Developmental Coordination Disorder DSM-5 315.4 (F82)
DSM-5 Category: Neurodevelopmental Disorders
Introduction
Disorders of attention, behavior, cognition, coordination and learning that are usually identified in childhood were classified in previous editions of the Diagnostic and Statistical Manual Disorders (American Psychiatric Association, 2000) as “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence”. The Fifth edition of the DSM (American Psychiatric Association, 2013) has reclassified these conditions as “Neurodevelopmental Disorders”. This new category includes intellectual disabilities, communication disorders, the autistic spectrum, attention deficit with and without hyperactivity, specific learning disorders, Tourette’s syndrome and related conditions and motor disorders. The latter group includes developmental coordination disorder, which is also called developmental dyspraxia and the “clumsy child” syndrome.
Neurodevelopmental disorders have undoubtedly been present throughout history, and various historical figures, ranging from Michelangelo and Mozart to Adolf Hitler and Jeffrey Dahmer, have been retrospectively diagnosed with one or another of these. The first modern description of developmental coordination disorder was the report of “congenital maladroitness” by Collier in 1900. Orton (1937) identified such maladroitness as “one of the six most common developmental disorders, showing distinct impairment of praxis”. In 1966, the term “minimal brain dysfunction” was proposed for apparently neurologically normal children with deficient attention or coordination.
Ayres (1972) suggested that motor incoordination could result from inefficient organization of sensory information within the central nervous system (“sensory integration disorder”), and developed diagnostic tests and treatment protocols. Gubbay (1978) identified the “clumsy child” syndrome, in which the predominant difficulty was dyspraxia, the inability to carry out motor actions despite normal strength and sensation. Other terms proposed for this disorder are developmental apraxia, disorder of attention and motor perception, developmental dyspraxia, perceptuo-motor dysfunction, motor learning difficulty and sensorimotor dysfunction (Gibbs, Appleton and Appleton, 2007).
Symptoms of Developmental Coordination Disorder
Multiple disturbances of gross and fine motor control have been described (Missiuna et al., 2008). Gross motor symptoms include poor timing and impaired balance, causing patients to trip over their own feet. Difficulty in combining movements into a sequence or in remembering movements in a sequence may be associated with proprioception or spatial awareness (Geuze, 2005). Proprioceptive impairment and left-right confusion can interfere with holding or transferring objects such as pencils or tools (Wilson and Mackenzie, 1998). Manipulation and dexterity are also compromised by fine motor symptoms, which can interfere with handwriting and many activities of daily life (Polatajko and Cantin, 2005).
Impaired control of the vocal apparatus, difficulty suppressing breathing and salivation while speaking, and central difficulties forming speech sounds and sequencing words can result in speech and language impairment, which is termed childhood apraxia of speech. Genetic mutations (FOXP1 and FOXP2) have been identified in families with this type of impairment (Vargha-Khadem, Gadian, Copp and Mishkin, 2005; Bacon and Rappold, 2012).
The gross and fine motor symptoms and disturbance of speech and language are often comorbid with attention deficit hyperactivity syndrome, autism spectrum disorder, impairment of mathematical ability and reading or writing (dyscalculia, dysgraphia, dyslexia), and abnormal muscle tone (Gilberg and Kadesjö, 2003). Abnormal sensory sensitivity is also often associated with coordination defects, and can interfere with occupational or social function or result in unrecognized injury (Miller et al., 2007). Specific language impairment, the abnormal development of language without apparent etiology, is also associated with developmental coordination disorder: students with the latter are 7 times more likely than students without to have impairment of visual-spatial memory (Alloway, 2007).
Diagnostic Criteria
The acquisition and execution of coordinated motor skills is substantially below that expected for the patient’s age and opportunities for learning. Clumsiness (dropping or bumping into objects) and slow inaccurate performance of motor skills (catching objects, handwriting, using utensils, bicycle-riding or participation in sports) are present, and interfere with activities of daily life and impact academic, occupational, recreational or social activities. Symptoms must begin in the early developmental period, and should not be better explained by intellectual disability or neurological condition affecting movement.
The diagnosis is made by synthesis of the developmental and medical history, physical and neurological examination, report from school or workplace and appropriate psychometric assessment. Criterion A (impaired coordination) is manifested differently at different ages: delayed motor milestones in some very young children, delay in acquiring or slowness and inaccuracy in performing skills such as stair-climbing or buttoning in older children, and slowness or inaccuracy in typing or handwriting or athletic pursuits in adolescence and adulthood. Criterion B (impairment of motor skills interferes with daily activities) is necessary for the diagnosis.
Cause
It is estimated that about 5 per cent of school-age children are affected, although up to 10 per cent of children may be uncoordinated in some way. The incidence is higher in the United Kingdom than in the United States. Boys are slightly more affected than girls (1.7:1), but there are no racial differences. Prematurity and in utero alcohol and drug exposure increase the risk (Lingam et al., 2009). Two studies have estimated the heritability of the disorder at 0.47 and 0.69, suggesting both hereditary and environmental factors, and a genome-wide analysis suggested the involvement of several genes but these have not been identified (Fliers et al., 2012).
Neuropsychological evaluations have suggested dysfunction in the parietal lobes , cerebellum, hippocampus , basal ganglia and corpus callosum. Functional MRI imaging has shown that children with developmental coordination disorder were less able than controls to switch rapidly between go and no-go motor tasks. Poor performance by clumsy children in visual-motor tasks was associated with decreased activation of the left parietal lobe. Children with developmental coordination disorder activated different brain regions than control children when performing a trail-tracing task, and activation of neural networks connecting the cerebellum with parietal and prefrontal cortex was reduced. One study of single-photon emission computed tomography indicated disruption of normal connections between cerebellum and cerebral areas involved in executing planned actions, visual-spatial perception and regulation of affect . Diffusion tensor imaging, which measures the asymmetrical diffusion of water molecules in tissues, showed differences in the characteristics of axons in developmental coordination disorder patients as compared to controls (Kashiwagi and Tamai, 2013).
Treatment
There are few treatment options, but these have been shown to produce better outcomes than no treatment (Blank et al., 2012). No pharmacologic therapy is effective for the coordination or developmental problems. Cognitive motor therapy attempts to teach movement patterns to children who have difficulty with those particular tasks, and to inculcate skills that are important in coordinated movement: planning a motor act, executing it and evaluating the result. Sensory integration therapy attempts to teach children who are excessively sensitive to stimuli how to cope with this while carrying out motor activities and aims to modify the environment to provide an acceptable degree of sensory stimulation; those who are insensitive to stimuli are subjected to gradually increasing stimulation. Improved sensory integration is felt to lead over time to better modulated motor responses. Kinesthetic therapy seeks to increase awareness of motion in space, which will lead to better control of motor function. The Bobath neurodevelopmental approach seeks to inhibit persisting primitive reflexes and abnormal patterns of muscular contraction , and to facilitate the appearance of age-appropriate reflexes and a normal sequence of muscle activation. Assistive technology is also helpful in making it easier for patients to use appliances and implements or to communicate effectively with the aid of computer technology (Zimmer and Desch, 2012).
Author: Miles E. Drake, Jr., M.D.
References
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