eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Motor Skills Disorder

Anna Maria Wilms Floet, MD, Assistant Professor, Assistant Professor of Pediatrics, Department of Pediatrics, Behavior and Developmental, University of Maryland School of Medicine
J Martin Maldonado-Durán, MD, Principal Investigator for Child and Family Center, Department of Psychiatry, Child and Adolescent Division, Family Service and Guidance Center; Jill Glinka, OTR, Occupational Therapist; Sari Lubin, OT, Occupational Therapist, Shoam Hospital, Israel

Updated: Dec 12, 2006

Introduction

Background

Movement clumsiness has gained increasing recognition as an important condition of childhood. However, its diagnosis is uncertain. Approaches to assessment and treatment vary depending on theoretical assumption about etiology and its developmental course.

During the last century, many terms have been used to describe children with clumsy motor behavior.Variation in labeling has been systematically different and has depended on cultural and/or professional backgrounds. For example, medical professionals use medical terms (eg, clumsy child syndrome, minimal brain dysfunction), whereas educational professionals use educational terminology (eg, poorly coordinated children, movement-skill problems, physical awkwardness). A variety of labels include assumptions about the etiology. Examples include developmental dyspraxia (which suggests underlying difficulties in motor planning), perceptual motor difficulties (which suggests problems in perceptual motor integration), minor neurologic dysfunction (MND), and sensory integrative dysfunction.

Although heterogeneity in labels is confusing and counterproductive, participants at an international multidisciplinary consensus meeting in 1994 agreed to use the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) term developmental coordination disorder (DCD). Although subsequent debate has emerged on several issues in the DSM IV definition, such as the construct of the term coordination, or what constitutes impaired functioning (both of which are in the current definition of DCD in the DSM IV), researchers and clinicians are increasingly accepting the use of a term that is "atheoretical."

The 4 DSM IV diagnostic criteria for DCD are as follows:

1. Performance in daily activities that require motor coordination is substantially below given the person's chronologic age and measured intelligence. This change may manifest as marked delays in achieving motor milestones (eg, walking, crawling, sitting) and as dropping things, clumsiness, poor performance in sports, or poor handwriting.
2. The disturbance in criterion 1 substantially interferes with academic achievement or activities of daily living.
3. The disturbance is not due to a general medical condition (eg, cerebral palsy, hemiplegia, muscular dystrophy), and it does not meet criteria for a pervasive developmental disorder.
4. If mental retardation is present the motor difficulties are in excess of those usually associated with it.

Little data clearly define the parameters of motor coordination difficulties in children. Various grades of severity and comorbidity seem to exist. Some children have only a relatively minor form of motor dyscoordination, whereas others have associated learning disabilities, attention deficit, and other difficulties.

In 1996, Fox and Lent found that, in contrast to the common belief that children grow out of these difficulties, they tend to linger without intervention. Early intervention is beneficial while the brain is changing dramatically during the first years of life and new connections and abilities are acquired.

Children with multiple conditions are at greatest risk of developing behavioral difficulties over time. Some evidence supports dividing DCD into subtypes based on main features such as manipulating objects, the speed of movement, catching objects (eg, balls during sports activities), or writing ability.

A discussion about including DCD, as currently defined, into the cerebral palsy category was held (Bax, 2005). This inclusion would put DCD on the low end of the continuum of neuromotor disabilities, also described as minimal cerebral palsy.

Pathophysiology

Motor coordination is the product of a complex set of cognitive and physical processes that are often taken for granted in children who are developing normally. Smooth, targeted, and accurate movements, both gross and fine, require the harmonious functioning of sensory input, central processing of this information in the brain and coordination with the high executive cerebral functions (eg, volition, motivation, motor planning of an activity). Also required is the performance of a certain motor pattern. These elements must work in a coordinated and rapid way to enable complex movements involving different parts of the body.

Our understanding of motor development in humans and its pathophysiology of motor clumsiness is only in its infancy. Because of its heterogeneity in presentation and definition, finding its cause has been difficult.

A variety of theoretical models explain the role of the nervous system in motor development.

In the traditional primitive reflex model (neuromaturational theory), higher centers exert increasing control over lower reflexes.In the dynamic systems model, the CNS interprets sensory feedback, and the appropriate movement strategy is selected on the basis of current experience, on the state of the internal and external environment, and on one's memory of similar movements.

