545
British Journal of Educational Psychology (2003), 73, 545–561
2003 The British Psychological Society
www.bps.org.uk
Intervention in children with Developmental
Coordination Disorder: The role of parents and
teachers
David A. Sugden* and Mary E. Chambers
School of Education, University of Leeds, UK
Background. Children with Developmental Coordination Disorder (DCD) are a
heterogeneous group who have a marked impairment in the performance of functional
skills. Provision for these children is usually made via a paediatrician through
occupational or physiotherapy though, with a prevalence rate of 5%, regular provision
is not possible due to limited professional resources.
Aims. The study aimed to determine the extent to which parents and teachers, with
guidance, can assist in the management of children with DCD; whether children with
DCD are helped in this way and how this may contribute to our understanding of the
condition.
Sample. Thirty-one children with DCD aged 7 to 9 years participated in the study.
Methods. Following assessment, individual profiles were developed and each week
teachers and parents were given guidelines for working with the children and each child
had three to four sessions a week lasting approximately for 20 minutes. In Phase 1, one
group of children worked with teachers and the other group worked with parents. In
Phase 2, the two groups of children swapped over. The children were assessed
regularly throughout the project using the Movement ABC, together with diaries and
comments from teachers and parents.
Results. At the end of the 40-week study, 27 children showed significant
improvement in their motor skills.
Conclusions. Both teachers and parents were able to provide effective intervention
for the majority of the children. It is possible that the children who did not improve
have difficulties that are of a more complex type which require more specialist therapy
to meet their need.
* Requests for reprints should be addressed to Professor David A. Sugden, School of Education, University of Leeds, Leeds LS2
9JT, UK (e-mail: [email protected]).
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David A. Sugden and Mary E. Chambers
Children with Developmental Coordination Disorder (DCD) are a heterogeneous group
who have a marked impairment in the performance of functional motor skills. DCD is
the most recent and preferred term describing a group of children who, over the years,
have been variously referred to as clumsy, maladroit, awkward, dyspraxic, showing
coordination difficulties, movement skill difficulties and perceptual motor difficulties.
The essential features of the disorder include a significant impairment in the
development of coordination; the impairment significantly interferes with academic
achievement or activities of daily living; and difficulties are not due to a general medical
condition such as mental retardation or cerebral palsy (American Psychiatric
Association, DSM-IV, 1994). Underlying deficits have been shown to involve perceptual
factors (Hulme, Biggerstaff, Moran, & McKinlay, 1982; Hulme, Smart, & Moran, 1982;
Hulme, Smart, Moran, & McKinlay, 1984; Laszlo & Bairstow, 1985; Laszlo, Bairstow, &
Bartrip, 1988; Lord & Hulme, 1987a, 1987b, 1988), speed of decision making (Rösblad
& von Hofsten, 1994; Smyth & Glencross, 1986; van Dellen & Geuze, 1990; van der
Meulen, Denier van der Gon, Geilen, Gooskens, & Willemse, 1991), and feedback and
motor programming differences (Lord & Hulme, 1988; Smyth & Glencross, 1986).
Prevalence rate has been estimated to be around 6% (APA, DSM-IV, 1994; WHO, ICD-10,
1992) for children of 5–11 years of age though a recent, more conservative, estimate is
somewhere around 4.5–5% (Wright & Sugden, 1996a). In most studies the prevalence
of boys is reported to be higher than that of girls, with a boy-girl ratio of at least 2:1
(Wright & Sugden, 1996a).
A common feature of children with DCD is difficulty in those motor skills necessary
for progress in the formal and informal learning environment of school. The impaired
ability to control functional movements often continues throughout the school years
with evidence to show that, without intervention, these difficulties persist into later life
(Cantell, Smyth, & Ahonen, 1994; Geuze & Börger, 1993; Gillberg, Gillberg, & Groth,
1989; Losse et al., 1991) and that the earlier treatment can begin, the better the
outcome (Cantell et al., 1994; Schoemaker, Hijlkema, & Kalverboer, 1994). Despite the
increase in the number of investigations into DCD, there are still problems to be solved
surrounding the classification of specific coordination disorders including terminology,
diagnostic criteria, associated features and overlap with other disorders (Barnett,
Kooistra, & Henderson, 1998). More problems exist when one examines the
management of the disorder as intervention studies have not figured as prominently
as those in the areas of identification, assessment, characteristics and associated
symptoms. The primary objective of all methods of intervention for children with DCD
is to improve their motor skills and their ability to function in everyday life. However,
individuals concerned with intervention approaches have approached this objective in
different ways. Intervention approaches vary but can generally be grouped into two
broad categories of process and task orientated approaches (Sugden & Chambers, 1998;
Sugden & Wright, 1998). In addition to these approaches, there are also other
approaches such as those used by physio and occupational therapists in clinical settings
which, though occasionally following one particular approach, very often are eclectic
in nature and incorporate features of both process and task approaches.
