Awareness and knowledge of developmental coordination disorder: A survey of caregivers, teachers, allied health professionals and medical professionals in Australia

Abstract Background To allow for accurate and timely diagnosis of developmental coordination disorder (DCD) key stakeholders must be familiar with and be able to identify features of this disorder. No studies to date have investigated the awareness of DCD among key stakeholders in Australia. Methods An online survey was complete by 494 Australian participants: primary caregivers (n = 153), teachers (n = 149), allied health professionals (n = 165) and medical professionals (n = 27). Results DCD and related terms were among the least known childhood disorders. Approximately half of the sample were familiar with the term DCD but every stakeholder group were more familiar with the term dyspraxia. Allied health professionals demonstrated greater knowledge of the features of DCD, particularly motor features. Every stakeholder group showed poor recognition of the social and psychological effects of DCD. A relatively low percentage of allied health (53%) and medical (33%) professionals reported they had identified or diagnosed DCD and less than 20% of these felt that the DSM‐5 contained adequate information to make a DCD diagnosis. Most teachers (82%) believed they should play a role in identifying early warning signs of this disorder, and 80% believed there are children in the school system who were labelled as lazy or defiant when they have motor skills impairments. Primary caregivers were supportive of a diagnosis of DCD being provided; however, only 16% were confident that a physician would provide an accurate and timely diagnosis. Conclusion Key stakeholders play a unique and important role in the identification of children with DCD. Though most participants acknowledge the role that they play, all stakeholder groups demonstrated poor familiarity with the term DCD and low levels of knowledge about the features of this disorder. Improved familiarity and knowledge of the disorder is needed for access to appropriate services and improved long‐term outcomes for this condition.


| INTRODUCTION
Affecting one in 20 children, developmental coordination disorder (DCD) is a common but underrecognized neurodevelopmental disorder characterized by impaired ability to acquire and execute coordinated motor skills quality (American Psychiatric Association, 2013).
DCD is well defined in the Diagnostic and Statistical Manual (fifth ed.) (DSM-5) which specifies the following four diagnostic criteria: (a) motor skills acquisition and execution are significantly below agematched peers, despite opportunities for learning and using these skills; (b) motor difficulties significantly and persistently interfere with age-appropriate activities of daily living, school and play; (c) symptoms begin during early childhood development; and (d) difficulties cannot be attributed to other conditions, such as intellectual disability, visual impairment or other neurological disorders that affect movement (American Psychiatric Association, 2013). The prevalence of DCD is approximately 5-6% of children (Blank et al., 2019) and multiple terms such as dyspraxia, clumsy child syndrome, motor learning difficulty, minimal brain dysfunction, sensory integration disorder and disorder of attention and motor perception (DAMP) have been used to describe this disorder (Gibbs, Appleton, & Appleton, 2007). Inconsistent terminology in clinical practice and in research is a barrier to accurate identification of this condition and is likely to have contributed to poor estimates in prevalence and poor comparability and knowledge translation in this field (Magalhães, Missiuna, & Wong, 2006;Polatajko, Fox, & Missiuna, 1995).
Issues of nomenclature were addressed at a consensus meeting of DCD experts in London, Ontario, Canada, in 1994. The international panel recommended the preferential use of DCD to describe children with significant difficulties in motor coordination (Polatajko et al., 1995). DCD does not appear to be well understood by relevant stakeholders, including primary caregivers, teachers and allied health/ medical professionals, despite this consensus, sound knowledge of the impact of this disorder, high incidence and clear diagnostic criteria. (Harris, Mickelson, & Zwicker, 2015;Wilson, Neil, Kamps, & Babcock, 2012).
In a sample of key stakeholders, Wilson et al. (2012) found that only 20% of parents, teachers and medical professionals had knowledge of DCD, highlighting the need for improved awareness of the condition. International recommendations for the definition, diagnosis and management of DCD were published in 2012 (Blank et al., 2012) and updated in 2019 (Blank et al., 2019). It is unclear if either version of these guidelines has improved the recognition of DCD among relevant stakeholders.
An estimated 25% of the children with the condition are identified prior to starting school (Gibbs et al., 2007), due to delayed developmental milestones, (e.g., crawling, walking and speech) or significant difficulties with self-care activities, poor ball skills or immature drawing. Delays in these early developmental milestones are not always evident and consequently; identification is more common in the first years of primary school, when parents and teachers recognize that the child is significantly behind their peers and not making necessary improvements in complex skills, such as handwriting and sports (Gibbs et al., 2007;Missiuna, Rivard, & Campbell, 2017). Due to large variations in typical motor development, it is recommended that a DCD diagnosis only be given to children under 5 years of age in the case of severe difficulties (Blank et al., 2019).

