Developmental coordination disorder (DCD) is used to refer to the difficulty in movement skills that children experience that is not primarily due to general intellectual, primary sensory, or motor neurological impairments (Gubbay, 1985; Hall, 1988; Cermak et al., 2002). DCD is a common yet unfamiliar disability that makes motor and learning tasks challenging to successfully complete, and a key feature of this condition is a difficulty in learning and performing everyday tasks in home, school, and play environments (Asonitou et al., 2012; Barnhart et al., 2003; Blank et al., 2011; Bo & Lee, 2013; Cairney et al., 2012; Cermak et al., 2002; Clark & Whitall, 2011; Smits-Engelsman et al., 2003; Zwicker et al., 2011). Despite the fact that there is extensive agreement regarding the notion that the motor behaviour of children with DCD is inferior to those without the condition, little is known about the cause of DCD, and many theories have been brought to light without much success (Cermak et al., 2002). The Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM IV-TR) categorizes children with DCD using five definitions (Barnhart et al., 2003). Long-term issues seen in individuals with DCD is the development of secondary mental disorders resulting from the inability to perform medial daily tasks individually. Therapeutic approaches are highly recommended at an early stage to help children learn how to successfully execute many of the motor tasks required on a daily basis, however, the condition is a chronic and usually permanent condition, and coordination difficulties do not go away entirely (Missiuna, 1999).

Historical Basis and Alternative Terms

Movement Experience for Children
KIN 366
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Instructor:	Dr. Shannon S.D. Bredin
Email:	shannon.bredin@ubc.ca
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A number of labels have been used to describe DCD including minimal cerebral palsy, minimal brain dysfunction, clumsy child syndrome, developmental dyspraxia, sensory integrative dysfunction, and mild motor problems (Dewey & Wilson, 2001). The concept of developmental motor disorder was first discussed by Collier in the early 1900s, when he used the term “congenital maladroitness” to describe the developmental motor problems evidenced by children (Dewey & Wilson, 2001). By the year 1925, many doctors and therapists situated in France were using the terms “motor weakness” or psychomotor syndrome” in order to describe the condition in which many children with disabilities were displaying motor awkwardness (Dewey & Wilson, 2001). More recently, Ayres used the term developmental dyspraxia to refer to the clumsiness seen in some learning disabled children (Dewey & Wilson, 2001). This term was defined as a disorder of sensory integration, in which the ability to plan and execute skilled or non-habitual motor tasks is impaired (Dewey & Wilson, 2001). In addition, Gubbay described these children with developmental dyspraxia as “clumsy children” because despite the fact that these children displayed normal intelligence and normal findings on a conventional neurological exam, they were unable to perform skilled movement (1985).

Initially, motor coordination issues present during childhood were considered trivial, as it was generally agreed upon that children would outgrow these problems in adolescence or adulthood (Dewey & Wilson, 2001). It is now recognized that clumsiness is not something that is eliminated with aging. Despite the fact that this condition has been described by a number of labels over the years, investigators agree that the motor coordination deficits seen in children with DCD are not due to any identifiable neurological defect (Dewey & Wilson, 2001). In 1994, the International Consensus Conference on Children and Clumsiness had declared DCD to be a more culturally appropriate term to declare this condition (Barnhart et al., 2003).

Classification

Since there is a large variation in regards to the signs and symptoms of DCD, the classification is just as diverse. Labeling a profile to a child is a subjective ordeal as etiology and symptoms are different for each case. As such, inconsistencies are found with diagnosis of a child.

According to Barnhart et al., there are five subtype profiles of children with DCD as stated by Diagnostic and Statistical Manual of Mental Disorders IV-TR (2003; Bo & Lee, 2013).