The process-orientated approach is aimed at pinpointing the underlying process or
processes which the child has not developed adequately for his or her age and which
are thought necessary for the successful performance and acquisition of motor skills. An
example of such processes includes sensory functions, memory, attention, planning
and the formulation of motor programmes (Laszlo & Bairstow, 1985; Laszlo et al.,
1988). Laszlo and colleagues (1985, 1988) have produced strong evidence for the
Intervention and developmental coordination disorder
547
process approach, particularly kinaesthesis, but their findings have not always been
supported by other research groups (Doyle, Elliott, & Conolly, 1986; Polatajko et al.,
1995; Sugden & Wann, 1987). Support for the method has been reported by Sims,
Henderson, Hulme, and Morton (1996) and Sims, Henderson, Morton, and Hulme
(1996) who found an improvement in children due to kinaesthetic methods, but they
were no more impressive than other methods of intervention. Sugden and Wright
(1998) noted that these studies are encouraging in that they demonstrate that using a
process-orientated approach often results in improved function in children. On the
other hand, many studies did not demonstrate improved function over and above the
results gained from other methods of intervention.
The second approach, a task-orientated approach, involves a concentration on the
tasks or group of tasks without an emphasis on underlying processes but, rather, using a
variety of practices in order that skill generalisation is promoted (Schmidt, 1975). As
such, the intervention strategy focuses on the tasks that are causing the child difficulties
(Henderson & Sugden, 1992; Revie & Larkin, 1993; Wright & Sugden, 1998). The term
‘task-orientated’ covers a multitude of approaches united by their emphasis on teaching
the skills that are absent or deficient. For example, Wright and Sugden (1997) in
Singapore developed an intervention based upon a cognitive-motor approach using a
task-orientated programme (Henderson & Sugden, 1992). In this study, the children’s
teacher, with assistance from a researcher, helped the children with their specific
difficulties during the normal lesson time. Wright and Sugden (1997, 1998) report
significant differences between pre- and post-test assessments for all children, with
anecdotal evidence from teachers available as confirmation.
It is generally accepted that in clinical practice physiotherapists and occupational
therapists use a variety of programmes to treat children with DCD and, as such, they
bring with them a variety of backgrounds and theoretical assumptions which inevitably
inform the choice of programme (Schoemaker et al., 1994). Although occasionally
therapists follow one particular approach they very often adopt an eclectic approach
combining elements of several treatment programmes in one. Using the sensorimotor
approach, Schoemaker and colleagues (1994) evaluated the effects of physiotherapy
finding immediate and medium terms gains in the children. The overall conclusion is
that there is strong support for the effectiveness of these approaches, but the reasons
for success are unclear.
Much of the research work on intervention approaches has shown various methods
to be successful. It is not surprising that specialist input such as physiotherapy works in
the majority of cases as this is expert input from skilled professionals. However, it is
clear that with an incidence figure of around 5%, exploring means of support other than
through specialists has become a priority. When non-specialists have been used, the
studies, which are very few in number, have been incomplete. Parents have been
involved in the education of their children in other areas such as reading, and have also
been involved with children with DCD but, to date, there are no controlled evaluative
studies.
This study examines the contribution of teachers and parents to the intervention
process for children with DCD. The main aims of the study were to determine the
extent to which teachers and parents were able to provide effective intervention for
children with DCD and whether children with DCD can be helped in this way. In
addition, because of the known heterogeneity of the condition it is expected that for
some children this approach will be insufficient, and an examination of such children
may contribute to our understanding of the condition.
548
David A. Sugden and Mary E. Chambers
Method
Assessment instrument
Children were assessed on both Movement Assessment Battery for Children (Movement
ABC) components which comprises a normative-referenced test and a criterionreferenced checklist (Henderson & Sugden, 1992). The Test provides norms for
children aged 4 to 12 years in four age related item sets. Each age band consists of 8
items measuring manual dexterity (3), ball skills (2) and balance (3). Children can score
between 0 and 5 on each item, so that the total score will range from 0 to 40 with
increased impairment associated with the higher scores. The Checklist is a screening
instrument as well as a means for planning intervention. The motor part of the checklist
is divided into 4 sections (12 items in each section) and represents the interaction
between the child and the environment. Scores for each item are marked on an ordinal
scale 0 to 3 and a total score is calculated with higher scores indicating impairment.
