Developmental Coordination Disorder

At Brad's recent evaluation (second opinion), the developmental pediatrician gave Brad a new diagnosis - "developmental coordination disorder" or "DCD." DCD is often used interchangeably with the term "dyspraxia." In theory, DCD is the term favored in the US, although in my experience, dyspraxia is widely used in common parlance in the US.

The New York Times reports that approximately 6% of school age children have some degree of this disorder. Like PDD and sensory processing disorder, DCD is hard to define.

The DSM-IV criteria follows:

A. Performance in daily activities that require motor coordination is substantially below that expected given the person's chronological age and measured Intelligence. This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling. sitting), dropping things, "clumsiness," poor performance in sports, or poor handwriting.

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living.

C. The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia. or muscular dystrophy) and does not meet criteria for a Pervasive Developmental Disorder.

D. If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it.

In light of C (above), technically, Brad's PDD diagnosis should rule out DCD. (Or maybe it's the other way around?) Moving on.

Wiki describes the motor challenges associated with DCD as follows:

• Poor timing.
• Poor balance (sometimes even falling over in mid-step). Tripping over one's own feet is also not uncommon.
• Difficulty combining movements into a controlled sequence.
• Difficulty remembering the next movement in a sequence.
• Problems with spatial awareness, or proprioception.
• Some people with dyspraxia have trouble picking up and holding onto simple objects due to poor muscle tone.
• This disorder can cause an individual to be clumsy to the point of knocking things over and bumping into people accidentally.
• Some dyspraxics have difficulty in determining left from right.
• Cross-laterality, ambidexterity, and a shift in the preferred hand are also common in people with dyspraxia.
• Dyspraxics may also have trouble determining the distance between them and other objects.
• Some dyspraxics have difficulty achieving and maintaining continence either of bladder or bowel or both. Bedwetting or nocturnal enuresis is common.

Wiki indicates that the following speech and language problems are associated with DCD:

• Difficulties controlling the speech organs.
• Difficulties making speech sounds
• Difficulty sequencing sounds within a word
• Forming words into sentences
• Difficulty controlling breathing and phonation.
• Slow language development.
• Difficulty with feeding

The Wiki description certainly fits Brad's present condition, but I'm skeptical as to the role of dyspraxia with respect to Brad's speech for two reasons. First, the Wiki description is unofficial and therefore should not be relied upon as authority. Second, Brad had a significant receptive language deficit at 24 months. (Early Intevention pegged his receptive language at 10 months when he was 24 months old.) My understanding is that a motor planning deficit, such as DCD, does not cause a receptive language delay (although it could cause an expressive language delay because talking itself requires motor coordination or praxis). Moreover, DCD doesn't account for the Brad's social deficits. While dyspraxia may play a role in Brad's speech challenges today, including phonological problems and stuttering (or "groping"), DCD doesn't appear to tell the whole story.

Update: The DCD label was included in Brad's "impression" report; it was part of his official diagnosis.

SLP vs BE

That's autism geekspeak for speech language pathologist (SLP) versus behavioral expert (BE).

Brad's SLP, my most trusted advisor in all things Brad, is going to sit in for one of Brad's Floortime sessions, administered by the "specialty provider", who is really an ABA provider (also referred to as a "BE"). The SLP is going to try to give the BE some gentle guidance on Floortime.

Who will be the victor?

Back to our regularly scheduled programming.

A quick update on Brad's services:

Brad's early intervention services have exceeded my expectations on many levels. Brad's speech language pathologist and occupational therapist are both trained in Floortime, and work the philosophy into the therapy. So they, along with the developmental specialist, are working in concert to foster his overall development, rather than focusing exclusively on their discrete specialties. The results have been incredibly positive. Brad's speech has exploded, he attends better, follows directions better, uses speech spontaneously, often seeks social praise and his muscle tone has greatly improved. We do OT exercises every day, which he seems to genuinely enjoy.

The "specialty service provider" is underwhelming. In theory, we're getting Floortime, but in practice, it's really ABA on the floor, minus the M&Ms. It's entirely instructor-led, not child-directed. Also, they appear to be using the same progress and evaluation system used for ABA, in that the daily notes aren't notes at all - they're plus and minus signs. For example, under the row heading "responds to name", there will be plus marks for when he responds and minus marks for when he doesn't. She's graphing it too. I'm not an expert, but I believe these working papers are the tools of the behavioral approach. Which is fine, but it's not what we signed up for.

Also, the therapist uses "prompts." For example, when Brad doesn't respond to his name, she touches his face. Well Brad doesn't like that. At all. Brad's speech language pathologist confirmed that such a prompt is inconsistent with a child-led approach.

I'm going to continue with the specialty provider through May 12, which is when I have my next visit with the developmental pediatrician. At that point, I'll have a better indication of his hearing as well. Unless my developmental pediatrician talks me out of it, I'm inclined to kick the specialty service provider to the curb.

The wheels of bureaucracy in motion.

Brad is now modestly ramped up on services. His schedule:

• Monday:
  9-10:15 Early Intervention playgroup (toddlers, an integrated program)
  3:15 - 5:15 Floortime with specialty provider
  
• Tuesday:
  8:45-9:45 Speech pathology
  
• Wednesday:
  9-10:15 Early Intervention playgroup
  3:15-5:15 Floortime with specialty provider
  
• Thursday:
  8:45-9:45 Floortime with speech pathologist
  10:00-11:00 Occupational Therapy
  3:15-5:15 Floortime with specialty provider
  
• Friday:
  3:30-4:30 Developmental specialist
  
  Total: 12.5 hours

So far, we're genuinely impressed with the Early Intervention services. In particular, Brad's speech pathologist, Robin, is a real angel. She comes twice a week, once for traditional speech pathology, and once for Floortime. Robin is formally trained in Floortime, and she genuinely embraces the child-led approach. All of her notes are really positive. She sees Brad's potential, and she does everything she can to tap into it. At a time when I'm looking for hope, she gives it to me.

The jury is still out on the specialty provider. Turns out the Floortime therapists are ABA therapists cross-trained in Floortime. I think in the normal course, they'd go to some one's house, perform an hour and a half of ABA, and maybe mix in a half hour of Floortime. So when I said "no ABA", they were a little stunned. And from what I can tell, their version of Floortime isn't truly child-directed. That's the bad news. The good news is that Brad's therapist, Sinead, is a real pro, and Brad seems to have taken to her already. And when she teaches him something, she does really drill it into him. For example, last week she taught him "I want", and now it's in high rotation in his verbal repetoire. (For better or worse.)

"Early intervention sucks"

No, I don't really think that early intervention sucks. On the contrary.

The heading of this post - my inaugural post - was the first thing I googled when Early Intervention flagged my son for autism. Self-serving quacks, I thought. There must be a gripe site dedicated to them.

And that's how my journey began. Denial and anger. That was January 25, 2008, just 13 days ago.

Even Google knew the error of my ways. My search prompted it to ask: "Did you mean to search for early intervention success?"