The effectiveness of exergames in improving physical activity behaviour and physical literacy domains in adolescents with developmental coordination disorder and cerebral palsy: A scoping review.

BACKGROUND: A large proportion of adolescents with developmental coordination disorder (DCD) are physically inactive. Physical literacy has been described as an important determinant in promoting health behaviours. The potential of exergames to improve physical literacy and activity has been recognized in typically developing children. The aim of the present scoping review was to identify and map the available evidence of this potential for adolescents with DCD. METHODS: A scoping review was performed via a literature search in PubMed, Web of Science, Embase, ERIC and CINHAIL. RESULTS: From 2860 search records, six studies (two studies in DCD and four studies in cerebral palsy [CP]) assessed physical activity, 12 studies discussed exergame features and 16 studies assessed physical literacy domains. In DCD, one study showed positive effects of exergaming on physical activity and the other failed to show any significant effects of exergaming. In CP, all four studies demonstrated positive effects of exergaming on energy expenditure and daily physical activity. Furthermore, positive effects of exergames on the different physical literacy domains were shown, namely motor competence, self-concept and affect, motivation and social/experiential. Finally, exergame features including multiplayer modes, realism, game rewards, challenges and enjoyment were shown to have a significant effect on motivating and encouraging adolescents to exert more effort while playing. CONCLUSION: Based on the positive effects of exergaming on physical activity in other populations, more in-depth research in adolescents with DCD is warranted such that the decline in physical activity behaviour that is present in individuals with DCD can be counteracted. Physical literacy should be regarded as an important determinant in this regard.

Awareness about developmental coordination disorder.

The present paper is designed to promote awareness of DCD outside the academic world. With a prevalence of 5-6% it is one of the most common disorders of child development. It is therefore surprising that so little is known about it among professionals in child healthcare and education. Parents have expressed frustration about this lack of awareness, including the general public. The general aim of this paper was to describe those critical aspects of DCD that will promote awareness.

End-state comfort planning after explicit goal instructions in children with and without probable developmental coordination disorder.

BACKGROUND: When completing grip-selection tasks, healthy adults generally plan for the most comfortable end-posture which is termed the end-state comfort (ESC) effect. Children with and without developmental coordination disorder (DCD) are less likely to plan for ESC which begs the question as to whether they are not able to perform this type of planning or whether they prioritize other aspects of the task. AIMS: (1) Examine if children with and without probable DCD (pDCD) are able to plan for ESC if they are explicitly instructed to and (2) if this transfers to another similar task. (3) Examine if children with and without pDCD perceive the level of comfort of the grips that they use differently and if this relates to ESC planning. METHODS: Twelve children with and 12 children without probable DCD (pDCD) (aged 5-9 years) received a 10-min training session in which children were explicitly instructed to end their movement in ESC, after which they formulated their own plan to reach this goal. The study consisted of a pre-post-test design in which changes in the proportion of ESC were analyzed on the task that was trained as well as on an untrained transfer-task. Furthermore, the perceived level of comfort was examined. RESULTS: Both groups of children showed a higher proportion of ESC on the post-test compared with the pre-test, on the task that was trained as well as on the transfer-task. There were no group differences regarding the perceived level of comfort of the different grip postures. CONCLUSION: The majority of the children with and without pDCD seems to be able to adjust their planning strategy and prioritize ESC if they are explicitly instructed to.

Motor and cognitive dual-task performance under low and high task complexity in children with and without developmental coordination disorder.

BACKGROUND: In everyday life, tasks are often performed simultaneously, which may be more difficult for children with developmental coordination disorder (DCD) than their peers. AIMS: To examine (1) the effects of task complexity and type of concurrent task on dual-task performance in children with and without DCD; and (2) if the amount of effort that children put into the task performance differs between the groups. METHODS: Participants were 64 children with and without DCD (aged 7-14 years). The dual-task paradigm consisted of a manual dexterity task of relatively low complexity (box and block test) or relatively high complexity (pegboard task), and a concurrent motor task (cycling task) or a concurrent cognitive task (word-listening task). To assess mental effort, children were asked how tired they felt before and after the experiment. RESULTS: Dual-task interference was highest when the manual dexterity task of relatively high complexity was combined with the concurrent motor task. There were no group differences in dual-task interference, but children with DCD reported a larger increase in the level of tiredness after the experiment indicative of greater mental effort. CONCLUSIONS: Depending on task demands, children with DCD are able to perform dual-tasks at the same level as their peers, but performance may take children with DCD more mental effort.

