1.Motor skill disorder and its diagnosis
Motor skill disorder is also known as developmental motor coordination disorder (DCD), which was once called “awkward child syndrome”. It is a specific developmental disorder, whose main characteristic is the obvious impairment of motor coordination, and its skills are assessed by standardized motor skill test to be more than 2 standard deviations below its age expectation. The prevalence rate abroad is about 1.6-6% in school-age children, more males than females, about 2.3:1. As there is no perfect diagnostic scale for motor skill disorders in China, the reported prevalence rate varies greatly and there is no authoritative statistical data yet. Most children with motor skill disorders have abnormal motor development in infancy and early childhood. Early prevention and intervention of motor skill disorders is a motor function abnormality that should be emphasized by pediatric neurologists, child development, neurorehabilitation, and pediatric clinical psychologists in addition to cerebral palsy, and long-term follow-up evaluation of early motor development abnormalities should be emphasized.
Numerous studies have shown that children with motor skill disorders often have multiple disorders coexisting as the DAMP syndrome, i.e., attention deficit, motor skill impairment, learning difficulties, and psychosocial adjustment difficulties, in addition to often being accompanied by apprehension/anxiety and behavioral problems. Motor skill deficits often pose significant difficulties in daily life and can severely impact academic achievement, and the deficits may not disappear with age.
Effective motor skills are the result of the interaction of intact neuromotor structural functions, environmental stimuli, genetics, and the psychological motivation of the individual. Complex motor skills, such as writing and drinking, require a complex series of movements and coordination of multiple movements, as well as a normal level of intelligence, movement pre-design and planning, timely movement modification in response to environmental changes, and coordination of movements. Research and clinical practice have confirmed that the causes of movement disorders are diverse, including many individual neurophysiological, environmental, and psychological factors, and minor injuries to frontal motor areas and supplementary motor areas, cerebellum, brainstem, and basal ganglia are considered to be the main causes.
The manifestations of motor skill impairment are diverse and vary in severity. Common symptoms are manifested in six major areas: abnormal muscle tone, lack of planning of movement, dyscontrol of movement, difficulty in persistence of movement, lack of stability of movement, and defective coordination of movement. Most of the affected children have shown varying degrees of motor retardation or abnormalities from the early development of infants and children, manifested by abnormal muscle tone, difficulties in movement posture transformation, and ataxic coordination of fine or gross movements significantly below the level that should be achieved at their age, while in older children the main manifestations are as follows.
(1) Clumsiness: It often refers to simple motor movements that are not abnormal in themselves, but the organization of complex movements is impaired or immature, and the completion of skilled movements is clumsy, especially slow in doing fine movements, with large movement amplitude, often reflexive and inefficient; it is difficult to maintain a static posture for a long time. These children are prone to body imbalance and poor hand-eye coordination when throwing objects. Clumsy movements may involve a specific group of muscles (e.g., facial muscles, hands and fingers, shoulder girdle muscles), several groups of muscles, or even the whole body musculature. There are often visual-spatial-motor impairments, such as some degree of stereoscopic vision, and difficulty operating cognitive tasks. They are unable to successfully walk through mazes, and have poor block building, model building, ball playing, tracing, and map recognition skills. These children’s social adjustment may be affected, especially in learning, with dysgraphia. These children have difficulties in organizing, planning, and performing complex movements in addition to difficulties in organizing, planning, and performing complex movements. There are often abnormalities in perception and thinking, there may be impairments and delays in language, there may be some kind of speech difficulties (affecting especially the clarity of articulation), difficulties in chewing, etc. The specific form of motor clumsiness also varies with age.
(2) Incidental movements: The child mostly has associated movements, dance movements, tremors, and muscle twitches. Associative movements are the most common and may be homogenous (symmetrical) or heterogenous (asymmetrical). Twitches usually occur in the face, mouth, head, neck, and diaphragm.
(3) Dyspraxia: Also known as dyspraxia, children with motor skill disorders are unable to organize and perform a series of effective random movements and complete skillful movements, or have difficulty learning skillful movements, despite normal muscle strength and perception and the integrity of the neuromuscular structures that perform the movements.
(4) Specific skill use disorder: manifested as inability to write or difficulty in writing, drawing and constructing disorder, motor speech disorder, etc.
