Survey of paediatric occupational therapists' understanding of developmental coordination disorder, joint hypermobility syndrome and attention deficit hyperactivity disorder.
Evidence suggests that developmental coordination disorder (DCD)
co-occurs with attention deficit hyperactivity disorder (ADHD) and joint
hypermobility syndrome (JHS). Paediatric occupational therapists working
with children with DCD need to consider the impact of co-occurring
conditions on the children they assess and treat. A survey investigating
the knowledge base and understanding relating to these conditions was
conducted. The results showed that therapists (n = 225, response rate
23%) have an understanding of DCD; however, a more detailed knowledge of
ADHD and JHS would allow them to consider the impact of the overlapping
nature of these conditions. This highlights a training need to ensure
understanding of these conditions and appropriate management.
Developmental coordination disorder, attention deficit hyperactivity disorder, joint hypermobility syndrome.
Attention-deficit hyperactivity disorder
(Development and progression)
Attention-deficit hyperactivity disorder (Care and treatment)
Occupational therapists (Beliefs, opinions and attitudes)
Occupational therapists (Practice)
Apraxia (Development and progression)
Apraxia (Care and treatment)
Joints (Development and progression)
Joints (Care and treatment)
|Publication:||Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 College of Occupational Therapists Ltd. ISSN: 0308-0226|
|Issue:||Date: August, 2010 Source Volume: 73 Source Issue: 8|
|Topic:||Event Code: 200 Management dynamics|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
In the United Kingdom (UK), around 40-60% of children seen by paediatric occupational therapists have coordination difficulties associated with developmental coordination disorder (DCD) (Green et al 2005). There is increasing evidence to suggest that DCD co-occurs with other conditions (Missiuna 1996, Sigmundsson and Hopkins 2005). Studies have shown that 35-50% of children with DCD have attention deficit hyperactivity disorder (ADHD) (Kadesjo and Gillberg 2001, Pitcher et al 2003). The co-occurrence of DCD with joint hypermobility syndrome (JHS) has also been demonstrated (Adib et al 2005, Kirby and Davies 2006). These difficulties have an impact on a child's occupational engagement and performance (Polatajko and Cantin 2006). Therefore, it is likely that therapists working with children with DCD are also seeing children with JHS or ADHD.
This study examined the current awareness and knowledge of paediatric occupational therapists in the UK with regard to:
* DCD, ADHD and JHS
* Their training needs relating to these conditions.
DCD is a developmental disorder where motor coordination is substantially below that expected of an individual given his or her age, experience and intelligence (American Psychiatric Association [APA] 1994). A diagnosis of DCD requires that two inclusion and two exclusion criteria are met (refer to the Leeds consensus statement, Economic and Social Research Council 2006). Assessing and providing intervention for children with DCD is complex because it co-occurs with other conditions (Kaplan et al 1998, Kadesjo and Gillberg 2001, Adib et al 2005). More severe outcomes are reported for children with overlapping conditions (Martin et al 2006). Thus occupational therapy would be particularly needed for these children.
The overlap of DCD with ADHD has been well established (Piek et al 1999, Kadesjo and Gillberg 2001, Kooistra et al 2005). According to the DSM-IV criteria (APA 1994), ADHD is characterised as a developmentally inappropriate, persistent and impairing difficulty with hyperactivity, impulsivity and sustaining attention, which is evident in more than one setting. Although coordination difficulties are not mentioned in the DSM-IV, Van Meel et al (2005, p451) stated that 'clumsiness is a symptom frequently reported by parents and teachers of a child with ADHD'. Despite the need for occupational therapy (Kirby et al 2007), few intervention studies with these children have been published (Chu 2003, Chu and Reynolds 2007).
