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Human Movement Science 27 (2008) 215229

www.elsevier.com/locate/humov

Activities of daily living in children

with developmental coordination disorder:
Dressing, personal hygiene, and eating skills
Janet Summers a,z, Dawne Larkin a,*, Deborah Dewey b,c
a
School of Human Movement and Exercise Science, M408, The University of Western Australia,
35 Stirling Highway, Crawley, Perth, WA 6009, Australia
b
Departments of Pediatrics and Community Health Sciences, University of Calgary, Canada
c
Behavioural Research Unit, Alberta Childrens Hospital, Calgary, Canada

Available online 17 March 2008

Abstract

In order to understand how age, culture, and problems in motor coordination impact the perfor-
mance of activities of daily living, we used focus groups and in-depth interviews with Australian and
Canadian parents to examine activities of daily living of younger (57 years of age) and older (8
9 years of age) children with and without DCD. By comparison with their typically developing
age group, children with DCD had more diculty with dressing, personal hygiene, and eating skills.
Diculties with postural control and ne-motor skills were reported to contribute to poorer perfor-
mance of activities of daily living. As expected, competence in the performance of activities of daily
living improved in the older children with and without DCD and there were few dierences in the
performance of daily living tasks between typical children in Australia and Canada. Overall, the
motor diculties of children with DCD had a signicant impact on performance of a wide range
of daily activities.
2008 Elsevier B.V. All rights reserved.

PsycINFO classication: 3250

Keywords: Activities of daily living; Developmental coordination disorder; Children; Motor coordination

*
Corresponding author. Tel.: +61 8 6488 2361; fax: +61 8 6488 1039.
E-mail address: dlarkin@cyllene.uwa.edu.au (D. Larkin).
z
Deceased.

0167-9457/$ - see front matter 2008 Elsevier B.V. All rights reserved.
doi:10.1016/j.humov.2008.02.002
216 J. Summers et al. / Human Movement Science 27 (2008) 215229

1. Introduction

Movement allows us to meet our basic needs, to communicate and to learn. It allows us
to participate in the everyday activities of daily living. When movement is impaired, chil-
drens participation in the activities of daily living can be compromised. Diculties in
movement are a signicant problem for approximately 613% of school age children
(American Psychiatric Association, 1994; Kadesjo & Gillberg, 1999). These movement dif-
culties have been labeled Developmental Coordination Disorder (DCD; American Psy-
chiatric Association, 1994). By denition, children with DCD display a marked
impairment in the development of motor coordination that signicantly interferes with
academic achievement or activities of daily living.
Children with DCD manifest motor decits in virtually every motor domain. They tend
to work more slowly than their typically developing peers (Missiuna & Pollock, 1995;
Schoemaker et al., 2001) and display decits in gross-motor (i.e., balance, gait) (Deconinck
et al., 2006; Geuze, 2005) and ne-motor skills (Rodger et al., 2003; Smits-Engelsman,
Niemeijer, & van Galen, 2001). Intuitively, one would expect that there would be a link
between these motor skill diculties and the performance of activities of daily living.
Case-Smith (1995), however, failed to nd a strong relationship between motor impair-
ment and performance of self-maintenance activities on standardized measures. In con-
trast, other research has reported that children with DCD have diculties with daily
living skills like dressing, personal hygiene, and eating (Mandich, Polatajko, & Rodger,
2003; May-Benson, Ingolia, & Koomar, 2002; Missiuna, Moll, King, & Law, 2007;
Rosenblum, 2006). Rodger et al. (2003) suggested that this lack of consistency could be
due to dierences between parents perceptions and childrens performance on more stan-
dardized evaluations, dierences in the context in which the activities of daily living were
performed, and cultural dierences. They suggested that investigation of children with
DCD in ecologically valid contexts such as the family was needed to improve our under-
standing of childrens participation in activities of daily living.
To explore the specic impact of motor impairment on the performance of daily living
skills, knowledge of typical childrens performance at various ages is required. Signicant
changes occur in childrens motor skills throughout childhood (Roncesvalles, Schmitz,
Zedka, Assaiante, & Woollacott, 2005; Smits-Engelsman, Sugden, & Duysens, 2006;
Smyth, Katamba, & Peacock, 2004) that inuence the performance of activities of daily
living. However, our knowledge regarding the development of activities of daily living
in typical children in the context of the family is limited (Gesell & Ilg, 1946). For example,
based on the current literature we do not know whether typical six-year-old children dress
themselves independently or need assistance. Further, if they need assistance, what type of
assistance do they require and from whom?
There is a growing body of literature that argues that human performance cannot be
isolated from the environmental context in which it occurs (Bronfenbrenner, 1979; Davis
& Burton, 1991; Dewey & Wilson, 2001; Dunn, Brown, & McGuigan, 1994; Gibson, 1977;
Newell, 1986). Weisner (1984) refers to each contextual setting (e.g., home, school) as an
ecocultural niche, and suggests that each should be studied separately and compared
within and across cultures. These theories support the view that performance of activities
of daily living is contingent on multiple factors, which include the unique attributes of the
individual, the context of the physical, socio-cultural environment and the specic
demands of the task (Law et al., 1996). Dierent approaches can be taken to understand
 J. Summers et al. / Human Movement Science 27 (2008) 215229 217

