Developmental coordination disorder: Clinical features and diagnosis

INTRODUCTION — Developmental coordination disorder (DCD) is characterized by problems with motor coordination that interfere with academic performance and social integration in otherwise healthy children. It typically presents in the early school years and persists into adolescence or adulthood.

The clinical features, evaluation and diagnosis of DCD will be discussed here. The management and outcome of DCD are discussed separately. (See "Developmental coordination disorder: Management and outcome".)

TERMINOLOGY — In this topic, we use the term "developmental coordination disorder" (DCD) to describe problems in motor coordination that interfere with academic performance and/or socialization and are not better explained by other medical or psychosocial conditions, such as brain tumors, metabolic conditions, and attention deficit hyperactivity disorder. DCD was first described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), and DCD is the preferred term in countries that use the DSM classification (eg, the United States) [1,2]. "Developmental motor coordination disorder" is the preferred term in the International Classification of Diseases 11th Revision (ICD-11), which is used in many European countries [3].

Although DCD is generally the preferred term in the United States, DCD is considered a mental health diagnosis for billing purposes and may not be covered by the child's medical insurance. Other terms for the diagnosis, such as "lack of coordination," "dyspraxia," and "dysgraphia," which are considered medical diagnoses, typically are covered by medical insurance.

Other terms that have been used to describe DCD are listed below [1,4-6]. These terms generally are avoided because they are ambiguous.

●Clumsy child syndrome

●Developmental dyspraxia or apraxia

●Sensory integrative dysfunction

●Perceptuomotor dysfunction

●Motor learning difficulty

●Physical awkwardness

●Movement difficulty

●Mild motor delay

●Disorder of attention and motor perception (called DAMP in Scandinavia and "DCD plus" elsewhere)

ETIOLOGY — The etiology of DCD is unknown. Normal motor function requires the coordination of neurologic, physiologic, and biologic processes, including proprioception, vestibular integration, strength, balance, coordination, dexterity, praxis, visual ability, and visual motor coordination. Problems in any of these areas can result in impairment of motor skills.

The population of children with poor motor skills is heterogeneous, and different mechanisms may underlie the difficulties in different children [1]. Factors related to the task (eg, complexity, speed), environment (eg, visual cues, opportunity for practice, encouragement), and individual child appear to contribute. Factors related to the child include motivation; perseverance; difficulty in executing motor tasks; problems with proprioception [7,8], and visual processing [9]; atypical brain development [10]; and genetic factors [11].

Atypical brain development is supported by neuroimaging studies in which children with DCD have different patterns of brain activation and white matter connections than typically developing children, with less activation of brain regions responsible for motor automaticity and increased activation of pathways for purposeful movement, and differences in the frontal-parietal connections (which integrate visual-spatial information) [10,12-18]. The increased prevalence of left-handedness or ambidexterity among children with DCD compared with the general population (50 versus 10 percent) suggests that incomplete lateralization may play a role [19,20].

Genetic factors are supported by a study of 10,895 twin pairs in which genetic effects were estimated to account for approximately 70 percent of the variation in children with DCD [11]. However, the comorbidity between DCD and other neurodevelopmental disorders, particularly attention deficit hyperactivity disorder and specific learning disorders, makes it difficult to determine which gene or genes are responsible for which conditions. Copy-number variations have been identified that may indicate a susceptibility for DCD and related coexisting conditions [21].

EPIDEMIOLOGY

●Prevalence – The prevalence of DCD varies with diagnostic criteria and patient population [1]. In most reviews, the prevalence among school-age children is approximately 6 percent [1,22-24]. However, in a cohort study with stringent diagnostic criteria (including significant impact on activities of daily living), the prevalence of DCD was 1.7 percent [25].

DCD is two to seven times more common in males than females [22,25]. The prevalence is not affected by socioeconomic status or educational level.

●Risk factors – DCD is strongly related to a history of preterm birth and low birth weight [26-30]. In a systematic review, the risk of DCD was higher in children born at <32 weeks and those with very low birth weight (<1500 g) than in full-term/normal birth weight children (odds ratio 6.3, 95% CI 4.4-9.0) [29]. In a large cohort study, early preterm birth and postterm birth were also associated with DCD [31].

