They're Bright but Can't Write: Developmental Coordination Disorder in school aged children

Handwriting problems are readily apparent to classroom teachers but may be only the tip of the iceberg for children who have significant coordination difficulties. School is a daily frustration for these children as their finished work does not reflect their abilities, they struggle with the simplest of tasks and are victimized by their peers. Strong evidence is now available indicating that children who appear to only have “mild” motor difficulties go on to experience serious secondary social and emotional problems. Educators have a pivotal role in early identification and in facilitating success using a strategy that will better M.A.T.C. H. each task to the child with coordination difficulties. In this article, the typical characteristics of these children are described, behavioral observations are explained, and practical suggestions are outlined. SUGGESTED CITATION: Missiuna, C. , Rivard, L. & Pollock, N. (2004) "They’re Bright but Can’t Write: Developmental Coordination Disorder in school aged children", TEACHING Exceptional Children Plus: 1(1), Article 3. Retrieved [date] from http://escholarship.bc. edu/education/tecplus/vol1/iss1/3 Missiuna, Rivard, Pollock They’re Bright but Can’t Write: Developmental Coordination Disorder in school aged children In many classrooms there is one, or even two, student(s) who are a real puzzle. They seem to be bright enough and are good readers. They participate actively in class discussions and, yet, they are struggling. They are slow to finish any written work and the end product of their efforts is usually messy and illegible. Although they can tell interesting and complex stories, they never seem to get around to writing anything down. They are the last to get ready to go outside for recess and, once there, wander the playground aimlessly. Clumsy and awkward, they are often isolated by their peers and are rarely chosen for competitive games. Their homework is usually incomplete because it never seems to make it from their desk to their backpacks. At the end of the day, they often go home frustrated and in tears. These children are a little recognized group who have a condition known as Developmental Coordination Disorder (DCD) (American Psychiatric Association, 2000). DCD affects 5-6% of school aged children; that is, approximately one child in every classroom. It is a movement skill syndrome involving physical awkwardness and a motor skill delay that impacts the child’s ability to perform everyday tasks. Despite the high prevalence and the evidence that is accumulating about the secondary consequences of DCD, very little information about this disorder has been described within educational literature. In an environment that stresses learning through “doing”, children with DCD fall short of their potential because they have coordination difficulties that impact their academic, social and physical development. This review article provides information that special educators need to recognize children with DCD, and practical strategies that can be used by classroom teachers to enhance the ability of these children to participate successfully in school. By definition, DCD is a motor impairment that affects a child’s ability to perform the skilled movements necessary for daily living, including the performance of academic and self-care tasks (APA, 2000). In most states and provinces, a diagnosis of DCD can only be made by a physician. It was once assumed that children with DCD would “grow out” of their difficulties (Fox & Lent, 1996). We now know that their motor problems continue at least into adolescence and often into adulthood and lead to devastating long-term secondary consequences (Rasmussen & Gillberg, 2000). Nearly every school activity, especially in the early school years, is a motor activity. For children who have coordination difficulties, participation in all schoolrelated activities that have a motor component requires tremendous effort and is often unsuccessful. Coordination difficulties also have an impact on the child’s life beyond the classroom since children with DCD have difficulty getting ready for recess, interacting with peers on the playground and participating in physical education. Early and ongoing failure leads to poor academic performance, feelings of low self-esteem, withdrawal, behaviour problems and in many cases, depression (Cantell, Smyth & Ahonen, 1994; Schoemaker & Kalverboer, 1994; Skinner & Piek, 2001). Typical Classroom Presentation Children with DCD may experience difficulty with fine motor activities, gross motor activities or both (Maeland, 1992). Usually, their ability to perform self-care activities such as doing Missiuna, Rivard, Pollock They’re Bright but Can’t Write: Developmental Coordination Disorder in school aged children up snaps, zippers and buttons, tying shoelaces, opening snack containers is poorer than expected for their age (MayBenson, Ingolia & Koomar, 2002). They