Symptoms of anxiety and depression in children with developmental coordination disorder: a systematic review

University of Groningen

Symptoms of anxiety and depression in children with developmental coordination disorder

Gomes Draghi, Tatiane Targino; Lopes Cavalcante Neto, Jorge ; Rohr, Liz Araujo; Jelsma,

Lemke Dorothee; Tudella, Eloisa

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Jornal de pediatria

DOI:

10.1016/j.jped.2019.03.002

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Gomes Draghi, T. T., Lopes Cavalcante Neto, J., Rohr, L. A., Jelsma, L. D., & Tudella, E. (2020).

Symptoms of anxiety and depression in children with developmental coordination disorder: a systematic

review. Jornal de pediatria, 96(1), 8-19. https://doi.org/10.1016/j.jped.2019.03.002

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JPediatr(RioJ).2020;96(1):8---19

www.jped.com.br

REVIEW

ARTICLE

Symptoms

of

anxiety

and

depression

in

children

with

developmental

coordination

disorder:

a

systematic

review

夽

Tatiane

Targino

Gomes

Draghi

_,

_Jorge

_Lopes

_Cavalcante

_Neto

_,

Liz

Araújo

Rohr

_,

_Lemke

_Dorothee

_Jelsma

_,

_Eloisa

_Tudella

a_{UniversidadeFederaldeSãoCarlos,DepartamentodeFisioterapia,SãoCarlos,SP,Brazil} b_{UniversidadedoEstadodaBahia,DepartamentodeCiênciasHumanas,Jacobina,BA,Brazil} c_{UniversityofGroningen,ClinicalandDevelopmentalNeuropsychology,Groningen,TheNetherlands}

Received15December2018;accepted18March2019 Availableonline26April2019

KEYWORDS Developmental coordination disorder; Emotionalhealth; Mentalhealth; Anxiety; Depression Abstract

Objective: Tofindevidenceofthesymptomsofanxiety/depressioninchildrenwith develop-mentalcoordinationdisorderascomparedtotheirtypicallydevelopingpeersatboththegroup andindividuallevel,andto identifyhow manydifferenttoolsareused tomeasureanxiety and/ordepression.

Methods: Electronicsearchesineightdatabases(PubMed/MEDLINE,Scopus,WebofScience, ERIC,PsycINFO,Embase,SciELOandLILACS),usingthefollowingkeywords:‘Developmental CoordinationDisorder,’‘BehavioralProblems,’‘Child,’‘Anxiety,’‘Depression,’‘MentalHealth,’ and‘MentalDisorders.’ThemethodologicalqualitywasassessedbyNewcastle-OttawaScale adaptedforcross-sectionalstudiesandtheNOSforcohortstudies.Thestudieswereclassified aslow,moderate,orhighquality.Toprovideclinicalevidence,theeffectsizeofthesymptoms ofanxietyanddepressionwascalculatedforeachstudy.

Results: Theinitial database searchesidentified581studies,andafter theeligibility crite-riawereapplied,sixstudieswereincludedinthereview.Allstudieswereclassifiedasbeing ofmoderatetohighquality,andtheeffectsizesfor bothanxietyanddepressionoutcomes weremedium.Theevidenceindicatedthatalloftheassessedstudiespresentedmore symp-tomsof anxiety anddepression inchildren with developmentalcoordination disorderthan intheir typicallydevelopingpeers.Onthe individuallevel, thisreviewfound children with clinicalsymptomsofanxietyin17---34%(developmentalcoordinationdisorder)and0---23% (typ-icallydeveloping),andofdepressionin9---15%(developmentalcoordinationdisorder)and2---5% (typicallydeveloping)ofthechildren.

夽 _{Pleasecitethisarticleas:DraghiTT,CavalcanteNetoJL,RohrLA,JelsmaLD,TudellaE.Symptomsofanxietyanddepressioninchildren} withdevelopmentalcoordinationdisorder:asystematicreview.JPediatr(RioJ).2020;96:8---19.

∗_{Correspondingauthor.}

E-mail:tati.targino@gmail.com(T.T.Draghi).

https://doi.org/10.1016/j.jped.2019.03.002

0021-7557/©2019SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND

Anxietyanddepressionindevelopmentalcoordinationdisorder 9

Conclusions: Childrenwithdevelopmentalcoordinationdisorderareathigherriskofdeveloping symptomsofanxietyanddepressionthantheirtypicallydevelopingpeers.