Participants
Thirty-one children (22 boys and 9 girls) aged from 7 to 9 years took part in the project.
The mean age of the children at the date of first testing was 8.04 years, the range was
7.01 years to 9.06 years and the standard deviation was 0.7 years. The children were
selected for the project through a staged process. As this research was funded by a
medical/health based charity, it was considered and approved by the NHS Local
Research Ethics Committee. After permission had been obtained from the local
education authorities, initial contact was made with schools to discuss the project with
headteachers, special educational needs coordinators (SENCOs) and class teachers.
Parental permission was obtained for all children prior to participation which was
voluntary on the part of the children. The class teachers and SENCOs identified children
in the age range with movement difficulties and these children were tested on the
Movement ABC (Henderson & Sugden, 1992), resulting in a total of 31 children. All the
children identified by the class teachers had movement difficulties that interfered with
academic achievement and/or activities of daily living and no child had a generic
learning difficulty or a medical condition such as cerebral palsy. On the Movement ABC
Test the children had an overall mean score of 17.5, with a range from 10 to 31.5 (Boys
– mean 17.20, range 10 to 25.5; Girls – mean 17.72, range 11 to 31.5). On this test,
scores increase with severity of difficulty and a score of 10 and above is within the
lowest 15% of the population, and a score of above 13 is at the 5th percentile. Eight of
the children scored between 10 and 13 with 23 children at 13.5 or above. For a child
with a score below the 5th percentile, intervention is recommended while borderline
children who score from the 5th to the 15th percentile, close monitoring is
recommended (Henderson & Sugden, 1992). Normally, we would look to intervene
with only those at the 5th percentile or below, in this case 23 children. However, eight
children identified by teachers scored within the borderline and, as teachers were
looking for help for them and had the support of parents, it was decided that it would
be unethical not to include them in the project. In addition to the test, the Movement
ABC Checklist was also administered and filled in by the teachers. The children had an
overall mean score on the checklist of 60.32, with the scores ranging from 7 to 83, again
high scores indicating increased severity of difficulty. All but three of the scores fell
below the 15th percentile for the appropriate age groups.
Intervention and developmental coordination disorder
549
Procedures
After the initial assessment sessions at which the children were identified, they were
left alone for 7 weeks with no intervention and then assessed again. Following this
second assessment, the children were randomly assigned to two groups, one working
with their teachers and one working with their parents. At the end of the 7-week period
the children were assessed again and the groups switched over; that is the children who
worked with the teachers now worked with their parents and vice versa. This work
with the children lasted a further 7 weeks. At the end of this period the children were
assessed again. A final assessment took place after a period of 7 weeks with no
intervention. The design involving periods of no intervention and intervention was
employed to isolate the effects of the parent and teacher intervention against possible
developmental/maturational effects and to examine the relative permanence of any
changes following intervention. All assessments were conducted using the Movement
ABC. Overall, the children were involved in the project for 40 weeks, 14 of which
involved intervention by parents and teachers, 14 weeks with no intervention and
approximately 12 weeks of assessment. Table 1 illustrates the schedule of events of
assessments and intervention periods.
Table 1. Sequence of events over the 40 week project period
Assessment of total Group
7 weeks No Intervention
Assessment of total Group
Group 1 Teacher Intervention 7 weeks Group 2 Parent Intervention
Assessment of total Group
Group 1 Parent Intervention 7 weeks Group 2 Teacher Intervention
Assessment of total Group
7 weeks No intervention
Assessment of total Group
Profiles and programmes
Following the first assessment, individual profiles were developed for each child. This
involved examining both the Movement ABC Test and Checklist results; the former is a
standardised test with normative data on children from 4 through to 12 years of age; the
latter is a criterion-referenced assessment instrument with a list of 48 functional tasks,
most of which can be observed in a child’s daily routine. From these, a profile detailing
both strengths and weaknesses was developed for each child. Teachers and parents
were asked to identify strengths and weaknesses for each child and assisted in
identifying priority areas for intervention. Priority areas are those in which both
teachers and parents felt the child needed most help and those skills which were felt to
be of most importance. Every week the teachers and parents were given guidelines for
working with the children; these guidelines were developed from the assessment
profiles and priorities of each child and prepared by the Project Team for each
individual child. The guidelines contained the abilities to work on, the activities to
550
David A. Sugden and Mary E. Chambers
include and suggestions for the manner of teaching. Most of the principles underlying
the guidelines came from ‘the cognitive-motor approach to intervention’ as outlined by
Henderson and Sugden (1992) and was best described as an eclectic approach to
intervention for children with coordination difficulties. It drew upon different bodies of
academic and clinical literature and translated them into practical guidelines. Since that
time, the approach has evolved taking into account more recent clinical practice and
academic input, yet it remains an eclectic approach and continues to evolve. The basic
components of the approach build upon the idea that the cognitive, affective, and
motor competencies of the child interact in a dynamic manner with the environment in
which action takes place, and the manner in which the activities are presented. The
emphasis is on children performing functional tasks in settings which are as near as
possible to everyday life; the approach is therefore task not process oriented. The
approach conceptualises the acquisition of movement competence as a problemsolving exercise involving action planning, action execution, and action evaluation.
