Contents
Identification of
Developmental
Coordination Disorder
10/21/2010 | 2
1. Movement ABC-2
2. Early signs of DCD
3. Identification of DCD at school age
4. Relationship between different measuring
Marina Schoemaker
University Medical Centre Groningen
Centre for Human Movement Sciences
Groningen
instruments
5. Conclusion
Movement Assessment
Battery for children
10/21/2010 | 4
Revision of the Movement
Assessment Battery for children
Marina Schoemaker
University Medical Centre Groningen
Centre of Human Movement Sciences
Groningen
Necessity for MABC-2 revision
Norm data 15 years old (US data)
Ambiguity in instructions
Expansion of age range
4-12+ -> 3-16 years
Reduction of Age bands 4 -> 3
More comparable tasks per section
task specificity
Scores that can be used for research
standard scores
Hygiene
plastic instead of wood
MABC-1 (1992)
Henderson &
Sugden
MABC-2 (2007)
Henderson, Sugden
& Barnett
What is new?
Extension of age range
2nd edition of the Test of Movement ABC
also includes 3-year-old-children !
3 and 4 year old children have norms per 6
months (not per year)
What is new?
Reduction of age bands
Primary uses of MovementABC2
10/21/2010 | 8
Identification
Age band 1
4,5,6 years
Age band 2
7,8 years
Age band 3
9,10 years
Age band 4
11,12 years
Clinical exploration and intervention planning
Treatment evaluation
Research (select participants for experimental
studies)
Age band 1
3,4,5,6 years
Age band 2
7,8,9,10 years
Age band 3
11-16 years
Standardization sample
10/21/2010 | 9
Changes in scoring system (1)
MABC-1:
Per item: raw scores converted in score
between 1 and 5.
Total score: Summation of 8 item scores (0-40)
Percentile ranks for different total scores

Changes in scoring system (2)
Raw score
Converted to
Standard score
(mean 10, sd 3)
Total test score(TTS)
Sum of standard
ScoresÆ converted to
Standard scores
Percentiles
Standardscores
Changes in scoring system
10/21/2010 | 13
10/21/2010 | 14
Traffic light system:
Age Band 1
3-6 years
Age Band 2
7-10 years
Age Band 3
11-16 years
Manual
Dexterity1
Posting coins
Placing Pegs
Turning pegs
Manual
Dexterity 2
Threading
beads
Threading
Lace
Triangle
with nuts
and bolts
Manual
Dexterity 3
A&C:
Catching
Bicycle Trail
I
Bicycle Trail
II
| 15
Bicycle Trail
III
Catching bean Two-hand
bag
catch
One-hand
catch
A&C:
Aiming
Throwing
bean bag
into box
Throwing
bean bag
into mat
Throwing at
wall target
Static
Balance
One-leg
balance
One-board
balance
Two-board
balance
Dynamic
Balance 1
Jumping in
squares
Hopping in
squares
Zig-zag
hopping
Dynamic
Balance 2
Walking heels
raised
Heel-to-toe
walking
Walking
backwards
Bicycle trails: age bands 1 and
2
10/21/2010 | 17
What is new?
Age band 1