JHS is thought also to co-occur with DCD (Kirby et al 2005); however, the conditions differ because coordination difficulties related to JHS are predominantly due to joint pain and instability in the joints (Hakim and Grahame 2003). JHS is considered to share common features of heritable connective tissue disorders, such as Ehlers-Danlos syndrome and Marfan syndrome (Simpson 2006), but there has been limited JHS research with children (Adib et al 2005). Historically, this condition was not commonly identified in children because it was not thought to have an impact on occupational performance (Grahame and Bird 2001, Murray and Woo 2001). This has been challenged more recently in a study of 125 children with JHS in a specialist rheumatology clinic, where 48% were considered 'clumsy' and 36% demonstrated 'poor coordination' (Adib et al 2005). However, as these children were severely affected, they might have been experiencing more functional difficulties than would be seen in other settings. Findings from Kirby et al (2005) also supported the functional difficulties of JHS, with 66% of children reporting problems with dressing, 69% with writing and 57% with riding a bike. Caution should be taken when interpreting these findings because the children with JHS also had features of DCD.
Despite the discrete nature of the diagnoses of DCD, ADHD and JHS, evidence suggests that children often do not fit neatly into just one of these categories (Kaplan et al 1998, Jensen et al 2001). Occupational therapists need to have an awareness of these conditions and the impact on occupational performance in order to ensure appropriate assessment and intervention (Kaplan et al 1998, Maillard and Murray 2003).
A postal questionnaire (see Appendix 1), based on the aims of the study, was used to gather a breadth of responses within time and resource limitations (Robson 2002). Modifications were made based on a pilot study of four paediatric occupational therapists working in different service settings. The questions were styled using choice boxes (recording training needs), Likert scales (recording respondents' self-reported knowledge) and space for descriptive responses (to confirm self-reported knowledge through definitions of the conditions).
A purposive sampling method (Robson 2002) was used, with the researcher determining the group of participants. Based on a similar study (Chu 2003), the College of Occupational Therapists' Specialist Section--Children, Young People and Families (CYPF) members were chosen to provide a manageable but representative sample. One thousand paediatric occupational therapists from the UK and Northern Ireland were represented at the time of the study (August 2007).
Data collection procedures
The questionnaire and a 2-page information sheet, detailing the aims and relevance of the study and giving a confidentiality statement, were distributed. Respondents were asked to return the completed questionnaire in the stamped, addressed envelope provided within 2 months. Owing to resource limitations, there was no opportunity for a reminder to be sent to the non-respondents.
Ethical approval was obtained through the University of Wales, Newport, and the Local Research Ethics Committee in South Wales.
The data were analysed using the Statistical Package for Social Sciences (SPSS), Version 15. Descriptive statistics were extracted to quantify responses, such as frequency distribution. A coding paradigm was used to interpret the qualitative data (Denscombe 2003). This involved the development of a coding dictionary (Robson 2002) based on the DSM-IV criteria for DCD and JHS (APA 1994) and the Brighton criteria for diagnosing JHS (Grahame et al 2000). A grounded theory approach (Denscombe 2003) was then used to add descriptive terms from the raw data (see Table 1). Responses were categorised as 'accurate', 'partially accurate', 'inaccurate' or 'no response' through using this coding dictionary (Robson 2002). In order to establish interrater reliability, a quarter of responses were re-coded by an independent, post-doctoral psychology graduate with 8 years' experience. The two raters were in agreement.
From 1000 questionnaires, there were 238 responses (24%). Thirteen responses were excluded for the following reasons: not working with the DCD client group, student or retired member. Therefore, 225 responses were included in the analysis, giving a response rate of 23%. Of the respondents, the majority (96%) were female, predominantly working in community paediatric teams (53%). Over half of respondents were at a Senior I level. There was a wide range of experience, from newly qualified to 43 years of experience, with an average of 13.6 years.
The therapists' ratings of their knowledge of DCD, JHS and ADHD are detailed in Table 2.
The therapists' definitions of the diagnostic characteristics of DCD, JHS and ADHD were interpreted based on the coding dictionary, with the results presented in Table 3. Pearson's chi-square analysis revealed no significant differences between therapists' knowledge relating to their years of experience.
