A clumsy child

Essentials

  • Physical activity is of central importance in playing and in the formation of peer relations throughout preschool age and the period of growth.
  • Clumsy children often have additional special developmental problems, which are important to consider when planning any supportive action. Delayed speech and linguistic development, problems in fine motor functions and attention deficits are common associated symptoms.
  • Supportive measures should be directed at motor training and minimizing associated problems but also at supporting the development of a healthy self-esteem.
  • Clumsy children are mostly treated in primary health care.
  • Assessment in specialized care is necessary if a clumsy child is suspected of having a myopathy or mild CP or has symptoms that are so extensive as to make the supportive measures available in primary health care insufficient.

Normal motor development

  • Children usually
    • learn to walk independently by the age of 18 months
    • take running steps and shift their body weight when kicking a big ball at the age of 2
    • can jump on two feet and rise up on their toes when asked to do so at the age of 3
    • can walk on their toes and walk a few steps along a line, can stand on one foot for a moment and climb stairs taking steps alternately with both feet at the age of 4
    • can jump several times consecutively on one foot and walk accurately along a line at the age of 5
    • can ride a two-wheeled bike, ski and skate at preschool and school age.

Definitions and prevalence

  • The terms developmental coordination disorder, DCD, and specific developmental disorder of motor function, SDD-MF, are based on the DSM IV or ICD-10 classifications.
  • Developmental coordination disorder is a neurobiological disorder that may be associated with other special developmental or neuropsychiatric disorders.
  • The prevalence of developmental coordination disorder is 5–6%.
  • The disorder is more common in boys (2:1–7:1). The risk of the disorder is 6 to 8 times higher in preterm or low-weight infants.
  • The problems are long-standing but not progressive.
  • In some cases, a child's skills may mature to the level of his/her peers during development.

Clinical picture

  • The symptoms are most commonly due to an immature or inaccurately functioning motor regulatory system.
  • A clumsy child has problems associated with planning, coordinating and producing motor functions and learning new skills.
  • Problems may occur in gross, fine as well as visual motor functions.
  • The extent and form of the disorder vary depending on the child's age and the stage of brain development.
  • During the first years of life, the symptoms may present as delayed independent walking or difficulty in learning more demanding motor skills, such as running, standing or jumping on one foot, catching a ball, buttoning up one's clothes, tying shoelaces, cutting with scissors, copying figures or writing by hand.
  • The problem may also appear as balance problems when walking up or down stairs or clumsy movements, making the child stumble, bump into things, run or jump rigidly or drop things.
  • These children often find it very difficult to use a pencil.

Clinical examination

  • In addition to motor performance, the following should be considered in clinical assessment:
    • To what extent does clumsiness prevent the child from participating in age-appropriate activities at home or elsewhere?
    • Do the problems cause the child any other disadvantage?
    • Are there any associated symptoms?
  • Occurrence of similar problems in other members of the close family may provide useful further information on the development of the problem with age.
  • Structured questionnaires may be used in addition to interviewing the parents.
    • For example, the FTF (Five to Fifteen) developmental and behavioural questionnaire also provides information on concentration, social skills and emotional development 1 .
    • Feedback from the day care centre or school provides information on the child's skills and progress compared to peers and how the child copes and participates in the group.
  • Exclusion of neurological diseases causing motor disturbances (e.g. CP, myopathies, peripheral nervous disorders)
    • Muscle weakness and diminished or absent tendon reflexes are typical for neuromuscular diseases.
      • Clumsy children may be hypotonic but their muscle strength and tendon reflexes are normal, as opposed to children with myopathy.
      • In children with neuromuscular disease, muscle weakness can be detected when the child stands up from the supine position; due to weak trunk muscles, the child gets up supporting him/herself with hands against the thighs.
  • Somatic diseases, such as rheumatoid arthritis, hypothyroidism and obesity may affect motor performance.

Neurological examination

  • Concentrates on detecting mild neurological deviations, suitable for use from the age of 4 years. See table T1.

