1. family and parenting
2. children

Developmental
Dyspraxia by Any Other
Name: Are They All Just
Clumsy Children?
D
evelopmental dy~pra.,,(ia. and sensor)! integrative
dysfunction are terms that have been used by
ai.ed confusion among researchers and clinicians il1
many/ields, including occupational therapy. Although
the diagnostic criteria appear to be similar to those
used to define clumsy children, children with developmental dyspraxia, or children with sen::.ory integrative
dysfunction, we are leji with the question. Are children
who receiue the diagnosis o/DCD the same as those
who receiue the other diagnoses, a subgroup. or an
entirelv distinct group a/children? This article ll'ill e.Yamine the theoretical and empirical literature and
use the results to support the thesis that these terms are
not interchangeable and yet ore not heinf!, used iii the
literature in a wav that dead]' defines each subgroup
0/ children. Clear definitions ~mct' charaeteri.stie features need to be identified and associated I/'ith each
term to gUide occupationol therapl' assessment and
intemention and clinical research.
occupational therapists during the past 20
years to describe and explain the motor learning and
coordination problems experienced by many young children. Children with developmental dyspraxia typically are
referred to occupational therapists for remediation of
handwriting difficulties, problems with independent
management of self-care activities, or the social isolation
that results from clumsiness during or lack of participation in sporting and playground activities. Although large
numbers of school-age children are presumed to experience functional problems as a result of their clumsiness,
theoretical papers and clinical research reports in occupational therapy, medical, and educational journals have
been few. Interest in and research with this population
has increased recently, however, due to the publication of
longitudinal studies suggesting that clumsiness in the early school years was strongly associated with later learning
difficulties, school failure, and psychological problems
(Cantell, Smyth, & Ahonen, 1994; Cermak, Trimble, Coryell, & Drake, 1990; Geuze & Borger, 1993; GiJlberg &
Gillberg, 1989: Losse et aL, 1991)
Just when more comprehensive studies of children
with developmental dyspraxia were beginning to develor. the waters became muddied by the introduction of a
diagnostic category in the Diagnostic and Statistical
iV/anual o(k/ental Disorders (DSM). del'elopmental coordination disorder COCO) (American Psychiatric Association IAPAI, 1987, 1994). This term has become the
focus of debate among clinicians and researchers in the
field. Although it is promising to see official recognition
given to tl1(' occupational performance problems of a
child who is clumsy, it is not clear whether children with
DCD are the same as, a subgrour of, or entirely distinCt
from children with developmental d1'~pra.A·ia or children
with sensor]' integraliue dJ'-'!imction. In this article, we
outline the origin of various terms that have been used to
describe children with motor coordination difficulties,
review empirical studies, and compare the performance
component problems associated with four of the most
common terms to develop the argument that the terms
are not interchangeable and that the distinction is important for occupational therapists to make when determining clinical intervention methods and selecting subjeCts
for research.
Cheryl Missiuna. Phi), OI(C). IS ASSIStanl Profes~or, School of
Occupational Therapy and Physiotherapy. IvlcMastcr- Universi·
ty, OT/PT Building, 12HO Malrl Street West. rlal11ilton. Ontano.
l.HS 4Kl and an Associate Member of the Neurodevelopl11ental Clinical Research llnil.
What Do We Call the Child Who Is Clumsy?
Cheryl Missiuna, Helene Polatajko
0/ the diagnostic categon' developmental coordination disorder ([JCD) (Americon
Psychiatric Association (APAJ, 1987, 1994). has gener-
The recent introduction
Helene PoJatajko, rhO. 0'1'(;). i::. Professor and Chair, Department of Occupational Therapy, Faculty of Applied Health Sciences. University of Western OntariO. I.ondon, Ontario.
fbis article I{'as accepledjor publiculion NOl'emiler
--I.
19CN.
The tei'mino]ubry that has been used over (he years to
describe children who are clumsy reflects the diverse
theoretical positions and different levels of analysis that
have charaeterized both the descriptive and empirical
literature in the field The historical development, definition, and use of four key terms that describe deve!opmen-
7he Alliericall jOllrllal oj' Occupatiollal lbeJ'upl'
Downloaded From: http://ajot.aota.org/ on 02/06/2015 Terms of Use: http://AOTA.org/terms
619
tal motor problems in children - clumsy child syndrome.
developmental dyspra.xia, sensory integrative dy~/'unc­
tion, and DCD -will be outlined in thIS section Other
terms that are found in the literature and that appear to
describe the same types of problems in children are listed
in the Appendix, Although these terms undoubtedly reflect different author's observations or theories of causation, none has achieved much popularity and therefore
will not be discussed further.
