developmental coordination disorder

4/7/2014 Developmental Coordination Disorder

http://emedicine.medscape.com/article/915251-overview 1/7

Developmental Coordination Disorder

Author: Stephen L Nelson Jr, MD, PhD; Chief Editor: Caroly Pataki, MD more...

Updated: Aug 31, 2013

Practice Essentials

Although a variety of labels have been used to describe movement clumsiness in children, the term developmentalcoordination disorder (DCD) has found increasing acceptance. Genetic, intrauterine, and environmental factorsmay contribute to poor abilities in motor functioning.

Essential update: New guidelines for spotting and evaluating motor delays in children

In May 2013, the Council on Children with Disabilities published guidance on the early identification and evaluationof motor delays in children, which include formal developmental screening of children for possible motor delays and

variations in muscle tone at their 9-, 18-, 30-, and 48-month well-child visits.[1, 2]

The Council advises that pediatricians not only should watch how children perform requested tasks but also should

pay close attention to general posture, play, and spontaneous motor functions.[2] Muscle tone deficiencies mayalso indicate neuromotor delays from disorders such as cerebral palsy.

The Council notes that MRI scans can be ordered for children with heightened muscle tone and advises that serum

creatine kinase concentrations should be measured in those with decreased muscle tone.[2] These studies can beperformed when children are referred to specialists for diagnosis.

Signs and symptoms

In infants, manifestations of difficulties in motor functioning are as follows:

Hypertonic or hypotonic appearanceStrongly reacting to any slight auditory or visual stimulation by becoming stiff or by arching the back (ie,hypertonicity and hyperreactivity)In a newborn, lying in a frog-leg posture suggests hypotonicityAfter around age 4 months, persisting head-lag when pulled to a sitting position or inability to place thebody in extension when suspended in a horizontal posture indicates hypotonicityAfter age 6 months, inability to sustain his or her weight when supported under the arms and thus tendingto slip through the supporters grasp signals hypotonicityParents may report that their baby is strong (ie, the muscles appear hard and tense)Persistence of several primitive reflexes (eg, Moro, plantar, or rooting reflex) after age 6-7 monthsAppearing almost ready to walk at a few months of lifeMoving as an entire unit without correcting the angle of the head toward the vertical line when held sidewaysDelay in achieving milestones such as the ability to roll over, to sit with help, and to sit without helpPersistence of a positive Babinski sign after age 10-12 monthsPersistence of crossed-adductor reflexes and clonus at the ankles after the neonatal period

During the second and third years of life, manifestations of difficulties in motor functioning are as follows:

Refusal of solid foods, or repeatedly choking on chewed foodAttempting to pick up small objects from a flat surface using a palmar grasp rather than a pincer grasp

TodayNewsReferenceEducationLog InRegister



Inability to walk by age 18 months (however, most of these children are healthy)

In preschool- and school-aged children, manifestations of difficulties in motor functioning are as follows:

Difficulty with hopping or jumpingLack of a hand preference or dominance by age 4-5 years or early development of a hand preferenceDifficulty with maturation of ability to grasp a pen, pencil, or crayon (eg, moving the entire upper limb towrite, or reporting pain after a few minutes of drawing or writing)

Easily performed tests to observe tasks and abilities include the following:

Tests for sustaining a position against gravity - Observation of muscle tone in sitting and standing positionsTest for motor sequencing - Touching the thumb against the other fingers of that hand in sequence, oneafter the otherNose-finger test (measures fine motor coordination, proprioception, and perception of movements in space)Moving a limb against resistance (feet, legs, thighs, arms, forearms, hand)Test of energy investment in a movement (eg, development of fatigue with sustained testing)Test of the ability to perceive spatial relationshipsTest of fine motor tasks - Activities such as coloring, drawing, building with blocks, or playing with miniaturetoys

Abnormalities that may be noted during such tests include the following:

Fine tremors of the fingers with sustained use of the handPersistence of overflow (performing a similar movement with the opposite side of the body, referred to asmirror movements) after age 7-8 yearsAdventitious movements (eg, grimacing, sticking the tongue out, or tics) when a fine or difficult motion isattempted

After motor difficulties are detected, investigating other areas (eg, visuomotor coordination) and testing for othersoft neurologic signs, attention span, writing, and reading may be necessary.

