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Pocket versionb Definition, diagnosis, assessment, and intervention of developmental coordination disorder (DCD)

EACD Recommendations

  1. Top of page
  2. EACD Recommendations
  3. Teams, Advisory Board, Coordination
  4. Pocket Version
  5. Recommendations based on formal consensus

International representatives

Rainer Blank (Chair of the Scientific Committee of the EACD, Task Force ‘Recommendations’).

Hans Forssberg (Chair of the EACD).

European panel of experts

The recommendations were approved by a European panel of experts at the EACD meeting in Brussels, 26 May 2010, and through further DELPHI rounds.

J M Albaret (France), A Barnett (United Kingdom), R Geuze (the Netherlands), D Green (Israel/United Kingdom), M Hadders-Algra (the Netherlands), S Henderson (United Kingdom), M L Kaiser (Switzerland), A Kirby (United Kingdom), R P Lingam (United Kingdom), H Polatajko (Canada), M Schoemaker (the Netherlands), B Smits-Engelsman (the Netherlands), H van Waelvelde (Belgium), P Wilson (Australia), S Zoia (Italy) (alphabetical order).

Teams, Advisory Board, Coordination

  1. Top of page
  2. EACD Recommendations
  3. Teams, Advisory Board, Coordination
  4. Pocket Version
  5. Recommendations based on formal consensus

General coordination

Prof Dr Med Rainer Blank, University of Heidelberg, Child Centre Maulbronn, D-75433 Maulbronn, Germany. E-mail: blank@kize.de.

Coordination of the specific sections of the Clinical Practice Guideline

‘Underlying mechanisms’: P Wilson (Australia).

‘Consequences’, ‘Comorbidity’, ‘Definition and assessment’: R Blank (Germany).

‘Treatment’: B Smits-Engelsman (the Netherlands).

Writing group

H Becker (Germany), R Blank (Germany), O Jenni (Switzerland), M Linder-Lucht (Germany), H Polatajko (Canada), F Steiner (Switzerland), R Geuze (the Netherlands), B Smits-Engelsman (the Netherlands), P Wilson (Australia).

International experts

The full guideline process was consistently advised by international experts in the field:

B Smits-Engelsman (Physiotherapist, the Netherlands).

H Polatajko (Occupational therapist, Canada).

P Wilson (Neuropsychologist, Australia).

R Geuze (Clinical physicist/neuropsychologist, the Netherlands).

Pocket Version

  1. Top of page
  2. EACD Recommendations
  3. Teams, Advisory Board, Coordination
  4. Pocket Version
  5. Recommendations based on formal consensus

Recommendations (R) and statements (S) (according to algorithms). Definition, assessment, treatment indication (algorithm).

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Definition, diagnostic criteria, assessment, treatment indication

  1. GCP++, good clinical practice (recommendation based on strong consensus: ++, more than 95% of the participants; +, 75–95% of the participants of the nominative group process). LOE, level of evidence; Aneg, strongly recommended that clinicians (do not) routinely provide the intervention/the assessment to eligible residents.