●Associated conditions – DCD is associated with other neurodevelopmental conditions, including attention deficit hyperactivity disorder; autism spectrum disorder; intellectual disabilities; language disorders; speech articulation disorders; specific learning disorders; and social, emotional, and behavioral problems [32,33]. (See 'Evaluation for associated conditions' below.)

CLINICAL FEATURES

Children — The diagnosis of DCD is typically made in children between 6 and 12 years of age. Most children with DCD have lifelong delays in achieving motor skills. The delays are most apparent when they begin to interfere with social-adaptive development or at the time of school entry, when the child is compared with their peers [34,35]. In retrospect, children with DCD may have had problems with sucking and swallowing during the first year, delayed achievement of motor milestones, persistent toe walking or wide-based gait after 14 months of age, speech problems, and/or persistent drooling (after 30 months of age) [35,36].

Caregivers may complain that the child has difficulties with everyday tasks, such as tying shoelaces and brushing teeth. Motor delays can interfere with childhood play activities, such as riding a bicycle or playing catch. There may be tension in the home related to delays in self-care skills, spills, or breakage of objects that the child has dropped or collided with [35,36].

Crude pencil grasp, poor handwriting, and inability to cut paper on a straight line may cause problems in the early school years [34,37,38]. Teachers may report that the child bumps into classmates, desks, and chairs. The child may be socially ostracized because of diminished motor skills [35,37,39].

Children with DCD may require repeated instruction to learn new motor skills. They also may avoid participation in physical activity and competitive sports [40,41]; they may use somatic complaints as an excuse to avoid physical activities. Avoidance of physical activity may result in obesity [42]. (See "Developmental coordination disorder: Management and outcome", section on 'Outcome'.)

Adolescents — Motor difficulties persist into adolescence in at least 50 percent of children with DCD [2,43]. In a literature review, clinical features of DCD in adolescents included difficulties in hand skills (eg, handwriting, ball skills), agility, balance, driving, and playing sports [1]. Coexisting nonmotor problems included difficulty with attention and executive function (eg, planning ahead), anxiety, symptoms of depression, low self-esteem, obesity, and poor general health. The associated problems appear to worsen over time. In observational studies, children with coexisting conditions had increased rates of educational, social, and emotional problems during adolescents [44-47].

Health consequences — DCD may be associated with short- and long-term health consequences, including decreased participation, poor physical fitness (eg, decreased flexibility, muscle strength, and endurance), obesity, poor pulmonary function, and increased cardiovascular risk factors (eg, elevated triglycerides and blood pressure). Health consequences of DCD are discussed separately. (See "Developmental coordination disorder: Management and outcome", section on 'Outcome'.)

DIAGNOSTIC CRITERIA — We use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) diagnostic criteria for DCD [2]. These criteria are similar to those recommended by the European Academy of Childhood Disability [1] and the International Classification of Diseases 11th Revision (ICD-11) criteria for specific developmental disorder of motor function [3].

The DSM-5-TR criteria for DCD include [2]:

●The achievement and performance of coordinated motor skills is substantially below that expected given the child's chronologic age and opportunity for skill learning and use.

●The poor performance significantly and persistently interferes with activities of daily living appropriate to chronologic age and impacts academic/school productivity, prevocational and vocational activities, leisure, and play.

●The symptoms began in the early developmental period.

●The impairments in motor skills deficits are not better explained by intellectual disability or visual impairment and cannot be attributed to another neurologic or neuromuscular condition affecting movement (eg, cerebral palsy, muscular dystrophy, degenerative disorder).

Although age ≥5 years is not a diagnostic criterion, the diagnosis of DCD is rarely made in children <5 years of age. Diagnosis of DCD in young children is problematic because assessment of motor function is unreliable (eg, due to variable cooperation and motivation during testing), differences in the age of achievement of various activities of daily living, and the possibility of spontaneous resolution of motor delay [1].

The diagnostic criteria for adolescents and adults are the same as those for children. However, tests of motor function that are commonly used for children have not been validated in adults.

STEPWISE APPROACH TO DIAGNOSIS

Clinical suspicion — DCD should be suspected in school-age children who have difficulty with developmental screening tasks such as drawing, imitative finger movements, hopping, and rhythmic skipping. Concerns about clumsiness may originate from the caregivers, clinicians, teachers, or therapists [23].

Clinical suspicion for DCD is supported by information from the history, including [1,23]:

●Which motor areas does the child (or caregiver) perceive as difficult? Children with DCD may have difficulty with gross motor and fine motor tasks, including speech and oral motor tasks.

