- Email: [email protected]
Developmental coordination disorder: Mechanisms, measurement and management
Human Movement Science 22 (2003) 407–411 www.elsevier.com/locate/humov
Editorial
Developmental coordination disorder: Mechanisms, measurement and management
Well at Cubs they did a bike rodeo. And we were outside setting up the cones and of course you could either ride a bike or rollerblade, which excluded him from both things. {because he could do neither} Paul’s Mom 1. Introduction Participation in the typical activities of childhood is essential to a child’s healthy development. Early competence in motor-based activities is an important predictor of successful development. As such, participation in physical activity plays an important role in the child’s ability to belong to peer groups and develop and maintain friendships. Inability to participate leads to marginalization and social isolation. As highlighted in the quote above, Paul, a 10-year-old boy with DCD is excluded from participating with his peers because of his inability to perform the same motor tasks as they. The World Health Organization has proposed a new framework for health and disability, the International Classification of Functioning, Disability, and Health (ICF). This model recognizes the importance of participation and acknowledges this with a new classification system that emphasizes body function and structure, activity, and participation (World Health Organization, 2001). Furthermore, ICF clearly highlights the importance of interaction between the person and the environment in producing health or disability. Consequently, understanding a disorder not only requires consideration of impairments of body structures and functions of children (mechanisms of the disorder) but also the context of everyday life. Disorders of children such as Paul, that restrict them from participation, have been described with a variety of terms such as developmental dyspraxia, minimal brain dysfunction, perceptual-motor dysfunction, physical awkwardness or, most commonly, the clumsy child syndrome (Polatajko, 1999). At an International Consensus Meeting held in London, Ontario, a multidisciplinary group of 43 experts from 8 countries reached consensus that the term Developmental Coordination Disorder (DCD) would be used to identify such children. ‘‘The essential feature of 0167-9457/$ - see front matter Ó 2003 Elsevier B.V. All rights reserved. doi:10.1016/j.humov.2003.09.001
408
Editorial / Human Movement Science 22 (2003) 407–411
Developmental Coordination Disorder is a marked impairment in the development of motor coordination. . . that significantly interferes with academic achievement or activities of daily living’’ (American Psychiatric Association [American Psychiatric Association], 1994, p. 53). Children with DCD represent a significant proportion of school-aged children. According to international estimates, the prevalence of DCD among children between the ages of 5 and 11 is about 6%. Longitudinal studies have shown that the disorder may persist into adulthood and may be related to ensuing social and emotional difficulties. The volume of research in the area of DCD has increased tremendously over the years, as has the opportunity for researchers to congregate and share their findings. Subsequent to the consensus conference, several international conferences have been held at which advances in the field have been shared. The first of these, DCD-I, was held in London (England) in 1995, DCD-II through V were held in Leeds, Cardiff, Groningen and Banff, 2002. Each has focused on specific topics and made a contribution to the field of DCD.
2. DCD V: Mechanisms, measurement and management Convened by Angie Mandich and Brenda Wilson, in Banff, Alberta, May 14–16, 2002, DCD-V focused on three research themes: mechanisms, measurement and management. DCD-V Conference brought together eighty-eight researchers from England, Wales, The Netherlands, Finland, Sweden, United States, Australia, South Africa, Japan, Singapore, Chile, Belgium, Norway and, of course, Canada. In addition, nearly 100 clinicians and students attended. The conference was a modified Gordon style conference that focused on sharing the latest research evidence and discussing future directions to further our understanding of DCD and its management. Following an opening keynote address by Dr. Sheila Henderson of the United Kingdom, in which she reviewed several key issues concerning DCD, including the label for the disorder and its formal diagnosis, as well as interventions and their evaluation, papers and posters were presented on three research themes. The evening session was devoted to an examination of advances in our understanding of these children in an effort to move toward establishing a minimum data set that might be used internationally in all research studies. Day two started with a second keynote address given by Dr. David Sugden in which he reviewed the efficacy of intervention in children with DCD. Dr. Sugden highlighted the fact that the literature has yielded mixed results, with some being cautiously optimistic and others more reserved in their conclusions. The conference culminated in an extended afternoon session in which research findings were summarized by three Canadian researchers; Dr. E. Roy, Dr. H. Polatajko and Dr. C. Missiuna who addressed knowledge acquisition to date and proposed future research directions in the respective theme areas: Mechanisms, Measurement and Management of children with DCD. Conference resolutions were facilitated and a plan was developed for a subsequent conference, two years from now, to be held in Italy.