R1The term developmental coordination disorder (DCD) should be used to refer to children with developmental motor problems in countries which adhere to the DSM IV-TR classification. In countries where International Classification of Diseases (ICD) 10 has legal status, the term specific developmental disorder of motor functions (SDDMF) (F82, ICD 10) should be usedGCP++
R3The diagnosis DCD (SDDMF) should be made within a diagnostic setting by a professional who is qualified to examine the specific criteriaGCP++
R2Children with DCD (SDDMF) having performance deficits in specific areas of motor performance, e.g. gross motor dysfunctions or fine motor dysfunctions (manipulative skills) should be classified according to the ICD subgroups (gross motor dysfunctions F82.0 or fine motor dysfunctions F82.1)GCP++
R3A dual diagnosis of DCD (SDDMF) and other developmental or behavioural disorders, e.g. autism spectrum disorder (ASD), learning disorders, attention-deficit–hyperactivity disorder (ADHD) should be given if appropriateGCP++
R4The onset of DCD (SDDMF) is usually apparent in the early years, but would not typically be diagnosed before 5y of age. If a child between 3 and 5y of age shows a marked motor impairment, even though there have been adequate opportunities for learning and other causes of motor delay have been excluded (e.g. deprivation, genetic syndromes, neurodegenerative diseases), the diagnosis of DCD (SDDMF) may be made based on the findings from at least two assessments performed at sufficiently long intervals (at least 3mo)GCP++
R5The use of questionnaires (e.g. DCDQ, Movement Assessment Battery for Children, 2nd version (M-ABC2) checklist) is not recommended for population-based screening for DCDLOE 4 Level Aneg
R2Criteria for the diagnosis of DCD (SDDMF) I. Motor performance that is substantially below expected levels given the child’s chronological age and appropriate opportunities for skill acquisition II. The disturbance in Criterion I significantly interferes with activities of daily living or academic achievement III. An impairment of motor coordination that is not solely explainable by mental retardation. The disturbance cannot be explained by any specific congenital or acquired neurological disorder or any severe psychosocial problemGCP++
R6Comorbidities should be carefully diagnosed and treated according to established clinical guidelines (e.g. ADHD, autism, dyslexia, specific language impairment)GCP++
S1Because of the high probability of comorbidity in DCD (SDDMF), disorders like ADHD, ASD, and learning disorder, particularly specific language disorder and in later age reading problems (e.g. reading comprehension) have to be checked by careful history taking, clinical examination and specific testing if possible according to existing clinical practice guidelines If there is any hint for interference (e.g. attentional problems) with objective motor testing the motor testing should be repeated, e.g. under medication or after other therapeutic intervention for attention problems++
R7Careful history taking is essential to support the application of Criteria I, II, III. History should include following aspects 1. Parental report (GCP++)  • Family history including DCD (SDDMF), comorbidities, environmental factors (e.g. psychosocial factors), neurological disorders, medical diseases, mental disorders, social condition of the family  • Personal history including exploration of resources and possible aetiology, for example pregnancy, birth, milestones, achievements, social contacts, kindergarten, school (grades, levels), previous and present disorders, especially neurological disorders, sensory problems (previous assessments), accidents  • History of the disorder (child) including DCD (SDDMF) and comorbidities and exploration of resources, activities of daily living (ADL) and participation, individual/personal