Blackwell Publishing LtdOxford, UKCCHChild: Care, Health and Development0305-1862© 2006 The Authors; Journal compilation © 2006 Blackwell

Pub-
lishing Ltd? 2006326723731Original ArticleComorbidity, co-occurrence, continuumB. Kaplan
et al

Original Article doi:10.1111/j.1365-2214.2006.00689.x

Comorbidity, co-occurrence, continuum:

what’s in a name?
B. Kaplan,*† S. Crawford,† M. Cantell,*† L. Kooistra*† and D. Dewey*†
*Department of Pediatrics, University of Calgary
†Behavioural Research Unit, Alberta Children’s Hospital Calgary, AB, Canada

Accepted for publication 12 June 2006

Abstract
Background Comorbidity, co-occurrence and continuum are three terms used when referring to
developmental problems such as Developmental Coordination Disorder (DCD), but they can be
confusing and misleading. Further, the terms can be upsetting to parents, and are not always helpful
in guiding the selection of clinical interventions.
Goals The main purpose of this paper is to question some of the terminology we employ when
referring to DCD and other developmental problems. A secondary purpose is to discuss some of the
conceptual frameworks that have been proposed that attempt to address the issue of the
interrelationships among developmental problems.
Approach The terminology is examined by first referring to the basic dictionary definitions. Second,
data we have published that relate to the issues of co-occurrence and continuum are reviewed in
light of the terminology questions. Finally, we review some alternative conceptual frameworks which
more accurately describe the relationships among developmental problems.
Conclusion The term ‘comorbidity’ has limited relevance to developmental problems, and its use is
questionable. In contrast, co-occurrence and continuum are more useful terms to use in regard to
Keywords developmental problems. Concepts such as atypical brain development and minor neurological
child development, child
disability, Developmental
dysfunction provide some possible explanations for the increased levels of co-occurrence of
Coordination Disorder developmental disorders in children who are more severely affected.

terms being used accurately? Which terms are more

Introduction
appropriate to use?
The main purpose of this paper is to question some
of the terminology we employ when referring to
The terminology
developmental problems such as Developmental
Coordination Disorder (DCD). It is common to Researchers and clinicians have attempted to clas-
hear people speak of DCD as being ‘comorbid’ with sify childhood developmental disorders into dis-
Correspondence:
Bonnie Kaplan, University of other conditions such as attention deficit hyperac- crete diagnostic categories such as those found in
Calgary – Pediatrics, 2888 tivity disorder (ADHD), or as ‘co-occurring’ with the Diagnostic and Statistical Manual of Mental
Shaganappi Trail NW,
problems such as a reading disability (RD). We also Disorders (American Psychiatric Association 1994)
Calgary, AB T3B 6A8, Canada
E-mail: bonnie.kaplan@ speak of developmental disorders like DCD as or the 10th edition of the International Classifica-
calgaryhealthregion.ca existing on a ‘continuum of severity’. Are these tion of Disease (World Health Organization 1992).
Original Article

© 2006 The Authors

Journal compilation © 2006 Blackwell Publishing Ltd 723
724 B. Kaplan et al.

In many cases, these children do not display a sin- (a)

gle discrete disorder but several; for example, chil-
dren with DCD often display ADHD and children
with ADHD are frequently diagnosed with reading DCD ADHD
disability (RD) (Gilger et al. 1992; Kaplan et al.
1998; Pliszka et al. 1999). When multiple diagnoses
are applied, the term comorbidity has been used to
cause
refer to the fact that the children meet diagnostic cause

criteria for more than one disorder.

The term ‘comorbidity’ is a relatively recent (b)
invention in the medical world: it does not seem
to be present in medical dictionaries of the 1970s
and 1980s. The online dictionary provided by DCD ADHD
the US Government’s National Library of Medi-
cine (and supported by Merriam-Webster) pro-
vides this definition: ‘existing simultaneously with
cause
and usually independently of another medical
condition’ (http://www.nlm.nih.gov/medlineplus/
mplusdictionary.html). Note that this definition (c)
specifies an association in time, but not a causal
relationship. In fact, the term comorbidity sug-
gests that the disorders are independent of each DCD ADHD
other (cf. Fig. 1a).
The Merriam-Webster online dictionary
(http://www.m-w.com/) definition for the prefix
‘co’ states the following: ‘with, together, joint’. cause cause