Although the reported knowledge of DCD was high, only 4% of the therapists were able to provide an accurate description of the condition. The majority of the therapists (78%) were able to provide a partially accurate description. For example:
Inaccurate descriptions (or no responses) of JHS were given by 72% of the respondents. Some respondents suggested that JHS had 'no significant impact on motor skills'. Other responses included:
The majority of the therapists (59%) were able to give an accurate or partially accurate description of ADHD. However, some examples highlighted a possible confusion with other conditions, such as autistic spectrum disorder: Distractibility more than developmentally appropriate, likely speech and language delay, difficulty sustaining attention to tasks.
Information on DCD was requested by 107 therapists (48%); for JHS by 163 therapists (72%); for ADHD by 127 therapists (56%); and for the overlapping conditions by 149 therapists (66%). This information may be used to develop subsequent training.
Robson (2002) reported that a response rate of 70% is good, which is well above what was collected from this study. However, the response rate of 23% is similar to that of other studies using the same database (for example, Berry and Ryan 2002, Howard 2002), although this study is acknowledged to be at a different time.
In rating their own knowledge of DCD, the majority of occupational therapists felt that they knew about this condition, which is to be expected considering its prevalence on therapists' caseloads (Green et al 2005). As similarities exist between the occupational presentation of children with DCD and that of those with JHS (Adib et al 2005), a lack of reported knowledge may imply that JHS is not being considered as a potential cause of the coordination difficulties. Thus children with JHS could be managed inappropriately.
Chu (2003) reported that 21% of therapists lacked the knowledge and skills about ADHD to work with a child with this diagnosis. This is mirrored in this survey because 23% of the respondents described their knowledge of ADHD as at a basic or poor level. These results suggest that for around one-fifth of therapists, the implications of ADHD on motor performance (Kooistra et al 2005) may not be considered.
Based on the qualitative responses, the majority of the therapists gave a partially accurate description of DCD. These results agree with those of Geuze et al (2001) that many therapists use a 'clinical definition' of DCD that does not match the DSM-IV criteria (APA 1994). This may be reasonable considering that developmental disorders do not appear to be separate entities (Kooistra et al 2005); however, management can differ depending on the condition(s) that the child is presenting with (Sergeant et al 2006) and, hence, an awareness of the diagnostic criteria is needed.
The therapists' definitions of JHS reflected their lack of understanding of the nature of this condition. For example, comments such as JHS having 'no significant impact on motor skills' may indicate confusion between simply having some hypermobility in the joints and having joint hypermobility syndrome; the latter is associated with symptoms such as pain and dislocations (Bird 2005). Another reported example showed little awareness of the functional implications of JHS (Adib et al 2005), which may suggest that some therapists in the present study did not feel that JHS featured as part of their caseloads. This has implications for providing appropriate assessments and intervention.
The findings suggest that there could be confusion with the nature of ADHD, with the notion that children with ADHD are antisocial and have behavioural problems; it could be conjectured that these opinions may not be based on clinical experience. Some therapists appeared to assume that children with ADHD would be seen only in specialist mental health services, indicating a lack of awareness regarding the overlap between ADHD and DCD (Martin et al 2006).
Encouragingly, 72% of the therapists requested further information on JHS and 66% on comorbidity, which indicates that paediatric occupational therapists see the benefits of, and are willing to engage with, continuing professional development opportunities.
Limitations of the study
Using only the COTSS--CYPF database may have introduced a bias because therapists with specific interests in joint conditions or mental health may belong to other interest groups. The respondents were not provided with guidance on how to distinguish 'high level' knowledge from 'good level' knowledge and therefore there may be inconsistencies in the way in which the therapists rated themselves. Inferences were made regarding the management of these conditions based on the therapists' knowledge of the diagnostic criteria rather than asking in detail about management. This could be a useful area for future research.