factors, burden of disease, consequences of the DCD (SDDMF)  • Exploration of problems: present level/deficits of motor functions, ADL, and participation 2. Teacher report (GCP++)  • Motor functions, activities/participation, environmental factors/support systems, individual/personal factors (ICF)  • School-based behaviour that bears on comorbidity for attentional disorders, autistic spectrum, learning disorders  • Academic achievement 3. Views of the child should be taken into account (GCP++); child-adapted questionnaires (see above) may be useful, but cannot be generally recommended (GCP++)GCP++
R8Concerning Criterion III: appropriate clinical examination with respect to medical, neurological and behavioural problems is necessary to verify that the disturbance is not due to a general medical, neurological, or behavioural conditionGCP++
S2The clinical examination should include the following:  • neuromotor status (exclusion of other movement disorders or neurological dysfunctions);  • medical status (e.g. obesity, hypothyreosis, genetic syndromes, etc.);  • sensory status (e.g. vision, vestibular function);  • emotional and behavioural status (e.g. attention, autistic behaviour, self-esteem);  • cognitive function should there be a history of learning difficulties at schoolGCP++
R9Concerning Criterion II: the complete assessment should include consideration of activities of daily living (e.g. self-care and self-maintenance, academic/school productivity, pre-vocational and vocational activities, leisure, and play) and the views of the child, parents, teachers, and relevant othersGCP++
R10Concerning Criterion II: it is recommended to use a validated questionnaire to collect information on the DCD (SDDMF)-related characteristics of the child from parents and teachers to support and operationalize Criterion IIGCP++
R11Concerning Criterion II: questionnaires like the DCDQ-R or the M-ABC2 checklist may be recommended for use in those countries where the questionnaire is culturally relevant and standardizedLOE 2 Level B
R12Concerning Criterion I: an appropriate, valid, reliable, and standardized motor test (appropriately norm-referenced) should be used 
R13Concerning Criterion I: in the absence of a criterion standard test for establishing Criterion I, the M-ABC2 may be recommended (level of evidence (LOE) 2, level B). Where available, the Bruininks–Oseretzky Test of Motor Proficiency, second version (BOTMP-2) may also be recommended (LOE 2, level B). However, no German translation and standardization of the BOTMP-2 is currently available. In the absence of generally accepted cut-offs for identifying DCD (SDDMF), it is recommended that when using the M-ABC, or other equivalent objective measures, approximately the 15th centile for the total score (standard score 7 or less) should be used as a cut-offLOE 2 Level B
R14Based on the limitations of the available instruments, classification of specific domains of dysfunction (e.g. gross motor or fine motor dysfunction [ICD numbers F82.0 and F82.1]), can be made on the basis of clinical judgement The use of gross motor or fine motor items of standardized assessments may be recommended alongside observation and reports of difficulties across relevant gross motor or fine motor and/or graphomotor tasks The guideline group suggests the fifth centile cut-off of the fine motor subdimension (e.g. M-ABC2, BOTMP-2) be used for the diagnosis F82.1 if Criteria II and III are met If all Criteria I, II and III are met and if fine motor function is within the normal range then the diagnosis F82.0 can be madeGCP++
R15Concerning Criteria I: for children between age of 3 and 5y, if the diagnosis is needed (e.g. for treatment purposes), a cut-off of less than the fifth centile is recommended for the total score on the M-ABC, or equivalent objective measures (see also R8)GCP++