●When did the clumsiness begin and how has it progressed?

•The clumsiness of DCD has onset in early childhood and is nonprogressive.

•Clumsiness that has acute onset, onset after early childhood, or is progressive is inconsistent with DCD, and other conditions should be considered. (See 'Differential diagnosis' below.)

●Review of fine motor (adaptive), gross motor, language, cognitive, and social skills (table 1) to determine whether the child's motor development is commensurate with that in other developmental domains [48].

●Has the child had opportunities to learn and practice motor skills? Having been given the opportunity to learn and use motor skills is an important caveat of the diagnostic criteria [2].

●Assessment of strength, coordination, and endurance (eg, by asking: "Is there anything that other children your child's age can do that is difficult for your child to do?") [48].

●Family history of DCD – It may be necessary to ask about DCD using other terms if the caregiver is unfamiliar with the term "DCD." (See 'Terminology' above.)

Evaluation for other causes — In children who are suspected to have DCD, other causes of impaired motor skills are evaluated through the history and physical examination. Laboratory and imaging studies are not routinely necessary. (See 'Differential diagnosis' below.)

Although exclusion of other causes of impaired motor skills is a criterion for the diagnosis of DCD [2], it can be difficult to distinguish between conditions that cause DCD and conditions that may coexist with DCD (eg, motor problems related to impulsivity or inattention may be due to isolated attention deficit hyperactivity disorder [ADHD] or to coexisting ADHD and DCD; intellectual disability) [1]. In such cases, referral to a specialist with expertise in diagnosing DCD may be warranted (eg, a developmental-behavioral pediatrician, pediatric neurologist). (See 'Diagnostic criteria' above and 'Evaluation for associated conditions' below.)

●History

•Past medical history – Aspects of the history that are important in evaluating other causes of impaired motor skills in children with suspected DCD include history of [1,2,49-53]:

-Vision problems

-Brain injury or severe head trauma

-Perinatal complications

-Musculoskeletal conditions (eg, arthrogryposis, arthropathy, hypermobility)

-Medications (eg, sedatives, antipsychotics)

•Family history – A family history of heritable neuromuscular (eg, muscular dystrophy) or neurodegenerative disorders (eg, spinocerebellar ataxia, Friedreich ataxia) should prompt additional evaluation [1,24,37]

●General physical examination – Aspects of the general physical examination that are important in evaluating other causes of motor impairment in children with suspected DCD include [1,24,48]:

•Measurement of weight and head circumference and comparison with standards for age and sex (see "The pediatric physical examination: General principles and standard measurements", section on 'Head circumference')

-Overweight or obesity may be associated with inactivity and reduced opportunity to develop or practice skills [54-56]

-Microcephaly or macrocephaly may be a finding associated with an underlying cause of motor impairment (see "Microcephaly in infants and children: Etiology and evaluation" and "Macrocephaly in infants and children: Etiology and evaluation")

•Neurocutaneous findings, such as:

-Hyperpigmented macules (picture 1), which may indicate neurofibromatosis (see "Neurofibromatosis type 1 (NF1): Pathogenesis, clinical features, and diagnosis", section on 'Clinical manifestations')

-Hypopigmented macules (picture 2), which may indicate tuberous sclerosis complex (see "Tuberous sclerosis complex: Clinical features")

•Assessment of visual acuity to determine if visual deficits are a factor in motor incoordination (see "Vision screening and assessment in infants and children")

•Funduscopic examination for the macular cherry red spot (picture 3), present in some neuropathies and gangliosidoses (eg, Niemann Pick or Tay-Sachs disease) (see "Overview of Niemann-Pick disease", section on 'Classification and clinical features')

•Musculoskeletal examination for joint abnormalities (eg, swelling, abnormal range of motion)

●Neurologic examination – The neurologic examination should include examination of mental status, cranial nerves, the motor system (including gait), deep tendon reflexes (DTRs), cerebellar function (balance and coordination), involuntary movements, the sensory system, and functional skills (eg, climbing stairs, hopping, skipping, writing, and drawing). (See "Detailed neurologic assessment of infants and children", section on 'Neurologic examination'.)

Weakness, ataxia, pronounced hypotonia or hypertonia, and increased or decreased DTRs, particularly when asymmetric, are inconsistent with DCD. Other diagnostic possibilities should be considered in children with these findings, and laboratory and imaging studies may be warranted. (See 'Differential diagnosis' below.)

