Developmental coordination disorder

Developmental coordination disorder
Other namesDevelopmental motor coordination disorder, dyspraxia
Shoes with undone laces
Many people with dyspraxia have difficulty with tying shoelaces, writing, and performing tasks that require coordination.
SpecialtyPsychiatry, neurology
SymptomsImpaired acquisition and execution of coordinated motor skills
ComplicationsLearning difficulties, low self-esteem, reduced engagement in physical activities like sports, increased risk of obesity
Usual onsetearly developmental period
DurationOften persists into adulthood
Differential diagnosisCerebral palsy, muscular dystrophy, neurological or neuromuscular disorders affecting movement, significant visual impairment, joint hypermobility syndrome, fetal alcohol spectrum disorder.
TreatmentPhysical therapy, occupational therapy
Frequency5–6% (of all school aged children)

Developmental coordination disorder (DCD), also known as developmental motor coordination disorder, developmental dyspraxia, or simply dyspraxia (praxis from Ancient Greek meaning "doing,", "action," "practice," or "transaction"'), is a neurodevelopmental motor disorder characterised by challenges with the acquisition and execution of coordinated movements and motor skills that are substantially below what would be expected given the individual's chronological age.

The etiology of DCD is unknown. Motor function requires the coordination of neurologic, physiologic, and biologic processes, including proprioception (body awareness), strength, balance, fine and gross motor coordination, dexterity, vestibular integration, oculomotor coordination, and visuo-motor coordination. Problems in any of these areas can result in impairment of motor skills. Deficits in fine or gross motor skills and movements interfere with activities of daily living. Difficulties may present as clumsiness, slowness and inaccuracy of performance of motor skills (e.g., catching objects, using cutlery, handwriting, pointing accurately at targets, riding a bike, use of tools or participating in team sports or swimming). A diagnosis of DCD is reached only when the motor skills deficit is not better explained by medical conditions affecting movement, such as brain tumors, cerebral palsy, multiple sclerosis, or Parkinson's disease, metabolic conditions, intellectual disability, or visual impairment. DCD has onset in early childhood and often persists into adolescence and adulthood.

Occupational therapy and physiotherapy can help people with DCD to develop and improve their coordination and motor control to achieve things that they might otherwise find extremely challenging to accomplish. While DCD is known to co-occur with other neurodevelopmental disorders, its related gross and fine motor impairment are not necessarily associated with lower intelligence. People with DCD may have low self-esteem because their age-related peers can often complete tasks and participate in activities that they struggle with on a daily basis. Developmental coordination disorder, like some other neurological conditions that are not immediately obvious to others but can greatly affect a person's life, is also typically a hidden disability to the general public.

Terminology

DCD was first described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R 1987). It is also called "developmental motor coordination disorder" in countries that use the International Classification of Diseases 11th Revision (ICD-11).

Other terms that have been used to describe DCD are listed below. These terms are recommended to be avoided because they are ambiguous (however, 'dyspraxia' remains in common use, especially in the UK):

Epidemiology

The etiology of DCD is currently unknown. The prevalence of DCD varies between patient populations and diagnostic criteria. In most reviews, the prevalence in the general population of school-aged children is 6% DCD is more often reported in boys, with a male to female ratio ranging from 2:1 to 7:1. Various areas of development can be affected by DCD (activities of daily living, academic performance, leisure, play, and social participation) and these may persist into adulthood.

Signs and symptoms

Childhood

While signs and symptoms of DCD can be noted before age 6, most become apparent when they interfere with social development or when children enter school at approximately age six and are subsequently compared with their peers. In retrospective reviews, children with DCD may have had problems with sucking and swallowing in their first year of life, delayed motor milestones such as sitting, crawling, walking, running, or jumping, persistent toe-walking or abnormal gait after fourteen months of age, speech problems and or persistent drooling after thirty months of age.

A child with DCD has difficulty with everyday tasks such as tying their shoes, dressing, self care, using cutlery, or brushing their teeth. Parents may also report difficulties with riding a bike, playing catch, breaking dropped objects, tripping, poor pencil grasp, difficulty with finger isolation and accurate pointing, inability to cut using scissors, inability to draw a straight line, difficulty with movements that require speed, or bumping into doorways or chairs. Such children may require longer and repeated instruction to learn new motor skills, may avoid participation in gym class or sport, or avoid physical activity and fitness, or their motor challenges may prevent participation in particular physical activities. Children with DCD may also have difficulty processing instructions with multiple steps as well as educational, emotional regulation, and social interaction challenges.

