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Assessment of children with developmental coordination disorder (DCD): motor, functional, self-efficacy and communication abilities.

ABSTRACT

This paper describes the motor, functional, self- efficacy and communication abilities of a cohort of consecutively referred children aged 4 years to 7 years 11 months who attended a University Physiotherapy Motor Clinic and met the DSM-IV criteria for Developmental Coordination Disorder (DCD). Sixty children, 40 males (66.7%) and 20 females (33.3%), with mean age 72.45 months (SD= 11.43 months) participated. In terms of motor performance on the Neuro-developmental Physiotherapy Assessment (NDPA) 95% or more of the children demonstrated gross motor, fine motor, proprioception, stability, postural, tactile and motor planning difficulties. The Movement Assessment Battery for Children (M-ABC) was used to divide the group into those performing above and below the 15th%ile (cut off point for presence of suspected motor difficulties). Only 58% of the referred group fell =15th %ile even though these children had reported (by parents via M- ABC parent checklist) and observable motor performance deficits on the NDPA. Dividing the group on the basis of performance under/over the 15th percentile on the M-ABC did not demonstrate any significant differences between the groups on any of the measures. The use of the M-ABC with a referred group of young children with motor difficulties is questioned. On the functional performance and self-efficacy measures, the children performed within the average range on fine motor skills, visual-motor integration and perceived self-efficacy of their physical and cognitive functioning. The Pediatric Evaluation of Disability Inventory (PEDI) Functional Self-Care subscale was the only subscale in which these children performed <1SD below the mean. On the communication measures, the children performed within the typical range for language and articulation with only the Verbal Motor Performance Assessment for Children Global (oral reflexes) and Focal (oral motor production) scores being markedly below that expected for children in this age group. Study limitations and future research directions are highlighted.

Key words: Developmental Coordination Disorder, dyspraxia, measurement, motor, functional performance, self-efficacy, communication.

INTRODUCTION

Developmental Coordination Disorder (DCD) is a motor disorder that can have immediate adverse effects on a child's day-to-day function (both academic and daily living skills) and significantly impacts on academic, psycho-social and vocational outcomes (American Psychiatric Association 2000). Despite presenting with significant difficulties in movement and function, children with DCD typically have at least average intellectual ability and no identifiable associated neurological or sensory problems. While there is no gold standard for the diagnosis of DCD (Crawford et al 2001; Missiuna, Rivard, & Bartlett 2006), in clinical practice and in research, diagnosis is usually made on the basis of a standardized measure of motor performance such as the Movement Assessment Battery for Children (M-ABC) (Henderson and Sugden 1992) and parent/teacher report of functional impact of the coordination difficulties. Performance at or below the 15th percentile (%ile) on the M-ABC indicates the child is at risk for motor difficulties, while performance below the 5th %ile is indicative of definite motor difficulties (Henderson and Sugden 1992). The 15th %ile cut off on the M-ABC has been widely used for the assessment and identification of children with DCD (Rodger et al 2003).

For many years clinicians have noted an apparent overlap between speech, language and motor skill deficits in children referred for therapy (e.g., Cermak et al 1986). An extensive review of the empirical literature by Hill (2001) concluded that there is co-morbidity between "specific language impairment" (SLI) and motor in-coordination. Previous studies have demonstrated that a considerable number of children with motor difficulties also have communication difficulties (Valtonen et al 2004). Estimates vary from approximately 21% of children with DCD having received speech and language assessment prior to physiotherapy referral (Bullock and Watter 1978), to 27% of children with motor difficulties (DCD) also having communication difficulties (Cutler et al 2001). The importance of these findings is clear: the presence of language difficulties carries a risk of associated motor dysfunction and the presence of motor difficulties carries a risk of associated speech and language disorders, and this overlap may be suggestive of a single underlying pathology. Hill (2001) recommended that "detailed descriptions and comparisons of these disorders" (p. 167) would help to clarify the causes of SLI and associated motor deficits.

While most previous research on children with DCD has been conducted with children between 7 and 12 years of age, early referral of children prior to school entry and in the first two years of school has become more common in the Australian context (Rodger et al 2003). These early years are critical for the development of speech, language and literacy skills, (Clark and Ireland 1994; Gillon 2004) and the refinement of fine and gross motor skills. Therefore, this study aimed to describe the performance of a referred group of children with DCD aged between 4 years and 7 years 11 months using multiple measures which capture the motor, functional, self-efficacy and communication abilities of these children.

Methods

Participants

Children referred to the Pediatric Physiotherapy Motor Clinic at The University of Queensland, Brisbane, Australia for assessment and management of their motor difficulties were recruited. Inclusion criteria were: (1) no known sensory, motor, neurological or intellectual impairment, (2) no known emotional/ social difficulties which may impact on development, (3) aged between 4 years (48 months) and 7 years 11 months (95 months), and (4) motor coordination difficulties that affected the child's functioning at home or school (motor based academic or sports difficulties). Sixty children, 40 males (66.7%) and 20 females (33.3%), whose ages ranged from 52 months to 95 months (M = 72.45 months, SD = 11.43 months) participated. Nineteen children (31.7%) were at kindergarten or preschool, with the remaining 41 children (68.3%) in grades 1, 2 or 3. (Children in Queensland, Australia, can commence grade 1 in January at the start of the school year as long as they have turned 5 by December 31 of the previous year).