The subtypes of developmental coordination disorder.

AIM: To identify subtypes in a large group of children clinically diagnosed with developmental coordination disorder (DCD) based on their pattern of motor, cognitive, and visual-motor abilities. METHOD: Standardized scores for verbal IQ, total IQ, Movement Assessment Battery for Children, Second Edition (MABC-2) balance, MABC-2 manual dexterity, MABC-2 ball skills, and Beery-Buktenica Developmental Tests of Visual-Motor Integration (Beery-VMI), Motor Coordination (Beery-MC), and Visual Perception (Beery-VP) were used. The NbClust complete procedure was used to best partition the data on 98 children (84 males, 14 females, mean [SD] age: 8 years [2 years 1 month]) into clusters. Deviation contrasts, multivariate analysis of variance, and post hoc comparisons were used to characterize the clusters. RESULTS: Four clusters were revealed: two clusters with a broad motor skill problem, one with relatively preserved visual-motor integration and Beery-MC skills, and a second with abnormal ball skills, balance, and Beery-MC skills. A third cluster with more specific gross-motor problems, and a fourth with relatively preserved ball skills but low Beery-MC and performance IQ, were identified. Balance scores were 'at risk' or 'abnormal' in all four clusters. INTERPRETATION: DCD is a heterogeneous condition. However, subtypes can be discriminated on the basis of more severe difficulties in fine-motor performance, gross-motor performance, or both. There was evidence for generalized motor impairments in around half of all children. Importantly, at least borderline level reduced balance was evident in each subtype. WHAT THIS PAPER ADDS: Four subtypes were identified in a large clinical group of children with developmental coordination disorder (DCD). Subtypes were based on motor, cognitive, and visual-motor abilities. There was evidence of generalized motor impairments in around 50% of children with DCD. A generalized balance problem is present across all subtypes of DCD.

Benefits of an Intensive Individual CO-OP Intervention in a Group Setting for Children with DCD.

Purpose: The present study focused on the impact of an adapted Cognitive Orientation to daily Occupational Performance (CO-OP) five-day intervention program for children with developmental coordination disorder (DCD). Important adaptations were the new combination of individual CO-OP sessions and group activities, the short and intensive program that was followed by a training and coaching trajectory, and the use of video logs. Materials and Methods: Eighteen children with DCD (aged 8-16 years) participated in the five-day intervention during which they worked on three intervention goals. After the intervention, during an eight-week training and coaching trajectory for parents and children, children worked on a transfer goal. Assessment took place at four moments in time: two pretest measures, a posttest measure, and a 3-month follow-up measure. Primary outcome measures focused on changes in performance and satisfaction of self-chosen intervention and transfer goals. The secondary outcome measure explored changes in children's attitude, motivation, and confidence in relation to motor skill activities, social skills, and level of participation. Results: Significant improvements were found with regard to the performance and satisfaction of intervention goals. For the transfer goal, only parents reported significant improvements. Finally, parents indicated potential improvements with regard to the attitude, motivation, and confidence of their children, but not for their social skills or level of participation. Conclusion: The findings are promising with regard to the efficacy of this adapted CO-OP intervention for improving intervention goals, but less effective for transfer of learned skills to other goals after the intervention. Future research should focus on how postintervention parental coaching can be improved in order to increase generalization and transfer.

Behavioral and Neuroimaging Research on Developmental Coordination Disorder (DCD): A Combined Systematic Review and Meta-Analysis of Recent Findings.

