Download John Cairney - Department of Family Medicine

Why Can’t Johnny Tie his Shoelaces?
Developmental Coordination Disorder in
Children: Implications for Primary Care
Dr. John Cairney
McMaster Family Medicine Professor of Child Health
Departments of Family Medicine, Psychiatry and Behavioural
Neurosciences
Offord Centre for Child Studies
CanChild Centre for Studies in Childhood Disability
What is DCD?


DSM-IV (American Psychiatric Association, 2000)
Essential feature is a “marked impairment in the
development of motor coordination”
(1) Impairment
must significantly interfere with
academic achievement or activities of daily living
(2) coordination difficulty not due to a general medical
condition (e.g., CP or MD), and criteria for
pervasive developmental disorder not met
(3) If mental retardation is present, motor difficulties
must be in excess of normal for that population
By other names …

“Specific Developmental Disorder of Motor Function” (WHO, 1992)

“Minimal Neurological Dysfunction” (Henderson et al., 1992)

“Playground Disability” (Hay and Missiuna, 1999)

“Clumsy Child Syndrome” (Bax, 1999)

“Dyspraxia” (Zoia, 1999)

This terminology was replaced by “Developmental Coordination
Disorder" or “DCD” based on the recommendations from the
International Consensus Meeting on Children and Clumsiness (London,
ON, Canada, 1996).
Signs and Symptoms

Gross Motor Deficits:
Hypotonia
 Immature balance responses
 Awkward running pattern
 Frequent falling
 Dropping of items
 Difficulty in imitating body positions
 Poor physical activity performance

Signs and Symptoms
 Fine
Motor Deficits:
 Handwriting
 Gripping
 Dressing
items
VIDEOS

subject3v2.wmv

subject4v2.wmv
Cause?
Uncertain
 Origins in fetal brain development
 Cerebellum

Prognosis? (clinical evidence)
DCD symptoms persist through
adolescence (adulthood?) contributing to
increased risk for:



psychiatric disorders
academic failure
physical health problems (associated with
inactivity – cardiovascular risk)
Intervention / Treatment
Mixed evidence
 Evidence of efficacy for cognitive,
client centered, task based
interventions
 Environmental accommodation –
coping & Advocacy

PHYSICAL
HEALTH
ACTIVITY
STUDY
TEAM
PHAST I

In 2004, my research team was awarded
$520,000 from CIHR to study:

Motor proficiency in relation to physical
activity, physical fitness, body weight and
self-efficacy over time (3 years), in a large
cohort of children in grade 4
PHAST I: Sample
Target Population: All children enrolled in
Grade 4 (Public School System) in Niagara
 Response (school level): 75 of 90 (83%)
schools consented to take part
 Response (student level): 2297 of 2378
(95.4%)

PHAST I: Design
Study Began Spring (May/June 2005)
 Tested twice a year (fall and spring)
 From grade 4 to present (children started
high school this past fall
 Data presented here is till grade 7
 All testing completed in schools

PHAST I: Design

75 schools were randomly assigned to 3 groups; motor testing
(BOTMP-sf) was conducted over 3 time points (25 schools per
wave). Trained Research Assistants administered the test (2-3
students)

After each test, 8 children (6 who scored <5th percentile, 2 who
scored >5th percentile) were randomly selected.

An OT, blind to the BOTMP-sf scores, assessed the children
on the K-BIT and the M-ABC
PHAST: Measures
BOTMP-sf (M-ABC, K-BIT)
 CSAPPA (Hay, 1992)
 Participation Questionnaire (Hay, 1992)
 BMI / Waist Girth (sitting height to derive
peak height velocity)
 VO2 Max – Shuttle Run
 Teacher Reported Physical Activity / Ability
 Harter Scales

Method Phase I: Survey and
Cardiovascular Risk Factor Assessment
Classroom
Gymnasium
Method Phase II: Motor-proficiency
Testing
BOTMP-SF:




14 item - short form
Gross motor skill
Fine motor skill
Blind and independent to
Phase 1 results

Evaluated parameters:

Running & response speed, strength, balance, agility, upper-limb coordination,
dexterity, bilateral coordination.
Three Important
Questions
1.
Prevalence?
2.
Who are we identifying using the BOMTP-sf
(administered by trained research assistants under
field conditions)?
3.
How stable are the motor assessments over time?
Prevalence
n=111 children (46 males, 65 females)
 5.3%

Results of the OT Assessment



21 of 24 (87%) children identified as probable cases of
DCD on the BOTMP-SF scored below the 15th percentile
of the M-ABC, a PPV of 0.88 (95% CI=0.69 to 0.96).
Fifteen of these children (71%) were below the 5th
percentile (PPV= 0.63; 95% CI=0.43 to 0.79).
Two children, both probable cases of DCD, were found to
have scores below 70 on the K-BIT
Cairney J, Hay J, Veldhuizen S, Missiuna C, Faught B. On the validity of using the short form of the
Bruininks-Oseretsky Test of Motor Proficiency to identify Developmental Coordination Disorder.
Child: Care, Health and Development (in press)
Stability of Motor Testing
We retested 77 children drawn from 5
randomly-selected schools
approximately two years after their
original assessment.
 Examiners (all new) were blind to the
original results.
 The correlation between the two sets
of scores was 0.70 (p<0.001)