Fifty children were referred by teachers, the remainder being referred by others (e.g., paediatricians, therapists, parents etc). All children met the DSM (IV) criteria for DCD as they all demonstrated significant motor deficits on the Neuro-developmental Physiotherapy Assessment (NDPA) (Watter 1996) (Criteria A). These impacted on their daily lives and / or academic performance, according to parent report (Criteria B). None had other medical or neurological conditions (Criteria C). None of the children had identified intellectual difficulties (Criteria D) and were in regular primary schools or preschools in the Brisbane metropolitan region.

Instruments

The Movement Assessment Battery for Children (M-ABC) (Hendersen and Sugden 1992) is a norm referenced, valid and reliable assessment of motor competence, which has been widely used in research to screen for children with and without motor coordination difficulties. It has also been used to confirm motor difficulties in referred children, but its sensitivity has been questioned (Geuze et al 2001; Smits-Englelsman et al 1998).

Neuro-developmental Physiotherapy Assessment (NDPA) (Watter 1996) is a clinical measure of underlying sensory and neuro-motor performance and specific motor skills. It is used to provide detailed information about the child's abilities in the aspects of: neurological signs, sensory--motor function (visual, tactile, vestibular), gross motor, postural control, fine motor and fine sensory, proprioception, stability, and motor planning. It uses uniform administration procedures, is criterion rated, and considers both qualitative and quantitative aspects of the child's performance. It is reliable and sensitive to changes in performance (Watter and Bullock 1987 1989), and commonly us ed by Australian physiotherapists (Williams and Unwin 1997). The NDPA comprises a number of non-standardised ratings. They are presented as cumulative ratings resulting from adding the rating for each assessment item within the areas of gross motor (12 items), fine motor (11 items), ocularmotor (7 items) and stability (4 items). Each item is rated on a 4 point scale with (1 = "normal" performance, 2 = "mild dysfunction"; 3 = "moderate dysfunction"; and 4 = "severe dysfunction"). Cumulative results range from 12-48 in gross motor, 11-36 in fine motor, 7-28 in ocularmotor and 4-16 in stability, with higher scores indicating more severe difficulties.

Clinical Evaluation of Language Fundamentals (CELF-3) (Semel et al 1995) is used to identify, and diagnose receptive and expressive language skill deficits in 6-21 year olds. This test is psychometrically sound in terms of reported reliability and validity (Semel et al 1995). The Clinical Evaluation of Language Fundamentals Preschool (CELF-P) (Wiig et al 1992) is also used to identify and diagnose receptive and expressive language deficits in younger children 3-6 years with good reliability and validity for clinical and non clinical children. Both assessments provide standard scores.

The Bus Story (Renfrew 1997) predicts language development (Bishop and Edmundson 1987) and assesses children's ability to give a coherent description of a continuous series of events. It was normed on 573 children aged 3-8 years in England. The Bus Story Information score was used. This is based on the number of information units that the child includes in re-telling the story. It reveals a mean raw score between 3:9 and 8:5 years.

Goldman-Fristoe Test of Articulation (GFTA) (Goldman and Fristoe 1986) is used to assess the articulation of individual Consonant Speech Sounds, Sounds in Words and Sounds in Sentences. It provides normative data for the Sounds in Words subtest as percentile ranks, with the normative data in 2 month intervals from 2:0 years through to 16+ years and divided by gender. It also gives percentile ranks for Stimulability at the single sound level with gender specific norms from 6:0 years through to 16+ years.

Verbal Motor Production Assessment for Children (VMPAC) (Hayden and Square 1999) allows investigation of the neuromotor innervation of peripheral muscles for speech. This valid and reliable test is divided into a number of subsections, however, only Global motor, Focal oro-motor, and Sequencing were utilised. These result in raw scores converted to percentages. The percent scored is then assigned to a deficit rating, within normal limits (WNL), mild, moderate, or severe based on normative data from 3-6 years, then a single band from 7-12 years.

The Peabody Developmental Motor Scale (PDMS) (Fine Motor) (Folio and Fewell 1983) is a measure of fine motor skills. It has been widely used to assess children with mild to moderate perceptual motor difficulties (e.g., Case-Smith 1995) and is recommended as a descriptive and evaluative measure for young children with DCD (Missiuna et al 2006). Standardized on 617 American children, it is psychometrically sound (test-retest reliability fine motor r = .99; inter-rater reliability fine motor r = .94 for fine motor subscale) and has well established content, construct and discriminant validity (Folio and Fewell 1983).

The Developmental Test of Visual Motor Integration (VMI) (Beery 1997) assesses the influence of visual processing on motor performance. Normed on 2, 614 children, the VMI is one of the most extensively used assessments of copying abilities. Very acceptable reliability (split half r = .88, test-retest r = .87, inter-rater r = .94) and validity have been reported (Beery 1997).