Clumsy Child Syndrome
Descriptions of children with developmental movement
difficulties appeared in the literature as early as 1911 in
the work of Dupre, who reported treating children with
clumsiness of voluntary movement (cited in DeAjuriaguerra & Stambak, 1969), Some of the early learning disability literature included references to children who
manifested clumsiness or psychomotor syndrome (Strauss
& Lehtinen, 1947) and described it as a common developmental disorder (Orton, 1937), It was not until the mid1960s that case studies and systematic empirical work
began to appear in the literature (Walton, Ellis, & Court,
1962), Gubbay (197'5a, 197'5b; Gubbay, Ellis, WaltOn, &
Court, 1965) summarized much of this early work and
attempted to delineate the essential features that he believed constituted clumsy child syndrome,
Gubbay defined the child who is clumsy as "one
whose ability to perform skilled movement is impaired,
despite normal intelligence and normal findings on conventional neurological examination" (1975b, p, 233), Key
features of this syndrome included a typical intellectual
capacity; an impaired ability - due to clumsiness - to successfully carry out activities in the home, at school, in the
gym, and on the playground; poor handwriting and impaired drawing ability; some motor activities performed
well and others poorly; and the necessity of ruling out
subtle neurological signs that might indicate other motor
system impairments, The features of Gubbay's clumsy
child syndrome have been used for subject selection by
numerous researchers in recent years and the term clumsy child is still Widely used in Great Britain, Australia, and
the Netherlands (Gordon & McKinlay, 1980; Hall, 1988;
Henderson & Hall, 1982; Hulme, Biggerstaff, Moran, &
McKinlay, 1982; Lord & Hulme, 1987a, 1987b, 1988a,
1988b; Parkin & Padley, 1989; van Dellen & Geuze, 1988;
van del' MeuJen, van der Gon, Gielen, Gooskens, & Willemse, 1991), Clumsy child is the term that occurs most
frequently throughout the English literature published in
the last 25 years (Missiuna, Kempton, & O'Leary, 1994)
Developmental Dyspraxia
In North America, during approximately the same time
period, the term developmental dyspraxia was introduced in the occupational therapy literature, The term
was used to describe the developmental motOr problems
that were observed in children who are clumsy (Ayres,
1972, 198'5; Ayres, Mailloux, & Wendler, 1987; Cermak,
198'); Conrad, Cermak, & Drake, 1983), Developmental
dyspraxia also appeared in a few publications in medical
literature from different parts of the world (Denckla,
1984; I1oeje, 1987; Njiokiktjien, 1988) and was used briefly
by Gubbay (1978), The Child Neurology Society Task
Force on Nosology of Disorders of Higher Cerebral Function (David et aL, 1981) appears to have been the first
group to give more official recognition to developmental
dyspraxia, describing the condition as a failure to learn or
perform voluntary moror activities despite adequate
strength, sensation, attention, and volition (David et aI.,
1981)
The term praxis, by definition, describes that
uniquely human, learned ability that allows us to plan,
organize, and execute purposeful, skilled movements
(Ayres, 1972, 198'5), Practic dysfunction presents itself in
two major disorders: apraxia and developmental dyspraxia, Apraxia, the loss of ability to perform previously
acquired movements, is observed most commonly in
adults with brain damage who have had a cerebrovascular
accident, Extensive research has linked apraxia to discrete areas of brain damage, the specific loci of which are
still debated (Gersh & Damasio, 1981; Geschwind, 197'5;
Kertesz, 198'5; Kimura, 1977; Poeck & Lehmkuhl, 1980),
Developmental dyspraxia, on the other hand, is a disorder of an evolVing central nervous system and as such is
not simply a "miniature version of adult apraxia" (Miller,
1986, p. 161), Ayres (1972), who originally used the term
developmental apraxia, later expressed a preference for
the term dyspraXia to describe the problems of children
who are slow and inefficient when formulating motor
plans (Clark, Mailloux, & Parham, 1989) Developmental
dyspraxia, then, is considered to be a constitutional disorder, typically identified in children, that affects the acquisition of new motor skills, The introduction of this term
was probably intended to reflect the belief that there
might be a link in causative mechanism of the two practic
disorders because the observations of children with dyspraxia who were trying to learn new skills and of adult
clients with apraxia who were trying to perform old skills
were fairly similar. This hypothesized link, however, has
never been established empirically,
Sensory Integrative Dysfunction
Use of the term sensory integrative dysfunction also has
its roots in the work of Ayres and colleagues but has
actually been used with greater frequency in the empirical
literature - especially the occupational therapy literature
---, of recent years than has developmental dyspraXia
(Missiuna et al., 1994), The term sensory integrative dysfunction was used to refer to children who performed
poorly on specific tests of sensory integrative function; its
620
Downloaded From: http://ajot.aota.org/ on 02/06/2015 Terms of Use: http://AOTA.org/terms
July/Augus! 1995, Volume 49. Number 7
usage increased as testing became more prevalent. In the
empirical literature, the term is found primarily in studies
conducted by occupational therapists that have investigated the efficacy of sensory integrative treatment
(Humphries, Snider, & McDougall, 1993; Law, Polatajko,
Schaffer, Miller, & Macnab, 1991; Po]atajko, Law, Miller,
Schaffer, & Macnab, 1991). The major purpose in introducing the phrase appears to have been to distinguish
between subjects with learning disabilities who did or did
not exhibit eVidence of difficulty with the integration of
sensory and sensorimotor information. Definitions for
this term vary across studies but usually include poor test
performance on a measure of sensory integrative functioning, such as the Sensory Integration and Praxis Tests
(Ayres, 1989) or the DeGangi-Berk Test of Sensory Integration (Berk & DeGangi, 1983), and observations made
by pediatric occupational therapists. Children with sensory integrative dysfunction are commonly described as
having gross motor balance and coordination difficulties
as well as difficulty integrating information such as would
be measured on perceptual motor tests. The term has not
achieved popularity outside of the field of occupational
therapy.
DeveLopmentaL Coordination Disorder
The term DCD was introduced in 1987 and was refined
and expanded in the DSM-N (APA, 1994). The exclusionary criteria that were outlined by Gubbay for clumsy child
syndrome (1975a) appear to have been maintained as
essential features of this diagnostic category. DCD is defined as a "marked impairment in the development of
motor coordination
only if this impairment significantly interferes with academic achievement or activities
of daily living
and is not due to a general medical
condition" (APA, 1994, p. 53). Although the earlier edition
required the exclUSion of children with mental retardation, the most recent classification states that if mental
retardation is present, the motor difficulties "are in excess
of those usually associated with it" (1994, p. 53). The
latest classification also allows for the concomitant presence of attention deficit and hyperactivity disorders but
indicates that, in the event that criteria for bOth disorders
Me met, both diagnoses should be given.
