Introduction to the day
Dyscovery Centre copyright 2009/10 Professor Amanda Kirby Not to be copied without permission
Aims of day 1 Introduce what DCD is Overlap with other developmental disorders Background to motor development/motor impairment How it presents in differing ages Assessment Profiling the whole child Case discussion
Aims of day 2 Recap on day 1 Assessment Intervention approaches Theory Practice
Review of the 2 days Glass of wine!
What is DCD? What is it not? Terminology
Sam He is 9 years old Sam walked at 19 months, talked indistinctly at 2 1/2 years of age, very fidgety and hyperactive when 4 years of age. Difficulty copying from the board He has an older brother who is in the hurling team locally. Sam does not like to play. He has fewer friends than his brother. His writing looks like this:
What could be going on here?
Developmental Coordination Disorder Historical journey DSM IV Criteria- why –because we have to have some consistency Co-morbidity-particularly with other developmental disorders Why is it an issue? Here and now.
DCD Incidence- depends how you measure it-if you use guidelines for MABC you will get 5%!!! Normal way in many other disorders is to take 2 SDs. Age effect- most studies 6-12. So what are they 3-5 and what are they post school age. Loads of potential for work. Bridgend work.
Definitions and confusions
Diagnostic criteria for Developmental Coordination Disorder (APA, 2000) A. Performance in daily activities that require motor coordination is substantially below that expected given the person’s chronological age and measured intelligence. This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling, and sitting), dropping things, “clumsiness”, poor performance in sports, or poor handwriting. B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living. C. The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet criteria for a Pervasive Developmental Disorder. D. If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it.
ICD10 also used
Dyspraxia Developmental dyspraxia is an impairment or immaturity of the organisation of movement. It is an immaturity in the way that the brain processes information, which results in messages not being properly or fully transmitted. The term dyspraxia comes from the word praxis, which means 'doing, acting'. Dyspraxia affects the planning of what to do and how to do it. It is associated with problems of perception, language and thought. Dyspraxia Foundation
“The term dyspraxic has been used to children demonstrating motor problems not due to documented basic motor impairment such as cerebral palsy”
Dewey, 1995
DCD has also been called... “Awkward” - “in the wrong way” derived from “awke” or wrong -from an Old Norse term “öfugr” meaning backward 1949-MBD 1963-“minimal cerebral palsy”; “minimal cerebral dysfunction” (Bax & MacKeith) 1965- perceptual-motor dysfunction (Ayres) 1967-visuo-motor disability in school children ( Brenner) 1968/70 -Clumsy child syndrome ( Illingworth) 1975- Developmental apraxia ( Gubbay) 1982- Developmental dyspraxia ( Denckla)
MBD
ADHD has also been called similar names.. 1940 Minimal Brain Syndrome 1957 Hyperkinetic Impulse Disorder 1960 Minimal Brain Dysfunction (MBD)
MBD Strauss and Lehtinen in 1947- minimal brain
damage
“a child who before, during, or after birth has received an injury to or suffered an infection of the brain. As a result of such organic impairment, defects of the neuromotor system may be present or absent; however, such a child may show disturbances in perception, thinking, and emotional behavior, either separately or in combination. Theses disturbances can be demonstrated by specific tests. These disturbances prevent or impede a normal learning process. Special educational methods have been devised to remedy
Atypical Brain Development (ABD) Common, underlying neurocognitive cause for the problems children face, or a mechanism explaining the specific but common effects on particular aspects of information processing (Hill, 2001; Kaplan et al., 1998).
Annell (1949) was said to describe the clumsy child as being:
“awkward in movements, poor at games, hopeless in dancing and gymnastics, a bad writer and defective in concentration. He is inattentive, cannot sit still, leaves his shoelaces untied, does buttons wrongly, bumps into furniture, breaks glassware, slips off his chair, kicks his legs against the desk, and perhaps reads badly”
So DCD is: A movement disorder affecting children in more than one setting Pervasive and enduring Developmental Has multiple causes
What are the reasons for poor movement?
