Physical Therapy Management of Children With Developmental Coordination Disorder: An Evidence-Based Clinical Practice Guideline From the Academy of Pediatric Physical Therapy of the American Physical Therapy Association

Abstract

Background: 

Developmental coordination disorder (DCD), classified as a neurodevelopmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), affects approximately 5% to 6% of school-aged children. Characteristics of DCD include poor motor coordination and delayed development of motor skills, not explained by other conditions. Motor deficits negatively affect school productivity, performance in activities of daily living, and recreation participation. Children with coordination problems, at risk for or diagnosed with DCD, should be evaluated by a team of professionals, including a physical therapist (PT).

Purpose: 

This clinical practice guideline (CPG) provides management strategies for PTs and informs clinicians and families about DCD. It links 13 action statements with specific levels of evidence through critical appraisal of the literature and provides recommendations for implementation.

Results/Conclusions: 

The DCD CPG addresses examination, referral, first choice and supplemental interventions, discharge, compliance audits, implementation, and research recommendations. Supplemental tools are provided to support PT management.

In Brief

This clinical practice guideline provides management strategies for physical therapists and informs clinicians and families about DCD. It links 13 action statements with specific levels of evidence through critical appraisal of the literature and provides recommendations for implementation.

DOCUMENT ORGANIZATION

This clinical practice guideline (CPG), supported by the Academy of Pediatric Physical Therapy (APPT) of the American Physical Therapy Association (APTA), describes physical therapy management of children with developmental coordination disorder (DCD) and those at risk for DCD. It is intended as a reference document to guide physical therapists' practice, to inform research on the physical therapy management of DCD, and to inform other health care professionals, families, and educators about physical therapy best practices for DCD. The methods of critical appraisal, assigning levels of evidence to the literature, and summarizing the evidence to assign grades to the recommended action statements followed accepted international methodologies of evidence-based practice.¹ The document provides the levels of evidence and grades (Tables 1 and 2) used to derive the 13 action statements (Table 3) organized into 3 major headings: (1) Physical Therapy Examination and Referral of Children with Coordination Difficulties, at Risk for or Diagnosed with DCD, (2) Physical Therapy Intervention for Children At Risk for or Diagnosed with DCD, and (3) Discharge Recommendations for Children with DCD, summarized in the Figure: Physical Therapy Patient Management Algorithm for DCD. The CPG action statements and supporting evidence are organized around the Institute of Medicine's (IoM) criteria for transparent CPGs.² Evidence Tables 10-14 on examination, first-choice interventions, and supplemental interventions are available as the Supplemental Digital Content, pages 17 to 31 (available at: https://links.lww.com/PPT/A305). Research recommendations follow each Action Statement and are also available in the Supplemental Digital Content, page 14 (available at: https://links.lww.com/PPT/A305).

Fig.: Physical therapy patient management algorithm for DCD. DCD indicates developmental coordination disorder.

TABLE OF CONTENTS

LEVELS OF EVIDENCE AND RECOMMENDATION GRADE CRITERIA

Level of Evidence (Table 1) 284

Recommendation Grades for Action Statements (Table 2) 284

Summary of Action Statements for the 2020 Developmental Coordination Disorder Clinical Practice Guideline (Table 3) 285

INTRODUCTION

Purpose of the 2020 DCD Clinical Practice Guideline 287

Background and Need for a CPG on DCD for Physical Therapists 287

The Scope of the Guideline 287

Statement of Intent 288

METHODS

Determining Priority Content 288

Search Strategy, Appraisals, and Review 288

Language 288

DEVELOPMENTAL COORDINATION DISORDER

Diagnostic Considerations for DCD 290

DSM-5: Diagnostic Criteria Description for Developmental Coordination Disorder and Criteria Key (Table 4) 290

General Information About Individuals With DCD 290

Role of the Interprofessional Team 291

Action Statements 291

I. PHYSICAL THERAPY EXAMINATION AND REFERRAL OF CHILDREN WITH COORDINATION DIFFICULTIES, AT RISK FOR OR DIAGNOSED WITH DCD 291

Common Co-existing Conditions and Differential Diagnoses for Children with DCD (Table 5) 293

Summary of Standardized Assessment Tools for Examination and Evaluation (Table 6) 301

II. PHYSICAL THERAPY INTERVENTION FOR CHILDREN AT RISK FOR OR DIAGNOSED WITH DCD 300

Summary of Recommended Intervention Approaches and Outcomes (Table 7) 305

III. PHYSICAL THERAPY DISCHARGE OF CHILDREN WITH DCD 307

DCD CPG Summary 309

Plan for Revision 309

Abbreviations 309

REFERENCES 309

SUPPLEMENTAL DIGITAL CONTENT TABLE OF CONTENTS (https://links.lww.com/PPT/A305) XX

Search Strategy, Appraisals, and Review 1

Supplemental Digital Content Table 1: Search Terms 1

Supplemental Digital Content Figure 1: Prisma Flow Chart 2

Supplemental Digital Content Table 2: Operational Definitions and Outcome Measure Descriptions 3

Supplemental Digital Content Table 3: ICF and ICD-10 Codes: 4

Description of Participation Outcome Measures: 6

Supplemental Digital Content Table 4: Participation and Goal Related Outcome Measures: 7

Description of Questionnaires used to Examine Activity Limitations: 7

Supplemental Digital Content Table 5: Summary of Questionnaires to Measure Activity Limitations (Criteria B): 8

Description of Standardized Measures for Motor Performance: 9

Supplemental Digital Content Table 6: Summary of Standardized Assessment Tools to Identify Motor Impairments (Criteria A) 9

Supplemental Digital Content Table 7: Component of Physical Fitness 10

Supplemental Digital Content Table 8: Measures for Body Functions and Structures Used in the DCD Literature 10

Description of Task-Oriented Interventions: 10

Description of Body Functions and Structures Interventions: 12

Supplemental Digital Content Table 9: Task-Oriented and Body Functions and Structures Interventions 12

Descriptions of Supplemental Activities: 13

General Guideline Implementation Strategies 13

Summary of Research Recommendations 14

Development of the Guideline 15

CAT-EI Appraisers: 15

Advisory Panel: 16

External Content Reviewers: 16

Agree II Reviewers: 16

Acknowledgements: 16

Supplemental Digital Content Evidence Tables 10 - 14 17

LEVELS OF EVIDENCE AND RECOMMENDATION GRADE CRITERIA

Levels of evidence are based on a combination of a risk of bias assessment and the quality of the tests or measures used in a study. Stronger or weaker levels of evidence may be assigned to individual tests and measures based on their psychometric properties, if many are used in one study. Recommendation grades A to C reflect levels of evidence in BRIDGE-Wiz software,³ which generates recommendations consistent with IoM transparency recommendations.² Theoretical/foundational recommendations (grade D), based on basic science or theory, and best practice recommendations (grade P), based on current physical therapist (PT) practice or topics that are difficult to research, are not generated by BRIDGE-Wiz software. Research recommendations identify the need for studies where evidence is conflicting or missing.

Table 1 presents the criteria used to determine the evidence level of examination and intervention studies. Levels 1 and 2 differentiate stronger from weaker studies by integrating the research design and the quality of the execution and/or reporting of the study. Table 2 presents the criteria for the grades assigned to each action statement. The grade reflects the highest levels of evidence available.

TABLE 1: - LEVEL OF EVIDENCE

Level	Criteria
I	Evidence obtained from high-quality diagnostic studies, prognostic or prospective studies, cohort studies or randomized controlled trials, meta-analyses, or systematic reviews (critical appraisal score >50% of criteria)
II	Evidence obtained from lesser-quality diagnostic studies, prognostic or prospective studies, cohort studies or randomized controlled trials, meta-analyses, or systematic reviews (eg, weaker diagnostic criteria and reference standards, improper randomization, no blinding, <80% follow-up) (critical appraisal score <50% of criteria)
III	Case-controlled studies or retrospective studies
IV	Case studies and case series
V	Expert opinion

TABLE 2: - RECOMMENDATION GRADES FOR ACTION STATEMENTS

Grade	Recommendation	Quality of Evidence
A	Strong	A preponderance of level I studies, but at least one level I study directly on the topic support the recommendation.
B	Moderate	A preponderance of level II studies, but at least one level II study directly on the topic support the recommendation.
C	Weak	A single level II study at <25% critical appraisal score or a preponderance of level III and IV studies, including consensus statements by content experts, support the recommendation.
D	Theoretical/foundational	A preponderance of evidence from animal or cadaver studies, from conceptual/theoretical models/principles, from basic science/bench research, or from published expert opinion in peer-reviewed journals supports the recommendation.
P	Best practice	Recommended practice based on current clinical practice norms, exceptional situations where validating studies have not or cannot be performed, and there is a clear benefit, harm or cost, and/or the clinical experience of the guideline development group.
R	Research	There is an absence of research on the topic, or higher-quality studies conducted on the topic disagree with respect to their conclusions. The recommendation is based on these conflicting or absent studies.

SUMMARY OF ACTION STATEMENTS FOR THE 2020 DCD CLINICAL PRACTICE GUIDELINE

TABLE 3:: SUMMARY OF ACTION STATEMENTS FOR THE 2020 DEVELOPMENTAL COORDINATION DISORDER CLINICAL PRACTICE GUIDELINE

INTRODUCTION

Purpose of the 2020 DCD Clinical Practice Guideline

The APPT of the APTA supports the development of CPGs. This CPG intends to assist physical therapists (PTs) with examination, evaluation, and development of a plan of care for children with coordination difficulties, at risk for or diagnosed with DCD, to optimize activity and participation outcomes. This CPG follows the framework defined by the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF)⁴ by addressing the categorical domains of body functions and structures, activity, and participation, in an order suggested for patient management. Components of the ICF model, including environmental considerations, barriers/facilitators, and performance/capacity, are addressed as the literature supports them.⁴ The purposes of the 2020 DCD CPG for children (ages 5-18 years) with coordination difficulties, at risk for or diagnosed with DCD are to:

• Appraise the current best evidence supporting physical therapy examination and interventions for this population to provide recommendations and reduce variation in care.
• Inform health care professionals, families, and educators about physical therapy best practices for DCD.
• Identify areas for investigation to improve the evidence for physical therapy management of DCD.

Background and Need for a CPG on DCD for Physical Therapists

Provision of physical therapy examination and intervention with individuals with coordination problems is well documented.^5–11 Dyspraxia, clumsiness, and discoordination are alternative diagnostic labels for individuals with impaired coordination. The diagnostic label and clinical description of DCD have been used more consistently in literature over the past 20 years, with a growing body of literature identifying the unique characteristics of these individuals. In the past 7 years, 6 systematic reviews^{5,7,8,12–14} have focused on motor-related intervention for individuals with DCD, and have begun to guide physical therapy practice. This CPG was inspired by the 2012 European Academy of Childhood Disability (EACD) international clinical practice recommendations on DCD,¹⁵ and more recently by the updated 2019 EACD recommendations,¹⁶ which address all aspects of management and care for individuals with this diagnosis. The 2019 EACD recommendations¹⁶ were authored by an international group representing North America, South America, Asia, Europe, Africa, and Australia, and were developed using both a group consensus process and evidence current through February 2017. Eight evidence-based recommendations relate to assessments and interventions,¹⁶ and provide important guidance for all health care providers who work with individuals with DCD. The 2019 EACD international recommendations included a suggestion that national guidelines be developed to address specific cultural and legal issues with national stakeholders to ensure implementation, highlighting the need for this APTA-supported CPG.