In the more recent neuronal group–selection theory, aspects of both models are combined. Functional groups of neurons exist on all levels of the CNS. These groups are determined by evolution, but their functional integrity depends on afferent information produced by movement and experience. In both cortical and subcortical structures, these neuronal groups serve as early repositories for motor behavior or the receipt of specific sensory information.

Motor development is described in 2 phases. The first phase of primary variability is characterized by crude and erratic motor activity that does not require sensory information for its initiation or guidance. These self-generated movements give rise to afferent (visual, kinesthetic) inputs that reinforce more specific synaptic connections in each group. In the second phase, sensory and motor factors interact, resulting in specific and complex muscle contraction patterns that characterize coordinated, goal-directed movement. As increasing efficient movement patterns are practiced, appropriate synaptic circuits are reinforced and subsequently established.

Adequate realization of a motion or sequence of movements requires the convergence of numerous pathways and a central system in charge of integrating the information. The motor cortex, cerebellum, and vestibular system (which provides input about directionality, gravity, motion) are all part of this central mechanism. Proprioceptive information (ie, sensation of where the body is in space and about the positions of the limbs and parts of the body), visual input (ie, where the body is in space and where it should go), and an adequate degree of alertness (ie, the reticular formation activated to an optimal degree) all provide information to the CNS. If one of these systems is not functioning adequately, the resulting planned movement may not be satisfactory or smooth.

Discussed in this article are some of the building blocks of motor functioning that are important in understanding difficulties with motor skills, their maturation, and the evaluation of children who struggle with these challenges. Main elements in this chain of events are discussed.

Muscular tone

Muscular tone refers to the basic and constant ongoing contraction or muscular activity in the muscles. It can be understood as a baseline or background level. Tone may be normal, too low, or too high. Hypotonic children appear floppy. For example, hypotonic babies have an appearance similar to a rag doll. Infants or young children who may be hypotonic have difficulty maintaining posture against gravity and prefer to sit, leaning against something, or they may prefer to lie on the floor. Preschool-aged children may sit in a fashion that appears lazy. Rather than sitting upright, they mostly sit in a slouching manner, leaning on the chair or a table with their head over the top of the table, or they may lie down during activities as much as possible. Of course, this positioning can also be observed in older children and is often erroneously interpreted as a sign of lack of interest or even disrespect.

By contrast, when muscular tone is too high (hypertonic), children appear somewhat stiff and do not move in a smooth and natural way. Youngsters may move somewhat like a puppet or robot, and they lack the ordinarily smooth nature of movement in small motor acts.

Basic muscle tone that is too low or too high is one of the components of impaired motor skills. Children must fight low muscular tone to carry out movements, expending energy to maintain postures and activities. Hypertonic children may make many mistakes because of the overactivation of the muscular units.

Gross motor skills

Gross motor skills refer to the ability of children to carry out activities that require large muscles or groups of muscles. Muscles or groups of muscles should act in a coordinated fashion to accomplish a movement or a series of movements. Examples of gross motor tasks are walking, running, throwing something, jumping, standing on 1 leg, playing hopscotch, and swimming. Posture is an important element to consider in the assessment of gross motor skills. Adequate posture may make all the difference between being able or not able to execute a movement. This is particularly true in infants and young children. Six-month-old infants may be able to reach for a toy if sitting, but they may be unable to organize this movement if their trunk is tilted or straining to maintain a vertical position.

Fine motor skills

Fine motor skills consist of movements of small muscles that act in an organized and subtle fashion, for instance, the hands, feet, and muscles of the head (as in the tongue, lips, facial muscles), to accomplish more difficult and delicate tasks. Fine motor skills are the basis of coordination, which begins with transferring from hand to hand crossing the midline when aged 6 months. Examples of fine motor activities are writing, sewing, drawing, putting a puzzle together, imitating subtle facial gestures, pronouncing words (which involves coordination of the soft palate, tongue, lips), blowing bubbles, and whistling. Many children who have difficulties in their fine motor skills also have difficulties in articulating sounds or words.

Muscular strength

Muscular strength refers to the intensity of the muscle contraction exerted voluntarily that may be required to carry out an activity. Some children who struggle with motor clumsiness appear weak and slender and may have an inadequate strength in their movements.