These are not discrete and separate entities but interact dynamically with one another
according to the environmental circumstances and manner of presentation. The role of
the professional, parent/teacher is to choose the relevant skill and locate it in an
appropriate setting. The task should be of optimal difficulty – hard enough to challenge
the child, but not so hard that success seems a distant unobtainable objective. Tasks are
chosen that form a group requiring similar abilities for their successful completion;
these tasks make up a ‘class of events’ or a ‘schema’, tasks which are different but
within a group of similar qualities. For example, manipulation skills where objects are
moved within the fingers – puzzle manipulation, peg turning, bead threading, coin
juggling within the fingers may form one group whereas reaching and grasping and
placing objects in different locations may form another group. The overlapping classes
of events or schema are determined from detailed assessments such as provided by the
two instruments in the Movement ABC.
The principles and guidelines are used by the researchers following assessment of
the child; a profile of the child is prepared, priorities identified which are then
translated into weekly practices parents and teachers can use. An example of a weekly
practice sheet is shown in Table 2.
Parent and teacher information
At all stages during the project, there was regular contact with teachers and parents.
This took a number of forms. First, every week the guidelines were distributed and any
queries answered. Secondly, informal contact was made to ensure that progress was
satisfactory and to respond to comments and questions. Teachers and parents were
encouraged to contact us if there were any problems, if they had any difficulties with
the activities or if they felt other activities and methods would be more appropriate for
the child. Regular contact was maintained with parents and teachers throughout the
intervention phases – this was to ensure that any problems which were encountered by
the children could be addressed in advance of the following week’s guidelines and, if
necessary, alternative activities incorporated into the guidelines at the earliest
opportunity. Midway through the intervention periods, a short questionnaire was sent
to teachers and parents asking for feedback concerning the amount of time spent on
the activities each week, the appropriateness of the activities for each child and
whether the activities were beneficial to the child. Parents were also asked to keep a
record of when and for how long they worked with their child at home to gain a record
Intervention and developmental coordination disorder
551
Table 2. An example of a weekly guideline sheet
GUIDELINES FOR INTERVENTION
WEEK 1
NAME OF CHILD
CLASS
SCHOOL
DATE
DIFFICULTIES SEEN
^
Fine motor skills
^
Handwriting – formation of letters, poor posture when writing
^
Passive and nervous and low self esteem. Disorganised
ACTION TO TAKE
^
Remind child’s name to sit up straight and move chair closer to the desk
^
Needs to use a pincer grip on her pen/pencil – use a pencil grip if needed
^
Needs to become more involved in activities, have a greater response
SPECIFIC ACTIVITIES
^
Constantly check on posture and pen grip and ensure child’s name is sat correctly at the desk and
her head is not too close to the desk. Encourage her not to turn the paper/book around as she
writes.
^
Directly involve her in question and answer sessions, and respond positively to any small
successes she may have – make her feel good about her progress.
^
Help her to be more organised through checking that she knows what to do before beginning an
activity – get her to repeat instructions back to you (start with 1 or 2 and gradually increase).
Partner her with a calm, patient child who can repeat instructions to her too.
of how convenient it was to work through the programme at home. The guidelines
were not a rigid structure but allowed both parents and teachers to work flexibly within
certain parameters.
Results and analysis
Children with DCD are not a homogeneous group, and researchers have often
described the subgroups found to exist in various studies (Dewey & Kaplan, 1994;
Hoare, 1994; Wright & Sugden, 1996b). However, although homogeneity is not a
feature, agreed common subgroupings have not been found. For these reasons, the
analysis is presented in two sections. First, group data for the 31 children are examined,
followed by an analysis of individual profiles over the 40-week period.
