Peer problems mediate the relationship between developmental coordination disorder and behavioral problems in school-aged children

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Peer problems mediate the relationship between developmental

coordination disorder and behavioral problems in school-aged children

Matthias Oliver Wagner

^a,

*, Klaus Bo¨s

^b

, Julia Jascenoka

^c

, Darko Jekauc

^a

, Franz Petermann

^c

aUniversityofKonstanz,78457Konstanz,Germany

bInstituteforSportsandSportsScience,KarlsruheInstituteofTechnology,76131Karlsruhe,Germany

cCentreforClinicalPsychologyandRehabilitation,UniversityofBremen,28359Bremen,Germany

1. Introduction

Thechild’sdevelopmentdependsontheinteractionofdifferentfunctionalareas,whichcanbedescribedbymotor, psychological, cognitive, perceptual,linguistic, and social aspects.The particular importanceof well developedmotor functionsisalreadyevidentinearlychildhood.Forinstance,theabilitytocrawlandwalkisnotonlyimportantforthe developmentofotherfunctionalskillssuchasrunning,hopping,andclimbing,butalsocanpositivelyaffectachild’ssocial and cognitivedevelopment(Piek,2006,p. 145). If‘‘Performancein daily activitiesthat requiremotorcoordination is substantially below that expected given the person’s chronological age and measured intelligence,’’ the presence of developmentalcoordinationdisorder(DCD)ispossible(DSM IV TR315.4A;AmericanPsychiatricAssociation,APA,2000,p.

58).However, aﬁnaldiagnosisofDCD shouldonlybemadewhenthedetected performanceproblemsinterferewith academicachievementsordailyactivitiesandarenotduetoageneralmedicalcondition.Further,‘‘IfMentalRetardationis present,themotordifﬁcultiesareinexcessofthoseusuallyassociatedwithit.’’(seeDSM IV TR315.4B D;APA,2000,p.58).

Keywords:

Peerproblems

Developmentalcoordinationdisorder Behavioralproblems

School-agedchildren

ABSTRACT

Theaimofthisstudywastogaininsightsintotherelationshipbetweendevelopmental coordinationdisorder,peerproblems,andbehavioralproblemsinschool agedchildren wherebothinternalizingandexternalizingbehavioralproblemswereconsidered.We assumed that the relationship between developmental coordination disorder and internalizing/externalizing problems in school aged children is mediated by peer problemsandtestedthehypothesisthatagreaterdegreeofmotorimpairmentcauses a greater degree of peer problems and thus a greater degree of internalizing or externalizing problems. Seventy boys and girls aged between 5and 11 years were examinedusingtheMovementAssessmentBatteryforChildren2andtheIntelligenceand DevelopmentalScales.Theresultsofpathanalysisshowedthattherelationshipbetween developmentalcoordinationdisorderandinternalizing/externalizingproblemsinschool agedchildrenismediatedatleastinpartbypeerproblems.However,thecross sectional designofthestudydoesnotprovideconclusiveevidenceforacause effectrelationship andonlyallowsfortheconservativeprognosisthatagreaterdegreeofmotorimpairment maycauseagreaterdegreeofpeerproblemsandthusagreaterdegreeofinternalizing/

externalizingproblems.Nevertheless,theresultsofthisstudyemphasizetheimportance ofbeingwell integratedintheirpeergroupespeciallyforchildrenwithdevelopmental coordinationdisorder.

*Correspondingauthor.

E-mailaddress:matthias.wagner@uni-konstanz.de(M.O.Wagner).

Konstanzer Online-Publikations-System (KOPS) URL: http://nbn-resolving.de/urn:nbn:de:bsz:352-0-346951

Erschienen in: Research in Developmental Disabilities ; 33 (2012), 6. - S. 2072-2079 https://dx.doi.org/10.1016/j.ridd.2012.05.012

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AccordingtoMaga˜lhaes,Cardoso,andMissiuna(2011)themostfrequentlycitedmotorissuesinchildrenwithDCDarepoor handwritingskills,difﬁcultiesinplayingballgamesandgettingdressed.

