Assessment & Diagnosis

What information can occupational and physical therapists provide?

Occupational therapists and physical therapists are skilled in the observation of fine and gross motor task performance and can assist in accurately identifying and assessing children with DCD.

Once other medical and neurological explanations for the child's clumsiness have been ruled out, an assessment by an occupational therapist (OT) and/or physical therapist (PT) would be helpful in order to confirm the presence of a motor coordination disorder, provide information on the severity of the difficulties and determine the impact of the motor coordination disorder on the child's daily functioning.

What types of assessment tools are used?

If a child is suspected of having DCD, the OT and/or PT may use several tools to determine the child's capabilities in a variety of functional areas, to plan appropriate intervention and to measure the effectiveness of the intervention, particularly regarding activity and participation levels. The tools used will depend on the age of the child and may include one or more of the following measures.

Motor Coordination

The Peabody Developmental Motor Scales (PDMS) (preschool children) and the Movement Assessment Battery for Children (M-ABC) (children 4 years of age and above) can provide useful information on the nature of the movement difficulties.

The PDMS can help to identify whether a young child is showing the characteristic features of DCD, and to determine the need for ongoing monitoring, intervention and/or follow-up assessment. This measure can also be used to evaluate the effectiveness of intervention.

The M-ABC assesses a child's fine motor ability, their performance with ball skills, and their balance, and is intended specifically to identify children with DCD. The test scores provide information about how the child's motor performance compares to his or her peers and can provide an indication of the severity of the motor difficulties. This tool can also provide additional detail about the child's muscle tone, postural control, speed, bilateral coordination, hand use, grasp patterns, effort, attention and behaviour during task performance. The M-ABC contains a behavioural checklist that can provide insight into the effect of motivation on assessment results and overall compliance with testing. In addition, a teacher checklist that addresses environmental context and guidelines for program planning are included.

Daily functioning

Another important aspect of assessment is to describe how the child's motor difficulties are impacting on his/her daily performance. 

Through interview, questionnaires and observation, it is possible to describe the impact of motor skill delays and in-coordination on:

• self-care activities, such as dressing, hygiene, eating, toileting, bathing
  
• leisure activities, such as sports, arts and crafts, extra-curricular activities,
  
• playing with friends and family outings
  
• school activities, such as academic progress, social relationships, following classroom routines and completing homework.
  

This information will be critical to set goals, plan intervention and develop strategies for ongoing management of the child with DCD.

Goal Setting

The Canadian Occupational Performance Measure (COPM) uses a semi-structure interview format and is both a goal setting and outcome measure. Prior to, and following intervention, the child and/or family identify areas of functional difficulty and rate current performance of, and satisfaction with, each task. This assists with planning appropriate goals and measuring performance and satisfaction with chosen tasks following intervention. The COPM is most suited for use with children over 8 or 9 years of age.

With younger children, the Perceived Efficacy and Goal Setting System (PEGS) may be a more appropriate goal setting tool. In this pictorial measure, children reflect on, and indicate their competence performing, 24 tasks that they need to do everyday. They then identify any other activities that are difficult for them and select and prioritize tasks as goals for therapy.

Effect of Intervention

Goal attainment scaling (GAS) is increasing in use as a measure to determine the effectiveness of intervention. This measure tracks changes in activity and participation levels following intervention. A measure providing similar types of information is the School Function Assessment (SFA), which looks at a child's participation in school-related settings and examines the amount of assistance and/or the type of adaptations required for the child to perform important school tasks. As the SFA requires observation of functional performance over time, it is usually completed by a therapist through interview of the teacher and others familiar with the child.

The characteristics of children with DCD are usually noticed first by those closest to the child (parents, classroom teacher) because the motor difficulties interfere with successful participation at home, at school or on the playground. DCD is commonly identified and diagnosed after age 5, when minor motor problems (often noted when the child was young) are made more noticeable by the structured demands of a school environment.

When a child is suspected of having motor coordination difficulties, it is critical that they are seen by a family doctor or pediatrician to ensure that that the movement problems are not due to any other physical, neurological, or behavioural disorders and to determine whether more than one disorder may be present. DCD can exist on its own or it may be present in a child who also has learning disabilities, speech/language impairments and/or attention deficit hyperactivity disorder. Information provided by parents, the child's teacher, and from an assessment by an occupational and/or physical therapist (OT and/or PT) can be very helpful in assisting a physician with making a diagnosis. For children with co-occurring language, attentional, and learning problems, the involvement of other health care practitioners will be important.

Diagnostic Criteria for DCD

A diagnosis of DCD is made by a medical doctor when the following criteria are observed:

1. Learning and execution of coordinated motor skills is below age level given the child's opportunity for skill learning
   
2. Motor difficulties significantly interfere with activities of daily living, academic productivity, prevocational and vocational activities, leisure and play
   
3. Onset is in the early developmental period
   
4. Motor coordination difficulties are not better explained by intellectual delay, visual impairment, or other neurological conditions that affect movement.
   

Source: Diagnostic & Statistical Manual 5th edition, 2013

Making a diagnosis:

Criteria D requires the involvement of a family practitioner or pediatrician to rule out other explanations for the motor difficulties. In most provinces and states, only a medical doctor or a psychologist is permitted to make this diagnosis.

Some diagnostic conditions are commonly associated with DCD. In the event that more than one of these conditions is present, more than one diagnosis should be given.

Children with DCD usually achieve early major motor milestones (e.g., walking) within the broad range of normal limits but may have difficulty learning new motor skills (e.g., riding a tricycle). In order to meet diagnostic criteria for DCD, the motor coordination difficulties must impact on the child's ability to perform in self-care and/or academic areas (e.g., difficulty with buttons/zippers, drawing/painting).

Why diagnose DCD?

A diagnosis of DCD can be quite helpful to the family, the school and the child. Even without a diagnosis, parents know that something is not right with their child's development. Without being able to identify the coordination difficulties as DCD, parents may search aimlessly as they try and explain their child's symptoms. Providing a diagnosis can reassure parents, confirm their observations, acknowledge the reality that this disorder places on their families, and give them something tangible to deal with. Children with DCD are more likely to become successful in home and school environments when task and environmental adaptations are made, both of which are made more possible through an accurate diagnosis. Recognition and diagnosis of DCD allows parents, extended family and teachers to access research literature, educational resources, tips, strategies and support groups and can provide access to the services and supports families need including possible formal identification within the educational system. Perhaps most importantly, the secondary consequences associated with DCD can be prevented.