European Academy for Childhood Disability (EACD): Recommendations on the definition, diagnosis and intervention of developmental coordination disorder (long version)

Abstract

Physical therapy enables children and adults to develop and optimize their mobility and movement-related functions. The purpose of the physiotherapy treatment is to achieve meaningful participation in areas of life as independently and unaided as possible and with high quality of life. Treatment priorities are based upon information from the child, parent, and school, as well as the professional knowledge of the therapist about motor learning, motor control, and constraints related to the disease and age. The hypothesis-oriented algorithm for clinicians II (HOAC II) is commonly used to guide clinicians when documenting patient care and incorporating evidence into practice.172 It helps to justify interventions for problems that require remediation and those that may occur in the future and that require prevention. Physical therapists are specialized in analysing motor development, movements, and specific activities as well as in determining relevant problems in cases of dysfunctions. Together with the social system of the client, goals will be arranged to cope with the problems. Physical therapists use different approaches depending on child, and family, goal and situation, for example process-oriented approaches like adapted neurodevelopmental therapy, sensory integration, strategic task-oriented approaches like CO-OP, or specific task-oriented interventions like neuromotor task training (NTT) and adaptation of environment. They use tests like M-ABC-2 or BOTMP in their assessments and parent/teacher questionnaires to evaluate the motor development and performance of the children and their needs. Counselling and coaching the parents and class teachers are important in physical therapy.

Full text

European Academy for Childhood Disability (EACD):
Recommendations on the definition, diagnosis and intervention of
developmental coordination disorder (long version)*
RA IN ER B LA NK
1
|BO U W IE N S M IT S - EN G EL S M AN
2
|H EL EN E P O LAT A J KO
3
|P ET ER W I LS O N
4
1Kinderzentrum Maulbronn and University of Heidelberg, Germany. 2Department of Biomedical Kinesiology, Katholic University Leuven, Leuven, Belgium and Avans University
for Professionals, Breda, the Netherlands. 3Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada. 4Discipline of Psychology,
School of Health Sciences, RMIT University, Melbourne, Australia.
O RG AN I Z AT I O N S AN D REP RES EN T AT I V ES
These recommendations were approved at two consensus conferences in Maulbronn (Germany) (26⁄27 March 2010 and 15⁄16
July 2010) with representatives from the the German and Swiss medical and therapeutic societies listed below and supervised
by the Association of the Scientific Medical Societies in Germany (AWMF, members comprising 154 specialty societies). The
AWMF represents Germany in the Council for International Organizations of Medical Sciences (for further information see
http://www.awmf.de).
The key recommendations of the clinical practice guideline on developmental coordination disorder (DCD) for Germany and
Switzerland are identical to the recommendations on DCD agreed upon by an expert panel initiated by the EACD. The recom-
mendations have been discussed with the European Academy of Childhood Disability (EACD). The EACD considers the pres-
ent Swiss–German guideline as recommendations for the definition, diagnosis, assessment, and intervention of DCD in other
countries.
The participants were as follows.
I nternational representatives
Rainer Blank (Chair of the Scientific Committee of the EACD)
Hans Forssberg (Chair of the EACD)
European panel of ex perts
The recommendations were approved by a European panel of experts at the EACD meeting in Brussels, 26 May 2010 and
through further Delphi rounds.
(in alphabetical order) J M Albaret (France), A Barnett (UK), R Geuze (the Netherlands), D Green (Israel⁄UK), M Hadders-
Algra (the Netherlands), S Henderson (UK), M L Kaiser (Switzerland), A Kirby (UK), R P Lingam (UK), H Polatajko (Canada),
M Schoemaker (the Netherlands), B Smits-Engelsman (the Netherlands), H van Waelvelde (Belgium), P Wilson (Australia) S
Zoia (Italy).
T EAM S , ADV I S O RY B O ARD, CO O RDI N AT I O N
Coordination of the specific sections of the clinical practice guideline
‘Underlying mechanisms’: P Wilson (Australia); ‘Consequences’, ‘Comorbidity’, ‘Definition and assessment’: R Blank (Ger-
many); ‘Treatment’: B Smits-Engelsman (the Netherlands)
W riting group
H Becker (Germany), R Blank (Germany), O Jenni (Switzerland), M Linder-Lucht (Germany), H Polatajko (Canada), F Steiner
(Switzerland), R Geuze (the Netherlands), B Smits-Engelsman (the Netherlands), P Wilson (Australia)
I nternational ex perts
The full guideline process was consistently advised by international experts in the field:
B Smits-Engelsman (Physiotherapist, the Netherlands); H Polatajko (Occupational therapist, Canada); P Wilson (Neuropsy-
chologist, Australia); R Geuze (Clinical physicist ⁄neuropsychologist, the Netherlands); The clinical practice guideline on DCD
for Germany and Switzerland has been approved by representatives of the following professional societies (not yet confirmed by
the boards of the associations).
*This long version of the recommendations is without country specific sections (implementation strategy and quality management). Terminology in this
document is consistent with that of the International Classification of Functioning (ICF).
5 4 DOI: 1 0 .1 1 1 1 / j .1 4 6 9 - 8 7 4 9 .2 0 1 1 .0 4 1 7 1 .x ªThe Authors. Developmental Medicine & Child Neurology ª2 0 1 1 Mac Keith Press
DEV EL O P M EN T AL M EDI CI N E & CH I L D N EU RO L O G Y EACD RECO M M EN DAT I O N S

M edical societies
Neuropaediatric Society for German-speaking countries (lead society); German Society of Child and Adolescent Medicine; Ger-
man Society of Social Paediatrics and Adolescent Medicine; German Society of Child Psychiatry and Psychotherapy; Swiss Soci-
ety for Developmental Paediatrics; Forum Praxispa
¨diatrie, Switzerland
T herapist societies
German Association of Occupational Therapists; Swiss Association of Occupational Therapists; Zentralverband Physiotherapie (Ger-
many); Physiotherapia Paediatrice, Schweizerische V ereinigung der Kinderphysiotherapeutinnen; Motopa
¨denverband (Germany)
P atient representatives
A Mundt (patient group representative from Selbsta
¨ndigkeits-Hilfe bei Teilleistungsschwa
¨chen eV [ SEHT eV ])
P rofessional representatives (G ermany, S w itz erland)
R Blank (Neuropaediatric Society for German-speaking countries)
S Akhbari-Ziegler (Physiotherapia Paediatrice, Schweizerische V ereinigung der Kinderphysiotherapeutinnen)
J Buchmann (German Society of Child Psychiatry and Psychotherapy)
A Jagusch-Espei (German Association of Occupational Therapists)
O Jenni (Swiss Society for Developmental Paediatrics, SGEP, Swiss Society of Paediatrics SGP)
M Linder-Lucht, V Mall (German Society of Child and Adolescent Medicine)
A Oberle (German Society of Social Paediatrics and Adolescent Medicine)
R Schmid (Resident Paediatricians’ Association of Germany)
J Seela
¨nder (German Association of Physiotherapists)
F Steiner (Forum Praxispa
¨diatrie, Switzerland)
H Trillen-Krayenbu
¨hl (Ergotherapieverband, Switzerland)
R Werthmann (Deutscher Motopaedenverband)
Coordinator of the Clinical P ractice G uideline and of the EACD Consensus
R Blank (Germany)
S ecretary
M Haag (Germany)
Contact for feedback and further development of the guideline:
M Haag; Prof Dr Med Rainer Blank, Kinderzentrum Maulbronn, Knittlinger Steige 21, D-7543 3 Maulbronn, Germany. E-mail:
info@ kize.de and haag@ kize.de
Duration of the validity
The clinical practice guideline was agreed on and written in March 2011. It is valid until the next revision, at the latest until
March 2016. A revision is planned about every 3 years by the representative group and the international advisory board. In case
of new knowledge or experience that have considerable infl uence on the recommendations of this clinical practice guideline, the
representative group and, if necessary, the international advisory board will rapidly produce the latest information.
E ACD Recommendations 5 5