Editorial / Human Movement Science 22 (2003) 407–411
409
Resulting from DCD-V was the resolution that the term ‘‘developmental coordination disorder’’ should be preserved. While it was recognized that DCD is probably not the most accurate descriptor of the disorder of interest, it was considered that this term had gained acceptance, was enjoying broad use and as a result had helped to unify the field. Thus, it was reaffirmed that DCD should continue to be the term of choice and serve as a key word in all peer-reviewed publications to facilitate communication of ideas and knowledge across countries and disciplines. In addition, it was decided to found the International Society for Research into DCD (ISR-DCD) with the aim to increase the understanding and management of Developmental Coordination Disorder by encouraging collaboration, disseminating information and translating research knowledge. A Steering Committee, with representatives from Canada, the United Kingdom, The Netherlands and Australia was established with the task to set up the Society over the next two years (see www.ISR-DCD.org.uk, for details).
3. Contents The papers in the present special issue on DCD were written by participants of DCD V. Following the conference, presenters were invited to submit papers related to their presentation for peer review and consideration for inclusion in this special issue. Eventually, 10 papers were selected. They focus on different aspects of DCD, extending our knowledge on long-term outcomes, assessment approaches, motor mechanisms, and management across the levels of the ICF model: body function/impairments, activity/activity limitations, and participation/participation restrictions. The first two papers address the continued impact of DCD on body function, activity and participation, across the lifespan. Cantell et al. and Cousins et al. provide further evidence for the persistence of DCD and its manifestations into adulthood, highlighting the activity limitations and participation restrictions faced by these children as they become adults. The paper by Cantell et al. addresses the prognosis of children with DCD as they enter adolescence, and shows that the impact of DCD can be twofold; for those children with more severe symptoms it well tend to persist, whereas in less serious cases it tends to resolve itself. In their study, the vast majority of children with DCD went on to vocational training rather than high school. Findings from this study confirm the long-term negative cognitive, social and vocational impact, at least for adolescents who have severe DCD. In the second paper, Cousins et al. extend our knowledge of DCD into adulthood and show significant activity limitations in such important activities of daily living as driving. Adults with DCD were given tests at the level of impairment and activity, including reaction time, movement time and sequencing, manual dexterity tasks, handwriting, ball skills and activities of daily living. Results indicated that adults with DCD performed worse than controls across all tasks. In activities of daily living they rated themselves as less competent than controls and had difficulty performing simple motor tasks. The findings from this study have important implications in that
410
Editorial / Human Movement Science 22 (2003) 407–411
they demonstrate that individuals with DCD do retain their motor difficulties into adulthood, which can profoundly affect their lives. Consistent with the ICF model, these first two papers show that the impairments of children with DCD result in activity limitations and participation restrictions continuing into adulthood. In the third paper, Rodger et al. discuss the approaches to measurement in DCD and propose that assessment should occur at all three levels proposed by the ICF. The Motor Assessment Outcomes Model is put forth as a means of evaluating and assessing children with DCD. The model addresses all the levels of the ICF and allows for investigating the relationships between the levels. Rodger et al. highlight the importance of comprehensive, contextually relevant assessment, emphasizing that no single assessment addresses all areas of skill. They argue that children with DCD are heterogeneous and that therefore a variety of assessments should be used. Visser acknowledges, in the fourth paper, the heterogeneity of children with DCD and suggests that in order to understand the aetiology and prognosis of DCD, a better understanding of current theories of subtypes and comorbidities is necessary. Visser reviews the literature regarding