Apraxia

Definition

Apraxia is neurological condition characterized by loss of the ability to perform activities that a person is physically able and willing to do.

Description

Apraxia is caused by brain damage related to conditions such as head injury, stroke, brain tumor, and Alzheimer's disease. The damage affects the brain's ability to correctly signal instructions to the body. Forms of apraxia include the inability to say some words or make gestures.

Various conditions cause apraxia, and it can affect people of all ages. A baby might be born with the condition. A car accident or fall that resulted in head trauma could lead to apraxia.

From 500,000 to 750,000 people need to be hospitalized each year for head injuries according to the American Medical Association (AMA). Men between the ages of 18 and 24 form the largest group of people with head injuries. While not all severe injuries result in apraxia, men in that age group are at risk.

Risk factors for strokes include high blood pressure, diabetes, and heart disease. Cigarette smoking also puts a person at risk for a stroke. Brain tumors are abnormal tissue growths in the skull. They may be secondary tumors caused by the spread of cancer through the body.

There is more than one type of apraxia, and a person may have one or more form of this condition. Furthermore, a milder form of apraxia is called dyspraxia.

Causes and symptoms

Apraxia is caused by conditions that affect parts of the brain that control movements. Apraxia is a result of damage to the brain's cerebral hemispheres. These are the two halves of the cerebrum and are the location of brain activities such as voluntary movements.

Apraxia causes a lapse in carrying out movements that a person knows how to do, is physically able to perform, and wants to do. A person may be willing and able to do something like bathe. However, the brain does not send the signals that allow the person to perform the necessary sequence of activities to do this correctly.

Types of apraxia

There are several types of apraxia, and a patient could be diagnosed with one or more forms of this condition. The types of apraxia include:

• Buccofacial or orofacial apraxia is the inability of a person to follow through on commands involving face and lip motions. These activities include coughing, licking the lips, whistling, and winking. Also known as facial-oral apraxia, it is the most common form of apraxia, according to the National Institute of Neurological Disorders and Stroke (NINDS).
• Limb-kinetic apraxia is the inability to make precise movements with an arm or leg.
• Ideomotor apraxia is the inability to make the proper movement in response to a command to pantomime an activity like waving.
• Constructional apraxia is the inability to copy, draw, or build simple figures.
• Ideational apraxia is the inability to do an activity that involves performing a series of movements in a sequence. A person with this condition could have trouble dressing, eating, or bathing. It is also known as conceptual apraxia.
• Oculomotor apraxia is characterized by difficulty moving the eyes.
• Verbal apraxia is a condition involving difficulty coordinating mouth and speech movements. It is referred to as apraxia of speech by organizations including the American Speech Language Hearing Association (ASHA).

A baby who does not coo or babble may display a symptom of apraxia of speech, according to ASHA. A young child may only say a few consonant sounds, and an older child may have difficulty imitating speech. An adult also has this difficulty. Other symptoms include saying the wrong words. A person wants to say "kitchen," but says "bipem" instead, according to an ASHA report.

A person diagnosed with apraxia may also have aphasia, a condition caused by damage to the brain's speech centers. This results in difficulty reading, witting, speaking, and understanding when others speak.

Post-apraxia changes

A person with apraxia could experience frustration about difficulty communicating or trouble performing tasks. In some cases, the condition could affect the person's ability to live independently.

Diagnosis

Diagnosis of apraxia could begin with testing of its underlying cause. Testing for conditions like a stroke or cancer includes the MRI (magnetic resonance imaging ) and CT scanning (computer tomography scanning). A brain biopsy is used to measure changes caused by Alzheimer's disease. In all cases, the physician takes a family history. Head trauma that could cause apraxia is first treated in the emergency room.

Other diagnostic treatment is related to identifying the type of apraxia. For example, the physician may ask the patient to demonstrate how to blow out a candle, wave, use a fork, or use a toothbrush.

Assessment for speech apraxia in children includes a hearing evaluation to determine if difficulty in speaking is related to a hearing loss. If the condition appears related to apraxia, a speech-language pathologist examines muscle development in the jaw, lips, and tongue. The examination of adults and children includes an evaluation of how words are pronounced individually and in conversation. The pathologist observes how the patient breathes when speaking and the ability to perform actions like smiling.

The costs of diagnosis vary because the process could include examinations and diagnostic screening related to the underlying cost of the apraxia. Insurance generally covers part of these costs.

Treatment

The treatment for apraxia usually involves rehabilitation through speech-language therapy, physical therapy, or occupational therapy. In addition, treatment such as chemotherapy is administered for the condition that caused the apraxia.

KEY TERMS

CT scanning— Computer tomography scanning is a diagnostic imaging tool that uses x rays sent through the body at different angles.

MRI— Magnetic resonance imaging is a diagnostic imaging tool that utilizes an electromagnetic field and radio waves.

Family education is an important component of apraxia treatment. The rehabilitation process takes time, and relatives can offer encouragement and support to the patient. They may be asked to help the patient with in-home exercises. Furthermore, family members sometimes need to take on the role of caregivers.

Speech-language therapy

Speech-language therapy focuses on helping the patients learn or regain communication skills. Therapists teach exercises to strengthen facial muscles used in speech. Other exercises concentrate on patients learning to correctly pronounce sounds and then turn those sounds into words.

In cases where apraxia limits the ability to speak, therapists help patients develop alternate means of communication. These alternatives range from gesturing to using a portable computer that writes and produces speech, according to ASHA.