Turn to your colleague and write down as many reasons as you can
Other Factors Genetic- Klinefelters, NF1, Downs Cerebral palsy/Muscular Dystrophy Hypermobility Epilepsy and BECTS Environmental- FAS,rough ground Visual
What is associated with DCD?
Pregnancy and childbirth No differences in labour length, Cx Smoking in pregnancy- higher rates
Developmental delay/disorder Out of 98 children with DCD 63.3% talked by the age of 2 years 64% had received speech therapy 31% had 3 or more ear infections per year 10% hearing difficulties 17% major medical problem
Delay Mean age to ride a bike- 80 months To do up buttons-80 months Tie shoe laces- 109 months
Difficulties 56% had been statemented 30% reading 52% spelling 84% takes longer than others to do written work 71% needs instructions repeated before they are able to understand 57% difficulties remembering times tables 76% difficulty planning and writing school work
Health 54% Temper tantrums 52% eating difficulties 73% Faddy eater 61% not eating enough 62% eating too much
55% sleep problems 72% getting off to sleep 78% waking in the night
Health 32% stomach aches 10% soiling pants
What is associated with/overlaps?
What is overlap?
• If definitions alter then overlap may be different • By presentation- depends on age and external demands • If you don’t look for it, how do you know it’s not there? • In time- changing presentation may be because of practice and /or intervention • Overlap in family functioning • What are adults left with... The bits of overlap or the motor bits?
Is co-morbidity the appropriate term? Co-morbidity-The presence of coexisting or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. This is 2 or more “ diseases” with separate and different aetiologies. (Perin & Last, 1995), which can present simultaneously or sequentially
Alternative terms • Co-occurrence-accompaniment: an event or situation that happens at the same time as or in connection with another (can have a causal relationships) • Associated-related to or accompanying • Co-existing-existing at the same time • Overlap- coincide partially or wholly
Routes into services Parent/teacher has a concern
Reading Spelling
Motor delay Social Writing communication Self care
Attention/ Negative behaviours
Recognition and Diagnosis • May be dependent on GP/teacher/parent knowledge • Service provision • Age of the child • Waiting lists • Referral routes • External pressures... Exams, jobs, entry into college
Child A
HEALTH 3y 7m, HV
18m, P
Education
4y, P
4y, SLT 4y, EP
4y, SEN
4y, OT 5y, OT
5y, SLT
7y, SLT
6y, GP 6y, EP
8y, SLT 8y, EP
8y, SLT 9y, EP
7y, Physio
7y, P
6y, EP
4y, OT
8y, SLT
7y, CP
7y, OT
7y SLT 8y, SEN Tribunal 8y, OT 8y, OT
9y, SLT (Feeding) 10y, OT 10y, EP
9y, Physio 10y, OT
Children may present in a variety of ways
• • • • • • • • • •
Delayed speech Fidgety Withdrawn Refusing to write Avoiding reading Delayed walking Failing at school ‘odd gait’ Parent has DCD Poor organisation and time management
Our interpretation of each of these behaviours may be different
We try to sort the symptoms and signs into boxes and label them up so they can be better understood
DA M
Dy sle
xi a a r p s y D
D H AD
P
xia
PDDNOS
e m o r d n y S s ' r e g r e p s ODD A
DCD
Specific language impairment
Conduct disorder
Pragmatic language impairment
Diagnosis dependent on presenting symptoms
The diagnosis a child gets May also be dependent on the door he goes through
80 70 60 50 40 30 20 10 0
Kirby & Salmon, 2006
DCD Dyspraxia
A
cc ur at e
DAMP
In ac cu P ra ar te t ia ll y ac cu ra te
D on ’t
kn ow
%
Child and adolescent Psychiatrists defining DCD/Dyspraxia/DAMP 90
%
OTs’ definition of ADHD
100 90 80 70 60 50 40 30 20 10 0
Accurate description
Partially accurate description
Baudinette & Kirby,2008