©2019SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/

4.0/). PALAVRAS-CHAVE Transtornodo desenvolvimentoda coordenac¸ão; Saúdeemocional; Saúdemental; Ansiedade; Depressão

Sintomasdeansiedadeedepressãoemcrianc¸ascomtranstornododesenvolvimento dacoordenac¸ão:umarevisãosistemática

Resumo

Objetivo: Encontrar evidências dos sintomas de ansiedade/depressão em crianc¸as com transtorno dodesenvolvimentodacoordenac¸ãoem comparac¸ãocomseusparescom desen-volvimentotípico,anívelindividualbemcomo emgrupo,eidentificarquantas ferramentas diferentessãoutilizadasparamediraansiedadee/oudepressão.

Métodos: Pesquisa eletrônica em oito bases de dados (PubMed/Medline, Scopus, Web of Science, Eric, PsycINFO, Embase, Scielo e Lilacs), utilizando as seguintes palavras-chave: ‘Developmental CoordinationDisorder’, ‘Behavioral Problems’, ‘Child’,‘Anxiety’,

‘Depres-sion’,‘MentalHealth’e‘MentalDisorders’.Aqualidademetodológicafoiavaliadapelaescala deNewcastle-Ottawa (NOS)adaptadaparaestudostransversais epelaescalade Newcastle-Ottawa (NOS) para estudos decoorte. Os estudosforam classificadosem: qualidadebaixa, moderada e alta. Para fornecer evidência clínica, o tamanho do efeito dos sintomas de ansiedadeedepressãofoicalculadoparacadaestudo.

Resultados: Asbuscasiniciaisnasbasesdedadosidentificaram581estudose,apósaaplicac¸ão doscritériosdeelegibilidade,seisestudosforamincluídosnarevisão.Todososestudosforam classificadoscomotendoqualidademoderadaaaltaeostamanhosdoefeitoparaosdesfechos deansiedadeedepressãoforammédios.Asevidênciasindicaramque100%dosestudos avali-adosapresentaram maissintomasdeansiedade edepressãoemcrianc¸ascomtranstornodo desenvolvimentodacoordenac¸ãodoqueemseusparescomdesenvolvimentotípico.Nonível individual,encontramoscrianc¸ascomsintomasclínicosdeansiedadeem17-34%(transtornodo desenvolvimentodacoordenac¸ão)e0-23%(desenvolvimentotípico)ededepressãoem9-15% (transtornododesenvolvimentodacoordenac¸ão)e2-5%(desenvolvimentotípico)dascrianc¸as.

Conclusões: Crianc¸ascomtranstornododesenvolvimentodacoordenac¸ãoapresentammaior riscodedesenvolversintomasdeansiedadeedepressãodoqueseusparescomdesenvolvimento típico.

©2019SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.

0/).

Introduction

Developmental coordination disorder (DCD) is a specific motor delay characterized by significant difficulties with motor skills; it is typically associated withpoor balance, coordination,andhandwriting.1_{According tothe}

Diagnos-ticandStatisticalManualofMentalDisorders---5thedition (DSM-5), the identification of DCD is composed of four criteria. These criteria aresubsequently: (A) motor skills performanceissubstantiallybelowthelevel whichcanbe expectedconsideringthechronologicalageofthechild;(B) motorskillsinterferewithactivitiesofdailylivingathome andat school;(C)the symptomswerepresentat anearly age; (D) the motor problems are not explained by intel-lectual,medical,orneurologicalconditions.1_DCDisoneof

themostprevalentmotordisorders,affectingabout6%of school-agechildren2---4_{andpersistingtoadulthood.}5

Significantlylowermotorskillshavebeenfoundto inter-fere withthe individualactivities of daily living,6 _making

theexecutionofmovementssignificantlychallenging.7,8_The

gapsinmotorskillspossessedbychildrenwithDCDdecrease theirparticipationinsportsandregularphysicalactivities.9

Inaddition,childrenwithDCDreportmoredifficultieswith self-care, which can interfere with their participation at school, onthe playground, and at home,10 _{which in turn}

cancausesocialisolationthatdecreasestheirsenseof self-worth.11

Lowself-esteemisonlyoneofthefactorsthatcanlead toincreasedsymptomsofanxietyanddepression.12_Anxiety

isdefinedas‘‘anemotioncharacterizedbyfeelingsof ten-sion,worriedthoughts,andphysicalchangeslikeincreased bloodpressure’’,1_{whilestressfullifeeventspredictperiods}

ofdepression,13,14_{ofwhich---amongstothers---symptomsof}

reducedinterestorpleasureinactivitiespreviouslyenjoyed, anddelayedpsychomotorskills arepresented.Considered a multifactorial disorder, the etiology is affected by the genetic and environmental context, which can influence thenormalcycleofdevelopmentinchildren.15_Thepresent

studyaimedatanalyzing dataregardingsymptomsof anx-ietyanddepressionfromscreening tests,whichsignalthe