Table 1.
Functional areas in the central nervous system Single task Abnormal, if
1. Posture and muscle tone Posture when sitting, standing, walking At least 2 of the following: abnormal posture or slightly abnormal muscle tone/strength in upper or lower extremities
  1. Muscle tone
  2. Muscle strength
2. Tendon reflexes
  1. Biceps, triceps
  2. Patella, Achilles
At least 2 abnormalities
Intensity, asymmetry
Babinski
3. Involuntary movements Spontaneous motor function At least 1 of the following: continuous clearly choreiform movements* distally or proximally in the limbs or in the facial area, distal athetotic movements**, constant tremor, lateral, cranial or caudal deviation of the arm, rotation of the arm from supination to pronation
Basic test + test assessing involuntary movements (standing with the arms stretched, hands in pronation, supination)
Face, eye, tongue movements
4. Coordination and balance
  1. Finger to nose test 1)
  2. Finger to finger test
Abnormality in at least 3 tasks
Diadochokinesis (DDK)2)
Heel-to-knee test3)
Reaction to being pushed when sitting, standing4)
Romberg5)
Walking a straight line6)
Standing on one foot7)
Jumping on one foot8)
5. Fine motor functions Finger opposition test (smoothness, smooth change of direction)9) Abnormality in at least 2 tasks
  1. Mimicking circular movements of the hands in the same and opposite directions
6. Associative and mirror movements Diadochokinesis Frequent associative/mirror movements in at least 3 tasks, taking into account the child's age
Finger oppositions
  1. Toe walking
  2. Heel walking
  3. Walking a straight line
7. Sensory functions Vision, visual fields Abnormality in at least 2 sensory functions
Hearing (if impairment is suspected, audiometry)
Graphaesthesia (recognition of a circle and cross written on the palm)
Kinaesthesia (recognition of movement, finger/toe)10)
Position sensation (recognition of direction of movement, finger/toe)11)
8. Cranial nerves At least 1 abnormality
  1. * Assessed with the child standing with arms and fingers extended, arms pronated, eyes closed; small, sharp, irregular movements in the fingers, arms, shoulders
  2. **Small, slow, irregular extension movements particularly in the fingers, tongue
  3. 1)Accuracy of touching one's own nose and the examiner's finger in 3 successive attempts for both hands separately; in patients under 5 years with their eyes open, in patients over 5 years with their eyes open and closed. In addition, observe the occurrence of any intention tremor, particularly at the end of movement.
  4. 2)Examine the pronation and supination of each forearm separately, the child standing with his/her elbow about 90 degrees flexed. Assess abduction of the elbow from the trunk during the movement (more than 5 cm being abnormal) and the smoothness (jerkiness) of the movement.
  5. 3)With the child lying supine, ask the child slide the heel smoothly down their opposite shin to the ankle, repeating this 3 times for both legs. Observe the accuracy of heel placement at the knee and the smoothness of movement without dropping the foot during the movement.
  6. 4)Observe balance reactions, sidestepping, using the hand for support.
  7. 5)Ask the child to stand in place with their eyes closed for 10–15 s. Observe balance reactions and corrective movements to maintain balance.
  8. 6)5-year-olds can walk a straight line touching the heel of one foot to the toe of the other, maintaining their balance with their arms but without sidestepping. 6-year-olds can set the pace for walking more evenly, and from the age of 9 years, children can move smoothly and evenly with no need for arms to balance their movement.
  9. 7)5-year-olds 10 s, 7-year-olds 20 s
  10. 8)5-year-olds no less than 3 jumps, and 6-year-olds no less than 10 jumps on one foot, 7-year-olds 20 jumps on each foot
  11. 9)The distal portions of the fingers are touched in turn with the tip of the thumb: 5–6-year-olds in the order 2-3-4-5-2-3-4-5, repeating the cycle 3 times, from the age of 7 years, doing this back and forth, i.e. 1-2-3-4-5-4-3-2-1-2-3-4-5, repeating this 5 times. Assess the speed and smoothness of movement (errors, halting, particularly changes of direction) and mirroring/associative movements of the opposite hand.
  12. 10)Gently grasp the distal segment of the child's forefinger / big toe at either side of the nail, and move the finger/toe back and forth; the child should recognize the direction of the movement with their eyes closed.
  13. 11)Move the child's forefinger / big toe to the extreme positions up and down; the child should recognize the direction of the achieved position.