AIM: The neurocognitive basis of Developmental Coordination Disorder (DCD; or motor clumsiness) remains an issue of continued debate. This combined systematic review and meta-analysis provides a synthesis of recent experimental studies on the motor control, cognitive, and neural underpinnings of DCD. METHODS: The review included all published work conducted since September 2016 and up to April 2021. One-hundred papers with a DCD-Control comparison were included, with 1,374 effect sizes entered into a multi-level meta-analysis. RESULTS: The most profound deficits were shown in: voluntary gaze control during movement; cognitive-motor integration; practice-/context-dependent motor learning; internal modeling; more variable movement kinematics/kinetics; larger safety margins when locomoting, and atypical neural structure and function across sensori-motor and prefrontal regions. INTERPRETATION: Taken together, these results on DCD suggest fundamental deficits in visual-motor mapping and cognitive-motor integration, and abnormal maturation of motor networks, but also areas of pragmatic compensation for motor control deficits. Implications for current theory, future research, and evidence-based practice are discussed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, identifier: CRD42020185444.

The diagnostic trajectory of developmental coordination disorder in the Netherlands: Experiences of mothers.

BACKGROUND: Receiving a diagnosis can have a major impact on the child and its family. Parental satisfaction concerning the diagnostic trajectory is important with regard to acceptance and coping with their child's problems. Our aim was to describe the diagnostic trajectory of developmental coordination disorder (DCD) in the Netherlands and identify factors that are related to parents' satisfaction. METHOD: Mothers of 60 children with a DCD diagnosis completed an online survey concerning their experiences during and after the diagnostic trajectory of obtaining this diagnosis. RESULTS: Forty percent of the mothers rated the diagnostic trajectory towards a DCD diagnosis as stressful and 47% rated the knowledgeability of the first professional they consulted (mostly a general practitioner, paediatric physical therapist, or youth health care physician) as having no or just superficial knowledge about DCD. Around 60% of the mothers described a lack of knowledge and support at their child's school after receiving the diagnosis. Notwithstanding this, the majority of the participating mothers was (very) satisfied with the diagnostic trajectory. Higher appreciation of both the manner of the diagnosing professional and the post-diagnostic support provided were predictive of higher satisfaction. CONCLUSIONS: Our results underline the importance of improving the knowledgeability in primary schools and primary health care professionals with regard to DCD.

Second-order motor planning difficulties in children with developmental coordination disorder.

The second-order motor planning ability of children with developmental coordination disorder (DCD) has often been studied using tasks that require judgements of end-state comfort (ESC). In these studies, children may have chosen to prioritize other aspects of performance (e.g., a comfortable start-posture) over ESC while still being able to complete the goal of the task. This is a limitation that is inherent to previously used ESC paradigms. To avoid this in the present study, 52 children with and without DCD (aged 5-12 years) completed a task that requires second-order motor planning for its successful completion. In the hexagonal knob task, children were instructed to grasp and rotate a hexagonal knob. The rotation angle varied in size: 60°, 120°, 180°, and 240° rotations. Both the 180° and 240° rotation conditions required an uncomfortable starting posture for successful task completion. Results showed that children with DCD were less likely to adjust their initial grip in anticipation of the required rotation angle, resulting in more task failures compared with typically developing (TD) children. Based on this finding we conclude that children with DCD experience genuine second-order motor planning difficulties. Analysis of temporal outcomes, showed that initial reaction time increased with rotation angle, but this was less pronounced for children with DCD than for TD children. There were no between group differences in timing of subsequent events. These results suggest that the difficulties of children with DCD are related to the initial planning process, that is, before the start of the movement.

Eliciting End-State Comfort Planning in Children With and Without Developmental Coordination Disorder Using a Hammer Task: A Pilot Study.

The end-state comfort (ESC) effect refers to the consistent tendency of healthy adults to end their movements in a comfortable end posture. In children with and without developmental coordination disorder (DCD), the results of studies focusing on ESC planning have been inconclusive, which is likely to be due to differences in task constraints. The present pilot study focused on the question whether children with and without DCD were able to change their planning strategy and were more likely to plan for ESC when demanded by complex object manipulations at the end of a task. To this end, we examined ESC planning in 18 children with and without DCD (aged 5-11years) using the previously used sword-task and the newly developed hammer-task. In the sword-task, children had to insert a sword in a wooden block, which could be relatively easily completed with an uncomfortable end-posture. In the hammer-task, children had to strike down a nail in a wooden pounding bench, which required additional force and speed demands, making it relatively difficult to complete the movement with an uncomfortable end-posture. In line with our hypothesis, the results demonstrated that children with and without DCD were more likely to plan for ESC on the hammer-task compared with the sword-task. Thus, while children with and without DCD show inconsistent ESC planning on many previously used tasks, the present pilot study shows that many of them are able to take into account the end-state of their movements if demanded by task constraints.