Occupational and physical therapies

Occupational and physical therapies focus on helping patients regain the skills impaired by apraxia. Physical therapy exercises concentrate on areas such as mobility and balance. Occupational therapy helps patients relearn daily living skills.

Treatment costs

The costs of therapy vary by the type of treatment, regional location, and where the therapy is offered. Fees can range for $40 per hour for in-office speech therapy for a child to $85 per hour for in-home physical or occupational therapy for a senior citizen. Part of therapy costs may be covered by insurance.

Alternative treatment

Most alternative treatments target Alzheimer's disease and other conditions that cause apraxia. Herbal remedies thought to help people with Alzheimer's include ginkgo biloba, a plant extract. However, organizations including the Alzheimer's Association caution that the effectiveness and safety of this herbal remedy has not been evaluated by the U.S. Food and Drug Administration. The government does not require a review of supplements like ginkgo. Furthermore, there is a risk of internal bleeding if ginkgo is taken in combination with aspirin and blood-thinning medications.

Prognosis

The prognosis for apraxia depends on factors such as what caused the condition. While Alzheimer's is a degenerative condition, a child with verbal apraxia or a stroke patient could make progress.

In some cases, treatment helps a person to relearn or acquire skills needed to function. A caregiver may be required, and some people with dementia require supervised, longterm care.

Prevention

The methods of preventing apraxia focus on preventing the underlying causes of this condition. This may not be entirely possible when there is a family history of conditions such as stroke, dementia, and cancer. However, a person at risk by not smoking, exercising, and eating a diet based on the American Heart Association guidelines.

Head injury can be prevented by wearing a helmet when participating in activities like sports and bicycling. Wearing a seatbelt when in a vehicle also helps reduce the risk of head injury.

Resources

BOOKS

PERIODICALS

ORGANIZATIONS

American Speech Language Hearing Association. 10801 Rockville Pike, Rockville, MD 20852-3279. 800-638-8255. 〈http://www.asha.org〉.

Alzheimer's Association. 225 North Michigan Avenue, Floor 17, Chicago, IL 60601. 800-272-3900. 〈http://www.alz.org〉.

National Institute of Neurological Disorders and Stroke, NIH Neurological Institute. P.O. Box 5801, Bethesda, MD 20824. 800-352-9424. 〈http://www.ninds.nih.gov〉.

National Rehabilitation Information Center. 4200 Forbes Boulevard Suite 202, Lanham, MD 20706-4829. 800-346-2742. 〈http://www.naric.com〉.

National Stroke Association. 9707 East Easter Lane, Englewood, CO 80112. 1-800-787-6537. 〈http://www.stroke.org〉.

OTHER

"Apraxia in Adults." American Speech Language Hearing Association. 2005. [cited March 29, 2005]. 〈http://www.asha.org/public/speech/disorders/apraxia_adults.htm〉.

"Childhood Apraxia of Speech." American Speech Language Hearing Association. 2005. [cited March 29, 2005]. 〈http://www.asha.org/public/speech/disorders/Developmental-Apraxia-of-Speech.htm〉.

Jacobs, Daniel H., M.D."Apraxia and Related Syndromes." e-medicine. October 27, 2004 [cited March 29, 2005]. 〈http://www.emedicine.com/neuro/topic438.htm〉.

"NINDS Apraxia Information Page." National Institute of Neurological Disorders and Stroke February 09, 2005 [cited March 29, 2005]. 〈http://www.ninds.nih.gov/disorders/apraxia/apraxia.htm〉.

Dyspraxia

Definition

Dyspraxia is a neurological disorder of motor coordination usually apparent in childhood that manifests as difficulty in thinking out, planning out, and executing planned movements or tasks. The term dyspraxia derives from the Greek word praxis, meaning "movement process."

Description

The earliest description of a syndrome of clumsiness, termed "congenital maladroitness," dates back to the turn of the twentieth century. Since that time, numerous names have been given to this syndrome of impaired coordination, including dyspraxia, developmental dyspraxia, developmental coordination disorder, clumsy child syndrome, and sensory integration disorder. Some sources ascribe different meanings to these terms, while others use them interchangeably. Researchers commonly use the term developmental coordination disorder (DCD); DCD is classified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSMIV-TR) as a motor skills disorder.

Dyspraxia is a variable condition; it manifests in different ways at different ages. It may impair physical, intellectual, emotional, social, language, and/or sensory development. Dyspraxia is often subdivided into two types: developmental dyspraxia, also known as developmental coordination disorder, and verbal dyspraxia, also known as developmental apraxia of speech. Symptoms of the dyspraxia typically appear in childhood, anywhere from infancy to adolescence, and can persist into adult years. Other disorders such as dyslexia , learning disabilities, and attention deficit disorder often co-occur in children with dyspraxia.

Demographics

Estimates of the prevalence of developmental coordination disorder are approximately 6% in children aged 5–11. Some reports indicate a higher prevalence in the 10–20% range. Males are four times more likely than females to have dyspraxia. In some cases, the disorder may be familial.

Causes and symptoms

Developmental dyspraxia is apparent from birth or early in life. As of 2004, the underlying cause or causes for dyspraxia remain largely unknown. It is thought that any number of factors such as illness or trauma may adversely affect normal brain development, resulting in dyspraxia. Genes may also play a role in the development of dyspraxia. It is known that dyspraxia can be acquired (acquired dyspraxia) due to brain damage suffered as a result of stroke , an accident, or other trauma.

