Dr. John Cairney McMaster Family Medicine Professor of Child Health

1. Why Can’t Johnny Tie his Shoelaces? Developmental Coordination Disorder in Children: Implications for Primary Care Dr. John Cairney McMaster Family Medicine Professor of Child Health Departments of Family Medicine, Psychiatry and Behavioural Neurosciences Offord Centre for Child Studies CanChild Centre for Studies in Childhood Disability

2. What is DCD? • DSM-IV (American Psychiatric Association, 2000) • Essential feature is a “marked impairment in the development of motor coordination” • Impairment must significantly interfere with academic achievement or activities of daily living • coordination difficulty not due to a general medical condition (e.g., CP or MD), and criteria for pervasive developmental disorder not met • If mental retardation is present, motor difficulties must be in excess of normal for that population

3. By other names … • “Specific Developmental Disorder of Motor Function” (WHO, 1992) • “Minimal Neurological Dysfunction” (Henderson et al., 1992) • “Playground Disability” (Hay and Missiuna, 1999) • “Clumsy Child Syndrome” (Bax, 1999) • “Dyspraxia” (Zoia, 1999) • This terminology was replaced by “Developmental Coordination Disorder" or “DCD” based on the recommendations from the International Consensus Meeting on Children and Clumsiness (London, ON, Canada, 1996).

4. Signs and Symptoms • Gross Motor Deficits: • Hypotonia • Immature balance responses • Awkward running pattern • Frequent falling • Dropping of items • Difficulty in imitating body positions • Poor physical activity performance

5. Signs and Symptoms • Fine Motor Deficits: • Handwriting • Gripping items • Dressing

6. VIDEOS • subject3v2.wmv • subject4v2.wmv

7. Cause? • Uncertain • Origins in fetal brain development • Cerebellum

8. Prognosis? (clinical evidence) • DCD symptoms persist through adolescence (adulthood?) contributing to increased risk for: • psychiatric disorders • academic failure • physical health problems (associated with inactivity – cardiovascular risk)

9. Intervention / Treatment • Mixed evidence • Evidence of efficacy for cognitive, client centered, task based interventions • Environmental accommodation – coping & Advocacy

10. PHYSICAL HEALTH ACTIVITY STUDY TEAM

11. PHAST I • In 2004, my research team was awarded $520,000 from CIHR to study: • Motor proficiency in relation to physical activity, physical fitness, body weight and self-efficacy over time (3 years), in a large cohort of children in grade 4

12. PHAST I: Sample • Target Population: All children enrolled in Grade 4 (Public School System) in Niagara • Response (school level): 75 of 90 (83%) schools consented to take part • Response (student level): 2297 of 2378 (95.4%)

13. PHAST I: Design • Study Began Spring (May/June 2005) • Tested twice a year (fall and spring) • From grade 4 to present (children started high school this past fall • Data presented here is till grade 7 • All testing completed in schools

14. PHAST I: Design • 75 schools were randomly assigned to 3 groups; motor testing (BOTMP-sf) was conducted over 3 time points (25 schools per wave). Trained Research Assistants administered the test (2-3 students) • After each test, 8 children (6 who scored <5th percentile, 2 who scored >5th percentile) were randomly selected. • An OT, blind to the BOTMP-sf scores, assessed the children on the K-BIT and the M-ABC

15. PHAST: Measures • BOTMP-sf (M-ABC, K-BIT) • CSAPPA(Hay, 1992) • Participation Questionnaire (Hay, 1992) • BMI / Waist Girth (sitting height to derive peak height velocity) • VO2 Max – Shuttle Run • Teacher Reported Physical Activity / Ability • Harter Scales

16. Classroom Gymnasium Method Phase I: Survey and Cardiovascular Risk Factor Assessment

17. Method Phase II: Motor-proficiency Testing BOTMP-SF: • 14 item - short form • Gross motor skill • Fine motor skill • Blind and independent to Phase 1 results • Evaluated parameters: • Running & response speed, strength, balance, agility, upper-limb coordination, dexterity, bilateral coordination.

18. Three Important Questions Prevalence? Who are we identifying using the BOMTP-sf (administered by trained research assistants under field conditions)? How stable are the motor assessments over time?

