exploring assessment tools and the target of intervention for children with developmental...

Exploring Assessment Toolsand the Target of Intervention

for Children with DevelopmentalCoordination Disorder

Cheryl MissiunaLisa Rivard

Doreen Bartlett

ABSTRACT. Purpose: We reviewed current practice for children withDevelopmental Coordination Disorder (DCD) using research evidenceand the International Classification of Functioning, Disability andHealth (ICF). Characteristics of children with DCD can be described atthe levels of body function (impairments), whole body movements (ac-tivities) and involvement in life situations (participation). Summary ofKey Points: Descriptive instruments measuring the extent of motor im-pairments or activity limitations can be used to: (1) identify childrenwho might benefit from intervention; and (2) determine the optimal typeof intervention and model of service delivery. Evaluative tools that mea-

Cheryl Missiuna, PhD, OT Reg(Ont), is Assistant Professor in the School of Reha-bilitation Science and an Investigator with CanChild, Centre for Childhood DisabilityResearch, McMaster University, Hamilton, Ontario. Lisa Rivard, BSc(PT), is a gradu-ate student at McMaster University and a pediatric physiotherapy consultant. DoreenBartlett, PhD, PT, is an Assistant Professor in the School of Physical Therapy, Univer-sity of Western Ontario, and an Associate Member of CanChild.

Address correspondence to: Cheryl Missiuna, PhD, OT Reg (Ont), McMaster Uni-versity, School of Rehabilitation Science, 1400 Main St. West, IAHS 414, Hamilton,Ontario, L8S 1C7, (E-mail: [email protected]).

Preparation of this manuscript was supported, in part, by a New Investigator awardand funding provided to Cheryl Missiuna by the Canadian Institutes of Health Re-search and the Social Sciences and Humanities Research Council of Canada.

Physical & Occupational Therapy in Pediatrics, Vol. 26(1/2) 2006Available online at http://www.haworthpress.com/web/POTP

© 2006 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J006v26n01_06 71

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sure activities or participation, but not primary impairments, should beused to determine change over time. Commonly used measures for de-scribing children with DCD and evaluating outcomes are reviewed anddiscussed in the context of the ICF framework. Intervention approachesare then outlined for children with DCD that are targeted to the levels ofativity, participation, and prevention of secondary impairments. Conclu-sions: Outcomes of children with DCD will be optimized with the use ofcurrent research evidence and the appropriate ICF level guiding bothassessment and intervention. [Article copies available for a fee from TheHaworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<[email protected]> Website: <http://www.HaworthPress.com>© 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Developmental coordination disorder, impairment, ac-tivity, participation, assessment, intervention

Physical and occupational therapists have a distinct role to play in thesupport of children who present with the characteristics of Develop-mental Coordination Disorder (DCD) (American Psychiatric Associa-tion (APA), 2000). Such children experience considerable difficultiesin motor learning and in the performance of functional motor tasks thatare critical for success in their daily lives. They demonstrate poor motorperformance that is not accounted for by age, intellect or neurologi-cal/medical disorders, and the impact of this is seen in both academicand daily life activities (APA, 2000). The World Health Organization’sInternational Classification of Functioning, Disability, and Health(ICF) (World Health Organization (WHO), 2001) is useful in character-izing differences at the following three levels: (1) body structure orfunction (impairments); (2) whole body movements or activities (activ-ity limitations); and (3) involvement in life situations (participation re-strictions). Children with DCD might exhibit impairments in coordinationor balance, activity limitations in catching or throwing a ball, and/orparticipation restrictions in playing baseball with peers.

These children are a heterogeneous population, differing in the extentof their gross and/or fine motor difficulties and in the extent to whichthey display other conditions such as attention deficit hyperactivity dis-order, speech/articulation difficulties, and non-verbal learning disabili-ties (Causgrove and Watkinson, 1996; Hill, 2001; Polatajko, 1999).This heterogeneity and differences in the names used to describe chil-