Recommendations in this CPG are based on a systematic review and the APTA Guide to PT Practice¹⁷ patient management process. It is different from previous guidelines that it is written specifically from the perspective of PTs as a member of an interprofessional team. This CPG references and expands upon the 2019 EACD recommendations to provide PTs with detailed management strategies that can be implemented across practice settings including clinics, school systems, home, and community environments. Research recommendations, implementation strategies (see the Supplemental Digital Content, pages 13-14, available at: https://links.lww.com/PPT/A305), and quality improvement suggestions are intended to increase evidence about DCD and reduce variability in physical therapy services. It is the intent of the CPG authors, who make up the guideline development group (GDG), to raise awareness about the management of individuals with DCD by providing detailed guidance for physical therapy services that align with current examination and intervention evidence.

The Scope of the Guideline

This CPG uses literature available from 2009 through January 2019 to address physical therapy management of children with or suspected of DCD, as members of interprofessional teams that provide care for this population. Because research is more limited on physical therapy examination and intervention with toddlers, adolescents, and adults with DCD, compared with children, this guideline focuses on the management of children between 5 and 18 years. It is assumed that readers have experience working with children. The CPG addresses the following:

• The PTs' roles related to the diagnosis of DCD using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5)¹⁸ criteria and the patient management process.
• Recommendations for screening, referral, examination, intervention, and discharge in settings where physical therapy services may be provided, within the ICF categories of body functions and structures, activity and participation.

This CPG does not specifically address:

• Handwriting examination and intervention, which may not be an area of expertise for PTs without additional training in this area.
• Executive function or other psychological constructs that are better addressed by psychology colleagues.
• Management of children with DCD and coexisting conditions (such as DCD and autism, attention-deficit disorder [ADD], or sensory differences) despite the high prevalence of these conditions. There is limited evidence for examination and intervention that differentiates children with DCD from those with a variety of coexisting conditions. This guideline provides evidence for children with DCD, as described in most articles appraised for this guideline. For children with DCD and coexisting conditions, the PT will need to do a thorough examination that addresses all areas of concern including coexisting conditions, and then consider integration of evidence-based interventions for these coexisting conditions along with those for DCD.

Statement of Intent

This CPG is intended to inform pediatric PTs, family members, educators, and other health care providers including physicians, occupational therapists (OTs), and psychologists, who work with children from 5 to 18 years with coordination difficulties, at risk for or diagnosed with DCD. It was not developed to serve as a legal standard of care. This CPG is a summary of practice recommendations that are supported with current published evidence that has been reviewed by health care practitioners, educators, and parents. The action statements are guidelines only, not mandates. Adherence to them will not guarantee a successful outcome in every patient, nor do they include all appropriate methods of care aimed at the same outcomes. The decision regarding a specific plan of care must be made with the patient/client/family, considering values, expectations, preferences, clinical information, examination and intervention options, the clinician's scope of practice, and clinical expertise. However, it is recommended that significant departures from accepted guidelines should be documented in patient records.

METHODS

The CPG was funded by the APPT. Funding support did not influence the CPG content. An advisory committee consisting of a physician, OT, psychologist, special education teacher, school principal, physical education teacher, and a parent interested in DCD were consulted on 2 occasions through conference calls. This group influenced the guideline content and scope and many participated as guideline draft content reviewers. Specific activities are highlighted in the Development of the Guideline (see the Supplemental Digital Content, pages 15-16, available at: https://links.lww.com/PPT/A305) and followed procedures documented in Pediatric Physical Therapy¹⁹ and the APTA CPG Manual 2018.¹

Determining Priority Content

Role-specific, web-based surveys were conducted with primary stakeholders (PTs, physicians, and parents of children with a diagnosis of DCD) to determine CPG priority topics, before action statement recommendations were developed. The parent surveys were approved by the Colorado Multiple Institutional Review Board (COMIRB) prior to distribution. Surveys for PTs were distributed through the APPT electronic newsletter. Surveys to physicians and parents were distributed based on contacts solicited through members of the GDG. Survey items were scored using a 5-point scale from “not important” to “critically important.” Physical therapists answered 24 questions, physicians answered 11 questions, and parents answered 20 questions—all similar, but modified for each group.

Comparing similar questions across the 3 groups, physical therapists (n = 174), physicians (n = 13), and parents (n = 3) agreed that understanding the definition of DCD, differential diagnostic information about DCD, and a quick reference guide about DCD management were critically important. Other critically important PT priorities were measuring functional activities, assessing participation domains, and identifying physical therapy interventions. All critically important priorities consistent across the 3 groups are addressed by this CPG.

Search Strategy, Appraisals, and Review

The search strategy, search terms (see Supplemental Digital Content Table 1, page 1, available at: https://links.lww.com/PPT/A305), selection criteria, appraisal process,^20–22 data extraction, external review procedures, Agree II²¹ review, and Prisma Flow Chart (see Supplemental Digital Content Figure 1, page 2, available at: https://links.lww.com/PPT/A305) are in the Supplemental Digital Content, pages 1 to 2 (https://links.lww.com/PPT/A305).

Language

This document is referred to as the 2020 DCD CPG and the DSM-5 diagnosis of developmental coordination disorder will be referred to as DCD. The phrase “child's primary physician” references pediatricians, developmental pediatricians, family physicians, or other referring physicians. In this guideline, educators, coaches, or other community activity providers are referred to as “other significant adults” because they may play an important role in the life of the family and child. This CPG discusses the process of moving from referral, through examination, to possible diagnosis. Children are often referred to PTs because of concerns about coordination, prior to having a formal diagnosis, and are described in this CPG as a “child with coordination difficulties.” A child may be described as “at risk for DCD” or “probable DCD” during the examination process when some of the DSM-5 diagnostic criteria for DCD are identified: these terms are operationally defined in Supplemental Digital Content Table 2, page 3 (available at: https://links.lww.com/PPT/A305). The term “other or unspecified lack of coordination” may be a familiar International Classification of Diseases, Tenth Revision (ICD-10) billing code that is not used as a diagnosis in this document but is described in Supplemental Digital Content Table 3, page 4 (available at: https://links.lww.com/PPT/A305). “Movement pattern coordination deficit” is a movement system diagnosis that PTs have proposed to describe a primary clinical movement problem²³; however, the literature does not yet clearly describe whether a movement pattern coordination deficit is synonymous with a DCD diagnosis. A list of abbreviations is provided at the end of this document.

DEVELOPMENTAL COORDINATION DISORDER

Diagnostic Considerations for DCD

Developmental coordination disorder is defined as a neurodevelopmental disorder and subcategorized as a motor disorder in the DSM-5.¹⁸ The incidence of DCD is reported to be approximately 5% to 6% of school-aged children, which may be an underestimate.²⁴

DCD is 1.7 to 2.8 times more likely in boys than in girls.²⁴ The term DCD was initially endorsed in 1994 at the International Consensus Meeting in London, Ontario, Canada, and eventually became part of the DSM-IV.²⁵ Prior to that, multiple labels were used to define DCD, including clumsy child syndrome, developmental dyspraxia, sensory integration disorder, perceptual-motor difficulties, and minor neurological dysfunction. In 2013, DCD was further defined in the DSM-5,¹⁸ with the diagnostic criteria listed in Table 4. This guideline uses the DSM-5 diagnostic criteria as the DCD definition.

TABLE 4: - DSM-5: DIAGNOSTIC CRITERIA DESCRIPTION FOR DEVELOPMENTAL COORDINATION DISORDER AND CRITERIA KEY^a

Diagnostic Criteria Descriptionb		Criteria Key
A	The acquisition and execution of coordinated motor skills are substantially below that expected given the individual's chronological age and opportunity for skill learning and use. Difficulties are manifested as clumsiness (eg, dropping or bumping into objects) as well as slowness and inaccuracy of performance of motor skills (eg, catching an object, using scissors or cutlery, handwriting, riding a bike, or participating in sports).	Motor Performance Deficits
B	The motor skills deficit in criterion A significantly and persistently interferes with activities of daily living appropriate to chronological age (eg, self-care and self-maintenance) and affects academic/school productivity, prevocational and vocational activities, leisure, and play.	Participation and ADL Deficits
C	Onset of symptoms is in the early developmental period.	Early Onset
D	The motor skills deficits are not better explained by intellectual disability (intellectual developmental disorder) or visual impairment and are not attributable to a neurological condition affecting movement (eg, cerebral palsy, muscular dystrophy, and degenerative disorder).	No Exclusionary Conditions

Abbreviation: ADL, activities of daily living.

^aFrom DSM-5.¹⁸

^bA, B, C, and D represent the description of each specific diagnostic criterion.

The diagnosis of DCD cannot be made by a PT; it requires a physician, psychologist, or psychiatrist to formally assign this diagnosis because making medical or psychiatric diagnoses is outside the scope of physical therapy practice in the United States. However, PTs may contribute substantially to the diagnostic process. The diagnosis description includes 4 criteria (Table 4). All 4 of the criteria (A-D) need to be met to diagnose a child with DCD. In this document, the criteria are referred to by the abbreviated “Criteria Key” terms in Table 4. These 4 combined criteria describe children with DCD as having: (A) motor coordination below what would be expected when considering their chronological age and exposure to motor activities, (B) movement qualities including clumsiness, slowness, or inaccuracy, which impact daily living skills, school productivity, leisure, and play, (C) symptoms which began in the developmental period, and (D) symptoms that cannot be explained by other conditions such as an intellectual disability or other neurological conditions with motor impairments.

The history, systems review, and examination findings that address the DSM-5 criteria contribute to a DCD diagnosis by a team of professionals, which may include PTs.^16–18 A DCD diagnosis is typically made when the child is around 5 years or older, when the DSM-5 criteria can be most clearly met; however, families and other professionals may notice differences in children's motor performance at much younger ages. Questionnaires and standardized assessments may aid in earlier identification of motor coordination difficulties in younger children, even if a formal DCD diagnosis is not made until age 5.²⁶ Possible ICF-level differences of children with DCD, ICD-10 codes for DCD, and operational definitions related to DCD are provided in Supplemental Digital Content Tables 2 and 3, pages 3 to 4 (available at: https://links.lww.com/PPT/A305).

