Motor abilities of adolescents with a disruptive behavior disorder: The role of comorbidity with ADHD

Research in Developmental Disabilities 40 (2015) 1–10

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Research in Developmental Disabilities

Motor abilities of adolescents with a disruptive behavior disorder: The role of comorbidity with ADHD Tine Van Damme a,b,*, Bernard Sabbe a, Dirk van West a,b,c, Johan Simons d a

Faculty of Medicine and Health Sciences, Collaborative Antwerp Psychiatric Research Institute, Antwerp University, Universiteitsplein 1, 2610 Wilrijk, Belgium b University Centre of Child and Adolescent Psychiatry Antwerp, Ziekenhuis Netwerk Antwerpen (ZNA), Lindendreef 1, 2020 Antwerp, Belgium c Faculty of Psychology, Department of Clinical and Lifespan Psychology, Vrije Universiteit Brussel, Pleinlaan 2, 1050 Brussels, Belgium d Faculty of Kinesiology and Rehabilitation Sciences, Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101, 3001 Heverlee, Belgium

A R T I C L E I N F O

A B S T R A C T

Article history: Received 6 November 2014 Received in revised form 29 December 2014 Accepted 19 January 2015 Available online

The aim of this study was to explore the incidence, type and severity of motor impairment in male adolescents with a disruptive behavior disorder (DBD) and evaluate the role of comorbid ADHD. The Bruininks–Oseretsky test of motor proficiency, Second Edition was administered to examine a detailed motor profile and to compare the motor abilities of individuals with DBD (n = 99) to those of controls (n = 87). Additional subgroup analyses were conducted within the clinical population and encompassed (1) analyzing differences in motor profiles between individuals diagnosed with oppositional defiant disorder (ODD) or conduct disorder (CD) and (2) comparing the motor profiles of individuals with or without comorbid ADHD. The results indicated that individuals with a DBD showed a mixed motor impairment profile. Even after controlling for IQ, the DBD group obtained significantly lower scores in comparison to controls. The ODD and CD subgroups showed a similar motor profile. Presence of comorbid ADHD did not produce major differences in the motor profile. As approximately 79% of the adolescents with a DBD suffered from motor impairment, motor ability needs to be adequately addressed in research as well as in clinical practice. ß 2015 Elsevier Ltd. All rights reserved.

Keywords: Motor abilities Disruptive behavior disorder ADHD Adolescent Bruininks–Oseretsky test of motor proficiency

1. Introduction The diagnostic and statistical manual of mental disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) acknowledges a separate disorder for children who lack developmental, age-appropriate motor skills, namely Developmental Coordination Disorder (DCD). Although motor disorders, including DCD, can occur in isolation, they regularly seem to coexist with other pediatric mental health disorders. From a more subjective point of view, the motor behavior of children and adolescents with a psychiatric disorder is often described as clumsy, wooden and less fluent. Several studies have examined and confirmed these observations by using standardized motor assessment instruments. On average,

* Corresponding author at: Collaborative Antwerp Psychiatric Research Institute, Universiteitsplein 1, Antwerp, 2610 Wilrijk, Belgium. Tel.: +32 486459788. E-mail addresses: [email protected], [email protected] (T. Van Damme), [email protected] (B. Sabbe), [email protected] (D. van West), [email protected] (J. Simons). http://dx.doi.org/10.1016/j.ridd.2015.01.004 0891-4222/ß 2015 Elsevier Ltd. All rights reserved.