subtypes and focuses on the merits of the Automatization Deficit Hypothesis for examining comorbidities. The issue of comorbidities is further explored by Smits-Engelsman et al. in a paper that examines the motor skills of children with DCD/LD (where DCD and LD are comorbid). Using kinematic movement analysis of fine-motor performance, Smits-Engelsman et al. compared the performance of children with DCD/LD to agematched control children. They showed that children with DCD/LD appear to rely more on feedback and have more trouble with complex open-loop tasks than control children. In the sixth paper, Wilson et al. further extend the knowledge of motor function in children with DCD by examining a different aspect of performance, namely procedural learning. The children in this study performed a serial reaction time (RT) task in which they were required to learn a spatial sequence that repeated itself. Results showed that most children displayed strong procedural learning and that procedural learning for simple sequential movements appears to be intact in children with DCD. The seventh paper provides the results of a study examining static balance in children at risk for DCD with balance problems. In this paper, Geuze shows that static balance improves with age, leaving only subtle differences between children with DCD and control children. Geuze concludes that under normal conditions static balance control is not a problem for children with DCD and only in difficult or novel situations do children with DCD experience increased postural sway. Moving away from studies of basic motor function the final papers in this issue focus on management of DCD. Jongmans et al. offer insight into effective intervention in children with DCD having handwriting difficulties. They investigated the effect of a task-specific self-instruction intervention to improve handwriting ability of children, and concluded that the task-oriented self-instruction method improves the quality of handwriting of children initially identified as having poor handwriting quality. Niemeijer et al. extend our knowledge of treatment principles that can be used in the management of DCD. They propose the Motor Teaching Principles Taxonomy,
Editorial / Human Movement Science 22 (2003) 407–411
411
which consists of a variety of teaching principles that can be used by therapists to treat children with DCD. Based on motor learning theory and video observations of treatment, teaching principles were categorised into three categories: giving instruction, providing or asking feedback, and sharing knowledge. The final paper by Mandich et al. presents the perspective of parents of children with DCD on the impact of DCD on the lives of their children. The parents highlighted the significant difficulties their children experienced as a result of their motor impairment. They also identified the significant positive impact that accrued for their children when they eventually became competent in the activities that were important to them. The parents identified far-reaching positive effects, extending beyond impairment reduction to increasing activity and social participation. Individually, each of these papers furthers our knowledge of DCD and highlights the complexity of the disorder. Framed collectively under the ICF, they illustrate the disabling effects of DCD at all levels––impairments, activity limitations and participation restrictions. We hope that this issue will provide a greater understanding of DCD and stimulate further research in the area. Acknowledgements We want to thank Peter Beek and Piet van Wieringen for giving us the opportunity to publish these papers in Human Movement Science and we thank the authors for their contributions. We are grateful to Eric Buckolz, Kent Campbell, Debbie Cameron, Jane Davis, Nora Fayed, Andy Freeman, Craig Hall, Sandra Hobson, Jeff Jutai, Jennifer Macnab, Rose Martini, Sara McEwen, Linda Miller, Cheryl Missiuna, Jan Polgar, Patty Rigby, Eric Roy and Sandy Spaulding for their reviewing work. References American Psychiatric Association (1994). The diagnostic and statistical manual of mental disorder (4th ed.). Washington, DC: Author. Polatajko, H. J. (1999). Developmental coordination disorder (DCD): alias the clumsy child syndrome. In K. Whitmore, H. Hart, & G. Willems (Eds.), A neurodevelopmental approach to specific learning disorders (pp. 119–133). London: Mac Keith Press. World Health Organization (2001). International classification of functioning, disability and health. Short Version. Geneva, Switzerland: World Health Organization.
