1. Intro p 498
   1. What PTs Can Do:
      1. • PTs look @ motor abilities & development to determine which motor behaviors are characteristic of a particular condition • PTs’ understanding of normal & abnormal motor control, motor learning & motor development can be used to ID & Eval the condition & plan programs
   2. Manifestations:
      1. • Frequently trip over their feet & pump into others w/clumsy, awkward mvmt • May have unusual gait pattern or unique way of “fixing” or stabilizing their jts • Observed to reach their motor milestones w/in normal age limits • Difficulty generalizing learned motor skills across settings or transferring skills to other contexts
   3. 5-6% of school-age kids have movement difficulties, unrelated to specific neurological conditions or cognitive impairment
2. Historical Background p 499
3. Definition & Prevalence p 499
   1. • Is a lifelong Chronic motor impairment disorder with both motor production & cognitive-linguistic components • A condition in which poorly developed fine &/or gross motor coordination & postural performance has substantial impact on motor skill performance w/far-reaching consequences of ADLs & scholastic achievement
   2. Preferred Practice Pattern: 5C: Impaired Motor Fnx & Sensory Integrity Assoc w/Nonprogressive Disorders of the CNS-Congenital Origin or Acquired in Infancy or Childhood
   3. • Affects 5-6% school age kids • Boys > Girls: 2:1 ratio • Preterm/low birth wt populations >
4. Dx p 499
   1. DCD is Dx ONLY by MD & is present when:
      1. 1. Motor impairment &/or motor skill delay significantly impacts kid’s ability to perform age-approp complex motor activities 2. Adequate opportunities for experience & practice have been provided 3. No other explanation can be offered for the motor impairment
   2. Dx must meet 4 criteria: Diagnostic Criteria for DCD:
      1. A. The motor impairment must be substantial & discrepant from other abilities B. Must have an impact on academic achievement or ADLs C. Must not meet the criteria for pervasive developmental disorder (PDD) D. If accompanied by cognitive difficulties, must be greater than what would accounted for by that cognitive impairment
         1. PTs facilitate the Dx by help MD confirm kid meets Criteria A &B
   3. DCD not present if:
      1. 1. Recent head injury/trauma has occurred 2. Progressive deterioration in previously acquired skills is evident 3. Increased or fluctuating mm tone 4. Where there’s a Hx of headaches or blurred vision, when evidence of assym tone or strength is observe or when Musculoskel abnormalities or Gowers’ sign are present
5. Co-occurring Conditions p 500
   1. DCD is correlated to:
      1. • ADHD • Specific language impairment • Language-based learning disabilities (spec reading) • Kid w/any of these=50% chance DCD is also present
6. LT Prognosis p 501
   1. • W/o intervention they don’t grow out of it • Higher risk of developing serious negative physical, social, emotional, behavioral and mental health consequences; secondary complications, inactive lifestyle and thus compromised cardiovascular syst
7. Describing Children w/DCD p 501
   1. Intro
   2. Body Structure & Fnx p 501
      1. Primary Impairments p 502
         1. Sensory/Perceptual Deficits p 502
            1. • Visual-spatial processing incld: determining object size & position & visual memory • Limited ability to use visual rehearsal strategies • Visual FB is managed differently & processed more slowly than typical developing kids • Deficiencies in kinesthetic process, poor proprioceptive fnx ; heavy reliance on visual FB to guide task performance • Lack automation in their movements & remain at an early stage of motor learning for much longer (since they heavily rely on vision to control mvmt)
         2. Motor Deficits p 502
            1. • Move awkwardly & slowly w/rigid jerky quality • Frequently bump into objects; trip & fall • Poor balance (esp during SLStance; difficulty maintaining postures • Compensate: demonstrate many associated movements • On PT exam: decreased muscle tone & neurologic soft signs • Impairment seen may lie in faulty motor control and motor learning processes
         3. Motor Control Deficits p 503
            1. • Inappropriate & ineffective NM strategies, both in muscular activation & in sequencing which is evident in use of atypical postural control strats, incl when balance is challenged • Increased level of muscle co-contraction • Use diff NM strats when performing reaching tasks that contrib to their slower & more variable mvmt & rnx times as well as mvmt inaccuracy • Gait differences • Decreased & variable force control & difficulties w/temporal precision (both mvmt production & time perception) • Variations in mvmt speed, timing & force across a series of diff tasks
