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2003; 83:722-731. PHYS THER.

and Vey M Nordquist


Robert C Barnhart, Mary Jo Davenport, Susan B Epps
Developmental Coordination Disorder
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Developmental Coordination
Disorder
F
or the last 100 years, poor motor coordination in children has been
recognized as a developmental problem.
1
As early as 1937, these
children were classified as clumsy.
1
Since then, other terms such as
motorically awkward, motor impaired, and physically awkward
have been used to describe these children, and the terms developmental
apraxia and perceptual motor difficulties have been used to characterize
this developmental problem.
2,3
Since the 1994 International Consensus
Conference on Children and Clumsiness, the term developmental coordina-
tion disorder (DCD) has been used to describe the condition of children
with motor incoordination.
1,4
The purpose of this article is to provide the following information about
DCD: (1) definition, (2) prevalence, (3) etiology, (4) discussion regarding
the difficulties in classifying these children, (5) common characteristics,
(6) long-term prognosis, and (7) brief review of treatment approaches.
Definition of DCD
Developmental coordination disorder, a chronic and usually permanent condition
found in children, is characterized by motor impairment that interferes with
the childs activities of daily living and academic achievement.
3,5
In order for
a child to be diagnosed with DCD, these motor impairments must negatively
affect some other aspect of his or her life.
6
Impairment alone, however, does
not qualify a child for the diagnosis of DCD; the motor impairment must not
be caused by or have the symptoms of an identifiable neurological problem.
2,5
That is, the child must not have any disturbances of muscle tone (ataxia or
spasticity), sensory loss, or involuntary movements. If mental retardation is
present, the testable IQ of the child must be greater than 70 and the motor
impairments must be greater than what would normally be expected for
children with mental retardation.
5
Finally, a child diagnosed with DCD must
not meet the criteria for a diagnosis of pervasive developmental disorder.
6
[Barnhart RC, Davenport MJ, Epps SB, Nordquist VM. Developmental coordination disorder. Phys Ther.
2003;83:722731.]
Key Words: Developmental coordination disorder.
Robert C Barnhart, Mary Jo Davenport, Susan B Epps, Vey M Nordquist
722 Physical Therapy . Volume 83 . Number 8 . August 2003
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Prevalence
Developmental coordination disorder appears to be a
fairly common disorder of childhood and is usually
identified in children between 6 and 12 years of age. Ten
years ago, researchers
7,8
estimated that DCD occurred in
10% to 19% of school-aged children. With a more
precise definition of DCD, the current prevalence is
estimated to be between 5% and 8% of all school-aged
children,
5,911
with more boys than girls (2:1) being
diagnosed with DCD.
12
This difference may reflect
higher referral rates for boys, because the behavior of
boys with motor incoordination may be more difficult to
manage at home and in the classroom.
8
In addition, a
higher incidence of DCD may be found among children
with a history of prenatal or perinatal difficulties.
3
Etiology
Due to the heterogeneity of DCD, finding its cause has
been difficult.
3
Several theories speculate that the etiol-
ogy of DCD is part of the continuum of cerebral palsy
5,13
;
is secondary to prenatal, perinatal, or neonatal insult
3
; or
is secondary to neuronal damage at the cellular level in
the neurotransmitter or receptor systems.
14
Hadders-
Algra
14
based her view that DCD is a result of damage at
the cellular level on evidence that cerebral palsy is often
caused by prenatal damage that cannot be identified by
current diagnostic techniques.
Although both standard and nonstandard functional
tests are available to identify the specific disabilities
experienced by a child with DCD, relating the observed
disabilities to the primary impairment(s) or any possible
neuropathology is not easily accomplished. The prob-
lems experienced by children with DCD are believed to
emanate from abnormalities in neurotransmitter or
receptor systems rather than from damage to specific
groups of neurons or brain regions.
15
Childrens diffi-
culties with coordination can result from a combination
of one or more impairments in proprioception, motor
programming, timing, or sequencing of muscle activity.