72 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

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dren with DCD has sometimes hindered their accurate identification(Missiuna and Polatajko, 1995). It was once believed that the character-istics demonstrated by children with DCD might diminish with age andmaturity; this belief de-emphasized the need for early intervention (Foxand Lent, 1996). It has been shown recently that children with DCD are,in fact, at great risk of developing secondary impairments related totheir withdrawal from participation in physical activity (Cantell andKooistra, 2002). Therapists have been challenged to re-think the impor-tance of implementing intervention strategies for children with DCD,not to try to change primary impairments, but to prevent the develop-ment of secondary impairments (Barnhart, Davenport, Epps andNordquist, 2003; Missiuna, Rivard and Bartlett, 2003;). In so doing, itmay be possible to prevent many of the detrimental consequences thathave been documented in children with DCD including decreased activ-ity, participation, strength and fitness as well as poor self-competenceand self-esteem (Bouffard, Watkinson, Thompson, Causgrove, Dunnand Romanow, 1996; Denckla, 1984; Laszlo, Bairstow, Bartrip andRolfe, 1988; McKinlay, 1987; Njiokiktjien, 1988; O’Beirne, Larkin andCable, 1994; Raynor, 2001; Schoemaker and Kalverboer, 1994; Wil-loughby and Polatajko, 1995).

The role of clinicians with regard to the recognition, early identifica-tion and overall management of children with DCD has been describedelsewhere (Missiuna et al., 2003). The focus of the current paper is to re-view, in greater detail, literature pertaining to the specific assessmenttools and intervention strategies that may be appropriate for use withchildren with DCD. The purposes of assessment and the targets of inter-vention will be explored in the context of the framework outlined in theICF (WHO, 2001). Recommendations are developed to assist practitio-ners in applying this knowledge in clinical practice.

ASSESSMENT

Purposes of Assessment

Assessment instruments can be used at various stages during servicedelivery. Some are intended to be used at more than one stage; othersare oriented to a specific point in the service delivery model. Prior tochoosing an assessment tool, it is important to identify the intended pur-pose(s) of the assessment. For this review paper, the purposes of assess-ment originally outlined by Kirschner and Guyatt (1985) and detailed

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by Law (1987), to describe, to predict and to evaluate, will be used asthey simplify the discussion. We will be focusing primarily on toolsused for the purpose of describing children with DCD and evaluatingthe outcomes of intervention.

A descriptive or discriminant tool is used to identify individuals whopossess similar characteristics (Law, 1987). These tools classify, cate-gorize or describe the individual. Measurement tools designed for thispurpose are often used in the initial stages of service delivery in order todetermine if service is likely required. Subsequent to that decision, fur-ther assessment might be necessary to provide more in-depth informa-tion. Measures that help to delineate movement difficulties, such asthose used for children with DCD, may include some measure of the se-verity of their movement problems. These types of measures ultimatelyanswer the question: “Have we identified the ‘right’ children?” or,“Have we correctly identified a child as having the characteristics of aparticular movement difficulty and distinguished them appropriatelyfrom those who do not?” Descriptive measures, due to their nature, usu-ally provide normative data for comparison. Children are assigned nor-mative scores and then grouped or classified according to the degree ofdifficulty that they are experiencing. In some service delivery models,only those children meeting certain “cut-off” criteria (such as function-ing 1.5 standard deviations below the mean) may be eligible for service.With regard to ICF levels, information is often gathered about the quali-tative aspects of movement (i.e., body function or impairment level)and/or the achievement of specific types of skills (i.e., activity level). Itis less commonly gathered to describe the child’s level of participation.Descriptive measures that demonstrate consistency and observer reli-ability, in addition to content and construct validity, will be the most ac-curate (Law, 1987).

Evaluative measures fulfill quite a different purpose of assessmentand are used to measure change over time as a result of maturation or aresponse to an intervention (Law, 1987). This type of tool usually mea-sures improvement by examining movement product outcomes at thelevel of activities. When the goal of assessment is to evaluate outcome,the assessment tool chosen must be responsive and able to detect mean-ingful change (Liang, 2000). Tests of primary motor impairment, al-though commonly used as measures of pre- and post-intervention status,should not be used as evaluative measures because they measure attrib-utes that are not expected to change.

It is important to understand an instrument’s intended purpose in or-der to select the appropriate tool to be used at different points in the as-


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sessment process. Once children have been correctly identified throughdescriptive or predictive measures as belonging to a particular group,intervention can be chosen that reflects the best current practice for thatgroup of children. Tools chosen to assess children with DCD mighthave distinct purposes: to identify impairments (primary and second-ary), to describe the severity of these impairments, or to describe activ-ity or participation limitations. Confirmation of the child’s movementdifficulties (identification) and description of the severity of impair-ment may be important to justify service or to guide the service deliverymodel or type of intervention. For example, children with DCD whopresent with greater impairment and activity limitations may benefitmore from an individualized treatment plan while those with lesser in-volvement may succeed well with group intervention (Pless, Carlsson,Sundelin and Persson, 2000).

