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Developmental Coordination Disorder

This program is designed to increase your knowledge about DCD and to increase your confidence in supporting a child's development and participation.

ABOUT CAUSES OF DCD

Q: What causes DCD?

A: It seems unlikely that a single deficit could explain the heterogeneous motor impairments that are observed in children with DCD. One of the factors currently being explored by researchers is genetics. The genetics studies have been very equivocal. Some have suggested a tendency for coordination difficulties to occur more in some families; others have indicated that there isn't much evidence for that. A familial component, or clustering, is thought to be involved in motor coordination problems but little is known about the specific genetic factors or the relationship between genetic and environmental factors that might cause DCD. For example, it is interesting to think about whether a parent who has DCD might be able to encourage physical participation and motor skill development in their own children. But, if it was simply lack of development of skills at home, children would catch up after some time at school, respond to some direct teaching of skills and, not continue to struggle with learning motor-based tasks. A simple environmental explanation is not sufficient.

A few studies suggest children with DCD recruit and use different neural networks and brain activation patterns than typically developing children; they have to pay more attention to the early learning phases of motor tasks to continue doing those tasks and need to concentrate hard to perform even a simple motor task. Imaging studies using structural MRI and functional MRI (fMRI) have suggested that cerebellar dysfunction may be involved in DCD. The cerebellum has a role in making tasks automatic so children with DCD might have difficulty making some tasks highly automatic. This lack of automatization becomes challenging when a second task is introduced because the child does not have the attentional resources to do both tasks. Although this hypothesis makes sense, it has not yet been fully validated.

ABOUT DIAGNOSING DCD

Q: Some parents may not seem to understand why their child's motor skill challenges need to be taken seriously and addressed. Why is it important to make a diagnosis of DCD?

A: Parents who have concerns about their child are often relieved to learn that their child does not have a progressive disorder such as MS and may not view motor coordination difficulties as something to be overly concerned about. Their reaction may be: "So, my kid isn't going to be an Olympic athlete, and that is OK with me". Be sure the parent understands how the motor skill challenges are impacting their child's participation and performance at school, at home, and in the community at the present time. A diagnosis can help provide access to information for both parents and teachers that suggest strategies to support the child at school, at home and in the community (e.g., www.dcd.canchild.ca). Accommodations within the school system such as access to a laptop may be hard to achieve without a diagnosis. It is important to also address the potential secondary consequences on mental health, self esteem, physical fitness and weight gain that can occur in the future if the DCD is not recognized, understood and strategies put in place to support the child's successful participation and performance in all daily activities.

Q: A parent has concerns about her 6 year-old son. He is constantly falling, tripping, bumping into other people, walls and furniture, falling off his chair, and is having trouble with dressing and undressing. He looks "unsteady and unsafe" on stairs and continues to put two feet on each step while holding the railing. Can I diagnose DCD?

A: DCD is a diagnosis of exclusion. Motor coordination difficulties have many causes. It is important to rule out any other medical conditions that might better explain these symptoms. If other explanations for the coordination difficulties are not present, then DCD is the most likely explanation.

Q: Can a child have only gross motor (GM) difficulties but no fine motor (FM) difficulties and still be diagnosed with DCD?

A: Some children with DCD only have GM difficulties, and their FM skills seem to be okay...or at least functional at their current grade, given the current demands. If a child is presenting with only GM difficulties, it is still necessary to assess for DCD, including asking questions about independence in self-care activities (which is often overlooked). Parents may report that the gym teacher or community sports coaches are describing their child as lazy, not trying, lethargic, clumsy or unfocused. Children with DCD who have GM difficulties often avoid gym or sports activities or even take on the role of "clown" so that others don't notice their limitations. Parents may report that their child has tried a variety of team sports, but always quits after one or two seasons. Diagnosis plays an important role in helping the family and other adults in the child's life understand why the child is having difficulty with activities requiring GM coordination. Appropriate resources can then be provided concerning the types of sports/leisure activities to encourage in children with DCD with the goal of preventing the secondary consequences of weight gain and decreased fitness and to promote mental health. Similarly, a child with DCD may first present with FM difficulties, but have adequate GM skills.

Q: At what age can I make a reliable diagnosis of DCD?