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children with a psychiatric disorder perform worse on standardized motor tests in comparison to typically developing peers (Emck, Bosscher, Beek, & Doreleijers, 2009; Emck, Bosscher, Van Wieringen, Doreleijers, & Beek, 2011; Simons, Verscheure, Vandenbussche, Adriaenssens, & Delbroek, 2013). The presence of possible co-occurring motor problems is of great clinical importance. Accumulating evidence indicates that motor impairment during childhood predisposes for a range of psychosocial, emotional, academic and physical problems (Dewey, Kaplan, Crawford, & Wilson, 2002; Losse et al., 1991; Piek, Bradbury, Elsley, & Tate, 2008; Rivilis et al., 2011; Schoemaker & Kalverboer, 1994; Skinner & Piek, 2001). Furthermore, several links have been established between motor impairment and poor prognostic outcome (Hellgren, Gillberg, Bagenholm, & Gillberg, 1994; Lingam et al., 2012; Piek et al., 2007; Rasmussen & Gillberg, 2000; Sigurdsson, Van Os, & Fombonne, 2002). The majority of the motor ability literature focuses on attention deficit hyperactivity disorder (ADHD) and Autism spectrum disorders (Fliers et al., 2008; Goulardins, Marques, Casella, Nascimento, & Oliveira, 2013; Harvey et al., 2007; Hilton et al., 2007; Kopp, Beckung, & Gillberg, 2010; Pan, Tsai, & Chu, 2009; Pan, 2014; Pitcher, Piek, & Hay, 2003; Staples & Reid, 2010; Verret, Gardiner, & Beliveau, 2010; Whyatt & Craig, 2012). Whereas considerable research attention has been paid to these disorders, the motor abilities of children and adolescents with a disruptive behavior disorder (DBD) remain largely unknown. To our knowledge, no studies have been published that directly investigate the prevalence of motor impairment in children with oppositional defiant disorder (ODD) and/or conduct disorder (CD). Only a handful of studies have examined topics related to this issue. Emck et al. (2011) assessed the gross motor skills of children with different psychiatric conditions, including a behavioral disorders group (n = 44) comprised of children with ADHD, ODD and CD. This study showed that the scores of these children on the test of gross motor development, 2nd edition (TGMD-2) (Ulrich, 2000) significantly differed from the norm population, reflecting marked delays in motor development for about three years. Livesey, Keen, Rouse, and White (2006) examined the relationship between externalizing behavior in 5 and 6 year old children and motor performance, measured by the Movement Assessment Battery for Children (M-ABC) (Henderson & Sugden, 1992). Only one subtest, ball skills, predicted externalizing behavior, with better ball skills being associated with less externalizing behavior. Kroes et al. (2002) investigated whether qualitative aspects of motor performance in 5 and 6 year old children are related to a later diagnosis of ADHD or ODD/CD. The results indicated that the qualitative domain Ball Skills, from the Maastricht Motor test (Vles, Kroes, & Feron, 2004) was predictive of ODD/CD. But in contrast to the findings of Livesey et al. (2006), they found that better performance on ball skills indicated an increased risk of ODD/CD. Moreover, they concluded that motor problems in ADHD are primarily related to the diagnosis of ADHD and are not a characteristic of ODD/ CD. A study by Kooistra, Crawford, Dewey, Cantell, and Kaplan (2005) explored to what extend ODD puts a child with ADHD at risk for motor impairment. Scores on the Bruininks–Oseretsky test of motor proficiency (BOTMP) (Bruininks, 1978) of children with ADHD, Reading Disorder (RD), ODD or various combinations of these, were compared to scores of typically developing controls. The results show that children in the ADHD + ODD group and the ADHD + RD + ODD group scored significantly lower on the Full Battery Composite of the BOTMP than controls. Moreover, a link between gross motor skills and ODD was established. Kadesjo¨ and Gillberg (1999) found increased percentages of children meeting criteria for ODD, if DCD and ADHD were comorbid with one another. A latent class analysis, performed by Martin, Piek, Baynam, Levy, and Hay (2010), indicated that motor problems and ADHD were not found in the same class, unless other mental health disorders were present. In another study, conducted by Iversen, Knivsberg, Ellertsen, Nødland, and Larsen (2006), the co-occurrence of motor coordination difficulties in children with severe behavioral and emotional problems was examined. The study revealed that 62.1% of the children scored in the borderline or definite motor problem range, measured by the M-ABC. Of the children with behavioral or emotional problems 55% fulfilled the criteria of DCD in comparison to 3.4% of the children in the control group. From a reversed perspective, examining the extent of associated difficulties in children with DCD, studies indicate that these children show a greater degree of internalizing and externalizing problems (Dewey et al., 2002; Green, Baird, & Sugden, 2006). In conclusion, research concerning motor abilities in children and adolescents with DBD is incomplete. Due to the scarcity of research, contradictory results, methodological insufficiencies and the absence of clearly defined clinical groups; no sound conclusions can be drawn from previous work. In order to address this paucity of research, the current study explores the incidence, severity and type of impairment in motor abilities in a group of male adolescents diagnosed with DBD. Although comorbidity is a widely acknowledged phenomenon, it is still quite often neglected in research as well as in clinical practice (Visser, 2003). A solid link between DBD and ADHD exists, as 42–90% of the children with ADHD also meet the criteria for ODD or CD (Rommelse et al., 2009). Furthermore, ADHD is associated with proneness for DCD, with prevalence estimates up to 50% (Kadesjo¨ & Gillberg, 2001; Piek, Pitcher, & Hay, 1999). While the main focus of this article lies on motor abilities of adolescents with DBD, the differences between adolescents with or without comorbid ADHD will be assessed and evaluated. 2. Method 2.1. Participants A total of 196 male adolescents aged 12–18 years participated in the study. The clinical sample was recruited from the University Centre for Child and Adolescent Psychiatry in Antwerp (Belgium). Many health care providers from all over Flanders (Dutch speaking part of Belgium) make referrals to this clinic. All boys stayed at the residential unit for behavioral