the interrelationship of the individual, environment, and task on human performance. One
in relation to motor performance put forward by Newell (1986) argues that movement is
constrained by factors within the individual, the environment, and the task. Others
describe aordances (Gibson, 1977) or supports (Dunn, 1993) that enable performance.
Dunn et al. (1994) consider that the personenvironment interaction aects all human
behavior, therefore, performance cannot be understood outside of its context.
The view that an individuals performance of activities of daily living is the result of per-
sonenvironmenttask interactions guided this study. This framework allowed us to exam-
ine activities of daily living in younger and older children with DCD in the context of their
family and their familys country of residence (Australia and Canada). To better under-
stand how problems in motor coordination impacted activities of daily living in these con-
texts, knowledge of typical childrens performance was obtained and dierences between
typically developing children and children with DCD were examined.

2. Methods

2.1. Design

Qualitative methods provide a richer source of contextual information about perfor-

mance of self-maintenance activities within the family context, than is obtainable through
questionnaires and quantitative research designs. The qualitative approach allowed us to
explore in detail the development of self-maintenance activities of dressing, personal
hygiene, and eating in typical children and children with DCD. In addition, the impact
of motor problems on self-maintenance behavior and the various strategies parents and
children employed to manage the challenges presented by these motor impairments were
elucidated. The specic qualitative methods used to obtain the parents perspectives
regarding the self-maintenance activities of their children were focus groups (Kreuger,
1994) and individual interviews (McCracken, 1988). The performance areas of self-main-
tenance, rest, play and leisure, and productivity described in the Occupational Perfor-
mance Model (Australia) (Chapparo & Ranka, 1997) were used to develop the focus
group and interview questions that allowed parents to begin the exploration of their chil-
drens activities of daily living.

2.2. Participants

Approval for the study was obtained from the relevant university human ethics com-
mittees in Australia and Canada and informed consent was obtained from participants.
Participants were recruited using purposeful sampling. Participants were parents of Aus-
tralian and Canadian younger (57 years of age) and older (89 years of age) typically
developing children and children with DCD. Parents of typically developing children were
purposively sampled through school and community contacts. Parents of children with
DCD were purposively sampled through contacts with therapists, clinics, and programs
that specialized in treating children with motor problems. The parents ranged in age from
30 to 50 years and the majority were married or in common law relationships. At least one
of each childs parents was born or had citizenship in Australia or Canada. Most of the
parents had some post-secondary education, were actively employed, and had family
incomes in the middle to high socioeconomic range. Focus groups and interviews were
218 J. Summers et al. / Human Movement Science 27 (2008) 215229

conducted with the parents of 87 children. The children ranged in age from 6 to 9 years: 34
typical Australian children, 15 typical Canadian children, 29 Australian children with
DCD, and 9 Canadian children with DCD. The typical children had not repeated a grade,
had no diagnosed neurological or behavioral disorders, no known condition that would
interfere with performance of daily activities, attended regular classes at school and were
not more than 2 weeks premature based on parent report. The children with DCD may
have repeated a grade or received intervention for language or specic learning diculties,
were not more than 2 weeks premature, and had motor performance levels below that of
their peers; the latter was based on the clinical judgment of professionals who had signif-
icant experience in identifying and treating children with motor diculties; and had
obtained scores on standardized motor assessment measures that indicated below average
performance. More specic details on the parents that participated in this research and
their children can be found in Tables 1 and 2.

2.3. Procedure

Focus groups included parents of either typically developing children or children with
DCD. Twelve focus groups, six for parents of typically developing children, and six for

Table 1
Participant characteristics
Australian Canadian
Married/common law 86% 80%
Age of participant
30 39 years 57% 47%
40 49 years 43% 53%
Educational level
Bachelors degree or higher 64% 87%
Employment
Not at all 18% 7%
Part time 68% 40%
Full time 14% 53%
Family income
<$52,000 30% 7%
$52,000$77,999 33% 27%
>$78,000 38% 67%
Country of birth 75% 100%

Table 2
Child characteristics
Australia Canada
Typical DCD Typical DCD
Age bracket 57 years 89 years 57 years 89 years 57 years 89 years 57 years 89 years Total
Boys 7 9 19 7 6 5 1 5 59
Girls 7 11 1 2 1 3 2 1 28
Total 14 20 20 9 7 8 3 6 87
 J. Summers et al. / Human Movement Science 27 (2008) 215229 219

parents of children with DCD were run. About half of the parents participated in one of
these groups. Individual interviews were conducted with parents that were not able to par-
ticipate in a focus group. Prior to the focus group or interview, parents were given an out-
line of the main questions that would be asked. They were also asked to monitor their
childs daily activities. The focus groups and interviews took approximately 6090 min.
These were audio and video taped, with the latter used in place of an assistant moderator
(Kreuger, 1994).

2.4. Data collection

The format of the focus groups and the individual interviews consisted of semi-struc-
tured and open-ended questions about daily activities that were designed to elicit broad
contextual information. These questions were followed by specic questions and probes
about the childs performance of self-maintenance activities of daily living within the home
context (Agar, 1996). Following each focus group or interview, the principal investigator
made detailed eld notes of the experiences, feelings, and thoughts that emerged (Patton,
1990). Analysis of data from the focus groups and interviews was ongoing throughout the
study and the emerging data were used to modify questions in subsequent focus groups
and interviews.