Symptoms of dyspraxia vary and may include some or all of the following problems:

• poor balance and coordination
• vision problems
• perceptual problems
• poor spatial awareness
• poor posture
• poor short-term memory
• difficulty planning motor tasks
• difficulty with reading, writing, and speech
• emotional and behavioral problems
• poor social skills

The symptoms of dyspraxia depend somewhat on the age of the child. Young children will have delayed motor milestones such as crawling, walking, and jumping. Older children may present with academic problems such as difficulty with reading and writing or with playing ball games.

Developmental verbal dyspraxia (DVD), a type of dyspraxia, can manifest as early as infancy with feeding problems. Children with DVD may display delays in expressive language, difficulty in producing speech, reduced intelligibility of speech, and inconsistent production of familiar words.

Diagnosis

The diagnosis of dyspraxia is based on observation of a patient's symptoms and on results of standardized tests. Findings from a neurological or neurodevelopmental evaluation may also be used to confirm a suspected diagnosis. The process of making a diagnosis of dyspraxia can be complex for a number of reasons. Dyspraxia may affect many different body functions, it can occur as a part of another syndrome, and symptoms of dyspraxia overlap with similar disorders such as dyslexia.

Diagnostic criteria

Various health professionals and organizations define the term dyspraxia differently. The Dyspraxia Foundation (England) describes it as "an impairment or immaturity of the organization of movement," and further adds that it may be associated with problems in language, perception, and thought. Other advocacy groups such as the Dyspraxia Association of Ireland and the Dyspraxia Foundation of New Zealand, Inc. offer slightly different definitions. The American Psychiatric Association lists four criteria in the DSM-IV-TR for the diagnosis of developmental coordination disorder:

• marked impairment in the development of motor coordination
• the impaired coordination significantly interferes with academic achievement or activities of daily living
• the coordination difficulties are not due to a general medical problem such as cerebral palsy or muscular dystrophy and do not meet the criteria for pervasive developmental disorder
• if mental retardation (MR) is present, the motor coordination problems exceed those typically associated with the MR

Treatment team

Treatment for individuals with dyspraxia is highly individualized because the manifestations vary from patient to patient. The treatment team for a child with dyspraxia may include a pediatric neurologist , a physical therapist, an occupational therapist, and a speech therapist, in addition to a family doctor or pediatrician. In some cases, the treatment team may also include a psychologist, a developmental optometrist, and specialists in early intervention or special education.

Treatment

Currently there is no cure for dyspraxia. Treatment mainly consists of rehabilitation through physical, occupational, and speech therapies. Other interventions such as special education, psychological therapy, or orthoptic exercises may be recommended on a case-by-case basis. The purpose of treatment for dyspraxia is to help the child to think out, plan out, and execute the actions necessary to try out new tasks or familiar tasks in novel ways.

Recovery and rehabilitation

There are specific therapies for dyspraxia. In physical therapy, a physical therapist may evaluate some or all of the following skill areas in order to formulate a plan of treatment with the patient's physician:

• muscle tone
• control of shoulders and pelvis
• active trunk extension and flexion (posture)
• hand-eye coordination (throwing a ball)
• foot-eye coordination (kicking a ball)
• midline crossing (writing)
• directional awareness (ability to move in different directions)
• spatial awareness (judge distances and direction)
• integration (moving both sides of the body simultaneously)
• knowledge of two sides/dominance of one side (knowing right from left)
• short-term memory
• motor planning (ability to plan movements needed to move from one position to another)
• self organization (dressing, eating, etc.)
• eye tracking

Physical therapy generally consists of activities and exercises designed to improve the specific skill weakness. For example, activities such as climbing, going through tunnels, and moving in and out of cones may assist a child who has poor spatial awareness. The physical therapist may also recommend that the child practice the treatment activities or exercises at home.

In occupational therapy, an occupational therapist may use standardized tests to evaluate the child's sensory integration skills. A therapeutic technique known as sensory integration may be recommended. Sensory integration techniques help a child to sort, store, and integrate information obtained by the senses so that it may be used for learning.

In speech therapy, a speech therapist may assist the child with areas such as muscle control, planning language, and forming concepts and strategies in order to communicate. The therapist may use language tests to assess language comprehension and production in order to develop a plan of treatment

Clinical trials

As of 2004, there was one clinical trial recruiting patients with a form of dyspraxia known as verbal dyspraxia. The aim of the study, entitled "Central Mechanisms in Speech Motor Control Studied with H2150 PET ," is to use radioactive water (H2150) and positron emission tomography (PET) scan to measure blood flow to different areas of the brain in order to better understand the mechanisms involved in speech motor control. Information on this trial can be found at <http://www.clinicaltrials.gov> (see study number 92-DC-0178) or by contacting the National Institute on Deafness and Other Communication Disorders (NIDCD) patient recruitment and public liaison office at (800) 411-1010.

Prognosis

The prognosis for dyspraxia varies. Some children "outgrow" their condition, whereas others continue to have difficulties into adulthood. Though early diagnosis and prompt treatment may improve the outcome for a given patient, the precise factors that influence prognosis are not well understood. For example, it remains unclear how factors such as a child's specific deficits and the underlying cause for the disorder influence rehabilitation potential. Also, the prognosis for dyspraxia is situational; it depends on the age of the patient and the demands of a given setting or environment.

