Dyspraxia

What is dyspraxia?

Dyspraxia or, as it is often known, developmental coordination disorder is an impairment or difficulty in the development of coordinated movement (motor coordination) to a degree that interferes with academic achievement and/or daily living.

Children with dyspraxia are characterised by marked delays in the development of ‘motor milestones’. For example, they are slower than other children in learning:

• to sit, crawl, walk

• to develop ball skills and other sport-related activities

• to master coordinated skills such as riding a bicycle

• to achieve fluent, legible handwriting.

A child with dyspraxia experiences difficulty learning such skills to a degree that is significantly greater than would be expected for other children of a similar age.

Case study: Christopher

Christopher is seven now, and just about to start junior school. We’ve always been worried about him, nothing you could put your finger on, just vague things that didn’t seem quite right.

I still remember, as he was rushed out of the delivery room, one of the hospital staff whispering on the internal phone that Christopher had ‘breathing difficulties’. As it turned out he was in an incubator for two weeks.

His weight had dropped in the first week and he was fed using a nasogastric tube but, after about two weeks, he came out of the incubator and we tried to feed him using a bottle. Trouble was he seemed only able to take small amounts, so little that I had to feed him every two or three hours.

As a baby he wasn’t like his older brother. Christopher always seemed to be irritable, constantly crying. The only time he seemed to stop was when he was being carried and rocked or was in his carrycot in the car.

During his first year, things sometimes got so bad that either his dad or I resorted to taking him out in the car just so we could get some peace!

He seemed to be much slower than his brother at things like sitting and walking, and he never crawled, just seemed to leave that out completely. He sort of bum-shuffled by pushing himself along on his bottom with his legs. I remember how he liked being in the kitchen, because he could push himself around on the shiny floor, which he couldn’t do on the lounge carpet.

His brother had been walking by about 11 months but Christopher didn’t learn to walk until way past his second birthday. Feeding him was a nightmare; up till the age of three I had to liquidise everything; anything solid and he just spat it out, almost like he couldn’t chew.

But in some areas he seemed much quicker than other children. He was able to respond to his name at about eight months, which was much quicker than his brother, and he recognised family relatives and friends by smiling or reaching out to them well before the age of ten months.

By 18 months he was fascinated by children’s books and when I turned the pages of his favourite book he was even able, without me prompting him, to make the sounds of the animals like ‘moo’ for the cow and ‘hee-haw’ for the donkey.

Even though he obviously loved the book, by the age of two years he still couldn’t turn the pages by himself, just couldn’t seem to master the business of using his thumb and forefinger to grip a single page and then turn it.

At age three and four, he seemed to have little difficulty in understanding what was said to him, but often seemed to have great difficulty speaking clearly. His brother and I were sometimes the only people able to understand what he was saying. Even his dad had difficulty.

Words were often jumbled, such as when he wanted a particular children’s video he might ask for ‘Builder the Bob’ or when trying to say long words like spaghetti or elephant they would come out as ‘pasgetti’ or ‘ephelant’.

It was when he went to nursery school that I began to notice big differences between Christopher and the other children. Alongside other children he looked awkward. When he walked, his gait looked unbalanced, like a much younger child, especially if he was in a hurry to do something, or excited.

He was always bumping into the other children or tripping over things. Even at the age of four to five years he always had to be taken to the toilet, because he still couldn’t pull his trousers up and down properly by himself.

This became more and more of a problem because he began to get upset about going to the toilet in the nursery, and for a long time would only use the toilet at home. He never used climbing frames and often ended up crying and frozen to the spot even when on just the second or third rung of the ladder on the slide in the playground.

Every time all the children went out into the playground or it was time to go home, one of the nursery staff always had to help Christopher put on his coat. At home and in shops, he always walked downstairs sideways, one step at a time. Getting on and off escalators is still a problem and, remember, he’s seven now.

He’s still always dropping things, knocking over cups, leaving food spread all around his plate. He has never seemed to be able to control a pencil as well as other children of his age; he never enjoyed colouring or scribbling games.

At school, unless they force him, he refuses to join in any activities involving pens, coloured pencils, paintbrushes or anything like that.

He never seems to like being in the company of other children. The funny thing is he has always really liked being with adults; even at school he still often ends up trailing around behind the teachers at play time.

They like his company and tell me he often says things, and knows things, well in advance of his age. The most frequent phrase I hear his teachers say about him is: ‘He’s a right little puzzle isn’t he?’

As with many developmental disorders, the needs of a pupil with dyspraxia are different at each stage of education. This is well illustrated by David’s mother’s story.

Case study: David

David is aged 12 years, just finishing his first year at secondary school. He’s come to hate going to school, some mornings even pretending to be ill to try to get out of going.

It’s really strange in some ways, because he’s a bit of a bookworm and spends most of his time reading, mainly factual books. At the moment he reads everything he can about the life of sea animals such as sharks, whales, sea lions, dolphins, etc.

Although he reads a lot, he gets low marks for almost everything he does at school, mainly because his handwriting is terrible. I remember when he was in the infants and early years of the junior school, he tried very hard at his writing, but he’s now all but given up. On some days he can’t even write his name legibly.

