Developmental Coordination Disorder Treatment & Management
- Author: Stephen L Nelson, Jr, MD, PhD, FAAP; Chief Editor: Caroly Pataki, MD more...
Typical goals of treatment for children with developmental coordination disorder (DCD) are as follows:
To ascertain problem areas for a given child in a comprehensive fashion
To design an intervention that will promote optimal adaptive functioning, 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 single type of treatment is applicable to all children with motor coordination disorder, nor is any individual treatment successful with all. Existing evidence does not permit the conclusion that any of the methods described below is generally or uniformly better than the others.
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). Thus, comparisons between patients and treatments are weaker than they would be if all children had the same problem and received the same intervention. Even the issue of intervention is unclear; therapists may think they are using only one method but may unwittingly introduce elements of others.
Two general approaches are used to treat motor coordination problems in children. One approach is a modular (top-down) approach, and the other is a more global or generalized (bottom-up) approach.
Despite a lack of best practice guidelines, there is overwhelming and consistent evidence to show that children who receive interventions such as physical therapy and occupation therapy have better outcomes than children who do not receive interventions.[40, 36]
No specific pharmacologic treatments improve motor performance. In children who have essential tremor severe enough to interfere with motor abilities, propranolol and other beta-blocker agents can be used. No surgical procedures exist to be used in these conditions.
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, but it should be only prescribed in severe cases and on the advice of a child neurologist. Medications are reserved for the treatment of associated conditions (eg, attention deficit hyperactivity disorder [ADHD]).
The first of the 2 general approaches to treatment, the modular or top-down (task-oriented) approach, attempts to remedy or improve specific difficulties by employing specific techniques aimed at the observed motor challenge (eg, difficulty with handwriting, catching a ball, or performing fine motor tasks with the fingers). It usually involves gradually targeting certain problem behaviors and implementing step-by-step interventions that focus on teaching and practicing the skill. This method tends to prevent failure and rewards the child, at least at first.
Because of its circumscribed nature, the modular approach lends itself to implementation by professionals such as schoolteachers. One of its core elements is practice (eg, prescribed practice of new skills and small steps toward mastery of the skill, with success achievable at every small step). Examples of this general approach are therapies such as the cognitive motor approach with task orientation or the task-oriented approaches with motor learning.
The second of the 2 approaches, the more global or generalized one (also described as a bottom-up, process-oriented, or deficit-oriented approach), is based on the theoretical assumption that the motor skills problem is just a manifestation of some underlying mechanism, such as impaired sensory integration or insufficient or inaccurate kinesthetic perceptions.
In the bottom-up approach, 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, and sensory integration therapy. As with many other forms of intervention and therapy, there is only limited evidence for the efficacy of these methods, particularly over the long term or regarding the end result.
Although the top-down approach is grounded in more current models regarding motor control and learning, and the data suggest that it is more effective than the bottom-up approach, no single approach has yet been substantiated as effective through research studies.
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 . Therapists design a set of exercises that children practice with the assistance of the parents until the task is learned gradually or mastered.
The emphasis is on motor performance, as well as on 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 goals.
Motor problems are selected, and new skills are taught one at a time to build ability gradually. The ability acquired in one context is expected to be generalizable to others. 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 of successful therapy.
Feedback is important at each step. Concrete positive reinforcers are gradually deemphasized and replaced with emotional reinforcers (eg, the satisfaction of learning new things). One of the advantages of this method is that it offers 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 therapy 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 include auditory stimuli, lighting and visual stimulation, tactile sensations, and others. Children who are excessively affected by such stimulation (and 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 way of contrast, in children who are hyposensitive, the amount of stimulation is gradually increased.
In all cases, signs of excessive or inappropriate stimulation are monitored. Techniques for helping the children self-modulate and self-regulate are also useful. Examples are time without stimulation with relaxation and brief periods of isolation to recuperate a state of calmness.
Sensory integration therapy is effective but not necessarily better than other methods. This approach also allows the incorporation of a variety of techniques 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.
A consensus statement from the American Academy of Pediatrics advised that sensory integration disorder should not be diagnosed and that sensory integration therapies have no proven value. The statement advised that sensory integration therapy may be of benefit when combined with occupational therapy but stated that it should be prescribed only after a thorough discussion with the parents regarding the lack of data.
Kinesthetic training relies on the studies carried out by Laszlo and Bairstow on kinesthetic development in children. This approach involves enhance kinesthetic sensitivity in children so as to improve motor control, with the intent of reducing perceptual-motor dysfunction.
Although this approach is popular, it has generated controversies regarding the successes the authors have claimed. Its aim is to generate improvement in children’s overall functioning in terms of perception of motion, but unlike other methods, it does not focus on teaching them specific skills. The theoretical rationale for kinesthetic training is that when general awareness of motion in space is improved, motor skills presumable will also improve as a secondary effect.
The basic principles of the neurodevelopmental treatment approach, first described by Karl and Bertha Bobath in the 1940s, involve inhibiting primitive (persisting) reflexes and abnormal motor coordination patterns while promoting higher-level reactions and normal muscular tone and movement patterns. Accordingly, emphasis is placed on the following:
Detailed evaluation of the patterns of development observed in the small child
Diagnosing the child’s developmental level
Designing a strategy to restore development to as normal a level as possible and to improve skills as much as possible
Craniosacral therapy was devised by the osteopathic physician John E Upledger. Trained therapists from a variety of professional backgrounds use highly sensitive palpation skills to address imbalances in the craniosacral system. This 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.
Osteopathic and chiropractic therapy
Segmental dysfunctions such as those commonly treated with manual therapy techniques are unlikely to be the cause of DCD; rather, they may be a consequence. A study indicated that in children with other comorbid processes, some improvements in motor skills may be enhanced with manual treatments.
Visual training is an approach that 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 to be ineffective and unacceptable.
In addition to various therapies, assistive technology is used to develop adaptive methods of enhancing function in children with motor difficulties. These modifications range from the simple (eg, attaching special pencil grips that make the pencil easier for the child to grasp) to the complex (eg, making voice-responsive computers available for children with writing difficulties).
Diet and Activity
No special diet is recommended for children with motor skills disorders, nor has any diet been demonstrated to improve the motor functioning of children.
By definition, activities and motor functioning are essential for the treatment of children with DCD. In addition to the treatment offered by occupational therapists or motor rehabilitation specialists, parents and other caregivers can provide considerable assistance for children at home in the form of specifically designed games and activities that could help improve the children’s motor functioning and self-esteem.
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 design beneficial programs for children with coordination problems.
In cases where concomitant learning disabilities are present, consultation with a specialist in psychoeducational testing (eg, 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 with difficulties in behavior and self-esteem. If these interfere with the child’s academic performance, motivation, or attitude toward learning, consultation with a medical professional (eg, a child psychiatrist or pediatric developmental specialist) is indicated.
If a more global neurologic concern is present (eg, global developmental delay, developmental regression, abnormal head size, worrisome neurologic examination findings, or other concerns), referral to a child neurologist is warranted.
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