Seminar 4 –
McMaster University, Ontario, Canada
New models for changing the environment, not the child
Over the years, we have seen the development and evaluation of many different approaches to intervention for children with developmental coordination disorder (DCD). Some of the early models such as sensory integration (Ayres, 1972; Ayres, 1979), kinaesthetic training (Laszlo & Bairstow, 1985; Laszlo, Bairstow, Bartrip, & Rolfe, 1988), and perceptual motor intervention (Lord & Hulme, 1987a; Lord & Hulme, 1987b) have been referred to as process-oriented or “bottom up” approaches (Mandich, Polatajko, Macnab, & Miller, 2001). In the past decade, task-oriented or “top down” approaches have received increasing emphasis in the literature. Examples of these include the cognitive motor approach (Henderson & Sugden, 1992), task-specific intervention (Revie & Larkin, 1993), Cognitive Orientation to Occupational Performance(Polatajko et al., 2001; Polatajko, Mandich, Miller, & Macnab, 2001), and imagery training (Wilson, Thomas, & Maruff, 2002). All of these approaches share one similarity . . . the emphasis of the intervention is upon producing change in the child.
There are several reasons why, in the new millennium, we need to be developing and researching models of intervention that do not presume to create change in the child but, instead, focus solely on changing the environment. Firstly, the high prevalence of DCD means that waiting lists for services are ridiculously long. Recent studies have illustrated that, in any given healthcare region, hundreds of children may await assessment for up to four years (Dunford, Street, O'Connell, Kelly, & Sibert, 2004; Peters, Henderson, & Dookun, 2004). Even if the focus of intervention is on mediator training (e.g., Sugden & Chambers, 2003), we will never be able to shorten waitlists if children are focused on individually and seen one at a time.
Secondly, we have evidence from parents of children with DCD that, once the child enters the school system, coordination difficulties are not of paramount concern. Parents are worried about the secondary consequences of motor incoordination – the impact on academic performance, social participation, self-esteem, and emotional health (Missiuna, Moll, King, King, & Law, in press). While the underlying motor impairment of children with DCD is unlikely to be modifiable, these secondary issues may be able to be prevented.
Finally, a study of ten “resilient” young adults with DCD has shown that, when they reflect back on their childhood and adolescence, they do not focus on coordination issues. Coordination difficulties impacted upon them in very specific contexts. What successful young adults recall are the accommodations that were helpful - at home, at school and in the community - and the people who supported them (Missiuna, Moll, King, Stewart & Macdonald, in preparation).
The ICF model challenges us to move from a focus on impairment, or activity limitation, to an emphasis on improving participation as the outcome of our intervention. The studies in the research program that I will describe are designed to address the relationship between factors in the environment and their impact on children’s participation.
Four studies will be outlined briefly as they are helping us build toward a new model in which education of people in the child’s environment is the intervention.
Study 1: Assisting Parents Waiting for Therapy (Missiuna, Pollock & Russell, ongoing)
A workshop was designed and developed that can be provided to parents whose children have been referred for services. Experienced parents identified what they would have wanted to know when their child was first identified as having DCD. A workshop was developed, tested with this expert group and then pilot-tested with parents of children who are newly-identified. The workshop contains an overview of evidence-based information about DCD and then helps parents understand the reasons why certain activities are more difficult for their child. A problem-solving approach (Missiuna, Pollock & Rivard, 2004) is introduced and suggestions are made to empower parents to advocate for their child. The desired outcomes of this intervention are change in parent knowledge and empowerment.
Study 2: Promoting inter-disciplinary identification and improved service delivery for children with DCD and their families (Gaines, Missiuna, Egan and McLean, ongoing).
This study focuses on education of the individuals to whom parents first take their child – family physicians. The goal of the project is twofold: to educate physicians so they are better able to identify children with DCD and to have family physicians provide educational material to families as the “intervention”. Traditional and innovative methods of knowledge transfer are being examined. The desired outcomes are physician and parent knowledge and empowerment.
Study 3: Developmental coordination disorder: examination of a feasible screening and intervention (Hay, Cairney, Mandigo, Owen, Calzonetti & Missiuna, ongoing).
Moving the focus of intervention into the school system, this project is a very large study in which children are screened at a population level for decreased participation in physical activity, as reported by the child. Children who score in the bottom 10% are tested further in order to determine whether or not they have motor impairment. General educational materials about DCD and about promoting participation in physical activity are provided to parents and teachers of these children. Target outcomes are change in parent knowledge, child fitness levels and participation.
Study 4: Enhancing participation through knowledge transfer: A model for children with DCD (Missiuna, Law, Russell & Magalhaes, ongoing).
While general education of parents, teachers and physicians is useful, children sometimes require more individualized intervention. In contrast with models of direct intervention or mediator training, this study examines a purely consultative model in which the target of the intervention is the parent and teacher. Following confirmation of the presence of DCD, the therapist works with the child, parent and teacher to identify current issues. Using the MATCH strategy (Missiuna et al., 2004), parents and teachers learn to problem-solve in a collaborative way to determine effective solutions. Measured outcomes are parent and teacher knowledge and empowerment.