2.5. Data management and data analysis

Each interview was transcribed verbatim, and NUD*IST software was used to assist
with data management and data analysis. Each phrase was analyzed separately, rst by
individual case (interview or focus group), and second by cross case analysis in which
responses to questions were grouped. A content analysis was conducted to identify, code,
and categorize the primary patterns from the data into a manageable classication (Agar,
1996; Patton, 1990). A second person was used to code the data separately to verify the
classication. The content was initially organized as descriptive data that addressed the
questions about childrens self-maintenance activities. This was followed by an inductive
analysis that identied emerging categories, patterns, and themes (Agar, 1996; Patton,
1990). The categories were scrutinized to determine consistency and contradictions, to
uncover the multiple perspectives of individuals, and to develop an understanding of their
experiences.
Strategies employed to enhance the trustworthiness of the study ndings included: (a)
collection of sucient data for saturation to occur and variation to be identied; (b)
use of an audit trail that documented the conceptual development of the research; (c) par-
ticipant verication of data by review of transcripts; and (d) an audit of the transcripts by
researchers and clinicians experienced in motor development.

3. Results

We rst present the perspectives of parents of younger and older typically developing
children regarding their childrens performance of self-maintenance activities of daily liv-
ing. These perspectives provided us with a better understanding of typical childrens per-
formance of self-maintenance activities and their development from 6 to 9 years of age.
The information gleaned from these focus groups and interviews provided the basis for
220 J. Summers et al. / Human Movement Science 27 (2008) 215229

exploring and identifying dierences between typically developing children and children
with motor coordination problems in performance of dressing, personal hygiene, and eat-
ing behaviors.

3.1. Dressing

Most typically developing younger and older Australian and Canadian children were
expected to dress themselves, and initiated and were independent in dressing. Most of
the Canadian children could manage the heavy outdoor clothing required in winter.
Putting the zip together to start on heavy winter jackets, however, was dicult for
the younger children. Parents noted that the main diculty for younger children was
tying shoelaces. By the end of Year/Grade 1, most typical six-year-olds had mastered
tying their shoelaces; however, some children continued to use Velcro fastenings on
shoes even when they could tie their own shoes, he learned to tie shortly into the school
(Kindergarten) year. But then he realized that the quicker youre ready, you get to be the
rst in the line,. . .and now he has Velcro shoes at school instead of his tie ones. He was
really adamant that Velcro was the way to go. Parents often assisted the younger chil-
dren with shoe lace tying because many children could not get their laces tight enough
to stay done up throughout the day, . . .most of the time he will come to me and ask me
to tie them before he runs out the door, cos he knows that they stay tighter. No di-
culties in tying shoelaces were reported among the older typical children; although some
still did not get the laces tight enough.
Although the younger typical children were independent in dressing, they required
supervision to select clothing that accommodated conditions such as weather, biting
insects, and activity requirements. Older children asked a parent what the weather would
be like and used that information to make decisions about what to wear, Like today she
decided to wear tracksuit pants [because] I said it was going to be a cold day and rainy. . .
The desire to wear favorite clothes, however, could override both the younger and older
childrens understanding of what was appropriate to wear.
Only two of the younger typical children had problems with orientation of clothing
. . .he needs help with his singlet. . .and sometimes he gets his [t-] shirt back to front. Youn-
ger girls were reported to be neater than boys who needed prompting, . . .hes not very
good at tucking in his shirt and pulling out his collar. Among the older children the need
to monitor for neatness was not mentioned. All of the typically developing children man-
aged to get their shoes on the correct feet. Orienting the heel of the sock, however, was
sometimes a problem for the younger children. I guess Im pretty casual and my kids
are casual. So if their socks are round the wrong way they go to school like that.
In contrast to the typically developing children, very few of the younger children
with DCD were fully independent for dressing. Many of these children did not initiate
dressing, You have to harass him to go and get dressed for school. Some of the chil-
dren still needed direct supervision and physical prompts to help with dressing. Most
parents facilitated dressing and a number of parents commented that their child was
slow at getting dressed:
I will lay his clothes out in the morning but Im at the stage now where Im very
much making him get ready on his own. But he, Ive got to keep coming back
and just reminding him [to get dressed]. . .he is slow.
 J. Summers et al. / Human Movement Science 27 (2008) 215229 221

