張淑峯 物理治療師 台東榮民醫院 復健科暨兒童早療 2005/10/25 發展性協調障礙兒童 張淑峯 物理治療師 台東榮民醫院 復健科暨兒童早療 2005/10/25

發展性協調障礙 (Developmental coordination disorder, DCD) A term first being used in the International Consensus Conference on Children and Clumsiness (1994) to describe the condition of children with motor incoordination. (Barnhart et al. 2003)

Various Terms Used in Different Countries Minimal Neurological dysfunctions. (Australia) Specific developmental disorder of motor function. (SDD-MF) (UK) Developmental dyspraxia (New Zealand) Dyspraxia (Italy) Deficits of attention, motor control and perception. (DAMP) (Sweden) Physical Awkwardness. (Canada) DCD (Holland, USA) (Henderson and Henderson, 2001)

大腦的分葉 額葉: 運動 頂葉: 聽覺、嗅覺 顳葉: 本體覺、 觸覺 枕葉: 視覺

動作協調 平順、有目標性、正確的粗動作或精細動作需倚賴以下器官的功能協調，才能完成具力量、速度及平衡的一系列動作。 1. 感覺輸入器官 2. 腦部訊息處理中樞及功能執行中樞 3. 骨骼關節及肌肉群 (林宏琪醫師，2005)

動作協調 1. 感覺輸入器官： 視覺 本體感覺(運動覺)， 末梢前庭器官 2. 腦部訊息處理中樞及功能執行中樞 大腦運動皮質區，小腦，前庭系統 動作計畫能力(motor planning) *執行動作的策略意象 * 執行中視覺監視、反應選擇，動 作自我修正 (林宏琪醫師，2005)

動作協調困難 Clumsy: 動作笨拙，不靈活 Dyspraxia (動作形成不良)：無法執行符合年齡的複雜協調性動作，同時並無合併動作或感覺器官受損。 Apraxia(失用症、運用不能)：大腦平質受損 (林宏琪醫師，2005)

The Diagnosis of DCD DSM-IV (Diagnostic Statistical Manual of Mental Disorders, 1994) Criteria: 1. Motor impairment interferes with the child’s activities of daily living. 2. The motor Impairment must not be caused by or have the symptoms of an identifiable neurological problems. 3. If mental retardation is present, the testable IQ of the child must be greater than 70 and the motor impairments must be greater than what would normally be expected for children with mental retardation. 4. A child diagnosed with DCD must not meet the criteria for a diagnosis of pervasive developmental disorder. (Barnhart, et al, 2003)

Difficulty in Diagnosing DCD Co-occurrence with other problems. AD/HD Dyslexia DCD Autism Learning disability

The Diagnosis of DCD DSM –IV Text Revision (2000) recommends use of clinical judgment rather than the mechanical application of the criteria. (Miyahara and Wafer, 2004)

DCD Prevalence Usually identified in Children between 6 to 12 years of age. 5% and 8% of all school-aged children. More boys than girls (2:1) DCD may be found among children with a history of prenatal or perinatal difficulties. (Barnhart, et al, 2003)

DCD Prevalence After tested 1188 Taiwanese school-aged children, Wu found: 1. 3.5% of DCD rate in 7-8 years old students. 2. 20.6% of DCD rate in 9-10 years old students. (謝秋雲，1992)

Etiology of DCD Clear etiology remains unknown. Several theories: 1. Damaged at the cellular level in prenatal stage. 2. Abnormalities in neurotransmitter or receptor systems. (Barnhart, et al, 2003)

Etiology of DCD 3. Automatization Deficit Hypothesis * Based on research of dyslexia. * Fluent reading and the smooth control of (particularly rapid) movement both depend heavily on learning and eventually, automatization. A lock of automatization will cause difficulties in both areas, even if a child has normal or above normal intelligence. (Visser, 2003)

DCD: Associated problems in attention, learning, and psychosocial adjustment Dewey, Kaplan, Crawford and Wilson (2002) studied 55 DCD children and 51 suspected DCD children comparied with 78 children without motor function difficulties. Result: DCD and suspected DCD children obtained significantly poorer scores on measures of attention and learning (reading, writing and spelling) than comparison children. They also have high level of social problems and display a relatively high level of somatic complaints based on parent report.

