International clinical practice recommendations on the definition, diagnosis, assessment, intervention, and psychosocial aspects of developmental coordination disorder

AUTHORS Coordinators* In some countries the diagnosis can only be made by a medical doctor. This means that the multi-professional team must include a medical doctor.

# Introduction
The present document is the pocket version of the international clinical practice recommendations (CPR) for developmental coordination disorder (DCD).
The pocket version contains the most important information, algorithms, and recommendations from the CPR-DCD long version. [bib_ref] International clinical practice recommendations on the definition, diagnosis, assessment, intervention, and psychosocial..., Blank [/bib_ref] For all background information, methods, and explanations see the long version. [bib_ref] International clinical practice recommendations on the definition, diagnosis, assessment, intervention, and psychosocial..., Blank [/bib_ref] The terminology in this document is consistent with that of the International Classification of Functioning, Disability and Health (ICF). The current classification systems, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10),use different terminology to describe the population of concern. The term 'developmental coordination disorder' is used throughout this document.
Since children and adults tend to be treated by different specialists in different contexts, these recommendations are presented in two sections: [bib_ref] International clinical practice recommendations on the definition, diagnosis, assessment, intervention, and psychosocial..., Blank [/bib_ref] 

## Children (section a) and
(2) adolescents and adults (section B). Within these two sections, the recommendations are specific for these target groups.
As a clinical practice guideline, the international CPR-DCD are not designed as a rule explaining what to do or how to act in a legal situation. These recommendations cannot be a basis for legal sanctions. In countries where ICD-10 has legal status, we also recommend the term Specific Developmental Disorder of Motor Function (SDDMF) (F82, ICD-10).
GCP  2 Diagnosis and assessment

## Definition and criteria

## R2
We recommend that the diagnosis of DCD is made by a medical professional or a multi-professional team * suitably qualified to assess the individual according to the specified criteria.
GCP 

## R3
We recommend the following criteria for the diagnosis of DCD. These criteria follow closely those proposed in DSM-5 with some minor changes, including the order of criteria III and IV:
I. The acquisition and execution of coordinated motor skills is substantially below that expected given the individual's chronological age and sufficient opportunities to acquire age-appropriate motor skills. II. The motor skills deficit described in criterion I significantly and persistently interferes with the activities of everyday living appropriate to chronological age (e.g. self-care and self-maintenance and mobility) and impacts upon academic/school productivity, prevocational and vocational activities, leisure, and play. III. The motor skills deficits are not better accounted for by any other medical, neurodevelopmental, psychological, social condition, or cultural background.

## Gcp 
IV. Onset of symptoms in childhood (although not always identified until adolescence or adulthood).
Comment: -Criterion I: The symptoms of DCD may include slowness and/or inaccuracy of motor skills performed in isolation or in combination. -Criterion III: This addresses issues of aetiology with regard to DCD and is designed to facilitate differential diagnosis. Examples of conditions which may rule out or influence the diagnosis of DCD are:
(1) Medical conditions: movement disorders with known aetiologies (e.g. cerebral palsy, muscular dystrophy, childhood arthritis), side effects of drugs (e.g. neuroleptics, chemotherapy, sedatives), sensory problems (e.g. substantial visual impairments or impairments of the vestibular organ) (2) Other neurodevelopmental disorders (e.g. severe intellectual disabilities) or other psychological disorders (e.g. anxiety, depression), or other psychological conditions (e.g. attentional problems) as primary causes of motor problems (3) Social conditions (e.g. deprivation, cultural diversity) Note: It may be difficult to differentiate between conditions that may be causal and those that may co-occur. * For example, a child from a culture, which limits physical activity or which provides little opportunity for motor learning may present like a child with DCD (at least initially). A child with ADHD might appear to have movement problems, which are in fact caused by impulsivity and/or inattention. Especially in unclear cases, multiprofessional or repeated assessments can be helpful to differentiate.
-Criterion IV: The onset of symptoms is usually evidenced in infancy and childhood.
The following recommendations are designed to offer guidance as to how to arrive at an accurate diagnosis of DCD. Instead of being listed according to the criteria I to IV they are given in the opposite order which is in line with how a medical professional would usually proceed with his/her examination. Thus, the process starts with: (1) considering the age and context of the child (criterion IV),
(2) ruling out other medical conditions causing motor problems (criterion III), (3) taking into account the impact on activities and participation (criterion II), (4) quantifying the motor impairment (criterion I).
It should be noted, however, that there are other pathways to diagnosis. For example, a child might be identified as having difficulties within a school system and be first assessed by a therapist or educational psychologist. Their assessments may show the child meets criteria I, II, and IV and only then might the child be referred to a medical doctor to exclude other conditions.