Special concerns

A child with a diagnosis of dyspraxia or developmental coordination disorder may be eligible to have an individual education plan (IEP). An IEP provides a framework from which administrators, teachers, and parents can meet the educational needs of a child with dyspraxia. Depending upon severity of symptoms and the presence of other problems such as learning difficulties, children may be best served by special education classes or by a private educational setting.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

Macintyre, C. Dyspraxia 5–11: A Practical Guide. London: David Fulton Publishers, 2001.

Portwood, M. Understanding Developmental Dyspraxia: A Textbook for Students and Professionals. London: David Fulton Publishers, 2000.

PERIODICALS

Cousins, M., and M. M. Smyth. "Developmental Coordination Impairments in Adulthood." Hum Mov Sci 22 (November 2003): 433–59.

Flory, S. "Identifying, Assessing and Helping Dyspraxic Children." Dyslexia 6 (July–September 2000): 205–8.

McCormick, M. "Dyslexia and Developmental Verbal Dyspraxia." Dyslexia 6 (July–September 2000): 210–4.

Payton, P., and M. Winfield. "Interventions for Pupils with Dyspraxic Difficulties." Dyslexia 6 (July–September 2000): 208–10.

WEBSITES

Apraxia Kids Home Page. (May 30, 2004). <http://www.apraxia-kids.org/index.html>.

The Dyspraxia Support Group of New Zealand Home Page. (May 30, 2004). <http://www.dyspraxia.org.nz/>.

Developmental Dyspraxia Information Page. The National Institute of Neurological Disorders and Stroke (NINDS). (May 30, 2004). <http://www.ninds.nih.gov/health_and_medical/disorders/dyspraxia.htm>.

ORGANIZATIONS

American Speech Language Hearing Association (ASHA). 10801 Rockville Pike, Rockville, MD 20852-3279. (301) 897-5700 or (800) 638-8255; Fax: (301) 571-0457. actioncenter@asha.org. <http://www.asha.org>.

The Dyspraxia Foundation. 8 West Alley, Hitchin, Hertfordshire SG5 1EG, United Kingdom. +44 (0) 14 6245 5016 or +44 (0) 14 6245 4986; Fax: +44 (0) 14 6245 5052. dyspraxia@dyspraxiafoundation.org.uk. <http://www.dyspraxiafoundation.org.uk/>.

The Dyspraxia Support Group of New Zealand, Inc. The Dyspraxia Centre, P.O. Box 20292, Bishopdale, Christchurch, New Zealand. +64 3 359 7072; Fax: +64 3 359 7074. praxisnz@xtra.co.nz. <http://www.dyspraxia.org.nz/>

Dawn J. Cardeiro, MS, CGC

Apraxia

Definition

Apraxia is a neurological disorder. In general, the diagnostic term "apraxia" can be used to classify the inability of a person to perform voluntary and skillful movements of one or more body parts, even though there is no evidence of underlying muscular paralysis, incoordination, or sensory deprivation. Additionally, motor performances in response to commands, imitation tasks, and use of familiar objects may be equally difficult but not attributable to dementia or confusion. These types of disturbances usually result from injuries, illnesses, or diseases of different regions of the brain normally responsible for regulating such abilities.

Description

The term apraxia is derived from the Greek word praxis, which refers to producing an action or movement. In 1861, Broca described in detail an 84-year-old man who suffered a sudden impairment of speech production, but preservation of oral musculature functions, overall language skills, and intelligence. Broca coined the term "aphemia" to classify the inability to articulate words in the presence of a good language foundation. In 1900, Leipmann reported a 48-year-old patient who was unable to execute various voluntary motor behaviors of the limbs and oral cavity, despite good muscle strength, intactness of certain automatic or previously well-rehearsed speech or bodily movements, and complete understanding of the intended acts. Liepmann popularized the diagnostic term "apraxia" to differentiate individuals with these types of select motor difficulties from those who struggle with movement disturbances because of weakness, paralysis, and incoordination of the muscles involved.

Demographics

There are no undisputed figures regarding the incidence of apraxia in the general population. However, because strokes are common causes, and African-American men are more susceptible to the development of this disease, by default this population may be at the greatest risk for this neurological disorder.

Causes and symptoms

Based on many additional case studies, Liepmann suggested that there are three major types of apraxia, each of which is caused by different sites of brain damage: ideational, ideo-motor, and kinetic.

Autopsy examinations and magnetic resonance imaging (MRI) scans have demonstrated that, in general, individuals with ideational, ideo-motor, and kinetic apraxias have pathologies involving either the back (parietal-occipital), middle (parietal), or front (frontal) lobes of the cerebral cortex, respectively. The individual with ideational apraxia cannot consistently produce complex serial actions, particularly with objects, due to disruptions at the conceptual stage of motor planning where the purpose and desire to perform specific movements are formulated. This

individual may begin an act with a set purpose and start its performance, but then suddenly cease because the original goal is forgotten. The primary problem is failure to form concepts and/or inability to retain the conceptual plan for a sufficient period of time to allow the desired movements to be effectively programmed and executed. For example, if patients with ideational apraxia are requested to demonstrate proper use of a toothbrush, they might first brush their nails, then hesitate and brush their pants, and finally, with prompting, brush their teeth. Their actions will likely be slow and disorganized, appearing as though they have to think out each movement along the way.

Ideo-motor apraxia is characterized by derailments of bodily movement patterns, due to disturbances in the motor planning stages of a well-conceived behavioral act. Breakdowns most often occur during verbal commands to use objects rather than when the same objects are being used spontaneously. The patient with this disorder fails to translate the idea to perform specific movements into a coordinated and sequential scheme of muscle contractions to achieve the desired motor goal. If asked to demonstrate use of a pair of scissors, unlike ideational apraxics, individuals with ideo-motor apraxia will not make the mistake of using this tool as if it were a screwdriver. Rather, they might grasp the scissors with both hands and repetitively open and close the blades, or pick up the paper in one hand and the scissors in the other and rub them against one another with hesitant motions.

