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Introduction

Developmental Coordination Disorder (DCD) is a motor skills disorder that affects 5-9% of all children and their ability to perform activities of daily living (ADLs) including self care, academic tasks, and leisure activities. Children with DCD often appear “lazy” or “clumsy” in their attempts at ADLs due to delays in motor skill development or difficulties with coordinating movements. Over time, these children tend to participate in more sedentary activities with reduced physical activity and may suffer from poor self-esteem and sense of self-worth.

DCD is generally not well understood and is felt to be significantly under-recognized. Obtaining a diagnosis for DCD has historically been a challenge due to the vagueness of the diagnostic criteria. The main purpose of this document is to provide an evidence-informed approach on why and how to properly assess children with possible DCD.

Based on further interpretation of the European Academy of Childhood Disability Recommendations (EACD) and a review of the most current literature available, including the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), this paper reviews the updated diagnostic criteria and discusses the most up-to-date evidence related to best practices.

Background

Developmental Coordination Disorder (DCD) is a “common but under-recognized movement skill disorder that significantly affects children’s everyday functioning” (CanChild 2014). DCDdoes not have specific subtypes; however, children may have impairment in gross motor skills, fine motor skills, or both (Polatajko, 2006)). “Regardless of which skills are affected, motor performance is usually slower, less accurate, and more variable in children with DCD than in their peers” (Zwicker, Missiuna, Harris & Boyd, p. 574, 2012). DCD is more than just the lower end of typical development in motor skills (Polatajko, 1999); “the motor impairment significantly impacts daily life and is not due to a neurological disorder or delayed cognitive development” (Zwicker et al., p, 574, 2012). This condition consistently affects how a child learns and performs complex motor tasks and it affects activities such as self care, academic tasks, and leisure activities.DCD frequently co-occurs with other disorders such as Attention Deficit Hyperactivity Disorder (ADHD), speech language impairments, and learning disabilities.

Early identification of DCD is crucial for optimal outcomes in this population. “The consequences of developmental coordination disorder include reduced participation in team play and sports, poor self esteem and sense of self worth, emotional and behavioral problems, impaired academic achievement, poor physical fitness, and reduced physical activity and obesity” (American Psychiatric Association, p 76, 2013). The sooner strategies and adaptations can be provided the more likely the child will experience success.

DCDoccurs in 5-9% of the population (Slater, Hillier, Civetta, 2010). Although itsetiology remains unclear, cerebellar dysfunction, mirror neurons, and other neurological mechanisms are noted in the research. Children born with low birth weight (under 1000g) or premature(29weeks or less) are at a higher risk for DCD than their full-term peers. Males tend to be more affected than females by a ratio of 1.9:1.0 (Zwicker,Missiuna, Harris, Boyd, 2012). Despite itsfrequency, the general awareness of this condition within health professions, education, and other community service providers is still very poor. For example, a 2012 Alberta study showed that 23-41% of physicians indicated knowledge about DCD and,of those, only 11-59% were aware of the psychological and secondary consequences of the condition (Wilson, Ruddock, Smits-Engelsman, Polatajko & Blank, 2011).As a result, many children and their families struggle through life without a diagnosis, with a misdiagnosis, or with the wrong assumption that the condition will be outgrown (Zwicker et al., 2012).

DCD is a complex condition with a variety of factors to consider.The International Classification of Function (ICF) framework may be used to assess the impact of restrictions on day-to-day living and academic function of a child with DCD. A multidisciplinary team assessmentis required to address all areas of concern(Blank, Smits-Engelsman, Polatajko & Wilson, 2011).

A thorough history-taking “enables the mapping of consistent patterns of behavior and the impact of motor difficulties on everyday functioning” (Kirby, Sugden, Purcell, p. 294,2014).The assessment team may begin with history taking and questionnaires in order to gather information about a child’s strengths and challenges in different environments. Based on this information, the team may decide to proceed with supporting the criteria in the DSM-5 (see Appendix A for a Quick Reference Guide).

Literature Review and Recommendations

The following information is a breakdown of how each component of the DSM-5 criteria can be met in order to assist a pediatrician in making a formal diagnosis. Please note that a diagnosis of DCD should not be given in any age group if motor performance cannot be assessed by a motor test because of low intellectual function, attention, or a medical disorder(Blank et al., 2011).