N ames and roles of the guideline group and consensus panel
Steering group
National/German speaking countries:
Becker, Blank (GNP, coordination), Jenni (SGEP/SGP), Lehmkuhl/
Buchmann (DGKJPP), Linder-Lucht (DGKJ), Steiner (Forum
Praxispädiatrie, SGEP), Jagusch-Espei (DVE), Oberle (DGSPJ)
International advisory board:
Polatajko, Smits -Engelsman, Wilson, Geuze
C oordinator/secretary
M aulbronn (Blank/H aag)
T reatment/
M anagement
Writing groups
critical appraisal of literature
Smits-Engelsman, B.
Schoemaker, M .
Becker, H .
Polatajko, H .
A khbari, S.
Blank, R .
C onsensus-panel/conference
Germany/Sw itzerland: Germany: Gesellschaft f. Sozialpädiatrie und
Jugendmedizin (A . Oberle)
Deutsche Gesellschaft fü r Kinder- und Jugendmedizin (V. M all, M . Linder-Lucht),
Deutsche Gesellschaft fü r Kinder- und Jugendpsychiatrie und -psychotherapie
(G. Lehmkuhl, from 2 0 1 0 J. Buchmann)
Deutscher Verband der Ergotherapeuten (A . Espei-Jagusch)
Z entralverband der Physiotherapeuten (J. Seeländer),
M otopädenverband (A . Werthmann)
Sw itzerland: Praxisforum Pädiatrie (F. Steiner), Schw eizer Gesellschaft fü r
Pädiatrie/Entw icklungspädiatrie (O. Jenni), Ergotherapeutenverband Schw eiz (H .
T rillen), Physiotherapeutenverband Schw eiz (S. A kbari)
European panel: J.M . A lbaret (F), A . Barnett (GB), R . Geuze (NL),
D. Green (Israel/GB), M . H adders-A lgra (NL), S. H enderson (GB),
M .L. Kaiser (C H ), A . Kirby (GB), R . P. Lingam (GB), H . Polatajko (C A N),
M . Schoemaker (NL), B. Smits-Engelsman (NL), H . van Waelvelde (BE),
P. Wilson (A U S) S. Z oia (I) (in alphabetical order).
Description and
underlying
mechansims
Key q uestion 1 Key q uestion 3
Diagnosis/
A ssessment
Blank, R .
Smits-Engelsman, B.
Jenni, O.
Steiner, F.
Linder-Lucht, M .
Key q uestion 2
Wilson, P.
Blank, R .
R uddock, S.
Smits-Engelsman, B.
5 6 Developmental Medicine & Child Neurology 2 0 1 2 , 5 4 : 5 4 – 9 3

CO N T E N T S
List of abbreviations
1 Introduction
1.1 Organizational background
1.2 General goals of the CPG–DCD
1.3 Target audience
2 Target group, scope, parent expectations
2.1 Target group
2.2 Clinical relevance
2.3 Scope
2.4 Expectations of the patients’ representative
3 Key questions
4 Areas of interest and relevance of outcomes
4.1 Areas of interest
5 Evaluation of the literature: methodological basis
5.1 Recommendations based on evidence
5.2 Recommendations based on formal consensus
6 Epidemiology
7 Definition, description, consequences, outcome, underlying mechanisms of DCD
7.1 Definition
7.1.1 Definition according to ICD-10: specific developmental disorder of motor function (SDDMF) (F82.0 or F82.1)
7.1.2 Definition according to DSM IV
7.1.3 Other definitions
7.1.4 Recommendations on the definition of DCD
7.2 Description, underlying mechanisms, clinical findings, consequences, and prognosis
7.2.1 Clinical findings with respect to the level of body functions
7.2.2 Clinical findings with respect to the level of activities and participation
7.3 Consequences
7.4 Outcome
7.5 Burden for society
7.6 Comorbidities
7.6.1 Functional and socio-emotional problems in children with DCD (SDDMF)
7.6.2 Coexisting disorders
8 Screening, assessment
8.1 Explanatory frameworks for different assessment approaches
8.2 Questionnaires
8.2.1 Evidence-based analysis of DCD (SDDMF) screening questionnaires
8.3 Clinical assessment
8.3.1 History
8.3.2 Clinical examination
8.4 Assessment with standardized tests
8.4.1 Assessments on motor functions according to criterion I
8.5 Treatment indication and treatment planning
9 Treatment
9.1 Therapeutic approaches
9.1.1 Therapeutic approaches: occupational therapy, physiotherapy, and education
9.1.2 Supplements and medication
9.1.3 Search results for terms and labels of intervention
9.1.4 Theoretical background
9.1.5 Intervention process and orientation
9.1.6 Environmental factors
9.2 Recommendations and statements
9.2.1 General recommendations
9.2.2 Specific recommendations
9.2.3 Supplements and medication
9.2.4 Approaches on the level of activities and participation
9.2.5 The role of environmental factors
9.2.6 Personal factors
9.2.7 Recommendations concerning specific treatment methods
9.2.7.1 Interventions on handwriting
9.3 Cost effectiveness
9.4 Further research questions
10 Summary of the recommendations: flowcharts
10.1 Assessment, treatment indication, and planning
10.2 Treatment planning, intervention, evaluation
11 Quality indicators and quality management
12 Implementation strategy and implementation (country specific)
13 Appendix I
13.1 Strategy used to search for, select, and appraise the evidence
13.2 Evaluation of the search strategy
13.3 Scoping of the literature and evidence tables
13.4 Tables
References
E ACD Recommendations 5 7

1 I N T RO DU CT I O N
1. 1 O rganiz ational back ground
This clinical practice guideline on developmental coordination
disorder (CPG–DCD) for German-speaking countries, partic-
ularly Germany and Switzerland, is strongly in accordance
with the European recommendations of the European Acad-
emy of Childhood Disability (EACD) from May 2010 (Brus-
sels) and an international consensus, the International Leeds
Consensus (2006).
1
It was formed by a nominal group-consen-
sus process chaired by an independent representative from the
Association of the Scientific Medical Societies in Germany
(AWMF). The AWMF represents Germany in the Council
for International Organizations of Medical Sciences. The
CPG–DCD was initiated by the Neuropaediatric Society for
German-speaking countries. It funded the second and third
consensus conference in Germany. The first consensus confer-
ence was connected with an international symposium in Maul-
bronn, Germany and funded by the Child Centre Maulbronn.
The financial responsibilities were not undertaken by any
other party.
The development of the CPG–DCD took place between
spring 2008 and autumn 2010. The systematic review of the lit-
erature related to the key questions was first performed in
autumn 2008 and then updated in January 2010 (reviewing all
relevant literature from 19 9 5 to January 2010). The following
panels were involved in the development of the CPG–DCD: (1)
national experts in the field; (2) international experts and an
advisory board; (3 ) national representatives of professional
groups; (4) a patients’ representative from a parent organization.
Because of a lack of research and recognized experts on
DCD in German-speaking countries, it was considered neces-
sary to involve a board of international experts. As DCD is
variously defined in different countries, it was also necessary
to initiate an international consensus to confirm and ⁄or mod-
ify the Leeds Consensus.
The CPG–DCD contains the essential elements of system-
atic guideline development published by the AWMF. The
consensus was obtained in a formal nominative group process.
This was based, wherever possible, on an evidence-based liter-
ature search. The recommendations were made in relation to
expected costs and benefits, for example intervention methods
using more sessions with the same outcome received lower
recommendation levels than methods requiring fewer sessions.
The goals of assessment and interventions were carefully anal-
ysed with respect to the International Classification of Func-
tioning (ICF).
The methodological process was in accordance with a previ-
ous report on an S3 -guideline (an S3 -guideline is the highest
quality standard of evidence-based practice recommendations
approved by the AWMF).
2
The present document is the long version of the CPG–
DCD. Further documents are a short version (German), a ver-
sion for Parents and Teachers (English ⁄German) and a pocket
version (algorithm; English and German). As a large proportion
of the target group are children below the age of 8 years, the
intention to write a child version has not been implemented.
1. 2 G eneral goals of the CP G – DCD
The general goals of this guideline are the following: (1) to
determine and prioritize key questions on aetiology, diagnosis
and intervention; (2) to raise high-priority practice questions;
(3 ) to provide knowledge on the best evidence-based practice;
(4) to point out research gaps; (5) to define individual diagnostic
and intervention strategies based on clinical decision rules and
evidence-based knowledge; (6) to make recommendations for a
variety of different disciplines and to define their roles within
clinical practice; (7) to recognize an interdisciplinary approach
with physicians of different disciplines and therapists; (8 ) to
identify specific national aspects, for example concerning the
use of the International Classification of Diseases, 10th revision
(ICD-10) compared with the Diagnostic and Statistical Manual
of Mental Disorders, 4th edition (DSM-IV ); (9 ) to provide an
P U B L I CAT I O N DAT A
Accepted for publication 1 6 th September 2 0 1 1 .
AB B REV I AT I O N S
ADHD Attention- deficit– hyperactivity disorder
ADL Activities of daily living
ASD Autistic spectrum disorder
AW MF Association of the Scientific Medical Societies in
Germany
BOTMP( - 2 ) ⁄SF Bruininck s– Oseretsk y Test of Motor Proficiency
( 2 nd revision) ⁄short form
CO- OP Cognitive- orientation to occupational performance
CPG Clinical practice guideline
CSAPPA Childrens self- perceptions of adeq uacy in and pre-
dilection for physical activity
DCD Developmental coordination disorder
DCD- Q ( - R) DCD- Q uestionnaire ( - revised version)
DSM( - IV ) ( - TR) Diagnostic and Statistical Manual ( F ourth E dition)
( Tex t Revision)
E ACD E uropean Academy of Childhood Disability
GCP+ + or + Good clinical practice ( recommendation
based on strong consensus: + + , > 9 5 % of the par-
ticipants; + , 7 5 – 9 5 % or the participants of the
nominative group process)
GRADE Grading of Recommendations Assessment, Devel-
opment and E valuation
HAW IK ⁄W ISC( - IV ) Hamburg- W echsler Intelligence test for children
( W echsler Intelligence Scale for children ( IV th
revision)
HRQ OL Health- related q uality of life
ICD International Classification of Diseases
ICF International Classification of F unctioning
LOE Level of evidence
M- ABC( - 2 ) Movement Assessment Battery for Children ( - sec-
ond revision)
M- ABC- C Movement Assessment Battery for Children –
Check list
NTT Neuromotor task training
PMT Perceptual motor training ⁄therapy
SDDMF Specific developmental disorder of motor function
SIT Sensory integration ⁄sensory integration therapy
TAC Trouble de l' acq uisition de la coordination
Z NA Z uerich Neuromotor Assessment Battery
5 8 Developmental Medicine & Child Neurology 2 0 1 2 , 5 4 : 5 4 – 9 3

