Children With Developmental Coordination Disorder and ADHD at Risk for Depression, Anxiety Symptoms

Deborah Brauser

November 05, 2009

November 5, 2009 (Honolulu, Hawaii) — Children with both developmental coordination disorder (DCD) and attention deficit hyperactivity disorder (ADHD) have significantly higher levels of depressive symptoms, with many above the threshold for clinical concern, compared with typically developing children or those with either disorder alone, according to a population-based study.

Presented here at the American Academy of Child & Adolescent Psychiatry 56th Annual Meeting, the study also showed that children with DCD, with or without ADHD, have significantly more anxiety symptoms than their typically developing peers or those with ADHD alone.

"This study suggests screening for mood and anxiety problems is necessary for children with comorbid DCD and ADHD, particularly since the symptoms can be significant, are often underestimated by parents, and in some cases included suicidal ideation," lead author Kathyryn Macdonald, MD, associate professor, Department of Psychiatry and Behavioral Neurosciences, McMaster University, Ontario, Canada, told Medscape Psychiatry.

"In clinical settings where ADHD is diagnosed, the presence of DCD may have implications for the child's response to standard treatment if the comorbidity goes unrecognized," she added.

DCD Highly Prevalent

According to the study, recent research has shown that children with DCD are often socially isolated, at risk for obesity, frequently suffer from attentional difficulties, and may have more mental health issues as adults.

"Given that the prevalence of DCD is 5% to 6% of the population, this represents a substantial cost to society in terms of healthcare and decreased productivity," said Dr. Macdonald.

"Part of the difficulty is that it's not a disorder people think about a lot," she continued. "So rehab specialists and occupational therapists tend to think of it frequently, but child psychiatrists less so, and so kids often don't get diagnosed."

In this 2-stage, cross-sectional study, the investigators sought to evaluate symptoms of psychological distress among a general population sample of children who had DCD only, those who had ADHD only, those who had both DCD and ADHD (DCD/ADHD), and those who were deemed "typically developing."

A total of 3151 children from 23 elementary schools in Canada were screened. Of these, 257 children were selected for full assessment.

The study group included those previously diagnosed with ADHD, those who scored less than the fifth percentile on DCD measures, and a randomly selected group of children with no diagnosis of either disorder.

Each child then went through a home-based occupational therapy assessment. This included the therapist-administered Movement Assessment Battery for Children and the Kaufman Brief Intelligence Test 2 and a clinical interview to focus on the effect of difficulties on everyday activities.

In addition, both the patients and parents completed self-reports on depression, using the Children's Depression Inventory, and anxiety, using the Screen for Child Anxiety Related Emotional Disorders.

Of the 244 children (60% boys; mean age, 11.4 years) who completed the study, 54 had DCD/ADHD, 68 had DCD only, 31 had ADHD only, and 91 were classified as "typical."

Higher Rate of Depression, Anxiety

Results showed that children with DCD/ADHD had the highest levels of depressive symptoms compared with children in the other groups. In addition, children with DCD only, ADHD only, or DCD/ADHD, as well as their parents, reported significantly higher levels of depression than in the typically developing group (P < .001 for all except child-reported ADHD only, which was P < .01).

Depressive Symptoms

Children's Depression Inventory DCD/ADHD DCD Only ADHD Only Typical
Child-reported symptoms 11.02 (6.58) 9.99 (7.07) 8.19 (5.76) 5.89 (5.06)
Parent-reported symptoms 17.17 (7.95) 12.42 (6.48) 14.90 (6.40) 7.83 (5.50)

For anxiety, significantly more symptoms were reported by children with DCD, with or without ADHD, than those who only had ADHD or were typically developing (P < .01).

Anxiety Symptoms

Screen for Child Anxiety Related Emotional Disorders DCD/ADHD DCD only ADHD only Typical
Child-reported symptoms 24.34 (13.00) 21.99 (13.29) 17.98 (10.30) 17.06 (11.76)
Parent-reported symptoms 14.39 (10.08) 14.69 (12.37) 14.42 (11.12) 7.39 (6.65)

In addition, children with ADHD only did not report more anxiety than the typical children. Finally, parents reported fewer symptoms of anxiety than the children did themselves across all 4 groups.

Earlier Screening Needed

"We now know that if we have kids in our practices who meet the criteria for DCD, with or without ADHD, that we need to be screening early on for mood and anxiety symptoms," said Dr. Macdonald.

She noted that the symptoms found were not always minor. "We picked up several kids who had suicidal thoughts, but no one had ever asked them [about that], so it can be potentially life-threatening if these symptoms are not recognized."

"Obviously, the sooner you treat these issues, the better off kids are, particularly with things like anxiety, where it usually progresses and kids often start using avoidance strategies, which tends to make the anxiety worse," explained Dr. Macdonald.

The recommended next steps include better screenings for DCD and ADHD, as well as for mood and anxieties in children presenting with diagnosed DCD or DCD/ADHD, and ways to improve access to treatment, said Dr. Macdonald.

"Are there things that can be done either in a school setting or in a community clinical setting? Or perhaps setting up cognitive behavioral therapy–type groups that could be helpful for these kids? Whatever we choose, the most important thing is that these children get access to something that's going to help them with these symptoms," she added.

Causality Not Shown

"I agree completely with the authors' suggestion for screening for mood and anxiety problems in the DCD/ADHD population," said Neal D. Ryan, MD, AACAP program committee chair, and professor of psychiatry at the University of Pittsburgh Medical Center in Pennsylvania.

However, Dr. Ryan, who was not involved with the study, did have some concerns with its design.

"This study looked at the cross-sectional comorbidity of DCD with other psychiatry problems. A very well understood limitation of all cross-sectional studies is that they do not give evidence about the causal relationship in these measured associations.

"For example, we don't know from this whether DCD 'causes' more depressive symptoms, whether some unmeasured third factor causes both DCD and depression, or even perhaps whether kids with comorbid DCD and depressive symptoms were more likely to agree to the study than other kids — a possibility, although not likely," Dr. Ryan told Medscape Psychiatry.

He added that the authors do show that they understand that causality was not shown and "word all their conclusions in a very thoughtful manner."

The study was supported by the Canadian Institutes of Health Research. Dr. Macdonald has disclosed giving past educational talks for AstraZeneca. Dr. Ryan has disclosed no relevant financial relationships.

American Academy of Child & Adolescent Psychiatry 56th Annual Meeting: Abstract 5.25. Presented October 30, 2009.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: