David Sugden
University of Leeds
Cork November 2011

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Take any age
Go through what happens in a day from getting up to going to bed
List the activities that are non motor!
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Motor development is a change and is lifelong
It is non linear with spurts and plateaus
Changes that occur include:
◦ Addition
◦ Substitution
◦ Modification
◦ Inclusion
◦ Mediation

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Cross sectional approachmoment in timequickish, cheapish.
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Longitudinal - follow a group over time-time consuming, expensive, drop out
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Hybrid methods

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How do children develop? This is the easier : how
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Both have answers which influence intervention:
◦ the first one gives indications of what to teach/use in
◦ the second one how to teach/use in therapy
◦ Question-I have always wanted to know the difference learning. Anybody know?

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Neural - gradual unfolding of neural mechanisms-traditional theories
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Information processing plans, schemas, input through to output models
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Dynamical systems multiple subsystems, self organisation, environment-animal match, linear and non linear
All the above must involve experience (Adolph).

We engage in examining this part of a child’s life because firstly many of the children we see are developmentally young and secondly it gives us some indications of progressions.

 Reflexes - selected-sucking, palmar grasp, ATN, do they mean?
◦ Spontaneous movements- eg supine kicking
◦ Postural control
◦ Locomotion
◦ Manual control
◦ Ages and stages of the above plus qualitative

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Body control
◦ Walking
◦ Running
◦ Jumping
◦ Hopping
◦ Throwing
◦ Balancing
◦ Catching
◦ Slow and fast movements
◦ Again ages and stages-how accurate are –range and variability?

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Manual skills , including writing and drawing, self help skills.
Why do you think a child can make a square from matches before they can draw it?
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Spatial and temporal accuracywhy is this so difficult for young children and how does it direct our teaching and therapy?

There is an argument that says that by seven years of age a child has acquired all of the naturally developing skills s/he will ever have.
After that period, they are refined, used for maximum performance, played with and utilised in novel situations. But no totally new ones emerge.

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Essential that fundamental skills are in place
During this period children start to refine skills, play with skills in different situations, combine them, social and recreational play
Maximum performance starts to play a part
Gender differencesbiological or cultural-examples?
How great are gender differences pre-puberty-where are they shown and if there are any, why?
Implications for therapy and PE in primary schools

Spatial and temporal accuracy starts to play a major part and during this period it is one area that improves significantly both in terms of prediction and performance

Resources of the Child
Outcomes
Environment in
Task which activity occurs

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A number of children will have difficulties in movement and one can place them into two large categories:
◦ Those with motor difficulties as a primary defining condition
◦ Those with motor difficulties as a secondary defining condition

Motor difficulties as a primary defining condition:
Cerebral palsy
Developmental Coordination Disorder
Other

Motor difficulties as a secondary defining characteristic:
Learning difficultiesgeneral/specific
Sensory difficultiessight/hearing/other
Behaviour difficulties
Other-ASD
The following slides are a short introduction to one of the above-DCD

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Historical journey-’Clumsy’ ‘dyspraxia’
DSM IV Criteriawhy –because we have to have some consistency
Co-morbidity -particularly with other developmental disorders
Why is it an issue? Here and now.

Criteria
A. Marked impairment in development of motor coordination
B. Significantly interferes with academic activities or activities of daily living
C. Not due to general medical condition(CP eg)
D. If mental retardation is present motor difficulties are in excess of expectation
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Issues surrounding ‘marked impairment’
◦ Individually administered and culturally appropriate, norm reference test of general motor competence.
◦ Recommend cut off point at 5% for definition in clinical and research settings. Recognise arbitrariness of this but it is reasonable and part of custom and practice.
◦ Recommend children between 5% and 15% not defined but closely monitored
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Issues surrounding ‘activities of daily living and academic performance’
◦ ADL-include self care, play, leisure and some school work (handwriting, PE).
◦ ADL-should include the views of the child, parents, teachers and relevant others.
◦ Establishment of a direct link between motor coordination and academic achievement is complex, although handwriting has an adverse effect. Other influences are more of an indirect nature such as motivation and self concept.
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Issues surrounding ‘general medical condition’ (e.g. CP or muscular dystrophy).
◦ Lack of clarity with Criterion C.
◦ Agree terms like ‘minimal brain damage’ and ‘atypical brain development’ are not helpful to diagnosis.
◦ DCD is a unique and separate neuro-developmental disorder and does co-occur with others such as
ADHD, ASD and developmental dyslexia.
◦ It is inappropriate to exclude the possibility of a dual diagnosis of DCD and PDD.
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Issues surrounding ‘mental retardation’ (cf general learning difficulty)
◦ Children with a measured or presumed IQ below 70 should not be given DCD diagnosis because of high risk of motor difficulties.
◦ But this should not exclude motor difficulties being a major objective for intervention
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Recommend not giving a diagnosis below the age of 5.
Problem of high variability between 3 and 5
Probably lead to over diagnoses
Self fulfilling prophecies
Limited resources
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BUT DOES NOT MEAN DO NOT INTERVENE
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Prevalence - depends how you measure it-if you use guidelines for MABC you will get 5%!!!
Normal way in many other disorders is to take 2 SDs. Lingham 2-4% (2009)
Age effectmost studies 6-12. So what are they 3-5 and what are they post school age.
Loads of potential for work.
Bridgend/Newport work.

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Progression - do children grow out of it?
Studies show some do many don’t! Data on recent 4 year longitudinal study-group, subgroup, individual analysis
Gender differencerange of incidence differences from almost the same to 3 or even 4 times to 1 in ‘favour’ of boys. I would go with 2 to 1. Why?

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Prevalence: 2-4%-6% depending on cut offs
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Gender differences-usually boys more than girls-upwards of 2.1
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Progression-some grow out of it, most do not without intervention
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Examples: ADHD 60% (Ramussen & Gillberg
2000); SLI 60%, (Hill, 1998); Reading difficulties 55% (Kaplan et al, 1998); social, emotional and behavioural difficulties 82%
(Losse et al, 1991).
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Figures differ depending on clinical or population samples.
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Effect of co-occurring characteristics on outcomes and planning for intervention
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Kinaesthesis
Visual perception
Balance and postural control
Memory and attention
Motor effector system
Slower reaction & response times
Motor planning
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From research studies we know that we will find a higher prevalence of the above in a group of children with DCD but never in all children
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Attention difficulties
Literacy difficulties
Social problems
Organisational problems
Planning problems
Are these co-occurring or are they features of the condition?

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Footprint study-with Amanda Kirby and Lisa Roberts
◦ Problem solving-planning and executing ‘crossing the river’
◦ Allows choices in natural contexts using natural tasks
◦ Quantitative and qualitative data-video
◦ Travel from one line over a ‘river’ to next line
◦ Do not fall in!
◦ As few strides as possible
◦ Continuous

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Results point to:
◦ Developmental trends in tdc-estimates of number of steps fewer in 9-11 than 7-9. eg; estimates more accurate; more control during action
◦ Children with DCD (aged 9-11) more like tdc 7-9 eg
◦ Personal variables such as confidence or playing safe
◦ Corrections after attempt
◦ Manner of execution-from film

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Some findings:
◦ DCD>TDC number of mats used
◦ DCD>TDC greater distance travelled (2 metres more in 8 metre course)
◦ Changes to mat placement following trial 3
◦ TDC>DCD consistency of stepping across trials
◦ DCD>TDC ‘unusual’ movements/patterns
◦ DCD>TDC difficulties on non motor items-SDQ,SNAP
IV, ASSQ
◦ Other differences but not significant-high within group variability-DCD ‘play safe’, attend to one item.
◦ But is this a sound test of perception-action?

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With Amanda Kirby, Lisa and Angela-taking work of Turvey, Solomon into children
Characteristics of unseen rod-eg length, weight, shape through wielding-dynamic touch-movement oriented.
Nature of the variables that are being attended to.
Use of more functional implements such as sports rackets.
43 TDC 13 DCD-all aged 9-11.

◦ Consistent underestimation which increased with rod length but similar when taken as a proportion of rod length.
◦ DCD children – surprisingly as good as tdc-so what is going on?
◦ Scaled: TDC 47% DCD 39%
◦ ‘Weight’: Both groups over 75%

TDC
30 26.12 (9.3)
45 40.93 (12.06)
60 48.84 (15.18)
DCD
26.38 (7.78)
37 (11.7)
52.15 (13.99)
75 56.95 (16.47)
90 67.41 (19.07)
64.69 (21.9)
78.23 (22.19)
All in cms

Mean values for rods
90
80
70
60
50
40
30
20
10
0
30 45 60 75 90
TDC
DCD

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Overall picture:
◦ Motor core
◦ Affects academic or activities of daily living
◦ Co-occurring characteristics
◦ 2-5% prevalence
◦ More boys than girls
◦ Stays with child without intervention
◦ Symptoms change
◦ Most work 6-12 but recent work on 3-5 and adults
◦ Heterogeneity of profiles suggesting individual assessment and intervention o
ASSESSMENT and INTERVENTION later

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Children’s learning is the end product of what we are trying to achieve
Children with movement difficulties by definition have not learned effectivelyreasons may vary
It is the outcome/dependent variable-the one we measure and can see the results of
Our methods are independent variables-how can we best use therapy or teach so that the children learn

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Schmidt and Lee (2005)
“a set of internal processes associated with practice or experience leading to a relatively permanent change in the capability for skilled behaviour”. (Page 320).
Let take this to pieces and see what it means for our work

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“ a set of internal processes..”
◦ You cannot see learning –only infer it from performances at various moments in time.
◦ Performances are one shot occurrences and liable to temporary influences
◦ Capturing numerous performances gives an indication of learning
◦ Performances can be deceiving!
This difference between performance and learning will permeate the work of the day

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“associated with practices or experiences..”
◦ Practice has a formality about it with a definite intention to learn-e.g. an OT session.
◦ Experience is more informal learning that we do in our daily lives-children with difficulties are not so skilled at this.
◦ Maturation is not part of learning-it is part of development
◦ Handwriting exercises are practices; writing a diary is experience. Both are important

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“leading to a relatively permanent change in capability for skilled behaviour..”
◦ Relatively permanent-not a temporary feature-but
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◦ It is not in performance-it is in the ‘capability’. So the performance can drop off but re-learning should be easier if it was learned in the first place

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If performance has not improved don’t assume there is no learning.
Wait ...but not too long
If performance has gone down-don’t assume it is lost-it is the capability that is learning
Also don’t get over excited about performance-it can exaggerate skill level and may be temporary.

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Improvement/accomplishment of skill
Consistency in performance
Stability in performance
Adaptability in performance
Performance more smooth with less effort
Parts become wholes
Skill becomes more automatic
Coordination dynamics change-freezing to freeing degrees of freedom
Persistence
How many of these do we assess or measure or directly and specifically name as outcomes for our intervention?

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Can now perform skill or perform better than previously
E.g. Child with cerebral palsy can now reach and pick up a cup

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E.g. The child with CP can now reach and pick up the cup 80% of the time as opposed to
40% previously

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The child can now get round ‘obstacles’ or perturbations.
E.g. Child with CP can now reach across the table avoiding milk jug and pick up the cup.

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The action can be accomplished in different locations with different objects.
The child with CP can reach for a different sized and shaped cup at home, school and in friends’ houses.

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It just looks better
There is less tremor, not jerky
It is more accurate
It looks smooth and effortless

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Reaching and grasping of the cup is no longer a reach followed by a new movementgrasp. It is now all one.
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Cf Driving-beginner to accomplished driver

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Individual can do two tasks at once because the task has become automatic leaving
‘space’ for other actions or words.
E.g. The child with CP can now reach and grasp cup while arguing with her brother.

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The individual progresses from a more rigid and restrictive movement to one that is more fluid and flexible
E.g.Child with CP does the movement the same, the end result is the same but controls more available dfs thereby offering greater flexibility if the task may change.
NB we occasionally purposefully restrict dfs when we are skilled such as carrying a cup of water that is filled to the top!
Other examples: painting a window; walking on icy pavements.

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Fitts’ 3 Stages:
◦ Cognitive stage-understanding the demands of the task; crude attempts at practice
◦ Associative stage-now understands and refining skill through trial and error and practice with appropriate feedback
◦ Autonomous stage-skill is virtually automatic-can do other things at the same time.

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What are the implications of the stages for:
◦ Instructions
◦ Demonstrations
◦ Explanations
◦ Feedback
When a child with CP first reaches for a cup what do we say? What do we say after they have done a few times?

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One of the most important variables in learning a skill with mounds of literature to back it up.
Various types:
◦ Intrinsic feedback
◦ Augmented feedback
◦ Knowledge of results
◦ Knowledge of performance

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Distribution of practice
Whole versus part learning
Instructions, demonstrations, explanations and feedback
Specificity and variability of practice
Mental rehearsal
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We will be covering the first three in more detail later

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Distribution of practice
◦ Mass versus distributed
◦ When to use which
◦ Types of task
◦ Allocation of resources
What do we know?

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Whole versus part
◦ What does this mean
◦ Which is best for which kind of task
◦ How to breakdown tasks
What do we know?

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Specificity and Variability of Practice
◦ What does this mean?
◦ What is a class of events?
◦ How variable
◦ Type of task and goal
What do we know?

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Mental rehearsal
◦ What is it?
◦ Is it beneficial?
◦ Type of task?
◦ How do you do it?
What do we know