Developmental coordination disorder

Developmental dyspraxia
Specialty	Neurology, psychomotor education

Developmental dyspraxia is a motor learning difficulty that can affect planning of movements and co-ordination as a result of brain messages not being accurately transmitted to the body.^[1] It may be diagnosed in the absence of other motor or sensory impairments like^{[2][full citation needed]} cerebral palsy,^{[3][full citation needed]} muscular dystrophy, multiple sclerosis or Parkinson's disease.

Dyspraxia is a specific learning difficulty (SpLD) so it does not affect overall intelligence or ability, but just affects particular aspects of development. The view that dyspraxia is associated with below-average intelligence is potentially damaging in two ways;^{[neutrality is disputed]} it can prevent people who are otherwise obviously able from obtaining appropriate help, and it can mean that people diagnosed with dyspraxia are treated as globally learning-disabled when they can be very able in other areas.

The concept of developmental dyspraxia has existed for more than a century, but differing interpretations of the terminology remains.^[4][5][6]

The Dyspraxia Foundation defines developmental dyspraxia as "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".^[7] Dyspraxia is described as having two main elements:

• Ideational dyspraxia: difficulty with planning a sequence of coordinated movements.
• Ideo-Motor dyspraxia: difficulty with executing a plan, even though it is known.

Ripley, Daines, and Barrett state that "Developmental dyspraxia is difficulty getting our bodies to do what we want when we want them to do it",^[8] and that this difficulty can be considered significant when it interferes with the normal range of activities expected for a child of their age. The word "dyspraxia" comes from the Greek words "dys" meaning impaired or abnormal and "praxis", meaning action or deed.

Developmental dyspraxia (referred to as developmental coordination disorder (DCD)^[9][4][5] in the US and Europe) is a life-long condition that is more common in males than in females, with a ratio of approximately four males to every female. The exact proportion of people with the disorder is unknown since the disorder can be difficult to detect due to a lack of specific laboratory tests, thus making diagnosis of the condition one of elimination of all other possible causes/diseases. Current estimates range from 5%–20% with 5–6% being the most frequently quoted percentage in literature.^{[10][full citation needed]}

Assessments for dyspraxia typically require a developmental history, detailing ages at which significant developmental milestones, such as crawling and walking, occurred. Motor skills screening includes activities designed to indicate dyspraxia, including balancing, physical sequencing, touch sensitivity, and variations on walking activities. A baseline motor assessment establishes the starting point for developmental intervention programs. Comparing children to normal rates of development may help to establish areas of significant difficulty.

However, research in the BJSE has shown that knowledge is severely limited in many who should be trained to recognise and respond to various difficulties, including Developmental Coordination Disorder, Dyslexia and DAMP. The earlier that difficulties are noted and timely assessments occur, the quicker intervention can begin. A teacher or GP could miss a diagnosis if they are only applying a cursory knowledge.

"Teachers will not be able to recognise or accommodate the child with learning difficulties in class if their knowledge is limited. Similarly GPs will find it difficult to detect and appropriately refer children with learning difficulties."^[11]

Various areas of development can be affected by developmental dyspraxia and these will persist into adulthood, as dyspraxia has no cure. Often various coping strategies are developed, and these can be enhanced through occupational therapy, physiotherapy, speech therapy, or psychological training.

Developmental verbal dyspraxia is a type of ideational dyspraxia, causing linguistic or phonological impairment. This is the favoured term in the UK; however it is also sometimes referred to as articulatory dyspraxia and in the United States the usual term is childhood apraxia of speech (CAS) ^[12]. Key problems include:

• Difficulties controlling the speech organs.
• Difficulties making speech sounds
• Difficulty sequencing sounds
  • Within a word
  • Forming words into sentences
• Difficulty controlling breathing and phonation.
• Slow language development.
• Difficulty with feeding.

