Out of order

5th November 2004 at 00:00
Co-ordination difficulties can occur for all sorts of reasons, so teachers must observe the whole child. Karen Gold reports on symptoms and solutions

When he gets up in the morning, Kevin's first struggle is with his socks.

Sitting down to put them on, his knees get stuck between his arms and his feet. If he stands on one leg, he falls over. By the time he gets to school, with cereal stains on his sweatshirt and no reading book in his backpack, Kevin is cross. He collides with another child in the playground - accidentally, on purpose? - who knows? Today, like many others, is going to end in tears.


Working out what is wrong with children like Kevin can preoccupy a school from a child's first reception day. Is he immature? Naughty? Clumsy? Is he backward? Or is he bringing into school the domestic stress etched on the face of his mum?

Every child with co-ordination and attention-based disorders is different, says Dr Amanda Kirby, director of the Dyscovery Centre in Cardiff, which specialises in diagnosing and treating children with dyspraxia (now often called development co-ordination disorder or DCD) and attention deficit hyperactivity disorder (ADHD; sometimes, with hyperactivity omitted, called ADD).

Confusing matters further is the frequent overlapping: 60 per cent of dyspraxic children also have ADHD. Many dyspraxic children have dyslexia (see SEN Extra October 2004); some have Asperger syndrome (see SEN Extra October 2003) too. Recent proof that these disorders are often genetic does not clarify individual cases: a chaotic child may have inherited ADHD, or may be that way as a result of living with an ADHD parent.

Given such variation, the only way to help individual children effectively is to start with extensive, individual observation, says Dr Kirby. "You need to look at the child as a whole; to look at each functional difficulty," she says. "You have to look for a pattern of difficulties; observe the child in a number of different settings. If you can see where the difficulties lie, then you can be much more successful in supporting that child."


Dyspraxia symptoms in younger children are predominantly physical.

Balancing, throwing and catching, threading, shape-sorting and pencil-holding may be beyond them. They may use both right and left hands, struggle with self-care - dressing, going to the toilet, using cutlery - and need to learn skills one-to-one instead of picking them up alongside others.

Older children with more motor control show more organisational or "praxis" difficulties. They may still dress messily, have a poor sense of direction and reverse letters and numbers, but they will also stand unconventionally close or far away in social interaction, have no sense of time, forget instructions, fail to copy from a textbook or whiteboard, cannot plan or sustain trains of thought.

All these children may be instantly distracted. They may wander from their seats, fidget, daydream, fail to finish work. But ADHD children will flit from one play activity to another, avoid sustained mental effort, lose things and forget what they are doing, run around, act impulsively, interrupt, talk excessively, fail to take turns. (Differentiating between children with ADHD and emotionally disturbed or difficult children remains controversial: the medical diagnostic consensus is that the more problem behaviours there are, the earlier they started and the longer they last, the more likely the child is to have ADHD).


Schools need to observe what children can and can't do in different contexts, says Gwent occupational therapist and dyspraxia expert Carolyn Dunford. "What we look for is a general co-ordination story. If a child has a handwriting problem but can ride a bike and tie shoelaces, that's not DCD," she says. "Sometimes it's difficult to tease out whether the child isn't doing something because they physically can't, or because they aren't attending long enough to the task to complete it."

Checklists are key for close observation. Mapping SEN, a new CD-Rom from David Fulton out next April, written by Dr Kirby, contains one. The Dyscovery Centre and Leeds University publish dyspraxia checklists; as do charities such as the Dyspraxia Foundation and the Hyperactive Children's Support Group (HASCG).


Schools observe; health professionals diagnose. GPs, psychiatrists, occupational therapists and physiotherapists may all be involved in identifying and supporting the dyspraxic or ADHD child. The latter may be prescribed cognitive behaviour therapy andor drugs such as Ritalin, although these remain controversial, particularly for under-sixes. Many families also experiment with adding fish oil or zinc to their children's diet, and withdrawing certain foods. All these interventions work for some children and not for others; schools are well placed to help parents monitor their everyday effect.

But health service diagnosis and intervention, particularly for dyspraxia, can take up to three years in some regions. With suspected DCD now burgeoning exponentially - some nurseries report not the standard one child in 20 but around half their intake showing gross and fine motor delay, for a plethora of suspected reasons including earlier video and computer use, parental anxiety about outdoor play, babies not being put down to play on their tummies - schools must act without waiting for formal medical diagnosis, says Durham psychologist and dyspraxia expert Dr Madeleine Portwood.

"We recently screened 400 nursery children: 60 per cent didn't reach the expected motor co-ordination level," she says. "Children couldn't walk sideways. It was astounding. If we don't intervene with a structured movement programme for three-year-olds, we will end up with a race of hyperactive children."


