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Abbreviations

DCD, developmental coordination disorder; OT, occupational therapist; PT, physiotherapist.

Case: “He’s so clumsy he still can’t even tie his shoelaces on his own.”

Cory is an 8-year old that you are seeing for his yearly check up. Parents express various concerns about problems at home and school. At school, he has troubles with written work, to the point where he can’t keep up with what the teacher writes on the board. Written assignments and tests are a disaster. Getting him to do any homework involving written work leads to crying and frustrated parents. In gym, he is always picked last for any teams. He is bullied and picked on for being clumsy, and spends lunches and recesses alone. At home, he prefers sedentary activities such as television and video games. His father is quite concerned, saying, “Our relatives tell us that he’s just lazy and we need to be firmer, but when we try to be firmer, he just gets overwhelmed and cries. We don’t know what to do!”

What is DCD?

Developmental coordination disorder (DCD) is a neurodevelopmental condition where there are:

• Significant motor coordination difficulties that interfere with school, work or activities of daily living, and 
• The motor skills deficits cannot be better explained by an intellectual disability, visual impairment, or a neurologic condition affecting movement (e.g. cerebral palsy, muscular dystrophy, or a degenerative disorder)

Because motor skills are required for every aspect of our lives, DCD can cause significant impairment in all domains of the child’s life (e.g. home, school and community) as well as affect the family.

Age-appropriate sensory/motor development contributes to physical, cognitive, emotional and social development as well, which means these areas may also be affected in a child with DCD.

Epidemiology

• 5% of children (i.e. 1 child in every classroom)
• Typically not diagnosed until after age 5

Diagnosis of DCD

• Children with DCD are defined as being:
  • Below the 5%ile on a standardized motor coordination test (or below the 15%le, if functional difficulties are present) and
  • Have significant impairment in daily living, academic achievement or play.
     
• Some physicians may feel comfortable making a clinical diagnosis of DCD. If not, it is best to collaborate with an occupational therapist (OT) or a physiotherapist (PT) who can perform a motor assessment. A physician can give a formal diagnosis based on the recommendations of the OT/PT.

DSM-5 Criteria for DCD

• Acquisition and execution of coordinated motor skills are below what would be expected based on the child’s chronologic age and opportunity for skill learning and use; difficulties are manifested as clumsiness (e.g., dropping or bumping into objects) and as slowness and inaccuracy of performance of motor skills (e.g., catching an object, using scissors, handwriting, riding a bike, or participating in sports)
• The motor skills deficit significantly or persistently interferes with activities of daily living appropriate to the child’s chronologic age (e.g., self-care and self-maintenance) and impacts academic/school productivity, prevocational and vocational activities, leisure, and play
• The onset of symptoms is in the early developmental period
• The motor skills deficits cannot be better explained by intellectual disability or visual impairment and are not attributable to a neurologic condition affecting movement (e.g., cerebral palsy, muscular dystrophy, or a degenerative disorder)

Clinical Presentation

DCD presents slightly differently over the lifespan

History / Screening Questions

Annual health examinations are ideal times to screen for DCD.

The questions from CanChild’s “Listening for DCD Interview Guide” can be used to ask parents about their child in a structured fashion:

Download a blank interview template that can be used during a visit

Link: http://canchild.ca/elearning/dcd_pt_workshop/assets/identification/listening-dcd-interview-guide.pdf

Other screening options include:

• Self-administered questionnaire for parents (available at www.cmaj.ca/cgi/content/full/1.../DC1),
• Simple screening activities administered in the doctor’s office (available at www.cmaj.ca/cgi/content/full/1... /DC1).

Children with symptoms or signs of a motor coordination disorder require further evaluation.

