Dyspraxia : General Information and Guidelines

MJ Connor

Original Here

These notes were prepared in response to a request for information concerning the nature of dyspraxia, its signs and symptoms, and the effects of the condition upon day to day activities including classroom performance.

General guidelines are offered in respect of intervention, but early identification is important in order to establish an individualised and structured programme for the use of parents, teachers and support staff under the guidance of a specialised therapist.

Introduction

Dyspraxia is a condition which affects motor development and skills. Typically, the child in question may be seen to be clumsy and poorly co-ordinated; and there is a risk that (s)he could be misperceived as deliberately awkward or provocative, as a result of inadvertently pushing other children for example.

Key words are "Muscles, Motor and Movement".

The most significant educational effects of the condition involve fine skills such as those used in writing or drawing, or planning and self-organisation. Weaknesses may also be observed in the mechanisms of speech production such that articulation is impaired and expressive language is inhibited.

There may be secondary effects in terms of poor self image and limited social acceptance by peers.

It would usefully be underlined that Dyspraxia is not simply a language disorder, but that the speech disabilities ("Verbal Dyspraxia") represent one constellation of symptoms of this widely pervasive motor condition.

A simple definition might be: "Impairment or immaturity of the organisation of movement, with associated problems of language, perception and thought".

Dyspraxia may also have been implicated in the following diagnostic categories:-

Clumsy Child Syndrome

Perceptuo-motor dysfunction

Minimal brain dysfunction

Motor learning difficulty

Therefore "Dyspraxia" describes difficulty with controlling and co-ordinating learned patterns of movement, despite the lack of observed damage to muscles or nerves.

"Verbal/Articulatory Dyspraxia" is a condition where the child has difficulty making and co-ordinating the precise movements which are used in the production of spoken language ... again without damage to muscles or nerves.

There may be a problem with producing individual sounds as well as in co-ordinating the increasingly complex sequences used in words, phrases, and sentences.

One might characterise the dyspraxic child as being unable to think and act simultaneously; much (motor-planning and effort are required for actions which are taken for granted among other children of a similar age.

A child diagnosed as having dyspraxia by a paediatrician, physiotherapist and occupational therapist will usually have generalised motor difficulties - where the child has problems co-ordinating gross and fine body movements. (These children were once called "clumsy children").

A child who has been diagnosed as dyspraxic by a speech and language therapist will have developmental verbal dyspraxia (sometimes referred to as "developmental articulatory dyspraxia"). This is characterised by marked difficulties in producing speech sounds and in sequencing them together in words. Expressive language is often delayed. Such children will often (but not always) have anoral (or oro-motor) dyspraxia- a difficulty in making and co-ordinating the precise movements of the lips, tongue and palate required to produce speech. [Verbal dyspraxia may have become an umbrella term for children with persisting and serious speech difficulties in the absence of obvious causation regardless of the precise nature of their unintelligibility.]

Some children may have both verbal dyspraxia and generalised dyspraxia. However, it is important to recognise those different forms of the condition because advice and guidelines that focus on the generalised motor dyspraxia may have little relevance to a child whose primary difficulty is with speech.

Dyspraxic children are at risk of having problems in developing reading, writing and spelling skills, particularly those with a persisting problem at five years and/or who have a family history of speech or literacy difficulties. Spelling is often particularly at risk. In addition, children with generalised motor dyspraxia are likely to have handwriting difficulties.

It may not be possible accurately to determine whether any given individual child with dyspraxia will have problems with literacy.

Further, like other speech and language difficulties, verbal dyspraxia is not a static condition, but there will be changes over time. Therefore, all encompassing labels may not be helpful; instead, one may seek to identify a particular pattern of strengths and weaknesses at any given time. The very title "developmental dyspraxia" implies that particular needs will become apparent with the passage of time.

[It should be noted that some research evidence suggests that there are two dyspraxic conditions. "True Dyspraxia" is a lifelong condition, albeit amenable to some compensation as a result of consistent, early, and structured intervention; "Immature Articulatory Praxis" is a matter of neurological immaturity, i.e. a delay rather than a deficit ... and which can be resolved over time, with appropriate treatment. The problem is that only time will determine the difference]

Areas of difficulty for the dyapraxic child

Movement:Gross and fine motor skills are hard to learn, difficult to retain and generalise and hesitant and awkward in performance.

Language:Articulation may be immature or even unintelligible in early years. Language may be late to develop also.

Perception:There is poor understanding of the messages that the senses convey and difficulty in relating those messages to actions.

Thought:Dyspraxic children of normal intelligence may have great difficulty in planning and organising thoughts. Those with moderate learning difficulties have such problems to a greater extent.