10 DraghiTTetal. presenceofmoreanxiousordepressedfeelingsthatmeet

theclinicalcriteriaofadisorder.16

Missiuna et al.12 _{studied children who had DCD}

com-bined withattention-deficit hyperactivitydisorder (ADHD) and found that they had more symptoms of anxiety and depressionthantheirpeerswhohadtypicaldevelopment. Lingamet al.17 _{identifiedmore risk for both physical and}

mentalhealthproblemsinapopulationwithDCD.Assuming thatchildrenwithDCDwidelypresentaprofileof vulnera-bilityduetothesepotentialmediatorscombinedwithmore exposuretocontributoryfactorsforincreasedsymptomsof depressionand anxiety,it washypothesized that children withDCD or probable DCDhave significantly more symp-tomsofanxiety/depressionthantheirtypicallydeveloping (TD)peers.Therefore,thepresentsystematicreviewstudy aimedtofindevidenceofsymptomsofanxiety/depression inchildrenwithDCDcomparedtotheirTDpeersatboththe groupandindividuallevel,andtoidentifyhowmany differ-enttoolsareusedtomeasureanxietyand/ordepression.

Methods

The methodology of this systematic review was devel-opedusingtheguidelinesoftheCochraneHandbook.18_The

review’sprotocolwasregisteredinthePROSPEROdatabase usingIDnumberCRD42018091859.

Databaseandkeywords

Initialsearchesweredone bytwoindependentreviewers. The searcheswere conducted in the following databases: PubMed/MEDLINE,Scopus,WebofScience,ERIC,PsycINFO, Embase,SciELO,andLILACS,usingthefollowingkeywords fromtheMedicalSubjectHeadings(MeSH)database: ‘Devel-opmental Coordination Disorder,’ ‘Behavioral Problems,’ ‘Child,’‘Anxiety,’‘Depression,’‘MentalHealth,’and ‘Men-tal Disorders.’ To optimize the results, five combinations ofthesekeywordswerecreatedbyusingtheBooleanAND operator:DevelopmentalCoordinationDisorderANDAnxiety ANDChild;DevelopmentalCoordinationDisorderAND Men-talHealthANDChild;DevelopmentalCoordinationDisorder ANDDepressionANDChild;DevelopmentalCoordination Dis-orderANDBehavioralProblems ANDChild;Developmental CoordinationDisorderANDMentalDisordersANDChild. Eligibilitycriteria

Articleswereselectedbyfulfillingallthefollowingcriteria: (1)Originalresearchconductedwithchildren withDCDor anyothertermsusedregardingDCD,suchaschildrenwith probableDCDor at risk for DCD, andpublished inEnglish betweenJanuary1,2007andNovember25,2018.(2)The diagnostic criteria for identifying children with DCD was basedon theDSM-IV or the DSM-5, which is composed of fourcriteria.1,19_{Thesecriteriaaresubsequently:(A)motor}

skills performance is substantially below the level which canbe expectedconsidering the chronological ageof the child;(B)motor skillsinterferewithactivities ofdaily liv-ingathomeandatschool;(C)thesymptomswerepresent atanearlyage;(D)themotorproblems arenotexplained

by intellectual, medical, or neurological conditions. The children needed to fulfill at least the criteriaA and B of theDSM-5.1 _{(3)Studies thatassessedsymptomsof anxiety}

and/or depression. (4) Studies thatassessed symptoms of anxietyand/ordepressionusingspecifictests,scales, ques-tionnaires,or other standardizedinstruments. (5)Original studies usingany designexcept case studies andreviews. (6)StudiesthatusedcontrolgroupsofTDchildren. Dataextractionandanalysis

The study’s data selection began with the initial search and then the removalof all duplicates. To make the ini-tial selections, two independent reviewers (L.A.R. and T.T.G.D.) screened the study titles. Next, the abstracts of the selected articles were assessed. Then, the full texts of the articles that remained were assessed, and those meeting the eligibility criteria were included in the review. Discrepancies and disagreements among the authors were solved by consensus with a third reviewer (J.L.C.N.).

The main results were summarized using the follow-ing four categories: (1) participants (age, sample size, comparisongroups,andinclusioncriteriaforDCD);(2) out-comes(symptomsofanxietyanddepression);(3)instrument assessment;and(4)methodologicalquality.

To assess the effects of the anxiety and depres-sion outcomes of DCD children in clinical practice, the effect sizes based on Cohen’s d20 _{were calculated,}

using the following reference values: small effect size (d=0.20---0.30); medium effect size (d=0.40---0.70), and large effect size (d=≥0.80). To calculate the effect sizes of the differences between the groups, this review used the difference between the means divided by the standard deviations presented in each study for each outcome (symptoms of anxiety and depression). When the authors did not show these values in the manuscript,thatstudywasexcluded fromtheeffectsizes analyses.