Adolescence and adulthood

Motor difficulties persist into adolescence and adulthood in the majority of cases. DCD may present as challenges with ball skills, agility, handwriting, typing, using a touch screen or mouse, driving, and playing sports. Individuals with DCD often have difficulty learning new motor skills or applying skills in a different environment (generalization of skills).

Health consequences

DCD may be associated with negative short and long term health consequences including decreased participation, social isolation, obesity, low self esteem, reduced mental well being, poor physical fitness (decreased flexibility, strength, endurance), poor pulmonary function, increased cardiovascular risk factors (elevated low density lipoprotein [LDL] cholesterol, and high blood pressure), and fatigue or stress associated with the increased effort and demands of performing motor tasks.

Motor-cognitive integration challenges

In DCD impairments in motor planning and coordination may interact with cognitive processes. Evidence from research and clinical practice indicates that DCD is not limited to a physical disorder, and there may be deficits in executive functions, behavioural organisation, and emotional regulation that extend beyond the motor impairments and which may occur independently of diagnoses of co-morbidities.

Motor coordination difficulties in DCD can affect the accuracy and timing of task performance, particularly in activities that require sequencing or sustained attention. Increased cognitive and motor planning demands may also place additional load on working memory and executive processes, contributing to errors in the order, timing, or completeness of movement. As a result individuals with DCD may produce movement responses that are incomplete, mis-sequenced, or delayed, even when they understand the task at hand. These effects are generally understood as reflecting challenges in motor–cognitive integration rather than a direct measure of underlying intellectual ability.

Emotional factors, especially anxiety regarding ability to complete a task, may influence motor performance in individuals with DCD. Anxiety is associated with changes in movement timing, variability, and visuomotor control, although the direction of this relationship remains uncertain.

In addition, DCD is associated with problems with memory, especially working memory. These difficulties may affect the ability to remember multistep instructions, organize time, meet deadlines, keep track of belongings, or carry out activities that require remembering steps in sequence such as cooking. While most of the general population experience these problems to some extent, they have a more significant impact on the lives of people with DCD. Many benefit from working in a structured environment, as repeating the same routine minimises difficulty with organizational ability and self regulation, and allows them to commit procedures to long-term memory.

Gross motor control

Whole body movement and motor coordination issues mean that major foundational motor skills including walking, running, climbing, and jumping can be affected, which can cause challenges when more difficult movements are attempted. These difficulties vary from person to person and can include the following:

Fine motor control

Fine-motor problems can cause difficulty with a variety of functional movements such as activities of daily living, school-related tasks, chewing, grip strength, pointing and finger isolation, handwriting, typing, drawing, cutting, dressing and fastening clothing, using cutlery, brushing teeth, grooming, handling or manipulating small objects, cooking or household tasks, and other activities requiring manual dexterity and bilateral coordinated use of both hands.

Handwriting and motor performance of text-based communication, including typing and pointing to letters or symbols, can present challenges for people with DCD. Specifically, this may include difficulties with:

Co-occurring disorders and secondary features

DCD is known to co-occur with other neurodevelopmental disorders, Attention Deficit Hyperactivity Disorder (ADHD), and autism. Approximately 50% of those with ADHD have concomitant DCD, although estimates vary depending on the population studied and diagnostic criteria used. Motor impairment and DCD are also highly prevalent in autism . Studies have demonstrated 79% of autistic children with definite motor impairment as measured by standardised motor assessments and approximately 90% at risk of DCD or met DCD criteria, despite the majority not receiving a formal diagnosis. In addition, increased severity of autism symptoms is associated with a higher risk of screening positive for DCD as well as greater severity of motor difficulties. Other co-occurring conditions and associated features are listed below. Prosopagnosia has also been reported in adults with probable DCD.

Reported co-occurring conditions include:


Reported associated features of DCD include:

It is unlikely for a person with DCD to have all of these conditions and features. The clinical profiles of individuals with DCD vary significantly; an area of major weakness for one person with DCD can be an area of strength for another. For example, while some individuals with DCD have difficulty with reading and spelling due to dyslexia, or with numeracy due to dyscalculia, others may have strong or above average reading and spelling or mathematical abilities. DCD and its related gross and fine motor impairment are not necessarily associated with lower intelligence. DCD is best viewed as a heterogeneous neurodevelopmental motor disorder, with variable motor, cognitive, sensory, academic, social, and emotional profiles.

