Motor Skills Disorder Clinical Presentation

Children who find performing certain motor tasks difficult, frustrating, or even impossible often become discouraged and subsequently avoid these tasks altogether. Statements such as, "I hate to draw,I hate writing," or "I hate sports," may be their way of disclosing the incompetence they feel while attempting to save face. Eventual avoidance of challenging physical tasks in a child who works hard on drawing or writing with poor results is understandable. Children with developmental coordination disorder (DCD) often end up feeling angry, frustrated, or sad.

Children who state their dislike for physical tasks may make identifying the true problem difficult for parents and clinicians. Children may not volunteer that, in addition to not liking specific activities or tasks, they feel inadequate in performing them. When a child reports not enjoying most physical activities, careful observation may be required after the child is asked to perform a few motor tasks to demonstrate the degree of challenge these activities pose to the child.

When the condition is serious and noticeable to everyone, the child is most likely to be stigmatized at school and often at home. Children with motor coordination difficulties often feel ashamed of their poor ability to perform many motor tasks, especially those required to participate in sports and to achieve skills in school (eg, cutting with scissors, coloring, drawing, writing).

The manifestations described above are based on the assumption that children have the opportunity to practice motor activities and are taught them. Children require a minimum of exposure and practice to develop dexterity with scissors and drawing. A child who is notably neglected or not exposed to usual physical tasks may have physical deficits for these reasons.

Crucial aspects in motor development are exposure to tasks, caretakers who recognize the child's developmental needs, the opportunity for the child to be taught skills, appropriate stimulation of the child, and an opportunity for the child to develop and practice new movements. These aspects have been termed the dynamic theory of motor development, which postulates that children develop new motor skills as they are needed, depending on the interactions with the environment and on the challenges presented. Practice, experience, and environment are important determinants of development, in addition to the child's intrinsic genetic capacities. Development is shaped by a process of selection in which children develop movement repertoires that are optimal for functioning in their specific environmental conditions.

The clinical picture of motor coordination problems is assessed from a developmental point of view, ie, by considering normal physical capacities at different ages. Evaluation of a child's development includes a consideration of individual variation, ie, by factoring in the range of time at which motor skills, for example, are normally acquired. Evaluating the overall development of a child is preferable; consider the characteristic style and strengths and weaknesses of each child.

• Manifestations in infancy

  • Infants with difficulties in motor functioning may appear hypertonic or hypotonic. If infants react strongly to any slight auditory or visual stimulation by becoming stiff or by arching the back, this is a sign of hypertonicity and hyperreactivity. Young infants maintain flexor tone in the first few months of life and only gradually develop extension patterns. When parents report that their baby is strong (ie, the muscles appear hard and tense), this merits careful examination of motor patterns. Clinicians should allow for individual variations; however, if primitive reflexes (eg, Moro, plantar, or rooting reflex) persist after 6 or 7 months, concern regarding motor development is warranted. One single sign may be insignificant, but persistence of several primitive reflexes should elicit full examination of motor functioning and overall development.
  • Anecdotal data suggest that infants in some racial groups, eg, African Americans, generally achieve gross motor skills more quickly than children of other racial groups. When small infants appear almost ready to walk at a few months of age, this is a sign for concern. Infants who move as an entire unit without correcting the angle of the head toward the vertical line when held sideways may have a motor developmental problem.
  • Infants with motor challenges are often delayed in achieving milestones such as the ability to roll over, to sit with help, and to sit without help. Infants with motor problems may not be able to sustain their weight after 6 months when supported under their arms. They have a tendency to slip through the supporter's grasp. This signals muscular hypotonicity.
  • At around age 4 months, infants can start anticipating the movement of objects, showing early visuomotor development. At around age 6 months, they can usually oppose the thumb in the grasping motion.
  • By age 9 months, while sitting by themselves, infants should be able to self-correct posture when tilted to 1 side or the other, rather than just being tipped over. In some infants, these self-correcting reflexes are absent. Infants also develop a refined pincer grasp around this age.
  • If the infant is not able to sit by him or herself by 9 months of age, this lack should concern the clinician and prompt detailed examination.
  • Infants who stand and who always point down with their toes may also be signaling hypertonicity of the lower limbs (or generalized hypertonicity) and high sensitivity to touch in the plantar surface of the feet. These infants may later walk on their tiptoes.
• Manifestations in the second and third years of life