## R4
The symptoms of DCD are usually apparent in the early years. However, due to the large variability in normal motor development, we recommend that a formal diagnosis of DCD under the age of 5 years is only made in cases of severe impairment. In such instances, the decision to make a diagnosis should be based on the findings from at least two motor assessments carried out at least 3 months apart.
Comment: Based on the persistence and the extent to which the motor problems interfere with daily life (criterion II), and after excluding other conditions that may explain the motor problems (criterion III), it should be decided whether any form of intervention should be recommended at this stage. Options will include formal intervention, the provision of opportunities for motor learning in a less formal setting, or advice plus clinical supervision.

## Gcp

## R5
For countries using ICD-10: for motor problems in individuals who do not meet criteria for DCD but where criterion III is fullfilled, we recommend the ICD-10 categories of R26, R27, or R29 be applied if appropriate.

## Gcp

## The process of assessment

## R6
To begin any assessment process, we recommend careful history taking to support the application of all four criteria.
Comment: Children: history should include the following aspects:
(1) Parental report  Reasons for referral and presenting problems.  Family history -to include information about the presence GCP of developmental disorders or other genetic conditions (e.g. muscular disorders in family members).  Medical history -to include information about major accidents, diseases, neurological disorders, relevant or associated psychological problems, sensory problems (e.g. documented in previous assessments, new symptoms arising), medication regime where relevant.  Developmental history -to include information about pregnancy, birth, milestones -motor and non-motor; history of motor engagement (e.g. family habits, home environment, access to motor activities), social competences, and ability to interact with others.  Educational history -educational progress through nursery, preschool, kindergarten, and grade school, and information about any measures of academic achievement.  Impact of the condition -including impact on ADL and participation.  Contextual factors -including amount and type of previous and current intervention/support; description of current family structure, social network and relationship status (e.g. social support, living with family, extended relatives, guardians, friends or others), social-economic status, personal resources.
(2) Sources other than parents  Formal documents and reports from relevant professionals and significant others (e.g. nursery, pre-school, kindergarten and school teachers, educational psychologists, therapists). These might include: (i) Written information or interview data from other family members or significant adults if appropriate and consent is given.
(ii) Reports about motor functions from physical education teachers or therapists as well as other areas of interest (as per the ICF): participation and levels of physical activity, environmental factors, support systems, individual/personal factors, etc.
(iii) Reports concerning cognitive functions (e.g. IQ data, scores on working memory, attention, other tests).
(iv) Reports concerning academic achievement.
(v) Reports concerning behaviour that might bear on differential diagnosis and/or possible dual diagnosis (e.g. ADHD, ASD, learning disorders).
(3) Child  Self-reports  Adapted questionnaires (see below)

## Criterion iii and ii: clinical examination

## R7
We recommend problem-oriented clinical observation and examination.

## Criterion ii: specific history and questionnaires

## R8
We recommend that the complete assessment considers ADL (e.g., self-care and self-maintenance), academic/school productivity, prevocational or vocational activities, leisure, sports, and play. We recommend that this information be gathered from multiple sources such as: self-reports, reports of parents, health care/educational professionals, and relevant others.
Comment: Because language is involved, handwriting and keyboarding are areas of motor competence that should be assessed separately.

## Gcp

## R9
We recommend that, if possible, the measure(s) used to collect GCP information on the DCD related characteristics of an individual, has appropriate standardization. These measures (e.g., questionnaires, observational assessment tools) may be completed by parents, teachers, the child himself/herself, or significant others in the child's life. We suggest that that the DCDQ-R * is used in a clinical setting as supplementary information in the diagnosis of children with DCD.
Comment: Athough many questionnaires (e.g. MABC-2-C, Motor Observation Questionnaire for Teachers, DCDDaily Questionnaire) are available, the DCDQ's psychometric properties have been studied most extensively and therefore can be suggested as offering supplementary information on motor-related problems.
The DCDQ-R has been shown to be a useful adjunct in studies using clinical samples. However, the DCDQ-R should not be used in population-based screening as it has been shown that the sensitivity is too low to identify children with DCD in the general population.
LOE 2, level B

## Criterion i: objective assessment of motor proficiency
R11 We recommend the use of an appropriate motor test that measures different areas of motor competence, has good reliability and validity, and has population-based standardization (appropriately norm-referenced). The test should measure different types of motor skills to describe one's motor competence or difficulties.
Comment: Because language is involved, handwriting and keyboarding are areas of motor competence that should be assessed separately with standardized and psychometrically sound measures.