Differential Diagnosis of Motor Coordination Problems

Developmental coordination disorder (DCD) is a diagnosis of exclusion, after ruling out other medical causes that would better explain the coordination problems such as:

Comorbid Conditions

Common conditions that often occur with DCD are:

Physical Exam

Management in General

• Refer to an OT, PT or pediatric multidisciplinary team, as they can help confirm the diagnosis, rule out comorbid conditions and initiate a management plan. Successful treatment approaches are multidisciplinary involving health professionals such as OT/PT as well as the child's parents and educators. 
• Inform the school by writing a physician’s letter that states the diagnosis of DCD as this may facilitate appropriate school accommodations, modifications and supports..
• Manage any comorbid issues such as:
  • Learning disorder(s):
    • Ensure school supports such as special education and/or psychology;
    • Consider referrals to services and supports for learning disorders.
  • ADHD:
    • Ensure appropriate school supports such as accommodations and modifications for ADHD
    • Consider services / supports for ADHD
    • Consider medications.
  • Anxiety / depression
    • Ensure appropriate school supports for students with anxiety/depression
    • Refer to services / supports for mental health.
  • Autism spectrum disorder (ASD):
    • Encourage appropriate school supports
    • Refer to services and supports for ASD.
  • Speech/language difficulties:
    • Refer to speech/language pathologist.
  • Provide psychoeducation such as:
    • Encourage participation in physical activities, with an emphasis on enjoyment rather than competition.
    • If the child is not interested in competitive or group activities, then encourage individual physical activities (e.g. walking, running, bicycling, swimming). Individualized lessons may be helpful.

Management: Strategies for Home

Below is a list of general recommendations that have been suggested by the CanChild Centre for Childhood Disability Research; note that these need to be individualized to meet the needs of the specific child and family.

General Principles to Help the Child with DCD Learn New Skills and Tasks:

• Be consistent: When teaching a task, try to practice it in the same place with the same materials each time.
• Provide repetition: Your child will need much more repetition than a child without DCD, and you may need to repeat the task for several days or even weeks. With each repetition, remain consistent in your instructions and in the environment (i.e. same place, same materials – as above).
• Demonstrate visually. Try to avoid overloading your child with lots of verbal instructions. Also show your child what you want her/him to learn.
• Praise efforts as opposed to results.  Often a child with DCD will put in a huge amount of effort and still not complete a task. It is important to praise the effort instead of the result.

General Strategies for Home and Community

• Encourage the child to participate in physical activities for the activity and enjoyment, rather than proficiency or competition. Encourage games and sports that are interesting to him/her and which provide practice in, and exposure to, motor activities.
   
• Introduce the child to new sporting activities or a new playground on an individual basis, before he/she is required to participate with a group. Review any rules and routines that are associated with the activity (e.g., baseball rules, soccer plays) at a time when the child is not concentrating on the motor aspects. Ask the child simple questions to ensure comprehension (e.g., "What do you do when you hit the ball?"). Private lessons may be helpful at certain points in time to teach the child specific skills.
   
• Encourage social participation. Encourage the child to interact with peers through social activities (e.g., cubs, music, drama, or art).
   
• Provide clothing that is easy for the child to manage. For example, sweat pants, sweat shirts, t-shirts, leggings, sweaters, and Velcro shoes. When possible, use Velcro closures instead of buttons, snaps or shoelaces. Teach the child how to manage difficult fasteners when you have more time and patience (e.g., on the weekend, or over the summer) rather than when you are pressured to get out the door
  .
• Encourage the child to participate in practical activities that will help improve his/her ability to plan and organize motor tasks. For example, setting the table, making lunch, or organizing a knapsack. Ask questions that help the child focus on the sequence of steps (e.g., “What do you need to do first?”). Recognize that, if your child is becoming frustrated, it may be time to help or to give specific guidance and direction.
   
• Recognize and reinforce the child’s strengths. Many children with DCD demonstrate strong abilities in other areas – they may have advanced reading skills, a creative imagination, sensitivity to the needs of others, and/or strong oral communication skills.