A number of theories have evolved in an attempt to shed
light on the specific neuronal processing deficits that
contribute to DCD. Current models used to explain the
neural regulation of posture and movement during
development can serve as a basis for the examination
RC Barnhart, PT, MS, PCS, is Assistant Professor and Academic Coordinator of Clinical Education, Department of Physical Therapy, College of
Public and Allied Health, East Tennessee State University, Johnson City, TN 37614-0624 (USA) (Barnhart@etsu.edu). Address all correspondence
to Mr Barnhart.
MJ Davenport, PT, MS, is Assistant Professor, Department of Physical Therapy, College of Public and Allied Health, East Tennessee State
University.
SB Epps, EdD, is Admission Coordinator, Department of Physical Therapy, College of Public and Allied Health, East Tennessee State University.
VM Nordquist, PhD, is Professor, Department of Child and Family Studies, The University of Tennessee, Knoxville, Tenn.
Mr Barnhart provided concept/idea, and Mr Barnhart and Ms Davenport provided writing. Dr Epps and Dr Nordquist provided consultation
(including review of manuscript before submission).
Developmental coordination disorder,
a chronic and usually permanent
condition found in children, is
characterized by motor impairment
that interferes with the childs
activities of daily living.
Physical Therapy . Volume 83 . Number 8 . August 2003 Barnhart et al . 723

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and management of individuals with DCD. Using these
models, many of the deficits of motor control observed
in these children can be described.
A variety of theoretical models exist to explain the role
of the nervous system in motor development. Forty years
ago, the primitive reflex model was a generally accepted
theory used to explain how the brain regulates early
motor behavior.
16
As development proceeded, the
higher centers exerted increasing control over the lower
reflexes.
16
These earlier models were based on a hier-
archy of motor control in which higher centers were
capable of planning and executing a motor plan without
external or internal feedback from lower centers of the
central nervous system (CNS).
The more recently proposed systems model suggests a
more complex interaction among various levels of the
CNS. In the systems model, sensory feedback is inter-
preted by the CNS, and the appropriate movement
strategy is selected based on current experience, the
state of the internal and external environment, and
memory of similar movements. Edelmans neuronal
group selection theory includes aspects of both of these
models and proposes that functional groups of neurons
exist at all levels of the CNS.
17
These neuronal groups
are determined by evolution, but their functional integ-
rity is dependent on afferent information produced by
movement and experience.
17
In this regard, these genet-
ically determined collections of interconnected neurons
(neuronal groups) in both cortical and subcortical struc-
tures serve as an early repertoire for motor behavior or
receipt of specific sensory information.
14,17,18
According to neuronal group selection theory, motor
development proceeds in 2 phases.
15
The first, the phase
of primary variability, is characterized by crude and
erratic motor activity that does not require sensory
information for its initiation or guidance. These self-
generated movements give rise to afferent (visual, kines-
thetic) inputs that reinforce more specific synaptic con-
nections within each group. An intermediate period in
which effective patterns are selected is followed by the
secondary variability phase. In this phase, sensory and
motor factors interact to establish the intercellular con-
nections that produce the specific and complex muscle
contraction patterns that characterize coordinated, goal-
directed movement. Reciprocal connections between
groups subserving movements in various body parts and
representing different parts of visual space are rein-
forced with each repetition of a particular function. As
the more efficient movement patterns are practiced, the
appropriate synaptic circuits are reinforced and subse-
quently established.
14,17,19,20
Difficulties in Classifying Children With DCD
The literature includes a wide variation in terminology
and criteria to describe DCD. This variation has made
studying the causes of DCD and developing treatment
approaches for the child with DCD difficult. In their
analysis of clinical trial data, Macnab et al
21
identified 5
different subtype profiles of DCD. The first subtype
included children with better gross motor than fine
motor skills, although both were still below normal while
standing balance and visual-perceptual skills were both
within normal ranges. Compared with children of the
same age with DCD, children in the second subtype
scored high on measures of upper-limb speed and
dexterity, visuomotor integration, and visual-perception
skills, but they demonstrated poor performance on
measures of kinesthetic ability (accuracy in discriminat-
ing movement and position of the upper limbs) and
balance. Children in subtype 3 demonstrated the great-
est overall motor involvement and were the only subtype
to have difficulty with both kinesthetic and visual skills.