Treatment: indication, planning, intervention, additional support, evaluation (algorithm)

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Treatment: indication, planning, intervention, additional support, evaluation

R16Children with the diagnosis DCD (SDDMF) should receive interventionLOE 1 Level A
R17In determining if treatment is indicated, an account of personal factors, environmental factors, burden of disease and participation should be taken into consideration. Sources of information include history (including previous diagnostic and therapeutic history), clinical examination, parental report and if possible self-report, teacher or kindergarten reports, questionnaire information, and motor test resultsGCP++
R18If treatment is indicated, information on personal factors, environmental factors and the burden of disease concerning participation should be used for planning the treatmentGCP++
S3In addition, when planning treatment, evidence of treatment efficacy including regime and/or dose should be considered. As children may have coexisting disorders, e.g. ADHD, treatment priorities need to be established. Individual factors, e.g. motivation or psychosocial factors (e.g. broken home, parents with psychiatric disorders) may strongly limit the efficacy of motor treatment or treatment may not be possible at all. On the other hand, in some children with DCD (SDDMF) compensatory and environmental support may be sufficient++
R19For treatment planning, individual goal setting should be used. Goals set at the level of activities and participation should be given priority and the child’s viewpoint should be taken into accountGCP++
R20To evaluate treatment effects, measures that capture the level of activities and participation should be used. Sources of evaluation are clinical examination, parent report, teacher/kindergarten reports, questionnaire information, motor test results and child’s viewGCP++
R21If testing is performed during the intervention period it should inform adjustments to treatment through adaptation of individual goal settingGCP++
R22Methylphenidate may be applied in children with DCD (SDDMF) and comorbid ADHD to improve fine motor symptoms (handwriting) We suggest methylphenidate, where there is appropriate clinical indication for the use of methylphenidate in children with ADHD and DCD (SDDMF) in combination with further treatment and support to overcome functional problems like writing and drawingLOE 2 Level B
R23We recommend using task-oriented approaches to improve motor tasks or selected activities based on goal settingLOE 1 Level A
R24Task-oriented approaches like the cognitive orientation to daily occupational performance (CO-OP) and neuromotor task training (NTT) may be recommended as intervention in children with DCD (SDDMF)LOE 2 Level B
S4On body-function-oriented approaches, interventions that aim at improving body functions and structures may be effective but it seems that they are less effective in improving activities in children with DCD (SDDMF) than task-oriented approaches++
S5Statements for body function oriented approaches Perceptual motor therapy (PMT) may be an effective intervention method for children with DCD (SDDMF) (LOE 2). The evidence is inconclusive for the effectiveness of sensory integration therapy (SIT) as an intervention for children with DCD (SDDMF) (LOE 3). The evidence is inconclusive for the effectiveness of kinesthetic therapy for children with DCD (SDDMF) (LOE 3). As there is no evidence for the specific efficacy on kinesthesis and inconclusive evidence for the effectiveness of kinesthetic therapy in children with DCD (SDDMF) it is not recommended++
R25In children with poor handwriting, we suggest a task-oriented self-instruction method to improve the quality of the handwritingLOE 2 Level B
R26There is no evidence that manual medical intervention is effective on the core symptoms of DCD (SDDMF)LOE 3 Level 0
S6 It is possible that training of gross motor functions and strength exercises may help in part of the children with DCD to achieve motor competence++
S7We do not know yet if motor imagery training is effective in children with DCD (SDDMF) (LOE 3)++
R27We do not suggest fatty acids plus vitamin E to improve motor functions as there is no evidence for an effect on motor functions (LOE 2, Bneg)LOE 2 Level Bneg
R28Methylphenidate may be applied in children with DCD (SDDMF) and comorbid ADHD to improve fine motor symptoms (handwriting). We suggest methylphenidate, where there is appropriate clinical indication for the use of methylphenidate in children with ADHD and DCD (SDDMF) in combination with further treatment and support to overcome functional problems like writing and drawingLOE 2 Level B
R29We recommend professional instruction to educate and coach the parents. This should promote a supportive attitude of parents and nursery nurses/teachers so that they recognize and understand the specific problems of the child with DCD (SDDMF) and so help the children with DCD (SDDMF) to get the opportunity to improve their motor abilities and their participation in daily activities (at home, school, leisure, sports)GCP++
S8 Children with DCD (SDDMF) need ample opportunity to learn and practice movements and their participation in daily activities (at home, school, leisure, sports). Therefore support from parents and teachers and other related persons is important for regular everyday practice of home exercises in addition to professional treatment++
R30We suggest considering carefully if a group setting is appropriate for a childGCP ++
S9 It is not suggested that children with DCD (SDDMF) at young ages (5–6y) participate in a non-specific group motor skill programme (LOE 2). Group therapy is suggested for some children with DCD (SDDMF), e.g. isolated graphomotor problems or DCD (SDDMF) with motor performance between the fifth and 15th centiles of a norm-referenced test In children with borderline DCD (SDDMF) and in children with behavioural comorbidities, occupational group therapy can be a method to achieve a positive effect on their self-esteem. Individual therapy may have more positive effects in children with severe DCD (SDDMF) (less than the fifth centile of a norm-referenced test)++
R31In children with poor handwriting, we suggest a task-oriented self-instruction method to improve the quality of the handwritingLOE 2 level B
R32Prewriting exercises for children with poor handwriting may be consideredLOE 3 Level B

Evaluation of the published peer-reviewed literaturea

Level of evidenceGradeOxford levelOxford definition (diagnostic studies)Oxford definition (intervention studies)
  1. aAccording to the scientific evidence: levels of evidence (modified according to Oxford Centre for Evidence-based Medicine [March 2009] and to SIGN 1999, hierarchy of evidence proposed by the United Kingdom National Institute for Health and Clinical Excellence) using the GRADE system. Grading/scorings adopted from the German S3-Guideline for Childhood Obesity (2009, available at http://www.awmf.org/uploads/tx_szleitlinien/050-002_S3_Therapie_der_Adipositas_im_Kindes-_und_Jugendalter_Lang_01-2009_01-2012.pdf) and from the GRADE Working Group (Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 1490, doi:10.1136/bmj.328.7454.1490).