Assessing Children with DCD

There is currently no widely accepted standard for the assessment ofchildren with DCD (Crawford, Wilson and Dewey, 2001; Hendersonand Barnett, 1998; Kaplan, Wilson, Dewey and Crawford, 1998;Maeland, 1992; Missiuna and Pollock, 1995; Polatajko, 1999; Wilson,Kaplan, Crawford and Dewey, 2000), in part due to the heterogeneousnature of DCD and the frequent presence of co-morbid disorders. Stud-ies conducted by Crawford, Wilson and Dewey (2001) and Maeland(1992) have reported inconsistencies in the number and type of childrenidentified using different assessment tools. Without a gold standard toidentify these children, researchers have often used more than one as-sessment tool to confirm the identity of children with movement prob-lems in a study sample (Wright and Sugden, 1996). The definition ofDCD (APA, 2000), with its emphasis on the impact of the motor coordi-nation difficulties, implies that a comprehensive assessment of the DCDchild will include some examination of the child’s ability to performfunctional, everyday tasks. There are only a few assessment measures,such as the Vineland Adaptive Behaviour Scale (Sparrow, Balla andCichetti, 1984) that include this functional and contextual emphasis.

Despite these limitations, a few assessment tools will now be exam-ined in greater depth with regard to their purpose, strengths and limita-tions with the DCD population. (For a more extensive overview of theseand other assessments, please see Burton and Miller, 1998; Crawford etal., 2001; Tan, Parker and Larkin, 2001; Wiart and Darrah, 2001). In thepreschool years, identification of children who may be at risk for DCD


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is critical (Missiuna et al., 2003) and can be achieved through the use ofdescriptive measures designed for this purpose. It is important to con-firm that a motor impairment is present and to determine the impact ofthat impairment on activity. Standardized assessments developed forpreschool children often examine activities by measuring the achieve-ment of developmental skills but do not usually focus on impairment inthe qualitative aspects of movement. Identification of a motor skill de-lay indicates the need for ongoing monitoring or intervention or for anassessment of motor impairment at a later age.

One tool used to assess early motor skills is the Peabody Develop-mental Motor Scales (PDMS) (Folio and Fewell, 2000). Popular amongclinicians, the PDMS is clinically relevant, has well-established reli-ability and validity, and has been reported to measure change over time(Folio and Fewell, 2000; Wiart and Darrah, 2001). The PDMS is, there-fore, both a descriptive and evaluative measure and is an appropriatechoice for assessment of the young child with characteristics of DCD.Given that the PDMS has evaluative properties, it could also be used asa pre- and post-intervention measure to evaluate whether change hasoccurred.

Two popular assessment tools used for children with DCD who arefour years and above are the Bruininks-Oseretsky Test of Motor Profi-ciency (BOTMP) (Bruininks, 1978) and the Movement Assessment Bat-tery for Children (MABC) (Henderson and Sugden, 1992). The BOTMPis reported as one of the most frequently used assessments with schoolaged children (Burtnor, McMain and Crowe, 2002; Burton and Miller,1998; Reid, 1987). Recently, its reliability and validity have been ques-tioned (Burton and Miller, 1998; Crawford et al., 2001; Hattie and Ed-wards, 1987; Tan et al., 2001; Wiart and Darrah, 2001; Wilson et al.,2000). There is speculation that the BOTMP may fail to identify somechildren with motor impairment, in comparison with other tests(Crawford et al., 2001; Tan et al., 2001). This inability to identify chil-dren with motor impairment is not alleviated even when more stringentcut-off scores are adopted (Tan et al., 2001). Some authors have sug-gested that the BOTMP may be out of date in relation to normative dataas there have been no revisions or re-standardization of the test in thelast 20 to 30 years (Tan et al., 2001). Of greater concern for the DCDpopulation, the BOTMP does not measure impairment in terms of qual-ity of movement but, rather, measures only the ability to perform agiven activity. It has been shown that children with DCD may achieveperformance criteria on an activity but still have such poor quality ofmovement and reduced speed that their performance is not functional


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(Missiuna and Pollock, 1995). Despite its wide usage, the BOTMP mayno longer be the most appropriate clinical assessment to identify chil-dren with DCD.