General Information About Individuals With DCD

Children have a higher risk of being diagnosed with DCD if they were born weighing less than 1500 g (3.3 lb) or were less than 32 weeks' gestation.²⁴ On average these infants are 2.2 times more likely to be diagnosed with DCD.²⁴ There is growing evidence that children with DCD have different brain activity and dysfunction of cortical networks compared with peers.⁵ Brain regions, including the primary sensorimotor cortex, posterior superior temporal gyrus, cerebellum, and supplementary motor area, all associated with timing, motor control, motor learning, and spatial and error processing show much less activation in children with DCD.^27,28 Difficulties with predictive motor control, learning of new internal models, rhythmic coordination and executive function have been most associated with deficits in control of motor actions.^5,27,28 Neuromaturational dysfunction in children with DCD impacts both the acquisition and execution of gross and fine motor skills and activities of daily living (ADL).^5,29 Other conditions frequently associated with DCD include hypotonicity or joint laxity,²⁴ balance deficits,⁵ and being overweight or obese.²⁴ Children at risk for DCD were found to have slower running speeds and lower cardiorespiratory fitness, both of which continue to worsen as they age compared with peers.³⁰ Body composition, muscle strength and endurance, anaerobic capacity, and physical activity are all associated with poor motor performance in children with DCD.³⁰

Profiles of children with DCD may include coexisting neurodevelopmental or neurobehavioral conditions, including ADD, attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), sensory differences, and other learning disabilities.^24,31 Intellectual disability (ID) may be a coexisting condition if motor difficulties are greater than those expected with ID. The DSM-5 allows for concurrent diagnosis of these frequently related conditions, with an understanding that testing may be more difficult if they exist.^18,24 Further, children with DCD may present with depression and anxiety,^24,27,32 difficulties with self-concept of physical competence,^27,32 reduced social interactions,^5,16,33 and decreased quality of life (QOL),^5,16,33 increasing the risks of bullying^5,16,33 and decreased physical activity.^5,16,33 Motor problems typically precede inactivity, which can lead to poor fitness and possible obesity in this population.³⁴ Motor and social/emotional difficulties appear to persist into adolescence and adulthood and are linked to impaired planning and disorganization in daily life.^5,24,35 Based on the results of the Adolescents and Adults Coordination Questionnaire, young adults at risk for DCD performed more poorly than peers on both academic and nonacademic functioning.^24,36

Researchers have sought to categorize children with DCD into subtypes based on extensive testing that resulted in different types of dyspraxia, including ideomotor dyspraxia, visuospatial constructional dyspraxia, and mixed dyspraxia.³⁷ However, subsequent literature has not clearly defined differences in intervention approaches applied to these categories. Scores on the Movement Assessment Battery for Children—Second Edition (MABC-2) provide another approach to DCD categorization.³⁸ Children who score less than or equal to the 5th percentile have been described as having significant movement difficulty (probable DCD). Children at risk of having movement difficulty (at risk for DCD) score between the 5th and 15th percentiles.³⁸ Research does not clearly differentiate approaches that should only be applied to children with probable DCD versus those at risk for DCD. Therefore, examination and intervention with children in either of these groups may be considered similarly.¹⁶ Physical therapists may also consider using these guidelines for children presenting with coordination difficulties, yet not described as at risk for or diagnosed with DCD, as many of the same strategies may apply, but are not formally addressed in the DCD literature.

Role of the Interprofessional Team

There is a consistent consensus that diagnosis and management of DCD requires an interprofessional team approach.^16,24 Team members ideally include the child and family, the child's primary physician, possibly associated specialists (eg, developmental pediatrician and child neurologist), a child psychologist, an OT and/or a PT with pediatric experience, and other significant adults.²⁴ Service coordination and communication are crucial, allowing providers, children, and parents/caregivers to discuss options for securing optimal care¹⁷ to address function, participation, and prevention of secondary consequences, while addressing family values. Pediatric PTs contribute their expertise in child development, motor control, motor learning, movement observation, functional training, and clinical reasoning. Occupational therapists have been leaders in the management of individuals with DCD. Physical therapists can collaborate with OTs in areas outside the typical scope of physical therapy practice or in areas with which an individual PT may be less familiar, such as handwriting or sensory differences.

Physical therapists work in a variety of settings where children at risk for or diagnosed with DCD may present, such as schools, clinics, home health, or community/recreational settings. Due to the unique nature of their interactions with children in these environments, they may be the first clinician to consider and pursue consultation with other professionals about a possible DCD diagnosis. Physical therapy management of DCD should include a comprehensive examination to address the 4 criteria of the DSM-5 DCD diagnosis. Task-oriented interventions that address activity and participation restrictions, along with interventions for impairments of body structure and function, are first-choice interventions in a comprehensive plan of care that also includes small group or individual sessions and home program activities dosed appropriately to achieve outcomes. Physical therapists may also consider supplemental activities for children with DCD, based on the interests of the child and family, the PT's expertise, and access to these options. This multilevel, evidence-based approach to intervention is currently the most effective plan of care for improving motor performance in children with DCD.⁵ Unfortunately, little evidence exists about the long-term prognosis of individuals with DCD, or the long-term impact of interventions that address motor performance, as most research has been focused on relatively short-term interventions.

ACTION STATEMENTS

I. PHYSICAL THERAPY EXAMINATION AND REFERRAL OF CHILDREN WITH COORDINATION DIFFICULTIES, AT RISK FOR OR DIAGNOSED WITH DCD

P Action Statement 1: COMPLETE A HISTORY AND SYSTEMS REVIEW. Physical therapists should obtain and document a comprehensive history and systems review for a child at risk for DCD or diagnosed with DCD to contribute evidence relevant to DSM-5 Criteria C (Early Onset) and Criteria D (No Exclusionary Conditions). (Evidence Quality: V; Recommendation Strength: Best Practice)

Action Statement Profile

Aggregate Evidence Quality: Level V, based on the APTA Guide to PT Practice, review articles, and expert clinical consensus.

Benefits:

• Screening can identify symptoms consistent with the DSM-5 criteria or other conditions.
• Systematic screening ensures that other conditions that may cause a lack of coordination or delays in gross and fine motor skills are ruled out or that timely referral for additional testing occurs.
• In states where PTs may screen and/or treat without physician referral, children can receive services more quickly.

Risk, Harm, and Cost:

• Costs may be associated a with physical therapy evaluation, which includes a history and systems review.
• PTs unfamiliar with DCD may not identify those at risk for DCD from the history or systems review.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: In some geographic locations or practice settings, particularly where direct access examination is permitted, PTs may be the first to screen a child for coordination difficulties. Other children may be referred to physical therapy with a diagnosis of DCD; however, the same screening process should occur as part of the examination.

Intentional Vagueness: None

Role of Patient/Parent Preferences: Parents/caregivers may provide valuable information on the child's medical and developmental history. This may be more challenging in a school or home health environment but should be pursued.

Exclusions: None

Quality Improvement: Physical therapists should document screenings of the neurological, musculoskeletal, integumentary, and cardiopulmonary systems to provide uniform data for more effective communication among clinicians and for entry in patient registries.

Implementation and Audit:

• Create or revise parent/caregiver history and systems review forms completed prior to the initial examination to assist with collecting the recommended data.
• Learn the 4 parts of the DSM-5 criteria for DCD necessary to receive a diagnosis.
• Provide training to enhance history and systems review consistency and reliability.
• Audit incidences in which system screens are consistent with DCD versus suggesting developmental delays or lack of coordination caused by other conditions.

Supporting Evidence and Clinical Interpretation

It is within the scope of physical therapy practice to screen for causes of developmental motor delay and/or decreased motor performance that affects participation in ADL.¹⁷ Screening for DCD is most appropriate beginning around age 5, because evaluation and diagnosis of DCD using the DSM-5 diagnostic criteria is suggested at this age.¹⁸ Several skills and activities described in the diagnostic criteria for DCD are not acquired at younger ages. A history and systems review provide evidence that contributes to differential diagnosis. Physical therapy screening should include an interview with the parent/caregiver, a review of medical records, and observation of the child's movement. Parental concerns provide helpful information for detection of developmental problems in children.³⁹ Based on the screening results, the PT should either refer to the child's primary physician if there are red flags or concerns for medical, developmental, emotional or other exclusionary conditions (Criteria D) or continue to examine factors that contribute evidence relevant to the DSM-5 criteria for DCD. The following elements should be documented:

History^24,31,40:

• Reason for referral
• Determine movement, task, or activity limitation impact on participation priorities
• General intake data:
• Date of birth
• Date of examination
• Gender
• Reason for referral
• Parent/caregiver concerns
• General health
• List of other service providers
• Cultural or religious considerations
• Medical history:
• Birth history
• Prematurity
• Birth weight
• Onset of symptoms that relate to motor concerns
• Medications
• Other medical conditions including vision or hearing concerns
• Coexisting conditions such as ADD, ADHD, ASD, or ID
• Events such as accidents or surgical procedures
• Medical interventions
• Developmental history
• Developmental milestones in gross/fine motor, language, and social/adaptive skills
• Other areas of intellectual or developmental concern
• Behavioral or emotional differences
• Family history:
• Medical or developmental conditions that exist in the family, such as clumsiness, DCD, ADD/ADHD, specific learning disabilities, and ID
• Educational history:
• Interventions received in early intervention or developmental preschool program
• Reports of difficulties with physical activities or academics
• Special education services in school
• Intellectual testing and determinations
• Participation history:
• Home ADL and chores
• Activities with family and friends
• Physical activity preferences that are motivating at home, school, and community
• Fitness level
• Additional history may include, with parent/caregiver consent:
• Reports secured from other professionals such as OTs, speech therapists, psychologists, physicians, teachers, or other significant adults

Systems Screen:

A systems screen should be completed using questions or checklists to determine whether to refer to the child's primary physician.¹⁷ Specifically, the child should be screened for medical/developmental/emotional concerns or exclusionary conditions other than DCD. The PT should gather information about the conditions that may coexist with DCD or those considered for differential diagnosis (Table 5).^24,31,40,41

• Musculoskeletal screen:
• Height and weight
• Symmetry in joint range of motion
• Muscle function and muscle mass
• History of acute onset of muscle weakness
• Skeletal abnormalities
• Neuromuscular screen:
• Atypical and asymmetrical muscle tone
• General coordination
• Fall history
• Toe walking
• Neurological signs (eg, hyperreflexia, ataxia, tremors, Gowers' sign, and waddling gait)
• Cranial nerve screening
• Headaches or pain
• Integumentary screen:
• Signs and symptoms of trauma
• Abnormal pigmentation
• Color of skin and nail beds
• Cardiovascular/Pulmonary screen:
• Activity level and endurance of the child at home, school, and in the community
• Cognitive/behavioral screen:
• Acute changes in cognitive function
• Ability to follow instructions and communicate needs
• Behavioral regulation and attention
• Ability to interact with adults and peers
• Vision screen:
• History of acute changes in visual function
• History of treated or untreated visual impairments or diagnoses

TABLE 5: - COMMON COEXISTING CONDITIONS AND DIFFERENTIAL DIAGNOSES FOR CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER^a

Coexisting Conditions (Not All-Inclusive)	Differential Diagnoses (Not All-Inclusive)
Autism spectrum disorder Attention-deficit hyperactivity disorder Dyslexia Specific language disorder	Cerebral palsy Congenital syndromes Genetic disorders Malignancies Musculoskeletal disorders (ie, hip dysplasia) Neurodegenerative disorders Toxic and teratogenic disorders Traumatic brain injuries Visual impairments

^aFrom Harris,²⁴ Kirby et al,³¹ Callanen,⁴⁰ and Missiuna et al.⁴¹

R. Research Recommendations:

• Clarify the precision of DCD screening procedures to establish more specific symptoms associated with DSM-5 Criteria C (Early Onset), and Criteria D (No Exclusionary Conditions).
• Clarify how medical, educational, and participation history and screening factors influence the child's functional outcomes and physical therapy diagnosis and prognosis.

P Action Statement 2: MAKE APPROPRIATE REFERRALS. Physical therapists should refer children to their primary physician if there are red flags or concerns for medical, developmental, or other exclusionary conditions (DSM-5 Criteria D), or when DCD is suspected, and no diagnosis has previously been assigned to contribute to evidence relevant to DSM-5 Criteria C (Early Onset). (Evidence Quality: V; Recommendation Strength: Best Practice)

Action Statement Profile

Aggregate Evidence Quality: Level V, based on the APTA Guide to PT Practice, review articles, and expert clinical consensus.

Benefits: Referral to the child's primary physician may assist in differential diagnosis and/or further referral to other health care or educational professionals to ensure timely, coordinated interventions.

Risk, Harm, and Cost: There may be costs for referral to the child's primary physician or other professionals. Collaboration among health care providers and significant adults could lower the overall cost of care.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: Referral to the primary care physician should result in care provided by a team of professionals, if needed, to ensure that coexisting conditions and those beyond the scope of the PT are addressed.

Intentional Vagueness: None

Role of Patient/Parent Preferences: Parents/caregivers may share information about other developmental or behavioral concerns with the PT and should expect these concerns to be addressed in the plan of care.