On the other end of the continuum, they may appear strong and muscular. For instance, children with hypertonicity in the leg muscles, who may tend to walk on their tiptoes, may develop a higher muscular mass in the leg muscles to maintain the tiptoe position. Children who are too strong often appear brusque in their movements. Instead of softly caressing someone on the face, they may involuntarily slap the person when they are attempting to show affection. The same occurs while giving a hug, which to others may feel more like a squeeze or like being physically crushed in the child's unintentional hypertonic grip.

By contrast, a youngster with diminished muscular strength appears floppy or scrawny with thin arms, forearms, and legs. These children may execute movements that other children take for granted only at great cost. Shaking the child's hand and asking him or her to squeeze the clinician's hand are techniques to assess the child's strength. Hypotonic children cannot apply much pressure in a handshake; therefore, their handshake feels weak. They fatigue easily and claim to be unable to carry out simple tasks. For example, they may write with only thin lines and barely visible traces, and the pencil may slip out of their hand too easily.

Motor planning

Motor planning consists of the ability of children to imagine a mental strategy to carry out a movement or an action; for instance, how to get on top of a table, how to move from point A to point B and overcome some obstacle, how to execute a dance step, or learning how to skip. Typical youngsters develop some preconscious planning in the sequencing of movements, including how the body and limbs coordinate, the amount of strength required, and the necessary steps needed to achieve a specific goal.

Most of the time in unaffected children, this function is achieved intuitively and without conscious planning. However, when children have difficulties in motor planning, they carry out movements using odd strategies; for instance, trying to reach something that is out of reach without getting up from a previous position. Another example is a child trying to get down from a chair without moving the trunk and preparing himself to go down and instead just letting himself fall. When these problems exist, parents notice that the child may fall just standing, or such children frequently fall from a chair or stool. The child seemingly lacks the intuitive ability to plan how to effect a movement.

Motor planning involves a number of abilities, including the visual detection of motion and errors in movement, selection of responses, and self-corrective motions. Movements must be timed adequately, and attention and concentration are also necessary.

Sequencing and speed of movements

Sequencing and speed of movements involves the order in which movements should proceed one after the other to accomplish a desired goal. This order is mostly unconscious or intuitive. When children try to manage a complex motor act or imitate something that has been modeled, their ability to do a series of movements may be compromised. These children often have problems in other activities that might require sequencing, such as in reading, writing their ideas, or even continuous speech.

Children with difficulties in motor skills often perform movements slowly as a result of their difficulty in organizing and coordinating motion. They may also rely on visual cues to perform the movement (eg, in handwriting) more than other children do. The necessity to view the movement slows the performance.

Sensory integration

Sensory integration refers to functioning of the brain, ie, how it manages input and produces output. Outputs include motor responses. Jean Ayres proposed this theory, which many authors, mostly in the field of occupational therapy but also in mental health, have further developed.

The central concept is that children may struggle to integrate sensory input (eg, visual, auditory, tactile, and proprioceptive cues) and develop aversions (eg, to being touched, to being exposed to new sounds). Also, children may become overstimulated in any of these sensory channels, and their behavior and motor performance deteriorate in circumstances of overstimulation. Each child has a unique profile of responses to sensory stimuli. Children with motor difficulties often have problems in the integration of sensory input, which make them vulnerable to problems resulting from sensory stimulation.

Frequency

United States

Few groups have examined the prevalence of motor skills disorders in an open population. Approximately 4-6% of children of school age struggle with motor difficulties to the degree that causes concern to them and those around them.

International

In 1998, Kadesjo and Gillberg found that motor coordination disorder frequently coexisted with poor attention span and concentration and that it was comorbid in about 6.1% of children in a sample of 409 nonreferred children in Sweden. Both disorders tended to remain stable, persisting on follow-up 8 months later. Boys were affected more frequently than girls.

In a 1996 study in Singapore by Wright and Sugden, 4% of children aged 6-9 y who were randomly sampled had difficulties in motor coordination. This study included only children with impairment in motor skills that notably interfered in their functioning in everyday life.

According to studies in different countries, the prevalence of motor coordination disorders varies widely. In some studies, rates are higher than that in the United States. For instance, in the United Kingdom, 10% of all children reportedly have motor coordination difficulties. A conservative estimate suggests that 5% of children have the disorder worldwide; an additional 10% of children may have a minor form of the problem.

Mortality/Morbidity

The disorder does not directly lead to mortality. The incidence of accidents may be increased in children who have motor challenges, because of clumsiness, for example. However, this clumsiness has not been documented to raise the mortality rate.

