Human Movement Science 17 (1998) 471±490

DCD may not be a discrete disorder

Bonnie J. Kaplan *, Brenda N. Wilson, Deborah Dewey, Susan G. Crawford
Alberta Children's Hospital, and University of Calgary, Calgary, Alberta, Canada

Abstract

The primary aim of this paper is to explore some of the issues surrounding the concept of
DCD as a ``speci®c'' learning diculty. Questions relating to the assessment and identi®cation
of DCD are addressed. The arguments we present are derived from data obtained in a study
which compared 224 children referred because of learning and attention problems (but not
motor diculties) and 155 typically developing children. These 379 children were all assessed
on a range of formal and informal tests, including several sensorimotor tests. Working criteria
for classifying a child as DCD were derived. In addition to the high prevalence ®gures ob-
tained for DCD in this group of children, the degree of comorbidity observed between
DCD and the other developmental disorders (reading disability and attention-de®cit/hyperac-
tivity disorder) was also striking. These results prompted us to re-evaluate the usefulness of
discrete diagnostic categories, and to consider a reconceptualization of childhood disorders
in general. It is proposed that the comorbidity found in childhood disorders re¯ects a single
underlying etiology: Atypical Brain Development. This de®cit may be manifested in a variety
of ways, including DCD, and explains why some childhood disorders are so often seen togeth-
er. Ó 1998 Elsevier Science B.V. All rights reserved.

PsycINFO classi®cation: 2221; 2330; 3230; 3253; 3270

Keywords: DCD; Reading disability; ADHD

*
Corresponding author. Address: Alberta Children's Hospital, 1820 Richmond Rd. S.W., Calgary,
Alberta, Canada T2T 5C7.

0167-9457/98/$19.00 Ó 1998 Elsevier Science B.V. All rights reserved.

PII: S 0 1 6 7 - 9 4 5 7 ( 9 8 ) 0 0 0 1 0 - 4
472 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

1. Introduction

Over the years, there has been much debate about how we might best con-
ceptualise the problems faced by children who experience unexpected dicul-
ty in some area of their development. In spite of being intellectually normal,
some children arrive in school to ®nd reading, for example, to be an impos-
sible task. These children are then labelled ``dyslexic''. Others whose language
skills are not in question have attentional problems and are labelled as having
Attention-De®cit/Hyperactivity Disorder (ADHD). Yet others fail to acquire
the movement skills that are required of them at home and at school, and
they are labelled as having developmental coordination disorder (DCD). Al-
though there is often one feature of these children's diculties that stands out
from all others, it is rarely the case that it is an entirely isolated problem. Far
more often, we ®nd children who have a whole combination of diculties to
a greater or lesser extent.
It is beyond the scope of this paper to produce a historical review of the
literature on classi®cation of developmental disorders in children. However,
in the following paper, we consider two of the issues that are particularly rel-
evant to the study of Developmental Coordination Disorder, the topic of this
Theme Issue: the question of how DCD should be assessed and identi®ed,
and the implications of the overlap between DCD and other so-called speci®c
learning diculties.
A number of authors have noted that there is no gold standard for the
assessment of motor skills, and hence the identi®cation of DCD (e.g.,
Henderson and Barnett, 1998). In addition, standardized tests are limited
in their ability to identify DCD due to the fact that learning e€ects cannot
be controlled and the quality of movement is dicult to assess (McCon-
nell, 1995; Missiuna and Pollock, 1995). Another problem is that we lack
agreement on how much impairment is necessary for a child to be catego-
rised as having DCD. For instance, even though in Europe and North
America we may rely on either norm-referenced or criterion-referenced in-
formation, the decision as to whether a child is within the low range of
normal or is impaired is still a somewhat arbitrary decision. In the study
we have undertaken, we attempted to resolve these problems through the
use of ``triangulation''; that is, the use of more than one source of infor-
mation in the decision process (Levine et al., 1982; Missiuna and Pollock,
1995). Before proceeding, however, it might be useful to note that these
are not problems unique to this domain of behaviour. As will emerge
from our discussions later, the same problem arises in the areas of dyslexia
 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490 473

(reading disability), ADHD, and other ``speci®c'' learning diculties not

dealt with here.
Although the question of assessment and identi®cation is crucial to the
study of DCD, our primary objective in conducting this investigation was
to consider the issue of overlap between three disorders: reading disability,
ADHD, and DCD. As indicated above, whether you call them associated
features (Henderson and Barnett, 1998) or comorbidities, the fact is that
most children display many di€erent symptoms. In fact, a child with ``pure''
DCD or ``pure'' ADHD appears to be hard to ®nd. Although some may con-
sider it extreme (Henderson and Barnett, 1998), this fact has led us to believe
that many of the syndromes we study are actually variable manifestations of
a single, underlying etiology. The etiology may not be brain ``damage'' in the
sense of a traumatically-induced disruption of brain development; hence, the
old term MBD (minimal brain damage or dysfunction) will not serve us well
because of the connotations which have accumulated over the years. Also, as
indicated elsewhere in this issue (Henderson and Barnett, 1998), the old term
of MBD was not adequate for dealing with issues such as subtyping, because
MBD is simply the inferred etiology as opposed to the observable, measur-
able de®cits. By examining the extent to which overlap occurred in our study,
we hope to be able to reconsider our conceptual framework for both research
and practice in a way that informs us not only about DCD in particular, but
also learning diculties in general.
Between 1992 and 1997 we were fortunate to obtain funding from the
Alberta government to conduct a study to improve our understanding of
the nature and etiology of developmental problems. To achieve this objective,
a large group of children with learning disabilities and their families were
compared to more typically functioning children. The children forming the
basis of the comparison sample came from two sources. The majority were
matched to the children with learning and/or attention disorders. The others
were included because their mothers were taking part in a study concerned
with the relationship between health history variables and later development.
For the purpose of the present paper, it is crucial to note that none of the
children was referred because of motor or coordination problems. Extensive
data were gathered on each child: educational abilities, sensorimotor skills,
praxis and sequencing, memory, health history, pregnancy and birth history,
craniofacial dysmorphology, dermatoglyphics, and psychiatric history. These
data were then used to address not only the two questions which form the
focus of the present paper, but also a series of other questions concerned with
the prevalence, nature, and aetiology of learning disabilities in general. In the
474 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