The Movement Assessment Battery for Children (MABC) has beennormed with children in the United Kingdom, Canada and the UnitedStates and has been shown to correlate well with other internationally-used assessments (Bouwein, Smits-Engelsman, Henderson and Michels,1998). Its use, until recently, was more widespread in the United King-dom, Europe and Asia than in North America. The MABC is basedupon the earlier Test of Motor Impairment (TOMI) (Stott, Moyes andHenderson, 1972) and the Test of Motor Impairment-Henderson Revi-sion (TOMI-H) (Stott, Moyes and Henderson, 1984) which, like theBruininks-Oseretsky Test of Motor Proficiency, evolved historicallyfrom the work of Oseretsky. Data on both the reliability and validity ofthe MABC is lacking and the possibility of cultural bias has been raised(Bouwein et al., 1998; Burton and Miller, 1998; Chow, Henderson andBarnett, 2001; Miyahara et al., 1998; Rosblad and Gard, 1998); how-ever, numerous studies have demonstrated that the MABC identifieschildren with DCD at the same prevalence rates in other countries aswould be predicted (Bouwein et al., 1998; Rosblad and Gard, 1998;Wright and Sugden, 1996). The psychometric research performed onthe TOMI, upon which the MABC is based, found it to be a reliable anduseful assessment (Crawford et al., 2001). Recently, in a study of theconcurrent validity of two other motor tests, the MABC was used as thecriterion standard (Tan et al., 2001). The MABC has several advantagesover other assessment tools. The age bands for this instrument coverfrom 4-0 to 12-0 years but testing time is short as the assessor only pre-sents activities appropriate for that child’s age. It has been found toidentify more children than the BOTMP (Dewey and Wilson, 2001) andappears to identify more readily those children who have additionallearning or attention problems (Crawford et al., 2001). One of its keycontributions to the assessment of children with DCD is its inclusion ofqualitative descriptors of motor behaviour (i.e., impairment-level de-scriptions) that the therapist can focus on during the administration ofeach test item. The MABC also contains a behavioural checklist thatcan provide insight into the effect of motivation on assessment resultsand overall compliance with testing. In addition, a teacher checklist thataddresses environmental context and guidelines for program planningare included. These unique features of the MABC might be of value tothe clinician and would appear to outweigh its current limitations.


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Evaluative assessment measures are far less well described in the liter-ature for children with DCD. Occupational therapists frequently use theCanadian Occupational Performance Measure (Law et al., 1998) as botha goal setting and outcome measure. This semi-structured interview isused prior to intervention to have the child and/or family identify areas offunctional difficulty (i.e., activity limitations or participation restrictions)and to rate the child’s current performance of, and satisfaction with, eachtask. Following intervention, the rater is asked to reflect upon their per-formance and satisfaction for each targeted goal and a change score canbe generated. The COPM is most suited for use with children over 8 or 9years of age. With children younger than this, the Perceived Efficacy andGoal Setting System (Missiuna, Pollock and Law, 2004) may be a moreappropriate goal setting tool. In this pictorial measure, children reflect on,and indicate their competence performing, 24 tasks that they need to doeveryday. They then identify any other activities that are difficult forthem and select and prioritize tasks as goals for therapy. Early evidenceindicates that children’s goals often differ from their parents so the viewsof both may need to be solicited (Dunford, Missiuna, Street and Sibert,2005).

Goal attainment scaling is increasing in usage as a rehabilitation out-come measure both with regard to program evaluation and individual-ized client outcomes (King et al., 1999). To date, its use with childrenwith DCD has mainly been described at a programmatic level. In thispopulation, goal attainment scaling focusing on the levels of activityand/or participation, not primary impairment, is warranted.

A measure that can be used to either describe or evaluate activityand/or participation is the School Function Assessment (SFA) (Coster,Deeney, Haltiwanger and Haley, 1998). The SFA evaluates a child’sparticipation in six school-related settings (Participation Scale) and alsoexamines the amount of assistance and/or the type of adaptations re-quired for the child to perform essential school tasks (Task SupportScale). A third scale is very detailed and focuses on the performance ofspecific activities. In addition to the more typical classroom tasks, a sec-tion of this scale focuses on the child’s mobility, ability to maintain andchange positions, manipulate objects and move on recreational equip-ment. The SFA requires observation of functional performance overtime so it is usually completed by the therapist through interview of theteacher and others familiar with the child. The SFA has been used to de-scribe the participation patterns of children with DCD (Wynn, 2003)but its use in a pre- to post-intervention study has not been reported.