            2. • Tend to “fix” or stabilize their joints during task performance->leads to lack of fluency in mvmts & contribs to their stiff, awkward, & clumsy appearance; increases time it takes to adapt to changes in mvmt environment
            3. o A strat to control multiple DOF of jts & muscles for efficient functioning o Those who do so are more likely to fatigue & demonstrate inconsistency in task performance o Results in less efficient movement patterns & reflect a less skilled stage of mvmt acquisition than
         4. Motor Learning Deficits p 503
            1. • Limited mvmt repertoires, lacking adaptability & flexibility in motor behavior=motor learning difficulties • Mvmts=inaccuracy & lack fluency; unable to accurately correct movement patterns thru error detection or FB • May achieve motor milestones w/in normal time limits but have difficulty learning new moto skill • Can’t see similarities btwn motor tasks=unable to transfer learned skill from one activity to a closely related one • Difficulty generalizing from one context /situation to another • DCD con’t to rely predom on visual input as if still in early stages of motor learning; so their motor performance=similar to that of younger kids than of their age group • Repeat task same way over & over regardless of success; thus=have difficulty understanding demands of task & its component parts, interpreting environmental cues & selecting best motor response of a task; thus they don’t effectively use FB originating from knowledge of their past performance to prepare for upcoming actions (anticipatory preparation) & have difficulty adapting to situational demands • Have difficulty w/error detection & movement correction during execution of motor skills
      2. Secondary Impairments p 504
         1. Physical p 504
            1. extra effort that motor skills seem to req & the struggle kids have in making adaptations & in "fine-tuning" mvmts =less evident than the typical slow awkward mvmts observed
            2. • Lack of energy & fatigue • Decr strength, power & endurance • Maintaining posture for extended pds of time=fatiguing so they may lean against wall or on other kids or assume slouched posture when sitting
            3. 2ndary impairments may be preventable and are appropriate targets for PT (as they may lead to participation restrictions in sports/leisure etc
         2. Social/Emotional/Behavioral p 504
            1. • May be quiet & withdrawn @school w/avoidance of schoolwork & frequent “off-task” behaviors • May act out in class being disrupting • Low frustration tolerance, decreased motivation & poor self-esteem • Give up on tasks easilyangry aggressive classroom behavior • Probs with task initiation & completion
   3. Origin & Pathophysiology p 505
      1. CURRENTLY NO SPECIFIC PATHOLOGIC PROCESS/SINGLE NEUROANATOMIC SITE has been definitively associated w/DCD
         1. SPECULATIONS:
            1. 1. Diffuse rather than distinct areas of brain may be affected, resulting in variable expression of the disorder & different profiles seen; implying that specific combo of co-occurring disorders depends on location & severity of neurologic insult
            2. 2. Strong association btwn motor, attn, & perceptual processes & point to the possible role of neuroanatomic structures: cerebellum & basal ganglia
            3. 3. Dual-task paradigm: indicating a lack of automatization of motor actions when attentional demands increase; implicating the cerebellum as possible site of pathophys given its role in the automatization & learning of motor taks
            4. thinking here: performance of 1 task will be negatively affected by 2nd if both tasks need to make use of the same "pool" of resources, incld visual & cognitive resources
            5. the plausible connection btwn cerebellum & motor coordination/motor impairments
            6. 4. Motor Imagery: impaired feed forward models could be a potential mechanism underlying DCD (efference-copy deficit hypothesis)--motor imagery deficits seen are related to difficulties in generating efference copies of motor commands thru feed foreard models, pointing to the possible involvement of the posterior parietal cortex
            7. 5. Impaired internal models: These are neural reps of the visual-spatial coordinates of intended motor actions
            8. Hypoth: DCD kids may have inadequate fwd modeling of mvmts & unable to form, access, or update their internal models (believed are located in cerebellum) which results in poor 'online" error correction & affects motor learning
            9. 6. Mirror neurons (housed in ventral premotor & posterior parietal cortices) may help explain how motor reps are formed during performance & in observation of performance
            10. Mirror neurons in posterior parietal cortex may work in concert w/internal models in cerebellum to code & updt mvmt