Kinetic apraxia is characterized by coarse, clumsy, groping, and mutilated movement patterns, especially on tasks that require simultaneous, sequential, and smooth contractions of separate muscle groups. These disturbances are usually proportional to the complexity of the task. The disorder does not involve ideation or concept formation, as the desired movement is almost always evident in the struggle. Typing, playing a musical instrument, and handwriting tasks are very difficult for the individual with kinetic apraxia. The problem is not with preliminary motor planning, as in ideo-motor apraxia. Instead, the kinetic apraxic suffers from disturbances in programming the motor plan into subunits of sequential muscle behaviors. Normally, such instructions are then conveyed directly to the primary motor system, which in turn initiates neural commands necessary to execute the intended act.

Apraxia of speech is a subtype of kinetic apraxia. This disorder is often observed following damage to the brain in an area named after Broca. Not infrequently, speech apraxia co-occurs with notable language disturbances, known as aphasia . Individuals with speech apraxia struggle with dysfluent articulation problems, as they grope to posture correctly sequential tongue, lip, and jaw movements during speech activities. Numerous, but variable articulatory errors occur, characterized by false starts, re-starts, sound substitutions, sound and word repetitions, and overall slow rate of speech. Multisyllabic words and complex word combinations are most vulnerable to these types of breakdowns.

Diagnosis

Testing for apraxia should employ basic screening tasks to identify individuals who do and do not require deeper testing for the differential diagnosis. Basic limb and orofacial praxis measures include the following commands:

• blow out a match
• protrude the tongue
• whistle
• salute
• wave goodbye
• brush the teeth
• flip a coin
• hammer a nail into wood
• cut paper with scissors
• tap the foot
• stand like a golfer
• jump up and down in place
• thread a needle
• tie a necktie
• recite isolated words, word sequences, and phrases

More detailed testing usually includes many additional tasks of increasing motor complexity.

Treatment team

Because the apraxias are neurological disorders, a clinical neurologist is often the team leader. A neurosurgeon may also be on the team, especially if the underlying cause requires surgical attention. Likewise, the primary medical care practitioner plays a very important role in taking care of the individual's overall health-related needs. The responsibilities of the nurse and clinical psychologist should not be underestimated, as many apraxic individuals experience the need for hospitalization, financial aid, social reintegration, and emotional and family counseling. Speech-language and occupational therapists are also key team members in those cases with clinically significant speech and/or limb-girdle movement abnormalities.

Treatment

Occupational therapists may employ exercises to rehabilitate proper use of eating utensils, health care and hygiene products, and self-dressing skills. The speech therapist focuses on retraining fluent and articulate movement patterns to improve overall speech intelligibility. Specific exercises may include tongue, lip, and jaw rate and rhythm activities, as well as combinations of complex sound and word productions.

Clinical trials

As of 2003, the National Institute of Neurological Disorders and Stroke (NINDS) sponsored two clinical trials that focused on patients with ideo-motor apraxia. These studies used different techniques to analyze brain activity as patients performed various movements and simple tasks.

The National Institute on Deafness and Other Communication Disorders (NIDCD) is also sponsoring a study. This clinical trial focuses on patients who experience speech and communication complications related to neurological illness.

Further information on these trials can be obtained by contacting the National Institutes of Health Patient Recruitment and Public Liaison Office.

Prognosis

The potential for significant improvements with treatments and self-healing (spontaneous recovery) are most likely in cases of mild apraxia with stable medical courses. For more severe cases, particularly those with progressive or unstable neurological pathologies, the prognoses for no-table gains with medical and behavioral interventions remain guarded at the outset. However, many such cases achieve sufficient gains to enable independent lifestyles.

Special concerns

People with apraxia who are elderly and/or who may also have co-morbid medical problems often require ongoing assistance with daily living activities. Nursing home facilities may be necessary for those individuals who do not have the opportunity or resources either to live by themselves or with family members, or to hire a home-based caregiver. Although apraxia most often afflicts adults, school-age children or adolescents with this disorder will require special education considerations and intensive academic and therapeutic programs.

Quality of life

Apraxia may be caused by very serious neurologic diseases or injuries. The quality of life of those afflicted with this disorder is usually influenced by its underlying cause. Many individuals have co-occurring physical, psychological, and intellectual disabilities, which complicate the differential diagnostic process and challenge the potential for meaningful rehabilitation and a fruitful quality of life. Others struggle with less intertwined functional disturbances. These individuals tend to lead more productive lives because they are not as severely impaired.

Resources

BOOKS

Hall, Penelope, Linda Jordan, and Donald Robin. Developmental Apraxia of Speech: Theory and Clinical Practice. Austin, TX: Pro Ed, 1993.

Icon Health Publishers. The Official Patient's Sourcebook on Apraxia: A Revised and Updated Directory for the Internet Age. San Diego: Icon Group International, 2002.

Vellemen, Shelley L. Childhood Apraxia of Speech. San Diego: Singular Publishing, 2002.

PERIODICALS

Geschwind, N. "The Apraxia: Neural Mechanisms of Disorders of Learned Movement." American Scientist 63 (1975): 188.