1. Better scores on gross motor skills than fine motor skills

a. Children’s overall motor skills are still considered below a normal standard
b. Children perform balance and visual-perception skills at a normal standard

2. Better scores on upper limb speed and dexterity, visual-motor integration, and visual-perception skills

a. Children perform balance skills at a much lower standard than normal
b. Children are unable to accurately discriminate upper limb movement and position

3. Better scores on overall motor involvement skills

a. Children perform poorly on kinesthetic and visual skills

4. Better scores on kinesthetic tasks than performance tasks

a. Children perform poorly on visual and dexterity skills

5. Better scores on visual-perception skills

a. Children perform poorly on running speed and agility tasks

Signs and Symptoms

Seeing as it is often difficult to detect DCD due to a lack of specific laboratory tests, and the large variation in theories explaining the etiology of DCD, it is not surprising that the signs and symptoms vary as well. Discriminating factors can be broken down into gross motor, fine motor and psychosocial, characteristics.

Gross Motor Control

In the case of neurological connectivity impairments, neural developmental delays can result in persistent primitive reflexes, hypotonia, and immature balance reactions particularly in young children. In older children it is common to see awkward running patterns, frequent falls, an inability to maintain a grasp, a struggle in imitating body positions, and difficulties following more than three consecutive motor tasks. As a result of these gross motor difficulties, these children may display slow reaction and movement times, thereby limiting success in physical activity (Barnhart et al., 2003).

Fine Motor Control

It can be challenging for children with DCD to successfully plan and execute a fine motor skill especially when speed is involved (Smits-Engelsman et al., 2003). This challenge can be explained by the potential link between DCD and impairments in the cerebellum and basal ganglia. These impairments can result in an inability to successfully plan and execute fine coordinated movements such as handwriting and drawing (Barnhart et al., 2003; Bo & Lee, 2013).

Psychosocial

Without a formal diagnosis, it is difficult to accurately comprehend a child’s inability to achieve certain developmental milestones as compared to their peers. Instead, these developmental delays are often attributed to behavioural issues. Consequently, it may be more difficult for children with DCD to engage in meaningful relationships with their peers. In learning environments, it is common for children with DCD to concomitantly experience a learning disability thus lowering their intelligence levels.

Observable Behaviour

DCD affects both movement and perception (Visser, 2003). As a result, observable behaviour in children with DCD includes clumsiness, poor posture, confusion about which hand to use, difficulties throwing or catching a ball, reading and writing difficulties, and an inability to hold a pen or pencil properly (Alloway & Temple, 2007). Also, DCD is associated with selective deficits in visuospatial short-term and working memory; consequently, these children struggle with remembering instructions, and organizing their time (Alloway & Temple, 2007).

Impact on Daily Life

The inability to successfully perform simple daily tasks such as tying shoelaces or using the toilet decreases the self-confidence of children with DCD. This inability to perform seemingly “easy tasks” places an added toll on their sense of independence when these tasks must be performed with assistance from others. In an academic setting, children with DCD have consistently reported lower intelligence levels due to the challenges they face in completing school related tasks. In addition, these children often suffer from comorbid learning disabilities as they find it challenging to perform tasks such as writing their name or using tools including scissors (Cairney et al., 2012; Smits-Engelsman et al., 2003; Zwicker et al., 2012). In addition to academic challenges, children with DCD experience motor difficulties and as a result, they often consider physical education classes a negative experience. Since they are unable to successfully perform many fundamental movement skills, they generally participate in fewer activities. Consequently, individuals with DCD display high obesity rates, putting them at risk for coronary vascular disease (Cairney et al., 2012; Zwicker et al., 2012). A significant number of individuals with DCD suffer from depression, behavioural disorders, and anxiety (Barnhart et al. 2003; Cairney et al., 2012). Long-term impacts of DCD, specifically due to mental disorders, include an increase in criminal offenses and substance abuse.

Diagnosis

In children with DCD, it is common for the child to have a history of delayed developmental milestones, particularly crawling, walking and speech, a difficulty with dressing themselves, poor ball skills, immature art work, and difficulty making friends (Cools et al., 2009). Thus, assessments for DCD require a developmental history, which can be provided by the parent (Cools et al., 2009). Furthermore there are several screening tests which can be used to assess movement skills associated with DCD including the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), Movement Assessment Battery for Children (M-ABC), Motoriktest fur Vier-bis Sechjarige Kinder (MOT 4-6), Peabody Developmental Motor Scales (PDMS), Korperkoordinationtest fur Kinder (KTK), Test of Gross Motor Development (TGMD), and the Maastrichtse Motoriek Test (MMT) (Cools et al., 2009). However, experts are divided as to the validity of these tests, as there is currently no “gold standard” (Barnhart et al., 2003). Ideally, assessment should be conducted as early as possible in order to implement appropriate interventions, thereby increasing the likelihood of seeing noticeable improvements (Zwicker et al., 2011).