Exclusions: Children who do not meet the diagnostic criteria for DCD (Table 4) should be fully examined by appropriate health care professionals to initiate an appropriate plan of care.

Quality Improvement: This recommendation promotes interprofessional collaboration for children with DCD and may result in earlier identification of children with the condition.

Implementation and Audit:

• Training for health care and educational professionals who see children suspected of DCD is needed to ensure that children are provided referrals.
• Physical therapists should share the 2020 DCD CPG with physicians and other health care and education professionals in their geographic area.
• Physical therapy documentation should include information supporting the reason for referral.

Supporting Evidence and Clinical Interpretation:

Physical therapists should refer to the child's primary physician if there are red flags or concerns for medical/developmental/emotional or other exclusionary conditions (Criteria D).³¹ Examples of red flags requiring immediate referral include history of trauma, headaches or blurred vision, deterioration in motor skills, or significant hypertonia or hypotonia.³¹ Referrals may occur after the initial screening, following the examination or anytime throughout the plan of care if concerns arise. Physical therapists may choose to continue the examination process before referral, in order to provide more data for consideration of a DCD diagnosis with the child's primary physician. Knowing that DCD is often “unrecognized and underdiagnosed,”³² it is important to refer to the primary physician as soon as possible to begin assembling an appropriate team. Coordinating with other professionals allows for an appropriate diagnosis using additional tests and measures and the DSM-5 criteria.¹⁶ Since making a medical diagnosis is not within PTs' scope of practice in the United States, prompt referral supports and early identification can guide service delivery to meet the needs of children with DCD and their parents/caregivers.³²

R. Research Recommendations:

Data are needed about the number of children with coordination difficulties, at risk for or diagnosed with DCD who are examined by PTs and are referred for concerns about coexisting or exclusionary conditions, or confirmation of the DCD diagnosis. These data would establish the incidence of conditions discovered during the examination process and the effectiveness of referral patterns.

P Action Statement 3: COMPLETE PARTICIPATION OUTCOME MEASURES. Physical therapists should document child or parent/caregiver perceptions of the child's participation in environments that are meaningful to the child, using one of these participation or goal-related outcome measures to contribute evidence relevant to DSM-5 Criteria B (Participation and ADL Deficits):

• Canadian Occupational Performance Measure (COPM), (Evidence Quality: II-III; Recommendation Strength: Moderate)
• Goal Attainment Scale (GAS), (Evidence Quality: V; Recommendation Strength: Best Practice)
• Perceived Efficacy and Goal Setting Program (PEGS), (Evidence Quality: V; Recommendation Strength: Best Practice)
• Children's Assessment of Participation and Enjoyment (CAPE) and Preferences for Activities of Children (PAC), (Evidence Quality: II-V; Recommendation Strength: Weak)

Action Statement Profile

Aggregate Evidence Quality: Expert clinical consensus.

Benefits:

• Inquiry about participation restrictions and goals may guide the plan of care and help to determine child and family satisfaction and success with the plan of care.
• Participation and goal-related outcome measures quantify meaningful change for children with DCD.
• Understanding participation restrictions provides opportunities for parent/caregiver education about resources or activities that may support goals.

Risk, Harm, and Cost:

• Some recommended standardized measures are proprietary and require purchase.
• Physical therapists may require training to enhance consistency and reliability for assessing participation or goal-related outcome measures.
• Physical therapists without pediatric experience may not interpret information from measures accurately if unfamiliar with the DSM-5 criteria for DCD.
• Available standardized measures may not address the full breadth of participation restrictions.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: Therapists should consider the child's social, emotional, and cognitive levels, culture, and primary language to determine the most appropriate standardized outcome measure and administration method. Alternatively, the parent/caregiver may be the most appropriate source for identifying participation or goal-related outcomes. Self-report through interview is adequate if standardized tools are not available.

Intentional Vagueness: None

Role of Patient/Parent Preferences:

• The child or parents/caregivers may provide valuable information about participation and goal-related outcomes.
• Parents/caregivers may place most value on improving their child's participation from physical therapy.

Exclusions: None

Quality Improvement: Standardized outcome measures objectively inform the effectiveness of the physical therapy intervention.

Implementation and Audit:

• Create or revise documentation records to include participation outcome measures.
• Audit incidences in which participation outcomes are documented.

Supporting Evidence and Clinical Interpretation:

Documentation of the ICF area of participation may occur at different points in the examination process but is most beneficial at the beginning to identify child- and family-centered participation priorities. Early knowledge of priorities can direct PTs toward movement observation and motor examination focused on those concerns.

DSM-5 Criteria B (Participation and ADL Deficits) states that a child's motor skill deficit must affect “academic/school productivity, prevocational and vocational activities, leisure and play,”¹⁸ areas included in the ICF participation domain.⁴² The APTA Guide to PT Practice suggests that it is important to use outcome measures across all domains of the ICF, including outcomes that reflect the individual's goals.¹⁷ It is also important for children to evaluate their capacity to perform tasks related to participation.⁴³

Participation difficulties are often the reason that children with or suspected of DCD come to physical therapy, and participation changes are often the ultimate measures of success for the child and family. Children with DCD participate less than typical children in school and community settings; therefore, it is important to establish goals to address these differences.⁴⁴ Shared decision-making with the child, parent/caregiver, and PT enhances satisfaction and adherence, especially if the goals are related to the cultural and social expectations for participation.^16,45 However, participation measurement in DCD studies is limited and the variability in measures makes definitive recommendations for specific measures difficult.⁴⁶ Diagnosis-specific standardized measures of participation for DCD do not exist, but a few measures have been used in the DCD literature that focus on improving participation and self-efficacy related to motor skills. Additional participation information, to complement the standardized measures, may be gathered through self-report, parent/caregiver interview, and other questionnaires or checklists.¹⁰

The measure chosen in a specific setting may be based on recommended ages, time to complete, cost, training, and whether specific goal-related outcomes or overall change in participation is desired. The COPM⁴⁷ and GAS^48,49 both focus on soliciting specific goals from the child or parent/caregiver. Improvement in participation may be reflected by a combination of several activity goals or may be a singular overarching goal. The CAPE and PAC⁵⁰ and PEGS⁴³ include numerous concepts that may together reflect an overall measure of participation, such as level of enjoyment, and frequency of, or preferences for participation. They may be used to identify specific activities for which an outcome may be developed. For detailed descriptions of these 4 standardized participation or goal-related outcome measures found in the DCD literature, see the Supplemental Digital Content, page 6, and Supplemental Digital Content Table 4, page 7 (available at: https://links.lww.com/PPT/A305).

R. Research Recommendation: Determine the most appropriate participation measure for children with coordination difficulties, at risk for DCD or diagnosed with DCD. Longitudinal studies that include participation measures would inform decisions about intervention and contribute to an understanding of participation restrictions over the lifespan.

P Action statement 4: EXAMINE MOTOR PERFORMANCE THROUGH MOVEMENT ANALYSIS/OBSERVATION. Physical therapists should complete observational movement analysis (OMA) in a clinical or natural environment to identify movement quality characteristics that contribute to impaired coordination and the reason for referral, to contribute evidence relevant to DSM-5 Criteria A (Motor Performance Deficits). (Evidence Quality: V; Recommendation Strength: Best Practice)

Action Statement Profile

Aggregate Evidence Quality: Expert clinical consensus.

Benefits:

• Movement observation can differentiate between DCD and other conditions.
• Movement observation can facilitate referrals to other specialists.
• Movement observations can guide the PT to more specific tests and measures.
• In states where PTs examine and/or treat without physician referral, children can receive services more quickly, based on initial movement observations.

Risk, Harm, and Cost:

• There is a cost for physical therapy examination, inclusive of OMA. PTs unfamiliar with DCD may not identify those at risk for DCD through OMA if unfamiliar with atypical movement profiles.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: In some geographic locations or practice settings, particularly where autonomous practice is permitted, PTs may be the first to examine a child for coordination difficulties.

Intentional Vagueness: Specific tasks for OMA are not outlined and are at the PT's discretion. Observation should begin with tasks identified as challenging for the child, related to the reason for referral, or are part of their expected cultural or social expectation for participation. Movement observations should also occur during motor performance examinations using standardized measures.

Role of Patient/Parent Preferences: Parents/caregivers, other significant adults, or the children may provide information about movement qualities observed with challenging motor tasks.

Exclusions: None

Quality Improvement:

• Documenting the OMA using a standardized format provides uniform data both for more effective communication among clinicians and for entry in patient registries. No standardized physical therapy movement observation format currently exists, but one may be created by a clinical site for consistent internal use.
• Observational movement analysis contributes to clinical decisions to rule out or refer for other conditions that may affect coordination.

Implementation and Audit:

• Adapt documentation records to include OMA data.
• Provide training to enhance OMA reliability.
• Audit the incidences in which OMAs identify movement difficulties associated with DCD or other conditions.

Supporting Evidence and Clinical Interpretation

Observational movement analysis (OMA), a foundation of the physical therapy profession's history and practice, is used to guide the PT's examination and identification of movement difficulties.⁵¹ Observational movement analysis describes a patient's kinesiological strategies for functional task completion.⁵²

Observational movement analysis should lead to further tests and measures to examine children with suspected DCD. For example, if a child is observed to be lacking control/stability while stair climbing, the PT may hypothesize deficits in strength or balance and selectively examine these impairments. In settings where standardized tests of motor performance are too expensive or not available, a systematic OMA in the natural environment may inform DSM-5 Criteria A (Motor Performance Deficits) by documenting movement qualities such as clumsiness, slowness, or inaccuracy. A “gold standard” examination of motor performance for DCD has not been identified; therefore, OMA is a valuable examination component.^10,11 Observational movement analysis may reconcile discrepancies between standardized assessment results to contribute to clinical decisions about a DCD diagnosis.⁵³ However, there must also be evidence that the “acquisition and execution of coordinated motor skills are substantially below that expected given the individual's chronological age and opportunity for skill learning and use” to fully satisfy Criteria A (Motor Performance Deficits).¹⁸ Opportunity may be influenced by the child's culture and environment.¹⁶

Systematic OMA is a more thorough process than the screening that occurs when first meeting a child. A systematic OMA of core functional activities (ie, sit-to-stand, walking, and reaching), or the activities for which the family/caregiver is seeking physical therapy, should include detailed and comprehensive documentation about movement quality characteristics. In the absence of a specified task, the GDG suggests observing tasks such as skipping, jumping jacks, jump roping, or bouncing/catching a tennis ball, as these tasks are often difficult for children with DCD. Movement analysis tools are available, such as described by Janssen et al,⁵⁴ but no studies that addressed examination for DCD in this CPG suggested a standardized OMA format. The following draft of OMA screening items was proposed by expert clinicians from the 2019 APTA Movement System Task Analysis Work Group of the APTA Movement System Task Force.

Observational Movement Analysis Characteristics:

• Speed (time to complete the task)
• Range (eg, movement excursions to complete an activity) documented through observation, photographs, or videos
• Symmetry (with awareness of natural asymmetries in an activity) reported for upper and lower extremities, spine, and overall balance
• Control (smoothness, coordination, stability, sequencing, and timing)

Some OMA qualities typical of children with DCD include increased time to complete tasks, asymmetries, decreased coordination, difficulties with motor planning evidenced by sequencing and timing deficits,³⁷ increased step widths, and more variability in double-limb stance and stride time during gait, suggestive of less mature patterns than age-matched peers.⁵⁵ After completing OMA, the PT should determine whether the activity is not impaired, impaired, or is not able to be completed, based on the movement characteristics and age norms. This determination should be followed by a consultation with the child's primary physician if there are significant concerns about signs or symptoms inconsistent with DCD, or continuation of examination to determine the extent to which movement characteristics are impaired.

