting was an obstacle to
enjoying and succeeding in school. Participants needed
to write notes, copy from the board, take tests, and
write reports. Printing (handwritten print letters) problems
were widespread and involved messiness, slowness, and
difficulty with letter formation. Tristan explained: ‘‘Um,
my normal printing, most people can’t read it; well it’s like
my dad can probably read it and my mum can probably.
My brother could probably but he’d say he couldn’t and
that it was really horrible.’’ Philip’s experiences revealed
an unwelcome result: ‘‘Sometimes if there’s a time limit I
like, have to rush and I get stuff wrong because I’m rush-
ing because I don’t want to take forever. I might end up
not finishing the test.’’ Other participants reported that
their impulse to skip over items arose from hand strain.
Thomas explained why printing was hard: ‘‘When I, I’m
writing some words sometimes I forgot what the letter is
supposed to look like.’’ Jack adds, ‘‘and um, the curving
and drawing that it takes.’’
Printing problems that were identified as such led to
strategies using technological and human resources.
Participants obtained some benefits from using computers,
tablets, and typing programs to address printing and
handwriting issues. However, what interfered with their
printing also interfered with effective keyboarding. Cindy
noted: ‘‘Um, the computer it’s hard because you have to
control all the keys like this so I just poke them with my
Zwicker et al.
fingers.’’ Despite considerable practice, some children
found typing to be difficult. Alison reported:
I’ve done three, two, um, typing things, typing pro-
grams both, the whole thing at my home and I’ve
done the same typing program almost twice in school
and it’s still, I’m still looking down and I can’t really
type fast.
In contrast to some participants’ frustrations with tech-
nology, others appreciated help from parents and teaching
staff. When describing how he keeps up in school, Jason
said: ‘‘I’ve got a, um, I forget what they’re called, the
person who helps you and she like, well, she writes, she
writes for me and she types for me because I’m also very
bad at typing.’’ These participants’ experiences were spe-
cific to printing, but handwriting problems also abounded.
Both limitations prompted negative feelings. Some partici-
pants like Alison, however, accepted their abilities: ‘‘I
could be practicing writing as much as I want all day
and stuff and I’d still, it still would be practically the
same.’’ Taking a different attitude than Alison’s, Philip
was highly critical of the limited awareness and compas-
sion he perceived from teachers:
It’s harder than it should be. And then most of my
teachers except for one were stupid and like, didn’t
notice . . . I lost a lot of marks in school because I had
messy handwriting which I didn’t think was
fair . . . They said oh, I’m just lazy . . . So how would
they feel if someone called them lazy when they’re
working their hardest. Or when you make a mistake
and they point it out to you every waking moment.
This theme demonstrates that participants tried to
master the fine motor skills needed for scholastic success
but that their efforts often came with emotional costs. This
theme indicates the overlap of physical and psychological
QOL domains that can be affected in children with DCD.
More than a motor problem: left out of left field
A word cloud of unhappy feelings permeated descriptions
of participants’ motor problems at school. Children often
identified their emotions precisely; other times, negative
feelings were inferred from words like ‘‘bothered’’ and
‘‘not good.’’ Tristan’s comment reflects the frustration
participants felt when trying to print, handwrite, and key-
board: ‘‘Lots of times when I write stuff, I just, I get mad
but just like. Once I got so mad I just took the pencil and
went bam, split it in two.’’ Although participants
expressed a range of feelings about not meeting self-care
and writing expectations, their strongest negative feelings
arose over school sports and social activities.
Sports activities that participants either had to do, or
wanted to do, required them to run, catch, throw, and
balance, and sometimes to use all these skills simultan-
eously. The description of feeling fatigued and having
sore muscles offered a perspective on the emotional
5
responses to their unsatisfying involvement in team
sports. Cindy said: ‘‘If I run like a long time then my
feet start to hurt and then, and then I walk. Sometimes
when I can’t do the same things as other friends and kids
and sometimes it bothers me.’’ Participants often con-
nected their fatigue and limited physical coordination to
negative feelings about team sports involvement. In the
context of tiring easily and feeling ‘‘bad, annoyed, and
frustrated,’’ Bill said: ‘‘Like, when we’re playing at kick-
ball I usually don’t do well, I just like quit on it.’’ Jack
revealed how physical limitations affect him: ‘‘I always
think I’m a loser and um, you know feel kind of sad for
quite a long time but I’ll get over it. It’s really sad and you
don’t think you can do it. And you stop trying.’’
Participants’ reports of feeling frustrated, sad, and/or
left out reveal the impact that repeated academic and
play failures had on their future involvement.
