4/7/2014 Developmental Coordination Disorder

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Developmental Coordination Disorder

Author: Stephen L Nelson Jr, MD, PhD; Chief Editor: Caroly Pataki, MD more...

Updated: Aug 31, 2013

Practice Essentials
Although a variety of labels have been used to describe movement clumsiness in children, the term developmental
coordination disorder (DCD) has found increasing acceptance. Genetic, intrauterine, and environmental factors
may contribute to poor abilities in motor functioning.

Essential update: New guidelines for spotting and evaluating motor delays in children

In May 2013, the Council on Children with Disabilities published guidance on the early identification and evaluation
of motor delays in children, which include formal developmental screening of children for possible motor delays and
variations in muscle tone at their 9-, 18-, 30-, and 48-month well-child visits.[1, 2]

The Council advises that pediatricians not only should watch how children perform requested tasks but also should
pay close attention to general posture, play, and spontaneous motor functions.[2] Muscle tone deficiencies may
also indicate neuromotor delays from disorders such as cerebral palsy.

The Council notes that MRI scans can be ordered for children with heightened muscle tone and advises that serum
creatine kinase concentrations should be measured in those with decreased muscle tone.[2] These studies can be
performed when children are referred to specialists for diagnosis.

Signs and symptoms

In infants, manifestations of difficulties in motor functioning are as follows:

Hypertonic or hypotonic appearance

Strongly reacting to any slight auditory or visual stimulation by becoming stiff or by arching the back (ie,
hypertonicity and hyperreactivity)
In a newborn, lying in a frog-leg posture suggests hypotonicity
After around age 4 months, persisting head-lag when pulled to a sitting position or inability to place the
body in extension when suspended in a horizontal posture indicates hypotonicity
After age 6 months, inability to sustain his or her weight when supported under the arms and thus tending
to slip through the supporters grasp signals hypotonicity
Parents may report that their baby is strong (ie, the muscles appear hard and tense)
Persistence of several primitive reflexes (eg, Moro, plantar, or rooting reflex) after age 6-7 months
Appearing almost ready to walk at a few months of life
Moving as an entire unit without correcting the angle of the head toward the vertical line when held sideways
Delay in achieving milestones such as the ability to roll over, to sit with help, and to sit without help
Persistence of a positive Babinski sign after age 10-12 months
Persistence of crossed-adductor reflexes and clonus at the ankles after the neonatal period

During the second and third years of life, manifestations of difficulties in motor functioning are as follows:

Refusal of solid foods, or repeatedly choking on chewed food

Attempting to pick up small objects from a flat surface using a palmar grasp rather than a pincer grasp
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Inability to walk by age 18 months (however, most of these children are healthy)

In preschool- and school-aged children, manifestations of difficulties in motor functioning are as follows:

Difficulty with hopping or jumping

Lack of a hand preference or dominance by age 4-5 years or early development of a hand preference
Difficulty with maturation of ability to grasp a pen, pencil, or crayon (eg, moving the entire upper limb to
write, or reporting pain after a few minutes of drawing or writing)

Easily performed tests to observe tasks and abilities include the following:

Tests for sustaining a position against gravity - Observation of muscle tone in sitting and standing positions
Test for motor sequencing - Touching the thumb against the other fingers of that hand in sequence, one
after the other
Nose-finger test (measures fine motor coordination, proprioception, and perception of movements in space)
Moving a limb against resistance (feet, legs, thighs, arms, forearms, hand)
Test of energy investment in a movement (eg, development of fatigue with sustained testing)
Test of the ability to perceive spatial relationships
Test of fine motor tasks - Activities such as coloring, drawing, building with blocks, or playing with miniature
toys

Abnormalities that may be noted during such tests include the following:

Fine tremors of the fingers with sustained use of the hand

Persistence of overflow (performing a similar movement with the opposite side of the body, referred to as
mirror movements) after age 7-8 years
Adventitious movements (eg, grimacing, sticking the tongue out, or tics) when a fine or difficult motion is
attempted

After motor difficulties are detected, investigating other areas (eg, visuomotor coordination) and testing for other
soft neurologic signs, attention span, writing, and reading may be necessary.

