Clumsy children. A study of apraxic and agnosic defects in 21 children

New trends in developmental coordination disorder: Multivariate, multidimensional and multimodal

Developmental coordination disorder (DCD) is a motor development disorder that affects an individual's growth and development, and may persist throughout life. It is not caused by intellectual or physical disability. Studies have suggested DCD often occurs in childhood, resulting in a series of abnormal manifestations that hinder children's normal development; cohort studies suggest a higher incidence in boys than in girls. Early diagnosis and appropriate interventions can help relieve symptoms. Unfortunately, the relevant research still needs to be further developed. In this paper, we first start from the definition of DCD, systematically investigate the relevant research papers in the past decades and summarize the current research hotspots and research trends in this field. After summarizing, it is found that this research field has attracted more researchers to join, the number of papers published has increased year by year and has become a hot spot in multidisciplinary research, such as education, psychology, sports rehabilitation, neurobiology, and neuroimaging. The continuous development of the correlation between perinatal factors and DCD, various omics studies, and neuroimaging methods also brings new perspectives and working targets to DCD research. DCD-related research will continue to deepen along the research direction of multivariate, multidimensional, and multimodal.

Developmental coordination disorder

Developmental coordination disorder (DCD) is a neurodevelopmental disorder that affects children's ability to execute coordinated motor actions, resulting in slow, clumsy, or inaccurate motor performances and learning difficulties (of new motor tasks or to adapt previously learned gestures to a modified or additional constraint). In the course of development, children with DCD exhibit a diversity of motor signs, including fine and gross motor problems with impaired postural control and balance, and sensorimotor coordination or motor learning difficulties. The prevalence ranges between 1.8% and 8%, depending on the diagnostic criteria used, based on the cutoff of motor scores from standardized scales. Four main hypotheses have been postulated to explain DCD in terms of deficits in visuospatial functions, procedural learning, internal modeling, or executive functions. Neuroimaging studies are scarce but have highlighted several brain regions, including the parietal, frontal, and cerebellar cortices. Meta-analyses have supported task-oriented approaches as effective therapies to improve motor performance in children with DCD.

Developmental Coordination Disorder in Chinese Children Is Correlated With Cognitive Deficits

Cognitive deficits have been commonly observed in children with developmental coordination disorder (DCD), including memory, attention, and executive function difficulties. The present study evaluates the specific cognitive deficits in Chinese children with DCD, through a number of tests. A total of 401 children aged 7 to 10 years old from primary schools in Guangdong Province, China, participated in this study. Using the guidelines of the Movement Assessment Battery for Children ("Movement ABC-2"), a measurement tool of motor function ability, the children were divided into a DCD group, a group identified as being at risk of DCD, and a normal control group. The results of our analysis revealed that children's overall motor abilities could predict their overall cognitive ability, reaction time, memory, and attention. The performance of the DCD children was worse than that of the other two groups in terms of reaction time. The DCD group also returned lower scores for executive function than the normal control group did. A regression analysis showed that the cognitive deficits in children with DCD center mainly on poor executive function rather than attention and memory issues. These findings provide preliminary results regarding the cognitive deficits in Chinese children with DCD and have potential applications for the diagnosis and treatment of the disorder.

Developmental Coordination Disorder Plus: A Diagnosis by Exclusion?

Cayden is a 6.3-year-old boy who you have been following in our practice since birth. He was born at 35.5 weeks at 6 pounds 4 ounces following a fraternal twin gestation. Both children were "on target" with their milestones, but Cayden did not seem to progress as quickly as his sister. He did not initiate play with his sister when they were toddlers and Cayden was the "shy" one.

Developmental Dyspraxia: Is it a Unitary Function?

Children ( N = 182) with known or suspected sensory integrative dysfunction and who ranged in age front 4 years, 0 months, to 9 years, 11 months, were assessed using tests and clinical observations to examine developmental dyspraxia. Correlations and factor analyses indicated strong associations between praxis, tactile sensory processing, visual perception, and repeating of sentences. The major factor represented visuosomatopraxis function with elements linked by concept formation. Auditory memory delineated a second factor and kinesthesia another factor. Any contribution of the vestibular system to praxis could not be clearly isolated. The study did not justify the existence of either a unitary function or different types of developmental dyspraxia; rather, it supported the idea of a general praxis function and of additional differentiated practic skills defined by behavioral goals.