present paper, however, we con®ne ourselves to the two issues outlined

above: the assessment of DCD, and comorbidity and its implications.

2. Method

2.1. Participants

Three hundred and seventy-nine children and their families participated in

this study: 224 children with learning/attention disorders and 155 controls.
The research protocol was reviewed and approved by our institutional review
boards for the ethics of human research; each family signed a form indicating
their willingness to volunteer for the study. The index group comprised chil-
dren referred to our project from agencies and private schools because they
had learning and/or attentional problems. No child was referred because of
problems in motor skills speci®cally. Two control groups were involved in
the study. The main control group was made up of 112 children, individually
matched to every second index child on age, sex, and socioeconomic status.
The remaining 43 controls, consisting of children with no apparent learning
or attention problems, were from another study concerned with children with
a history of family health problems (e.g., their mothers su€ered from a phys-
ical disorder) on whom we had identical data. All children were between the
ages of 8 and 18 years.
Table 1 shows the gender distribution, ages, and estimated IQs of the three
groups of children. There were no signi®cant di€erences between the two con-
trol groups on age at testing, estimated full scale IQ, BOTMP (Bruininks
Oseretsky Test of Motor Pro®ciency; Bruininks, 1978) Full Battery score

Table 1
Age, IQ and sex distribution of samples

Learning/attention problem Control sample A Control sample B

sample
n ˆ 224 n ˆ 112 n ˆ 43

Mean age in years (SD) 12.1 (2.2) 11.3 (2.2) 11.6 (2.6)
Range 8.3±16.9 8.0±16.2 8.0±17.9
Males 169 82 23
Females 55 30 20
Mean IQ (SD) 99.4 (13.3) 110.7 (12.8) 110.8 (14.8)
Range 77±138 80±141 85±141
 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490 475

or BOTMP Short Form. In fact, the only variable on which the two groups
di€ered was gender, which was an artifact of ascertainment method: the chil-
dren in the larger control group were selected to match every second child in
the group of children with learning disabilities, which of course was dispro-
portionately male. Consequently, there was a signi®cant association between
sex and group, X2 (1) ˆ 4.55, p < 0.05, as a function of the method of subject
recruitment. Since the two control groups did not di€er in any meaningful
way, from this point on they will be treated as one group.

2.2. Procedure

All children in this study were tested between 1992 and 1997. Each child
was tested individually, by a specialist in the ®eld being assessed, such as a
psychometrician or occupational therapist. Testers were blind as to whether
the child being assessed was believed to have learning/attention problems or
whether he/she was a control subject. The psychoeducational assessment
took approximately 3 h (12 day); the motor assessment was carried out on a
di€erent day and also required approximately 12 day.

2.3. Assessment of cognitive ability

For the purposes of this study, the data derived from our cognitive assess-
ment were used to exclude any child whose diculties might be attributed to
generally delayed development. Each child under 16 was tested on the short
form of the Wechsler Intelligence Scale for Children ± 3rd edition (WISC-III)
(Wechsler, 1991); for those over 16 the adult version was used (Wechsler,
1981). Any child whose estimated IQ fell below 75 was excluded from the
study.

2.4. Assessment of motor performance

Two tests and a questionnaire were used to identify children with DCD,
yielding a total of six scores. The BOTMP was used with all children and
yielded four scores: Fine Motor (FM), Gross Motor (GM), Battery Compos-
ite (BC), and Short Form (SF) scores. The Short Form was used only if the
Battery Composite was unavailable for a child. Only about half the children
were tested on the Movement Assessment Battery for Children (Movement
ABC) (Henderson and Sugden, 1992), as it was not used until March 1995.
The sixth score came from the DCD Questionnaire, or DCDQ, an 18-item
476 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

parent-report questionnaire developed for school-aged children; additional

details are available from the authors (Wilson et al., in preparation). Each
item was scored on a ®ve point Likert scale. The wording of some items
was reversed to reduce bias, but in the ®nal scoring the values of these re-
versed items were accounted for (i.e., 5 became 1, etc.). The score of each item
was added to give a total score out of 90, with higher scores indicating greater
impairment. Further criteria are given in Section 3.2. Since discussion of the
usefulness of these measures in the classi®cation of DCD is one of the objec-
tives of this paper, details of the way we evolved our criteria for classi®cation
are presented in Section 3.1.

