Physical & Occupational Therapy in Pediatrics, 35(2):93–96, 2015 C 2015 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/potp DOI: 10.3109/01942638.2015.1013758
EDITORIAL
Prospecting in the Field of Developmental Coordination Disorder In the beautiful city of Ouro Preto, Brazil, 150 scientists and clinicians came together to seek out nuggets of truth that can be used to improve the lives of children with developmental coordination disorder (DCD) and their families. Ouro Preto is an old mining town and the myriad of pathways that need to be traversed to find each gem of evidence was apparent in the myriad of research approaches presented at the 10th conference of the International Society for Research in DCD (ISR-DCD). The theme, “celebrating the past, anticipating the future,” attracted papers that ranged from how our understanding of causal mechanisms has progressed, to the evolution and cultural validation of measures, reflection on the paradigm shift toward population-based intervention approaches, debate over newer research methodologies such as the use of “big data,” and the call for innovative and evidence-informed knowledge translation tools. Although high quality conferences such as DCD-10 have been run by ISR-DCD since the mid-1990s, there is still no peer-reviewed journal devoted to research in the field of DCD. Hence, we are grateful to Drs. Annette Majnemer and Bob Palisano, editors of Physical and Occupational Therapy in Pediatrics, for their willingness to host this special issue that presents some of the top clinically relevant papers from DCD-10. In this editorial, we will discuss implications of the new diagnostic criteria for DCD that were introduced at the conference and will profile the manuscripts selected for this issue. We believe both will provide future direction for clinical practice, research, and policy. A highpoint of the conference was Dr. Gillian Baird’s introduction of the diagnostic criteria for DCD now cited in DSM-5 (American Psychiatric Association [APA], 2013), which offers the first major change in nearly 15 years. After consideration of the available evidence, the decision made by the DSM-5 task force is that the diagnostic criteria for DCD will now include (paraphrased): (A) acquisition and execution of coordinated motor skills below those expected given the child’s age and opportunity for skill learning and use; (B) motor difficulties significantly interfere with age-appropriate activities of daily living (self-care) and impact academic productivity, prevocational and vocational activities, leisure and play; (C) onset is in the early developmental period; and (D) motor coordination difficulties are not better explained by intellectual delay, visual impairment, or other neurological conditions that affect movement. In contrast with DSM-IV (APA, 2000), Criterion A now emphasizes the evidence that children with DCD are not just delayed in motor skill performance but have difficulty acquiring new motor skills, even when they have been exposed to 93
94
Editorial
them and have been given adequate opportunity for skill learning and practice. An obvious challenge for therapists is that practice for children with DCD needs to happen very differently—mere repetition does not lead to improvement. DSM-5 has highlighted, however, that the difficulty goes beyond just learning and practicing; children with DCD have ongoing problems executing or performing the skills that they have learned. This execution may be seen behaviorally as clumsiness or as slower or less accurate movements and continues to challenge children’s ability to participate in some activities throughout life. One of the most important changes in DSM-5 is seen in Criterion B with the acknowledgement that the motor challenges of individuals with DCD impact not only self-care and academic activities but extend into the arena of leisure and play as well. No longer focusing solely on school productivity and school-aged children, the impact of DCD on the family, the home environment, and the child’s engagement in the community is now acknowledged. The fact that evidence now shows that DCD is a chronic health condition present throughout life is validated in the statement that there is persistent interference with prevocational and vocational activities, as well as leisure activities, across the lifespan. Future directions in research, therefore, will require more concentrated efforts at examining the issues of adolescents and adults with DCD, a largely neglected area to date. Longitudinal studies beginning in childhood or adolescence are needed to determine which of the characteristics that we observe in adults who have DCD result from comorbid or cooccurring conditions, and which occur as secondary consequences of DCD. Research will also be needed to examine what the impact is on the life trajectories of individuals with DCD in different countries when cultural demands vary. Reflecting the increasing evidence that DCD can now be identified in preschool children, Criterion C now specifies that the onset