Relationship between Sensory Responsivity, Loneliness, and Anxiety among Indian Adults with Developmental Coordination Disorder (DCD)

1SRM College of Occupational therapy, SRM Institute of Science and Technology, Kattankulathur, Chennai, India. 2College of Medicine, Imam Abdulrahman Bin Faisal University, P.O.Box 1982, Dammam 31441, Saudi Arabia. 3Deanship of Quality and Academic Accreditation, Imam Abdulrahman Bin Failsal University, P.O.Box 1982, Dammam 31441, Saudi Arabia. *Corresponding author E-mail : dreamsfuture000@gmail.com

Developmental coordination disorder (DCD) is a developmental Motor disorder with marked characteristics of difficulty in coordinating body movements and well established difficulty in communication. Difficulty in sensory processing is a predominant difficulty in adults with DCD 1 . Every individual has their own pattern of sensory responsiveness. Each one is present with an individualized pattern. Environment will provide a good amount sensory input in all the activities of daily life. How the environmental demands were placed on the adults with DCD and how the sensory information is processed and how they respond to the environmental demands was paid attention when analyzing an adult with DCD 2 .
When the sensory responsiveness is depicted with a bell-shaped distribution, majority of the adults have mild response to sensory stimulus from the environment and few individuals respond more immensively. As every individual has a unique sensory pattern, not all the sensory stimulus or input will produce a response equally for the entire individual, there will be individual differences. The stimulus which is desired to bring a response in an individual should have to exceed the neurological threshold to stimulate the nervous system 3 .The individual differences in perceiving and responding to a neurological input are based on the neurological thresholds. Either the individual will be having high or low neurological thresholds.
When examined The Dunn's Sensory Processing model it has been clear that sensory responsiveness will emerge based on the interaction that pins between high or low threshold and selfregulation. Neurological threshold is needed to respond to events in everyday life. Individuals with low threshold will respond to environmental stimulus more easily as their neurological system activates easier to sensory inputs. But contrarily individuals with high threshold will not respond to the input because strong input will favor activation of neurological system.
Hypersensitivity will also correlate positively with social skills in adults with DCD. Anxiety is the baseline factor which interlinks sensory hyper-responsivness and loneliness. When these three factors interlink it affects the physical and emotional imbalances which is manifested in and as gastrointestinal problems. In adults with DCD there is a high prevalence rate of Sensory hyper-responsiveness and it affects visual perception, auditory stimulus reception, tactile response to input from the environment, smell, taste, and proprioception. Loneliness affects the psychological well being of the adult with DCD 6 . It directly interferes with the mental and physical health of adults. DCD adults were affected by social isolation, the reason underlies social isolation is difficulties in interacting with peer group with social skills, leading to deeper consequences of loneliness. However, research on the relationship between loneliness and mental health in adults with DCD is still in debate.

Sample size
The sample size for this current study was calculated to assess of the effects of evaluation of sensory responsively, loneliness, and anxiety in Indian adults with developmental coordination disorder (DCD). The sample size was analyzed based on a confidence interval of 95%.

Procedure
The principal investigator Dr.Ganapathy sankar has obtained approval for the research (A-NO-25) from research meet at SRM College of occupational therapy, SRM institute of science and technology and included adults with DCD from the developmental therapy centers and organizations. The principal investigator gained the confidence of the participants by explaining the study in detail and by submitting the information sheet of the study to the parents and caregivers of the adults with DCD.
The characteristics of participants included in the study are presented in (Table  1). Participants were diagnosed with DCD in accordance to DSM-IV criteria and the adults with DCD were included into the study (n = 15, age group: 20-40 years). All participants had a documented diagnosis of DCD by a registered psychiatrist. The principal investigator assessed the information sheet and the assessment done by the psychiatrist. Dr.U.Ganapathy sankar confirmed the diagnosis by the AAC-Q. Excluded the adults with IQ less than 70. During the baseline assessment reading and writing skills were tested by instructing the adults to read a paragraph and write it. All the adults were from India, English / Tamil papers were provided by considering their native language.

