Dyspraxia

What is dyspraxia?

Dyspraxia is a motor disorder of the co-ordination of intentional movements, and so it affects complex muscle activities such as handwriting, balance, ball skills, and dancing. Dyspraxia is a developmental disorder, which means that it affects the way the parts of the nervous system that co-ordinate these kinds of activities develops in childhood. As a result, motor 'milestones', such as the age of first walking, tend to be delayed.

Dyspraxia in children can also affect other activities which involve co-ordination of muscle and brain activity, including speaking, intellectual ability and organising complicated tasks. Dyspraxia does not affect intelligence. It does, however, place extra hurdles in the way of children during their educational years.

In any group of children there is a broad range of abilities, and children develop at different rates. Children with dyspraxia are not abnormal children; they are the group of children whose motor co-ordination is developing most slowly, so that some things are harder for them to learn. This doesn't mean the skills which they find difficult cannot be learned, just that children with dyspraxia will find them harder to learn than other children do.

Dyspraxia symptoms

Dyspraxia can affect different children in different ways and to different degrees.

Some children may just have mild problems with co-ordinating their movements, whilst others are more severely affected. The problems may interfere with a child's ability to participate and function in daily activities and life skills, including education. For many people, dyspraxia can persist into adulthood and so work and employment may be affected. Having dyspraxia doesn't mean that a child is any less intelligent but it does mean that their learning ability is affected.

Symptoms of dyspraxia in preschool children

• Is 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.

What causes dyspraxia?

We don't know why some children have dyspraxia. However, for any human ability there is a broad range of 'normal', with an average, and some of us more or less able than others. Just as some children have much better co-ordination than average (including some who, for example, go on to become successful sportspeople or dancers), others may have much worse co-ordination.

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, although exposure to these toxins will have many other additional effects too.

Why is dyspraxia important?

Dyspraxia affects your child's learning of many of the tasks they need for success. If they don't have the help and understanding they need then they can become discouraged. Many children with dyspraxia develop low self-esteem. To avoid this, others give up on the things they find difficult, so losing the opportunity to develop and improve that children who are more able in those areas can take advantage of.

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

What is dyspraxia in children like?

Dyspraxia particularly tends to affect co-ordinated muscle movements of various types. Doctors talk about children's development in terms of 'fine' and 'gross' motor skills. Dyspraxia can cause delay in the development of both types of skills, although the pattern and severity will vary between children.

The 'typical' child with dyspraxia struggles with handwriting, avoids sport, is disorganised and a bit messy, and can seem naughty or difficult because these difficulties can make it harder for them to do the things they want, need, or are expected to do.

How does dyspraxia affect gross motor skills?

These are movements that involve the large muscles of the body or groups of muscles. Examples of gross motor skills are walking, jumping, running, hopping on one leg, kicking a ball, managing the stairs and throwing an object.

Children with dyspraxia typically walk later than the average child. They may have poor 'ball skills' when it comes to trying to kick or throw a football, and it may be a long time before they can manage the stairs. They may have difficulty keeping their balance and riding a bike. Some children with dyspraxia are mistakenly thought to be 'clumsy' or careless.

As children progress through school those with dyspraxia are often seen as not 'natural' sports players. This can result in them losing interest in sport and excluding themselves from team sports. This is likely to make things worse, as they won't be practising and improving their skills as their peers do.

How does dyspraxia affect fine motor skills?

Fine motor skills - this means problems with performing tasks that are carried out by the smaller muscles of the body, including the muscles of the hands, feet and head or face (including the tongue and the lips). They are more difficult and delicate movements. Examples include handwriting, drawing, painting, doing a jigsaw puzzle, using cutlery and pronouncing words.

Children with dyspraxia may therefore tend to be untidy in their schoolwork, may manage a pencil late and may tend to break things unintentionally when trying to do fine work. Their 'hand-eye' co-ordination may be affected, so that everyday tasks like tying shoelaces and buttoning shirts are difficult.

This may affect their school performance early, as learning fine motor skills like handwriting tends to be a focus of the early school years. If dyspraxia is recognised at this stage, children can be given extra help in developing their skills, rather than being told off or made to feel they are not trying hard enough.

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 in engaging with groups of other children.

They may also have problems with organising their thoughts, which can affect 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. Your child's teacher or a special needs co-ordinator in school may also be a good person to speak to. Your GP may suggest that your child be referred to a paediatrician or to a Child Development Centre.

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

The assessment usually involves healthcare professionals observing your child and looking at your child's 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.

What are the tests for dyspraxia?

There are no specific blood tests or other investigations that are usually needed unless the healthcare professionals want to rule out any other underlying problems. The diagnosis is made through talking to you and examining your child. Sometimes, depending on the age of your child, reports from school will also be helpful.

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.

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 of dyspraxia in children means that treatment (which essentially is directed at practising and improving motor skills) can be started early. This will help children 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 work with your child to 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 likely to be important for you to encourage them to practise, as it is through repeating and over-learning tasks that their 'nerve connections' will become effective.

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 - lots of children describe the misery of being forced to learn an instrument - but for some children it can be very helpful.

• Repetition, positive feedback and encouragement: 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.

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.

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.

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.

What is dyspraxia in adults?

Children with dyspraxia may go on to be adults with dyspraxia, but the degree of difficulty this causes them will depend on how severe their dyspraxia was in childhood, how it was approached and what challenges they take on as adults. Some children with dyspraxia may overcome some of their difficulties. Others will have chosen areas of work that play to their strengths. However, for most, problems will persist in adulthood and cause ongoing difficulties.

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.

What are the symptoms of dyspraxia in adults?

The symptoms of dyspraxia in adults are very variable. They may include:

Problems with motor skills

• People with dyspraxia may be clumsy, and be less able than average at motor tasks - eg, poor at ball skills and 'co-ordination' sports like tennis and football.

• They may have a lack of rhythm when dancing and may dislike dancing or feel 'silly' if they try to do it.

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

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

Problems with thought organisation

• Many different kinds of routine tasks can be more difficult and this can cause difficulties with some types of employment - for instance, if organisation and planning are needed and you find them very hard.

• Difficulty organising thought processes, so that planning is difficult and memories are not well organised. May find mental maths particularly difficult, and short-term memory poor.

• Difficulty reading books - problems with eye tracking, so tending to lose their place.

• More difficult to learn new skills in education and work, affecting promotion prospects.

• Lack of personal organisation can lead to untidiness and failure to finish important tasks.

• May tend to opt out of or avoid difficult tasks.

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.