is in the early developmental period; this is truly a neuro-developmental condition that is present from birth. We may not yet have sufficient evidence about how to recognize it reliably in very young children, but we should be studying children from 1–3 years who are at high risk for DCD so that we learn what observations can be made and so that identification can occur as early as possible. The extremely controversial Criterion D has opened up the possibility that children who have autism spectrum disorders (ASD) can also have DCD, a conclusion that has already been recognized in children born preterm. It is important not to lose sight of the rest of this criterion, however, which includes the phrase “not better explained by.” While admittedly this is open to interpretation, it will often be the physiotherapist or occupational therapist who will be in the best position to determine whether the motor challenges of a child with ASD, neurological impairment, or an intellectual delay are better explained by those conditions or whether the motor learning difficulties also reflect the cooccurrence of DCD. So, from all of the gems of wisdom shared at DCD-10, why have we selected the new DSM-5 diagnostic criteria (which are still highly controversial) as the focus of an editorial in a journal for rehabilitation practitioners? Because, of the thousands of articles now published on DCD, nearly all have participants who have “probable DCD” or “meet diagnostic criteria for DCD”: remarkably few children whose results are described in the literature were ever diagnosed with DCD. Therefore, it behooves physiotherapists and occupational therapists who are most likely to no-
Editorial
95
tice and “identify” children who have DCD to be aware of the observations that reflect the characteristic presentation of DCD and to label them. While increased awareness and diagnosis by a physician is an important aim, diagnosis does not lead to cure. As we will see in the articles in this issue, it is much more important for therapists and families to be aware of the term “DCD” so they understand the child’s issues and have a mechanism for accessing family-friendly and educator-friendly strategies for managing children with DCD. The issue begins with a Commentary by Henderson and Geuze that is provocative—reviewing the progress that has been made in research over the last 20 years but also challenging the field to consider longstanding clinical issues and questions that are as yet unresolved. As an international community we must reflect on the multiple times researchers and clinicians have mined down pathways that have shown limited progress, focusing on remediation of motor impairment, rather than on how to improve children’s ability to participate in the daily activities of life. We anticipate that many nuggets of truth will be found as we focus more on studying how children with DCD learn and how to facilitate their engagement and participation across the lifespan. In the absence of updates to diagnostic criteria since 2000, the European Academy of Childhood Disability produced guidelines for assessment, diagnosis, and intervention in 2012 (Blank et al., 2012). Barnett and colleagues used a consensus process to review and adapt these guidelines to the health care pathways and services in the United Kingdom and also to extend them for use with adults, an important population now recognized in DSM-5. The importance of parent and educator questionnaires as one source of evidence is certainly recognized in the EACD process. Wilson and team carefully examined the psychometric properties of a parent questionnaire, the Little DCD-Q, which has been developed systematically to facilitate earlier identification of children as young as 3 years. Barnett’s paper and the article by Ray-Kaeser highlight the need to not just translate measures and guidelines into different languages when they appear, but to take the time to ensure that cross-cultural research is conducted to look at cultural, and even linguistic, differences in interpretation and application. Around the world, we are seeing a shift away from 1:1 intervention provided in clinics toward more group- or population-based management in community settings. Health promotion was the theme of Ferguson et al.’s study involving physiotherapy students delivering a fitness program in low-income primary schools in South Africa. Not surprisingly, the motor skills and fitness of both the children with DCD and typically developing children improved, with children with DCD making even more gains on measures of motor proficiency. Maximizing the generalizability that becomes evident when interventions are provided in more natural settings, Zwicker et al.’s team provided an intensive summer camp opportunity to work on functional child-chosen motor goals in groups. Benefits reported by parents and children included increased confidence to try new things and highlighted the value of social interaction with other children with DCD. Both of these studies demonstrate approaches that could serve greater numbers of children in community-based settings. Knowledge translation as a method of increasing awareness about DCD, and also as a science, was highlighted at the conference. The set of articles by Rivard