(5) Neurological soft signs: Neurological soft signs represent a group of heterogenous phenomena that often occur in younger children and disappear with age. If the signs are still present beyond a certain age (8 to 9 years), they are abnormal. Children with motor skill disorders often have positive neurological soft signs.
The above signs often overlap, with mild children often having only one or two abnormalities, and more than three being moderate to severe disorders.
Diagnosis
The diagnosis of motor skill disorder includes the steps of symptom, sign determination and differential diagnosis. Roughly, it includes the following elements and procedures.
(1) Primary symptoms, including information on current medical history, developmental history (especially development of motor skills in infancy and early childhood), maternal and perinatal status, family educational environment, and academic achievement of the child (reading, writing, and arithmetic skills). When taking a history of these children, it is important to know whether there have been any abnormalities in fine motor, gross motor, visual, adaptive, or physical activity during their development, and to evaluate them using standardized assessment methods. These children must be evaluated not only for motor skills, but also for associated or concomitant impairments.
(2) Medical testing (including physical examination, neurological examination, visual, auditory, electroencephalography, cranial imaging, etc.).
(3) Neuropsychological tests.
(4) Specific tests for assessment and evaluation. The specificity scales were selected according to different disorders.
(1) Clumsiness: Denckla’s Finger Tapping Test and Peg-Moving Procedures Test for Clumsiness can be used for the screening of clumsiness. Standardized tests can be used to assess the degree of clumsiness.
(ii) Incidental movements: The Fog Test (Fog Test) and the Associated Movements Procedures Screening Method adopted by Wolff et al. can be used for diagnosis and screening.
The Bruinink-Oseretsky Test (The Bruinink-Oseretsky Test) is a commonly used test for use disorders. The Bruinink-Oseretsky Test is commonly used to test for the presence and severity of dysfunctions by having children imitate different hand postures, perform gestural activities, and use actual objects (e.g., pens, teacups) in a normal way.
(iv) Specific skill use disorder: Writing inability can be tested by observing writing. The Bender-Gestalt test is used to allow children to imitate drawing. Imitation of architectural design can test for constructive disorders. The Reynell Developmental Language Inventory is used to screen for motor speech disorders.
⑤ Neurological soft signs: Screening can be done using the Neurological Soft Signs Examination and Neurological Examination Scale or the Child’s Neurological Microsigns Examination. examins examinations include counting, visual acuity testing, speech testing, nystagmus, eye symmetry, hand control, cross control of arms and legs, left-right self-orientation, left-right orientation to the examiner, bilateral hand stimulation, face-hand orientation, finger orientation, skin writing sensation, Stereoacuity, linked movements, finger-nose test, alternating movements, and passive head rotation.
(6) Southern California Sensory Integration Test: Dr. Jean Aryes designed the Southern California Sensory Integration Test (SCST), which consists of four tests: the Spatial Test (AST), designed to assess perceptual speed and spatial imagination; the Southern California Motor Accuracy Test (SCMAT), an objective instrument designed to measure fine motor discrimination and hand glance accuracy; and the Southern California Touch and Kinesthetic Test (SCKT), a six-item subtest designed to assess tactile and kinesthetic perception. (SCKT), a six-item subtest designed to evaluate perceptual dissonance induced by children’s body organs; and the SCFG, which evaluates an individual’s ability to select shapes from a background. It is a valid tool used to evaluate abnormalities in sensory integration and motor function in children.
Here, the Abilities of Young Children Test (AYCT), Kinesthetic Sensitivity Test (KST), and Mild Neurological Sensitivity Test (MNST) are also available.
Sensitivity Test), Examination of The Child with Minor Neurological Dysfunction, Test of Gross Motor Development, MOVEMENT ABC Test, and the Gonzalez ABC Test. MOVEMENT ABC Test) and the Rapid Neurological Screening Test compiled by Gong Yao Xian to assess motor skill disorders. These tests are some representative diagnostic tools. When selecting tests for the diagnosis of motor skill disorders, the child’s specific movement disorders in daily activities should be taken into account, and the appropriate tool should be chosen flexibly according to the child’s specific situation. The results should be judged with reference to age, gender, intelligence, level of cooperation, individual maturity and environmental background.