The individualoutcomes ofchildren scoring within the clinical rangeof the used measurement tools for anxiety and/ordepressionarereportedinpercentageswithineach group(DCDvs.TD),whenreported.

The methodological quality was determined by three independentreviewers,anddifferenceswerediscussedand solved by consensus. The Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies and NOS for cohort studies21 _wereused.

The NOS uses a system of stars for scoring the arti-cles, considering specific criteria. Cohort studies could score a maximum of four stars for the selection crite-ria, two stars for the comparability criteria, and three stars for the outcome criteria, totaling a maximum of nine stars. The authors considered the studies as high quality when they scored ≥7 stars and moderate qual-ity as 5---6 stars, according the classification adopted by Xingetal.22 _{Regardingcross-sectionalstudies,amaximum}

of five stars was scored for the selection criteria, three starsfor the comparabilitycriteria, and twostarsfor the outcomecriteria,totalingamaximumoftenstars.The cri-teria adopted by Wang et al.23 _{were used to classify the}

Anxietyanddepressionindevelopmentalcoordinationdisorder 11 cross-sectional studies,whoconsidered low-qualityscores

as 0---4, moderate-quality scores as5---6, and high-quality scoresas≥7.

Results

Theinitialdatabasesearchesidentified581studies,ofwhich sixstudiesmetalleligibilitycriteria(Fig.1).24_Fivearticles

werecross-sectional studies, andone wasa cohortstudy. Thecumulativesamplesizeofalltheincludedstudieswas 7920 children(653 withDCD, 7213TD peers,and 54with ADHD --- who werenot considered in theseanalyses). The participants’agesrangedfrom4yearsand4monthsto11 yearsand6months(Table1).

The body of evidence from the six studies indicated significantly more symptoms of anxiety and depression in children with DCD than in their TD peers. In five of the sixstudies, theeffectsizescouldbecalculatedfor symp-tomsofanxiety12,25---28_{andsymptomsofdepression.}12,24,27,28

All included studies reported similar results of increased symptomsof anxiety and depressionin children withDCD comparedwiththeirtypicalpeers(Table1).

Intheincludedstudies,theDSM5criteriaAandBwere themost commonly considered criteria, evaluatingmotor performanceandinterferenceofcoordinationdifficultiesin academicachievementordailylifeactivities,respectively. Toevaluatemotorperformanceassessment(criteriaA), 67% of the studies (n=4)12,26---28 _{included used the}

Move-mentAssessment Battery for Children(MABC) with≤15th percentile,ortheMABC-2with≤5thpercentiletoindicate DCD;one27_{ofthemalsousedtheBruininks---OseretskyTestof}

MotorProficiency(BOTMP)withacut-offstandardscoreof <40forDCD.Onestudy17_{usedtheAvonLongitudinalStudy}

ofParentsandChildren(ALSPAC)CoordinationTestwitha score<15thpercentile,andonestudy25_{usedtheMcCarron}

AssessmentofNeuromuscularDevelopment (MAND)witha score≤85indicatingDCD.

To evaluate criteria B, three of the six studies12,26,27

included used the Developmental Coordination Disorder Questionnaire (DCDQ) and two studies17,28 _{analyzed the}

reportedoutcomesofaparentquestionnaire.,Thestudies usedambiguousterminologyto refertothe children with DCD. Ofthe sixstudies included, threeused DCD, twoat riskforDCD,andoneprobableDCD.

PRISMA 2009 Flow Diagram

Records identified through database

searching (n = 581) Title excluded (n = 377)

Title screened (n = 204)

Identification

Screening

Eligibility

Included

Title duplicates removed (n = 128)

Full-text articles excluded (n = 18): Articles type review, critical analysis of another

article, book chapter ,study protocol (n = 5) No subject of anxiety and/or depression

(n = 5)

Text not available in English (n = 2) Absence of typical group of children (n = 4) Children were not test on motor performance

(n = 1)

Evaluated the symptoms of depression in adolescence (n = 1) Abstract screened

(n = 76)

Full-text articles screened (n = 24)

Studies included (n = 6)

Records excluded (n = 52): Date and theme (n = 45) Review articles that were not identiflied

in the title (n = 5) Abstract not disposable (n = 2)

12

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Table1 Summaryofresultsfromthestudiesincluded. Study Design Sample Inclusion

criteriafor DCD

DCD termi-nology

DCDgroup Controlgroup Motor per-formance assess-ment Anxiety/ depression assess-ment (respon-dents) Purposeof study Results regarding tothe symptoms of anxiety/ depression assess-ment

Effectsize(Cohen’sd)

n Meanage (SD) n Meanage (SD) Anxiety assess-ment Depression assessment Pieketal. (2008) Cross-sectional