●Laboratory and imaging studies – Laboratory and imaging studies are not routinely necessary in the evaluation of a child with suspected DCD, but may be warranted in children with acute or progressive changes in gross motor skills or abnormal findings on neurologic examination (eg, clumsiness, ataxia, weakness, abnormal DTRs and/or abnormal tone, or asymmetric neurologic findings).

The evaluation is tailored to the conditions being considered and may include magnetic resonance imaging in children who are thought to have focal brain abnormalities. Measurement of lactate dehydrogenase and creatine kinase may be warranted in children who have poor muscle mass or limited physical exertion (to evaluate for neuromuscular disease). (See 'Differential diagnosis' below and "Muscle enzymes in the evaluation of neuromuscular diseases" and "Approach to the metabolic myopathies".)

Assessment of functional impact — Interference with age-appropriate activities of daily living and negative affect on academic/school productivity, prevocational and vocational activities, leisure, or play are criteria for the diagnosis of DCD [2]. (See 'Diagnostic criteria' above.)

The evaluation for DCD must include assessment of the effects of motor impairment on the ability to perform activities of daily living (eg, eating, self-care) and to actively participate at home, school, or work and in recreational or leisure activities in the community [1]. The evaluation should include assessment of academic achievement and mental health effects (eg, symptoms of depression or anxiety). Handwriting and keyboard skills should also be assessed. Information about functional impact may include report cards; information from caregivers or other family members; reports from clinicians, teachers, therapists, or coaches; self-report; or questionnaires. Functional impact can be assessed with the Vineland Adaptive Behavior Scales, third edition or Adaptive Behavior Assessment System, third edition.

Fine motor impairments may have a greater impact on academic performance and achievement, whereas gross motor impairments may have a greater impact on social interaction (eg, play, sports participation, recreational activities) [1].

Standardized assessment of motor skills — We generally refer children in whom a diagnosis of DCD is being considered to a pediatric physical or occupational therapist for standardized assessment of motor skills. These tests assess the child's motor competence in a variety of domains (eg, hopping, jumping, threading beads).

Clinical judgment is required to interpret the degree to which poor motor skills satisfy the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision criterion that performance in daily activities is substantially below that expected given chronologic age, particularly in children with coexisting conditions [1,2]. The Leeds Consensus Statement recommends that a validated, standardized test be administered to assess the child's motor skills and that a score below the 5^th percentile provides evidence of abnormal motor skills [57]. Children scoring in the 5^th to 15^th percentile range may benefit from monitoring to judge what impact their motor skills have on their activities of daily living. Some experts suggest repeating testing with a different motor assessment tool for children in whom DCD is strongly suspected who score in the 5^th to 15^th percentile range [1].

The most commonly used and best-studied tests of gross motor impairment in children with suspected DCD are the Movement Assessment Battery for Children, second edition (MABC-2) and the Bruininks-Oseretsky Test of Motor Proficiency, second edition (BOT-2) [1,58,59]. The MABC-2 is most commonly used in research, and the BOT-2 is more commonly used by therapists to make the diagnosis. Neither test provides a complete analysis across the full spectrum of motor skills. In addition, there is lack of agreement about the percentile threshold (eg, 2.5^th versus 5^th versus 15^th percentile) that should be used to define DCD. The MABC-2 is generally superior to the BOT-2 as a test for DCD but remains limited by its restricted range of tasks (eg, does not include handwriting, which is a complex rather than "pure" motor task) and inability to detect children with disabilities in specific domains (ie, lack of reliability at the individual item level) [1].

Standardized assessments for DCD in adolescents and adults are lacking [1]. The MABC-2, BOT-2, Adult Developmental Coordination Disorder/Dyspraxia Checklist, Adolescents and Adults Coordination Questionnaire, and Functional Difficulties Questionnaire have been used to assess motor function in adolescent and adult patients, but additional evaluation of these tests is necessary before they can be routinely used to diagnose DCD in adolescents and adults [1,60,61].

Other validated, standardized tests (eg Zurich Neuromotor Assessment Battery; Peabody Developmental Motor Scales, second edition; Bayley Scales of Infant Development, fourth edition; Zuk Assessment Tool) may be used but have not been specifically evaluated for the diagnosis of DCD [1].