OTHER

Apraxia-Kids. Childhood Apraxia of Speech Association. December 9, 2003 (March 11, 2004). <www.apraxiakids.org>.

NINDS Apraxia Information Page. National Institute for Neurological Disorders and Stroke. December 17, 2001 (March 11, 2004). <http://www.ninds.nih.gov/health_and_medical/disorders/apraxia.htm>.

ORGANIZATIONS

National Institute of Deafness and Other Communication Disorders. 31 Center Drive, MSC 2320, Bethesda, MD 20892. (800) 411-1222. prpl@mail.cc.nih.gov. <http://www.nidcd.nih.gov/>.

National Institutes of Health Patient Recruitment and Public Liaison Office. 9000 Rockville Pike, Bethesda, MD 20892. (800) 411-1222. prpl@mail.cc.nih.gov. <http://www.nih.gov/>.

National Institute of Neurological Disorders and Stroke. P.O. Box 5801, Bethesda, MD 20824. (301) 496-5751 or (800) 352-9424. <http://www.ninds.nih.gov>.

Wayne State University, Department of Otolaryngology, Head and Neck Surgery. 5E-UHC, 4201 St Antoine, Detroit, MI 48201. (313) 577-0804. <http://www.med.wayne.edu/otohns/index.htm>.

James Paul Dworkin, Ph.D.

Developmental Coordination Disorder

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Developmental coordination disorder is diagnosed when children do not develop normal motor coordination (coordination of movements involving the voluntary muscles).

Description

Developmental coordination disorder has been known by many other names, some of which are still used today. It has been called clumsy child syndrome, clumsiness, developmental disorder of motor function, and congenital maladroitness. Developmental coordination disorder is usually first recognized when a child fails to reach such normal developmental milestones as walking or beginning to dress him- or herself.

Children with developmental coordination disorder often have difficulty performing tasks that involve both large and small muscles, including forming letters when they write, throwing or catching balls, and buttoning buttons. Children who have developmental coordination disorder generally have developed normally in all other ways. The disorder can, however, lead to social or academic problems for children. Because of their underdeveloped coordination, they may choose not to participate in activities on the playground. This avoidance can lead to conflicts with or rejection by their peers. Also, children who have problems forming letters when they write by hand, or drawing pictures, may become discouraged and give up academic or artistic pursuits even though they have normal intelligence.

Causes and symptoms

The symptoms of developmental coordination disorder vary greatly from child to child. The general characteristic is that the child has abnormal development of one or more types of motor skills when the child’s age and intelligence quotient (IQ) are taken into account. In some children these coordination deficiencies manifest as an inability to tie shoes or catch a ball, while in other children they appear as an inability to draw objects or properly form printed letters.

Some investigators believe that there are different subtypes of developmental coordination disorder. While there is disagreement over how to define these different subtypes, they can provide a useful framework for the categorization of symptoms. There are six general groups of symptoms. These include:

• general unsteadiness and slight shaking
• an at-rest muscle tone that is below normal
• muscle tone that is consistently above normal
• inability to move smoothly because of problems putting together the subunits of the whole movement
• inability to produce written symbols
• visual perception problems related to development of the eye muscles

Children can have one or more of these types of motor difficulties.

Developmental coordination disorder usually becomes apparent when children fail to meet normal developmental milestones. Some children with developmental coordination disorder do not learn large motor skills such as walking, running, and climbing until a much later point in time than their peers. Others have problems with such small muscle skills as learning to fasten buttons, close or open zippers, or tie shoes. Some children have problems learning how to handle silverware properly. In others the disorder does not appear until they are expected to learn how to write in school. Some children just look clumsy and often walk into objects or drop things.

There are no known causes of developmental coordination disorder. There are, however, various theories about its possible causes. Some theories attribute the disorder to biological causes. Some of the possible biological causes include such prenatal complications as fetal malnutrition. Low birth weight or prematurity are thought to be possible causes, but there is no hard evidence supporting these claims.

Demographics

It is estimated that as many as 6% of children between the ages of five and 11 have developmental coordination disorder. Males and females are thought to be equally likely to have this disorder, although males may be more likely to be diagnosed. Developmental coordination disorder and speech-language disorders seem to be closely linked, although it is not clear why this is the case. Children with one disorder are more likely to have the other as well.

Diagnosis

The diagnosis of developmental coordination disorder is most commonly made when a child’s parents or teachers notice that he or she is lagging behind peers in learning motor skills, is having learning problems in school, or has frequent injuries from falls and other accidents resulting from clumsiness. In most cases, the child’s pediatrician will perform a physical examination in order to rule out problems with eyesight or hearing that interfere with muscular coordination, and to rule out disorders of the nervous system. In addition to a medical examination, a learning specialist or child psychiatrist may be consulted to rule out other types of learning disabilities.

The types of motor impairment that lead to a diagnosis of developmental coordination disorder are somewhat vague, as the disorder has different symptoms in different children. There are many ways in which this kind of motor coordination problem can manifest itself, all of which may serve as criteria for a diagnosis of developmental coordination disorder. The core of the diagnosis rests on the child’s being abnormally clumsy. To make this determination, the child’s motor coordination must be compared to that of other children of a similar age and intelligence level.

The difference between a child who has developmental coordination disorder and one who is simply clumsy and awkward can be hard to determine. For a child to be diagnosed with developmental coordination disorder there must be significant negative consequences for the child’s clumsiness. The negative effects may be seen in the child’s performance in school, activities at play, or other activities that are necessary on a day-to-day basis. Also, for developmental coordination disorder to be diagnosed, the child’s problems with motor coordination cannot result from such general medical conditions as muscular dystrophy, and cannot result directly from mental retardation. Some criteria require that the child have an IQ of at least 70 to be diagnosed with developmental coordination disorder.