40 MAND Atriskfor DCD 14 4.4±0.33 26 4.4±0.33 MAND≤85 CBCLfor ages1.5---5 (parents) To investigate the rela-tionship between motor coordina-tion, emotional recogni-tion,and internaliz-ing behavior Anxiety/ depression: DCD signi-ficantly higher thanTD d=1.26 d=1.26 Missiuna etal. (2014) Cross-sectional 244 CSAPPA DCDQ’07 MABC DCD DCD:68 ADHD:54 DCD+ADHD: 31 DCD: 11.6±1.4 ADHD: 11.9±1.4 DCD+ADHD: 12.0_±1.5 91 12.0_±1.5 MABC <15thP CDI (children + parents) SCARED (children +parents) To determine if symptoms of depression and anxiety were greater among children withDCD, ADHDthan theirpeers Anxiety: DCD signi-ficantly higher thanTD Depression: DCD signi-ficantly higher thanTD d=0.41 d=0.82

Anxiety and depression in developmental coordination disorder 13 Table1(Continued)

Study Design Sample Inclusion criteriafor DCD

DCD termi-nology

DCDgroup Controlgroup Motor per-formance assess-ment Anxiety/ depression assess-ment (respon-dents) Purposeof study Results regarding tothe symptoms of anxiety/ depression assess-ment

Effectsize(Cohen’sd)

n Meanage (SD) n Meanage (SD) Anxiety assess-ment Depression assessment Prattand Hill(2011) Cross-sectional 62 DCD-Q MABC-2 DCD 27 10.0 35 9.3 MABC-2 <5thP SCAS-P (parents) To investigate levelsof anxietyin children withDCD and typically developing children Anxiety: DCD signi-ficantly higher thanTD d=0.31 ---Lingam etal. (2012) Cohort 6902 ALSPAC anddaily livingscale derived from parent-completed question-naire Probable DCD 346 7---8years forDCD evalua-tion; 9---10years formental health assess-ment 6556 7---8years DCDfor evalua-tion; 9---10years formental health assess-ment ALSPAC coordina-tiontest <15thP SMFQ (children) Toassess the associ-ations between probable DCDand mental health difficulties and explore the mediating factorsin this rela-tionship Depression: DCD signi-ficantly higher thanTD ---

---14 Draghi TT et al. Table1(Continued)

Study Design Sample Inclusion criteriafor DCD

DCD termi-nology

DCDgroup Controlgroup Motor per-formance assess-ment Anxiety/ depression assess-ment (respon-dents) Purposeof study Results regarding tothe symptoms of anxiety/ depression assess-ment

Effectsize(Cohen’sd)

n Meanage (SD) n Meanage (SD) Anxiety assess-ment Depression assessment Chenetal. (2009) Cross-sectional 270 DCDQ-C. MABC BOTMP Atriskfor DCD 144 7.74±0.81 126 7.74±0.81 BOTMP<40 MABC ≤15thP CBCL ---Chinese version (parents) Toexplore the psy-chosocial and atten-tional character-isticsof children withDCD Anxiety/ depression: DCD signi-ficantly higher thanTD d=0.55 d=0.55 Vanden Heuvel etal. (2016) Cross-sectional 402 MABC-2 Problems inmotor control reported inaparent question-naire DCD 23 7.0 379 7.2 MABC-2 ≤5thP TRF (teacher) To investigate teachers’ identifica-tionof emotional and behavioral problems inchildren withDCD Anxiety/ depression: DCD signi-ficantly higher thanTD d=0.52 d=0.52

DCD,developmentalcoordinationdisorder;TD,typicaldevelopmental;SD,StandardDeviation;ADHD,attentiondeficithyperactivitydisorder;MAND,McCarronAssessmentof Neuromus-cularDevelopment;CBCL,ChildBehaviorChecklist;CDI,Children’sDepressionInventory;SCARED,Self-reportforChildhoodAnxietyandRelatedEmotionalDisorders;MABC,Movement AssessmentBatteryforChildren;CSAPPA,Children’sSelf-PerceptionsofAdequacyinPredilectionforPhysicalActivityScale;DCDQ,DevelopmentalCoordinationDisorderQuestionnaire; SCAS,SpenceChildren’sAnxietyScale;SMFQ,ShortMoodandFeelingsQuestionnaire;ALSPAC,AvonLongitudinalStudyofParentsandChildren;BOTMP,Bruininks---OseretskyTestofMotor Proficiency;TRF,Teacher’sReportForm.