Children with DCD were also reported to have diculty with buttons and fastenings;
hes learned buttons, but again on school uniforms for little boys they are tiny little buttons
so he does nd those hard and hell often get it a bit wrong; and spatial orientation of
clothing
I put his shirt on over his head and then he puts his arms through the sleeves. . . So I
help him with his t-shirt,. . . And he often has trouble getting one leg into each pant
leg. Often ends up both in the same one, so Ill help him get them going the right
way.
Poor balance appeared to be a factor in dressing for some children;
For his pants he needs to sit down, he cant balance to stand up to put them on. So
he sits down and we spread the pants out in front of him with the front on top, and
then he pulls his legs through and sometimes I help him with that because it takes
him a long time to get his foot all the way through the leg.
Socks were the most dicult item of clothing to put on, with orientation and manipu-
lation of the socks a signicant problem
[He] gets very frustrated with socks. Hes got very wide big feet and he cannot get
the concept of bunching the sock up. . . And I watch other kids get their socks, get
their shoes and o they go and [he] is still struggling to get it [the sock] over his toe.
Tying shoelaces was also a major area of diculty for children with DCD. Only 3 of the
younger children could tie shoelaces with any degree of competency. Some parents
reported that the task was too hard and the children became very frustrated and gave
up. Being independent at tying shoe laces was not an issue for most parents; it was viewed
as just one more pressure on their child.
[Learning to tie laces] was an extra pressure on him that we could all do without.
Because he is so negative, like he really complains, like I dont want to do it, so why
do I have to do it, and its very distressing to have that so in the end I thought Im
not going to do it because it is too stressful, and its just tying his shoelaces.
In terms of overall dressing, a few of the older children with DCD were reported to be
managing at the level of the typical children; however, most displayed varying degrees of
diculty in initiating dressing, of slowness at dressing, and spatial orientation of clothing.
Prompting was still a common strategy and parents were conscious of keeping clothing
simple. A common theme was that the older children with DCD werent interested in their
own personal appearance. Clothes might be twisted, rucked or tucked into other clothing
(e.g., pants tucked into socks, or shirts into underpants). Putting on socks continued to be
a problem for these older children. To reduce dressing demands some of the older children
with DCD left their coats on indoors (Canadian), whereas others wore to bed the t-shirt
that they were going to wear to school the next day. One mothers comment regarding
these strategies was that you pick your battles. It is noteworthy that many of the older
children with DCD adopted strategies that simplied dressing such as pulling trousers with
zips or clips on and o without undoing them or leaving fastenings on coats undone. A
similar strategy was used with shoes where they were slipped on and o without untying
the laces.
222 J. Summers et al. / Human Movement Science 27 (2008) 215229

3.2. Personal hygiene

3.2.1. Bathing
For typically developing younger children, parents or an older sibling typically turned
the taps of the bath or shower on and o and were responsible for adjusting the temper-
ature and monitoring the water level; most younger children were left to wash themselves,
although some prompting might occur from a distance. Parental supervision was mainly
to make sure the children had washed properly, to dole out shampoo and assist with hair
washing, and to keep them on task if they became distracted with play we will put sham-
poo on her hair and give it a good scrub and she continues and then she does everything else
herself. Most of the typical younger children got out of the bath unsupervised and dried
themselves,
[Hes] pretty good actually [at getting dried]. I suppose I should watch that, that he
is making sure he is drying between his toes and his bottom and stu. But most of the
time we dont have huge puddles coming out of the bathroom.
Typical older children were independent in bathing/showering, He does everything
[soap and shampoo] I just send him to the shower. Most were capable of handling the
hot and coldwater taps, and adjusting the water; however, temperature of the hot water
was an issue that prevented some parents from allowing their child to take control of
the water, No I do that [the water control]. I just had a bad experience as a child myself.
Older children were unsupervised getting out of the bath and dried themselves. Many of
them were independent in hair washing, hes more fastidious about his hair. . .[he washes
his] hair almost automatically every second day. However, hair washing was one aspect
of personal care that was sometimes still supervised or done for the older children, I wash
it [hair]. I just dont think she rinses the shampoo out properly and she doesnt leave the con-
ditioner in long enough and she doesnt get to the right areas. The only notable dierence
between typical Australian and Canadian children was in the frequency of bathing/show-
ering. In Australia bathing/showering was daily, whereas in Canada not all of the children
bathed/showered on a daily basis.
Similar to their typical peers, younger children with DCD needed parental help with
bathing. A parent generally looked after turning on taps and running the bath. Most of
the children with DCD could wash themselves, but needed help with shampooing hair.
A few parents reported that their children needed help washing their face because they
do not like water on it. In contrast to the younger typical children, most parents helped
with drying as the child was unable to do it properly. [he is] just learning to dry but he
nds it hard to get the, to coordinate the towel and that sort of thing.
Unlike the typical older children, most of the older children with DCD were dependent
on the parents for bathing or showering. They relied on a parent to turn the taps on and
o and to regulate the water temperature. Most of these children wash themselves and
their hair; however, some parents reported assisting with hair washing. In contrast to
the typical children, most of the older children with DCD received assistance from their
parents with drying both their body and hair.