Oddly enough his spelling is pretty good, but only if you ask him to spell it out by saying the letters. Ask him to write it down and you won’t be able to read it. It’s not just that individual letters are the wrong shape, he often writes letters in words so they overlap and very often he can’t keep letters on a line.

He’s even been known to keep writing until his pen slips off the edge of the page. In his school books, the first few lines of an exercise might be just legible but the rest of it will be a complete mess.

All his schoolbooks look like they’ve been written in by someone who has no persistence, loses interest quickly, doesn’t care, is lazy and not very bright. When he’s asked to write something nobody can read it and, more often than not, he can’t even read it himself.

In class his teachers say he answers questions better than most of the other kids; everybody knows he’s clever. But ask him to write anything down and it’s hopeless, completely illegible.

A lot of his teachers in the secondary school, particularly those who only see him once or twice a week, simply think he’s not trying very hard. But I’ve seen him crying at home just trying to get his homework done, particularly when he’s interested in the subject.

A lot of his teachers give him low marks all the time; they cover his exercise books with comments that are different ways of saying ‘must try harder’.

It’s a bit of a self-fulfilling prophecy in the sense that, when it comes to writing or homework, David does everything he can to get out of it, delay it or finish it quickly with the minimum effort. Now he’s in secondary school, his teachers’ comments, sadly, contain more than just a grain of truth.

When he’s writing, David looks awkward, even the way he sits. He looks tense, his feet are often crossed, sometimes seeming to even grip one of the chair legs. He holds the pencil almost in his fist, rather than his fingers, and seems to literally ram it into the paper.

When he was younger, he tried so hard that he sometimes bit his lip until it bled but he hasn’t tried that hard in a long time. Not since he realised that no matter how hard he tried, his writing was always bad. His classmates took to calling him ‘geek’.

David has always been the last into and out of the school changing rooms. In the junior school he once put his football boots on the wrong feet, a mistake that one of the other boys noticed in the middle of a game and pointed out to everybody else in a loud, clear voice. David ran off the field in tears and the teacher had to coax him out of the toilet cubicle where he’d locked himself.

When David leaves a changing room after a game or at the swimming pool, his shirt buttons are often done up in the wrong order, his shoe laces undone and he’s long since given up trying to reknot his school tie. He acutely feels this loss of face to a degree where he has taken to forging his own ‘sick notes’ to get out of games and swimming.

In the school playground, David never tries to play with other children. He always seems to be hovering on the outskirts of any game or a crowd of boys, sort of present but not playing or being part of the group.

He used to try to join in but when they picked teams, he was always the last to be chosen, and often even that was after a loud discussion among the better players as to which side should be ‘handicapped’ by having David in their team.

Outside school, David does not join in with other children because he can’t really ride a bike or use a skateboard, at least not like the other kids. When he’s on a skateboard, he’s a positive danger to himself and other people.

When he was nine we took him on a skiing holiday but he spent almost every day in tears of frustration on the nursery slopes, pretending to be injured or, on the last day, refusing to leave the hotel room.

In conversation with adults, though, David is a different boy: quick-witted and clever. In his efforts to gain popularity with his peer group, he often misjudges how caustic some of his comments can be and some of the targets of his humour strike back, physically.

It is difficult to judge whether this is bullying because in the inevitable ‘he-said-I-said’ enquiry by teachers or us, David has often had to admit that some remark he’s made, although both clever and funny to everybody else, is often very upsetting to the person on the receiving end.

As parents, we are becoming worried that he’s now almost isolated among his peer group. He rarely leaves the house after school and seems to have no real friends. He tends to spend his life curled up with a book or watching videos on his own.

Only this month, I’ve twice found him crying in his room. When I ask him why he just says, ‘I’m a useless geek’ but won’t explain further.

Diagnosis of dyspraxia

If you think that your child shows signs of dyspraxia, the first step is to contact your family doctor who may refer your child to an appropriately qualified medical professional, usually a paediatrician and/or an occupational therapist.

Causes, incidence and long-term consequences of dyspraxia

Causes

The exact causes of dyspraxia are not yet fully understood. It is thought to be underpinned by poor or slow development of those areas of the brain involved in performing sequences of coordinated muscle movements (motor movements), for example, the coordination required in catching and throwing a ball, riding a bicycle, using a computer ‘mouse’ and handwriting.

There is no good research evidence to suggest that it is caused by environmental factors such as poor diet, pollution or immunisations.

Incidence

During the past decade, developmental dyspraxia has come to be known as the ‘hidden handicap’ because it is often more difficult to diagnose than many of the other disorders of childhood. Developmental dyspraxia affects between two and five per cent of the population with a ratio of four boys to every girl.

Long-term consequences

There is general consensus that dyspraxia is a life-long condition. There is no research that shows that it can be ‘cured’. However, evidence from many clinicians and parents shows that early therapy reduces the levels of distress caused by many of the symptoms.

After adolescence, movement difficulties become less problematic, if only because, as an individual matures, he becomes more able to cope. For example, after schooling, the individual can ‘choose’ whether or not to take part in particular sports and avoid, or at least limit, his need to engage in tasks that require a particularly high degree of coordination.