DCDdoesnotdescribeasingleentitybutshouldratherbeunderstoodasacollectivetermforavarietyofdifferentsubtypes (Visser,2003).Especiallychildrenwithgeneralizedsensorimotordeficitsoftenshowcomorbiddisorderssuchasattention deficit/hyperactivitydisorder(ADHD;Gillberg&Kadesjo¨,2000)orreadingdisability(Kaplan,Wilson,Dewey,&Crawford, 1998).Hence,thestatementbyGilgerandKaplan(2001,p.465)thatinthefieldofdevelopmentaldisabilities‘‘[...]comorbidity [...]istheruleratherthantheexception’’obviouslyalsoappliestothefieldofDCD.Selectedtheoriesoncomorbiditypromisea betterunderstandingofthenature,etiology(recentlyMoruzzietal.,2010versusLoh,Piek,&Barrett,2011)andtheprognosisof DCD(seeVisser,2003).However,tofacilitateacomprehensivedevelopmentalprognosisandtodesigneffectiveinterventions forchildrenwithDCD,itisespeciallyrelevanttounderstandhowmotorandnon motorproblemsinfluenceeachotherina child’s development(e.g., Kastner, Lipsius, Hecking,Petermann, Petermann, Mayer & Springer (2011)Wagner, Kastner, Petermann,Worth,&Bo¨s,2011)andtoidentifycontextualcharacteristicsthatareimportantforthisrelation.

Green,Baird,andSugden(2006)concludethatchildrendiagnosedwithDCDgenerallyfaceemotionalandbehavioral problems.Morespecifically,thefindingsbyDewey,Kaplan,Crawford,andWilson(2002)indicatethatchildrenwithDCD show a greater degree of internalizing and externalizing problems compared to typically developing children. Both internalizingandexternalizingproblemscanbeconsideredassubgroupsofemotionalorbehavioralproblems.Internalizing behaviors are best characterized as inward directed, while externalizing behaviors manifest themselves as outward directed.Indicationsofinternalizingbehaviorsincludeachildbeingdepressedorhavingunfoundedfearsandphobiasor excessiveworries.Externalizingbehaviorsincludeachildviolatingsocietalnormsorrules,ignoringteachers’reprimandsor beinghyperactive(Smith,2007). TherelationbetweenDCDandthedifferentaspectsofinternalizingandexternalizing problemshasbeenstudiedextensivelyintheliterature.ThemostsignificantfindingsarethatDCDisrelatedwithhigher levelsof anxiety(e.g.,Pratt &Hill,2011), depression(e.g.,Piek,Bradbury,Elsley, &Tate, 2008)and introversion(e.g., Schoemaker&Kalverboer,1994)aswellasADHD(e.g.,Rasmussen&Gillberg,2000)andtheexpressionofdeviantbehaviors (e.g.,Kanioglou,Tsorbatzoudis,&Barkoukis,2005).

Inadditiontoproblemsinpsychosocialadjustment,childrenwithDCDmaybeatriskforpeerrelationshipproblems(Dewey etal.,2002).Forinstance,childrenwithDCDoftenspendtheirrecessalone(Bouffard,Watkinson,Thompson,CausgroveDunn,

&Romanow,1996),generallychoosemorequietactivities(Jarus,Lourie Gelberg,Engel Yeger,&Bart,2011),showalow engagementinsocialphysicalplay(Smyth&Anderson,2000)ororganizedsports(Maga˜lhaesetal.,2011)andperceiveless enjoymentindailyactivities(Bart,Jarus,Erez,&Rosenberg,2011)aswellaslesssocialsupport(Skinner&Piek,2001).Especially boysdiagnosedwithDCDtendtoshowalowengagementinmoderatetovigorous(Greenetal.,2011)aswellasstructuredand unstructured (Poulsen, Ziviani, Cuskelly, & Smith, 2007) group physical activities. These ﬁndings support the general impressionofapoorsocialization(Kanioglouetal.,2005)orevensocialisolation(Smyth&Anderson,2000)inchildrenwith DCD;aphenomenonthatappearstoremainstablethroughoutadolescence(Cantell,Smyth,&Ahonen,1994).

Inaddition,themeta analysisbyReijntjes,Kamphuis,Prinzie,andTelch(2010),therandomizedcontrolledintervention studybyWitvliet,vanLier,Cuijpers,andKoot(2009)andtheshorttermprospectiveinvestigationbySchwartz,McFayden Ketchum,Dodge,Pettit,andBates(1998)supporttheideathatpeerproblemsandinternalizing/externalizingproblemsare closelyrelated.