Motor planning is, in some ways, the highest and most complex form of function in children. Because it involves conscious attention, it is closely linked to mental and intellectual functions. It depends upon very complex sensory integration throughout the brain stem and cerebral hemispheres. The brain tells the muscles what to do, but the sensations from the body enable the brain to do the telling. Motor planning is the "bridge" between the sensory-motor and intellectual aspects of brain function.

In the dyspraxic child, there is a defect within this process of CNS - muscle message-giving and feedback. The communication pathways are not established, and without consistent and guided repetition of movements, improvements will not be achieved because "gaps" in the neural pathways remain unclosed. Each time a neural message passes through a neuronal junction (synapse), the structure and chemistry of that synapse will change so that the message will be transmitted more effectively in future. The repetition of movements will be reflected by the repeated use of synapses for particular sensory-motor functions and a neural memory (a pathway) is consolidated.

Aetiology

For most children there is no known cause, although it is thought to be an immaturity of neurone development in the brain rather than brain damage. Dyspraxic children have no clinical neurological abnormality to explain their condition, but the source of dyspraxic difficulties is thought to be withinimmatureneuronal development. Such immaturity within left hemsipheric development may be particularly implicated.

Possible aetiological factors may include:

Pre- and pen-natal trauma

Environmental deprivation

Febrile illness in the early years ) in the early years

Neurological Trauma )

Genetic factors

Neurological immaturity

Unestablished cerebral dominance

Research evidence suggests that the incidence of dyspraxia [with varying degrees of severity] is around 5 or 6 per cent of all children.

As with other language related conditions, there is a predominance of males compared to females in groups of dyspraxic children identified ... dyspraxic "populations" appear to comprise between 70% to 90% boys.

Observations suggest a strong family incidence of language/learning problems ... in particular, a high percentage of dyspraxic children are found to have fathers or paternal family members with a history of delayed speech development, articulation difficulties, stammering, or dyslexic-type difficulties.

[It is noted that Developmental Articulatory Dyspraxia may be known as "DAD" ... seems very appropriate!]

Recent evidence supports the view that (verbal) dyspraxia is, to a large extent, a motor impairment, i.e. this condition is largely the result of a phonetically based articulation disorder resulting from impaired motor control, as opposed to a phonologically based language disorder as the major underlying mechanism.

Initial Identification

Dyspraxia may affect different children in varying degrees, from mild to severe.

The following are the diagnostic features of verbal dyspraxia present in any permutation among children affected:

i) Difficulty in control of the speech apparatus (lips; tongue; soft palate; larynx; muscles used to control breath during speech and the muscles used for facial expression).

ii) Possible difficulty in feeding.

iii) Difficulty in speech sound production (limited sounds used arid inconsistent production).

iv) Difficulty in sequencing sounds to make a word.

v) Difficulty in regulating breathing and in controlling the speed, rhythm and volume for speech.

The Pre-School Child

There is usually a history of lateness in such activities as rolling over, sitting, walking and speaking. The child may not yet be able to run, hop or jump. He/she appears not to learn anything instinctively but must be taught all skills. Poor at dressing and slow and hesitant in most actions, he/she has a poor pencil grip and cannot do jigsaws or shape-sorting games. Art work is very immature. There is no understanding of in/on/behind/in front of, etc., and the child is unable to catch or kick a ball. Dyspraxic children are commonly anxious and distractible. They find it difficult to keep friends or judge how to behave in company.

However, the child's understanding of what is said is relatively normal. It is the slowness in the development of babbling, first words, and word joining that is critical. Difficulties with length and complexity of sentences and with grammatical structure, may be persistent over a long time scale.

The School Age Child

All of the problems of the pre-school child may still be present with little or no improvement. P.E. is avoided. The child does badly in class but significantly better on a one-to-one basis. Attention span is poor and the child reacts to all stimuli without discrimination. There may be trouble with maths and reading and great difficulty may be experienced in copying from the blackboard. Writing is laborious and immature. He/she is unable to remember and/or follow instructions and is generally poorly organised.

The longer the dyspraxic child goes without being identified, the greater the experience of failure, the more experience of being criticised or reprimanded, and the poorer the self esteem and self confidence.

Avoidance strategies may come into play... missing games or P.E., poor attendance, associating with younger children, et. There is a risk, therefore, that by secondary age, the dyspraxic who has not be identified or provided with support will be relatively isolated and generally frustrated. Such a student may well become involved in undesirable behaviour, i.e. (s)he will be prepared to join in deviant behaviours if that is the price for being accepted in a group. Many of the children and young people seen to be candidates for the label of emotionally and behaviourally disturbed may be dyspraxic but not recognised as such.