96
Editorial
et al. and Camden et al. illustrate the systematic approach that needs to be taken in order to produce a high quality knowledge transfer tool: in this case, on online module to provide continuing education to physiotherapists (and occupational therapists) about management of children with DCD. This special issue concludes with a practical article, also by Camden et al., that shows innovative direction in services for children with DCD when the emphasis is on function and participation, not on remediation. Education of families is another key component of this graduated approach to community-based service delivery. The nuggets of knowledge discovered at DCD 10 and shared in this special issue operationalize the paradigm shift that is occurring in rehabilitation of children with DCD and demonstrate the excellence of research that is now transpiring around the world. Looking to the future, there is most definitely much to anticipate! We would like to acknowledge the many graduate students and scientists who submitted their manuscripts for consideration and to thank the reviewers who so thoughtfully contributed to this work; in particular, Dr. Wenonah Campbell. Abstracts are already being reviewed for the next ISR-DCD conference, DCD 11, in France in 2015. Au plaisir de se voir a` Toulouse! Cheryl Missiuna Professor, School of Rehabilitation Science, John & Margaret Lillie Chair in Childhood Disability Research, Scientist, CanChild, McMaster University, 1400 Main Street West, Hamilton ON Canada L8S 1C7, E-mail: [email protected] ˜ L´ıvia de Castro Magalhaes Professor, Occupational Therapy Department, Escola ˜ F´ısica, Fisioterapia e Terapia Ocupacional, Universidade Federal de de Educac¸ao ˆ Minas Gerais, Av. Antonio Carlos 6627, 31270-901, Belo Horizonte, MG, Brazil, E-mail: [email protected] Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, D.C.: American Psychiatric Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Association. Blank R, Smits-Engelsman B, Polatajko H, Wilson P. (2012). European academy for childhood disability (EACD): Recommendations on the definition, diagnosis and intervention of developmental coordination disorder (long version). Developmental Medicine & Child Neurology 54:54–93. doi: 10.1111/j.1469-8749.2011.04171.x
Copyright of Physical & Occupational Therapy in Pediatrics is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
EDITORIAL
Prospecting in the Field of Developmental Coordination Disorder In the beautiful city of Ouro Preto, Brazil, 150 scientists and clinicians came together to seek out nuggets of truth that can be used to improve the lives of children with developmental coordination disorder (DCD) and their families. Ouro Preto is an old mining town and the myriad of pathways that need to be traversed to find each gem of evidence was apparent in the myriad of research approaches presented at the 10th conference of the International Society for Research in DCD (ISR-DCD). The theme, “celebrating the past, anticipating the future,” attracted papers that ranged from how our understanding of causal mechanisms has progressed, to the evolution and cultural validation of measures, reflection on the paradigm shift toward population-based intervention approaches, debate over newer research methodologies such as the use of “big data,” and the call for innovative and evidence-informed knowledge translation tools. Although high quality conferences such as DCD-10 have been run by ISR-DCD since the mid-1990s, there is still no peer-reviewed journal devoted to research in the field of DCD. Hence, we are grateful to Drs. Annette Majnemer and Bob Palisano, editors of Physical and Occupational Therapy in Pediatrics, for their willingness to host this special issue that presents some of the top clinically relevant papers from DCD-10. In this editorial, we will discuss implications of the new diagnostic criteria for DCD that were introduced at the conference and will profile the manuscripts selected for this issue. We believe both will provide future direction for clinical practice, research, and policy. A highpoint of the conference was Dr. Gillian Baird’s introduction of the diagnostic criteria for DCD now cited in DSM-5 (American Psychiatric Association [APA], 2013), which offers the first major change in nearly 15 years. After consideration of the available evidence, the decision made by the DSM-5 task force is that the diagnostic criteria for DCD will now include (paraphrased): (A) acquisition and execution of coordinated motor skills below those expected given the child’s age and opportunity for skill learning and use; (B) motor difficulties significantly interfere with age-appropriate activities of daily living (self-care) and impact academic productivity, prevocational and vocational activities, leisure and play; (C) onset is in the early developmental period; and (D) motor coordination difficulties are not better explained by intellectual delay, visual impairment, or other neurological conditions that affect movement. In contrast with DSM-IV (APA, 2000), Criterion A now emphasizes the evidence that children with DCD are not just delayed in motor skill performance but have difficulty acquiring new motor skills, even when they have been exposed to 93