However,todatethecomplexrelationshipbetweenDCD,peerproblemsandinternalizingorexternalizingproblemsis largely unknown. A betterunderstanding of this relationship is important for a more comprehensive developmental prognosisandthedevelopmentofeffectiveinterventionsforchildrenwithDCD.

TheaimofthisstudywastogaininsightsintotherelationshipbetweenDCD,peerproblems,andbehavioralproblemsin school agedchildren.Bothinternalizingandexternalizingbehavioralproblemswereconsideredbecauseoftheirpotential co developmentanduni directional(ingirls)/bi directional(inboys)progressionshowninafour yearcross laggedpanel studybyLeeandBukowski(2012).

Basedontheassumptionthatdevelopmentresultsofadynamicandaction mediatedperson environmentinteraction (seealsoLerner,1998)andconsideringtheresultsoftheliterature,weassumedthattherelationshipbetweenDCDand internalizing/externalizingproblemsinschool agedchildrenismediatedbypeerproblems.Wehypothesizedthatagreater degreeof motorimpairmentcausesa greaterdegreeofpeer problemsandthus a greaterdegreeofinternalizingand externalizingproblems.

2. Materialsandmethods 2.1. Sample

Thirty ﬁve children who underwent occupational therapy¹ (occupational therapy group, OTG; for demographic informationseeTable1)and35typicallydevelopedchildrenmatchedforageandgender(controlgroup,CG)wereincluded inthiscross sectionalstudy.

1Atthetimeoftheinvestigation,thechildrenhadreceivedamaximumofﬁve50-mintherapysessions,whereeachtherapistusingtheirownindividual approach.

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Participants were recruited from selected occupational therapy practices and elementary schools. The Movement AssessmentBatteryforChildren2(MovementABC 2;Henderson,Sugden,&Barnett,2007;Petermann,2011)wasusedto determinechildren’sdegreeofmotorimpairmentinbothgroups(foramoredetaileddescriptionofthetestprocedure,see Section2.2).TheresultingMovementABC 2rawscoresweretransferredintocorrespondingpercentileranksonthebasisof Germannormativedata(Petermann,2011).Table2showstheaveragepercentileranks(PR)intheoccupationaltherapy group.

TheaveragePRclearlyshowedthatboysandgirlsintheoccupationaltherapygroupmetthecriteriaofasigniﬁcantmotor impairment (PR<5) or should at least be carefully monitored (PR 6 15). In other words, these children ‘‘[...] fell substantiallybelowperformanceexpectedgiventheirchronologicalage[...]’’(DSM IV TR315.4A;APA,2000,p.58).OTG Children’smotorimpairment‘‘[...]signiﬁcantlyinterferedwiththeiracademicachievementoractivitiesofdailyliving.’’

(DSM IV TR315.4B;APA,2000,p.58),was‘‘[...]notduetoageneralmedicalcondition(e.g.,cerebralpalsy,hemiplegia,or musculardystrophy)and[did]notmeetcriteriaforaPervasiveDevelopmentalDisorder.’’(DSM IV TR315.4C;APA,2000,p.

58).Atotalof21childrenwereexcludedpriortotheinvestigationduetopoorcognitiveperformances(nonverbalIQ<70;

ICD 10F82.0D;WHO,2005),whereforeDSM IVTR315.4Dwasnotconsidered.

2.2. Measurements

TheGermanversion(Petermann,2011)oftheMovementAssessmentBatteryforChildren2(MovementABC 2;ageband1 3;Hendersonetal.,2007)wasusedtodeterminechildren’sdegreeofmotorimpairment.Measurementsforeightsubtests assignedtothethreedimensions‘manualdexterity’(MD),‘aimingandcatching’(AC)and‘balance’(BL)wererecordedand summedtoaTotalScore(TS).Thesupplementaryparents questionnaireoftheIntelligenceandDevelopmentalScales(IDS,² Grob,Meyer,&Hagmann vonArx,2009)wasusedtodeterminechildren’sdegreeofpeerproblemsandtheirdegreeof internalizingandexternalizingproblems(seealsoKastner&Petermann,2010).Anexampleforeachsubscaleisshownin Fig.1.