Compared with their peers with DCD, children in sub-
type 4 performed well on kinesthetic tasks but demon-
strated poor performance on tasks requiring visual and
dexterity skills. Children in subtype 5 demonstrated
poor performance on measurements of running speed
and agility compared with their peers with DCD; how-
ever, they performed well relative to their peers with
DCD in the tasks involving visual-perception skills. The
development of different classification systems for DCD
may have been influenced by the design of motor tests.
21
For example, items testing one motor skill may be
influenced by a related motor skill (eg, ball-throwing
skills cannot be separated from visuomotor skills). In
addition, a test may have an over-representation of one
skill that could unduly influence the childs perfor-
mance on the test. For example, having a greater num-
ber of items testing gross motor rather than fine motor
skills could either positively or negatively influence a
childs score, depending on the childs specific strengths
and weaknesses.
Another difficulty in interpreting the literature on DCD
is the lack of inclusion criteria. Geuze et al
22
reviewed
164 publications on the study of DCD and found that
only 60% of the studies had objective inclusion criteria.
Because of this lack of inclusion criteria, Geuze et al
recommended that a child scoring below the 15th
percentile on standardized tests of motor skills and
having an IQ score above 69 would qualify for a diagno-
sis of DCD.
The inconsistency among standardized motor tests used
to identify children with DCD is another problem. In
one study,
5
the Bruininks-Oseretsky Test of Motor Pro-
ficiency (BOTMP) and the Movement Assessment Bat-
tery for Children (M-ABC) were administered to 157
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children with DCD and 155 children with no motor
difficulties; the test results were in agreement 82%
(kappa.62) of the time in distinguishing children who
had DCD from children who did not have DCD. This is
considered a substantial level of agreement.
23
In a study
of 202 children (101 with DCD and 101 without DCD),
the BOTMP and M-ABC agreed only 67% of the time
(kappa.41), which was considered a moderate level of
agreement.
24
Because the BOTMP and the M-ABC are 2
of the most commonly used tests for identifying children
with DCD, the potential lack of agreement by these tests
in identifying children who have DCD is a concern.
Two primary factors may explain the difference in
outcomes between the BOTMP and M-ABC when used
to identify children with DCD.
24
First, the BOTMP allows
the tester to verbally prompt and correct the child
during the testing procedure, allowing the child who is
dependent on more external controls to do better on
the BOTMP. The BOTMP tends to under-identify chil-
dren with DCD. Second, the M-ABC requires more
careful instruction on the part of the examiner and
allows more opportunities for the examinee to practice,
but does not allow any verbal or physical prompting by
the examiner. Children with attention problems may
have more difficulty with the careful instructions for the
M-ABC.
Another difficulty in classifying children with DCD is the
overlap with other disorders. Approximately 41% of
children with attention-deficit/hyperactivity disorder
(ADHD) and 56% of children with learning disabilities
also have DCD.
5,21
Further confusing the classification
scheme is that the terms developmental coordination
disorder, for which no identifiable organic brain dam-
age is present, and apraxia, which is caused by identi-
fiable brain damage, have been used interchangeably.
3
Characteristics of Children With DCD
Children with DCD may have a wide range of dysfunc-
tions. These dysfunctions can be grouped into 3 areas:
gross motor, fine motor, and psychosocial.
Gross Motor
Many children with DCD have neurological soft signs
such as hypotonia, persistence of primitive reflexes, and
immature balance reactions that interfere with gross
motor development.
5,25
These children also may demon-
strate an awkward running pattern, fall frequently, drop
items, and have difficulty imitating body positions and
following 2- to 3-step motor commands.
