Running head: DCD 1

Developmental Coordination Disorder: A Case Study about Natalie

Mariana Hall, Elizabeth Hares, Sam Mitchell, Sylvia Niemyjski, Tiffany Poon, & Emily
Severance
Touro University Nevada
























Developmental Coordination Disorder 2

Occupational Performance
Natalie is a six year old girl with developmental coordination disorder (DCD) who lives
at home with her immediate family and maternal grandmother. She has a twelve year old brother
and a four year old sister. Natalie participates in a regular education classroom and receives
support from a special education teacher who consults with her classroom teacher. She also
receives occupational therapy and physical therapy services twice a week for thirty minutes per
visit at school. Natalies functional performance as a student is impacted by her poor
coordination, bilateral coordination, and fine motor skills. She walks independently but tires
easily. Natalie was also recently diagnosed with a learning disability. She has good persistence
and a high frustration tolerance when participating in activities that she enjoys (freeze tag,
concentration memory, and cooking). Natalie has very supportive parents who want to help her
to become more successful in the academic setting.
Activities of Daily Living
Natalie requires minimum assistance when getting ready in the morning. The Pediatric
Evaluation of Disability Inventory (PEDI) was administered and scores indicate an age delay in
accomplishing dressing using fasteners only; all other scores on the PEDI were within age level.
Natalie needs assistance before and after using the restroom to button and unbutton her pants.
She also struggles to independently turn on and off the sink to wash her hands due to her poor
bilateral coordination. Natalie has problems self-feeding while at school. She struggles to open
ziploc bags and containers that hold her lunch items. Additionally, Natalie needs assistance when
her shoes become untied throughout the day.
Instrumental Activities of Daily Living
Natalie is responsible for cleaning up for herself during lunchtime. Natalie is
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independent in this area when she brings lunch from home. She is able to clean up after herself
only utilizing her dominant hand and avoids performing bilateral task when possible. However,
when buying lunch at school, Natalie has difficulty carrying and manipulating the lunch tray and
requires moderate assistances. In terms of mobility, Natalie tires easily when transitioning
between classrooms (as assessed by the SFA). She often stops to rest, leans on the wall, and
often lets all other students go ahead of her. Natalie also trips and bumps into desks and tables
occasionally due to her decreased coordination. With regard to emergency responses, Natalie has
completed two fire drills per year in first grade and kindergarten. She has been assigned a
classroom buddy to hold hands with to ensure that she gets out of the building quickly yet safely.
Play
At recess, Natalie does not participate fully on the playground. She prefers to sit and
watch others chase after each other and play games. She enjoys watching others play kickball
and baseball, but rarely joins her peers to play. During physical education classes, her teacher has
a hard time getting Natalie to participate. The teacher does grade certain activities, which
prompts Natalie to want to engage in the activities, even though it takes her longer to complete a
gross motor tasks than her peers. After school, Natalie is normally tired and does not like to play
games that require a high energy level with her siblings.
Leisure
As previously mentioned, Natalie likes to help her parents cook dinner simple meals
when shes allowed to help, and she enjoys baking activities. She also loves card games; her
favorite is concentration memory. Although she does not always enjoy gross motor activities, she
likes participating in musical chairs and freeze tag with her friends. Natalie likes to watch
television with her grandmother and siblings on the weekends. Her parents limit her television
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viewing during the weekdays to one hour per day.
Social Participation
Natalie is friendly and outgoing. She has many friends in the classroom, but tends not to
play with them at recess. Natalie sometimes distracts her peers throughout the day by talking and
starting conversations, because of her inability to complete academic activities that are
challenging for her. She has occasional sleepovers with her closest friend from school. Natalie
does not have problems interacting with her parents, grandmother, or siblings at home. She
maintains good eye contact when socializing with peers and interacting with adults within the
community.
Education
Natalie is currently in the first grade, and was placed in a regular education classroom
with occasional support from the special education teacher. Natalie has difficulty with fine motor
tasks and tasks that require bilateral coordination, therefore, many academic activities throughout
the school day are challenging to her. Natalie cannot use scissors independently, and gets easily
frustrated during classroom art activities. Natalies handwriting skills are also poor. She struggles
when engaging in far point visual tasks, such as copying her homework assignments into her
planner from the whiteboard). Natalies parents are happy with her progress in her reading
abilities. Postural stability also becomes an issue when sitting for long periods of time. Natalie is
often seen demonstrating poor posture, or leaning on her desk for support.
Rest/Sleep
Natalie is independent in her nightly routine to get ready for bed (except for needing
assistance with zippers and fasteners on her pants). Natalie sleeps well throughout the night, and
goes to bed at a similar time throughout the week. She falls out of her bed occasionally, and
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sometimes trips when getting into and out of bed. Her parents have recently installed a bed guard
to address this problem.