Thus, early identification and intervention are very important not only in dealing with the "primary" difficulties but also in minimising "secondary" disorders.

Dyspraxia is most readily recognised when the child in question may be directly observed alongside his/her peers during activities requiring balance or co-ordination. For example, the dyspraxic child may move too quickly or too slowly, will lack control, and will not appear to recognise environmental signals. Reaction time will be slower than the norm for the group.

Constant and involuntary movement may be commonly observed, particularly during quiet or formal occasions (such as assembly) when the effort expended to control movement will actually produce all the more nervous movement.

Alongside difficulties with self organisation, getting books out, taking messages, getting changed, etc., the child may be confused over time sequences, past, present and future. Recalling events will be challenging, and if a particular word or event is not remembered, the child will go off at a tangent.

Behaviour mayappeardisruptive as a result of the difficulties with planning or with maintaining attention to the task. (S)he is not able to anticipate the effect of behaviour, with consequences for integration within peers.

Particular difficulty may be observed in handwriting, in respect of positioning the work on the page, letter-spacing, confusion among similar letters, etc., but even if the writing is neat, it will have involved considerable effort and possible stress.

Further Diagnostic Indicators

Dyspraxia may be implicated if the child has not achieved (motor) milestones at an age comparable with the norm, e.g.

Rides a tricycle

Jumps up with both feet together.

andif the following problems are also observed:-

1. Does things in an inefficient way.
2. Has low muscle tone, which makes him seem weak.
3. Needs more protection than other children ... has trouble "growing up". His mother may have to be overprotective since he has such a hard time with life.
4. He is accident-prone. He has many little accidents, such as spilling milk, and big accidents, such as falling off his tricycle. He may unknowingly knock into other children.
5. Is more emotionally sensitive to things that happen to him. His feelings are easily hurt. He cannot tolerate upsets in plans and expectations.
6. Complains more about minor physical injuries. Bruises, bumps and cuts seem to hurt him more than they do other children.
7. Is apt to be stubborn or uncooperative. His nervous system is inflexible, so he wants things his way.
8. Is very sensitive to high levels of noise.
9. Is usually the last to be chosen as a partner.

Formal assessment measures may include:

1. Wechsler Intelligence Test... (where one would be looking for wide discrepancies between subtest scores.
2. Analysis of handwriting... (in terms of speed, muscle tone, and pencil grip; and of a preference for printing, a mixture of upper and lower case letters, erratic spacing and letter height, and an absence of punctuation.
3. Achievement tests ... (where one would be seeking any discrepancy between performance in literacy, and general cognitive ability; or between verbally expressed ideas and written output).
4. Motor skill tests... (such as the Bruininks Test of Motor Proficiency or the Movement Assessment Battery).

It is worth repeating the term "'dyspraxia" may be applied to children who present a wide range of difficulties. Further, one would usefully note the caveat quoted by Portwood(1996).....

"It is hoped that the diagnosis of dyspraxia does not suffer the same fate as dyslexia so that every child who may be a little forgetful, disorganised, and clumsy is diagnosed as dyspraxic"

i.e., dyspraxia is a relatively severe condition, and awareness of, and concern for, the difficulties experienced by the dyspraxic child may be inhibited if the diagnosis is applied loosely and carelessly.

In-School Implications

The following guidelines and implications for school experience have been set out in two sections. The first concerns children where the focus of difficulty is verbal, and the second is more concerned with the generalised form of dyspraxia.

However, it should be stressed that such a division is somewhat arbitrary (albeit designed to structure these notes more simply) and any dyspraxic child may show an individual pattern of motor, verbal, perceptual and social weaknesses, and will require an equally individual form of compensatory activities and "allowances".

The significance of consistent and structured support is reinforced by evidence for the benefits thereof; and it would appear that dyspraxia is not an immutable condition but can be overcome to a considerable extent. In other words, early referral to a specialist therapist is desirable in order that an individual programme can be prepared whose implementation may be shared by teachers and carers in liaison with the therapist. The need is to confront the very activities which the child finds difficult and provides consistent programme of activities.

Evidence exists that benefits accruenotsimply as a result of time and greater maturity, but that thepracticeof motor movements will bring about further and more complex neuronal connections in the brain such that skills are learnt and consolidated.

Dyspraxic symptoms ... the awkwardness and lack of co-ordination in movement... are suggestive of miscommunication of messages in the central nervous system. The purpose of the exercises is to form the neural pathways such that skills can be fixed.

