Problems With Coordination

It’s no surprise that children differ in how coordinated they are, and how early they develop  motor skills. But when children are notably uncoordinated, compared to their peers, and fail to meet milestones for motor development, they may have a disorder called developmental coordination disorder (DCD), or dyspraxia.

Children with developmental coordination disorder drop things, break things, bump into things — the disorder was originally called clumsy child syndrome. They may have trouble eating with a spoon, holding a crayon. When preschoolers are singing “Itsy Bitsy Spider” they can’t do the hand gestures to make the spider climb up the waterspout.

But there’s nothing wrong with their muscles. “It’s actually a disconnect between the brain and the body,” observes occupational therapist Lindsey Biel, MA, OTR/L, who has worked with many children with DCD. “Everything works — they just can’t pull it together. They can’t get the body to do what the brain wants.”

There are two kinds of motor skills, and some children with DCD have more trouble with one than the other.

“Some of the kids we see cannot get their hands to work the way they want them to even when they’re trying their hardest, even when they have models of what they’re trying to do,” explains Matthew Cruger, PhD, a clinical neuropsychologist at the Child Mind Institute. These are kids who struggle with what are called fine motor issues. By the time they get to school age, they have trouble with handwriting, drawing, using things like scissors.

“And then there’s a whole other set of kids who struggle with coordinating their body in space,” adds Dr. Cruger. These are children who are impaired in gross motor skills, like catching an object, or riding a bike.

There is a range of severity within developmental coordination disorder. “In the mildest form we see kids who are otherwise coordinated and can get by in the world, but they have problems using tools and instruments like pencils.”

Kids who are on the most severely impaired end, Dr. Cruger adds, “we’ll send to a neurologist who will probably find a neurological problem that leads to the motor problems.”

When does being uncoordinated become a disorder? When it interferes with their ability to do age-appropriate things like dressing, grooming, play and schoolwork.

DCD can also affect motor planning, which is what experts call the process of figuring out how to carry out the movement you need to accomplish something. It involves breaking the action down into steps, and it usually happens so instantaneously the movement seems automatic. In kids who develop typically, feedback from trial and error quickly leads to learning the most effective way to do something, and being able to repeat that process

Weakness in motor planning interferes with a child’s ability to learn motor skills, as they are less likely to learn from the feedback they get, and improve their ability to perform a task they’ve done repeatedly. It makes them not only slow to learn new skills, but slow to perform ordinary tasks like tying shoes.

DCD is often noticed in infants and toddlers, as they are delayed in meeting developmental milestones, like sitting, crawling and walking. Babies might continue to eat with their fingers when other children have mastered using utensils.

They often have trouble with what Biel calls “bimanual coordination,” or coordination between the sides of the body, such as holding down the paper with one hand while coloring with a crayon in the other, or stabilizing a bowl while you are scooping out food with the other.

They often have trouble with hand gestures that go with children’s songs. One test Biel uses when evaluating younger children is to have them do “Head, Shoulders, Knees, and Toes,” where they are expected to put their hands on the right body part. “You really need to help them to sequence that,” she adds.

While DCD may have been evident earlier, it is often diagnosed when kids get to school and are struggling with things like holding a pencil, or doing buttons and zippers. Kids often have trouble with balance, jumping and hopping, and mastering physical activities. They stumble a lot, trip and fall. They start to get teased for being clumsy in gym class and during recess.

Also, as they struggle with writing and drawing, they start to avoid them. And they may avoid physical activities.

“Often, when a child is having difficulty with coordination, they’re like, ‘I’m just going to watch TV or play video games,’” Biel notes. “So, they’re not going to be out riding their bicycles, building their muscles, climbing on the monkey bars and building up that upper body strength. So, often — though not always — you’ll end up with weakness.”

Another risk long term is social isolation, when kids (and later adolescents and adults) don’t feel comfortable participating in activities that feel like opportunities to fail.

The goal of treatment for DCD is to improve a child’s motor coordination. Occupational therapists working with kids identify tasks they’re having trouble with and break them down into constituent parts, if need be. Then they do what anyone does who’s trying to master a motor skill, from a musician to an athlete: practice, practice, practice.

“A typically developing child may be able to learn something by observing it once and then imitating it. Another child may need to practice a couple of times to master it,” says Biel. “Kids with this disorder need to practice dozens of times. Sometimes with hand-over-hand help to get it. Sometimes with a lot of visual cues.”

In practicing, they are building stability and dexterity in the muscles, and breaking down complex tasks into little manageable steps, Biel adds. In riding a bike, for instance, you have to focus on both peddling the bicycle and standing on one foot. When handwriting is a challenge, Biel uses apps that aid in handwriting practice, like Letterschool, and iTrace.

But accommodations are also available, like allowing the child to use a keyboard, or even a voice-activated laptop like Dragon Speaking Natural.

How much improvement can be accomplished by occupational therapy? The best results, Biel says, are a product of effective intervention and strong motivation. Kids also do best when they have a champion — someone who focuses on what the child can do instead of what they can’t, and helps them to build on that, use their strengths to offset their challenges.

She gives the example of a 9-year-old boy she’s been working with. “He can’t seem to learn how to ride a bicycle but he’s become the most wonderful dancer.”

Not every child needs to master every skill. Take shoelaces, she adds. “It’s really hard for a lot of kids to tie them and at a certain point we throw on the slip-ons, the Velcro shoes, the elastic shoelaces and go. You have to do triage — decide what’s more important and what’s not so important.”

Dr. Cruger agrees that practicality is should be the guiding principle. And he notes that many kids, with or without DCD, would benefit if we took more time to teach them how to do things that we tend to assume they can do automatically. In that category he puts not just physical activities but organizational skills like how to put things in your backpack.

And if more adults took the time to teach kids the skills they want them to acquire, from academic to athletic, there would be fewer times the kids who have DCD would be humiliated by being the ones who just don’t pick these things up automatically. That, in turn, would be very good for their self-esteem.