Participants told stories about being left out of gym
activities (voluntary or otherwise) that helped to explain
their sadness and frustration. Nicolas linked feeling
‘‘depressed or sad’’ to ‘‘having not to do what other kids
can do like run fast or, um, or do a lot of fun stuff that I
can’t do.’’ This depth of feeling was unsurprising given
Nicolas’ experience of basketball drills: ‘‘Nobody usually
passes to me so I just run around and try to get the ball
and maybe pass it to someone else. And that’s okay but I
don’t usually get to have the ball.’’ Thomas revealed a
pattern of exclusion from play:
No one ever passes the ball to me and when I’m playing
hockey, no one passes me the puck. Ringette no one
ever passes the hoop to me. I’d rather have the thing
sometimes . . . But I can’t get to them as fast as everyone
else.
Reflecting what happened to many participants who
described fatigue and low fitness levels, Peter stated:
‘‘I’m getting left out at running activities.’’
Some participants described feeling afraid of balls and
other play equipment and getting hit frequently during
games like dodge ball. Recess was challenging as play typ-
ically involved monkey bars, four-square games,1 and
other activities requiring continuous movement. Sarah
summarized her feelings about physical activities:
Well for the skipping rope it’s, it’s I might trip on it and
fall and hurt myself. Monkey bars I lose my grip, fall.
And with soccer I’m afraid I might kick it but instead
of kicking it put my foot on the ball and then slip when
the ball goes. And this, I’m afraid I might fall and hurt
myself. So is mostly afraid.
Sarah’s inability to use playground equipment led to her
being alone and, like other children, feeling lonely. She
explained:
I have this corner as I have no one to play with at
recess, and I just sit there and color or anything and I
do something and wait for the recess bell so I can go
6 British Journal of Occupational Therapy 0(0)
in. . . . I’m not really strong enough to say ‘‘can I play
with you?’’
Self-exclusion and engagement in quiet play were
benign outcomes compared to the stories that male par-
ticipants told about being excluded and bullied.
Classmates responded to participants’ different abilities
and vulnerabilities and none of these left children feeling
good. Thomas explained:
There’s this guy in my class who’s really good at things
so when I’m on the same team as him, he tells to get the
team so they can make up a plan, he never includes me
in the plan.
Nicolas described being teased but recognized the injustice
of being blamed for sports outcomes he could not control.
There are a few kids in my class who say ‘‘you didn’t do
anything, you didn’t do anything.’’ Well, it’s because I
don’t usually have the ball, not because I don’t get to
do much [but] because I don’t get the ball, nobody
passes it to me.
The male participants described instances of hassling and
bullying ranging from critical remarks about their dancing
ability to physical altercations. Peter offered this story:
And everybody laughs at me when I try to run on the
grass . . . They sometimes bully me and chase me and all
that. And it’s not making me feel that good. When I’m
playing out on the field with my friends and they come
up and push me around, and I push them back and
because they’re making me really mad and I, sometimes
I can’t control my madness.
This description of bullying demonstrates the social
and emotional implications of DCD that may be second-
ary to an individual’s difficulties with motor skills. As
Philip concluded: ‘‘It kind of makes you feel different.
Not in a good way, though.’’ This theme illuminates
types of exclusion and accompanying negative feelings
for participants whose abilities do not meet age expect-
ations, and shows how DCD affects QOL across three
domains of functioning – physical, psychological, and
social. The final theme depicts participants’ agency in
managing the challenges of living with DCD.
Coping strategies: thinking differently and
emphasizing strengths
Participants developed various strategies to cope with
their experience of difference that arose from not meeting
age-related expectations. Children described cognitive
strategies that contributed to their self-esteem and contin-
ued participation in activities that were important to them.
Jason reframed his situation: ‘‘DCD isn’t like the whole
thing ruling your life or anything . . . You, you’ll still be
very, very good at everything, just get a scribe and
everything will be all right, yeah man.’’ Taking a similar
approach, Alison said: ‘‘I think, whatever, I’m still just
me. . . . I’m not gonna let it ruin my life, it’s going to con-
tinue.’’ These perspectives helped participants who were
facing limited skills, feeling frustrated, or being sidelined
attribute these difficulties to the motor impairment rather
than define them.
Participants chose solitary activities that engaged their
imagination such as writing stories, reading, and drawing.
The physical activities they selected were less competitive,
required fewer people, and aligned with their interests and
skills. For example, Sarah chose individual activities with
others where she could exercise some control over the out-
come; thus, ballet lessons, Jazzercise, choir, and swimming
were good fits. In situations where participants felt fru-
strated or recognized their limitations, they did something
different to feel better. Cindy reported: ‘‘Sometimes I wish
I could, um, play tag better but, um, I feel okay when I
walk around by myself at recess.’’