See Presentation for more detail.

Diagnosis

DCD has 4 diagnostic criteria, as follows:

Acquisition and execution of coordinated motor skills are below what would be expected at a given
chronologic age and opportunity for skill learning and use; difficulties are manifested as clumsiness and as
slowness and inaccuracy of performance of motor skills
The motor skills deficit significantly or persistently interferes with activities of daily living appropriate to the
chronologic age 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

Recommendations regarding laboratory and imaging studies are as follows:

No specific laboratory tests for motor skills disorder exist; however, male children should have a creatine
kinase (CK) level checked to evaluate for Duchenne muscular dystrophy
Comorbid conditions (eg, high lead levels, anemia, iron deficiency, hypothyroidism) should be ruled out
No imaging studies are typically used if the child has otherwise normal neurologic examination findings and
no clinical indications of an underlying structural or medical/metabolic etiology

Evaluation approaches include the following:

Normative functional skills approach

General abilities approach
Neurodevelopmental approach
Dynamic systems approach
Cognitive neuroscience approach

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The normative functional skills approach draws from traditional developmental theory. The most commonly used
tests of motor impairment in this approach are as follows:

Movement Assessment Battery for Children (MABC or M-ABC)

Bruininks-Oseretsky Test of Motor Proficiency (BOTMP)
Test for Gross Motor Development (TGMD-2)

The general abilities approach is based on the assumption that sensory-integrative and sensorimotor functions
provide the platform for later motor and intellectual development. The most commonly used test is the Sensory
Integration and Praxis Tests (SIPT); however, less than 50% of the SIPT is related to motor function.

The neurodevelopmental evaluation includes both a general and neurologic examination, along with an assessment
that focuses on subtle deficits in neural functioning. Test batteries include the following:

Touwen test for children with minor neurologic dysfunction (normative data are lacking)
Physical and Neurological Examination for Soft Signs (PANESS)[3] (normative data are lacking)

The dynamic systems approach is based on the dynamics between perception and movement; it uses
biomechanical or kinematic analysis of movement and emphasizes the importance of assessing contextual factors
that contribute to or limit skill acquisition.

The cognitive neuroscience approach provides a framework that accounts for the development of motor skills in
terms of brain-behavior interactions. Hypotheses generated with this framework include the following:

Motor imaging pathways in the parietal lobe and premotor cortex

Motor timing
Linking deficits of time perception
Sequential tapping to possible deficits in the cerebellum

See Workup for more detail.

Management

No single type of treatment can be applied to all children with motor coordination disorder. Two general treatment
approaches are used, as follows:

Modular (top-down; task-oriented)

Relatively global or generalized approach (bottom-up; process-oriented or deficit-oriented)

The modular approach has the following characteristics:

Attempts to remedy or improve the specific difficulty (or difficulties) with specific techniques aimed at
improving the motor challenge that is observed (eg, difficulty with handwriting, catching a ball, performing
fine motor tasks with fingers)
Usually involves gradually targeting certain problem behaviors and implementing step-by-step interventions
to teach the skill and to practice it
Tends to prevent failure and rewards the child, at least in the beginning
Lends itself to implementation by schoolteachers
A core element is practice (eg, prescribed practice of new skills and small steps toward mastery of the skill
with success at every small increment)

The relatively global or generalized approach has the following characteristics:

Is based on the theoretical assumption that the motor skills problem is a manifestation of some underlying
mechanism (eg, sensory integration problems or insufficient or inaccurate kinesthetic perceptions)
Instead of initially addressing the observable motor challenge, the therapist focuses on how children
manage their bodies, process stimulation, and deal with problems
The expectation is that the improved sensory-motor functioning becomes generalized and eventually
improves the motor skills
Examples include the kinesthetic training approach, sensorimotor integration therapy, and sensory
integration therapy
As with many other forms of intervention and therapy, evidence of the efficacy of these methods is limited,
particularly over the long term or regarding the end result

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Specific therapies employed include the following:

Cognitive motor intervention

Sensory integration therapy
Kinesthetic training
Neurodevelopmental treatment
Craniosacral therapy
Osteopathic/chiropractic therapy
Visual training

See Treatment and Medication for more detail.