However, anecdotal biographical evidence suggests that it is not unusual for someone with dyspraxia to continue to show a range of emotional problems, such as low self-esteem, into adulthood. This seems to come from living a childhood in which he came to believe that he was ‘poor at almost everything’.

What is it like to have dyspraxia?

One way of explaining this to an adult who has no difficulties in motor planning is to describe the motor movements involved in a relatively common event such as picking up a wine glass when being offered a drink.

Using motor planning to pick up a wine glass

Imagine you are at a party and that in front of you is a tray of wine glasses standing, as is often the case, upside down (with the stems uppermost). Now assume that your host is walking towards you with a bottle of wine and offers you a drink, which you accept. Just think through what usually happens as you pick up the wine glass.

If you’re right-handed, you’ll use this arm and hand to reach towards the stem of one of the wine glasses. Most people will then rotate their right arm and wrist anticlockwise until the hand is almost upside down before pinching the stem of one of the wine glasses between the finger and thumb.

Then, as the glass is lifted, the wrist is turned clockwise in a smooth movement. This ensures that, by the time the movement is finished, the glass is in an upright position ready for the wine to be poured.

The whole action is completed in one smooth movement, all of which is planned automatically and without conscious thought as you first reached for the glass. It is unlikely that anybody taught you how to do this – you do it naturally.

But think it through again and, if you can, try it with a wine glass. The movement is actually very awkward at the start. You turn your wrist right over.

However, this is because you are adept at motor planning. You automatically knew the best lifting action to make sure that the glass was in the correct position when it came to pouring the drink. You do not have a motor planning difficulty.

What would that be like if you had dyspraxia?

A person with dyspraxia finds such motor planning difficult. It does not necessarily mean that he will drop the glass or even look terribly awkward. The likelihood is, however, that the person with dyspraxia will first pick up the glass in one hand, then use both hands to turn it over, before holding it out with one hand ready for the drink to be poured.

How your motor planning is affected by your skill level

This might seem a very rare example of motor planning using a task that doesn’t happen very often, unless of course you go to a lot of parties! But let’s take another example.

Imagine the day that you passed your driving test. Immediately after you had passed your driving test, if a friend had been in the car with you the likelihood is that your friend would have looked at your driving and commented on how good it was.

For example, before pulling away from the kerb-side, because these things were fresh in your mind, you would have looked in the mirror, let off the handbrake, operated the indicator, placed the car in gear and moved slowly and safely away. For the next few miles your friend would have been impressed with your driving skill.

Now imagine that your friend had then begun to engage you in a deep conversation that required you to think. Eventually you would probably have told your friend, possibly in an exasperated voice, to be quiet because you needed to focus on your driving.

This would have been because, at that time, your driving skill was in a state where you needed to think about the movements that you were making. Listening and responding to your friend would simply have got in the way.

There is no doubt that, if you have been driving for a few years, you can now drive automatically in the sense that you have no difficulty carrying on a conversation and moving the steering wheel appropriately while at the same time manipulating the clutch, gears and accelerator, noticing the cyclist behind you, the bus in front beginning to pull out and the traffic lights changing 50 metres ahead.

What would that be like if you had dyspraxia?

A person with dyspraxia may learn to drive, and be able to drive perfectly safely, but may not perform driving actions completely automatically. So as an example, an adult with dyspraxia may not feel comfortable talking and driving.

How are other tasks affected?

Now think about the many skilled planned movements that you make every day: doing up shoelaces, washing and drying up dishes, ironing clothes, manipulating pots and pans while cooking. The magic is that most of us can do these tasks automatically, even while we are thinking of something else.

The likelihood is that an adult with dyspraxia will also be able to do all these tasks, but has to think about it, focusing on it rather more than we do.

If he is in a conversation or thinking about something else, it is at that point that he is likely to make a mistake.

What’s it like for a child with dyspraxia?

Now transfer this kind of thinking to a child with dyspraxia:

• A seven year old won’t be able to do up the laces on a pair of trainers while at the same time talking to other people in the changing room.

• A nine year old may not be able to pour milk from a carton into a glass while at the same time watching a video.

• A twelve year old won’t be able to write legibly when answering an exam question while worrying about the time limit.

It’s hard to do two things at once

People with dyspraxia have difficulty with motor planning, which means that they may learn to perform a task effectively but may still have difficulty performing the task automatically. To put it in cartoon form: a person with dyspraxia can walk and talk – but if walking down a street and talking at the same time, may walk into a lamp post!

For a person with dyspraxia, the difficulty with motor planning will pervade almost every aspect of everyday life.

KEY POINTS

n    The causes of dyspraxia are unknown

n    Approximately five to seven per cent of children are dyspraxic with a boy to girl ratio of four to one

n    Children with dyspraxia are slow to develop motor milestones – for example, sitting up, crawling, running

n    Children with dyspraxia have difficulty planning motor movements – for example, difficulties with dressing skills, ball skills and handwriting

n    Children with dyspraxia often lack self-esteem

n    Children and adults with dyspraxia often have difficulty doing two things at once – finding it hard to combine physical activity with a task requiring thought