Movement, Postural Reactions, and Reflexes
Movement
Natalie can walk unassisted, but becomes fatigued quickly. When transitioning between
classes she stops and rests frequently. During community outings, she does not utilize any
assistive technology devices, but chooses to sit whenever possible. Her muscles are fully
developed, but she demonstrates weak postural stability when sitting, standing, and walking.
When participating in games that require advanced gross motor abilities, Natalie can execute
tasks but performs them much slower than her peers. She also occasionally trips and bumps into
her surroundings. Activities that require bilateral coordination are extremely difficult for Natalie.
Similarly, she has trouble performing fine motor tasks. Natalie cannot open and close zippers,
buttons, or fasteners without assistance. Handwriting is also a major concern.
Postural Reactions
Natalie has low coordination and postural stability which results in immature postural
reactions. Natalie demonstrates delayed protective and righting reactions. Deficits are also
present in her equilibrium and anticipatory reactions. Such deficits contribute to her difficulties
in performing her daily activities. Natalies deficits in all areas of postural reactions contribute to
her difficulties during the day, especially during times of transitioning between classes.
Reflexes
The reflexes section does not apply to Natalie.
Self-Regulation
Natalie demonstrates low levels of self regulation when engaging in activities that she
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does not like and/or views as difficult. Such activities include (but are not limited to):
handwriting, using scissors and glue, and engaging in ball sports. When asked to participate in
activities that she considers hard, Natalie demonstrates a higher level of tolerance (and higher
levels of self regulation skills) if verbal praise is provided. Her tolerance for a difficult activity is
also increased when the activity is appropriately graded to her ability. However, when
participating in activities she views as enjoyable, Natalie demonstrates a much higher level of
persistence and controls her frustration. As previously mentioned, Natalie really enjoys helping
her parents cook and bake, playing concentration memory, and engaging in freeze tag with her
peers.
The Person Environment, Occupational Performance Model (PEOP)
The Person, Environment Occupational Performance Model (PEOP) uses a top-down
approach that centers on the childs and the parents concerns. The childs values and areas of
interest should guide the choice of activities that will be used in the intervention process
(Willard, year). According to the information gathered on Natalie, the activities that she enjoys
most are the same activities that she has the greatest difficulties with. This can be an advantage
for intervention because she is inherently motivated to work on those tasks (Brown, 2014).
Natalie enjoys doing crafts, cooking, and playing card games but at the same time she
struggles with activities that require fine motor skills and bilateral coordination. She is also very
social and likes to watch peers play kickball during recess but she does not participate. Her
evaluation suggests that Natalies lack of participation in recess is due to fatigue and difficulties
with postural control. Natalies persistence and high frustration tolerance of activities she enjoys
will contribute to her willingness to participate in them as part of the intervention plan (Brown,
2014).
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The PEOPs approach is also especially suitable for individuals with disabilities because
it pays particular attention to the interaction between person, occupation and environment.
Dysfunction is most likely to occur when there is a poor fit between the child and the
environment. Because school classrooms are mainly designed for the typical child, mainstream
classrooms are more likely to be a barrier for occupational performance in the case of a child
with disabilities. However, as the PEOP states, the environment can be more readily modified
than the childs performance; thus adaptive equipment and environmental modifications can
quickly eliminate barriers of performance while making the environment more supportive and
conducive to independent functioning for children with disabilities (Brown, 2014).
For example it has been noted that children with DCD become very fatigued and are
clumsy on the playground. Therefore, an adaptation for Natalie especially during physical
activities is to give her a 2 minute break for every 10 minutes she actively participates in the
activity. Her difficulty with transitions from one school setting to another could be minimized by
pairing all the children in the class with a buddy in order to motivate Natalie to keep up with her
classmates. Natalies writing difficulties could be addressed by providing a pencil with a better
grip, more comfortable sitting, a chair with arm rests for added support or perhaps she could type
on a computer for part of the day in order to rest her hands and help with legibility and writing
speed (Brown, 2014).
Most Appropriate Theories and/or Practice Models
Dynamic Systems Theory
The Dynamic Systems Frame of Reference takes a similar approach as the PEOP Model
in that it emphasizes the context and the interaction of many subsystems that form part of the
childs life. Additionally, the Dynamic Systems Model states that children learn best when
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allowed to explore and try different strategies until they can identify the most effective
movement pattern. Since the core symptom of Developmental Coordination Disorder is
weakness and poor endurance, lack of postural control and stability could be impacting Natalies
handwriting skills negatively. Natalie might be using compensatory techniques to make up for
poor posture that might interfere with the quality and speed of her writing due to maladaptive
posture. In other words, intervention should address trunk strength and stability by engaging
Natalie in gross motor activities on the play-ground. As the Dynamic Frame of Reference states,
Natalie should be allowed to experiment with different movement strategies to determine what
works best (OBrien & Williams, 2010).