Contributor Information and Disclosures

Author
Stephen L Nelson Jr, MD, PhD Assistant Professor of Pediatrics, Neurology and Psychiatry, Uniformed
Services University of the Health Sciences, F Edward Hebert School of Medicine; Attending Physician,
Pediatric Emergency Medicine, Sinai Hospital and Shady Grove Hospital; Assistant Professor of Pediatrics and
Neurology, Tulane School of Medicine

Stephen L Nelson Jr, MD, PhD is a member of the following medical societies: Academic Pediatric
Association, American Academy of Neurology, American Academy of Pediatrics, American Medical
Association, Association of Military Surgeons of the US, and Child Neurology Society

Disclosure: Nothing to disclose.

Coauthor(s)
Jennifer L Jaskiewicz, DO Resident Physician, Department of Pediatrics, Walter Reed Army Medical Center

Jennifer L Jaskiewicz, DO is a member of the following medical societies: American Academy of Pediatrics and
American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor
Caroly Pataki, MD Clinical Professor of Psychiatry and Pediatrics, Keck School of Medicine of the University
of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent
Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors
Chet Johnson, MD Professor and Chair of Pediatrics, Associate Director, Developmental Pediatrician, Center
for Child Health and Development, Shiefelbusch Institute for Life Span Studies, University of Kansas School of
Medicine; LEND Director, University of Kansas Medical Center

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

J Martin Maldonado-Durn, MD Principal Investigator for Child and Family Center, Department of Psychiatry,
Child and Adolescent Division, Family Service and Guidance Center

J Martin Maldonado-Durn, MD is a member of the following medical societies: Kansas Medical Society

Disclosure: Nothing to disclose.

Anna Maria Wilms Floet, MD Assistant Professor of Behavioral and Developmental Pediatrics, Department of
Pediatrics, University of Maryland School of Medicine

Anna Maria Wilms Floet, MD is a member of the following medical societies: American Academy of Pediatrics
and Society for Developmental and Behavioral Pediatrics

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Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References

1. Henderson D. Guidance for Identifying Motor Delays in Children. Available at

http://www.medscape.com/viewarticle/804990. Accessed June 4, 2013.

2. Noritz GH, Murphy NA. Motor delays: early identification and evaluation. Pediatrics. Jun
2013;131(6):e2016-27. [Medline].

3. Touwen BCL. Examination of the child. Cambridge Univeristy Press; 1984.

4. American Psychiatric Association. American Psychiatric Association: Diagnostic and Statistical Manual
of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

5. American Psychiatric Association. DSM-IV-TR. Diagnostic and Statistical Manual of Mental Disorders.
4th ed. Washington, DC: American Psychiatric Association; 2000:1965-71.

6. Fox AM, Lent B. Clumsy children. Primer on developmental coordination disorder. Can Fam Physician.
Oct 1996;42:1965-71. [Medline].

7. Bax M, Goldstein M, Rosenbaum P, et al. Proposed definition and classification of cerebral palsy, April
2005. Dev Med Child Neurol. Aug 2005;47(8):571-6. [Medline].

8. Baxter P. CP or not CP?. Dev Med Child Neurol. Aug 2005;47(8):507. [Medline].

9. Ayres J. Sensory Integration and the Child. Los Angeles, Calif: Western Psychological Services; 1979:55-
67.

10. Piek JP, Edwards K. The identification of children with developmental coordination disorder by class and
physical education teachers. Br J Educ Psychol. Mar 1997;67 ( Pt 1):55-67. [Medline].

11. Ferrari F, Gallo C, Pugliese M, et al. Preterm birth and developmental problems in the preschool age. Part
I: minor motor problems. J Matern Fetal Neonatal Med. Jun 19 2012;[Medline].