Group data
The group scores on the Movement ABC Test over the five testing sessions are shown in
Table 3. The children are listed in order of amount of change – those making most
552
David A. Sugden and Mary E. Chambers
improvement are listed first. The amount of improvement made is determined by the
scores between Test 2 and Test 4. Children 29 to 31 have incomplete data sets.
Table 3. Profiles of the children participating in the project
ASSESSMENT
Child
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Age
8.10
9.02
9.00
7.11
9.03
7.04
7.05
7.03
8.10
9.06
7.01
9.00
9.03
7.07
7.05
9.06
7.11
8.08
7.05
8.11
8.04
7.09
7.03
8.05
8.06
8.06
8.05
8.08
6.08
8.07
8.06
M/F
M
M
M
F
M
M
M
F
M
F
F
M
F
M
M
M
F
F
F
M
M
M
M
M
F
M
M
M
M
M
M
INTERVENTION
ABC Test Scores
3
4
1
2
14
20
25.5
11
19.5
18.5
24.5
16
25.5
23.5
31.5
17.5
17
12.5
14.5
25
15.5
18.5
13
12.5
10
15.5
19.5
12.5
13.5
14.5
15
10
10.5
19
225
29
23.5
27.5
17
17
17
23
16.5
26.5
20
37
23
16
13.5
13.5
17
12
17
12
21
10
17.5
17.5
10
15.5
15.5
16.5
10.5
24
21
20
15.5
17.5
21
16.5
12
9.5
18
10
19
12.5
31
15
5
12.5
10.5
15
11.5
11.5
7
17
6.5
14
16.5
8.5
16.5
12
13
11.5
14.5
8.5
12.5
11
7
13.5
3.5
4.5
4.5
10.5
4.5
14.5
8
25.5
11.5
6.5
4
2.5
8
5
10
5
14.5
4
11.5
13
6
13
15
16.5
11.5
–
–
–
5
6.5
9.5
14
2
6
3
12
8.5
9
3.5
25
8.5
8.5
5
2
7
4.5
12.5
4
6
7.5
8
10.5
5.5
15.5
16
12
6
–
–
12
Times per week
School
Home
3
1–2
2
2
2
1–2
1–2
3–4
5
2–3
2–3
3–4
2–3
1–2
3–4
4–5
4
4–5
2–3
3
3
3
2–3
1–2
1–2
3
1–2
3
2–3
3
3–4
3–4
3–4
3
3–4
3
4–5
6–7
6
4–5
3–4
3–4
2–3
3
2
2–3
5
2–3
3–4
2–3
3
5
3–4
5
2
3–4
7
3
4–5
–
–
–
From this table a number of general descriptors can be pulled out. First, if a score of
13 (5th percentile) is taken as an indicator of motor impairment, at Test 1 there were 23
in this category, and by Test 5 there were only four. In addition, all those scoring
between 10 and 13 (n = 8) on Test 1, scored a maximum of 7.5 by Test 5. Recognising
that growth and development may have occurred and influenced some scores,
progression between Tests 1 and 2 and Tests 4 and 5, when there was no intervention,
was examined using the same cut-off criteria. By Test 2 the 23 who scored above 13
increased to 26 with one child moving out of this category and four moving in. By Test
4, when the two intervention sessions had been completed, six children remained in
the plus 13.5 group and by Test 5 this had reduced to four. Using a broad brush
Intervention and developmental coordination disorder
553
categorical analysis, it suggests that no improvement has taken place between Tests 1
and 2 but improvement has taken place between Tests 2 and 4 during the intervention
phase, and that this improvement was maintained to Test 5 during a period of no
intervention.
All statistical analyses were computed using the statistical software SPSS Version 9
(SPSS, 1999). An analysis of the raw interval data, a 2 (group) by 5 (test) ANOVA with
repeated measures on the last factor was performed. A significant difference between
mean test scores was found, F (1, 2539) = 237.00, p < .0001, indicating that as a result
of treatment the children made significant gains in their motor performance. The
analysis confirmed that there was a significant difference between the mean scores of
Test 1 (17.35) and Test 3 (13.60) (p < .05), Test 1 (17.35) and Test 4 (9.42) (p < .01)
and Test 1 (17.35) and Test 5 (8.62) (p < .01), Test 2 (18.59) and Test 3 (13.60)
(p < .05), Test 2 (18.59) and Test 4 (9.42) (p < .01) and Test 2 (18.59) and Test 5 (8.62)
(p < .01) and also between Test 3 (13.60) and Test 4 (9.42) (p < .01) and Test 3 (13.60)
and Test 5 (8.62) (p < 0.01) indicating that where intervention programmes had been
employed (between Test 2 and Test 4) the children improved their motor performance,
and this improvement was maintained following a period of rest. There was no
significant difference between the mean scores for Test 1 and Test 2 and Test 4 and
Test 5, indicating that where there was no intervention no improvement took place.