See Presentation for more detail.

Diagnosis

DCD has 4 diagnostic criteria, as follows:

Acquisition and execution of coordinated motor skills are below what would be expected at a givenchronologic age and opportunity for skill learning and use; difficulties are manifested as clumsiness and asslowness and inaccuracy of performance of motor skillsThe motor skills deficit significantly or persistently interferes with activities of daily living appropriate to thechronologic age and impacts academic/school productivity, prevocational and vocational activities, leisure,and playThe onset of symptoms is in the early developmental periodThe motor skills deficits cannot be better explained by intellectual disability or visual impairment and arenot attributable to a neurologic condition affecting movement

Recommendations regarding laboratory and imaging studies are as follows:

No specific laboratory tests for motor skills disorder exist; however, male children should have a creatinekinase (CK) level checked to evaluate for Duchenne muscular dystrophyComorbid conditions (eg, high lead levels, anemia, iron deficiency, hypothyroidism) should be ruled outNo imaging studies are typically used if the child has otherwise normal neurologic examination findings andno clinical indications of an underlying structural or medical/metabolic etiology

Evaluation approaches include the following:

Normative functional skills approachGeneral abilities approachNeurodevelopmental approachDynamic systems approachCognitive neuroscience approach



The normative functional skills approach draws from traditional developmental theory. The most commonly usedtests of motor impairment in this approach are as follows:

Movement Assessment Battery for Children (MABC or M-ABC)Bruininks-Oseretsky Test of Motor Proficiency (BOTMP)Test for Gross Motor Development (TGMD-2)

The general abilities approach is based on the assumption that sensory-integrative and sensorimotor functionsprovide the platform for later motor and intellectual development. The most commonly used test is the SensoryIntegration and Praxis Tests (SIPT); however, less than 50% of the SIPT is related to motor function.

The neurodevelopmental evaluation includes both a general and neurologic examination, along with an assessmentthat focuses on subtle deficits in neural functioning. Test batteries include the following:

Touwen test for children with minor neurologic dysfunction (normative data are lacking)

Physical and Neurological Examination for Soft Signs (PANESS)[3] (normative data are lacking)

The dynamic systems approach is based on the dynamics between perception and movement; it usesbiomechanical or kinematic analysis of movement and emphasizes the importance of assessing contextual factorsthat contribute to or limit skill acquisition.

The cognitive neuroscience approach provides a framework that accounts for the development of motor skills interms of brain-behavior interactions. Hypotheses generated with this framework include the following:

Motor imaging pathways in the parietal lobe and premotor cortexMotor timingLinking deficits of time perceptionSequential tapping to possible deficits in the cerebellum

See Workup for more detail.

Management

No single type of treatment can be applied to all children with motor coordination disorder. Two general treatmentapproaches are used, as follows:

Modular (top-down; task-oriented)Relatively global or generalized approach (bottom-up; process-oriented or deficit-oriented)

The modular approach has the following characteristics:

Attempts to remedy or improve the specific difficulty (or difficulties) with specific techniques aimed atimproving the motor challenge that is observed (eg, difficulty with handwriting, catching a ball, performingfine motor tasks with fingers)Usually involves gradually targeting certain problem behaviors and implementing step-by-step interventionsto teach the skill and to practice itTends to prevent failure and rewards the child, at least in the beginningLends itself to implementation by schoolteachersA core element is practice (eg, prescribed practice of new skills and small steps toward mastery of the skillwith success at every small increment)

The relatively global or generalized approach has the following characteristics:

Is based on the theoretical assumption that the motor skills problem is a manifestation of some underlyingmechanism (eg, sensory integration problems or insufficient or inaccurate kinesthetic perceptions)Instead of initially addressing the observable motor challenge, the therapist focuses on how childrenmanage their bodies, process stimulation, and deal with problemsThe expectation is that the improved sensory-motor functioning becomes generalized and eventuallyimproves the motor skillsExamples include the kinesthetic training approach, sensorimotor integration therapy, and sensoryintegration therapyAs with many other forms of intervention and therapy, evidence of the efficacy of these methods is limited,particularly over the long term or regarding the end result



Specific therapies employed include the following:

Cognitive motor interventionSensory integration therapyKinesthetic trainingNeurodevelopmental treatmentCraniosacral therapyOsteopathic/chiropractic therapyVisual training

See Treatment and Medication for more detail.