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disorders and were selected by consecutive sampling. The sample consisted of 107 adolescents with a clinical diagnosis of oppositional defiant disorder or conduct disorder. All subjects were diagnosed according to DSM-IV-TR criteria (American Psychiatric Association, 2000) by an experienced child psychiatrist. The standardized assessment protocol from the unit includes parent and child interviews, parent and child questionnaires, clinical observations made by the staff and neuropsychological testing. As can be expected in a clinical population, comorbid disorders were common and encompassed: ADHD (n = 53), posttraumatic stress disorder (n = 7), reactive attachment disorder (n = 12), impulse control disorder (n = 6), Autism spectrum disorders (n = 16), depression (n = 3), dysthymia (n = 17), anxiety disorder (n = 2) and substance abuse (n = 14). Various combinations of co-occurring disorders appeared in the clinical sample, ranging up to three diagnostic classifications on axis I of the DSM-IV-TR. The control group comprised 89 typically developing boys. Subjects were recruited through schools and participated on voluntary basis. Exclusion criteria were defined as follows: (a) a history of psychopathology; (b) receiving interventions by a physiotherapist addressing motor abilities; (c) physical disability that makes motor assessment difficult. To ensure that no characteristics of mental health disorders were present in the control group, all participants and parents completed the Dutch version of the strengths and difficulties questionnaire (SDQ) (Goedhart, Treffers, & van Widenfelt, 2003). Participants who obtained a total SDQ-score within the clinical range, either self-reported or reported by the parents, were excluded from the study. A psychomotor therapist carried out the assessment of motor abilities. Depending on age, the Wechsler Intelligence Scale for Children (WISC-III-NL) or Wechsler Adult Intelligence Scale (WAIS-III-NL) was administered by an experienced psychologist. In order to maintain homogeneity in the sample, all adolescents with an intellectual quotient (IQ) of 70 were excluded. Based on scores within the clinical range on the SDQ, two control participants were excluded. Another eight participants from the clinical sample were excluded, due to low intellectual functioning. The final sample consisted of 99 adolescents in the DBD group and 87 adolescents in the control group. Their characteristics are presented in Table 1. With regard to evaluating potential differences within the clinical population, the DBD group was divided into subgroups. Separate groups were formed, based on type of behavioral disorder (ODD or CD) and presence or absence of comorbid ADHD. 2.2. Ethics Ethics approval was granted by the Ethics Committee of the University of Antwerp, Faculty of Medicine and the local Ethics Committee of the clinic (Ziekenhuis Netwerk Antwerpen). All participants signed informed consent forms, in addition to their parents or caregivers. 2.3. Motor assessment Because total motor scores do not provide information on the ability in a specific motor domain, a detailed profile will be examined, using the Bruininks–Oseretsky test of motor proficiency, Second edition (BOT-2) (Bruininks & Bruininks, 2005). The BOT-2 is an individually administered test that uses goal-directed activities to measure a wide range of motor abilities in individuals aged 4–21 years. In contrast to other standardized motor assessment instruments, the BOT-2 provides gender-specific scores across a full range of ability, measuring variation from well below to well above average performance. The BOT-2 consists of eight subscales, thus providing a detailed motor profile. The performance on a subscale is converted into a standardized scale score (mean = 15  5). Subscales that assess related aspects of a motor area are combined into a composite score. In total the BOT-2 generates four composite scores and a total motor composite (TMC), representing the overall motor abilities. According to the norms that are based on the American population, all composite scores have a mean of 50 (10). The authors of the BOT-2 examined the psychometric properties and report in the manual that the BOT2 has demonstrated reliability and validity (Bruininks & Bruininks, 2005). The content and structure of BOT-2 is presented in Fig. 1. Because normative values for the BOT-2 have not been developed on a Dutch population, comparisons between the DBD group and control group were made. Table 1 Sample characteristics. Group