Despite parents, teachers and medical practitioners in the United
States, United Kingdom and Canada having a poor of knowledge of DCD , this has yet to be established in the Australian context. This study aims to examine the current knowledge and perceptions of DCD among key stakeholders in Australia. Specifically, the study compared levels of familiarity with, and knowledge of, DCD across different stakeholder groups.
2 | ETHICS thical approval (No. 2019-00106-HUNT) was obtained from the Human Research Ethics Committee of Edith Cowan University. All participants provided informed consent prior to commencing the study.

| METHODS
A quantitative cross-sectional survey (see Appendix S1) was adapted with permission  and was distributed online for an 8-week period from August to October 2019, using Qualtrics.

Key Messages
• Despite affecting one in 20 children, DCD is one of the least familiar childhood conditions among Australian parents, teachers, allied health and medical professionals.
• Most stakeholders were unaware of the impact of DCD on mental health (e.g., anxiety and depression) and quality of life.
• Ongoing knowledge translation is necessary to raise awareness and increase supports and services for children with DCD.

| Participants
A recruitment flyer containing a link to the survey was distributed throughout Australia via social media and e-mail to relevant professional associations, schools, paediatric and general medical practices and therapy providers to recruit primary caregivers, teachers, allied health and medical professionals. Recipients were asked to share the survey link, enabling snowball sampling.
Participants were required to be residents of Australia, able to complete the survey in English and care for or work with children (<19 years old). Teachers with experience of working within this age range were eligible to participate, as were health professionals with experience working in a caseload of at least 15% children. All professionals were required to hold a current registration with the relevant registration board either in their state/territory or nationally.

| Data collection
The survey was piloted in Western Australia with a sample of 223 participants (Falck, 2018), with changes subsequently made to the demographic sections of the survey to allow respondents from across Australia to participate. A response option of 'unsure' was also added to all knowledge questions.
The survey contained four sections. Section A collected demographic information and determined stakeholder eligibility and category. Participants then answered only those questions related to their specific stakeholder group. If a participant met the criteria for more than one stakeholder category (i.e., parent and professional), they were placed into their professional category for data analysis, assuming that the greatest knowledge of childhood conditions would come from their professional role. If a stakeholder was a professional and a parent but did not meet inclusion criteria for the professional group, they were placed in the primary caregiver category.
In section B, participants were required to rate their level of famil- 'What are the major factors that influenced your answers to the above questions?'

| Data analysis
All data were analysed using descriptive and non-parametric statistics to compare levels of familiarity with, and knowledge of, DCD across different stakeholder groups. Continuous variables (demographics) were reported as median and range (min, max) and analysed with the Kruskal-Wallis H test. Chi-square tests with pairwise post hoc comparisons were used to analyse the association between level of familiarity (categorical data) across stakeholder groups. The level of significance was set at α < 0.05 with Bonferroni correction for multiple comparisons. The open-ended question was analysed using content analysis to supplement the quantitative findings (Lindgren, Lundman, & Graneheim, 2020).

| Participant demographics
A total of 581 respondents agreed to participate in the survey, with 87 excluded as they did not meet inclusion criteria (i.e., caregivers with children over 20 years, nonregistered practitioners, teachers or professionals who had never worked with at least 15% of children in their caseload). A total of 494 participants completed the survey with the distribution by stakeholder group shown in Table 1. Allied health professionals were the largest group, with over 70% being occupational therapists. The residency of all respondents is presented in Figure 1 with all states represented. As expected, the largest cohort was from Western Australia (the researcher's state of residence).
The median years of experience across all professional groups was 13 (IQR = 6-21), with a significant difference between professional groups (H = 10.9, P = 0.004). Post hoc pairwise comparisons showed medical professionals had significantly more years of experience than allied health professionals (P = 0.003) and teachers (P = 0.031) ( Table 1).

| Stakeholder familiarity with childhood disorders
DCD and associated terms for this disorder (dyspraxia, motor learning disability and clumsy child syndrome) were among the least familiar terms across all stakeholder groups. Familiarity across stakeholder groups from most to least familiar is shown in Table 2. Teachers and parents were more familiar with older terminology for motor coordination difficulties. All stakeholder groups were more familiar with the term dyspraxia than DCD. Conversely, stakeholders were more familiar with current terms used for all other childhood conditions. Specifically, all stakeholder groups were more familiar with autism spectrum disorder and intellectual disability compared with Asperger's syndrome and mental retardation, respectively. The level of familiarity with DCD differed significantly between the stakeholder groups and for each of the associated terms for this disorder: clumsy child