Contributor Information and DisclosuresAuthorStephen L Nelson Jr, MD, PhD Assistant Professor of Pediatrics, Neurology and Psychiatry, UniformedServices University of the Health Sciences, F Edward Hebert School of Medicine; Attending Physician,Pediatric Emergency Medicine, Sinai Hospital and Shady Grove Hospital; Assistant Professor of Pediatrics andNeurology, Tulane School of Medicine

Stephen L Nelson Jr, MD, PhD is a member of the following medical societies: Academic PediatricAssociation, American Academy of Neurology, American Academy of Pediatrics, American MedicalAssociation, Association of Military Surgeons of the US, and Child Neurology Society

Disclosure: Nothing to disclose.

Coauthor(s)Jennifer L Jaskiewicz, DO Resident Physician, Department of Pediatrics, Walter Reed Army Medical Center

Jennifer L Jaskiewicz, DO is a member of the following medical societies: American Academy of Pediatrics andAmerican Osteopathic Association


Chief EditorCaroly Pataki, MD Clinical Professor of Psychiatry and Pediatrics, Keck School of Medicine of the Universityof Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and AdolescentPsychiatry, New York Academy of Sciences, and Physicians for Social Responsibility


Additional ContributorsChet Johnson, MD Professor and Chair of Pediatrics, Associate Director, Developmental Pediatrician, Centerfor Child Health and Development, Shiefelbusch Institute for Life Span Studies, University of Kansas School ofMedicine; LEND Director, University of Kansas Medical Center

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics


J Martin Maldonado-Durn, MD Principal Investigator for Child and Family Center, Department of Psychiatry,Child and Adolescent Division, Family Service and Guidance Center

J Martin Maldonado-Durn, MD is a member of the following medical societies: Kansas Medical Society


Anna Maria Wilms Floet, MD Assistant Professor of Behavioral and Developmental Pediatrics, Department ofPediatrics, University of Maryland School of Medicine

Anna Maria Wilms Floet, MD is a member of the following medical societies: American Academy of Pediatricsand Society for Developmental and Behavioral Pediatrics




Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College ofPharmacy; Editor-in-Chief, Medscape Drug Reference


References

1. Henderson D. Guidance for Identifying Motor Delays in Children. Available athttp://www.medscape.com/viewarticle/804990. Accessed June 4, 2013.

2. Noritz GH, Murphy NA. Motor delays: early identification and evaluation. Pediatrics. Jun2013;131(6):e2016-27. [Medline].

3. Touwen BCL. Examination of the child. Cambridge Univeristy Press; 1984.

4. American Psychiatric Association. American Psychiatric Association: Diagnostic and Statistical Manual

of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

5. American Psychiatric Association. DSM-IV-TR. Diagnostic and Statistical Manual of Mental Disorders.

4th ed. Washington, DC: American Psychiatric Association; 2000:1965-71.

6. Fox AM, Lent B. Clumsy children. Primer on developmental coordination disorder. Can Fam Physician.Oct 1996;42:1965-71. [Medline].

7. Bax M, Goldstein M, Rosenbaum P, et al. Proposed definition and classification of cerebral palsy, April2005. Dev Med Child Neurol. Aug 2005;47(8):571-6. [Medline].

8. Baxter P. CP or not CP?. Dev Med Child Neurol. Aug 2005;47(8):507. [Medline].

9. Ayres J. Sensory Integration and the Child. Los Angeles, Calif: Western Psychological Services; 1979:55-67.

10. Piek JP, Edwards K. The identification of children with developmental coordination disorder by class andphysical education teachers. Br J Educ Psychol. Mar 1997;67 ( Pt 1):55-67. [Medline].