12. Edwards J, Berube M, Erlandson K, et al. Developmental coordination disorder in school-aged children
born very preterm and/or at very low birth weight: a systematic review. J Dev Behav Pediatr. Nov
2011;32(9):678-87. [Medline].

13. Lingam R, Hunt L, Golding J, Jongmans M, Emond A. Prevalence of developmental coordination disorder
using the DSM-IV at 7 years of age: a UK population-based study. Pediatrics. Apr 2009;123(4):e693-700.
[Medline].

14. Martins I, Lauterbach M, Slade P, et al. A longitudinal study of neurological soft signs from late childhood
into early adulthood. Dev Med Child Neurol. Aug 2008;50(8):602-7. [Medline].

15. Fliers E, Vermeulen S, Rijsdijk F, et al. ADHD and poor motor performance from a family genetic
perspective. J Am Acad Child Adolesc Psychiatry. Jan 2009;48(1):25-34. [Medline].

16. Fliers EA, Vasquez AA, Poelmans G, et al. Genome-wide association study of motor coordination
problems in ADHD identifies genes for brain and muscle function. World J Biol Psychiatry. Mar
2012;13(3):211-22. [Medline].

17. Kadesjo B, Gillberg C. Attention deficits and clumsiness in Swedish 7-year-old children. Dev Med Child
Neurol. Dec 1998;40(12):796-804. [Medline].

18. Wright HC, Sugden DA. A two-step procedure for the identification of children with developmental co-
ordination disorder in Singapore. Dev Med Child Neurol. Dec 1996;38(12):1099-105. [Medline].

19. Cantell MH, Smyth MM, Ahonen TP. Two distinct pathways for developmental coordination disorder:
http://emedicine.medscape.com/article/915251-overview 5/7
4/7/2014 Developmental Coordination Disorder

persistence and resolution. Hum Mov Sci. Nov 2003;22(4-5):413-31. [Medline].

20. Losse A, Henderson SE, Elliman D, et al. Clumsiness in children--do they grow out of it? A 10-year
follow-up study. Dev Med Child Neurol. Jan 1991;33(1):55-68. [Medline].

21. Cousins M, Smyth MM. Developmental coordination impairments in adulthood. Hum Mov Sci. Nov
2003;22(4-5):433-59. [Medline].

22. Lingam R, Golding J, Jongmans MJ, Hunt LP, Ellis M, Emond A. The association between developmental
coordination disorder and other developmental traits. Pediatrics. Nov 2010;126(5):e1109-18. [Medline].

23. Kastner J, Petermann F. [Developmental coordination disorder: relations between deficits in movement
and cognition]. Klin Padiatr. Jan-Feb 2010;222(1):26-34. [Medline].

24. Bax M, Hart H, Jenkins SM. Developmental disorders. In: Child Development, Child Health. Blackwell
Scientific; 1990:106-48, 229-68.

25. Gillberg C, Kadesjo B. Why bother about clumsiness? The implications of having developmental
coordination disorder (DCD). Neural Plast. 2003;10(1-2):59-68. [Medline]. [Full Text].

26. Kopp S, Beckung E, Gillberg C. Developmental coordination disorder and other motor control problems in
girls with autism spectrum disorder and/or attention-deficit/hyperactivity disorder. Res Dev Disabil. Mar-
Apr 2010;31(2):350-61. [Medline].

27. Wang TN, Tseng MH, Wilson BN, Hu FC. Functional performance of children with developmental
coordination disorder at home and at school. Dev Med Child Neurol. Oct 2009;51(10):817-25. [Medline].

28. Cairney J, Hay JA, Veldhuizen S, Missiuna C, Faught BE. Developmental coordination disorder, sex, and
activity deficit over time: a longitudinal analysis of participation trajectories in children with and without
coordination difficulties. Dev Med Child Neurol. Mar 2010;52(3):e67-72. [Medline].

