Developmental Coordination Disorder Update

Author Pam Versfeld MSc (Physio) UCT, Physical Therapist Read more

What is developmental coordination disorder (DCD)

About 6-8 % of children appear to be developing in the usual way yet have difficulties with coordination and with learning new skills which affects their function and participation at home, at school and in the playground. Developmental Coordination Disorder (DCD) is the internationally accepted name for this condition.

Recent research has shown that the underlying reason for the movement difficulties children with DCD experience is related to atypical brain development that affects the way in which the brain forms connections (internal models) between different parts of the brain when learning a new skill. This in turn impacts on the child's ability to use information from the senses to plan, adapt and control their movements.

DCD affects fine and gross motor abilities, balance and posture, basic motor patterns (walking, running, jumping) and in skilled action that require practice, planning, attention and working memory (ball skills, drawing and handwriting, sport skills).

DSM 5 Manual Diagnostic Criteria

A Motor performance that is substantially below expected levels, given the person's chronological age and previous opportunities for skill acquisition. The poor motor performance may manifest as coordination problems, poor balance, clumsiness, dropping or bumping into things; marked delays in achieving developmental motor milestones (e.g., walking, crawling, sitting) or in the acquisition of basic motor skills (e.g., catching, throwing, kicking, running, jumping, hopping, cutting, coloring, printing, writing).

B. The coordination disturbance significantly and persistently interferes with activities of daily living or academic achievement.

C. Onset of symptoms is in the early developmental period.

D The motor skill deficits are not better explained by intellectual disability (intellectual development disorder) or visual impairment and are not attributable to a neurological condition affecting movement (e.g., cerebral palsy, muscular dystrophy, degenerative disorder). The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy).

What is dyspraxia?

Children with coordination difficulties are sometimes given a diagnosis of dyspraxia. Dyspraxia is a loose "diagnosis" that lumps coordination difficulties with a whole range of attention, emotional self-regulation, anxiety, short term and working memory problems.

Unlike DCD, there are no formal criteria for a diagnosis of dyspraxia and this makes it very confusing because different people use the term dyspraxia in different ways. It is also the reason why a diagnosis of dyspraxia is not recognized by many pediatricians and school authorities.

Including all these different developmental difficulties into one diagnosis has serious drawbacks because it prevents clear thinking about the different factors contributing the everyday difficulties the child is experiencing. The better option is to separately identify the motor learning difficulty (DCD) as well as the associated developmental difficulties such as anxiety disorder, attention difficulties, developmental language disorder, poor working memory and autism. This provides a better insight into the range of difficulties the child has as well as access to information about the different conditions.

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The link between DCD, attention and an anxious nature

Children with DCD often have a very cautious, fearful or anxious temperament. This temperament trait is known as behavioral inhibition (BI) and affects a child's behavior, attention skills and ability to take on challenges and learn new skills. Some children with poor coordination also have generalized joint hypermobility which is in turn associated with a cautious/fearful nature.

BI and anxiety behaviors

Very cautious or fearful response to an event or situation that is new, challenging or unpredictable
Poor attention and emotional self-regulation - tantrums and meltdowns, distractible, fight or flight response to challenges
Avoidance as a strategy to manage negative arousal and anxiety
Intolerance of failure, do not like making mistakes, perfectionism
Fear of heights, loud and unpredictable noises, busy environments, uncertainty
Social anxiety and separation anxiety

What causes DCD?

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 for learning, planning and coordination of motor skills.

The cause of different brain development in DCD but there seem to be some genetic factors involved. Preterm birth and stressful birth circumstances are also linked to DCD.

In addition children with a diagnosis of DCD often have one or more co-occurring developmental difficulties related to a very cautious/ highly sensitive nature, 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.

Why a child with DCD has poor coordination

DCD is a specific motor learning developmental disorder. Children with DCD have difficulty learning and adapting the internal models. These internal models are the blueprints 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. Practice and experience allow the internal models are to be updated to reflect changing circumstances and improve accuracy.

Drinking water from a plastic beaker

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. Your movement brain first gatherers information about where the beaker is relative to your hand and then turns this into a set of commands to the muscles move the hand in the right direction and at the right angle with the fingers opened wide enough to grasp the beaker with just the right amount ot pressure.

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 a set of internal models.

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 later 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.

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Children with DCD learn in a different way

Children with DCD do not make effective use of everyday experience for building new, and adapting already established internal models to guide and plan movements in the same easy way as typically developing children.

They often require additional guided practice to learn new skills. Guided practice sessions include helping the child to understand the requirements of a task, how to pay attention to important visual cues for planning an action, how to use feedback from the success or failure of an action to adapt their movements next time around.

A coaching session with Thabo

Young children learning to throw a beanbag onto a target mat need to learn to adapt how hard and high they throw the bag in order to succeed at the task. If on the first attempt the bag does not land on the target mat, they will adapt the way they throw the bag on the next try. After several attempts the typically developing child will have learned to adapt the throwing action so that they succeed on most attempts.

Six year old Thabo needs some help to learn to throw a beanbag onto a mat successfully. He repeatedly overshoots the target, blames the beanbag saying that it is too soft and quickly looses interest in the task.

Our training session starts with getting Thabo to stand with both feet on a mat and instructing him to keep his feet on the mat when he throws. Next I get him to look at the target mat and to keep looking at the mat as he moves his arm backwards in readiness for throwing the beanbag. Research shows that visually fixing on a target helps with motor planning.