See Appendix B for the complete DSM-5 description of DCD.

The team should consider the child and the environment when deciding which assessment tool to use in each category. There are other widely used tests (e.g. Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition) in practice; however, when considering recent literature, the EACD recommendations, and information from other sources, the tools listed below are considered best practice.

Motor Assessment (ages five and over)

  • Movement Assessment Battery for Children-2nd Edition (MABC-2)- measures the motor capability of children between the ages of 3 and 16 years
  • Includes qualitative descriptors of motor behavior and a behavioral checklist that looks at the influence of motivation and compliance on assessment results
  • “Should not be used in isolation for diagnosis or referral of children between 4 and 8 years of age, as it does not provide sufficiently detailed information about their motor performance” (Watter et al, p 348, 2008)
  • 15th percentile cutoff is recommended(Blank et al., 2011).
  • Domain specific DCD is possible(Blank et al., 2011) (e.g., if a child scores below the fifth percentile in fine motor tasks but performs above the 15th percentile on other domains, the child could be considered to have a domain specific DCD as long as the other criteria for diagnosis are met)
  • MABC-2 does not:
  • Consider restrictions in activity and participation (Watter et al.,2008)
  • Identify handwriting abilities (Geuze, Jongmans, Schoemaker, & Smits-Engelsman, 2001)
  • Identify kinesthetic abilities(Smyth & Mason, 1998)
  • Identify motor planning, bilateral integration, or sequencing abilities (High, Gough, Pennington, & Wright, 2000)

Printing Assessment

  • Children with DCD often have difficulty with fine motor skills affecting their ability to print and write, which adversely influences academic achievement (Blank et al., 2011).
  • McMaster Handwriting Assessment Protocol-2nd Edition
  • Comprehensive, functional examination of all aspects of printing and writing for children between Kindergarten and grade 6
  • Encourages evaluation of environment, postural control, endurance, attention and motivation, writing from memory, near and far point copying, dictation and composition, grasp, pressure, paper positioning, cursive, and speed
  • Provides grade expectations
  • Available on the CanChild (2014) website

Based on the deficits identified in the McMaster Handwriting Assessment Protocol – 2nd Edition, the following standardized tools can be used for further assessment.

  • Evaluation Tool of Children’s Handwriting (ETCH)
  • Criterion-referenced tool for evaluation of printing and cursive skills of children in grades 1-6
  • Evaluates legibility, pencil grasp, hand pressure, pencil pressure, and manipulative skills
  • Detailed Assessment of Speed of Handwriting (DASH)
  • For children between the ages of 9 and 17 years that exclusively measures speed of handwriting
  • DASH17+ is for people between the ages of 17 and 25 years
  • Handwriting fluency test for older children may be useful for diagnosing a writing disorder(Blank et al., 2011).

Gathering information from all of the child’s environments is crucial for satisfying Criterion B. Information can be obtained from:

  • Detailed child and parent interview
  • Observation of the child innatural environments
  • Parent, child, and teacher questionnaires described below:

Parent Questionnaires

  • Developmental Coordination Disorder Questionnaire-2007 (DCDQ-07) - designed to screen for coordination disorders in children aged 5 to 15 years (Wilson Crawford, 2007)
  • Examines postural control during movement, fine motor/handwriting, and general coordination
  • Three age groups with cutoff scores to help identify children with probable DCD (Wilson et al., 2009)
  • Strong correlations found with the Movement Assessment Battery for Children (MABC)(Cairney, Missiuna, Veldhuizen, & Wilson,2008)
  • Significant differences noted by gender (Rivard, Missiuna, Pollock, & Steyer-David, 2012)
  • Boys tend to have stronger gross motor skills while girls tend to develop better fine motor skills; therefore, girls could be under-identified and those identified may have more severe difficulties while boys may be over-identified (Rivard etal., 2012)
  • Movement Assessment Battery for Children-2nd Edition Checklist (MABC-2 Checklist) – focuses on how children aged 5 to 12 years manage everyday tasks at home and at school
  • Strongly correlates with the DCDQ-07 and the MABC-2 (Schoemaker, Niemeijer, Flapper, & Smits-Engelsman, 2012)
  • Teacher may need to provide some information
  • Vineland Adaptive Behavior Scale-2ndEdition (VABS-II) - measure of adaptive behaviors in individuals from birth to 90 years of age
  • Useful tool for measuring participation in self care, productivity, and leisure(Blank et al., 2011).
  • VABS-II is unnecessary if a psychologist has provided information from the Adaptive Behavior Assessment Scale-2nd Edition (ABAS-II)

