Developmental coordination disorder and dyspraxia

What is DCD?

Developmental coordination disorder (DCD) is the term used to describe a range of difficulties 6-8% of children experience with posture, movement and coordination, without there being a specific medical reason for these difficulties. These difficulties are severe enough to adversely affect their everyday function and school activities.

There are a number of other terms or labels used for the difficulties experienced by children including low muscle tone, minimal neurological disorder, and clumsy child syndrome.  The trouble with each of these labels is that make an assumption about the cause of the difficulties the child has - whereas the underlying cause is not known.

What is dyspraxia? 

The term dyspraxia is sometimes used as an alternative term for DCD.  
 
There are no formal criteria for a diagnosis of dyspraxia.  This makes it very confusing: different people use the term dyspraxia in different ways.  

It is also the reason why a diagnosis of dyspraxia is not recognised by many pediatricians and school authorities. 

The information provided by the dyspraxia support group websites tend to list a range d by a child who has been diagnosed as having dyspraxia, including poor emotion regulation, attention, short-term and working memory and other cognitive difficulties.

Including all these different developmental difficulties into one diagnosis has its drawbacks because it prevents clear thinking about the different factors contributing the everyday difficulties the child is experiencing. 
 
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What causes DCD? 

DCD is not really a single disorder with a known cause, a typical developmental pathway or known outcome.
 
it is now generally accepted that children with DCD have atypical brain development that affects the way they learn new skills. They appear to have difficulties forming internal representations (also called internal models) that  form the basis learning, planning and coordination of motor skills.  
 
In addition children with a diagnosis of DCD often have difficulties related to self-regulation, anxiety, attention and working memory which impact on their learning of new skills.
 
Together this means that in order to help a child with DCD it is necessary to understand all the factors that contribute to poor motor performance so that a suitable plan of action can be implemented to help the child. 
 
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Why a child with DCD has poor coordination 

DCD is a specific motor learning developmental disorder

It is now generally accepted that children with DCD do not create internal representations of the subroutines involved in performing everyday actions in the same way as typically developing children do. 

Internal representations are the blue prints within the brain that link information from the body sensors (muscles, joints, eyes) with the motor commands for activating muscle contraction at the right time, in the right order with the right amount of force for an action. 

Children with DCD do not make effective use of everyday experience for building a large bank of internal representations to guide and plan movements. They often require additional guided practice to learn new skills in order to develop the internal representations / models that will form the basis for future performance of the skill.   

The many representations needed for an everyday task

Take for example picking up a plastic beaker of water to take a drink. This looks like a fairly simple task - reach, grasp and lift.

But think about it carefully.  The amount of pressure you apply to the beaker and the speed that you lift it all depend on making judgments about how flexible/soft the beaker is and how full it is. 

If the beaker is made of thin plastic, it is important not to grip the sides too hard. If it is full you need to lift it more carefully so as not to spill the water, and you also need to adjust your grip so that it does not slip out of your hand. 

Each of these aspects of pick-up-and-drink-from-a-beaker action is controlled by an internal representation.

Cutting out a circle with a pair of scissors

Many children with DCD / dyspraxia have difficulties cutting out a circle with a pair of scissors. 

The pictures below show how one child's skill at this task improves over time. In the first frame she is 4 years old and having difficulties positioning and holding the paper. One year she cuts out a circle with confidence - mostly because she has learned to to hold the paper closer to the line of cutting. 

Two things have happened in the intervening year and many hours of cutting experience. The first is that with age and experience her ability to plan her actions so that the two hands work together to cut along the line.

The second is that at 5 years she expects to produce a good end product. She now pays attention to outcome and uses her mistakes to improve her accuracy each time she cuts out a circle. 

Read more: Cutting with scissors: refining control through experience  

R 3y 9m scissor cutting 24.jpgR 5y 3m  cutting circle 3.jpg

 

Helping a child with DCD

Research has shown that providing a child with additional guided practice improves performance of everyday and school related tasks. In other words, individualised coaching in the learning of new tasks pays off. 

Parents play a vital role in such coaching. Some coaching will require setting aside specific time for practice. But in many instances it can and should form part of a family's everyday activities.

Once you understand the requirements for a task and why a child has difficulty performing a task, building help into your interactions with your child pays off in terms of your child's ability to be independent, self-confidence and ability to participate with peers in the playground. 

More about understanding and coaching motor skills

How Nick practises walking through the house without bumping into things - an example of parent coaching

Children with DCD and dyspraxia often have hypermobile joints and associated muscle weakness

About 20% of people have joints that are more mobile than usual. This is because the capsule and ligaments that hold the joint together are more pliable (they can be more easily stretched) than usual. The muscles are also more pliable and more easily stretched than usual. The body parts are only loosely held together which means that the muscles have to work harder to hold the body steady and move it against the ever present downward pull of gravity. 