3.2.2. Hair brushing and styling

Boys in general had their hair cut short and hair brushing or combing was less impor-
tant than with girls who tended to grow their hair long I cant remember the last time
 J. Summers et al. / Human Movement Science 27 (2008) 215229 223

that [he] brushed his hair [laughter], it doesnt make any dierence anyway. Although the
younger typical girls were capable of doing their hair, some parents undertook this role,
I do her hair, because I would prefer it to look a bit neater than when she does it. Older
girls were typically responsible for doing their own hair, She brushes her own hair, when
it was longer shed put in her own barrettes and do her own pony tail and has for a while.
Both younger and older girls could manage a hair band but had diculty putting their
hair up
They [twins] brush it and they have to wear it with a head band and they have to
put it in a ponytail, so they just do that themselves. . .if they want it plaited or
braided or something I will always do that.
Older typical children, both boys and girls, were becoming more conscious about style
and how they look and this was reected in how they managed their hair . . .he has started
to take more care with his hair and it is a fashion conscious thing and hell put gel in it. And
he will do that himself.
Most of the younger children with DCD were dependent on a parent for assistance with
hair care and parents noted that they kept the childs hair short because it was easier for
them to care for their childs hair We keep her hair fairly short, in a pixie cut or page boy,
its easier too maintain. Most parents indicated that their children had diculty with
brushing or combing their hair and some even commented that their child had diculty
with coordinating brushing. [She] forgets the sides, and she cant seem to do it properly
at the front or get to the back. Older children with DCD were similar to typical children
in that they were able to brush or comb their hair. In contrast, they were reported to take
little interest in hair style.

3.2.3. Hand washing and nail care

Younger typical children needed to be reminded and sometimes supervised with hand
washing I remind her about washing her hands and using soap, sometimes its a pretty quick
rinse under the water. Older children required less supervision and would initiate hand
washing in some circumstances.
Overall, both younger and older children with DCD performed at a level similar to typ-
ical younger children; however, some of the younger children with DCD were reported to
have diculty with turning taps on and o she has a hard time turning taps. She often uses
the disabled taps when we go into restaurants and stu.
Most parents of younger and older typical children and children with DCD cut and
manicured their childs nails, although the child might remind them, I do them, he wants
to do them. But I said no, I think you are just a little bit too young. In one case, demon-
strating motor performance variation, a typical six-year-old girl, who was described as
having very good ne-motor skills, cuts her own nger nails and toe nails, with the nail
clippers, I do the right hand because she cannot nish o properly.

3.2.4. Oral hygiene

Typical children and children with DCD brushed their teeth twice a day, they are into
the habit now of every morning and every evening just about. Most of the younger typical
children were supervised to some extent by parents. This ranged from the parent being
there and prompting proper brushing technique to frequent inspection and parents brush-
ing their childs teeth, I do brush them once in a while because the dentist expects us to do
224 J. Summers et al. / Human Movement Science 27 (2008) 215229

that. . .because the children will not do it well. Some parents, however, did not supervise
their childrens brushing,
No [we do not supervise his brushing]. He actually has teeth with big gaps in
between, and it hasnt been a problem,. . .weve had good feedback from the dentist.
Because hes got good ne motor skills I havent seen it as a problem.
Parents reported that some of the younger typical children needed assistance with open-
ing and squeezing the toothpaste, the tubes we have now are not easy to open, they ip
instead of screw on and he needs my help for that. For both younger and older typical chil-
dren, parents ossed their childs teeth occasionally. The children were not deemed dexter-
ous enough to do this properly, I dont oss them every day, no she doesnt oss, her
dexterity isnt good enough.
Some of the Australian parents reported only being given advice on ossing from the
dental clinic or dentist once their older children turned 10. In contrast, most Canadian
parents ossed the teeth of their younger and older children on a regular basis. Some chil-
dren, particularly older children attempted ossing themselves. These parents were acting
on advice from the dentist.
The younger children with DCD had diculty with the skills needed for oral hygiene.
Only three parents reported that their children cleaned their teeth independently; the
remaining parents assisted or cleaned their childrens teeth, often because the child had dif-
culty with oral awareness, and performing and coordinating the action.
I do that for him, he doesnt have a good sense of his tongue and just his whole oral
awareness just doesnt seem to be very good and he has trouble getting the tooth-
brush where it needs to be. . .
Youve got to show him how to clean his teeth from his direction. You cant just say
go up and down and round and round, youve got to show him what it feels like [so
you put your hand over his].
Only one parent of a younger child with DCD reported that her child could manage
toothpaste. Most parents reported that their children had diculty controlling the squeez-
ing of toothpaste and so they often assisted with this aspect of teeth cleaning; he manages
to open the toothpaste and he makes a mess everywhere. He might put too much toothpaste
on the brush so that there is an excess so that he gets sticky hands. . .
Some parents of older children with DCD reported that their children were independent
with brushing teeth but needed reminding. Others reported that they cleaned their chil-
drens teeth once a day because they had concerns about the childs ability. A few children
still had diculty managing the toothpaste and were messy. One parent commented on her
childs poor postural control and how it impacted teeth cleaning:
Often times I will go up and he will be leaning brushing his teeth, leaning all over the
counter. . . He will be leaning against the wall, his arm will be on the counter as hes
brushing his teeth, so hes all really sloppy. . .