Brunininks-Oseretsky Test of Motor Proficiency

The BOTMP is a subjective assessment to assess fine and gross movement skill development. In particular, it is a tool used to identify individuals with motor coordination deficits. It is a subjective assessment as the assessor is able to verbally provide corrections during the test. In other words, the final outcome may be vary as a result of the influence put upon the child (Barnhart et al., 2003).

Movement Assessment Battery for Children

The M-ABC assesses the developmental status of fundamental motor skills which can indicate the presence of any delays or deficiencies (Cools et al., 2009). The M-ABC test is stricter in the process of evaluation, does not allow verbal corrections, and uses normative data as comparisons. Results are measured based on manual dexterity, ball skills, and static and dynamic balance (Zwicker et al., 2012). However, this assessment does allow for the child to take additional time to practice the required task increasing the opportunity for greater success. Therefore, outcome measures would still not truly reflect a child’s disorder level (Barnhart et al., 2003; Blank et al., 2011).

Motoriktest fur Vier-bis Sechjarige Kinder

The MOT 4-6 test is used to assess fundamental motor skill development, and it can detect any potential delays or deficiencies. It is used for a very small age range (4-6 year olds), and it features 18 different items including locomotion, stability, object control, and fine movement skills (Cools et al., 2009).

Peabody Developmental Motor Scales

The PDMS-2 assesses gross and fine movement skills, and estimates a child’s motor competence relative to his or her peers, identifies skill deficits, and evaluates progress. The test is designed for children from birth to 6 years of age. The gross movement subtests include: reflexes, stationary performances, locomotion, and object manipulation, and the fine movement subtests include: grasping, and visuo-motor integration (Cools et al., 2009).

Korperkoordinationtest fur Kinder

The KTK assesses gross body control and coordination, mainly dynamic balance skills. The test is designed individuals aged 5-14 years old, and it is considered highly reliable and easy to administer (Cools et al., 2009).

Test of Gross Motor Development

The TGDM-2 measures gross movement performance based on qualitative aspects of movement skills. The test is designed for individuals aged 3-10 years old, and it can be used to identify any children significantly below their peers in gross motor performance, thereby allowing for the delivery of appropriate interventions (Cools et al., 2009).

Maastrichtse Motoriek Test

The MMT is an objective test used to assess qualitative aspects of movement skill patterns, and quantitative movement skill performance. The test is designed for children aged 5-6 years old, and it measures both fine and gross movement skills (Cools et al., 2009).

Cognitive Neuroscience Approach

Imaging scans and noting the acquisition of neurological milestones can provide visual evidence of a child’s developing brain. Any abnormalities in the progress of brain growth indicates the potential for neurological disorders. Without early detection, and opportunities for children to improve neural connections, the risk for learning disabilities including DCD become much larger (Blank et al., 2011; Bo & Lee, 2013).

Epidemiology

DCD is a fairly common disorder of childhood, and it is usually identified in children between the ages of 6 and 12 (Barnhart et al., 2003). The prevalence of DCD is approximately 5-8% for school-aged children, and it has been found that children with a history of prenatal or perinatal difficulties display a higher incidence than those who do not (Asonitou et al., 2012; Barnhart et al., 2003; Blank et al., 2011; Cairney et al., 2012; Clark & Whitall, 2011; Zwicker et al., 2012). In particular, DCD is seen in more male children than female children with a ratio of 2:1 respectively. The exact percentage of children with DCD varies greatly as not many individuals are aware of this condition and thus, parents may not get their children assessed and/or practitioners may not diagnose the child accurately (Zwicker et al., 2012). In particular, exact diagnosis may be challenging as DCD commonly overlaps with other disorders. According to Barnhart et al., approximately 41% of children with attention-deficit/hyperactivity disorder (ADD/ADHD) and 56% of children with learning disabilities also have DCD (2003; Bo & Lee, 2013).

