016 - Developmental Coordination Disorder

This episode delves into the epidemiology, neurobiology, and differential diagnosis of Developmental Coordination Disorder (DCD), including its frequent co-occurrence with autism intellectual developmental disorder or ADHD, and stresses the importance of occupational and physical therapies to improve outcomes, highlighting that DCD should be identified and addressed rather than being subsumed into other conditions.

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This is not medical advice. Please see a licensed physician for any personal questions regarding your own or your child's health.

Transcript

Welcome to PsyDactic CAPS board study edition. Today is Sunday, March 2nd, 2025, and I am your host, Dr. O'Leary, a child and adolescent psychiatry fellow in the National Capital Region. This is a podcast I designed to help myself and other child and less psychiatry fellows study for their boards while driving back and forth to work, enjoying a run, or boiling spaghetti. But anyone interested in human development and mental health will also likely get something out of this. I use artificial intelligence to assist me with the content creation. When I first began making this podcast, I had used AI only to help summarize and organize content. Now, I have a tool that allows me to feed it high quality peer-reviewed articles and book chapters and it will generate an actual audio discussion of the content. I provide this AI tool with a select group of papers and then I give it multiple prompts each of which produces about a 10 to 20 minute audio. I then review each of these audio files and remove any obvious mistakes, repetitive content, and annoying introjections. and then I choose the best parts and paste them together. The AI does make mistakes, but I find that it is at least as reliable as any human. Many of the mistakes it makes are small, like pronunciation errors. It doesn't obviously understand what it's talking about, but when I'm talking, I often don't really understand what I'm talking about either, but what it produces is very helpful. Today, the AI and I will discuss developmental coordination disorder. Now, developmental coordination disorder is a disorder defined by the DSM5 where the acquisition and execution of motor skills and related coordination are below what is expected based on age. Now, these deficits of motor skill and coordination have to significantly interfere with daily life in the domains of things like self-care, scholastics, work, leisure, and play. And to be developmental, it has to have started in childhood. And of course, the deficits can't be better explained by any other condition. I had not considered DCD much before starting this episode. It looks to me like a rather heterogeneous category that catches new numerous ways that our motor learning, planning, and execution can be quirky. Prior to the 1950s, doctors would refer to DCD as a pathologically severe form of clumsiness. In the late 50s, a plethora of other terms came into use, such as developmental dyspraxia or sensory integration dysfunction or perceptual motor dysfunction or are my favorite developmental dyspraxia dysgnosia among other names. DCD is frequently present with other neurodevelopmental disorders such as autism or intellectual disabilities or ADHD and it is rarely isolated only to motor functions. Motor planning might be impaired due to difficulties with executive functioning or with vis spatial perceptions or functional connectivity between brain regions. So there could be problems in your parietal and temporal loes that result in DCD. There could be problems within your premoter cortex. There could be problems within your cerebellum. There could be problems with the white tracks that connect any of these regions together. So that's a lot of things that can cause someone to be pathologically clumsy. One major point that I took away from this journey is that people with coordination disorders can see dramatic improvements if given the right occupational and physical therapies. And this is evident in the fact that the prevalence of this disorder in adulthood is half of that in childhood. So it's important not to let this diagnosis be subsumed into other neurodedevelopmental disorders but identified as a particular opportunity for intervention whether or not it occurs by itself or occurs with something else. So with that being said, I hope you learned something from the following AI adventure.

Welcome in everybody to another deep dive.

Yeah.

Um today we're going to be talking about developmental coordination disorder or DCD for short. I I think this is a really interesting one because this is something that comes up quite a bit when you're working with kids and it's a pretty complex diagnosis.

Yeah.

So to start off, why don't we talk about like what the heck is DCD? Like how do we diagnose it? What does it look like? So the DSM5, which is kind of the gold standard for diagnosis in our field,

has some criteria that that we use.
Um and it's actually pretty simple. Like there's only three criteria,

but the criteria themselves can be a little bit

vague and hard to define. So the first one is that the acquisition and execution of coordinated motor skills is substantially below that expect given the individual's chronological age and opportunity for skill learning and use. Basically, what it means is that the child's motor skills are way worse than what you would expect for their age,

right?