The description of children with DCD appears to be
very similar to the characteristic features outlined in many
of the British and Australian studies of children who are
clumsy. Prevalence estimates obtained from around the
world for such children (Gubbay, 1975a; Henderson &
Hall, 1982; Iloeje, 1987) have also tended to concur with
those reported for children with DCD, suggesting that
about 5% to 6% of the school-aged population is affected.
Due to the recent introduction of the category, few studies have been published thus far that have described their
subjects as children with DCD; all but one (Henderson,
Rose, & Henderson, 1992) were reported in a special
issue of the Adapted Physical ActiviZv Quarter(y on DCD
(Henderson, 1994).
Are the Terms Synonymous?
The Child Neurology Society (David et a!., 1981) appears
to have been the first group to attempt to distinguish
developmental dyspraxia, a motor planning disorder,
from a motor execution disorder that they labelled developmental maLadroitness. They determined that the latter syndrome was most common in isolation and was
characterized primarily by slow, ineffectual movements
and by an apparent breakdown of previously acquired
motor skills with stress. The frequent presence of a poor
self-image and secondary emotional and behaVioral difficulties was also highlightecl. The distinction suggested by
the Society between two types of developmental movement problems was an important one, yet it has not received wide acceptance, and studies reponed in the literature have nOt attempteu to draw a distinction. More
recently, Cermak (1985) and Sugden and Keogh (1990)
raised the issue again, distinguishing developmental dyspraxia from the poor quality of performance of motor
skills that characterizes the child who is clumsy. Sugden
and Keogh (1990) considered that any use of terminology
implying a praetic disorder should reflect the specific
observation that the child is having difficulty planning or
conceptualizing motor acts.
It would appear, from the diagnostic criteria cited for
DCD in the DSM-N (APA, 1994) and the difficulties outlined in the defInition, that the motor execution disoruer
may have been the ill[ended focus of this new classification. Yet developmental dyspraxia and sensory integrative
dysfunction al-e still the terms that are used by occupational therapists in North America to describe the problems of the child who is clumsy (Missiuna et aI., 1994).
Although the terms may not be synonymous, the question arises whether they may be relatively interchangeable at a practical level when an occupational therapy
practitioner is reading the research literature. To answer
this question, we conducted a review of literature that
analyzed the performance components that have been
described concel-ning the problems of children who are
clumsy.
Are We Talking About the Same Child?
A comprehensive literature search was conducted with
four computerized literature indexing databases. The
search was limited to literature that had been published
from 1970 onward, was written in English, and pertained
to children. To access as much literature as possible Without predetermining terminology, key terms such as molar (fine, gross, Visual, perceptual, coordination, sensory)
were crossed with terms that would imply dysfunction
(clumsy, difficuLlV, disorder, probLems, poor) and then
The American Journal olOccupalional Therapv
Downloaded From: http://ajot.aota.org/ on 02/06/2015 Terms of Use: http://AOTA.org/terms
621
narrowed until the abstracts appeared to reflect work
With children with mmor problems All of the major terms
(please see Appendix and other terms that have heen
itali(lzed throughout) that were generated by this initial
search were then entered as well. Finally, articles were
eliminated if they were (a) theoretical articles (did not
report actual results of work with children); (h) studies
designed to estahlish the reliahility or validity of a panicular test; or (c) studies that involved the assessment or
treatment of suhjects who had learning disahilities withOut evidence of mmor difficulties, who were cognitively
developmentally delayed, or who were rerorted to have
other medical conditions.
Eighty-six anicles were ohtained that reponed some
type of assessment or treatment of children who demonstrated developmental motor prohlems. (A complete list
of the studies is available from the first author.) Evidence
of the hurgeoning interest in this client ropulation is
shown in thal '53% of the anicles had been rublished
since 1990. Seventy-six of the anicles were classified as
descriptive studies, articles in which children were assessed or asked to rerform tasks, but no intelvention was
rrovided The remaining 10 articles were classified as
intervention studies, in that some form of treatment was
conducted.
Most descriptive studies have been conducted by
rsychologists or rhysicians, whereas occupational therarists have performed the most intervention studies (see
Tahle 1) England, the United States, and Australia have
produced most of the descrirtive studies, but Nonh
Table 1
Discipline, Country and Methodology Used in Studies
Reviewed
Study Type
Discipline of researcher
Psychology/medical
Occupational \her3py
Physical therapy
Educ3lOrs
Olher
CounllY
England
llnited Swte,
AuStr31i3
Netherlands
Scandinavia
Canada
Other
Methodology
Correlational
LongilUdinal
Case slUdy
Other «2%)
PretCsl- Posnest
Pre, Post, Follllw-[ ip
Crnssovt:r
Descriptive
(76 ,lUdic,)
Inlelyel1lllll1
110 studtc's)
(%)
(~)
.19
1Il
60
1Il
.~
1
11
9
10
In
29
2l
0
to
[7
'iO
12
C)
n
n
'i
-Ill
Il
66
1:1
:I
10
"i!\
N!\
Ni\
lH
N!i\
N'A
'ill
-111
N!A
10
American occurational therapists from both Canada and
the United States have heen the rrimary investigators in
sruelies thaI useel a pretest-pOSHest method of evaluating
clinical intelvcntion The most common type of study was
one that attempted to correlate performance of children
on one tyre of test or task with performance on other
tests or tasks.