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In summary, for the purpose of identifying whether a child shows thecharacteristic features of DCD, the Peabody Developmental MotorScales (Folio and Fewell, 2000) can be used for preschool children andthe Movement Assessment Battery for Children (Henderson and Sugden,1992) for children 4 years and above. Depending upon the target of in-tervention, measures that can be used to evaluate the efficacy of inter-vention include the Peabody Developmental Motor Scales (Folio andFewell, 2000), the Canadian Occupational Performance Measure (Lawet al., 1998), Goal Attainment Scaling (King et al., 1999)and the SchoolFunction Assessment (Coster et al., 1998). Further research is needed tovalidate other instruments.

INTERVENTION

Goals of Intervention

According to the ICF (WHO, 2001), interventions are directed at sev-eral distinct goals in order to remediate impairment, reduce activity limi-tations and/or improve participation. In the past, treatment interventionsused with children with DCD were aimed primarily at changing impair-ment, either by trying to improve the child’s processing abilities (vision,kinaesthesis, proprioception) or the performance components (balance,strength) that were felt to contribute to poor performance. These interven-tions have been referred to as “bottom-up” interventions as they tend toaddress movement problems by emphasizing the building of founda-tional skills. These approaches were based on the theoretical belief that,by changing these underlying deficits, task performance would be im-proved (Mandich, Polatajko, MacNab and Miller, 2001). Some of these“bottom-up” interventions are still employed by therapists today whenworking with children with DCD but research on their effectiveness hasdemonstrated minimal change in functional outcome and does not seemto indicate any clear advantage of one approach over the other (Mandichet al., 2001; Miyahara, 1996). The question has also been posed, whengains are seen, whether they may be more a function of general learningprinciples than of the treatment itself (Miyahara, 1996; Sigmundsson,Pedersen, Whiting and Ingvaldsen, 1998; Sugden and Chambers, 1998).

Current beliefs regarding the nature of motor learning and increasingknowledge about children with DCD suggest that addressing second-ary, preventable impairments such as loss of strength and endurance,may be an appropriate focus of intervention. This may involve increas-


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ing children’s ability to perform and participate in the typical activitiesof childhood. Dynamic systems theorists have proposed that improve-ment in functional tasks relies on many variables and tends to be envi-ronment-specific (Thelen, 1995). This way of thinking emphasizes thatintervention must be contextually based, with intervention occurring ineveryday situations and being of significance to the individual child.More recent interventions reflect these beliefs and now tend to empha-size the development of specific skills rather than underlying skill com-ponents alone. These have been referred to as ‘top-down’ interventions(Mandich et al., 2001) and emphasize motor learning principles in com-bination with other theories that emphasize the role of cognitive pro-cesses in the learning of new movement skills (Missiuna and Mandich,2002).

Intervening with Children with DCD

When selecting an intervention approach for children with DCD, atherapist needs to consider the motor learning difficulties that are partic-ularly evident in this population. Children with DCD appear as if theyare in an early stage of learning; their movements are often clumsy andinaccurate (Goodgold-Edwards and Cermak, 1990). They remain lon-ger in this new learning phase than their age-matched peers, often un-able to correct their movement patterns through error detection orfeedback. While these children may achieve motor milestones withinnormal limits, they have difficulty learning new skills (Missiuna, 1994).They tend to have greater difficulty with skills that must be taught suchas handwriting, playing the piano or riding a bike. In particular, skillsrequiring accuracy and refined eye-hand coordination and which re-quire constant monitoring of feedback pose significant challenges forthe child with DCD (Missiuna, Mandich, Polatajko and Malloy-Miller,2001; Sugden and Sugden, 1990). Difficulties with the transfer of skills(from one activity to a closely related activity) and with the generaliza-tion of motor skills (performing motor activities in different contexts orsituations) have been frequently noted (Goodgold-Edwards and Cermak,1990; Missiuna, 1994; Missiuna et al., 2001; Sellers, 1995). Childrenwith DCD have difficulty analyzing task demands, and interpreting ap-propriate cues from the environment. They tend not to use knowledge oftheir performance to prepare for upcoming actions, and have difficultyadapting to situational demands (Missiuna, 1994; Missiuna and Mandich,2002). It would seem reasonable, then, from a motor learning perspec-tive, that providing feedback at the right stage of learning as well as op-


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portunities to solve movement problems may be instrumental guidingprinciples for children with movement difficulties (Missiuna andMandich, 2002). It is likely that interventions that directly target thetransfer and generalization of new skills and which emphasize motorlearning will be the most successful.