   4. Activity Limitations p 506
      1. Intro
         1. Kids w/DCD have difficulties with:
            1. • Skills that must be TAUGHT • Skills requiring accuracy & refined eye-hand coordination & that req constant monitoring of FB • Overall difficulties w/fine motor and/or gross motor activities
      2. Fine Motor Activity Limitations p 506
         1. Self-Care p 506
            1. • Kids w/impairments in sequencing skills can't correctly sequence the steps in shoe typing for ex even tho they've practiced it many times before • When these kids make a mistake in one step of the sequence, they have to start over again rather than simply redo the last step. Or they might omit a different step in the sequence ea/time they try to tie their shoes
         2. Academic p 506
            1. • Difficulties in printing & handwriting • Work illegible & inconsistent in sizing & reqs great effort; last to finish, avoidance of activities • Frequent erasures; inaccurate spacing of works; unusual letter formation • Writing utensil=awkward grasps, written work not well aligned • Frequency pencil drops & lead broken or paper torn due to excessive pressure on pg
      3. Gross Motor Activity Limitations p 506
         1. • Lack good balance & postural control thus have difficulties w/flexibility & adaptability req’d for gross motor activities • May show delays ea/time they learn a novel skill (riding a push toy, or bike, pumping a swing) • Poorly coordinated running, skipping, hopping, jumping; possible difficulty managing stairs, especially maneuvering around others • Problematic coordination of eyes & hands at whole body level; thus difficulty w/throwing, catching, kicking a ball accurately; difficulty judging amt of force req’d to throw/kick • Difficulty w/gross motor activities that req constant changes in body position or adaptation to changes in the environment (baseball/tennis/jumping rope) • Difficulty in tasks requiring coordinated use of both sides of body (swinging bat, handing hockey stick)
   5. Participation Restrictions p 508
      1. is a major concern for parents
      2. They're clumsier so last to be picked for games, don't understand rules well; become more isolated from peers
   6. Personal Factors p 508
      1. When they stop participating in gross motor skills they become less fit; avoidance of fine motor skills leads to decrease opportunities for practice, preventing ongoing academic skill development
   7. Environmental Factors p 509
      1. • If PE class restricts performance to certain activities; the DCD can be prevented from participation • If parents restrict Kid’s outdoor play to certain environments, peer relationships are limited • If family is uncomfortable eating at restaurants b/c kid is messy eater=restricts ensue and social interactions are limited
8. Role of the PT p 510
   1. Intro
      1. PT obervations (lack of adaptive flexibility, or pre-movement organization,& fixing; poor motor performance leading to activity lims & participation restrictions) can facilitiate early ID which can help prevent 2ndry impairments
      2. PT can provide education & guidance that'll encourage the engagement of kids in the typical activities of childhood, thereby reducing risk of decr'd physical health & decr'd self-esteem, self-efficacy, & social participation
   2. Identification & Referral to PT p 510
      1. • Although DCD must be considered at least theoretically to be PRESENT FROM BIRTH, kids differ w/respect to apparent age of onset, as developmental progression varies depending upon environmental & task demands placed upon the kid in early years • Kids don’t display the full extent of their functional difficulties until they are of school age • Their coordination difficulties may not be easy to observe until they reach the point at which they attempt to learn & perform skills that req adaptations in speed, timing, & grading of force • They are commonly underrecognized until academic failure beings to occur & often aren’t ID’d before age 5
      2. 2 Routes of Referral:
         1. Health Care System
            1. via musculoskeletal, neurologic, ligament lax, low tone, unusual gait, reg monitoring p premature birth/low birth wt
         2. Educational System
            1. made when poor motor performance affects academic functioning
         3. **most referred via educational route
   3. Examination & Evaluation p 510
      1. Intro
         1. • Prental, delivery & postnatal Hx • Hx of current functional status from fam & school • PT must differentiate the motor behaviors of DCD from those of other movement disorders (CP, muscular dystrophy, global developmental delay etc) • Kids w/DCD are commonly underrecognized until academic failure begins to occur & often aren’t ID’s b4 age 5