94
Editorial
them and have been given adequate opportunity for skill learning and practice. An obvious challenge for therapists is that practice for children with DCD needs to happen very differently—mere repetition does not lead to improvement. DSM-5 has highlighted, however, that the difficulty goes beyond just learning and practicing; children with DCD have ongoing problems executing or performing the skills that they have learned. This execution may be seen behaviorally as clumsiness or as slower or less accurate movements and continues to challenge children’s ability to participate in some activities throughout life. One of the most important changes in DSM-5 is seen in Criterion B with the acknowledgement that the motor challenges of individuals with DCD impact not only self-care and academic activities but extend into the arena of leisure and play as well. No longer focusing solely on school productivity and school-aged children, the impact of DCD on the family, the home environment, and the child’s engagement in the community is now acknowledged. The fact that evidence now shows that DCD is a chronic health condition present throughout life is validated in the statement that there is persistent interference with prevocational and vocational activities, as well as leisure activities, across the lifespan. Future directions in research, therefore, will require more concentrated efforts at examining the issues of adolescents and adults with DCD, a largely neglected area to date. Longitudinal studies beginning in childhood or adolescence are needed to determine which of the characteristics that we observe in adults who have DCD result from comorbid or cooccurring conditions, and which occur as secondary consequences of DCD. Research will also be needed to examine what the impact is on the life trajectories of individuals with DCD in different countries when cultural demands vary. Reflecting the increasing evidence that DCD can now be identified in preschool children, Criterion C now specifies that the onset is in the early developmental period; this is truly a neuro-developmental condition that is present from birth. We may not yet have sufficient evidence about how to recognize it reliably in very young children, but we should be studying children from 1–3 years who are at high risk for DCD so that we learn what observations can be made and so that identification can occur as early as possible. The extremely controversial Criterion D has opened up the possibility that children who have autism spectrum disorders (ASD) can also have DCD, a conclusion that has already been recognized in children born preterm. It is important not to lose sight of the rest of this criterion, however, which includes the phrase “not better explained by.” While admittedly this is open to interpretation, it will often be the physiotherapist or occupational therapist who will be in the best position to determine whether the motor challenges of a child with ASD, neurological impairment, or an intellectual delay are better explained by those conditions or whether the motor learning difficulties also reflect the cooccurrence of DCD. So, from all of the gems of wisdom shared at DCD-10, why have we selected the new DSM-5 diagnostic criteria (which are still highly controversial) as the focus of an editorial in a journal for rehabilitation practitioners? Because, of the thousands of articles now published on DCD, nearly all have participants who have “probable DCD” or “meet diagnostic criteria for DCD”: remarkably few children whose results are described in the literature were ever diagnosed with DCD. Therefore, it behooves physiotherapists and occupational therapists who are most likely to no-
Editorial
95
tice and “identify” children who have DCD to be aware of the observations that reflect the characteristic presentation of DCD and to label them. While increased awareness and diagnosis by a physician is an important aim, diagnosis does not lead to cure. As we will see in the articles in this issue, it is much more important for therapists and families to be aware of the term “DCD” so they understand the child’s issues and have a mechanism for accessing family-friendly and educator-friendly strategies for managing children with DCD. The issue begins with a Commentary by Henderson and Geuze that is provocative—reviewing the progress that has been made in research over the last 20 years but also challenging the field to consider longstanding clinical issues and questions that are as yet unresolved. As an international community we must reflect on the multiple times researchers and clinicians have mined down pathways