## Gcp
R12 We suggest criterion I be satisfied by using the MABC-2 or the BOT-2.
Comment: At present there are no biological markers that provide definitive cut-off points for diagnosing DCD (or any other developmental disorder). Consequently, statistically defined criteria must suffice.
In the absence of generally accepted cut-offs for identifying DCD, and in addition to the other criteria being satisfied, it is LOE 2, level B * The term 'DCDQ-R' is used throughout this document and is consistent with the term DCDQ'07, which is also used to refer to the revised version of the DCDQ.
recommended that when using the MABC-2 or other equivalent objective measures, the 16th centile (1 SD) for the total score (standard score of 7 or less) should be used as a cut-off. Scores at or below the fifth centile should be considered as unequivocal evidence of DCD, provided the child meets all other criteria.
R13 If there are clear indications of increased risk for DCD from the history and clinical examination (criteria IV, III, and II), and the results of one standardized motor test are above specified cut-off criteria, we recommend the use of a second standardized motor test or a second examination by another expert. Further studies of reliability and validity on the clinical reference standard are required.

## Co-occurring disorders
R14 Owing to the high degree of co-occurrence among developmental disorders, we recommend that dual or multiple diagnoses including DCD and any other disorder be given when appropriate. To ensure that this is done properly, appropriate assessments should be undertaken and interpreted according to established clinical guidelines.
Comment: To ensure that co-occurrence is not missed when assessing a person referred for problems in the motor domain, difficulties in other areas of development and educational attainment should be recorded and any necessary further assessment and intervention planned.

## Gcp

## Psychosocial issues

## S1
Research evidence shows that, for many children with DCD, substantial psychosocial difficulties often have an impact on engagement, participation, psychosocial well-being, and quality of life. Individual and environmental factors will work together, influencing both the expression and management of these associated issues.

## Therapeutic approaches
R22 If an intervention is to be provided then we recommend that activity-oriented and participation-oriented approaches be used as a means to improve general, fundamental, and specific motor skills in individuals with DCD.
Comment: Activity-oriented or participation-oriented approaches are interventions that focus on ADL (including personal care, play, leisure/sports, arts and crafts, and academic, prevocational, and vocational tasks) within the intervention process. Intervention must also aim to generalize to daily function, activity, and participation across environmental contexts in which the child needs to perform. Activity-oriented or participation-oriented approaches should involve family, teacher, significant others, and/or environmental support to cascade and promote essential opportunities for practice and generalization. This is necessary to give enough opportunity for motor learning and consolidation of skills. Formally investigated activity-oriented or participation-oriented approaches, based on this and the previous review, include but are not limited to task-specific training, NTT, and cognitive orientation to daily occupational performance approach (CO-OP).

## Loe 1, level a
R23 If handwriting problems are present in children with DCD, we suggest activity-oriented and participation-oriented intervention (including ways to self-evaluate performance) to improve the quality of the handwriting.
LOE 2, level B
R24 If handwriting problems are present in children with DCD, in addition to activity-oriented and participation-oriented handwriting intervention, we suggest teaching keyboarding from early on, to improve the legibility and neatness of schoolwork.

## Gcp

## S2
Some interventions that aim to improve body functions and structures may be effective, but there is limited evidence whether body-function-oriented interventions are effective in improving activity and participation in children with DCD.

## Gcp

## S3
The following interventions cannot be recommended as empirical support, because their effectiveness is inconclusive, absent, or negative: (1) the evidence is inconclusive for the effectiveness of sensory integration therapy as an intervention for children with DCD;
(2) the evidence is inconclusive for the effectiveness of kinesthetic sensitivity training for children with DCD.
Other approaches used in children with DCD (e.g. brain-gym, complementary and alternative therapies) have not been systematically evaluated so cannot be recommended.

## Gcp
R25 Active video games may be recommended as a useful adjunct to more traditional activity-oriented and participation-oriented interventions in children with DCD, in supervised settings or group intervention.
LOE 2, level B R26 We recommend that physical fitness (e.g. strength, endurance, flexibility) is considered as part of intervention planning.