And it's not just because they haven't had the chance to practice or learn those skills.

And we're really talking about the persistence of these difficulties, too. You know, this isn't just kind of a one-off thing.

Yeah. It's a consistent pattern.

Yeah. It's got to be a consistent pattern.

Yeah. And the second criterion is that the motor skill deficit described in criterion A significantly and persistently interfere with activities of daily living appropriate to chronological age and impact academic school productivity, prevocational and vocational activities, leisure and play.

So, and

Right. And it's impacting them functionally.

Yeah. Exactly. So, like it's not just that they're a little bit clumsy or uncoordinated. It's like really interfering with their ability to do everyday things.

It's like impacting their ability to function at school or at home with their peers in play. So, it's not just, oh, you know, they trip every once in a while, you know?

Right. It's like they can't get dressed by themselves.

Yeah. Or they can't write legibly enough to complete their schoolwork.

And then the third one is that the onset of symptoms is in the early developmental period.

So, we're not talking about someone who like had a stroke or something and then suddenly developed these motor problems, right?

It has to be something that's been present since they were little.

It's interesting because that was a change in the DSM5. you know, previously it wasn't as explicit about that onset occurring in the developmental period. So, that was a a key change and I think it's a really important one because, you know, it helps us to really differentiate

from other things that could be going on.

Yeah.

Like you said, a stroke or like some sort of traumatic brain injury where, you know, the motor problems came on suddenly. This is something that's been there all along.

Absolutely.

Um, and then the DSM also goes on to say that the motor skills deficits are not better explained by intellectual disability, visual impairment, or other neurological conditions that affect movement.

Yeah. And that's a really important piece. You know, we got to be thorough in our assessment. You know, we need to look at their developmental history. We need to do a good physical exam to make sure there's nothing else going on,

right? And it can be tricky because sometimes kids with DCD might also have some other things going on,

right? And you know, I think it's also important to note that that part of the criteria about it not being better explained by intellectual disability. You know, there's been a lot of debate over the years about whether or not there's an IQ cut off for DCD.

Yeah.

And you know, the DSM5 doesn't actually have an IQ cut off, right?

But there is research that suggests that, you know, children with DCD tend to have lower IQ scores on average,

but it's not a hard and fast rule. You know, there are certainly children with DCD who have average or even above average IQs,

right? It's not like a defining characteristic.

Exactly.

So, we've got the what of DCD, right?

Diagnostic criteria. Yeah. Now, let's delve into the who who is actually getting diagnosed with this. What can you tell us about the epidemiology and demographics of DCD?

Yeah. Well, we know that it's more common than many people realize. I think estimates are around 5 to 6% of school-aged children. Wow.

Which has been relatively stable over the past few decades.

That's a pretty significant chunk of kids.

It is. It is.

And I found this really interesting study from Denmark that found a link between delayed independent walking and an increased risk of DCD.

Oh, interesting.

So, children who weren't talking on their own by 15 months were three times more likely to develop DCD.

Motor development follows a pretty predictable trajectory. Right.

And if there are early deviations from that trajectory, it could be a sign of things to come.

Yeah. Like a red flag.

Exactly.

And then there's also the gender difference.

Right.

Research shows that boys are about twice as likely as girls to be diagnosed with DCD.

Yeah. That's a consistent finding across studies. Yeah.

Why is that?

Well, Well, we don't know for sure, but there are a few theories out there. Some folks think it could be hormonal differences or differences in brain development between boys and girls.

Okay?

Others think it might be more societal expectations.

You know, the way we encourage boys and girls to engage in different types of play,

right? Like boys are maybe more encouraged to be like rough and tumble and girls are maybe more encouraged to do like quieter activities. So, it's definitely something to be aware of when we're assessing kids.

Absolutely. You know, we got to take the whole picture into account the child's individual context, not just their motor skills in isolation.

Right. Because if we have a little girl who's not meeting those motor milestones, but she's also not really being given the opportunities to practice those skills.

