Research in Developmental Disabilities 35 (2014) 2773–2780
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Physical fitness and overweight in Israeli children with and
without developmental coordination disorder: Gender
differences
N. Lifshitz a,*, S. Raz-Silbiger b,c, N. Weintraub b, S. Steinhart c,
S.A. Cermak d, N. Katz e
a
Department of Occupational Therapy, Faculty of Health Professions, Ono Academic College, Israel
School of Occupational Therapy, Hebrew University Jerusalem, Israel
Alyn Hospital, Pediatric & Adolescent Rehabilitation Center, Jerusalem, Israel
d
Division of Occupational Science and Occupational Therapy, College of Health Professions, University of Southern California, LA, USA
e
Research Institute for Health and Medical Professions, Ono Academic College, Israel
b
c
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 18 May 2014
Accepted 7 July 2014
Available online
Physical fitness and overweight among children has become paramount in the general
population and more so in children with developmental coordination disorder (DCD). The
purpose of the current study was to examine the association between physical fitness and
overweight in a sample of Israeli children in comparison to typical children, and to
examine gender differences. DCD was identified through total scores on the movement
assessment battery for children 2 (MABC-2) equal to or less than the 16th percentile as
well as parents’ report that the child’s deficits in motor skills interfered with at least two
daily life activities. The sample included a group of children with DCD (n = 22, M age = 8.70
[SD = 1.36], 16 boys [73%]) and a control group of typical children (n = 47, M age = 8.90
[SD = 1.52], 34 boys [72%]). Measures included the strength subtest of the Bruininks–
Oseretsky test of motor proficiency (BOT-2), the six minutes’ walk test (6MWT) with heart
rate measure, BMI and the percentage of body fat. Significant differences between DCD and
typical children were found on all variables of physical fitness and weight. A two-way
analysis of variance (ANOVA) analysis (group/gender) also revealed significant interactions for the percentage of body fat (F = 8.51, p < .005) and BMI (F = 4.50, p < .038) meaning
that less fit children are more obese. The current study supports previous findings that
children with DCD are less physically fit and more overweight compared to typically
developing children. Moreover, in comparing between the genders, the girls in the study
sample weighed more and had a significantly higher percentage of body fat than boys, it is
essential to further our understanding of the relationships between obesity, physical
fitness and gender among children with and without DCD.
ß 2014 Elsevier Ltd. All rights reserved.
Keywords:
Developmental coordination disorder
Physical fitness
Overweight
Gender
BMI
Body fat
1. Introduction
Developmental coordination disorder (DCD) is a motor neurodevelopmental disorder characterized by clumsiness as well
as slow, inaccurate performance of motor skills. A diagnosis of DCD is assigned only if the impairment in motor skills
* Corresponding author. Tel.: +972 5 45670535; fax: +972 3 5356120.
E-mail address: [email protected] (N. Lifshitz).
http://dx.doi.org/10.1016/j.ridd.2014.07.020
0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
2774
N. Lifshitz et al. / Research in Developmental Disabilities 35 (2014) 2773–2780
interferes with participation in activities of daily living, school productivity, leisure and play. The prevalence of DCD in
children ages 5–11 years is 5–6%, with a male/female ratio ranging between 2:1 and 7:1 (American Psychiatric Association,
2013).
Studies show that children with DCD participate less in physical activities due to their motor difficulties (Beutum, Cordier,
& Bundy, 2013; Bouffard, Watkinson, Thompson, Causgrove Dunn, & Romanow, 1996; Cermak & Katz, 2013; Rivilis et al.,
2011). Since physical activity provides fundamental health benefits for children and youths (World Health Organization,
2011a), the physical health of children with DCD has increasingly become a topic of interest (Chirico et al., 2012; Rivilis et al.,
2011). Whereas some studies have focused on comparing the physical health of children with DCD with that of typically
developing (TD) children worldwide, others have focused on the relationship between physical fitness and overweight
among children with DCD in comparison to TD children (Beutum et al., 2013; Cairney et al., 2010; Faught, Demetriades, Hay,
& Cairney, 2013; Rivilis et al., 2011; Tsiotra, Nevill, Lane, & Koutedakis, 2009; Zhu, Wu, & Cairney, 2011). The various studies
present conflicting findings and the gender issue was mostly not considered.