effective implementation strategy of the guideline by involving
all medical and paramedical organizations relevant in assess-
ment and treatment; (10) to identify possible barriers for imple-
mentation; (11) to provide a basis for clinical training and for
implementation in quality management systems.
In addition, specific goals of the CPG–DCD are the follow-
ing: to improve the identification of children with DCD; to
increase the use of effective treatments and reduce the use of
ineffective treatments; to decrease the burden of the disorder
and increase quality of life; to improve performance of every-
day activities and participation at home, school, and at leisure;
to improve personal and environmental resources; to improve
access to services, in particular healthcare services; to help
clarify responsibilities and propose models of cooperation
among the various relevant professionals, for example by
defining clinical pathways; to help prevent long-term conse-
quences of DCD, for example by timely, effective interven-
tion; to raise community awareness of DCD.
As with every CPG, the CPG–DCD is not a rule of what to
do or how to do in a legal sense. It cannot be a basis for legal
sanctions.
3 ,4
The CPG–DCD has been developed on the basis of the
methodological recommendations of the AWMF and the Ger-
man Instrument for Methological Guideline Appraisal.
1. 3 T arget audience
The clinical practice guideline may be used by healthcare pro-
fessionals involved in the care of children with confirmed or
suspected DCD (physicians, therapists), and by parents and
nursery nurses, teachers, or other educational professionals
(the adapted version).
To support the application of the CPG in practice, a short
version of the guideline, a table of all recommendations with
levels, a fl owchart with links to the recommendations, and a
version for parents, teachers, and nursery nurses will be
provided (available from: www.awmf.org/leitlinien/detail/ll/
022-017.html).
2 T ARG ET G RO U P , S CO P E, P ARE N T EX P ECT AT I O N S
2. 1 T arget group
The CPG–DCD should apply to children with long-standing,
non-progressive problems of specific motor skill performance,
not attributable to any other known medical or psychosocial
condition. Children may suffer from motor problems for which
the guideline does not apply such as cerebral palsy,
neurodegenerative disorders, traumatic brain injuries, infl am-
matory brain diseases, toxic and teratogenic disorders, malig-
nancies, any motor problem due to other diagnosed medical
conditions that may explain the poor motor performance. Chil-
dren with mental retardation are generally not identified as
having DCD because of assessment difficulties (pragmatic rea-
sons). These children, however, may also have symptoms of
poor motor coordination. Therefore, general recommenda-
tions for treatment indications and specific intervention meth-
ods may also be applied to the group of children with mental
retardation, though the research so far has excluded these chil-
dren from evaluation.
2. 2 Clinical relevance
DCD is a frequently occurring disorder with estimates of 5 to
6% being the most frequently quoted percentage in the litera-
ture.
5,6
It is a chronic disorder with considerable consequences
in daily life. At least 2% of all children with normal intelligence
suffer severe consequences in everyday living, and a further 3 %
have a degree of functional impairment in activities of daily liv-
ing or school work.
7
Nonetheless, DCD is largely underrecog-
nized by healthcare and educational professionals.
8 ,9
On the other hand, there are considerable costs for long-
term treatment, with questionable efficacy. According to the
‘Heilmittel-Report 2008 ’, the treatment of ‘sensorimotor dis-
orders’ ranked number one within occupational therapy inter-
ventions with 2.5 million therapy sessions (costing almost
€125 million) in 2006 reported by the AOK, the largest health
insurance company in Germany,
10
alone. About €400 million
are spent for sensorimotor therapy in occupational therapy.
10
This is almost 50% of all occupational therapy interventions
and over 9 0% of all occupational therapy sessions with chil-
dren and adolescents under 15 years.
2. 3 S cope
There are several questions and issues concerning DCD.
Major problems arise from the current lack of consensus on
the following: definition and terminology (how to define, best
name for the disorder); diagnosis and assessment (how to
assess for diagnosis, how to monitor during development and
treatment); epidemiology (how many diagnosed, undiagnosed
cases); outcome and prognosis (what consequences, in which
areas of everyday living and participation); underlying mecha-
nisms (developmental and ⁄or learning disorder, poor informa-
tion processing, etc.); comorbidities (what to treat, barriers to
treatment); treatment indication (when and what to treat);
intervention methods (which, how long, how intensive).
These questions were the reason for the development of this
CPG. The authors of the guideline hope to achieve improve-
ments in the definition (national and international), diagnosis,
and assessment of DCD as well as in the treatment indication
and specific intervention. Further, the CPG–DCD should help
to increase professional attention to this area which is, so far,
widely neglected in German-speaking countries. The research
on DCD is extremely underdeveloped in these countries: for
example, there have been almost no original papers in interna-
tional journals in the past 10 years coming out of Germany.
2. 4 Ex pectations of the patients' representative
To ensure that the guideline is responsive to the expectations of
the children and their parents, a parent organization for chil-
dren with learning disorders took part in the entire guideline
process (Annette Mundt, Parent support group: Selbstaendig-
keitshilfe bei Teilleistungsschwaechen). The following expecta-
tions were identified: (1) more awareness and recognition of the
problem by the community, healthcare professionals, nursery
nurses, and parents; (2)improved access to services, particularly
healthcare services; (3 ) establish a clear diagnosis (transparency
of diagnostic criteria, explaining the diagnosis, and initiating
the necessary examinations); (4) better information about thera-
E ACD Recommendations 5 9