Diagnosis — The diagnosis of DCD is established through meeting the diagnostic criteria [1,2]. (See 'Diagnostic criteria' above.)

For children who meet diagnostic criteria before age five years, some experts suggest that the standardized motor assessment be repeated after three months before the diagnosis is established [1].

Children in whom the diagnosis is uncertain (eg, score on a standardized assessment of motor skills that does not meet the threshold for diagnosis [often <5^th percentile]) should be monitored over time. Those with loss of milestones or evidence of progressive incoordination should be evaluated for progressive neurologic conditions. Referral to a specialist with expertise in DCD (eg, a developmental-behavioral pediatrician, pediatric neurologist) may be warranted. (See 'Progressive incoordination' below.)

DIFFERENTIAL DIAGNOSIS

Nonprogressive incoordination — The following nonprogressive conditions should be considered in the differential diagnosis of DCD [1,2,6,62]:

●Intellectual disability – Moderate to severe intellectual disability (ID) is commonly associated with motor delays and poor dexterity and is usually readily identified. However, identification of mild ID may be delayed into the school years.

Formal cognitive testing should be performed in clumsy children in whom ID is a concern. DCD may be diagnosed in a child who is intellectually disabled, but only if the motor difficulties are in excess of those that are usually associated with ID. (See "Intellectual disability (ID) in children: Clinical features, evaluation, and diagnosis", section on 'Terminology' and "Intellectual disability in children: Evaluation for a cause", section on 'Approach to diagnostic testing'.)

●Attention deficit hyperactivity disorder – DCD and attention deficit hyperactivity disorder (ADHD) commonly coexist. However, children with isolated ADHD may be clumsy because of inattentiveness and impulsivity rather than incoordination. The distinction between isolated ADHD and coexisting DCD and ADHD may be particularly difficult in the preschool and early primary school years. The clumsiness associated with isolated ADHD usually improves with time [37]. (See "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis".)

●Autism spectrum disorder – DCD and autism spectrum disorder (ASD) may coexist. However, children with isolated ASD also have deficits in nonmotor domains (ie, social interaction/communication; restricted/repetitive behaviors, interests, or activities) that are not present in children with isolated DCD [2,63]. (See "Autism spectrum disorder in children and adolescents: Clinical features".)

●Vertigo – Vertigo may affect balance and motor performance and is sometimes caused by otitis media [50-53]. However, in contrast to DCD, vertigo usually has acute onset. In addition, Romberg testing usually is positive in patients with vertigo (ie, they fall or tilt to one side when asked to stand upright with the feet together and close the eyes) but negative in patients with DCD. Nystagmus in primary gaze (looking straight ahead) is another finding that may differentiate vertigo from DCD. (See "Causes of vertigo", section on 'Otitis media' and "Evaluation of the patient with vertigo".)

Other conditions that generally can be readily excluded by history include lack of opportunity for motor skill development (eg, related to deprivation or cultural practices), acquired brain injury [64,65], neonatal encephalopathy, tic disorder, and orthopedic and rheumatologic impairments (eg, arthrogryposis, traumatic or rheumatologic arthropathy, hyperextensible joints).

Progressive incoordination — Although DCD is not a progressive disorder, progressive neurologic conditions may appear to be static at initial presentation. Diagnoses to be considered in children if the clumsiness progresses include:

●Brain tumors (see "Overview of the clinical features and diagnosis of brain tumors in adults")

●Metabolic conditions (eg, aminoacidurias, storage diseases, Wilson disease) [66] (see "Inborn errors of metabolism: Classification" and "Wilson disease: Clinical manifestations, diagnosis, and natural history")

●Neuromuscular disease (eg, neuropathy, muscular dystrophy, myositis) (see "Overview of acquired peripheral neuropathies in children" and "Duchenne and Becker muscular dystrophy: Clinical features and diagnosis", section on 'Clinical phenotypes' and "Juvenile dermatomyositis and other idiopathic inflammatory myopathies: Epidemiology, pathogenesis, and clinical manifestations", section on 'Clinical manifestations')

●Hydrocephalus (see "Hydrocephalus in children: Clinical features and diagnosis", section on 'Physical examination')

●Ataxia (see "Approach to the child with acute ataxia")

●Myoclonic epilepsy (see "Overview of infantile epilepsy syndromes", section on 'Myoclonic epilepsy in infancy')

EVALUATION FOR ASSOCIATED CONDITIONS — DCD is associated with other neurodevelopmental conditions [24,32,33,47]. Limited research suggests that children with more severe DCD have a greater risk of coexisting conditions [43,67].

