Dyspraxia: Is it the hidden handicap?

Dyspraxia:  Is it the hidden handicap?

by Katherine J. Collmer, M.Ed., OTR/L

Dyspraxia, most concisely described, is a learning difficulty that “possesses the most interesting ‘melting pot’ mix of physical and mental characteristics.” (Patrick 2015 p. 11)  Once called a “disorder of sensory integration by Jean Ayes in 1972 and then labeled as “Clumsy Child Syndrome” in 1975, dyspraxia continues to be a confusing condition to classify.   The terms “Dyspraxia” and “Developmental Coordination Disorder” are commonly used interchangeably, however, it is felt by some professionals that they are not the same condition.  Dyspraxia is defined by the Dyspraxia Foundation USA as “a neurological disorder throughout the brain” that often comes with a variety of comorbidities, the most common [of these being] Developmental Co-ordination Disorder (also known as DCD). (“1 in 10 Odds”)  The UK branch further explains that “while DCD is often regarded as an umbrella term to cover motor coordination difficulties, dyspraxia refers to those people who have additional problems planning, organising and carrying out movements in the right order in everyday situations” and can also experience difficulties with “articulation and speech, perception and thought.” (“What is Dyspraxia,” Section “What is Dyspraxia?”)   Alison Patrick, in her book “The Dyspraxic Learner,” stresses that “the significant role that the mind plays in this condition cannot be underestimated.” (Patrick 2015 p. 17)

Developmental Dyspraxia, the term more commonly used to describe the developmental problems observed in children who are clumsy, describes the condition as “a failure to learn or perform voluntary motor activities despite adequate strength, sensation, attention, and volition (Missiuna & Polatajko, p. 620)”  It is felt that the term was chosen as a result of the belief that a link existed between apraxia and dyspraxia.  Due to the lack of empirical data that shows a causative link between apraxia – the condition that involves “the loss of ability to perform previously acquired movements” most commonly observed in adults who have experienced a cerebrovascular accident resulting in brain damage – and the problems of children who have the symptoms described above, the condition is often labeled simply as “Dyspraxia.” (Missiuna & Polatajko 1995 p. 620)  The roots of this confusion over labelling stem from two facts:  first, that there is no internationally agreed upon definition for the term “dyspraxia” and second, that the DSM-V does not list it among diagnosable conditions.  Instead, it is felt that dyspraxia would most suitably fall under the new reclassification of “Neurodevelopmental Disorders-Motor,” as some consider it a developmental coordination disorder (“Highlights of Changes”).  Steinman, et. al. make a further distinction that developmental dyspraxia should be considered in terms of praxis “rather than a diagnostic label” and referred to instead as “a specific neurologic sign of impaired execution of skilled learned movements. (p. 5)”  The authors stress that it can exist in children who demonstrate no other signs of neurological impairments, as well as in conjunction with other neurodevelopmental disorders such as autism and language disorders.  After all the discussions have been heard, it is not difficult to imagine a more fitting label than “the hidden handicap.” (Udoh & Okoro 2013, Kirby 1999)

It is difficult to estimate exactly how many children are affected by DCD/Dyspraxia due to the lack of an official diagnosis and consistent use of behavioral information to identify them.   However, 2009 study results out of the UK “suggested that up to one in every 20 children between seven and eight years of age may be affected by the condition to some degree.  It is felt that the disorder occurs three or four times more in boys than girls and that the condition “sometimes runs in families.”  (Developmental Co-ordination, Section “Who is affected).

Despite the confusion, understanding developmental dyspraxia remains an important concern for occupational therapists who are often presented with referrals for children who have handwriting difficulties, problems with self-care management, and social isolation that results from their clumsiness and uncoordinated behaviors (Missiuna & Polatajko 1995).  Without a clear definition for dyspraxia nor a diagnosis that outlines the symptoms associated with it, our assessment will be based upon our knowledge of the condition itself.  Children who present with these school-, home-, and socially based needs will appear physically capable, will not have intellectual needs, and often will not have any identifiable disease or medical condition.  Since dyspraxia is a developmental condition, it can present itself in the early years as children meet the prescribed developmental gross-motor milestones late and experience difficulty with fine-motor activities of daily living, such as tying their shoes or fastening buttons, very much like developmental coordination disorder.  From an occupational therapy standpoint, then, dyspraxia and the behaviors associated with it must be differentiated from those same behaviors that exist with a motor coordination condition.  Dyspraxia, in our practice area, is not viewed as a primary problem in motor coordination and the child must present with difficulties with ideation and planning to be regarded as dyspraxic from our point of view. (9)  Rather than be the result of a problem with motor execution, dyspraxic behaviors are felt to be a difficulty in formulating a plan of action, the problem presenting itself as the inability to efficiently plan and carry out skilled non-habitual motor acts in the correct sequence.   Although children with dyspraxia may have difficulty learning a new task, once they are able to master the skills that it demands, they can use those skills to repeat the task.  (9)  Their ability to use their skill development in the mastery of other similar activities is limited, however, as they are not able to effectively plan and execute new motor actions or generalize motor actions in a new situation.  (9)  From an occupational therapy standpoint, the child with dyspraxia will present with the following behaviors (10) that can be fall into four categories: (7)