Race

No evidence indicates an increased or decreased frequency of the condition according to racial groups.

Sex

Boys are thought to be affected more frequently than girls, though this possibility has not been systematically studied.

Age

Disturbances in motor abilities are most evident during school age as children face challenges such as physical education, sports, and writing. In many cases, children with motor coordination disturbances present at an early age, and motor coordination disturbances may be detected in children younger than school age.

Clinical

History

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 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.
  • 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.

Physical

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) descried as deficits in attention, motor control, and perception (DAMP syndrome) indicates the same connection.
  • 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.

Causes

• 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.
  • 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.

Differential Diagnoses

Learning Disorder: Written Expression
Pervasive Developmental Disorder

Other Problems to Be Considered

Cerebral palsy
Muscular dystrophy
Congenital hypotonia
Progressive metabolic disorders
Ataxia
Visual disorder
Diffuse CNS storage disease or slow virus infection

Workup

Laboratory Studies

• No specific laboratory tests for motor skills disorder exist.
• Comorbid conditions, such as high levels of lead, anemia, and iron deficiency, should be ruled out.

Imaging Studies

• Because the condition is not a specific neurologic disorder per se, no imaging studies are typically used in children with motor clumsiness difficulties.

Other Tests

• Several approaches are available to assess children with clumsy motor behavior, as listed below. Some of the assessment approaches are directly linked to proposed treatments or interventions; these are discussed in Treatment.
• Normative functional skills approach.
  • The normative functional skills approach draws from traditional developmental theory, and remains the cornerstone of motor assessment.
  • Assessment is descriptive and concerned with acquisition of fundamental motor and functional skills, as referenced against age norms.
  • The most commonly used tests of motor impairment are the Movement Assessment Battery for Children (MABC) and the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP).
    • The MABC is the most commonly used tool for screening of DCD in research. The MABC is designed to yield a general index of motor impairment. It has 2 parts: a performance test that is designed to be administered individually and that requires the child to perform a series of motor tasks in a standard way, and a checklist that is designed to be completed by an adult familiar with the child's day-to-day motor functioning. The performance part covers manual dexterity, ball skills, and static and dynamic balance. The checklist addresses progressively complex interactions between the child and the physical environment. The MABC provides norms for children aged 4-12 years. It has good psychometric properties.
    • The BOTMP is the most commonly diagnostic instrument therapists use. The BOTMP generates a general motor ability factor. It is divided into 8 subsections, including the ability to run and general agility, how well the child can maintain balance, and coordination of bilateral movements. It is also used to assess the strength of movement, coordination, speed and dexterity of upper limbs, the speed of response, and visual motor control. The BOTMP provides norms for children and adolescents aged 4.5-14.5 years. It has good psychometric properties.
• General abilities approach
  • The general abilities approach is based on the assumption that sensori-integrative and sensorimotor functions provide the platform for later motor and intellectual development.
  • The most commonly used test is the Sensory Integration and Praxis Tests (SIPT).
• Neurodevelopmental theory
  • The neurodevelopmental examination includes general examination, neurologic examination, and assessment that focuses on subtle deficits in neural functioning.
  • Several batteries have been designed, examples including the Touwen test for children with MND and the Physical and Neurological Examination for Soft Signs (PANESS).
  • Normative data are lacking for these tests at this time. Advances in neuroimaging and functional imaging may possibly provide insights into hard signs of neural dysfunction.
• Dynamical systems approach
  • This approach is based on the dynamical systems theory, describing the dynamics between perception and movement. It uses biomechanical or kinematic analysis of movement.
  • The importance of assessing contextual factors that contribute to or limit skill acquisition is emphasized.
• Cognitive neuroscience approach
  • The cognitive neuroscientific approach provides a framework that accounts for the development of motor skills in terms of brain-behavior interactions.
  • Several hypotheses have been generated by using this framework. For example, the focus on deficits for children with DCD in an internal model of an intended but uninitiated movement (in motor control terms motor imagery) could explain the difficulties that some children with DCD have performing tasks that require accurate body-scaled (mental) transformations (eg, remembering modeled movements).
  • Neuroanatomic pathways involved in this include those in the parietal lobe and premotor cortex.
  • Other hypotheses involving the cognitive neuroscientific framework include motor timing, linking deficits of time perception, and sequential tapping to possible deficits in the cerebellum.

Histologic Findings

No specific histologic patterns exist for these conditions.