Speech, language, and communication difficulties

Speech and language difficulties have been reported in some individuals with DCD, and DCD may co-occur with developmental language disorder, speech sound disorder, or childhood apraxia of speech (CAS) (formerly known as developmental verbal dyspraxia (DVD) in the UK, later adopted as CAS in 2024). CAS primarily affects the planning and programming of movements for speech, whereas DCD is a broader disorder affecting the planning and execution of both fine and gross motor movements. When motor-speech difficulties are present, speech may be slow, effortful, inconsistent, difficult to understand because of challenges with motor planning and coordinating the movements required for speech. Some research suggests DCD and associated oral motor impairments as a motor-based explanation for limited functional speech in minimally speaking and nonspeaking autistic individuals, however the extent to which these difficulties are specificlly atributued to DCD remains uncertain. Speech and language difficulties reported in people with DCD include:

Some individuals with DCD have co-occurring language-development difficulties, which should be distinguished from impairments in the motor production of speech. Language abilities in individuals with DCD are variable. Some children meet criteria for Developmental Language Disorder (DLD), while others have age-level language skills. However, even when language is intact, many individuals with DCD experience difficulties with academic tasks that reflect a combination of motor coordination difficulties, increased cognitive load during task performance, and differences in working memory and executive functioning, rather than language ability alone.

Sensory processing or sensory modulation difficulties

A large proportion of children with DCD show sensory processing or sensory modulation differences but numbers vary widely, particularly in proprioceptive and visual-spatial domains. The extent of concomitant sensory processing disorder as a distinct diagnosis is unclear because the latter is not consistently defined in the literature.

Some individuals with DCD exhibit increased or decreased responsiveness to sensory input, although the type and extent of these differences can vary. These differences may involve tactile, visual, auditory, or proprioceptive and can thus affect motor coordination, body awareness, and interaction with the environment. As an example, altered proprioceptive processing may contribute to difficulties in judging body position and movement, while sensory modulation differences (how a person adjusts and regulates response to sensory input) may influence a person's response to environmental stimuli. People with DCD may have difficulty modulating the amount of sensory information input and as a result may be more prone to sensory overload, especially in environments with high sensory demands.

Psychological and social consequences

Psychological domain

Children with DCD may experience lower self-efficacy and reduced self-perceived competence, especially in social and peer-interactions. These difficulties are often associated with being continuously challenged in motor-based and everyday activities.

Social domain

Children with DCD may be at increased risk of social exclusion, peer difficulties, and bullying, which can contribute to feelings of loneliness and reduce social participation.

Support domain

Adolescents and adults with DCD may face challenges in accessing appropriate educational and institutional support. Lack of recognition and understanding of DCD can contribute to under-identification and lack of support.

Screening

DCD should be suspected in school-age children who have difficulty with developmental tasks and milestones such as crawling, jumping, hopping, drawing, and imitative finger movements. Concerns about clumsiness may originate from the parents, clinicians, teachers, or therapists.

The Developmental Coordination Disorder Questionnaire (DCDQ), intended for ages 5 years 0 months and 15 years and 0 months, and the Little DCDQ, intended for ages 3 years 0 months and 4 years 11 months, are screening tools used to identify children who are suspected to have DCD. They can be administered by a parent, teacher, or caregiver. The child is rated on how they compare to peers in areas like handwriting, ball skills, coordination, dressing, running, motor speed, and general clumsiness. If the child is below a certain cutoff score, the next step is to carry out a formal assessment for DCD.

Diagnosis

A DCD diagnosis is a multi-step process. A physician will take a history of the developmental period and take note of any motor learning challenges early in life. A physician must also rule out other possible medical or neurological explanations for the motor difficulties. Where intellectual disability is suspected, a standardized IQ test or cognitive assessments may be used to determine whether the motor difficulties exceed what would be expected for the person's cognitive and intellectual ability. In autistic individuals with significant motor and communication impairments, assessment selection and response demands may affect the interpretation of cognitive abilities. Research in DCD indicates that motor demands may affect performance on standardized cognitive assessments, especially in timed processing-speed tasks. Similar testing limitations have been documented in cerebral palsy, Rett syndrome, and spinal muscular atrophy, where motor, speech, visual, or other response demands may lead to underestimation of cognitive abilities. The validity of standardized scores may be limited when no reliable communication or response method is available or when the test's sensory-motor demands cannot be accomodated. Inability to complete a test should not itself be interpreted as evidence of intellectual impairment or refusal to participate..