## Gcp

## Interventions delivery mode: (group) settings
R27 We recommend considering small group intervention because it can be effective.

## Gcp
R28 We suggest considering carefully if and when a group setting is appropriate for a child.
Comment: We suggest considering the level of anxiety and movement skills of the children when composing groups (and their GCP size) for group-based intervention. The optimum staff to child ratio has yet to be ascertained.

## Interventions: intensity and scheduling

## S4
Current information on the effectiveness of intervention does not allow clear recommendations on intensity, duration, and timing because comparison studies are lacking. Mean duration of new effective studies was 10 weeks (range 2-18wk).
Overall, long training protocols (20-30h) do not seem to be more effective than shorter ones (10-15h) when measured using standardized tests assessing body function/activity. However, these tests may not capture the transfer of skills to complex situations and the level of automaticity needed in everyday life.

## Gcp

## Resea rch note 2
Additional comparison studies on types of intervention, intensity, and duration are required. Group versus individual approaches must also be evaluated.

## The role of environmental factors
R29 We recommend that individuals with DCD are given ample opportunity to practise movement skills in order to learn them and to participate in daily activities (e.g. at home, school, in community and leisure settings, and in sports).
Comment: Once they have learned the basic skills through targeted intervention (which provided them with appropriate feedback and strategies), individuals with DCD should also be given additional opportunities and time to practise these required skills in context, to develop an adequate level of competency. This is particularly true of skills that are complex in nature or that require high levels of planning. We recommend professionals support parents, teachers, significant others, and other stakeholders to encourage the children to participate in relevant activities at home and school, and in the community (e.g. games that require diverse movement activities, extracurricular sports, cultural events, etc.) to promote their practice and newly acquired motor skills.
GCP We suggest that involved professionals give parents and relevant others (teachers, etc.) advice on the specific abilities and the GCP problems of the child with DCD and how to help them improve their motor functions and participation in daily activities (at home, school, leisure, sport, and cultural activities).

## Resea rch note 3
There is a lack of studies reporting outcomes on motor skills after systematic intervention conducted at the school or parent level. There is only extrapolated evidence to show that it may work at the school level.

## Somatic interventions: drugs, additives
R31 We do not suggest fatty acids + vitamin E to improve motor functions as there is no evidence for an effect on motor functions.

## Loe 2, level b negative s5
Where there is co-occurring DCD and ADHD, it is known that methylphenidate in combination with further intervention is helpful in overcoming functional problems. Methylphenidate has been shown to improve some aspects of apparent motor function. The effectiveness of other medications and/or supplements has not been systematically evaluated.

## Gcp

## Monitoring
R32 We recommend that ongoing behavioural observation be performed during the period of intervention to provide information about the necessity of adjustments to a treatment plan and/or to facilitate the adaptation of an individual's intervention goals.
GCP R33 We recommend that formal standardized outcome measures are used for assessment, and are repeated at the end of intervention or at least every 3 months if intervention is longer, to evaluate the effects of an intervention programme and goal attainment and to determine whether further intervention is required. We recommend to evaluate intervention effects using psychometrically sound outcome assessment tools that capture the levels of both activities and participation. We also recommend other evaluation sources including clinical examination, the child's self-report, family report, teacher/kindergarten reports, questionnaire information, activity monitoring, etc.

## Gcp

## B
Adolescents and adults 1 Terminology, diagnosis, and assessment We recommend the following criteria for the diagnosis of DCD. These criteria follow closely those proposed in DSM-5 with some minor changes, including the order of criteria III and IV. I. The acquisition and execution of coordinated motor skills is substantially below that expected given the individual's chronological age and sufficient opportunities to acquire ageappropriate motor skills. I. The motor skills deficit described in criterion I significantly and persistently interferes with the activities of everyday living appropriate to chronological age (e.g. self-care, selfmaintenance, and mobility) and affects academic productivity, prevocational and vocational activities, leisure, and work. II. The motor skills deficits are not better accounted for by any other medical, neurodevelopmental, psychological, social condition, or cultural background. V. Onset of symptoms in childhood (although not always identified until adolescence or adulthood).