Verbal Self-Guidance as a Treatment Approach for Children with Developmental Coordination Disorder: A Systematic Replication Study

Children with developmental coordination disorder (DCD) experience many occupational performance difficulties in all areas of daily living. For the most part, research has failed to identify an effective treatment approach for these children. Verbal self-guidance (VSG), a new approach, first explored by Wilcox and Polatajko (1993), appears to have good potential in helping children with DCD become competent in the occupations of their choice. The purpose of this study was to carry out a systematic replication of the first VSG study to determine if a different therapist could achieve similar results. Repeating the VSG procedure with four different children, using a single case study design, a different therapist was able to replicate the earlier findings. This provides further evidence of the potential of VSG as an effective approach for enabling children with DCD to surmount their motor challenges.

Aspects of Motor Performance and Preacademic Learning

This study examined preschool children's performance on a pursuit tracking task in relation to specific performance on motor and cognitive measures of preacademic skill development. Fifty children, ages 4.3 to 5.8 years were tested using the Miller Assessment for Preschoolers (MAP)and number/counting items. High and low performance groups were designated based on performance on the MAP, individual MAP spatial items as well as number/counting items. Groups were compared based on their performance on a pursuit tracking task. Results indicated that the low performance number/counting concept group demonstrated a significantly slower average response time, overshoot movement time and reaction time. These findings offer support for an underlying perceptual-motor difficulty in children exhibiting low scores on preacademic tasks of mathematical concepts. The low MAP and spatial groups demonstrated a significantly higher rate of overshoots, suggesting difficulty in processing visual spatial information.

Developmental coordination disorder: core sensori-motor deficits, neurobiology and etiology

Among developmental disorders, DCD is one of the least studied and less understood one (Bishop, 2010). This review summarizes the current understanding of developmental coordination disorder in neuropsychology with a focus mainly on high level sensorimotor impairments, its etiology and its neural bases. We summarize these core deficits in the framework of an influent motor control model (Blakemore et al., 2002). DCD has several environmental risk factors which probably interplay with genetic factors but those have not been sufficiently identified. High-level sensori-motor deficits are probably multifactorial in DCD and involve predictive coding deficits as well as weaknesses in perceptual and sensory integration. At the brain level, DCD is associated with impaired structure and functions within the motor network. Throughout the review we highlight exciting new findings as well as potential future lines of research to provide a more comprehensive understanding of this disorder.

Developmental coordination disorders: state of art

In the literature, descriptions of children with motor coordination difficulties and clumsy movements have been discussed since the early 1900s. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), it is a marked impairment in the development of fine or global motor coordination, affecting 6% of school-age children. All these children are characterized for developmental coordination disorder (DCD) in motor learning and new motor skill acquisition, in contrast to adult apraxia which is a disorder in the execution of already learned movements. No consensus has been established about etiology of DCD. Intragroup approach through factor and cluster analysis highlights that motor impairment in DCD children varies both in severity and nature. Indeed, most studies have used screening measures of performance on some developmental milestones derived from global motor tests. A few studies have investigated different functions together with standardized assessments, such as neuromuscular tone and soft signs, qualitative and quantitative measures related to gross and fine motor coordination and the specific difficulties -academic, language, gnosic, visual motor/visual-perceptual, and attentional/executive- n order to allow a better identification of DCD subtypes with diagnostic criteria and to provide an understanding of the mechanisms and of the cerebral involvement.

Developmental coordination disorder plus: a diagnosis by exclusion?

Cayden is a 6.3-year-old boy who you have been following in our practice since birth. He was born at 35.5 weeks at 6 pounds 4 ounces following a fraternal twin gestation. Both children were "on target" with their milestones, but Cayden did not seem to progress as quickly as his sister. He did not initiate play with his sister when they were toddlers and Cayden was the "shy" one.