Control DBDa ODDb CDc DBD + ADHDd DBD ADHD a b c d

n

87 99 36 63 53 46

Age

IQ

M

SD

Range

M

SD

Range

15.32 15.33 14.95 15.54 15.09 15.61

1.50 1.41 1.31 1.44 1.38 1.41

12.25–18.50 12.08–17.75 12.91–17.58 12.08–17.75 12.08–17.58 12.42–17.75

104.57 90.41 87.81 91.90 90.55 90.26

11.69 11.67 10.75 11.99 12.41 10.89

78–127 71–126 71–113 71–126 72–126 71–118

DBD = disruptive behavior disorder. ODD = oppositional defiant disorder. CD = conduct disorder. ADHD = attention deficit hyperactivity disorder.

[(Fig._1)TD$IG]

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Fine motor precision Fine Manual Control Fine motor integration Manual Dexterity Manual Coordination Bilateral coordination

TOTAL MOTOR COMPOSITE

Balance Body Coordination Upper-limb coordination Running speed and agility Strength and Agility Strength

Fig. 1. Structure of the Bruininks–Oseretsky test of motor proficiency, second edition.

2.4. Procedure Each participant was tested individually. In line with the testing procedure from the BOT-2 manual, all motor tasks were explained and demonstrated by the therapist. Whenever appropriate, extra information was provided. Adolescents from the DBD group were assessed in the clinic where they resided. Stimulant medications were discontinued on the day of motor and IQ assessment. The tests were considered a part of the standard assessment protocol from the unit. A psychologist evaluated the intellectual functioning of the participants, whereas a psychomotor therapist administered the BOT-2. While participants from the control group were assessed in a single session, adolescents from the DBD group were tested on two occasions. For practical reasons, a separate session took place for the administration of the BOT-2 and the evaluation of intellectual functioning. The infrastructure from the local schools was used for the test administration of the control group. Regular breaks were proposed, whenever desirable. 2.5. Statistical analysis All data were analyzed, using SPPS, Version 22. Statistical significance for the two-tailed tests was set at p < 05. Effect size estimates were computed as Eta Squared. In accordance with the guidelines from Cohen (1998), the effect size was interpreted as follows: .01 = small effect, .06 = moderate effect, .14 = large effect. There were no missing data for any of the variables. Descriptive statistics were used to characterize the sample. Preliminary checks were performed to ensure that parametric assumptions were not violated. There were no significant differences between the DBD group and the controls for age (t(184) = .013, p = .990). In contrast, a significant difference in IQ emerged between the two groups (t(184) = 8.251, p = .000), with the DBD group obtaining significantly lower IQ-scores than the controls. No significant differences for age and IQ emerged between the clinical subgroups ODD and CD (Age: t(97) = 2.033, p = .045; IQ: t(97) = 1.697, p = .093) and between the subgroups DBD + ADHD and DBD ADHD (Age: t(97) = 1.843, p = .068; IQ: t(97) = .121, p = .904).