The diagnosis of motor skill disorders is often made during preschool and school age. Its diagnosis can be made using the following two diagnostic criteria. One is the diagnostic criteria for motor skill disorders in the 4th edition of the American Diagnostic Statistics of Mental Disorders.
① the motor coordination of life is lower than that of normal children of the same age, manifested by obvious motor delays, such as in walking, crawling, sitting alone, throwing, as well as clumsy sports performance and poor writing skills.
(ii) where the motor impairment significantly affects academic performance or daily life.
③ such motor difficulties are not caused by systemic diseases (such as cerebral palsy, hemiplegia or muscular atrophy) and do not correspond to systemic developmental diseases.
④Motor difficulties caused by intellectual disorders are not included in such disorders.
Second, the diagnostic criteria for motor skill disorders of the Chinese Classification and Diagnostic Standard of Mental Disorders, 3rd edition.
① fine skills, gross motor coordination is significantly lower than the level of children of the same age and their development should be.
② normal or basically close to normal intelligence.
③ Not caused by auditory-visual defects, neurological diseases, myopathies or joint diseases.
2.Early detection of motor skill disorder
(1) Pay attention to the follow-up of high-risk children: Paying attention to high-risk children who may have motor skill disorders and motor developmental delays that occur during infancy is one of the keys to early detection. In terms of etiology, perinatal injuries may play an important role. It is mostly believed that the disease is associated with high-risk factors and brain injury during pregnancy and perinatal period. Infants and children with intrauterine growth retardation, mild asphyxia, mild perinatal brain injury, prematurity, younger than gestational age, and malnutrition may be left with impaired motor skills, so regular follow-up evaluation of the early development of motor function in high-risk children should be emphasized. The acquisition of motor skills is also influenced by genetic and environmental factors, with the latter playing a greater role and affecting different individuals to varying degrees. Inappropriate parenting and child-rearing practices may also lead to deficits in motor integration and fine skills. Infants and children who lack comprehensive sensory stimulation early in development and lack training in the process of motor skill formation should also be given regular checkups. Follow-up examinations and evaluations can be conducted using the Gesell Infant and Toddler Developmental Scales, the GMFM Motor Function Scale, etc. In addition, more emphasis should be placed on motor and postural transition skills. Since the developmental abnormalities that accompany children with motor skill disorders may be multifaceted, children with motor skill disorders should also be evaluated in other areas of functioning, and those with motor developmental delays in infants and young children should also be followed up over time.
(2) Identify early manifestations of motor skill disorders: Early manifestations often vary with age and are manifested in infancy and early childhood as some difficulty in reaching psychomotor development goals, such as delayed motor skill development (or central motor coordination disorder) in hand grasping, sitting, crawling, running, putting on shoes, fastening and zipping. Parents and physicians often overlook subtle fine motor difficulties that are already present in early childhood, for example, in running, buttoning, and spoon holding, and that do not diminish or disappear with age, and these children do not have deficits in this area alone, but also in other areas, such as: attention deficit/hyperactivity disorder, learning disabilities, difficulty with writing, drawing skill deficits, etc. and delayed emotional maturation (disorder). These concomitant deficits may also worsen with age and appear in educational, social, and emotional problems.
(3) Effective management of early detection efforts: Emphasize the respective roles and responsibilities of parents or caregivers, community health practitioners, and specialists. Parents are often an important part of the earliest detection of problems. Developmental questionnaires and self-assessment forms can be given to parents on a regular basis, and through daily observation and attention by parents or direct caregivers, referrals are made to health care personnel for assessment and examination when abnormalities are detected. The health care provider conducts an initial developmental assessment of the infant or child with suspected motor developmental abnormalities identified by parents or others, and refers the infant or child to a specialist if there are abnormalities. The specialist will make a full assessment and diagnosis. In clinical practice, children with DCD are often seen for a particular presentation, such as clumsiness, learning difficulties, excessive inattention, behavioral problems, or/and emotional problems, etc. Clinical neurologists or psychiatrists often focus only on one of these complaints and ignore the other abnormalities. Therefore, multidisciplinary long-term follow-up and intervention for children with DCD is necessary. Long-term follow-up of children with prenatal and perinatal injuries should include neuromotor, psychobehavioral and cognitive development.
