Why Can’t Johnny Tie his Shoelaces? Developmental Coordination Disorder in Children: Implications for Primary CareDr. John Cairney

McMaster Family Medicine Professor of Child HealthDepartments of Family Medicine, Psychiatry and Behavioural

NeurosciencesOfford Centre for Child StudiesCanChild Centre for Studies in Childhood Disability

What is DCD?

DSM-IV (American Psychiatric Association, 2000)

Essential feature is a “marked impairment in the development of motor coordination”(1)Impairment must significantly interfere with academic

achievement or activities of daily living

(2)coordination difficulty not due to a general medical condition (e.g., CP or MD), and criteria for pervasive developmental disorder not met

(3)If mental retardation is present, motor difficulties must be in excess of normal for that population

By other names …

“Specific Developmental Disorder of Motor Function” (WHO, 1992)

“Minimal Neurological Dysfunction” (Henderson et al., 1992)

“Playground Disability” (Hay and Missiuna, 1999)

“Clumsy Child Syndrome” (Bax, 1999)

“Dyspraxia” (Zoia, 1999)

This terminology was replaced by “Developmental Coordination Disorder" or “DCD” based on the recommendations from the International Consensus Meeting on Children and Clumsiness (London, ON, Canada, 1996).

Signs and Symptoms

Gross Motor Deficits:HypotoniaImmature balance responsesAwkward running patternFrequent fallingDropping of itemsDifficulty in imitating body positionsPoor physical activity performance

Signs and Symptoms

Fine Motor Deficits:HandwritingGripping itemsDressing

VIDEOS

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Cause?

Uncertain Origins in fetal brain development Cerebellum

Prognosis? (clinical evidence)

DCD symptoms persist through DCD symptoms persist through adolescence (adulthood?) contributing to adolescence (adulthood?) contributing to increased risk for:increased risk for: psychiatric disorderspsychiatric disorders academic failureacademic failure physical health problems (associated with physical health problems (associated with

inactivity – cardiovascular risk) inactivity – cardiovascular risk)

Intervention / Treatment

Mixed evidence Evidence of efficacy for cognitive,

client centered, task based interventions

Environmental accommodation – coping & Advocacy

PPHYSICALHYSICAL

HHEALTHEALTH

AACTIVITYCTIVITY

SSTUDYTUDY

TTEAMEAM

PHAST I

In 2004, my research team was awarded $520,000 from CIHR to study:Motor proficiency in relation to physical

activity, physical fitness, body weight and self-efficacy over time (3 years), in a large cohort of children in grade 4

PHAST I: Sample

Target Population: All children enrolled in Grade 4 (Public School System) in Niagara

Response (school level): 75 of 90 (83%) schools consented to take part

Response (student level): 2297 of 2378 (95.4%)

PHAST I: Design

Study Began Spring (May/June 2005) Tested twice a year (fall and spring) From grade 4 to present (children started

high school this past fall Data presented here is till grade 7 All testing completed in schools

PHAST I: Design

75 schools were randomly assigned to 3 groups; motor testing (BOTMP-sf) was conducted over 3 time points (25 schools per wave). Trained Research Assistants administered the test (2-3 students)

After each test, 8 children (6 who scored <5th percentile, 2 who scored >5th percentile) were randomly selected.

An OT, blind to the BOTMP-sf scores, assessed the children on the K-BIT and the M-ABC

PHAST: Measures

BOTMP-sf (M-ABC, K-BIT)CSAPPA (Hay, 1992)Participation Questionnaire (Hay, 1992)BMI / Waist Girth (sitting height to derive

peak height velocity)VO2 Max – Shuttle RunTeacher Reported Physical Activity / AbilityHarter Scales

Method Phase I: Survey and Method Phase I: Survey and Cardiovascular Risk Factor AssessmentCardiovascular Risk Factor Assessment

Classroom

Gymnasium

BOTMP-SF:BOTMP-SF: 14 item - short form14 item - short form Gross motor skillGross motor skill Fine motor skillFine motor skill Blind and independent to Blind and independent to

Phase 1 resultsPhase 1 results

Evaluated parameters: Running & response speed, strength, balance, agility, upper-limb coordination, dexterity, bilateral

coordination.

Method Phase II: Motor-proficiency Method Phase II: Motor-proficiency TestingTesting

Three Important Questions

1. Prevalence?

2. Who are we identifying using the BOMTP-sf (administered by trained research assistants under field conditions)?

3. How stable are the motor assessments over time?

Prevalence

n=111 children (46 males, 65 females) 5.3%

Results of the OT Assessment

21 of 24 (87%) children identified as probable cases of DCD on the BOTMP-SF scored below the 15th percentile of the M-ABC, a PPV of 0.88 (95% CI=0.69 to 0.96).

Fifteen of these children (71%) were below the 5 th percentile (PPV= 0.63; 95% CI=0.43 to 0.79).

Two children, both probable cases of DCD, were found to have scores below 70 on the K-BIT

Cairney J, Hay J, Veldhuizen S, Missiuna C, Faught B. On the validity of using the short form of the

Bruininks-Oseretsky Test of Motor Proficiency to identify Developmental Coordination Disorder. Child: Care, Health and Development (in press)

Stability of Motor Testing

We retested 77 children drawn from 5 randomly-selected schools approximately two years after their original assessment.