Using such a movement programme 20 minutes a day for a term, Dr Portwood found all but a handful of the nursery children with co-ordination delay caught up to normal developmental levels. A similar hopeful outcome occurred in a recent Leeds University study, Movement Difficulties in Children, by Professor David Sugden, using parents and teaching assistants to do individually tailored exercises with children aged seven to nine. All had DCD, some severely. Half progressed so much after two years they no longer counted as having DCD. Most of the rest improved but fell back, suggesting intervention needed to be more intense or more sustained. Only 10 per cent failed to improve at all.

Dyspraxia experts emphasise that such programmes are simple: they involve activities such as balancing, throwing and catching with bean bags and balloons - softer and slower than balls - inventing travelling movements using arms and legs, riding scooters. All fall easily into the PE curriculum, says Dr Kirby, adding that some schools and parents buy into expensive exercise schemes dressed up with complex-sounding science when daily PE would be as good: "This isn't rocket science. Children need to learn to move and move to learn. They don't need fancy programmes. Doing the hokey cokey is just as effective."


All kinds of small classroom-based adjustments can make a difference to children with attention andor co-ordination difficulties, without waiting for an occupational therapist visit, she says. (Sencos and local authority advisers should take the initiative and call their region's occupational therapy department, and use advice lines at the Dyscovery Centre or Dyspraxia Foundation for immediate help with resources or a child's specific problems, says Carolyn Dunford. They offer extensive training too.)

Practical solutions for younger children include putting their coat peg at the end of a row, using a writing slope on top of a table, fat-barrelled paintbrushes, spring-loaded scissors, pen grips, attention and concentration games, such as Kim's game, or spotting the difference between similar pictures.

Older children need transparent pencil cases, clipboards for loose paper, cloze procedure worksheets rather than copying activities as they lose their place when they look away. They need mind-mapping software and time to learn to touch type, or to familiarise themselves with the keyboard.

Teachers need to ask themselves where and how these children are sitting - near the front, away from distractions such as windows or glass-panelled doors? Are they at the right height for writing, with desktop at elbow height when they first sit down? Are their feet flat on the floor? Do right-handers and left-handers have their writing arms on the outside edge of shared tables?


If teachers imagine when standing at the front of the class that they are communicating with these children not face to face but through a crackling walkie-talkie, that suggests both what the child is experiencing and how the teacher needs to adjust. (In effect, that is what happens inside a child with co-ordinationattention difficulties: interference muddles any messages travelling between their brains and their senses.) So the teacher's messages need to be utterly simple and clear. If you give a string of instructions, these children will hear only the first and last.

(Maybe not even the first.) They need routine and structure (change unsettles them), frequent quiet reminders to stay on task, specific, positive instructions, predictable rewards, concrete prompts: a buzzer when they can change tasks, a promise that they can go out to play when they have written a page rather than when the lesson ends, or at 10.30. (Many struggle to make sense of clocks and time.) They also need reminding of classroom etiquette which other children absorb automatically. Practice in turn-taking, signs on the wall saying "Stop and think", encouragement to every child in the class to answer questions in one sentence, modelling thinking by sometimes encouraging students to speak their thought processes aloud, will all have an impact on their learning.


But they will not produce a miracle. Handwriting is particularly intractable, although movement programmes can help. (occupational therapists encourage practice in groups of letters based on the same formation - c, a, d, g, o, q, for example, all start with a c shape, so teachers can check the child is forming it with the proper curly top.) The Dyscovery Centre has had success with Write Dance, a programme comprising music and movement and no handwriting practice at all.) For this reason, schools need to put their main effort not only into enabling children to set themselves realistic goals, but to succeed, says Dr Kirby: "Many children with DCD have poor self-perception and poor motivation. You need to start from what the child wants to do and create a graded programme together. The child might say 'I want better handwriting', so you might try and improve his shoulder stability because he's wobbly and can't hold a pen. But the child knows it's for handwriting, not 'You've got dyspraxia, let's do arm waving'."

Sustaining these children's self-esteem is crucial, says Dyscovery Centre co-director and occupational therapist Sharon Drew. Partly because if children experience continual failure, they give up. But also because of the emotional damage that otherwise ensues: "These children lose confidence when they are small; when they become adolescent, self-esteem and confidence become their primary problem. Many end up with long-term mental health issues. You can't wait 14 months for help; you have to act now."


Developmental Dyspraxia, a manual for parents and professionals, by Madeleine Portwood (David Fulton); madeleine.portwood@durham.gov.uk

Movement Difficulties in Children, send pound;5 cheque payable to University of Leeds, to Prof David Sugden, School of Education, University of Leeds, LS2 9JT

Mapping SEN CD-Rom, by Amanda Kirby, (David Fulton, April 2005, pound;35) Write Dance, a music and movement handwriting programme (Lucky Duck); www.dyscovery.co.uk



ADD information and support services: www.addiss.co.uk


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