Developmental dyspraxia

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Overview
Developmental dyspraxia is one or all of a heterogeneous range of psychological development disorders affecting the initiation, organization and performance of action. It entails the partial loss of the ability to coordinate and perform certain purposeful movements and gestures in the absence of motor or sensory impairments.

Developmental dyspraxia (referred to as developmental coordination disorder (DCD) in the US) is a life-long condition that is more common in males than in females; the exact proportion of people with the disorder is unknown since the disorder can be hard to detect. Current estimates range from 5% - 20% with at least 2% being affected severely. Ripley, Daines, and Barrett state that 'Developmental dyspraxia is difficulty getting our bodies to do what we want when we want them to do it', and that this difficulty can be considered significant when it interferes with the normal range of activities expected for a child of their age. Madeline Portwood makes the distinction that dyspraxia is not due to a general medical condition, but that it may be due to immature neuron development. The word "dyspraxia" comes from the Greek words "dys" meaning bad and "praxis", meaning action or deed.

Dyspraxia is described as having two main elements:
 * Ideational dyspraxia : Difficulty with planning a sequence of coordinated movements.
 * Ideo-Motor dyspraxia : Difficulty with executing a plan, even though it is known.

Assessment and diagnosis
Assessments for dyspraxia typically require a developmental history, detailing ages at which significant developmental milestones, such as crawling and walking, occurred. Motor skills screening includes activities designed to indicate dyspraxia, including balancing, physical sequencing, touch sensitivity, and variations on walking activities. A baseline motor assessment establishes the starting point for developmental intervention programs. Comparing children to normal rates of development may help to establish areas of significant difficulty.

However, research in the BJSE has shown that knowledge is severely limited in many who should be trained to recognise and respond to various difficulties, including Developmental Coordination Disorder, Dyslexia and DAMP. The earlier that difficulties are noted and timely assessments occur, the quicker intervention can begin. A teacher or GP could miss a diagnosis if they are only applying a cursory knowledge. "Teachers will not be able to recognise or accommodate the child with learning difficulties in class if their knowledge is limited. Similarly GPs will find it difficult to detect and appropriately refer children with learning difficulties."

Developmental profiles
Various areas of development can be affected by developmental dyspraxia and many or all can persist into adulthood. Often various coping strategies are developed, and these can be enhanced through physiotherapy.

Speech and language
Developmental verbal dyspraxia is a type of ideational dyspraxia, causing linguistic or phonological impairment. This is the favoured term in the UK; however it is also sometimes referred to as articulatory dyspraxia and in the USA the usual term is apraxia of speech. Key problems include:
 * Difficulties controlling the speech organs.
 * Difficulties making speech sounds
 * Difficulty sequencing sounds
 * Within a word
 * Forming words into sentences
 * Difficulty controlling breathing and phonation.
 * Slow language development.
 * Difficulty with feeding.

Fine motor control
Difficulties with fine motor co-ordination lead to problems with handwriting, which may be due to either ideational or ideo-motor difficulties. Problems associated with this area may include:
 * Learning basic movement patterns.
 * Developing a desired writing speed.
 * The acquisition of graphemes – e.g. the letters of the Latin alphabet, as well as numbers.
 * Establishing the correct pencil grip
 * Hand aching while writing

Whole body movement, coordination, and body image
Issues with gross motor coordination mean that major developmental targets including walking, running, climbing and jumping are affected. One area of difficulty involves associative movement, where a passive part of the body moves or twitches in response to a movement in an active part. For example, the support arm and hand twitching as the dominant arm and hand move, or hands turning inwards or outwards to correspond with movements of the feet. Problems associated with this area may include:


 * Poor timing
 * Poor balance (sometimes even falling over in mid-step) Tripping over one's own feet is also not uncommon. [2]
 * Difficulty combining movements into a controlled sequence.
 * Difficulty remembering the next movement in a sequence.
 * Problems with spatial awareness, or proprioception
 * Some people with dyspraxia have trouble picking up and holding onto simple objects [3] due to poor muscle tone.
 * This disorder can cause an individual to be clumsy to the point of knocking things over and bumping into people accidentally.
 * Some dyspraxics have difficulty in determining left from right [citation needed].
 * Cross-laterality, ambidexterity, and a shift in the preferred hand are also common in people with dyspraxia[citation needed].
 * Dyspraxics may also have trouble determining the distance between them and other objects.