Motor imagery and action observation for predictive control in developmental coordination disorder.

In 2019, international clinical practice recommendations on the definition, diagnosis, assessment, intervention, and psychosocial aspects of developmental coordination disorder (DCD) were published. Informing our understanding of mechanisms, recent systematic reviews have shown that children with DCD have difficulties with the predictive control of movements, including aspects of motor planning, which is expressed as the internal modeling deficit hypothesis. This motor control deficit is most evident when the spatial and temporal demands of a task increase. An increasing number of empirical studies suggest that motor planning problems can be remediated through training based on one or a combination of motor imagery and action observation. In this review, we show evidence of motor planning problems in children with DCD and show that task demands or complexity affects its appearance. Implications of these findings are treatments based on motor imagery and action observation to remediate motor planning issues. The article concludes with recommendations for future research.

Development of motor planning in children: Disentangling elements of the planning process.

Second-order motor planning of grasping movements is usually measured using tasks that focus on the relative (dis)comfort of end posture of the arm and hand regardless of the objective outcome of performance. This may underestimate the ability for forward planning in young children. In the current study, we aimed to examine the developmental mechanisms of motor planning in children using a task that necessitates second-order motor planning for its successful completion. We tested 311 children (aged 5-12 years) who were instructed to grasp and rotate a hexagonal knob over 60°, 120°, 180°, or 240°. The 180° and 240° rotation conditions necessitated adjustment of the preferred start grip for successful task completion. We examined successful or unsuccessful task completion, reaction time (RT), and movement time (MT) as a function of task demands (i.e., rotation angle) and age. Results showed that most children of all ages were able to successfully complete the task in the 180° rotation condition. In the most demanding 240° rotation condition, many children had difficulty in completing the task, but successful task completion increased with age. Time course analysis showed increased RT and MT with increasing task demands. Furthermore, whereas RT decreased with age for each rotation angle, MT remained stable with the exception of an increase in MT for the most demanding rotation condition. Together, these results exemplify that children aged 5-12 years are indeed able to engage in forward planning. With development, second-order motor planning proficiency increases, especially for more demanding movements, and the process becomes more efficient.

Activation of Mirror Neuron Regions Is Altered in Developmental Coordination Disorder (DCD)-Neurophysiological Evidence Using an Action Observation Paradigm.

Children with Developmental Coordination Disorder (DCD) have difficulty performing and learning motor skills. Automatic activation of the mirror neuron system (MNS) during action observation and its coupling to the motor output system are important neurophysiological processes that underpin observational motor learning. In the present study, we tested the hypothesis that MNS function is disrupted in children with DCD by using sensitive electroencephalography (EEG)-based measures of MNS activation during action observation. Specifically, we predicted reduced mu-suppression and coherence in DCD compared with typically developing children. Neural activation of the motor network was measured by EEG, specifically event-related desynchronization (ERD) of mu rhythms and fronto-parietal coherence. Children (15 DCD/15 controls) were tested under two task conditions: observational learning (imitation of an observed action) and detection (report a deviant movement after observation). EEG-metrics were compared between groups using linear mixed-effects models. As predicted, children with DCD showed lower levels of mu suppression and reduced modulation of coherence during the observational learning task compared with their non-DCD peers. Notably, mu suppression was reduced in DCD over the entire imitation task (repetitions, and both observation and pause intervals). Action observation can be used for the acquisition of new motor skills. This form of learning entails the transposition of the observed action to the existing internal representations of the observer's own motor system. The present neurophysiological results suggest that this process of learning is impaired in children with DCD. The results are discussed in relation to current hypotheses on mechanisms of DCD.

Motor planning in children with cerebral palsy: A longitudinal perspective.