Treatment

Medical Care

No single type of treatment can be applied to all children with motor coordination disorder, nor is 1 treatment successful with all. Existing evidence does not permit the conclusion that 1 of the methods described below is generally or uniformly better than the others.

Clinicians typically attempt to (1) ascertain problem areas for a given child in a comprehensive fashion and (2) then design an intervention to promote optimal adaptive functioning or the acquisition of skills that are underdeveloped or affected or the amelioration of coordination difficulties. Several studies focused on the efficacy of therapeutic interventions and even involved comparisons of different methods. In general, these studies showed that the interventions described are helpful and that parents were satisfied with the results. However, no conclusive evidence indicates that 1 technique is better than the others.

Indeed, this research field is complex because of the different problems in each child and because of the issues of comorbidity, motivation, associated emotional difficulties, and adherence to treatment (particularly with practice sessions at home). The factors make comparisons between patients and treatments weaker than if all children had the same problem and received the same intervention. Even the issue of intervention is unclear because therapists may think they are using solely 1 method, but they may unwittingly introduce elements of further or different therapeutic interventions.

Two general approaches are used to treat motor coordination problems in children. One approach is a modular approach (top-down approach), and the other is a more global or generalized approach (bottom-up approach).

The first approach, the modular or top-down approach, attempts to remedy or improve the specific difficulty (or difficulties) with specific techniques aimed at improving the motor challenge that is observed (eg, difficulty with handwriting, catching a ball, performing fine motor tasks with fingers). This approach usually involves gradually targeting certain problem behaviors and implementing step-by-step interventions to teach the skill and to practice it. This method tends to prevent failure and rewards the child, at least in the beginning.

This approach lends itself to implementation by schoolteachers because of its circumscribed nature, for example. One of its core elements is practice (eg, prescribed practice of new skills and small steps toward mastery of the skill with success at every small increment). Examples of this general tendency are therapies such as the cognitive motor approach with task orientation or the task-oriented approaches with motor learning.

The second approach is a relatively global or generalized one that is also described as a bottom-up approach. It is based on the theoretical assumption that the motor skills problem is just a manifestation of some underlying mechanism, eg, sensory integration problems or insufficient or inaccurate kinesthetic perceptions. In this method, the therapist does not initially address the observable motor challenge. Rather, the expert focuses on how children manage their bodies, process stimulation (sensory information), and deal with problems. The expectation is that the improved sensory-motor functioning becomes generalized and eventually improves the motor skills. As children become comfortable with their bodies, they gain control of their motor (and other) functions.

Examples of this school of thought are the kinesthetic training approach, sensorimotor integration therapy, or sensory integration therapy. As with many other forms of intervention and therapy, evidence of the efficacy of these methods is limited, particularly over the long term or regarding the end result.

Cognitive motor intervention

Cognitive motor intervention consists of delineating a plan to teach movement patterns or skills to children who have a challenge in that particular task or set of tasks, for example, similar to those in the Movement ABC Manual. Therapists design a set of exercises that children practice with the assistance of the parents until the task is learned gradually or mastered. Emphasis is on motor performance and also emotional, motivational, and cognitive aspects. The trend is toward solving motor deficits. Children are taught how to plan a motor act, how to execute it, and how to evaluate the quality of the result. Motivation of the patient is essential because building self-confidence and positive reinforcement are important aspects.

Motor problems are selected, and new skills are taught 1 at a time, gradually building skills. The ability acquired in 1 context is expected to generalize to other contexts. For example, this could be used for teaching handwriting, catching balls, or increasing speed of movement. Other objectives could be teaching the child to throw a ball overhand and to kick, bounce, and catch a ball. Following the piagetian theory of learning, the therapist hopes to create a schema that children can use later in different situations.

Feedback is important at each step. Concrete, positive reinforcers are gradually de-emphasized and substituted with emotional reinforcers, eg, the satisfaction of learning new things. One of the advantages of this method is a measurable goal; therefore, obtaining objective feedback about the development of new concrete skills is possible.

Sensory integration therapy

Occupational therapists and physical therapists widely use sensory integration in the treatment of children with certain difficulties that interfere with consistent, coordinated, and effective motor function. Sensory integration therapy addresses the underlying difficulties many clumsy children have with regulating, processing, and/or integrating sensory input. Accurate, coordinated, and functional motor responses are based on well-modulated, selective, and consistent information from both internal and external sources, which the brain then adequately integrates. Treatment involves specific input for the particular child and the facilitation of desired adaptive responses. Examples of internal senses are those of posture, proprioception, and awareness of position of the body in general and of limbs and body parts in particular (ie, vestibular input).

