Dyspraxia

What is dyspraxia?

Dyspraxia is a disorder of co-ordination and movement; it affects complex muscle activities such as handwriting, balance, ball skills, and dancing.

Dyspraxia is a developmental disorder, which means that it develops in childhood. Motor milestones, such as the age of first walking may be delayed.

Dyspraxia can also affect other activities involving co-ordination of muscle and brain activity, including speaking and organising complicated tasks. Dyspraxia does not affect intelligence but it does place extra hurdles in the way of children during their educational years, and adults during higher education and in the workplace.

Children with dyspraxia have slower development of motor skills than others, so that some things are harder for them to learn, but with appropriate support these skills can be taught.

What causes dyspraxia?

We don't know why some people have dyspraxia. For any human ability there is a broad range of 'normal', with an average; some are more or less able than others.

This means there is a wide spectrum of motor co-ordination development, from very poor to very good. When this development is markedly impaired, we term it dyspraxia, as we realise it represents a real challenge to your child.

A number of things have been suggested that may increase the risk of dyspraxia:

• Dyspraxia seems to run in families, so it seems to have a genetic component - the way your child is 'made'. This suggests that, in some children, a less effective development of the motor nerves may be something that is pre-programmed into their genes.

• Premature babies, particularly those of very low birth weight, seem to be at greater risk of dyspraxia.

• There is evidence that exposure to high levels of alcohol, or to illegal drugs during pregnancy, can cause dyspraxia

How common is dyspraxia?

Dyspraxia is a common condition, affecting as many as 10% of children in the UK to varying degrees. Boys seem more likely than girls to have dyspraxia. However, the discrepancy in diagnosis could be due to later referrals for girls or symptoms in girls being missed - though the evidence is still being reviewed.

The diagnosis of dyspraxia is not usually made until children reach the age of 4 or 5 years. This is because there is no simple test for dyspraxia and until that age the range of conditions that can cause similar symptoms is very wide. In particular, natural variations in children's muscular strength can seem to affect their motor skills.

Some children, however, are diagnosed much later. Dyspraxia is a very common condition but it is very easy to miss as its symptoms overlap with many other conditions. Unfortunately, it can look just like naughtiness or boredom - and children who are not engaging in class because of dyspraxia may become naughty or bored, which then disguises the real cause. We should always give children the 'benefit of the doubt' - but you have to be thinking of dyspraxia in order to see it.

Dyspraxia in adults

Children with dyspraxia may overcome some of their difficulties, but other elements are likely to persist into adulthood. Some adults may not have been diagnosed as a child, particularly because awareness of conditions such as dyspraxia was lower in the past than it is now. Some adults will have chosen areas of work that play to their strengths.

Dyspraxia may also be acquired later in life through injury or illness - for example, as a result of a stroke or a head injury. This type of dyspraxia is not called DCD, as this term refers specifically to the developmental condition, although it can cause similar symptoms.

Dyspraxia symptoms

Dyspraxia can affect different children in different ways and to different degrees, varying from mild to severe. The problems may interfere with a child's ability to participate and function in daily activities and life skills, including education.

Symptoms of dyspraxia in preschool children

• Late in reaching developmental milestones - eg, sitting, standing, walking, toilet training and speaking (although most children who are late to some milestones do not have dyspraxia).

• Feeding and sleeping difficulties in early childhood.

• Lack of interest in construction toys like Lego® and stacking toys.

• May not be able to run, hop, or jump, or catch or kick a ball when their peers can do so.

• Many have trouble managing walking up and down stairs.

• Doesn't make friends easily; may prefer adult company.

• Fidgetiness.

• Always falling over.

• May not like solid food that needs to be chewed.

• Has little understanding of concepts such as 'in', 'on', 'in front of', etc.

• Poor at getting dressed.

• 'Clumsiness' - not good at picking up small things; tends to break small toys.

• Slow and hesitant in most actions; tends to trip up.

• Appears not to be able to learn anything instinctively but must be taught skills.

• Poor pencil skills - drawing, holding a pencil.

• Cannot do jigsaws or shape-sorting games.

• Drawings seem very immature compared to those of other children.

• May seem easily distracted.

• Muscle tone may be high (the muscles seem hard or tense).

