HDCD The Highland Developmental Co-ordination Disorder Group

HDCD Highland Developmental Co-ordination Disorder Group Text

19 Appendices

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Appendix B - Terminology

Terminology relating to Developmental Co-ordination Disorder (DCD) including Dyspraxia

The diagnostic criteria for health conditions are internationally standardised and catalogued by both the World Health Organisation (ICD10) and the America Psychiatric Association (DSMIV). The following definition is taken from the diagnostic criteria for Developmental Co-ordination Disorder (DCD) as outlined in DSM IV.

A	Performance in daily living activities that requires motor co-ordination is substantially below that expected given the person’s chronological age and measured intelligence. This may be manifested in delays in achieving motor milestones e.g. walking, crawling, sitting, dropping things – “clumsiness”.
B	The disturbance in Criteria A significantly interferes with academic achievement or activities of daily living.
C	The disturbance is not due to a general medical condition e.g. Cerebral Palsy, Hemiplegia or Muscular Dystrophy and does not meet criteria for a pervasive developmental disorder.
D	If mental retardation is present the motor difficulties are in excess of those associated with it.

To be given a diagnosis a child with DCD must fulfil the criteria of A, B, C and where appropriate D.

The diagnostic criteria as per ICD10 are also often quoted in literature. The condition in this classification is referred to as “specific developmental disorder of motor function”. It is described as “a disorder in which the main feature is a serious impairment in the development of motor co-ordination that is not solely explicable in terms of general intellectual retardation or of any specific congenital or acquired neurological disorder”. Nevertheless, in most cases a careful clinical examination shows marked developmental immaturities such as choreiform (jerky involuntary) movements of unsupported limbs or mirror movements and other associated motor features, as well as impaired fine and gross motor co-ordination.

Terms used

Include: Clumsy Child Syndrome, Developmental Co-ordination Disorder, and Dyspraxia

Exclude: Abnormalities of gait and mobility (R26-) Lack of co-ordination (R27-) Secondary to mental retardation (F70-F79)

DCD has had many labels and different names. Over the years they have included Motor Learning Difficulties, Minimal Brain Dysfunction, Sensory Integrative Dysfunction, Specific Learning Difficulties, spatial problems or Developmental Dyspraxia.

The name given to the condition often reflects the ‘model’ or ‘theory’ the practitioner is using.

At present, Developmental Co-ordination Disorder (as described in DSM-IV) is becoming the favoured term among clinicians and researchers. Dyspraxia is a more specific name to describe a particular aspect of DCD, i.e. particular difficulty with movement planning. All children with DCD do not have “Dyspraxia” in its true sense.

However, in the UK many people use the term “Dyspraxia” in a more general way, which should be recognised when reading literature and when producing written work.

Children with DCD often have delays in other non-motor milestones, such as speech and/or language difficulties.
Children often have difficulties using a knife and fork, buttoning clothes, running or playing ball games.
The course is variable and some un-coordination continues into adulthood.
If criteria for both disorders are met then both diagnoses can be given.

The Child

There are many characteristic features which are commonly found in children with DCD. It is unlikely that any one child will display all of these features but many display a cluster. It should not be assumed, however, that a child who shows only one or two features necessarily has Developmental Co-ordination Disorder. In fact, many of these features may be seen within the normal population of children who have no apparent or marked difficulties.

The following are some of those features which may alert us to the likelihood of DCD and which you may recognise in your child or pupil:

Gross Motor Skills	Large movements
Late motor milestones	e.g. sitting, crawling (if achieved), walking, etc.
Low muscle tone	Child feels ‘floppy’ and unstable around joints.
Balance problems	Child may be unreasonably afraid or conversely unaware of danger in precarious situations.
Poorly integrated primitive reflexes	The child may retain some of the early babyhood reflexes, impairing the development of more skilled movements.
Poor bilateral integration	Integration (co-ordination) of the two sides of the body may be limited and certain activities consequently impaired: e.g. crawling, jumping, skipping, pedalling a bike, catching a ball, etc.
General	The child may look generally ‘unco-ordinated’ when unco-ordination running, hopping, jumping, and kicking (due to any of the above features).
Planning/Organisation	Some children have particular difficulty with the planning of movement. They may have difficulty finding way their way round new environments and have a fear of getting lost.

Fine Motor Skills	Hand skills
Immature grasp	Of pencil or small objects/toys.
Poorly established dominance	The child is not clearly right or left-handed (or is late developing laterality). He/she tends to reach with or use whichever hand is nearer to the object.
Limited bilateral integration	Poor at bilateral tasks e.g. shoelaces, cutlery, construction toys etc.
Poor pencil control	Difficulty with the actual control of movement, often the movement is a ‘whole arm’ movement rather than isolated finger movement.
Drawing/writing problems	May have difficulty with the construction of shapes, letters etc: or with direction (e.g. reversals).