Diagnosis

  • To make a diagnosis, both neurological examination (differential diagnosis) and motor testing are needed.
  • The diagnosis can be made in children of 5 years or older, in more severe cases at the age of 3 to 4 years, already, based on two separate examinations performed at least 3 months apart.
  • Some children with developmental delay will develop their age-appropriate skills later (late/slow maturers).
  • The diagnosis of DCD requires the use of standardized motor testing.
    • The Movement-ABC-2 test (MABC-2, 3 to 16 years) used by physiotherapists measures fine motor and ball skills as well as static and dynamic balance.
    • The Bruininks–Oseretsky test (BOTMP-2, 4 to 21 years) used by occupational therapists can also be used.
    • The same tests can be used to follow up on rehabilitation.
  • Further differential diagnostic examinations can be carried out as clinically indicated.
    • If a myopathy is suspected, plasma creatine kinase (P-CK) should be measured.
    • In specialized care, examinations such as ENMG or, if CP is suspected, MRI of the brain can be performed.

Associated disorders

  • Children with DCD have more developmental learning disorders and problems related to social perception, behaviour or emotions.
    • Developmental speech and language disorder
    • Dyslexia
    • Attention deficit hyperactivity disorder (ADHD)
    • Autism spectrum disorder (ASD)
    • Nonverbal learning disorder syndrome (NLD)
  • Due to the high probability of associated disorders in children with DCD, it is important to specify their scope and to address them.
  • DCD is diagnosed in as many as 70% of children with developmental speech and language disorder.
  • Developmental speech and writing disorders are common in school age children.
  • Children with DCD have been found to have specific disorders related to spatial perception (visuospatial functions) but also with understanding language, working memory and processing speed.
  • Accumulation of disorders will worsen a child's prognosis.
  • Particular attention should be paid to social and emotional development in children with DCD, boys in particular.
  • Due to motor problems, children with DCD tend to avoid physical exercise and participation in team sports, which may lead to withdrawal and problems with self-esteem as late as in adulthood.
  • Anxiety and behavioural problems have been interpreted as results of long-standing daily negative experiences and experiences of being inferior.
  • As a result of insufficient physical exercise, particularly boys with DCD run a risk of obesity problems.
  • About 50 to 70% of children with DCD have a permanent motor disturbance, seen in adulthood as difficulty in serial movements, slow movement and variable performance.

Rehabilitation

  • Clumsy children may need help with daily tasks, such as eating (e.g. peeling boiled potatoes) or dressing (buttoning up, tying shoelaces).
  • If problems are extensive, rehabilitation must be considered to improve the child's possibilities for participation.
  • The targets should always be defined individually with the child and his/her parents.
  • Lack of motivation or the psychosocial family situation may complicate the rehabilitation process.
  • In some cases, compensatory action and support from the environment may be sufficient.
  • If the child has significant difficulties with fine motor functions and writing by hand, a computer should be used as a writing aid when the amount of material to be written increases.
  • In addition to therapy, support from parents and teachers for regular daily training at home is important for achieving skills and applying them in the daily environment.

References

1. Airaksinen EM, Michelsson K, Jokela V. The occurrence of inattention, hyperactivity, impulsivity and coexisting symptoms in a population study of 471 6-8-year old children based on the FTF (Five to Fifteen) questionnaire. Eur Child Adolesc Psychiatry 2004;13 Suppl 3:23-30  [PMID:15692876]


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