Toward a narrower, more pragmatic view of developmental dyspraxia

Apraxia traditionally refers to impaired ability to carry out skilled movements in the absence of fundamental sensorimotor, language, or general cognitive impairment sufficient to preclude them. The child neurology literature includes a much broader and varied usage of the term developmental dyspraxia. It has been used to describe a wide range of motor symptoms, including clumsiness and general coordination difficulties, in various developmental disorders (including autistic spectrum disorders, developmental language disorders, and perinatal stroke). We argue for the need to restrict use of the term developmental dyspraxia to describe impaired performance of skilled gestures, recognizing that, unlike acquired adult-onset apraxia, coexisting sensory and motor problems can also be present.

Incidence of pre-, peri-, and post-natal birth and developmental problems of children with sensory processing disorder and children with autism spectrum disorder

As the diagnosis of sensory processing disorder (SPD) is advanced, it is important to investigate potential contributing factors to this disorder as well as early diagnostic signs. An exploratory descriptive study, utilizing retrospective chart review, was conducted to investigate the incidence of pre-, peri- and post-natal, birth and developmental problems in a sample of 1000 children with SPD and of 467 children with autism spectrum disorder (ASD), who also had SPD. This study revealed that although no one factor was strongly associated with SPD or ASD, an average of seven events for children with SPD and eight events for children with ASD occurred across categories. These included: one pre-natal/pregnancy problem, delivery complication, assisted delivery, gestational or birth-related injury/illness; one or more early childhood illnesses or injuries; two or more infancy/early childhood developmental problems; and one or more delayed early childhood developmental milestones. When comparing results to national studies of the typical population, most remarkable was the incidence of jaundice, three to four times higher in both the SPD and ASD groups than in typical children. In addition, rates of breech position, cord wrap/ prolapse, assisted delivery methods (particularly forceps and suction deliveries), and high birth-weight were greater in both groups. Incidence of premature birth was higher in the ASD although not significantly different from the SPD group. Also of note was a high frequency of absent or brief crawling phase, and high percentages of problems with ear infections, allergies, and maternal stresses during pregnancy.

Entwicklungsbedingte Koordinationsstörung

Zusammenfassung. Bewegung spielt im Kindesalter eine herausragende Rolle, damit sich Kinder altersentsprechend entwickeln können. Die Kernsymptome bestehen in Defiziten in den Bereichen der Grob- und Feinmotorik, die das Ausführen alltäglicher Handlungen erschweren und sich zudem negativ auf die Schulleistungen der Betroffenen auswirken. Die Ursache der Störung konnte bisher nicht geklärt werden. Viele Studien deuten darauf hin, dass sich die Defizite nicht auf das Kindesalter beschränken, sondern dass viele Personen auch im Erwachsenenalter noch Symptome aufweisen. In der Regel treten die motorischen Beeinträchtigungen nicht isoliert auf, sondern werden von einer Vielzahl psychosozialer Probleme begleitet. Dazu zählen vor allem ein verringertes Selbstwertgefühl sowie die soziale Isolation. Der diagnostische Prozess sollte umfassend sein um zu gewährleisten, dass betroffene Kinder angemessen behandelt werden, um ihren Entwicklungsverlauf positiv zu beeinflussen.

[Non-verbal learning disabilities: developmental dyspraxia]

Dyspraxia is a non verbal neuropsychological dysfunction still unrecognized but which can generate scholar learning and behavioural disabilities. We propose, at first time, to do a state of art with the various terminologies and typologies which lead to put together clumsiness, motor coordination disorder and the different types of dyspraxia. Then, we will bring an integrative model and clinical data in children with developmental dyspraxia, allowing a better pointing, to make a diagnostic and then we suggest some advices for remediations.

Disorders of motor development (clumsy child syndrome)

This presentation will focus on motor competence, the clumsy child, perceptual deficits in clumsy children and possible neurological dysfunction in this group of children. Motor competence not only allows children to carry out everyday practical tasks, but it is also an important determinant of their level of self-esteem and of their popularity and status in their peer group. Research has shown that about 6-10% of children have motor competences well below the norm. It is unusual for motor problems to simply disappear over time. In the absence of intervention the syndrome is likely to manifest itself. In the clinical literature attempts have been made to establish causal links between surface manifestations of clumsiness and underlying perceptual deficits. In this respect the attention is primarily directed towards the concept of inter- and intra-modal matching, particularly with respect to vision and proprioception, an ability deemed to underlie many real-life motor skills. Neurobehavioural model of inter- and intra-modal matching and deficit model is presented. Findings from studies using this paradigm are discussed and it is argued that clumsiness must be seen as a neurological dysfunction (insufficiency).