11. Ferrari F, Gallo C, Pugliese M, et al. Preterm birth and developmental problems in the preschool age. PartI: minor motor problems. J Matern Fetal Neonatal Med. Jun 19 2012;[Medline].

12. Edwards J, Berube M, Erlandson K, et al. Developmental coordination disorder in school-aged childrenborn very preterm and/or at very low birth weight: a systematic review. J Dev Behav Pediatr. Nov2011;32(9):678-87. [Medline].

13. Lingam R, Hunt L, Golding J, Jongmans M, Emond A. Prevalence of developmental coordination disorderusing the DSM-IV at 7 years of age: a UK population-based study. Pediatrics. Apr 2009;123(4):e693-700.[Medline].

14. Martins I, Lauterbach M, Slade P, et al. A longitudinal study of neurological soft signs from late childhoodinto early adulthood. Dev Med Child Neurol. Aug 2008;50(8):602-7. [Medline].

15. Fliers E, Vermeulen S, Rijsdijk F, et al. ADHD and poor motor performance from a family geneticperspective. J Am Acad Child Adolesc Psychiatry. Jan 2009;48(1):25-34. [Medline].

16. Fliers EA, Vasquez AA, Poelmans G, et al. Genome-wide association study of motor coordinationproblems in ADHD identifies genes for brain and muscle function. World J Biol Psychiatry. Mar2012;13(3):211-22. [Medline].

17. Kadesjo B, Gillberg C. Attention deficits and clumsiness in Swedish 7-year-old children. Dev Med ChildNeurol. Dec 1998;40(12):796-804. [Medline].

18. Wright HC, Sugden DA. A two-step procedure for the identification of children with developmental co-ordination disorder in Singapore. Dev Med Child Neurol. Dec 1996;38(12):1099-105. [Medline].

19. Cantell MH, Smyth MM, Ahonen TP. Two distinct pathways for developmental coordination disorder:



persistence and resolution. Hum Mov Sci. Nov 2003;22(4-5):413-31. [Medline].

20. Losse A, Henderson SE, Elliman D, et al. Clumsiness in children--do they grow out of it? A 10-yearfollow-up study. Dev Med Child Neurol. Jan 1991;33(1):55-68. [Medline].

21. Cousins M, Smyth MM. Developmental coordination impairments in adulthood. Hum Mov Sci. Nov2003;22(4-5):433-59. [Medline].

22. Lingam R, Golding J, Jongmans MJ, Hunt LP, Ellis M, Emond A. The association between developmentalcoordination disorder and other developmental traits. Pediatrics. Nov 2010;126(5):e1109-18. [Medline].

23. Kastner J, Petermann F. [Developmental coordination disorder: relations between deficits in movementand cognition]. Klin Padiatr. Jan-Feb 2010;222(1):26-34. [Medline].

24. Bax M, Hart H, Jenkins SM. Developmental disorders. In: Child Development, Child Health. BlackwellScientific; 1990:106-48, 229-68.

25. Gillberg C, Kadesjo B. Why bother about clumsiness? The implications of having developmentalcoordination disorder (DCD). Neural Plast. 2003;10(1-2):59-68. [Medline]. [Full Text].

26. Kopp S, Beckung E, Gillberg C. Developmental coordination disorder and other motor control problems ingirls with autism spectrum disorder and/or attention-deficit/hyperactivity disorder. Res Dev Disabil. Mar-Apr 2010;31(2):350-61. [Medline].

27. Wang TN, Tseng MH, Wilson BN, Hu FC. Functional performance of children with developmentalcoordination disorder at home and at school. Dev Med Child Neurol. Oct 2009;51(10):817-25. [Medline].

28. Cairney J, Hay JA, Veldhuizen S, Missiuna C, Faught BE. Developmental coordination disorder, sex, andactivity deficit over time: a longitudinal analysis of participation trajectories in children with and withoutcoordination difficulties. Dev Med Child Neurol. Mar 2010;52(3):e67-72. [Medline].