R. Research Recommendation:

• Identify movement quality characteristics and key activities to observe in infants and young children that predict DCD.
• Create a standard taxonomy of OMA characteristics for DCD.
• Verify OMA reliability and validity.

P Action Statement 5: EXAMINE ACTIVITY LIMITATIONS USING QUESTIONNAIRES. Physical therapists should document activity limitations that affect participation in the home, school, and/or community using standardized questionnaires completed by the child, parent/caregiver, or other significant adult, as part of the initial examination of children with coordination difficulties, at risk for or diagnosed with DCD, to contribute evidence relevant to DSM-5 Criteria B (Participation and ADL Deficits) choosing from the:

• Developmental Coordination Disorder Questionnaire 2007 (DCDQ'07), (Evidence Quality: I and V; Recommendation Strength: Moderate)
• Movement Assessment Battery for Children—Second Edition Checklist (MABC-2-C), (Evidence Quality: I and V; Recommendation Strength: Moderate)
• Questionnaires or Interviews, (Evidence Quality: V; Recommendation Strength: Best Practice)

Action Statement Profile

Aggregate Evidence Quality: Levels I to V, based on the APTA Guide to PT Practice, review articles, expert clinical consensus and test manuals.

Benefits:

• Detecting activity limitations that contribute to participation restrictions can direct the plan of care.
• Questionnaires can identify children who have movement difficulties in everyday settings relevant to the DSM-5 criteria.
• The DCDQ'07 is available to clinicians at no charge (https://dcdq.ca/).
• Using standardized tools or checklists contributes to group data that may help interpret service impact.

Risk, Harm, and Cost:

• PTs unfamiliar with DCD may not identify those at risk for DCD through standardized questionnaires if unfamiliar with the DSM-5 criteria for DCD or pediatric norms.
• Proprietary standardized assessments have associated costs.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: Documenting activity limitations that affect participation in the home, school, and community is part of the physical therapy examination.¹⁷

Intentional Vagueness: The DCDQ'07⁵⁶ is recommended, despite a lack of evidence that it is the best measure of activity limitations, including ADL and participation.

Role of Patient/Parent Preferences: Parents/caregivers provide valuable information on the effect of motor impairments across a variety of settings. Physical therapists should also gather information from teachers and other significant adults to determine the effect of activity limitations on academics and participation in other environments.

Exclusions: None

Quality Improvement: Documentation of activity limitations affecting participation at home, school, and community provides data to identify common activity profiles of children with coordination difficulties, at risk for or with a diagnosis of DCD.

Implementation and Audit:

• Create or revise examination documentation forms or electronic records to include measures of activity limitation.
• Clinicians may require training to perform consistent administration, scoring, and interpretation of reliable standardized questionnaires.
• Audit the use of standardized questionnaires.

Supporting Evidence and Clinical Interpretation:

DSM-5 Criteria B (Participation and ADL Deficits) states that a child's motor skill deficit must significantly and persistently “interfere with activities of daily living appropriate to chronological age (e.g., self-care and self-maintenance).”¹⁸ These items are included in the Activities (execution of a task) component of the ICF model.⁴² Standardized questionnaires like the DCDQ'07,⁵⁶ MABC-2-Checklist (MABC-2-C),³⁸ DCDDaily,⁵⁷ DCDDaily-Q,⁵⁸ and the School Function Assessment (SFA)⁵⁹ assess performance in activities related to participation. Although the reviewed DCD literature does not include all of these standardized assessments, detailed descriptions of the tools and comparisons are in the Supplemental Digital Content, page 7, and Supplemental Digital Content Table 5, page 8 (available at: https://links.lww.com/PPT/A305). Additional information about activity deficits related to participation can be gathered through self-report, caregiver interview, and other questionnaires or checklists to complement standardized measures.¹⁰

The most common examination methods to measure ADL performance found in 24 articles were the DCDQ'07 (9 articles),^60–68 MABC-2-C (1 article),⁶⁹ and subjective questionnaires, interviews, and self-reports (8 articles).^70–77 The remaining articles did not describe how Criteria B (Participation and ADL Deficits) was met (4 articles),^78–81 or the participants in the study already had a formal diagnosis of DCD (2 articles).^82,83

The GDG recommends using the DCDQ'07⁵⁶ to contribute evidence relevant to DSM-5 Criteria B (Participation and ADL Deficits) because it is free of charge, has been used in several DCD-related articles, and its use will contribute to more standardized practice.⁸⁴ If PTs have access to the MABC-2-C,³⁸ particularly in schools, it may be used as a more expanded measure of movement difficulty with contributions from teachers and providers. When there is limited access to parents/caregivers, PTs should conduct interviews, questionnaires, or checklists with other significant adults to identify participation and ADL deficits.⁸⁵

R. Research Recommendation: Develop or clarify a comprehensive questionnaire to assess the breadth of activity limitations in children with DCD relevant to DSM-5 Criteria B (Participation and ADL Deficits).

B Action Statement 6: EXAMINE MOTOR PERFORMANCE USING STANDARDIZED MEASURES. Physical therapists should document difficulties in motor performance (ability to perform a motor skill) that are below what is expected based on age and experience, for children with coordination difficulties, at risk for or diagnosed with DCD, as part of the initial examination to contribute evidence relevant to DSM-5 Criteria A (Motor Performance Deficits) choosing from the:

• Movement Assessment Battery for Children—Second Edition (MABC-2) (Evidence Quality: II-V; Recommendation Strength: Moderate)
• Bruininks-Oseretsky Test of Motor Proficiency—2nd edition (BOT-2) (Evidence Quality: II-V; Recommendation Strength: Moderate)

Action Statement Profile

Aggregate Evidence Quality: Levels II to V, based on systematic reviews, review articles, and expert clinical consensus.

Benefits:

• Standardized assessments can determine the degree of motor performance difficulty relevant to the DSM-5 criteria.
• Detection of motor difficulties can direct the plan of care.
• Motor performance examination establishes a baseline to objectively quantify intervention effects.

Risk, Harm, and Cost:

• PTs without pediatric experience may not interpret information from standardized motor assessments accurately if unfamiliar with the tests, the DSM-5 criteria for DCD, or typical child development.
• Recommended standardized assessments are proprietary and costly.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: Standardized tests are preferred objective measures of motor performance. Some clinical settings may not be able to purchase one of the described tests; therefore, documentation of motor skill performance that is significantly below what is expected for age and experience of the child may need to be adapted.

Intentional Vagueness: None

Role of Patient/Parent Preferences: Parents/caregivers and other significant adults provide valuable supplemental information on motor performance across a variety of settings.

Exclusions: None

Quality Improvement:

• Examination and documentation of motor performance provide objective data to assist in the diagnosis of DCD.
• Documenting standardized motor performance tool results provides uniform data for patient registries.

Implementation and Audit:

• Create or revise documentation forms or electronic records to include motor performance data collected from standardized measures.
• Clinicians may require training to enhance standardized assessment reliability.
• Audit the frequency of completed standardized assessments.

Supporting Evidence and Clinical Interpretation

Standardized measures are available to determine whether the acquisition and execution of coordinated motor skills are substantially below the individual's chronological age to meet DSM-5 Criteria A (Motor Performance Deficits). These delays may present as clumsiness, slowness, and inaccuracy of fine and gross motor skills.¹⁸ The MABC-2³⁸ and the BOT-2⁸⁶ are used most often to quantify difficulties in motor skill performance.^11,16,31,87 Smits-Engelsman et al⁸⁸ reported the MABC (edition 1 or 2) was used 73% of the time to assess motor performance for children with suspected DCD, followed by the BOTMP or BOT-2 (7.4%). However, these assessment tools do not address all the DCD diagnostic criteria, nor are they considered gold standards.⁸⁹ While the MABC-2 and the BOT-2 do support Criteria A (Motor Performance Deficits),^6,11 they do not adequately assess Criteria B (Participation and ADL Deficits),^10,89 nor the ICF domain of participation.⁶ The GDG recommends that the MABC-2 or the BOT-2 be the first-choice measure to determine whether motor difficulties exist for children suspected of having DCD; PTs may choose based on test availability and time to administer.⁶ If the first-choice measures are not available, the Test of Gross Motor Development—2nd Edition (TGMD-2),⁹⁰ which needs further psychometric justification for use with children with DCD,¹¹ is noteworthy for its validity and reliability to assess gross motor performance, and possibly a less costly option.^6,11 The 3rd Edition of the TGMD was published in 2019.⁹¹ A detailed description of the standardized tools to assess motor performance is provided in the Supplemental Digital Content and Supplemental Digital Content Table 6, page 9 (available at: https://links.lww.com/PPT/A305).

Those who cannot purchase standardized tests may have or may develop a motor skills checklist for children 5 years and older, based on literature about gross motor skill norms. Such a checklist should address motor skill acquisition at expected age levels to determine whether motor skills are substantially below the individual's chronological age, acknowledging that the psychometric rigor of established standardized tests are preferred. A checklist could include motor skills such as:

• Rhythmic galloping—attained by age 4⁹²
• Standing on either foot for 8 to 10 seconds–attained by age 5⁹²
• Hopping 8 to 10 times on one foot—attained by age 5⁹²
• Skipping with alternating feet—attained by age 5⁹²
• Standing on either foot for more than 10 seconds—attained by age 6⁹²
• Riding a bike without training wheels—attained by age 6⁹²

Motor task execution may be considered in different ecological environments, such as when the child is alone, when the child is with a few children in a quiet environment, or when the child is attempting the task in a large group with more distractions. A checklist and/or OMA may provide a low-cost option to contribute evidence relevant to DSM-5 Criteria A (Motor Performance Deficits).

R. Research Recommendation:

• Determine how scores obtained on the MABC-2 and BOT-2 correlate with activity and participation measures for children with DCD.
• A free motor skills checklist should be developed to standardize a core group of skills that could be used to assess children at risk for DCD.

B Action Statement 7: EXAMINE IMPAIRMENTS OF BODY FUNCTIONS AND STRUCTURES. Physical therapists should document impairments at the ICF level of body functions and structures for a child with coordination difficulties, at risk for DCD or diagnosed with DCD, as part of a comprehensive physical therapy examination. (Evidence Quality: II-V; Recommendation Strength: Moderate)

Action Statement Profile

Aggregate Evidence Quality: Levels II to V based on a systematic review, randomized controlled trials (RCTs) and expert clinical consensus.

Benefits:

• Determining impairments of body functions and structures that affect motor performance and participation in physical activities or recreation informs the plan of care.
• Examination of body functions and structures establishes baselines to measure components of physical fitness progress.

Risk, Harm, and Cost:

• Some standardized assessment tools are costly, but there are free alternatives to measure body functions and structures.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: Physical therapists should hypothesize how specific impairments of body functions and structures may affect activities or participation before testing. Careful test selection should be based on experience with the test, availability, and clinical necessity. Test data must be interpreted accurately and documented as part of any physical therapy examination when impairments are suspected to interfere with motor performance or participation.

Intentional Vagueness: A prescribed list of impairment-level tests and measures is not provided; however, suggested components of physical fitness (see Supplemental Digital Content Table 7, page 10, available at: https://links.lww.com/PPT/A305) should be considered if they relate to impairments of body functions and structures hypothesized to interfere with task performance.

Role of Patient/Parent Preferences: Parents/caregivers and significant adults provide valuable information on the effect of impairments related to physical fitness and participation across a variety of settings.

Exclusions: None

Quality Improvement: Objective measures of body functions and structures provide data for monitoring change, testing hypotheses, and more effective communication among clinical settings. Objective data can contribute to patient registries.