Eye Movements
Poor visual tracking	Difficulty in following a moving object smoothly with the eyes without excessive head movements.
Poor localisation	Cannot look quickly and effectively from object to object (e.g. book to book, blackboard to jotter, etc).
Poor eye/hand co-ordination	Poor ability visually to direct hand movements.

Specific Learning Difficulties
Reading	Failure or lack of progress; may read words backwards or letters in the wrong sequence. The child may have auditory discrimination problems making phonic work difficult.
Writing	Layout and organisation or direction and flow may be affected. Some letters or numbers may be reversed, letter sequence may be affected and whole word reversals may occur. Handwriting speed may be affected as may size being too large or too small.
Spelling	Sequencing of letters in a word, difficulty ‘translating’ sounds into letters, etc, and letter string combinations.
Number	e.g. difficulty with rote learning (i.e. learning by heart) or with layout on page. The child may also have difficulty during sequencing activities.

Speech and Language
Delayed acquisition	Many children with DCD are late to speak their first of speech words or sentences.
Immature speech	Persisting ‘immature’ speech is often an early predictor of DCD.
Poor auditory	Child may misunderstand what has been said discrimination particularly in early years when prior knowledge and situational knowledge are less likely to compensate.
Poor auditory	Difficulty acting on two-fold instruction. May also have sequential recall difficulty learning nursery rhymes, songs, counting days of the week, recalling narrative not supported by pictures or other visual stimuli, remembering new, uncommon or unusual words.
Poor planning	May lead to difficulty organising thoughts into and organisation sentences. Older children may have difficulty collating and organising information to present in spoken or written form.
Secondary symptoms	Experience of failure in certain speaking situations may lead to anxiety in those situations and possible avoidance. Anxiety is known to undermine performance.

Co-Morbidity

There may be other associated conditions, e.g. Attention Deficit (Hyperactivity) Disorder (ADHD), Dyslexia, Social/Communication problems.

Personality and Behaviour
Behaviour	Many of these children display ‘behaviour problems’. It is very important to distinguish between the different causes. One type of child is often restless and lacks control. It has been suggested that this behaviour may be part of an overall lack of inhibition in the Central Nervous System, affecting the whole performance and making it hard for the child to regulate or modulate responses. Other children may have problems with attention or be overactive or underactive (ADD/AHDH). Another child’s behaviour may be the direct result of his DCD difficulties. The latter is often an unhappy, lonely child, with poor self-esteem and lack of confidence who develops apparent ‘behavioural problems’ as a way of opting out or of being laughed at on his/her own terms when feeling threatened or because things are too difficult. Alternatively, this behaviour may simply be the result of frustration because of cognitive ability exceeding achievement, and efforts to do things resulting in failure.
Emotional Problems	These are common because of pressures on the child by other children and adults who fail to understand what is a very complex, difficult-to-define problem. The child will also have his/her own perceptions about ability and self-worth, etc. Examples may include school refusal, peer relationship problems (i.e. difficulty with friendships), enuresis (bedwetting), psychosomatic disorders, opting out behaviour, etc. Some children with DCD are simply very labile emotionally, i.e. become easily upset.
Anxiety and Tension	These also obviously have an adverse effect on the child and on movement, therefore should be avoided where possible.

It should also be remembered that there are many children with behavioural and emotional problems that are in no way related to DCD.

Variability

This is a very important factor in both the child’s performance and his emotional ability to cope. There may be some days, or phases, where he can do things better than at other times. It is easy to think ‘he could do it yesterday, so he must be able to do it today’. This is not necessarily the case. These children seem to have ‘good days’ and ‘bad days’; it is as though their Central Nervous Systems can ‘get things together’ better at some times than at others.

These are some of the features, frequently seen in children with DCD. Where several of them exist, the child may be experiencing very real difficulties but, as already stated, they should never be taken in isolation as necessarily indicating motor problems or Specific Learning Difficulties.

Characteristics required for efficient movement and learning For efficient movement and learning, we require several other factors:
Postural security	A feeling of ‘safety’ and stability even when our body position is changed.
Bilateral integration	The ability to co-ordinate and integrate the two sides of the body; for this to occur and in order to sort out direction, etc, we need to establish a ‘dominant’ or preferred hand.
Praxis	The ability to plan and execute skilled, unfamiliar movement. In order to achieve this, we also need the following:
Body Scheme (body plans)	Awareness of the position of body parts, which requires adequate interpretation and integration by all our sensory systems.
Screening	(of sensory input) – Our Central Nervous Systems are constantly receiving information. We need to be able to filter out what is irrelevant and focus on what is important. In a classroom, for example, a child needs to attend to the teacher’s voice and the blackboard and ‘screen out’ irrelevant sounds and visual stimuli such as noise in the next area or a bird or a plane flying past the window. To do this we require:
Inhibition	(in our nervous systems) – Some people suggest that inhibition suppresses the irrelevant, thereby helping us to focus on the relevant. This results in the ability to attend, regulation of movement, rate of speech, etc.
Facilitation	This is believed by many to involve the ‘speeding up’ of transmission of information through our Central Nervous Systems to allow rapid responses when required. For normal function, we need a balance between facilitation and inhibition.
Attention	When the balance is achieved we are able to attend.