This study investigated the awareness and knowledge of DCD, JHS and ADHD, and the overlap between these conditions, within a group of paediatric occupational therapists. The knowledge base of DCD was good; a more detailed knowledge of ADHD and JHS would have allowed the therapists to consider the impact of overlapping conditions on their assessment and management of children with DCD. This has implications for future training provision.
This study has been developed from the first author's Master's dissertation, conducted and funded by the University of Wales, Newport. The author would like to thank the occupational therapists who responded to the survey; Jennie Sparks, University of Wales, Newport, who supervised the study; Professor Amanda Kirby, The Dyscovery Centre, for her advice and guidance; the College of Occupational Therapists Specialist Section-- Children, Young People and Families for their support in using their database, and the guidance of research adviser, Dr Eve Hutton. Conflict of interest: None.
* Paediatric occupational therapists need to consider the impact of co-occurring conditions on children's occupational performance.
* Training needs around JHS and ADHD have been highlighted.
What the study has added
This study highlighted a training need for paediatric occupational therapists to ensure understanding of the issues relating to co-occurring conditions causing coordination difficulties and their appropriate management.
Focus on research
Theses donated to the COT Library are available for loan, but are not downloadable. Please contact the Library for details.
Andreas D Diamantis
Assessment methods used by occupational therapists working with children in independent practice in the United Kingdom. Coventry University, 2004. MSc in Occupational Therapy. The purpose of this study was to collect information on the use of assessment methods by occupational therapists working with children in independent practice in the United Kingdom. The research design was a cross-sectional descriptive survey, using a postal questionnaire as the data collection tool.
Out of 89 questionnaires sent, 66 (74%) were returned and 48 (54%) of these were deemed as eligible. The findings demonstrated that the independent practitioners used a combination of assessment methods for the assessment process with a high preference for interviewing, which was always used by most of the respondents. The most preferred standardised tests used regularly were the Movement Assessment Battery for Children and the Developmental Test of Visual-Motor Integration. Most of the respondents were facing obstacles to the use of what they considered to be the best assessment method. The high cost of assessment tools, time requirements and inadequate facilities were some of the reported obstacles. The majority of the respondents were satisfied or very satisfied with the assessment methods used. The most frequently mentioned factors influencing the satisfaction level were issues intrinsic to standardised tests, inadequate information for the client, positive client feedback and adequate time. Some of the issues related to standardised tests were their unsuitability for the client, the high cost and their excessive time requirements.
A comparison of the present study's findings with similar studies is presented. Furthermore, interpretations of the main findings and their implications for the independent practitioners and educators are discussed. This study has some limitations, mainly in terms of the sample and the data collection tool.
It is suggested that similar research be undertaken in order to investigate the different requirements, if any, in the assessment process in the public and private sector. Moreover, further research on other issues related to the standardised tests is suggested.
Submitted: 14 October 2008.
Accepted: 15 June 2010.
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Karina Baudinette, (1) Jennie Sparks (2) and Amanda Kirby (2)
(1) Canterbury Christ Church University.
(2) University of Wales, Newport. Corresponding author:
Karina Baudinette, Senior Lecturer, Occupational Therapy Department, Faculty of Health and Social Care, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent CT1 1QU. Email: email@example.com
Reference: Baudinette K, Sparks J, Kirby A (2010) Survey of paediatric occupational therapists' understanding of developmental coordination disorder, joint hypermobility syndrome and attention deficit hyperactivity disorder. British Journal of Occupational Therapy, 73(8), 366-372.
Dyspraxia--functional motor difficulties especially with handwriting, fine motor skills, scissor skills, using knife and fork. Poor spatial awareness, poor dressing, clumsy, falls, poor handwriting, poor concentration, opting out, good academic/ verbal performance etc. high verbal IQ, low performance IQ.
Would imagine hyperextension of joints--never had a child diagnosed with this. I guess mostly with aching joints and hypermobile joints--seen in elbows and fingers mostly.