Do 'clumsy' children have visual recognition problems?

OBJECTIVE

Visual recognition by 8-year-old children with hand-eye co-ordination problems (HECP), and by a control group of children without such problems was tested using a task of visual closure.

DESIGN

The task required the children to identify common objects from an incomplete visual presentation.

RESULT

As predicted, it was found that the HECP children, who were designated as such solely on the basis of their motor difficulties, identified significantly fewer correct objects than their control counterparts.

CONCLUSIONS

This finding raises the possibility that the visual processing problems of clumsy children contribute to, or even strongly determine, not only their movement problems but also their learning difficulties.

Static balance in children with hand-eye co-ordination problems

OBJECTIVE

The aim of the present study was to examine static balance on one leg in 10-year-old children with and without hand-eye co-ordination problems (HECP) in an attempt to come closer to an understanding of developmental co-ordination disorder in children.

METHOD

The children were compared on three different balance tasks with the right and/or left leg together with a systematic manipulation of vision.

RESULTS

The results showed that when the scores for both legs were combined, the control group, in general, had superior performance in all conditions. Separate preferred and non-preferred leg analyses demonstrated that the differences between the HECP group and control group could be accounted for by lowered performances when the non-preferred leg was used in only one static balance task, stork stand with vision. In the two other balance tasks, balance on beam and one-board balance, the HECP group displayed significantly worse performance than the control group irrespective of the use of the preferred or non-preferred leg.

CONCLUSIONS

Explanation related to the development of the hemispheres controlling the preferred and non-preferred leg is invoked to account for the poor performance in the HECP group.

Do 'clumsy' children have visual deficits

Visual processing by 10-year-old children diagnosed on the basis of standardised tests as having developmental 'clumsiness' syndrome, and by a control group of children without motor difficulties, was tested using three different psychophysical tasks. The tasks comprised a measure of global motion processing using a dynamic random dot kinematogram, a measure of static global pattern processing where the position of the target was randomised, and a measure of static global pattern processing in which the target position was fixed. The most striking finding was that the group of clumsy children, who were diagnosed solely on the basis of their motor difficulties, were significantly less sensitive than the control group on all three tasks of visual sensitivity. Clumsy children may have impaired visual sensitivity in both the dorsal and ventral streams in addition to their obvious problems with motor control. These results support the existence of generalised visual anomalies associated with impairments of cerebellar function.

Differences in postural control and movement performance during goal directed reaching in children with developmental coordination disorder

Poor upper-limb coordination is a common difficulty for children with developmental coordination disorder (DCD). One hypothesis is that deviant muscle timing in proximal muscle groups results in poor postural and movement control. The relationship between muscle timing, arm motion and children's upper-limb coordination deficits has not previously been studied. The aim of this study was to investigate the relationship between functional difficulties with upper-limb motor skills and neuromuscular components of postural stability and coordination. Sixty-four children aged 8-10 years, 32 with DCD and 32 without DCD, participated in the study. The study investigated timing of muscle activity and resultant arm movement during a rapid, voluntary, goal-directed arm movement. Results showed that compared to children without DCD, children with DCD took significantly longer to respond to visual signals and longer to complete the goal-directed movement. Children with DCD also demonstrated altered activity in postural muscles. In particular, shoulder muscles, except for serratus anterior, and posterior trunk muscles demonstrated early activation. Further, anterior trunk muscles demonstrated delayed activation. In children with DCD, anticipatory function was not present in three of the four anterior trunk muscles. These differences support the hypothesis that in children with DCD, altered postural muscle activity may contribute to poor proximal stability and consequently poor arm movement control when performing goal-directed movement. These results have educational and functional implications for children at school and during activities of daily living and leisure activities and for clinicians assessing and treating children with DCD.