2.5. Assessment of reading ability

Several standardized tests were used to obtain a comprehensive overview

of the children's reading ability: parts of the Woodcock±Johnson Psychoed-
ucational Battery ± Revised (WJ-R) (Woodcock and Johnson, 1989), the
Woodcock Reading Mastery Test (Woodcock, 1987), the Wide Range
Achievement Test ± Revised (WRAT-R) (Jastak and Wilkinson, 1984), and
the Auditory Analysis Test (AAT) (Rosner and Simon, 1971). Taken togeth-
er, these assessments permitted the evaluation of higher level reading skills
such as comprehension, as well as some of the components of basic reading
skills such as phonological awareness. From this series of tests, seven scores
were obtained for determination of reading status.

2.6. Criteria for reading disability (RD)

For the present purposes, there seemed to be no justi®cation for selecting a

speci®c type of reading problem to the exclusion of others; to have done so
would have assumed some a priori knowledge about its association with
DCD, whereas in fact we have been unable thus far to ®nd such a connection
(Kaplan et al., 1997). Therefore, we included children in the category of RD
no matter whether their de®cit was in higher level skills such as comprehen-
sion, or in the basic component skills such as phonics.
In order to be categorised as RD, a child could have any of three di€erent
types of reading diculties: evidence of de®cits in basic reading skills (scored
at or below the 16th percentile on the Basic Reading cluster of the WJ-R),
evidence of de®cits in reading comprehension (scored at or below the 16th per-
centile on the WJ-R Reading Comprehension cluster), or de®cits in phonolog-
ical skills (de®ned using two sets of criteria: (1) scored at or below the 30th
 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490 477

percentile on the WJ-R Word Attack subtest, or had a delay of 2 or more

years on the Woodcock Reading Mastery Word Attack Subtest, and (2)
scored at or below the 16th percentile on the WRAT-R spelling subtest or
the WJ-R spelling subtest, and scored less than or equal to 16 on the AAT).

2.7. Assessment of ADHD

Several sources of information were used for the evaluation of ADHD.

Each child was assessed with the Diagnostic Interview Schedule for Children
(DISC) (Costello et al., 1985) for DSM-III-R criteria for ADHD. As well,
each parent was asked to complete the Child Behaviour Checklist (CBCL)
(Achenbach and Edelbrock, 1983) and the Abbreviated Symptom Question-
naire (Goyette et al., 1978). Finally, many of the children had been diagnosed
by a physician as ADHD, in which case we had diagnosis and treatment in-
formation.

2.8. Criteria for ADHD

ADHD is even more dicult to de®ne than RD or DCD. Without a single,

universally accepted test, we relied on a combination of structured psychiat-
ric interview, checklist, and physician's diagnosis. All three of these ap-
proaches are commonly used in the ®eld, which provides justi®cation for
considering all three types of information to be valid sources of diagnostic
data. The three criteria for categorising a child as ADHD were the following:
(a) met the DSM-III-R criteria on the parent version of the DISC, or (b) ob-
tained a T score greater than or equal to 70 on the CBCL and a score greater
than or equal to one standard deviation above the mean for age and sex on
the Abbreviated Symptom Questionnaire, or (c) had been diagnosed by a
physician as ADHD and was currently taking medication (i.e., Ritalin).

2.9. Statistical analyses

Pearson correlations were used to examine the intercorrelations among the

various motor tests. Between group comparisons used chi-square tests of
association for categorical variables (e.g., sex), and one-way analysis of vari-
ance (ANOVAs) for continuous variables (e.g., age, IQ). Agreement between
tests was calculated using the raw proportion of observed agreement between
tests (Po), and the same agreement corrected for chance (Kappa). Kappa of-
fers the most realistic estimate of agreement between tests. Excellent degrees
478 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

of agreement are reported to be present if the value of Kappa is 0.75 or great-

er, with fair to good agreement between 0.40 and 0.75, and poor agreement
less than 0.40 (SPSS, 1996).

3. Results

3.1. Overall agreement among measures of motor performance

As noted above, there is still much to learn about the strengths and weak-
nesses of the various instruments used to assess children with movement
problems. No single test is accepted as the gold standard against which other
tests might be judged, and independent criteria for the assignment of the label
DCD are sadly lacking. Before deciding on the criteria we might adopt for
categorising a child as having a Developmental Coordination Disorder, we
decided ®rst to look at the relationships among the six measures of motor
performance available from our study. The correlations for the entire sample
are shown in Table 2. Since all are statistically signi®cant and suggest a mod-
erate degree of commonality among the measures available to us, we felt it
was acceptable to derive a classi®cation scheme which used all six scores.

3.2. Criteria for DCD

In order to develop criteria for the designation of DCD among our chil-
dren, the ®rst task was to de®ne ``impairment'' on each of the separate mea-
sures available. For the four BOTMP measures, the de®nition from the

Table 2
Correlations between motor tests (entire sample)

BOTMP BOTMP BOTMP BOTMP Movement ABC DCDQ

Battery Gross motor Fine motor Short form percentile
composite

BOTMP BC ± 0.9082 0.8251 0.9104 0.6085 0.5093

BOTMP GM ± 0.5719 0.8465 0.6148 0.4310
BOTMP FM ± 0.7727 0.4338 0.4795
BOTMP SF ± 0.5072 0.4484
M-ABC ± 0.5275
DCDQ ±

p < 0.001 for all correlations reported above.