1.
2.
3.
4.
5.
6.
7.
8.
Material instructions different
Tasks different
posting coins in a bank box
(each hand),
threading beads;
drawing a line into a trail;
different trail
catching a bean bag
throwing bean bag onto mat
standing on one leg ;
walking heels raised on a line
jumping on mats.
What is new?
Age band 2
What is new?
Age band 3
Bicycle trail
•
•
Throwing bean bag onto mat
What is new?
Age band 3
•
•
•
•
•
•
•
•
Turning pegs
Triangle with nuts and
bolts
Bicycle Trail III
One-hand catch
Throwing at wall target
Two-board balance
Zig-zag hopping
Walking backwards
•
•
•
•
•
•
Turning pegs
Triangle with nuts and
bolts
Bicycle Trail III
One-hand catch
Throwing at wall target
Two-board balance
Zig-zag hopping
Walking backwards
What is new?
Age band 3
•
•
•
•
•
•
•
•
Turning pegs
Triangle with nuts and
bolts
Bicycle Trail III
One-hand catch
Throwing at wall target
Two-board balance
Zig-zag hopping
Walking backwards
What is new?
Age band 3
•
•
•
•
•
•
•
•
Norms
Turning pegs
Triangle with nuts and
bolts
Bicycle Trail III
One-hand catch
Throwing at wall target
Two-board balance
Zig-zag hopping
Walking backwards
2010: Dutch standardization of MABC-2
Dutch norms deviate from UK norms!!
Æ standardization in Norway is
recommended.
Why is early identification
important?
1. Early recognition of DCD
10/21/2010 | 27
10/21/2010 | 28
DCD is often not diagnosed until the age
Decreased
Physical fitness
of 5 or 6.
Less social
ParticipationÆ
Decreased
self-esteem
At risk for
co-morbidity
Reason: before that age, motor
development can be rather variable.
Little is known about possible risk factors!
Early recognition of
DCD is important
Early
Intervention
Variability in motor development
102 typically developing children
at 23 months
Also measured at 9,11, 13,16
and 21 months
Gross motor signs of DCD in the
pre-school child:‘red flags’
10/21/2010 | 30
Frequency of scores below the 16th percentile
Gross
motor
skills
Fine
motor
skills
1x
2x
3x
4x
5x
16
8
7
2
3
21
11
7
1
0
Darrah et al., (2003) Early Human Development,
72(2), 97-110
›
›
›
›
›
›
Delayed motor mile stones
Falls often
Difficulty jumping or skipping
Dislikes climbing (anxious)
Late riding tricycle; Cannot ride bicycle
Fatigues easily
Fine motor signs of DCD in the
pre-school child
10/21/2010 | 31
Instruments for 3-5 year old
children
10/21/2010 | 32
Early Years Movement Skill (3-5 years)

› Little interest in construction play
› Difficulty manipulating small objects
(LEGO, puzzles)
› Difficulty using utensil (pencil, scissors)
› Difficulty with bimanual activities
› (doing up buttons, cutting)
Recently developed
questionnaire:
23 items
Limited information about reliability and validity
MABC2 (2007): ageband 1: 3-5 years
10/21/2010 | 33
Little DCD-Q
3-5 years of age
15 items
To be filled out by parents
Proposed motor function
assessment: prenatal
period to age 5 years1
Phase I: Screening for motor function
difficulties in the preschool years

Failure to meet motor milestonesÆ Ages and Stages
Questionnaire
Additional questions:
Cross cultural study (Canada, Israel, Brasil,

Belgium, England, Germany, The Netherlands)
Reliability and validity

Proposed motor function
assessment: prenatal
period to age 5 years (2)
Phase II: Proposed ‘‘second-order’’
assessment of children who fail a screening
phase (administration of a motor test)
Phase III: Protocol for specialist (clinical)
assessment to detect the onset/offset of
specific developmental motor disorders
(dimensional measure(s) of motor difficulty)

Diagnosis (CP, DCD, Muscular dystrophy etc.)
‘‘Is there anything your baby/child is doing with their
arms, legs or body movements that concerns you?’’
‘‘Is there anything your baby/child is not doing with
their arms, legs and body movements that concerns
you?’’
‘‘Is there anything that you have tried to teach your
infant/child to do involving their hands or whole body
movementthat has taken longer to learn than you
think it should?’’
1Rosenbaum et al. (2009)
Conclusion early
identification of DCD
10/21/2010 | 36
Difficult before the age of 5
Before the age of 5: DCD should not ne diagnosed
before the age of 5!!