Hence, the term co-occurrence holds no implica-

tions for relatedness. If two disorders co-occur, Figure 1. Three conceptual models of the interrelationship
they are simply happening together, and may not of coexisting disorders. (a) comorbidity, (b) co-occurrence
with related aetiologies, (c) co-occurrence with unrelated
be causally related. Co-occurrence is a purely tem- aetiologies. ADHD, attention deficit hyperactivity disorder;
poral concept, and may reflect either an underlying DCD, Developmental Coordination Disorder.
causality (Fig. 1b) or completely unrelated aetiolo-
gies (Fig. 1c).
‘Continuum’ is defined by the Merriam-Webster cated the presence of at least two diseases. For
online dictionary as ‘a coherent whole character- example, an individual with asthma and diabetes is
ized as a . . . progression of values or elements said to be comorbid for these two independent
varying by minute degrees’. This concept very diseases. In contrast, a patient experiencing exces-
explicitly defines a relationship across points. As sive thirst and frequent urination is not said to be
applied to a disorder, it implies that the points on comorbid for those two conditions because they
the continuum may differ linearly in terms of are symptoms; their co-occurrence suggests mor-
severity, and it suggests that related causality is bidity for a specific disease, namely diabetes. When
probable (but not assured). the term comorbidity was transferred to the devel-
opmental disabilities world, one element was miss-
ing that prevented its accurate application; that is,
The issues presented by
the precise distinction between symptoms and dis-
the terminology
ease (or in this case disorder). For example, when
Comorbidity is a term that has been borrowed a child has difficulties with learning, behaviour,
from physical medicine. Its original meaning indi- mood and writing, the child is displaying symp-

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Journal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development, 32, 6, 723–731
 Comorbidity, co-occurrence, continuum 725

toms that could be indicative of a learning disabil- been suggested that developmental disorders such
ity, ADHD and/or DCD. The co-occurrence of as DCD and ADHD represent the lower extreme
these symptoms causes problems in diagnosis and end of the continuum from normality (Latash &
treatment and raises questions about the aetiology Anson 1996; Bradshaw 2001; El-Sayed et al. 2003).
and the mutual interdependence of various devel- It is also possible that greater severity in the pre-
opmental disorders (Gilger et al. 1992). sentation of a disorder such as DCD could be asso-
Angold and colleagues provided an excellent dis- ciated with more co-occurring conditions
cussion of the problems associated with the term (Bradshaw 2001) and that more co-occurring con-
comorbidity in research on child and adolescent ditions are associated with greater severity in overall
psychiatric disorders (Angold et al. 1999), which is functioning (Ahonen 2001). In other words, there
relevant to the present paper. As with psychiatric may be a continuum of severity in terms of the
disorders, it is important to note that when talking number of diagnoses, with children identified with
about the developmental problems such as DCD, only one developmental disorder displaying better
ADHD and learning disabilities, we are referring to overall functioning than children diagnosed with
disorders, not diseases. Diseases are well-defined two or more developmental disorders.
clinical entities whose aetiologies are often known.
In contrast, disorders are psychological syndromes
The data on comorbidity, co-occurrence
that deviate from some standard of normality
and continuum in DCD
(Angold 1988). When we say that two or more
developmental disorders are comorbid, we seem to To further address the issues about terminology
be presuming that these are simultaneous, inde- employed when referring to DCD and other devel-
pendent disorders. It may in fact be the case that opmental disorders, we present data from a series of
the child is suffering from a single underlying investigations that we have conducted with school-
condition that displays features of two arbitrarily aged children (Kaplan et al. 1998, 2001; Dewey et al.
defined and differentiated disorders (Bradshaw 2002; Kooistra et al. 2005; Crawford et al. 2006).
2001). Thus, the comorbidity found among devel- Three sets of analyses are reviewed below. Diagnos-
opmental disorders could be due to how the differ- tic criteria were set for the three disorders examined
ent symptoms are lumped together or split apart across all analyses: DCD, ADHD and RD.
by the various classification systems used for diag- The diagnostic criteria for DCD were as follows:
nosis (Angold et al. 1999; Bradshaw 2001).
The clinical and research literature on develop- • Children had an estimated Full Scale Intelligence
mental disorders has acknowledged that a ‘contin- Quotient (FSIQ) of >75 based on the Wechsler
uum of severity’ exists in developmental disorders Intelligence Scale for Children – Third edition
(August & Garfinkel 1989; Gilger et al. 1992; Brad- (WISC-III) (Wechsler 1991).
shaw 2001; Kaplan et al. 2001). For example, we • Developmental Coordination Disorder was
now speak of the autism spectrum disorders, which defined as a score of ≤10th percentile on at least
include a range of conditions with similar pheno- two of six possible scores. The scores used were
types (autistic disorder, Asperger’s disorder and the Bruininks-Oseretsky Test of Motor Profi-
pervasive developmental disorder – not otherwise ciency (BOTMP) (Bruininks 1978), Fine Motor,
specified). Whether these individual diagnoses BOTMP Gross Motor, BOTMP Battery Com-
reflect clinically or theoretically meaningful distinc- posite, BOTMP Short Form scores, the Move-
tions remains controversial (Fein et al. 1999); how- ment Assessment Battery for Children (M-ABC)
ever, the use of the term spectrum implies that there (Henderson & Sugden 1992) total impairment
is a range in variability across the autism dimension score and the Developmental Coordination Dis-
with some individuals displaying more severe autis- order Questionnaire total score (Wilson et al.
tic-like features (i.e. autistic disorder) than others 2000).
(i.e. Asperger’s disorder, pervasive developmental • Children were assigned to a ‘Suspect DCD’ group
disorder – not otherwise specified). Similarly, it has if they (i) scored ≥11th percentile and <25th per-