 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490 479

manual (Bruininks, 1978) was adopted: impairment was a standard score

6 42. For the Movement ABC, a score at or below the 15th percentile was
employed, as recommended by the authors (Henderson and Sugden, 1992).
For the DCDQ, performance was required to be one standard deviation
below the mean (which was 69.8 in our sample), which meant that a score
at or below 59 (out of a total possible score of 90) was de®ned as impaired.
As there was no statistical or theoretical reason to believe that one would be
more in¯uential than another, all measures received an equal weighting in the
next step of the procedure.
Two considerations led to a decision to de®ne DCD as performance below
the designated cuto€s on at least two of the measures. First, this de®nition
avoided categorising as DCD the child who had only an occasional problem
with motor skills (poor performance on a single measure). Second, it had
been observed that it was not uncommon for children to score within the av-
erage range on one of these tests, but below average on another. De®ning
DCD by low performance on at least two measures took into account this
type of variability.
The application of this criterion yielded the data shown in Table 3. From
our total sample of 379 children, 81 were categorised as having DCD and 298
were considered to be free from the condition. This ®gure represents a prev-
alence of 21.4%. Of the 81 children classi®ed as DCD, 61 came from the orig-
inal referred sample, and 20 from the control group. A comparison of the
DCD vs. non-DCD children irrespective of their original group showed that
DCD children were not signi®cantly di€erent from the non-DCD children in
terms of age (F (1, 378) ˆ 0.55, n.s.). They did, however, have signi®cantly
lower estimated IQs (F (1, 326) ˆ 24.21, p < 0.001). There was a signi®cant

Table 3
Description of sample

Total sample DCD non-DCD

n ˆ 379 n ˆ 81 n ˆ 298

Mean age in years (SD) 11.8 (2.2) 11.6 (1.9) 11.8 (2.3)
% male 72% 59% 75%
Mean IQ (SD) 104.3 (14.4) 97.1 (13.8) 106.3 (13.9)

% of control sample (n ˆ 155) 12.9% 87.1%

% of learning/attention problem
sample (n ˆ 224) 27.2% 72.8%
480 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

association between group membership and sex (X2 (1) ˆ 8.34, p < 0.01), with
more boys in the non-DCD group.
As shown in Table 3, the proportion of children classi®ed as having DCD
from the sample of typically developing (control) children was almost 13%
(i.e., 20 out of 155 control children). This ®gure is somewhat higher than that
reported elsewhere (American Psychiatric Association, 1994). One possible
reason for this is that the criteria chosen for the standardized tests and the
DCDQ (one standard deviation or 15th percentile) were too lenient (see Hen-
derson and Barnett, 1998). Another possibility is that using more than one
score from the BOTMP (GM, FM, and the BC or the SF) put too much
weight on this test in the assignment of subjects to the overall category of
DCD/non-DCD.
In Table 4, therefore, the above exercise was repeated, using only three of
the six measures: the Movement ABC, the DCDQ, and the BOTMP Battery
Composite. Only 69 control children from the original sample had scores for
all of these three measures. For these 69 children, using all six criteria, 10 chil-
dren had been originally assigned to the DCD group. Using the data from
only three measures, we found that among the 10 children a total of six chil-
dren (i.e., 6/10 ˆ 60%) met the criterion of failure on two of the three tests,
and an additional 10% (i.e., 1/10 ˆ 10%) met the criteria on all three tests.
There was no child who met the criteria for non-DCD using six measures
who met the criteria for DCD using these three, indicating the validity of
using only three tests. If we use a criterion of below cuto€ scores on two
out of three tests, so that children meeting DCD criteria on at least two of
the three tests are classi®ed as DCD, the prevalence of DCD is 10.1% (i.e.,
7/69). This value is lower than that found using the original six criteria, where
the prevalence of DCD was 12.9% (i.e., 20/155), and is closer to that reported
in the literature (Fox and Lent, 1996).

Table 4
Percentages of control children meeting DCD criteria on BOTMP Battery Composite, Movement ABC,
and/or DCDQ

DCD group non-DCD group

n ˆ 10 n ˆ 59

Failed to meet DCD criteria on all three tests 0% 88%

Met DCD criteria on only one test of the three 30% 12%
Met DCD criteria on two tests of the three 60% 0%
Met DCD criteria on all three tests 10% 0%
 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490 481

3.3. Agreement among the tests of DCD

Although the absence of a de®nitive test of DCD precludes the evaluation

of the sensitivity and speci®city of the instruments used here, it would never-
theless be useful to look in more detail at the agreement between the tests in
their assignment of children to the ``pass'' or ``fail'' categories. Table 5 re-
ports, for the entire sample, both the raw proportion of observed agreement
between tests (i.e., Po), and Kappa, which is the same agreement but correct-
ed for chance. As Table 5 shows, the best agreement among tests was for the
BOTMP Battery Composite and Gross Motor Composite, and the Move-
ment ABC. The Battery Composite of the BOTMP showed fair to good
agreement with the Movement ABC and all other BOTMP composite scores,
but poor agreement with the DCDQ. In addition, the BOTMP Gross Motor
Composite score showed fair to good agreement with the Movement ABC.
Using the criteria above, the DCDQ had poor agreement with all other tests.
Table 6 shows the percentage of children who scored below the cuto€s on
combinations of the six tests used, demonstrating further the degree of over-
lap, or agreement, between tests. The data presented in this table consider the
agreement between tests only for children scoring below our designated cut-
o€s. Thus, Table 6 shows only one component of the agreement between
tests (i.e., for children scoring below cuto€), as opposed to Table 5 where
Po takes into account the total agreement between tests for the entire sample

Table 5
Agreement among tests for the entire sample as measured by Po (proportion of observed agreement) and
Kappa (adjusted for chance)