The desired outcomes of task-specific intervention are skill acquisition; cognitive approaches add an emphasis on the transfer and generalization of these skills; accommodation of the task and the environment encourages the child’s participation; education of persons in the child’s environment is designed to empower the child and family to manage throughout life. All four types of intervention may be required at some point in time. When the emphasis of the intervention is on creating change in the environment, there is very little assessment of the child and post-intervention measures focus on change in knowledge, empowerment, advocacy, dissemination of information to others and prevention of secondary consequences through participation.
So, how does this help with lengthy waitlists? It is time for us to move toward a cascade model that focuses on health promotion. If parents, teachers and healthcare professionals become more knowledgeable about children with DCD, they will be identified earlier and have accommodations provided that prevent deterioration in academic performance, behaviour, self-esteem, physical and emotional health. Some children may still require group intervention that utilizes cognitive and motor learning principles. A few children who have comorbid conditions or challenging family situations may require direct intervention. The types of models that are illustrated represent our preliminary thoughts, based on the evidence that we have gathered thus far. Much more research will be needed! I am grateful to the funders of these studies, and to my colleagues who are outlined on the final slide of this presentation.
1. Ayres, A. J. (1979). Sensory integration and the child. Los Angeles: Western Psychological Services.
2. Ayres, A. J. (1972). Sensory integration and learning disorders. Los Angeles: Western Psychological Services.
3. Dunford, C., Street, E., O'Connell, H., Kelly, J., & Sibert, J. R. (2004). Are referrals to occupational therapy for developmental coordination disorder appropriate? Archives of Disease in Childhood, 89(2), 143-147.
4. Henderson, S. E., & Sugden, D. A. (1992). Movement assessment battery for children. London: The Psychological Corporation.
5. Laszlo, J. I., & Bairstow, P. J. (1985). Perceptual motor behaviour: Developmental assessment and therapy. London: Holt, Rinehart and Winston.
6. Laszlo, J. I., Bairstow, P. J., Bartrip, J., & Rolfe, V. T. (1988). Clumsiness or perceptuo-motor dysfunction? In A. Colley, & J. Beech (Eds.), Cognition and action in skilled behaviour (pp. 293-316). Amsterdam: North Holland.
7. Lord, R., & Hulme, C. (1987a). Kinaesthetic sensitivity of normal and clumsy children. Developmental Medicine and Child Neurology, 29, 720-725.
8. Lord, R., & Hulme, C. (1987b). Perceptual judgement of normal and clumsy children. Developmental Medicine and Child Neurology, 29, 250-257.
9. Mandich, A. D., Polatajko, H. J., Macnab, J. J., & Miller, L. T. (2001). Treatment of children with developmental coordination disorder: What is the evidence? Physical & Occupational Therapy in Paediatrics, 20(2-3), 51-68.
10. Missiuna, C., Moll, S., King, G., King, S., & Law, M. (in press). A troubling trajectory: The impact of coordination difficulties on children's development. Physical and Occupational Therapy in Paediatrics.
11. Missiuna, C., Pollock, N., & Rivard, L., (2004). They’re bright but can’t write! Developmental coordination disorder in school aged children. TEACHING Exceptional Children Plus, 1(1), Article 3 (10 pages). Also available at www.fhs.mcmaster.ca/canchild/
12. Peters, J. M., Henderson, S. E., & Dookun, D. (2004). Provision for children with developmental co-ordination disorder (DCD): Audit of the service provider. Child: Care, Health and Development, 30(5), 463-479.
13. Polatajko, H. J., Mandich, A. D., Miller, L. T., & Macnab, J. J. (2001). Cognitive orientation to daily occupational performance (CO-OP): Part II--the evidence. Physical & Occupational Therapy in Paediatrics, 20(2-3), 83-106.
14. Polatajko, H. J., Mandich, A. D., Missiuna, C., Miller, L. T., Macnab, J. J., & Malloy-Miller, T. et al. (2001). Cognitive orientation to daily occupational performance (CO-OP): Part III--the protocol in brief. Physical & Occupational Therapy in Paediatrics, 20(2-3), 107-123.
15. Revie, G., & Larkin, D. (1993). Task specific intervention with children reduces movement problems. Adapted Physical Activity Quarterly, 10, 29-41.
16. Sugden, D. A., & Chambers, M. E. (2003). Intervention in children with developmental coordination disorder: The role of parents and teachers. The British Journal of Educational Psychology, 73(Pt 4), 545-561.
17. Wilson, P. H., Thomas, P. R., & Maruff,
P. (2002). Motor imagery training ameliorates motor clumsiness in children.
Journal of Child Neurology, 17(7), 491-498.