To begin to examine the performance difficulties
that were reroned in different groups of children, articles
wt're coded for the term that was used to describe the
children and the major definition thaI the term was given
in each article. The four most frequently encountered
terms are presented in Tahle 2 Although each term arpears to he most closely associated with a ranicular definition, the only term that has used a single definition
consistently is sensory integrative dysfunction
Because suhject differences may also be attributable
to the methods used to obtain subjects for study, the
suhject selection methods and other demograrhic characteristics were summarized (see Table 3). Descrirtive
studies seemed to include children across a wider range
of ages, whereas intervention was geared toward younger
children. The ratio of boys to girls was found to be relatively similar in all studies, suggesting that about 70% to
80% of children with these difficulties are boys. Most
descrirtive studies have selected children from large porulation bases, although intervention studies have tended
to be rerformed with children who were referred to clinical settings. The heavy emrhasis on intellectual testing in
both tyres of studies was surpriSing, considering that all
of the terms defining thiS population descrihe primary
problems in the area of physical, not cognitive, performance. The arbitrary determination of cutoff scores (e.g.,
a score above or below one standard deviation) has heen
used frequently for subject selection, a rrocedurc used
with this rorulation that has recently heen criticized
(Missiuna & Pollock, 1994).
The ohservation and rer0rting of particular tyres of
impairment may reflect what is actually harpentng with
the children but may also he influenced by the characteristics that researchers choose to measure. The 66 articles
thaI used one of the four terms that are the focus of this
article were examined more closely. We hypothesized
thaI researchers who choose to use a particular term
might he anticirating the rresence of certain characterls,
tics in their suhJects and thus would choose only to evalu
ate or rer0rt these Table 4 rre.)ents the performance
components and areas of ()('cupatiomil[x'!'forlnance thaI
were evaluated or reported on III thesestudit's Not .)llr
prisingly, gros.) moror c()()rdtnatloll was measured 111
nearly all studies; sensory lIltegratlVC h.IIKti(1I1 allrl fint'
motor coordination were measured in most of the stIlt!
ies A numher of other areas that have heen sugg,.\tul 111
the literature to he prohlematl\ for these dlildwl1. in
eluding social-emotional difficultIes and aHt'ntional and
org:lIlizational problems, are not heing measured or com-
622
Downloaded From: http://ajot.aota.org/ on 02/06/2015 Terms of Use: http://AOTA.org/terms
!ul)'/August 1995, votunU! 49. N1IInher
7
Table 2
Definitions Associated With Four Most Frequently Used Terms
Tvpc of LitcratLIrc
Term
Definition l!'icd
Descriptivc
(;V = 57)
InrcrVCllfinn
(/,·,1=9)
AITC.'i/SI
Gubbav
APA
Other/nom:
41
-J
14
1
I
10
15
6
6
0
5
0
I
0
0
3
Clumsy child
DCD
Developmental dyspraxia
Sensory integrative dysfuncrion
6
5
o
o
5
5
0
0
NOle. DCD = developmental coordination disorder, 51 = sensorv integration, APA = Amc,'ican Pwchi,mic A"oci~ti()n.
mented on by most researchers. Occupationai performance in academic areas, including handwriting, was reported in nearly one half of the studies; very little
attention, however, had been given to performance in
leisure or self-care activities.
Finally, we hypothesized that researchers might select terms on the basis of the impairments that were
actually observed in the children with whom they
worked. Examining the 66 articles again, we looked only
Table 3
SUbject Selection Information
Stud~'
Tvpe
Dcscrip-
Intcl'-
ti\'C
\"t~ntion
(76 sludics)
(10 studies)
Mean numbcr of subjects
49
Mean number of comparison subjccts
21
47
N/A
Mean age (years)
92
69
Gendcl' (I'atio of malcs/fcmales)
38
.;U
Method of obtaining subjects:
Population scrcen
Clinical caseload
Teacher-referred
Other
3)·0/
/0
609'0
20%
).0
·0.
20%
0%
38%
40%
32%
1096
89-6
':;09-0
10%
Standardized assessments
(used to assess children for inclusion):
fntcliJgcnce teSt
Test of motOr impairment"
SIPTiSCSIT"
Bruininks-Osel'ctsky"
Dcvelopmental test of Visual-MolOl'
Integration"
Ncurological tests
Other « 2%)
Clinical observations
Subjects excluded on basis of
Medical observations
Arbitral'Y score on assessment
Definitional cl'ite,-ia (eg, mental
I'erardation)
40%
7<)0
7%
at the results reported in the eight areas most frequently
measured by researchers. Each characteristic was considered to be an area of impairment if more than 50% of
children in the study were reponed to have difficulty with
it or if assessment data were presented that suggested
impairment (see Figure 1). Gross motOr coordinarion
difficulries were again found to be reponed in the majority of children, regardless of the term used. Reponed
impairment in each of the other areas, however, was
varied and particular terms did not appear to be associated with particular areas of impairment. This figure needs
to be interpreted with reference to the low number of
studies that evaluated some of these potential areas of
impairment (see Table 5).
It would appear from the empirical literature, then,
that the four terms that are used most frequently to
describe developmental motor problems in children-
clumsy child syndrome, developmental dyspraXia, senintegrative dYsfunction, and DCD - are not inter·
Sal)!
changeable terms. Individual terms also do not appear to
20°"
4%
10%
0%
629f)
-4091\
1596
')og()
-J 3 'Yo
-/091,
55%
)0%
20%
30 0(,
;Vole SIPTISCSIT = Sensory Intcgration and Pl'axis Tests/Southern California Sensory Integration Test.
"StOll, D. H., Moyes. F. A.. & Hendcrson, S E. (1984). TiJe [-Jenderson
Reu/sion oj'lbe Tesl o/MOlor Impa/nnenl London: Ps}'choJogical.
"Ayres, A. J (19R9). Sens01)' Inlegralion (lnd Pmxis Tesls. Los Angclcs:
Western Psychological Services.
cBruininks, R. H. (1978). BruininRs-OsereISk.l' Tesl o/.VlOlor Pro/icienc\,.