Participants were creative and distracted and/or dis-
tanced themselves emotionally when experiencing prob-
lems. Thomas took this approach when sidelined for
being ‘‘out’’ early in team sports: ‘‘Luckily, my head is
full of things to think about. . . . I write little songs in my
head.’’ Nicolas described feeling frustrated when a peer
repeatedly tricked him in four-square games and said:
‘‘But I usually have, have a laugh or have a bit of fun
maybe. I just laugh along maybe.’’ These strategies reflect
participants’ agency, although their words hinted at an
unspoken emotional burden. Despite the challenges of
DCD, participants like Grant (‘‘I’m really good at being
a goalie’’) and Bill (‘‘I have a very good imagination’’)
were able to describe their talents and anticipated a posi-
tive future. Nicolas captured this hopefulness: ‘‘There’s
always something that you can do that other kids
can’t. . . . Like your talent, everyone has a talent.’’ These
attitudes and activity choices offer an alternative to the
typically negative connotation of a motor ‘‘difference,’’
suggesting that for some participants, their differences
do not negatively influence their QOL.
Discussion and implications
The four themes stemming from this work resonate with
existing literature. The first two themes have been noted in
many other studies and, in fact, the struggle to succeed in
everyday self-care and academic activities is one of the
diagnostic criteria of DCD (Criterion B) (APA, 2013).
Children with DCD are also known to participate less in
physical and social activities than typically developing
peers (Zwicker et al., 2013). Further, difficulty with
school-related tasks is a problem that arises in almost all
literature about children with DCD. While handwriting is
often presented as the dominant concern, strategies to sup-
port children with DCD, such as using a computer, may
initially be as challenging for them as handwriting.
Struggles at school extend far beyond handwriting and
do not seem to improve with age: a qualitative study
of 11 teenagers revealed that all reported difficulty
Zwicker et al.
at school – academically, socially, and in sports (Lingam
et al., 2014). In many jurisdictions, students with DCD do
not receive any support at school, further perpetuating the
negative trajectory and psychosocial problems.
While some of the findings from this study are not
surprising given a recent systematic review of the literature
of QOL domains affected in DCD (Zwicker et al., 2013),
this is the first study to specifically ask children about their
own subjective experience of living with DCD. The quota-
tions from the children highlight the extensive impact of
DCD on their QOL and reaffirm that DCD is more than a
motor impairment.
Another novel contribution that came through the
voices of children in this qualitative study was the extent
to which they highlighted the emotional toll of attempting
to perform daily activities, without success. The
Elaborated Environmental Stress Hypothesis (Cairney
et al., 2013) is a recently introduced conceptual model,
based upon literature about children with DCD, that
posits that DCD is a primary stressor that leads to a var-
iety of secondary psychosocial stressors, including peer
victimization and low social support; these secondary
stressors eventually result in children and adolescents
with DCD experiencing internalizing problems, such as
anxiety and depression. The voices of the children pre-
sented in this study support a direct link between DCD
and psychosocial stressors and highlight the many reasons
why children may withdraw from physical activities. In the
third theme, children noted their inability to keep up and
participate in many of the structured and unstructured
sports and games that are typical of outdoor play at
school. There were also poignant descriptions of the emo-
tional impact of being left out, teased, or bullied as a
result. On a more positive note, the fourth theme in this
study also highlighted factors that could potentially mod-
erate the psychosocial outcomes. The model proposes that
increasing social resources (including peer and parental
support) and increasing personal resources (including a
child’s sense of mastery and improved self-esteem) could
moderate the relationship between the known psycho-
social stressors and internalizing problems. Children in
this study described the benefits of having a scribe,
having access to technology, or of having a parent persist
with trying to teach bike-riding. While there was limited
evidence of social resources, ways of increasing personal
resources were definitely identified. Children described
choosing to engage in individual sports activities in the
community, such as swimming and dance. In these types
of activities, children are not in competition with others
but are encouraged through verbal teaching to learn
motor skills sequentially and to gradually increase the effi-
ciency of the performance as they work toward mastery.
Joining a choir, writing little songs in their head or having
a laugh to block the feeling of being left out were other
ways that children protected their self-esteem.
More recently, Mancini and colleagues (2016) summar-
ized evidence showing that this negative relationship
between motor skills and symptoms of internalizing dis-
orders holds not only for children with DCD but also
7
across a broad spectrum of children who have varied
motor skills. This suggests that universal programs that
are designed to support motor skill development could
benefit many children, particularly those with DCD.
Service delivery models such as Partnering for Change
may be a first step in putting resources in place to support
the participation of children with DCD, and all children
who are experiencing motor challenges, in the school con-
text (Missiuna et al., 2012). Consideration must also be
given to ensuring that social supports are established on
the playground and that bullying and leaving children out
of play situations is actively discouraged (Missiuna and
Campbell, 2014).