Implementation and Audit:

• Create or revise documentation forms or electronic records to include data about impairments of body functions and structures that relate to components of motor performance and physical fitness.
• Clinicians may require training to enhance standardized assessment reliability.
• Audit the incidences in which impairments of body functions and structures informed intervention.

Supporting Evidence and Clinical Interpretation

Physical therapists should examine body functions and structures that make up components of physical fitness and activity for children with coordination difficulties, at risk for or diagnosed with DCD. While no specific impairment tests and measures are recommended by the GDG, PTs should use OMA and motor performance measure observations to guide choices. Although body function and structure impairments do not contribute to the DSM-5 criteria, they are part of a comprehensive physical therapy evaluation to inform the plan of care.^17,42 Impairments in motor performance in children with DCD are strongly correlated with poor physical fitness and physical activity outcomes.³⁰ It is not known whether decreased physical fitness is a primary or secondary condition in children with DCD.⁸¹ The physical fitness components most often examined in the DCD literature are muscular strength,^{62,70,71,76,93,94} muscular endurance,^70,71,76,77 cardiorespiratory fitness,^{70,71,76–78,95,96} power,^62,70,71,93 and balance.^{60–62,66,78} These components of body functions are reflected in many health and skill components described by the President's Council on Sports, Fitness and Nutrition (see Supplemental Digital Content Table 7, page 10, available at: https://links.lww.com/PPT/A305).⁹⁷ Impairment-level assessment tools reviewed in the DCD literature, some of which are costly or may require equipment and additional space, are described in Supplemental Digital Content Table 8, page 10 (available at: https://links.lww.com/PPT/A305).

Impairment-level assessment tools recommended on the APPT Fact Sheet titled, “List of Pediatric Assessment Tools Categorized by ICF Model,”⁹⁸ also objectively measure muscular endurance, muscular strength, cardiorespiratory fitness, and balance. Other options are using the MABC-2 balance subtest or the BOT-2 balance, bilateral coordination and strength subtests for specific impairments of body functions and structures.

R. Research Recommendation: Determine whether improving components of physical fitness increases physical activity participation for children with coordination difficulties, at risk for DCD or diagnosed with DCD—specifically, determining whether participation is positively impacted by strength, power, balance, or cardiorespiratory fitness/endurance improvements.

Summary of Examination Recommendations

Having objectively documented the history, systems review, OMA, participation, activity, and body function and structure impairments, the initial examination is complete. If the information gathered from Action Statements 1 to 7 indicate below age-level coordination concerns or DCD is suspected, with parent/caregiver permission, the PT should provide a complete examination report to the child's primary physician, psychologist, or interprofessional team. If professionals are not familiar with DCD, the PT may also provide general information about DCD such as diagnostic information (Table 4) or the physical therapy patient management algorithm for DCD (Figure) and/or other supplemental tools designed for this guideline. The physician or psychologist should consider the 4 DSM-5 criteria for DCD, using their own examination findings along with those from the PT's documentation to determine an appropriate diagnosis. In addition to diagnostic consideration, a referral should also include the PT's evaluation of the examination information and the plan of care for the child. An abbreviated summary of all recommended examination tests and measures is in Table 6.

TABLE 6:: SUMMARY OF STANDARDIZED ASSESSMENT TOOLS FOR EXAMINATION AND EVALUATION

II. PHYSICAL THERAPY INTERVENTION FOR CHILDREN AT RISK FOR OR DIAGNOSED WITH DCD

A Action Statement 8: PROVIDE TASK-ORIENTED INTERVENTIONS COMBINED WITH RELATED BODY FUNCTIONS AND STRUCTURES INTERVENTIONS AS THE FIRST-CHOICE INTERVENTION. Physical therapists should provide and document a combination of task-oriented and body functions and structures interventions as the first-choice intervention, choosing as appropriate from the list below, to improve motor performance for a child at risk for DCD or diagnosed with DCD:

Task-Oriented Interventions

• Motor Skill Training (MST), (Evidence Quality: I; Recommendation Strength: Strong)
• Neuromotor Task Training (NTT), (Evidence Quality: I; Recommendation Strength: Strong)
• Cognitive Orientation to daily Occupational Performance (CO-OP), (Evidence Quality: I-III; Recommendation Strength: Moderate)
• Motor Imagery (MI), (Evidence Quality: I; Recommendation: Moderate)

Body Functions and Structures Interventions

• Core Stability Training, (Evidence Quality: II; Recommendation: Moderate)
• Cardiorespiratory Training, (Evidence Quality: II; Recommendation: Moderate)
• Functional Movement-Power Training Program (FMPT), (Evidence Quality: II; Recommendation: Moderate)

Action Statement Profile

Aggregate Evidence Quality: Levels I to III based on systematic reviews, meta-analyses, and RCTs.

Benefits:

• Improved outcomes in children receiving a combination of task-oriented and body functions and structures interventions compared with no intervention.
• Improved motor proficiency in children receiving intervention compared with no intervention.

Risk, Harm, and Cost:

• Intervention costs may be a burden for families.
• PTs without pediatric experience may provide less effective interventions if knowledge of the disorder is limited.

Benefit-Harm Assessment: Preponderance of benefits.

Value Judgments: Physical therapists should choose interventions aimed to improve motor performance and decrease body function and structure impairments to enhance participation at home, school, and in the community; however, the direct effect of motor performance intervention on participation in physical activities is unknown at this time.^5,7

Intentional Vagueness: The GDG is unable to establish a clear distinction between NTT and MST, both of which are task-oriented approaches based on the theories of motor control and motor learning. Both approaches have been successful in improving motor performance, components of physical fitness and parent/child satisfaction.

Role of Patient/Parent Preferences: Children and parents/caregivers must be motivated to adhere to intervention plans and home programs to maximize benefits.

Exclusions: None

Quality Assurance: This recommendation may reduce unwarranted variations in practice and provide consumers with guidance for evidence-based interventions.

Implementation and Audit

• Documentation forms and electronic records may need to be revised to include specific task-oriented and body functions and structures approaches.
• Audit the types of task-oriented and impairment-based interventions to determine their overall benefits to children.
• Audit PT adherence to provide a combination of task-oriented and impairment-based approaches as the first-choice intervention or reasons for deviating from the recommendation.

Supporting Evidence and Clinical Interpretation

PTs should use a task-oriented approach, in combination with interventions for reducing body function and structure impairments, based on the examination results. The combination of task-oriented and impairment-based interventions yields the most significant effect on motor performance compared with either intervention alone (g = 0.83).⁵ Task-oriented interventions are motor activities or programs to improve the acquisition and execution of a specific functional motor task.^5,7,8,12,99 Task-oriented interventions are based on theories of motor control and motor learning,^100,101 focus on goal attainment through active participation, and progressively increase task demands.¹⁰² These approaches include MST,^{61–63,70,77–79,81} NTT,^71,103 CO-OP,^67,69,72,74 and MI.¹⁰⁴ While MST and NTT have the highest recommendation strength, the GDG does not recommend one specific method of task-oriented training. The CO-OP approach integrates motor control and learning theories with cognitive-behavioral theories and requires training to design a plan of care. ^105–108 Physical therapists may choose to pursue further training in these methods but should rely on basic motor control and motor learning strategies that are typically taught in US-accredited PT education programs. Common principles of task-oriented training methods include:

• Part practice to whole practice
• Multiple repetitions
• Task-specific practice in variable environments
• Adapt training based on progress; increase environmental and task demand
• Facilitate self-discovery using creative methods (eg, encourage child viewing of task practice videos, with PT guidance to identify modifiable task components)
• Feedback provision

Multiple high-quality systematic reviews^5,7,8,12 and meta-analyses^7,12 report the effects of motor-based interventions for children with DCD. The most common outcome measure evaluated across the systematic reviews was motor performance. Other outcome measures included components of physical fitness (body functions and structures), cognitive/emotional/psychological factors, satisfaction of intervention, and participation in physical activity. These were evaluated qualitatively or quantitatively depending on the systematic review and meta-analysis. Task-oriented approaches were shown to have a positive effect on motor performance^5,7,8,12 (Hedges' g = 0.63; 95% CI [0.31, 0.94]; P < .001),⁵ cognitive/emotional/psychological factors (Hedges' g = 0.65; 95% CI [0.25, 1.04]; P = .001),⁵ and components of physical fitness (qualitative summary)^5,7,8 compared with no intervention (z = 3.17; 95% CI [−5.88, −1.39]; P = .002).¹² Interventions to reduce impairments and improve body functions and structures are sometimes referred to as process-oriented approaches or bottom-up approaches. These approaches hypothesize that improving underlying deficits will result in changes in motor performance.¹⁰² However, impairment-based interventions used alone had minimal to no significant impact on motor performance (Hedges' g = 0.20; 95% CI [−0.45, 0.84]; P = .549)⁵ and are not recommended in isolation. Further, the effect of any intervention on increased participation in physical activities remains inconclusive.^5,7 It should be noted that systematic reviews investigating motor-based intervention effects reported moderate to high heterogeneity^5,7,8,12 secondary to the variety of intervention approaches, clinical settings (school, community, and home), intervention doses, child-chosen goals, intervention methods (group vs individual), and diagnostic variation in the sample groups (at risk for DCD vs probable DCD). The systematic reviews' inclusion and exclusion criteria supporting this recommendation vary, creating discrepancies in the reported effect sizes.^5,7,8,12

The DCD literature provides clear explanations of a direct relationship between the task addressed in task-oriented intervention and the impairment addressed with body functions and structures interventions. Only 3 body functions and structures interventions are addressed in the DCD literature for which there are positive outcomes: core stability training (CST),⁷⁸ cardiorespiratory training (CRT),⁷⁶ and functional movement-power training (FMPT).⁶² These approaches are described in the Supplemental Digital Content, page 10 to 11, and Supplemental Digital Content Table 9, page 12 (available at: https://links.lww.com/PPT/A305). Impairments identified in the examination may be addressed by these interventions; however, this list does not include all possible impairment interventions because evidence specific to DCD is lacking. The GDG recommends that PTs use one or more of the recommended task-oriented approaches combined with targeted impairment-based interventions relevant to the child's goal.

R. Research Recommendation: Determine whether improved motor performance and/or components of physical fitness affect participation in physical activities.

A Action Statement 9: USE SMALL GROUP OR INDIVIDUAL SESSIONS. Physical therapists should document and deliver interventions using individual (1:1) or small group (4-6:1) sessions for a child at risk for DCD or diagnosed with DCD. (Evidence Quality: I; Recommendation Strength: Strong)

Action Statement Profile

Aggregate Evidence Quality: Level I based on 3 systematic reviews.

Benefits:

• Improved outcomes have been demonstrated in children receiving individual and small group interventions.
• Physical therapy delivered in small groups (4-6:1) to address both social and motor objectives may be delivered at a lower cost and most applicable in camp or community settings.

Risk, Harm, and Cost:

• Child anxiety may increase if groups are too large.
• Social group dynamics are unpredictable and may impact individual outcomes.
• Time constraints for small group sessions may be limiting for parents and children.
• Space and resource availability may be limited.
• Group-based charges may not be covered by third-party payers.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: Caution should be taken when using group-based interventions for children, such as monitoring for signs of increased anxiety, avoidance of group participation, or lack of enjoyment. Children should be given the opportunity to express how they feel about an intervention method.

Intentional Vagueness: None

Role of Patient/Parent Preferences: Parents/caregivers and other significant adults provide valuable information on the effects that an intervention may have on their child. Children may have preferences for either individual or small group sessions that should be taken into account when developing interventions.