3. Early intervention and treatment of motor skill disorders
Motor skill disorders are receiving increasing attention from the medical, educational and psychological communities. In clinical work, how to correct movement disorders is also an extremely important research topic. Currently, there are two main aspects of its treatment: first, the need to pay attention to the early prevention or intervention treatment of motor developmental delay, so as not to eventually lead to motor skill disorders; second, the rehabilitation treatment of children with motor skill developmental disorders.
(1) Early prevention of motor skill disorders: Motor developmental delay is often an early manifestation of motor skill disorders. Since 0 to 3 years old is the main stage of motor skill development, among which 0 to 1 year old is an important period of gross motor development in infants and 1 to 3 years old is an important period of fine motor ability development in infants’ hands. Therefore, attention should be paid to the development of motor skills in this period. When parents are instructed to train motor skills, they should pay attention to the quality of movement postures and the training of the transition process of movement postures, and avoid premature training of age-inappropriate movements or skipping a certain movement stage in the process of learning motor skills, for example, going directly to the standing and walking stages without going through crawling.
① Early intervention and training goals for gross motor ability development: According to the different ages and characteristics of motor development delay, the training contents are formulated to achieve the goals of head lifting, turning over, sitting alone, crawling, walking alone, standing on one leg and leaping on one foot in order of development, so as to achieve the development of enhanced trunk and limb strength, body coordination, body balance and ability to control the balance of objects.
② Early intervention and training goals of fine motor skills: according to the characteristics of different ages and motor development delays, the training contents are formulated to achieve the following goals: to train infants’ ability to work with both hands, to develop different division of labor and cooperation between infants’ hands; to develop grip strength and flexibility of fingers, and the ability to control objects with fingers; to develop infants’ grasp of distance, volume and spatial concepts of objects; to develop infants’ ability to discover The infant is trained to discover the characteristics of objects and to express the infant’s needs through the use of objects; the infant is trained to grasp his or her own balance and to develop the balance of objects, and to know how to use and create balance. Infants develop their own balance, their coordination, and their ability to control objects; they train to master the laws of social life and communication, and to demonstrate their mastery of these laws through the control of objects. The infant develops finger dexterity and the infant’s ability to respond to social norms through movement; it trains the infant to generate and develop the ability to construct ideas; it trains to conceive the content of its actions and to realize them through its hands.
In the process of training gross and fine motor skills, it is important to set milestones. Special attention should be paid to the training and psychological training of the learning process of various motor skills.
(2) Rehabilitation treatment for children with motor skill disorders
Sensory integration training: It is an important and commonly used rehabilitation method for children aged 4 to 12 years old. Its meaning is to provide adequate sensory stimuli such as inner ear vestibule and skin touch, and to scientifically and appropriately control the amount of stimulus input and environment, so that children can gradually and consciously form compliance and adaptation, and then stimulate their self-confidence and potential, and eventually improve their coordination and control ability. According to the types of sensory stimuli, the correction methods of sensory integration disorder are classified into tactile stimulation therapy, vestibular stimulation therapy, proprioceptive stimulation therapy, and compliance response. Due to the individual differences of children, sensory integration training is beneficial for the correction of some movement disorders, but it is not effective for the correction of all movement disorders.
②Motion therapy: It is an effective treatment method to correct movement disorders and improve individual movement behavior. The neuromotor skill target training (NTT) method is often used. The method is that the therapist helps the child to integrate or break down the required training or specific tasks into effective motor behavior patterns, motor control, and motor learning in order to facilitate more complex fine and coordinated movements. One of these methods is: recording the breakdown of the movement to be trained in an interactive format on a CD; having the child watch the interactive CD video; and imagining the movement to be imitated.
Step-by-step implementation of the movements. In movement therapy, children are provided with a series of movement activities based on the theoretical principles of movement development and psychological development, including tension-relaxation control exercises, body awareness training, movement imagery training, and somatic perception training to help develop basic movement skills such as walking, running, and jumping in a gradual manner, in order to improve movement coordination, body balance, and the ability to consciously control the movements of various body parts. To achieve the purpose of improving movement disorders, fine and complex movement skills, and enhancing mental health.
③Psychotherapy: Psychotherapy can also be given during the process of sensory integration training and movement therapy. Behavioral and psychological support therapy is often used.
In order to enable the child to focus on cooperation with the treatment, and to make the treatment and education at the same time, the principle of combining treatment-play-education should be used. The role of parental involvement is also emphasized.