peutic options and types of therapy for parents; (5) information
about effectiveness of intervention with respect to (a) improve-
ment of motor function, (b) improvement of performance in
daily activities, (c) improvement of participation, particularly at
school; (6) finally,parents expect information on how the guide-
line is implemented (knowledge translation).
3 K EY Q U ES T I O N S
The guideline group decided to focus on three basic key ques-
tions.
1. H ow is DCD defined? W hich functions are impaired in
children w ith DCD?
The definition of DCD was subject to expert consensus. For
communication between experts, health professionals, and par-
ents, it was regarded as important to develop a generally recog-
nized definition of DCD based on the ICD-10 (DSM-IV , Text
Revision [ -TR] in countries where it is the legal basis
11,12
).
The findings of impaired functions or underlying mecha-
nisms were extracted from a systematic literature search. The
impairment should refl ect the levels of the ICF such as body
function and structure (motor, sensory, cognitive function,
emotional⁄affective function), activities of daily living (basic
and instrumental), participation (home, school, and commu-
nity), and personal and environmental factors. The question
on impairment does not aim at specific clinical practice rec-
ommendations but to increase understanding of the disorder,
its severity, and its natural course.
2. H ow is DCD assessed and monitored? H ow should
children w ith DCD w ith and w ithout treatment (natural
course) be monitored (q ualitative⁄q uantitative aspects)?
Applicability and test criteria of assessment instruments were
subject to a systematic literature search and, where not possi-
ble, were addressed by experts’ opinions and a consensus con-
ference.
The question of how DCD can be identified should be
answered by examining the role of medical history and inter-
view, questionnaires, clinical examination, and motor tests.
Further, assessment instruments should be discussed with
respect to daily living, school ⁄leisure and the role of clinical
compared with natural settings.
The answer to how and when to measure progress should
refl ect levels of body function and structure (e.g. motor func-
tions, sensory, cognitive functions, emotional⁄affective func-
tions, language functions), and activities of daily living (e.g.
self-care, academic performance) and participation (at home,
school and community), acknowledging personal and environ-
mental factors.
3. H ow effective are the treatment methods for DCD?
The treatment efficacy should be answered by systematic eval-
uation of the literature and, where not possible, answered by a
nominative group process during a consensus conference.
As in the key question on assessment, the levels of the ICF
should be considered as body function and structure (motor,
sensory, cognitive function, emotional⁄affective function),
activities of daily living (basic and instrumental) and participa-
tion (home, school, and community), and personal and envi-
ronmental factors.
Effectiveness should also be discussed with respect to effi-
ciency (cost–benefit).
F urther q uestions of interest
Several further questions were of great interest but could only
be addressed to some extent in this guideline. Which interac-
tions do occur by treating comorbid conditions (e.g. pharmaco-
logical treatment with stimulants of children with attention-
deficit–hyperactivity disorder [ ADHD])? Are there barriers to
access healthcare services or treatment services for DCD (e.g.
parental education, language, cultural, geographic, socio-eco-
nomic status, health services policies)? What are the views and
opinions about DCD of parents, patients, and teachers?
4 AREAS O F I N T ERES T AN D REL EV AN CE O F
O U T C O M ES
4. 1 Areas of interest
Based on the key questions, the identified main areas of inter-
est for clinical recommendations are identification ⁄diagnosis,
treatment indication, and treatment outcome.
Using a democratic group process (blind voting) the guide-
line group decided on the relevance (priorization) of target vari-
ables with respect to the systematic literature search (1, very
important: critical for making a decision; 9 , not important at all
[ e.g. surrogate, no evidence for correlation with hard end-
point]). Relevant target variables are shown in Tables I and II.
5 EV AL U AT I O N O F T H E L I T E RAT U RE:
M ET H O DO L O G I CAL B AS I S
5 . 1 Recommendations based on evidence
Original papers addressing of key questions 2 (assessment) and
3 (treatment) were categorized according to the level of evi-
dence using the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) and Oxford systems.
In contrast to intervention studies, an established grading sys-
tem for the different types of diagnostic study does not exist.
Therefore, the GRADE system and the Oxford definition had
to be modified and adapted (see Table V II in Appendix I). In
some studies the level of evidence (LOE) had to be adjusted
according to specific criteria. The level of evidence was
decreased in cases of serious ()1) or very serious ()2) limita-
T able I : T a r g e t v a r i a b l e s f o r o u t c o m e
Body function
and structure
Motor performance, basic motor skills
Personal factors Quality of life (well-being, satisfaction), coping
Activities Activities of daily living, school performance,
activity limitation
Participation Social integration, social burden of disorder,
sports participation
Environmental
factors
Socio-economic resources (nursery ⁄school
facilities, financial resources, therapeutic
resources, availability of sports club, etc.),
coping ⁄compensation (by family, teachers,
adaptive materials, sport instruments, etc.)
6 0 Developmental Medicine & Child Neurology 2 0 1 2 , 5 4 : 5 4 – 9 3

tions to study quality, important inconsistency ()1), imprecise
or sparse data ()1), high probability of reporting bias ()1).
The level of evidence was increased in case of consistent evi-
dence from two or more observational studies with no proba-
ble confounders (+ 1), evidence of a dose response gradient
(+ 1), all probable confounders would have reduced the effect
(+ 1). The levels and strength of recommendations used is
directly related to the level of evidence (Tables III and IV ).
5 . 2 Recommendations based on formal consensus
Several recommendations are based on a formal consensus
within a nominative group process, particularly those dealing
with definition. Recommendations based on group consensus
(good clinical practice [ GCP]) are included in the guideline. A
strong agreement (strong consensus ‡9 5% ; if only 10 or fewer
participants were present, ‡9 0% agreement) is marked as
GCP+ + ; a moderate agreement (consensus ‡75–9 5% ; if only
10 or fewer participants were present, ‡9 0% agreement) is
marked as GCP+ .
6 EP I D EM I O L O G Y
Current prevalence estimates for DCD range from 5 to 20% ,
with 5 to 6% being the most frequently quoted percentage in
the literature.
13
It is generally recognized that these children
have problems with motor skills that are significant enough to
interfere with both social and academic functioning.
6
Kadesjo
et al.
6
found a prevalence rate of 4.9 % for severe DCD and of
8 .6% for moderate DCD in a population-based study of
7-year-old children in Sweden. The Avon Longitudinal Study
of Parents and Children study found 1.8 % of children aged
7 years had severe DCD, with another 3 % defined as having
probable DCD with consequences for everyday life.
7
We note
that epidemiological information is largely dependent on how
strictly selection criteria are applied.
DCD is more common in males than in females, with male:-
female ratios varying from 2:1 to 7:1.
6,7
Although DCD is rela-
tively common, it is still largely unrecognized by healthcare
professionals and nursery nurses.
8 ,9
Motor performance diffi-
culties of children with DCD are often viewed as ‘mild’ and,
thus, not warranting attention compared with the needs of
children with more severe impairments such as cerebral palsy.
7 DEF I N I T I O N , DES CR I P T I O N , CO N S EQ U EN CES ,
O U T C O M E, U N DERL Y I N G M ECH AN I S M S O F DCD
7 . 1 Definition
DCD occurs across cultures, races, and socio-economic condi-
tions. The disorder is idiopathic in nature, although several
hypotheses for the cause of DCD have been recently proposed
(see section 7.2). In the clinical practice and the scientific com-
munity, there are still many ambiguities in the definition and the
diagnosis of DCD. Evidence suggests that DCD is a unique and
separate neurodevelopmental disorder which can, and often
does, co-occur with one or more other neurodevelopmental and
neurobehavioural disorders. Commonly, these disorders
include ADHD, specific language impairment, specific learning
disabilities, autistic spectrum disorder (ASD) and developmen-
tal dyslexia or reading disability. Some of these comorbidities
are so strongly associated with DCD that DCD has even been
regarded as a part of these disorders (e.g. ASD and DCD is not
allowed according to DSM-IV classification; furthermore, the
concept of deficits in attention, motor control and percep-
tion
14,15
includes aspects of ADHD and DCD).
Because key question 1 relates to this topic, definitional
recommendations are made based on a nominative group
process.
7.1.1 Definition according to ICD-10: specific developmental
disorder of motor function (SDDMF) (F82.0 or F82.1)
According to the ICD-10 (revised version 2007), DCD, called
SDDMF, is defined as a ‘disorder in which the main feature is
a serious impairment in the development of motor coordina-
tion that is not solely explicable in terms of general intellectual
disability or of any specific congenital or acquired neurological
T able I I : Re l e v a n c e o f o u t c o m e s : a r e a s o f i n t e r e s t a n d t a r g e t v a r i a b l e s a s
r a t e d b y t h e g u i d e l i n e g r o u p
Diagnosis Treatment
indication
Treatment
outcome
Body function and structure 1
Deficit in motor performance
and psychomotor functions
Poor basic motor skills and
perceptual ⁄motor functions
Activities 1 1 1
Activities of daily living (self-
care, etc. [ basic activities of
daily living { ADL}
a
] , school
performance, instrumental
ADL
b
)
Participation 1 1
Social integration (e.g. sport
participation)
c
Personal factors 1
Coping (individual
resources, intelligence, etc.)
Quality of life, well-being,
satisfaction
Environmental factors 1
Socio-economic resources
(nursery⁄school facilities,
financial resources,
therapeutic resources,
availability of sports club, etc.)
Coping ⁄compensation (by
family, teachers, adaptive
materials, sport
instruments, etc.)
1, Very important: critical for making a decision.
a
Basic ADL (self-care,
toileting, eating ⁄drinking, etc.).
b
Instrumental ADL (using a pen,
scissors, playing with toys, etc.).
c
Possible participation restriction as a
consequence of activity limitations.
T able I I I : Le v e l s o f r e c o m m e n d a t i o n s
Level of
evidence Recommendation for ⁄against Description
1 ‘ should’, ‘ should not’, ‘ is not indicated’ A
2 ‘ may’, ‘ may not’ B
3 or 4 ‘ may be considered’ or ‘ do not know’ 0
E ACD Recommendations 6 1