Variability of motor development before this age
Gross motor development is essentially well established
by about the age of 5 years (postural control skills and
locomotor skills)
Children with ‘red flags’ need to be followed, as they
may be at risk for DCD.
2. Identification of DCD at school age
10/21/2010 | 37
Diagnostic Criteria for Developmental Coordination Disorder
(DSM-IV)
Criterion A. “Performance in daily activities that require motor coordination is
substantially below that expected given the person’s chronological age and
measured intelligence”.
Criterion B. “The disturbance in criterion A significantly interferes with
academic achievement or activities of daily living.”
“Tests don’t diagnose,
people do!”
Criterion C. “The disturbance is not due to a general medical condition (e.g.,
cerebral palsy, hemiplegia or muscular dystrophy) and does not meet criteria
for a Pervasive Developmental Disorder.”
Criterion D. “If mental retardation is present, the motor difficulties are in excess
of those usually associated with it.”
DSM Criterion A
10/21/2010 | 39
“Performance in daily activities that require motor
coordination is substantially below that expected given
the person’s chronological age and measured
intelligence.
This may be manifested by marked delays in achieving
motor milestones (e.g., walking, crawling, sitting),
dropping things, “clumsiness”, poor performance in
sports, or poor handwriting. ” (DSM-IV-TR, 2000 p. 58).
Leeds Criterion A. Diagnosis
10/21/2010 | 40
Developmental coordination disorder (DCD) is evident when
there is a marked impairment in the performance of motor
skills.
Core aspects of the disorder include difficulties with gross
and/or fine motor skills, which may be apparent in
locomotion, agility, manual dexterity, complex skills (e.g. ball
games) and /or balance.
Individually administered and culturally appropriate,
How do we measure criterion A?
What is meant with ‘substantially below’?
norm-referenced test of general motor competence.
The cut off point at or below the 5th percentile.
Checklists may be used as an initial screening tool.
Children that score below the 15th should be monitored
Norm referenced motor tests
Available tests
BGMA
Basic Gross Motor Assessment
Advantages:
Objective
standardized
BOT-2
Bruininks-Oseretsky Test 2nd ed.
M-ABC
Movement Assessment Battery for Children
Disadvantages:
Snapshot Æ Influence of performance variables
(fatigue, anxiety)
Time consuming
Qualified tester is necessary
MAND
McCarron Assessment of Neuromuscular
Development
PDMS-2
Peabody Developmental Motor Scale 2nd
ed.
TGMD-2
Test of Gross Motor Development
ZNA
Zurich Neuromotor Assessment
10/21/2010 | 41
10/21/2010 | 42
Best rated tests1
10/21/2010 | 43
M-ABC
2001: used in 67% of the studies published until then
Most popular test for DCD at the moment
Reliable and valid
TGMD-2
Not often used in DCD population
Validity and reliability only demonstrated for TD group
DSM Criterion B
10/21/2010 | 44
“The disturbance in criterion A significantly interferes
with academic achievement or activities of daily
living.” (DSM-IV-TR, 2000 p. 58).

academic achievement: writing and physical education
activities of daily living: drawing/writing, dressing,
locomotion, speech and use of tools/objects
Bruininks- Oseretsky Test
Used in 6% of the studies published until 2001
Reliability and validity have been critized
Mainly used in USA
1 Slater et al. (2010). Pediatric Physical Therapy
Leeds Criterion B. Diagnosis
10/21/2010 | 45
The specific skill of handwriting is usually
affected, and is known to adversely affect
academic achievement and should therefore
be assessed.
Tests for measuring ADL?
MABC(2)
– test for motor skills, but not for ADL
PEDI
Assessment should reflect culturally relevant
developmental norms relating to activities of
daily living tasks and should include
consideration of self-care, play, leisure and
schoolwork (including handwriting, PE and
tool use).
– is not discriminative enough for use in
children with DCD
(School)-AMPS (Assessment of Motor and
Process Skills)
– limited to functional skills at school
How to measure criterion B?
How to measure criterion B?
10/21/2010 | 47
10/21/2010 | 48
At present no test of ADL has been developed.
Questionnaires are used to assess functioning in ADL
tasks
Advantage:

Performance across a larger time scale is taken into
account
Fast and easy to administer
Disadvantage:
Subjective, raters may lack sufficient knowledge to rate
motor behavior (knowlegde of motor development)

Parent-questionnaire

Teacher-questionnaires

DCD-Q
Checklist-Movement ABC
Motor Observation Questionnaire for Teachers
(MOQ-T, previously called GMO)
TEAF
Child-questionnaire