• Muscle tone may be low (a baby may seem floppy when being held).

• Delayed language development or problems with speech. For example, speech is odd and inconsistent, so that it is difficult to understand.

Symptoms of dyspraxia in children of school age

• Similar problems to those above may persist.

• Having difficulty in group situations.

• Having problems with maths and writing.

• Having trouble copying things from the board in school.

• Appearing disorganised.

• Having poor concentration and listening skills.

• Seeming unable to follow instructions.

• Avoiding PE and games.

• Feeling angry, upset or frustrated with themselves.

Symptoms in adults

The symptoms of dyspraxia in adults are very variable. They may include the following problems with motor skills:

• People with dyspraxia may be clumsy, and less able than average at motor tasks, such as sports that require the use of a ball, or other co-ordination skills.

• They may have a lack of rhythm when dancing and try to avoid this.

• They may be poor at tasks requiring fine skills like needlework, crafts and musical instruments. Handwriting may be poor and typing may be difficult

• Tasks such as getting dressed, particularly where buttons or shoelaces are involved, may be difficult and slow.

• Poor posture and muscle fatigue are common symptoms, which may be improved by physiotherapy and directed exercise to improve muscle tone.

Why is dyspraxia important?

Dyspraxia affects learning; both children and adults can become discouraged if not given the support that they need to learn effectively.

Many children with dyspraxia develop low self-esteem, particularly if they are told to 'be less clumsy' or 'try harder'. Some give up on the things they find difficult, so losing the opportunity to develop and improve. They may not take part in sport, which can affect their fitness and health, as well as excluding them from the opportunity to learn from being part of a team.

There is help available for dyspraxia; the earlier you find it, the more chance your child has of overcoming these difficulties.

How does dyspraxia affect everyday life?

Dyspraxia may affect everyday life skills in many ways, both because of the motor difficulties and because of difficulties with organisation. Children may have problems with self-care, organising themselves and their belongings, and engaging with groups of other children.

They may also have problems with organising their thoughts, affecting organised mental tasks like mental maths, learning new skills, learning material for examinations, and planning timetables.

Dyspraxia can cause social and emotional difficulties as well as problems with self-organisation.

What is verbal dyspraxia or speech dyspraxia?

Verbal dyspraxia (sometimes called oromotor dyspraxia) is a problem with the articulation (formation) of words, which can make your child's speech more difficult to understand. Verbal dyspraxia can be present on its own, or alongside motor dyspraxia. It is sometimes called a 'speech sound disorder'.

Children with verbal dyspraxia often use a limited range of words and sounds. They can make unusual pronunciation errors and sometimes leave gaps between syllables of words. They may not be able to say all consonants and vowels, and their speech may sound different (rather than less mature) to that of other children of their age.

Some children with verbal dyspraxia also have difficulty with co-ordinating their tongue and lips during eating, which may make them 'messy' eaters.

Verbal dyspraxia is uncommon in small children, compared to functional speech disorders. These are when children 'mislearn' the way to say a word, because they find it much easier, such as saying 'f' instead of 'th' or saying 'w' instead of 'r'.

Types of dyspraxia

Some health professionals divide dyspraxia into different descriptive 'types', depending on which problems most affect your child. You may hear some of the more common 'types' discussed:

• Verbal (oromotor) dyspraxia.

• Constructional dyspraxia - this is to do with spatial relationships.

• Ideational dyspraxia - affects the ability to perform co-ordinated movements in a sequence.

• Ideomotor dyspraxia - affects organising single-step tasks.

These different presentations are all part of the same condition, but focusing on the areas of difficulty may be helpful for therapists trying to find the best strategies to help.

How is dyspraxia diagnosed?

If you are concerned that your child may have dyspraxia, you should discuss this with your health visitor or your GP, as well as your child's teacher. Depending on the pathways in your area, referral may be via the GP or via the school or nursery, and it may be to a paediatrician or to a Child Development Centre.

Dyspraxia is usually diagnosed after assessment of your child by one or more healthcare professionals including a paediatrician, a physiotherapist, a speech and language therapist, an occupational therapist and a psychologist.