Difficulties with fine motor co-ordination lead to problems with handwriting, which may be due to either ideational or ideo-motor difficulties. Problems associated with this area may include:

• Learning basic movement patterns.
• Developing a desired writing speed.
• The acquisition of graphemes – e.g. the letters of the Latin alphabet, as well as numbers.
• Establishing the correct pencil grip
• Hand aching while writing

Fine-motor problems can also cause difficulty with a wide variety of other tasks such as using a knife and fork, fastening buttons and shoelaces, cooking, brushing one's teeth, applying cosmetics, styling one's hair, opening jars and packets, locking and unlocking doors, shaving and doing housework.^[13]

Issues with gross motor coordination mean that major developmental targets including walking, running, climbing and jumping can be affected. The difficulties vary from child to child and can include the following:

• Poor timing.
• Poor balance (sometimes even falling over in mid-step). Tripping over one's own feet is also not uncommon.
• Difficulty combining movements into a controlled sequence.
• Difficulty remembering the next movement in a sequence.
• Problems with spatial awareness, or proprioception.
• Some people with dyspraxia have trouble picking up and holding onto simple objects such as picking pencils and things up, owing to poor muscle tone and or proprioception.
• This disorder can cause an individual to be clumsy to the point of knocking things over and bumping into people accidentally.
• Some people with dyspraxia have difficulty in determining left from right.
• Cross-laterality, ambidexterity, and a shift in the preferred hand are also common in people with dyspraxia.^[14]
• People with dyspraxia may also have trouble determining the distance between them and other objects.^[15]

In addition to the physical impairments, dyspraxia is associated with problems with memory, especially short-term memory.^{[13][16][17][18][19]} This typically results in difficulty remembering instructions, difficulty organizing one's time and remembering deadlines, increased propensity to lose things or problems carrying out tasks which require remembering several steps in sequence (such as cooking.) Whilst most of the general population experience these problems to some extent, they have a much more significant impact on the lives of dyspraxic people.^[18] However, many dyspraxics have excellent long-term memories, despite poor short-term memory.^[18] Many dyspraxics benefit from working in a structured environment^[20], as repeating the same routine minimises difficulty with time-management and allows them to commit procedures to long-term memory.

People with dyspraxia may have sensory integration dysfunction, including abnormal oversensitivity or undersensitivity to physical stimuli, such as touch, light, and sound.^[15] This may manifest itself as an inability to tolerate certain textures such as sandpaper or certain fabrics and including oral toleration of excessively textured food (commonly known as picky eating), or even being touched by another individual (in the case of touch oversensitivity) or may require the consistent use of sunglasses outdoors since sunlight may be intense enough to cause discomfort to a dyspraxic (in the case of light oversensitivity). An aversion to loud music and naturally loud environments (such as clubs and bars) is typical behavior of a dyspraxic individual who suffers from auditory oversensitivity, while only being comfortable in unusually warm or cold environments is typical of a dyspraxic with temperature oversensitivity. Undersensitivity to stimuli may also cause problems. Dyspraxics who are undersensitive to pain may injure themselves without realising^[15]. Some dyspraxics may be oversensitive to some stimuli and undersensitive to others.^[15]

People with dyspraxia sometimes have difficulty moderating the amount of sensory information that their body is constantly sending them, so as a result these people are prone to panic attacks^[18]. Having other autistic traits (which is common with dyspraxia and related conditions)^[17] may also contribute to sensory-induced panic attacks.

Dyspraxia can cause problems with perception of distance, and with the speed of moving objects and people^[15] This can cause problems moving in crowded places and crossing roads and can make learning to drive a car extremely difficult or impossible.