Children who are diagnosed with DCD should be evaluated for previously undiagnosed coexisting neurodevelopmental conditions [1]. Coexisting conditions may require additional evaluation or treatment and may affect participation in school or community activities and quality of life.

●Attention deficit hyperactivity disorder – DCD is strongly associated with attention deficit hyperactivity disorder (ADHD). In population-based studies, approximately 50 percent of children with DCD also have ADHD, and approximately 50 percent of children with ADHD meet criteria for DCD [22,68,69]. The strongest association appears to be between the inattentive subtype of ADHD and fine motor skill deficits [70,71]. The risk of motor difficulties in children with ADHD does not appear related to the severity of ADHD.

The clinical features of ADHD are discussed separately. (See "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis", section on 'Clinical features'.)

●Autism spectrum disorder – DCD is common in children with autism spectrum disorder (ASD) [1,2,63,72]. In an observational study of 101 children with ASD, approximately 80 percent had definite and 10 percent had borderline motor impairment as assessed by performance on the Movement Assessment Battery for Children and the Developmental Coordination Disorder Questionnaire parent questionnaire [72]. Conversely, in a population-based study, approximately 5 percent of 346 children with DCD had ASD [25]. (See "Autism spectrum disorder in children and adolescents: Clinical features", section on 'Motor deficits'.)

The motor difficulties in children with ASD typically correlate with the degree of cognitive, social, and emotional impairments and tend to be more severe than those in children with co-occurring DCD and ADHD [73,74]. Diagnosing coexisting ASD in children with DCD may facilitate receipt of services. Intellectual disability (ID) is common in children with coexisting ASD and DCD (given the frequency of coexisting ASD and ID). The clinical features of ASD are discussed separately. (See "Autism spectrum disorder in children and adolescents: Clinical features".)

●Oral motor/speech articulation disorders – Oral motor/speech articulation disorders are common in children with DCD. (See "Etiology of speech and language disorders in children", section on 'Articulation disorders'.)

●Specific language impairment/language disorders – Developmental language disorders frequently coexist with DCD [75,76]. In an observational study, approximately one-third of children with specific language impairment had concomitant DCD [75]. (See "Etiology of speech and language disorders in children", section on 'Specific language impairment'.)

●Learning disabilities/specific learning disorders – DCD commonly coexists with nonmotor learning disabilities (eg, reading disability, math disability, written language disability). Children with DCD may have difficulties in executive function and struggle with cognitive tasks such as nonverbal working memory, fluency, inhibition, and planning. Theses executive deficiencies are particularly apparent in emotional situations [77-79]. However, children with DCD without specific language impairment perform similarly to typically developing children in verbal tasks [77,80]. These findings suggest that motor deficits are more related to visuospatial skills than verbal skills. Difficulties in executive function may interfere with classroom learning.

The clinical features of learning disabilities are discussed separately. (See "Specific learning disorders in children: Clinical features", section on 'Clinical features'.)

●Social, emotional, and behavior problems – Children with DCD are more likely than their peers to have poor social competence, poor motivation, low self-esteem, and sadness.

Children with DCD are described by caregivers as isolated, introverted, easily frustrated, and socially immature [81]. In a systematic review of 41 studies, most noted worse social (eg, making friends, maintaining friendships) and psychological functioning (eg, self-concept, self-efficacy, emotional health) in children with DCD than their peers [82].

Poor motor skills are an independent risk factor for peer victimization in children with and without DCD [83-87]. The degree of victimization appears to be proportionate to the degree of motor difficulty [83-85].

Longitudinal studies, twin studies, and cross-sectional studies consistently find an association between childhood DCD and adolescent anxiety, depression, and underdeveloped social skills, particularly in female adolescents [39,47,88-93]. In most studies, the association between childhood motor difficulties and subsequent internalizing symptoms is mediated by social communication skills [86,88,92]. Better mental health outcomes have been observed in children with DCD who have a normal verbal intelligence quotient (IQ) and good social communication skills and who report less bullying and higher self-esteem [94]. Mental health outcomes are worsened by social difficulties and bullying; bullying appears to drive much of this correlation [83,85,95-98]. The relationship between motor difficulties and subsequent internalizing symptoms may be attenuated by interventions that improve social skills and caregiver and social support [91,92].