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Journal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development, 32, 6, 723–731
726 B. Kaplan et al.

centile on at least two of the six tests or (ii) scored In the first set of analyses, we examined the per-
≤10th percentile on one of the six tests plus centage of children with DCD who also met criteria
≥11th percentile and <25th percentile on one of for ADHD and/or RD. There were 45 children who
the six tests. met our criteria for DCD, 51 who were labelled
• ‘non-DCD’ was defined as a score ≥25th percen- with ‘suspect DCD’ and 143 children categorized
tile on at least five of the six tests. as ‘non-DCD’. It should be noted that all groups,
even the ‘non-DCD’ group, included children with
The diagnostic criteria for ADHD were as a diagnosis of ADHD and/or RD (Dewey et al.
follows: 2000). The amount of overlap ranged from 13%
(those with DCD met criteria for ADHD) to 36%
• Children had an estimated FSIQ of >75 based on (those with DCD who also met criteria for both
the WISC-III, and they had to meet at least one ADHD and RD). When we asked the general
of the following three criteria: question of how many children with DCD also had
• They met the criteria for ADHD on the Parent attention and/or reading problems, we found a
Diagnostic Interview Schedule for Children linear decrease across groups: 82% of those with
(Costello et al. 1985), or DCD, 53% of those with ‘suspect DCD’ and 32%
• They obtained a T score ≥70 on the Child of our ‘non-DCD’ group met diagnostic criteria for
Behaviour Checklist (CBCL) (Achenbach ADHD and/or RD. These findings suggest that co-
1991) Attention subscale and were ≥1 SD occurrence of more than one disorder was more
above the mean for age and sex on a short- common than not for children with DCD.
form of the Abbreviated Symptom Question- In the second set of analyses, which used an
naire (Goyette et al. 1978), or overlapping dataset, we evaluated the concept of a
• They had been diagnosed by a physician and continuum of severity in relation to ADHD (Craw-
were taking methylphenidate. ford et al. 2006). In this study, we examined the
impact of co-occurring disorders on cognition and
The diagnostic criteria for RD were as follows: behaviour of children with ADHD. Co-occurring
disorders were evaluated by counts (i.e. ADHD
• Children had an estimated FSIQ of >75 based on alone, ADHD and one other disorder, and ADHD
the WISC-III, and they had to meet criteria for with two or more other disorders), in the manner
reading comprehension difficulties and/or pho- employed by Klassen and colleagues (2004). Three
nological coding deficits based on the following groups of children participated: 20 children with
criteria: ADHD and no other disorders, 42 children with
• Their scores on basic reading from the Wood- ADHD plus one other disorder and 40 children
cock Johnson Psychoeducational Battery- who met criteria for ADHD plus at least two other
Revised (WJ-R) (Woodcock & Johnson 1989) disorders. The other disorders evaluated were RD,
had to be ≤16th percentile, or DCD, oppositional defiant disorder, conduct dis-
• Their reading comprehension score from the order, anxiety and depression. We hypothesized
WJ-R was ≤16th percentile, or that a continuum of severity would be displayed;
• They met criteria for Phonological Coding i.e. that children with at least two other disorders
Dyslexia, as follows: in addition to ADHD would show significantly
• They scored ≤24th percentile on the word more impairment on tests of memory, visual per-
attack subtest of the WJ-R, and ceptual skills and daily functioning than children
• They scored ≤16th percentile on WJ-R spell- with ADHD alone or children with ADHD and
ing subtest or the Spelling Subtest of the only one coexisting disorder. A short form of the
Wide Range Achievement Test-Revised WISC-III, the Wide Range Assessment of Memory
(Jastak & Wilkinson 1984), and and Learning (Sheslow & Adams 1990) and the
• They scored ≤16th percentile on the Audi- Developmental Test of Visual Motor Integration
tory Analysis Test (Rosner & Simon 1971). (Beery 1989) were administered (Sheslow & Adams

