Diagnosis and management of developmental coordination disorder

What is developmental coordination disorder?

As described in the American Psychiatric Association’s latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),4 the child with developmental coordination disorder has motor coordination below expectations for his or her chronologic age, may have been described as “clumsy” and may have had delays in early motor milestones, such as walking and crawling. Difficulties with coordination of either gross or fine motor movements, or both, interfere with academic achievement or activities of daily living. Coordination difficulties do not relate to a medical condition or disease (e.g., cerebral palsy, muscular dystrophy, visual impairment or intellectual disability). If intellectual disability is present, the motor difficulties are in excess of those expected for the child’s IQ.

In the previous DSM edition (DSM-IV-TR),developmental coordination disorder was included under the broad category of “learning disorders”; in DSM-5, it is subcategorized as a motor disorder within the broader category of “neurodevelopmental disorders.” An additional criterion included in DSM-5 is that the onset of symptoms occurs during the developmental period.

What are the risk factors?

A 2011 systematic review of 16 studies involving school-aged children showed significantly greater odds of developmental coordination disorder among children who had very low birth weights (< 1500 g) or were very preterm (< 32 wk) than among age-matched controls born at term with normal birth weights (odds ratio [OR] 6.29, 95% confidence interval [CI] 4.37–9.05] to 8.66, 95% CI 3.40–22.07). Boys are 1.7 to 2.8 times more likely than girls to have the disorder.

Additional risk factors were explored in a large (n = 33 354) national cohort study of Danish children followed up for seven years.7 In addition to male sex, other factors associated with developmental coordination disorder included very preterm birth (OR 6.28, 95% CI 3.99–9.89), small for gestational age (OR 1.74, 95% CI 1.46–2.08) and independent walking at 15 months or later (OR 3.05, 95% CI 2.57–3.60). A retrospective study involving children 4–5 years of age confirmed the associations with male sex and low birth weight; it also found an association with postnatal exposure to steroids.8 Children with developmental coordination disorder are at increased risk of being overweight or obese.

In a prospective, population-based cohort study in southwestern England, probable developmental coordination disorder was identified in 346 children aged 7–9. Risk factors associated with the disorder were difficulties with attention (OR 1.94, 95% CI 1.17–3.24), social communication (OR 1.87, 95% CI 1.15–3.04), repetition of nonwords (e.g., unfamiliar spoken nonwords, such as barrazon, that the child is asked to repeat) (OR 1.83, 95% CI 1.26–2.66), spelling (OR 2.81, 95% CI 2.03–3.90) and reading (OR 3.35, 95% CI 2.36–4.77).

When is the disorder suspected and how is it screened?

Developmental coordination disorder could be present in a child whose parents, caregiver or schoolteacher expresses concerns that he or she is unusually clumsy and is showing persistent delays in gross or fine motor milestones. In our clinical experience, difficulties with oral motor coordination, such as closing lips to blow bubbles or blowing out birthday candles, may also be reported. Box 2 outlines a series of questions a general practitioner can ask the parent or caregiver when a child is referred with these types of concerns. The questions are in part evidence-based (e.g., preterm birth, age at independent walking) and in part based on our clinical experience.

If the parent answers affirmatively to some or all of the screening questions, and if other possible causes of motor difficulties (e.g., cerebral palsy) have been ruled out by careful history taking and physical examination, it is prudent to refer the child for expert assessment.

How is the disorder diagnosed?

According to recommendations from the European Academy of Childhood Disability, developmental coordination disorder should be diagnosed by a multidisciplinary team of professionals qualified to examine the specific DSM-5 criteria for the disorder. Ideally, the team should include a physician (e.g., child psychiatrist, developmental pediatrician, child neurologist) and an occupational therapist or physical therapist trained in the standardized motor tools used to assess children suspected of having the disorder. Box 4 outlines the diagnostic criteria for developmental coordination disorder4 and includes examples of how these criteria can be assessed.

What conditions may coexist with the disorder?

Children who have developmental coordination disorder frequently have other childhood disorders (e.g., attention-deficit/hyperactivity disorder [ADHD], autism spectrum disorder or specific learning disabilities). Whereas the DSM-IV-TR did not allow for concurrent diagnoses,the DSM-5 does.

Children with developmental coordination disorder (with or without ADHD) have been found to be at increased risk of anxiety and depression. In one study, children who had the disorder without ADHD reported depressive symptoms five times more often, and anxiety symptoms about one and a half times more often, than typical peers.

Other problems commonly associated with developmental coordination disorder are psychosocial difficulties, overweight or obesity, hypermobility of joints, compromised physical fitness, and decreased participation in daily-living, physical and social activities.

In a recent systematic review on the influence of developmental coordination disorder on physical, psychological and social functioning, the authors concluded that “children with DCD report lower self-efficacy and competence in physical and social domains, experience greater symptoms of depression and anxiety, and display more externalizing behaviours when compared to typically developing children.”:

How is the disorder managed?