Test BOTMP BOTMP BOTMP BOTMP Movement DCDQ

Battery Gross Fine motor Short form ABC
composite motor

BOTMP
Battery composite: Po ± 0.910 0.870 0.925 0.819 0.809
Kappa ± 0.735 0.515 0.725 0.465 0.387
Gross motor: Po ± 0.803 0.874 0.813 0.783
Kappa ± 0.356 0.587 0.479 0.378
Fine motor: Po ± 0.891 0.736 0.803
Kappa ± 0.516 0.155 0.272
Short form Po ± 0.800 0.837
Kappa ± 0.327 0.393
Movement Po ± 0.800
ABC: Kappa ± 0.371

Kappa values: ˆ Above 0.75, excellent agreement; 0.4±0.75, fair to good agreement.
482 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

Table 6
Percentages of subjects scoring below cuto€s on combinations of tests

Below cuto€ on

BOTMP BOTMP BOTMP BOTMP Movement DCDQ

BC (%) FM (%) GM (%) SF (%) ABC (%) (%)

Below cuto€ on BOTMP BC ± 49 90 64 81 51

(n ˆ 68)
Below cuto€ on BOTMP FM 75 ± 68 59 54 48
(n ˆ 45)
Below cuto€ on BOTMP GM 71 35 ± 51 71 46
(n ˆ 86)
Below cuto€ on BOTMP SF 96 56 93 ± 91 58
(n ˆ 47)
Below cuto€ on Movement ABC 44 18 51 26 ± 39
(n ˆ 39)
Below cuto€ on DCDQ (n ˆ 45) 50 32 59 42 64 ±

(i.e., for both the children who scored above the cuto€ on both tests and the
children who scored below the cuto€ on both tests). The data in Table 6
should therefore be examined in rows horizontally, rather than vertically.
Each row takes the subgroup of children who scored below the cuto€ for that
particular test, and speci®es the percentage of that subgroup that also scored
below average on each of the other tests used in this study. If the data in
Table 6 are read horizontally, it can be seen that the percentage of agreement
ranged from 18% to 96%. The average agreement of each test was also calcu-
lated: The BOTMP-Short Form had the highest average agreement with
other tests (79%), followed by the three composite scores of the BOTMP
(55±67%), with the DCDQ and the MABC having the lowest average agree-
ment at 49% and 36%, respectively. The higher average agreement of the tests
of the BOTMP could be a re¯ection of the internal consistency of these
scores, making their overall agreement with each other predictable. The rel-
atively lower scores of the MABC and DCDQ may re¯ect their independence
as measures of motor skills, as well as how thoroughly they measure speci®c
areas, such as ®ne motor skills.

3.4. Comorbidity

Before considering the question of comorbidity in this particular sample of

children, it is important to note that the three categories of developmental
problems used for the classi®cation are not exhaustive. There are many other
 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490 483

developmental learning/attention/behaviour disorders that were not evaluat-

ed: written language diculties, math disability, social skills de®cits, to name
a few.
For this analysis, the children for whom complete data were not available
were excluded. Hence, comorbidity was examined for a sample of 162 chil-
dren. As shown in Fig. 1, using the three-way classi®cation to categorise
these children, 53 children obtained scores on the various tests which allowed
us to classify them as ``pure'' cases, 47 children did not meet criterion for any
of the three conditions, and 62 were classi®ed as ``comorbid cases''. Of the 53
``pure'' cases, 26 met our criteria for DCD, 19 for RD, and only eight for
ADHD. Among the comorbid cases, 39 children met criteria for two prob-
lems, and the other 23 had diculty in all three areas measured.

4. Discussion

An important question to ask is whether our inability to ®nd tidy groups of

developmental disorders is due to the nature of the instruments we use and the

Fig. 1. Overlap of three diagnostic categories.

484 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

absence of an agreed-upon gold standard for diagnosis, or whether it is due to

the nature of the disorders. On the ®rst point, di€erent tests appear to identify
di€erent children, either because di€erent children have distinct types of mo-
tor problems, or because the tests tap separate functions. An example of this
latter possibility is that the Movement ABC allows for clear teaching of the
task but penalizes the performance of children who are unable to attend to
or remember speci®c instructions during the test item. The BOTMP, on the
other hand, provides less opportunity for practice of a test item but allows
for more coaching during the actual test, which helps those children with poor
attention. Consequently, it is possible that one test captures/identi®es those
children with a concomitant attention or memory problem more often than
the other one does. In addition, neither of these normative tests completely
measures the important factor of quality of movement: some children can suc-
cessfully achieve criteria on a test item, but the quality and speed are far below
that of their peers (McConnell, 1995; Missiuna and Pollock, 1995). So one
possibility is that the ``mixed bag'' of movement disorders that investigators
identify and have so much trouble subtyping is the result of standardized mea-
sures that are limited in their ability to speci®cally de®ne DCD and possible
subgroups. Recently, we have begun to consider the advantages of categoris-
ing children as having DCD, not having DCD, or being suspect for the disor-
der (Wilson et al., in preparation).
We propose, however, that there is growing evidence that it is the nature of
the disorders themselves which explains the large degree of overlap between
conditions. In the area of childhood disorders, comorbidity is the rule rather
than the exception. This state of a€airs is really very odd. When comorbidity
is the rule in physical health, a single underlying disorder is usually assumed.
For instance, when a child is found to have strep, a fever, a certain type of
heart problem, and joint pain, the diagnosis is acute rheumatic fever. It
would be pointless to assign two diagnoses to the child (heart problems
and joint pain, for instance): both symptoms can occur in children indepen-
dently, but their co-occurrence results in a di€erent diagnosis. Yet in the area
of childhood behavioural/emotional/coordination disorders, we continue to
use independent labels such as RD and DCD, as if the child has demonstrat-
ed two distinct, unique conditions.

