MOTOR PLANNING: THE DISORGANISED CHILD - Erin Rayner & Chang Sun 2nd year Masters of Occupational Therapy students University of Sydney

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  MOTOR PLANNING:
  THE DISORGANISED CHILD
Erin Rayner & Chang Sun
2nd year Masters of Occupational Therapy students
University of Sydney                          29th August, 2012

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OUTLINE FOR TODAY
¢ Dyspraxia – what do we know?
¢ Praxis terminology

¢ Diagnostic criteria

¢ In the classroom - what would you see?

¢ Why is this important?

¢ The sensory link

¢ Top down vs. bottom up approaches

¢ Classroom strategies for teachers

¢ Steps to take if problems are evident

¢ Question time

¢ References

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DYSPRAXIA: WHAT DO WE KNOW?
¢ A neurologically based developmental disability
   which is present from birth
à It is believed to be caused by an immaturity in parts
   of the motor cortex, which stops messages being
   properly transmitted into the body.

¢   It is a motor planning disorder, not a muscular
     deficit

¢ Dyspraxia affects up to 10% of all children
à Approximately 70% of those affected are boys
(Australian Dyspraxia Association, 2012)

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PRAXIS TERMINOLOGY
¢   Praxis: is the ability to interact successfully with the
     physical environment, to plan, organise and carry
     out a sequence of unfamiliar actions and to do what
     one needs and wants to do (Kranowitz, 1998)

Three Components of Praxis:
1. Ideation – knowing what to do

2. Planning – knowing how to do it

3. Execution – carrying out the action

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PRAXIS TERMINOLOGY
¢   Dyspraxia: a breakdown of praxis à inability to
     utilise voluntary motor abilities effectively in all
     aspects of life from play to structured skill tasks (Gibbs,
     Appleton & Appleton, 2006)

¢   Currently the preferred / more common term
     globally is Developmental Coordination Disorder
     (DCD)

¢   DCD: a severe impairment in the development of
     motor coordination, significantly interfering with
     daily activities and academic achievement         (Green,
     Lingam, Mattocks, Riddoch, Ness & Emond, 2010)

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SO WHAT’S THE DIFFERENCE?
¢   Most health and educational professionals demonstrate
     uncertainty regarding the distinction between the two
     terms

¢   Research suggests that both DCD and Dyspraxia should
     be regarded as synonymous (Gibbs, Appleton & Appleton, 2006)
¢   Or DCD is the umbrella term which includes
     Dyspraxia (Pattern, 2005)

¢   We will refer to both terms with an emphasis on children
     who have difficulty with planning, sequencing and
     executing movement known as Motor Dyspraxia.

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DIAGNOSTIC CRITERIA FOR DCD: DSM-IV
¢   A: Performance in daily activities that require motor
     coordination is substantially below that expected given
     the person’s chronological age and measured
     intelligence.

¢   B: The disturbance in criterion A significantly interferes
     with academic achievement or activities of daily living.

¢   C: The disturbance is not because of a general medical
     condition (eg, cerebral palsy, hemiplegia, or muscular
     dystrophy) and does not meet criteria for a pervasive
     developmental disorder.

¢   D: If mental retardation is present, the motor difficulties
     are in excess of those usually associated with it.
(Polatajko & Cantin, 2006)

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DYSPRAXIA IN SIMPLE TERMS

    Motor coordination problem with
      difficulty coordinating and
           organising actions
                (May-Benson, 2012)

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IN THE CLASSROOM: WHAT DO YOU SEE?
Problem at school            Examples of behaviour
Arousal                      Over active, disorganised, darts from
                             one task to next, high / loud voice,
                             irregular / rapid respiration, rapid
                             heart rate
Coordinating movements       Clumsy, trouble using scissors,
                             throwing/catching, kicking a ball, rigid
                             and controlling movements
Handwriting                  Slow & messy, difficulties with; grip,
                             pressure, alignment and formation
Generalising learnt skills   Unable to transfer skills competently
                             to achieve similar tasks, longer to
                             learn new skills

IN THE CLASSROOM: WHAT DO YOU
SEE?
Problem at school      Examples of behaviour
Timing and rhythm      Trouble sequencing/ timing the
                       actions involved in a motor
                       task, following daily schedules
Problem solving        Trouble analysing what is
                       needed for a task, preparing for
                       the next stage in activities
Spatial organisation   Bumping into things, unaware
                       of personal space, difficulty
                       imitating actions, watches
                       limbs when performing
                       movements

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THE TRAGEDY OF FIRST POSITION