A graphic picture of the group results is shown in Figure 1. This figure shows a slight
detriment in performance between Tests 1 and 2 followed by a dramatic improvement
from Test 2 to 4 and then a levelling off to Test 5.
Figure 1. Mean scores on the Movement ABC Test for the whole group
The analysis was also performed to establish if there were any differences in the
mean scores between the teacher intervention phase and the parent intervention
phase. The repeated measures ANOVA indicated that there was an interaction effect for
554
David A. Sugden and Mary E. Chambers
treatment. The group which received teacher intervention scored significantly better
than the group which received parent intervention at Test 3 (Teacher group mean
score = 11.87, Parent group mean score = 15.43, F (1, 140.25) = 6.69, p < .05). There
were no significant differences between the children who received teacher intervention and the children who received parent intervention at Test 4 and Test 5. These
results are shown graphically in Figure 2. Additionally, no significant differences in
mean scores were found between the boys and girls in any of the tests.
Figure 2. Differences in mean total scores between the two intervention groups
A chi square statistical analysis was performed on the data to establish whether there
was a difference between the numbers of children scoring above the 5th percentile
(13.5 and above). Significant differences were found between Test 1 (8 children) and
Test 4 (22 children) (À2 = 6.56, p < .01), Test 1 (8 children) and Test 5 (25 children)
(À2 = 8.77, p < .01), Test 2 (5 children) and Test 3 (17 children) (À2 = 6.59, p < .01),
Test 2 (5 children) and Test 4 (22 children) (À2 = 10.74, p < .01) and Test 2 (5
children) and Test 5 (25 children) (À2 = 13.36, p < .001). These results confirm that
improvement took place between Test 2 and Test 4, during the intervention phases,
and that this improvement was carried over from Test 4 to Test 5, when there was no
intervention.
Parent, teacher and child data
Data were collected from teachers and parents in a number of ways – a short
questionnaire sent midway through the two phases of intervention, interviews with
teachers, parents and children during the final stages of the project, a record kept by
parents during the intervention phases, and by informal contact during the project.
Teachers and parents were asked if they thought that there had been any improvement
in the motor skills of their child. The opinions of the teachers and parents corresponded
Intervention and developmental coordination disorder
555
well with the test results. A number of teachers and parents commented that the
children had increased their confidence and self-esteem which, in turn, had improved
their motivation and ultimately their motor skills. The children were also asked if they
thought they had improved – most children said that they thought they had done so,
but four thought they had not improved in any skill. Overall, teachers and parents
commented that the activities were enjoyable for the children to do. Only one teacher
and one parent said that their child did not find the activities enjoyable – the teacher
reported the child would rather be doing the same activities as the rest of the class,
while the parent commented that the child would prefer to be playing with friends.
When the children were asked if they had enjoyed the activities, all but one of them
replied that they had.
One of the questions which teachers and parents were asked concerned the
convenience of incorporating the activities into the normal routine of each day. Of the
replies received, the majority of teachers and parents commented that the activities for
the children were difficult to fit into the normal routine of the day; teachers felt that the
demands on their time were such that any activities over and above the normal routine
were not easily dealt with. Parents also felt that it was not easy to incorporate the
activities into their days – the most often quoted reason being that the children were
tired after a day at school and not easily persuaded to participate in the activities.
Despite these comments, both teachers and parents managed to fit in a number of
sessions a week – these ranged from once a week to five times a week at school and
from once a week to seven times a week at home. Some teachers commented that the
only way that they could incorporate the activities into the routine was to withdraw a
child from a lesson for a short time or work on the activities at break times. Three
children had teaching assistants who spent some time each day working with them.
Many parents reported that other family members became involved with helping the
children – younger and older siblings often became involved in the activity sessions
which, parents reported, was a very enjoyable activity for all involved. In addition, both
teachers and parents commented that activities such as monitoring posture while
sitting at a desk or table, correct grips for writing instruments and cutlery were ongoing
activities which were done routinely at school or home.