4.1. The concept of atypical brain development

We submit that there are no reliably identi®able, discrete developmental

disorders because they are all a re¯ection of heterogeneous, Atypical Brain
 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490 485

Development (ABD) (Gilger and Kaplan, submitted). As Powell and Bishop

(1992), p. 762, have suggested previously, ``It seems more likely that a
wide range of learning disabilities can be caused when early development
of the brain is disrupted, but the speci®c pattern of cognitive de®cits will de-
pend on the extent and the location of the underlying neurological abnor-
mality''. In other words, the general underlying etiology of ABD may
express itself in a wide variety of behavioural symptoms, depending upon
the timing, location, and severity of the disruption in brain growth and devel-
opment.
Obviously, some broad subgroups of developmental disorders do exist.
For instance, it would be foolish to argue that there is no such thing as
DCD. DCD is a well-validated syndrome which is demonstrable in many
populations. What we are suggesting, however, is that the study of syn-
dromes such as DCD would bene®t from an acknowledgement that they
are not ``pure''. We think it is very unlikely that ``pure DCD'' or ``pure
ADHD'' occurs very often. Clearly, each exists. But a more accurate concep-
tualization of these syndromes would acknowledge that each represents a
pattern of impairments which are manifestations of a more general underly-
ing de®cit that we are describing as ABD.
In genetics, variable expressivity is a term that captures the ¯avour of our
meaning: there is a single, unifying, underlying de®cit that can manifest itself
in several ways. It cannot reveal itself in an in®nite variety of ways: for exam-
ple, we are not suggesting that the ABD that is responsible for DCD might
also be expressed as petit mal epilepsy. Hence, it is unlikely that ABD is a
unifying, underlying concept that would explain both, even though some chil-
dren with epilepsy do display motor problems. What we propose is that atyp-
ical brain development is an underlying condition that can be expressed in a
child in many di€erent ways, including the three highly overlapping disorders
described in this paper (DCD, RD, ADHD).
Bolstering our argument that di€use Atypical Brain Development is a
worthwhile unifying concept is the fact that the existing literature on
brain-behaviour relationships does not really support the idea that unique
brain areas are associated with individual developmental disorders (DCD,
ADHD, etc.). Many methodologies have been employed to look at brain
structure and function in children with various types of developmental dis-
abilities: brain scans, EEG, event-related potentials, and autopsy studies
(Galaburda et al., 1985; Hynd and Semrud-Clikeman, 1989; Hynd et al.,
1990; Hynd et al., 1992; Marosi et al., 1990, 1992; Riccio and Hynd, 1996).
Currently, there does not seem to be a one-to-one correspondence between
486 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

biology and disorder. This is easiest to illustrate not with DCD (for which
little neuroanatomical research has been conducted), but rather with RD
and ADHD. Consider the following: there is at least a 40% comorbidity be-
tween RD and ADHD, in both directions. In other words, at least 40% of
children with reading problems meet the criteria for ADHD, and at least
40% of the children with ADHD have reading problems (August and Gar®n-
kel, 1990; Cantwell and Baker, 1991; Dykman and Ackerman, 1991; Semrud-
Clikeman et al., 1992). Our results are consistent with this (Fig. 1): 63% of
our sample with ADHD had RD, and 42% of our sample with RD met
our criteria for ADHD. The neuroanatomical evidence on RD (derived from
autopsy data and brain imaging studies) focuses on de®cits in the left tempo-
ral-parietal area. However, as Hynd and his colleagues have shown, if investi-
gators look elsewhere, widespread evidence of atypical brain development is
visible in people with dyslexia, ranging across both hemispheres, and both
cortical and subcortical areas (Hynd et al., 1992; Riccio and Hynd, 1996).
Likewise, the neuroanatomical evidence on ADHD (derived primarily from
brain imaging) has focused on de®cits in the prefrontal cortex and its connec-
tions (particularly striatal). Yet when scientists have looked elsewhere, evi-
dence of atypical brain development has been found in both hemispheres
and in the corpus callosum, as well as the striatum (Hynd et al., 1990).
Some might argue that we cannot ®nd the common underlying disorder for
the very reason that we have not yet ®gured out how to de®ne the discrete
categories or subtypes of disorders. For example, maybe a certain type of
motor planning problem is most likely to co-occur with a speci®c type of lan-
guage/reading problem, but if neither of these two disorders is very precisely
de®ned, the relationship will be lost when other children who have di€erent
types of reading or motor problems are included in a sample. Recently, we
attempted to determine whether particular patterns of motor impairment
(in this case, de®cits in ®ne or gross motor skills) were associated with unique
types of reading diculties. Examination of three subtypes of reading disabil-
ities in 224 children revealed no consistent association of RD subtype with
DCD subtype (Kaplan et al., 1997). Similarly, Casey and colleagues recently
tried to determine whether children with subtypes of ADHD might exhibit
di€erent patterns of learning disabilities (Casey et al., 1996). Again, although
many children with ADHD had learning problems, they could ®nd no con-
sistent pattern of relationships. Although further work of this type may be
warranted, we think these results support the growing evidence that a single,
di€use underlying etiology is responsible for a variety of these developmental
problems.
 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490 487