         2. PT Differentiation of hypothesizing origin of coordination difficulties w/help of asking a young kid these:
            1. Is there evidence of increased or fluctuating tone?
            2. alterations in tone might suggest CEREBRAL PALSY
            3. present w/muscle hypertonicity that increases w/faster movements
            4. Are the delays more global rather than in the motor domain alone?
            5. Global Developmental Delay may be suspected
            6. Have the difficulties been present from an early age?
            7. Are motor concerns appearing to worsen over time?
            8. Has there been a loss of previously acquired skills?
            9. If so, might be suggestive of MUSCULAR DYSTROPHY
            10. Esp if parent describes pattern of typical motor development followed by recent decr in strength & loss of ability to climb stairs I'ly
            11. MMT shows weak gastroc & pseudophypertophy
            12. IF DCD is hypothesized then:
            13. Pt presents w/ low muscle tone w/shoulder, elbow, & knee hyperext
            14. Pt can't imitate body postures or follow 2 or 3-step motor commands; frequent demonstration & actual physical (A) may be needed to accomp items on standardized tests
      2. Clincal Assessment Tools for DCD p 512
         1. Initial Screening p 512
            1. Keep in mind that regardless of screening tool used, it's just the 1st step and Pt. should undergo a more detailed assessment intended for use w/DCD kids to confirm their motor difficulties
         2. Parent Report p 512
            1. The Developmental Coordination Disorder Questionnaire (DCDQ)
            2. • Provide impact of motor coordination difficulties on ADL • Parent report screening tool at ICF activity level that measures the functional impact of kid's motor coordination difficulties • Originally intended for parents of kids 8-14 y/o but now extended to use of 5-15 yo • 15 item tool that describes tasks that are of concern w/kids w/motor impairment (catching ball riding bike, writing) & parents are asked to compare their kid’s coordination to that of kids the same age by choosing ratings on 5-pt scale • Percentiles: “Definite” motor difficulties, “Suspect” motor difficulties & “No” motor difficulties
            3. Psychometric Props:
            4. • Internal consistency of the test items • Construct validity • Concurrent validity w/both Movement Assessment Battery for Children (MABC) test of motor impairment & the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) • High sensitivity & specificity • Construct & concurrent validity
         3. Teacher Checklists p 512
            1. The Movement Assessment Battery for Children Checklist (MABC-C)
            2. • Somewhat lengthy/time-consuming • Internal consistency, construct validity & concurrent validity when measured against the Movement Assessment Batter for Children (MABC) test of motor impairment • But has been noted to have poor sensitivity, • **There’s a newly revised MABC Checklist-2 with fewer items but psychometric props haven’t been determined yet
            3. the Children Activity Scale for TEachers (ChAS-T)-kids 4-8 y/o
            4. the Motor Observation Scale for Teachers (MOQ-T) PKA Groningen MOtor Observation Scale-kids 5-11
         4. Child Report p 512
            1. the Children's Self-Perceptions of Adequacy in, and Predilection for, Physical Activity Scale (CSAPPA)
            2. • 19 item measure of self-efficacy w/regard to physical activity • Intended for kids 9-16 y/o • Is a participation measure of kids’ perceptions of their adequacy in performing & their desire to participate in, physical activity • 3 subscales: Perceived Adequacy, Predilection to Physical Activity & Enjoyment of Physical Education Class • Kids choose from 2 statements the choice that best describes them & then indicate whether the statement is true or very true for them
            3. Psychometric Props
            4. • High test-retest reliability • Predictive & Construct Validity
      3. Evaluation of MOtor Impairment p 513
         1. Intro
            1. • 1 of the DSM-IV discriminating criteria for DCD is that motor coordination is markedly below expected levels for the kid’s chronologic age • W/o a gold standard to ID these kids, researchers have often used more than 1 assessment tool to confirm the identity of kids w/movement probs in research study samples; just keep in mind that different tools may measure diff constructs (what a kid is capable of vs what the kid actually does)
         2. Young Children p 513
            1. WHEN DCD IS SUSPECTED, IT'S IMPORTANT TO CONFIRM THAT A MOTOR IMPAIRMENT IS PRESENT & TO DETERMINE THE IMPACT OF THAT IMPAIRMENT ON ACTIVITY
            2. the Peabody Developmental Motor Scales--2nd Ed (PDMS-2)
            3. • Is a diagnostic & evaluative measure that’s appropriate for assessment of young kids w/characteristic DCD • w/it’s evaluative props it could also be used as a preintervention & postintervention measure to evaluate whether change has occurred