A physiotherapist or occupational therapist may administer a standardized motor assessment such as the Movement Assessment Battery for Children (MABC) OR the Bruininks-Oseretsky Test of Motor Proficiency (BOT). A baseline motor assessment establishes the starting point for developmental intervention programs and comparing children to normal rates of development may help to determine areas of difficulty and support needed.

The disorder is diagnosed using DSM-5 criteria:

In children who are suspected to have DCD other causes of motor impairment are assessed through medical history and physical examination. Although exclusion of other causes of impaired motor skills is necessary, it can be difficult to distinguish between conditions that cause DCD and conditions that may coexist with DCD. In such cases, referral to specialist physician, physiotherapists, or occupational therapists with expertise in diagnosing and assessing DCD may be warranted. A 2005 study of 105 teachers and 105 general practitioners in Wales found limited knowledge of DCD, in both profession groups. The earlier these difficulties are noted and the earlier timely assessments occur, the sooner intervention can begin.

ADL and motor function assessment

Clinical judgment is required to interpret the degree to which performance in daily activities is affected by motor function impairment and found to be substantially lower than that of age matched peers. The Leeds Consensus Statement identified scores at or below the 5th percentile as evidence of abnormal motor skills and recommended to monitor children between the 5th and 15th. More recent clinical practice recommendations recognize total scores at or below the 16th percentile as indicitive of potential DCD in children 6 years and older, but with results interpreted alongslide developmental history, functional impact, and the other diagnostic criteria for DCD.

Motor assessment in subjects with communication differences

The MABC or BOT may have limitations when used with individuals who have significant communication and motor planning challenges. These assessments rely on imitation, task comprehension, and structured motoric responses, while factors such as anxiety, physical readiness, attention, information processing, and sensory sensitivities may affect performance independently of underlying motor ability. As a result, test scores may show limited sensitivity at lower levels of performance, or not fully capture an individual's motor performance, areas of challenge, needed support, and motor learning potential. This highlights the need for cautious interpretation and, in some cases, adapted or supplementary assessments. An observational study of 85 Australian physiotherapists assessing young autistic children found that parent reports, clinical observations, and movement analysis were used more frequently than standardized motor assessments.

Intervention

There is no cure for the condition . Instead, it is managed through therapy. Management and treatment of DCD include:

Research supports task oriented Physical Therapy and Occupational Therapy interventions for improving functional motor performance and participation as effective interventions for DCD. International clinical practice recommendations for DCD emphasise interventions that improve functional participation, motor performance, physical health, and quality of life, rather than focusing solely on impairment reduction.

Occupational therapy interventions for DCD can include targeting functional daily activities, fine motor skills, motor planning, self-care, school participation, sensory accomodations, keyboarding and written communication, and participation in meaningful occupations. One of the evidence based OT approaches for DCD is the Cognitive Orientation to daily Occupational Performance (CO-OP) approach, a task-oriented intervention designed to help children develop cognitive and problem-solving strategies for motor tasks that are selected by the child.

Physiotherapy interventions for DCD often focus on gross motor coordination, balance, gait, postural control, strength, endurance, motor learning, proprioception, and participation in physical activity and sport. Clinical practice guidelines for physical therapists recommend task-oriented motor training, motor skill practice, strength and balance interventions, and physical activity participation as central components of intervention. Neuromotor Task Training may also be used by PTs and OTs.

Research has shown that exercise, adapted physical activity, and sport-based interventions have positive effect on motor function in DCD. Studies have reported improvements in balance, hand-eye coordination, physical fitness, motor coordination, and participation with interventions such as aquatic therapy, martial arts, active video gaming, fundamental movement skill programs, balance training, movement-based therapy, and school-based physical activity programs. Evidence for improvement psychosocial outcomes is less conclusive.

Types of therapy

The types of occupational and physical therapy for DCD can be classified according to the primary target of the intervention:

History

Developmental coordination disorder has also been called "minimal brain dysfunction" and is a term that is no longer used. The term "clumsy child syndrome" is also discouraged from use because of pejorative connotations, though it remains in use in some countries. Collier first described developmental coordination disorder as "congenital maladroitness". In 1972, an occupational therapist named A. Jean Ayres described sensory integrative dysfunction, which is related to sensory processing and motor performance but distinct from the modern diagnostic framework of DCD, while in 1975 Sasson Gubbay, MD, called it the "clumsy child syndrome".

Actor Daniel Radcliffe has dyspraxia.

Fictional characters

Public figures

People who have publicly stated they have been diagnosed with developmental coordination disorder include:

See also

References

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