The Pediatric Evaluation of Disability Inventory (PEDI) (Haley et al 1992) is a measure of functional ability for children with significant neuromotor dysfunction (e.g., cerebral palsy, traumatic brain injury). It comprises two sections involving parental report on the child's functional self-care, mobility and social abilities and amount of carer assistance required with self-care, mobility and social abilities. Excellent internal r=.95 to r=.99 and inter-interviewer consistency ranging from r=.96 to r=.99 and validity have been reported in relation to change in functional performance with age. Discriminant validity of PEDI as a determinant of clinical (n=102) vs non-clinical (n=412) status has also been demonstrated (Haley et al 1992). Standard normative scores for functional ability and carer assistance are provided.

The Pictorial Scale of Perceived Competence and Social Acceptance (PCSA) (Harter and Pike 1983, 1984) is a self-report measure of young children's social acceptance (peer and maternal) and perceived competence (physical and academic/ cognitive function). Discriminant validity supports students' and teachers' ratings (Harter and Pike 1984). Moderate to good test retest correlations (r=.62 to .81) have also been reported (Klein and Magill-Evans 1998), with competence perceptions more stable than acceptance perceptions. Michael (1990) supported the use of the PCSA for research, but advised caution due to limited and inconclusive reliability, validity and normative data. Ratings from 1-4 on each item are summed and a mean rating for each domain provided.

Procedure

After ethical clearance was received from the University of Queensland institutional ethics committee, all children between 4 years and 7 years 11 months referred to the Paediatric Physiotherapy Motor Clinic during 2001 and 2002 were invited to participate in the study. Children whose parents provided written consent were involved in the study, and were first seen by a physiotherapist who completed a demographic information questionnaire, the M-ABC, and the NDPA. On two further occasions of 90 minutes duration, children's communication skills were assessed individually by a speech pathologist and their functional skills and self-efficacy by an occupational therapist.

DATA ANALYSIS

In the first instance descriptive data for the primary motor, communication, self-efficacy and functional measures were determined for all the children. All children had motor performance significantly below that expected for age, according to clinical motor assessment on the NDPA. This confirmed parent report of functional motor difficulties (M-ABC checklist). Second, the group was divided according to the children's performance on the M-ABC. Children were included in Group 1 if they satisfied the DSM-IV criteria for DCD as well as scoring ? 15th %ile on the M-ABC. Children were included in Group 2 if they satisfied the DSM-IV criteria for DCD but scored > 15%ile on M-ABC. Mean scores on the standardised measures of these two groups were then compared to reveal whether there were any significant between-group differences. Given that the communication, self-efficacy and functional results were based on standardised measures, independent sample t tests were undertaken. Levene's Test for Equality of Variances determined that t tests were appropriate for all the standardised measures. NDPA scores for motor performance are not standardised hence statistical comparison between groups was not undertaken.

Results

Motor skills and abilities

First, the NDPA was used to evaluate motor performance. This confirmed the presence of significant motor difficulties in all children. Table 1 shows percentage of children's rated 2, 3, 4 for the items in each aspect of the NDPA. In terms of motor performance on the Neuro-developmental Physiotherapy Assessment (NDPA) 95% or more of the children demonstrated gross motor, fine motor, proprioception, stability, postural, tactile and motor planning difficulties. This was not intended for further analysis here, merely to demonstrate the performance of these referred children against typical performance (i.e., rating of "1"). Further analysis of these findings is provided elsewhere (Watter et al in press).

The children were then grouped according to M-ABC %ile scores as described, and the ages, means, standard deviations and ranges for M-ABC scores are shown in Table 2. Next, the performance of the whole group of referred children on the M-ABC is reported, to provide a further overview of their motor skills. In Figure 1 the breakdown of the three M-ABC subscales--balance, ball skills and manual dexterity- which contribute to the total impairment score of the M-ABC for all the children in the sample is shown. Inspection of Figure 1 demonstrates the heterogeneity of the performance deficits in this group of referred children, with deficits spread across the three subscales for children in the two groups.

Table 3 illustrates the performance of children in this sample on aspects of the NDPA, when they are divided into two groups according to their M-ABC scores. The children in both Group 1 ([less than or equal to] 15%ile) and Group 2 (> 15%ile) demonstrated mean summed NDPA criterion scores much higher than expected of typical scores indicating significant sensory, perceptual and motor performance issues. In particular the aspects of fine motor, gross motor, postural control, proprioception and stability were problematic for the children in both groups.

Communication skills and abilities

The performance of the whole sample of children on the standardized measures for communication and function in terms of means, standard deviations and ranges is presented in Table 4. This table reveals that children performed within the typical range for language and articulation, with only the VMPAC Global and Focal motor production scores being markedly below that expected for children in this age group. No significant differences were found between the two groups of children on any of the communication measures as shown in Table 5.

Functional Performance and self-efficacy

In relation to the functional performance measures (i.e., PDMS, VMI, PEDI) and children's perceived efficacy of their physical and cognitive abilities and social acceptance (PCSA), the children performed, on average, within the normal range on fine motor skills, visual-motor integration and perceived self-efficacy. PEDI Functional Self-care was the only subscale in which children in the group performed, on average, more than 1SD below the mean. See Table 4.