Clinical and research diagnostic criteria for developmental coordination disorder: a review and discussion

The aim of this review was to investigate the selection criteria used in the past in studies of children with developmental motor problems (excluding those suffering from neurological dysfunctions such as cerebral palsy, muscular dystrophy, etc.). We therefore conducted an extensive analysis of 176 publications. First, an overview of the main characteristics of these studies (terminology, population, type and purpose) and the selection criteria that are reported in these publications are presented. Following this, the DSM-IV selection criteria for developmental coordination disorder (DCD) are contrasted with the selection criteria reported in 41 publications that have used this terminology to classify the children. The results of this comparison show that the inclusion criteria are largely followed, albeit with little consistency concerning selection instruments and quantitative cut-offs, while adherence to the exclusion criteria is not common practice. Strengths and weaknesses of the DSM-IV criteria, complementary to the previous discussion by Henderson and Barnett in the HMS special issue on DCD in 1998 on this same topic, are discussed. The results of the review also show that many studies have used additional selection criteria related to the specific research questions of the study concerned. In the broader context of clinical practice as well as basic research, the latter result suggests the usefulness of a distinction between Clinical Diagnostic Criteria and Research Diagnostic Criteria. This distinction helps to develop a unifying view on the use of diagnostic criteria for research and clinical practice. We conclude with a number of recommendations concerning the selection criteria for children with DCD.

Clinical description of children with developmental coordination disorder

Occupational therapists working within School Health Support Services are receiving increasing numbers of referrals, relative to past rates, for children who are experiencing motor problems and may have developmental coordination disorder. Based upon clinical experience, therapists indicate that these children are typically referred in the early school years and that most have handwriting difficulties; to date, however, there has been little empirical evidence to support these observations. In this paper, descriptive information is presented for 556 children who may be presumed to have developmental coordination disorder and who had been referred to school-based health services in two centres. Typical reasons for referral, co-morbidity information, and assessment practices are presented. Findings confirmed the presence of many occupational performance issues in this population, including handwriting difficulties, and challenge therapists to broaden the current scope of school health assessment and intervention practices.

Perceptions of three terms to describe physical awkwardness in children

A survey examined the perceptions of 125 Ss who completed a 20-item Semantic Differential ratings for three terms: developmental dyspraxia (DD); developmental coordination disorder (DCD); clumsy child syndrome (CCS). Ss included parents, teachers, physicians, occupational therapists, physiotherapists, psychologists, and speech therapists. Analyses revealed significant main effects for term and role, and interactions between them on certain items. DD is perceived as severe, complex, strong, difficult, serious and technical, whereas CCS as mild, simple, weak, easy, humorous and nontechnical. Both DD and DCD are regarded as more sensitive, positive, graceful and objective than CCS. DD is considered more permanent than DCD and CCS. The meaning of the terms varies as a function of role surrounding children with physical awkwardness.

Inter- and intrasensory modality matching in children with hand-eye coordination problems: exploring the developmental lag hypothesis

This study set out to explore the suggestion that the problems experienced by 8-year-old children diagnosed as clumsy in the area of hand-eye coordination (HECP) might be attributed to a developmental lag. The performances of this group of HECP children were compared with those of groups of 5-year-old and 8-year-old controls without such deficits, when required to carry out a task involving pointing, without vision, to targets located, visually, visually/proprioceptively, or proprioceptively, the dependent variable being the distance error score from the centre of the target. The performances of the HECP children, when vision or vision/proprioception was used to locate the targets, were shown to be inferior to those of the two control groups of children thereby supporting a visual deficit hypothesis. When the targets had to be located proprioceptively, the performance of the HECP children was shown to be similar to that of the 5-year-olds, while both groups were inferior to the 8-year-olds, thereby supporting a developmental lag hypothesis in proprioceptive terms. However, when the scores for the preferred and non-preferred hands were analysed separately a marked deterioration in the performances of both the 5-year-old controls and the HECP children was observed while the 8-year-old controls were unaffected. While this finding supports a developmental lag explanation of the inferior performances of the HECP children, it was necessary to qualify such an explanation when the within-group performances using the preferred and non-preferred hands were compared. Only the HECP children, under the visual/proprioceptive or proprioceptive conditions, showed significant performance differences, in favour of the preferred hand. This finding was taken as a suggestion that the developmental lag exhibited by the HECP children might have pathological overtones possibly related to the development of the corpus callosum.