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Journal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development, 32, 6, 723–731
 Comorbidity, co-occurrence, continuum 727

1990). Children’s behaviour was assessed with the (a)

CBCL (Achenbach 1991); the Parent Ratings of 120
Everyday Cognitive and Academic Abilities (Will- 100

iams et al. 1991) was used to assess the children’s 80

60 DCD
everyday functioning in memory, language, higher Suspect
40
cognitive abilities, co-ordination, learning behav- Comparison
20
iour and academic skills. The results of this study
0
supported our hypothesis: poorer performance on L-W Pass Read Word
Iden Com Voc Att
tests of memory and visual-motor skills, more
prevalent behavioural problems and more impair- DCD
(b) Suspect
ment in everyday functioning were associated with Comparison
a higher number of coexisting disorders in children 120

with ADHD. 100

In the third and final set of analyses to be 80

reviewed, we examined problems of attention, 60

learning and psychosocial adjustment in children 40

with different degrees of motor impairment 20

0
(Dewey et al. 2002). This study evaluated the idea Dict WritS Proof WritF Punc Word
of a continuum of severity from a slightly different Use
perspective by determining whether greater sever- (c)
ity in the presentation of a disorder, in this case 120
DCD, was associated with more problems in other
100
areas of functioning. For this comparison, there
80
were 45 children identified as having DCD, 51 chil- DCD
60 Suspect
dren identified as suspect for DCD and 78 com-
Comparison
40
parison children without motor problems. The
measures of attention, reading, writing, spelling 20

and psychosocial adjustment have been mentioned 0

WJ Spell WRAT-R
above. The result of this analysis across virtually all
measures suggested that there was a linear relation- Figure 2. Linear relationship between severity of motor skill
impairment and impairment on tests of (a) reading. L-W
ship between severity of DCD and impairments on
Iden, letter-word identification; Pass Com, passage compre-
the cognitive and psychosocial measures being hension; Read Voc, reading vocabulary; Word Att, word
assessed (see Fig. 2). These findings are very con- attack. (b) writing. Dict, dictation; WritS, writing sample;
sistent with other work published from the per- Proof, proofreading; WritF, writing fluency; Punc, punctua-
tion; Word Use, word usage. (c) spelling. WJ Spell, Wood-
spective of ADHD (Kooistra et al. 2005). cock Johnson spelling; WRAT-R, WRAT-R spelling. DCD,
Developmental Coordination Disorder; WJ, Woodcock
Johnson Psychoeducational Battery; WRAT-R, Wide Range
The terminology and Achievement Test-Revised.
alternative concepts
The ‘comorbidity’ of developmental disorders is a Gillberg 2001; Newcorn et al. 2001; Tervo et al.
vexatious issue. The research evidence has clearly 2002; Cantell et al. 2003; Crawford et al. 2006).
shown that various developmental problems tend What is not clear, however, is whether children
to co-occur (Sugden & Wann 1987; Powell & with these co-occurring problems display two or
Bishop 1992; Silver 1992; Fawcett & Nicolson 1995; more independent disorders, or a number of
Dewey & Wall 1997; Hill 1998; Kadesjo & Gillberg symptoms associated with a single underlying con-
1998; Kaplan et al. 1998; Piek et al. 1999), and that dition. Our own work and that of the researchers
developmental problems exist along a continuum mentioned above suggest that these conditions are
of symptom severity (Jensen et al. 2001; Kadesjo & not independent and provide support for our

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Journal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development, 32, 6, 723–731
728 B. Kaplan et al.

