CASE STUDY VIII

1. CASE STUDY VIII JILL KLOESEL, SPT MARIANA LICATA, SPT PT 7336 Spring 2009

2. Overview Practice Patterns Our Case Differential Diagnosis Treatment NCMRR Model Conclusions

3. HISTORY • 8 year old boy • Weakness in LLE post cast removal • Out of control with too much energy the day he broke his leg • Difficulty in school • Talks out of turn • Not sitting still • Not playing well in organized games

4. EVALUATION • He forgets the last steps of a multi-step motor command • Easily distracted by other noises

5. Differential Diagnosis • Developmental Coordination Disorder (DCD)??? • Attention Deficit Hyperactivity Disorder (ADHD)??? • BOTH???

6. What is DCD? • A chronic condition found in children characterized by motor impairment that interferes with the child’s activities of daily living or academic achievement1 (APTA, Section on Pediatrics) • A marked impairment in the development of motor coordination which cannot be attributed to a general medical condition or mental retardation2(J. Visser, 480) • Often associated with ADHD, phonological disorder, expressive language disorder, or mixed receptive-expressive language disorder1(APTA, Section on Pediatrics)

7. Motor Low muscle tone Persistence of infantile reflexes Difficulties maintaining balance Awkward running pattern Falls frequently Difficulty follow 2- to 3- step motor pattern Drops things Difficulty: handwriting, gripping, utensils, dressing Psychosocial Learning difficulties Reading problems Behavior problems Poor interactive play skills Lower self-esteem Lower self-worth Increased anxiety Avoids physical activity Characteristics of DCD1

8. Subtypes of DCD2 • While studies have attempted to classify subtypes, there has been no consensus • Differences have been noted in areas such as visual motor, gross motor, fine motor and balance • Common result: “emergence of a subtype characterized by difficulties on all sensorimotor measures” 2(Visser, 483) • Possible link between subtypes and comorbidities

9. DSM-IV Diagnostic Criteria for DCD

10. What is significant? • Marked delays • Forgets lasts steps of multi-step motor command which most likely leads to poor performance in sports • Formal assessment of motor skills not available at this time

11. What is ADHD? • A chronic, pervasive childhood disorder characterized by developmentally inappropriate activity level, low frustration tolerance, impulsivity, poor organization of behavior, distractibility, and inability to sustain attention and concentration. 3(Cormier, 345) • Symptoms are associated with impairments in several domains of functioning, including academic achievement and deportment in school, interactions with parents and siblings, and peer relationships. 3(Cormier, 345)

12. Subtypes of ADHD3 • Inattentive Type • Hyperactivity/Impulsivity Type • Combined

13. The following chart is the DSM-IV Diagnostic Criteria for ADHD.

15. What is significant? • Inattention • Difficulty sustaining attention in task or play activities • Difficulty organizing tasks and activities • Is easily distracted by extraneous stimuli • Hyperactivity • Squirms in seat • Is often “on the go” • Impulsivity • Difficulty awaiting his turn

16. Presentation • ADHD3 • 3 – 7% of school age children • Does My Child have ADHD? • DCD1,2,4 • 6% of children 5-11 years • DVD of child with DCD from Campbell textbook

17. DCD and ADHD: Comorbidity • Co-morbid up to 50%5 • Both occur in male>female5 • ADHD inattentive/combined type  more likely to have DCD5 • PT interventions can beneficial impact DCD, ADHD, and DCD/ADHD6

18. DCD and ADHD: A link? • Genetics5 • Shared etiology seems to be due to genetics • Twin Studies • DCD (fine motor) and ADHD (inattentive) most strongly linked • Differences • DCD has visual-spatial deficits • ADHD has response inhibition deficits

19. DCD and ADHD: A link? • Associated Movements (AMs)7 • Movement not actively involved in performance of motor skills which decreases the efficacy of movements • Results • Typical children • AMs disappear with age • DCD • Increased AMs • DCD/ADHD • increased AMs • DCD=DCD/ADHD performance

20. DCD and ADHD: A link? • Motor Imagery8 • DCD • Inability to generate imagined movements • ADHD/DCD • Ability to generate image, slow response • ADHD • Typical generation of image • Results weaken argument for shared etiology

21. As if that’s not enough… • Sensory Processing Disorder • Dysfunction of the body’s processing of sensory input • Often presents like ADHD, DCD, Behavioral Problems and a host of other conditions • SPD with Dr. Lucy Jane Miller • Children with DCD have more trouble coping with altered sensory input, such as performing standing balance. 9

22. Differential Diagnosis • Additional Assessments for DCD • DCDQ: Developmental Coordination Disorder Questionnaire • BOT-2: Motor Skills • MABC: Movement Assessment Battery for Children • Additional Assessments for ADHD • CBCL: Child Behavior Checklist • SWAN: Strengths and Weaknesses of ADHD Symptoms and Normal Behavioral Scale

23. Differential Diagnosis • Based on available information… ADHD

24. NCMRR MODEL • Pathophysiology: ADHD (possibly combined with DCD) • Impairment: dyspraxia, clumsy, inhibition control, balance impairment(possible) • Functional Limitation: limited motor planning and adaptation, difficulty progressing from parts to whole, altered attention span • Disability: limited ability to play sports, can’t bike ride with friends, academic challenges • Societal Limitations: exclusion from sports/teams, depressions/ self worth, low education level/achievement

