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Developmental Dyspraxia has been recognised by doctors and therapists since very early last century, when Collier first described it as 'congenital maladroitness'. In 1937 Dr Samuel Orton declared it to be 'one of the six most common developmental disorders, showing distinctive impairment of praxis'. Since then it has been described and labelled by many, such as A. Jean Ayres, who in 1972 called it a disorder of Sensory Integration, or Dr Sasson Gubbay who in 1975 called it the 'Clumsy Child Syndrome'. Other labels have included developmental awkwardness, sensorimotor dysfunction, minimal brain dysfunction, motor sequencing disorder, and most recently Developmental Coordination Disorder. The World Health Organisation currently lists it as Specific Developmental Disorder of Motor Function. Gradually over the years professionals have become increasingly able to sift out the symptoms and more closely identify the disorder.
Here in New Zealand it is felt that the term 'Dyspraxia' indicates more the large range of processing difficulties experienced by our children. We see them affected in most areas of development, with pervasive motor planning difficulties at the heart of them. So, for now, for us, 'Dyspraxia' stays. What it is called matters far less to the child than does the understanding and help from those around him/her. Whatever it is called, Developmental Dyspraxia causes disruptions of major proportions in the lives of those whom it afflicts and of the families and world around them.
Developmental Dyspraxia (also known as Developmental Co-ordination Disorder, and the Clumsy Child Syndrome) is a neurologically based disorder of the processes involved in praxis or the planning of movement to achieve a predetermined idea or purpose, which may affect the acquisition of new skills and the execution of those already learned. More specifically, it is a disorder of praxis, or the process of ideation (forming an idea of using a known movement to achieve a planned purpose), motor planning (planning the action needed to achieve the idea), and execution (carrying out the planned movement).
Dyspraxia may affect any or all areas of development - physical, intellectual, emotional, social, language, and sensory - and may impair the normal process of learning, thus is a learning difficulty. It is not a unitary disorder (like measles or chicken pox, where all those affected share a common set of symptoms), and affects each person in different ways at different ages and stages of development, and to different degrees. It is inconsistent, in that it may affect the child one day but not the next - as if sometimes information is 'put away in the wrong drawer' - and it may affect children in different ways at different ages and developmental stages.
It is a hidden handicap as, under normal circumstances, children with Dyspraxia may appear no different from their peers, until new skills are tried or known ones taken out of context, when difficulties may become apparent. In many affected children, Dyspraxia occurs with or as part of other neurological conditions so that defining common symptoms may be confusing. Therefore a diagnosis, naming the disorder, is often very difficult, and sometimes the closest may be 'shows some Dyspraxic tendencies'. In New Zealand, following a major international, multi-disciplinary conference on Dyspraxia held here in 1997, it has become easier for parents to find a professional who is confident in making a diagnosis.
The World Health Organisation states in their 'Diagnostic and Statistics Manual-IV', that it affects 6% of all children to varying degrees, while other estimates vary between 10-20%. It is commonly believed by those in New Zealand who treat Dyspraxia that this number could be as high as 10%, but as yet insufficient studies have been done to confirm this number. Whatever the incidence, it is only those children whose disorder markedly impairs their learning and development who stand a chance of having their difficulties recognised, diagnosed, and treated.
AETIOLOGY - DEVELOPMENT
The pre-birth growth and development of the baby follows a set pattern and time-frame. At conception the fertilised egg begins to multiply; very soon some separate from the rest and, taking a unique form, continue to multiply at their own increased rate, as the nerve cells (neurons) of the brain. By about six months gestation (3 months before birth) the full complement of neurons, with their axons, has been produced; after that time no further new neurons are grown. They do not regenerate, so a neuron which is damaged or dies, or does not complete its growth (and reach its destination) in time, will not be replaced or renewed, as are cells in other parts of the body. Thus, if a cell or group of cells, fails to complete its growth and reach its destination within the time-frame, future sensory information from that area will be impaired.
Development which does continue to occur (and does so until old age) is that of the individual cells, as they grow dendrites and connections within the brain. There are billions of neurons in every brain, each with very many connections with other cells. For correct functioning, neurons have to have developed in sufficient numbers in the right areas of the brain, extending to the correct destination, by the appropriate time or they never will. There are two kinds of neurons - those carrying messages to the brain (sensory) and those carrying messages from the brain (motor).
At about 3 months before birth the axons begin to develop an insulating fatty sheath called myelin; this allows messages to be efficiently carried along them - a bit like insulating an electric wire, without it the messages or impulses may scatter everywhere, with it they are concentrated, focussed and aimed at the right destination. This sheath is in place by around 3 months of age; babies younger than that can be observed to make random reactive movements, without purposeful intent. After myelination movements may achieve a purpose, eyes may become more focussed, and the baby may recognise or touch a face and smile.