Psychosocial implication of poor motor coordination in children and adolescents Subjects: a group of children aged 8-10 years, and a group of children 12-14 years compared with control groups. Results: 1.DCD groups had lower self-worth and higher level of anxiety than the control groups. 2. Adolescents appear to be more disadvantaged socially and emotionally, perceiving less social support and experiencing more anxiety than younger children. (Skinner and Piek, 2001)

Classification of DCD: Hoare (1994) used measurements of visual perception, visuomotor integration, manual dexterity, kinesthetic acuity, balance and running speed found 5 subtypes. Dewey and Kaplan (1994) used balance, bilateral coordination, upper limb coordination, transitive gestures, and motor sequencing and ended up with 4 subtypes. Miyahara using running speed, agility, balance, strength, upper limb speed, and dexterity found 4 subtypes. One common result: the emergence of a subtype characterized by difficulties on all sensorimotor measures. (Visser, 2003)

Movement Assessment Battery for Children (M-ABC) A screening test for the assessment of motor function in children aged 4-12 years. There are 4 age bands, 4-6y., 7-8, 9-10 and 11-12y. A total of 8 items, 3 in manual dexterity, 2 in ball skills and 3 in static and dynamic balance. Each item is scored from 0-5. The maximum total score is 40, with the higher scores indicating lower motor competence. Total impairment scores at the 5th percentile or more indicate definite motor difficulties, and scores between 5th and 15th percentiles indicate borderline motor difficulties.

Intervention: General Ability approach Theory: This approach Implies that age-appropriate reflexes, postural reactions and perceptual-motor abilities all underlie functional motor skills and conceptual development. Intervention: Facilitation of balance and other physical abilities and training in specific perceptual and motor tasks.

Sensory integration (SI) Approach Theory: It assumes that development of cognition, language, academic, and motor skills depend on sensory integrative ability. Children with sensory-motor problems are believed to be inadequately oriented to their physical environment and need help in making adaptive response to improve the brain process and to organize sensory input.

Sensory integration Approach Intervention: Proprioceptive, tactile, and vestibular stimulation activities that consist of full body movements and training in specific perceptual and motor skills. Result: No clear improvement has been found.

Specific Skills Approach Theory: It suggests that specific motor control and motor learning processes underlie skilled movement. These processes all involve the interaction of genetic and experiential factors. Intervention: Correct functional skills performance, appropriate repetition, and sufficient guidance and time to facilitate skill retention and generalization. (Pless & Carlsson, 2000)

Motor Skill Intervention on DCD It is most effective when: Children with DCD over age 5. The specific skill theoretical approach. Intervention conducted in a group setting or as a home program. Intervention frequency of at least 3 to 5 times per week. (Pless & Carlsson, 2000)

Intervention in DCD children: The role of parents and teachers Sample: 32 children with DCD aged 7-9 years participated in the study. Methods: Following assessment, individual profile were developed and each week teachers and parents were given guidelines for working with the children and each child had 3 to 4 sessions a week lasting appraximally for 20 minutes. Results: At the end of the 40 weeks study, 27 children showed significant improvement in their motor skills. (Sugden and Chambers, 2003)

Diet Intervention Approach Theory: A relative lack of certain polyunsaturated fatty acids may contribute to related neurodevelopmental and psychiatric disorders such as dyslexia and AD/HD. Methods: A randomized, controlled trial of dietary supplementation with w-3 and w-6 fatty acids, compared with placebo, was conducted with 117 DCD children (5-12 years of age). Result: 1. No effect on motor skills. 2. Significant improvement in reading , spelling, and behavior . Conclusion: Fatty acid supplementation may offer a safe efficacious treatment option for educational and behavioral problems among children with DCD. (Richardson and Montgomery, 2005)

DCD Prognosis-Motor Aspect At a population-based screening of 5-6 yrs old children, 37 children were identified as DCD, when reexamined in 7-8 y old, most children with definite motor difficulties continue to have such difficulties. (Pless et al, 2002)

DCＤ Prognosis-Psychosocial Aspect Without intervention, the long term consequences of DCD include the problems of self-esteem, peer relationships, loneliness, depression, and educational underachievement. (Henderson and Henderson, 2001)

DCD Prognosis-As Adolescent Two results: Children with more severe symptoms it well persist. Children in less serious cases it tends resolve itself. * Majority of children with DCD went on to vocational training rather than high school. (Cantell et al, 2003)