contention that the term comorbidity does not MND, or complex MND (Hadders-Algra 2002), was
provide a satisfactory explanation for the associa- said to reflect minor dysfunction of the brain that
tions among these developmental problems. could not be ‘repaired’ by the onset of puberty and
Over the past 50 years, a number of conceptual was associated with co-occurring problems in
frameworks have been proposed that attempt to motor, behavioural and cognitive functions.
explain the associations among developmental dis- The concept of DAMP (Gillberg et al. 1982) dif-
orders, and the increased co-occurrence of these fers from MBD and MND in that it seems to
disorders in more severely affected children. They represent a specific disorder of attention, motor
include minimal brain dysfunction (MBD), minor control and perception. Further, it suggests that the
neurological dysfunction (MND), deficits in atten- problems in these three areas are ‘dimensional’ in
tion, motor control and perception (DAMP) and nature. Thus, individuals with severe DAMP fall in
atypical brain development (ABD). All of these the lowermost portion of the normal distribution
conceptual frameworks are based on the notion in terms of their attention, motor and perceptual
that developmental disorders are associated with skills. These individuals are also more likely to dis-
anomalous brain development of some kind. These play co-occurring problems in cognition and affect
concepts also imply that children whose brains are in addition to their difficulties in attention, motor
more severely affected would display more signifi- functioning and perception.
cant anomalies in motor, cognitive and affective The concept of ABD, introduced by Gilger and
components of behaviour. Kaplan (Gilger & Kaplan 2001), does not represent
The concept of MBD proposed over 40 years ago a specific disorder like DAMP, but instead refers to
(Clements & Peters 1962) characterized school- developmental variation of the brain (and sub-
aged children with a broad array of cognitive and sequent brain-based skills) on both sides of the
motor difficulties as having damaged or dysfunc- age-typical norm. The fundamental underlying
tional brains. This term was very popular for many assumptions of the ABD concept are that individ-
years, but eventually fell out of favour for a variety ual differences in behaviour are due to variable
of reasons. Certainly, the reference to ‘damage’ in brain structure and function, and that ultimately,
the original MBD term was inappropriate for devel- individual differences are the result of the complex
opmental disorders. Second, the tendency of diag- interplay of genes and the environment. ABD dif-
nosticians to use MBD as a way of grouping many fers significantly from the older concept of MBD
heterogeneous symptoms into one diagnostic cate- (Clements & Peters 1962). First, the use of ‘atypical’
gory was inconsistent with the dominant trend in in the phrase indicates that this conceptual frame-
the 1970s and onward, where diagnostic systems work is not limited to dysfunction or damage.
have shown a strong predisposition towards split- Further, in contrast to the above-mentioned
ting clusters of symptoms into categorical diagnoses. frameworks, ABD encompasses brain development
In contrast to the breadth of MBD, the concept that yields exceptionally high skills as well as
of MND, introduced by Hadders-Algra, Huisjes and impairments. Although the concept of ABD
Touwen (Hadders-Algra et al. 1988), and Soorani- addresses the issue of variation in abilities, it does
Lunsing Hadders-Algra, Huisjes and Touwen not address how the brain is organized or how
(Soorani-Lunsing et al. 1994), focused more nar- specific areas of the brain explain particular abili-
rowly on the relationship between developmental ties, as do some other theories (e.g. see Luria 1973;
‘soft’ signs (e.g. involuntary movements, dysrhyth- Pennington 1991; Eden & Zeffiro 1998). It does,
mia, overflow, mirror movements) and motor dys- however, accommodate the idea of functional con-
function. According to the MND concept, ‘soft’ tinua for the representation of variations in sever-
signs could indicate a nervous system that is wired ity, in that an individual said to have ABD might
differently from normal, which would increase the express a variety of strengths and weaknesses in
vulnerability of the brain to exogenous influences, different skill areas, in differing degrees.
such as diseases, uninformed rearing attitudes and How does the ABD concept relate to terminology
adverse psychosocial circumstances. Persistent explaining the associations among developmental

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Journal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development, 32, 6, 723–731
 Comorbidity, co-occurrence, continuum 729