1 (High)Evidence from a meta-analysis or systematic review of randomized controlled or other well-controlled studies with homogenous findings; homogeneity of the results. Very good quality of the results (e.g. validity and reliability measures >0.8)IaSystematic review or meta-analysis of well-controlled studies with homogenous findingsEvidence from a meta-analysis or systematic review of randomized controlled trials (with homogeneity)
 Evidence from at least one randomized controlled trial (intervention study) or well-controlled trial with well-described sample selection (diagnostic study); confirmatory data analysis, good standards (e.g. QUADAS rating >10) Very good quality of the results (e.g. validity and reliability measures >0.8)IbValidating cohort study with good reference standard; clinical decision rule tested within on clinical centre, e.g. randomized/representative or consecutive sample; confirmatory statistics; prospective cohort study with good follow-up (>80%)Evidence from at least one randomized controlled trial
2 (Moderate)Evidence from at least one well-designed, controlled study without randomization; sufficient standards (e.g. QUADAS rating >7); homogeneity of the results. Good quality of the results (e.g. validity and reliability measures >0.6)IIaSystematic review of level I or II studiesEvidence from systematic review of cohort studies (with homogeneity) or evidence from at least one controlled study without randomization
 Evidence from at least one well-designed other type of quasi-experimental study (non-randomized, non-controlled) Good quality of the results (e.g. validity and reliability measures >0.6)IIbAt least one exploratory cohort study with good reference standards; clinical decision rule after derivation or validated on split-sample or databases or retrospective cohort study with consecutive sampleIndividual cohort study (including low-quality randomized studies, e.g. <80% follow-up) Evidence from at least one other type of quasi-experimental study
3 (Low)Evidence from well-designed non-experimental descriptive or observational studies, e.g. correlational studies, case–control studies, QUADAS rating >4; moderate homogeneity of the results Moderate quality of the results, e.g. validity and reliability measures >0.4IIINon-consecutive cohort study or studies without consistently applied reference standards or descriptive studyEvidence from case-control studies or evidence from observational studies
4 (Very low)Evidence from expert committee reports or expertsIV/V Evidence from expert committee reports or experts

Levels of recommendations

Level of evidenceRecommendation for/againstDescription
1‘should’, ‘should not’, ‘is not indicated’A
2‘may’, ‘may not’B
3 or 4‘may be considered’ or ‘do not know’0

Strength of recommendations based on level of evidence

  1. Adapted from the Canadian Guide to Clinical Preventive Health Care and from US Preventive Services Resources.

Strength of recommendationDescriptionCriteria
A (Aneg)Strongly recommended that clinicians (do not) routinely provide the intervention/the assessment to eligible residentsGood quality of evidence and substantial net benefits
B (Bneg)Recommended that clinicians (do not) routinely provide the intervention/the assessment to eligible residentsFair quality of evidence and substantial net benefit or Good quality of evidence and moderate net benefit or Fair quality of evidence and moderate net benefit
0No recommendation for or against routine provision of the intervention/the assessmentGood quality of evidence and small net benefit or Fair quality of evidence and small net benefit
 Insufficient evidence for recommendation of the intervention/the assessmentPoor quality of evidence (conflicting results; balance between benefits and risks difficult to determine; and poor study design)

Recommendations based on formal consensus

  1. Top of page
  2. EACD Recommendations
  3. Teams, Advisory Board, Coordination
  4. Pocket Version
  5. Recommendations based on formal consensus

Several recommendations are based on a formal consensus within a nominative group process, particularly those dealing with definition. Recommendations based on group consensus (GCP) are included in the guideline. A strong agreement (strong consensus ≥95%, if only ten or fewer participants were present ≥90% agreement) is marked as GCP ++; a moderate agreement (consensus ≥75–95%, if only ten or fewer participants were present ≥90%) is marked as GCP+.