They will observe your child and look at their ability to carry out everyday activities and play. They may ask your child to perform certain tasks, depending on their age, such as throwing or kicking a ball, drawing, tying shoelaces and taking off and putting on their coat, etc. You may also be asked questions about your child's development and abilities.

During the process of diagnosis the health professionals will be considering the other possible causes of similar symptoms, including the various conditions which can overlap with, or co-exist with, dyspraxia. These are discussed below.

If you think that you have undiagnosed dyspraxia, it is not usually possible to get this assessment on the NHS in adults. If you are still in education then your college or university may be able to arrange it, otherwise you would usually have to sort out a private assessment.

What is the treatment for dyspraxia?

The treatment for dyspraxia is based around helping children to learn the skills they need, often through breaking down complex activities into simple ones. The principle of treatment is that it is repeated practice that helps our brains make new and effective nerve connections.

We know that most tasks that humans can learn, including physical and mental tasks, can be improved by the right kind of practice. Some people talk about a 'ten thousand hours rule' - which suggests that we can become experts in anything that we have practised for ten thousand hours.

Early diagnosis can help children to address and manage their difficulties, and reduce the impact of the condition by helping them catch up with their peers.

Treatment will usually involve one or more people from the same team of healthcare professionals who were involved in the diagnosis of dyspraxia. For example:

• An occupational therapist can help your child with everyday activities at home and school, such as eating, getting dressed and holding a pen or pencil to write.

• A physiotherapist may help with motor skills.

• A speech and language therapist can help their speech and communication (see below).

• An educational psychologist may help if your child is having difficulty progressing at school.

• One treatment approach is a 'task-based' approach called perceptual motor training. This involves giving your child a series of different tasks to practise.

• Learning a musical instrument may be particularly difficult for children with dyspraxia, but this may be why it is sometimes effective (since it involves repeated practice in a situation where it is permitted to do badly and make mistakes). Learning to play the piano or guitar, for example, may not only interest a child but also develops motor, co-ordination and memory skills.

Whatever treatments your child is offered, it is important for you to encourage them to practise, as they will learn through repetition. There are no medications, scans or blood tests that can help with dyspraxia, although some companies offer these things for sale. Patients and their parents should be advised to avoid them.

Children with dyspraxia also benefit from extra help at school, where it is important that they are encouraged to do the things they find difficult, rather than being allowed to avoid them.

See below for particular things that you, and your child's school, can do to help.

What is the treatment for verbal dyspraxia?

Verbal dyspraxia is treated by speech and language therapists. Treatment and progress are often quite slow. Some children need to learn to sign in order to help them communicate with less frustration.

Most children will improve, given the right help. This usually means one-to-one sessions with a therapist, together with exercises which you will be given to practise with your child. As with the making of motor connections in the brain, it is likely that it is the repeating of tasks which helps children make the connections they need to improve their speaking skills.

What can I do to help my child with dyspraxia?

The biggest thing that you can do is encourage your child, realising that things that you may think should be easy to learn may be much harder.

• You can help them to process and organise tasks by helping break things down into a series of tasks (so that, for example, getting dressed is tackled as a series of many tasks to be learned one at a time). Rehearse and practise things and try to establish a sense of routine so that your child starts to realise the order in which things should be done (underwear first, for example).

• Help young children to improve their memory and organisation by asking them in detail about their day. Rehearse the order in which everyday routines, such as getting dressed and having breakfast, occur.

• You can help your child plan by keeping a family calendar, making lists and helping them put their things away in an orderly manner. Labelling their drawers and cupboards may help them organise.

• Help them practise the things they find difficult. Use recreational time for physical activities like playgrounds and family ball games. Encourage small gains. Hand-eye co-ordination can be improved by using a small racquet, for instance. Look for toys that appeal to your child and that might help them with using their hands ... and help them in their play.

• Some children with dyspraxia take up musical instruments and, because they enjoy the music, will do the practice that improves motor skills and memory. This isn't for everyone, but for some children it can be very helpful.

• The biggest thing that you can do is to persuade your child, positively and optimistically, to keep trying to learn the things that are difficult, and to help them see the small improvements they will make. Things that they give up at, they won't get better at - but things that they don't give up at, they will get better at. Give

Can dyspraxia get worse with age?