The connections between nerve cells (dendrites and synapses) continue to increase throughout one's lifetime, their growth stimulated by the demands of the environment, and as learning takes place.
The brain consists of neurons, connected (by nerve fibres or axons) to their various destinations in the body, and arranged in convoluted lobes in two halves or hemispheres. Each hemisphere is also divided into lobes - the Frontal, Parietal, Temporal, and Occipital lobes. The Limbic System is among other things the emotional centre of the brain. Different functions of the body are controlled by different parts of the brain. "Messages" and information travel along nerve fibres by way of the Spinal Cord, Cortex, Cerebellum and the Corpus Callosum. Incoming information from the senses - touch, taste, sight, smell, hearing, movement, balance, warmth, word, life, self - is organised and stored in the brain, to be retrieved for use as it is needed.
Praxis is the skill or process that makes us human, the link between brain and behaviour; it allows us to make choices, to plan our lives and our actions. With it we can function in our physical world, dress ourselves, eat with utensils, play, write, build, change our.. environment to meet a purposeful goal. To do these things, one first needs the idea of doing them (ideation), then to know how to do them (motor planning), and then be able to perform the actions (execution). That is Praxis - the ability to organise our activities in new and creative ways, not automatically.
Everything is interdependent. Ideation, motor planning, and execution are each dependant on accurately recalling the neurological knowledge (or 'gnosis') gained from experience and sensory information. (In other words, we can't get the idea, plan the movements, or execute them unless we know from past experiences that we can.) And all are dependant on messages travelling the right pathways and making the right connections.
Praxis develops, just as other skills develop. It does not build or add up like blocks. Praxis at 2 years is not a miniature version of Praxis at 5 years; it is rather a new version (because more connections have been made and used in the brain), enabling more actions of increasingly better quality, and allowing for more complicated and refined plans of action to be made.
Animals do not have Praxis. An infant developing normally begins by making random, uncontrolled movements, arms and legs waving without intent or purpose. Gradually he learns to lift his head, roll over, reach for a toy; when these actions are controlled by his will and done with a premeditated purpose - to see mother or to hold the toy - some motor planning, and early Praxis, has been involved. The action is not reflexive, random, accidental, or automatic. When a child learns to talk, he has to organise a specific set of muscles (the oro-facial and breathing muscles) to produce the right controlled set of sounds in the right sequence at the appropriate time, to match a word pattern he knows, and to achieve a planned purpose. To use language, he has to have the ability to organise his thoughts, has to have the retrievable memory of the sequence of movement of those muscles, and the meaning of the sound-pattern it produces, so that he can repeat it. This is Praxis.
Dyspraxia is a disorder of Praxis, where somewhere between sensory information gathering and storing, ideation, motor planning, and execution, the messages are not getting through, are not producing the right result. Maybe the information from the senses was not collected, transmitted, or sorted and stored properly, or stored in the wrong place, or not found, or even used but then returned to the wrong storage area; or maybe the motor plan was incomplete or unable to be made, or did not connect with the right nerve fibres or muscles for execution. Whatever it is, Praxis is inconsistently failing. Inconsistently, because yesterday or this morning the messages may have been getting through, the needed information retrieved, and the child may have been able to perform the task, but now he can't, now the plan has been lost somewhere. It may turn up again at another time or the child may have to relearn the plan, skill, or task.
Because of the multiple nature of Praxis, there are a vast number of possible sites of malfunction. It is not known at which point along the 'practic chain' the malfunction(s) occur - it could be anywhere from sensory information collection and storage to execution of actions.
Developmental Dyspraxia is not an illness or disease from which one can recover, but a neurologically based disorder which one gets 'around', not 'over'.
It is not a 'unitary' disorder. (Unitary means a disorder where there is a specific set of symptoms common to each case, like measles or chicken pox.) Each child is affected in different ways, and to different degrees. It is possible for a child who is affected in one developmental area to show symptoms in another area later, according to developmental demands. Or several different sets of symptoms may be present from the start. It may occur in isolation or (as is frequently, the case) as part of another disorder. Skills learned in one context may not be able to be transferred to a new context, and need to be learnt anew, a point which shows clearly as the child moves to a new developmental stage.
Developmental Dyspraxia (D.D.) is different from Acquired Dyspraxia (A.D.) in that there is no memory of Praxis for the system to recall. as treatment is given and Praxis learnt, it builds developmentally, increasing the amount and quality of actions, the brain affected in D.D. is immature, where that in A.D. has already matured, so children with Developmental Dyspraxia have no neurological memory of Praxis to work towards.