19. Prevalence • n=111 children (46 males, 65 females) • 5.3%

20. Results of the OT Assessment • 21 of 24 (87%) children identified as probable cases of DCD on the BOTMP-SF scored below the 15th percentile of the M-ABC, a PPV of 0.88 (95% CI=0.69 to 0.96). • Fifteen of these children (71%) were below the 5th percentile (PPV= 0.63; 95% CI=0.43 to 0.79). • Two children, both probable cases of DCD, were found to have scores below 70 on the K-BIT Cairney J, Hay J, Veldhuizen S, Missiuna C, Faught B. On the validity of using the short form of the Bruininks-Oseretsky Test of Motor Proficiency to identify Developmental Coordination Disorder. Child: Care, Health and Development (in press)

21. Stability of Motor Testing • We retested 77 children drawn from 5 randomly-selected schools approximately two years after their original assessment. • Examiners (all new) were blind to the original results. • The correlation between the two sets of scores was 0.70 (p<0.001)

22. Statistical Analysis • Mixed effects models (HLM) • In all models, we tested for: • Main effects for pDCD, gender and time • Interactions between these factors • non-linear effects of time on each outcome • We included random intercepts at the school and student levels, as well as a random slope for time. Analysis of the data revealed possible seasonal effects, so we chose to use an unstructured covariance matrix.

23. Relative Weight & Abdominal Fat Outcomes: BMI (kg/m2) Waist girth (cm) Overweight/obesity (BMI cut-points derived from Cole et al. 2000) Cairney J, Hay J, Veldhuizen S et al. (in press) Trajectories of Relative Weight and Waist Circumference in Children with and without Developmental Coordination Disorder Canadian Medical Association Journal

24. Figure 1. Predicted BMI for children with and without pDCD by gender.

25. Figure 2. Predicted waist girth for children with and without pDCD by gender.

26. Figure 3. Predicted probability of obesity for males with and without pDCD.

27. PHAST II • All children (n=61) screened positive for DCD and 61 age, sex and school matched controls selected for further study • Lab based assessment; full clinical assessment for DCD (intelligence testing, impairment assessment); cardiovascular health assessment • In-home interviews conducted with child and parent (ADHD/ADD, social anxiety, self-esteem, competence)

28. Discussion • Trajectories suggest that the cross-sectional differences we have previously observed between children with pDCD and typically-developing children are maintained, and in some cases increase, over time (this developmental period) • Our concern about long-term risk is justified (things do not appear to be getting better)

29. The STACK Study The STACK Study Screening, Tracking and Assessing Coordination in Kids “Examining the co-occurrence of psychological problems in a population based sample of children with Developmental Coordination Disorder” Funded by Canadian Institutes for Health Research (CIHR) January 2007 - 2009

30. Objectives Examine prevalence of depression and social anxiety in children with DCD, ADHD, DCD&ADHD, compared to controls. ** Screen for DCD and ADHD in a general population sample ** In the process help promote DCD awareness for teachers, parents and students and provide educational materials and recommendations for families.

31. Design Two-stage, population-based, cross-sectional study Children in Grades 4-8 recruited from 23 schools in 2 school boards 3151 children (1590 boys, 1561 girls) screened OT visits to home to conduct motor assessments, interview parents and children

32. Research Criteria Applied

33. Assessments • Parent & Child Completed Measures of Depression and Anxiety • Children’s Depression Inventory (CDI) • Screen for Child Anxiety Related Emotional Disorders (SCARED)

34. Results: Description of the Children

35. * * * * * Results: CDI Child and Parent Total Differs from Typically Developing *p<0.01

36. Results: CDI Child by gender * * * * Differs from Typically Developing **p<0.001

37. Children with DCD in Primary Care Settings • Greater risk of risk for CVD • Inactivity, obesity, other risk markers • Greater risk for emotional/behavioural problems • Depression, anxiety, low self-esteem

38. Primary Care • Annual health examinations are ideal times to screen for DCD. • Parents can be asked to complete a self-administered questionnaire • E.G., DCDQ http://dcdq.ca/

39. Primary Care • Physician can conduct a structured interview, listening for difficulties commonly associated with DCD. • In addition, the physician can assess the child using simple screening activities administered in his or her office • Children with symptoms or signs of a motor coordination disorder require further evaluation.

42. An assessment that takes into account the differential diagnosis of DCD is necessary, since DCD is a diagnosis of exclusion.

44. New Study • Framed in the context of pediatric obesity & ParticipACTION • We tested 335 children, randomly drawn from our PHAST study using two different motor tests • Of the children who scored poor on both tests, 50% were overweight/obese • Perhaps more importantly, of all the children who were overweight/obese (85), 40% had poor motor coordination by one or both tests • When you children in your clinic with weight issues, are you thinking about diet and physical activity? Are you asking, what if they can’t be physically active for reasons related to motor ability?

45. Importance of Identification • Rule out other medical problems • Successful treatment approaches involve various allied health professionals, and the child's parents, physician and teachers - Goal is management strategies • Advocacy

46. CanChild website (www.canchild.ca) • Provides easy access to CanChild materials • Receives almost 4,000 visits per week by users in over 130 countries