Many dyspraxics struggle to distinguish left from right, even as adults, and have extremely poor sense of direction generally.^[13][21]

Moderate to extreme difficulty doing physical tasks is experienced by some dyspraxics, and fatigue is common because so much extra energy is expended while trying to execute physical movements correctly.^[22] Some (but not all) dyspraxics suffer from hypotonia, which in this case is chronically low muscle tone caused by dyspraxia.^{[23][24][full citation needed]} People with this condition can have very low muscle strength and endurance (even in comparison with other dyspraxics) and even the simplest physical activities may quickly cause soreness and fatigue, depending on the severity of the hypotonia. Hypotonia may worsen a dyspraxic's already poor balance.^[25]

Dyspraxics may have other difficulties that are not due to dyspraxia itself but often co-exist with it. This is sometimes referred to as comorbidity.^[26] Dyspraxics may have characteristics of dyslexia (difficulty with reading and spelling), dyscalculia (difficulty with mathematics), dysgraphia (an inability to write neatly and/or draw) expressive language disorder (difficulty with verbal expression), ADHD (poor attention span and impulsive behaviour), or Asperger syndrome (consisting variously of poor social cognition, a literal understanding of language [making it hard to understand idioms or sarcasm] and rigid, intense interests). However, they are unlikely to have problems in all of these areas. The pattern of difficulty varies widely from person to person, and it is important to understand that a major weakness for one dyspraxic can be a strength or gift for another. For example, while some dyspraxics have difficulty with reading and spelling due to an overlap with dyslexia, or numeracy due to an overlap with dyscalculia, others may have brilliant reading and spelling or mathematical abilities. Similarly, some have autistic traits such as lacking an appreciation of irony or social cues, while others thrive on an ironic sense of humour as a bonding tool and a means of coping.^[27]

Students with Dyspraxia struggle most in visual-spatial memory. When compared to their peers who don’t have motor difficulties, students with dyspraxia are 7x more likely than typically developing students to achieve very poor scores in visual-spatial memory.^[28] As a result of this working memory impairment, students with dyspraxia have learning deficits as well.^[29]

Students with dyspraxia can also have comorbid language impairments (SLI). Research has found that students with dyspraxia and normal language skills still experience learning difficulties despite relative strengths in language. This means that for a student with dyspraxia their working memory abilities determine their learning difficulties. Any strength in language that they have is not able to sufficiently support their learning.^[30]

Collier first described developmental dyspraxia as 'congenital maladroitness'. A. Jean Ayres referred to it as a disorder of sensory integration in 1972 while in 1975 Dr Sasson Gubbay called it the 'clumsy child syndrome'.^[9] It has also been called minimal brain dysfunction although the two latter names are no longer in use. Other names include:

• Dyspraxia
• Developmental Co-ordination Disorder - a subtly different condition by definition, in practice, very similar.
• Sensorimotor dysfunction
• Perceptuo-motor dysfunction
• Motor Learning Difficulties

The World Health Organisation currently lists Developmental Dyspraxia as Specific Developmental Disorder of Motor Function.^[9]

Living people who have publicly stated they have been diagnosed with dyspraxia include:
Actor Daniel Radcliffe,^[31] David Bailey (photographer),^[32], Florence Welch from Florence and the Machine ^[33], Actress Hannah McDonnell^[34]

It is difficult to ascertain whether someone now deceased, who was not diagnosed in his/her lifetime, was dyspraxic or not. However, some deceased people suspected to have been dyspraxic include:
Physicist Albert Einstein ^[35] (Although this is subject to some debate; he is thought to have Asperger's Syndrome. It is possible he had both conditions.^[36])

Authors/ writers: Emily Bronte,^[36] Charlotte Bronte,^[36] Samuel Taylor Coleridge (Poet),^[37] G.K. Chesterton (see main article), Ernest Hemingway,^[36] Jack Kerouac,^[36] George Orwell.

Helen Burns from Jane Eyre (written by Charlotte Bronte - see above) is alleged to have been based on the author's dyspraxic elder sister Maria Bronte.^[38][35]

There are also fictional characters in TV series who are intended to be Dyspraxic. Dr. Tony Hill from TV Series Wire in the Blood has admitted being 'dyspraxic as well as socially inept' (see main article).