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Group comparisons on BOT-2 subscales, composite scores and TMC were conducted using independent t-tests. As IQ differed significantly between the two groups, a one-way ANCOVA was performed to examine group differences while accounting for IQ. Bonferroni corrections were applied in order to account for an inflated type I error by multiple testing. Performance on the BOT-2 was classified in five descriptive categories: well below average (2SD), below average (1SD), average (<1SD–>1SD), above average (1SD) and well above average (2SD). An analysis of the frequencies of adolescents in the five descriptive categories was conducted. In order to evaluate the clinical severity of the aforementioned group differences, the percentage of adolescents in each group were tested using Chi-square tests. Additional subgroup analyses in the clinical population were carried out using independent t-tests. Motor profile differences between the two behavioral disorders (ODD and CD) and adolescents with or without ADHD were explored. Finally, adolescents from the DBD group with and without motor ability difficulties were compared on several variables. A series of Chi-square analyses were conducted, to compare both groups on age, IQ, diagnosis (ODD/CD), presence or absence of ADHD and number of comorbid diagnoses. 3. Results 3.1. BOT-2 results: DBD group versus control group 3.1.1. Group differences in motor abilities The results of the group comparisons on the BOT-2 motor composites and TMC are presented in Table 2. Means, standard deviations, t-test results or F-test results, effect size estimates and mean differences are reported. Each variable takes up two rows. In the first row, the results of the independent t-tests are presented. The second row contains the results of the oneway ANCOVA, thus statistically controlling for group differences in IQ. The DBD group obtained a mean TMC slightly below 1SD from the mean population norm. The mean TMC of the control group was 51, which is close to the population norm. Table 2 shows that the DBD group displayed more motor ability problems in comparison to the control group, with significant differences between the groups for all composite scores. While controlling for IQ, the results continue to yield significant p-values. The effect size estimates of these between group differences are situated in the moderate to large range (Cohen, 1988). 3.1.2. Type of impairment in motor abilities Fig. 2 illustrates the mean motor scores on the eight subscales of the BOT-2. The DBD group scored significantly lower on all subscales, in comparison to the control group. With regard to the type of difficulties, Fig. 2 shows a mixed motor impairment profile for the DBD group, with difficulties in all subscales, except for subscale 6, representing running speed and agility. Fig. 2 indicates that the largest impairment is situated in the subscales fine motor integration and bilateral coordination. 3.1.3. Severity and incidence of impairment in motor abilities Analysis of the frequencies of adolescents in the five descriptive categories shows that 13.1% of the adolescents from the DBD group exhibit definite motor problems. None of the adolescents from the control group scored below 2SD from the mean. Furthermore, 65.7% showed borderline motor difficulties in comparison to 18.4% in the control group. The majority of the control group (66.7%) scored within the normal range. Proportions of participants in each descriptive category are presented in Table 3. Chi-square analyses showed strongly significant group differences for the total motor composite (x2(4) = 71.010, p = .000) and the four motor composites (FMC: x2(4) = 54.190, p = .000; MC: x2(4) = 25.566, p = .000; BC: x2(4) = 61.305, p = .000; SA: x2(4) = 39.275, p = .000). [Insert Table 3 around here]. Table 2 Group comparisons on BOT-2 composite scores. DBDa (n = 99) Total motor composite Without controlling Controlling for IQ Fine manual control Without controlling Controlling for IQ Manual coordination Without controlling Controlling for IQ Body coordination Without controlling Controlling for IQ Strength and agility Without controlling Controlling for IQ a

p

h2

10.51 49.72

.000 .000

.38 .21

11.21 8.09

7.78

8.89 38.26

.000 .000

.30 .17

9.14 7.12

49.95 48.86

8.84

5.81 13.33

.000 .000

.16 .07

7.31 5.26

6.60

47.91 46.62

7.02

10.02 46.37

.000 .000

.35 .20

10.05 7.64

8.50

60.24 58.80

7.52

6.44 13.22

.000 .000

.18 .07

7.57 4.85

Controls (n = 87)

M

SD

M

SD

39.85 41.31

6.17

51.06 49.40

8.09

36.93 37.88

5.97

46.07 44.99

42.65 43.60

8.23

37.86 38.99 52.68 53.95

DBD = disruptive behavior disorder.

T or F

Mean difference

[(Fig._2)TD$IG]

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Fig. 2. Motor profile of DBD group and control group. Note: DBD = disruptive behavior disorder; FMP = fine motor precision ; FMI = fine motor integration; MD = manual dexterity; BC = bilateral coordination; BA = balance; RA = running speed and agility; ULC = upper-limb coordination; ST = strength, *** p < .000.