Exclusions: None

Quality Improvement: Documentation of outcomes and the sessions using group versus individual approaches can contribute to patient registries.

Implementation and Audit:

• Documentation forms may need to be revised to include group and individual options.
• Audit the types of interventions using group and individual sessions and the outcome measures used.

Supporting Evidence and Clinical Interpretation

There is evidence to support both small group-based (4-6:1) or individual-based intervention sessions as beneficial for children with coordination difficulties, at risk for or diagnosed with DCD.^16,109 The evidence is inconclusive on whether an individual approach is superior for improving motor performance,^7,8 components of physical fitness (impairment level)⁷ or QOL outcomes compared with a group-based approach.¹⁰⁹ Large effect sizes on motor performance were found for both group-based (Cohen's d = 1.46) and individual-based (Cohen's d = 1.05) sessions.⁷ Significant improvements in QOL outcomes¹⁰⁹ and impairment measures were reported in both group^63,71,77 and individual^61,62,78,81 sessions across multiple intervention studies. A combination of group and individual sessions also yielded significant improvements in performance and satisfaction with ADL.¹⁰⁹

The exact ratio for group-based intervention needs further investigation. The ratio ranged from 4-6:1^7,16 to 2:1.⁶⁷ Physical therapists should be aware of adverse events reported for children participating in a large group (11:1).⁶³ Children had significant increases in anxiety and lower levels of enjoyment,⁶³ though studies using individual sessions did not measure anxiety.¹⁰⁹ The GDG recommends that PTs be mindful of each child's response during group-based sessions. A combination of small group and individual sessions could be used to encourage participation with peers, generalize skills within natural circumstances, as well as address individual goals. The child's comfort with and benefit from group interventions must be considered a priority over any potential cost savings by providing physical therapy in groups.

R. Research Recommendation:

• Clarify the factors that influence decisions about group versus individual sessions, such as participants' motor impairment severity or diagnostic status of at risk for versus diagnosed DCD.
• Determine optimal combinations of group- and/or individual-based sessions for improving motor performance in children with DCD.

A Action Statement 10: RECOMMEND SUPPLEMENTAL ACTIVITIES TO AUGMENT THE FIRST-CHOICE INTERVENTIONS. After appraising the appropriateness for the child, physical therapists may recommend and document the supplemental activities of soccer training, taekwondo, and other physical activities, as adjuncts to the first-choice interventions for the child at risk for DCD or diagnosed with DCD. These may include:

• Soccer training provided by a trained coach. (Evidence Quality: I; Recommendation Strength: Strong)
• Taekwondo (TKD), provided by a certified instructor. (Evidence Quality: II; Recommendation Strength: Moderate)
• Other physical activities, including participation in sports. (Evidence Quality: V; Recommendation Strength: Best Practice)

Action Statement Profile

Aggregate Evidence Quality: Levels I to V based on systematic reviews and RCTs.

Benefits:

• Supplemental activities may improve outcomes when combined with first-choice interventions.
• Supplemental activities can reinforce physical therapy goals and may promote child participation in physical activities with peers in the community.

Risk, Harm, and Cost:

• Most supplemental activities require a trained specialist or occur in an environment outside of school or clinic settings.
• Specific supplemental activities may not be available in all geographic regions.
• The costs of supplemental activities including program fees, time, travel, and equipment may be a burden for families.
• Active video gaming (AVG) may decrease time spent playing outdoors.⁶⁴

Benefit-Harm Assessment: Neutral

Value Judgments: Physical therapists should recommend supplemental activities with the strongest evidence to augment first-choice interventions and that are of interest to the child. Participation in physical activities within the community that are enjoyable for the child may improve self-confidence and QOL outcomes.

Intentional Vagueness:

• The list of supplemental activities is not all inclusive.
• There is no clear evidence that individual or small group sports should be recommended over larger team sports for children with DCD. However, extrapolation of evidence about possible anxiety in larger groups¹⁶ and less participation of children with DCD in team sports¹¹⁰ suggests that individual or small group sports are preferable. The choice of sports should incorporate shared decision-making with the child, family, and knowledge of available community opportunities.

Role of Patient/Parent Preferences: Parents/caregivers or the child may inquire about community activities in which their child could successfully participate or that would help improve motor skill performance.

Exclusions: None

Quality Improvement: Documentation of participation in supplemental activities may improve data to understand how they may contribute to motor skill performance and components of physical fitness.

Implementation and Audit

• Create or revise documentation forms and electronic records to include the type and dosage of supplemental activities in which the child participates.
• Audit the types and dosage of supplemental activities to determine the effects on children at risk for DCD or diagnosed with DCD.
• Physical therapists should create lists of community resources for children with DCD (eg, camps or other community activities) and providers familiar with DCD, as a family resource.

Supporting Evidence and Clinical Interpretation

Supplemental activities in this guideline are: (1) activities that occur in the home or community, (2) activities that may support the goals of the child and parent/caregiver and, (3) activities that are typically not included in ongoing physical therapy intervention. Supplemental activities may include activities that use task-oriented approaches and/or those that address impairments of body functions and structures.

Supplemental activities that are favored adjuncts to first-choice interventions include soccer training, TKD and other physical activities in the community. Soccer training with a trained coach allows for practice of skills that require speed, agility, power, endurance, and coordination. Soccer training^7,8,12,75 and TKD^8,60,82 are supported in the DCD literature. Taekwondo, learned from a certified instructor, may improve impairments of balance and leg strength, but it is unclear whether these gains translate to function or motor performance. Other physical activities in the community, particularly individual sports that are of interest to the child, may help foster self-confidence in physical skills that could be progressed to well-supervised team sports.^63,110 The Supplemental Digital Content, page 13 (available at: https://links.lww.com/PPT/A305) provides a detailed description of recommended supplemental activities for Action Statement 10.

Vision therapy is not included in the recommendations for supplemental activities because PTs do not typically have this expertise. Vision therapy addresses ocular motor control including monocular, biocular, and binocular exercises.¹¹¹ There is evidence of favorable outcomes in motor performance with vision therapy when used with children who were at risk for or diagnosed with DCD, between the ages of 8 and 12 years, when carried out by an optometrist-trained researcher for 18, 40-minute weekly sessions.^7,111 Physical therapists should consult with the child's primary physician or ophthalmologist to determine whether a vision therapy referral for ocular motor deficits is warranted, based on the history, systems review, and OMA.

Active video gaming (AVG) is not a recommended supplemental activity. Active video gaming combines a gaming platform (eg, Wii Fit or PlayStation with Xbox) and voluntary active physical participation by the child. Active video gaming has been examined in multiple studies to determine its effects on motor performance,^66,68,70,71 balance,^64,66,73,80 functional strength,^70,71 cardiorespiratory fitness,^64,66,70,71 and physical activity⁶⁴ with mixed results. A reported adverse outcome using the PlayStation and Xbox console as a home program found that children spent significantly less time playing outside during the AVG intervention period.^64,112 There is insufficient evidence that AVGs increase school-based participation in physical activities for children with DCD or typical children.¹¹³ Similarly, the current evidence is inconclusive for the use of AVG to improve motor performance in children with DCD.¹¹⁴ Further research, including protocols and the type of gaming console, is needed to make an accurate recommendation for AVG as a supplemental activity for children with DCD.

R. Research Recommendation: Clarify which supplemental activities improve motor performance or increase participation in physical activities or recreation.

Summary of Intervention Approaches and Outcomes

PTs should begin with a first-choice task-oriented approach in combination body functions and structures interventions, and then consider supplemental activities to augment interventions, with the family. Table 7 may be used to review the approaches and expected outcomes to address the child's goals.

TABLE 7:: SUMMARY OF RECOMMENDED INTERVENTION APPROACHES AND OUTCOMES

B Action Statement 11: PROVIDE EDUCATION AND HOME EXERCISE PROGRAMS TO CHILD/PARENTS/CAREGIVERS OR OTHER SIGNIFICANT ADULTS. Physical therapists should provide recommendations and education for parents/caregivers and other significant adults about teaching methods or exercises to support physical therapy interventions. (Evidence Quality: I, II, and V; Recommendation Strength: Moderate)

Action Statement Profile

Aggregate Evidence Quality: EACD guideline,¹⁶ Level II cohort and outcomes studies, and expert clinical consensus.

Benefits:

• Education empowers parents/caregivers and other significant adults to implement activities that reinforce physical therapy goals.
• Education provides the parents/caregivers or other significant adults with strategies to address motor concerns in the home and community.
• Education and home programs may improve goal achievement.

Risk, Harm, and Cost:

• Time required for implementation of home activities may be a burden for families.
• Parents/caregivers or other significant adults may have difficulty applying instructions.
• Parents/caregivers or other significant adults may decrease the intensity of home exercises if they perceive that the PT is implementing the treatment.
• Not implementing home activities may risk physical inactivity for children and diminish the potential for meaningful goal achievement.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: None

Intentional Vagueness: None

Role of Patient/Parent Preferences: Parents may be interested in learning strategies to help their child learn motor tasks not addressed by physical therapy, such as general fitness or sports activities preferred by the family. Parents/caregivers may not be able to implement home program activities if it places undue burden on the family for time or finances.

Exclusions: None

Quality Improvement: Documentation of home program participation provides data to understand the effect of practice on physical therapy outcomes within a comprehensive plan of care.

Implementation and Audit:

• Access APPT supplemental tools to provide families with resources to learn about DCD (pediatricapta.org/clinical-practice-guidelines).
• Develop community relationships with individuals or groups that offer individual or small group sports activities to provide families with options.
• Create or revise documentation forms and electronic records to include education provided to parents.
• Create methods to track adherence and barriers to home programs.
• Create educational materials that explain task analysis, task-specific training, and motor learning principles for the lay reader.

Supporting Evidence and Clinical Interpretation

Consistent with the EACD, PTs should educate parents/caregivers and other significant adults about teaching methods and motor learning techniques to use at home, school, or in the community.¹⁶ Compliance with task-oriented home programs for motor skills training intervention correlated with positive changes in motor proficiency and postural control compared with children who received a core stability-focused home program (P = .030).⁷⁸ Parents who observed task-oriented techniques, such as breaking down tasks and allowing the children to make mistakes and learn from them, felt their children gained independence and confidence.⁷⁴ Home programs were also used in intervention studies about CO-OP, although no measures were used to assess outcomes related to the home program.⁷⁴ Education about practice and repetition as crucial for motor learning and attaining new skills supports physical therapy interventions and the general health of the child. Parents/caregivers and other significant adults may need training in task-oriented methods and principles of motor learning to encourage a child's success.¹⁶ A thorough list of specific adult education methods used for children with DCD does not exist in the literature. Parents/caregivers can be directed to the CanChild M.A.T.C.H framework, which suggests that they: (1) Modify the environment, (2) Alter expectations, (3) Teach strategies, (4) Change the environment, and (5) Help by understanding.¹¹⁵ Examples of teaching strategies the PT should encourage with parents/caregivers and other significant adults gathered from DCD studies and other task-oriented, motor learning literature include:

• breaking the task into smaller simple components
• beginning with decreased environmental and task demands
• repetition of task components followed by the whole task practice
• gradually increasing the demands until the child can generalize skills to perform the task
• if the child is capable, encouraging self-discovery of problem areas and MI

R. Research Recommendation: Determine the most effective training methods that PTs can provide for parents/caregivers and other significant adults to facilitate long-term training effects and general health.