## Comment:
 Criterion I: the symptoms of DCD may include slowness and/or inaccuracy of performance of motor skills in isolation or in combination.  Criterion III: this criterion addresses issues of aetiology with regard to DCD and is designed to facilitate differential diagnosis.
Examples of conditions that may rule out or influence the diagnosis of DCD are:
(1) Medical conditions: movement disorders with known aetiologies (e.g. cerebral palsy, muscular dystrophy, childhood arthritis), side effects of drugs (e.g. neuroleptics, chemotherapy, sedatives), sensory problems (e.g. substantial visual impairments or impairments of the vestibular organ).
(2) Other neurodevelopmental disorders (e.g. severe intellectual disabilities) or other psychological disorders (e.g. anxiety, depression), or other psychological conditions (e.g. attentional problems) as primary causes of motor problems.

## Gcp
(3) Social conditions (e.g. deprivation, cultural constraints).
(4) Acquired motor difficulties (e.g. trauma or Parkinson disease, Huntingdon chorea, multiple sclerosis, stroke, brain tumours, arthropathies). Note: it may be difficult to differentiate between conditions that may be causal and those that may co-occur. For example, an adult with ADHD might appear to have movement problems, which are in fact caused by impulsivity and/or inattention. Especially in unclear cases, multi-professional assessments can be helpful in differentiating motor from attentional problems.  Criterion IV: the onset of symptoms is usually evidenced in infancy and childhood.
The following recommendations are designed to offer guidance for arriving at an accurate diagnosis of DCD. Instead of being listed according to the criteria I to IV, they are given in the opposite order, which is in line with how a medical professional would usually proceed with the diagnostic process. Thus, the process starts with (1) considering the age and context of the individual (criterion IV), (2) ruling out other medical conditions causing motor problems (criterion III), (3) taking into account the impact on activities and participation (criterion II), (4) quantifying the motor impairment (criterion I).
It should be noted, however, that there are other pathways to diagnosis. For example, an adult may be identified as having difficulties in employment or education and be first assessed by an occupational therapist, psychologist, or an educational psychologist.
R35 It is noted that some motor performance tests are currently being used to help identify and describe DCD in adolescence and adulthood. These include the BOT-2 and the MABC-2. These have been recommended for use with children with DCD but further work is needed to establish their use with adults. The ADC has been most widely used in research with adults with DCD, and other, shorter screening tools are available (e.g. Adolescents and Adults Coordination Questionnaire, Functional Difficulties Questionnaire). Further work is needed with these instruments to establish their psychometric properties.
Research note 4: There is a lack of standardized assessments for adults with DCD at present.

## Loe 2, level b
Comment: History, examination, and criterion-referenced assessments are required to gain a complete picture. Differentiating motor difficulties that are acquired in adulthood need to be checked where possible before a diagnosis of DCD can be made.

## Intervention
Resea rch note 5
There is a lack of research on interventions in adolescents and adults with DCD.

## Resea rch note 6
Longitudinal studies are needed to obtain more information about the developmental course of DCD in adolescence and adulthood. Age-appropriate standardized assessments are needed for diagnosis and evaluation of intervention of DCD in adolescence and adulthood.

## S6
It is acknowledged that access to services for adolescents and adults varies both within and between countries and is often very limited. However, it is recognized that most young people and adults with DCD benefit from individualized support to (1) learn specific motor skills for ADL, education, or vocational activities (e.g. using tools, keyboarding, driving); (2) deal with associated problems (e.g. psychological/psychiatric disorders); (3) address the impact of DCD on psychosocial skills and participation in various activities; (4) minimize the risk of longer-term problems (e.g. weight gain, physical inactivity).

## Gcp

## Evidence and methodological basis
For detailed information about the evidence and medodological basis, see the CPR-DCD long version. 1

## Good clinical practice (gcp) recommendations
The vast majority of the CPRs are based on group consensus of international experts, as well as with other processes. All GCP recommendations received strong consent (>90% consensus; ).