8
Because of
their gross motor problems, children with DCD also
perform poorly in sporting events,
2
possibly due, in part,
to their slow reaction and movement times.
7
Their
decreased participation in sports may result in decreased
muscle force.
8
Fine Motor
Difficulty with handwriting or drawing often is the first
identifiable sign of a fine motor problem and is the most
frequently mentioned motor problem experienced by
children with DCD. Children with DCD frequently have
difficulty planning and executing other fine motor skills
such as gripping and dressing.
2629
Psychosocial
Unfortunately, children with DCD may experience prob-
lems not limited to fine or gross motor areas. These
children also may experience psychosocial problems at
school. Children with DCD may have learning disabili-
ties or reading problems and may be at increased risk for
lower intelligence.
5,8
They may act out in class more than
other children,
13
may be the class clown, and may exhibit
less socially desirable means of gaining recognition and
friends.
8
Adolescents with DCD have been found to have
fewer friends, and they have more feelings of low self-
worth and more anxiety than peers without DCD and
younger children with DCD.
30
Prognosis
Historically, parents have been told not to worry about
their childs clumsiness because the child will outgrow
the problem.
31
However, current researchers in the area
of DCD report that the children do not outgrow clum-
siness and that, without intervention, they will not
improve.
1,8,12,27,31
Losse et al
31
tested 17 children aged 6
years and retested them at age 16 years. The children
with motor difficulties at 6 years of age continued to
exhibit problems at 16 years of age.
In another study,
32
818 children with DCD were tested
for reading comprehension at age 7 years and then again
at age 10 years. A positive correlation in poor reading
comprehension existed for children with DCD at 7 and
10 years of age.
A follow-up study was conducted on 22-year-old individ-
uals (N55) who at age 7 years had either DCD or
attention-deficit/hyperactivity disorder (ADHD), or
both.
33
The children with DCD and those with both DCD
and ADHD had poorer outcomes than their similarly
aged peers without DCD and children with ADHD only.
The children with DCD and those with both DCD and
ADHD were found to have had more criminal offenses,
more incidences of substance abuse and other psychiat-
ric disorders, and lower levels of schooling.
Treatment Approaches
Treatment approaches used by occupational therapists
and physical therapists can be broadly categorized
into either bottom-up or top-down approaches
(Tab. 1).
10,12,3436
Bottom-up approaches are based on
hierarchical theories of motor control. These theories
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tend to explain the remediation of motor dysfunction
through activation of higher levels of neuronal function-
ing in a child. The bottom-up approaches frequently
used in managing children with DCD are sensory inte-
gration, the process-oriented treatment approach, and
perceptual motor training.
34
In sensory integration therapy, the child is provided
sensory stimulation designed to promote motor develop-
ment and higher cortical learning. A child undergoing
sensory integration therapy may show some gains in
motor development, but these gains often do not gen-
eralize to functional skills.
34
Kinesthesia (the perception of ones own body parts,
weight, and movement) is integral to the acquisition of
motor skills in process-oriented treatment approaches.
Therapeutic intervention with process-oriented treat-
ment is based on specifically designed kinesthetic train-
ing activities. As described by Laszlo and Bairstow,
37
this
approach has an inherent reward system built into it
through its use of positive reinforcement, presentation
of desirable activities within the capabilities of the child,
and judicious progression of the level of difficulty. The
usefulness of the process-oriented treatment approach
has been the subject of considerable study.
9,10,37,38
Sims
and colleagues
35
suggested that much of the success of
this approach can be attributed to a strong motivation
effect, fostered by positive feedback and a sense of
self-competence.
Perceptual motor training, an eclectic approach, offers
the child with DCD a wide range of motor experiences
along with ample opportunities to practice these skills.
Often, in outcome studies, children who receive percep-
tual motor training are compared with children who
receive either sensory integration therapy or process-
oriented treatment. Children receiving perceptual
motor training have been found to demonstrate motor
improvements equal to or greater than those of children
receiving either sensory integration therapy or process-
oriented treatment.