A. Verbal

• Prognoses for improvement will be greater with earlier intervention and early liaison between the Speech and Language Therapist and the parents (and teachers).
• As implied by the above, a signiticant factor in producing benefits is ensuring that the child has access to regular practice at home of the exercises to establish correct motor patterns and sound production (and has access to a good model of speech, involving short sentences and clear articulation). Regular therapy, plus supportive work at home, beginning at around 3 years is linked to a reasonable probability of acceptable speech by school entry at 5 years. (Earlier entry to school with an emphasis upon formal skills rather than on a nursery/developmental curriculum may highlight the disadvantages experienced by the dyspraxic child)
• Where therapy is begun later, the greater maturity and responsiveness of the child towards the intervention may compensate ...butlater intervention may be linked to other difficulties (literacy and pre-literacy weaknesses, social and emotional problems, etc.)
• Given the likely risk of literacy difficulties in children with dyspraxia, it is important to work as early and consistently as possible upon speech since the better the speech, the better the prognosis for literacy acquisition.
• It is necessary to check that children understand the language used by teachers and other adults. Instructions should be kept simple and single.
• The child should be encouraged to use signs and gestures to reinforce communication, and to be given models of such signs by the adults working with him/her.
• Listening skills have to be "tuned"... by preparing them to attend, by repetition, and by the provision of simultaneous visual cues. Listening will be aided by routines, such that the child can anticipate what will happen next, and by encouraging eye contact with the speaker. (Also the child should be encouraged to watch the speaker closely in order to be able to imitate lip movements and facial expressions.)
• To some extent, certain difficulties may be similar to those associated with attention deficit, i.e. the span of attention for a task will be all the shorter if the task isdifficultfor the child, if there are anydistracters, or if the information and stimuli arecomplexsuch that the child is unsure what is relevant. The dyspraxic child appears unable to filter out the unimportant or irrelevant sounds and sights, and will be helped if competing stimuli are reduced as far as possible.

B. Generalised Motor

• Given the co-ordinating problems, and difficulty in planning ahead or carrying out (a combination of) motor tasks, it is necessary to recognise the frustrations experienced by the dyspraxic child in activities normally taken for granted - moving round the school, carrying the lunch tray, changing for P.E., etc.
• Physical skills must be taught, they will not simply develop. Complex physical skills should be broken down into smaller and simpler parts such that failure and diminished self confidence are avoided,

e.g. low apparatus in gymnastics
brightly coloured, large balls for throwing and catching
large headed, short-handled bats
games with few children on each side, etc.

• A regular programme of exercises (planned by occupational therapists in association with language therapists and educational psychologists) can be effective in bringing about improvements. The exercises may include repetitive tasks such as walking between two lines, walking heel to toe along a line, balancing exercises, work with finger puppets, following a particular direction marked out with hoops, etc.
• Recording of work may be aided by:
  • A series of coloured dots, for starting and finishing points.
  • - Pre-prepared templates - where to put headings, pictures, etc.
  • - (For older pupils®access to photocopied notes, to word processing and to audio-taping of material; the use of mind-maps as a way of taking notes; the use of "scribes", access to examination concessions, etc.)
• Homework may present particular problems, and alternative arrangements may be necessary:
  • Modification of the task to ensure demand is reasonable.
  • Use of alternatives to written work (W.P., Taping, "Mind-map" forms of notes)
  • Adult support time to assist in organising the task.
  • Clarification to all concerned (pupil, parent, teachers) that time spent on the work should not exceed a given period.
  • Provision of a set of organiser trays, labelled with days of the week, in which are put books and equipment needed for particular days.
• The area in which the child is to work may be too great (especially with outdoor games and P.E.), so that "artificial" boundaries may be helpful ... made with hoops, or drawn lines; and the more timid children could even be allowed to work on an individual mat.
• Care is necessary to ensure that the dyspraxic child can see and hear the teacher clearly during group activities and games.
• It needs to be recognised that the dyspraxic children may need more time than other children to plan their work and to complete a given task. One must avoid rushing themandexpecting them to be able to concentrate for as long as, or longer than, the norm for their age.
• In respect of motor skills, the moral is to encourage the child to "compete against himself" rather than against some ideal or average target, i.e. whether the task concerns quantity of writing, accuracy of throwing, etc., the child seeks to improve performance gradually, whatever the level of skills shown by peers.
• With younger children, the type of clothes worn may minimise the difficulties and length of time associated with changing for P.E./games/swimming, e.g. using Velcro instead of buckles or buttons; choosing clothes with an obvious back and front; using enlarged buttons and button holes; etc.
• In respect of writing, one might experiment in finding what is most comfortable for the child. For example, if there is difficulty with printing and if letters are poorly formed and spaced, then simple, cursive writing could be taught. Subsequently, it may be appropriate to reduce stress linked to writing by helping the child to use a simple and portable word processor.
• Reading may be aided by focusing visual attention (and by compensating the effect of possible eye muscle weakness) by means of a simple cardboard frame to put over words or small groups of words. In general, the early stages of reading will require a systematic and structured approach (multi-sensory and multi-cue).