Decreased attention span. Behavioural issues. Emotional issues. Impact on social skills--criminal /antisocial behaviour etc. Difficulties with attending, decreased eye contact, 'on the go'. Never tend to see children for assessment with ADHD as referrals go to child psychiatry team.
Appendix 1. Survey: Knowledge of children with developmental coordination disorder (DCD), joint hypermobility syndrome (JHS) and attention deficit hyperactivity disorder (ADHD) Which category best describes your place of work? (Please tick) Child development unit  Private practice  Community paediatric team  Community mental health  Social services  Other (Please state)--  What grade and band are you? (Please tick and write in band) Consultant (band--)  Clinical specialist (band--)  Senior 1 (band--)  Senior 2 (band--)  Basic grade (band--)  Other (please state)--  Age:-- No. of years qualified:-- Gender: Male/Female In which geographical area of the UK do you work? (Please state) How do you rate your knowledge of DCD? (Please circle) 1 = Poor 5 = Very good 1 2 3 4 5 Can you describe key symptoms and signs you would use to alert you to a diagnosis of DCD? (Please circle) Yes/No/Not sure If yes, please describe:-- How do you rate your knowledge of JHS? (Please circle) 1 = Poor 5 = Very good 1 2 3 4 5 Can you describe key symptoms and signs you would use to alert you to a diagnosis of JHS? (Please circle) Yes/No/Not sure If yes, please describe:-- Do you routinely screen/check for JHS? (Please circle) 1 = Never 5 = Always 1 2 3 4 5 Do you use any tools/checklists to look for JHS? (Please circle) Yes/No If yes, which tools/checklists do you use? (Please list):-- If you recognised a child with signs of JHS, what would you do? (Please tick)  Same management as a child with DCD  Not sure  Different management to a child with DCD Would you refer on to another professional? (Please circle) Yes/No If yes, who would you refer on to? (Please list):-- How do you rate your knowledge of ADHD? (Please circle) 1 = Poor 5 = Very good 1 2 3 4 5 Can you describe key symptoms and signs you would use to alert you to a diagnosis of ADHD? (Please circle) Yes/No/Not sure If yes, please describe:-- Do you routinely screen/check for ADHD? (Please circle) 1 = Never 5 = Always 1 2 3 4 5 What tools/checklists do you use to look for attention and concentration difficulties? (Please list) -- If you recognised a child with signs of ADHD, what would you do? Please tick)  Same management as a child with DCD  Not sure  Different management to a child with DCD Would you refer on to another professional? (Please circle) Yes/No If yes, who would you refer on to? (Please list):-- Would you like additional information on (Please tick):  DCD  JHS  ADHD  Comorbidity? If yes, how would you prefer to receive this information? (Please tick)  Small group training  Book/leaflet  Web-based training  Conference  CD ROM  Other (Please describe)-- Thank you for completing this survey
Table 1. Coding dictionary In answers with a '/' in between, any of the responses is acceptable for that number. Developmental coordination disorder Accurate A. Meets the DSM-IV criteria for developmental coordination disorder. Needs to meet B. Meets the ICD-10 criteria (for Specific one of the Developmental Disorder of Motor Function following [SDDMF]). criteria, that is, A or B or C C. 1. Developmental/childhood/not a new condition/delayed motor milestones/below expected given age/child/young person and 2. Poor coordination/movement difficulties/ clumsy/motor difficulties and 3. Average intelligence/good cognitive ability/movement problems in excess of other areas of development (that is, IQ)/ underachievement at school/no indication of learning difficulty and 4. Scores poorly on a standardised movement test/Movement Assessment Battery for Children/Bruininks-Oseretsky/Peabody and 5. (Any of the following) Motor coordination problems impacting on activities of daily living (ADL)/academic performance/poor functional performance/poor occupational performance/problems could be seen in handwriting, dressing, ball skills, sports, using cutlery, ADL, self/care posture, hand/ eye coordination, fine motor coordination, gross motor coordination, organisational skills, visual perception, motor