29. Cairney J, Veldhuizen S, Szatmari P. Motor coordination and emotional-behavioral problems in children.Curr Opin Psychiatry. Jul 2010;23(4):324-9. [Medline].

30. Chirico D, O'Leary D, Cairney J, et al. Longitudinal assessment of left ventricular structure and function inadolescents with developmental coordination disorder. Res Dev Disabil. Mar-Apr 2012;33(2):717-25.[Medline].

31. Coverdale NS, O'Leary DD, Faught BE, et al. Baroreflex sensitivity is reduced in adolescents withprobable developmental coordination disorder. Res Dev Disabil. Jan-Feb 2012;33(1):251-7. [Medline].

32. Li YC, Wu SK, Cairney J, Hsieh CY. Motor coordination and health-related physical fitness of childrenwith developmental coordination disorder: a three-year follow-up study. Res Dev Disabil. Nov-Dec2011;32(6):2993-3002. [Medline].

33. Cairney J, Kwan MY, Hay JA, Faught BE. Developmental Coordination Disorder, gender, and bodyweight: examining the impact of participation in active play. Res Dev Disabil. Sep-Oct 2012;33(5):1566-73. [Medline].

34. Lingam R, Jongmans MJ, Ellis M, et al. Mental health difficulties in children with developmentalcoordination disorder. Pediatrics. Apr 2012;129(4):e882-91. [Medline].

35. Pieters S, Desoete A, Van Waelvelde H, Vanderswalmen R, Roeyers H. Mathematical problems inchildren with developmental coordination disorder. Res Dev Disabil. Jul-Aug 2012;33(4):1128-35.[Medline].

36. Shevell M, Ashwal S, Donley D, et al. Practice parameter: evaluation of the child with globaldevelopmental delay: report of the Quality Standards Subcommittee of the American Academy ofNeurology and The Practice Committee of the Child Neurology Society. Neurology. Feb 112003;60(3):367-80. [Medline].

37. Zwicker JG, Missiuna C, Harris SR, Boyd LA. Developmental coordination disorder: a pilot diffusion tensorimaging study. Pediatr Neurol. Mar 2012;46(3):162-7. [Medline].

38. Smits-Engelsman BC, Niemeijer AS, van Waelvelde H. Is the Movement Assessment Battery forChildren-2nd edition a reliable instrument to measure motor performance in 3 year old children?. Res Dev



Medscape Reference 2011 WebMD, LLC

Disabil. Jul-Aug 2011;32(4):1370-7. [Medline].

39. Peters LH, Maathuis KG, Kouw E, Hamming M, Hadders-Algra M. Test-retest, inter-assessor and intra-assessor reliability of the modified Touwen examination. Eur J Paediatr Neurol. Jul 2008;12(4):328-33.[Medline].

40. Blank R, Smits-Engelsman B, Polatajko H, Wilson P. European Academy for Childhood Disability(EACD): recommendations on the definition, diagnosis and intervention of developmental coordinationdisorder (long version). Dev Med Child Neurol. Jan 2012;54(1):54-93. [Medline].

41. Zimmer M, Desch L. Sensory integration therapies for children with developmental and behavioraldisorders. Pediatrics. Jun 2012;129(6):1186-9. [Medline].

42. Laszlo JL, Bairstow PJ. Perceptual-Motor Behavior: Developmental Assessment and Therapy. Austin, Tx:Holt, Rinehart and Winston; 1985.

43. Cuthbert SC, Barras M. Developmental delay syndromes: psychometric testing before and afterchiropractic treatment of 157 children. J Manipulative Physiol Ther. Oct 2009;32(8):660-9. [Medline].

44. Learning disabilities, dyslexia, and vision: a subject review. Committee on Children with Disabilities,American Academy of Pediatrics (AAP) and American Academy of Ophthalmology (AAO), AmericanAssociation for Pediatric Ophthalmology and Strabismus (AAPOS). Pediatrics. Nov 1998;102(5):1217-9.[Medline].

developmental coordination disorder

Documents