A high percentage of records kept by parents were returned at the end of the
intervention phases. These records indicated when and for how long the parents had
worked with their child. Of the records which were returned, detailed information had
been kept of activities that had been practised and the length of time the children had
spent on the activities each day. The amount of time given to the activities ranged from
5 minutes to 40 minutes and, similarly, the number of days that the activities were
practised ranged from twice a week to every day. Some of the parents had adapted
some of the activities to fit in with their routines and life styles, and when they had
done so, this was indicated in the record.
Individual data
Individual profiles provide evidence of the variable effects of the intervention
programme. Table 3 gives details of each child involved in the project; for each child,
there are details of age and gender and the scores for the five assessments with the
Movement ABC Test. The final two columns note the number of times per week that
each child received intervention at school and at home – this information was gathered
from records kept by teachers and parents.
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David A. Sugden and Mary E. Chambers
While examining individual profiles of the children, differential responses to
intervention were evident. As is clear from the statistical analysis, most children
improved significantly during the intervention periods and this was maintained over the
final non-intervention period. Records from parents and teachers enabled detailed case
study records of all children to be developed. In addition, most parents and teachers
closely followed the intervention procedures. Extracts from two are presented below.
Child 8
This child typified a large number whose parents precisely followed the intervention
process and who both improved and maintained this improvement.
Movement problems observed by the teacher included general clumsiness, poor
coordination and poor PE skills. The class teacher also noted that this child was
disorganised. Other areas affected included the child’s social skills and handwriting. In
addition, the child’s movement problems were made worse when speed was involved
and also if she was put under pressure. Her strengths included having lots of ideas in
class, expressing herself well and achieving a good standard in reading and drama.
Priority areas for intervention were identified as increasing confidence in PE (hopping,
skipping and ball skills), handwriting and presentation skills.
The initial assessment on the Movement ABC Test placed her below the 5th
percentile. After the first phase of intervention (i.e., no intervention), she remained
below the 5th percentile. During the school phase of intervention, she received
between three and four sessions a week and improved her score by 6.5 points, which
placed her at the 15th percentile. She received six sessions of intervention a week
during the home phase of intervention and continued to improve, this time by 5.5
points. Her total improvement of 12 points placed her well above the 15th percentile.
After the final phase of 7 weeks of no intervention, her score had increased slightly
(poorer performance) but remained above the 15th percentile. These test results are
shown graphically in Figure 3.
Figure 3. Movement ABC Test scores for Child 8
Intervention and developmental coordination disorder
557
Both her class teacher and her parents commented on the general overall
improvement that Child 8 displayed, and also her increased confidence; there was a
general improvement in schoolwork as well as specific skills targeted as priority areas.
The class teacher commented that it had been fairly easy to incorporate the activities
into the normal routine of the day, but PE skills had been slightly more difficult. The
parents noted that it was easier to do the activities at weekends, though they did
manage to work on one activity most days during the week. Both the class teacher and
the parents commented that Child 8 had worked hard at all the activities and appeared
to enjoy doing them. Child 8 noted that she had enjoyed working on the activities, but
did not think that she had improved much.
Child 26
This child was one of a very small number who did not improve despite parents and
teachers closely following the intervention procedure.
The major movement problems observed by the teacher were organisation skills and
the great slowness with which Child 26 completed tasks. The class teacher also noted
that he was passive, timid, tense and disorganised. Other areas affected included
frequent failure to complete work and poor presentation of work. In addition, Child 26
was unable to join in playground activities – he merely stood and watched the other
children, preferring to be on the periphery of any activity which was occurring. His
strengths included being always willing to attempt activities in class, despite the great
difficulty which he obviously experienced. Priority areas for intervention were
identified as fine motor skills, handwriting and presentation skills, organisational skills
and confidence.
The initial assessment on the Movement ABC Test placed him below the 5th
percentile. After the first phase of intervention (i.e., no intervention), he remained
below the 5th percentile. During the school phase of intervention, he received three
sessions a week and improved his score by 3.5 points and moved to between the 10th
and 15th percentile. He received intervention every day during the home phase of
intervention but failed to show any improvement; he regressed by 3 points which took
him within 0.5 points of where he initially started – below the 5th percentile. His total
improvement of 0.5 points was 1 point lower than the initial assessment and below the
5th percentile. Additionally, after the final phase of 7 weeks of no intervention, his
score had again regressed by 1 point. These results are shown graphically in Figure 4.
