What is Dyspraxia?

Some children despite adequate teaching, a stimulating environment and with a generally normal intellect, have difficulty with movement and specific aspects of learning. Dyspraxia is a difficulty with thinking out, planning and carrying out sensory / motor tasks.

• How can Dyspraxia be recognised?
• Dyspraxia in the pre school and school age child
• Tips for Teachers

What We Do

The Dyspraxia Association of Ireland is active in the following areas

• Promoting awareness of Dyspraxia in Ireland in order to create a better understanding of the difficulties children and parents face
• Working and liaising with other related organisations, particularly those dealing with spectrum disorders
• Lobbying government departments and relevant bodies in the areas of education, health and therapies etc
• providing a national telephone information and help line, distributing information packs circulating newsletters to members
• Organising annual conferences with professional speakers and giving presentations to schools and colleges
• Liaising with our regional support groups throughout the country
• Fundraising for all the above

What is the background?

Developmental Co-ordination Disorder (DCD) and Dyspraxia are not new. For well over a century different terms have been used to describe children with a predominant picture of motor difficulties - terms such as “the clumsy child”.

Annell (1949) was said to describe the clumsy child as being:

“awkward in movements, poor at games, hopeless in dancing and gymnastics, a bad writer and defective in concentration. He is inattentive, cannot sit still, leaves his shoelaces untied, does buttons wrongly, bumps into furniture, breaks glassware, slips off his chair, kicks his legs against the desk, and perhaps reads badly”

The difficulties are defined on the basis of a failure to gain skills in both gross and fine movements which cannot be explained by impaired general learning or a medical condition such as cerebral palsy. There is extensive evidence that these difficulties can have considerable impact on children’s lives as they struggle to plan and organise themselves. This commonly affects the child both in school and at home, and in contrast to similar aged children acquiring these skills with little effort.

Today, Dyspraxia is the most commonly used term in the UK with varying definitions, but the most recent, formal and widely internationally used term to describe these children is Developmental Coordination Disorder (DCD). It appears in both the Diagnostic and Statistical Manual for Mental Disorders (APA, DSM-IV, 1994; APA, DSM-IV-TR, 2000) and the International Classification of Diseases and Related Health Problems (WHO, ICD-10, 1992a; 1992b; 1993).

Increasing interest in these children in both academic research and in clinical and educational practice is starting to lead to a greater understanding of identification, management and longer-term impact on the child and the family (ESRC seminar series, Sugden, 2004-2005).

How are children identified and classified?

Children are identified usually by either a parent or teacher concern, or on screening. There are several checklists including the DCDQ for parents and the Early Years Movement Checklist for younger children and Movement ABC checklist for professionals. The commonest assessment tool used in the UK is the Movement ABC Battery and in the USA is the Bruininks-Oseretsky Test of Motor Proficiency which identifies a level of motor difficulties.The child also needs to show that these difficulties are at both home and at school. Other reasons for the difficulties need also to be excluded such as Cerebral palsy or Muscular Dystrophy.

Is there overlap with other conditions?

Overlap with other specific learning difficulties is common.

Evidence from Gillberg (1998), Pitcher et al (2003), and Rasta & Eliot (1999), show overlap of DCD with other neurodevelopmental disorders. For example in the Canadian population study (Kaplan et al (1997)), 23% of children showed signs of DCD, 8% met criteria for ADHD, and 19% were categorised as dyslexic. Nearly 25% of the affected children were found to have all three, while 10% had both ADHD and DCD, and 22% had dyslexia and DCD. Gillberg (1998) also described the DAMP (deficits in attention, motor and perception) model where a 40% overlap of ADHD and DCD was described.

Additional summaries of work in this area can be found in Kirby (2005) and Green and Baird (2005). In addition, recent work by Adib et al (2005) and Kirby (2004) has also shown an association between motor difficulties and joint hypermobility syndrome( JHS). JHS is where children and adults have hypermobile joints and they may have increased clicks, bruising and are “ double-jointed”. Some children dislocate some joints as well. Further research is being undertaken at the Dyscovery Centre at present. (http://www.hypermobility.org/)

Over the last 15 years an overlap of DCD with other conditions has been identified and these include:

• Reading, attention and motor deficits (O’Hare and Khalid (2002), Kaplan et al (1997), Powell & Bishop (1992), Tervo et al ( 2002), Kooistra et al ( 2005))
• ADHD and DCD (Biederman et al (1996), Rasmussen and Gillberg (2000), Salmon and Kirby(2007)
• Social, emotional and behavioural difficulties, anxiety, and depression (Geuze & Borger (1993), Hellgren et al (1994), Sigurdsson et al (2002))
• Speech and Language Impairment (Hill (1998), Elbert (1993), Powell and Bishop (1992))
• Social and communication impairment (Green et al (2002))

Where do children go to be assessed?

At present children with motor difficulties commonly present to Occupational Therapists, Physiotherapists and Paediatricians. Psychiatrists are less aware of DCD, even though a large percentage of children presenting to them in ADHD clinics will have motor difficulties that may impact on their everyday lives. ( Kirby and Salmon, 2007)

There is a need for designing provision that takes into consideration the overlapping picture of developmental disorders, rather than segmentation of services which currently commonly exists.