Sample School Letter for a school aged child with DCD

Dear Educator:

I am writing to provide you with information regarding your student who has a diagnosis of Developmental Coordination Disorder (DCD), a neurologic condition that causes difficulties with motor coordination, and affects their ability to perform fine motor skills (e.g. handwriting, printing, copying from the board, doing up buttons), and/or gross motor skills (such as riding a bicycle, throwing a ball, jumping, hopping)

I would like to suggest:

• School accommodations. Accommodations are essential for this student to be able to access the curriculum and participate fully in all aspects of school life. Below are some recommended accommodations.
• A referral to an occupational therapist (OT) and/or physiotherapist, in order to help devise a plan for the student.

Specific accommodations will need to be determined in collaboration with the school, student and family. Below is a list of general recommendations from CanChild: an OT and/or PT will be able to individualize these suggestions.

For more information about DCD including classroom accommodations for specific ages, please visit the DCD section of the CanChild Centre for Childhood Disability website at: www.dcd.canchild.ca.

Thank you for your time and support of this student.

Feel free to contact me if you have any further questions,

YOUR NAME, MD

Sample School Letter for an Adolescent with DCD

Dear Educator:

I am writing to provide you with information regarding your student who has a diagnosis of Developmental Coordination Disorder (DCD), a neurologic condition that causes difficulties with motor coordination, and affects their ability to perform fine motor skills (e.g. handwriting, printing, copying from the board, doing up buttons), and/or gross motor skills (such as riding a bicycle, throwing a ball, participating in sports)

I would like to suggest:

• School accommodations. Accommodations are essential for this student to be able to access the curriculum and participate fully in all aspects of school life. Below are some recommended accommodations.
• A referral to an occupational therapist (OT) and/or physiotherapist, in order to help devise a plan for the student.

Specific accommodations will need to be devised in collaboration with the school, student and family. Below is a list of common issues and strategies that have been suggested by the CanChild Centre for Childhood Disability Research:

For more information about DCD, please visit the DCD section of the CanChild Centre for Childhood Disability Research website (www.dcd.canchild.ca).

Thank you for your time and support of this student.

Feel free to contact me if you have any further questions,

YOUR NAME, MD

Case, Part 2

After you have observed Cory in your office during his yearly check up, you wonder about whether his difficulties are consistent with a clinical diagnosis of DCD, and thus you refer him to an OT. The motor assessment completed by the OT is consistent with DCD, and you make a formal DCD diagnosis. You write a letter to the school. He and his family start receiving input from the OT, including education around his motor difficulties and how to manage them. Over time he begins to show small improvements in his functional abilities despite the fact that his motor coordination difficulties persist.. At school, he starts receiving accommodations and modifications for his coordination difficulties. His teachers become more understanding, and no longer rush or hurry him with motor activities. He starts coping with school better, and Cory no longer complains about stomachaches when he leaves for school. At the last visit to your office, he proudly tells you that he now looks forward to school, and seeing his friends and that he is enjoying participating in community swimming lessons. Most importantly, at home, he reports that his parents are more understanding of his coordination difficulties. As a result, they have modified their expectations of him, and he feels less stress and more accepted overall.

Websites

Information about DCD from the CanChild Centre for Childhood Disability Research website at McMaster University for children, families, educators and professionals http://www.canchild.ca

Online CME module for physicians about DCD at MacHealth.ca

https://machealth.ca/programs/developmental_coordination_disorder/    

Clinical Practice Guidelines

European Academy of Childhood Disability DCD Guidelines: Definition, Diagnosis, Assessment and Intervention of Developmental Coordination Disorder (DCD). German-Swiss Interdisciplinary Clinical Practice Guideline according to the Association of Scientific Medical Societies in Germany, UK version, 2012. Retrieved July 17, 2015 from

http://www.eacd.org/publications.php

About this Document

Written by Drs Cheryl Missiuna (PhD, OT Reg. (Ont), McMaster University), Lisa Rivard (PhD, PT, McMaster University) and members of the eMentalHealth.ca for Primary Care team (Drs Mireille St-Jean (Family Physician, University of Ottawa), Eric Wooltorton (Family Physician, University of Ottawa), Farad Motamedi (Family Physician, University of Ottawa) and Michael Cheng (Psychiatrist, University of Ottawa).

Disclaimer

Information in this pamphlet is offered 'as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

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