Developmental dyspraxia and developmental coordination disorder

This article discusses the role developmental dyspraxia plays in developmental coordination disorder (DCD), based upon a review of literature on apraxia, developmental dyspraxia, and DCD. Apraxia and dyspraxia have often been equated with DCD. However, it is argued that apraxia and dyspraxia primarily refer to the problems of motor sequencing and selection, which not all children with DCD exhibit. The author proposes to distinguish developmental dyspraxia from DCD. Other issues discussed include the assessment, etiology, and treatment of developmental dyspraxia and DCD, and the relationship between DCD and learning disabilities. A research agenda is offered regarding future directions to overcome current limitation.

Physiotherapy for clumsy children: an evaluation study

This study reports the findings of an effect-evaluation study of physiotherapy for clumsy children. 18 children were identified by school doctors as having poor motor co-ordination. They were followed for three months in order to exclude spontaneous improvement of motor problems; none spontaneously improved. Subsequently, these children were enrolled on a regular physiotherapy programme. Treatment was administered individually twice a week over three months. The effects of treatment for clumsy children appeared to be promising: important improvements were found on various motor skills. These benefits were maintained for a three-month period after the end of treatment.

Impaired motor skill (clumsiness) in otherwise normal children: a review

Some children, who are otherwise normal, experience unusual difficulties with the acquisition and performance of motor skills. These children are commonly described as being clumsy. Impaired performance of motor skills, to the degree experienced by clumsy children, is unlikely to present a serious problem. However, a review of the literature suggests that significant associated and secondary emotional problems are common. In particular, such problems are likely to result in children not achieving their full potential. Therefore, it is important that the cause of affected children's impaired motor skills be recognized early so that these problems can be avoided, or at least minimized, by a sympathetic understanding of their difficulties. The problem is that, whilst severely affected children can be readily recognized, identification of mildly and moderately clumsy children is difficult.

Neuropsychological identification of motor problems: can we learn something from the feet and legs that hands and arms will not tell us?

The degree of structural and functional specialization that differentiates between upper and lower limb use in humans is quite unparalleled among primates. It is argued that less neural resources are devoted to leg and foot control than to arm and hand control, and that this aspect of lower limb innervation, together with the uniquely restricted use of the lower limb, renders lower limb function more sensitive to general neural insult. In addition, the status of leg and foot control differs from that of arm and hand control both early in life and during the later years of decline.

Discrimination of normal and at-risk preschool children on the basis of neurological tests

A set of neurological tasks was administered to normal three- and five-year-old preschool children as well as to equal-age children identified as being at-risk for learning disabilities. 12 neurological test items were identified that differentiated normal from at-risk children at one or both ages. Follow-up of the five-year-olds at age seven showed a significant linear relation between scores on neurological tasks and the Wechsler Intelligence Test for Children. The neurological examination at age five also had predictive value regarding class placement at age seven. The findings suggest that a simple neurological test may be helpful for the early identification of preschool children who are at risk for learning difficulties.

Poorly coordinated children: a survey of 95 cases

Screening of 717 5-year-olds and 757 7-year-olds, found 55 of the former and 77 of the latter possibly to be poorly coordinated. Further diagnostic testing with the McCarthy Motor Scales confirmed the problem in a total of 95 children, a prevalence of 6.4%. Neurological examination showed 43% of the 5-year-olds and 21% of the 7-year-olds to have choreiform movements. Of the total 95, proprioception was abnormal in 40%, but abnormal muscle tone present in only 4%. An increased prevalence of hearing loss and obesity and a history of developmental delays was found. Low birth weights, prematurity, post-maturity and perinatal problems were significantly associated with poor coordination. Socioeconomic status was not a significant factor. The difficulties of testing and measuring poor coordination and the need for more precise measures are discussed. Follow-up of at risk children at age 5 with tests of motor coordination is recommended.