General difficulties
Dyspraxic people may have Sensory Integration Dysfunction, a condition that creates abnormal oversensitivity or undersensitivity to physical stimuli, such as touch, light, and sound. This may manifest itself as an inability to tolerate certain textures such as sandpaper or certain fabrics, or even being touched by another individual (in the case of touch oversensitivity) or may require the consistent use of sunglasses outdoors since sunlight may be intense enough to cause discomfort to a dyspraxic (in the case of light oversensitivity). An aversion to loud music and naturally loud environments (such as clubs and bars) is typical behavior of a dyspraxic individual who suffers from auditory oversensitivity, while only being comfortable in unusually warm or cold environments is typical of a dyspraxic with temperature oversensitivity. This typically occurs if the dyspraxia is comorbid to an autistic spectrum disorder (PDD) such as autistic disorder or Asperger syndrome.

Dyspraxic people sometimes have difficulty moderating the amount of sensory information that their body is constantly sending them, so as a result these people are prone to panic attacks. Having other autistic traits (which is common with dyspraxia and related conditions) may also contribute to sensory-induced panic attacks.

Dyspraxics (along with people who have similar conditions) may have difficulty sleeping since there is an inability to force the brain to stop thinking and "shut down". A dyspraxic is nearly always thinking about several unrelated things at once, (the inverse is also possible, with only one dominant thought occupying the dyspraxic's entire attention span at any given time) so this may cause easy distractibility and daydreaming. It is quite easy for someone with dyspraxia to concentrate entirely on a particular thought instead of on the situation at hand. For this reason, dyspraxia may be misdiagnosed as ADHD since on the surface both conditions have similar symptoms in some areas. Many people with dyspraxia have short-term memory issues and may forget instructions they received only seconds before, tend to forget important deadlines, and are constantly misplacing items.

Moderate to extreme difficulty doing physical tasks is experienced by dyspraxics, and fatigue is common because so much extra energy is expended while trying to execute physical movements correctly. Some (but not all) dyspraxics suffer from hypotonia, which in this case is chronically low muscle tone caused by dyspraxia. People with this condition have very low muscle strength and endurance (even in comparison with other dyspraxics) and even the simplest physical activities may quickly cause soreness and fatigue, depending on the severity of the hypotonia. Hypotonia may worsen a dyspraxic's already poor balance to the point where it is necessary to constantly lean on sturdy objects for support.

Dyspraxics may wish to live alongside others, although they often find it difficult. They can be messy and cluttered with a tendency to outburst including aggression, 'good and bad days' (mood swings) and difficulty in understanding the meaning of everyday interactions within a household Because of this, they sometimes end up arguing with people they care deeply about and regretting it when the mood swing is over.

Often, their moods do not last too long, but they are very intense. When angered, a dyspraxic may feel beyond furious but soon the mood will be over and he\she may regret things they did when they were angry.

Overlap with other conditions
Dyspraxics may have other difficulties that are not due to dyspraxia itself but often co-exist with it. They may have characteristics of dyslexia (difficulty with reading and spelling), dyscalculia (difficulty with mathematics), expressive language disorder (difficulty with verbal expression), ADHD (poor attention span) or Aspergers Syndrome (poor social cognition, and a literal understanding of language, making it hard to understand idioms or sarcasm). However, they are unlikely to have problems in all of these areas. The pattern of difficulty varies widely from person to person, and it is important to understand that a major weakness for one dyspraxic can be a strength or gift for another. For example, while some dyspraxics have difficulty with reading and spelling due to an overlap with dyslexia, or numeracy due to an overlap with dyscalculia, others may have brilliant reading and spelling or mathematical abilities. Similarly, some have autistic traits such as lacking an appreciation of irony or social cues, while others thrive on an ironic sense of humour as a bonding tool and a means of coping. 

Frustration and low self-esteem are common to many dyspraxics, whatever their profile of difficulties. 

Other names
Collier first described developmental dyspraxia as 'congenital maladroitness'. A. Jean Ayers referred to it as a disorder of sensory integration in 1972 while in 1975 Dr Sasson Gubbay called it the 'clumsy child syndrome'. It has also been called minimal brain dysfunction although the two latter names are no longer in use. Other names include:


 * Dyspraxia
 * Developmental Co-ordination Disorder - a subtly different condition by definition, in practice, very similar.
 * Sensorimotor dysfunction
 * Perceptuo-motor dysfunction
 * Motor Learning Difficulties

The World Health Organisation currently lists Developmental Dyspraxia as Specific Developmental Disorder of Motor Function.