that have shown limited progress, focusing on remediation of motor impairment, rather than on how to improve children’s ability to participate in the daily activities of life. We anticipate that many nuggets of truth will be found as we focus more on studying how children with DCD learn and how to facilitate their engagement and participation across the lifespan. In the absence of updates to diagnostic criteria since 2000, the European Academy of Childhood Disability produced guidelines for assessment, diagnosis, and intervention in 2012 (Blank et al., 2012). Barnett and colleagues used a consensus process to review and adapt these guidelines to the health care pathways and services in the United Kingdom and also to extend them for use with adults, an important population now recognized in DSM-5. The importance of parent and educator questionnaires as one source of evidence is certainly recognized in the EACD process. Wilson and team carefully examined the psychometric properties of a parent questionnaire, the Little DCD-Q, which has been developed systematically to facilitate earlier identification of children as young as 3 years. Barnett’s paper and the article by Ray-Kaeser highlight the need to not just translate measures and guidelines into different languages when they appear, but to take the time to ensure that cross-cultural research is conducted to look at cultural, and even linguistic, differences in interpretation and application. Around the world, we are seeing a shift away from 1:1 intervention provided in clinics toward more group- or population-based management in community settings. Health promotion was the theme of Ferguson et al.’s study involving physiotherapy students delivering a fitness program in low-income primary schools in South Africa. Not surprisingly, the motor skills and fitness of both the children with DCD and typically developing children improved, with children with DCD making even more gains on measures of motor proficiency. Maximizing the generalizability that becomes evident when interventions are provided in more natural settings, Zwicker et al.’s team provided an intensive summer camp opportunity to work on functional child-chosen motor goals in groups. Benefits reported by parents and children included increased confidence to try new things and highlighted the value of social interaction with other children with DCD. Both of these studies demonstrate approaches that could serve greater numbers of children in community-based settings. Knowledge translation as a method of increasing awareness about DCD, and also as a science, was highlighted at the conference. The set of articles by Rivard
96
Editorial
et al. and Camden et al. illustrate the systematic approach that needs to be taken in order to produce a high quality knowledge transfer tool: in this case, on online module to provide continuing education to physiotherapists (and occupational therapists) about management of children with DCD. This special issue concludes with a practical article, also by Camden et al., that shows innovative direction in services for children with DCD when the emphasis is on function and participation, not on remediation. Education of families is another key component of this graduated approach to community-based service delivery. The nuggets of knowledge discovered at DCD 10 and shared in this special issue operationalize the paradigm shift that is occurring in rehabilitation of children with DCD and demonstrate the excellence of research that is now transpiring around the world. Looking to the future, there is most definitely much to anticipate! We would like to acknowledge the many graduate students and scientists who submitted their manuscripts for consideration and to thank the reviewers who so thoughtfully contributed to this work; in particular, Dr. Wenonah Campbell. Abstracts are already being reviewed for the next ISR-DCD conference, DCD 11, in France in 2015. Au plaisir de se voir a` Toulouse! Cheryl Missiuna Professor, School of Rehabilitation Science, John & Margaret Lillie Chair in Childhood Disability Research, Scientist, CanChild, McMaster University, 1400 Main Street West, Hamilton ON Canada L8S 1C7, E-mail: [email protected] ˜ L´ıvia de Castro Magalhaes Professor, Occupational Therapy Department, Escola ˜ F´ısica, Fisioterapia e Terapia Ocupacional, Universidade Federal de de Educac¸ao ˆ Minas Gerais, Av. Antonio Carlos 6627, 31270-901, Belo Horizonte, MG, Brazil, E-mail: [email protected] Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, D.C.: American Psychiatric Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Association. Blank R, Smits-Engelsman B, Polatajko H, Wilson P. (2012). European academy for childhood disability (EACD): Recommendations on the definition, diagnosis and intervention of developmental coordination disorder (long version). Developmental Medicine & Child Neurology 54:54–93. doi: 10.1111/j.1469-8749.2011.04171.x
Copyright of Physical & Occupational Therapy in Pediatrics is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