What is the Problem?

It is thought that the problem of Developmental Co-ordination Disorder may be caused by failure of the Central Nervous System adequately to interpret, integrate and process the information required to produce an appropriate response. This may be a motor response, such as reacting to save ourselves from falling, or a conceptual one such as recognising a complete object from the sensory information received.

In order to understand this, we need to consider, very simply, how the normal Central Nervous System (CNS) works. It takes in, interprets, sorts out and connects sensory information, organises it and processes the response. All this goes on automatically, below the level of awareness.

‘Sensory Information’ needs further explanation. There are the more obvious senses, which we all know about, such as hearing, vision, taste and smell. However, every bit as important is the input which we rarely think about Tactile, Proprioceptive and Vestibular information.

To explain more fully:

Tactile refers to touch. There are two basic parts to our tactile systems: one responds to light or unexpected touch and protects us from potential danger. The other is discriminatory and helps us to gain information about the quality of what we feel hard or soft, rough or smooth, etc.

Proprioceptive. Our proprioceptors give us information from muscles, ligaments, tendons and joints and therefore let us know the position of our body parts and our position in space, without our needing to look. They also help with the detection of force resulting in the ability to achieve force control.

Vestibular refers to our balance system. This lets us know our relationship to gravity and our body position in space, e.g. whether the body or environment is moving, how fast we are moving, which way up we are, etc. Our Vestibular Systems along with Proprioceptive System are responsible for maintenance of posture.

All these senses must receive information accurately and then the CNS must interpret and integrate it in order for us to function normally. For example, not only do we need adequate vision but also our systems need to interpret what we see and then integrate it with information from our other senses. This applies to all types of sensation.

Implications in the School Setting
Praxis	Required for the organisation and sequencing of movements required for writing, for layout of work. See The Dyspraxic Child later in this section.
Visual Perception	Recognising letters, words, position in space of similar letters, e.g. b and d.
Auditory Perception	Breaking down/discriminating strings of sound into meaningful and recognisable phonemes- syllables-words- sentences.
Eye-hand Co-ordination	Efficient use of eye and hand together.
Inhibition	To govern rate of output, control of movement, level of attention.
Facilitation/inhibition	To stay alert and be able to attend to task.
Language skills	Organising thoughts into written language.

Therefore, if a child has difficulty with several, or occasionally all, of these processes, he/she will have considerable difficulty with writing. The same applies to any other process from fairly basic motor tasks such as jumping, hopping, etc through to more complicated tasks such as riding a bicycle or tying shoelaces, to the most sophisticated areas of academic learning.

A simple way to look at it is to imagine the brain as being a bit like a telephone exchange where, in the child with DCD, the wiring is incomplete, inefficient or crossed. The result, to use a another metaphor, has been described as being ‘something like a rush-hour traffic jam’.

Sometimes interpretation and integration seem inadequate; sometimes different types of sensory input seem to be ‘at odds’ with one another. An example of the adverse way in which normal people react to conflicting stimuli is travel or seasickness, where if we watch the horizon we feel better than we do if we look at something that is stationary, e.g. a map in the car. In the former instance our vestibular and visual systems are giving us the same information: we are moving. In the latter, they are ‘at odds’ – our vestibular systems will give us signals that we are moving, but our vision is interpreting something static. Similarly, in a treatment session, a child with visual perceptual problems closed his eyes and produced much better ‘patterns’ on a board; he was relying on his very adequate tactile and proprioceptive systems and eliminating the conflicting information from his poor visual perception.

In order to move on from movement to learning, there are further requirements based on the preceding ones. Some of these are:

Oculomotor control	Smooth efficient eye movements are required for reading, looking from board to book, etc. Eye-hand co-ordination Links vision and hand movement.
Visual perception	Which includes the ability to recognise a shape, to be aware of its position in space, and to sequence a series of shapes – as required for reading, maths concepts, etc.
Directionality	Linked with acquiring laterality (or handedness) and bilateral integration; required for direction of letters (e.g. b and d), words and letter formation.
Language skills	Essential for learning.