Many techniques to foster motor learning can be incorporated into in-tervention and include providing verbal instructions, positioning, han-dling and/or providing opportunities for visual or observational learning.Physically demonstrating or modeling movement strategies may also behelpful. The use of frequent practice, practice in variable settings and theconsistent provision of feedback should be key elements of any interven-tion approach for children with DCD. It is important to create practice op-portunities in different environments so that each repetition of the actiongoal becomes a new problem-solving opportunity (Missiuna and Mandich,2002).

A growing body of research demonstrates the value of task specificintervention (Pless and Carlsson, 2000; Revie and Larkin, 1993;Sigmundsson et al., 1998). Task specific intervention has, as its focus,the direct teaching of functional skills in their environments with the in-tended goal of reducing activity limitations and, by implication, in-creasing participation levels. It is an individualized approach whichattempts to increase the efficiency of movements by optimizing the wayin which skills are performed, given the constraints within each of theseveral systems that interact during task performance–the child, the taskitself, and the environment (Larkin and Parker, 2002). As the child at-tempts to solve a movement problem, they may discover several waysto complete a motor task. Children explore different solutions to motorproblems, and are encouraged to experience the resulting effects of us-ing different aspects of their bodies or the environment. The therapistguides the child in choosing which of these different ways of perform-ing represents the most efficient, optimal way for them individually,and in a specific environment. In task specific intervention, the therapistis directive, providing verbal instructions, visual prompts or physicalassistance by guiding and directing movement so that children can ap-preciate the “feel” of efficient movement. Based on tasks that the childneeds or wants to perform, the goal of task specific instruction is toteach “culturally normative tasks in mechanically efficient ways (p. 238)”(Larkin and Parker, 2002) with the result that children will be lessclumsy and will derive more enjoyment from the performance of tasksthat were previously performed poorly (Revie and Larkin, 1993). Whilethere is good evidence for children learning the tasks that are taught


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through a task-oriented approach (and since they are culturally norma-tive skills, this is important), there is not much evidence for transfer orgeneralization in this approach (Miyahara, 1996; Revie and Larkin,1993), significant considerations when choosing an effective interven-tion for the child with DCD.

Like the task-oriented approach, interventions employing cognitiveapproaches also address activity and participation goals. Cognitive ap-proaches use direct skill teaching in their approach but differ in theirunique problem-solving framework that attempts to help children gener-alize from the learning of one skill to the next. They stress the importanceof children learning to monitor their performance and use self-evaluation.Mediation is used wherein children are guided to discover problems, gen-erate solutions and evaluate their success independently (Missiuna,Mandich, Polatajko and Malloy-Miller, 2001). Emerging research exam-ining a specific cognitive approach, the Cognitive Orientation to Occupa-tional Performance, is showing promise (Mandich, Polatajko, Missiunaand Miller, 2001; Miller, Polatajko, Missiuna, Mandich and MacNab,2001; Polatajko, Mandich, Miller and MacNab, 2001). This cognitive ap-proach has been shown to be effective in a research clinic setting and, ofnote, has shown some generalization and transfer of skills (Polatajko etal., 2001). Ongoing research will determine if this approach can be usedeffectively in other settings.