Etiology

There are several theories which indicate that the etiology of DCD is secondary to prenatal, perinatal, or neonatal insult, is part of the continuum of cerebral palsy, or is secondary to neuronal damage at the cellular level in the neurotransmitter or receptor systems (Barnhart et al., 2003). The specific disabilities experienced by a child with DCD can be identified using both standard and nonstandard functional tests, but relating these observed disabilities to the primary impairments or any possible neuropathology is not simple (Barnhart et al., 2003). As neuronal groups or brain regions have not been known to be damaged in children with DCD, the problems experienced by children with DCD are believed to be associated with defects in neurotransmitter or receptor systems (Barnhart et al., 2003). Coordination difficulties are associated with a combination of one or more impairments in proprioception, motor programming, timing, or sequencing of muscle activity (Barnhart et al., 2003). Thus, models explaining the neural regulation of posture and movement during development can be useful in describing many of the deficits of motor control observed in these children (Barnhart et al., 2003). In particular the neuronal group selection theory, introduced by Edelman, proposes that functional groups of neurons exist at all levels of the CNS and these respective groups are determined by evolution, but their functional integrity is largely dependent on afferent information produced by movement and experience (Barnhart et al., 2003). Therefore, these neuronal groups serve as an early repertoire for motor behaviour or reception of specific sensory information (Barnhart et al., 2003).

Something that is becoming more noticeable in children diagnosed with DCD is that they were born at a very low birth weight or preterm (Blank et al., 2011; Zwicker et al., 2012). As a result, the development of neurotransmitters and receptors in the brain are affected. Especially if a child is deprived of sensory information to aid in the formation of neural connections, specifically in the cerebellar, parietal, and frontal regions of the brain, the circuitry of gross and fine motor skills cannot be attained (Zwicker et al., 2011; Zwicker et al., 2012) Consequently, children may also have or eventually have secondary neurological conditions to DCD such as cerebral palsy (Barnhart et al., 2003; Clark & Whitall, 2011; Miller et al., 2001).

Prognosis

As the cause of DCD is still unclear, there is no defined projection for an outcome to a cure (Clark & Whitall, 2011). The brain is a complex system that is extensively individualized. Trying to locate a specific area and cause for DCD that could apply to a general population is nearly impossible. Children will not completely outgrow their motor impairments but they can attempt to maintain or even improve their skills through therapy (Bo & Lee, 2013; Barnhart et al., 2003; Zwicker et al., 2012).

Treatment

Occupational therapists help clients acquire the ability to perform everyday tasks independently, and live a more meaningful life. Physical therapists help clients improve their motor ability in order to ensure that they are able to safely participate in everyday activities (Zwicker et al., 2012). Therapists utilize a variety of treatment methods to help DCD patients develop and enhance their coping strategies. Although there is no cure for DCD, symptoms can be improved through individualized treatment approaches as each case is different. Providing opportunities for motor learning for individuals with DCD is essential as early as possible, and these opportunities can be in the form of structured activities or even free play. Motor learning facilitates the formation of additional neural connections which can make daily tasks easier, and thereby create a healthier and more positive individual (Cairney et al., 2012; Zwicker et al., 2012).

Bottom-Up Approach

According to Barnhart et al., a bottom-up approach is based on theories pertaining towards improvements in motor control deficiencies (2003). This approach can be conducted by occupational therapists or physical therapists (Zwicker et al., 2012; Barnhart et al., 2003). Sensory stimulation is provided with the hopes of activating neural connections in the brain to create new pathways for learning. However, this non-repetitive approach does not utilize the cognitive system concurrently, and accordingly, the new connections made may not be effective enough to be retained (Barnhart et al., 2003).

Top-Down Approach

Like the bottom-up approach, this intervention is conducted by occupational therapists or physical therapists (Zwicker et al., 2012; Barnhart et al., 2003). However, the top-down approach differs from the bottom-up approach as it utilizes task specific interventions focusing on the processes involved in creating meaningful connections in the brain and improving general motor actions. Although not specific to particular movements, cognitive treatments can address more activation areas in the brain to provide opportunities for connections to be made. Thus, a top-down approach is used more frequently than a bottom-up approach and it is highly recommended as it involves learning opportunities to improve neural retention.