Physical fitness refers to a set of attributes that are either health- or skill-related (Caspersen, Powell, & Christenson, 1985),
and includes body composition, flexibility, strength, speed and cardiorespiratory fitness (Triostra et al., 2009). Among other
things, poor health-related physical fitness is an important risk factor for cardiovascular disease (Li, Wu, Cairney, & Hsieh,
2011). Studies have shown that on average, children with DCD have lower fitness levels compared to their TD peers (Li et al.,
2011; Rivilis et al., 2011), with lower VO2 peaks (Burns et al., 2009; Chia, Guelfi, & Licari, 2010; Silman, Cairney, Hay,
Klentrou, & Faught, 2011; Wu, Lin, Li, Tsai, & Cairney, 2010); lower aerobic fitness scores on the Léger 20 meter run (Cairney,
Hay, Faught, Flouris, & Klentrou, 2007; Faught, Hay, Cairney, & Flouris, 2005); and lower endurance, flexibility and strength
(Burns et al., 2009; Chia et al., 2010; Silman et al., 2011; Wu et al., 2010).
According to the World Health Organization (2011b) overweight and obesity are defined as an abnormal or excessive
accumulation of fat that may impair health. Childhood obesity is associated with a higher chance of adult obesity, premature
death and disability. In addition to increased future risks, obese children may experience breathing difficulties, increased risk
of fractures, hypertension, and early markers of cardiovascular disease, insulin resistance and psychological effects.
Several studies have examined the relationship between DCD and overweight. Recently, Zhu et al. (2011) found that the
prevalence of overweight and obesity among Taiwanese children aged 9–10 with DCD was higher than among children with
TD. Similar results were found among children aged 7–11 in Australia (Beutum et al., 2013) and Canada (Cairney et al., 2010)
and among school-aged children in Hong Kong (Fong et al., 2011). In a large-scale longitudinal study in Great Britain, Osika
and Montgomery (2008) reported a significant association between teachers’ assessments of hand control, coordination, and
clumsiness at age 7 and obesity at age 33. However not all studies showed significant differences in body mass index (BMI)
between DCD and TD children in same-aged groups (7–11 years) in primary schools (Castelli & Valley, 2007; Hands, 2008;
Wu et al., 2010).
According to Zhu et al. (2011), inconsistencies can be found with respect to gender differences in relation to the
association between motor performance and obesity. In a large study of 578 children ages 9–14, Cairney, Hay, Faught, and
Hawes (2005) found that DCD may be a risk factor for overweight/obesity among boys, but found no difference in the
prevalence of overweight/obesity between children with and without DCD among girls. However in a later study, Cairney
and colleagues (2010) found no evidence of interaction between gender and overweight or obesity among children with
possible DCD. Furthermore, in a study by Zhu et al. (2011) in which groups of normal-weight, overweight and obese children
were examined, more boys with DCD were found in the obese group than in the other two groups. Results differed for the
girls in the sample, such that there was a higher prevalence of girls with DCD in both the overweight and obese groups than in
the normal-weight group. Other researchers reported that obese boys performed gross motor skills more poorly than
normal-weight boys. However, these differences were not found in a comparable group of girls (Mond, Stich, Hay, Krämer, &
Baune, 2007). In sum there is no consistency among the various studies which leads to the need in further research.
The purpose of the current study was to examine the association between physical fitness and overweight among
children with DCD in Israel, and to compare children with and without DCD with respect to physical fitness and overweight.
Given the inconsistencies found in previous studies with respect to gender differences, comparisons of these variables also
will be examined between the boys and girls in the study sample.