            4. Psychometric Props
            5. • High test-retest reliability & internal consistency • Construct Validity & Concurrent Validity w/previous version of tool
         3. Older Children p 513
            1. Bruininks-Oseretsky Test of MOtor Proficiency (BOTMP) w/ Revision: BOT-2
            2. BOTMP:
            3. • BOTMP-one of most frequently used assessments w/school-age kids 4.5-14.5 y/o • Standardized, norm-referenced discriminative & evaluative measure of the construct of motor ability (Fine & gross motor) • Available in short or long form • Doesn’t measure impairment in terms of quality of mvmt but measures only the ability to perform a given activity • Became outdated and in need of revision bc it couldn’t ID kids w/motor impairment
            4. BOT-2
            5. • For ages 4-21 y/o • 4 motor area composites (fine manual control, manual coordination, body coordination, & strength & agility) • With 2 subsets in each composite, both long & short form available • Scoring syst lengthy & prone to error • The use of total scores may pose probs in cases where kids ave poor motor skills in a single area only; using total score, these kids may score well overall despite having significant difficulties in one area of their motor performance • Doesn’t assess handwriting • May not be most appropriate assessment to ID kids w/DCD given these concerns
            6. Psychometric Props
            7. • Good interrater reliability • Evidence of test-retest reliability for the total motor composite & short form (reliability is variable when looking specifically at the composites & subtests & a practice effect is noted) • High internal consistency for the total motor composite & acceptable for the short form (except in case of 4-8 y/o) & borderline to high for the subtests • Construct validity & concurrent validity w/BOTMP & PDMS-2
            8. the Movement Assessment Battery for Children (MABC) w/Revision: MABC-2
            9. MABC-2
            10. • Used to ID kids w/motor impairment • Is a norm-referenced exam • Contains 3 sections, & each section includes 8 items for each of the 3 age bands: 3-6 y/o; 7-10 y/o; & 11-16 y/o • Items are divided into manual dexterity (3 items), aiming & catching (2 items) & balance (3 items) & incld activities like threading beads, putting pegs into pegboard, catching & throwing beanbag, balancing on 1 leg, jumping, hopping & heel-to-toe walking • Scores: performance w/in normal ranges, motor performance borderline or at risk; if motor impairment is present; if motor impairment is significant • The age bands covers from 3-0 to 16-0 yrs but testing time is short as assessor presents only activities appropriate for that child’s age • Contains a behavioral checklist that can provide insight into effects of motivation on assessment results & overall compliance w/testing • Original version IDs more kids w/coordination difficulties than the BOTMP & appears to ID more readily those kids who have additional learning or attention probs
            11. Psychometric Probs
            12. • Acceptable test-retest reliability (was less reliable when a younger age band was used) • More research needed on validity & reliability
            13. MABC
            14. Psychometric Probs
            15. • Good test-retest reliability • Concurrent validity w/BOTMP • MABC IDs kids w/DCD @ same prevalence rates as would be predicted
      4. Additional Assessment Tools p 515
         1. the Vineland Adaptive Behavior Scale, 2nd Ed
            1. Functional & contextual emphasis ; impact of motor coordination difficulties on ADLs
9. Facilitating a Dx of DCD p 515
   1. Intro
      1. Not w/in PT scope to Dx DCD (will have to realy findings to MD & suggest to have child seen by PCP
      2. PTs thru exam & eval are in ideal position to recognize the motor a& behavioral characteristics of DCD & can provide useful info to kid’s MD regarding:
         1. Criteria A of DSM-IV
            1. • Indicates a sigif impairment in motor coordination must be present (can be difficult to determine in MD office) • PT can observe & test for motor impairment & provide info to both family & MD
         2. Criteria B of DSM-IV
            1. • States that the motor impairment must interfere w/academic achievement &/or ADLs • PT can gather info from parents, teachers & child about what tasks are difficult for the kid to perform & relay this info to MD
   2. Referral to other Disciplines p. 515
10. INTERVENTION p 515
    1. Direct Intervention Approaches p 515
       1. Intro
          1. "Bottom-Up" Interventions
             1. • Bottom Up-tend to address movement probs by emphasizing the building of foundational skills • In past Tx were aimed primarily at changing body structure & fnx impairments by trying to improve either the kid’s sensory processing abilities (vision, kinesthesis) or the difficulties in individ motor components (bal & strength) that were believed to contrib to poor performance • Reflect more traditional theories of motor development & based on belief that by changing these underlying deficits, task performance will improve • Many Systematic reviews on effectiveness of these approaches found them to produce minimal change in functional outcomes & to offer no clear advantage of 1 approach over another