Inaccurate description
No response
Teachers (n=105)
100%
GPs (n=105)
80% 60% 40% 20% 0% Aspergers
ADD
Dyspraxia
Dyslexia
DCD
DAMP
Kirby et al, 2004, BJSE
Models of disability Medical model Need to have 'it' to get 'it Issues of who to diagnose Being “ treated”.. Correcting the problems
Social model Environment (including “ us” )enables the individual to meet their potential
The Dyscovery Centre copyright 2008
Movement ABC-1 less than 5% DCD + ADHD-C
DCD+ADHD-in
Ab In
Ab Hi
Ab ASSQ
Total SDQ
SDQ Impact
SDQ Hyperactivity
SDQ Peer
SDQ Conduct
SDQ Emotion
SDQ Prosocial
MABC percentile
<1
2
1
Manual Dexterity score
10.5
12
5
4
Ball skills score
ALL HAVE DCD DCD only
2
1
<1
<1
2
1
2
2
11
Unknown
3
15
11
9
13
13
9
8
Unknown
9
9
7
0
4
0
3
Overlap is the rule rather than the exception .. for example As many as 65% of children with ADHD will have one or more co-morbid psychiatric or other disorders (Beiderman et al, 1991).
Start from any point , you will end up seeing an overlapping picture
*
* *
* Sig difference p< 0.01
TOTAL SCORE
Co-occurring Disorders in Children (n=579) ADHD alone 31%
Tics 11%
Conduct Disorder 14% Mood Disorders 4%
Oppositional Defiant Disorder 40% Anxiety Disorder 34% MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096
ADHD + Asperger’s
21% of children with severe ADHD met criteria for Asperger’s syndrome 36% showed ‘autistic traits’
(Fitzgerald and Corvin, 2001)
ADHD +dyslexia and maths Approximately 33% of children with ADHD have been noted to have specific problems in spelling, reading and mathematics, unaccounted for by low intelligence (Szatmari et al, 1989).
ADHD and social difficulties
Many children with ADHD have social difficulties and difficulties with communication About 20% described as socially disabled (Greene et al, 1996, 2001), met full criteria for Asperger’s syndrome and 36% of children with ADHD showed ‘autistic traits’ (Fitzgerald and Corvin, 2001)
Asperger’s + ADHD More than 50% of adolescents with Asperger’s showed moderate to severe symptoms of inattention and hyperactivity (Lecavalier ,2006,Fombonne et al ,2001)
Behaviour + Language
Children with poor understanding have more behavioural difficulties Children with difficulty expressing themselvesmore socially withdrawn and anxious
Summary by the Centre for Integrated Healthcare Research, 2006
14 children in a PRU Diagnostic category
Number of students identified
Dyslexia
4
Developmental Coordination Disorder
0
Joint Hypermobility Syndrome
2
Attention Deficit Hyperactivity Disorder
2
Autistic Spectrum Disorder
1
Moderate Learning Disability
5
Conduct Disorder
1
Language Disorder
8
Student Chronologi cal age
Reading age
Spelling age
Discrepa ncy reading age
Discrepa ncy spelling age
A
14.3
8
8
6.3
6.3
B
13.4
9.1
8.5
4.3
4.9
C
14.2
7
8
7.2
6.2
D
12.6
9.1
12
3.5
0.6
E
14.8
9.1
8
5.7
6.8
H
12.2
9
7
3.2
5.2
I
14.8
12
12
2.8
2.8
J
11.6
7
6
4.6
5.6
K
9.8
6
5
3.8
4.8
L
11.4
6.1
6.6
5.3
4.8
M
12.5
8
8.1
4.5
4.4
N
13.7
11.2
9.3
2.5
4.4
4.5
4.7
Aver age
ADHD + Dyslexia
3-6%
25% 40%
3-6%
Early manifestation of delayed language & inattention
ADHD and Dyslexia
Speech and Language Impairment +DCD Early years speech difficulties- higher risk of those children having associated motor difficulties- 60% ( Missiuna et al, 2007) Hill(1998), Rintala (1998) Carte, Nigg, & Hinshaw, (1996) Elbert, (1993) Powell and Bishop (1992)
ADHD + Dyslexia + DCD A Canadian population study (Kaplan, Crawford, Wilson & Dewey, 1997) Out of those showing DCD had also 25 % ADHD +Dyslexia 22% + Dyslexia 10% + ADHD Additional work by (Biederman, Faraone, Mick, Moore, & Lelon, 1996,O’Hare and Khalid 2002) Kadesjo¨ and Gillberg (2001) found that 47% of their ADHD children also had DCD
DCD+ and Visual perception
Crawford and Dewey 2008.