Anxietyanddepressionindevelopmentalcoordinationdisorder 15 Various instruments were used toassess the children’s

mental-healthoutcomes,butthemostcommonlyusedwas theChildBehaviorChecklist(CBCL)(n=2).25,27_Furthermore,

Children’sDepressionInventory(CDI)12_{andtheShortMoods}

andFeelingsQuestionnaire(SMFQ)17_{scoredbychildrenwere}

usedtomeasuredepression.TheSelf-reportfor Childhood AnxietyandRelatedDisorders(SCARED)12_{scoredbychildren}

and the Spence Children’s Anxiety Scale Parental version (SCAS-P)26_{scoredbyparentswereusedtomeasureanxiety.}

TheTeacher’sReportForm(TRF)28_{wasusedbyteachersto}

score the emotional and behavioral problems of the chil-dren.

Atanindividuallevel,presentedinTable2,theresultsof thestudiesincludedinthisreviewinferthatapercentage ofchildrenwithDCDhaveahigherprobabilityofpresenting symptomsofanxietyordepressionintheclinicalrangewhen comparedtochildrenwithtypicallydevelopment.

The methodologicalqualityoftheincluded studieswas classifiedashighqualityinfivearticles.Twoofthem reach-ing90%ofmethodologicalcriteria,25,27_{onestudyreached,}

88%,17 _{andtworeached70% ofthecriteria.}12,28 _Onestudy

wasofmoderatequality,reaching60%ofthecriteria.26

Noneofthecross-sectionalstudies,evaluatedbytheNOS adaptedforcross-sectionalstudies,scoredtwostarson out-comecriterion1(independentblindevaluationor analysis by registry).However,the sixstudies (fivecross-sectional andonecohort)scoredonthecriterion‘‘controlsthemost important factor’’ (comparabilityA, one star).All details aredisplayedinTable3.

Discussion

Thepresentreviewcompiledevidencefromsixarticlesthat assessedsymptomsofanxietyand/ordepressioninchildren withDCDascomparedwithsymptomsinTDpeercontrols. Theresultsshowedthatinallstudiesevidencewasfoundfor increasedpresenceofsymptomsofanxietyanddepression

inchildrenwithDCDcomparedtoTDchildren, supporting thehypothesisofthisstudy.

Pieketal.,25 _Chenetal.,27 _{andvandenHeuvel etal.}28

showedthatanxietyanddepression inDCDissignificantly higherthan in TD children. Children’smotor coordination ability was negatively associated with reported anxious-depressed behavior, so when the children scored poorly in coordination, more anxiety/depression was reported by parents.25 _{However, of this group, no individual child}

was reported as scoring in the clinical range of anx-ious/depressivebehavior.25,27_{Thisisanimportantfindingto}

report,sincethismeansthattherewasnocausalityfound forDCDresultinginclinicalsymptomsofanxietyand depres-sion.ItonlybringsforwardthatchildrenwithDCDhavemore vulnerabilityfactorsthatmayleadtoincreasedsymptoms ofanxiety anddepression in some ofthe children. Invan denHeuveletal.,28 _{anxietyanddepressionwerepartofan}

emotionalandbehaviorproblemsscalethatinvolvesother emotionalproblems; 15%of theDCDchildrenpresented a clinicalTRFintheDCDgroupcomparedtotheTDchildren. Missiunaetal.12_{andLingametal.}17_{foundsimilarresults}

ofsignificantdifferencesbetweenchildrenwithDCD com-paredtoTDchildrenregardingdepression.Basedonthese results, similar percentages of individual children were observedwhoscoredwithintheclinicalrangebyboth chil-drenwithDCDandparents(11.8%and11.9%,respectively) for children12,17 _{and 9.1% for parents,}12 _{eventhough they}

weremeasuredbydifferenttools.Again,thisonly demon-strates that a minority of children with DCD would feel moredepressedcomparedtotheirpeers.Moreinformation isneededregardingself-esteem,sociallifestyle,academic scores,andsupportofparentsand/orteachersinorderto understandmoreof theprocessesleadingtosymptomsof depression.

Missiunaetal.12 _{andPrattandHill}26 _{showedsignificant}

differences between children with DCD compared to TD children regarding anxiety. But the mean of the SCARED respondedtobyparentsandchildrendidnotreachthe clin-icalrange.However,16.7%ofparentsand33.8%ofchildren

Table2 Numberandpercentageofchildrenwithsymptomsofanxiety/depression.

Study Outcome Numberand%ofchildrenwithsymptomsof

anxiety/depressionintheclinicalrange

DCDgroup TDgroup

Pieketal.(2008) Anxiety/depression N/A N/A

Missiunaetal. (2014)

Depression Child’sreport:n=8 (11.8%) Parents’report:n=6 (9.1%) Child’sreport:n=2 (2.2%) Parents’report:n=2 (2.2%)

Anxiety Child’sreport:n=23 (33.8%) Parents’report:n=11 (16.7%) Child’sreport:n=21 (23.1%) Parents’report:n=1 (1.1%)

PrattandHill(2011) Anxiety n=7(25.9%) n=0(0%)

Lingametal.(2012) Depression n=28(11.9%) n=279(5.3%)

Chenetal.(2009) Anxiety/depression N/A N/A

vandenHeuveletal. (2016)

Anxiety/depression n=3(15%) n=7(2.3%)

16

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Table3 StudyqualityassessmentusingNewcastle-OttawaScaleforcross-sectionalandcohortstudies.