Minneapolis, MN: American Guidance Service.
dBee,)', K., & Buktenica, N. A. (1982) Del'elopmenlal Tesl 0/ Vmwl;'dolor Inlegralion - Rel'ised Cleveland, OH: Modcrn Curriculum Prcs,.
Table 4
Number of StUdies in Which Characteristics Were
Measured by Researchers
Term Used
Performance Component
Gross motor skills
Coordination
Balance
Sensory integrative functioning
Fine moror skills
Visual perceptual skills
Social-emOtional functioning
Kinesthetic functioning
Organizational skills
Attention
Behavior
Speech
Perceptual-moror skills
Area of Occupational Performance
Academic
Handwriting
PlayiLeisure
Self-care Activities
Senson'
Develop- Intcgramental
tin" Dl'sClumsy DCD Dl'spraxia function
(45)
(6)
(5)
(10)
31
6
4
4
13
I
0
28
~
0
4
24
19
5
3
4
:3
1
3
0
1
0
0
3
2
2
I
3
0
0
15
13
11
8
2
2
5
1
5
I
20
2
0
9
20
5
4
-:;
1
1
1
0
4
4
0
0
0
7
0
'2"
:3
0
0
DCD = Developmental coordination disorder
TiJe American journal o/Occupalional Therap) ,
Downloaded From: http://ajot.aota.org/ on 02/06/2015 Terms of Use: http://AOTA.org/terms
623
120% ,-----~~~~~~~~~--~~-,---~-~---,
+clumsy (N=45)
toeD
100%
•
(N=6)
Dev Dyspraxia (N=5)
*51 Dys (N=10)
80%
60%
40%
20%
__---'----'---
O%'-~----------
0~
«.~
~~
~~
~<:)
----_--J
~~
Figure 1. Studies reporting impairment of more than 50% of subjects. DCD = developmental coordination disorder, dev
dyspraxia == developmental dyspraxia, SI dys == sensory integrative dysfunction, GM == gross motor, FM == fine motor, SID
== sensory integrative dysfunction, KIN == kinesthetic, HAND == handwriting, ACAD == academic, SE == social-emotional, VP
== visual perceptual.
be reflective of distinct populations or clear subgroups of
children with identifiable characteristics or common definitions. Although gross motor coordination problems
seem to be common to all four groups of children, other
reports of performance components that are or are not
areas of impairment for these children vary tremendously, depending on the population and way in which the
children are seleCted. Consensus is lacking among clinicians and researchers concerning the basic information
that should be assessed and reported in empirical studies
conducted with these children. On the basis of the literature available to date, the potential accuracy of each definition in describing the children and the rationale for
selecting one term before another cannot be determined.
Why Should Occupational Therapists Begin to
Make a Distinction?
The argument has been made by many occupational
therapists who provide service to this client porulation
that the use of different terms does not matter and, further, that the selection of any particular term will depend
upon the audience (Missiuna & Polatajko, 1994). Although most would agree that discussions with c1ient~
and parents WIll reqUire the use of language that is comprehensible, occupational therapy practitioners are still
faced with the discrepancy of terminology within the
health care profession itself Clinical researchers and the
practitioners who read the research are clearly not using
common terminology or common methods of discerning
which children are arpropriate for investigation.
One of the critical implications of a distinction in
terminology may be its effect on subject selection. An
example of a study that used very careful and welldescribed subject seleCtion may be used to illustrate the
point (Wilson, Kaplan, Fellowes, Gruchy, & Faris, 1992).
More than 200 children were referred to the investigators
by teachers and occurational therapists according to
their observations that the children had problems in fine
and gross motor coordination and were, in their determination, clumsy. After testing, only 29 of these children
were eventually determined to have vestibular-based sensory integrative dysfunction and motor incoordination.
Another small group was determined to have a "sensory
integration pronk: that suggested primary dyspraxia or
somatosensory problems" (Wilson et aI., 1992, p. 7): rossibil' a group of children 'Nith developmental dyspraxia?
More than 100 of the referred children were eliminated
624
Downloaded From: http://ajot.aota.org/ on 02/06/2015 Terms of Use: http://AOTA.org/terms
.Iul"/flugust 1995, Volume 49, Number 7
from the study for mher reasons, inCluding the finding
that their motor skills were age-appropriate on normarive
tests. From an occupational performance perspeerive,
however, these children were having some difficulty functioning within their occupational role as stuclents. Did
some or all of these children have DCD' The elimination
of this group from a study of the efficacy of sensory integration treatment is probably very appropriate. How
many of our efficacy studies have been as cautious about
subject selection' Is this one of the reasons why the results of man}' of our clinical trials have been so inconclusive (Polatajko, Kaplan, & Wilson, 1992)'
Conclusion
The issues raised in this paper are concern.s that have
been shared by clients, clinicians, and researchers ;lround
rhe world. In Oerober 1994, an International Consensus
Meeting on Children and Clumsiness was held in London,
Ontario, Canada, to reach a cunsensus on the description, definition, assessment, management, and - of most
importance - the name of the disability. This meeting was
organized by Dr. M. fox and Dr. H. J. Polatajko, was
sponsored by the Department of Occupational Therapy
of the University of Western Ontario, and was funded by
both private foundation.s and government agenCies. The
43 international, multidisciplinary experts who attended
reached agreement on a number of issues, including nomenclature, description and definition, assessment, management, and essential data to include in scientific commUlllcarions. These decision.'i have been summarized in a
statement entitled The London Consensus (Fox & Polatajko, 1994), and copies of the complete .'itatement may
be obtained by writing directly to Dr. PoJatajko. SeJeered
~ections of the statement are reported in the April 1995
issue of the Canadian journal a/Occupational Therapy
so that occupational therapi.'its can begin to consider the
effect of these decisions for research and practice (Pola[ajko, Fox, & Mis.~iuna, 1995).