ADHD + DCD( Dyspraxia) Kadesjo¨ and Gillberg (2001) found that 47% of their ADHD children also had DCD
DCD+ JHS
ng
ke
Fr ie nd s
Re ad in g Sp el lin g
in g
so rs
W r it
Sc is
Dr es si
Bi
Ba ll
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% DCD
JHS
JHS+DCD
by Adib, Davies, Grahame et al ( 2005) Rheumatology,Feb22. 125 children in a JHS clinic- parent reported • • • •
48% 36% 40% 48%
considered clumsy poor co-ordination handwriting difficulties limitations on physical activity at school
• 12% clicky hips • 14% speech and language difficulties • 43% easy bruising ***Most usually involved joints- knees, elbows, wrists, MCP and ankles
JHS • Joint Hypermobility Syndrome (JHS) is reported to affect around 11% of the population (Seckin et al, 2004) • F: M = 2.5:1( Didia, Dapper and Boboye(2002) • Huge variation
14 12 10 8
Totals DCD
6
totals normal
4 2 0 hands on the floor
bend thumb back
contort
double jointed
joint pains
bruise
flat feet
FH Double joint
Ages • Mean age of JHS group :9 years 7 months • Mean age of DCD group :8 years
• Information gathered in both groups by parental reporting
Do individuals with JHS have similar functional difficulties to children with DCD?
• • • • • • • •
Ball Learning to ride a bike Dressing Scissor skills Writing Making friends Spelling Reading
Hypermobility and limitations of movement
Pes planus
In class present with writing pains fidgety poor ball skills
fixing to throw and catch right hand hook for writing to maintain stability
BECCTS
BECTS
Aldo Scabar, Raffaella Devescovi, Marco Carrozzi, Stefania Zoia S.C. di Neuropsichiatria Infantile IRCCS BURLO - TRIESTE - Italy
6 out of 8 with MABC <1% had BECTS
BECCTS Benign Epilepsy of Childhood with Centrotemporal Spikes
◦ Motor cortex ◦ Abnormal EEG pattern ◦ Night time seizures… thought to not be as significant but may have an impact on learning ◦ Preservation of consciousness ◦ Pooling of saliva ◦ Speech arrest ◦ 75% at night
One study from Italy( Scabar,2005)
• Rutter (1982) commented there appears to be an interactive effect between the DCD and ADHD • children with the combination have many more academic problems + autistic type behaviours than would be suggested by having the added effects of the two separate conditions.
di ffi c
SD Q :P
pa ct
s
ty
em
ivi
s
s
AS SQ
m
pr ob l SD Q :I
ee r
yp er ac t
em
ul tie
on du ct pr ob l
ot al
SD Q :H
SD Q :C
SD Q :T
SDQ and ASSQ
25
20
15 DCD
10 DCD+ADHD
5
0
More problems lead to increased severity
*
* *
* Sig difference p< 0.01
TOTAL SCORE
ac ts
y
e
be fo re
th in k in
g
co nc en tra tio n
fid ge t
re st le ss /o ve ra ct iv
100 90 80 70 60 50 40 30 20 10 0 DCD
DCD-ADHD
Overlap… AND visual perception Dyslexia
VP ADHD
Where there is DCD + there are worse scores on TVPS and VM Crawford and Dewey 2008.