Dyspraxic Behaviors Chart
Dyspraxic Behaviors
Categories of Dyspraxia

The appearance of “clumsiness” stems from their difficulty in transitioning from one body position to another, their poor discrimination of tactile input, an overall difficulty in relating their bodies to physical objects and space, and challenges with imitating actions or perceiving the direction of movement.  They are slower to develop both gross- and fine-motor skills and are often referred to occupational therapy for these reasons, particularly handwriting.  They may tend to prefer talking rather than performing and will often avoid new tasks altogether.  Their social behaviors result from their becoming frustrated with new situations because they are unable to approach these activities in an organized manner. The culmination of these symptoms and behaviors can be low self-esteem or self-concept.  (9)

Patten, in her newsletter article, “Dyspraxia from an Occupational Therapy Perspective,” suggests a battery of standardized assessments that will assist in the assessment process.  Goodgold-Edwards and Cermak, (10) stress that we must also have an understanding of the motor, sensory integrative, and cognitive and conceptual components of movement as we observe the children in both standardized testing environments and the performance of everyday activities.  Treatment strategies we select can include sensory integrative, perceptual motor, sensorimotor, cognitive goal-directed, and compensatory skill development approaches. (9)  These will most likely be combined in a remedial plan that addresses each child’s individual needs and will include skill areas such as rule learning as it applies to motor planning and motor learning; planning for managing movements as they occur that include goal-directed activities with performance expectations; the use of tasks that have a clear, functional identification within the practicing environment; the inclusion of cognitive strategies that allow for the child’s learning abilities and styles; and, perhaps most importantly, will be fun as well as challenging.  (10)  Of course, the complex nature of dyspraxia and the multiple needs that a child may experience will necessitate the development of a team approach. (7)

The implications of dyspraxic behaviors for the school-based occupational therapist are that we must consider the “whole child” in our development of a remedial plan or recommendations for adaptations.  Although the child may have been referred to therapy because of handwriting difficulties, it is vital that we look below the surface and develop the overall picture of his behaviors, from home, to school, to the playground, and the community.  With or without an official diagnosis, dyspraxia exists and will continue to present itself in our therapy rooms and clinics.

Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine
Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine

occupational therapist who specializes in the assessment and remediation of handwriting skills. In her current book, Handwriting Development Assessment and Remediation: A Practice Model for Occupational Therapists, she shares a comprehensive guide and consistent tool for addressing handwriting development needs. She can be contacted via her website, Handwriting With Katherine.

Collmer Handwriting Development Assessment and Remediation

 
 
 
 
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  1. Patrick, Alison. “Introduction and Chapters 1 and 2.” The Dyspraxic Learner: Strategies for Success. 2015 ed. London: Jessica Kingsley Pub., 2015. 11-54. Print.
  2. “1 in 10 Odds Are That You Know Someone With Dyspraxia.” Dyspraxia Foundation USA. Dyspraxia Foundation USA, n.d. Web. 08 Oct. 2015. <http://www.dyspraxiausa.org/>.
  3. “What is Dyspraxia?” Dyspraxia Foundation.org.uk. Dyspraxia Foundation UK, n.d. Web. 8 Oct. 2015. <https://www.dyspraxiafoundation.org.uk/about-dyspraxia/>.
  4. Missiuna, C., and H. Polatajko. “Developmental Dyspraxia by Any Other Name: Are They All Just Clumsy Children?” American Journal of Occupational Therapy 49.7 (1995): 619-27. Web. 8 Oct. 2015.
  5. “Highlights of Changes From DSM-IV to DSM-5.” Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013): n. pag. DSM5.org. American Psychiatric Publishing. Web. 8 Oct. 2015. <http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf>.
  6. Steinman, K. J., S. H. Mostofsky, and M. B. Denckla. “Toward a Narrower, More Pragmatic View of Developmental Dyspraxia.” Journal of Child Neurology 25.1 (2009): 71-81. Web. 8 Oct. 2015.
  7. Udoh, Nsisong A., and Cornelius C. Okoro. “Developmental Dyspraxia—Implications for the Child, Family and School.” International Journal of Academic Research in Progressive Education and Development IJARPED 2.4 (2013): 200-14. Web. 9 Oct. 2015.Caroline Lacey. London:
  8. Caroline Lacey, 1997. Ludlowlearning.com. OAASIS, Cambian Education Services. Web. 8 Oct. 2015. <http://www.ludlowlearning.com/downloads-icpa/Oaasis-Dyspraxia.pdf>. OAASIS website: www.oaasis.co.uk Cambian Education Services website: cambianeducation.com
  9. Patten, Natasha, Bcc OT. Dyspraxia from an Occupational Therapy Perspective (n.d.): n. pag. Dyspraxia Foundation.org.uk. Dyspraxia Foundation UK. Web. 8 Oct. 2015. <http://dyspraxiafoundation.org.uk/wp-content/uploads/2013/10/dyspraxia_and_Occupational_Therapy.pdf>.
  10. Goodgold-Edwards, S. A., and S. A. Cermak. “Integrating Motor Control and Motor Learning Concepts With Neuropsychological Perspectives on Apraxia and Developmental Dyspraxia.” American Journal of Occupational Therapy 44.5 (1990): 431-39. Web. 8 Oct. 2015.
  11. Kirby, Amanda. Dyspraxia: The Hidden Handicap. 2002 ed. London: Souvenir, 1999. Print.
  12. “Developmental Co-ordination Disorder (dyspraxia) in Children .” NHS Choices. National Health Services UK, n.d. Web. 09 Oct. 2015. <http://www.nhs.uk/Conditions/Dyspraxia-(childhood)/Pages/Introduction.aspx>.
 
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