29. Cairney J, Veldhuizen S, Szatmari P. Motor coordination and emotional-behavioral problems in children.
Curr Opin Psychiatry. Jul 2010;23(4):324-9. [Medline].

30. Chirico D, O'Leary D, Cairney J, et al. Longitudinal assessment of left ventricular structure and function in
adolescents with developmental coordination disorder. Res Dev Disabil. Mar-Apr 2012;33(2):717-25.
[Medline].

31. Coverdale NS, O'Leary DD, Faught BE, et al. Baroreflex sensitivity is reduced in adolescents with
probable developmental coordination disorder. Res Dev Disabil. Jan-Feb 2012;33(1):251-7. [Medline].

32. Li YC, Wu SK, Cairney J, Hsieh CY. Motor coordination and health-related physical fitness of children
with developmental coordination disorder: a three-year follow-up study. Res Dev Disabil. Nov-Dec
2011;32(6):2993-3002. [Medline].

33. Cairney J, Kwan MY, Hay JA, Faught BE. Developmental Coordination Disorder, gender, and body
weight: examining the impact of participation in active play. Res Dev Disabil. Sep-Oct 2012;33(5):1566-
73. [Medline].

34. Lingam R, Jongmans MJ, Ellis M, et al. Mental health difficulties in children with developmental
coordination disorder. Pediatrics. Apr 2012;129(4):e882-91. [Medline].

35. Pieters S, Desoete A, Van Waelvelde H, Vanderswalmen R, Roeyers H. Mathematical problems in

children with developmental coordination disorder. Res Dev Disabil. Jul-Aug 2012;33(4):1128-35.
[Medline].

36. Shevell M, Ashwal S, Donley D, et al. Practice parameter: evaluation of the child with global
developmental delay: report of the Quality Standards Subcommittee of the American Academy of
Neurology and The Practice Committee of the Child Neurology Society. Neurology. Feb 11
2003;60(3):367-80. [Medline].

37. Zwicker JG, Missiuna C, Harris SR, Boyd LA. Developmental coordination disorder: a pilot diffusion tensor
imaging study. Pediatr Neurol. Mar 2012;46(3):162-7. [Medline].

38. Smits-Engelsman BC, Niemeijer AS, van Waelvelde H. Is the Movement Assessment Battery for
Children-2nd edition a reliable instrument to measure motor performance in 3 year old children?. Res Dev
http://emedicine.medscape.com/article/915251-overview 6/7
4/7/2014 Developmental Coordination Disorder

Disabil. Jul-Aug 2011;32(4):1370-7. [Medline].

39. Peters LH, Maathuis KG, Kouw E, Hamming M, Hadders-Algra M. Test-retest, inter-assessor and intra-
assessor reliability of the modified Touwen examination. Eur J Paediatr Neurol. Jul 2008;12(4):328-33.
[Medline].

40. Blank R, Smits-Engelsman B, Polatajko H, Wilson P. European Academy for Childhood Disability
(EACD): recommendations on the definition, diagnosis and intervention of developmental coordination
disorder (long version). Dev Med Child Neurol. Jan 2012;54(1):54-93. [Medline].

41. Zimmer M, Desch L. Sensory integration therapies for children with developmental and behavioral
disorders. Pediatrics. Jun 2012;129(6):1186-9. [Medline].

42. Laszlo JL, Bairstow PJ. Perceptual-Motor Behavior: Developmental Assessment and Therapy. Austin, Tx:
Holt, Rinehart and Winston; 1985.

43. Cuthbert SC, Barras M. Developmental delay syndromes: psychometric testing before and after
chiropractic treatment of 157 children. J Manipulative Physiol Ther. Oct 2009;32(8):660-9. [Medline].

44. Learning disabilities, dyslexia, and vision: a subject review. Committee on Children with Disabilities,
American Academy of Pediatrics (AAP) and American Academy of Ophthalmology (AAO), American
Association for Pediatric Ophthalmology and Strabismus (AAPOS). Pediatrics. Nov 1998;102(5):1217-9.
[Medline].

Medscape Reference 2011 WebMD, LLC

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