Treatments

No treatments are known to work for all cases of developmental coordination disorder. Experts recommend that a specialized course of treatment, possibly involving work with an occupational therapist, be drawn up to address the needs of each child. Many children can be effectively helped in special education settings to work more intensively on such academic problems as letter formation. For other children, physical education classes designed to improve general motor coordination, with emphasis on skills the child can use in playing with peers, can be very successful. Any kind of physical training that allows the child to safely practice motor skills and motor control may be helpful.

It is important for children who have developmental coordination disorder to receive individualized therapy, because for many children the secondary problems that result from extreme clumsiness can be very distressing. Children who have developmental coordination disorder often have problems playing with their peers because of an inability to perform the physical movements involved in many games and sports. Unpopularity with peers or exclusion from their activities can lead to low self-esteem and poor self-image. Children may go to great lengths to avoid physical education classes and similar situations in which their motor coordination deficiencies might be noticeable. Treatments that focus on skills that are useful on the playground or in the gymnasium can help to alleviate or prevent these problems.

Children with developmental coordination disorder also frequently have problems writing letters and doing sums, or performing other motor activities required in the classroom—including coloring pictures, tracing designs, or making figures from modeling clay. These children may become frustrated by their inability to master tasks that their classmates find easy, and therefore may stop trying or become disruptive. Individualized programs designed to help children master writing or skills related to arts and crafts may help them regain confidence and interest in classroom activities.

Prognosis

For many people, developmental coordination disorder lasts into adulthood. Through specialized attention and teaching techniques it is possible over time for many children to develop the motor skills that they lack. Some children, however, never fully develop the skills they need. Although many children improve their motor skills significantly, in most cases their motor skills will never match those of their peers at any given age.

KEY TERMS

Maladroitness —Another word for awkwardness or clumsiness.

Motor skills —Skills pertaining to or involving muscular movement.

Prevention

There is no known way to prevent developmental coordination disorder, although a healthy diet throughout pregnancy and regular prenatal care may help, as they help to prevent many childhood problems.

See alsoDisorder of written expression.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Sadock, Benjamin J., and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry, 7th ed. Vol.2. Philadelphia: Lippincott Williams and Wilkins, 2000.

PERIODICALS

Kadesjo, Bjorn, and Christopher Gillberg. “Developmental Coordination Disorder in Swedish 7-Year-Old Children.” Journal of the American Academy of Child and Adolescent Psychiatry 38 (July 1999): 820–29.

Rasmussen, Peder, and Christopher Gillberg. “Natural Outcome of ADHD with Developmental Coordination Disorder at Age 22 Years: A Controlled, Longitudinal, Community-Based Study.” Journal of the American Academy of Child and Adolescent Psychiatry 39 (Nov. 2000): 1424.

Smyth, Mary M., Heather I. Anderson, and A. Church. “Visual Information and the Control of Reaching in Children: A Comparison Between Children With and Without Developmental Coordination Disorder.” Journal of Motor Behavior 33 (Sept. 2001): 306.

ORGANIZATIONS

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. Telephone: (847) 434-4000. <http://www.aap.org>.

OTHER

National Library of Medicine. National Institutes of Health. “Developmental Coordination Disorder.” <http://www.nlm.nih.gov/medlineplus/ency/article/001533.htm>.

Tish Davidson, A.M.
Emily Jane Willingham, PhD

Developmental coordination disorder

Definition

Developmental coordination disorder is diagnosed when children do not develop normal motor coordination (coordination of movements involving the voluntary muscles).

Description

Developmental coordination disorder has been known by many other names, some of which are still used today. It has been called clumsy child syndrome, clumsiness, developmental disorder of motor function, and congenital maladroitness. Developmental coordination disorder is usually first recognized when a child fails to reach such normal developmental milestones as walking or beginning to dress him- or herself.

Children with developmental coordination disorder often have difficulty performing tasks that involve both large and small muscles, including forming letters when they write, throwing or catching balls, and buttoning buttons. Children who have developmental coordination disorder have often developed normally in all other ways. The disorder can, however, lead to social or academic problems for children. Because of their underdeveloped coordination, they may choose not to participate in activities on the playground. This avoidance can lead to conflicts with or rejection by their peers. Also, children who have problems forming letters when they write by hand, or drawing pictures, may become discouraged and give up academic or artistic pursuits even though they have normal intelligence.

Causes and symptoms

The symptoms of developmental coordination disorder vary greatly from child to child. The general characteristic is that the child has abnormal development of one or more types of motor skills when the child's age and intelligence quotient (IQ) are taken into account. In some children these coordination deficiencies manifest as an inability to tie shoes or catch a ball, while in other children they appear as an inability to draw objects or properly form printed letters.

Some investigators believe that there are different subtypes of developmental coordination disorder. While there is disagreement over how to define these different subtypes, they can provide a useful framework for the categorization of symptoms. There are six general groups of symptoms. These include:

• general unsteadiness and slight shaking
• an at-rest muscle tone that is below normal
• muscle tone that is consistently above normal
• inability to move smoothly because of problems putting together the subunits of the whole movement
• inability to produce written symbols
• visual perception problems related to development of the eye muscles

Children can have one or more of these types of motor difficulties.