3.2.5. Toilet hygiene

The younger typical children were all independent in bladder control during the day
although some still had occasional accidents at night. Bowel management had been mas-
 J. Summers et al. / Human Movement Science 27 (2008) 215229 225

tered by all of the children and most children could wipe their bottoms although some had
not yet fully mastered it. Younger children were reported to be aware if they had not
cleaned themselves properly, yesterday she came home and had changed her knickers,
and I said why did you do that, and she said, I didnt wipe myself properly at school. Older
children were fully independent in their toileting, including ushing and washing their
hands, and were reported to wipe their bottoms eciently.
Most of the younger children with DCD had achieved bladder control during the
day; however, some parents reported that their child had occasional accidents Shell
still have the occasional accident at school. A number of children still had bed wetting
accidents and one parent reported that her child had urinary incontinence at night.
Bowel management had been mastered by all of the children, but a number of parents
reported that their child was delayed in achieving control. Younger children with DCD
were reported to have more trouble with wiping their bottoms than the typical children
of this age group; I still have to wipe his bottom. . .he still hasnt got that all nice, his
twin sister has, shes been independent for a long time. The majority of the older chil-
dren with DCD were independent in their toileting; however, a few children still had
diculty with wiping themselves clean.

3.3. Eating Behavior

3.3.1. Manipulative Skills

Both typical younger and older children had mastered the use of a fork and spoon.
Although parents presented some food already cut, most of the younger children were
beginning to develop the skill of using a knife and fork. They used their knife to push food
onto the fork, and were capable of cutting soft food but needed assistance to cut meat such
as steak.
He can cut his sausages; if its like quiche he can cut that. Stews, casserole type
things, chicken hes pretty good with I think, and hes getting better at roast pota-
toes, the other things he can do, the pumpkins and carrots and things.
Similar to the younger children, older children were able to handle a fork and spoon in
a coordinated manner and could cut soft foods. Cutting meat in a procient manner with a
knife was still a developing skill for many of these children. Typical children were
described as neat in their eating habits, and not prone to spills or messiness. We have rice
most meals so she probably has one or two bits of rice outside her plate, she eats very neat.
One noticeable dierence between Canadian and Australian parents was that Austra-
lian parents were more insistent that their children should learn to use a knife and fork
correctly. Yes and they have to use a knife and fork. . .that is one of my absolute values. . .
I am very tough on that. . . And if they pick up the fork in this [dominant] hand I tell them to
swap.
The younger children with DCD used a spoon, fork or ngers to eat meals. The
spoon and fork were used separately; most parents reported that their children were
unable to coordinate a spoon and fork together. In a few cases, children were
reported to have immature or awkward grasps that aected control. Almost half
the children were described as being unable to use a knife and fork in a coordinated
manner. Similar to younger typical children, children with DCD had their meat cut
for them and some were able to cut soft foods such as cooked vegetables and sau-
226 J. Summers et al. / Human Movement Science 27 (2008) 215229

sages. Parents described their younger children with DCD as poorly coordinated, very
awkward, very messy and slow in learning to use utensils. Eating with ngers was the
preferred option for many of these children. Slowness in eating was a problem for
some children and in some of these cases mothers reported having resorted to feeding
their child.
Older children with DCD were assumed to have the manipulative ability to manage cut-
lery. However, they were often described as messy eaters, She is so messy with the knife
and fork, or if she is eating curry with a fork and spoon. She will get rice or whatever she is
eating, spaghetti. . .everywhere. Some parents noted that their children had poor oral
awareness of the quantity of food in their mouth.
He usually overlls his mouth with chewing things, he doesnt seem to realize that if
you have a lot of bulk in there, it doesnt leave much room. . .he looks as if hes going
to choke any minute.
The manipulative skills of older children with DCD were quite variable. Some children
had developed competencies in using a knife and fork, Hes ne with cutting unless things
are a bit tough, and. . . Ill make it into more manageable pieces. Others were reported as
being not skillful and having diculty applying pressure to the knife or coordinating the
knife and fork. Hes lousy coordinating a fork and a knife together, I think his skills in that
area are still a little bit below par for his age. Some of these older children with DCD were
also described as reluctant or lazy in their use of cutlery.
[She] is quite capable of using a knife and fork, quite often she wont bother, if its
nger kind of looking food she will pick it up o the plate. If its a piece of steak, I
will usually cut it in half, and let her go for it, and if she cant shell say oh can you
cut this its too hard.
Others rather than using a knife to cut their food would pick up a large piece of food on
their fork and bite pieces o. . .
Youll nd him with a huge great big lump of . . .something on the end of a fork-
and then youll have to say, can you please cut that up and hes really reluctant.
Many older children with DCD still preferred to eat with their ngers.

3.3.2. Postural skills

Parents of typical children reported that their children did not appear to have any dif-
culty sitting at meals, although some younger children did get in and out of their seat. In
contrast to typical children, most children with DCD were reported to dget (e.g., rocking
their chair, leaning the chair forward, constantly changing of position, standing up while
eating)
[He] sits on half the chair with one foot on the oor and hell get up about 4 times
during the meal and he wont be going any where, he just gets up and Ill say sit
down please, [lots of laughter and agreement] then hell sit back down and then hell
sit on his knees. . .
Others were reported to have diculty aligning themselves properly in front of their
plate and maintaining reasonable posture when seated, He sits well but he is a sloucher.
So youve got to tell him to sit up all the time.
 J. Summers et al. / Human Movement Science 27 (2008) 215229 227