disorder. Nevertheless, in most cases a careful clinical examina-
tion shows marked neurodevelopmental immaturities such as
choreiform movements of unsupported limbs or mirror move-
ments and other associated motor features, as well as signs of
impaired fine and gross motor coordination.’
The definition excludes abnormalities of gait and mobility
(R26–), isolated lack of coordination (R27–), and motor
impairment secondary to mental retardation (F70–F79 ) or to
other medical and psychosocial disorders.
The definition of DCD according to ICD-10 requires that
the diagnosis is not solely explicable by mental retardation or
any specific congenital or acquired neurological disorder.
7.1.2 Definition according to DSM-IV
DCD is included in the section ‘Learning disorders’ and the
section ‘Motor skills disorders’ (3 15.4 Developmental coordi-
nation disorder). The term was endorsed in the International
Consensus Meeting in London ⁄Ontario, Canada, in 19 9 4.
DCD according to DSM-IV is defined by the following
four criteria.
A. Performance in daily activities that require motor coordi-
nation is substantially below that expected given the person’s
chronological age and measured intelligence. The disorder
may be manifested by marked delays in motor milestones (e.g.
walking, crawling, sitting), dropping things, by ‘clumsiness’
and by poor performance in sports or poor handwriting.
B. The disturbance described in criterion A significantly
interferes with academic achievement or activities of daily
living.
C. The disturbance is not due to a general medical condition
(e.g. cerebral palsy, hemiplegia, or muscular dystrophy) and
does not meet criteria for a pervasive developmental disorder.
*
D. If mental retardation is present, motor difficulties are in
excess of those usually associated with mental retardation.
Coding note If a general medical (e.g. neurological) condition
or sensory deficit is present, code the condition on axis III
(DSM-IV ).
Looking at original papers, the term ‘DCD’ was used in
52.7% , ‘clumsy children’ in 7.2% , and ‘developmental dyspr-
axia’ in 3 .5% of articles (see systematic review from January
19 9 5 to December 2005 by Magalhaes et al.
16
). In 23 .5% of
the articles other terms were used. In the Leeds Consensus,
1
the term DCD was favoured.
The existence of subtypes of DCD is likely, but could not
be consistently confirmed by research evidence (see, for exam-
ple, review by V isser
17
).
7.1.3 O th er definitions
The Dyspraxia Foundation (UK) recommends the use of the
term ‘developmental dyspraxia’.
18
This term defines dyspraxia
as ‘an impairment or immaturity of the organization of move-
ment’ and in many patients there are associated problems with
language, perception and reasoning. A distinction between
developmental dyspraxia and DCD has been postulated.
19
Indeed, a dysfunction in the process of forming ideas, motor
planning, and execution can be found in DCD. However, the
term ‘dyspraxia’ has not become recognized as separate entity
or subgroup of DCD (see section 7.2).
20,21
Another definition comes from Sweden. Gillberg et al.
15
have argued for the presence of a syndrome called deficits in
attention, motor control, and perception (DAMP). However,
this concept has not become recognized outside Sweden.
Non-verbal learning disability is believed by some to be a
neuropsychological disability.
22
Although it has been studied
for the past 3 0 years,
22
it has not yet been included as a diag-
nostic category in the DSM-IV -TR. Many characteristics
associated with non-verbal learning disability are similar to
T able I V : S t r e n g t h o f r e c o m m e n d a t i o n b a s e d o n l e v e l o f e v i d e n c e
Strength of
recommendation Description Criteria
A (Aneg) Strongly recommended that clinicians
(do not) routinely provide the
intervention ⁄assessment to
eligible residents
Good quality of evidence and substantial net benefits
B (Bneg) Recommended that clinicians (do not)
routinely provide
the intervention ⁄assessment to
eligible residents
Fair quality of evidence and substantial net benefit
or
Good quality of evidence and moderate net benefit
or
Fair quality of evidence and moderate net benefit
0 N o recommendation for or against
routine provision of
the intervention ⁄assessment
Good quality of evidence and small net benefit
or
Fair quality of evidence and small net benefit
Insufficient evidence for
recommendation of the
intervention ⁄assessment
Poor quality of evidence (confl icting results; balance
between benefits and risks difficult to determine; and
poor study design)
The Canadian Guide to Clinical Preventive Health Care. Recommendations by Strength of Evidence. Accessed March 12, 2003.
U S PreventiveServices Task Force. Translating evidence into recommendations. Accessed March 6, 2003. http:/ / qmweb.dads.state.tx.us/ falls/
StrengthRecomm.htm
*
The Leeds Consensus Statement.
1
This considers the high incidence of
comorbidity within neurodevelopmental disorders and that it is inappro-
priate to exclude the possibility of a dual diagnosis of DCD with a perva-
sive developmental disorder ⁄autism spectrum disorder (p6).
6 2 Developmental Medicine & Child Neurology 2 0 1 2 , 5 4 : 5 4 – 9 3

those that describe other, more ‘established’ disorders, such as
Asperger syndrome, specific learning disabilities, and DCD.
7.1.4 R ecommendations on th e definition of DCD
At present, the DSM-IV criteria are better defined than the
ICD-10 criteria. The Leeds Consensus group (2006) agreed
to re-confirm the London consensus and accept the DSM-IV -
TR
11,12
as the most suitable set of diagnostic criteria that are
currently available. The consensus of the guideline group also
decided to use the DSM name DCD and their criteria. In
Table V the official terminology for DCD is given as it applies
to other languages.
Recommendation 1 (G CP + + )
The term developmental coordination disorder (DCD) should
be used to refer to children with developmental motor prob-
lems in countries which adhere to the DSM-IV -TR classifica-
tion. In countries where ICD-10 has legal status, the term
specific developmental disorder of motor functions (SDDMF)
(F8 2, ICD-10) should be used.
Comment
The term DCD is used because this wording is well recog-
nized in the English literature. It is taken from the DSM clas-
sification. However, in several European countries, the ICD-
10 has legal status. Thus, the terminology of the ICD-10 must
be used in those countries. Accordingly, the term SDDMF is
added in brackets throughout this document (for the purposes
of countries using ICD-10 terminology). Moreover, the fol-
lowing recommendations were also related to the ICD-10.
Where concepts differ between DSM and ICD-10, specific
comments are provided (specific recommendations 2a and 6a,
see Supporting Information, section 13 .7).
Recommendation 2 (G CP + + )
Criteria for th e diagnosis of DCD (SDDMF)
I. Motor performance that is substantially below expected
levels given the child’s chronological age and appropriate
opportunities for skill acquisition.
The poor motor performance may manifest as (1) poor
balance, clumsiness, dropping or bumping into things, or (2)
persistent difficulty in the acquisition of basic motor skills
(e.g. catching, throwing, kicking, running, jumping, hopping,
cutting, colouring, printing, handwriting).
Marked delays in achieving developmental motor mile-
stones (e.g. walking, crawling, sitting) may be reported.
II. The disturbance in criterion I significantly interferes
with activities of daily living or academic achievement (e.g.
self-care and self-maintenance, handwriting, academic⁄school
productivity, pre-vocational and vocational activities, and lei-
sure and play).
III. An impairment of motor coordination that is not solely
explainable by mental retardation. The disturbance cannot be
explained by any specific congenital or acquired neurological
disorder or any severe psychosocial problem (e.g. severe atten-
tionaldeficits or severe psychosocial problems,e.g. deprivation).
Comment
This CPG–DCD aims to minimize differences in interpreta-
tion and classification between ICD-10 and DSM-IV , because
the disorders are considered to represent similar conditions.
Criterion III is largely consistent with criteria C and D in the
DSM-IV (the exception is the exclusion of ASD see recom-
mendation 6).
Comments
Clarification of criterion III 1. DCD (SDDMF) should not be
diagnosed if (1) motor performance cannot be assessed by a
motor test (e.g. because of mental retardation or a medical dis-
order) or (2) if, after a comprehensive assessment including
clinical history, examination and consideration of teacher and
parent reports, the motor dysfunction can be explained by
another condition including a neurological or psychosocial
disorder or severe mental retardation.
In the comments of F8 2 (ICD-10), it is mentioned that
some children with DCD (SDDMF) may show marked
‘neurodevelopmental immaturities’ such as choreiform move-
ments of unsupported limbs or mirror movements and other
associated motor features. According to the current literature
and clinical practice experience, the roles of these motor fea-
tures are still largely unclear and need further evaluation.
2. DCD (SDDMF) and mental retardation. The problem
of diagnosing DCD (SDDMF) in children with learning dis-
ability (mental retardation) was discussed intensively within
the guideline group and within the European consensus
group. It was, however, recognized that defining a specific
IQ below which the diagnosis of DCD (SDDMF) is pre-
cluded seems artificial. Given the complexities of arbitrating
between cut-offs and determining discrepancy scores, it is
recognized that a categorical decision (above or below a spe-
cific IQ level) may be extremely difficult. Looking at a meta-
analysis on underlying mechanisms of DCD referring to key
question 1 of the CPG (see section 7.2) a specific IQ level
does not seem to be helpful to distinguish between children
with DCD and children with coordination problems due to
mental retardation.
It was agreed that the motor dysfunction should be defined
as DCD (SDDMF) if the other criteria are fulfilled and if clin-
ical history and examination cannot explain the motor prob-
lems and their impact on daily activities by cognitive status.
3 . DCD (SDDMF) and coexisting diagnoses. It is widely
recognized that children with DCD (SDDMF) often have
T able V : T e r m i n o l o g y f o r d e v e l o p m e n t a l c o o r d i n a t i o n d i s o r d e r a c c o r d i n g
to language
Language Disorder Abbreviation
English Developmental coordination disorder DCD
German U mschriebene Entwicklungssto
¨rung
motorischer Funktionen (specific
developmental disorder of motor
function)
U EMF
(SDDMF)
French Trouble de l’acquisition de la coordination TAC
E ACD Recommendations 6 3