34
While perceptual motor training,
like process-oriented treatment, may promote learning
through positive feedback and reinforcement, these
techniques do not facilitate cognitive and problem-
solving strategies to the extent that top-down approaches
do.
Top-down approaches typically use a problem-solving
approach to motor skill development and have been
greatly influenced by the dynamic systems approach to
motor learning and control. This approach suggests that
motor skills develop from an interaction of many sys-
tems, both internal and external to the child.
39
Top-
down approaches also emphasize the context in which
motor behavior occurs. Task-specific intervention and
cognitive approaches or strategies are the 2 most com-
monly used.
Task-specific intervention focuses on direct teaching of a
skill. The theoretical foundation for task-specific inter-
vention in a childs motor performance is the result of
learning focused on a specific task. Motor tasks are
broken down into steps, with each step taught indepen-
dently and then organized to accomplish the entire
task.
34
Children managed with this approach have dem-
onstrated gains in motor skills.
34
Cognitive approaches to motor development emphasize
active problem solving.
36
The cognitive approach strat-
egy involves the GPDC framework:
Goal: What am I going to do?
Plan: How am I going to accomplish the skill?
Do it: Go ahead and perform the skill.
Check: How well did my plan work?
The child uses verbal self-guidance to apply the GPDC
framework to motor learning. In this approach, the
therapist acts as a guide by helping the child figure out
how to improve his or her motor performance on
various motor skills.
36
Table 1.
Summary of Bottom-Up Versus Top-Down Approaches
Approach Theoretical Basis Examples
Bottom up Focus is on remediating underlying deficits
through selective transmittal of sensory
information, which the central nervous system
interprets and organizes into the development of
an appropriate movement strategy
10,12,34,35
Sensory integration therapy
Process-oriented treatment
Perceptual motor training
Top down Emphasis is on cognitive or problem-solving skills
to select and implement the most appropriate
strategies for successful task performance
12,34,36
Task-specific intervention
Cognitive approaches (cognitive orientation
to daily occupational performance)
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Like task-specific intervention, the results of initial stud-
ies of cognitive approaches are encouraging. In one
study,
25
10 children with DCD who were treated with a
cognitive approach to motor development were com-
pared with 10 children who were treated with a
bottom-up approach. The children were matched for
diagnoses, age, and handedness. Both groups showed
improvements on various standardized motor tests after
receiving 10 treatment sessions. However, children in
the cognitive approach group maintained motor skill
longer and generalized to nonclinical situations better
than children who were treated using the bottom-up
approach.
Task-specific interventions and the cognitive approach
both provide repetition and practice of specific motor
skills, and the cognitive approach has the added advan-
tage of promoting independent problem solving. The
greater success of top-down approaches, when compared
with bottom-up approaches,
36,40
might be a result of the
top-down approaches inclusion of both spatial and
motor learning sequences, combined with requirements
for attention to task and working memory as the child
actively engages in problem-solving activities. The results
of these studies, in addition to outcome measures of the
different approaches in children with DCD, would sug-
gest that approaches that integrate systems theory (with
emphasis on sensory information being only part of the
picture) and motor learning theory might be most
effective for these individuals. Table 2 provides a brief
summary of several recent clinical trails evaluating the
effectiveness of various treatment approaches used with
children with DCD.
10,35,36,4043
The neuronal group selection theory can provide a
framework for interpreting the differences in reported
outcomes among the various approaches. While chil-
dren with moderate to severe cerebral palsy (CP) have a
limited repertoire of primary neuronal networks, which
guide crude, nonspecific movements, children with DCD
are believed to experience difficulty at the level of
secondary variability, that is, in selecting and reinforcing
the most efficient and effective pathways for a given
situation.
15,44
During normal postnatal development,
experience plays a primary role in the neuronal group
selection process that establishes the circuitry necessary
for efficient, goal-directed, and coordinated move-
ments.