3.2. Additional subgroup analysis within the DBD group 3.2.1. Comparison between the DBD subgroups The motor profile of adolescents with ODD (n = 36) was compared to the motor profile of adolescents with CD (n = 63). None of the subscale and composite scores differed significantly between the two groups. In addition, motor profiles of adolescents with DBD and comorbid ADHD (n = 53) and those without comorbid ADHD (n = 46) were assessed. No statistical significant difference between these two groups was established, with the exception of the body coordination motor composite. The difference in body coordination slightly reached statistical significance (t(97) = 2.064, p = .042), with a small effect size (h2 = .043). The motor profiles of the clinical subgroups are illustrated in Figs. 3 and 4. 3.2.2. Comparison between adolescents with or without motor impairment The DBD group was split into two groups. One group consisted of adolescents with impairment in motor abilities, as defined by a TMC score of at least one standard deviation below the control population mean (n = 78). The other group consisted of the adolescents without impairment in motor abilities, as defined by a TMC score within the normal range (n = 21). Chi-square analyses yielded no statistical significant results, thus indicating that both groups are similar in terms of age, IQ, DBD diagnosis, comorbidity with ADHD and the number of comorbid psychiatric disorders. The results are presented in Table 4.

Table 3 Descriptive categories of motor composite scores in %. Category

TMCa DBD

Well-below average (2SD) Below average (1SD) Average Above average (1SD) Well-above average (2SD) a b c d e f g

f

13.1 65.7 20.2 1.0

TMC = total motor composite. FMC = fine manual control. MC = manual coordination. BC = body coordination. SA = strength and agility. DBD = disruptive behavior disorder group; C = control group.

FMCb g

C

18.4 66.7 12.6 2.3

DBD 9.1 59.6 29.3 2.0

MCc C

DBD

17.2 64.4 16.1 2.3

6.1 37.4 53.5 2.0 1.0

BCd

SAe

C

DBD

C

DBD

C

17.2 63.2 18.4 1.1

24.2 49.5 24.2 1.0 1.0

2.3 16.1 63.2 16.1 2.3

20.2 31.3 40.4 7.1 1.0

2.3 6.9 71.3 18.4 1.1

[(Fig._3)TD$IG]

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Fig. 3. Motor profile of adolescents with ODD or CD. Note: ODD = oppositional defiant disorder; CD = conduct disorder; FMC = fine manual control; MC = manual coordination; BC = body coordination; SA = strength and agility; TMC = total motor composite.

[(Fig._4)TD$IG]

Fig. 4. Motor profile of DBD + ADHD and DBD ADHD. Note: DBD + ADHD = disruptive behavior disorder with comorbid attention deficit hyperactivity disorder; DBD ADHD = disruptive behavior disorder without comorbid attention deficit hyperactivity disorder; FMC = fine manual control; MC = manual coordination; BC = body coordination; SA = strength and agility; TMC = total motor composite, * p < .05.

4. Discussion 4.1. Main findings To our knowledge, this is the first study that directly investigates the motor abilities of adolescents with a disruptive behavior disorder. According to our results, there were four central findings. First, the motor abilities of adolescents diagnosed with DBD were significantly poorer in comparison to the control group. Differences were revealed for the total motor composite and the four motor areas, with moderate to large effect sizes, even after controlling for initial differences in IQ. Second, the motor profile outlined in this study showed a mixed motor impairment profile for the DBD group. Third, motor profiles of the clinical subgroups showed a similar pattern of impairment in motor abilities. Fourth, adolescents with or without motor impairment did not differ in terms of age, IQ, type of behavioral disorder and comorbidity rates. It is rather striking that approximately 79% of the adolescents with DBD suffer from clinically relevant motor difficulties. However, not all adolescents with DBD show these deficits. Thus, while atypical motor abilities can be associated with DBD, it cannot be considered a core feature of the disorder. Therefore, when motor impairment is present in adolescents with DBD, a comorbid diagnosis of DCD would be recommended. Remarkably, accompanying symptoms of ADHD did not produce major differences in the motor profile of adolescents with DBD. Only the body coordination composite differed significantly between the two groups. In this motor area,

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Table 4 Comparison between adolescents with or without motor impairment. Variable

No impairment (%, n)

Impairment (%, n)

a

Age 12–13 14–15 16–17 IQ 70–85 86–100 101–115 116–130 DBDb ODDc CDd ADHDe Present Absent Comorbidityf 0 1 2 3 4 a b c d e f

29.4 (5) 21.3 (10) 17.1 (6)

70.6 (12) 78.7 (37) 82.9 (29)

15.0 23.1 27.2 50.0

85.0 76.9 72.2 50.0

(6) (9) (5) (1)

x2

df

p

1.031

2

.622

2.461

3

.441

1.459

1

.307

.139

1

.807

2.938

4

.600

(34) (30) (13) (1)