25. Multidisciplinary Approach • Physician • Pharmacological Management for ADHD3 • Stimulants • Methylphenidate (MPH): Ritalin, Concerta • Amphetamine: Adderall, Dexedrine • Non-stimulants • Atomoxetine (Strattera) • Psychiatrist • Behavioral Specialist • Teachers • OT/PT • Parents

26. APTA Practice Patterns Neuromuscular 5A- Primary Prevention/Risk Reduction for Loss of Balance and Falling 5C-Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System-Congenital Origin or Acquired in Infancy or Childhood

27. Treatment Goals LTG: 3 months Pt will design and complete a 4 step obstacle course c min cues for redirection to show an increase in motor planning to be able to play on the playground c other kids. Pt will I ride a two-wheeled bike X 500 ft. on level surface to increase social interaction. STG: 1.5 months Pt will follow a 4 step motor command c min cues for redirection. Pt will maintain I tall kneeling on platform swing s LOB X 5 min.

28. Treatment: Physical Therapy • Both DCD and ADHD involve similar PT interventions • Top-down, or cognitive, approach to therapy10,11 • Task-specific, focus on performance skills6 • Emphasizing organization, planning, adaptation and safety • “Multi-tasking”

29. Strategies for…. • Part to Whole • Integrating steps to learn new skills

30. Strategies for… • Safety • Look before you leap! • Safety Equipment • Supervision

31. Strategies for… • Balance/Postural Control • Hopscotch • Balance Boards • Uneven surfaces (e.g. big cushions) • Standing, tall kneeling, ½ kneeling on swings • Combine other activities such as throwing balls, bowling, etc

32. Make a Plan… • Allows the child to guide treatment, increasing interest and participation

33. Obstacle Course • Emphasizing planning and memory • Either therapist- or child-directed • Organization of tasks, both cognitive and motor, to complete successfully

34. Use the Entire Brain • Or…how to walk and talk at the same time… Volunteers to play a game?

35. Learn to Ride a Bike • Loose the Training Wheels • Lose the Training Wheels • Bike riding has tremendous social implications • Sense of accomplishment • “Rite of Passage” • Family and Friends

36. Make it FUNctional • Swimming/Aquatics • Improving swimming or learning to swim • Kids like the water… • Aquatic Therapy • Organization • Multi-step • Lots of thought and motor together

37. Peer Interactions • Siblings, other patients, etc • Listening skills • Safety skills • Turn-taking • Planning • Sharing • Compromising • Impulsivity ……all while being asked to do motor skills!

38. Future Challenges… • Participation in sports and increasing demands of physical education/complexity of physical activity in play • Increasing demands of academic work • Psychosocial problems: low education, depression, etc • Changing situations and requirements into adulthood • ADHD with DCD has poorer long-term outcomes12

39. Conclusion • Both ADHD and DCD have widespread effects on an individual, especially psychosocially • Emerging evidence of a genetic link between the two • More high quality research is needed13 • PT intervention benefits both populations (as well as combined presentations) • PT intervention should use a “top-down” or cognitive approach to reach the child’s and family’s goals, especially addressing planning, adaptation and safety.

40. References • Pediatrics APTA. Developmental Coordination Disorder: Fact Sheet. 2006. www.pediatricapta.org. Accessed March 3, 2009. • Visser J. Developmental coordination disorder: a review of research on subtypes and comorbidities. Hum Mvt Sci. 2003;22(4):479-493. • Cormier E. Attention Deficit/Hyperactivity Disorder: A review and update. J of Ped Nurs. 2008;23(5):345-357. • Missiuna et al. Description of children identified by physicians as having developmental coordination disorder. Dev Med & Child Neuro. 2008;50:839-844. • Martin NC, Piek JP, Hay D. DCD and ADHD: A genetic study of their shared aetiology. Hum Mvt Sci. 2006;25(1):110-124. • Whatemburg M, Waiserburg N, Zuk L, Lerman-Sagie T. Developmental coordination disorder in children with attention-deficit-hyperactivity disorder and physical therapy. Dev Med & Child Neuro. 2007;49:920-925. • Licari M, Larkin D, Miyahara M. The influence of developmental coordination disorder and attention deficits on associated movements in children. Hum Mvt Sci. 2006;25(1):90-99. • Lewis M, Vance A, Maruff P, Wilson P. Differences in motor imagery between children with developmental coordination disorder with and without the combined type of ADHD. Dev Med & Child Neuro. 2008;50:608-612. • Cherng R, Hsu Y, Chen Y, Chen J. Standing balance of children with developmental coordination disorder under altered sensory conditions. Hum Mvt Sci. 2007;26(6):913-926. • Sugden D. Current approaches to intervention in children with developmental coordination disorder. Dev Med & Child Neuro. 2007;49:467-471. • Niemeijer AS, Smits-Engelsman BCM, Reynders K, Schoemaker MM. Verbal actions of physiotherapists to enhance motor learning in children with DCD. Hum Mvt Sci. 2003;22(6):567-581. • Rasmussen P, Gillberg C. Natural outcome of ADHD with Developmental Coordination Disorder at Age 22: a controlled longitudinal, community-based study. J Am Acad Child Adolesc Psych. 2000;39(11):1424-1431. • Sergeant JA, Piek JP, Oosterlaan J. ADHD and DCD: a relationship in need of research. Hum Mvt Sci. 2006;25(1):76-89. • Cosper SM, Lee GP, Peters SB, Bishop E. Interactive Metronome training in children with attention deficit and developmental coordination disorders. Int J of Rehabil Res. 2009. [Epub ahead of Print].