coexisting diagnoses. It should be considered that ADHD,
ASD or conduct disorders may interfere with motor perfor-
mance and testing, as well as with activities of daily living mak-
ing motor assessment of children with DCD (SDDMF)
difficult (see recommendation 5).
Recommendation 3 (G CP + + )
The diagnosis of DCD (SDDMF) should be made within a
diagnostic setting by a professional who is qualified to examine
the specific criteria.
Comment
This may require a multidisciplinary approach.
Recommendation 4 (G CP + + )
Concerning criterion II: the complete assessment should
include consideration of activities of daily living (e.g. self-care
and self-maintenance, academic ⁄school productivity, pre-
vocational and vocational activities, leisure and play) and the
views of the child, parents, teachers, and relevant others.
Comments concerning criterion II
By definition, activities of daily living imply cultural differ-
ences. When applying this criterion, it is therefore crucial to
consider the context in which the child is living and whether
the child has had appropriate opportunities to learn and prac-
tice activities of daily living (see criterion I ‘previous opportu-
nities for skill acquisition’).
Establishing a direct link between poor motor coordination
and academic achievement is complex. However, the specific
skill of handwriting is usually affected, and is known to
adversely infl uence academic achievement and should there-
fore be assessed.
The complete assessment should refl ect culturally relevant
developmental norms.
Recommendation 5 (G CP + + )
Children with DCD (SDDMF) having performance deficits in
specific areas of motor performance (e.g. gross motor or fine
motor dysfunctions [ manipulative skills]) should be classified
according to the ICD subgroups (gross motor dysfunctions
F8 2.0 or fine motor dysfunctions F8 2.1).
Comment
For countries using ICD-10: Graphomotor disorders are spec-
ified as a subtype of DCD (SDDMF) by the ICD-10 and clas-
sified on the basis of impaired fine motor functions (F8 2.1).
Expressive writing disorders are classified under F8 1.8 accord-
ing to the ICD-10. Isolated handwriting problems without
additional graphomotor or other fine motor problems may
not justify the diagnosis of F8 2.1.
Recommendation 6 (G CP + + )
A dual diagnosis of DCD (SDDMF) and other developmental
or behavioural disorders (e.g. ASD, learning disorders,
ADHD) should be given if appropriate.
Comment
For countries using DSM classification: recommendation 6a
(see section 13 .7, Supporting Information). Dual diagnosis
also serves the setting of priorities for intervention (see state-
ment 3 and Recommendation 18 ).
Recommendation 7 (G CP + + )
Comorbidities should be carefully diagnosed and treated
according to established clinical guidelines (e.g. ADHD, aut-
ism, dyslexia, specific language impairment).
Recommendation 8 (G CP + + )
The onset of DCD (SDDMF) is usually apparent in the early
years, but would not typically be diagnosed before 5 years of
age.
If a child between 3 and 5 years of age shows a marked
motor impairment, even though there have been adequate
opportunities for learning and other causes of motor delay
have been excluded (e.g. deprivation, genetic syndromes,
neurodegenerative diseases), the diagnosis of DCD
(SDDMF) may be made based on the findings from at least
two assessments performed at sufficiently long intervals (at
least 3 mo).
Comment
According to the guideline group considerable problems exist
for the diagnosis of DCD (SDDMF) in children below 5 years
of age for the following reasons.
1. Y oung children may show delayed motor development
with a spontaneous catch up (late developer).
2. The cooperation and motivation of young children for
motor assessments may be variable. Thus, test performance
may be unreliable and finally result in poor predictive validity
(criterion I).
23 ,24
Nevertheless, a very recent study from Smits-
Engelsman et al.
25
indicates that motor assessment by the
Movement Assessment Battery for Children – second revision
(M-ABC-2) has a very good test–retest reliability also for 3 -
year-old children.
3 . The rate of acquisition of activities of daily living skills is
variable in children at kindergarten age. Thus, the evaluation
of criterion II of the diagnostic criteria in children under
5 years is unreliable.
4. Finally, there are no reliable data on the value of early
intervention in preventing DCD (SDDMF).
The lack of stability of DCD (SDDMF) diagnosed at early
ages has been shown with the exception of DCD (SDDMF) in
cases with coexisting ASD.
23 ,24,26
Nevertheless, the assessment itself may be reliable for exam-
ple using the M-ABC,
27
repeated assessment within short
intervals (e.g. 3 wk) are not recommended because of practice
effects.
28
A follow-up study underlines that only in definite
(severe) cases of DCD being detected before school age is the
disorder stable 2 to 3 years later.
29
This supports the recom-
mendation that in 3 - to 4-year-old children the fifth centile of
quantitative measures like the M-ABC may be used for identi-
fication (see recommendation 17).
6 4 Developmental Medicine & Child Neurology 2 0 1 2 , 5 4 : 5 4 – 9 3

Comment
The guideline group additionally expresses concerns about the
diagnosis of DCD (SDDMF) (first identification of DCD
(SDDMF)) after 16 years of age. The criteria for DCD
(SDDMF) need to be reconsidered for adults. Although there
is a problem with lack of suitable instruments, a diagnosis in
adulthood should be possible.
Symptoms must be present in early childhood (but may not
become fully manifest until movement challenges exceed
limited capacities with respect to context and opportunities).
7 . 2 Description, underlying mechanisms, clinical findings,
conseq uences, and prognosis
7.2.1 Clinical findings w ith respect to th e level of b ody
functions
The systematic search of the literature identified 23 descrip-
tive studies and 3 6 studies covering additional aspects like pos-
sible consequences of DCD. Further, 13 1 studies on different
underlying mechanisms plus 28 studies covering additional
aspects of DCD have been identified.
Some studies describe decreased basic strength and fit-
ness.
3 0,3 1
Several studies describe certain deficits in fine motor
skills, balance, and ⁄or visuomotor skills.
3 2–3 5
Further studies address the visuospatial dysfunction:
O’Brien et al.
3 6
found evidence for a global spatial process-
ing deficit in children with DCD (SDDMF). Mon-Wil-
liams et al.,
3 7
on the other hand, found difficulties in body-
centred spatial judgments (especially limb position) which
may lead to an inappropriate relationship between percep-
tion and action.
Severalstudiesconsiderproprioceptivedysfunction,
3 8 ,3 9
espe-
cially processing of kinaesthetic information,
40,41
as crucial in
DCD (SDDMF). V olman et al.,
42
on the other hand,considered
the coupling of different afferent components (visual, proprio-
ceptive, etc.) as deficient, leading to difficulties in maintaining
posturalstabilityinaction.
42
Abnormalities in the processing of efferent information
were also suggested as underlying mechanisms in DCD
(SDDMF)
43 –45
as well as deficient inhibition of the pre-cued-
induced urge to move attention.
46,47
Other authors find mainly immature movements in children
with DCD (SDDMF) underlining the aspect of development.
Thus Mon-Williams et al.
48
found mainly prolonged duration
of movements as in much younger children, whereas Missiuna
et al.
49
found, especially in writing tasks, not only immature
pencil grasps but also slow movements with poor control of
distal movements, as can be seen in younger children.
In the past 5 years more refined techniques have allowed a
better description of the deficits in DCD (SDDMF). Macken-
zie found, that children with DCD (SDDMF) showed no
problems with coordination of basic gross-motor tasks (e.g. of
coordinating their clapping to their footfalls while marching
in place). But the same task coupled with increased variety led
to increased problems (mainly associated with the arm move-
ments).
50
This study shows that the more a task demands the
integration of different information, the more vulnerable it is.
Deconinck
51
, on the other hand, found that children with
DCD (SDDMF) showed less difficulty in maintaining balance
and control of velocity in walking under visual control than
without. He found further that children with DCD
(SDDMF) showed diverging gait patterns (especially gait
length and trunk inclination) from typically developing chil-
dren, suggesting adaptation of their gait to their poor balance
control.
Difficulties in visual memory
52
and deficits in language pro-
cessing
53
have also been interrelated with DCD (SDDMF).
Underlying organic defects are addressed in the last two
studies: Katschmarsky
44
considered a parietal dysfunction.
This may relate to the former diagnosis of a ‘minimal cerebral
dysfunction’, which receives some support from the fact that
children born preterm are much more likely to develop DCD
(SDDMF).
7
Goez et al.,
54
on the other hand, found more
often left-handedness than right-handedness in DCD
(SDDMF), thus implying a genetic variability.
To prioritize and clarify the main findings from the numer-
ous studies on underlying mechanisms members of the guide-
line group performed a careful meta-analysis.
From the initial literature search, 128 studies were identified
as suitable for a meta-analysis. Within a careful selection pro-
cess it was important to use studies that permitted a comparison
between children with DCD (SDDMF) and typically develop-
ing children. From here, studies were categorized according to
their relevant theoretical paradigm (e.g. information process-
ing, dynamical systems, cognitive neuroscience, hybrid
approach). Then, all dependent measures were listed and coded
according to a conceptual scheme that best represents the
underlying mechanisms being assessed. Among the studies with
critical effect-size estimates (k‡10), the largest effect sizes were
found for kinematic parameters associated with reaching and
catching: kinematic catching (r= 0.9 2), and kinematic target-
directed reaching within personal space (r= 0.8 2) and outside of
personal space (r= 0.8 1) were the highest discriminating mea-
sures between DCD (SDDMF) and comparison groups. Large
effect sizes were also found for pattern variability during gait
(r= 0.58 ), static balance under postural control (r= 0.56), and
measures of forward modelling including covert orienting
(r= 0.57) and motor imagery (r= 0.50). Moderate effect sizes
were found for both visuospatial and verbal working memory
(r= 0.43 and 0.45, respectively).
Of those categories that yielded high magnitude effect sizes
but with k< 10, high magnitudes were found for forward mod-
elling: motor imagery (r= 0.9 8 ), and covert orienting that used
valid and invalid precues (r= 0.8 3 and 0.8 3 , respectively). Other
high effect sizes were found for contralateral (r= 0.9 5) and
ipsilateral (r= 0.9 4) target-directed aiming movements.
Taken together, these results suggest that children with
DCD (SDDMF) show underlying problems in visual–motor
translation (namely inverse modelling) for movements directed
within and outside peripersonal space, adaptive postural con-
trol, and the use of predictive control (namely forward model-
ling), which impacts the ability to adjust movement to
changing constraints, in real time.
E ACD Recommendations 6 5