Joint hypermobility affects the way a child learns to move and often results in the child developing inefficient pattens of movement and posture. Although the child's joints and muscles are very flexible, some muscles such as the hamstrings and iliotibial band may be very tight and this affects sitting posture and also hampers the child's performance of agility and balance tasks.

Children with joint hypermobility also often have poor endurance.

The muscle weakness and tightness and the poor endurance can be substantially improved by a programme of exercises tailored to meet the child's specific needs and abilities.

 

Children with DCD and dyspraxia also often have a diagnosis of “low muscle tone”

Children are said to have low muscle tone when they have poor posture and difficulty sitting erect and keeping the trunk steady when moving the arms.

In most cases the cause of these difficulties is muscle weakness and poor endurance usually associated with joint hypermobility.

It is important to recognise the muscle weakness as this can improved by a programme of exercises to strengthen weak muscles, improve endurance and train more effective postural control.  

Read more about low muscle tone

roan 5y eagg and spoon.jpg    
  

 

4y transferring soil into a bucket.jpg

DCD often co-occurs with other developmental disorders 

Children with DCD frequently have co-occurring developmental difficulties which impact on the child's everyday function and capacity for learning. 

Recognizing each specific area of difficulty  and how it impacts on learning of movement skills, attention and behaviour in general is very important.  It makes it easier to understand the child's behaviour and also allows parents and teachers to address each area of concern in an appropriate way. 

Co-occurring difficulties include:

  • Attention difficulties: these may be related to anxiety and poor emotional self-regulation. 
  • Poor emotion self–regulation: which is often related to having an anxious nature 
  • Poor working memory which makes it difficult for the child to remember instructions and keep a goal in mind.
  • A very cautious nature which is associated anxiety and hypersensitivity to sensory stimuli, and often allergies and asthma 
  • Joint hypermobility and associated weakness with associated muscle weakness "low muscle tone" and poor levels of fitness
For more on related difficulties see CanChild: DCD Related Disorders
 

Movement difficulties a child with DCD may experience  

Usually a child is given a diagnosis of DCD because he or she is having difficulties with the control, organization and planning of posture and movements.

However, these children often have associated difficulties with the attention and thinking skills needed for organizing themselves, staying on task, persisting with a task, and remembering and learning a new task. .  

Together these difficulties impact on the child's ability to complete everyday tasks and learn new skills, such as:

  • Balance and agility activities - such as hopping, skipping, climbing on the jungle gym
  • Ball skills - catching, throwing and kicking
  • Getting dressed - particularly buttons and laces
  • Sitting still and upright at a table
  • Eating with a knife and fork
  • Building with construction toys
  • Handwriting is slow and untidy, the child complains of discomfort in the shoulder and hand and dislikes writing, complains that it is boring    More about handwriting
  • Slow to learn to ride a bicycle
  • Slow to learn to swim
  • Games and PE at school - tires quickly, cannot keep up with the other children

What is the cause of DCD?

In many cases the reason why a child develops DCD is not known.  The cause may lie in atypical development of the brain. 

The effective control of all our actions and thoughts depends on the different areas of the brain working together in a coordinated fashion.  In the young baby the connections between the different parts of the brain are present, but not well developed. Over time, as the child’s brain grows and develops these connections become much more clearly defined and specific, and as a result child becomes able to perform more complex tasks which involve doing more than one thing at a time.

The richness and complexity of these connections is influenced by the particular way in which the individual child’s brain develops and the way in which the child engages and interacts with the social and physical environment. Our brains are shaped by the variety and range of our experience.  

Some researchers believe that children with DCD do not create these links between the different brain areas in the same way as typically developing children – everyday experience is not enough, they seem to require additional help.   

There may also be a genetic connection. DCD sometimes runs in families  – there is often  a parent, an aunt or uncle in the family who had difficulties with balance, coordination and motor planning as a child.

Some children born very early also have movement difficulties as a result differences in brain development caused by the pre-mature birth. 

Children on the autistic spectrum sometimes have poorly developed motor skills – possibly also related to atypical brain development.

A child who has hypermobile joints with related muscle weakness (sometimes called low muscle tone) often has difficulty acquiring movement skills in the usual way.

Temperament also plays a role in the development of movement-based skills. A child with a very cautious temperament may avoid activities that are new and appear difficult and require that require mental and physical effort. This affects their ability to learn new skills in the usual easy way. 

Can DCD be cured? 

Children with DCD can learn to perform most everyday tasks given the right opportunities and support.  It just takes more practice and learning to pay attention in a special way to compensate for the way in which their brains learn new skills. 

But even when a child with DCD has learned to perform a task quite well, it might take more effort than usual and require added attention and more time. This needs to be remembered particularly in school tasks where time demands can have a very negative impact on a child's ability. 