Child Questionnaires

  • Children’s Self-Perceptions of Adequacy in and Predilection toward Physical Activity (CSAPPA) – for children between 9 and 16 years of age
  • DCDQ-07 and CSAPPA look at motor coordination issues from different perspectives

(i.e., parent vs. child) (Cairney et al., 2008)

  • Advantages of the CSAPPA (Cairney et al., 2007):
  • Can be administered to groups of children
  • Can be completed in approximately 15-20 minutes
  • Easy to score
  • Can be administered by teachers or researchers
  • Optimal cutoff scores for diagnosing DCD in males and females using the CSAPPA have been determined (Hay, Hawes, & Faught,2004)

Considerations:

  • Literature suggests that awareness of physical competence is a strength for young children (Damon Hart, 1982)
  • Children under the age of eight years tend to have difficulty with accurate self-evaluation (Rodger, Watter, Marinac, Woodyatt, & Ziviani, 2007)

Teacher Questionnaires

  • School Function Assessment (SFA) – measures level of participation, adaptation and assistance needed, as well as performance in the academic and social aspects of school
  • Evaluates individual and contextual factors and defines function by the outcome of the performance rather than by the methods used
  • Distinguishes between children who differ in functional tasks that require cognitive abilities versus those that require physical abilities
  • Wang, Tseng, Wilson, Hu(2009) concluded that children’s motor performance is not always consistent in different contexts, especially when there are differences in time pressures between home and school; in addition, “perceptions of parents as primary caregivers may be quite different from the judgment of teachers, who may value independence more than direct care…..children with DCD are a heterogeneous group, and those who have poor functional performance at home may not necessarily experience limitations at school, or vice versa”(p. 823).
  • Although the SFA has not been referenced specifically to the DCD population,there is a moderately high correlation between the related parts of the SFA and the VABS(Hwang, Davies, Taylor, & Gavin, 2002)
  • Motor Observation Questionnaire for Teachers (MOQ-T) – helps identify children in the 6-11 year old range with possible DCD
  • Evaluates qualitative descriptors of motor performance
  • Significantly correlateswith the DCDQ-07 andM-ABC (Schoemaker, Flapper, Reinders-Messelink, & de Kloet, 2008)
  • Teacher Estimation of Activity Form (TEAF) - measures a student’s general aptitude for and enjoyment of physical activity
  • Supports physical education teachers in differentiating between children with and without DCD
  • “The impacts of DCD do not limit themselves only to participation in physical activities but rather influence participation in other leisure activities, which is important to consider when planning for intervention” (Engel-Yeger, Hanna-Kassis,& Rosenblum, p. 1012, 2012)
  • Teachers were less likely to observe motor impairments in children with disruptive behavior (Rivard, Missiuna, Hanna, & Wishart, 2007)
  • Teachers assess motor skills differently depending on the type of motor task, reporting more concern for gross motor problems than fine motor problems (Rivard et al., 2007)

Academic Performance

Emerging evidence suggests that some children with deficits in manual dexterity may havecompromised academic achievement in school(Sartori, Lamp, Von Baranov, Goncalves, & Brauner, 2013).If the child is not functioning at grade level, further investigation of intellectual ability is warranted.

Theoretically, DCD is present from birth; however, it is not recommended that adiagnosis be given to children under the age of five due to wide variability in:

  • Stability of testing results for intellectual and motor functioning (Blank et al., 2011).
  • Motor development (Blank et at., 2011).
  • Cooperation and motivation(Blank et at., 2011).
  • Performance between environments
  • Performance from day to day

Early developmental milestones may develop spontaneously and may not be impacted or delayed. At school age, delays become more apparent with learned skills such as handwriting, kicking a ball, and independent dressing. When tasks require adaptation in speed, timing, force or distance of movement, delays become more observable. Deficits in the early developmental period are subtle yet apparent. Watch for the following (adapted from Missiuna, Rivard, & Barlett, 2003):