Study Design NOS

Selection1 Selection2 Selection3 Selection4 Comparability 1a

Comparability 1b

Outcome1 Outcome2 Outcome3 NOStotal score Pieketal. (2008) Cross-sectional         9/10(90%) Missiunaetal. (2014) Cross-sectional   N/A   N/A   7/10(70%) Chenetal. (2009) Cross-sectional         9/10(90%)

VandenHeuvel etal.(2016)

Cross-sectional

  N/A    N/A  7/10(70%)

PrattandHill (2011)

Cross-sectional

N/A N/A N/A _{    } 6/10(60%)

Lingametal. (2012)

Cohort _{     } N/A _{ } 8/9(88%)

Anxietyanddepressionindevelopmentalcoordinationdisorder 17 fromthe DCDgroupscored positive for clinical symptoms

of anxiety.Pratt andHill26 _{showedsimilarpercentages of}

individual children that scored within the clinical range; 25.9%DCDchildren reportedsymptomsof anxiety.It isof interesttogainmoreunderstandingregardingwhyparents scoretheirchildrenlowerinsymptomsofanxietythanthe childrenthemselves.

The effect size couldbe calculated for fiveout of six studies included in this review. Considering these studies (n=5 for symptoms of anxiety and n=4 for symptoms of depression, assuming that in two studies both outcomes wereevaluatedtogether)themeanofcalculatedeffectsize forsymptomsofanxietywasd=0.61,whileforsymptomsof depressionitwasd=0.78,indicatingamediumeffectsize for the clinical implications of both symptoms of anxiety anddepressioninchildrenwithDCD.ThismeansthatDCDis notafullycontributingfactortothepresenceofsymptoms ofanxietyordepression.Infact,aconsiderablenumberof childrenwithDCDmaynotdevelopsymptomsofanxietyor depression. Other factors,like the factors putforward in thestudy by Lingametal.17 _{of lowverbal IQ,poorsocial}

communication,beingavictim,lowself-esteem,andpoor scholasticcompetencemaycontributeevenmore.Further researchisneededtodisentangletherelationshipbetween the motor competence of children with DCD, the history oftreatmentandsupport,andtheeffectsonself-esteem, socialcommunication,andisolation,preferablyindifferent cultures.

Giventhecurrentdiagnosticcriteriaforidentifying chil-drenwithDCDbasedonDSM-5,1_{itispossibletoinferthat}

each of the four criteria takes the child’s daily life and hisor heropportunitiesforpracticeintoaccount.In addi-tion,itcanbeinferredthat,inadditiontoopportunitiesfor practice,childrenshouldbesurroundedbypsychosocial pro-tectivefactors,includingpositivesocialsupportfromfamily, friends,andteachers.Thissupportmustbeadequateto pro-motetheencouragementthatthesechildrenneedtotryto overcometheirmotordeficitsand/orbecomesociallymore involved and minimize their risk for anxiety and depres-sion.Theycanbeclumsy,butcanbuildupsufficientsocial relationshipswiththeirpeers.

Fromthisreview,itisclearthatanxietyand/or depres-sion are measured inconsistently by different tools, i.e.,

six differenttools were usedandwere completed by dif-ferentrespondents. Sofar, it is unclearwhether parental or teacher scoresof mental healthitems correspondwith theexperiencedfeelingsofthechildren.Someissuesshould benotedregardingthedifferencesbetweenthesymptoms of anxiety and depression. For example, whereasanxiety includesexcessiveworryaboutfutureactionscombinedwith tensionor stress, depression is characterizedby low self-esteem,mooddisturbanceor dysregulation,andsadness.1

Often, both conditions frequently co-occur12 _{in the same}

period or sequentially and, overtime, an increase of the presence of both conditions is seen29_{; therefore,}

assess-ments for both conditions are often conducted together, particularlyin non-clinicalstudies.Given this,fourof the six studies included in the present review assessed both anxiety and depression in children with DCD and peer controlgroups.12,25,27,28 _Onestudy26 _{assessedonly anxiety,}

and another one17 _{assessed only depression. Taking into}

considerationthatsymptomsofanxietyanddepressionare composed of different characteristics,29 _{it is possible to}

induceabiaswhenbothassessmentsareperformedbythe sameinstrument.Ontheotherhand,forresearchpurposes theresearcherscansavetimeandresourcesusingonlyone standardizedquestionnaireforscreeningsymptomsofboth anxietyanddepression.However,moreadditionaldetailed informationisneededwhenachildscores‘atrisk.’