External stimuli that may facilitate or hinder performance may include auditory stimuli, lighting and visual stimulation, tactile sensations, and others. Children who are excessively affected by such stimulation (who are, therefore, hypersensitive) are helped to cope with increasing amounts of stimulation, and the environment is modified to provide an acceptable level of sensory input. By contrast, in children who are hyposensitive, the amount of stimulation is gradually increased. In all cases, signs of excessive or inappropriate stimulation are monitored. Also, techniques to help the children self-modulate and self-regulate are useful. Examples are time without stimulation with relaxation and brief periods of isolation to recuperate a state of calmness.

This therapy is effective but not necessarily better than other methods. Sensory integration approaches also provide for a variety of techniques that can be incorporated into the home and classroom to promote improved adaptive function. Examples are methods to provide the extra proprioceptive input that a particular child may seek and need, such as carrying book crates during transitions, holding heavy doors, and chair pushups. The general idea is that improved sensory integration will lead to more modulated motor responses, better perception of the movements, and improved coordination of fine and gross motor patterns.

Kinesthetic training

Kinesthetic training relies on the studies on kinesthetic development in children by Laszlo and Bairstow (1985). It deals with improving the kinesthetic sensitivity in children to improve motor control. The intent is to improve perceptual-motor dysfunction. Although popular, the approach has generated controversies about success the authors have claimed. This method tries to generate improvement in the overall functioning of children in terms of perception of motion, but it does not focus on teaching them specific skills, as other methods do. Therefore, the theory behind this training is that when general awareness of motion in space is improved, the motor skills also improve as a secondary effect.

Neurodevelopmental treatment

Karl and Bertha Bobath, 2 physical therapists in England, described the neurodevelopmental treatment approach beginning in the 1940s. The basic principles of treatment involve inhibition of primitive (persisting) reflexes and abnormal motor coordination patterns. At the same time, it promotes higher-level reactions and normal muscular tone and movement patterns. Therefore, these authors emphasize detailed evaluation of the patterns of development observed in the small child, diagnosing the child's developmental level, and designing a strategy to restore development to as normal a level as possible and to improve skills as much as possible.

Craniosacral therapy

Osteopathic physician John E. Upledger devised the technique of craniosacral therapy. Trained therapists from a variety of professional backgrounds use highly sensitive palpatory skills to address imbalances in the craniosacral system. The treatment is reported to be successful mostly in children who have the most compromised motor skills, who have some spasticity or hypertonia, and who have an abundance of health problems including motor coordination difficulties.

Visual training

Visual training is an approach some optometrists or trained occupational therapists use to address specific difficulties with oculomotor function. Some visually related difficulties or difficulties with visual-motor integration interfere with coordinated motor skill performance and equilibrium. The American Academy of Pediatrics has officially deemed this visual training of eye movements as ineffective and unacceptable.

Assistive technology

In addition to various therapies, assistive technology is used to develop adaptive methods to enhance the function of children with motor difficulties. These modifications include things as simple as special pencil grips (making the pencil easier for the child to grasp) to the use of voice computers for those with writing difficulties.

Surgical Care

No surgical procedures exist to be used in these conditions.

Consultations

• Evaluation by an occupational therapist with experience in assessing all aspects of motor functioning and sensory integration abilities is useful in characterizing the problem. An occupational therapist can also assist in developing an intervention strategy.
• A physical therapist with experience in evaluating children can help to design beneficial programs for children with coordination problems.
• In cases of comorbid learning disabilities, consultation with a specialist in psychoeducational testing (a psychologist or a teacher with this training) can assist in designing a treatment strategy.
• Problems with attention span and hyperactivity are often associated with motor skills problems, as well as difficulties in behavior and self-esteem. If these interfere with the child's academic performance, motivation, or attitude toward learning, consultation with a mental health professional is indicated.

Diet

No special diet is recommended for children with motor skills disorders, nor has any diet been described to improve the motor functioning of children.

Activity

By definition, activities and motor functioning are essential for the treatment of these children. See Medical Care. Of importance, besides the treatment occupational therapists or motor rehabilitation specialists offer, parents and other caregivers can provide considerable help for children at home with specifically designed games and activities that could assist in improving the child's motor functioning and self-esteem.