Examiners (all new) were blind to the original results.

The correlation between the two sets of scores was 0.70 (p<0.001)

Statistical Analysis

Mixed effects models (HLM) In all models, we tested for:

Main effects for pDCD, gender and time Interactions between these factors non-linear effects of time on each outcome

We included random intercepts at the school and student levels, as well as a random slope for time. Analysis of the data revealed possible seasonal effects, so we chose to use an unstructured covariance matrix.

Relative Weight & Abdominal Fat

Outcomes:1) BMI (kg/m2)2) Waist girth (cm)3) Overweight/obesity (BMI cut-points derived from

Cole et al. 2000)

Cairney J, Hay J, Veldhuizen S et al. (in press) Trajectories of Relative Weight and Waist Circumference in Children with and without Developmental Coordination Disorder Canadian Canadian Medical Association JournalMedical Association Journal

Figure 1. Predicted BMI for children with and without pDCD by gender.

Figure 2. Predicted waist girth for children with and without pDCD by gender.

Figure 3. Predicted probability of obesity for males with and without pDCD.

PHAST II

All children (n=61) screened positive for DCD and 61 age, sex and school matched controls selected for further study

Lab based assessment; full clinical assessment for DCD (intelligence testing, impairment assessment); cardiovascular health assessment

In-home interviews conducted with child and parent (ADHD/ADD, social anxiety, self-esteem, competence)

Discussion

Trajectories suggest that the cross-sectional differences we have previously observed between children with pDCD and typically-developing children are maintained, and in some cases increase, over time (this developmental period)

Our concern about long-term risk is justified (things do not appear to be getting better)

The STACK Study

The STACK Study

Screening, Tracking and

Assessing Coordination in Kids

“Examining the co-occurrence of psychological problems in a population based sample of children with Developmental Coordination Disorder”

Funded by Canadian Institutes for Health Research (CIHR)

January 2007 - 2009

Objectives

Examine prevalence of depression and social anxiety in children with DCD, ADHD, DCD&ADHD, compared to controls.

** Screen for DCD and ADHD in a general population sample **

In the process help promote DCD awareness for teachers, parents and students and provide educational materials and recommendations for families.

Design

Two-stage, population-based, cross-sectional study

Children in Grades 4-8 recruited from 23 schools in 2 school boards

3151 children (1590 boys, 1561 girls) screened

OT visits to home to conduct motor assessments, interview parents and children

Research Criteria Applied

Assessments

Parent & Child Completed Measures of Depression and Anxiety

• Children’s Depression Inventory (CDI)

• Screen for Child Anxiety Related Emotional Disorders (SCARED)

Results: Description of the Children

DCD onlyDCD/ ADHD

ADHD only

TypicalTotal

Children who met criteria (N)

68 54 31 91 244

Gender: Male 56% 65% 87% 51% 60%

Female 44% 35% 13% 49% 40%

IQ109.81

(14.1)

103.48

(13.12)

103.68

(12.25)

108.01

(12.1)

106.96

(13.1)

Age in years: 11.0 (1.48) 11.6 (1.51) 11.3 (1.49) 11.5 (1.49) 11.4 (1.50)

Results: CDI Child and Parent Total

0

2

4

6

8

10

12

14

16

18

20

CDI Child CDI Parent

DCD only

DCD and ADHD

ADHD only

Typically developing

**

***

Differs from Typically Developing *p<0.01

Results: CDI Child by gender

0

2

4

6

8

10

12

14

DCD only DCD and ADHD TypicallyDeveloping

Males

Females

****

Differs from Typically Developing **p<0.001

Children with DCD in Primary Care Settings

Greater risk of risk for CVDInactivity, obesity, other risk markers

Greater risk for emotional/behavioural problemsDepression, anxiety, low self-esteem

Primary Care

Annual health examinations are ideal times to screen for DCD.

Parents can be asked to complete a self-administered questionnaire

E.G., DCDQ http://dcdq.ca/

Primary Care

Physician can conduct a structured interview, listening for difficulties commonly associated with DCD.

In addition, the physician can assess the child using simple screening activities administered in his or her office

Children with symptoms or signs of a motor coordination disorder require further evaluation.

An assessment that takes into account the differential diagnosis of DCD is necessary, since DCD is a diagnosis of exclusion.

New Study

Framed in the context of pediatric obesity & ParticipACTION

We tested 335 children, randomly drawn from our PHAST study using two different motor tests

Of the children who scored poor on both tests, 50% were overweight/obese

Perhaps more importantly, of all the children who were overweight/obese (85), 40% had poor motor coordination by one or both tests

When you children in your clinic with weight issues, are you thinking about diet and physical activity? Are you asking, what if they can’t be physically active for reasons related to motor ability?

Importance of Identification

Rule out other medical problems Successful treatment approaches

involve various allied health professionals, and the child's parents, physician and teachers - Goal is management strategies

Advocacy

CanChild website (www.canchild.ca)

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