Children with developmental coordination disorder typically receive different types of therapies (e.g., occupational therapy or physical therapy) aimed at improving their motor performance. For children who also have ADHD, drug therapies (e.g., methylphenidate) have been used. Recent evidence is summarized below.

In a well-executed systematic review and meta-analysis, the efficacy of various interventions on motor performance in children with developmental coordination disorder was examined.29 Twenty-six studies (systematic reviews, randomized controlled trials and crossover studies) published between 1995 and 2011 were included and divided into four categories: task-oriented intervention; traditional occupational therapy or physical therapy; process-oriented therapies; and chemical supplements. The task-oriented interventions were aimed at learning specific motor skills that are particularly difficult for the child, and the process-oriented therapies focused on more global functions (e.g., sensory integration, visual-motor perception and muscle strength).29 The largest effect sizes were shown for task-oriented interventions (weighted Cohen d [dw] = 0.89) and for occupational or physical therapy (dw = 0.83), with only a weak effect for process-oriented approaches (dw = 0.12) Thus, referral to an occupational therapist or physical therapist, or both, who can focus treatment on helping the child perform everyday tasks is recommended.

In this same systematic review, the effects of methylphenidate on fine motor performance were reported from three studies involving children who had developmental coordination disorder and ADHD; the effect size was medium (dw = 0.79). In a blinded study published after the systematic review, motor performance measured on the Movement Assessment Battery for Children, second edition, was substantially improved when children with developmental coordination disorder and concurrent ADHD were taking methylphenidate.Unfortunately, we found no studies that evaluated the effects of chemical supplements in children who had developmental coordination disorder without ADHD.

In a 2014 review of prospective clinical trials examining the safety of medications for children with ADHD, long-term (≥ 1 yr) adverse effects associated with methylphenidate included headache, decreased appetite, insomnia, abdominal pain, tics and weight loss (with incidence ranging from about 5% to 20%). As with other research on this topic, the authors reported that most of the adverse effects were mild or moderate. We found no comparable studies of adverse effects of medications among children with developmental coordination disorder and concurrent ADHD.

In the systematic review mentioned earlier, only one study, a randomized controlled trial, examined the effects of dietary supplementation with fatty acids. Although there were no changes in motor performance, improvements in reading, spelling and behaviour were reported.

Box 5 summarizes risk factors, concurrent diagnoses, secondary consequences and therapies relevant to developmental coordination disorder.

What is best practice in meeting the needs of children with developmental coordination disorder?

In a scoping review of more than 500 research studies, practice guidelines and grey literature, Camden and associates identified 31 documents that focused on children 16 years or younger who had developmental coordination disorder and provided “population-level recommendations.” Their qualitative analysis of the information, which included the European Academy of Childhood Disability guideline1 and studies from Canada, the United Kingdom, Germany and New Zealand, yielded two overarching themes and five principles for best practice, each supported by multiple references. Not surprisingly, the authors identified the need to increase awareness of the disorder and to coordinate services. The importance of consumer involvement in identifying treatment goals was another important principle they identified, as was the need for evidence-based intervention.

We hope that by sharing these principles and providing relevant resources for parents, physicians and educators (see Resources box at end of article), readers of this review will embrace best practice strategies for developmental coordination disorder. We also apply the results of our review to two fictional cases (Box 6) to assist clinicians in this goal.

What are the lifetime consequences?

Like children with other types of developmental disabilities, children with developmental coordination disorder do not “outgrow” their disorder. There is far less research on issues in adulthood, however. Several studies have assessed psychosocial, motor and executive functions in adults with developmental coordination disorder. Small observational studies noted that adults with the disorder had significantly high levels of depressive symptoms and anxiety, as well as decreased levels of participation in everyday life, and lower quality of life and life satisfaction. In addition, small studies based on self-reported data found that motor skills (e.g., playing team sports, parking a car and handwriting) and executive functioning (e.g., planning ahead and managing money) continued to be compromised in adulthood.

A large case–control study of the functional profile of young adults in Israel found that those with probable developmental coordination disorder (based on Adolescents and Adults Coordination Questionnaire scores) performed significantly worse (p < 0.001) than controls on measures of academic (e.g., handwriting) and nonacademic (e.g., activities of daily living requiring organization and planning) functioning.

Unanswered questions

Because developmental coordination disorder affects 5%–6% of school-aged children, primary care practitioners will likely have such children in their practice and should be aware of how to screen for this disorder and when and to whom to make a referral. Although research in this area is growing at a remarkable pace, there continues to be a pressing need for additional research in the following key areas.

How reliable and valid is screening for developmental coordination disorder in primary care for the eventual diagnosis of the disorder by a multidisciplinary team?

What are the benefits and harms of early intervention for children with the disorder?

Which interventions result in the best outcomes for children and adults with the disorder, especially with respect to participation in daily-living, physical and social activities?

Does early intervention for children with the disorder result in improved outcomes in adulthood?