             2. Examples:
             3. • Perceptual-motor training • Process-oriented approach • Sensory integration (SI) • Neurodevelopmental Therapy (NDT)
          2. "Top-Down" Interventions
             1. • Top-Down-focuses on motor learning principles in combo w/other theories that emphasize the role of cognitive processes in the learning of new movement skills • Is where dynamic systems theorists come into play=proposed that improvement in functional tasks relies on many variables & tends to be environment-specific • Emphasizes that intervention must be contextually based, w/intervention occurring in everyday situations & being of significance to the individ child • More recent interventions emphasize the development of specific skills rather than underlying skill components alone
             2. Examples:
             3. • Task-specific interventions • Cognitive Approaches
          3. SELECTING AN INTERVENTION:
             1. • Consider the motor learning difficulties that are particularly evident in this pop such as the inability to transfer & generalize skills & learn from past performance • Seems reasonable from a motor learning perspective that giving FB at the right stage of learning as well as opportunities to solve movement probs are instrumental guiding principles for interventions w/kids w/movement difficulties • It’s likely that interventions that directly target the transfer & generalization of new skills & that emphasize motor learning will be the most successful • Many techniques to foster motor learning can be incorporated into intervention: providing verbal instruction, positioning, handling & providing opportunities for visual or observational learning • Physically demonstrating or modeling mvmt sequences & helping kids to learn strategies for managing FB & organizing their bodies so they can attend to the most salient environmental cues may also be helpful (esp w/young kids) • Use of frequent practice, practice, practice in variable settings, & consistent provision of FB should be key elements in any intervention approach • Important to create practice opportunities in a variety of environments so that each repetition of action goal becomes a new problem-solving opportunity
       2. Task-Specific Approaches p 516
          1. • Useful to teach specific gross motor skills; its indirect effect in enhancing general participation in physical activity is also emphasized • Focuses on the direct teaching of functional skills in appropriate environments w/intended goal of reducing activity limitations & by implication, increasing participation levels • Individualized approaches attempting to increase the efficiency of movement by optimizing the way in which skills are performed, given the constrains w/in each of the several systs that interact during task performance—child, task itself & environment • As kids attempt to solve a mvmt prob, they may discover several ways to complete a motor task; kids explore a variety of solns to motor probs & are encouraged to experience the resulting effects of using diff aspects of their bodies or the environment; PT guides kid in choosing which of these diff ways reps the most efficient, optimal way for him individually & in a specific environment • PT is DIRECTIVE, providing verbal instructions, visual prompts or physical (A) by guiding & directing mvmt so kid can appreciate the “feel” of efficient mvmt
          2. Examples:
             1. Neuromotor Task Training
             2. Emphasizes components of motor learning such as verbal feedback & variable practice but there's not much evidence for transfer or generalization in this approach
       3. Cognitive Approaches p 517
          1. • Addresses activity & participation goals • Use direct skill teaching in their approach • Their unique problem-solving framework attempts to help kids develop cognitive strategies, acquire tasks & generalize from the learning of 1 skill to the next • Are based on the premise that kids w/DCD may be deficient in “declarative knowledge” related to motor tasks; thus they lack knowledge of HOW TO approach at ask, how to determine what is req’d for the task & how to develop strategies to use when learning & performing a motor task • This approach stresses the importance of Kids learning to monitor their performance & use self-evaluation • Meditation is used wherein kids are guided to discover probs, generate solns & eval their success I’ly
          2. Cognitive Orientation to Daily Occupational Performance (CO-OP)