disorders? For instance, within the ABD framework, aimed at intervention will improve significantly as
an individual with DCD, ADHD and a learning continued research improves our understanding of
problem would be seen as expressing symptoms of the co-occurrence of developmental disorders. In
an atypical brain affecting multiple areas of behav- closing, we suggest that continued interdisciplinary
iour simultaneously. In that sense, the concept of research acknowledging the individual and multi-
ABD emphasizes the interrelatedness of develop- dimensional quality of developmental pathways is
mental disorders, an idea which underlies contin- necessary for increasing our understanding of
uum conceptualizations. The term ‘comorbidity’ atypical development and for implementing inter-
would not be appropriate to use in describing this vention programmes for affected children.
individual, because it would erroneously assume
independent aetiologies for DCD, ADHD and the References
learning problem, thereby rendering it incompati-
Achenbach, T. M. (1991) Child Behavior Checklist for
ble with the ABD framework. It would be more
Ages 4–18, Parent Form. University of Vermont,
accurate to describe this individual as having weak-
Burlington, VT, USA.
nesses in motor skills (specified), attention and Ahonen, T. (2001) Comorbidity of attention-deficit/
learning (again, specified with details). hyperactivity disorder and Developmental Coordina-
tion Disorder: what do we know? In: The Many Faces
of Attention-Deficit/Hyperactivity Disorder (eds K.
Conclusion Michelsson & S. Stenman), pp. 69–79. Gyllenberg
In summary, the term comorbidity has no rele- Foundation, Helsinki, Finland.
American Psychiatric Association (1994) Diagnostic and
vance and is misleading when used to explain asso-
Statistical Manual of Mental Disorders, 4th edn. Amer-
ciations among developmental disorders, because ican Psychiatric Association, Washington, DC, USA.
it inaccurately assumes that the underlying patho- Angold, A. (1988) Childhood and adolescent depression
physiologies of these disorders are independent I: epidemiological and aetiological aspects. British
and not causally related. Co-occurrence and con- Journal of Psychiatry, 152, 601–617.
tinuum are both more appropriate and accurate Angold, A., Costello, E. J. & Erkanli, A. (1999) Comor-
terms to use in describing associations among bidity. Journal of Child Psychology and Psychiatry, 40,
57–87.
developmental disorders. Co-occurrence can be
August, G. J. & Garfinkel, B. D. (1989) Behavioral and
used when there are assumptions about shared
cognitive subtypes of ADHD. Journal of the American
aetiology and can also be used in cases with com- Academy of Child and Adolescent Psychiatry, 28, 739–
pletely unrelated aetiologies. Continuum, the third 748.
term we considered, accurately describes the distri- Beery, K. E. (1989) The Developmental Test of Visual-
bution of abilities in children across functional Motor Integration, 3rd edn. Modern Curriculum Press,
domains. Cleveland, OH, USA.
It is not expected that any of the conceptual Bradshaw, J. L. (2001) Developmental Disorders of the
Frontostriatal System: Neuropsychological, Neuropsy-
frameworks discussed (i.e. MBD, MND, DAMP, or
chiatric, and Evolutionary Perspectives. Psychology
ABD) will revolutionize either research or clinical
Press, Philadelphia, PA, USA.
practice. In research, the utilization of standardized Bruininks, R. H. (1978) Bruininks-Oseretsky Test of Motor
criteria for defining samples of children with spe- Proficiency. American Guidance Service, Circle Pines,
cific symptom profiles or disorders is necessary in MN, USA.
order to compare data across laboratories. And it Cantell, M. H., Smyth, M. M. & Ahonen, T. P. (2003)
is the reality of the clinical world that multiple Two distinct pathways for Developmental Coordina-
diagnostic labels can facilitate access to resources tion Disorder: persistence and resolution. Human
Movement Science, 22, 413–431.
for helping children with developmental problems.
Clements, S. G. & Peters, J. E. (1962) Minimal brain
But we believe it is important for both researchers dysfunctions in the school-age child. Archives of Gen-
and clinicians to keep in mind the dimensional eral Psychiatry, 6, 185–197.
nature of developmental disorders, which is Costello, E. J., Edelbrock, C. S. & Costello, A. J. (1985)
embodied clearly in the concept of ABD. Tactics Validity of the NIMH Diagnostic Interview Schedule

© 2006 The Authors

Journal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development, 32, 6, 723–731
730 B. Kaplan et al.