Statistical Analysis


Mixed effects models (HLM)
In all models, we tested for:




Main effects for pDCD, gender and time
Interactions between these factors
non-linear effects of time on each outcome
We included random intercepts at the school and
student levels, as well as a random slope for time.
Analysis of the data revealed possible seasonal
effects, so we chose to use an unstructured
covariance matrix.
Relative Weight &
Abdominal Fat
Outcomes:
1)
BMI (kg/m2)
2)
Waist girth (cm)
3)
Overweight/obesity (BMI cut-points derived from
Cole et al. 2000)
Cairney J, Hay J, Veldhuizen S et al. (in press) Trajectories of Relative Weight and Waist
Circumference in Children with and without Developmental Coordination Disorder Canadian
Medical Association Journal
Figure 1. Predicted BMI for children with and without pDCD by
gender.
Figure 2. Predicted waist girth for children with and without pDCD by
gender.
Figure 3. Predicted probability of obesity for males with and
without pDCD.
PHAST II



All children (n=61) screened positive for DCD
and 61 age, sex and school matched
controls selected for further study
Lab based assessment; full clinical
assessment for DCD (intelligence testing,
impairment assessment); cardiovascular
health assessment
In-home interviews conducted with child and
parent (ADHD/ADD, social anxiety, selfesteem, competence)
Discussion

Trajectories suggest that the cross-sectional
differences we have previously observed
between children with pDCD and typicallydeveloping children are maintained, and in
some cases increase, over time (this
developmental period)

Our concern about long-term risk is justified
(things do not appear to be getting better)
The STACK Study
The STACK Study
Screening, Tracking and
Assessing Coordination in Kids
“Examining the co-occurrence of psychological problems in a
population based sample of children with Developmental
Coordination Disorder”
Funded by Canadian Institutes for Health Research (CIHR)
January 2007 - 2009
Objectives
Examine prevalence of depression and social anxiety in children
with DCD, ADHD, DCD&ADHD, compared to controls.
** Screen for DCD and ADHD in a general population sample
**
In the process help promote DCD awareness for teachers,
parents and students and provide educational materials and
recommendations for families.
Design

Two-stage, population-based, crosssectional study

Children in Grades 4-8 recruited from 23
schools in 2 school boards

3151 children (1590 boys, 1561 girls)
screened

OT visits to home to conduct motor
assessments, interview parents and
children
Research Criteria Applied
Assessments

Parent & Child Completed Measures
of Depression and Anxiety
• Children’s Depression Inventory
(CDI)
• Screen for Child Anxiety Related
Emotional Disorders (SCARED)
Results: Description of the
Children
DCD only
DCD/
ADHD
ADHD
only
Typical
68
54
31
91
244
Gender:
Male
56%
65%
87%
51%
60%
Female
44%
35%
13%
49%
40%
IQ
109.81
(14.1)
103.48
(13.12)
103.68
(12.25)
108.01
(12.1)
106.96
(13.1)
11.0 (1.48)
11.6 (1.51)
11.3 (1.49)
11.5 (1.49)
11.4 (1.50)
Children
who met
criteria (N)
Age in
years:
Total
Results: CDI Child and Parent
Total
20
*
18
16
14
12
10
8
*
*
*
*
DCD only
DCD and ADHD
ADHD only
Typically developing
6
4
2
0
CDI Child
CDI Parent
Differs from Typically Developing
*p<0.01
Results: CDI Child by
gender
14
12
**
**
10
8
Males
6
Females
4
2
0
DCD only
DCD and ADHD
Typically
Developing
Differs from Typically Developing
**p<0.001
Children with DCD in
Primary Care Settings

Greater risk of risk for CVD


Inactivity, obesity, other risk markers
Greater risk for emotional/behavioural
problems

Depression, anxiety, low self-esteem
Primary Care
Annual health examinations are ideal
times to screen for DCD.
 Parents can be asked to complete a
self-administered questionnaire
 E.G., DCDQ http://dcdq.ca/

Primary Care



Physician can conduct a structured
interview, listening for difficulties commonly
associated with DCD.
In addition, the physician can assess the
child using simple screening activities
administered in his or her office
Children with symptoms or signs of a motor
coordination disorder require further
evaluation.

An assessment that takes into
account the differential diagnosis of
DCD is necessary, since DCD is a
diagnosis of exclusion.
New Study





Framed in the context of pediatric obesity &
ParticipACTION
We tested 335 children, randomly drawn from our
PHAST study using two different motor tests
Of the children who scored poor on both tests, 50%
were overweight/obese
Perhaps more importantly, of all the children who were
overweight/obese (85), 40% had poor motor
coordination by one or both tests
When you children in your clinic with weight issues,
are you thinking about diet and physical activity? Are
you asking, what if they can’t be physically active for
reasons related to motor ability?
Importance of Identification
Rule out other medical problems
 Successful treatment approaches
involve various allied health
professionals, and the child's parents,
physician and teachers - Goal is
management strategies
 Advocacy

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