A: DCD is generally unrecognized until children begin to experience difficulty at school, so there is little literature regarding children who are not yet in school. Evidence indicates that if you know what you are listening for, parents are able to report many "red flags" for DCD in preschoolers. Children younger than three can be hard to identify. However, as soon as children begin to "use" tools such as utensils and crayons, their difficulties can be observed. Parents talk about noticing the dependence of their child (more than that of other children of the same age) in areas of self-care and play (children who need support to climb a slide, are passive in assisting with dressing, finger feed beyond when most children do, etc). They also notice a tendency to verbally engage with adults, rather than with other children.

Evidence for early intervention is obviously more difficult as there are few children who have been appropriately identified. Focus on providing parents with information to encourage participation in physical activity and in teaching their children task-specific skills that are necessary for life.

Q: Can a 6 year-old child who was born prematurely and is now presenting with motor coordination difficulties be diagnosed with DCD?

A: The types of coordination difficulties seen in preterm children are often very similar to those of children who have DCD and, in fact, about 1/3 of these children will show motor delay and motor challenges. Most of the resources and strategies that are helpful for children with DCD can also be helpful for children born prematurely and exhibiting coordination challenges. In most countries, there is no distinction made between children who are preterm and children who have DCD, if the presenting difficulties are motor-based.

Q: Can a child have a dual diagnosis of ASD and DCD?

A: Children who have autism spectrum disorder (ASD) may have some symptoms that are similar to, or overlapping with, those of children with DCD. The ASD diagnosis can be given with the diagnosis of DCD, in the same way that a child could have a diagnosis of ADHD and DCD. The DSM-V explicitly states if more than one diagnosis is appropriate, then more than one should be given. The question of whether ASD is a neurological condition that explains the DCD is a little more challenging. If the child with ASD is very low functioning, then the intellectual delay element comes into consideration- is the child not learning new motor skills due to their intellectual delay? But if the child with ASD is high functioning, then recognizing the presence of a motor learning problem is really important in order to provide the appropriate strategies to support participation in motor-based activities as well as strategies for any other issues faced by a child with ASD.

Q: Can a child with an intellectual disability also have DCD?

A: The bottom line is to determine whether or not the motor coordination difficulties that are being exhibited by the child are attributable to the cognitive delay, or whether there may be something else going on (i.e., DCD). Children with intellectual disability may demonstrate delays in motor skill development due to their inability to problem-solve and flexibly apply basic motor skills in new and different ways, but this may or may not reflect a primary coordination issue.

It is important to recognize that, due to the diagnostic criteria in DSM IV, most research studies were conducted with children who had an IQ of at least 70 and did not have other neurodevelopmental conditions such as ASD or cerebral palsy. Few studies have been conducted with children who have an intellectual disability. Many (but not all) of the general tips and strategies suggested to parents of children who have DCD may also be appropriate for children who have intellectual and motor skill delay, particularly if the emphasis is on healthy participation in physical and social activities.

Q: Are DCD and cerebral palsy (CP) on a spectrum of severity or are they distinct diagnoses?

A: Although we still do not know the cause of DCD, we do not think that DCD and CP occur along the same continuum. Cerebral palsy is a health condition that results from some type of damage or influence on the brain, usually around the time of birth. Children with cerebral palsy often show a tendency to have the "tone" of their muscles (the resting state) be higher or tighter than in children whose motor development is typical. They may always have difficulty performing some particular motor skills, even when they have learned them. DCD is a health condition that also affects motor skill development but children who have DCD are those who do not have any other explanation for their motor difficulties, including cerebral palsy. DCD is still not well-recognized so it is possible that a physician might have thought that the child had mild CP. Most children with DCD, however, have "low tone" (muscles that seem a bit more relaxed in their resting state) or normal tone. While they have difficulty learning new motor skills, they are able to learn many and, once learned, may perform them quite well. We do not have evidence that the presence of DCD would show up on an MRI in the way that damage that causes CP might. We have early evidence that there may be some differences on a functional MRI (fMRI) with certain types of motor learning, when compared with children who do not have DCD – this type of imaging, however, is not able to be used for diagnostic purposes.

Q: Are sensory processing disorder and DCD the same thing?