Exactly.

Then that might not be DCD. It might just be a lack of opportunity.

Right.

So now let's switch gears a little bit and talk about something that I think can be really confusing for a lot of people.

Yeah.

The relationship between DCD and autism spectrum disorder.

Yeah, it's a tricky one

because there's a lot of overlap in terms of the motor difficulties.

Absolutely.

And I was reading that a whopping 87% of children with ASD experience some kind of motor impairment.

Yeah, it's incredibly common.

That's huge.

It is.

But here's the catch. Only a subset of those children actually meet the criteria for a dual diagnosis of DCD.

And that's where things get tricky because, you know, just because a child has motor difficulties and autism doesn't automatically mean they have DCD. You know, there's got to be that specific constellation of symptoms and a certain level of severity.

So, how do we tease that apart? Like, how do we know if it's just motor difficulties related to ASD or if it's actually DCD?

Well, I think first and foremost, it's got to be a comprehensive evaluation. You know, we need to be looking at their history, taking into account their current presentation, doing standardized motor assessments.

Okay. So, what kind of standardized assessments are out there?

Well, one of the most common ones is the movement assessment battery for children or MMAC2. Okay.

And that's a really good tool because it allows us to quantify their motor skills and compare them to norms.

So we can see like, okay, how far behind are they really?

Exactly.

And is it significant enough to warrant a diagnosis,

right? Okay.

But, you know, beyond the standardized tests, we also need to look at, you know, how are those motor difficulties manifesting in their daily life? You know, are they having trouble with dressing? Are they having trouble with eating? Are they having trouble with writing? You know, we got to look at the big picture.

And there's this really interesting study that I came across that looked at brain connectivity in children with ASD with and without DCD.

Oh wow.

And they found that even though the motor impairment levels were very similar between those two groups.

Okay.

The patterns of brain connectivity were totally different.

That is fascinating.

So it's almost like the same behavioral presentation.

Yeah.

But very different underlying neurobiology.

Right. And that's a gamecher in terms of how we think about these conditions.

Yeah. Because it's not just like oh they both have motor problems so they must be the same thing.

It's like, no, there's actually something different going on in their brains.

Exactly. And I think it really highlights the need for more nuanced research in this area.

Yeah, for sure.

You got to disentangle these overlapping features,

you know, beyond just autism, we also have to think about other things that could look like DCD.

Oh, right. Like what?

Well, things like cerebral palsy, muscular distrophe.

Okay.

Even some metabolic disorders can sometimes present with motor difficulties.

So, it's a real process of elimination

it is

okay

it is it's detective work

and this meticulous approach is so crucial because as we've seen DCD isn't just about you know being a little bit clumsy

it can have a huge impact on a child's life and their mental health

you know you think about the frustration that these kids must feel

oh yeah

constantly struggling with things that seems so easy for everyone else and

like it must be really demoralizing

it is and And studies have shown that kids with DCD tend to have lower self-esteem. They feel less competent, especially when it comes to physical activities and social situations.

Yeah. Because those are the things that kids are often judged on.

Exactly. Yeah.

And so this can lead to social anxiety withdrawal, even depression.

It's like a ripple effect.

It is. It's a ripple effect that goes way beyond just the motor skills.

Yeah.

So, we got to be paying attention to the whole child,

right? Their mental health, their emotional well-being, not just their ability to like catch a ball or tie their shoes. So, we've talked about the diagnostic criteria. We've talked about the epidemiology and the differential diagnosis. Now, let's get into the brain stuff.

What do we actually know about the neurobiology of DCD?

Ooh, the brain stuff. I love the brain stuff.

Yeah, it's fascinating.

It is. It is. So, this is where things get really interesting because while we don't have a definitive answer, you know, you don't have like a DCD brain, right?

Research is starting to show us that there are some subtle neurological differences.

Okay, I'm all weird.

That might be at play. So one area that's been studied a lot is the cerebellum.

Okay.

Which as you know plays a huge role in motor control, coordination and motor learning,

right?