How are children assessed?

Children with DCD are assessed in a variety of ways, but currently there is no gold standard assessment instrument, and no instrument that goes from childhood to adulthood that is appropriate. In many countries, a notable exception being the USA, the Movement ABC Battery-2 (Henderson and Sugden, 1992;2008) is the most widely used instrument, and contains a standardised normative referenced test, plus a criterion referenced checklist. The latest version extends from 3-16 years. However, other instruments are used such as Bruininks–Oseretsky Test of Motor Proficiency (Hattie and Edwards (1987)) in the USA which extends to 21 years.

Other tests include :

• DCDQ - a screening tool for parents.
• DASH- Detailed Assessment of Speed of Handwriting-9- 16 years 11 months (Barnett, Henderson, Scheib and Schulz)- extension is due out in the Autumn
• PEGS- Perceived efficacy of Goal Setting

Other tests that are used include:

• Beery Test- Visual perception test
• MVPT- motor visual perception test

What is the underlying cause of DCD?

It is highly unlikely that there is a single gene for DCD and it is likely there are a number of causes. In addition there is likely to be a gene/environmental interplay. For example there is evidence that lead ingestion and other substances may have an effect on co-ordination. Co-ordination difficulties are more often seen in very prematurely born children. Some evidence of maternal consumption of fish in pregnancy has a link to both language and motor development has recently been found in the ALSPAC longitudinal study Twin studies in Australia have also shown linkage with certain sub types of ADHD and fine motor co-ordination difficulties ( Piek and Pitcher).

Impact of DCD in the short- and longer-term

There was a view until the early 90s that children with DCD “grow out” of the condition. However children with DCD are not unaffected by their difficulties and have been reported to have lower self-esteem. Studies in DCD have shown that children perceive themselves as less competent than their peers not only in the domain of physical play (athletic competence), but also in several other domains including physical appearance and social acceptance (Rose et al (1997), Schoemaker and Kalverboer (1994), Skinner and Piek (2001)).

Overlap with ADHD and other specific learning difficulties certainly seems to have a worse long-term prognosis. Hellgren et al’s (1993) long-term study of individuals showed those with this mixed picture were more likely to continue to have difficulties into adulthood.

Rasmussen’s (2000) longitudinal community-based study followed children who had been diagnosed at seven years with DCD and found that at 22 years of age the research participants were more likely than their matched controls to be unemployed, to have had problems with breaking the law, to be alcohol or drug misusers and to have mental health difficulties.

Eighty percent of the participants with DCD had poorer outcomes compared to 13% in the comparison group without DCD.

Children with DCD have also been shown to be more likely to have health problems at a higher rate than children in the general population (Hellgren et al (1993). Losse‘s (1991) 10-year follow up study highlighted also the variable outcome for children with DCD. She showed that 11 out of the 15 original children described as “clumsy” remained “poor” or “very poor” compared to age-matched controls.

The psychiatric interviews used with adolescents with DCD have shown many psychiatric symptoms ranging from mood and anxiety disorders to social negativism and withdrawal (Hellgren et al,1994).

Children with DCD may also be at greater risk of obesity and heart disease. There is some early evidence of this (Cairney et al,2005) especially in males.

Recent work from Kirby (2008) studying students in college and university with DCD has shown that young adults may have greater difficulties learning to drive (especially with parking, distance estimation), and writing and organisational skills continue to be difficult for many of them. At least 50% will have continued handwriting difficulties, and organisational difficulties with work and for the individual commonly remain an issue.

What is the prevalence of DCD?

The American Psychiatric Association suggests a figure of around 6% for the age range 5-11 years. Gender differences have been examined on numerous occasions and the consensus is that the condition is more prevalent in boys than girls, with estimates ranging from a small difference to three or four to one.

What do we know about intervention?

In general, the research on progression in children with DCD concludes that without intervention, the majority of children ( around 60-70%) do not grow out of the condition (e.g. Losse et al (1991), Hellgren et al (1994), Cantell et al (2003), Cousins & Smyth (2003) Kirby et al, (2008,2010).

There is a body of literature that can point to success in intervention (Polatajko et al (1995), Mandich et al (2001), Sugden & Chambers (1998)). So far there have been two major approaches to intervention, under different labels but often referred to as either process-oriented or task-oriented approaches.

Process-oriented are broad-based, usually administered by health professionals such as occupational or physiotherapists include such methods as Sensory Integration Therapy, and aim at pinpointing the underlying process or processes that the child has not developed appropriately and which are thought necessary for successful performance and acquisition of motor skills. Thus the intervention for example would aim to improve the child’s kinaesthetic functioning with the aim of this transferring to the functioning of several motor skills (see Sugden & Chambers (2005) for a review).

Task-oriented approaches use a range of methods but all concentrate on the tasks themselves. A significant set of these involve what have come to be called cognitive methodologies and success using these approaches has been achieved with a range of children. The basis of these approaches is the interaction between the child resources, the task to be learned and the context in which it is set. The task is often determined through consultation with parents and the child is taught the task directly, sometimes broken down into component parts. (Henderson & Sugden (1992), Polatajko et al (1995), Mandich et al (2001), Shoemaker & Smits-Englesman (2005), Sugden & Chambers (2005)). In meta-analyses of the different approaches the task-oriented ones have emerged at this time as more successful (Pless & Carlsson (2000), Wilson (2005)).