2. Method
2.1. Study design and sampling
The design of this study is comparative and correlational, using convenience sampling. Participants were recruited from a
children’s developmental treatment center and a children’s workout facility, both of which are located in a children’s
rehabilitation hospital in central Israel. Others were recruited by referrals.
DCD was determined by: (a) total scores at or below the 16th percentile on the movement assessment battery for children
2 (MABC-2; Henderson, Sugden, & Barnett, 2007); (b) reports of parents in the Demographic, Medical and Motor
Questionnaire (Cermak, 2007), and the determination that a child’s motor skill deficits interfered with at least two functions
in school (e.g., writing, playing, participating in gym) and/or activities of daily living (ADL; e.g., dressing, grooming,
recreation at home or school). Children were excluded from the study if they had a chronic illness that may have affected
their appetite and food intake (i.e., heart disease, cancer, thyroid disorder, cystic fibrosis, and/or gastrointestinal disease); if
N. Lifshitz et al. / Research in Developmental Disabilities 35 (2014) 2773–2780
2775
they had a developmental disability other than DCD; or if they regularly received a medication that may affect their activity
level, growth or appetite (e.g., steroids or stimulants).
2.2. Participants
The study sample included 69 children between the ages of 6–11 years. All of the children studied in regular education
elementary schools. The sample comprised two groups: (a) children with DCD (n = 22; M age = 8.70 [SD = 1.36], 16 boys [73%]
and 6 girls [27%]); and (b) typically developing (TD) children (n = 47; M age = 8.90 [SD = 1.52], 34 boys [72%] and 13 girls
[28%]).
2.3. Measures
2.3.1. DCD diagnosis
2.3.1.1. Movement assessment battery for children-2 (MABC-2; Henderson et al., 2007). The MABC-2 is a norm-referenced, valid
and reliable performance test. It was designed to evaluate gross and fine motor functioning and assess motor impairment in
children aged 3:0–16:11 years, as well as to screen and identify children with DCD (Missiuna, Rivard, & Bartlett, 2006). The
instrument is used worldwide to assess motor coordination abilities and has been used to identify DCD in many studies.
2.3.1.2. Demographic, Medical and Motor Questionnaire (Cermak, 2007). This is a parent-report questionnaire, developed with
the purpose of collecting demographic information (e.g., age, gender, country of origin, parental education, etc.), the child’s
medical history and current status, and information about the child’s motor coordination skills, as well as his/her past and
present daily life abilities, as reflected in 24 functional activities. The questionnaire was translated into Hebrew and adjusted
for Israeli children.
Inclusion in the DCD group was comprised of the MABC-2 the total score equal to or less than the 16th percentile, and the
parents’ report that the child’s deficits in motor skills interfered with at least two functions daily life activities.
2.3.2. Instruments
2.3.2.1. BMI and body fat percentage. Anthropometric measures (height and weight) were obtained for each participant. Each
child’s height was measured with a Wall Mounted Stadiometer (SECA, Germany) calibrated to 0.1 cm, and weight/percent
body fat was measured with a Tanita digital scale (Tanita Corp., Tokyo, Japan). Body mass index (BMI) was calculated from
measures of height and weight using age- and gender-specific growth charts (CDC; National Center for Health Statistics
[NCHS], n.d.) for children ages 2–20, and LMS parameters needed to generate percentile and z-scores. z-Scores were used
because the sample included male and female participants ranging from 6 through 11 years, and research with children has
shown that BMI varies as a function of the child’s age and gender (CDC, 2013). A BMI z-score of 1.04 was used as an indicator
of at-risk-for-overweight (85th percentile) and 1.65 as an indicator of overweight (95th percentile).
2.3.2.2. Strength subtest of the Bruininks–Oseretsky test of motor proficiency – second edition (BOT-2) (Bruininks & Bruininks,
2005). The BOT-2 is a norm-referenced test that assesses gross and fine motor coordination in children ages 4–21 years. The
strength subtest includes five items that assess gross motor strength through muscular endurance tasks such as push-ups,
sit-ups, and standing broad-jump. Scores for subtests are reported in standard scores (M = 15, SD = 5). Reliability and validity
are provided in the manual (Bruininks & Bruininks, 2005) and several subsequent test reviews have examined its
psychometric properties (Wuang and Su, 2009; Deitz et al., 2007).