Dyspraxia is not the result of poor physical strength, impaired primary sensation, delayed development, body deformity, or anything that would show up on normal neurological examination. It can be acquired through damage to the brain from a stroke, an accident, or medical disaster to the brain. These people are often older, and have a neurological memory of praxis to work towards. However, damage acquired at an early age may also impair the normal course of development, and thus be developmental. Developmental Dyspraxia occurs from birth or an early age, thus affecting the normal development of the child, and its causes are not obvious. There may be an inherited tendency towards similar neurological disorders.
There may have been a glitch of some kind (illness, slight trauma, momentary lack of oxygen, etc.) at the crucial developmental time or at birth which caused damage to some cells. It may be that the growth of the dendrites or the connections - synapses and neurotransmitters - which connect the cells is at fault. It may be a matter of which cells, and how many, failed to grow and develop enough to reach their destination at the right time before birth. It often co-exists with other disorders (e.g. mild Cerebral Palsy, Dyslexia, Attention Deficit Disorder, etc.) This fact also makes diagnosis difficult, as symptoms intermingle or are shared by more than one disorder. The gathering, sorting, and storing of sensory information may be faulty. Or the cause may remain completely unknown. In other words, very little is known of the causes, despite considerable research over the years.
ASSESSMENT AND DIAGNOSIS
"Diagnosis depends not on the severity of the motor disorder, but also on the demands of the environment, social acceptability, tolerance of errors, and on the child's ability to cope emotionally. So it may not become apparent until the impaired planning and execution systems are overtaxed." (Gubbay) Actions which are learnt sufficiently well to become 'automatic' no longer involve praxis. Thus, a Dyspraxic child among his peers doing familiar, learned things does not stand out as different, seems just the same as the others. It is only when new or unfamiliar tasks are involved that differences may become apparent, although, as a Dyspraxic child quickly learns techniques for covering his inabilities, even then it is not obvious unless the observer knows what to look for. Different tests may be given by occupational therapists, speech therapists, teachers, psychologists, and paediatricians. As praxis affects many different functions of the body, complete assessment and evaluation is complicated. Basically it must - exclude other disorders, identify Dyspraxic signs and symptoms, according to age and stage of development, professionals examining the child should share findings to gain a whole, and more accurate, picture, on a team approach. Because Dyspraxia may occur in isolation (with no other obvious abnormality), or as part (or a symptom of) another disorder, diagnosis can be complicated and difficult. Additional problems can include hyperactivity, learning difficulties, dyslexia, etc. Parents play a major role in assessment by highlighting the ways in which the disorder affects the child, themselves, and the family.
The multiple nature of Developmental Dyspraxia means that therapy covers many areas, and may include perceptual motor training (sensory integration therapy), speech and language therapy, maths and numeracy, reading and literacy, spelling, environmental. manipulation, behaviour modification, and medication and treatment for any other disorders.
The aim of treatment is to teach the child Praxis - to be able to form ideas of trying new things and familiar things in new ways - to plan the actions, and to execute them. It also focuses on the different stages of Praxis, and helps it to develop following the developmental plan. Treatment should if possible be given with a team approach, each aspect tying in with the others holistically. Each child's program of treatment is individual to that child, and regularly reviewed.
Occupational Therapists may use the Southern California Sensory Integration Tests to test and assess the child, and in treatment use Sensory Integrative based techniques, which reinforce and help to integrate information gathered by the senses, so that it can be stored and accurately retrieved as it is needed. It also helps the child to use action to gain and organise sensory information, and to use this information to plan and to achieve the intended action.
Speech and Language Therapists help the child to gain control over the speech muscles, so that controlled sounds can be produced at will, to learn to plan language, to learn concepts with which to form strategies, and to use these strategies to make connections and to help form judgements.
Psychologists assess cognitive development and learning ability and potential, and cognitive therapy aims to help the child to use the gathered and stored information to form concepts, which in turn help him to make sense of the world. Therapists also encourage fine motor skills with toys such as puzzles, etc.
Remedial Teachers (Specific Learning Disorder, or SPELD teachers) can help a child, on a one- to-one basis, with specific problems - reading, spelling, maths, etc. This is often given in conjunction with specifically designed sensory integrative-based exercises, and using teaching methods suited to the individual child. Lessons help the child to retrieve learned information for use. Teacher-aides in the classroom, if obtainable, can help the child to achieve and to learn, working on a one-to-one basis. Brain Gym exercises with their cross-lateral element, can help the child integrate messages between the hemispheres of the brain.
A Developmental Optometrist will identify problems with control over eye muscles and eye tracking difficulties, and give exercises to help. A child with eye-tracking difficulties will have problems e.g. in copying from the blackboard or a book.
A Social Worker or Counsellor may be involved if behavioural, emotional or family difficulties are present.
Classroom teachers need to understand Dyspraxia and the accompanying learning difficulties children with Dyspraxia may experience. Both their expectations and their individual teaching method for that child may have to be adjusted. The Specialist Education Service may arrange a needs analysis, and if it is deemed necessary, may arrange any extra help the child may be seen to need.