Dyspraxia is not an illness and it won't get worse in the way that some illnesses do. However, because it can affect children in different ways at different stages in their lives, it may have more impact at some stages than at others. This is because the way it affects children depends in part on what challenges they are facing, and what demands are being made of them.

What goes wrong in dyspraxia?

Dyspraxia is thought to be a problem with the way the connections develop between some of the nerve pathways in the brain. These connections are not all present at birth - they develop as we learn to do things as a child (this is sometimes referred to as brain 'plasticity', or the ability of the brain to organise itself according to the tasks it is given).

The process of learning tasks like walking, hopping or playing an instrument depends on our doing the repeated activity, and our nerves learning to make the connections that the activity requires. New connections form as we learn the activities, and these connections become more permanent and effective as we repeat those activities.

For example, the formation of a set of nerve connections in order to learn to hop on one foot, involves:

1. Practising the activity (in this case, hopping on one foot).

2. Input from the senses - for example, the sense of touch, balance and vision. This input comes via 'sensation' nerves called sensory neurons.

3. The integration of this information in the brain, to understand what is happening.

4. Brain planning of a movement in response.

5. Passage of instructions from the brain to the muscles via nerves called motor neurons.

6. Responding action by the muscles.

Our ability to learn new tasks (and to form new connections) is greatest in childhood; however, in children with dyspraxia, it is thought that the fifth step in this process, involving connections to the motor neurons, develops at a slower rate.

Similar processes are involved in learning mental tasks, such as learning multiplication tables or learning the lines in a play.

What kinds of things help children with dyspraxia at school?

Dyspraxia can cause classroom learning issues that may affect your child's progress, and also their self-esteem. Teachers may think a child with dyspraxia is not trying hard enough, or allow them to opt out of team sports or extra lessons.

Dyspraxia often impacts on writing, reading and spelling, so your child may need more time to process new tasks. A step-by-step approach can be helpful. Handouts to back up what has been taught in class, and headings written on whiteboards, can help.

One of the unfortunate effects of dyspraxia can otherwise be that, because children do not seem to be 'good at' things like sport, or art, or making things, they are not chosen for those roles and so they practise them less. The gap between them and the children who are 'good at' sport becomes greater, and the competitive nature of school teams tends to encourage this. Try to keep your child playing sport. It is important for schools to include everyone, as well as to encourage healthy competition. This may mean having several teams and being quite organised - but this is the school's problem, not your child's.

Teachers who know your child has dyspraxia are more likely to understand and provide support if your child seems not to be engaging with lessons. The following are some strategies that may be helpful at different stages:

Early school years

• Provide balance or wobble boards, walking on the line and hand-to-hand throwing using bean bags or water-filled balloons.

• Practise multi-sensory letter formation - eg, sandpaper letters and sky writing. Use pencil grips.

• Supply timetables, daily diaries and instructions for specific activities in sequenced picture cards.

• Some children will find recorded materials a useful aid to learning.

• Make a list of class rules to which your students contribute. This can help all students with social skills.

• Offer support with tasks needing fine motor skills.

• Repetition (sometimes called over-learning) is crucial for children with dyspraxia.

• Children with dyspraxia may find it easier to write using wide-barrelled pencils and pens, or those with rubber grips to their writing utensils. Graph paper and lined paper can help with letter placement and spacing.

• Children with dyspraxia should sit at the front of the room as they will be less distracted and will have a greater sense of one-to-one engagement with the teacher

• Repetition, positive feedback and encouragement.

Later school years

• All of the above

• Handwriting needs practice - but handwriting is hard for some children with dyspraxia, and this can get in the way of class learning. Pairing children with note-taking buddies, or giving the class handouts may help. This way the child can engage with the lesson without worrying about writing it down.

• Touch-typing skills can be very helpful to children with dyspraxia. The earlier they learn this, the sooner they will benefit. Courses for children, such as the TTRS course, are designed to help children with learning difficulties.

• Offer extended and flexible deadlines for homework.

• Directions should be emphasised in step-by-step form. This will help all children. Using checklists for complex assignments will help organisation.

• Introduce children to written planning skills such as bullet points and paragraph headings.

• Encourage team membership and participation in sport.

• Repetition, positive feedback and encouragement!