Developmental apraxia among Nigerian children in Enugu, Nigeria

Developmental apraxia was studied among 421 eight- to 12-year-old children attending a normal school in Enugu, Nigeria. 25 children were found to be clumsy, a rate of 5.9 per cent. Neurological examination revealed a higher incidence of abnormality, principally dysdiadochokinesia, among the clumsy children than among a control group. There were no significant differences in perinatal factors between the two groups. The social, educational and psychological implications of developmental apraxia are discussed.

Evaluation of praxis in preschoolers

This article draws from the research and clinical work of A. Jean Ayres to present a rationale and set of procedures for occupational therapy evaluation of the preschooler whose presenting problems suggest dyspraxia. The concept of praxis is briefly discussed and the problems of evaluating praxis in the preschooler are outlined. Based on the literature in this area, two major domains for evaluation are examined: sensory processing and praxis. In the domain of sensory processing, special attention is given to assessment of tactile, proprioceptive, vestibular, auditory, and visual functions. The domam of praxis is organized according to three primary processes: ideation, motor planning, and execution. Procedures for each domain are suggested, including administration of standardized test items, parent interviews, and structured observations, as well as observation of behavior in unstructured situations. Precautions in interpretation of data and suggestions for presenting evaluation findings in the clinical report are delineated. Finally, consideration is given to issues related to recommendation of occupational therapy, referral to other professionals, and setting of treatment goals for the dyspraxic child.

The neurological examination in child psychiatry: a review of its uses

This review is an attempt to evaluate critically some of the recent literature on the clinical utility of the neurological examination in child psychiatric practice. Three separate but related issues are discussed; the accuracy of the examination in assessing cerebral dysfunction, the strength of the association between neurological signs and behaviour disorders and finally the clinical significance of this association. It is pointed out that not all neurological signs are of equal significance, but that developmental neurological signs which indicate cerebral immaturity are weakly associated not only with hyperactivity, but possibly with other behaviour disorders as well. Some of the methodological weaknesses in this literature are pointed out. Recent studies of children with motor impairment (clumsiness) are briefly mentioned as a potentially more fruitful avenue of research. It is concluded that the neurological examination may be useful in identifying sub-groups of behaviourally disturbed children who differ from other children with behaviour disorders in terms of etiology, prognosis or treatment needs. Unfortunately, little work has been done in this specific area and further research is needed.

Computerized axial tomography in clumsy children with developmental apraxia and agnosia

Fifty-one children who were clumsy because of perceptual disabilities and/or defects of motor organization were surveyed with computerized axial tomographic (CT) head scanning and compared to 33 controls by using both linear measurements and visual appraisal of the scans. Thirty-nine percent of these so-called clumsy children described as having developmental apraxia and agnosia, compared to 9% of the controls, were either abnormal or normal variants. These presumed abnormalities included ventricular dilatation, peripheral atrophy and parenchymal lesions. The Evans Ratio and Intercaudate Distance in the clumsy children were not significantly different from the controls, but the Ventricular Area Index was found to be very significantly different in the two groups.

Visual, kinaesthetic and cross-modal judgements of length by normal and clumsy children

The ability of normal and clumsy children to match the length of lines within and between the modalities of vision and kinesthesis was studied. The clumsy children showed perceptual impairments, as indicated by their poor performance on the visual, kinaesthetic and cross-modal judgements of length and also by their low scores on spatial subtests of the WISC. Variations in motor skill correlated with performance on the visual perceptual measures, but not with performance on the kinaesthetic or cross-modal tasks. The idea that clumsiness may be caused by an impairment of visual perception is discussed, together with some alternative interpretations of this pattern of results.

Developmental neuropsychiatry: concepts, issues and prospects

The empirical findings on the cognitive and behavioral sequelae of head injury in childhood are integrated with others in the literature in order to consider some of the outstanding issues and dilemmas that remain in the field of developmental neuropsychiatry. Particular attention is paid to the apparent nonspecificity of the cognitive sequelae of localized brain lesions in childhood, possible specificities in brain-behavior relationships, the probable importance of age effects in altering the impact of brain lesions, and the threshold above which brain injury may have persistent psychological sequelae.