DCD
ROCF
DCD+ DCD
Visual sequential memory
Dyslexia ADHD control
Visual memory
0
5
10
15
20
25
30
35
TVPS 130 125 120 115 TVPS 110 105 100 95 control
ADHD
Dyslexia
DCD
DCD+
Implications of overlap in the longterm
Swedish longitudinal study • At 16 years, the MPD-ADD group were more likely to have speech and language problems. • 8 /13 in the MPD-ADD group were still “appeared clumsy” • Substance abuse was more common in boys in the MPD-ADD group than controls. •Children seen at 5-7-11-16- 22 years
Swedish group at 22 years ADHD/DCD • 16% of the ADHD and DCD group also had a diagnosis of Aspergers disorder. • 33% had personality disorders diagnosed. • 58% reading /writing disorder. • 49% inattention but hyperactivity was now at a much lower level.
Conclusions • • •
Definition Issues of overlap Impact of overlap – for assessment and diagnosis
What do we know about causes?
Shared environment
Shared genetics
ENVIRONMENT GENES
SYMPTOMS writing
attention
socialising
reading
DIAGNOSIS DCD
ADHD Asperger Dyslexia
Environmental factors
Changing lives
Fish consumption Parent reporting
?
Fish 60.00% 50.00% 40.00%
Never Less than once a week
30.00%
2-3 times a week Everyday
20.00% 10.00% 0.00% Never
Less than 2-3 times once a a week week
Everyday
13.5% of children reported having eaten fish as part of a meal in previous 24 hours
Eating together 50% 45% 40% 35% 1991 -National telephone survey parents of 12-17 year olds
30% 25%
2008
20% 15% 10% 5% 0% Every day
4-6 times
1-3 times
never
Eating and watching TV Child reported 46%
never 30% sometimes 24%
always/almost always
Linear approach environment
Genes
symptoms
diagnosis
xp le cia so or Po
Dynamic systems model
Traumatic experiences
Child with additional learning needs
s ce ien er
Low self worth
Fail exams
Low self worth Poor co-ordination
Poor reader Parent with poor literacy Hereditary factors
Poor nutrition
Poor fitness levels overweight
ENVIRONMENTAL
BEHAVIOURAL
NEURAL
GENETIC
“Meshes of influence” Turvey,2006
Smythe,2008
Candidate Genes in ADHD • SLC6A1, SLC9A9, HES1, ADRB2, HTR1E, DDC, ADRA1A, DBH, DRD2, BDNF, TPH2, HTR2A, SLC6A2, PER1, CHRNA4, SNAP25, and COMT. • ADRA2A improvement of inattentive symptoms with methylphenidate
Genetic and biochemical level Genes involved in dopamine regulation (DRD4 and DAT1) receptor genes have been highlighted in ADHD- and may control attention and EF… DAT1 and spatial attention have been associated (Bellgrove and Mattingly,2008)
(J.M. Swanson et al. / Neuroscience and Biobehavioral Reviews 24 (2000) 21–25 )
Genetic level • Martin, Piek and Hay (2006) • 1285 twin pairs aged 5 and 16 years were analysed using the criteria from DSM1V for ADHD and alternative SWAN (Strengths and Weaknesses of ADHD Symptoms and Normal Behaviour scaleand (DCDQ) • The DCD (fine motor) and ADHD (inattentive) were most strongly linked using the DSM-IV based scale. • On the SWAN scale results were similar but also general coordination scale were strongly linked.