planning, sequencing of movements/core stability/ playing sports. Partially Any of the elements in section C, but not all. Must accurate include some reference to movement. Not accurate Low muscle tone/fatigue/avoids crossing midline/ problems following verbal instructions/avoids difficult tasks/compensates with verbal explanation/slow to move/easily frustrated/lack of functional independence/nothing mentioning motor or coordination/score discrepancy in educational psychologist's report. No response Joint hypermobility syndrome Accurate A. Meets the Brighton criteria. Needs to meet B. 1. The increased flexibility in 4 or more one of the joints/hypermobility in 4 or more joints/ following ligamentus laxity in 4 or more joints/ criteria, that Beighton scale or criteria/Bulbena criteria is, A or B and 2. Pain-ache in 4 or more joints for more than 3 months or thin skin or dislocation or subluxation-Ehlers-Danlos-Marfans- unequivocally affected first-degree relative. Partially 1. The increased flexibility/ accurate hypermobility/hyperextension/ligamentus laxity/movement of joints beyond the normal range of movement/excessive extension and flexion at joint/above average movement/increased ROM/range of movement in joints extreme/double jointed/joint stability/Beighton scale and 2. Pain-ache or thin skin or dislocation or subluxation-Ehlers-Danlos-Marfans- unequivocally affected first-degree relative. Not accurate Hypotonia/low muscle tone/motor planning difficulties/absence of patterns of performance/ soft neurological signs/linear vestibular differences/difficulties with strength/ difficulties with stability/poorly sustained grasps/observations during assessment of handwriting/low self-esteem/confidence. No response Attention deficit hyperactivity disorder Accurate A. Meets the DSM-IV criteria for ADHD. Needs to meet B. 1. Inattentive/attention and concentration one of the problems/difficulty staying on task/ following inability to attend to a task/limited criteria, that attention span/difficulties attending/short is, A or B focus/easily distracted/poor concentration and 2. Hyperactivity/hyperactive/increased activity levels/overactivity/restlessness and 3. Impulsivity/impulsive/not thinking before acting/lack of inhibition and 4. Functional impact is pervasive/occurs across settings/school and home/occurs in more than one setting/impaired ADL at home and school/in all environments. Partially Any two or three of the terms in section B. accurate Not accurate/ Bad behaviour/naughty behaviour/challenging no response behaviour/not performing well at school/poor social skills/listening skills/poor visual attention/ decreased eye contact/developmentally inappropriate/cannot control talking/pattern of abilities across standardised assessments difficulty engaging in tasks/poor listening/none of these terms/no response/decreased motor skills/ poor co-contraction/poor sleep pattern/poor skill acquisition/poor grading of activities/memory difficulties/difficulty with temper/sensory processing/sensory modulation/auditory discrimination/tactile discrimination/poor fine motor skills due to distractibility. Table 2. Therapists' reported knowledge of DCD, JHS and ADHD (n = 225) Ratings Frequency Percentage Developmental coordination disorder High level 38 17 Good level 98 44 Average level 53 24 Basic level 22 10 Poor level 3 1 Missing data 11 5 225 Joint hypermobility syndrome High level 5 2 Good level 27 12 Average level 62 28 Basic level 78 35 Poor level 48 21 Missing data 5 2 225 Attention deficit hyperactivity disorder High level 24 11 Good level 57 25 Average level 91 41 Basic level 38 17 Poor level 14 6 Missing data 1 0.4 225 Table 3. Therapists' qualitative descriptions of DCD, JHS and ADHD (n =225) Ratings Frequency Percentage Developmental coordination disorder Accurate description 8 4 Partially accurate description 175 78 Inaccurate description 17 8 No response 25 11 225 Joint hypermobility syndrome Accurate description 5 2 Partially accurate description 58 26 Inaccurate description 111 49 No response 51 23 225 Attention deficit hyperactivity disorder Accurate description 10 4 Partially accurate description 123 55 Inaccurate description 70 31 No response 22 10 225
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