Parents play the major role in continuing daily treatment routines and exercises, as well as teaching self-care and life skills - dressing, cleaning teeth, washing, making the bed, etc. Regular re-assessment during ongoing treatment, to check on progress and adjust the program as needed, should be given. Regular contact and discussion between teachers, therapists, and family, to coordinate treatment and teaching, is highly desirable. Above all others, the progress of the child who has Dyspraxia will reverse if he is pulled in too many different ways at once.
IMPLICATIONS FOR THE CHILD, FAMILY AND SCHOOL
Each child shows a different set of symptoms, possibly in different areas - constructional, organisational, facial, ocular, verbal, etc. As perceptual-motor abilities are central to all areas of development, its malfunction may affect a wide range of areas at home and at school, from life functions such as dressing or feeding oneself, to playing, reading, writing, or maths, etc.
Dyspraxia is a hidden handicap. If a person wears glasses, or a hearing aid, or a brace, it is immediately obvious that he or she has a disability, and allowances are made. The Dyspraxic child appears just like any other until learned skills are taken out of context or new skills tried, when difficulties become apparent. It affects all areas of development thus:-
School work may have its problems, even if not initially. Reading, writing, maths, all require a great deal of planning and organisation. Difficulties may not appear until the demands of later stages of development show them up. Teachers may, find the child's ability to retain learning inconsistent, may find sequence in all areas, word-finding skills, communication, handwriting, reading (especially aloud), and following instructions all affected, making it difficult to gauge either what the child's intellectual potential might be, or how much information the child has retained or can recall. He or she will certainly need to discover the child's strengths and encourage these in order to maintain self- esteem.
Inconsistency means that a skill or ability today may be a disability tomorrow. This is not laziness - he simply can't. A perceived 'lack of concentration' may simply mean that his planning (or praxis) deserted him mid-task. He is an expert in covering his inabilities. Pressure makes it worse, not better. These children need to learn, would if they could, but - sometimes - can't.
They may become less articulate when they are upset or excited, and need to tell you what's wrong. They may be inarticulate when telling long stories, e.g. about what happened yesterday. Verbal sequence may be affected; the right word may be known but unable to be retrieved.
They may have difficulty in adjusting to new situations, things out of routine or out of context, new people, places, classes. They may be unable to spend a night away from home (e.g. school camps). They may need to plan for birthdays or Christmas for a whole year - and still not cope well. Having visitors, expected or not, may cause confusion and difficulties for him.
Because difficulties may show in one area and not others, it is sometimes hard for professionals who treat one area to see it as a 'global' thing, and not specific to their own field of expertise. It has been noted that there are different types of Dyspraxia (verbal, motor, cognitive, etc.); a child may be affected in any or all areas at various stages of development, and to different degrees.
At home, life can be a challenge, both for the Dyspraxic child and for those around him. He may be incapable of being anything but noisy at times! The constant need for repetition of his own statements and questions, our answers and questions, and for overt planning can be trying. He needs extra attention, which may cause contention among other family members. Dyspraxia affects judgement in all sorts of issues, and may affect the ability to pick up on subtleties. Relationships between all family members carry extra strain. At some stage the child will need to understand the disorder, as will all family members.
Dyspraxic children are normal, bright, lovable, intelligent children who have difficulty planning and organising appropriate actions or behaviour. The understanding and help of all who deal with them is an essential part of their learning process. He or she is not dumb, not stupid, not lazy, and not often un-cooperative.
As has been indicated, the main aim of treatment is to help the child circumnavigate his difficulties, to learn and to achieve his potential. Without the appropriate help at the right time, the possibility exists of him growing into an extremely frustrated, and probably unemployable adult. However, given early therapy and help he can learn, achieve, and eventually become a happy, satisfied, useful adult. There are those in many highly responsible positions throughout our society who have achieved their ambitions and work successfully within their particular fields of interest, in spite of their dyspraxia; equally, there are those who, without early help, are a constant drain on our welfare and prison systems, and live constantly with frustration.
REFERENCES AND BIBLIOGRAPHY
'The Clumsy Child', by Dr. Sasson Gubbay.
'Sensory Integration and the Child', by A. Jean Ayres.
Conference proceedings of the conference, 'Getting it Together', Christchurch, September 1997.
'Planning to Move, Moving to Plan - Living with Developmental Dyspraxia in New Zealand', by Judy Davies.
'Praxis makes perfect', by the Dyspraxia Foundation of the U.K.
'Dyspraxia, a Guide for Teachers and Parents', by Kate Ripley, Bob Daines, and Jenny Barrett.
'Sensory Integration Theory and Practice', by Fisher, Price, and Bundy.
'Dyspraxia', by Niklas Miller.
'The Cognitive Neurosciences', edited by Michael Gazzangia.
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