Angela Mandich School of Occupational Therapy Faculty of Health Sciences The University of Western Ontario London, Ont., Canada N6G 1H1 Tel.: +1-519-661-3894 Fax: +1-519-661-2111 E-mail address: [email protected]
Helene J. Polatajko Department of Occupational Therapy Faculty of Medicine University of Toronto Toronto, Ont., Canada M5G 1V7 Tel.: +1-416-978-5936 Fax: +1-416-946-7102 E-mail address: [email protected]
Editorial
Developmental coordination disorder: Mechanisms, measurement and management
Well at Cubs they did a bike rodeo. And we were outside setting up the cones and of course you could either ride a bike or rollerblade, which excluded him from both things. {because he could do neither} Paul’s Mom 1. Introduction Participation in the typical activities of childhood is essential to a child’s healthy development. Early competence in motor-based activities is an important predictor of successful development. As such, participation in physical activity plays an important role in the child’s ability to belong to peer groups and develop and maintain friendships. Inability to participate leads to marginalization and social isolation. As highlighted in the quote above, Paul, a 10-year-old boy with DCD is excluded from participating with his peers because of his inability to perform the same motor tasks as they. The World Health Organization has proposed a new framework for health and disability, the International Classification of Functioning, Disability, and Health (ICF). This model recognizes the importance of participation and acknowledges this with a new classification system that emphasizes body function and structure, activity, and participation (World Health Organization, 2001). Furthermore, ICF clearly highlights the importance of interaction between the person and the environment in producing health or disability. Consequently, understanding a disorder not only requires consideration of impairments of body structures and functions of children (mechanisms of the disorder) but also the context of everyday life. Disorders of children such as Paul, that restrict them from participation, have been described with a variety of terms such as developmental dyspraxia, minimal brain dysfunction, perceptual-motor dysfunction, physical awkwardness or, most commonly, the clumsy child syndrome (Polatajko, 1999). At an International Consensus Meeting held in London, Ontario, a multidisciplinary group of 43 experts from 8 countries reached consensus that the term Developmental Coordination Disorder (DCD) would be used to identify such children. ‘‘The essential feature of 0167-9457/$ - see front matter Ó 2003 Elsevier B.V. All rights reserved. doi:10.1016/j.humov.2003.09.001
408
Editorial / Human Movement Science 22 (2003) 407–411
Developmental Coordination Disorder is a marked impairment in the development of motor coordination. . . that significantly interferes with academic achievement or activities of daily living’’ (American Psychiatric Association [American Psychiatric Association], 1994, p. 53). Children with DCD represent a significant proportion of school-aged children. According to international estimates, the prevalence of DCD among children between the ages of 5 and 11 is about 6%. Longitudinal studies have shown that the disorder may persist into adulthood and may be related to ensuing social and emotional difficulties. The volume of research in the area of DCD has increased tremendously over the years, as has the opportunity for researchers to congregate and share their findings. Subsequent to the consensus conference, several international conferences have been held at which advances in the field have been shared. The first of these, DCD-I, was held in London (England) in 1995, DCD-II through V were held in Leeds, Cardiff, Groningen and Banff, 2002. Each has focused on specific topics and made a contribution to the field of DCD.
2. DCD V: Mechanisms, measurement and management Convened by Angie Mandich and Brenda Wilson, in Banff, Alberta, May 14–16, 2002, DCD-V focused on three research themes: mechanisms, measurement and management. DCD-V Conference brought together eighty-eight researchers from England, Wales, The Netherlands, Finland, Sweden, United States, Australia, South Africa, Japan, Singapore, Chile, Belgium, Norway and, of course, Canada. In addition, nearly 100 clinicians and students attended. The conference was a modified Gordon style conference that focused on sharing the latest research evidence and discussing future directions to further our understanding of DCD and its management. Following an opening keynote address by Dr. Sheila Henderson of the United Kingdom, in which she reviewed several key issues concerning DCD, including the label for the disorder and its formal diagnosis, as well as interventions and their evaluation, papers and posters were presented on three research themes. The evening session was devoted to an examination of advances in our understanding of these children in an effort to move toward establishing a minimum data set that might be used internationally in all research studies. Day two started with a second keynote address given by Dr. David Sugden in which he reviewed the efficacy of intervention in children with DCD. Dr. Sugden highlighted the fact that the literature has yielded mixed results, with some being cautiously optimistic and others more reserved in their conclusions. The conference culminated in an extended afternoon session in which research findings were summarized by three Canadian researchers; Dr. E. Roy, Dr. H. Polatajko and Dr. C. Missiuna who addressed knowledge acquisition to date and proposed future research directions in the respective theme areas: Mechanisms, Measurement and Management of children with DCD. Conference resolutions were facilitated and a plan was developed for a subsequent conference, two years from now, to be held in Italy.