And there's some evidence to suggest that kids with DCD might have subtle structural or functional differences in their cerebellum.

Interesting. So like their cerebellum might not be working quite as efficiently as it should be,

right? And this could explain some of the motor difficulties that we see.

Okay. And I remember reading about a study that used fMRI to look at brain activity. in kids with DCD.

Yeah.

While they were doing motor tasks.

That was a really cool study. And what they found was that there was some distinct differences in brain activation patterns.

So like the kids with DCD

were using different parts of their brain to do the same task

kind of. Yeah. They found reduced activity in the cerebellum.

Okay.

And in the supplementary motor area which is involved in planning and sequencing movements.

So it's not just that the cerebellum isn't working as well,

right? it's that the communication between different brain regions involved in motor control is impaired.

So like the signals aren't getting through as clearly. And that makes sense because you know if you're trying to coordinate a complex movement,

right,

you need all those different parts of your brain to be talking to each other. And then there's also research on white matter, right?

Which is like the brain's communication network.

Yeah. The superighways of the brain.

And studies have shown that some kids with DCD have abnormalities in their white matter.

Interesting. specifically in the tracks that connect the cerebellum to other motor areas.

Okay. So, what does that mean in like plain English?

Well, it means that the connections between those different parts of the brain might not be as strong

or as efficient as they should be.

And so, that could explain why they're having trouble with motor planning, sequencing, and execution.

Right? It's like their brains are having to work harder to achieve the same level of motor control. And this really highlights the need for interventions that target Not just the motor skills themselves, right? But also the underlying neurological processes. So it's not enough to just teach a kid how to tie their shoes or catch a ball, right?

We also have to address those underlying brainbased challenges.

Yeah. We got to work on those connections, strengthen those pathways.

Oh. Well, there's still a lot we don't know about the neurobiology of DCD.

Oh, yeah. A ton.

The research is definitely giving us a much better understanding of how the brain plays a role in motor coordination.

Absolutely.

But it's important to remember that DCD is more than just a bunch of brain scans. neurological findings,

right?

It's a real lived experience that can have a significant impact on a child's life.

And that brings us to, you know, a really important question. How can we as clinicians and researchers support these individuals throughout their lifespan,

right? Because it's not like DCD just goes away when a kid becomes an adult.

No, it doesn't.\n


Like these motor challenges, they can stick around and they can even manifest in new ways as people get older and have to deal with more complex demands.

You know, think about a teenager with DCD who is trying to learn how to drive or an adult who wants to pursue a certain career but their fine motor skills are holding them back.

It's a lifelong journey.

It is.

So, let's talk about treatment and management.

What kind of strategies are out there that can actually make a difference for people with DCD?

One approach that has a lot of evidence behind it is task oriented training.

Okay. What's that?

So, basically it involves breaking down complex movements into smaller, more manageable steps. and then practicing those steps over and over again in a really structured and supportive environment. And the cool thing is that you can really tailor this type of training to the individual's needs and goals.

So like for a kid who's struggling with handwriting, it might be practicing how to form letters correctly or working on their pencil grip.

And for an adult who's learning to drive, it might be practicing specific maneuvers like parallel parking.

Okay, so it's all about creating a personalized road map for each person.

And this is where Allied health professionals like occupational therapists and physical therapists can be so helpful,

right? Because they're the experts in movement and coordination.

OT's can help kids develop the fine motor skills they need for everyday tasks like getting dressed or eating.

And PTS can focus on the bigger movements like walking and running.

And beyond direct therapy, there are other strategies that can make a difference

like what?

Well, things like assistive devices.

Okay.

So, for example, a kid who has trouble gripping a pencil might benefit from using a special pencil grip.

Oh, that makes sense.

Or someone who struggles with typing might find it easier to use a keyboard with larger keys.

Right. So, it's all about leveling the playing field.

Exactly. Giving people with DCD the tools they need to succeed.

Yeah. We can also modify the environment to make things easier.

Absolutely.

Yeah.

So, for example, if a child is having trouble seeing the board at school, we can move their desk closer to the front.