Children’s self-perception of adequacy in and
predilection for physical activity (CSAPPA)
Checklist Movement-ABC2
10/21/2010 | 49
Aim: assessment of motor performance of
children in the school environment
• Age: children from 4 to 12 years of age
• To be filled out by teachers
• 30 questions, divided over 2 sections
Section 1
The child is stationary
and the environment stable
Stand on one leg in a stable
position.
Section 3
The child is stationary
and the environment
is changing
Intercept and stop a moving
object as it approaches.
Checklist MM-ABC: reliable and valid
(Schoemaker et al., submitted))
3 Sections
10/21/2010 | 51
2 Motor section (A and B)
Section 2
The child is moving and
the environment stable
Skip or gallop a distance
of 4.5 meter.
Section A
Section 4
The child is moving and the
environment is changing
Run to catch an
Approaching ball.
Section B
MOQ-T
Motor Observation Questionnaire
for Teachers
10/21/2010 | 52
Aim: screening of movement problems at school by
1 Non-motor section (section C:
teachers
impulsiveness, distractibility, passiveness,
upset by failure etc.)
Scoring: Total Test Score (summed score for
sections A and B)
Interpretation: Traffic Light system
age: 5 - 12 yrs
filled in by: teacher; requested time 5 minutes
18 items, measuring 2 factors:
General motor functioning
handwriting
Separate norms for age and gender
MOQMOQ-T (previously: GMO): reliable and valid
(see Schoemaker et al, 2008)
DCD-Q
Developmental Coordination
Disorder-Questionnaire
10/21/2010 | 53
Aim: screening of problems with gross and fine motor
coordination
. age: 8 to 14;6 yrs
filled in by: parent(s); approximately 5 minutes
15 items; 3 factors:

Motor control
Fine motor skills / handwriting
General coordination
DCDDCD-Q : reliable and valid
(see Wilson et al., 2000; Schoemaker et al., 2006))
New instrument for ADL
To develop an instrument to assess ADL in
children with DCD
Goals:
Representative set of ADL
Objective and systematic
30 Minutes

Development of a new measuring
instrument for ADL skills
10/21/2010 | 55
To be used in addition to the M-ABC
Literature study and expert interviews

To compose a list of ADL skills that might be
difficult for children with DCD
The DCDDaily
(Van der Linde, Van Netten, Schoemaker)
10/21/2010 | 56
DCDDaily: Motor assessment
Reflect ‘A normal day’
Self-maintenance (home)
Productivity (school)
Play
21 items

Expert meeting
Scoring: performance and speed (good, moderate, poor)
DCDDaily-Questionnaire (child and parent)
(Occupational model, Dunford et al., 2005;
DCDDaily: items
Reed and Sanderson, 1992)
Movie 1
10/21/2010 | 57
‘Home’
Cutting gingerbread
Box and Bag
Walk to school
‘School’
Tinkering: folding,
coloring, cutting
Constructional play:
Lego
Handwriting
‘Break’
Pooring a drink
Walking with drink to table
‘Shopping’
Dressing: socks, polo-shirt,
trousers, body warmer
‘Outdoor play activities’
Playing with marbles
Hopping
Discriminative ability
10/21/2010 | 60
23 DCD and 72 TD (6-8 years)
Discriminative ability
How to use the DCD-Daily?
(nDCD = 17; nTD = 69)
To assist in assising criterion B
To get an impression of problems with
3
functional skills at home or at school
To evaluate treatment
Item scores
2,5
DCD
TD
2

Treatment: shift from process-oriented to more
functional task-oriented approaches.
1,5
1
13*
10*
20*
8*
9*
5
7*
2*
6*
15*
17*
12*
18*
14*
4*
1*
11*
19*
21*
3
16*
Items
Usefulness of questionnaires for
identification of children with DCD?
Conclusion
10/21/2010 | 64
Present situation: Only questionnaires are
available to assess ADL performance and to
decide whether the performance of a child
meets Criterion B.
Important aspects of a
screening instrument:
Two samples:
Random sample (children from mainstream
schools)
Referred sample (50% children referred to child
rehabilitation; 50% control children)
10/21/2010 | 65
Sensitivity
Specificity
Can only be reliably determined if there is an accepted
gold standard.
10/21/2010 | 66
Sensitivity: The percentage of children who fail
the M-ABC who are correctly identified by a
screenings-instrument.
In Table: a / (a+c)
Gold standard: a diagnostic test that is regarded as
definitive
A hypothetical ideal gold standard test has a :
sensitivity, of 100% (it identifies all individuals with a
disease; it does not have any false-negative results)
specificity of 100% (it does not falsely identify someone
with a condition that does not have the condition; it does not
have any false-positive results).
DCD: gold standard: ???? Æ does not exist!
But: M-ABC is often used as a gold standard
Questionnaire DCD
(< 15th %)
No DCD
> 15th %
DCD
a
c
M-ABC
No DCD
b
d
Sensitivity of the questionnaires
(M-ABC is gold standard (15th % cut-off criterion))
10/21/2010 | 67
Sensitivity
Specificity: The percentage of children who pass
the M-ABC who are correctly identified by a
screenings-instrument.
In Table: d / (b+d)
Questionnaire DCD
(< 15th %)
No DCD
> 15th %
DCD
a
M-ABC
No DCD
b
c
False
positives
Referred
sample
Checklist
M-ABC 2
44%
??
DCD-Q
29%
82%
MOQ-T
39%
81%
d
Specificity of the questionnaires
(M-ABC is gold standard (15th % cut-off
criterion))
Specificity
Random
sample
Random
sample
Conclusion
10/21/2010 | 70
Sensitivity of questionnaires:
is good in referred sample,
but too low for population screening (random
sample)
Referred sample
Checklist MABC2
91%
??
DCD-Q
89%
89%
MOQ-T
89%
62%
Specificity of questionnaires:
Is good for population screening,
Is good for DCD-Q in referred sample
but slightly too low for MOQ-T in referred
sample
Why should we be careful to use
the M-ABC as a gold standard?
10/21/2010 | 71
1. DCD is a heterogeneous disorder
2. M-ABC does not cover the full range of motor
abilities that might be implicated.
10/21/2010 | 72
Motor Abilities
Prospective study
1
2