Some skills that require a great deal of co-ordination make remain a problem - but then these need not be part of the child's life. Team sports and learning to ride a bicycle on rough terrain are examples of activities that can be avoided. 

Handwriting is the one school activity that can cause long term issues, and the child may need access to a keyboard for school work.  

General fitness can be improved and can make a big difference to how the child perceives his or her abilities. Being able to keep up with the other children in the playground is important and running fitness and coordination can usually be improved with a bit of effort. 

Therapy for children with DCD

Children with DCD are often referred for physiotherapy and / or an occupational therapy.  Although there is a lot of overlap between these therapies, each profession tends to focus on certain aspects of the child’s function. 

Physiotherapists tend to focus on posture and gross motor skills as well as strength, flexibility, agility, endurance. 

Occupational therapists usually pay more attention to fine motor control, hand function, handwriting, perception and daily activities.

However, depending on the therapist's interests, skills and training a therapist may cross these boundaries.

Ideally therapy enlists parents' help in providing everyday opportunities for training motor skills

Learning a motor skill takes repeated practice along with persistence and an ability to tolerate failure.  Parents and teachers are best placed to encourage repeated practice as part of everyday life. 

Common intervention approaches include:

CO-OP is a cognitive based approach which has been well researched. The Canchild website has more information on Co-op as well as some good information on DCD

Sensory Integration Therapy (SIT) is an the approach commonly used by occupational therapists. The assumption in SIT is that the problems experienced by children with DCD/Dyspraxia are due to an underlying disorder of the ability to process sensory information.

Neuromotor task training, an approach developed and used in the Netherlands has provided some evidence for its effectiveness.

 

 

CanChild 

for the most 
up to date, evidence based information on DCD

 

Developmental Gym Approach 

The Developmental Gym approach assumes that there are many different factors that impact on the learning and performance op movement tasks - and that all these factors need to be considered when planning physiotherapy intervention for children with movement difficulties.

It differs from other programs in that it does not view a child's thinking, emotional and movement skills as separate entities - but approaches the child as a complex being with a range of needs and functioning in a family environment.

It also differs from cognitive approaches, such as CO-OP in that physical factors such as strength, endurance and flexibility that may be limiting a child's are addressed at the same time as addressing cognitive, emotional, attention and movement planning issues that are hampering a child's movement performance.

It differs from traditional physiotherapy approaches in that the physical factors limiting task performance are not addressed in isolation from the emotional and thinking aspects of movement performance.

Children with DCD often need encouragement to engage in the effortful physical activity needed to be fit for the classroom and playground and able to keep up with their peers.  

The Fit for Action Webspace provides parents with a range of ideas for improving a child's strength, endurance and flexibility, based on the Developmental Gym approach. 

The Handwriting Gym website is a good place to find out more about drawing and handwriting.

 

Comments

13year old son - possible hypermobility?

hi
My son is 13. He has never liked running, he is quite awkward when he runs and can't keep up with the others. He has never been very good and catching or throwing/kicking a ball although is better now he is older. I noticed when he was about 6 that his posture was really bad and that he had flat feet, making his knees knock together at the side, he also complained of knee pain. I got an appointment at the orthotics department at the hospital and he now wears insoles in his shoes which I think have helped a lot. However, his posture is still dreadful and getting worse - even the way he walks and just holds himself is very awkward, he also seems to stand or sit with his head very forward from the rest of his body. He doesn;t seem to be able to stand up straight with good posture even when he tries, his back is arched and he seems to be bearing all his weight on the lower part of his back making it arch in at the bottom and hump out at the top. He also finds it very difficult with handwriting and has been diagnosed with dysgraphia by an educational psychologist. I am becoming very concerned about his posture and gait and would like him to see someone about it but not sure where to go or what kind of doctor to ask for. He is also qutie clumsy, walking into things or tripping over his own feet. Aside from these issues, he is generally a happy and bright child who who seems fine with making friends. I would really appreciate any advice, I feel terrible nagging him all the time about his posture but I am also worried that if I don't he will end up with an arc or humped back. (it really is that bad)!

Hypermobility and DCD

Hello and thank you for your comment.

It sounds like your son has joint hypermobility and maybe also DCD.. Joint hypermobility is associated with lax  joints and some tigh muscles along with muscle weakness all of which impact on his posture, will affect his running and cause the knee pain. 

Your best bet is to get an appointment with a physiotherapist who can do a full assessment and prescribe the right exercises for your son along with some postural training. If you live in the UK you can request a physiotherapy appointment at at the local NHS community physiotherapy department. 

Another option is to check whether the local community gym has a personal trainer who has some expertise working with teenagers. 

As you say nagging is not really a good option - you need to remember that standing and sitting up straight is difficult and uncomfortable and it is hard work to maintain a good posture for any length of time. 