Itis important torealize thatdeprivation,in this case childrenwhoarenotexposedtopracticemotorskillsorhave anactivelifestyleinearlychildhood,mayleadto neurode-velopmentalproblems, whichcan berelatedtosymptoms of depression in adolescence.30 _{Therefore,besides motor}

performancelevel,thecontextofthechildregarding par-enthood,environment,andsocialeconomicstatuscangive abetteroverviewregardingfactorsthatmaypredict symp-toms of anxiety and/or depression. Further research is neededtodeterminewhichfactorsplaythemostimportant roletobecome‘atrisk’forpsychologicalproblems.

All cross-sectional studies scored onthe selection cri-terion4(validatedassessments),thus itcanbeconcluded thatthestudiesincludedinthisreviewstrictlyfollowedthe recommendedcriteriafor studies with thisdesign, avoid-ingpossiblebiases.Thisisalsoappropriateforcriterion2, whichreferstostatisticaltestsusedforanalysis,reinforcing thatthosewereappropriatetodemonstratetherelevance oftheresults.BesidestheNOScross-sectional,noneofthe selectedstudiesscoredtwostarsontheoutcomecriterion1, correspondingtoindependentblindevaluationoranalysisby registry.Thislackoffulfillingindependentblindevaluation oranalysisby registry(alsocriterion1 for cohortstudies) infersthat for this outcome of anxiety and/or depression symptoms,theuseofself-completedquestionnairesseemed tobea questionable choice,since theevaluation is done byan interviewerwhomayhavehadadirectinfluenceon therespondent’s response.To avoidthe tendency to give overlypositiveself-descriptions,self-reportquestionnaires without the influence of an interviewer couldbe used to minimizesociallydesirableresponses(SDR),31_{orself-report}

questionnairesansweredbyparentsorteachers.

The findings of the present review both support the importanceofinvestigatingthepsychosocialaspectsof chil-drenwithDCDand reinforcethe recommendationsof the EuropeanAcademyforChildhoodDisability(EACD)regarding clinicalpracticeinchildrenwithDCD.32 _{Theentireprocess}

of evaluation and intervention must involve not only the motoraspects,butalsopersonalandindividualfactors,and shouldinclude a review of allitems present in the Inter-nationalClassificationofFunctioning,Disability,andHealth (ICF).33 _{Infact,evaluationsandinterventionsthatfocuson}

theindicative symptomsofanxiety anddepressionin chil-drenwithDCDcorrespondtothepersonalandenvironmental factorsoftheICF. Inaddition,consideringthe multifacto-rialaspects,improvementsin thesepsychosocialcuescan improvethestructureandfunctionofthebodyand partic-ipationindailyactivities.Thus,theresultsof thepresent reviewsupporttheimportanceofconsideringtheindicative symptomsofanxietyanddepressioninchildrenwithDCD.

To avoid confusion when studies are compared, researchersandtherapistsmust beawareof theterms in thecurrentliterature.Theauthorsencourageresearchersto

18 DraghiTTetal. followtheclassificationbasedonSmits-Engelsmanetal.,34

which consider the DSM-5 criteria to be described and observedusingstandardizedassessments,andalsothe chil-dren’sage.

Thissystematicreviewhassomelimitations.Thevarious designsadoptedbytheincludedstudiesresultedinvarious interpretationsoftheir findings.Notably,thecohortstudy wascapableofevaluatingtherelationshipsbetweencauses andeffects,andthecross-sectionalstudieswerenot. Fur-thermore,thevarietyofsamplesizes,instrumentsusedto assessmotorperformance,andthepsychosocialoutcomes ofinterest(anxietyanddepression)mayhaveaffected inter-pretation of the studies’ results. However, regarding the outcomesofinterest, higherrisksof symptomsof anxiety anddepressioninchildrenwithDCDwerefoundinallstudies includedinthereview.

Conclusions

ChildrenwithDCDappeartobeatincreasedriskof present-ing symptoms of anxiety and/or depression than children withtypical development.This implies that the effectof motor problems may be facilitating an increased risk for symptomsof anxiety and/or depression, eventhough this isnotthecaseforallchildren.Clinicianshavetobeaware oftheserisksandmayconsiderextendingtheirassessments toquestionnaires aimed tomeasure symptoms of anxiety ordepression.Ifmoreattentionispaidtothesesymptoms andchildrenaremeasuredmoreconsistently,more knowl-edgewillbegainedregardingthemediatingeffectsofmotor problemsonsymptomsofanxietyanddepression.

Funding

Theauthorswouldliketothankthefinancialsupportfrom CoordinationfortheImprovementofHigherEducation Per-sonnel(CAPES).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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