When the group was split at the 15th %ile on the M-ABC, with the exception of PDMS Total and Manual Dexterity subscale of the PDMS, no significant differences between the two groups were found. Some differences in the number of children who undertook each individual test is noted due variable attention and motivation to complete the testing. See Table 5.

[FIGURE 1 OMITTED]

DISCUSSION

This paper presents the motor, functional, self efficacy and communication skills of a referred group of children with DCD using multiple assessments typically employed by therapists. These will be discussed along with issues relating to the use of the M-ABC for a young group of referred children with motor difficulties.

Motor abilities and Measurement Issues

All of the parents reported that their children experienced significant motor deficits conforming to the DSM (IV) Criteria B for DCD (APA 2000). The presence of motor difficulties was confirmed by a clinical tool (NDPA). The variability in the children's performances on the M-ABC (as shown in Figure 1) corroborates the heterogeneity of the group (Missiuna 1994, Sellers 1995).

The M-ABC was used to divide the group as described. The unexpected finding that only 58% of the referred group fell =15th %ile even though these children had reported (by parents via M-ABC parent checklist) and observable motor performance deficits on the NDPA warrants discussion. If the M-ABC had been used alone, 42% of children with identified motor problems would not have been classified as being at risk or having motor difficulties. This is consistent with other authors, such as Smits-Engelsman et al (1998) who studied a group of 74 referred children aged 5-12 years. In their study, only 59% of children scored =15th %ile on the M-ABC. This suggests that the current findings were not an anomaly in referred groups. Smits-Engelsman et al (1998) proposed that in their referred sample, the children may have been more distractible than normal. This would have affected their daily performance; however, with therapist guidance they may have attended better during assessment enhancing performance. However, this is an unlikely explanation since attention deficit/ hyperactivity was not related to M-ABC scores in clumsy children according to Miyahara (1994). While the M-ABC has been used to identify children with motor coordination difficulties from the general population (screening), its use with referred groups (whose members have been identified as having difficulties) has been questioned in terms of its sensitivity (Smits-Engelsman et al 1998), and its inability to detect children with DCD who have specific motor coordination difficulties such as poor handwriting (Geuze et al 2001). Nevertheless the M-ABC is becoming accepted as a "gold standard" and is extensively used in the literature. The current study would support Smits-Engelsman et al (1998) who concluded that no one instrument provides a clear view of the underlying realities of the problems in children with motor impairments.

One major difference between the NDPA and the M-ABC is in the requirement to maintain performance. The M-ABC requires only single or limited production of movements, but a sustained performance is assessed in the NDPA. Hence, children may not be able to score well with a "one off" achievement if the NDPA is used. Since variability is a hallmark of performance in both young children (Woollacott et al 1989) and those with DCD (Hadders-Algara 2002), it seems appropriate to use a test that captures this aspect of performance in children with poor motor coordination. The data in the present study support the need to assess capacity for sustained performance, and suggest that the M-ABC may under-identify coordination problems. Adequate assessment of motor performance in children with DCD should accommodate both their variable performance and poor ability to sustain or repeat a skilled movement (Hadders-Algara 2002).

A number of studies have reported issues with the M-ABC, for example, High et al (2000) reported that when comparing the M-ABC and NDPA that the M-ABC does not provide information on motor planning, bilateral integration or sequencing. In addition, Smyth and Mason (1998), from a study of 146 children aged 5-8 years, reported that the M-ABC did not identify children scoring poorly on the Kinaesthetic Sensitivity Test. These factors do affect motor performance and are evaluated during the NDPA, perhaps contributing to the disparity between the NDPA and M-ABC findings. It appears that the M-ABC may have a limited ability to identify children who have motor problems associated with sensory-motor perceptual, integration or planning problems.

Another important issue noted when assessing this 4-8 year group was the considerable range of motor skills within the two age bands. It may be that the age bands (4-6 years, 7-8 years) are too large and not sensitive enough to discriminate well between children with and without motor problems during this period. The variable nature of performance in this younger age group is supported by Woollacott et al (1989). They described these changes in the maturation of the sensory systems and their contribution to variable motor performance during the "transition period" from 4-6 years. This may limit the usefulness of normative data across such a wide age range. Even between 7-8 years there are considerable changes in aspects of motor control which may affect the variability of performance and limit the usefulness of broad age bands within such assessment tools. In addition to possible age-related effects, the age group used in the current study is younger than those often reported. Pless et al (2002) reported that children performing in the group scoring [less than or equal to] 15th%ile on M-ABC at 5-6 years of age were likely to change groups when retested at 7-8 years.

Functional Performance abilities and self-efficacy

Jongmans et al (1996) showed that the correlation between the M-ABC and the Visual Motor Integration Test (VMI) is low in a 6 year old group, and suggested that if the M-ABC is used then a separate measure of sensory-motor performance is needed to adequately describe performance (as was done in the current study). On the VMI, children in the current study had a mean performance within the average range, however, there was a wide range of scores. This was not unexpected as children with DCD are often found to perform within the average range on the VMI as it is not a timed test. Missiuna and Pollock (1995) investigated the VMI with 24 children with DCD and 24 age and motor matched controls. Consistent with the current study, most of their children performed within the average range on the VMI, possibly due to a speed / accuracy trade off when accuracy can be attained with reduced speed. In the current study, when the sample was split at the 15th %ile on the M-ABC there were no significant differences on VMI performance between children in the [less than or equal to] 15th %ile group and those above that rank.