Pam 

I am sure a physiotherapist

I am sure a physiotherapist will be able to help your son greatly with his gait and posture. Get a referral from your GP or go private.

13year old son - possible hypermobility?

hi
My son is 13. He has never liked running, he is quite awkward when he runs and can't keep up with the others. He has never been very good and catching or throwing/kicking a ball although is better now he is older. I noticed when he was about 6 that his posture was really bad and that he had flat feet, making his knees knock together at the side, he also complained of knee pain. I got an appointment at the orthotics department at the hospital and he now wears insoles in his shoes which I think have helped a lot. However, his posture is still dreadful and getting worse - even the way he walks and just holds himself is very awkward, he also seems to stand or sit with his head very forward from the rest of his body. He doesn;t seem to be able to stand up straight with good posture even when he tries, his back is arched and he seems to be bearing all his weight on the lower part of his back making it arch in at the bottom and hump out at the top. He also finds it very difficult with handwriting and has been diagnosed with dysgraphia by an educational psychologist. I am becoming very concerned about his posture and gait and would like him to see someone about it but not sure where to go or what kind of doctor to ask for. He is also qutie clumsy, walking into things or tripping over his own feet. Aside from these issues, he is generally a happy and bright child who who seems fine with making friends. I would really appreciate any advice, I feel terrible nagging him all the time about his posture but I am also worried that if I don't he will end up with an arc or humped back. (it really is that bad)!

statement

How long does it take to get a statement for my child I have seen a the community paediatric and she has wrote to me that my child has dyslexia dyspraxia also he has chromosome imbalance . I do find it hard coping but I get great reward when I sort him out and clam him down .

Do I Need to Push for What My Girl Needs?

Firstly I am so happy to have found this page, as opposed to NHS websites that just outline with no feedback. My daughter was diagnosed with DCD in year 1. We really had no idea, looking back I now know there were many signs (falling off a chair placed right in front of her just one example). She is seeing the OT tomorrow and now I want to ensure that she is being sufficiently helped. Year 1 her help was so limited. Does she need clear targets for each term?? Things relating specifically to what she does at school?? Her targets last year seemed so small. Is there any other help apart from the OT assessments that I should be asking for? She currently uses hand gyms whenever she is sat on the mat. Is this enough? I know year two is going to be tough so I need her to have as much assistance as she can get!! She gets so worried, on her irst day back to school she got so confused with where to hang her bag and put her book she broke down. It breaks my heart . Just don't want her to be struggling so . Thanks in advance for any suggestions. Laura

Become a knowledgeable and assertive parent

Dear Laura

Thank you for this very important question at the beginning of the school year. 

My experience of school systems is that you are going to need to be an advocate for you child and push for the support she needs. And the best way you can do this is to become as knowledgeable as possible not least about how the system works and what your child is entitled to. 

I suggest you join the Dyspraxia  Foundation support group whose members know all about getting the school system to work for their children 

Children with DCD are able to learn new skills but it takes dedicated learning opportunities - and the only people who really have the time for this are family.  This is where you need to become knowledgeable about how to help your daughter learn new skills.  

Also make sure that you communicate with your daughter's OT regularly and that she lets you know what you can work on.  Discuss the IEP with her and find out how you can assist with extra training to achieve the goals. 

Talk to your daughter's teacher, find out how she perceives your daughter's difficulties and how she hopes to help her. Classes are big and the demands on the teacher's time are many - some teachers are better at dealing with this than others, some find it overwhelming.   Go gently and nudge a little here and there to help the teacher understand your daughters needs if needs be.

In terms of what is expected of your daughter - a few targets that can reasonably be met is better than a lot that are not achieved.     Discuss this with your OT. It may be that the most important targets for the first term are about your daughter settling in and managing her anxiety so that school is a happy place. 

I would like to know how you get on.

Pam

 

 

 

 

 

Hi

HI MY SON IS 2yrs old and has coordination disorder ....very hard FOR HIM TO DO THINGS..HE JUST GIT
DENIED Ssi ..I try ed every doctor out there for my son still no new no body knows what really
Wrong with my son

dyspraxia diagnosis

Hello.When my son was two our PEDs office referred us to an early intervention program which then got him connected to an OT at our local elementary school. He's 3.5 now and is in preschool in which he is able to see her one out of the two days. We also brought him to a behavioral clinic where he was diagnosed. We are still in process of the long term outcomes but our resources are very helpful in helping and coaching as a parent. Not sure if you will have these options where you live but this has been the road we are on and it is slowly helping aside from regular 3 yr old behavior :) so just some ideas to look into. Hope that helps:)

Early intervention is the best

Thank you for your post. 

Getting access to early intervention is the best possible option where it is available.  

Pam

 

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