Measures
Sensory Profile: The Adult Sensory Profile is used to analyze the sensory processing and this is the reliable and valid test in examining the sensory profile. It contains 60 questions, which analyzes four factors of sensory processing skill. Total score lies in the range of 15-75.
Anxiety: The Beck Anxiety Inventory (BAI) was used to examine the anxiety and its severity. The BAI has 21 items that assess the severity of anxiety in adults. Participants were instructed to report the symptoms they experience using a 4 point (0 = "not at all," 3="severely"). Total scores lies between 0 to 63.
Loneliness: The short-form UCLA loneliness scale is used and scored using a 4-point Likert scale ranging from 1 (never) to 4 (always). Total score is from 8-32 A A C -Q : A d o l e s c e n t a n d a d u l t s Coordination Questionnaire was used to identify the DCD Adults.
Demographic Information: Participants were assessed in the baseline and questioned for emographic profile that lists the information including age, gender, associated psychiatric disorders, educational status, employment, marital status, personal habits (TABLE 1). Data Analysis. SPSS 20.0 for Windows

ReSUltS
Sensory responsivity in adults with DCD mean scores were 40.1, 42.2, 42.6 and 40.6 respectively. The mean score for anxiety was 20.0 and reported severe level of anxiety. The mean score resulted for loneliness was 25.2 on the ULS-8 The correlation matrix was used to assess the relationship between sensory hyper-responsiveness, anxiety and loneliness. There is a perfect correlations existed among the above mentioned variables. A significant positive correlation was obtained between sensory avoiding and anxiety, it highlights that adults with DCD resulted with greater level of anxiety when sensory avoiding is present , they cant execute the ADL by overcoming the environmental demands placed on them. DCD and sensory avoiding were correlated positively with loneliness and anxiety(p < 0 001).

DiSCUSSion
The current study was to summarize the association Between sensory avoiding, anxiety, and loneliness in adults with DCD. The results suggest that in adults with DCD, more sensory avoiding was correlated with higher level of anxiety and loneliness. Loneliness is expressed as a moderator between sensory avoiding and anxiety. Thus sensory processing difficulties not only present in children with DCD, however it also invigilates into adults and adolescents.
This result is consistent with that of a study by Dr. Ganapathy sankar,, which revealed that caregivers burden is greater with DCD children and that study highlighted that if not diagnosed at the earlier stage , children will not outgrow of DCD, but they suffer with coordination disorder in Adult life too. The sensory feature will be subjected to variation in each age band and the consideration must be given to gender difference too. But these types of hypothesis need further examination and this is considered to be the limitation in the initial pilot trail. Adults with Developmental coordination disorder reported sensory avoiding and they experience more feeling of loneliness and they found themselves isolated from the environment and the society in which they live. Furthermore, loneliness is considered to be the important factor that serves as an mediator for sensory avoiding and anxiety. Moreover, the lack of treatment strategies for treating adults with sensory processing difficulties could also affect their emotional wellbeing. Self-regulation is based on the behavioral strategies. Two instances can demonstrate selfregulation in detail, individual when placed at a position to receive multiple sensory stimuli from the environment, but responds without any passive self-regulation strategy will respond to all the input and ends with frustration. Few adults were mastered in adapting a self-regulation strategy to the multiple environmental stimuli placed around him. Adults with DCD may exhibit a low or high neurological threshold to environmental sensory stimulus. Sensory hyper-responsively correlated with sleep problems in ADULTS with DCD 4,5 . It has been proved that auditory sensitivity affects the adults ability to process information by listening.
When considering the general population, loneliness has a negative effect over physical & psychological well being 10 .Adults with DCD may be more prone to anxiety if they experience more sensory hyper-responsiveness and perceive greater loneliness. Thus, our results conclude that feelings of loneliness have high impacts on the psychosocial wellbeing of adults with DCD. The findings of the current study have important implications in designing the subsequent therapeutic interventions in adults with DCD.

Data Availability
The data used in this study are available from the corresponding author upon request.

ACknowleDGMentS
We thank the individuals who participated in this research.