The tragedy of first position – YouTube

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   THE SENSORY LINK
Receives
information                                PRAXIS                            MUSCLE
from the                                                                       S
senses

                                                               3.      Message
SIGHT                   1.IDEATION        2. PLANNING
                                                           EXECUTION   sent to
SOUND                                                                  muscle /
BALANCE                                                                action
TOUCH                                                                  performed

                          Receives and modifies feedback

         (Adapted from: Missiuna, 2003)

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WHY IS THIS IMPORTANT?
These children also experience:
¢ Low self-esteem

¢ Poor self-concept

¢ Easily frustrated & avoid new situations

¢ May prefer talking to doing

¢ Often late and forgetful

¢ Disorganised approach to tasks
(Pattern, 2005)

 Overall everything is more difficult and therefore they
                require greater support!

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TWO APPROACHES: BOTTOM UP VS. TOP
DOWN
¢Bottom up – emphasises remediation of
underlying neural mechanisms to improve
function, targeting long lasting change.

¢   Top down – emphasises cognitive attention to
          task to improve function with no
          attention on improving underlying
          mechanism. (May-Benson, 2012)

¢   Strategies discussed today are top down approaches
     and can be achieved in the classroom.

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CLASSROOM STRATEGIES FOR TEACHERS
1. Arousal

¢ Alert program
à How does your engine run?

¢   Social stories

¢ Heavy work
à Create an organising environment and prepare
   child so they are in a ‘just right place’

(May-Benson, 2012)

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CLASSROOM STRATEGIES FOR TEACHERS
2. Coordinating movements

¢ Adapt the task
à Provide larger balls when playing handball/games

à Place coloured ribbon on the left or right hand to
   help children discriminate/coordinate their
   movements

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CLASSROOM STRATEGIES FOR TEACHERS
2. Coordinating movements

¢ Physical assistance
à Help the child by physically moving them
  through the actions required of the task
à Use hand-over-hand guidance
(Jenkinson, 2010)

¢ Backwards chaining
à Completing the first few steps of the activity for the child
à Allowing them to complete the last step
à Gaining a sense of accomplishment
(May-Benson, 2012)

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CLASSROOM STRATEGIES FOR TEACHERS
3. Handwriting

¢ Pencil grips
à Individualised pencil grips to aid finger positioning
   (cross-over for finger wrap)

¢ Pressure control
à Heavy pressure: regular exercises where pressure
   is placed through the upper limbs / light up pens /
   carbon paper / hard leaded pencil HB
à Light pressure: angled board / softer lead pencil 2B
(Addy, 2005)

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CLASSROOM STRATEGIES FOR TEACHERS
3. Handwriting

¢ Writing alignment
à Always use lined paper with margins

à Use coloured lines on plain/ pastel coloured paper
   and encourage child to write on a different colour
   each line (easily achieved using a computer)

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CLASSROOM STRATEGIES FOR TEACHERS
3. Handwriting

¢ Letter formation
à Playing games which reinforce shape and size: sorting
   boxes, ball games, shape stencils
à Create letter shapes using dough / clay encouraging the child
   to mould and knead the material into a clear shape
à Encourage the establishment of individual shapes before
   introducing new ones
à Using index finger create letters and shapes in trays of sand,
   shaving foam, rice trays of chalk outside.
à Ground, grass, sky templates   	
  

(Addy, 2005)                      	
  

                                  	
  

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CLASSROOM STRATEGIES FOR TEACHERS
3. Handwriting

¢ Organising written work
à Ensure work area is clear of all but essential equipment

à Keep alphabet and number charts nearby for easy
   reference
à Practice writing on grid paper placing each letter in a
   square and a space between each word.
à Place a finger tip after each word before writing the next
   word.
à Use board games which involve spatial organisation
   such as connect 4, peg board patterns etc
(Addy, 2005)

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CLASSROOM STRATEGIES FOR TEACHERS
4. Generalising Learnt Skills

¢ Break down tasks and link skills
à Work on specific skill areas and link skills
   together with similar tasks
à Use a favourite/achievable task and reinforce each
   stage or skill with a visual reminder.
(Jenkinson, 2008)

¢ Awareness
à Be aware that the child needs to learn tasks as a new
   skill and need to practice each stage of the learning
   process. Extra adult support is required.
(Pattern, 2006)

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CLASSROOM STRATEGIES FOR TEACHERS
5. Timing and Rhythm

¢ Pictures/list on the whiteboard
à Order the days activities
  and demonstrate visually
  to help the child organise
  their day for smoother
  transitions