Once he has thrown the bag we talk about the outcome. If it overshoots the target mat he has thrown the bag too hard, and if the beanbag lands on the near side of the target he has not thrown hard enough. After several attempts he manages to throw the beanbag onto the middle of the target mat. He is very happy that he has succeeded and this brief burst of elation helps the brain to register the connection between the intended action, the motor plan and the successful achievement of the goal.

Now Thabo is interested in working at the task. He has a better understanding of the importance of paying attention to the goal of the task and the importance of practice in learning a new skill.

DCD, joint hypermobility and muscle weakness

Children with DCD often also have joint hypermobility which adds to the difficulties the child has with coordination and learning new skills.

About 20% of people have joints that are more mobile than usual. This is because the connective tissue that forms the the structures that hold the joints and muscles together and give them stability is very pliable and easily stretched. The body parts are only loosely held together which means that the muscles have to work harder to stabilize and move the head, trunk and limbs 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.

DCD is often associated with poor fitness levels

Children with DCD often have poor fitness levels compared to their peers. They tire quickly when walking distances, and perform poorly on fitness tests that involve running or jumping. The poor fitness is partly due to not participating with their peers in play and sporting activities that promote fitness.

In particular children with DCD perform poorly on fitness tests that require rapid movements and good coordination.

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Helping your child to become fitter is very important: studies show that fitness can be improved with short bouts of fitness training Read more

DCD or low muscle tone?

Children with coordination difficulties are often given a diagnosis of low muscle tone. This is unfortunate because it distracts from the difficulties a child has with coordination, sometimes associated joint hypermobility and associated weakness and poor fitness levels. Read more about low muscle tone

DCD often co-occurs with other developmental disorders

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

Recognizing each specific area of difficulty and how it impacts on learning of movement skills, attention and behavior in general is very important. It makes it easier to understand the child's behavior 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
Specific language impairment
Joint hypermobility and associated weakness with associated muscle weakness "low muscle tone" and poor levels of fitness

Making sense of all the many challenges faced by children with DCD

Understanding how attention and emotion regulation difficulties associated with having a highly cautious/fearful (anxious) temperament impact on motor control and learning, as well as the impact of generalized joint hypermobility (when it is present) on motor control, strength and fitness allows parents to make sense of the many and varied challenges faced by children with DCD. Read more

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
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

Why do children with DCD have poor coordination?

The coordination difficulties experienced by children with DCD seem to be caused by differences in the way the child learns new skills and forms connections in 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 often have poor postural, balance, gross and fine motor abilities which have been related to differences in the connectivity between different brain areas. .

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 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 neatness, precision and speed demands can have a very negative impact on a child's ability to complete a task.

Some skills that require a great deal of co-ordination 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 with poor and slow handwriting skills may need access to a keyboard for school work. Working on a keyboard is not always faster than writing by hand, but it does make the work legible and easier to correct.

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. Physical therapists 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.

There is growing evidence to support task, activity and participation oriented approaches to therapy for children with DCD. This means that the child is provided with opportunities for practicing tasks that they need to master, starting with an easier version of the task and then increasing the difficulty as the child's abilities and confidence improve. Task oriented approaches also take into account the many different factors that affect task performance, such as the child's tendency to avoid challenges, anxiety when encountering new tasks, as well and the impact of the environment (home, school, playground, community) on a child's behavior, willingness and ability to succeed at a task.

Cognitive Orientation to Occupational Performance (CO-OP)

A rehabilitation approach known as Cognitive Orientation to Occupational Performance uses problem-solving strategies to help children learn motor skill. There have been several randomized control trials that demonstrated the effectivenes of CO-OP in improving function and participation in children with DCD.

A recent study used MRI to examine white matter microstructure after a CO-OP intervention in 8-12-year-old children with DCD (n = 28) and with DCD and co-occurring ADHD (n= 25)..

"In this study children with DCD showed significant improvement in white matter microstructure in the bilateral anterior thalamic radiation, bilateral sensorimotor tract, bilateral cingulum, fornix, splenium and body of corpus callosum, right inferior fronto-occipital fasciculus, and white matter pathways to bilateral inferior gyri, right middle frontal gyrus, frontal medial cortex, and left cuneus." (Izadi-Najafabadi, 2022)

The researchers suggested that "these rehabilitation-induced neural changes in children with DCD occurred in regions associated with attention, self-regulation, motor planning, and inter-hemispheric communication, which positively affected brain connectivity and motor function." (Izadi-Najafabadi, 2022)

In contrast, children with DCD and co-occurring ADHD did not show any brain changes following the intervention. The researchers suggested that modifications to the treatment protocol might help address the attentional and self-regulatory needs of children with a dual diagnosis.I

From the International Guidelines recommendations

"Activity-oriented or participation-oriented approaches are interventions that focus on ADL (including personal care, play, leisure/sports, arts and crafts, and academic, prevocational, and vocational tasks) within the intervention process. Intervention must also aim to generalize to daily function, activity, and participation across environmental contexts in which the child needs to perform.

Activity-oriented or participation-oriented approaches should involve family, teacher, significant others, and/or environmental support to cascade and promote essential opportunities for practice and generalization. This is necessary to give enough opportunity for motor learning and consolidation of skills.

Ideally therapists enlist 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." Read more

Bibliography

Blank, R., et al (2019). International clinical practice recommendations on the definition, diagnosis, assessment, intervention, and psychosocial aspects of developmental coordination disorder. Developmental medicine and child neurology, 61(3), 242–285.

Izadi-Najafabadi, S., Rinat, S., & Zwicker, J. G. (2022). Brain functional connectivity in children with developmental coordination disorder following rehabilitation intervention. Pediatric research, 91(6), 1459–1468. https://doi.org/10.1038/s41390-021-01517-3

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