Children with DCD report lower assessment of self-worth in childhood and in adolescence [39]. In observational studies, lower self-worth has been associated with lower motor skills, perceived poor social supports, and victimization by peers [39,99,100].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Developmental coordination disorder".)

SUMMARY AND RECOMMENDATIONS

●Developmental coordination disorder (DCD) is characterized by problems with motor coordination that interfere with function in academics, social integration, or recreation and are not better explained by other medical or psychosocial conditions. (See 'Terminology' above.)

●The prevalence of DCD among school-age children is approximately 6 percent. It is more common in males than females and among children born preterm/low birth weight than among children born at term. DCD is associated with other neurodevelopmental conditions (eg, attention deficit hyperactivity disorder [ADHD]; autism spectrum disorder [ASD]; intellectual disabilities (IDs); speech articulation disorders; language disorders; specific learning disorders; and social, emotional, and behavior problems). (See 'Epidemiology' above.)

●DCD typically presents in the early school years with difficulty performing simple motor tasks (eg, running, buttoning, or using scissors). Motor difficulties persist into adolescence in at least 50 percent of children. (See 'Clinical features' above.)

●We use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria for DCD, which include:

•The acquisition and performance of coordinated motor skills is substantially below that expected given the person's chronologic age and opportunity for skill learning and use.

•The poor performance significantly and persistently interferes with activities of daily living appropriate to chronologic age and impact academic/school productivity, prevocational and vocational activities, leisure, and play.

•The onset of symptoms is in the early developmental period.

•The motor skills deficits are not better explained by ID or visual impairment and are not attributable to a neurologic condition affecting movement (eg, cerebral palsy, muscular dystrophy, degenerative disorder).

The DSM-5-TR criteria are similar to those recommended by the European Academy of Childhood Disability and the International Classification of Diseases, 11th revision criteria. (See 'Diagnostic criteria' above.)

●The stepwise diagnostic process begins with clinical suspicion. DCD should be suspected in school-age children who have difficulty with developmental screening tasks such as drawing, imitative finger movements, hopping, and rhythmic skipping. Clinical suspicion for DCD is supported by information from the history. (See 'Clinical suspicion' above.)

●In children who are suspected to have DCD, other causes of impaired motor skills are evaluated through the history and physical examination. Laboratory and imaging studies are not routinely necessary unless there is a history of acute or progressive changes in gross motor skills or abnormal findings on neurologic examination. (See 'Evaluation for other causes' above and 'Differential diagnosis' above.)

●The next step in the diagnostic process is assessment of the effects of motor impairment on the ability to perform activities of daily living (eg, eating, self-care) and to actively participate at home, school, or work and in recreational or leisure activities in the community. Information about functional impact may include report cards; information from caregivers or other family members; reports from clinicians, teachers, therapists, or coaches; self-report; or questionnaires. (See 'Assessment of functional impact' above.)

●The final step in the diagnostic process is standardized assessment of motor skills (eg, Movement Assessment Battery for Children, second edition or the Bruininks-Oseretsky Test of Motor Proficiency, second edition). This assessment is usually performed by a physical or occupational therapist. A score below the 5^th percentile provides evidence of abnormal motor skills. (See 'Standardized assessment of motor skills' above.)

●The diagnosis of DCD is made in children who meet the diagnostic criteria. Children in whom the diagnosis is uncertain should be monitored over time. Referral to a specialist with expertise in DCD (eg, a developmental-behavioral pediatrician) may be warranted. (See 'Diagnosis' above.)

●The differential diagnosis of DCD includes other conditions that can cause motor incoordination in children, including:

•Nonprogressive disorders (eg, ID, ADHD, ASD, vertigo)

•The early presentation of progressive disorders (eg, brain tumor, metabolic conditions, neuromuscular disease, hydrocephalus, ataxia, myoclonic epilepsy)

These disorders usually can be differentiated from DCD by history and physical examination. (See 'Differential diagnosis' above.)

●Children who have been diagnosed with DCD should be evaluated for associated conditions, including ADHD; ASD; ID; speech articulation disorders; language disorders; specific learning disorders; and social, emotional, and behavior problems. (See 'Evaluation for associated conditions' above.)