Editorial / Human Movement Science 22 (2003) 407–411
409
Resulting from DCD-V was the resolution that the term ‘‘developmental coordination disorder’’ should be preserved. While it was recognized that DCD is probably not the most accurate descriptor of the disorder of interest, it was considered that this term had gained acceptance, was enjoying broad use and as a result had helped to unify the field. Thus, it was reaffirmed that DCD should continue to be the term of choice and serve as a key word in all peer-reviewed publications to facilitate communication of ideas and knowledge across countries and disciplines. In addition, it was decided to found the International Society for Research into DCD (ISR-DCD) with the aim to increase the understanding and management of Developmental Coordination Disorder by encouraging collaboration, disseminating information and translating research knowledge. A Steering Committee, with representatives from Canada, the United Kingdom, The Netherlands and Australia was established with the task to set up the Society over the next two years (see www.ISR-DCD.org.uk, for details).
3. Contents The papers in the present special issue on DCD were written by participants of DCD V. Following the conference, presenters were invited to submit papers related to their presentation for peer review and consideration for inclusion in this special issue. Eventually, 10 papers were selected. They focus on different aspects of DCD, extending our knowledge on long-term outcomes, assessment approaches, motor mechanisms, and management across the levels of the ICF model: body function/impairments, activity/activity limitations, and participation/participation restrictions. The first two papers address the continued impact of DCD on body function, activity and participation, across the lifespan. Cantell et al. and Cousins et al. provide further evidence for the persistence of DCD and its manifestations into adulthood, highlighting the activity limitations and participation restrictions faced by these children as they become adults. The paper by Cantell et al. addresses the prognosis of children with DCD as they enter adolescence, and shows that the impact of DCD can be twofold; for those children with more severe symptoms it well tend to persist, whereas in less serious cases it tends to resolve itself. In their study, the vast majority of children with DCD went on to vocational training rather than high school. Findings from this study confirm the long-term negative cognitive, social and vocational impact, at least for adolescents who have severe DCD. In the second paper, Cousins et al. extend our knowledge of DCD into adulthood and show significant activity limitations in such important activities of daily living as driving. Adults with DCD were given tests at the level of impairment and activity, including reaction time, movement time and sequencing, manual dexterity tasks, handwriting, ball skills and activities of daily living. Results indicated that adults with DCD performed worse than controls across all tasks. In activities of daily living they rated themselves as less competent than controls and had difficulty performing simple motor tasks. The findings from this study have important implications in that
410
Editorial / Human Movement Science 22 (2003) 407–411
they demonstrate that individuals with DCD do retain their motor difficulties into adulthood, which can profoundly affect their lives. Consistent with the ICF model, these first two papers show that the impairments of children with DCD result in activity limitations and participation restrictions continuing into adulthood. In the third paper, Rodger et al. discuss the approaches to measurement in DCD and propose that assessment should occur at all three levels proposed by the ICF. The Motor Assessment Outcomes Model is put forth as a means of evaluating and assessing children with DCD. The model addresses all the levels of the ICF and allows for investigating the relationships between the levels. Rodger et al. highlight the importance of comprehensive, contextually relevant assessment, emphasizing that no single assessment addresses all areas of skill. They argue that children with DCD are heterogeneous and that therefore a variety of assessments should be used. Visser acknowledges, in the fourth paper, the heterogeneity of children with DCD and suggests that in order to understand the aetiology and prognosis of DCD, a better understanding of current theories of subtypes and comorbidities is necessary. Visser reviews the literature regarding subtypes and focuses on the merits of the Automatization Deficit Hypothesis for examining comorbidities. The issue of comorbidities is further explored by Smits-Engelsman et al. in a paper that examines the motor