             1. • CO-OP shows evidence for the effectiveness of a cognitive approach • It guides the kid in discovering verbally based strats that help him prob-solve in new movement situation • Emphasizes a child-centered approach w/goals that are ecologically valid & performed in realistic settings • Practice focuses on kid’s ability to select, apply, evaluate, & monitor task-specific cognitive strategies w/emphasis on facilitating transfer & generalization of the newly learned strategies • Approach has been shown to be effective in a research clinic setting, of note, demonstrated some generalization & transfer of skills in kids w/DCD
          3. Applying approach to younger kids:
             1. a participatory or consultative approach may be most effective; Important to provide appropriate FB & help them to focus on the salient aspects of a given activity by modeling and/or providing them w/verbal guidance as they proceed thru it
          4. Applying approach to older kids:
             1. Direct Intervention w/a more cognitive approach can be used to encourage them to think I’ly thru motor probs
       4. Tools for Goal Setting & Measuring Intervention Effectiveness p 518
          1. Best for kids older than 8 or 9
             1. The Canadian Occupational Performance Measure (COPM)
             2. • Used for goal setting & outcome measure • Used before intervention to have the kid &/or family ID areas of functional difficulty & rate kid’s current performance of, & satisfaction with, each task • After intervention, the rater is asked to reflect upon his performance & satisfaction for each targeted goal, & a change score is generated
          2. For kids younger than 8 or 9:
             1. the Perceived Efficacy & Goal Setting System (PEGS)
             2. Pictorial measure where kids reflect on & indicate their competence in performing 24 tasks that they need to do every day; then they ID any other activities that are difficult for them & select & prioritize tasks as goals for therapy
          3. Goal Attainment Scaling (GAS)
             1. • Is increasing in usage as a rehab outcome measure w/regard to both program eval & assessment of individualized client outcomes • 5 possible levels of specific functional attainment are developed for a kid to create a criterion-referenced individualized measurement • Its use w/DCD has been described mainly at a programmatic level; here GAS that focuses on the levels of activity &/or participation, not on primary impairment, is warranted
          4. School Function Assessment (SFA)
             1. • Can be used to describe or evaluate activity &/or participation • Evals a kid’s participation in 6 school-related settings (Participation Scale) & it also examines the amt of (A) &/or the types of adaptations req’d for the kid to perform essential school tasks (Task Support Scale) • A 3rd scale is very detailed & focuses on the performance of specific activities • A section of this scale focuses on the kid’s mobility & ability to maintain & change positions, manipulate objects & move on recreational equipment • SFA reqs observation of functional performance over time, so its usually completed by PT through interview of teach & others familiar w/kid • SFA has been used to describe participation patterns
    2. Education As Intervention p 518
       1. Helping parents to understand their kid's strengths & limitations is an important component of 2ndry prevention & risk mgmt
       2. When kid has ADHD & DCD the term DAMP (dysfunction of attention, motor control, and perception) has been used
    3. Consultation Regarding Physical Activity p 519
       1. Intro
       2. Physical Education Class p 519
          1. Teachers can learn how to "MATCH" tasks to fit the needs of individual children w/DCD to encourage maximal participation
             1. M
             2. M-Modify the Task
             3. A
             4. A-Alter their expectations
             5. T
             6. T-Teach Strategies
             7. C
             8. C-Change the environment
             9. H
             10. H-Help by understanding
          2. • Emphasis should always be placed on encouraging fun, effort, & participation rather than proficiency • Noncompetitive games in which goals are measured against one’s own performance & not that of other kids may be helpful
       3. The School Playground p 520
       4. Sports & Leisure Activities p 520
11. Transition to Adulthood & Lifelong Mgmt of DCD p 520
    1. • Identification of strategies to prevent impairments in body fnx from limiting activity or restriction participation can be one of the most important outcomes of PT • Appropriate leisure activities that foster what the Pt lacks: strength, endurance & joint protection should be encouraged • Activities should minimize competition & the need for quick motor responses
    2. Jobs that minimize the need for changing motoric & environmental expectations should be emphasized
       1. Henderson & Sugden's 4-Level Categorization of MOtor Skill Difficulty:
          1. • Vocations that involve skills in which neither the individ nor the environment is moving/changing would be top choices • Vocations in which the individ is moving & the environment is changing would be more challenging for the young DCD adult