2.3.2.3. Six-minute walk test (6MWT). This test requires the child to walk as rapidly as possible for six continuous minutes in
a 30-m long hallway (American Thoracic Society, 2002). It is widely used as an outcome measure in cardiopulmonary
rehabilitation to assess physical capacity and has been used as a measure in over 1400 published research articles (PubMed
review, April 2013). Although the majority of research has been with adults, several studies have been conducted with
healthy children in the UK (deGroot and Takken, 2011), Austria (Geiger et al., 2007), China (Li et al., 2005, 2007) and in the
U.S. (Roush et al., 2006) have used it with children with moderate–severe disabilities. A practice walk was conducted.
In order to interpret the 6MWT and understand the range of factors that may influence the fitness of children with DCD,
we also assessed heart rate with a Polar monitor while the child performed the 6MWT.
2.3.2.4. Heart rate (HR). The heart rate was assessed before, during, and after the 6MWT using a Polar monitor (Polar1,
Finland) with an elastic chest strap and sensor attached. This monitor stores information on HR during the test period and
was downloaded on to a computer for analysis. We measured pre-exercise heart rate, average heart rate during exercise,
percent of time in the target zone (60–80% of maximum heart rate), and post-exercise heart rate immediately following the
test and at 1 and 2 min post-walking. Heart rate may be considered a proxy measure of the effort exerted. (Freedson and
Miller 2000) suggested that monitoring simultaneous heart rate with motion may facilitate examinations of responses to
physical activity.
N. Lifshitz et al. / Research in Developmental Disabilities 35 (2014) 2773–2780
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2.4. Procedure
Following ethical approval of the Helsinki Committee for Human Rights, children were recruited to the study. One
member of the research team conducted initial phone screening interviews to determine if the child could participate in the
study and what is expected from the child and parents. The assessment battery was administered in a quiet, bright and
spacious room by four other qualified pediatric occupational therapists trained in administering the battery; inter-rater
reliability had been established among them. They collected the data and were blind as to group composition (with or
without DCD). In the first session a written consent from both parents and child was obtained and the parents filled out the
questionnaires as the child underwent the MABC-2 test. Next the child’s weight was measured using the Tanita and height
was measured using a stadiometer. BMI was calculated using height and weight. A practice 2-minute walk test, including
heart rate monitoring, was administered to familiarize the child with these assessments. In a second session, the strength
subtest of the BOT-2 was performed, followed by the six-minute walk test (6MWT) with a Polar monitor to measure heart
rate.
2.5. Statistical analysis
Data analysis was done using SPSS for Windows version 20. Descriptive statistics and comparisons of the two groups (i.e.,
DCD and TD) and between gender (boys and girls within the groups) were done using t-tests. In order to study the interaction
effect of group and gender a 2-way ANOVA was further conducted. Within the DCD group Pearson correlations were
calculated between the variables and the significant results are presented as graphs with the R2 level of variance explained.
The significance level of all the statistical analyses was set at 0.05.
3. Results
Means and standard deviation with t-test analyses between DCD and TD children were performed to compare measures
of weight, body fat percentage and BMI, physical fitness on the 6MWT and strength on the BOT-2. For all the above variables
significant differences were found between the diagnostic groups with the TD group performing better (t = 2.35–2.60,
p < .05) and for the BOT-2 (t = 5.65, p < .000) (see Table 1).
Means and standard deviations for subgroups according to gender (girls and boys) in each group were calculated (see
Table 2). In all comparisons the means were higher for the DCD group within each gender. Additionally, within the DCD
group a significant difference was found between girls and boys for percent body fat (t = 2.36, p < .028); such that it was
lower among the boys and approached significance in the same direction for BMI (t = 1.89, p < .074).