A: DCD is a diagnosis of a chronic health condition found in the DSM. Sensory processing disorder is not the same thing. It is a term used to describe a cluster of symptoms that some children exhibit if they are having difficulty interpreting and responding to sensation from certain sources (visual, auditory, tactile, etc.). Children with DCD may have some sensory processing issues, but most children with DCD do not. It is important to note that evidence shows that treatment of those issues through sensory integration therapy is not effective. For children who have sensory processing differences, there is some evidence which supports an approach that involves understanding the child's sensory processing issues and adjusting the activities and environments to better match the child's profile to promote participation.

ABOUT DISCUSSING DCD WITH FAMILIES AND CHILDREN

Q: I was asked by a family if DCD is a "disability".

A: It is important to help the family understand that their child has challenges learning new motor tasks and needs to use different strategies to learn and master these tasks. Research tells us that, if we teach and support these children differently and encourage their participation in daily activities, then a "disability" should not be the result.

Q: How should I talk to the child about this disorder – how can I explain it to them?

A: Begin by explaining a bit about the brain to them. The brain has two big jobs, one is the thinking job that helps us to learn, to remember, to understand, to read, to speak, etc. The other one – which we tend to forget about – is the doing part, the part that tells our muscles how to move. The thinking part of your brain is really smart, but the doing part of your brain has a few glitches in it. Use analogies such as the computer (it needs to be debugged, or the connection to the printer cable is loose so we need to tighten it up). Another helpful analogy is that of a radio. The brain is sending signals to the muscles, like a radio station sends signals to your radio. If it gets a bit off the station, it is hard to understand what is being said so we need to tune it. Your muscles aren't hearing the station (or your brain) clearly so they aren't sure what to do and when to do it. Above all, reassure the child that they are smart and that there are lots of things that they can do well.

OTHER QUESTIONS

Q: Is there a connection between DCD and toileting issues?

A: Yes, there definitely can be a link between DCD and difficulty with going to the bathroom. Both accidents and constipation have been reported by families of children with DCD. There can be issues with the coordination of the muscles for the bowel movement or for controlling the sphincter, difficulty getting clothing off in time if they are rushing to the bathroom at the last minute, and so on. The sensation of needing to void (bowel or bladder) can be diminished as well, making last minute trips more likely.

Q: Can the muscle tone of a child with DCD be changed?

A: Low muscle tone is a core feature of DCD. Most children with DCD have low tone in their trunk and this makes stable sitting difficult and adds to their movement challenges. Muscle tone is the state of readiness of the muscles to contract. It is controlled by signals sent from the brain. Muscle tone cannot be permanently changed; it is how we are wired. However, it can be changed in the moment (i.e., before we sit down to do homework, we can do preparatory activities to increase our tone). A good analogy is to think about when your computer goes into sleep mode, you have to shake the mouse to "wake" it up. Children with DCD need to wake up their tone. Heavy work activities, such as lifting and moving a chair, tug of war, push ups, carrying heavy books or grocery bags, as well as activities that provide joint compression such as jumping jacks can all help to increase tone. Ice water sipped through a straw also helps to increase tone. Muscle strength can be changed, however, so it is important for the child to be physically active and to do some exercise to build muscle strength.

Q: Are teachers familiar with the diagnosis of DCD?

A: Awareness of DCD is increasing in many professions, including amongst educators. However, it cannot be assumed that a teacher will be familiar with DCD and know how to support the child's participation and performance in the classroom. In addition to making the diagnosis of DCD, it is important to provide resources (e.g., www.dcd.canchild.ca), recommendations, and make the appropriate referrals so the teacher understands and supports the child in the school environment.

Q: What is the Developmental Coordination Disorder Questionnaire (DCDQ) and where can I obtain a copy?

A: The Developmental Coordination Disorder Questionnaire (known as the "DCDQ") is a parent-report questionnaire used to identify motor coordination problems in children 5 to 15 years of age. The most recent 15-item version of this questionnaire is the DCDQ'07. For more information on this questionnaire, including recent research, see the Developmental Coordination Disorder Questionnaire website.

Q: Are there any courses, seminars, or conferences that I can attend?

A: Every 2 years, an international DCD conference is held inviting academics, researchers and clinicians to come together to share research about children with DCD. For information about the most recent or upcoming DCD international conference, it is recommended that you search the internet for "international conference on children with DCD".