Dyspraxia and Apraxia

Individuals who are clumsy, whose handwriting is significantly impaired, or who exhibit other major weaknesses in motor and coordination skills are now generally diagnosed as having developmental coordination disorder - DCD (also called dyspraxia, and previously and inappropriately known as clumsiness syndrome¹). Dyspraxia has been used to describe difficulty with certain complex voluntary actions and complete loss of function is known as apraxia.
In the UK, the term dyspraxia has often been used as an umbrella term for children with coordination difficulties but occupational therapists in the UK have used the term dyspraxia to refer specifically to deficits in motor planning accompanied by perceptual problems, and not to mean more general coordination difficulties.
The integrity of primary motor function is maintained but patients are unable to perform certain action sequences under particular conditions. Component actions may be unaffected but complete sequence is impaired. The underlying cause of motor coordination difficulties is unknown.

• DCD is a common condition, present in about 5-10% of school-age children
• More common in boys than girls.
• More common in children with a history of premature birth

• A marked impairment in the development of motor coordination
• The diagnosis is made only if this impairment significantly interferes with academic achievement or activities of daily living
• The diagnosis is made if the coordination difficulties are not due to a general medical condition, e.g., cerebral palsy, hemiplegia or muscular dystrophy, and the criteria are not met for pervasive developmental disorder
• If mental retardation is present, the motor difficulties are in excess of those usually associated with it

Classified by 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 real object may be unimpaired.
• Constructional dyspraxia: inability to build simple construction or copy a drawing. Mostly caused by non-dominant hemisphere lesions.
• Dressing dyspraxia: inability to dress due to impaired sense of clothes orientation and sequence (non-dominant 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 is very variable in terms of severity. There may be a history of delay in achieving moter development milestones. There may be a slowness and hesitancy with actions. Difficulties may be first identified by parents or at school. Particular difficulties include:

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

• Any child with concerns of developmental coordination disorder should be assessed by a paediatrician in order to consider possible specific causes and to initiate a multi-disciplinary management plan.
• The child may first be identified as having difficulties by the school 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.

• Neuromuscular or hypotonic problem, and/or a myotonic, myopathic or connective tissue disorder.
• Degenerative condition or a storage disorder.
• Ligamentous laxity may be a variant or a mild form of Ehlers-Danlos syndrome
• Some affected children have neuromas or cafT au lait spots, and may have a variant of neurofibromatosis (NF1).

• Ask patient to mime - using an object e.g. hairbrush; action sequence, e.g. folding and sealing a letter; symbolic action such as waving.
• Ask patient to alternate flat hand and fist with both hands.

• Often coexists with poor attention span and concentration
• Dyslexia, dyscalculia
• Attention deficit hyperactivity disorder
• Asperger's syndrome
• Tactile defensiveness - over-sensitive to touch
• Other learning disorders

• May involve occupational therapists, physiotherapists and educational psychologists. The key is a coordinated approach between parents, 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, such as adapted scissors, use of a computer instead of handwriting, organizational 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

• Motor problems of children with 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.