are often the last to be able to get snowsuits, jackets and boots on or to get their knapsacks organized to go home at night. Activities requiring good eye-hand coordination will always present problems for children with DCD (David, 2000). Printing/handwriting may be illegible, inconsistent in sizing, messy and very effortful (Parush, Pindak, HahnMarkowitz, & Mazor-Karsenty, 1998). Frequent erasures of work, inaccurate spacing of words and unusual letter formation are evident. Pencil/crayon grasps may be awkward and written work not well aligned. Pencils may be dropped frequently and pencil leads broken or paper torn because they use excessive pressure on the page (Case-Smith & Weintraub, 2002). Many children with DCD tend to avoid art projects and craft activities that require cutting and pasting (May-Benson et al, 2002). Coordination of eyes and hands at a whole body level is equally problematic so children with DCD usually have difficulty with activities such as throwing, catching and kicking a ball accurately. At recess, children may be hesitant to participate in playground games and are often the last to be chosen for competitive sports (Watkinson et al, 2001). Balance difficulties are displayed in poorly coordinated running, skipping, jumping and hopping. Learning new skills in physical education is a continuous challenge and children may try to avoid these classes with complaints of illness or problem behaviour. Slow awkward movements are typical of children with DCD and are easy to casually observe. What is less evident is the extra effort that motor skills seem to require and the struggle that children have to adapt and “fine-tune” movements (CaseSmith & Weintraub, 2002). Maintaining a posture for a long time is often fatiguing for these children so they may appear to be slumped over their desk, falling off their chairs and complaining that their hands are tired when they are writing. Sitting on the floor is also a problem because children fatigue easily when trying to maintain sitting balance so they may try to lean against the wall or onto other children. Although teachers often notice many of the above physical characteristics, it is usually the child’s behavioural problems that become the forefront of concern in the classroom. Disruptions in the classroom are common as children with DCD may knock things over, drop objects or bump into other children’s desks. Clumsiness, in school lineups or walking between classes, can be irritating when it leads to stumbling into and tripping over children and objects in their path. Children with DCD frequently have organizational difficulties (May-Benson et al, 2002; Leew, 2001) and task initiation and task completion are often major issues. Avoidance of written work can result in “behaviour” such as needing to sharpen the pencil multiple times, talking and asking questions, attention-seeking and interference with other children. A lack of interest in motor tasks, low frustration tolerance, decreased motivation and poor self-esteem are commonly observed (Schoemaker & Kalverboer, 1994; Skinner & Piek, 2001). Is it actually DCD? In medical circles, differential diagnosis is important because figuring out the exact type of disorder may lead to a Missiuna, Rivard, Pollock They’re Bright but Can’t Write: Developmental Coordination Disorder in school aged children radically different type of treatment. In education, though, effective intervention strategies may be quite similar across exceptionalities so obtaining a diagnosis may be less critical. It is important, however, to figure out whether or not motor coordination problems are present and whether they are occurring in combination with another recognized condition. Strong associations have been demonstrated between DCD and Attention Deficit Hyperactivity Disorder (ADHD), speech/articulation difficulties and learning disabilities (Hill, 2001; Kadesjo & Gillberg, 1998; Rasmussen & Gillberg, 2000). When a child has any of these conditions, there is at least a 50% likelihood that DCD is also present and teachers need to be aware of the implications of having both. Interventions that are appropriate for one condition, such as the use of kinesthetic and multisensory methods to teach letters to a child with a learning disability, may be inappropriate if the child has DCD (Martini, Heath & Missiuna, 1999). It is now recognized that children who have DCD in addition to ADHD have a significantly poorer outcome than children with ADHD alone (Tervo, Azuma, Fogas, Fiechtner, 2002; Rasmussen & Gillberg, 2000). Implications for Special Education Practice Special educators can play an instrumental role in the early detection of children with DCD. Classroom teachers will often identify concerns such as difficulty learning to print or avoidance of written work. Through awareness of the characteristics of DCD, special educators can facilitate early identification and more timely intervention. Children who are showing signs of DCD should be referred to a physician for diagnosis