As with the VMI, there was a large standard deviation with scores on the PDMS (Folio and Fewell 1983) indicating variability of performance. When the group was split at the 15th %ile on the M-ABC (See Table 5) there was a significant difference between the two groups on the PDMS total score and the Manual Dexterity subscale score. However, given the use of multiple t tests and associated risks of increasing the type 1 error, the finding for manual dexterity at p= .05 should be treated with caution. The significant finding for PDMS total scores (p=.03) may have been influenced by weaker performance on Manual Dexterity than any of the other scales.

Many older children in the sample achieved maximum scores on the Hand Use and Grasp subtests (i.e., ceiling effect). This influenced the group size for calculations of between group differences. The overall PDMS analysis thus revealed a between group difference at the level of total test scores but not for individual subtests (possibly due to lower cell sizes due to ceiling effects, which reduced the number of usable cases in the subtest calculations).

The participation of the children in typical activities of daily life and their self-perception of their own performance were reported using the PEDI (Haley et al 1992) and the PCSA (Harter and Pike 1984). These measures assessed functional self-care, mobility and communication, and perceived competence and social acceptance (respectively). The group as a whole showed mean functional self-care skills that were greater than one standard deviation below the normative mean. Some of the self-care items which parents reported as difficult for these children were related to fine manipulative skills, organization and sequencing. These can impact negatively on the functional performance of complex self-care tasks such as putting toothpaste on a brush, combing hair, doing buttons and zips, and tying shoe laces. Items such as eating food involving chewing and managing difficult textures were also problematic for some children. The parent reported difficulties are consistent with clinical observations made during the eating tasks of the VMPAC (further discussed under communication abilities).

When the data were split at the 15th %ile, there were no between group differences on the PEDI domains of self-care, mobility or social abilities for either functional performance or levels of carer assistance. Some of these items are not related to communication underpinning social function per se, but rather to problem solving, safety and motor skills. To date the PEDI has mostly been used with children with more significant physical disabilities; hence the assessment includes items such as managing transfers and general community mobility, none of which would be expected to cause difficulties for children with DCD. Despite the intuitive link between poor fine motor skills and difficulties with dressing, grooming and bathing, more research is needed to identify the relationships between underlying skill deficits and performance issues in self-care (Case-Smith 1995).

When assessed by the PCSA (Harter and Pike 1984), on average the children in the sample scored towards the positive or competent end of the four point rating scale on both physical and cognitive competence and peer and maternal acceptance. These findings support the reports of Pless et al (2002) that motor outcome between 5-8 years was not in accordance with self perception. This may explain some of the current findings where the 4-8 year old children did not identify themselves as experiencing problems. It may be that at this age children have not experienced significant failure, and that their self concept has not yet adjusted to the reality of their difficulties.

These findings, however, are in contrast to those of studies of older children with DCD that children aged 6-9 years perceive themselves as being less competent and socially accepted than control children (Schoemaker and Kalverboer 1994). This finding may be related to: (1) a bias towards socially desirable responses, which is an issue in all self-report research and not unique to younger groups (Sturgess et al 2002); (2) the inability of younger children to discriminate between responses and the tendency to answer towards the extreme ends of the scale (in this case the more competent child); and (3) the finding that younger children may not yet be comparing themselves with their peers (Schunk 1989). Evaluation of self against others' standards does not appear to occur developmentally until approximately 8-9 years of age when children understand that ability, not just effort, impacts on perceptions of performance (Schunk 1989). In the present study, there were no between group differences in relation to perceived competence and social acceptance.

Communication Abilities

For the communication measures for the whole group, the children's language skills were within the normal range, and no significant differences were identified between the two groups for any of the speech and language assessments. A previous study has found that relative communicative participation in a cooperative task could not be predicted by considering the children's performance on standardized language tests (Brinton et al 1998). Therefore, although the current study suggests that the language skills of children with DCD fall within the average range, the measures chosen may not have tapped into the skills necessary for the children to participate in everyday communication.

Similarly, no significant differences were found between the groups for the speech sounds assessment (i.e., GFTA). Furthermore, the results were all within the average range for the children's ages as many of the errors noted were due to lisped speech (i.e., either interdentalised or lateralized /s/ or /sh/ sounds). This error pattern was noted by the examiner for almost half of the group both during assessment and conversational speech. Although errors in /s/ production are common in the typically developing population (Bauman-Waengler 2004), 90% of children have been reported to have a correct, spontaneously produced /s/ by the age of 42 months (Dodd et al 2002). Hence, the high proportion of sound distortion noted in this group represents an area that warrants further study.

All children were determined to be intelligible in the opinion of the examiner at the time of the communication assessment. Few studies have formally assessed intelligibility (i.e., clarity of speech), and most of these have used informal judgment (McLeod 2002). No further assessment of spontaneous or conversational speech was undertaken as most available tools are outcome measures rather than diagnostic tools.