à    Supply time-tables, daily
     diaries and instructions
     for specific activities in
     sequenced picture cards
(Jenkinson, 2008)

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CLASSROOM STRATEGIES FOR TEACHERS
4. Timing and Rhythm

¢ Give one direction at a time
à After one direction is successfully completed, add
   another direction

¢   Divide tasks into stages and allow sufficient time for
     each stage

¢ Prepare child for transitions
à Use a timer or warn ahead of time so child is aware of
   when the activity is going to change
(May-Benson, 2012)

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CLASSROOM STRATEGIES FOR TEACHERS
5. Problem Solving
¢ Give simple step by step instructions
à Help the child to identify the steps required to
   complete the task
à Demonstrate or ask another student to model the
   activity first
à Ask the child to try again

¢ Help student to plan out their tasks
à Ask questions such as “What materials do you need
   for this activity?” or “ What are you going to do
   first?”
(May-Benson, 2012)

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CLASSROOM STRATEGIES FOR TEACHERS
6. Problem Solving

¢ Consistent place of storing materials
à To aid development of organisational skills and
   ensure child knows where to collect and return
   items to during a task.
à Colour code equipment
(Jenkinson, 2008)

CLASSROOM STRATEGIES FOR
                                                              !
TEACHERS
7. Spatial Organisation

¢ Own Space on Floor
à Place a carpet square/ tape the outline of a square onto
   the floor to help child remain in their own space during
   floor time/activities.

¢ Teach rules around personal space
à Use social stories

¢ Body and Spatial Awareness Activities
à Provide frequent opportunities for graded resistive
   activities to help increase child’s body awareness
(May-Benson, 2012)

STEPS TO TAKE IF YOU SUSPECT A
PRAXIS DEFICIT
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1.   Referral to a Paediatrician

2.   Referral to an Occupational Therapist

3.   Referral to a Optometrist

QUESTIONS

REFERENCES
¢   Addy, L. (2005). Handwriting and Dyspraxia. Retrieved 10th August, 2012, from
     www.dyspraxiafoundation.org.uk/download
¢   Australian Dyspraxia Association. (2012). What is Dyspraxia? Retrieved 10th August, 2012, from
     www.dyspraxia.com.au.
¢   Buitendag, K., & Aronstam, MC. (2010). The relationship between developmental dyspraxia and sensory
     responsivity in children aged four years through eight years: Part I. South African Journal of
     Occupational Therapy, 40 (3), 16 – 20.
¢   Gibbs, J., Appleton, J., & Appleton, R. (2007). Dyspraxia or developmental coordination disorder? Unravelling the
     enigma. Arch Dis Child, 92, 534 – 539.
¢   Goodgold-Edwards, S., & Cermak, S. (1990). Integrating motor control and motor learning concepts with
     neuropsychological perspectives on apraxia and developmental dyspraxia. The American Journal of Occupational
     Therapy, 44 (5), 431 – 439.
¢   Green, D., Lingam, R., Mattocks , C., Riddoch, C., Ness, D., & Emond, A. (2011). The risk of reduced physical
     activity in children with probable developmental coordination disorder: A prospective longitudinal study. Research
     in Developmental Disabilities, 32, 1332 – 1342.
¢   Jenkinson, J. (2010). Building blocks for learning, occupational therapy approaches : practical strategies for the
     inclusion of special needs in primary school. Chichester, U.K. : Wiley-Blackwell.
¢   Kranowitz, C. (1998). The out-of-sync child : recognizing and coping with sensory integration dysfunction.
     New York, NY: Perigee Book.
¢   Missiuna, C. (2003). Children with developmental coordination disorder: At home and in the classroom.
     Retrieved 21 August, 2012, from www.fhs.mcmaster.ca/canchild.
¢   May-Benson, T. (2012). Clinical assessment and practical interventions for praxis: From ideation to execution.
     Sensory Tools.net, 1 – 100.
¢   Pattern, B. (2005). Dyspraxia from an occupational therapy perspective. Retrieved 10th August, 2012, from
     www.dyspraxiafoundation.org.uk/downloads
¢   Polatajko, H., & Cantin, N. (2006). Developmental Coordination Disorder (Dyspraxia): An Overview of the State of
     the Art. Seminars in Pediatric Neurology, 12 (4), 250 – 258.
¢   Williamson, G., Anzalone, E., & Hanft, B. (2008). Assessment of sensory processing, praxis, and motor
     performance. Journal of Developmental and Learning Disorders, 2, 155 – 185.