Developmental coordination disorder usually becomes apparent when children fail to meet normal developmental milestones. Some children with developmental coordination disorder do not learn large motor skills such as walking, running, and climbing until a much later point in time than their peers. Others have problems with such small muscle skills as learning to fasten buttons, close or open zippers, or tie shoes. Some children have problems learning how to handle silverware properly. In others, the disorder does not appear until they are expected to learn how to write in school. Some children just look clumsy and often walk into objects or drop things.

There are no known causes of developmental coordination disorder. There are, however, various theories about its possible causes. Some theories attribute the disorder to biological causes. Some of the possible biological causes include such prenatal complications as fetal malnutrition. Low birth weight or prematurity are thought to be possible causes, but there is no hard evidence supporting these claims.

Demographics

It is estimated that as many as 6% of children between the ages of five and 11 have developmental coordination disorder. Males and females are thought to be equally likely to have this disorder, although males may be more likely to be diagnosed. Developmental coordination disorder and speech-language disorders seem to be closely linked, although it is not clear why this is the case. Children with one disorder are more likely to have the other also.

Diagnosis

The diagnosis of developmental coordination disorder is most commonly made when a child's parents or teachers notice that he or she is lagging behind peers in learning motor skills, is having learning problems in school, or is suffering frequent injuries from falls and other accidents resulting from clumsiness. In most cases, the child's pediatrician will perform a physical examination in order to rule out problems with eyesight or hearing that interfere with muscular coordination, and to rule out disorders of the nervous system. In addition to a medical examination, a learning specialist or child psychiatrist may be consulted to rule out other types of learning disabilities.

The types of motor impairment that lead to a diagnosis of developmental coordination disorder are somewhat vague, as the disorder has different symptoms in different children. There are many ways in which this kind of motor coordination problem can manifest itself, all of which may serve as criteria for a diagnosis of developmental coordination disorder. The core of the diagnosis rests on the child's being abnormally clumsy. To make this determination, the child's motor coordination must be compared to that of other children of a similar age and intelligence level.

The difference between a child who has developmental coordination disorder and one who is simply clumsy and awkward can be hard to determine. For a child to be diagnosed with developmental coordination disorder there must be significant negative consequences for the child's clumsiness. The negative effects may be seen in the child's performance in school, activities at play, or other activities that are necessary on a day-to-day basis. Also, for developmental coordination disorder to be diagnosed, the child's problems with motor coordination cannot result from such general medical conditions as muscular dystrophy, and cannot result directly from mental retardation . Some criteria require that the child have an IQ of at least 70 to be diagnosed with developmental coordination disorder.

Treatments

No treatments are known to work for all cases of developmental coordination disorder. Experts recommend that a specialized course of treatment, possibly involving work with an occupational therapist, be drawn up to address the needs of each child. Many children can be effectively helped in special education settings to work more intensively on such academic problems as letter formation. For other children, physical education classes designed to improve general motor coordination, with emphasis on skills the child can use in playing with peers, can be very successful. Any kind of physical training that allows the child to safely practice motor skills and motor control may be helpful.

It is important for children who have developmental coordination disorder to receive individualized therapy, because for many children the secondary problems that result from extreme clumsiness can be very distressing. Children who have developmental coordination disorder often have problems playing with their peers because of an inability to perform the physical movements involved in many games and sports. Unpopularity with peers or exclusion from their activities can lead to low self-esteem and poor self-image. Children may go to great lengths to avoid physical education classes and similar situations in which their motor coordination deficiencies might be noticeable. Treatments that focus on skills that are useful on the playground or in the gymnasium can help to alleviate or prevent these problems.

Children with developmental coordination disorder also frequently have problems writing letters and doing sums, or performing other motor activities required in the classroom— including coloring pictures, tracing designs, or making figures from modeling clay. These children may become frustrated by their inability to master tasks that their classmates find easy, and therefore may stop trying or become disruptive. Individualized programs designed to help children master writing or skills related to arts and crafts may help them regain confidence and interest in classroom activities.

Prognosis

For many people, developmental coordination disorder lasts into adulthood. Through specialized attention and teaching techniques it is possible over time for many children to develop the motor skills that they lack. Some children, however, never fully develop the skills they need. Although many children improve their motor skills significantly, in most cases their motor skills will never match those of their peers at any given age.

Prevention

There is no known way to prevent developmental coordination disorder, although a healthy diet throughout pregnancy and regular prenatal care may help, as they help to prevent many childhood problems.

See also Disorder of written expression

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text revised. Washington DC: American Psychiatric Association, 2000.

Sadock, Benjamin J., and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.

PERIODICALS

Kadesjo, Bjorn, and Christopher Gillberg. "Developmental Coordination Disorder in Swedish 7-year-old Children." Journal of the American Academy of Child and Adolescent Psychiatry 38 (July 1999): 820-829.

Rasmussen, Peder, and Christopher Gillberg. "Natural Outcome of ADHD with Developmental Coordination Disorder at Age 22 years: A Controlled, Longitudinal, Community-Based Study." Journal of the American Academy of Child and Adolescent Psychiatry 39 (November 2000): 1424.

Smyth, Mary M., Heather I. Anderson, A. Church. "Visual Information and the Control of Reaching in Children: A Comparison Between Children With and Without Developmental Coordination Disorder." Journal of Motor Behavior 33 (September 2001): 306.

ORGANIZATIONS

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000. <www.aap.org>.

Tish Davidson, A.M.

Developmental disorders see Pervasive developmental disorders