Although the results for speech and language behaviours for the whole group were essentially within the normal range, the scores for the Global and Focal sub-scales on the VMPAC were significantly poorer than expected for children of the ages tested. The presence of primitive reflexes (e.g., rooting, mouth-opening) in almost half of the group was demonstrated in the Global subscale. These are expected to be extinguished by 6 months (Scroufe et al 1988). As mentioned previously, a similar number demonstrated marked difficulties in chewing and swallowing during the prescribed VMPAC tasks. Such difficulties are not expected in a non-neurological cohort of this age but are consistent with the significantly poor whole-group results on functional self-care tasks on the PEDI. This included questions related to the children's skills in eating and chewing foods of different textures.

The Focal subscale of the VMPAC measures tongue and lip movements and sequenced movements in non-speech tasks that are elicited verbally, produced in imitation or prompted by tactile cuing. The difficulties shown by the participant cohort on these tasks are in contrast to the findings by Ozanne (1992) that most typically developing children over 4 years are able to imitate oro-motor movements. Nevertheless, these poor oro-motor skills were not reflected in poor speech sounds in the GFTA or in the Sequencing subscale of the VMPAC. They may, however, explain the proportion of children who had lisps as these errors are articulatory or motor-based (i.e., related to oral musculature, postural, and/or motor skills).

CONCLUSION

This study has described the motor, functional, self-efficacy and communication abilities of a referred cohort of children with DCD aged 4 to 7 years 11 months. To date, there has been no other reported study that has utilized an interdisciplinary battery of measures with these children. In addition there is a paucity of literature about referred children in the 4-8 years age range, against which findings could be compared.

The limitations of this study include the sample arising from one pediatric Motor Clinic in a metropolitan city, suggesting that the results may not generalize to all children referred to physiotherapy services. Future research studies may thus need to incorporate multiple centres and larger numbers. Additionally, concerns regarding burden on the children with respect to the number of assessments and length of time required, limited those included. Inclusion of other assessments of function, self-efficacy and communication that tap children's participation in their daily lives should be included in future studies. Missiuna et al (2006) also called for an increased emphasis on measurement of participation level impact and intervention outcomes for children with DCD.

This study raises questions about the use of the M-ABC with a referred cohort of young children with DCD, particularly if, contrary to the authors' recommendation, it is used in isolation, without other assessments of motor performance i.e., particularly the qualitative aspects of movement. The results of this study suggest that if the M-ABC is used in isolation (with the 15th%ile as a cut off for at risk children), it may fail to identify a significant number of children with poor motor skills, who meet the DSM-IV criteria for DCD (APA 2000) in terms of the impact of their motor difficulties on academic and daily activities. While it is acknowledged that the M-ABC was developed as a tool for population based screening, it appears that (in reported research and clinical use) it is often used to identify children with DCD referred by teachers and parents. Its use to identify DCD is therefore questioned.

KEY POINTS

* The M-ABC should be used with caution with young referred children, as distinct to its use for screening purposes.

* Self care appears to be a major area of functional deficit for young children with DCD.

* Oral motor production and presence of oral reflexes were problematic for many young children with DCD.

* Multidisciplinary assessment is needed to comprehensively understand the motor, functional, communication abilities and self-efficacy of children with DCD.

ACKNOWLEDGMENTS

This study was funded by a University of Queensland Small Research Grant awarded to the authors.

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ADDRESS FOR CORRESPONDENCE

Sylvia Rodger, Children's Research Unit, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, 4072, Australia. Phone: 61 07 33651664. Fax: 61 07 33652652. Email: s.rodger@uq.edu.au

Sylvia Rodger, BOccThy, MEdSt, PhD

Pauline Watter, BPhty, MPhty, PhD

Julie Marinac, BSpThy(Hons), PhD

Gail Woodyatt, BSpThy, PhD

Jenny Ziviani, BAppSc(OT), BA, MEd, PhD

Children's Research Unit: Communication, Occupation and Movement, School of Health and Rehabilitation Sciences,

The University of Queensland, Australia

Anne Ozanne, BA(Psych), MSc(Hum Comm), PhD

School of Human Communication Sciences, La Trobe University, Melbourne, Australia
Table 1. The Percentages of Children Rated 2, 3 or 4 (Mild, Moderate
or Severe Dysfunction) on the NDPA.

 % [greater than
NDPA Item or equal to] 2

Neurological Aspect 23%
General tone 100%
Deep Tendon Reflexes 0%
Clonus 0%
Resting tremor 0%
Intention tremor 3%
Involuntary movements 3%
Associated reactions 27%

Visual Aspect 50%
Optokinetic nystagmus 27%
Strabismus 33%
Head eye dissociation 57%
Visual fixation 0%
Eye follow 67%
Convergence 43%
Gaze fixation and release 23%
Fast eye follow 27%
Tactile Aspect 95%
Reaction to touch 30%

Tactile awareness 7%
Body localisation 87%
Hand localisation 67%
Simultaneous stimulation 70%
Stereognosis 7%

Vestibular Function Aspect 87%
Vest. head righting tone 97%
Vest. head righting reactions 97%
Movement fear 43%
Post-rotatory tone 17%
Pre-movement tone 23%
Post movement tone 37%
Movement fear 7%