27.8 (10) 17.5 (11)

72.2 (26) 82.5 (52)

22.6 (12) 19.6 (9)

77.4 (41) 80.4 (37)

15.4 (2) 29.7 (11) 17.9 (7) 11.1 (1) 0 (0)

84.6 (11) 70.3 (26) 82.1 (32) 88.9 (8) 100 (1)

Age = in years. DBD = disruptive behavior disorder. ODD = oppositional defiant disorder. CD = conduct disorder. ADHD = attention deficit hyperactivity disorder. Comorbidity = number of comorbid disorders (including ADHD).

adolescents with a comorbid diagnosis of ADHD performed worse than adolescents with DBD only. The effect size was small and accounted for 8% of the variation. The finding that motor problems in DBD are not mainly explained by a comorbid diagnosis of ADHD challenges the idea that motor impairment is a fundamental characteristic of ADHD. In contrast, these results suggest that impairment in motor abilities is associated with DBD, rather than with the presence of ADHD. 4.2. Limitations Some limitations, regarding the study design should be mentioned. First, both the DBD group and the control group were convenience samples. Despite the detailed description of the groups and the sample size, the samples may include some unknown sampling bias. Second, a cross-sectional study design was used. Thus, leaving the development of motor abilities of individuals diagnosed with DBD unknown. A longitudinal study would provide more insight into this trajectory. Furthermore, the motor abilities of adolescents with DBD were compared to those of typically developing peers. However, it is not clear whether the motor abilities of adolescents with DBD differ from those of adolescents with other psychiatric disorders. Therefore, it would be interesting to make a comparison across different psychiatric disorders, in order to identify motor profiles, potentially specific to a diagnosis. In this study, only male adolescents were included, which restricts the generalization of the findings. However, several motives serve as a justification for gender-specific research. Gender differences have been reported for motor performance in typically developing children and adolescents (Barnett, van Beurden, Morgan, Brooks, & Beard, 2010; Thomas & French, 1985) and some researchers suggest that motor impairment is more prevalent in boys than in girls (Kadesjo¨ & Gillberg, 1999). In addition, a different pattern in motor abilities can be found in male and female adolescents, when using the BOT-2 (Bruininks & Bruininks, 2005). On average females perform better on the subscales fine motor precision, fine motor integration and manual dexterity. In contrast, males generally perform better on strength, running speed and agility. Moreover, the prevalence of DBD is higher in males than in females (Maughan, Rowe, Messer, Goodman, & Meltzer, 2004). In order to obtain an adequate sample size and reduce the potential confounding influence of gender differences, only male adolescents were the focus of this study. Although the type and degree of motor impairment has been shown to differ between ADHD subtypes (Piek et al., 1999), this issue was not addressed in the study. As the majority of the adolescents were diagnosed with the ADHD combined type and only a few (n = 4) were diagnosed with the predominantly inattentive subtype, comparisons would not be appropriate. 4.3. Clinical applications The results of this study suggest that impairment in motor abilities is highly prevalent in male adolescents diagnosed with DBD. Therefore, objective assessment of motor abilities should be considered part of the routine clinical evaluation.

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Unfortunately, the recognition that individuals with DBD may also suffer from motor impairment is rarely considered. It seems that the presence of severe behavioral disorders may obscure the presence of these motor problems. Which is illustrated by the fact that, prior to this study, none of the adolescents from the DBD group were diagnosed with DCD. 5. Conclusion Motor impairment is a feature of many different pediatric mental health disorders, which also seems to be the case for DBD. Despite the fact that the findings from this study require further validation, justification for standard assessment of motor abilities in adolescents with DBD is provided. Within the field of child psychiatry, disruptive behavior disorders are a major concern, because of their high degree of impairment and poor prognosis. Regardless of the fact that they are not easily treated, the core symptoms and associated impairments should be actively attended to by a combination of treatments, including approaches concentrating on impairment in motor abilities. So far, motor abilities of children and adolescents with DBD have received little attention in research. Future studies, adequately addressing the area of motor abilities, are recommended. References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Barnett, L. M., van Beurden, E., Morgan, P. J., Brooks, L. O., & Beard, J. R. (2010). Gender differences in motor skill proficiency from childhood to adolescence. Research Quarterly for Exercise and Sport, 81, 162–170. Bruininks, R. H. (1978). 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