Sensory Integration Therapy

This therapeutic treatment involves providing sensory information to a child with the hope that it will improve the development of motor skills and neural connections. Unfortunately, DCD patients undergoing sensory integration therapy have not shown significant improvements in motor development, as it does not transfer well to functional skills (Barnhart et al., 2003).

Kinesthesia

Kinesthesia, as defined by Barnhart et al., is the “perception of one’s own body parts, weight, and movement” (2003). Using this process-oriented approach, a child is able to learn fundamental movement skills through body awareness in different environments. Treatment using kinesthesia is most beneficial when positive external feedback is provided.

Perceptual Motor Training

Despite the fact that a cognitive component is not integrated within this approach, perceptual motor training has been shown to result in motor developmental improvements. A more dynamic technique, this approach requires the child to participate in various motor tasks with repeated practice of each task (Barnhart et al., 2003).

Task-Specific Interventions

Task-specific interventions focus on specific motor progressions in order to facilitate the accomplishment of a particular motor task. These progressions allow children to understand difficult concepts in parts, and provide opportunities for subsequent improvements. This is very beneficial as it can boost a child’s self-esteem through successful completion of particular tasks (Barnhart et al., 2003).

Cognitive Interventions

Cognitive interventions help children understand the motor skill they want to accomplish. An extensively studied cognitive treatment approach is the Cognitive Orientation to Daily Occupational Performance (CO-OP) (Miller et al., 2001). In addition, Barnhart et al., describes the GPDC framework to aid in cognitive motor learning (2003). Firstly, it is important for the child to think about the skill that they are trying to achieve (Goal). Secondly, the child should use problem-solving skills to break the skill down into its parts in order to determine a method for how it can be completed (Plan). Thirdly, the child should execute the plan that they have determined is most effective for the situation (Do It). Lastly, the child is required to assess their performance and evaluate the execution of their plan (Check). It has been determined that this treatment is the most effective in regards to retention of skills and the transfer of knowledge to other motor tasks (Barnhart et al., 2003; Miller et al. 2001).

Practical Applications

A major concern for children with DCD is their progress in the school environment. Therefore, it is of utmost importance for parents and teachers, who are in a position to intervene and help these children, to be competent in managing the difficulties that these children may display including, but not limited to, poor posture when seated, excessive force when manipulating objects for fine motor skills, fidgeting, slowness of movements, and poor balance (Missiuna, 1999).

Tips for Parents at Home (Missiuna, 1999)

Exposure to motor activities is very important, this can be accomplished by encouraging the child to participate in games and sports that they enjoy.
Prior to including the child in a group setting, it is important to introduce the child to new activities (e.g., sports) or new environments (e.g., playground) on an individual basis. Explain any rules and routines associated with the activity when the child is not performing any motor tasks, and ask the child questions to ensure that they understand (e.g., “what do you do when you catch the ball”)
If he/she does not want to participate in team sports, then try to encourage the child to interact with peers through activities that they will be likely to succeed in such as music or cubs.
Encourage the child to wear clothing that is easy to change in/out of (e.g., Velcro shoes, sweat pants)
Encourage the child to partake in practical activities to improve his/her ability to plan and organize motor tasks (e.g. setting the table: what is the first step?)
Children with DCD often demonstrate strengths in other areas. Therefore, it is very important to acknowledge your child’s strengths, and ensure that they continue to improve in these areas (e.g., creative imaginations, advanced reading skills)

Tips for Teachers at School (Missiuna, 1999)

First and foremost, talk to the child’s parent about specific difficulties that he/she may present, and discuss strategies that have worked well in the past
Ensure the child’s positioning is adequate to begin table work (e.g., feet flat on the floor, desk at an appropriate height, and forearms are comfortably supported on the desk)
Set realistic short-term goals to ensure continual motivation for both you and the child
Provide extra time to complete fine motor activities such as math, printing, writing a story, practical science tasks, and artwork.
Help the child learn how to use a computer as early as possible in order to reduce the amount of handwriting that will be required in higher grades. This may be difficult initially, but children with movement problems can become quite proficient over time.
Provide specific strategies (e.g., handwriting) to encourage them to perform tasks in a consistent manner (e.g., printing or writing letters).
Provide paper which matches the child’s handwriting difficulties (e.g., if the child writes too large, provide paper with widely spaced lines).