Gross Motor Skills Aspect 100%
1 leg stand + vision 97%
1 leg stand - vision 100%
Hop rating 100%
Skip rating 77%
Gallop 97%
Side stepping 93%
Forward jump 93%
Backward jump 93%
Forward-back jump 97%
Side-to-side jump 97%
Stride jump 97%
Scissor jump 100%

Posture Aspect 97%
Adaptive placing reactions 27%
Positive support response 67%
Body on body righting 3%
Tone rating 80%
Optical head righting reactions 77%
Optical head righting fear 27%
Protective reactions 90%
Parachute reactions 37%
Equilibrium reactions 100%

Fine Motor Skills Aspect 100%
Finger circles + vision 93%
Finger circles - vision 93%
Lumbrical holds 93%
Dissociation of lumbrical action 93%
Finger drumming on table 100%
Dysdiadokinesia pattern 93%
Dysdiadokinesia variance 93%
Ball skills 83%

Fine Sensory Aspect 90%
Hand proprioception 83%
Upper limb (UL) proprioception 90%
Tactile hand localisation 67%

Proprioception Aspect 100%
Autoposition awareness 27%
Synkinesis 63%
Static hold, UL extension + vision 87%
Static hold, UL extension - vision 100%
Response to proprioceptive cues 87%

Stability Aspect 100%
Stability in 4 pt kneel 100%
Stand with UL extension + vision 87%
Stand with UL extension - vision 100%
1 leg stand + vision 97%
1 leg stand - vision 100%

Stereotypical Patterns Aspect 83%
Extensor Thrust 7%
Asymmetrical tonic neck reflex 83%
Symmetrical tonic neck reflex 80%
Stability 100%
Tonic labyrinthine reflex 23%

Motor Planning Aspect --
Crossing the midline 100%
Visual copy 100%
Verbal copy 97%

Table 2. The Mean Age, Gender ratio, and M-ABC Percentile Ranks for
the Total Sample (N=60) and separately for Groups 1 and 2.

Sample Age (months) Gender Mean SD Range
 Mean (SD) Male:Female %ile %ile
 rank rank

Total 72.9 (11.7) 40:20 17.1 19.4 1-96
(N=60)

Group 1 72.7 (11.7) 23:12 6.0 4.5 1-15
[less than
or equal to]
15Th %ile
(n= 35)

Group 2 73.0 (12.0) 17:8 32.7 21.5 16-96
[greater than
or equal to]
16Th %ile
(n = 25)

Table 3. Mean Summed NDPA Criterion Scores for Children
[less than or equal to] 15th percentile (Group 1) and >15th percentile
(Group 2) on M-ABC, compared with Typical Criterion Score.

Aspect of NDPA Typical Group 1 Group 2
 score (n=35) (n=25)

Neurological 7 9.1 9.3
Stereotypical reactions 5 9.7 9.5
Fine motor 11 29.3 24.8
Gross motor 12 34.5 29.6
Postural control 9 16.7 15.5
Stability 4 11.2 10.3
Visual motor 7 10.3 9
Tactile 6 9.9 9.2
Proprioception 7 15.5 14.4
Vestibular 7 13 12.8
Motor planning 3 8.4 8.7

The higher the NDPA score the more significant/severe the
dysfunction.

Table 4: Descriptive Results for the Communication, Functional and
Motor Measures for the Entire Study Sample (N=60).

Measure No. Mean

Communication
CELF 3/P 60 103.0 (standard score; mean = 100)
Bus Story 58 1.3 (1-4; normal- severe rating)
GFTA 60 35.0 (percentile rank)
VMPAC Global 60 3.3 (1-4; normal-severe rating)
VMPAC Focal 60 2.8 (1-4; normal-severe rating)
VMPAC Sequencing 60 1.6 (1-4; normal-severe rating)

Functional
PDMS Total (a) 58 27.1 (percentile rank)
PDMS Grasp 50 62.2 (percentile rank)
PDMS Hand use 40 69.7 (percentile rank)
PDMS Manual Dexterity 60 42.3 (percentile rank)
PDMS Eye-Hand 60 36.5 (percentile rank)
VMI 60 40.8 (percentile rank)
PEDI Function Self-care 57 38.6 (standard score; mean=50)
PEDI Function Mobility 57 51.2 (standard score; mean=50)
PEDI Function Social 57 43.1 (standard score; mean=50)
PEDI Carer Self care 57 49.9 (standard score; mean=50)
PEDI Carer Mobility 57 53.2 (standard score; mean=50)
PEDI Carer Social 57 50.5 (standard score; mean=50)
PCSA Physical 56 3.3 (1-4; negative-positive)
PCSA Cognitive 56 3.4 (1-4; negative-positive)
PCSA Peer 57 3.0 (1-4; negative-positive)
PCSA Maternal 57 3.1 (1-4; negative-positive)

Measure SD Range

Communication
CELF 3/P 13.8 65-143
Bus Story 0.9 1-4
GFTA 25.9 4-99
VMPAC Global 1.1 1-4 *
VMPAC Focal 1.3 1-4 *
VMPAC Sequencing 0.9 1-4

