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School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy


CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET
Focused Question:
What interventions improve motor performance skills in children with developmental
coordination disorder?
Prepared By:
Samantha Burneo, OTS and Nicholas Druzinski, OTS
Department of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89074
Date Review Completed:
9/11/15
Clinical Scenario:
According to OBrien and Williams (2010), children with developmental coordination disorder
(DCD) experience deficits in balance, gross motor control, and fine motor eye-hand
coordination. These deficits can cause problems with activities of daily living, school, feeding,
and social participation. Early signs of DCD are seen in delayed achievement of motor
milestones such as buttoning clothes or holding a knife. In middle childhood, children experience
deficits in motor milestones such as playing ball and handwriting. Once a child enters into early
adulthood, DCD continues to cause deficits. At this age, learning complex motor skills is
difficult such as the skills needed to drive (American Psychiatric Association, 2013).
In order to be diagnosed with DCD, children have to meet a specific criteria. According to the
DSM V, there are four criteria that must be met in order to be diagnosed with DCD. The criteria
are as follows: coordinated motor skills are well below that of normally developing children;
motor skill difficulties are interfering with activities of daily living, school productivity,
prevocational and vocational activities, leisure, and play; symptoms occur in early
developmental period; and the motor difficulties are not due to an intellectual disability, visual

impairment, or neurological condition (American Psychiatric Association, 2013). Onset of DCD


usually occurs early in childhood. Approximately 5-6% of children age 5-11 years old are
diagnosed with DCD. There is a higher prevalence of DCD in males than females, approximately
a ratio between 2:1- 7:1. The course that DCD takes is inconsistent, but usually becomes stable at
least one year after being diagnosed (American Psychiatric Association, 2013).
There are environmental and genetic factors that may contribute to the occurrence of DCD.
Environmentally, prenatal exposure to alcohol and a low birth weight are contributing factors to
DCD. Genetically, it is unclear what is affecting DCD, but it has been suggested that there is a
genetic effect on DCD due to the fact that there is a high prevalence of co-occurrence with
attention-deficit/hyperactivity disorder, specific learning disabilities, and autism spectrum
disorder. These disorders do in fact have a contributing factor from genetics (American
Psychiatric Association, 2013).
As the prevalence rate of DCD continues to increase, the need for occupational therapists
throughout the continuum of care will persist to assist children with the engagement in
meaningful activities. Currently, textbooks such as Occupational Therapy for Children
recommend using interventions that are in the naturalistic environment for children with DCD,
but there are no specific interventions stated (OBrien & Williams, 2010).
Summary of Key Findings:
Summary of Levels I, II and III:
Level I
Research indicated that motor skill and core stability interventions were beneficial in
improving motor performance in children with DCD. The core stability exercise
program was as effective as task-oriented training in improving motor proficiency
among children with DCD (Au, Chan, Lee, Chen, Chau, & Pang, 2014). The change in
motor proficiency demonstrated no significant between-group differences, indicating
that the effectiveness of the two programs in enhancing motor function is similar (Au,
Chan, Lee, Chen, Chau, & Pang, 2014). Group motor skill intervention had positive
effects in children with DCD with borderline motor difficulties. However, for children
with definite motor difficulties, this type of intervention cannot be recommended (Pless,
Carlsson, Sundelin, & Persson, 2000).
No Level II studies were appraised
Level III
Research indicated that virtual reality interventions, including using the Wii, are
beneficial to use to improve motor performance in children with DCD. Parents reported
a significant change in their childrens daily motor performance as determined by
overall test scores as well as their comments (Ashkenazi, Weiss, Orian, & Laufer, 2013).