Tips for Teachers in Physical Education (Missiuna, 1999)

Break down the activity into smaller parts
Reward effort, not skill, and choose activities that will ensure the child is successful
Choose activities that require coordinated responses from arms and/or legs (e.g., skipping)
Make participation, not competition, the primary objective
Allow the child to take on leadership roles (e.g., captain of the team)
Give positive, encouraging feedback whenever possible

References

Alloway, T. P., & Temple, K. J. (2007). A comparison of working memory skills and learning in children with developmental coordination disorder and moderate learning difficulties. Applied Cognitive Psychology, 21(4), 473-487.

Asonitou, K., Koutsouki, D., Kourtessis, T., & Charitou, S. (2012). Motor and cognitive performance differences between children with and without developmental coordination disorder (DCD). Research in Developmental Diseases, 33, 996-1005.

Barnhart, R., Davenport, M., Epps, S., Nordquist, V. (2003). Developmental coordination disorder. Journal of the American Physical Therapy Association, 83, 722-731

Blank, R., Smits-Engelsman, B., Polatajko, H., & Wilson, P. (2011). European academy for childhood disability (EACD): recommendations on the definition, diagnosis and intervention of developmental coordination disorder (long version). Developmental Medicine & Child Neurology, 54, 54-93.

Bo, J. & Lee, C. (2013). Motor skill learning in children with developmental coordination disorder. Research in Developmental Disabilities. 34, 2047- 2055.

Cairney, J., Kwan, M., Hay, J. & Faught, B. (2012). Developmental coordination disorder, gender, and body weight: examining the impact of participation in active play. Research in Developmental Disabilities. 33, 1566-1573.

Cermak, S. A., & Larkin, D. (2002). Developmental coordination disorder. Cengage Learning.

Clark, J. & Whitall, J. (2011). Developmental coordination disorder: function, participation, and assessment. Research in Developmental Disabilities, 32, 1243-1244.

Cools, W., De Martelaer, K., Samaey, C., & Andries, C. (2009). Movement skill assessment of typically developing preschool children: A review of seven movement skill assessment tools. Journal of sports science & medicine, 8(2), 154.

Dewey, D., & Wilson, B. N. (2001). Developmental coordination disorder: What is it?. Physical & occupational therapy in pediatrics, 20(2-3), 5-27.

Gubbay, S. S. (1985). Clumsiness. Handbook of clinical neurology, 2(46), 159-167.

Hall, D. M. B. (1988). The children with DCD. British Medical Journal, 296, 375-376.

Miller, L., Polatajko, H., Missiuna, C., Mandich, A., & Macnab, J. (2001). A pilot trial of a cognitive treatment for children with developmental coordination disorder. Human Movement Science. 20, 183-210.

Missiuna, C., & Ont, O. R. (1999). Children with developmental coordination disorder: At home and in the classroom. CanChild Centre for Childhood Disability Research.

Smits-Engelsman, B., Wilson, P., Westenberg, Y., & Duysens, J. (2003). Fine motor deficiencies in children with developmental coordination disorder and learning disabilities: an underlying open-loop control deficit. Human Movement Science, 22. 495-513.

Visser, J. (2003). Developmental coordination disorder: a review of research on subtypes and comorbidities. Human movement science, 22(4), 479-493.

Zwicker, J., Missiuna, C., Harris, S., & Boyd, L. (2011). Brain activation association with motor skill practice in children with developmental coordination disorder: an fMRI study. International Journal of Developmental Neuroscience, 29, 145-152.

Zwicker, J., Missiuna, C., Harris, S., & Boyd, L. (2012). Developmental coordingation disorder: a review and update. European Journal of Paediatric Neurology, 12, 573-581.