Abstract
‘Developmental dyspraxia’, also known as ‘developmental coordination disorder’ (DCD), describes a condition of impaired motor function. Children with the disorder are impacted to the extent that activities of daily living are impaired. It is generally thought that there will be at least one child with DCD in each class at school. Therefore, it is important that GPs are aware of how DCD presents and the type of challenges that children with the condition face. It is also useful to know some practical strategies that can be used to make the environment easier for children with DCD.
The GP curriculum and developmental dyspraxia
Demonstrate an awareness that a significant minority of any practice population will include patients with reading, writing and comprehension difficulties
Demonstrate an awareness that the health needs of patients with learning disabilities are met appropriately by primary care and community services
Demonstrate an understanding of the importance of developing and maintaining continuing learning on physician-based issues that are barriers to health care for people with learning disabilities
Demonstrate an understanding that people with learning disabilities are more prone to the effects of prejudice and unfair discrimination
Describe the impact of learning disabilities on family dynamics and the implications for physical, psychological and social morbidity in the patient's carers
Demonstrate an understanding of the importance of multi-agency working
Coordinate care with other primary care professionals, paediatricians and other appropriate specialists, leading to effective and appropriate care provision, taking an advocacy position for the patient or family when needed
Describe the importance of supporting parents who have special needs
Assess children and young people's developmental needs in the context of their family and environmental factors
Understand the organization of care—-care pathways and local systems of care
Background
There has been some confusion regarding the nomenclature of dyspraxia, and many different names have been used to describe the same disorder. In the past, the term ‘clumsy child syndrome’ was used but more recently children have been given diagnoses such as ‘developmental dyspraxia’ or ‘sensory integrative dysfunction’ among many others. The inconsistency in the naming of the condition was clarified in 1994 when healthcare professionals met at the International Consensus Conference on Children and Clumsiness and decided to use the name ‘developmental coordination disorder’ (DCD), which is used in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 2000). DCD is now the most widely used and acceptable term.
Epidemiology
The prevalence of DCD varies according to which diagnostic criteria are used and generally ranges from 1.4 to 19%. However, a recent UK-based study found the prevalence to be 1.8% when using stringent criteria (Lingam et al., 2009).
DCD is four times more common in males than females, and infants born prematurely or with low-birth weights are also at an increased risk.
Clinical features
The diagnosis is usually made in children between the ages of 6 and 12 years. However, clinical features can be evident before this, and around 25% of children will be referred before they are at school. The presentation is diverse and children are affected to varying extents.
Typically, children will have difficulty with gross and fine motor tasks. There is also a psychological component as children with DCD frequently suffer with low self-esteem and anxiety as a consequence of their motor function problems. Consequently, their social integration can also be affected. Children may tend to avoid certain activities, such as sport, which pose particular challenges. Activities of daily living are specifically affected and the ability of children to perform tasks such as dressing and washing will be below that of their peers.
Children in the pre-school age bracket may present with delayed developmental milestones. For example, parents may notice that their child's painting is less sophisticated than other children's or that their child is delayed in crawling and walking.
DCD frequently coexists with other conditions such as attention deficit hyperactivity disorder or other learning difficulties. However, such co-morbidities are considered to be distinct and not components of DCD. Figure 1 gives examples of the type of problems school-aged children with DCD face.
Activities that school aged children with DCD may find challenging.
Diagnosis
It is important to get a detailed history and to take particular note of the developmental milestones. A key point in the history is to establish whether there is regression of motor skills, as this would point to an alternative diagnosis. It may be the case that a child has had subtle motor problems throughout his or her life that have become more prominent as school activities are more challenging. Differential diagnoses must be considered as motor problems can be a component of other medical conditions. Box 1 gives examples of diagnoses that can be mistaken for DCD.
Neurological disorders initially diagnosed as DCD/dyspraxia
Becker's muscular dystrophy
Myotonic dystrophy
Hereditary motor and sensory neuropathy (HMSN) types 1a and 11
Myotonia congenita (autosomal recessive)
Congenital myasthenia
Cerebral palsy
Brain tumour (slow growing in the posterior fossa)
Pantothenate kinase-associated neurodegeneration (Hallervorden—Spatz disease)
Perisylvian (opercular) syndrome
Benign familial chorea
Epilepsy
Friedreich's ataxia
Pelizaeus—Merzbacher disease
Ehlers—Danlos syndrome
GM1 gangliosidosis (juvenile onset)
A multidisciplinary approach to diagnosis and treatment is essential. Occupational therapists, teachers, physiotherapists, speech and language therapists, educational psychologists and doctors may play an important part in diagnosing and managing children with DCD. Obtaining a collateral history from a variety of sources is useful. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 2000), lays out diagnostic criteria, which are summarized in Box 2.
GPs with concerns about a child's movement would tend to refer to a paediatrician to exclude a neurological or medical cause of the child's presentation. If no organic cause is found, an occupational therapist can carry out tests of motor function to diagnose DCD. A range of assessment tools are used with the most popular tool being the ‘Movement Assessment Battery’. This is used in children between the ages of 4 and 10 years and is made up of the following components: a checklist that focuses on motor function and a practical assessment of a child's skills.
Diagnostic criteria for DCD
Ability to carry out tasks involving motor coordination is significantly below that expected for age, e.g. handwriting
The motor impairment impacts on activities of daily living or academic achievement
Other medical causes have been excluded
If learning difficulties coexist, the motor disturbance exceeds that which would be expected
Management
Children benefit from prompt intervention that is why recognition of DCD is important. Adverse effects on academic performance, engagement in sporting activities and self-esteem can ensue if children are left untreated. In undiagnosed children, symptoms will continue on into adulthood that can also lead to problems such as unemployment.
Occupational therapists primarily carry out interventions used in DCD, with assistance from educational psychologists and physiotherapists depending on the child's specific needs. A range of approaches are used including task-specific approaches that involve breaking down an activity so that each step can be taught independently. Involving the family is particularly important as adaptations to the home environment and routine have a significant impact in a child's progress. Goal-setting is also used but it is important that the child is involved in this process as a parent's or teacher's goal for a child may differ from the child's own objective. Intervention can be done as part of a group or on an individual basis.
Tips that GPs can give
There are some very simple tips that GPs can give to families.
Examples of useful advice include:
Using Velcro as opposed to buttons or zips
Wrapping food in foil as opposed to cling film which is harder to manipulate and
Using a bottle for drinks as opposed to a fiddly carton
Practical measures can be taken to make the surroundings easier for children, for example, to help the child keep time, a kitchen timer can be used as it displays the time that the child has left for a task.
Having a routine is useful, for example, asking teachers to give out letters for parents on a certain day. Using a clear timetable American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th edition). (2000) text revision.
American Psychiatric Association ISBN 0890420246 incorporates symbols and colours can also be helpful for children. Parents can be advised to send children to school in clothing that is easy for the child to remove, for example, elasticized clothing as opposed to items with lots of buttons.
At school, teachers can help by taping papers to the child's desk and ensuring that the child is positioned away from too many distractions. Using large coloured arrows is helpful for children trying to navigate themselves around a busy school.
Key points
DCD is common; approximately one child per class is affected
Fully explore concerns raised by parents and teachers as features can be subtle
Impact of symptoms on activities of daily living is fundamental to diagnosis
Clinical spectrum and presentation are diverse
Prompt diagnosis and intervention improve outcome