## Recommendations based on evidence (loe)
Five established working groups (mechanisms, assessments, interventions, psychosocial issues, adolescents and adults) reviewed the literature and new studies published since the previous CPR-DCD [bib_ref] European Academy for Childhood Disability. European Academy for Childhood Disability (EACD): recommendations..., Blank [/bib_ref] to prepare recommendations on the basis of evidence.
Original papers addressing key question 2 (assessment) were categorized according to the Oxford Levels of Evidence system 6 [fig_ref] Table I: Classification of the body of evidence Evidence from at least two well-designed,... [/fig_ref]. Intervention studies were classified using an adapted version of the Scottish Intercollegiate Guidelines Network 7 [fig_ref] Table I: Classification of the body of evidence Evidence from at least two well-designed,... [/fig_ref]. Therefore only original studies related to the specific key questions of the recommendations were included in the systematic analysis of the literature. For more information about the literature search, methodological background, and the evidence tables on mechanisms and assessments, see Appendices S2 and S3 (online supporting information), and Tables SI to SXV (online supporting information).
Each recommendation is based on the highest level of available evidence; a group of original papers or systematic reviews (if applicable) were summarized giving an overall level of evidence (LOE) using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system [fig_ref] Table I: Classification of the body of evidence Evidence from at least two well-designed,... [/fig_ref] where possible. These GRADE levels (LOE) were transferred into CPRs [fig_ref] Table I: Classification of the body of evidence Evidence from at least two well-designed,... [/fig_ref]. The levels and strength of recommendations correspond directly to the GRADE LOE.
The CPR-DCD includes eight recommendations based on evidence from systematic literature searches in the sections on assessments and interventions. The GRADE levels of these recommendations could directly be transformed to the corresponding recommendation level (e.g. GRADE level 1 has led to strong recommendation [A], GRADE level 2 to a [moderate] recommendation , and lower GRADE levels to an inconclusive recommendation [0]).For information about systematic literature searches and evidence tables of the other three working groups, with no LOE recommendations, underlying mechanisms, psychosocial issues, and adolescents and adults, see Appendices S4, S5, and S6 (online supporting information), and Tables SXVI, SXVII, and SXVIII (online supporting information). For a comparison of the current CPRs with the 2012 CPRs see [fig_ref] Table I: Classification of the body of evidence Evidence from at least two well-designed,... [/fig_ref].
The whole process was supervised by the AWMF (regional association; members: 177 specialist societies). The AWMF represents Germany in the Council for International Organizations of Medical Sciences (see www.awmf.de for further information). Only original studies related to the specific key questions of the recommendations were included in the systematic analysis of the literature. b The expert panel agreed to require at least two well-controlled studies from different study groups in order to reduce bias. c An 'Absolute SpPin' is a diagnostic finding whose specificity is so high that a positive result rules-in the diagnosis. An 'Absolute SnNout' is a diagnostic finding whose sensitivity is so high that a negative result rules-out the diagnosis. CDR, Clinical Decision Rule; RCT, randomized controlled trial.

## Acknowledgements
A full disclosure of interests document is provided online (Appendix S7, online supporting information). The authors have stated that they had no interests that might be perceived as posing a conflict or a bias.

## Supporting information
The following additional materials may be found online:
[fig] Figure 1: Flowchart assessment, treatment indication, and planning. DCD, developmental coordination disorder; ADL, activities of daily living; R, recommendation. recommend the use of the term Developmental Coordination Disorder (DCD) for individuals fulfilling the DCD criteria (Recommendation 3) in all research publications. For clinical and educational purposes we recommend the term DCD in countries which adhere to the DSM-5 classification (315.4). [/fig]
[fig] GCPFigure 2: Flowchart treatment planning, intervention, and evaluation Flowchart treatment planning, intervention, and evaluation. DCD, developmental coordination disorder; R, recommendation; S, statement. [/fig]
[table] Table I: Classification of the body of evidence Evidence from at least two well-designed, controlled studies without randomization from different working groups. Sufficient standards; homogeneity of the results. Good quality of the results (e.g. validity and reliability measures >0.6) 2++ High quality systematic reviews of case control or cohort studies or High quality case-control or cohort studies with a very low risk of confounding bias, or chance and a high probability that the relationship is causal Evidence from at least one well-designed other type of quasiexperimental study (non-randomized, non-controlled). Good quality of the results (e.g. validity and reliability measures >0.6) II b Exploratory cohort study with good reference standards. CDR after derivation, or validated only on split-sample or databases 2+ Well-conducted case control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal Evidence from well-designed non-experimental descriptive or observational studies (e.g. correlational studies, case-controlstudies). Moderate homogeneity of the results. Moderate quality of the results (e.g. validity and reliability measures >0.4)Evidence from expert committee reports or experts IV/V Case-control study, poor or non-independent reference standard/expert opinion without explicit critical appraisal, or based on physiology, bench research or 'first principles' [/table]
[table] Table SI: Mechanisms: evidence table-study results for the internal modelling task category. [/table]
[table] Table SV: Mechanisms: evidence table-study results for the gait task category. [/table]
[table] Table SX: Mechanisms: evidence table-study results for the executive function task category. [/table]