for Children: a comparison between psychiatric and Developmental Medicine and Child Neurology, 44, 561–
pediatric referrals. Journal of Abnormal Child Psychol- 571.
ogy, 13, 579–595. Hadders-Algra, M., Huisjes, H. K. & Touwen, B. C. L.
Crawford, S. G., Kaplan, B. J. & Dewey, D. (2006) Effects (1988) Perinatal correlates of major and minor neuro-
of co-existing disorders on cognition and behavior in logical dysfunction at school-age – a multivariate anal-
children with ADHD. Journal of Attention Disorders ysis. Developmental Medicine and Child Neurology, 30,
(in press). 482–491.
Dewey, D. & Wall, K. (1997) Praxis and memory deficits Henderson, S. E. & Sugden, D. A. (1992) Movement
in language impaired children. Developmental Neurop- Assessment Battery for Children. The Psychological
sychology, 13, 507–512. Corporation, London, UK.
Dewey, D., Wilson, B., Crawford, S. G. & Kaplan, B. J. Hill, E. L. (1998) A dyspraxic deficit in specific language
(2000) Comorbidity of Developmental Coordination impairment and Developmental Coordination Disor-
Disorder with ADHD and reading disability. Journal der? Evidence from hand and arm movements. Devel-
of the International Neuropsychological Society, 6, 152. opmental Medicine and Child Neurology, 40, 388–395.
Dewey, D., Kaplan, B. J., Crawford, S. G. & Wilson, B. Jastak, S. & Wilkinson, G. S. (1984) The Wide Range
N. (2002) Developmental Coordination Disorder: Achievement Test-Revised. Jastak Associates,
associated problems in attention, learning, and Wilmington, DE, USA.
psychosocial adjustment. Human Movement Science, Jensen, P. S., Hinshaw, S. P., Kraemer, H. C., Lenora, N.,
21, 905–918. Newcorn, J. H., Abikoff, H. B., March, J. S., Arnold,
Eden, G. & Zeffiro, T. (1998) Neural systems affected in L. E., Cantwell, D. P., Conners, C. K., Elliott, G. R.,
developmental dyslexia revealed by functional neu- Greenhill, L. L., Hechtman, L., Hoza, B., Pelham,
roimaging. Neuron, 21, 279–282. W. E., Severe, J. B., Swanson, J. M., Wells, K. C., Wigal,
El-Sayed, E., Larsson, J. O., Persson, H. E., Santosh, P. J. T. & Vitiello, B. (2001) ADHD comorbidity findings
& Rydelius, P. A. (2003) ‘Maturational lag’ hypothesis from the MTA Study: comparing comorbid sub-
of attention deficit hyperactivity disorder: an update. groups. Journal of the American Academy of Child and
Acta Paediatrica, 92, 776–784. Adolescent Psychiatry, 40, 147–158.
Fawcett, A. J. & Nicolson, R. I. (1995) Persistent deficits Kadesjo, B. & Gillberg, C. (1998) Attention deficits and
in motor skill of children with dyslexia. Journal of clumsiness in Swedish 7-year-old children. Develop-
Motor Behavior, 27, 235–240. mental Medicine and Child Neurology, 40, 796–804.
Fein, D., Stevens, M. C., Dunn, M., Waterhouse, L., Kadesjo, B. & Gillberg, C. (2001) The comorbidity of
Allen, D., Rapin, T. & Feinstein, C. (1999) Subtypes of ADHD in the general population of Swedish school-
pervasive developmental disorder: clinical characteris- age children. Journal of Child Psychology and Psychia-
tics. Child Neurology, 5, 1–23. try, 42, 487–492.
Gilger, J. W. & Kaplan, B. J. (2001) Atypical Brain Devel- Kaplan, B. J., Wilson, B. N., Dewey, D. M. & Crawford,
opment: a conceptual framework for understanding S. G. (1998) DCD may not be a discrete disorder.
developmental learning disabilities. Developmental Human Movement Science, 17, 471–490.
Neuropsychology, 20, 465–481. Kaplan, B. J., Dewey, D. M., Crawford, S. G. & Wilson,
Gilger, J. W., Pennington, B. F. & DeFries, J. C. (1992) A B. N. (2001) The term ‘comorbidity’ is of questionable
twin study of the etiology of comorbidity: attention- value in reference to developmental disorders: data and
deficit hyperactivity disorder and dyslexia. Journal of theory. Journal of Learning Disabilities, 34, 555–565.
the American Academy of Child and Adolescent Psychi- Klassen, A. F., Miller, A. & Fine, S. (2004) Health-related
atry, 31, 343–348. quality of life in children and adolescents who have a
Gillberg, C., Rasmussen, P., Carlstrom, G., Svenson, B. diagnosis of Attention-Deficit/Hyperactivity Disorder.
& Waldenstrom, E. (1982) Perceptual, motor and Pediatrics, 114, 541–547.
attentional deficits in six-year-old children: epidemio- Kooistra, L., Crawford, S., Dewey, D., Cantell, M. &
logical aspects. Journal of Child Psychology and Psychi- Kaplan, B. J. (2005) Motor correlates of ADHD:
atry, 23, 131–134. contribution of reading disability and oppositional
Goyette, C. H., Conners, C. K. & Ulrich, R. F. (1978) defiant disorder. Journal of Learning Disabilities, 38,
Normative data on revised Conners parent and teacher 195–206.
rating scales. Journal of Abnormal Child Psychology, 6, Latash, M. L. & Anson, J. G. (1996) What are normal
221–236. movements in atypical populations. Behavioural and
Hadders-Algra, M. (2002) Two distinct forms of minor Brain Science, 19, 55–106.
neurological dysfunction: perspectives emerging from Luria, A. R. (1973) The Working Brain. Penguin,
a review of data of the Groningen Perinatal Project. Baltimore, MD, USA.