Thesubscalesforpeerproblems(fouritems,

a

⁼^0.931)^and^forinternalizing(sixitems,

a

⁼^0.809)^andexternalizing (sevenitems,

a

⁼^0.895)^problems^were^defined^basedôn^the^factorânalyticalconsiderationsbyKastner(2010).Thehigh internalconsistencyofthePeerProblemSubscaleallowsfortheformationofaPeerProblem(Subscale)Score(PPS=sumofitem scores/number ofitems; [0 4]). Similarly, subscalescoresfor internalizing(IPS; [0 4]) and externalizing (EPS;[0 4]) problems wereformed. The Total Score (TS;[0 15]) wascomputed according to theMovement ABC 2 manual (see Hendersonetal.,2007,p.82).Higher(subscale)scoresrepresentagreaterdegreeofmotorimpairment,peerproblemsand internalizing/externalizingproblems.

2.3. Procedure

Allparentsreceiveddetailedinformationabouttheresearchprojecteitherinwrittenformororally(intheformofa parent’sevening).Thewrittenconsentoftheparentswasobtainedbeforethestartofthetestprocedureswiththeoptionto revoketheirconsentatanytime.Themotortestingwasconductedasasingletestinselectedpracticesandschools.The questionnairewasusuallycompletedbytheaccompanyingmotherinaseparateroomatthesametimetheirchildrenwere Table1

Demographicinformationontheoccupationaltherapygroup.

Total Boys Girls

Meanage 7.69 7.52 8.25

SD 1.55 1.65 1.04

Min 5.00 5.00 7.00

Max 11.00 11.00 10.00

N 35 27 8

Table2

AveragepercentileranksoftheMovement-ABCmotortestintheoccupationaltherapygroup.

Total Boys Girls

Mean 4.77 4.68 5.05

SD 4.94 5.33 3.67

Min 0.10 0.10 0.40

Max 16.00 16.00 9.00

N 34 26 8

2TheIDSisageneraldevelopmentaltestwithanintegratedintelligencetestandrepresentsarevisionoftheKramer-IntelligenceTestthatcanbeusedin 5;00to10;11year-oldchildren.

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tested.Inappreciationoftheirparticipation,participantscouldrequestapersonalconversationwheretheyreceivedtheir testresults.

2.4. Dataanalysis

Testingthepostulatedmediationsbetweenmotorimpairment,peerproblems,andinternalizing/externalizingproblems simultaneouslyusingtherespectivetotalscoresisamultivariateproblem;thecorrespondingpath diagramisshownin Fig.2.

Accordingtothehypothesis,allmodelpathsbetweentheexogenous(TS)andendogenous(PPS,IPS,EPS)variablesand betweentheendogenousvariablesaredirected.Therefore,one tailedtestingwasperformed,andtheerrorprobabilitywas setapriorito

a

⁼^0.05.

Full informationmaximumlikelihood(FIML)estimationwasperformedusingAMOS(Arbuckle,2006)Version20(IBM, Armonk,NY).Assumingmultivariatenormaldistributionofthedataandthatdataaremissingatrandomorcompletelyat random,FIMLprovidesunbiasedparameterestimates(Enders&Bandalos,2001).³Theproportionofmissingdataforeach variableinthemodelrangedfrom2.9%to10.0%.Theoverallproportionofmissingdatawas5.7%(16of280responses).

MCAR Test by Little(1988) wasnot signiﬁcant(

x

²⁼^6.90; ^df⁼^13; ^p⁼^0.907) ^indicating ^that ^themissingness was not systematic.Moreover,nostrikingpatterncouldbefoundwithinthemissingdata.

To evaluate the model ﬁt, selected incremental ﬁt indices were referenced including Root Mean Square Error of Approximation(RMSEA)andComparative Fit Index(CFI).TheindiceswereselectedaccordingtoBeauducelandWittmann (2005)andevaluatedbasedontherecommendationsofHuandBentler(1999).

3. Results

3.1. Descriptivemeasures

TheresultspresentedinTable3showedthatthechildrenintheoccupationaltherapygrouphadconsistentlyhigher scoresthanthoseinthecontrolgroup,whichindicatesagreaterdegreeofmotorimpairmentandagreaterdegreeofpeer, internalizingandexternalizingproblems.