Table 1
T-test analyses between children with DCD and typically developing children on weight variables, number of activities performed, physical fitness and
strength.
Children with DCD (n = 22)
Typical children (n = 47)
Variable
M
SD
M
SD
Weight
Percentage body fat
BMI
Total distance on the 6MWT
Strength subtest, BOT-2
34.64
22.66
19.13
0.53
10.23
9.90
9.20
3.93
0.08
3.01
29.10
17.09
16.86
0.60
15.38
7.11
5.79
2.15
0.11
3.75
t-Values
2.35*
2.60*
2.54*
2.52*
5.65***
Note: DCD, developmental coordination disorder; BMI, body mass index; 6MWT, six-minute walking test; BOT-2, Bruininks–Oseretsky test of motor
proficiency – 2nd edition.
* p < .05.
*** p < .000.
Table 2
Weight, percentage body fat, and BMI in boys and girls with DCD and typically developing children’s groups.
Group
Variable
DCD (n = 22) 16 boys: 6 girls
M
Boys
Weight
% Fat
BMI
32.79
20.08
18.21
Girls
Weight
*% Fat
BMI
39.56
29.52
21.56
Typical (n = 47) 34 boys: 13 girls
SD
9.034
8. 63
3.50
11.27
7.39
4.23
Note: DCD, developmental coordination disorder; BMI, body mass index; % fat, percentage body fat.
M
SD
29.52
17.60
16.86
7.99
5.03
2.38
28.01
15.75
16.85
4.01
7.58
1.42
N. Lifshitz et al. / Research in Developmental Disabilities 35 (2014) 2773–2780
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Table 3
Two-way ANOVA by group (DCD and typically developing children) and by gender.
SS
df
MS
F
p
Weight
Group
Gender
Group * gender
654.480
82.905
204.562
1
1
1
654.480
82.905
204.562
10.22
1.29
3.19
.002
.259
.079
% Fat
Group
Gender
Group * gender
786.209
171.541
379.552
1
1
1
786.209
171.541
379.552
17.63
3.85
8.51
.000
.054
.005
BMI
Group
Gender
Group * gender
109.469
33.140
33.689
1
1
1
109.469
33.140
33.689
14.62
4.43
4.50
.000
.039
.038
0.060
0.000
0.002
1
1
1
0.060
0.000
0.002
5.91
0.01
0.18
.018
.916
.671
307.691
0.764
0.344
1
1
1
307.691
0.764
0.344
24.00
0.06
0.03
.000
.808
.870
Total distance 6MWT
Group
Gender
Group * gender
BOT-2
Group
Gender
Group * gender
Note: DCD, developmental coordination disorder; BMI, body mass index; % fat, percentage body fat; 6MWT, six-minute walking test; BOT-2, Bruininks–
Oseretsky test of motor proficiency – 2nd edition.
*p < .05.
***p < .000.
Bold values are statistically significant at *p<.05. and ***p<.000.
[(Fig._1)TD$IG]
Heart Rate [aer 2 minutes]
150
R² = 0.3589
100
50
20
30
40
50
60
Weight in kg
Heart Rate [aer 2 minutes
150
R² = 0.2767
100
50
10
15
20
25
30
BMI
Fig. 1. Distribution of weight and BMI with heart rate in the DCD group during the 6MWT. Note: kg, kilograms; BMI, body mass index; DCD, developmental
coordination disorder; 6MWT, six-minute walking test.
[(Fig._2)TD$IG]
N. Lifshitz et al. / Research in Developmental Disabilities 35 (2014) 2773–2780
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Total Distance Km
0.70
0.60
0.50
R² = 0.2333
0.40
10
15
20
25
30
BMI
Fig. 2. Distribution of BMI with total distance walked on the 6MWT among children with DCD. Note: km, kilometers; BMI, body mass index; DCD,
developmental coordination disorder; 6MWT, six-minute walking test.
