Developmental coordination disorder (DCD) is a neurodevelopmental disorder characterised by physical awkwardness and difficulty learning new motor skills. Children with DCD are typically slower and less skilled than their peers in performing age-appropriate activities such as getting dressed, organising school books and participating in team sports. The delay in skill development negatively impacts children´s occupational performance in important life areas and DCD has been frequently associated with secondary difficulties such as depression and social isolation. The role of occupational therapists in supporting children with DCD is to address their occupational performance difficulties in areas of self-care, productivity and play. While early intervention is recommended to support children with DCD, to date few studies have investigated DCD in preschool-aged children, and none to our knowledge have explored the impact of DCD on play. Play is widely recognised as an important childhood occupation that supports physical, cognitive and social development. Furthermore, it may also be associated with promoting wellbeing or quality of life.
The studies within this thesis were conducted in Germany where DCD has until recently been a relatively unknown and under-researched disorder. The aims were: (1) to explore the play skills and engagement in play of preschool children with and without DCD, and (2) to investigate the relationship between engagement in play and wellbeing using a proposed adaptation to the International Classification of Functioning, Disability and Health – Children & Youth Version (ICF – CY). This adaptation involves consideration of the activity deficit hypothesis and the inclusion of wellbeing.
Three studies were undertaken, the first being a translation, cross-cultural adaptation and validation of the Developmental Coordination Disorder Questionnaire 2007 (DCDQ´07) which supported participant recruitment in the subsequent studies. Following piloting of the pre-final version, the psychometric properties and clinical utility of the questionnaire were tested with children aged between 5.0 to 7.11 years from both clinic (n = 55) and community (n = 67) populations. The main study was a quasi-experimental study comparing the developmental play skills, frequency of engagement in play, and wellbeing of German preschool children aged 4.0 to 6.11 years with (n = 32) and without (n = 31) DCD (referred to as probable DCD [pDCD]). Participating children were videotaped during free-play at preschool for 15 minutes indoors and 15 minutes outdoors giving a total of 30 minutes for each child. Their play was rated using the Revised Knox Preschool Play Scales (RKPPS), which measures developmental play skills and the Play Observation Scale (POS) which uses a time-sampling method to measure the amount of time a child engages in different types of social and cognitive play. Wellbeing was measured using the Revised Children Quality of Life Questionnaire (KINDLR), a parent-proxy questionnaire which captures seven dimensions of wellbeing including physical, emotional, self-esteem, family, social contacts, wellbeing at preschool and general wellbeing. Non-parametric statistics (Mann-Whitney U) were used to compare the play
and wellbeing scores of the two independent groups. A series of standard multiple regressions were conducted to determine whether selected variables from the POS predicted the outcome of wellbeing as measured by the KINDLR total score and separately for all seven dimensions of wellbeing.
The third study, which involved a pilot intervention with preschool children with pDCD (n = 3) and their teachers (n = 3), evolved from the main study. It used case study methodology to explore the use of occupational performance coaching (OPC) with the preschool teacher and a play-based intervention with the child to increase the children´s play skills and occupational performance. Outcome measures included the Canadian Occupational Performance Measure (COPM), the RKPPS and the POS.
Study 1: The Developmental Coordination Disorder Questionnaire – German (DCDQ-G) was the result of the translation and adaptation of the DCDQ ´07 and was found to be culturally appropriate and psychometrically sound. Specificity and sensitivity for the total sample were 52.4 % and 90% respectively. Sensitivity for the clinic sample was 72.7% and specificity 95%. The community sample had a sensitivity of 30 % and a specificity of 86.7%. The completion of Study 1 allowed the use of the DCDQ-G in conjunction with the German translation of the Movement Assessment Battery for Children – Second Edition (MABC-2) in the main study to select children with pDCD as per the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition-Text Revision (DSM-IV-TR) criteria.
Study 2: Preschool children with pDCD were found to have a significantly lower overall developmental play age compared to their typically developing peers and engaged less frequently in group play and more frequently in on-looking and unoccupied behaviour. Children with pDCD were also found to be more frequently involved in aggression both as aggressor and victim. Parents of children with pDCD rated their child´s wellbeing as significantly lower at preschool compared to the parents of typically developing children. Unexpectedly, engagement in play was not related to wellbeing for children with pDCD however for the typically developing children, engagement in type of social play predicted the total KINDLR score as well as several of the subscales.
Study 3: Teachers found OPC to be useful in raising their awareness of issues surrounding occupational performance difficulties and in generating solutions to those difficulties in the preschool environment. Improvements were noted in the children´s occupational performance, in their developmental play skills, and in their frequency of engagement in group play.
Children with pDCD did not engage in play at preschool to the same extent as their peers and according to parent report, experienced a lower level of wellbeing at preschool. There is a need for early intervention aimed at increasing participation in play of children with pDCD as early as preschool. Furthermore, children with pDCD are potentially at risk of involvement in aggressive incidents and while this remains to be confirmed, given the potential consequences of aggressive behaviour this should be a future research priority with this age group. The intervention piloted in this thesis offers one potential mode of early intervention however this also needs further investigation. Finally, the proposed adaptation to the ICF-CY may offer a way of understanding the links between wellbeing and play and how the associations are potentially moderated by increased engagement in activity such as play as well as by enhancing environmental supports.