Please tick the most appropriate answer:

4 3 2 1 0

aHas many friends

¤ ¤ ¤ ¤ ¤

bIs anxious, worried

¤ ¤ ¤ ¤ ¤

cIs overly aggressive with peers

¤ ¤ ¤ ¤ ¤

0 = no problem; 1 = slight problem; 2 = moderate problem; 3 = serious problem; 4 = very serious problem

Fig.1.Exemplaryitemsfromthesubscaleson:(a)peerproblems,(b)internalizingproblems,and(c)externalizingproblemsusedintheIntelligenceand DevelopmentalScales.

Fig.2.PathdiagramshowingtherelationshipbetweentheTotalScore(TS),thePeerProblemScore(PPS),theInternalizingProblemScore(IPS),andthe ExternalizingProblemScore(EPS).

3Evenwhentheassumptionofmultivariatenormalityisviolated,FIMLprovidesrelativelygoodestimationscomparedtodeletionormeanimputation methods(Enders&Bandalos,2001).

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3.2. Hypothesistesting

TheresultsofthepathanalysisareshowninFig.3.The

x

²^statistic^revealed^no ^signiﬁcantdifferencesbetween the theoreticalandtheempiricalcovariancematrix(

x

²⁼^0.530;^df⁼^1;^p⁼^0.467).^Theincrementalﬁtindices(RMSEA=0.000 [0.000;0.284];CFI=1.000)werebelowtheupperlimitofRMSEA(<0.08)andabovethelowerlimitofCFI(>0.95).

Thefollowingdirectandindirecteffectswereobserved:

(i) Thegreaterthedegreeofmotorimpairment,(a)thegreaterthedegreeofpeerproblems(

b

⁼^0.281;^p<0.01)and(b)the greaterthedegreeofinternalizing(

b

⁼^0.318;^p<0.01)andexternalizing(

b

⁼^0.220;^p<0.05)problemsinschool aged children.

(ii)Thegreaterthedegreeofpeerproblems,thegreaterthedegreeofinternalizing(

b

⁼^0.197;^p<0.05)andexternalizing (

b

⁼^0.405;^p<0.01)problemsinschool agedchildren.

Hence,therelationshipbetweenDCDandinternalizing/externalizingproblemsinschool agedchildrenwasmediatedby peerproblems.However,thesigniﬁcantdirectpathsbetweenmotorimpairmentandinternalizing/externalizingproblems contradicttheassumptionofacompletemediation.

4. Discussion

TheaimofthisstudywastogaininsightsintotherelationshipbetweenDCD,peerproblems,andbehavioralproblemsin school agedchildrenwherebothinternalizingandexternalizingbehavioralproblemswereconsidered.Theresultsofthis Table3

DescriptivemeasuresoftheMovement-ABCTotalScoreandtheIntelligenceandDevelopmentalScales(subscale)scoresforthetwosamplegroupsandthe entirestudysample.

TS^a PPS^b IPS^c EPS^d

OTGê CG^f Total OTGê CG^f Total OTGê CG^f Total OTGê CG^f Total

Mean 10.77 4.79 7.78 1.67 1.08 1.37 1.03 0.50 0.76 1.23 0.53 0.87

SD 1.79 2.36 3.66 1.09 0.95 1.06 0.62 0.61 0.67 0.91 0.61 0.84

Min 8.00 0.00 0.00 0.00 0.00 0.00 0.17 0.00 0.00 0.00 0.00 0.00

Max 14.00 11.00 14.00 3.50 3.75 3.75 3.17 2.50 3.17 3.00 2.57 3.00

Skew 0.18 0.38 0.16 0.23 1.09 0.62 1.25 1.68 1.13 0.39 1.88 0.98

Kurt 1.08 0.32 1.03 1.05 0.68 0.66 3.08 2.86 1.63 0.61 3.63 0.11

N 34 34 68 33 34 67 32 34 66 31 32 63

aTotalScore.

b PeerProblemScore.

cInternalizingProblemScore.

d ExternalizingProblemScore.

eOccupationaltherapygroup.

f Controlgroup.

Fig.3.Resultsofthepathanalysis(StandardizedRegressionWeights).TS,TotalScore;PPS,PeerProblemScore;IPS,InternalizingProblemScore;EPS, ExternalizingProblemScore;e1–e3,errorvariables;r²,SquaredMultipleCorrelations;df,degreesoffreedom;p,probabilitylevel;*p<0.05;**p<0.01;

RMSEA,Root-Mean-Square-ErrorofApproximation;CFI,Comparative-Fit-Index.