In order to further explore the relationships between diagnostic groups and gender, a 2-way analysis of variance was
performed (see Table 3). For all comparisons significant main effects were found between diagnostic groups where the TD
had better scores. Significant main effects for gender were found for BMI (BMI, F = 4.43, p < .039) within the DCD group. A
significant interaction effect was found for fat percentage (F = 8.51, p < .005) and BMI (F = 4.50, p < .038).
The distribution of weight and BMI with heart rate during the 6MWT was analyzed among the DCD group participants
and the results are presented in Fig. 1. These indicate that as weight and BMI increase, heart rate increases as well (weight,
R2 = .358; BMI, R2 = .276). Fig. 2 shows the same relationship for distance walked on the 6MWT and BMI, such that children
with a higher BMI walked a shorter distance (BMI R2 = .233).
4. Discussion
In recent years researchers have demonstrated a growing interest in the consequences of DCD on children’s health.
Special attention has been focused on factors that underlie children’s physical health such as physical fitness and
overweight/obesity. The purpose of the study was to examine the association between physical fitness and overweight in a
sample of Israeli children in comparison to typical children, and to examine gender differences
The current findings on Israeli children are consistent with most of the literature and add to the results of previous
studies, in which a significant difference was found between typical children and children with DCD in physical fitness
(Burns et al., 2009; Cairney et al., 2007; Silman et al., 2011; Wu et al., 2010). Furthermore, similar results have been reported
regarding weight (Beutum et al., 2013; Cairney et al., 2010; Fong et al., 2011; Zhu et al., 2011), suggesting that the profile of
physical fitness and weight in children with DCD is a worldwide phenomenon.
The relationships between weight and BMI with heart rate during the 6MWT and the total distance walked suggests that
overweight may have implications with respect to physical fitness as the variance explained was between R2 = 0.23 and 0.35
(see Figs. 1 and 2). Overweight has been reported to be a major concern for all children, but of an even greater concern for
children with disabilities in whom obesity rates were 38% higher than for children without disabilities (CDC, 2014; Rimmer,
Rowland, & Yamaki, 2007). The influence of overweight and obesity on physical fitness has also been demonstrated among
children with attention deficit hyperactive disorder (ADHD) (Braet, Claus, Verbeken, & Van Vlierberghe, 2007) and learning
disabilities (LD) (Bandini, Curtin, Hamad, Tybor, & Must, 2005).
Moreover, gender differences between boys and girls with DCD have demonstrated that girls weigh more, and have a
significantly greater percent of body fat than boys. However, this group comprised only six girls so the generalizability of
these findings requires the employment of a larger sample size. Results of most other studies with children with DCD did not
examine gender, and those that did, reported inconsistent findings demonstrating that the distribution of overweight within
gender was different in these populations. In the current study, girls with DCD were more overweight than boys. In contrast,
some studies examining the ADHD population showed that boys were more overweight, as well as more hyperactive and
impulsive compared to typically developing children, but these findings were not found among girls (Braet et al., 2007).
These inconsistent findings in the literature regarding gender obesity among children with DCD, warrant further
investigation. Furthermore, the relationship between physical fitness and obesity and its implications requires further study.
It is even more important as the risks related to obesity increases with age (Cairney et al., 2010).
The main limitation of the study is its small sample size and especially the size of the DCD group, thus results should be
considered with caution in the subgroups according to gender. However, in spite of the small sample size the comparison
between gender and the interactions were highly significant especially for the DCD group suggesting that girls with DCD may
be at greater risk for overweight.
N. Lifshitz et al. / Research in Developmental Disabilities 35 (2014) 2773–2780
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5. Conclusion
The current study highlights the findings that children with DCD have lower physical fitness and are overweight
compared to typical children. It is essential to study the relationships between overweight, physical fitness and gender in
order to increase participation in physical activities in children with DCD as well as with other disabilities.
Acknowledgements
We thank all the children and parents who participated in the study, to Alyn Hospital for enabling this study to be
performed, and to Yossi Frier-Dror at Mashav for his statistical advice.
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