The Dyspraxia Foundation (see Further Reading below) offers information sheets and has pages offering classroom guidance on how best to help children with dyspraxia. Which ones work for your child will depend on how exactly their dyspraxia affects them.

Is there anything good about dyspraxia?

It is very easy for an article about dyspraxia to be all about 'abnormalities', and things that seem to make your child less able. Children are far more complicated and clever than a 'label' like dyspraxia suggests.

Dyspraxia presents huge challenges to children, but learning to overcome challenges can give them advantages that other children don't always have, because if you don't have to try so hard, you may never learn to persevere.

Children with dyspraxia learn to compensate for some of the things they find difficult. They are often 'holistic' problem solvers who learn to think creatively because they are forced to find a way. Learning certain skills may take them longer but, if they are encouraged and helped along the way, they may learn a perseverance and commitment to tasks that children who are 'luckier' with their abilities never learn. Some of the 'shortcuts' that may help them at school, such as learning to touch-type (so that being allowed to use a laptop in examinations overcomes handwriting difficulties) may be a huge help in later life.

Dyspraxia does not affect intelligence. However, memory tasks like learning lines or 'times tables' may take longer to manage. Once learned, though, they are just as much learned as in a child who did not have to work as hard. Children with dyspraxia have the same potential as other children; it may just take them longer to get there.

What is the difference between dyspraxia and dyslexia?

Dyslexia and dyspraxia are the two most common specific learning difficulties. They often go together, with some studies suggesting that as many as half of children with dyslexia also have dyspraxia. The two conditions are probably about equally common, and there is some overlap between the symptoms, particularly in the case of verbal dyspraxia.

Dyslexia mainly affects the development of literacy and language-related skills. People with dyslexia may struggle to process some sounds and to perform 'routine' language tasks like decoding reading. Like dyspraxia, dyslexia can affect children's self-esteem and school performance.

What else could cause the symptoms of dyspraxia?

There are several other conditions which can cause clumsiness and poor co-ordination in childhood. If you or others think your child may have dyspraxia it is important that you and your doctors consider these possibilities. They include common conditions such as visual or hearing disturbance, as well as some rarer conditions:

• Attention deficit hyperactivity disorder (ADHD).

• Poor vision - if children don't see well they may disengage in class at school and may be more prone to tripping and 'clumsiness'.

• Hearing difficulties (temporary or permanent).

• Functional speech disorders.

• Emotional distress.

• General learning difficulties.

• Medical causes of neuromuscular problems - eg, cerebral palsy.

• Muscular dystrophy (this is a rare condition that tends to run in families).

• Genetic disorders (eg, Down's syndrome).

What is the outlook for children with dyspraxia?

There is no cure for dyspraxia but the condition can improve as a child grows and adapts. Early diagnosis and treatment of dyspraxia are very important. This is because the brain changes and develops rapidly during a child's first few years of life. It is during this time that new connections are made within the brain and nervous system and a child starts to develop new skills and abilities.

If dyspraxia is diagnosed and treated as early as possible in a child's life, they will have a greater chance of improvement. Work on a child's self-confidence, feelings of belonging and helping them to participate in daily activities is very important.

Some children with dyspraxia will continue to have difficulties with co-ordination, organisation and learning as adults. Other children, particularly if their dyspraxia was less severe, will improve as they mature, and learn (and are taught) how to overcome their difficulties.

This may be partly due to having worked on their motor skills through practice, and may also be because allowing them as adults to choose roles that play to their strengths allows them to adapt to manage their dyspraxia.

Where can I find further information and support on managing dyspraxia?

There are a number of organisations offering help and support. In the UK, Dyspraxia UK offers information sheets for children, teenagers and adults, and advice and support for those affected and for their families. In the USA, the Dyspraxia Foundation offers similar support and advice. See Further Reading below.

Linked conditions

• Dyspraxia in adults is sometimes linked to other conditions which can be present at the same time. These include attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorders (ASD).

• Poor sleep, stress and depression are common.

• Adults with dyspraxia can be prone to low self-esteem, emotional outbursts, phobias, fears, obsessions and compulsions, and addictive behaviours.

Dr Mary Lowth is an author or the original author of this leaflet.