Synonyms: developmental co-ordination disorder

Dyspraxia

This is the partial loss of the ability to co-ordinate and perform certain purposeful movements and gestures in the absence of motor or sensory impairments. The integrity of primary motor function is maintained but patients are unable to perform certain action sequences under particular conditions.

It may be acquired (e.g. as a result of brain damage suffered from a stroke or head injury), or associated with failure or delay of normal neurological development. The underlying cause of motor co-ordination difficulties is unknown.

Individuals who are clumsy, whose handwriting is significantly impaired, or who exhibit other major weaknesses in motor and co-ordination skills are now generally diagnosed as having developmental co-ordination disorder (DCD) - also called dyspraxia, and previously and inappropriately known as clumsiness syndrome).¹

Occupational therapists in the UK use the term dyspraxia to refer specifically to deficits in motor planning accompanied by perceptual problems, and not to mean more general co-ordination difficulties.

Apraxia

This term is used to describe complete loss of the ability to co-ordinate and perform certain purposeful movements and gestures in the absence of motor or sensory impairments.

Epidemiology

• Developmental co-ordination disorder (DCD) is a common condition, present in about 5-10% of school-age children.
• It is more common in boys than in girls.
• It is more common in children with a history of premature birth.
• Apraxia can also follow any neurological disorder affecting the left inferior parietal lobule, frontal lobes or corpus callosum, especially a stroke or dementia.²

Classification

Classified by the body area affected, e.g. oral (buccofacial) apraxia, or by type of movement sequence affected:

• Ideational dyspraxia: difficulty with actions requiring planning or sequencing.
• Ideomotor dyspraxia: inability to mime the use of an object even though action with the real object may be unimpaired.
• Constructional dyspraxia: inability to build a simple construction or to copy a drawing. This is mostly caused by nondominant hemisphere lesions.
• Dressing dyspraxia: inability to dress due to an impaired sense of clothes' orientation and sequence (nondominant hemisphere).
• Callosal dyspraxia: left-hand inability upon verbal command.
• Gait dyspraxia: gait disorder in which individual components of walking are unimpaired. Common in the elderly, seen with posterior temporal lesions, bilateral frontal lesions and hydrocephalus.

Presentation

Presentation is very variable in terms of severity. There may be a history of delay in achieving motor development milestones. There may be a slowness and hesitancy with actions. Difficulties may be identified first by parents or at school.

Particular difficulties may include:

• Dressing.
• Eating.
• Writing; using scissors.
• Puzzle activities.
• Running, hopping, jumping, riding a bicycle.
• Ball skills.
• Doing activities under time pressure.

Assessment

• Any child with concerns of developmental co-ordination disorder (DCD) should be assessed by a paediatrician in order to consider possible specific causes and to initiate a multidisciplinary management plan.
• The child may first be identified by the school as having difficulties and is then usually referred to an educational psychologist.
• Further assessment from occupational therapy or other professionals, e.g. physiotherapists, may also be required.
• The criteria used and testing performed to elicit the diagnosis vary from profession to profession. There is no true benchmark of criteria and assessment tools for establishing the diagnosis.

Differential diagnosis

• Neuromuscular or hypotonic problem.
• Myotonic, myopathic or connective tissue disorder.
• Degenerative condition or a storage disorder.
• Joint hypermobility syndrome, Ehlers-Danlos syndrome.
• Neurofibromatosis type 1 (NF1).

Assessment

• Ask the patient to mime:
  • Using an object, e.g. a hairbrush.
  • Actioning a sequence, e.g. folding and sealing a letter.
  • Carrying out a symbolic action, e.g. waving.
• Ask the patient to alternate flat hand and fist with both hands.

Associated disorders

• Often coexisting with a poor attention span and concentration.
• Dyslexia, dyscalculia.
• Attention deficit hyperactivity disorder.³
• Asperger's syndrome.
• Tactile defensiveness - oversensitive to touch.
• Other learning disorders.

Management

The approaches to assessment and treatment may be varied, according to different theoretical assumptions about the aetiology of the condition and its developmental course.⁴
• It may involve occupational therapists, physiotherapists and educational psychologists. The key is a coordinated approach between parents, carers, teachers and health professionals.
• It is essential to share all assessment information and management recommendations with parents, teachers and anyone else involved with the child's education and welfare.
• Suggestions to help parents:
  • Provide suitable tools to help with difficult tasks, e.g. adapted scissors, use of a computer instead of handwriting, organisational techniques.
  • Work on gross motor strength: introduce suitable sports such as swimming, riding, canoeing, walking, badminton.
  • Maintain self-esteem: look at hobbies that the child will enjoy.
  • Maintain good liaison with the school, so that there is a parent-school partnership.

Prognosis

• Motor problems of children with developmental co-ordination disorder (DCD) persist at least into adolescence.
• Initial difficulties often lead to secondary physical health, mental health and educational problems, e.g. poor physical fitness, poor social competence, academic problems, being bullied, behavioural problems and low self-esteem.
• The prognosis of acquired dyspraxia will depend on the nature and severity of the underlying cause.

Document references

1. Peters JM, Barnett AL, Henderson SE; Clumsiness, dyspraxia and developmental co-ordination disorder: how do health and educational professionals in the UK define the terms? Child Care Health Dev. 2001 Sep;27(5):399-412. [abstract]
2. Chawla J et al; Apraxia and Related Syndromes, eMedicine, Jan 2009
3. Landgren M, Kjellman B, Gillberg C; Attention deficit disorder with developmental coordination disorders. Arch Dis Child. 1998 Sep;79(3):207-12. [abstract]
4. Wilson PH; Practitioner review: approaches to assessment and treatment of children with DCD: J Child Psychol Psychiatry. 2005 Aug;46(8):806-23. [abstract]

Internet and further reading

• Wilms Floet AM et al; Motor Skills Disorder, eMedicine, Jan 2010
• Querne L, Berquin P, Vernier-Hauvette MP, et al; Dysfunction of the attentional brain network in children with Developmental Brain Res. 2008 Dec 9;1244:89-102. Epub 2008 Jul 29. [abstract]

Acknowledgements