Functional
PDMS Total (a) 26.1 1-95
PDMS Grasp 47.4 2-99
PDMS Hand use 44.9 2-99
PDMS Manual Dexterity 28.5 4-99
PDMS Eye-Hand 33.8 2-99
VMI 26.1 4-98
PEDI Function Self-care 12.6 9.9-72.1 *
PEDI Function Mobility 11.5 9.9-60.7
PEDI Function Social 14.4 23-91
PEDI Carer Self care 11.7 21.3-78.3
PEDI Carer Mobility 7.3 9.9-59.2
PEDI Carer Social 12.1 32.7-74.1
PCSA Physical 0.5 2-4
PCSA Cognitive 0.7 1.3-4
PCSA Peer 0.7 1-4
PCSA Maternal 0.6 1.7-4

Note: * indicates scores that represent areas of difficulty for this
referred group (e.g., more than one standard deviation below the mean,
or in the moderate to severe range). Lower N in PDMS hand use due to
ceiling effect. CELF= Clinical Evaluation of Language Fundamentals,
GFTA= Goldman Fristoe Test of Articulation, VMPAC= Verbal Motor
Production Assessment for Children, PDMS= Peabody Developmental Motor
Scales, VMI= Developmental Test of Visual Motor Integration, PEDI=
Pediatric Evaluation of Disability Inventory, PCSA= Pictorial Scale
of Perceived Competence and Social Acceptance.

Table 5. Results for the Standardised Measures of Communication and
Function for Group 1 and Group 2.

Measure Group 1 Group 1
 N Mean (SD)

Communication
CELF 3/P 35 101.4 (12.6)
Bus Story 33 1.3 (0.9)
GFTA 35 35.8 (28.7)
VMPAC Global 34 3.1 (1.2)
VMPAC Focal 34 2.9 (1.2)
VMPAC Sequencing 34 1.7 (1.0)

Functional
PDMS Total (a) 26 594.8 (24.8)
PDMS Total (b) 34 83.6 (11.6)
PDMS Grasp 30 66.8 (46.3)
PDMS Hand use 24 74.4 (42.7)
PDMS Manual Dexterity 35 36.2 (25.4)
PDMS Eye-Hand 35 30.9 (31.0)
VM1 35 36.6 (23.9)
PEDI Function Self-care 34 37.2 (10.6)
PEDI Function Mobility 34 50.0 (11.3)
PEDI Function Social 34 42.8 (16.2)
PEDI Carer Self care 34 49.5 (11.5)
PEDI Carer Mobility 34 53.1 (8.6)
PEDI Carer Social 34 49.3 (12.6)
PCSA Physical 33 3.3 (0.6)
PCSA Cognitive 33 3.3 (0.8)
PCSA Peer 33 3.0 (0.8)
PCSA Maternal 33 3.1 (0.6)

Measure Group 2 Group 2 t p
 N Mean (SD)

Communication
CELF 3/P 25 105.2 (15.2) 1.08 .29
Bus Story 25 1.3 (0.9) .06 .95
GFTA 25 33.8 (21.9) .29 .77
VMPAC Global 25 3.4 (1.0) 1.09 .28
VMPAC Focal 25 2.5 (1.4) 1.23 .22
VMPAC Sequencing 25 1.4 (0.8) 1.25 .22

Functional
PDMS Total (a) 21 622.8 (49.5) 2.37 .03 *
PDMS Total (b) 24 92.9 (16.2) 2.42 .02 *
PDMS Grasp 20 55.2 (49.4) .85 .40
PDMS Hand use 16 62.6 (48.5) .81 .42
PDMS Manual Dexterity 25 50.9 (30.7) 2.03 .05 *
PDMS Eye-Hand 25 44.3 (36.5) 1.53 .13
VM1 25 46.7 (28.3) 1.50 .14
PEDI Function Self-care 23 40.6 (15.1) 1.02 .32
PEDI Function Mobility 23 52.8 (11.7) .90 .37
PEDI Function Social 23 43.5 (11.5) .16 .87
PEDI Carer Self care 23 50.5 (12.4) .31 .76
PEDI Carer Mobility 23 53.4 (4.7) .13 .90
PEDI Carer Social 23 52.2 (11.2) .89 .38
PCSA Physical 24 3.5 (0.7) 1.75 .09
PCSA Cognitive 24 3.6 (0.7) 1.51 .14
PCSA Peer 24 3.1 (0.6) .19 .85
PCSA Maternal 24 3.1 (0.6) .39 .70

Note: * = significance demonstrated at or below p=.05. Lower N in
PDMS hand use due to ceiling effect.

CELF= Clinical Evaluation of Language Fundamentals, GFTA= Goldman
Fristoe Test of Articulation, VMPAC = Verbal Motor Production
Assessment for Children, PDMS= Peabody Developmental Motor Scales,
VMI= Developmental Test of Visual Motor Integration, PEDI= Pediatric
Evaluation of Disability Inventory, PCSA = Pictorial Scale of
Perceived Competence and Social Acceptance.
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Title Annotation:Research Report
Author:Rodger, Sylvia; Watter, Pauline; Marinac, Julie; Woodyatt, Gail; Ziviani, Jenny; Ozanne, Anne
Publication:New Zealand Journal of Physiotherapy
Geographic Code:8NEWZ
Date:Nov 1, 2007
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