Task specific and cognitive approaches target intervention at thelevel of activity. In order to increase participation levels, a key role forphysical and occupational therapists lies in consultation with familiesand physical educators about appropriate leisure activities that will bemost successful for children with DCD with the long-term goal of pre-venting the physical effects of inactivity. While the primary impair-ments of the child with DCD cannot be changed, the decrease instrength and fitness that can result from the avoidance of physical activ-ity is not inevitable. In sports and leisure activities, the emphasis shouldbe placed on encouraging participation and fitness rather than competi-tion. Activities should be encouraged that do not require constant moni-toring of feedback during the performance of the task including lifestylesports such as swimming, cycling, running, skating and skiing (Handsand Larkin, 2002; Missiuna et al., 2003). As would be expected for thechild with DCD when learning new skills, these sports may initiallypose a challenge. However, these children can become quite successfulwith many sports that have a repetitive nature to the movements. Theneed for ongoing adaptation to changes in the environment is also a con-sideration: running on a smooth surface like a road, for example, will be


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much easier for a child with DCD than running on a forest trail. Sportsthat have a high degree of spatial uncertainty or unpredictability such asbaseball, hockey, football and basketball are less likely to be successfulfor children with DCD (Hay and Missiuna, 1998). Sports that tend to betaught through verbal guidance such as karate and swimming may beeasier for children with DCD to learn. Parents have found that theirchild’s involvement in organized sports is greatly enhanced if coachesare flexible about the child’s role (e.g., having the child with DCD bethe goalie or the referee) (Missiuna, Moll, Law, King and King, 2006).Self-esteem is promoted through participation in these types of activi-ties and children appreciate when effort and personal mastery are em-phasized (Causgrove Dunn and Watkinson, 2002). Resources regardingother ways to promote increased participation in community sports andleisure activities are available for parents, service providers, coachesand community leaders on the website of CanChild Centre for Child-hood Disability Research (CanChild, 2004). A summary of key sugges-tions appears in Table 1.

In a practical sense, the way in which the intervention approachesoutlined above are used will depend on the age of the child. For youn-ger children, a participatory or consultative approach may be most ef-fective. Using the principles of motor learning, it is important toprovide children with DCD with appropriate feedback and to helpthem to focus on the salient aspects of a given activity by giving themverbal guidance as they proceed through it. For older children, directintervention with a more cognitive approach can be used where thechild is encouraged to think independently through motor problems.Whether a direct or consultative method of intervention is used, in-creasing a child’s self-efficacy should be a major aim of therapy(Stephenson and McKay, 1991).

SUMMARY AND CONCLUSIONS

Physical and occupational therapists can have an impact on the par-ticipation levels of children with DCD by using appropriate descriptiveinstruments to determine who might benefit from particular types of in-tervention, and providing intervention based on current best evidence.Although reducing primary impairment may no longer be an appropri-ate goal, therapists can provide intervention that will prevent secondaryimpairments in strength, fitness and endurance by improving perfor-


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mance of, and participation in, motor activities. Through consultation toparents and educators regarding the specific types of sporting and lei-sure activities that are likely to be successful for children with DCD,therapists can encourage a healthy lifestyle and improved physical fit-ness (Missiuna et al., 2003). These will, in turn, go a long way toward


TABLE 1. Promoting Participation in Physical Activity in Children with Develop-mental Coordination Disorder

• REWARD EFFORT; provide frequent encouragement

• During physical activities, encourage participation rather than competition; emphasizefun, fitness and skill building

• If possible, provide one-to-one instruction when teaching new skills

• Use different teaching methods to demonstrate new skills (e.g., show the movement whileusing language to describe it)

• Provide hand over hand instruction during the early acquisition phase (e.g., have childdemonstrate a new skill to a group with the instructor guiding the movement)

• Break down skills into smaller, meaningful parts

• When giving feedback, use clear and specific language (e.g., “raise your arm up higherwhen you throw”)

• Keep the environment as predictable as possible when teaching a new skill

• Explain new activities and rules of game play when the child is not concentrating on themovements

• Modify/adapt equipment for safety (e.g., use nerf balls, bean bags)

• Reduce the motor part of craft activities (pre-cut/paste craft pieces, pair with another childto cut/paste)

• Use markers for printing, colouring, drawing–focus on enjoyment, not the final product

• Ensure child is seated supportively during table activities

• Allow child to change positions/move frequently

• Use verbal/visual instructions frequently during activities and games

• Be consistent with routines

• Encourage child to take on a different, but meaningful, role in some activities(e.g., referee, scorekeeper, time keeper)

• Recognize child strengths and reinforce social interaction

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ending the cycle of withdrawal from activity, diminished opportunitiesfor physical development, and decreasing fitness and strength over time,a pattern so common for children with DCD.

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exploring assessment tools and the target of intervention for children with developmental...

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