Children with balance problems are less proficient than typical developing children in
playing the Wii games. Training with the Wii improved their motor performance
(Jelsma, Geuze, Mombarg, & Smits-Engelsman, 2014). Although more research is
needed on neuromotor task training, task-oriented treatment approaches were shown to
have positive effects on children with DCD (Niemeijer, Smits-Engelsman, &
Schoemaker, 2007). During a group motor skills intervention, participants demonstrated
gains in movement skill proficiency. Parent satisfaction and perception of their childs
performance also improved. These results were maintained three weeks after the
intervention (Kane & Staples, 2014). Children with DCD perform manual actions
differently than typically developing children. After using a sensorimotor approach on
16 children with DCD, it was shown that these children are able to learn more complex
motor skills when given an appropriate learning environment (Snapp-Childs, MonWilliams, & Bingham, 2013). Sensory integration, in conjunction Le Bon Depart, has
been shown to be beneficial in improving motor performance in children with DCD.
Motor performance of children with DCD improved significantly on all dependent
variables after the combination of treatments. Le Bon Depart led to more improvement
than sensory integration (Leemrijse, Meijer, Vermeer, Ader, & Diemel, 2000). Unlike
the positive relationship between sensory integration and Le Bon Depart, sensory
integration used with perceptual motor interventions were not as successful. The
combined interventions were found to be ineffective at a 12-month follow up.
Significant improvements were found only for fine motor skills and visual-motor
integration (Davidson & Williams, 2000).
Summary of Level IV and V:
Level IV
Neuromotor task training and using the Nintendo Wii were found to be very beneficial
interventions to use with children with developmental coordination disorder. Both
interventions were useful in improving motor and anaerobic performance from baseline
to post-measurement. Also, the children with DCD who were in the neuromotor task
training group showed greater meaningful changes in motor proficiency compared to the
Wii group. This study demonstrated that the neuromotor task training approach is an
effective approach to address motor coordination, functional strength, and
cardiorespiratory fitness in children with DCD when used in a group format (Ferguson,
Jelsma, & Smits-Engelsman, 2013).
No Level V studies were appraised
Contributions of Qualitative Studies:

No qualitative studies were appraised


Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Bottom Line for Occupational Therapy Practice:


The clinical and community-based practice of OT:
There are multiple interventions that can be implemented and are effective for children with
DCD. The most evidence based interventions with the most significant results were NTT
training, task-specific training, and virtual reality. These interventions should be used by
occupational therapists with children with DCD in order to improve motor performance. Not one
intervention should solely be used for children with DCD. It is important to note that every child
with DCD needs to be taken into consideration to find the most beneficial intervention that will
work with them. Other interventions that may have statistically significant benefits for children
with DCD are motor skill training, tracing task, Le Bon Depart, and core stability training.
Program development:
There are multiple interventions that can be utilized to create a program for children with DCD.
When creating a program, it is important to note that all children are different. There is not one
intervention or program that is going to work for all children with DCD. These articles found
multiple different interventions that improve motor performance in children with DCD.
Therefore, incorporating aspects NTT, task-specific training, and virtual reality games may have
the greatest impact on children with DCD in regards to improving motor performance.
Societal Needs:
Educating society on interventions that are beneficial for children with DCD can help children
with DCD make progress at home. Their parents will understand that allowing their children
with DCD to participate in certain activities at home they may see a significant increase in their
childrens motor performance. Many households contain different virtual reality games such as
the Wii which can be incredibly beneficial for children with DCD. According to Jelsma, Geuze,
Mombarg, & Smits-Engelsman (2014), using the Wii Fit with children with DCD increased
balance, manual dexterity, speed, and agility. Implementing the Wii or any virtual reality gaming
system is also motivating to children to participate in. Motor skills training is also an
intervention that can be implemented in the home. Play is an important intervention for children
and allowing children to participate in play with their siblings and their friends will allow them
to work on important motor skills that will help improve motor performance in children with
DCD.
Healthcare delivery and policy:
All of the interventions discussed in the articles may be reimbursed by insurance companies and
can be utilized in both a home health and outpatient setting. The interventions such as core
stability and motor skills training can also be utilized in a school setting. Virtual reality games

