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NEURAL PLASTICITY VOLUME 10, NO. 1-2, 2003

EDITORIAL

The Clumsy Child: Where Are We and Where Are We Going?

In June 2002, a meeting was held in Groningen,the Netherlands on ’The Clumsy Child’. Hereneuroscientists who presented recent findings onthe organization and development of motor controlmet clinicians involved in the management and-.care of children with clumsy motor behavior. Thepresent special issue of Neural Plasticity containsthe main contributions of this meeting, as well asan edited version of the lively discussion held atthe end of the meeting.

The issue begins with the paper of Hendersonand Henderson who eloquently describe all thedifficulties that researchers run into when dealingwith children with clumsy motor behavior. Toavoid difficulties with terminology, they plea forthe general use of the DSM-IV term Develop-mental Coordination Disorder (DCD, AmericanPsychiatric Association, 1994) to describe thisgroup of children. The authors also discuss thehurdles encountered in diagnosing DCD and thecomorbid signs and symptoms of in the hetero-geneous population of children with clumsy motorbehavior.

Next is a theoretical paper by Hopkins, whopoints out that the development of action can beconsidered as consisting of changes in the task-specific couplings between perception, movementand posture. He argues that this perception-actionapproach can provide a much-needed basis fromwhich attempts can be made at theoreticallyunifying the constituents of the clinical continuumof normal motor behavior to motor clumsiness. Inthe following paper, Sigmundsson discusses theissue of perceptual deficits in clumsy children. Heargues that in particular asymmetries in theprocessing of information and motor control might

result in motor coordination problems.The following two papers address the etiology

of clumsy motor behavior. Hadders-Algra proposesthat in only a minority of children can clumsiness beattributed to a lesion of the brain, particularly to

damage of the fiber systems connecting the varioussupraspinal regions. She argues that in most clumsychildren, clumsiness represents the lower scale ofthe normal distribution of motor function. Suchmotor performance probably reflects non-patho-logical-brain function due to factors like geneticconstitution and stress during early life. Mercuri andBarnett report on the motor consequences ofneonatal encephalopathy in full-term infants andconclude that especially infants who on MRI showsigns of severe basal ganglia and internal capsuleinvolvement are at risk for the development ofmotor impairment, such as cerebral palsy andclumsy motor behavior. The next paper by Gillbergand Kadesj6 addresses comorbidity in childrenwith DCD. Psychiatric disorders like attentiondeficit hyperactivity disorder (ADHD) and autistic

spectrum disorders are much more common inchildren with DCD than in those without thisdevelopmental motor disorder, a notion havingclinical implications.

The following section contains seven papersreviewing the role of a specific part of the nervous

system in motor control. Kernell begins with a

scholarly survey on how motoneurones and motorunits are used for the gradation of muscle forceduring motor behavior. The next two papers dealwith the effect of a lesion of corticospinal tract.Whishaw and his colleagues studied the effect ofcomplete and partial lesions of the pyramidal tract

in adult rats. They found not only that complete

(C) 2003 Freund & Pettman, U.K.

EDITORIAL: THE CLUMSY CHILD

lesions result in clear motor deficits but also thatpartial lesions induce motor abnormalities, albeitminor ones that can be detected only with the helpof a detailed analysis of the performance ofreaching behavior. The paper by Eyre presents anoverview on the development and plasticity of thecorticospinal tract in man. She points out that thecorticospinal system develops from a rather diffusesystem into a specific contralateral system and thereorganizational processes induced by unilateraland bilateral cortical lesions differ. The next twopapers discuss the basal ganglia in motor control.Groenewegen succinctly describes the anatomy ofthe basal ganglia, a neural system that supports awide range of sensorimotor, cognitive, andemotional-motivational brain functions. He pointsout that a major role of the basal ganglia is thelearning and selection of the most appropriatemotor or behavioral programs. The second paperon basal ganglia is by Keitz, Martin-Soelch andLeenders who review the literature on dopa-minergic circuitries in reward processing andspeculate upon the role of reward-processingneural systems in motor behavior. Two papers onthe role of the cerebellum in the development ofmotor behavior conclude this section. Grams-bergen presents a review on cerebellar neuroana-tomy, neurophysiology, and cerebellar development.He stresses the relative late maturation .ofcerebellar structure and points to the possibleconsequences of the timing of cerebellardevelopment for normal and--in particular---forabnormal development induced by perinataladversities like fetal growth retardation. The secondpaper is by Ivry. He discusses the association ofcerebellar anomalies and developmental disorderslike ADHA, dyslexia, and autism, and the putativecausational links between cerebellar anomalies andthese various disorders. In addition, he suggeststhat the major role of the cerebellum might be thecontrol of timing of neural events, a role that is

restricted not only to motor events but also might

hold true for perceptual tasks.The final contribution is by Schoemaker et al.

They deal with the important issue of clinicalmanagement of clumsy motor behavior ofchildhood. The authors point out that traditionalphysiotherapeutic intervention, following theprinciples of neurodevelopmental or sensoryintegration, is only moderately successful. Novelforms of intervention using a task-orientedapproach seem to be more promising for theremediation of clumsiness.

The papers in this special issue reveal that our

understanding of motor development in humansand the pathophysiology of motor clumsiness inchildhood is only in its infancy. This implies not

only that our current knowledge is relativelylimited but also that it has a vigorous potential to

grow, as illustrated by some promising perspectivesopened in the recent past. For example, the intro-duction of physiological measurement techniquesthat can be applied in children, including recordingthe EMG of multiple muscles during everydaychildhood motor tasks and functional imaging ofthe brain, will help us to explain the neural basisof clumsiness. This, in turn, will facilitate the

development of effective intervention strategies.The possibilities are promising and exciting andform the feeding fuel on the long route to the fullunderstanding of clumsy motor behavior and its

management. A route that will consist of multi-

disciplinary research in fields ranging frommolecular neurobiology to neurorehabilitation,with a major role for studies using the techniquesof systems physiology.

Mijna Hadders-Algra and Albert Gramsbergen

ReferenceAmerican Psychiatric Association. 1994.Diagnostic and Statistical Manual of MentalDisorders, 4tla ed. Washing, DC, USA: APA.

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