M-ABC
VMI
BHK (handwriting)

IQ-test (WISC-R)

Child Behavior Check List
Teacher Report Form

4
Motor
performance
5

6
7
8
Outcome Prospective study
(N=107, all referred)
Features of “Non-DCD group”
DCD
M-ABC < 15th
percentile
Non-DCD
(M-ABC > 15th
percentile
M-ABC
86 (80%)
21 (20%)
Medical problem
0
2
IQ < 70
0
1
Co-morbidity
according to CBCLscores
58%
52%
13 out of 19 non-DCD children had fine
motor problems :

Handwriting (BHK)
Visuo-motor problems (VMI)
Conclusion: When only the M-ABC is
used for criterion A, children with fine
motor disorders may be missed.
3. What is the agreement between
different measures designed to
identify children with DCD?
Participants:
10/21/2010 | 77
Teachers
Parents
MOQ-T
DCD-Q
Children
M-ABC
10/21/2010 | 78
Random sample:
• 233 children
(126 boys / 107 girls)
• Age range 5-11 years old
• Mean age: 8 years 1 months
• All attending meanstream
schools
Referred sample:
• 76 children
(68 boys / 8 girls)
• Age range 5-11 years old
• Mean age: 7 years 3 months
• Referred to rehabilitation
clinic for coordination
problems.
Random sample
M-ABC 15th percentile
Population sample (N=233)
10/21/2010 | 80
DCD-Q
6%
Instruments identify partly
MOQ-T
3.8%
1.7%
6.4%
5%
4%
4.7%

9.8%

N=21
M-ABC
the same partly different
children
If 15th centile is used, only
4% of the children (n=10)
are identified by all
measures (1.7 % (n=4) if
the 5th centile is used)
M-ABC does not identify
children with primarily fine
motor problems (n=9)
Using failure on the MABC as the only criterion
for DCD might lead to
over-identification
(21/233).
DCD-Q < 15th % or
MOQ-T < 15th %
24%
56/233
M-ABC < 15th %
M-ABC < 5th %
9%
21/233
4%
9/233
Referred sample (N=76)
Referred sample
10/21/2010 | 82
DCD-Q
1%
MOQ-T
13%
4%
54%
9%
7%
5%
M-ABC
Overlap between
measures is relatively
large.
6.4% 13% of the children are
not identified by the MABC because of fine
motor problems
Not all children referred
to a rehabilitation clinic
can be diagnosed as
DCD (other
developmental, school
or educational
problems)
Conclusions
DCD-Q < 15th % or
MOQ-T < 15th %
88%
67/76
M-ABC < 15th %
70%
53/76
M-ABC < 5th %
51%
39/76
Conclusion
10/21/2010 | 83
1. Some children fail on the MABC but do not
have problems according to either parents or
teachers.
2. Children with fine motor problems might be
missed when only the M-ABC is used as an
instrument to identify children with DCD.
3. Multiple measures are recommended to be
used to identify children with DCD
10/21/2010 | 84
Identification of children with DCD: not as easy
as it seems to be!
Multiple measures are needed to identify
children with DCD in a reliable way, according
to the diagnostic criteria for DCD
The development of new measuring
instruments might be helpful in the
identification process.