DCD Prognosis-As Adults Adults with DCD continue to have difficulties in daily activity, which may limit their ability to drive. (Cousins & Smyth, 2003)

專業人員的角色 幫助家長及兒童了解自己的權益，協助孩童找出有效的代償方式來參與活動。 找出預防功能限制(functional limitations)的方式，以避免進一步的障礙(disability)產生。 降低孩童參與活動的困難度並鼓勵與同儕互動。 協助家長了解孩童的動作限制以避免不蕩的期待。 (David, 1995)

專業人員介入策略 直接治療 間接治療 諮詢

諮詢 環境 協助孩童應付環境變化的需求。 協助提供服務者(如：老師)在孩童的動作障礙與功能性代償技巧間取得平衡。 協助學校老師對孩童建立適合的期望並符合學校環境的需求。

課程設計的原則 在課程中讓別的孩子一起加入，以增加同儕的支持。 課程中的活動應以合作性取代競爭性。 課程中加入與韻律有關的活動。 選擇適合年齡的活動，但遊戲規則可以依照孩子的程度加以改變。 除了讓兒童練習不會做的項目之外，也必須練習已經會做的活動以增加自信心。

課程設計的原則 訓練的時間不宜過長。 將活動分成小步驟 讓孩子以自己的速度練習，不要在一旁催促。 針對特定的目標練習，如穿脫衣物、丟接物等日常生活的活動。

  對於教師來說， 他們「所面臨的最緊迫的任務就是 去了解這個尚未被認識的兒童， 並把他從所有的障礙中解放出來。」 蒙特梭利

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References Cousins, M.,Smyth, M.M. (2003), Developmental coordination impairement in adulthood. Human Movement Science 22, 433-459 David, K.S. (1995) Developmental coordination disorders . In Campbell, S.K. (Ed) Pediatric Physical Therapy for Children (pp. 425-458). Philadelphia W. B. Sauder Co. Dewey, D., Kaplan, B.J., CrawfordS. G., and Wilson , B.N.(2002). Developmental coordination disorder: Associated problems in attention, learning , and psychosocial adjustment. Human Movement Science 21, 905-918 Gillberg, C.,(2003), Emerging Evidence that AD/HD and DCD Interact Multiplicatively. Child and Adolescent Mental Health . 8, No. 3, p117. Henderson, S.E. and Henderson(2001,July). Toward an understanding of Developmental Coordination Disorder. The Second G. Lawrence Rarick Commemorative Lecture 2001. Presented at the 13th International Symposium for Adapted Physical Activity. July 3-7, 2001, Vienna, Austria. Macnab, J.J. Miller, L.T. Polatajko, H.J. (2001). The search for subtypes of DCD; is cluster analysis the answer? Human Movement Science. 20, 49-72. Pless, M., Carlsson, M. Sundelin, C. and Persson, K. (2002). Preschool children with developmental coordination disorder: a short-term follw-up of motor status at seven to eight years of age. Acta Padiatr 91, 521-528. Pless, M., and Carlsson, M. (2000). Effect of motor skill intervention on developmental coordination disorder: A Meta-Analysis. Adapted Physical Activity Quarterly. 17, 381-401.

References Skinner, R.A. and Piek, J.P. (2001). Psychosocial implications of poor motor coordination in children and adolescents. Human Movement Science. 20, 73-94. Richardson, A.J. and Montgomery, P. (2005). The Oxford-Durham Study: A randomized, controlled trial of dietary supplementation with fatty acids in children with developmental coordination disorder. Pediatrics, 115, 1360-1366. Sonuga-Barke, E.J.S., (2003). On the intersection Between AD/HD and DCD: The DAMP Hypothesis. Child and Adolescent Mental Health . 8, No. 3, 114-116. Sugden, D.A .and Chambers, M.E.(2003), Intervention in children with Developmental Coordination Disorder: The role of parents and teachers. British Journal of Educational Psychology ,73, 545-561. Visser, J. (2003). Developmental coordination disorder: a review of research on subtypes and comorbidities. Human Movement Science 22, 479-493. 林宏琪(民94). 發展性協調障礙─神經科醫師的看法。發展性協調障礙學術研討會暨個案討論會，九十四年台北市早期療育相關人員培訓課程。 謝秋雲 (民92)。 我國八歲至九歲學童動作協調能力之一年追蹤研究。 國立台灣體育學院體育研究所碩士論文，未出版。