B Action Statement 12: PROVIDE APPROPRIATE INTERVENTION DOSAGES TO IMPROVE MOTOR PERFORMANCE. The dosage for direct physical therapy intervention should be determined based on opportunities for practice in home and school environments and with supplemental activity options in the community. A high-frequency practice schedule of 2 to 5 times per week should be distributed among physical therapy sessions and other practice opportunities, until the goal-related task is achieved; this usually averages 9 weeks, depending on goal complexity. (Evidence Quality: I; Recommendation Strength: Moderate)

Action Statement Profile

Aggregate Evidence Quality: Level I based on 1 systematic review with a meta-analysis.

Benefits:

• Improved physical therapy outcomes with appropriate intervention frequency and duration.
• Combining direct PT services with home practice and community/recreation activities promotes appropriate social participation for children and families.

Risk, Harm, and Cost:

• Increased cost and time spent traveling for intervention.
• Increased demands on space and resources in different settings.
• Large group interventions proposed to meet dosage requirements may cause increased anxiety and decreased enjoyment for the child.

Benefit-Harm Assessment: Preponderance of benefits.

Value Judgments: A higher practice frequency is necessary to achieve short-term outcomes. However, the practice schedule design may be dependent on the PT's experience to creatively encourage practice with non-PTs (eg, parents/caregivers, teachers, physical education teachers, paraprofessionals, coaches, and community activity providers). More home-/community-based opportunities for practice may be optimal depending on financial resources.

Intentional Vagueness: None

Role of Patient/Parent Preferences:

• Child and parent/caregiver adherence to the prescribed home program directed by the PT is needed to obtain the optimal dosage for benefits.
• The plan of care may need to be flexible to accommodate parent/caregiver resources.

Exclusions: None

Quality Assurance:

• Dosage recommendations for clinicians and consumers provide guidance for evidence-based interventions including the time commitment needed to see meaningful improvement.
• Objective data on intervention dosages (physical therapy, home programs, and supplemental) contribute to patient registries.

Implementation and Audit

• Documentation forms and electronic records may need to be revised to include intervention approaches (physical therapy, home or school practice, and supplemental activities) and dosage parameters. PTs should document practice frequencies from direct service, home, or school and supplemental activities to the extent practical.
• Audit intervention approaches and respective dosages to determine the overall benefits to children.

Supporting Evidence and Clinical Interpretation

Yu et al's systematic review of 66 studies about motor skills training for children with DCD yielded 18 studies for a meta-analysis.⁵ Interventions varied: 44% were task-oriented, 15% process-oriented (body functions and structures interventions in this guideline), 12% combined task-oriented and process-oriented, and 15% were undefined.⁵ Motor performance was a primary outcome in many studies, but others used visual motor skills, cardiorespiratory fitness, balance, neurosensory, and kinesthetic function outcome measures.⁵

There is no single definitive prescribed dosage for intervention established at this time. Therapeutic dosages are reported as the length of sessions, total number of sessions/week, total number of Other/Sports weeks, and the total minutes of sessions; practice schedules were not provided solely as direct intervention by a PT in Yu et al,⁵ but included a variety of delivery methods and service providers. The session totals were highly variable, ranging from 10 minutes to 6 hours, 1 to 5 times per week for 4 to 24 weeks (180-2500 minutes). The most significant factors that impacted immediate motor performance in the meta-analysis were the total minutes of intervention (approximately 100/week) and the frequency of sessions per week.⁵ Practice schedules of 4 to 5 times per week (Hedges' g = 1.67, P < .001),⁵ over at least 9 weeks (Hedges' g = 0.93, P ≤ .001),⁵ regardless of the length of the sessions or total number of sessions, resulted in significant improvement in motor performance. However, even 2 to 3 times per week (Hedges' g = 0.80, P = .008)⁵ and once a week (Hedges' g = 0.38, P = .003)⁵ resulted in improved short-term motor performance gains with increased practice over time.

The evidence supports frequent practice scheduled over several weeks, or until the goal-related outcomes are achieved. The PT should determine the number of direct intervention sessions needed to achieve a cumulative practice schedule of 2 to 5 times per week and anticipate an average of 9 weeks to achieve a goal-related task, depending on the goal complexity. The practice schedule may include a combination of direct intervention sessions, home program practice or practice with school personnel, and supplemental activities related to the intervention outcomes. An optimal example of this type of schedule is: 1 to 2 direct physical therapy sessions/week, with a home program and/or additional time to practice during the school day for school-based settings. Supplemental activities should be recommended to complement the primary physical therapy intervention. Measurable progress toward child-centered goals would determine the duration of intervention. This sample schedule may be implemented in a variety of settings but may need to be modified based on child motivation, parent/caregiver needs and resources, school practice opportunities, goal complexity, and the child's baseline performance.

R. Research Recommendation: Develop standardized methods for documenting intervention dosages and clarify the optimal dosages for combined task-oriented and body functions and structures interventions that result in long-term motor performance improvements, accounting for motor impairment severity or diagnostic status of at risk for versus diagnosed DCD.

III. PHYSICAL THERAPY DISCHARGE OF CHILDREN WITH DCD

P Action Statement 13: PROVIDE COLLABORATIVE COMMUNICATION ABOUT DISCHARGE RECOMMENDATIONS FOR THE EPISODE OF CARE. Physical therapists should: (1) initiate consultation with the child's primary physician, specialists, and parents/caregivers about the child's progress during the episode of care and discharge plans, (2) discuss ongoing activity recommendations with families, and (3) discuss with families how and when to access future re-evaluations. (Evidence Quality: V; Recommendation Strength: Best Practice)

Action Statement Profile

Aggregate Evidence Quality: Review articles and expert clinical consensus.

Benefits:

• Consultation with the child's primary physician may address options for maintenance of lifelong fitness.
• Providing a plan to parents/caregivers may help to address ongoing motor concerns.
• Discharge when activity/participation goals are met is a cost-efficient method of care.

Risk, Harm, and Cost: Consultations and possible subsequent interventions may add to the cost of care.

Benefit-Harm Assessment: Preponderance of benefit.

Value Judgments: Collaborative and coordinated care is in the best interest of the child, reflects family-centered care, and acknowledges that DCD is a developmental condition that may require episodic intervention over many years.

Intentional Vagueness: The GDG is intentionally vague about the need for re-evaluation of children with DCD. Timelines for follow-up are not discussed in the literature and are at the discretion of the PT in consultation with the parent/caregiver, child's primary physician, and other professionals. Families should be encouraged to request physical therapy re-evaluations following growth spurts or when new movement challenges are not responding to family-initiated modifications.

Role of Patient/Parent Preferences:

• Parents/caregivers may choose not to reinitiate physical therapy if it places undue burden on the family for travel, time, or finances.
• Parents should be advised at discontinuation of direct physical therapy that they may request physical therapy re-evaluations if they have new concerns or goals for their child and resources are available for services.
• The impact of DCD on QOL across the lifespan^16,31 should be discussed with parents/caregivers over the episode of care and at discharge, along with guidance about how PTs can assist with adaptations as needs arise.

Exclusions: None

Quality Improvement:

Long-term data about frequency and dosage of physical therapy episodes of care may allow therapists to share information with parents about the expected amount of lifetime intervention for a child with DCD.

Implementation and Audit:

• Educate parents/caregivers about the potential need for periodic episodes of physical therapy care based on child or parent/caregiver goals. Reasons to reinitiate physical therapy would be functional decline or new functional goals important for the child's participation in the home, school, or community.
• Audit the number of times physical therapy is reinitiated, the overall frequency and dosage of physical therapy per year, per child, and the number of times physical therapy is discontinued before children's goals are met.

Supporting Evidence and Clinical Interpretation

Physical therapists coordinate and communicate about physical therapy services through an episode of care from examination through discharge to ensure optimal management of the child with DCD.¹⁷ Consultation with the child's primary physician, specialists, parents/caregivers, or other significant adults to discuss on-going concerns, potential referrals, or a discharge plan is part of physical therapy management with children with DCD.¹⁷ If goals developed by the child or parent/caregiver have been achieved, a plan for discharge should be discussed. Individuals with DCD may require multiple episodes of care, periodic physical therapy re-evaluations, and intervention over the child's lifespan. The child's parents should be educated about the process of reinitiating physical therapy in the same setting or other settings. An annual physical therapy checkup, if available, would provide another opportunity to review goals and consider goal-oriented reinitiation of physical therapy. At the time of discharge, a review of home program suggestions, activity modification and progression, supplemental activities, and community physical activity options should be discussed with the family.

Most children with DCD do not outgrow their deficits when they reach adolescence and adulthood, resulting in potential consequences in fitness, physical activity, and social participation.^16,31 Sensitivity to parents/caregivers about the ongoing nature and changing context of DCD over time is the responsibility of the PT and other team members. Referrals or recommendations for psychologists, other medical providers, or community physical activities may be appropriate for this population.

R. Research Recommendations:

• Develop long-term follow-up studies of children with DCD to describe factors and adaptations contributing to successful adult life.
• Determine whether adolescents or adults with DCD benefit from physical therapy interventions to address specific goals related to school, recreation, or job-related performance.

DCD CPG SUMMARY

A review of the literature resulted in 13 graded action statements with varying levels of recommendation that address screening, referral, examination, evaluation, first-choice physical therapy and supplementary interventions, and discharge recommendations, with suggestions for quality improvement. Strategies for guideline implementation,^116–120 additional methodological processes, measurement and intervention descriptions, evidence tables, and a summary of research recommendations are available in the Supplemental Digital Content (available at: https://links.lww.com/PPT/A305). Flow sheets for examination and intervention for DCD and summaries for families and professionals are available as supplemental tools on the APPT Web site (https://pediatricapta.org/clinical-practice-guidelines/). This CPG addressed the highest priority topics about DCD requested from PT, physician, and parent stakeholders.

Plan for Revision

The GDG recommends that the CPG be reviewed for updating within 5 years as the evidence expands. An updated systematic review will begin in 2023 to update or reaffirm the DCD CPG by 2025.

Abbreviations

-

ADD	attention-deficit disorder
ADD	attention-deficit disorder
ADHD	attention-deficit hyperactivity disorder
ADL	activities of daily living
APPT	Academy of Pediatric Physical Therapy
APTA	American Physical Therapy Association
ASD	autism spectrum disorder
AVG	active video gaming
BOTMP	Bruininks-Oseretsky Test of Motor Performance
BOT-2	Bruininks-Oseretsky Test of Motor Performance-2
CAPE	Children's Assessment of Participation and Enjoyment
COMIRB	Colorado Multiple Institutional Review Board
CO-OP	Cognitive Orientation to Daily Occupational Performance
COPM	Canadian Occupational Performance Measure
CPG	clinical practice guideline
CRT	cardiorespiratory training
CST	core stability training
DCD	developmental coordination disorder
DCDQ'07	Revised Developmental Coordination Disorder Questionnaire 2007
DSM-IV	Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
DSM-5	Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
EACD	European Academy of Childhood Disability
FMPT	functional movement-power training
GAS	Goal Attainment Scale
GDG	guideline development group
ICF	International Classification of Functioning, Disability and Health
ICD-10	International Classification of Diseases, Tenth Revision
ID	intellectual disability
IoM	Institute of Medicine
MABC	Movement Assessment Battery for Children
MABC-2	Movement Assessment Battery for Children— Second Edition
MABC-2-C	Movement Assessment Battery for Children— Second Edition Checklist
MI	motor imagery
MST	Motor Skill Training
NTT	Neuromotor Task Training
OMA	observational movement analysis
OT	occupational therapist
PAC	Preferences for Activities of Children
PEGS	Perceived Efficacy and Goal Setting Program
PT	physical therapist
QOL	quality of life
SFA	School Function Assessment
TGMD-2	Test of Gross Motor Development—2nd Edition
TKD	taekwondo
WHO	World Health Organization