© 2006 The Authors

Journal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development, 32, 6, 723–731
 Comorbidity, co-occurrence, continuum 731

Newcorn, J. H., Halperin, J. M., Jensen, P. S., Abikoff, Soorani-Lunsing, R., Hadders-Algra, M., Huisjes, H. &
H. B., Arnold, L. E., Cantwell, D. P., Conners, C. K., Touwen, B. (1994) Neurobehavioural relationships
Elliott, G. R., Epstein, J. N., Greenhill, L. L., Hecht- after the onset of puberty. Developmental Medicine
man, L., Hinshaw, S. P., Hoza, B., Kraemer, H. C., and Child Neurology, 36, 334–343.
Pelham, W. E., Severe, J. B., Swanson, J. M., Wells, Sugden, D. A. & Wann, C. (1987) Kinaesthesis and motor
K. C., Wigal, T. & Vitiello, B. (2001) Symptom profiles impairment in children with moderate learning diffi-
in children with ADHD: effects of comorbidity and culties. British Journal of Educational Psychology, 57,
gender. Journal of the American Academy of Child 225–236.
and Adolescent Psychiatry, 40, 137–146. Tervo, R. C., Azuma, S., Fogas, B. & Fiechtner, H. (2002)
Pennington, B. F. (1991) Diagnosing Learning Disorders: Children with ADHD and motor dysfunction com-
A Neuropsychological Framework. Guilford Press, New pared with children with ADHD only. Developmental
York, NY, USA. Medicine and Child Neurology, 44, 383–390.
Piek, J. P., Pitcher, T. M. & Hay, D. A. (1999) Motor Wechsler, D. (1991) Manual for the Wechsler Intelligence
coordination and kinaesthesis in boys with attention Scale for Children, 3rd edn. Psychological Corporation,
deficit-hyperactivity disorder. Developmental Medi- New York, NY, USA.
cine and Child Neurology, 41, 159–165. Williams, K. S., Ochs, J., Williams, J. M. & Mulhern,
Pliszka, S. R., Carlson, C. L. & Swanson, J. M. (1999) R. K. (1991) Parent report of everyday cognitive
ADHD with Comorbid Disorders. Guildford Press, New abilities among children treated for acute lym-
York, NY, USA. phoblastic leukemia. Journal of Pediatric Psychology,
Powell, R. P. & Bishop, D. V. M. (1992) Clumsiness and 16, 13–26.
perceptual problems in children with specific language Wilson, B. N., Kaplan, B. J., Crawford, S. G., Campbell,
impairment. Developmental Medicine and Child Neu- A. & Dewey, D. (2000) Reliability and validity of a
rology, 34, 755–765. parent questionnaire on childhood motor skills. Amer-
Rosner, J. & Simon, D. P. (1971) The auditory analysis ican Journal of Occupational Therapy, 54, 484–493.
test: an initial report. Journal of Learning Disabilities, Woodcock, R. W. & Johnson, M. B. (1989) Woodcock-
4, 384–392. Johnson Psychoeducational Battery – Revised. DLM
Sheslow, D. & Adams, W. (1990) Wide Range Assessment Teaching Resources, Allen, TX, USA.
of Memory and Learning. Jastak, Wilmington, DE, World Health Organization (1992) The ICD-10 Classifi-
USA. cation of Mental and Behavioural Disorders: Clinical
Silver, L. B. (ed.) (1992) The Misunderstood Child. Tab Descriptions and Diagnostic Guidelines. World Health
Books, Blue Ridge Summit, PA, USA. Organization, Geneva, Switzerland.

© 2006 The Authors

Journal compilation © 2006 Blackwell Publishing Ltd, Child: care, health and development, 32, 6, 723–731