17
According to the neuronal group selection
theory, this refinement of motor skill occurs during the
stage of secondary variability as a combined result of
trial-and-error exploration of neuronal groups, selection
of specific neurons within each group, repetition of
synaptic firing within and among neuronal groups, and
sensory experience.
Functional synaptic connections, which act in parallel
and involve cortical and subcortical (striatal and cerebel-
lar) structures, form following exposure to a variety of
motor experiences. Formation of these connections is
highly dependent on sensory information. Bottom-up
approaches such as sensory integration, process-oriented
treatment, and perceptual motor training emphasize
sensory experience, with less emphasis on cognitive
processing and cortically driven motor programming.
Although an intervention based entirely on information
processing may provide the experience necessary to
select the most effective neuronal networks, bottom-up
approaches may not provide sufficient opportunity for
motor practice of cognitively initiated and goal-directed
tasks in order to reinforce and establish these connec-
tions. Top-down approaches focus less on the specific
impairments contributing to decreased coordination
and more on the gestalt of coordinated movement, that
is, the dynamic interrelationships among a number of
CNS structures and systems and the environment within
which the task is performed.
Treatment based on a top-down approach uses task-
specific interventions that provide the child the oppor-
tunity to engage in conscious problem solving, while
coincident afferent input provides subcortical structures
the feedback and error signals needed to identify and
select the most efficient movement strategies for the
task.
36
Because sensorimotor integration, internal repre-
sentation of motor programs, and appropriate motor
commands occur at the level of secondary variability,
15
the emphasis on sensory rather than cognitive factors by
the bottom-up approaches may, in part, be responsible
for the observed differences in outcomes following
treatment.
A number of motor learning theories have been pro-
posed in an attempt to explain the process through
which previously learned actions are incorporated into
more complex movements.
39
According to the motor
control and procedural learning theory proposed by
Hikosaka and colleagues,
45
motor sequence circuits that
involve the basal ganglia and cerebellum become
encoded following long-term practice. Once these bi-
directional and parallel functioning neuronal circuits
become established through practice, the child is able to
incorporate previously learned sequential motor actions
into yet more complex movements. Hikosaka and col-
leagues proposed 2 stages to such learning, the first of
which relies primarily on sensory input to encode neu-
ronal sequencing. It is during the second stage that the
sequential processes necessary to accomplish the specific
motor tasks become firmly established through the
parallel and sequential pathways involving the basal
ganglia and cerebellum. Learning new sequences in the
first stage of learning requires attention and working
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Physical Therapy . Volume 83 . Number 8 . August 2003 Barnhart et al . 729

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memory. The motor sequences then become established
in the late stage of learning through repetition and
practice. Interventions using top-down approaches meet
both of these requirements, whereas bottom-up
approaches stress serial information processing only.
Determining the location and nature of the neural
deficiency in children with DCD is a difficult, if not
impossible, task. Motor control processes are complex
and depend on integrated functioning of sensory, per-
ceptual, cognitive, and motor systems. Not only are
children with DCD a heterogeneous group in terms of
functional disabilities but, the specific locus of the
problems observed can vary greatly from one child to the
next. Because of these factors, an integrated approach to
the management of children with DCD is advocated.
Conclusion
Developmental coordination disorder is a complex dis-
order affecting approximately 5% to 6% of school-aged
children. Without intervention, these children will con-
tinue to exhibit poor motor skills and show deficits in
other areas as well. Directions for future research may
include determining: (1) the most appropriate level of
intervention intensity, (2) which interventions produce
results that generalize to the environment and provide
long-term improvement in motor function, (3) what
effect environmental adaptations have on the childs
motor performance, and (4) whether improved motor
skills lead to improved academics and, if so, the process
involved that leads to the improvement.
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2003; 83:722-731. PHYS THER.
and Vey M Nordquist
Robert C Barnhart, Mary Jo Davenport, Susan B Epps
Developmental Coordination Disorder
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