Therapeutic interventions for children with DCD are
often provided individually; a recent systematic review
and meta-analysis concluded that there was lack of evi-
dence for impairment-oriented interventions but that there
was evidence to support task-oriented approaches (for
example Neuromotor Task Training, Cognitive
Orientation to daily Occupational Performance (CO-
OP)), which help children improve their ability to perform
selected daily activities (Smits-Engelsman et al., 2013). The
perceptions shared by the children in this study would
support this emphasis on individual mastery of daily activ-
ities. In fact, a recent quasi-experimental study of 20 boys
with DCD showed that a 10-week program using the CO-
OP approach resulted in improvements in daily life activ-
ities and overall participation, based on child-selected
goals (Thornton et al., 2016). The impact of these
improvements on participation in school or community
sports activities is not known.
Limitations
Children who were interviewed in this study were aware of
their motor challenges and were able to provide relatively
rich descriptions of their daily struggles. The experiences
may not be the same for children who are unaware that
they have motor coordination difficulties, or those who
have commonly co-occurring conditions such as attention
deficit hyperactivity disorder. As QOL is a difficult con-
cept for children to understand, we opted to ask questions
related to the domains of QOL: physical, psychological,
and social functioning. Second interviews with each par-
ticipant may have deepened our analysis; however, this is
the first known study to explicitly ask school-age children
what life is like from their own perspective. While the
findings appear to provide additional evidence in support
of the elaborated environmental stress hypothesis, this
study was cross-sectional and it is not known whether
any participants went on to experience internalizing
problems.
Conclusion
Parents, educators, physicians, therapists, and others
working with children with DCD need to listen closely
to recognize the physical and emotional effort exerted by
children just to participate in everyday life activities.
8 British Journal of Occupational Therapy 0(0)
School is a daily challenge; not just coping with academic
expectations, but dealing with the social ramifications of
having a motor disorder that affects participation in sports
activities. Resilience may be fostered and self-esteem built
through participation in activities that are successful for
the child and that align with their strengths.
Key findings
. Children with DCD struggle to perform everyday
activities.
. Physical efforts are complicated by secondary emo-
tional and social challenges.
. Encouraging a positive attitude and recognizing
strengths may foster resilience.
What the study has added
Qualitative research findings reflecting the quality of
life of children with DCD have deepened our under-
standing of the impact of physical challenges on their
social participation and the resulting emotional toll.
Acknowledgments
We thank the children and families who participated in this study and
Dr. Anne Klassen for her contributions to the methodology.
Research ethics
Ethics approval was obtained from the University of British
Columbia Behavioural Research Ethics Board, 27 November 2008.
Parents provided written consent and all children assented to partici-
pate in the study.
Declaration of conflicting interests
The authors confirm that there is no conflict of interest.
Funding
This research was funded by the Michael Smith Foundation for
Health Research. Dr. Zwicker is funded by the Michael Smith
Foundation for Health Research, BC Children’s Hospital Research
Institute, Sunny Hill Foundation, Canadian Child Health Clinician
Scientist Program, and Canadian Institutes for Health Research. Dr.
Missiuna holds the John & Margaret Lillie Chair in Childhood
Disability Research.
Note
1. Four-square is a ball game played on a court with four equal-
sized, numbered squares that contain each player. The goal is to
advance to square number 4 through one’s skilled ball-handling
and hand–eye coordination errors made by one’s opponents.
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Appendix
Interview guide
Children will take photographs of activities they enjoy and
activities they wish they could or would like to do; these
photographs will be used to initiate conversation.
1. Tell me about the activities you like to do. Why do you
like these activities?
2. Tell me about the activities you wish you could or would
like to do. What has stopped you from doing these
activities?
3. Some people use the name ‘‘developmental coordination
disorder’’ or ‘‘DCD’’ to describe children who have diffi-
culty with motor skills, such as handwriting, riding a
bike, or tying shoes.
a. Is that term familiar to you? [Probe: ask if there is a
different term or phrase they would like to use, for
example ‘‘difficult to do certain things.’’]
b. What activities do you find hard to do? Why? [Probe:
self-care (such as dressing, tying shoes, using utensils);
school activities (such as handwriting, gym class);
recreation/leisure activities (such as sports, games,
playing a musical instrument).]
4. Please describe a typical day and where DCD may impact
your daily routine. Let’s start from when you get up in
the morning until you go to bed at night. [Probe for
thoughts and feelings.]
5. Has having DCD affected what you do with your friends?
If so, how?
6. Has having DCD affected how you feel about yourself?
7. Do you think DCD has affected how others feel about
you? How? [If necessary, ask if he/she has been teased or
bullied, if they have lots of friends, etc.]
8. What is the hardest or most difficult thing about having
DCD?
9. If you were talking to another child who just found out
that they have DCD, what would you want him or her to
know? What have you learned?
10. Any final thoughts about what life is like with DCD?