We would like to highlight the point raIsed by Polatajko (1992): It is not the name itself that is important, but
the meaning it conveys to others. \Xfhether we refer to
clients as children wjth developmental dyspraxia, .'iensory
integrative dysfunction, DCD, or clumsy child syndrome
is far less important than the 3ssociated meaning that is
attached to each term. We hope that the previous discussion wilJ encourage clinicians to con.'iicler critically the
occupational perform;mce and performance component
difficulties of each child and to review the subject selection sections of studies carefully when determining appropriate methous of intelvcntion. We also hope that this
discussion will lead some researchers to return to theil
original data and, perhaps, to reconsider their results,
given the possibility of distinct subgroups of children.
Continued debate in thiS area will be beneficial to our
profession and to our clients ....
Appendix
Terms Used Infrequently to Describe the Child Who Is
Clumsy
Apracragnosia (DeQuiros & Schrager, 1979; Miller, 1986)
Developmental output failure (LeVine, Oberklaid, & Meltzer,
1981; Siegel & Feldman, 1981)
Developmental Gerslmann Syndrome (Benson & Geschwincl.
1970; Denckla, 1978; PeBenito, 1987)
tlemisyndrome of RighI Cerebral Dysfunction (Brumback, 1988)
Morar coordination prohlems (Maeland, 1992)
Motor dysfunerional (Snow, Blondis, & English, 1991)
Morar learning difficulties (McKinlay, 19R7; Stephenson, McKay
& Chesson, 1991)
PerceptUOmOlor dysfunction (Laszlo, BairslOw, Banrip, & Rolfe,
1(88)
Poorly coordinated (O'Beirne, Larkin, & Cahle, 1994)
Acknowlegments
We acknowledge Kim Kempton and Catherine O'Leary for their
assistance in reviewing and organizing the liter31ure and Nancy
Polllxk. MS. (.n. fur her- contrihutions to the development of the
manusnipr.
References
American Ps\'chialric Assuciation (1987) Category 31 ')-10
Developmental cOOldinalion disorder. Diagnoslic and Slatislical,v!amwl (3rd ed. rev.). Washingron, DC: Aurhor
Amet'ican Psychiatric Association. (199-i). Caregory 31').-1
Developmental coordination disorder. Diagnoslic and Sialislical /I;{anual (4th ed.) Washington, DC: Author
Ayres, A. J (1972). Sellsoll' inlegralion and lemning disorders. Los Angeles: Weslern Psychoiogicli Services.
Avres, A . .J (1.98'1). LJet'elopmenlal d)'sprtl_l,'ia al/(I adull01151'1 dvspra,\'ia.
Torrance. CA: Sensory Inregrarion 1£1lernarionaJ.
A)'res, A .I ([989). SellsolT IlIlegraliUri und Praxis Tesls
Ond rrinting). Los Angeles Western Psychulogical Services.
A)'res, A. .J" Mailloux, Z. K. & Wendler, C. L. (1987). Developrnenral dyspraXia Js ir a unital"V function> Occupalional Tberapr JOll/nul of Nesea /'C/). 7. 9:\-110.
Beery. K. E., & Bukrenica. N. A. (1982) f)el'elopmental Tesl
o(VislIal-;l1olur Inlegralion - Reeised. Cleveland, OH: Modern
Curriculum Pres.s.
Benson, 0. F., & Gesclll':jmJ, N. (1970). Developmenral
Ge,-slmann Syndrome. Nelirolu?,.J', J(). 29.).
Berk. R A.. 8; DeGangi. (; A. (1983). f)eCwlgi-Berk Tesl
0/ Sensor)' Integralioll Los Angelt:s: We.'1ern Ps)'chological
Services.
Bruininks. R II. (1978) I3ruininks-Oseretsky TeSI of Ivloror
Pmficiency. Minneapolis. MN Alnerican Guidance Service.
Brumback, R. A. (1988). Childhood depression and medically treatahle learning disabiliry. In D. L Molfese Jnd S. J Scgalowirz (Eds.), Brain lateralixaliun in children: Developmenlal implications (PP 463-4971 New York: Guilford Press.
CanrelJ, M. H., Smyth, M. M., & Ahonen, T P. (1994). Clurnsiness in adolescence: Educalional, moror, and social outcomes
of motor delay derected ar '1 years. Adapled Pbl'sical AClil'il.J'
Quarter/v, 11(2), 1 J5-129
Cermak, S. (1985). Devclopmemal dyspraxia. In E. A. Rol'
(Ed.), Neuropsycbological siudies of apraxia and related disorders (pp. 22')-248) Arw;terdam, Netherlands: Elsevier
(Norrh-Holland) .
Cermak, S A, Trimhle, H., Coryell, J, & Drake, C (1990).
Tbe American .!OU/7W! o/Occup({/iolla! {hemp!'
Downloaded From: http://ajot.aota.org/ on 02/06/2015 Terms of Use: http://AOTA.org/terms
625
Bilateral motor coordination in adolescents with and without
learning disabilities. Physical and Occupational Therapy in
coordination disorder.journal o,fChild PsychologV and Psychiatry, 33, 89'5-905
Pediatric, 10, 5-18.