INTRODUCTION: Motor planning is important for daily functioning. Deficits in motor planning can result in slow, inefficient, and clumsy motor behavior and are linked to disruptions in performance of activities of daily living in children with cerebral palsy (CP). However, the evidence in CP is primarily based on cross-sectional data. METHOD: Data are presented on the development of motor planning in children with CP using a longitudinal design with three measurement occasions, each separated by 1 year. Twenty-two children with CP (9 boys, 13 girls; age in years;months, M = 7;1, SD = 1;2) and 22 age-matched controls (10 boys, 12 girls, M  = 7;1, SD = 1;3) participated. Children performed a bar transport task in which some conditions ("critical angles") required participants to sacrifice initial posture comfort in order to achieve end-state comfort. Performance on critical trials was analyzed using linear growth curve modeling. RESULTS: In general, children with CP showed poor end-state planning for critical angles. Importantly, unlike in controls, motor planning ability did not improve across the three measurement occasions in children with CP. CONCLUSION: These longitudinal results show that motor planning issues in CP do not resolve with development over childhood. Strategies to enhance motor planning are suggested for intervention.

Development of motor imagery ability in children with developmental coordination disorder - A goal-directed pointing task.

Children with developmental coordination disorder (DCD) have difficulties with the predictive control of movements. This was shown in studies that target motor imagery and motor planning, and appears to become particularly evident with increases in task complexity. In this study, we used a complex mental chronometry paradigm to examine the development of motor imagery ability in children with DCD, using a longitudinal design. Thirty children were included in the DCD group (aged 6-11 years) and age- and gender-matched to 30 controls. The DCD group had a Movement Assessment Battery for Children-2 score ≤16th percentile and the control group ≥25th percentile. Results of this study showed that children with DCD indeed had a significantly lower correlation between executed and imagined movements. Importantly, the increase in the correlation and linear fit during subsequent measurements was comparable for the DCD and control group. Together, these findings suggest a delayed developmental onset of motor imagery ability in DCD, but a similar rate of development over time compared to the control group. Based on these results, it seems likely that explicit motor imagery instructions can be used to improve predictive control in children with DCD.

Development of motor imagery and anticipatory action planning in children with developmental coordination disorder - A longitudinal approach.

Children with impaired motor coordination (or Development Coordination Disorder - DCD) have difficulty with the predictive control of movements, evidenced by cross-sectional studies that show impaired motor imagery and action planning abilities. What remains unclear is whether this deficit in predictive control reflects immaturity of the motor system (a developmental delay) or some deviation from normal development (a disorder). To advance this discussion the present study used a longitudinal design to examine the development of motor imagery and action planning in children with DCD. Thirty children were included in the DCD group (aged 6-11years) and age- and gender-matched to 30 controls. The DCD group had a mABC-2 score≤16th percentile, the control group>20th percentile. Motor imagery was assessed with the hand rotation task, action planning with a test for end-state comfort. Children participated in three measurements, with one year in between measurements. Results showed that children with DCD were slower and less accurate than their typically developing peers in all subsequent years but were able to improve their motor imagery ability over time. Furthermore, children with DCD showed less planning for ESC at the start of the present study, but were able to catch up with their peers during two-year follow up. These results exemplify that improvement of motor imagery and action planning ability is possible in DCD, and they lend theoretical support to the use of new training techniques that focus on training motor imagery to improve motor skills in children with DCD.

Feasibility of Motor Imagery Training for Children with Developmental Coordination Disorder - A Pilot Study.

Children with Developmental Coordination Disorder (DCD) experience movement difficulties that may be linked to processes involved in motor imagery (MI). This paper discusses recent advances in theory that underpin the use of MI training for children with DCD. This knowledge is translated in a new MI training protocol which is compared with the cognitive orientation to daily occupational performance (CO-OP). Children meeting DSM-5 criteria for DCD were assigned to MI (n = 4) or CO-OP (n = 4) interventions and completed nine treatment sessions, including homework exercises. Results were positive, with two children in the MI group and three in the CO-OP group improving their m-ABC-2 score by ≥ 2 standard scores, interpreted as a clinically meaningful change. Moreover, all children and parents noticed improvements in motor skills after training. This is the first study to demonstrate the feasibility of a theoretically principled treatment protocol for MI training in children with DCD, and extends earlier work. Trial registration: The complete trial is registered at the Dutch trial register, www.trialregister.nl (NTR5471). http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5471.