7.2.2 Clinical findings w ith respect to th e level of activities
and participation
The systematic search of the literature yielded few studies
addressing the level of activities and participation in children
with DCD (SDDMF). Only five studies were identified (see
Table V III in Appendix I).
The results can be summarized as follows. Two studies
3 4,55
address the question of predicting ball fl ight. Lefebvre et al.
3 4
found that healthy children could predict ball fl ight better
with increasing age depending on training but 40 children
with DCD (SDDMF) could predict ball fl ight significantly
worse than their healthy peers at 5 to 7 years. Deconinck
et al.
55
found in a small case–control study of nine male chil-
dren that those with DCD (SDDMF) adapted as well as
healthy male children to temporal structure and velocity of
ball fl ight but showed less opening of the hand and slower
closing on the ball than comparisons. They deduced that the
male children with DCD (SDDMF) showed more problems
in the executive plan rather than visuo-perceptive or action-
planning processes. Again this is a very small study group.
Two other studies
56,57
address the question of emotional
implications in children with DCD (SDDMF). Cairney
et al.
56
found in a large, population-based study that children
with DCD (SDDMF) performed more poorly on a simple aer-
obic task (running) than their healthy peers. At least one-third
of the effect was found to be due to their conviction of their
own inadequacy. This study shows that emotional factors play
a significant role in the participation in everyday life in chil-
dren with DCD (SDDMF). In a much smaller study (10 male
children) Lloyd et al.
57
found differences in cognitive coping
strategies for motor planning in different motor tasks (hockey
shot and peg solitaire) in children with DCD (SDDMF) com-
pared with typically developing peers. Differences in emo-
tional handling of the task were only seen in the sport specific
problem (hockey shot). This interesting finding tends to
underline the necessity of supporting children with DCD
(SDDMF) in their daily activities rather than treating the
underlying condition. As the study group was very small, this
question should be addressed again with a more representative
sample.
Finally, Pless et al.
58
addressed the measures taken by the
involved parents in supporting their children (before the diag-
nosis is made). They found that parents of children with DCD
(SDDMF) are more frequently assisting and encouraging their
children in motor tasks but are also more worried concerning
the wisdom of their actions.
7 . 3 Conseq uences
The systematic search found 3 0 studies presenting data on the
consequences of DCD (SDDMF) in different areas of the
ICF. Eighteen studies presented findings at the level of body
and mental functions, 20 studies described consequences in
activities and participation, 16 studies reported results on
personal factors, and 15 studies provided findings about the
environment (as defined by the ICF). Because the results of
this literature search are not directly relevant for specific rec-
ommendations concerning the key questions, only those
results in the area of activities and participation are presented
(see also Table IX in Appendix I).
There is no doubt that DCD (SDDMF) leads to an
impaired functional performance in activities of daily
living.
59 ,60
These children require a higher level of structure
and assistance in these activities than their typically developing
peers.
61
The impact of motor coordination problems on physical
activity engagements throughout life is infl uenced by a multi-
tude of factors (social, cultural, physical environment, individ-
ual characteristics)
62
but there is evidence that children with
DCD (SDDMF) show less physical activity and especially par-
ticipation in team sports.
63 ,64
This may lead to poor self-effi-
cacy in adolescents with DCD (SDDMF)
65,66
and lower life
satisfaction.
67
Indeed, Piek et al.
68
found a significant
correlation between motor ability and anxiety disorders at kin-
dergarten age. Behavioural problems but also problems in
social interactions persisted in a long-term follow-up.
69
This
affected the whole family system and especially the parents
over a long time period
60,69
and leads to concern of the par-
ents about their children’s participation in society.
70
Some studies highlight the negative effect of DCD
(SDDMF) on body fitness,
71,72
which is mostly ascribed to less
physical activity than in typically developing peers.
7 . 4 O utcome
There are several studies which addressed the natural course
of DCD (SDDMF) (see Table X in Appendix I). There is
compelling evidence that DCD (SDDMF) persists well into
adolescence
73 –77
and persists in an estimated 50 to 70% of
children,
77
which is further proof of the independency of this
disorder, although it can be associated with other learning or
behavioural disorders: In kindergarten age motor problems
seem to be associated with language and communication prob-
lems.
78 ,79
These can persist into school age. Kadesjo
¨and Gill-
berg
8 0
found restricted reading comprehension in children
diagnosed with DCD (SDDMF) at the age of 7. At school age
there are further indications that some children with DCD
(SDDMF) show poorer outcome in scholastic achievements
8 1
than their healthy peers, especially in the arithmetic domain.
8 2
This aspect can be related to the known difficulties of some
children with DCD (SDDMF) in the visuo-spatial plane.
Cairney et al.
64
found in a big study group, a correlation
between DCD (SDDMF) and subsequent development of
obesity in male children, whereas there was no such conse-
quence observed in female children. One explanation may be
that the participation in team play activities and sport teams is
diminished in children with DCD (SDDMF).
8 1,8 3 –8 5
This
may also be a reason why long-term participation in social
activities is generally reduced.
Concerning coping mechanisms, Causgrove et al.
8 6
found
a higher perceived competence in children with DCD
(SDDMF) after physical education classes emphasizing a
very motivational climate thus reducing the burden of the
disorder.
6 6 Developmental Medicine & Child Neurology 2 0 1 2 , 5 4 : 5 4 – 9 3