  • Awkward gait
  • Fixing joints
  • Slowness of movement
  • Frequent tripping
  • Bumping into others and obstacles
  • Restricted repertoire of play
  • Rigid and jerky movements
  • Fatiguing quickly
  • Heavy reliance on vision
  • Repeating motor tasks in the same way regardless of success
  • Inability to generalize skills across settings
  • Avoidance of motor tasks
  • Messy eating
  • Lack of independence in ADLs

The Peabody Developmental Motor Scale-2nd Edition (PDMS-2) is a good tool fordescribing and evaluating change over time of motor skills in young children under the age of 72 months (Rivard, Missiuna, Pollock, & Steyer-David, 2012).

Considerations for Criterion C:

  • Although developmental milestones are not necessarily delayed in children with DCD, the quality of the movement may be impacted and should be observed

A comprehensive physical assessment should be completed by all professionals involved in order to rule out other possible causes of motor difficulties (Adah, 2011, Callanen, 2012).

Intellectual Function

If the child is not functioning at grade level, further investigation of intellectual ability is warranted.

Academic achievement can be evaluated by a psychologist or a teacher (level B trained) using an assessment of learning such as the Wechsler Individual Achievement Test-3rd Edition (WIAT-III).

  • Emerging evidence of a cognitive profile specific to DCD includesdeficits in processing speed, perceptual reasoning, language, attention, working memory, and executive function (Biotteau, Albaret, Lelong, & Chaix, 2013).

Cognitive function can be measured by a psychologist using the Wechsler Intelligence Scale for Children – 4th Edition (WISC-IV)or screened by a trained rehabilitation professional using the Kaufmann Brief Intelligence Test – 2nd edition (KBIT-2).

  • KBIT-2:
  • Estimates a child’s verbal versus nonverbal intelligence and can be helpful in identifying children who require a more comprehensive evaluation
  • Neither the WIAT-III nor the KBIT-2 identify memory or processing speed deficits which are integral to determining a full scale IQ
  • The authors of the KBIT-2 also caution againstusing the screen for labeling and placement based on the IQ standard score and when using the KBIT-2as the only IQ measurement in a reading disability evaluation (Chin et al., 2001).

In the past, children scoring less than 70 on IQ testing were excluded from a diagnosis of DCD. However, if the motor impairment fits the criteria for DCD and the history and examination preclude any other cause for a motor impairment, then a DCD diagnosis should be given(Blank et al., 2011). Since these recommendations, preliminary research has emerged that provides parameters to guide reasoning to determine the point at which motor difficulties are in excess of those usually associated with cognitive deficits: “for each standard deviation lower IQ, a mean loss of 10 percentile motor points would be expected“(Smits-Engelsman Hill, p. 954, 2013). The confidence interval is wide and must be taken into account (Figure 1).This Smits-Engelsman and Hill study applies to children with an intellectual disability and an IQ of <80.

Figure 1. Relationship between motor percentile and IQ scores: expected motor percentile score based on 10-point IQ bands (n = 460) (From: Smits-Engelsman & Hill, p 954, 2013)

Visual Function

The DSM-5 (American Psychiatric Association, 2013) indicates that visual impairments must be ruled out as a cause of motor skill deficits. Prior to assessing for DCD, both visual acuity and ocular motor skills need to be screenedby trained therapists (Coetzee & Pienaar, 2013, Piquette & Boulet 2013,). Screening includes:

  • Horizontal and vertical pursuits
  • “Vertical pursuits are significantly impaired relative to children without DCD” (Robert et al., p 597, 2014)
  • Saccades
  • Convergence
  • Suppression
  • “significant strabismus was three times more common in severe DCD than in typically developing children” (Creavin, Lingam, Northstone and Williams, p 166, 2014)
  • Ocular mobility

These results should be report to the pediatrician and included in a referral to anoptometrist for a comprehensive evaluation.

Neurological Status

Evidence is emerging that indicates thatneurological soft signs (NSS) may provide insight into achild’s neurological condition. Van Hoorn, Maathuis, Peters, Lieke, Hadders-Algra, 2010found a strong correlation between impaired handwriting, visual-motor integration, and NSS. The Quick Neurological Screening Test – 3rd Edition (QNST-3)is a screening tool of NSS that looks at how a person plans and executes motor movements.