Hulme, C, Biggerstaff, A, Moran, G. & McKinlay,!. (1982),
Visual, kinaesthetic and cross-modal judgments of length by
normal and clumsy children. Developmental Medicine and
Child tVeurologv. 24, 461-471
Humphries, T W, Snider, L., & McDougall, B. (1993), Clinical evaluation of the effectiveness of sensory integrative and
perceptual motor therapy in improving sensory integrative
function in children with learning disahilities Occupational
Therapy journal of Research. 13, 163-182
I1oeje, 5. O. (1987). Developmental apraxia among Nigerian children in Enugor, Nigeria. Developmental Medicine and
Child Neurolog,y, 22, 502-507.
Kertesz, A (1985). Apraxia and aphasia: Anatomical and
clinical relationship. In E. A. Roy (Ed.), Neuropsychological
studies of apra:x:ia and related disorders (pp. 163-178). Amsterdam, Netherlands: Elsevier (North Holland).
Kimura, D. (1977). Acquisition of a motor skill after lefthemisphere damage. Brain, 100, 527-542.
Laszlo';' 1., Bairstow, P.]., Bartrir.]., & Rolfe, U. T (1988).
Clumsiness or perceptuo-motor dysfunction? In A. M. Colley &]
R. Beech (Eds.), Cognition and action in skilled hehaviour
(pp. 293-310). Amsterdam: North Hol.land.
Law, M .. PoJatajko, H., Schaffer. R., Miller, J, & Macnah,],
(1991). The impact of heterogeneity in a clinical trial: Motor
oucomes after sensory integration therapy. Occupational Therapy journal of Research, 11. 177-189.
Levine, M. D., Oberklaid, F., & Meltzer, L. (1981) Developmental outrut failure: A study of low productiVity in school-aged
children Pediatrics, 67, ItJ-25
Lord, R., & Hulme, C (1987a). Perceptual judgements of
normal and clumsy children. Deuelopmental Medicine and
Child Neurologv. 29, 250-257
Lord, R., & Hulme, C 09tJ7b). Kinaesthetic sensitivity of
normal and clumsy children. Developmental Medicine and
Child Neurology, 29, 720-725.
Lord, R., & Hulme, C. 0988a). Patterns of rotary pursuit
performance in clumsy and normal children .Journal of Child
PSjichology and p,ychiatry, 29, 691-701.
Lord, R., & Hulme. C. (l988b). Visual perception and drawing ability in clumsy and normal children. British journal of'
Developmental Psychologji, 6, 1-9.
Losse, A., Henderson. S. E., Elliman, D., Hall, D., Knight, E.,
& ]ongmans, M. (1991). Clumsiness in children - Do they grow
out of it' A lO-year follow-up study. Deuelopmental iVledicine
and Child Neurologl'. 33, ')5-68
Maeland, A. F. (1992). Identification of children with motor
coordination problems. Adapted Physical Activitv Quarterll', 2.
330-342
McKinlay,!. (1987). Chi/dl'en with motor difficulties: Not so
much a syndrome-A way of life Phvsiotherapv, 73.635-637,
Miller, N. (1986). DJJ,praxia and its management. Beckenham, Kent, England: Croom Helm Ltd.
Missiuna, c., Kempton, K., & O'LeaIY, C. (1994) Deuelopmental coordination disorder: A reconciliation of terms. Unpublished manuscript, McMaster Universitv.
Missiuna, C. & Polatajko, H. (1994. ]uly). Developmental
dl'spraxia by any other name. Roundtable discussion at the
Combined Annual Conference of the American Occupational
Therapy Association and the Canadian Association of Occupational Therarists, Boston. MA.
Missiuna, C, & Pollock, N. (1994). Bel'ond the norms: Use
ofmultiple sources o.ldata in the assessment ofchildren. Man u-'
script submitted for [1uhlication.
Njiokiktjien. C (1988). Developmental dysprCL'(ja. In Pediatric hehauioral neurology. Volume 1- Clinical principles
Clark, F., Mailloux, Z., & Parham, D. (1989). Sensory integration and children with learning disabilities. In P.N. Pratt & A.
S. Allen (Eds.), Occupational therapy for children (2nd ed.)
(pp. 457-509). 5t Louis: Moshy.
Conrad, K. E., Cermak, S. A, & Drake, C (1983). Differentiation of praxis among children. Amen'can journal of Occupational Therapy, 37, 466-473
David, R., Deuel, R., Ferry, P., Gascon, G., Golden, G.,
Rapin, 1., Rosenberger, P., & Shaywitz, B. (1981). Proposed no-
sology of disorders of h(gher cerehralfunction in children
Task Force on Nosology of Disorders of Higher Cerehral
Function in Children. Child Neurology Society. Unpublished
manuscript.
DeAjuriaguerra, J, & Stambak, M. (1969) Developmental
dyspraxia and psychomotor disorders. In P ] Vinken & G. W
Bruyn (Eds.), Handbook oj clinical neurology (pp. 443-464)
Amsterdam: North Holland.
Denckla, M. B. (1978). Minimal brain dysfunction. In] S.
Chall & A. F. Mirsky (Eds.), Education and the hrain (pp.
223-268). Chicago: The University of Chicago Press.
Denckla, M. (1984). Developmental dyspraxia: The clumsy
child. In M. D. Levine & P Satz (Eos.), IHiddle childhood Development and dJ'_\function (pp. 24)-260). Baltimore: University
Park Press
DeQUlros,] B., & Schrager, O. C. (1979) Neuropsychologicalfundamentals in learning disabilities Novato, California:
Academic Therapy Publications,
Fox, A. M., & Polatajko, H.] (Eds.). (1994, October), The
London consensus: A statement from the lnte171ational Consensus Meeting on Children and Clumsiness. University of
Western Ontario, London, Ontario, Canada.