In adolescents and adults the need to be practical about approaches is essential and work with the individual on what their goals and motivations are. There is a need to concentrate on independent living skills and seek out hobbies where success can be achieved. Switching to a computer for recording is essential if handwriting remains a problem as it is unlikely that sufficient time can be applied when there are other priorities to improve it greatly in teen years. Adaptation such as using an automatic car to learn to drive can make the difference between success and failure.

Future direction and challenges

In the UK as in many other countries in the past few years there has been increased awareness by parents regarding DCD. This greater awareness has also resulted in increased demand on the service (Dunford & Richards (2003)). One of the challenges for supporting children with DCD and their families will be providing effective management models based on a good evidence base, and the need for random controlled trials comparing intervention models is the obvious next stage.

However a starting point for clinicians is to make sure initial enquiry not only looks across at the developmental spectrum but also provides a method of triaging patients so that those with the most complex difficulties do not sit waiting for support or therapy for several years.

There is a need for using different methodologies such as “expert parent training” as has been seen to be used successfully in the care of children with Asperger’s (Sofronoff et al (2004)), and is being started in this field.

In addition there needs to be a method of “profiling” children in school who are causing concern either to the parent or teacher. Intervention needs to be in a step-by-step manner. The first stage needs to be assessing the developmental level of the child and providing enrichment. This will differentiate the child who lacks experience from the child who has a specific difficulty. If this is not satisfactory, additional information and mapping needs to take place and guidance be given to the teacher from the SENCO. If this is not satisfactory, then the child at this stage may require referral for a more detailed assessment and, if necessary, specialised intervention. Red flags (i.e. additional concern) should expedite this process.

Red flags for motor difficulties are as follows:

• Deterioration in function in the past three months noticed in school and/or at home - such as could do a skill but can no longer do it - feeding, writing skills deteriorating
• Visit to accident and emergency on more than two occasions in the last 3 months – with injury to head or loss of consciousness
• Headaches – especially if waking in the night, causing sickness, blurring of vision, lasting more than a day
• History of road traffic accident/recent trauma prior to onset of recognition of motor difficulties
• Child's limbs seem stiff or using only one limb or side of the body in preference
• Walking began after 18 months
• Toe-walking
• Weight or appetite loss along with motor deterioration
• Unintentional weight loss over a period of 3 months
• Waking in the night with pain for more than 2 weeks
• Visual impairments (untreated)
• History of global developmental delays
• Neurocutaneous lesions e.g. café au lait spots or fibromas
• Avoidance of eye contact, unwilling to engage socially
• Gowers’ sign – difficulty rising to a standing position
• Odd gait

Key identifiers for the classroom

• Writing difficulties compared to peers/colouring in, painting, cutting.
• Ball skills, especially team games - avoidance or slow to learn the skills and the rules of the game
• Bumping into and knocking into things and people
• Self-care tasks - dressing, buttoning, zips and shoelaces, use of cutlery
• “Fidgety” in the classroom
• Associated organisational difficulties and difficulties with time management
• Difficulty with mathematical concepts - learning times tables, geometry

Other associated specific learning difficulties - such as ADHD, Dyslexia, Aspergers Syndrome, Specific Language Impairment.

More associated difficulties are additive. The more you have, the more likely they are to continue and the worse it is for the young person.

Approaches to intervention in children with DCD

Select, Optimise and Compensate (where necessary) – SOC

Select where the difficulties are and support or compensate.

Optimise strengths (e.g. if the child has good visual skills, using techniques such as mind mapping to make notes).

Once the child has moved to secondary school it is unlikely he or she will have time to practise handwriting – if this is still poor then consider using alternative methods of recording such as using photocopied sheets to annotate and using a keyboard.

• Little and often, targeted and at a level the child can achieve - 10-15 minutes per day several times a week is better than an hour of “treatment”- what does the child need to do, and want to do and what does the parent think the child needs to do - intervention is a home/school process.
• Intervention needs to be in the context of where the skill is required.
• Make sure the child sees the target they are aiming for and it is achievable.
• Get the child to talk through what has worked or not and how he or she sees improvements that can be made - involve the child in the plan.
• Praise specifically - so the child can see where improvements have been made.
• Ensure the tasks are graded to the right developmental level.
• Consider the environment when undertaking a task - handwriting improvement linked more to shoulder stability and posture (height of table and chair) than pencil grip.
• TIE - consider always the Task, Individual and the Environment and check all of these to see which needs altering e.g. improving handwriting - it has been shown that it is more important to check on posture and shoulder stability.
• Prepare for times of change such as from primary to secondary school. This may need to start early and support continue for at least 2 terms. Informing new staff of the child’s difficulties is important.
• Encourage the child to develop hobbies where he or she can be succesful – martial arts, drama, swimming, fencing, rowing may all be easier to undertake than team sports such as football or netball.