4. Discussion

This study explored self-maintenance activities of daily living in younger and older typ-
ically developing children and children with DCD from Australia and Canada in the con-
text of the family. Few dierences were noted between Australian and Canadian children
in terms of their ability to participate in activities of daily living and both typical children
and children with DCD showed improved skills in the areas of self-maintenance from 6 to
9 years of age. Our study also conrmed the ndings of previous research that children
with DCD experience signicant diculties in the performance of self-maintenance activ-
ities relative to their typically developing peers and that motor diculties had a consider-
able inuence on these childrens ability to be independent in their participation in self-
maintenance activities of daily living (Mandich et al., 2003; Missiuna et al., 2007; Rodger
et al., 2003; Rosenblum, 2006). The parents in this study described how their childrens
motor problems had a signicant eect on the lives of their children. In terms of dressing,
slowness, and problems in spatial orientation (buttons in wrong holes, clothing back to
front, socks upside down and shoes on the wrong feet) were identied as major diculties
by most parents of children with DCD. The parents also identied various strategies that
they and their children had developed to cope with these diculties; some children left
their coats on indoors (Canadian); others wore clothes to bed that they were going to wear
to school the next day; verbal prompting and physical assistance were provided by parents;
the child was provided with clothing that did not demand signicant coordination skills.
Although parents reports suggested that children with DCD develop greater indepen-
dence in self-maintenance from 6 to 9 years of age, relative to their typically developing
peers they continued to display delays in some aspects of self-maintenance. They still
had diculties with dressing, turning taps on or o, regulating the water temperature, dry-
ing their body and hair, controlling the ow of toothpaste from a tube, and coordinating
the brushing of their teeth. In terms of eating skills, the main issues that emerged for chil-
dren with DCD were problems with poor coordination of utensils, inability in using a
knife to cut food, and slowness in eating. In addition, they were often described as messy
eaters and as having diculties aligning themselves at the table. It is important to note
that in some areas of self-maintenance (i.e., grooming skills), the performance of children
with DCD was not so dierent from typical children. Further, although younger children
with DCD were delayed in achieving bladder control and needed assistance with toileting
by 8-years of age children with DCD were independent in their toileting and functioning
similarly to typical children. The two overriding motor factors that were identied by par-
ents as signicant issues in their childrens participation in self-maintenance activities
(including dressing, bathing, teeth cleaning, and eating) were postural control and motor
coordination.
The ndings of this study indicate that ecological models that support the view that an
individuals performance is inuenced by personenvironmenttask interactions (Newell,
1986) are useful when examining the impact of DCD on activities of daily living. This model,
combined with a qualitative approach, allowed for the emergence of the relationships
among the motor competence of the child, the family environment and the specic self-
maintenance tasks in which the child was engaged. It also allowed us to identify specic per-
sonenvironmenttask interactions that restrict or enhance childrens participation in activ-
ities of daily living. For example, it was clear that many parents and children developed
coping strategies to lessen the impact of DCD on participation in activities of daily living.
228 J. Summers et al. / Human Movement Science 27 (2008) 215229

Sample selection and study design limit the conclusions that can be drawn from the
study. As is common in qualitative research, purposive sampling was used and the
majority of the Australian and Canadian parents that participated were highly educated,
middle class and married or living with a partner. It is possible that the perspectives of
parents from less privileged circumstances or other cultural backgrounds regarding their
childrens self-maintenance activities could be dierent. The focus of qualitative research
is exploratory and hypothesis generating, not hypothesis testing, and although the study
suggests that children with DCD display diculties in self-maintenance activities of daily
living, we cannot denitively conclude this based on the ndings reported here. A cross
sectional design was used to examine the development in self-maintenance activities in
children; however, a longitudinal prospective study is needed to strengthen the credibility
of the developmental changes in self-maintenance activities identied in the present
study.
According to the DSM-IV (APA, 1994) interference in activities of daily living as a
function of motor incoordination is a criterion for identifying children with DCD. Most
studies that have identied children with DCD have focused on these childrens impair-
ments in coordination and few have specically investigated in a detailed manner how
the impairment in motor coordination impacts the performance of activities of daily living
and particularly self-maintenance activities in the family context. This qualitative investi-
gation suggests that the motor impairments of children with DCD signicantly interfere
with these childrens abilities to engage in basic self-maintenance activities such as dress-
ing, personal hygiene and eating, which is consistent with the ndings of Rodger et al.
(2003) and Missiuna et al. (2007). The ndings also revealed that children with DCD gen-
erally needed much more parental support and assistance than their same aged peers in
order to successfully perform basic self-maintenance activities and that postural control
and motor coordination were identied by parents as signicant factors that impacted
the participation of these children. The next step in this research is to examine the relation-
ship between standardized measures of activities of daily living and these childrens perfor-
mance of self-maintenance activities in the context of the family. Such research would
further inform our understanding of the impact of the motor diculties on the childrens
everyday activities and could assist us in developing family based interventions that would
improve long term outcomes for children with DCD.