7 . 5 B urden for society
There is no doubt that diagnosis and intervenion is costly,
both to these children and to society as a whole. The numer-
ous data on consequences and outcome of DCD (SDDMF)
clearly underline that DCD (SDDMF) is a burden for society.
The marked infl uence of DCD (SDDMF) on everyday activi-
ties and school performance and, secondarily, on social partici-
pation as well as the high prevalence indicate that the burden
is considerable.
The meta-analysis on underlying mechanisms shows that
DCD (SDDMF) is a neurobiological disorder with complex
neuropsychological deficits concerning motor imagery, plan-
ning, and execution (see section 7.2).
7 . 6 Comorbidities
There is strong evidence that DCD (SDDMF) is combined
with several emotional, social, and specific learning difficul-
ties.
8 7
In some children, it cannot always be determined to what
extent behavioural problems are co-existing disorders or the
consequences of longstanding negative experiences with clum-
siness in everyday life. Kaplan et al.
8 8
question the term ‘com-
orbidity’ as there is large overlapping between DCD
(SDDMF), learning disorders and ADHD. They prefer the
term ‘atypical brain development’.
However, the guideline group decided to stick with the
term comorbidity as for assessment it seems to be more appro-
priate to look for the distinct disorders and set priorities for
choosing interventions as necessary.
7.6 .1 Functional and socioemotional prob lems in ch ildren
w ith DCD (SDDMF)
Regarding socioemotional problems as consequences and out-
come, we refer to sections 7.3 and 7.4. The cooccurrence of
DCD (SDDMF) and social, emotional, and attential problems
are well known.
8 2,8 9 ,9 0
7.6 .2 Coex isting disorders
ADHD has been found to be the most frequent comorbid dis-
order to DCD (SDDMF). Several studies – mostly examining
clinical samples – suggest a rate of greater than about 50% of
comorbidity.
9 1
However, data from population-based studies suggest that
about half of children with DCD (SDDMF) and half of children
with ADHD have combined problems.
6
In a further paper,
Kadesjo
¨andGillbergdescribe thatDCD (SDDMF) diagnosedin
7-year-old Swedishchildrenpredictedreading comprehension at
the age of 10 years.
8 0
DCD (SDDMF) itself remained stable at
leastwithin1 yearfollow-up.Inafurtherpopulation-basedstudy,
Kadesjo
¨and Gillberg
9 2
found that 8 7% of children with ADHD
had comorbidities. ADHD with DCD (SDDMF) seems to be
more common in clinical and support groups than in school
groups (incontrastto conductproblems,etc.).
9 3
A further study underlines the important clinical role of
DCD (SDDMF) in the context of ADHD. Rasmussen et al.
9 4
found in a 22-year longitudinal, community-based follow-up
that individuals with ADHD with DCD (SDDMF) had a
much worse outcome than individuals with ADHD without
DCD (SDDMF). Antisocial personality disorder, alcohol
abuse, criminal offending, reading disorders, and low educa-
tional level were overrepresented in the ADHD⁄DCD
(SDDMF) group (58 % vs 13 % in the ADHD group without
DCD [ SDDMF]) (Fig. 1).
The comorbidity of DCD (SDDMF) and specific language
impairment has been shown in up to 70% of the children with
language problems.
79 ,9 5–9 7
Further, there are frequent comor-
bidities between DCD (SDDMF) and reading disorders and
writing disorders.
8 2,8 8 ,9 8 ,9 9
Coexisting learning difficulties has been interpreted as an
indicator for severity and for perceptual–motor dysfunction.
100
Montgomery et al.
9 8
point out that fl uency and speed in
writing are essential underpinning skills contributing to spell-
ing accuracy and compositional ability in examination perfor-
mance.
Children with developmental disorders often show neuro-
psychological deficits. Kastner and Petermann
101
looked for
cognitive deficits in children with DCD (SDDMF). Children
with DCD (SDDMF) scored below average in the Hamburg-
Wechsler Intelligence test for children (Wechsler Intelligence
Scale for children [ IV th revision]) (verbal comprehension, per-
ception reasoning, working memory, and processing speed).
The general IQ scored one standard deviation below the com-
parison group. Other studies report less differences of total
IQ .
3 8
Alloway et al.
102
also found selective deficits in visuo-
spatial short-term and working memory in children with
DCD (SDDMF). In the same study they found deficits in
verbal short-term and working memory in children with lan-
guage impairments.
ASD is also known to be associated with DCD
(SDDMF).
9 7,103 ,104
In a population-based study, a comorbidi-
ty of ASD was found in 10 of 122 children with severe DCD
(SDDMF) and in nine of 222 children with moderate DCD
(SDDMF).
7
Because of the comorbidities of DCD (SDDMF), ADHD,
learning disorders, and autism, a common aetiology has been
discussed.
An overrepresentation of DCD (SDDMF) in preterm and
low-birthweight children (about 2:1) is known.
7,105
In a recent genetic study ina large group of twinsa consistent
comorbidity was only confirmed in severe cases. In this twin
M oderate A DH D only
5 .4 %
Severe
A DH D only
2 .0 %
M oderate A DH D plus DC D
5 .4 %
Severe A DH D
plus DC D
1 .7 %
M oderate or severe DC D only 7 .3 %
F igure 1: O v e r l a p p i n g o f AD H D a n d D C D ( a c c o r d i n g t o Ka d e s j ç a n d
G i l l b e r g
6
) .
E ACD Recommendations 6 7

study, it could be shown that the motor symptoms of DCD
(SDDMF) were in most children distinct from behavioural fea-
tures like conduct disorder and ADHD. Only in severe cases
was comorbidity common (latent classes 5–7, in Table V I).
There was one cluster with children with severe reading disor-
ders and fine motor functions and handwriting problems and
one further cluster with movement control and gross motor
planning.
In conclusion, despite numerous comorbidites in children
with DCD (SDDMF) there is some evidence that DCD
(SDDMF) exists as a distinct disorder at least as well as other
ADHD, ASD, and developmental and learning disorders.
DCD (SDDMF) seems to be critical for the outcome for
example in ADHD and other socioemotional problems and it
seems to predict success in some school abilities.
S tatement 1 (+ + )
Because of the high probability of comorbidity in DCD
(SDDMF), disorders like ADHD, ASD, and specific learning
disorder, particularly specific language disorder and in later
age reading problems (e.g. reading comprehension), have to
be checked by careful history taking, clinical examination, and
specific testing if possible, according to existing clinical prac-
tice guidelines.
If there is any hint for interference (e.g. attentional prob-
lems) with objective motor testing, the motor testing should
be repeated, for example under medication or after other ther-
apeutic intervention for attention problems.
8 S CREEN I N G , AS S E S S M EN T
The requirement for objective reliable and norm-referenced
tests in criterion I as recommended by the guideline group
was the basis for the systematic search of the literature. A total
of 3 4 studies and four (not systematic) reviews and overviews
were found on this subject. V ery recently, after the search per-
iod, a systematic review on measures of gross-motor function
was published.
107
This was included in the evaluation.
Further, a norm-referenced test or questionnaire to support
criterion II may be useful.
Early identification of children with motor impairments has
been recommended.
108 ,109
Instruments identifying motor
impairments before the age of 5 are available and may be
applied. However, screening instruments for this purpose are
not sufficiently refined to enable highly valid and reliable
assessment. On the other hand, the diagnosis DCD (SDDMF)
before the age of 5 years is not generally recommended. This
has already been discussed above (section 7.1.4).
8 . 1 Ex planatory framew ork s for different assessment
approaches
According to the evaluative review by Wilson,
110
the following
assessment approaches can be distinguished.
1. Normative functional skill approach. Assumptions about
movement difficulties are largely process neutral. Approaches
to assessment are descriptive, product-oriented (focus on func-
tional skills), and norm-referenced. For example, the M-ABC
is based on this approach.
2. General abilities approach. The guiding assumption here
is that impaired sensorimotor integration underpins both per-
ceptual–motor problems and learning difficulties. These
impairments refl ect neural damage. According to this
approach, basic general abilities (like sensory–motor integra-
tion) can be measured, for example by the Sensory Integration
and Praxis Test, and then should be a focus for treatment to
improve motor functions.
3 . Neurodevelopmental theory (biomedical model). Early
neurological markers (e.g. clumsiness) predict disease states,
for example ‘minimal brain dysfunction’. This may be assessed
by neurodevelopmental examination. An eclectic blend of
neurological and learning tasks (e.g. soft signs or minor neuro-
logical dysfunction) will be tested. Normative data on soft
signs are existing.
111–113
A new version of the Examination of
the Child with Minor Neurological Dysfunction is avail-
able.
114
The manual contains criteria, cut-offs, and description
of psychometric properties. Evidence is emerging that chil-
dren with DCD often exhibit minor neurological dysfunction,
in particular quite often the ‘complex form of minor neuro-
logical dysfunction’.
115–117
This issue may deserve further
attention. Advances in neuroimaging and functional imaging
will provide insights into hard and soft signs of neural dysfunc-
tion. On the other hand, the role of minor brain dysfunction
and minor neurological dysfunction for the development of a
theory of DCD (SDDMF) has been questioned.
110
4. Dynamical systems approach.
118
This approach suggests
that the child with DCD (SDDMF) has had reduced opportu-
nities to form movement synergies through interaction with
learning tasks and environment. Assessments used within this
framework include biomechanical, kinematic, and observa-
tional analyses.
T able V I : C o m o r b i d i t i e s o f d e v e l o p m e n t a l c o o r d i n a t i o n d i s o r d e r ( s p e c i f i c
d e v e l o p m e n t a l d i s o r d e r o f m o t o r f u n c t i o n s ) ( D C D [ S D D M F ] ) w i t h l e a r n i n g
a n d b e h a v i o u r a l d i s o r d e r : c l u s t e r a n a l y s i s i n a l a r g e t w i n s t u d y
Latent
class
a
Clinical feature Frequency
a
Percentage
a
1 U naffected 1957 62
2 Moderate inattentive–impulsive
with ODD
440 14
3 Severe reading problems with
moderate fine
motor ⁄handwriting
267 9
4 Control during movement with
moderate gross motor planning
201 6
5 Inattentive–impulsive with reading
problems, ODD, fine motor and
general control
140 4
6 Inattentive–impulsive with ODD 114 4
7 Moderate to severe for combined
ADHD, RD, ODD, and DCD scales
with some CD
29 1
Total 3148 100
ODD, oppositional defiant disorder; ADHD, attention-deficit–
hyperactivity disorder; RD, reading disorder; CD, conduct disorder.
a
Frequencies and percentages for a 7 latent class solution concerning
different pattern<