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studysuggestthattherelationshipbetweenDCDandinternalizing/externalizingproblemsinschool agedchildrenisindeed mediatedatleastinpartbypeerproblems.Inaddition,thesignsofthepathweightsindicatethatagreaterdegreeofmotor impairmentcausesagreaterdegreeofpeerproblemsandthusagreaterdegreeofinternalizing/externalizingproblems.

Basedontheresultsofthisstudy,thequestionariseswhychildrenwithDCDoftenhaveproblemsingettingalongwith theirpeers.Oneessentialprerequisiteforsocialinteractionandthedevelopmentofsociallydesirablebehaviorsistheability forempathy(Thompson,1987).Thedevelopmentofempathicabilitiesinturnrequirestheabilitytoperceivevisualstimuli inaninterpersonalcontext(Lemerise&Arsenio,2000).EspeciallychildrenwithDCDoftenshowdifﬁcultiesinrecognizing emotionalstimuliinthefacialexpressionoftheirpeers(Cummins,Piek,&Dyck,2005).Thus,theyoftentendtoshowan inadequateamountofempathy(Kastner&Petermann,2010),whichisonepossibleexplanationforthedeﬁcitsinpeer relationships shown by Dewey et al. (2002). Therefore, visual perceptual skills (see also Tsai, Wilson, & Wu, 2008) presumablymediatetherelationshipbetweenmotorskillsandthoseemphaticskillsthatarerelevantforthedevelopment andmaintenanceofpositivepeerrelationships(seealsoKastner&Petermann,2010).

Further, the relationship between peer problems and internalizing/externalizing problems may be interceded by mediatingvariables.Forinstance,SkinnerandPiek(2001)reportedlowerself worthinchildrenwithDCD.Includingself worthisrelevantbecause(i)therelationshipbetweenpeerproblemsandinternalizingsymptomsismediated(ingirls)or moderated(inboys)byanegativeself worth(cf.Grills&Ollendick,2002),and(ii)internalizingproblemscanbeassumedin aself conceptmediated,reciprocal deterministicrelationshipwithexternalizingbehaviorproblems(Lee&Stone,2012).

Interestingly,DCD inﬂuencedpeerproblemsaremorestronglyrelatedtoexternalizingthantointernalizingproblems.

Thisresultscanbeexplainedassumingareciprocal deterministicrelationshipbetweenbehaviorandself concept(Lee&

Stone,2012)orbetweenself perceptionandpeerrelationships(Salmivalli&Isaacs,2005),respectively.Althoughneither internalizing(seeReijntjesetal.,2010)nor(forboys)externalizing(cf.Kochenderfer&Ladd,1997)reactionspromisea reductionofvictimizationandexclusion,childrenwithexternalizingdisordersappeartobemoreinterestedinbondingwith deviantpeers(Patterson,Forgatch,Yoerger,&Stoolmiller,1998;Rasmussen&Gillberg,2000).Badcompanyprospectively reinforceschildren’sowndeviantbehavior,whichisapossibleexplanationfortherelativelystrongermediationfoundinthe presentstudy.However,becausetheprevalenceofexternalizingbehaviorsisgenerallyhigherinboysthaningirls(recently Yang,Li,Zhang,Tein,&Liu,2008)thedifferenceinthestrengthbetweenthetwomediationscouldalsobeexplainedbythe overrepresentationofboysinthestudy.Inanycase,thestrongermediationbetweenmotorimpairment,peerproblems,and externalizing problems servesas a statistical explanation forthe relativelystronger signiﬁcantdirect effect ofmotor impairmentoninternalizingthanonexternalizingproblems.However,itispossiblethatbothdirecteffectswoulddecrease withtheinclusionoftheaforementionedmediators.