4.2. Clinical and research implications

What are the implications of a conceptual shift to thinking of DCD as an

expression of ABD? In other words, what's in a name? Does it matter if
DCD, RD, ADHD, etc. are all variable manifestations of a single underlying
etiology?
Referring to the diagnostic categories and subtypes as manifestations of
ABD has many advantages. First and foremost, it keeps us all aware that
these disorders re¯ect an underlying reorganization in the brain itself. In
other words, the children so-designated are not being lazy or careless; they
are attempting to master a skill for which their brains have not been fully de-
veloped.
A second advantage is that it removes the pressure to pigeonhole each
child in precise diagnostic categories. For instance, there are certainly chil-
dren with weak ®ne motor and handwriting (or graphic) skills who would
not meet the criteria for DCD that we presented above, yet their de®ciency
does warrant a clinical referral and treatment. We contend that it would be
helpful rather than harmful for a child in that situation to be labelled
ABD, followed by a list or description of the measurable ®ne motor skills def-
icits. To take a more complex situation, there are children who display clear
motor de®ciencies warranting a diagnosis of DCD, but they also struggle
with minor problems in reading and writing. Again, we suggest it would be
helpful for such children to be diagnosed as ABD with evidence of DCD, fol-
lowed by a description of the language-related problems that were found on
assessment. While the term ABD may be seen as quite ``soft'' compared to
other types of diagnoses, in reality the use of speci®c descriptors of the prob-
lems exhibited by a child actually provides a ``harder'' de®nition of the child's
problems than does a term such as DCD.
A third important advantage is that this approach would help us avoid get-
ting into theoretical hassles about, for instance, what cuto€s to use for our
de®nitions of disorders, or how many motor problems are needed before ap-
plying the label DCD.
In research, there are additional implications of such a shift. First of all,
those of us searching for the gene(s) for dyslexia are probably, in reality,
searching for genes that contribute to atypical brain development in a broad-
er sense (Kaplan and Field, in preparation). Such relationships will likely be
found if investigators begin evaluating their subjects for disorders other than
dyslexia. Second, it seems as if subtyping research is not too worthwhile any-
more. It is reminiscent of the statistical conundrum of cluster analysis: when
488 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

you run a cluster analysis, by de®nition you ®nd clusters. But are they mean-
ingful? Not necessarily. Likewise, when you categorise children and attempt
to subtype them into di€erent skill/de®cit categories, you will most certainly
®nd subtypes. But given the comorbidities, are they meaningful? Again, we
would say not necessarily. In a di€erent context, Costello has recommended
that research should be focusing on symptoms rather than syndromes (Cost-
ello, 1992). We propose that a similar argument could be made for DCD, to
focus on symptoms (skills de®cits) rather than on subtypes. In treatment
research, for instance, very speci®c inclusion and exclusion criteria are
necessary to avoid heterogeneity within groups; broad labels are inadequate
for this purpose (Missiuna and Polatajko, 1995). The careful listing of specif-
ic de®cits, rather than focusing on diagnostic categories or subtypes,
could allow more precise subject selection and presumably clearer treatment
results.
In both the clinical and the research ®elds, it is evident that people are not
using common terminology to de®ne DCD, and that the di€erent terms used
do not necessarily re¯ect the distinct characteristics and/or subgroups of
motor problems (Missiuna and Polatajko, 1995). Use of a single identifying
term such as ABD, with descriptions of speci®c problems, could achieve more
consensus, and therefore better understanding, between researchers and prac-
titioners and between professionals and parents (Gilger and Kaplan, sub-
mitted).

5. Summary

Those areas of our personal and professional lives that are predictable and
logical are comfortable; perhaps that is why we search for causal relation-
ships and linear explanations. Yet there are many areas of life for which there
are no such simple explanations, where random events must be accepted.
Traditionally, there has been a search for some logical taxonomy of develop-
mental disorders and this search has been extended to the study of DCD in
recent years. What we have proposed in this paper is that there are no pre-
dictable, ``pure'' diagnostic categories of developmental disorders, but rather,
semi-random clusters of symptoms related to motor coordination, attention,
learning and so on, which re¯ect an underlying Atypical Brain Development.
We base our argument on the substantial overlap of disorders, which sug-
gests the possibility that there is a single underlying etiology that is variably
expressed.
 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490 489

Acknowledgements

We thank the Alberta Mental Health Research Fund and the Alberta Chil-
dren's Hospital Foundation for ®nancial support.