  • Subtle difficulties in motor functioning of children in the early years may be difficult to identify. For instance, toddlers who have subtle motor skills deficits in chewing may not accept foods that require greater chewing ability. Eating solid food requires the coordinated functioning of approximately 31 pairs of muscles and the coordination of breathing with the swallowing of the bolus. Toddlers who do not eat solids may be displaying a marker of motor challenge that may extend beyond chewing. This also applies to toddlers who repeatedly choke on chewed food.
  • Children may have difficulty in the ability to make a pincer grasp (to pick up small objects with the index finger and the thumb). A pincer grasp normally appears around the eighth or ninth month but may appear later. It can be tested by allowing children to pick up a small object from a flat surface, such as a piece of breakfast cereal. Infants may continue trying to pick up these objects with a palmar grasp (ie, with the whole anterior surface of the hand). If so, they should be observed for fine motor delay.
  • At the end of the first year of life, most infants start making efforts to walk while holding onto furniture and take their first steps shortly afterward. Infants who are unable to walk after age 18 months may have hypotonicity or hypertonicity, poor muscular strength or coordination, and difficulty with managing equilibrium, balance, and posture. In a 1990 study by Bax et al, most children who did not walk at age 18 months turned out to be healthy, but a small percentage had motor difficulties, including cerebral palsy and other developmental delays.^[7]
  • The ability to walk largely depends on the capacity to maintain balance and not fall over. Walking takes more than the sheer muscular strength to support the weight. The challenge is to displace the weight without falling; however, both abilities are necessary. Other factors involved in walking onset include temperament style, opportunity and motivational factors.
• Manifestations in preschool- and school-aged children

  • At the age of 3-5 years, many skills are acquired and refined with exposure to activities and games that require motor practicing. Children obviously vary in the speed of their development, and strict dates or milestones of age that are totally accurate cannot be established. By age 2 years, many children can make a brief 2-foot take-off jump if someone holds their hands. At 3-4 years, most children can hop on 1 foot; with the dominant leg, they can hop about 3 times. This hopping can be performed about 10 times in children aged 5-6 years. By age 5 years, most children can jump about 3 feet in distance and about 1 foot in height.
  • By the age of 4-5 years, most children have developed a clear hand preference or dominance. Lack of a hand preference may signal that the normal dominance and specialization of the brain hemispheres is not occurring. Such children do many things with either hand or with 1 hand or the other at different times. In some cases, true ambidexterity is present (the ability to actually perform tasks well with either hand). However, in many cases, the brain is not developing an adequate specialization of neuronal pathways to control motor function with one hemisphere. In those cases, the clinician can observe hesitations and the inability to select one side, resulting in relative clumsiness in both limbs.
  • Another sign of concern is difficulty with maturation of pencil grasp. Concern arises in children who have practice opportunities and who still cannot hold a pencil with a mature pattern.
  • Many experts think that difficulties in fine motor skills (ie, in managing the fingers and wrist) are more a reflection of malfunctioning in the proximal areas of the upper limbs than in other areas. Children may be unable to handle the pen, crayon, or pencil in the dynamic tripod pattern described above. This is considered the mature and efficient way to tackle writing tasks. During that activity, only the wrist joint moves, while the other joints in the upper limb remain fixed. Nevertheless, when the shoulder girdle is weak, children compensate when they have to use the distal part of the upper extremity (fingers, hand). Instead of using the wrist to write, children have to move the entire upper limb to write.
  • Inability to hold and use a pencil in a typical fashion may indicate a problem in differentiating various muscle areas and activating them at will. This pattern of writing or painting is inefficient because it makes the children use extra energy for these tasks. Having to control the whole limb requires more energy than just controlling the wrist. As a result, the youngsters tire quickly and report that their hand hurts when writing. After a few minutes of drawing or writing, children who cannot use proper grasp may give up because it hurts them to continue.
  • These problems may be additive because teachers who are unaware of these difficulties may believe that the students are lazy or defiant. In objective terms, affected children cannot perform these delicate and fine movements until they maturationally achieve good differentiation of motion between the shoulder joint and the rest of the limb. Treatment of this condition is programmed exercise to strengthen the shoulder belt, causing weight bearing on the area, and also planned work on the hands to strengthen the shoulder, arm, and forearm.
  • When one evaluates young children, a great deal of the neurologic examination can be carried out in the context of play. Evaluative play tasks, including hand shaking, squeezing the examiner's fingers to assess strength, throwing and kicking a ball, cutting something with a pair of scissors, drawing, coloring, tying shoes, and taking off or putting on a coat.
• Some easily performed tests to observe tasks and abilities