Gersh, F., & Damasio, A. R. (1981). Praxis and writing of the
left hand may he served by different callosal pathways. Archives
of Neurology. 38, 634-636,
Geschwind, N. (1975). The apraxias: Neural mechanisms of
disorders of learned movement. American Scientist, 63, 188195
Geuze, R., & Borger, H. (1993). Children who are clumsy:
Five years later. Adapted Physical Activity Quarterlv, 10, 10-21.
Gillberg, I. c., & Gillberg, C (1989). Children with preschool minor neurodeveJopmental disorders IV: Behaviour and
school achievement at age 13. Developmental lVledicine and
Child Neurology, 31, 3-13.
Gordon, N., & McKinlay, I. (Eds.). (1980). Helping clums)1
children. Edinburgh, United Kingdom: Churchill Livingstone.
Gubhay, S. S. (1975a). The clumsy child London:
Saunders.
Gubbay, S. S. (1975h). Clumsy children in normal schools.
Medical journal of Australia, 1, 233-236
Gubbay, S. S. (1978). The management of developmental
apraxia. Developmental Medicine and Child Neurology, 20,
643-646.
Gubbay, S. S., Ellis, E., Walton,]. N., & Court, S. D. (1965)
Clumsy children: A study of apraxic and agnosic defects in 21
children. Brain, 88. 295-312.
Hall, D. M. B. (1988). Clumsy children. British lVledical
j01.trnal, 296, 375-376.
Henderson, S. E. (Ed,). (1994). Developmental coordination disorder. Adapted Phvsical Activitv Quarterlv, 11 (2).
Henderson, S. E, & Hall. D. M. B. (1982). Concomitants of
clumsiness in young school children. Developmental Medicine
and Child Neurology, 24, 448-460
Henderson, 1.., Rose, P., & Henderson. S. E, (1992) Reaction time and movement time in children with developmental
626
Downloaded From: http://ajot.aota.org/ on 02/06/2015 Terms of Use: http://AOTA.org/terms
julvlAugust 1995, Volume 49. Numher 7
(pp. Lt)(i-285). Amsrerdam, The Netherlands: Suyi.
O'Beirne, C, Larkin, D. & Cahle. T. (1994) Coordination
problems and anaerobic performance in children. Adapted
Physical Actiuity Quarterly, 11, 141-149.
Orton, S. (1937). Reading, writing and speed) problems in
children. New York: Norton.
Parkin, S., & Padley, M. (1989). Working with clumsy children. Sheffield, England: Sheffield Education Department, National Curriculum Council.
PeBenito, R (1987). Developmental Gersrmann Syndrome:
Case report and review of the literature. Deuelopmental and
Behavioral Pediatrics, 8, 229-232.
Poeck, K., & Lehmkuhl, G. (1980).ldeatoryapraxia in a lefthanded patient with right-sided brain lesion. Corte.x, 16, 273284.
Polarajko, H. J. (1992) Naming and framing occupational
therapy: A lecture dedicated to the life of Nancy B. Canadian
joumal of Occupational Therapv. 59, 189-200.
Polatajko, H, Fox, M., & Missiuna, C (1995) An inrernational consensus on children with developmental coordination
disorder Canadian joumal of Occupational Therapy. 62.
3-6
Polarajko, H.]., Kaplan, B.)., & Wilson, B. N. (1992). Sensory integration treatment for children with learning disahilities:
Its staws 20 years later. Occupational Therapv journal of Research. 12, 323-341.
Polatajko, H., Law, M., Miller,]., Schaffer, R, & Macnah, J.
(1991). The effect of a sensory integrarion program on academic
achievement, motor performance and self-esteem in children
identified as learning disabled Results of a clinical trial. Occupational Therap1' joumal of Research. JJ. J 55-176
Siegel. L S., & Feldman, W (1981). Nond)'slexic children
'1he American
jO/l1I1lI1
with comhined writing and arithmetic learning disahilities.
Clinical Pediatrics. 22. 241-244.
Snow, J H., Blondis, T. A, & English, R A (1991) Neuropsychological skills with motor dysfunerional and motor normal
children. Archilles of Clinical Neuropsychology, 6, 271-278.
Srephenson, E., McKay, C, & Chesson, R (1991). The identification and tI'eatment of motor learning difficulties: Parents'
perception and the role of the therapist. Child: Care, Healtb,
and Del'elopment. 17, 91-113
Strauss, A. A, & Lehtinen, L E. (1947). P,ychopathology
and education o.! the brain-injured child New York: Grune &
Stratton.
St()[t, D. H., Moyes, F. A., & Henderson, S E. (1984). The
Henderson revision of the Test of Motor Impairment. London,
England: Psychological COI'poration.
Sugden, D A, & Keogh. J F. (1990). Pmblem~ in mouemen! skill deuelopment. Columhia, SC University of South
Carolina.
van Dellen, T .. & Geuze, K H. (198fl). Motor response
programming in clumsy children. journal of Child Psyehologv
and P.~))cbia/r)'. 29. 489-500
van c1er MeuJen. J. H. P., van der Gon,J J D., Gielen, C C,
Gooskens. R. H. & Willemse, J (1991). Visuomoror performance of n0l'l11al and clumsy children, 1: Fast goal,directed arm
movements with and without visual feedhack. DevelopmenJal
,IIedicine and Child Neurologl', 33, 40-')4.
Walron, J. N, Ellis, E., & Court, S (1962). Clumsy children:
Developmental apraxia and agnosia. Brain, 85, 603-612.
Wilson, B. N., Kaplan, B.J., Fellowes, S, Gruchy, C, & Faris.
P (1992). The efficacy of sensory integration treatment compared ro tutoring. f'bl'sieal and Oeeupalional Therapy in Pedicaries. 72. 1-36
o/Occupmional Therapl'
Downloaded From: http://ajot.aota.org/ on 02/06/2015 Terms of Use: http://AOTA.org/terms
627