Both his class teacher and his parents commented on the slight improvement in
confidence that Child 26 displayed. However, other skills did not appear to have
improved and he remained very slow at completing activities and tasks. The class
teacher commented that it had been fairly easy to incorporate the activities into the
normal routine of the day and had, at times, included the whole class in some activities,
as they were good general skills for all the children. The parents noted that it had been
fairly convenient to do the activities every day and they had managed to do something
most days. The parents commented that Child 26 had worked hard at the activities and
appeared to enjoy doing them. Child 26 noted that he had enjoyed working on the
activities at home and thought that he had improved a little.
A small number of children received only a small amount of intervention and again
the response was varied with some showing improvements while others remained in
their initial condition.
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David A. Sugden and Mary E. Chambers
Figure 4. Movement ABC Test scores for Child 26
Summary and discussion
From the results it was confirmed that both teachers and parents were able to provide
effective intervention for children with DCD with the majority of the children
improving during the two periods of intervention and this improvement was
maintained over a 7-week period during which no intervention took place. More
specifically, out of the 23 children who were below the 5th percentile at the beginning
of the project, only four remained there by the end of the project. In addition, the
improvement shown all took place during the two periods of intervention and no gain
was evident during the periods of no intervention at the beginning and end of the
project. Of the eight children who scored between the 5th and the 15th percentile at
the beginning of the project, seven scored above the 15th percentile at the end of the
project (one left the project). These results support the proposal by Sugden and
Chambers (1998) that most interventions are effective with most children identified as
having DCD. There is good evidence to show that without intervention children with
DCD continue with their difficulties into later life (Cantell et al., 1994; Geuze & Börger,
1993; Gillberg et al., 1989; Losse et al., 1991). However, the question of how much and
what type of intervention is required has rarely been approached.
From the results it can be seen that for most of the children who received adequate
intervention (averaging 3 plus sessions a week) their motor skills performance
improved. However, there were a small number of children who, despite receiving an
adequate amount of intervention, displayed little or no improvement by the end of the
project period. It may be that these children have difficulties that are of a more complex
type and would require specialist therapy in order to meet their needs or they may need
a longer period of intervention. There was also a small group of children who, despite
receiving little intervention, made significant progress. They did receive some help,
usually up to twice a week, and this may have triggered a development that had been
delayed. In addition, the process of assessment plus any intervention may have
contributed to a general increase in such attributes as attention and motivation. It is also
Intervention and developmental coordination disorder
559
possible that individual children may show instability in this disorder, although we did
try to control for this by including periods of non-intervention. Finally, there was one
child who received little or no intervention and did not show any improvement.
It has been noted by various researchers that children with DCD do not form a
homogeneous group. Differences between children with and without DCD has long
been an investigating priority and more recently researchers have examined intra group
characteristics (Cantell et al., 1994; Dewey & Kaplan, 1994; Hoare, 1994; Larkin &
Hoare, 1992; Sugden & Sugden, 1991; Wright & Sugden, 1996b). These studies, while
not showing agreed stable subgroups, do show the children to have different profiles. It
is possible that, just as characteristics are showing differences across clusters of
children, differences are evident in the manner to which children respond to
intervention. Some children may require varying amounts of exposure to activities
with the amount being the influential factor, whereas with others, most notably the
ones who did not improve following intervention, a qualitatively different type of
approach may be required. A more radical explanation concerns the identification of
the children in the first instance. Like other studies, this investigation took the
assessment and identification of the children by the Movement ABC as being valid.
Although the Movement ABC is the most widely used assessment instrument for
identifying DCD, it may be that other methods used in tandem, such as a clinical
assessment by a skilled paediatric occupational therapist, would provide the optimal
solution. The disorder is complex and as yet there is no gold standard of assessment
instruments.
A question to be asked is whether efficacy of intervention within a given child should
be examined in order to make a statement about the initial diagnosis. In other specific
learning difficulties it has been argued that a child’s ability to profit from an intervention
programme should be a most important piece of information in making a diagnosis
(Vellutino, Scanlon, & Tanzman, 1998). The case made by the authors is that focusing
exclusively on psychometric-type characteristics does not provide definitive identifying
criteria and does not provide guidelines for remediation. Response to intervention may
be a useful addition to the diagnostic discussion. This will be monitored over the next
two years as the children in this study are being tracked on a continuous basis, with an
examination of their total educational progress, in addition to their motor
competencies. From this it is hoped to provide a more total picture of the children
from identification to management together with associated characteristics.
Acknowledgements
This research study was supported by Action Research. The authors wish to thank the head
teachers, class teachers, the children and their parents for their time and assistance which they
generously contributed to this study.
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Received 13 December, 2001; revised version received 21 November, 2002