  • Test for sustaining a position against gravity: Observation of muscular tone in sitting and standing positions gives an impression of the child's ability to sustain a position against gravity.
  • Test for motor sequencing: Touching the thumb against the other fingers of that hand in sequence, 1 after the other, is a way to assess whether the child can sequence movements at a certain speed. The clinician observes for errors in the sequence. Observing each hand and noting the effect of muscles getting tired quickly, which leads to additional errors, is important. In this as in other activities, fine tremors of the fingers can be observed. Also observed is an effect of overflow (performing a similar movement with the opposite side of the body), which should disappear around the age of 7 or 8 years. When children who are affected attempt a fine or difficult motion, one can observe adventitious movements, such as grimacing, sticking the tongue out, or tics.
  • Nose-finger test: This test is performed to measure fine motor coordination, proprioception, and perception of movements in space.
  • Moving a limb against resistance (feet, legs, thighs, arms, forearms, hand): This maneuver allows for an evaluation of children's strength in different areas. Some youngsters have normal strength in the lower limbs but not in the upper body, or vice versa.
  • Test of energy investment in a movement: This test is done to determine if children can perform a movement or sequence and how difficult performance of the movement is. This issue is not often considered in the assessment of writing ability or other fine movements. A child may be able to carry out this task but only with great focus and concentration, and the child may invest practically all of his or her energy in writing a few words. The child is obviously soon fatigued and unable to maintain this energy-wasting activity for a long time. As a consequence, testing for only a brief period may be misleading, whereas sustained effort and tiredness may elicit errors in performance and coordination. Sustained testing stimulates real life, where the child must sustain an activity (eg, doing homework) for more than 2 or 3 minutes.
  • Test of the ability to perceive spatial relationships: This ability is not strictly a motor task; it depends on proprioception and the realization of where one's body is in space. Children with difficulties in these functions may bump into things, crash into people, miscalculate the strength of their movements, or knock down a glass that they are attempting to take from a table.
  • Test of fine motor tasks: Activities such as coloring, drawing, or building with blocks directly reflect the child's fine motor coordination. Engaging children in play with miniature toys (eg, small cups, saucers, silverware in a pretend tea party) helps in assessing their coordination of small movements. Clinicians rarely examine only motor abilities. After motor difficulties are detected, investigating other areas, eg, visuomotor coordination, and testing for other soft neurologic signs, attention span, writing, and reading may be necessary because these are frequent comorbidities. Observations by school staff may be valuable because they have daily contact with the children when the children are attempting to perform these tasks.
  • Test for gross motor difficulties, a physical education teacher or a physical therapist may be the better resource for information about physical ability in children than a classroom teacher, as shown in a 1997 study by Piek and Edwards.^[8]

The diagnosis of problems in motor skills and coordination relies on a careful history of functioning while the child is performing motor tasks, a history of development in the motor and sensory integration areas, and the physical findings.