The limitationsof this studyinclude itscross sectional designthat does notallowfor identifyingthecause effect relationshipbetweenmotorimpairment,peerproblems,andinternalizing/externalizingproblems.Otherlimitationsofthis studyarethewideage range,theunequaldistributionofgenders,theheterogeneousnumberoftreatmentsandthedifferent therapyapproachesusedintheoccupationaltherapygroup.Concerningmeasurementinstruments,ithastobequestioned whethertheMovementABC 2actuallyprovidesavaliddiagnosisofmotorimpairment(recentlySchulz,Henderson,Sugden,

&Barnett,2011,Wagner,Kastner,Petermann,&Bo¨s,2011).Acorrespondingcompendiumforearlydiagnosisofmotor functionshasbeenpublishedrecently(seeWagner,Macha,etal.,2011).Finally,themeasurementofpeerandbehavioral problemsshouldbediscussedmorecritically:althoughthepsychometricpropertiesoftheIDSappearquitestrong,the findingsofthisstudyshouldbeconfirmedinfuturestudiesusingmorestandardizedmeasurementssuchas,forinstance,the Juvenile Victimization Questionnaire (JVQ; Finkelhor, Hamby, Ormrod,& Turner, 2005)and the Strengthand Difficulties Questionnaire(SDQ;Goodman,1997).

Insummary,theassumeddirectionofthepathsshouldbefurtherinvestigatedinlongitudinalstudieswithanage and gender homogenoussampleafterreceivingacomparablenumberofsimilarOT treatments.Therefore,thediscussionon other intrapersonal(e.g., visual perception, emotional recognition, self worth) and contextual (e.g.,parents, teachers) mediators (includingtheir reciprocaldependencies)and moderators (e.g.,gender)hasto becontinuedaswell asthe discussiononvalidmeasurementsforthedifferentconstructs.

InexpansionoftheﬁndingsofDeweyetal.(2002),theresultsofthecurrentstudyshowedthattherelationshipbetween DCDandinternalizing/externalizingproblemsinschool agedchildrenismediatedatleastinpartbypeerproblems.In regardtoamorecomprehensivedevelopmentalprognosisforchildrenwithDCDitcanbeassumedwithcautionthata greaterdegreeofmotorimpairmentmaycauseagreaterdegreeofpeerproblemsandthusagreaterdegreeofinternalizing/

externalizingproblems.

Ourﬁndingssuggestthatintegrationintothepeergroupisparticularlyimportantforachievingapermanentreductionof psychosocialbehavioralproblemsinchildrenwithDCD.However,integrationintothepeergroupnotonlydependsonthe improvementofmotorskillsusingtasks orientedapproacheswithcognitiveelements(foranoverviewseePolatajko&

Cantin,2006),butalsocanalso undertheassumptionofreciprocal determinism resultfromappropriatebehavioral interventions(seeoverviewin Weisz,Hawley,&Jensen Doss,2004). Thesuccessandsustainabilityofsuchcombined measurespresumablydependonhowparents,teachers,andfriendssucceedinenhancingempathy,cooperationandself worthoftheaffectedchildren.Theabilitytoconsiderthefeelingsofothers,acceptrulesandstandardsandfocusonone’s ownstrengthsandweaknessesimprovesachild’sprospecttopermanentlyestablishthemselvesintheirpeergroup.Positive andstablepeerrelationshipscanbeseenasthebasisforanincreasedparticipationinphysical/sportsactivities(fortheeffect ofin deﬁcitpeerrelationshipsonphysicalactivitypatternsseeStorch,Milsom,DeBraganza,Lewin,Geffken&Silverstein,

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2007).Resultingincreaseofmovementandsocializationexperiencespresumablyinitiatesandsupportstheself regulatory processagainstestablishmentofcomplexmotorandpsychosocialbehavioralproblems.

5. Conclusion

TherelationshipbetweenDCDandinternalizing/externalizingproblemsinschool agedchildrenismediatedatleastin partbypeerproblems.Agreaterdegreeofmotorimpairmentmaycauseagreaterdegreeofpeerproblemsandthusagreater degreeofinternalizingorexternalizingproblems.

Disclosurestatement

Theauthorsdeclarethatthereisnoactualorpotentialconﬂictofinterest.

Acknowledgments

TheauthorswouldliketothankPriv.Doz.Dr.AnnegretMu¨ndermann(ABRSolutions)whoprovidedscientiﬁcwriting serviceson behalfof the authors. Furthermore, the authorswould liketo thank Prof. Dr. Hans Christian Waldmann (UniversityofBremen)andProf.Dr.SonjaPerren(JacobsCenterforProductiveYouthDevelopment,Zurich)forproductive andcollegialdiscussions.

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