Testing predictive control of movement in children with developmental coordination disorder using converging operations.

Recent systematic reviews (Wilson et al., 2013, Dev. Med. Child Neurol., 55, 217; Adams et al., 2014, Neurosci. Biobehav. Rev., 47C, 225) suggest that a common underlying problem in developmental coordination disorder (DCD) is the internal modelling deficit. The study presented here is the first to test this hypothesis using a within-subject design, assessing motor imagery, action planning, and rapid online control (ROC) in a sample of children screened rigorously for DCD. Participants were 66 children; 33 children (26 boys and seven girls) aged 6-11 years in the DCD group and 33 controls (gender and age matched). Motor imagery was assessed with the hand rotation task (HRT), action planning with an end-state comfort effect test, and ROC with the double-step pointing task. Results showed that children with DCD were slower and less accurate than controls in the HRT. Reduced forward planning for comfortable end-state was also shown in DCD. Finally, no group differences were found on the ROC task. Collectively, children with DCD manifest deficits in the internal modelling of movements, but this varies under different task constraints, particularly those related to movement complexity.

Motor imagery difficulties in children with Cerebral Palsy: A specific or general deficit?

AIM: The aim of this study was to examine the specificity of motor imagery (MI) difficulties in children with CP. METHOD: Performance of 22 children with CP was compared to a gender and age matched control group. MI ability was measured with the Hand Laterality Judgment (HLJ) task, examining specifically the direction of rotation (DOR) effect, and the Praxis Imagery Questionnaire (PIQ). RESULTS: In the back view condition of the HLJ task both groups used MI, as evidenced by longer response times for lateral compared with medial rotational angles. In the palm view condition children with CP did not show an effect of DOR, unlike controls. Error scores did not differ between groups. Both groups performed well on the PIQ, with no significant difference between them in response pattern. CONCLUSION AND IMPLICATION: The present study suggests that children with CP show deficits on tasks that trigger implicit use of MI, whereas explicit MI ability was relatively preserved, as assessed using the PIQ. These results suggest that employing more explicit methods of MI training may well be more suitable for children with CP in rehabilitation of motor function.

Motor imagery training for children with developmental coordination disorder--study protocol for a randomized controlled trial.

BACKGROUND: Previous studies have shown that the predictive control of movements is impaired in children with Developmental Coordination Disorder (DCD), most likely due to a deficit in the internal modeling of movements. Motor imagery paradigms have been used to test this internal modeling deficit. The aim of the present study is to examine whether a training focused on the mental imagery of motor skills, can help to improve the motor abilities of children with DCD. METHODS/DESIGN: A pre-post design will be used to examine the motor performance, motor imagery and motor planning abilities before and after a training of 9 weeks. Two groups will be included in this study (1) one receiving motor imagery (MI) training focused on the forward modeling of purposive actions, (2) one receiving Cognitive Orientation to daily Occupational Performance (CO-OP) training focused on identifying effective cognitive strategies that will increase motor competence. MI training will be given with the use of instruction videos of the motor skill that will be trained. Both groups will participate in 9 individual sessions of 45 min (once a week) with a paediatric physical or occupational therapist, added with homework sessions. Inclusion criteria are: (1) aged 7-12 years, (2) meeting the DSM-V criteria for DCD (motor performance substantially low (score on the m-ABC ≤ 16th percentile) and motor problems that interfere with daily life (DCDQ, and request for help at a paediatric physical or occupational therapist)). Exclusion criteria are IQ < 70 and other medical conditions causing the motor impairment. DISCUSSION: The results of this study will help to make treatment protocols for children with DCD more evidence-based. This study will increase our knowledge about the efficacy of both the MI training and CO-OP training, and both children with DCD and therapists will benefit from this knowledge. TRIAL REGISTRATION: www.trialregister.nl/NTR5471.