• Physical findings

  • Physical examination can be carried out almost in its entirety in the context of everyday activities or play. The examination should include an assessment of dysmorphic features and abnormal neurologic signs. Activities or tests that evaluate children's strength, speed of movement, sequence of movement, coordination, tone, right and left sides, and ability to perform everyday tasks in a smooth and controlled way are all important.
  • The DSM IV emphasizes a marked impairment in the development of motor coordination, which must interfere with academic achievement or with activities of daily living. A general medical condition that might explain the trouble with movement control must be excluded, eg, muscular dystrophy or cerebral palsy. Examples provided are school-aged children who have difficulty with running, holding a knife and fork, buttoning clothes, or playing ball games.
  • The International Classification of Diseases, Tenth Edition (ICD 10), describes motor skills disorder as a "specific developmental disorder of motor functioning." It emphasizes that, even when no formal neurologic condition is present, careful clinical examination shows marked neurodevelopmental immaturities, perhaps choreiform movements of limbs when unsupported or overflow movements (ie, mirror movements). Other extraneous motor actions often occur when children are attempting a specific complex movement, as well as impaired fine and gross motor coordination. Also, the condition must have existed since early in the child's life (ie, it is developmental rather than acquired). No marked difficulties in perceptual systems, such as vision or hearing, and no specific neurologic disorder should be present.
  • No criterion standard is universally accepted to test children for motor clumsiness. Rather, a number of tests and techniques of examination may help in reliably identifying the problem with similar results among the tests. The main role of the pediatrician is to detect difficulties in motor coordination and development rather than engaging in systematic or standardized testing or therapy. Commonly used instruments are discussed in Other Tests.
• Comorbidities

  • Many children with clumsiness or motor coordination difficulties also have other difficulties. Some of the most common problems that aggravate the motor coordination difficulties in children are problems in attention and concentration as well as hyperactivity (see Attention Deficit Hyperactivity Disorder). The condition that Swedish researchers Gillberg and Kadesj (2003) described as deficits in attention, motor control, and perception (DAMP syndrome) indicates the same connection.^[9]
  • Children with autism spectrum disorders, notably those with Asperger syndrome, have long been reported to have motor clumsiness. The type of motor dysfunction observed in autism has not been properly delineated in an empirical study.
  • Many children with motor difficulties have speech difficulty (eg, stuttering, problems with phonology, receptive language disorders, mixed language disorders) and may have problems in written expression (see Differentials) and other learning disabilities as well.
  • These perceptual-learning problems (see Learning Disorder: Mathematics, Learning Disorder: Reading) may be predominant in the visuomotor coordination, perceptual skills, and perception of space relationships. The problem must be addressed from several points of view and by account for all of the child's challenges.

• Genetic, intrauterine, and environmental factors may contribute to poor abilities in motor functioning.

  • Exposure to alcohol and drugs (eg, cocaine, methamphetamine) in utero increases the risk for motor coordination problems in the fetus. Alcohol has direct effects on the neurons of the embryo or fetus, and cocaine and other stimulants are suggested to affect the contraction of arterial vessels in various areas, leading to microinfarctions (eg, in the brain of the fetus).
  • Another major risk factor is prematurity. The more premature the baby, the more the migration and connections of neurons may be disturbed, leading to difficulties with attention span, self-control, self-inhibition, and motor coordination problems, as shown in follow-up studies.
  • Even tobacco is reported to have a negative effect.
  • Also, comorbid conditions, such as high levels of lead, anemia, and iron deficiency should be ruled out.
• Genetic influences may also contribute to motor coordination difficulties.

  • For instance, familial clumsiness was noted in a study of 1134 children in Sweden by Landgren et al in 1998.^[10]
  • In many instances, the factors mentioned above are absent; however, the child is nonetheless challenged in movements and needs special assistance to carry out everyday activities.