skills of children with DCD/LD (where DCD and LD are comorbid). Using kinematic movement analysis of fine-motor performance, Smits-Engelsman et al. compared the performance of children with DCD/LD to agematched control children. They showed that children with DCD/LD appear to rely more on feedback and have more trouble with complex open-loop tasks than control children. In the sixth paper, Wilson et al. further extend the knowledge of motor function in children with DCD by examining a different aspect of performance, namely procedural learning. The children in this study performed a serial reaction time (RT) task in which they were required to learn a spatial sequence that repeated itself. Results showed that most children displayed strong procedural learning and that procedural learning for simple sequential movements appears to be intact in children with DCD. The seventh paper provides the results of a study examining static balance in children at risk for DCD with balance problems. In this paper, Geuze shows that static balance improves with age, leaving only subtle differences between children with DCD and control children. Geuze concludes that under normal conditions static balance control is not a problem for children with DCD and only in difficult or novel situations do children with DCD experience increased postural sway. Moving away from studies of basic motor function the final papers in this issue focus on management of DCD. Jongmans et al. offer insight into effective intervention in children with DCD having handwriting difficulties. They investigated the effect of a task-specific self-instruction intervention to improve handwriting ability of children, and concluded that the task-oriented self-instruction method improves the quality of handwriting of children initially identified as having poor handwriting quality. Niemeijer et al. extend our knowledge of treatment principles that can be used in the management of DCD. They propose the Motor Teaching Principles Taxonomy,
Editorial / Human Movement Science 22 (2003) 407–411
411
which consists of a variety of teaching principles that can be used by therapists to treat children with DCD. Based on motor learning theory and video observations of treatment, teaching principles were categorised into three categories: giving instruction, providing or asking feedback, and sharing knowledge. The final paper by Mandich et al. presents the perspective of parents of children with DCD on the impact of DCD on the lives of their children. The parents highlighted the significant difficulties their children experienced as a result of their motor impairment. They also identified the significant positive impact that accrued for their children when they eventually became competent in the activities that were important to them. The parents identified far-reaching positive effects, extending beyond impairment reduction to increasing activity and social participation. Individually, each of these papers furthers our knowledge of DCD and highlights the complexity of the disorder. Framed collectively under the ICF, they illustrate the disabling effects of DCD at all levels––impairments, activity limitations and participation restrictions. We hope that this issue will provide a greater understanding of DCD and stimulate further research in the area. Acknowledgements We want to thank Peter Beek and Piet van Wieringen for giving us the opportunity to publish these papers in Human Movement Science and we thank the authors for their contributions. We are grateful to Eric Buckolz, Kent Campbell, Debbie Cameron, Jane Davis, Nora Fayed, Andy Freeman, Craig Hall, Sandra Hobson, Jeff Jutai, Jennifer Macnab, Rose Martini, Sara McEwen, Linda Miller, Cheryl Missiuna, Jan Polgar, Patty Rigby, Eric Roy and Sandy Spaulding for their reviewing work. References American Psychiatric Association (1994). The diagnostic and statistical manual of mental disorder (4th ed.). Washington, DC: Author. Polatajko, H. J. (1999). Developmental coordination disorder (DCD): alias the clumsy child syndrome. In K. Whitmore, H. Hart, & G. Willems (Eds.), A neurodevelopmental approach to specific learning disorders (pp. 119–133). London: Mac Keith Press. World Health Organization (2001). International classification of functioning, disability and health. Short Version. Geneva, Switzerland: World Health Organization.
Angela Mandich School of Occupational Therapy Faculty of Health Sciences The University of Western Ontario London, Ont., Canada N6G 1H1 Tel.: +1-519-661-3894 Fax: +1-519-661-2111 E-mail address: [email protected]
Helene J. Polatajko Department of Occupational Therapy Faculty of Medicine University of Toronto Toronto, Ont., Canada M5G 1V7 Tel.: +1-416-978-5936 Fax: +1-416-946-7102 E-mail address: [email protected]