Medication

No medications are specifically designed to improve motor functioning, coordination, or related conditions. Propranolol, like other beta-blockers, has been used to treat intense essential tremor, which sometimes is an associated condition in children with coordination problems. Medications are used to treat associated conditions, such as attention deficit disorder. Medical approaches to attentional problems are described in a separate article (see Comorbidities).

Follow-up

Inpatient & Outpatient Medications

• No specific pharmacologic treatments improve motor performance.
• In children who have essential tremor that is severe enough to interfere with motor abilities, propranolol and other beta-blocker agents can be used. This therapy is described in the eMedicine article Essential Tremor.

Complications

• Some children with DCD become demoralized, develop poor self-esteem, and withdraw from daily activities including those involving motor tasks (eg, drawing, writing).
• They may develop a feeling of being different.
• In some cases, children who show withdrawal behaviors are mistakenly believed to be poorly motivated, lazy, or not willing to make the effort to do a good job.
• Pediatricians and other health professionals must be sensitive to the signs and symptoms of emotional withdrawal based on a child's fear of failure and a sense of hopelessness.
• Children who have poor self-esteem and who accept the premise that they are lazy, incapable, or stupid require intervention from a mental health professional. Children who continue to have these feelings without help often show poor social functioning and compromised emotional development.

Prognosis

• In the absence of intervention, children with motor coordination disorder tend to have symptoms that persist through adolescence into adulthood.
• In follow-up study of children in whom motor coordination disorder was diagnosed at the age of 15 years, Cantell et al (1994) found that 46% had persistent symptoms at the age of 25 years.

Patient Education

• Children aged 6 or 7 years can be positively counseled to make modifications in school and in social situations to make the best of their limitations in motor tasks.
• Acknowledging these facts and helping the children understand that this problem is not voluntary on their part and not due to lack of effort or intellectual skill is important.
• As with other chronic medical conditions, the patient can be helped to understand the nature of the condition, to live with it, and to participate in its treatment.

Miscellaneous

Special Concerns

• Controversy exists regarding how much accommodation should be implemented in school for a child with a motor coordination difficulty.
  • In a child who has severe problems writing, opinions regarding how school personnel should attempt to help differ. Some think that the child should be expected to practice extensively with the expectation that the handwriting will improve; others believe that this child should be allowed to exclusively use a word processing keyboard. In some cases, a child with a writing problem dictates his or her thoughts to others and does not attempt to write.
  • These complicated decisions regarding the creation of the most responsible and effective school intervention for a given child can be decided only on a case-by-case basis after experienced professionals performed individualized evaluations.
• A controversial issue is whether adolescents with DCDs should be able to obtain a license to drive a car.
  • Adolescents are typically eager to learn to drive to increase their mobility and to expand peer relationships.
  • Adolescents with DCDs may have difficulties with right-left coordination, crossing the body midline, depth perception, or other abilities that compromise optimal driving ability.
  • No generalizations can be applied to this situation because a rational and responsible decision depends on an individual evaluation of the given adolescent's abilities or difficulties and on the degree of danger of the activity.

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Keywords

motor skills disorder, developmental coordination disorder, DSM IV, developmental motor coordination disorder, motor clumsiness, clumsy child syndrome, developmental dyspraxia, specific developmental disorder of motor function, ICD 10, clumsiness, dyscoordination disorder, motor dyspraxia, minimal cerebral palsy, developmental coordination disorder, DCD

Contributor Information and Disclosures

Author

Anna Maria Wilms Floet, MD, Assistant Professor, Assistant Professor of Pediatrics, Department of Pediatrics, Behavior and Developmental, University of Maryland School of Medicine
Anna Maria Wilms Floet, MD is a member of the following medical societies: American Academy of Pediatrics and Society for Developmental and Behavioral Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

J Martin Maldonado-Durán, MD, Principal Investigator for Child and Family Center, Department of Psychiatry, Child and Adolescent Division, Family Service and Guidance Center
J Martin Maldonado-Durán, MD is a member of the following medical societies: Kansas Medical Society
Disclosure: Nothing to disclose.

Jill Glinka, OTR, Occupational Therapist
Disclosure: Nothing to disclose.

Sari Lubin, OT, Occupational Therapist, Shoam Hospital, Israel
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
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