References

Achenbach, T.M., Edelbrock, C., 1983. Manual for the Child Behavior Check List and Revised Child
Behavior Pro®le. University of Vermont, Burlington, VT.
American Psychiatric Association, 1994. Diagnostic and Statistical Manual for Mental Disorders, 4th
edition. American Psychiatric Association, Washington.
August, G.J., Gar®nkel, B.D., 1990. Comorbidity of ADHD and reading disability among clinic-referred
children. Journal of Abnormal Child Psychology 18, 29±45.
Bruininks, R.H., 1978. Bruininks±Oseretsky Test of Motor Pro®ciency: Examiner's Manual. American
Guidance Service, Circle Pines, MN.
Cantwell, D.P., Baker, L., 1991. Association between attention de®cit-hyperactivity disorder and learning
disorders. Journal of Learning Disabilities 24, 88±95.
Casey, J.E., Rourke, B.P., Del Dotto, J.E., 1996. Learning disabilities in children with attention de®cit
disorder with and without hyperactivity. Child Neuropsychology 2, 898.
Costello, C.G., 1992. Research on symptoms versus research on syndromes. British Journal of Psychiatry
160, 304±308.
Costello, E.J., Edelbrock, C.S., Costello, A.J., 1985. Validity of the NIMH diagnostic interview schedule
for children: A comparison between psychiatric and pediatric referrals. Journal of Abnormal Child
Psychology 13, 579±595.
Dykman, R.A., Ackerman, P.T., 1991. Attention de®cit disorder and speci®c reading disability: Separate
but often overlapping disorders. Journal of Learning Disabilities 24, 95±103.
Fox, M., Lent, B., 1996. Clumsy children: Primer on developmental coordination disorder. Canadian
Family Physician 42, 1965±1971.
Galaburda, A.M., Sherman, G.F., Rosen, G.D., Aboitiz, F., Geschwind, N., 1985. Developmental
dyslexia: Four consecutive patients with cortical anomalies. Annals of Neurology 18, 222±233.
Gilger, J.W., Kaplan, B.J. Learning disabilities are manifestations of atypical brain development:
Implications for research, diagnosis and practice, submitted.
Goyette, C.H., Conners, C.K., Ulrich, R.F., 1978. Normative data on revised Conners parent and teacher
rating scales. Journal of Abnormal Child Psychology 6, 221±236.
Henderson, S.E., Barnett, A.L., 1998. The classi®cation of speci®c motor coordination disorders in
children: some problems to be solved. Human Movement Science, 17, 449±469.
Henderson, S.E., Sugden, D.A., 1992. Movement Assessment Battery for Children. The Psychological
Corporation, Kent.
Hynd, G.W., Semrud-Clikeman, M., 1989. Dyslexia and brain morphology. Psychological Bulletin 106,
447±482.
Hynd, G.W., Semrud-Clikeman, M., Lorys, A.R., Novey, E.S., Eliopulos, D., 1990. Brain morphology in
developmental dyslexia and attention de®cit disorder/hyperactivity. Archives of Neurology 47, 919±
926.
Hynd, G.W., Semrud-Clikeman, M., Lorys, A.R., Novey, E.S., Eliopulos, D., Lyytinen, H., 1992. Corpus
callosum morphology in attention de®cit-hyperactivity disorder: Morphometric analysis of MRI. In:
Shaywitz, S.E., Shaywitz, B.A. (Eds.), Attention De®cit Disorder Comes of Age. Austin. Pro-ed,
Texas.
490 B.J. Kaplan et al. / Human Movement Science 17 (1998) 471±490

Jastak, S., Wilkinson, G.S., 1984. The Wide Range Achievement Test-Revised. Jastak Associates,
Wilmington, DE.
Kaplan, B.J., Crawford, S.G., Wilson, B.N., Dewey, D.M., 1997. Comorbidity of developmental
coordination disorder and di€erent types of reading disability. Journal of the International
Neuropsychological Society 3, 54.
Kaplan, B.J., Field, L.L. Genetics of dyslexia and comorbid disorders, in preparation.
Levine, M.D., Busch, B., Aufseeser, C., 1982. The dimension of inattention among children with school
problems. Pediatrics 3, 387±395.
Marosi, E., Harmony, T., Becker, J., 1990. Brain stem evoked potentials in learning disabled children.
International Journal of Neuroscience 50, 233±242.
Marosi, E., Harmony, T., Sanchez, L., Becker, J., Bernal, J., Reyes, A., deLeon, A., Rodriguez, M.,
Fernandez, T., 1992. Maturation of the coherence of EEG activity in normal and learning-disabled
children. Electroencephalography and Clinical Neurophysiology 83, 350±357.
McConnell, D., 1995. Processes underlying clumsiness: A review of perspectives. Physical and
Occupational Therapy in Pediatrics 15 (3), 33±52.
Missiuna, C., Polatajko, H., 1995. Developmental dyspraxia by any other name: Are they all just clumsy
children? The American Journal of Occupational Therapy 49 (7), 619±627.
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 (4), 57±71.
Powell, R.P., Bishop, D.V.M., 1992. Clumsiness and perceptual problems in children with speci®c
language impairment. Developmental Medicine and Child Neurology 34, 755±765.
Riccio, C.A., Hynd, G.W., 1996. Neuroanatomical and neurophysiological aspects of dyslexia. Topics in
Language Disorders 16, 1±13.
Rosner, J., Simon, D.P., 1971. The auditory analysis test: An initial report. Journal of Learning
Disabilities 4, 384±392.
Semrud-Clikeman, M., Biederman, J., Sprich-Buckminster, S., Lehman, B.K., Faraone, S.V., Norman,
D., 1992. Comorbidity between ADDH and learning disability: A review and report in a clinically
referred sample. Journal of the American Academy of Child and Adolescent Psychiatry 31, 439±448.
SPSS, 1996. SPSS Base 7.0 Applications Guide. SPSS Inc, Chicago.
Wechsler, D., 1981. Wechsler Adult Intelligence Scale ± Revised. Psychological Corporation, New York.
Wechsler, D., 1991. Wechsler Intelligence Scale for Children, third edition. Psychological Corporation,
New York.
Wilson, B.N., Dewey, D.M., Kaplan, B.J., Crawford, S.G. Reliability and validity of a parent
questionnaire on childhood motor skills, in preparation.
Woodcock, R.W., 1987. Woodcock Reading Mastery Tests. American Guidance Service, Circle Pines,
MN.
Woodcock, R.W., Johnson, M.B., 1989. Woodcock±Johnson Psychoeducational Battery ± Revised. DLM
Teaching Resources, Allen, Texas.