may be used in the school setting if this type of equipment is available for use. Use of clinical
reasoning should always be used to determine the best intervention strategy for each child with
DCD. Not one specific intervention should be used, rather multiple interventions should be used
in conjunction with one another. Research should be funded to further the understanding of
different interventions that may be beneficial in increasing motor performance in children with
DCD.
Education and training of OT students:
Occupational therapy students need to be educated in numerous areas for the diagnosis of DCD.
First, students need to be educated on the prevalence of DCD. They need to know there is
research that states children with DCD are capable of learning complex motor tasks. This will
help the students learn how to set realistic goals for children with DCD. Second, evidence based
interventions need to be taught. These interventions include using virtual reality games, NTT
training, task-specific training, and motor skills training. This will give the future clinicians the
tools necessary to treat children with DCD. Students also need to be educated that sensory
integration currently does not have the necessary research to conclude it is a significant effect on
children with DCD. Sensory integration interventions have only been shown to have a minor
effect in improving motor performance with children with DCD. Since there is a lack of research
in the area of DCD, students can conduct their own research using interventions with children
with DCD.
Refinement, revision, and advancement of factual knowledge or theory:
Currently there is not a lot of research supporting interventions and treatment for children with
DCD. The sample sizes of current research are relatively small and the level of research is low.
Further research needs to be conducted using a larger population of children with DCD at a
higher level. By conducting higher level research it will help determine that the outcomes are
more correlated with the interventions being conducted. Specifically conducted research on
virtual reality games, NTT training, and task-specific training need to be conducted. Research
needs to focus on determining what the best frequency and duration is for these interventions
when working with children with DCD.
Review Process:

Development of focused question, focusing on specific population, intervention, and


outcomes
Inclusion/exclusion criteria for evidence table were identified
Developed focused question to answer PICO
Question was submitted and approved by instructor
Developed and maintained a current list of key terms and databases to be used for the
comprehensive literature search

Comprehensive literature search was completed and submitted for instructor review
Revised inclusion/exclusion criteria for evidence table were identified
Evidence table completed and submitted to instructor
Instructor provided feedback for evidence table
Summarized information into CAT
Completed CAT and submitted to instructor for review
Procedures for the Selection and appraisal of articles:
Inclusion Criteria:

Articles between 2000 to present


Article must address children with DCD, intervention, and improved motor performance
Article must be written in English
Article must be Level I-IV

Exclusion Criteria:

Non-English publications
Articles below Level IV were not appraised

Search Strategies:
Categories
Patient/Client Population
Intervention
Outcomes

Key Search Terms


Developmental coordination disorder/ Children with DCD/
Developmental disabilities
Sensory integration/ Virtual reality/ Interventions/ Treatments
Improved motor performance
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Databases and Sites Searched

PubMed
CINAHL
Google Scholar

Quality Control/Peer Review Process:

Authors identified key terms used to conduct a comprehensive literature review using
known databases

Following literature search, authors changed focused question to increase clarity of


question
Ten articles were split evenly between the two authors
Each author read five articles and completed five literature review forms
After completion, the authors traded their completed forms and articles and the previous
process was performed
Each review form was reviewed/approved by OCCT 643 instructor
Evidence table was reviewed/approved by OCCT 643 instructor
CAT was completed based on the revisions of the authors and OCCT 643 instructor

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence
I

Study Design/Methodology of Selected Articles

Systematic reviews, meta-analysis, randomized


controlled trials
II
Two groups, non-randomized studies (e.g., cohort,
case-control)
III
One group, non-randomized (e.g., before and after,
pretest, and posttest)
IV
Descriptive studies (e.g., single-subject design)
V
Case reports and expert opinion
Other
Qualitative Studies
TOTAL:
Limitations of the Studies Appraised:

Number of Articles
Selected
2
0
7
1
0
0
10

Levels I, II, and III


Level I:
The BOT-2 Short Form was used rather than the Complete Form. If the
Complete Form had been used, a more comprehensive picture of the motor
proficiency could have been obtained (Au, Chan, Lee, Chen, Chau, & Pang,
2014)
The Sensory Organization Test evaluated only the contribution of different
sensory systems in postural control. Postural control involves multi-dimensional
systems which include sensory, neuromotor, and biomechanical systems (Au,
Chan, Lee, Chen, Chau, & Pang, 2014)
Few study participants in the group increased the risk for a type II statistical
error (Pless, Carlsson, Sundelin, & Persson, 2000)