For movement and learning to occur, our brains need to ‘put together’ all the preceding factors efficiently and eventually automatically. It seems that in some children, the process does not work entirely efficiently. If we take a complex process like writing and analyse it, we can see how many components are required. Some of these are:

Posture Vestibular processing is needed for basic sitting stability and adjustment when required. Touch We need adequate tactile information in order to feel the pencil, know how tightly we are holding it or how hard we are pressing. Proprioception Required for efficient grasp and joint movement and detection of force required. Bilateral Integration We need to use two hands together efficiently, one to hold the pencil and the other to stabilise the page. Directionality Develops as part of the above and is required for direction of letters, letter formation, working from left to right of a page. Language Skills Essential for learning.

In the child with DCD problems it seems that these early functions are not complete. There are many reasons for this, such as:

Inadequate or inaccurate interpretation of sensory information leading to limited or inaccurate information to the Central Nervous System on which to base further experience.
Avoidance of those things that are difficult or threatening, also limiting experience and opportunity to develop more skilled movements.
Limited speech and language development because we use language and movement to support one other.
Limited exposure to natural movement experiences.
Poorly integrated primitive reflexes – adversely affecting normal movement, etc.

When this groundwork is not complete, movement continues to be conscious (or thought through) rather than automatic, and consequently the child is less able to cope with and think about the more sophisticated complex parts of tasks.

It has been said that, “there is nothing less efficient than the cortex (or ‘thinking’ part of the brain) thinking its way through movement”. In many DCD children, this is precisely what appears to be happening, having a considerable effect on sophisticated skills and academic learning.

Finally, no two children are exactly the same, and there are many different sorts of Motor and Specific Learning Difficulties. The child’s problems with perception and processing can lie in several different areas.

The problem may be mainly related to balance and posture, and sometimes associated with bilateral skills and direction, etc.
It may be Dyspraxia and therefore mainly associated with movement planning, affecting everything from organising gross movement to coping with the complex skill of writing, and often including organisation of self in relation to the environment.
It may be mainly visual perceptual and therefore often affecting drawing, writing, etc.
Sometimes a child may have difficulty in regulating his response to sensations in the environment, such as touch or movement. The adverse responses may then present as poor behaviour or difficulty with attention.

Frequently there is a combination of more than one of these possibilities.

Sometimes, sadly, a child has generalised problems affecting all these areas and often (though not always) this may be associated with restlessness and poor attention. In these cases, the child who obviously has no compensating area of strength may gain less from treatment.

Whatever the problem, the result is a child with co-ordination problems, specific learning difficulties and often speech and language problems; a child whose self-esteem is usually low, who lacks confidence and who is often a lonely child, may develop strong opting out strategies and other behavioural or emotional problems.

In short, children with these difficulties need understanding and positive help if life is not to become frustrating and unhappy for family, teachers and, most of all, themselves.

The Dyspraxic Child

Praxis is the ability by which we figure out how to use our hands and body in skilled tasks such as playing with toys, using a pencil or fork, building a structure, straightening up a room or engaging in many occupations.

A	Ideation – forming the idea and knowing what to do.
B	Motor Planning – organising the sequence of movement involved in the tasks.
C	Execution – carrying out the planned movements in a smooth sequence. Praxic skill is one of the essential skills that enables us “to do” in the world.

It is unique in human skills and is one of the most critical links between brain and behaviour. Praxis is to physical work what speech is to the social world.

Dyspraxia is an impairment of the organisation of movement, i.e. ideation –motor planning – execution. A dyspraxic child has difficulty using his or her body, including relating to some objects in the environment. A dyspraxic child often has trouble with organising his/her own behaviour.

Associated with this there are problems of language perception, thought and emotional behaviour.

All these problems will manifest themselves in learning activities, e.g. writing, reading, spelling and activities of daily living e.g. dressing.

Ref: Chu: OT and Sensory Integration- cited in “Dyspraxia Trust – Praxis makes Perfect.”

Bibliography

DSMIV. Diagnostic and Statistical Manual of Mental Disorders: American Psychiatric Association, 2000, Fourth Edition. Motor Skill Disorders, 315.4 Developmental Co-Ordination Disorder, pages 56-58, ISBN 0-89042-025-4.

ICD10. International Statistical Classification of Diseases and Related Health Problems, World Health Organisation, Geneva, 1992, Vol. 1, Tenth Revision, Code F82, page 375, ISBN 92-4-154419.8.

Ayres A J. Sensory Integration and the Child. Western Psychological Services, 1987, ISBN 0-87424-158-8.

Ayres A J. Sensory Integration and Learning Disorder. Western Psychological Services, ISBN 0-87424-303-3.

Fisher Murray, Bundy. Sensory Integration – Theory and Practice. F A Davies, ISBN 0-8036-3565-6.

Kranowitz C S. The Out of Sync Child. The Berkley Publishing Group, 1998, New York, ISBN 0-399-52386-3.

Stephenson E. The Child with Developmental Co-ordination Disorder. Waverley Press, 2000, Aberdeen.

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