References

Agar, M. H. (1996). The professional stranger (2nd ed.). San Diego: Academic Press.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.).
Washington, DC: American Psychiatric Association.
Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press.
Case-Smith, J. (1995). The relationships among sensorimotor components, ne motor skills, and functional
performance in preschool children. American Journal of Occupational Therapy, 49, 645655.
Chapparo, C., & Ranka, J. (1997). Occupational performance model (Australia): Denition of terms. In C.
Chapparo & J. Ranka (Eds.), Occupational performance model (Australia): monograph 1 (pp. 5860).
Lidcombe, NSW: Authors.
Davis, W. E., & Burton, A. W. (1991). Ecological task analysis: Translating movement behavior theory into
practice. Adapted Physical Activity Quarterly, 8, 154177.
Deconinck, F. J. A., de Clercq, D., Savelsberg, G. J. P., van Coster, R., Oostra, A., Dewitte, G., et al. (2006).
Dierences in gait between children with and without developmental coordination disorder. Motor Control,
10, 125142.
 J. Summers et al. / Human Movement Science 27 (2008) 215229 229

Dewey, D., & Wilson, B. N. (2001). Developmental coordination disorder: What is it?. Physical and Occupational
Therapy in Pediatrics 20, 527.
Dunn, W. (1993). Measurement of function: Actions for the future. American Journal of Occupational Therapy,
47, 357359.
Dunn, W., Brown, C., & McGuigan, A. (1994). The ecology of human performance: A framework for
considering the eect of context. American Journal of Occupational Therapy, 48, 595607.
Gesell, A., & Ilg, F. L. (1946). The child from ve to ten. New York: Harper and Brothers Publishers.
Geuze, R. (2005). Postural control in children with developmental coordination disorder. Neural Plasticity, 12,
183196.
Gibson, J. J. (1977). The theory of aordances. In R. Shaw & J. Bransford (Eds.), Perceiving, acting and knowing:
Toward an ecological psychology (pp. 6782). Hillsdale, NJ: Lawrence Erlbaum.
Kadesjo, B., & Gillberg, C. (1999). Developmental coordination disorder in Swedish 7-year-old children. Journal
of the American Academy of Child and Adolescent Psychiatry, 38, 820828.
Kreuger, R. A. (1994). Focus groups: A practical guide to applied research (2nd ed.). Thousand Oaks, CA: Sage.
Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The personenvironmentoccupation
model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63,
923.
Mandich, A. D., Polatajko, H. J., & Rodger, S. (2003). Rites of passage: Understanding participation of children
with developmental coordination disorder. Human Movement Science, 22, 583595.
May-Benson, T., Ingolia, P., & Koomar, J. (2002). Daily living skills and developmental coordination disorder.
In S. Cermak & D. Larkin (Eds.), Developmental coordination disorder (pp. 140156). Albany NY: Delmar.
McCracken, G. (1988). The long interview. Newbury Park: Sage.
Missiuna, C., Moll, S., King, S., & Law, M. (2007). A trajectory of troubles: Parents impressions of the impact of
developmental coordination disorder. Physical and Occupational Therapy in Pediatrics, 27, 81101.
Missiuna, C., & Pollock, N. (1995). Beyond the norms: Need for multiple sources of data in the assessment of
children. Physical and Occupational Therapy in Pediatrics, 15, 5771.
Newell, K. M. (1986). Constraints on the development of coordination. In M. G. Wade & H. T. A. Whiting
(Eds.), Motor development in children: Aspects of coordination and control (Vol. 34, pp. 341360). Dordrecht:
Martinus Nijho Publishers.
Patton, M. Q. (1990). Qualitative evaluation and research methods (2nd ed.). Newbury Park: Sage.
Rodger, S., Ziviani, J., Watter, P., Ozanne, A., Woodyatt, G., & Springeld, E. (2003). Motor and functional
skills of children with developmental coordination disorder: A pilot investigation of measurement issues.
Human Movement Science, 22, 461478.
Roncesvalles, M. N., Schmitz, C., Zedka, M., Assaiante, C., & Woollacott, M. (2005). From egocentric to
exocentric spatial orientation: Development of posture control in bimanual and trunk inclination tasks.
Journal of Motor Behavior, 37, 404416.
Rosenblum, S. (2006). The development and standardization of the children activity scales (ChAS-P/T) for the
early identication of children with developmental coordination disorder. Child: Care, Health and
Development, 32, 619632.
Schoemaker, M. M., van der Wees, M., Flapper, B., Verheij-Jansen, N., Scholten-Jaegers, S., & Geuze, R. H.
(2001). Perceptual skills of children with developmental coordination disorder. Human Movement Science, 20,
111133.
Smits-Engelsman, B. C. M., Niemeijer, A. S., & van Galen, G. P. (2001). Fine motor deciencies in children
diagnosed as DCD based on poor grapho-motor ability. Human Movement Science, 20, 161182.
Smits-Engelsman, B. C. M., Sugden, D., & Duysens, J. (2006). Developmental trends in speed accuracy trade-o
in 610-year-old children performing rapid reciprocal aiming movements. Human Movement Science, 25,
3749.
Smyth, M. M., Katamba, J., & Peacock, K. (2004). Development of prehension between 5 and 10 years of age:
Distance scaling, grip aperture, and sight of the hand. Journal of Motor Behavior, 36, 91103.
Weisner, T. S. (1984). Ecocultural niches of middle childhood: A cross-cultural perspective. In Panel to review the
status of basic research on school-age children. Development during middle childhood: The years from 6 to 12
(pp. 335369). New York: National Academic Press.