| Identification of DCD
A relatively low percentage of allied health professionals (53%) reported they had identified DCD and one third of medical professionals reported they diagnosed this disorder. More than 80% of allied health and medical professionals felt that the DSM-5 contained inadequate information to make a DCD diagnosis. Many allied health and medical professionals stated that they needed more information to either identify or diagnose this condition, respectively, adding that identification is difficult because DCD 'can look like other conditions' (Allied Health Professional 31) or because 'assessment requires a multidisciplinary team that comprises of paediatric physio, OT and sometimes a paediatric neurologist, to be sure' (Medical Professional 17).
Issues of identification were also evident in text responses where many allied health professionals cited medical professionals as 'blocks' to diagnosis, including statements that 'paediatricians are either not confident to diagnose children or have never heard of DCD' (Allied Health Professional 32) and 'the need to find a paediatrician who is experienced and can consolidate info to give a diagnosis is the major hurdle' (Allied Health Professional 87).
One paediatrician stated 'I'm not sure that I agree that DCD is a medical diagnosis. I think we over medicalise children … there will always be clumsy children (and adults)' (Medical Professional 12).
T A B L E 2 Percentage of participants who stated they were 'very familiar' or 'somewhat familiar' with childhood conditions

| DISCUSSION
This study is the first known Australian study to investigate knowledge and familiarity of DCD among primary caregivers, teachers, allied health and medical professionals. We found that more than one third of Australian primary caregivers and teachers were familiar with DCD, which is an improvement compared with the 6% of parents and 23% of teachers (in the United Kingdom, Canada and the United States) who were familiar with DCD . Despite this increase, DCD and related terms remain among the least familiar diagnostic terms across all stakeholder groups, and the vast majority of stakeholders were unfamiliar with DCD. Similar to findings by Wilson et al. (2012), key stakeholders in our study were more familiar with outdated terminology, such as dyspraxia. Clinicians may well use the term dyspraxia in the knowledge that there is greater familiarity with this label across all stakeholders, but the terms dyspraxia and motor learning disability should not be used as they fail to account for the many complex features of this disorder. It is crucial that the term DCD is used and that adoption of consistent nomenclature among key stakeholders provides the first step to timely and accurate identification of DCD.
T A B L E 3 Percentage of stakeholders in each group who correctly identified features that are a 'common feature of the condition of DCD' or 'may be a feature of the condition of DCD'  (Gibbs et al., 2007).
Notably, every stakeholder group in our Australian sample showed poor knowledge of the social and emotional consequences of DCD, which is consistent with the finding among physicians and teachers in the study of Wilson et al. (2012). The nonmotor features of DCD, including clinically significant levels of anxiety and depression (Missiuna et al., 2014), must be considered in the treatment of children with DCD as they have considerable impact upon quality of life (Gagnon-Roy et al., 2016;Zwicker et al., 2013;Zwicker et al., 2018).
Without any intervention, the consequences of DCD are lifelong (Kirby et al., 2014); thus, it is crucial that stakeholders are aware of motor and nonmotor features of DCD.
Increased familiarity and knowledge of DCD will assist stakeholders to identify 'who' might require assessment, but it  Table 4 outlines resources (created knowledge) and dissemination strategies as a first step in the action cycle for increasing awareness of DCD among all stakeholder groups in Australia.
All stakeholders in this study play a unique and important role in the identification of children with DCD. Improved familiarity and knowledge of the disorder is needed for access to appropriate services and improved long-term outcomes for this condition. First, parents and teachers need to identify delays in motor skills acquisition so that they might seek professional assistance. Allied health professionals currently have the highest levels of familiarity and knowledge and should therefore play a part in educating others, in addition to their role in identifying the disorder. Ultimately, medical professionals must make a diagnosis so that children and families might receive appropriate support and services.

| STRENGTHS AND LIMITATIONS
To our knowledge, this is the first study of the awareness and knowledge of DCD in the Australian population. Although results may not be directly generalizable to other countries, the findings are similar to those of Wilson et al. (2012) which included stakeholders from the United States, the United Kingdom and Canada. The overall sample size in this study was small, particularly in regard to medical professionals, which may reflect the level of interest in completing a survey of DCD. Although the majority of respondents were from Western Australia, there was representation from each state in Australia and in most stakeholder groups.
There was a disproportionate number of occupational therapists in the allied health group; however, this is consistent with recent findings that most Australian families who accessed therapy for their child's movement difficulties had seen an occupational therapist (79.5%), compared with 45.5% seeing a physiotherapist and 19.6% seeing a specialized exercise physiologist (Licari et al., 2020).

| RECOMMENDATIONS FOR CLINICAL PRACTICE AND FUTURE RESEARCH
Improved knowledge translation should be a priority for clinicians and researchers in the field of DCD. A key knowledge translation principle for clinicians is to monitor knowledge use (Graham et al., 2006) which can be achieved with clinical audits to monitor diagnosis, assessment and intervention of children with DCD. Future research in this field should explore barriers to knowledge use across all stakeholders.