No Level II studies were appraised


Level III
No attention was paid to the underlying causes of DCD, or to the components of
the treatments that were responsible for the effects (Leemrijse, Meijer, Vermeer,
Ader, & Diemel, 2000)
Participants were not blind to the therapy they received, which could have led to
an improvement in scores (Davidson & Williams, 2000)
Assessments were not carried out blindly, the administrators knew that the
children had been receiving an intervention (Davidson & Williiams, 2000)
No follow-up assessments were included which did not allow the administrators
to conclude whether the attained skills and abilities were retained (Ashkenazi,
Weiss, Orian, & Laufer, 2013)
The study lacked a control group and only a small number of children were
included (Ashkenaziz, Weiss, Orian, & Laufer, 2013)
Co-morbidity may have brought a limited attention span and cause poor motor
performance once the tasks became complex and required divided attention
(Jelsma, Geuze, Mombarg, & Smits-Engelsman, 2014)
Results cannot be generalized due to the small number of participants and the
heterogeneous nature of their clinical presentations (Kane & Staples, 2014)
Levels IV and V
Level IV
No limitations were stated
No Level V studies were appraised
Other
N/A
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Articles Selected for Appraisal:


Ashkenazi, T., Weiss, P. L., Orian, D., & Laufer, Y. (2013). Low-cost virtual reality intervention
program for children with developmental coordination disorder: a pilot feasibility
study. Pediatric Physical Therapy: The Official Publication Of The Section On Pediatrics
Of The American Physical Therapy Association, 25(4), 467-473.
doi:10.1097/PEP.0b013e3182a74398

Au, M. K., Chan, W. M., Lee, L., Chen, T. M., Chau, R. M., & Pang, M. Y. (2014). Core stability
exercise is as effective as task-oriented motor training in improving motor proficiency in
children with developmental coordination disorder: a randomized controlled pilot
study. Clinical Rehabilitation, 28(10), 992-1003.
Davidson, T. & Williams, B. (2000). Occupational therapy for children with developmental
coordination disorder: A study of the effectiveness of a combined sensory integration and
perceptual-motor intervention. The British Journal Of Occupational Therapy, 63(10),
495-499.
Ferguson, G.D., Jelsma, D., & Smits-Engelsman, B.C.M. (2013). The efficacy of two taskorientated interventions for children with developmental coordination disorder:
Neuromotor task training and nintendo wii training. Research in Developmental
Disabilities, 34(9), 2449-2461. doi: 10.1016/j.ridd.2013.05.007
Jelsma, D., Geuze, R. H., Mombarg, R., & Smits-Engelsman, B. C. (2014). The impact of Wii Fit
intervention on dynamic balance control in children with probable Developmental
Coordination Disorder and balance problems. Human Movement Science, 404-418.
Kane, K. J. & Staples, K. L. (2014). A Group Motor Skills Program for Children with
Coordination Difficulties: Effect on Fundamental Movement Skills and Physical Activity
Participation. Physical & Occupational Therapy In Pediatrics. doi:
10.3109/01942638.2014.978934
Leemrijse, C., Meijer, O., Vermeer, A., Ader, H., & Diemel, S. (2000). The efficacy of Le Bon
Depart and Sensory Integration treatment for children with developmental coordination
disorder: a randomized study with six single cases. Clinical Rehabilitation, 14(3), 247259.
Niemeijer, A. S., Smits-Engelsman, B. M., & Schoemaker, M. M. (2007). Neuromotor task
training for children with developmental coordination disorder: A controlled
trial. Developmental Medicine & Child Neurology, 49(6), 406-411.
Pless, M., Carlsson, M., Sundelin, C., & Persson, K. (2000). Effects of group motor skill
intervention on five- to six-year-old children with developmental coordination
disorder. Pediatric Physical Therapy, 12(4), 183-189.
Snapp-Childs, W., Mon-Williams, M., & Bingham, G. P. (2013). A sensorimotor approach to the
training of manual actions in children with developmental coordination disorder. Journal
Of Child Neurology, 28(2), 204-212. doi:10.1177/0883073812461945

Other References:

OBrien, J. & Williams, H. (2010). Occupational therapy intervention: Performance areas. CaseSmith, J., & OBrien, J. C. (Eds) Occupational Therapy for Children (6th ed.) (pp.245270). Maryland Heights, MO: Mosby.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.