ADHD • Swanson et al. (1998) and Sergeant (2005) hold that inhibition is a symptom rather than a core deficit of ADHD • Within each domain of the disorder (inattention, hyperactivity, impulsivity), there are deficits associated with specific cognitive processes (e.g., executive control, alerting/arousal, attention), that are the result of abnormalities in assorted brain regions. • ? abnormalities in the frontal lobes, the prefrontal cortex, and their networks with other brain regions
Unity and Diversity of EF • Need to look at the components rather than a composite • Different individuals have a profile of strengths and weaknesses • … along with their cognitive profiles
12
10
8
6
4
2
0 activation
action
emotion
working memory
effort
At a symptom level DCD and ADHD have been seen to overlap... Lots of research • • • • • •
Denckla and Rudel (1978). Gillberg, C. (2003) Deficits in attention, motor control and perception: a brief review. Archives of Disease in Childhood. 88, 904-910 Kaplan et al(1998) study in Canada~29% ADHD-C had movement difficulties Pitcher,Piek and Hay (1999)- 30% with ADHD-C Karatekin et al (2003) Clark et al (1999) ADHD and autistic symptoms
So EF and DCD?
Motor control/Dyspraxia
• Motor control includes planning, organizing, monitoring and controlling complex motor coordination, cross-modal integration, and great demands for speed and/or accuracy
DCD and EF • Concentration difficulties and distractibility to external stimuli have been seen in children with DCD (Dewey et al, 2002, Kaplan et al, 1998) • Attentional and executive deficits- with visuospatial conflict or a central cuing task (Mandich et al,2002;Wilson et al,1997)
• A gap between attention and visuo motor integration ( Wilmut et al, 2007).. Deficits in attention for action at the level of execution. • Praxis… is this an EF?
27a 800 700 600 500 400 300 200 100 0 -1 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 0
1 2
3 4
5
6 7
8 9 10
Stepping patterns 70 60 50 40
DCD
30
TDC
20 10 0 one to one
one to two
Comb
TDC
DCD + ADHD combined
12b
25a
800
800
700
700
600
600 500
500 400
400
300
300
200
200 100
100 0 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0
1
2
3
4
5
6
7
8
9 10
DCD only
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0
1
2
3
4
5
6
7
8
9 10
DCD+ ADHD-I 20a
27a 800 700 600 500 400 300 200 100 0 -1 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 0
0
1 2
3
4 5
6
7
8 9 10
800 700 600 500 400 300 200 100 0 -1 -1 -1 -1 -1 -1 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 5 4 3 2 1 0
3 4
5 6
7 8
9 10
DCD and EF • Piek et al (2004) found that controlling for age, DCD was significantly associated: • with attention (parents’ ratings) • performance in a trail making task, a task that involves cognitive control as well as working memory.
Brain structures • 9 children with DCD and 10 controls (8-13 years) performed go-no go tasks • DCD significantly different on go-tasksslower and more variable
Writing Motor task… or also inattention
Paragraph copy task: 3 groups
In Air time (seconds)
250 200 150 100 50 0 Inattentive
Poor readers Group
Control
Basis of DCD Basal ganglia has been proposed as being effected in DCD (Groenewegen,2003) Defects of maturation of the white matter affecting intrahemispheric and basocortical connections have been reported in children born prematurely who presented praxis and attentional deficits (Fujii et al., 1993; Skranes et al., 1993). Striatum contributes to inhibition of motor responses (Brown et al., 2004; Mink, 1996), but could also play an important role in automatization of cognitive and motor processes with practice (Brown et al., 2004; Laubach, 2005). Visser (2003) proposed that children with DCD could have impaired capacities to automatize motor behavior with practice and consequently continue to exert top-down control processes during behaviour or tasks which are normally automatized with practice in healthy children.
Brain structures 9 children with DCD and 10 controls (813 years) performed go-no go tasks DCD significantly different on go-tasksslower and more variable
Querne et al, 2008
Control
DCD
Control
DCD
Control
DCD
fMRI Middle frontal cortex (MFC) and anterior cingulate cortex (ACC) to the parietal cortex on left is increased in children with DCD Information between striatum and parietal cortex decreased in children with DCD in right hemisphere. DCD children may be able to compensate for difficulties in switching attention by more actively engaging the anterior cingulate cortex.
DISCUSSION