General "handling" Implications

A major role of the teacher is that of reducing the potential stress of the dyspraxic child, not only by the kind of activities/structuring described in the previous sections, but also by:

• Counselling:
  Letting the child realise that his difficulties are recognised; allowing him/her to express feelings and anxieties; and establishing a routine for planning individual targets.
• Discreet watch over playground experience:
  If there is a threat of bullying, or if the child finds the playground space and noise daunting, allow the child to come into school (with one or two other children).
• Check the language used to the child:
  Minimise the probability of using phrases like, "You're so slow to finish"; "You are last again"; "Can't you sit still?"
• Regular home-school liaison:
  Ensuring that everyone working with the child has the same understanding and can offer consistent support.
• Relaxation:
  Teaching children the technique of breath control may minimise anxiety, or anger born of frustration,andmay enhance general self-control.
• Information-sharing:
  With due tact, and gaining the permission of the dyspraxic child's parents if necessary, some information about dyspraxia can be provided to other children in the class and to their parents (so that the child is not seen as "naughty" or specially favoured).
• Avoid rewards to encourage better behaviour:
  Offering rewards when the child lacks the skill or planning to achieve the behaviour in question may only increase pressure. Instead, one highlights what has gone wrong, targets the next step, and plans with the child how to structure the situation to achieve that step.
• Extra support:
  A case may arise for enhance provision (atanystage of the Code of Practice) if time on task and organisation is a marked problem for the child (and teacher) and if there are secondary issues of frustration and negative behaviour.

Conclusions

1. Generalised and verbal dyspraxia are significant conditions, differentiable from other learning and language disorders, with their source in sensori-motor dysfunction.
2. Early identification is critical in order to establish a pattern of frequent and consistent interventions in which parents, therapists and teachers can work together.
3. For the generalised form of the condition, multi-modal treatment is indicated, with an emphasis upon structured exercises, designed to establish neural communication networks, plus modifications to the classroom setting.
4. In respect of verbal dyspraxia, the critical issue is early recognition of the condition in order to minimise a negative impact upon literacy acquisition and the development of secondary social and behavioural symptoms.

Further Sources

Information on both aetiology and remedial strategies is available from:

The Dyspraxia Foundation, 8 West alley, Hitchin, Hertfordshire, 5G5 1 EG

AFASIC, 347 Central Markets, Smithfield, London, EClA 9NH

I-CAN Training Centre, New Road, Weybridge, Surrey, KT13 9BW

Further Reading

Stackhouse J (1992): Developmental Verbal Dyspraxia - A review and critique.European Journal of Disorders of Communication 27 19-34.

Portwood M. (1996). Development Dyspraxia.Educational Psychology Service. County Hall. Durham DL 1 5VJ

Connor M. (1991). Identifying and Differentiatng Dysphasia and Dyspraxia.Educational Psychology Service, Surrey County Council, County Hall, Kingston upon Thames, KT1 2DJ

Grunwell P. (editor) (1990). Development Speech Disorders.Churchill Livingstone. Edinburgh.

Acknowledgements

This paper does not claim to be original, but has attempted to bring together evidence and advice from a variety of sources to form a coherent whole for the use of colleagues within Surrey LEA. The absence of references (apart from those listed above) reflects this, especially as much of the material was not labelled or attributable.

However, it would be appropriate particularly to acknowledge the various notes provided by The Dyspraxic Foundation, The I-CAN Training Centre, and the Hampshire Educational Psychology Service.

Joshua Muggleton BSc (Hons)., MRes., MBPsS., FRSA, has Asperger's Syndrome. Since 2005 he has been giving talks on high functioning Autism and Aspergers Syndrome across the UK. Drawing on personal experience, anecdotes, and academic research, Josh aims to give his audience an insight into life with Aspergers Syndrome. His interactive, informal and experience based approach has made him a highly popular speaker with parents, teachers and professionals alike. Often using his own personal story, Joshua also delivers speeches at other awareness raising events, highlighting the difficulties he has faced and the successes he has achieved, to deliver a positive, inspirational and motivating message. Joshua's first book "Raising Martians" was published by Jessica Kingsley Books in 2011. Find out more about Josh . 

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