Intervention on the playground should be done without peers at first until Natalie feels
confident enough to play around other children. Activities such as going down the slide and
playing on the swings can promote trunk control, strength, posture balance and endurance that
might improve Natalies quality of writing. Additionally, the therapist should also use writing
activities and allow Natalie to experiment with a variety of motor pattern so Natalie can identify
what motor pattern feels most comfortable, fast and effective (OBrien & Williams, 2010). In
order to do this, Natalie can explore writing movements by writing on different positions and
surfaces. She can try writing standing up, sitting on chairs of different heights and firmness,
write on a vertical board, a tilted or horizontal surface. A white board and markers can be used to
reduce friction and surface resistance and writing on paper with crayons and pencils can also be
tried for Natalie to develop good hand proprioceptive awareness for better hand control when
writing. Natalie could even try to write on sand paper for maximum resistance to increase hand
strength and endurance for writing.
The Dynamic Systems Theory also stresses that a child learns best when self-correcting
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because this way they learn to rely on internal cues to evaluate their own performance. Filming
Natalie while she writes and asking her reflective questions that encourage her to identify both,
effective aspects of her writing techniques as well as thing that could be improved can be very
effective in helping the child self-correct and find her own solutions (OBrien &
Williams,2010).
Motor Learning Theory
Motor Learning theory is another frame of reference that would be very useful in this
case because addresses ways to promote the acquisition or modification of motor skills. Even
though the model states that massed practice is best when first learning a skill this might not be
the most appropriate method for Natalie because it might contribute to fatigue since the practice
period is greater than the rest time. Distributed practice should be used instead, not only because
writing is not a new skill for Natalie, but also because this technique alternates long resting times
with short practice periods. Mixing tasks such as alternating gross motor activities that involve
playground activities to improve postural control with fine motor activities that involve
handwriting will allow Natalie to have better endurance since she wont be using the same
muscles for too long (OBrien & Williams, 2010).
Assessments Appropriate for Client
Various types of assessments are important to use on children in order to find out what
areas need work. Once it is clear what areas a child needs help in, it will be easier to create an
efficient intervention and begin treatment.
In the case of 6 year old Natalie, she was given the School Functioning Assessment
(SFA) in order to outline what problems she had when it came to school participation. The
scores suggested that a main area of difficulty for Natalie was transitions. Because of her
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physical condition, Natalie has a difficult time getting from one area of the school to another for
she needs to use the wall for additional support. This was an appropriate assessment to use for
Natalie because it studies a childs ability to perform functional activities that support
participation in an educational setting. It was clear that Natalie was having difficulties with
participation due to her physical condition. It was difficult for her to partake in recess activities
so she would stand by and observe.
The second assessment that was done on Natalie was the Pediatric Evaluation of
Disability Inventory. The purpose of this assessment is to see where a child scores in the areas
of: self-care, mobility and social function. This was also an appropriate assessment to give
Natalie since it picked up an age delay in self-care, more specifically, dressing while using
fasteners.
Although not administered, the Evaluation Tool of Childrens Handwriting would be
beneficial in the case of Natalie. It would be important to assess Natalie on handwriting since it
was noted she was having difficulties with it and it is a skill that is crucial in school. The
assessment is intended to be administered to those who have handwriting deficits. Once these
deficits are identified, the occupational therapist can create an intervention plan to address these
deficits.
Function Problem Statements
Functional problem statements states the areas of occupation that are limited due to
certain underlying factors. It is a list of problems that can be treated by an occupational therapist
and provides a central understanding of the childs problem areas. Natalies functional
performance are limited due to several factors such as her learning disability and DCD. Natalies
functional problem statements are as follows:
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(1) Client is unable to write legible letters due to poor hand muscle strength and coordination.
(2) Client is unable to kick a ball and climb a jungle gym due to lack of endurance, balance, and
muscle strength.
(3) Client is unable to participate with peers in transitioning between classes due to poor muscle
strength, balance, and endurance.
(4) Client is unable to fasten her coat due to deficit in fine controlled movements of her hands.
(5) Client has difficulty completing art projects involving following sequential steps of cutting,
pasting, coloring, drawing, and writing due to fine motor manipulation deficits and bilateral
incoordination.
By determining these problem areas, the occupational therapist will be able to focus on
the underlying factors and develop long and short term goals to improve Natalies overall
functional performance as a student.
Family/Caregiver/Child Goals
When determining goals for children, it is important to take into consideration the goals
and ambitions of parents and caregivers. While many parents will want to improve their child's
abilities in all aspects of their children's lives, a therapist must work in conjunction with parents
and caregivers to create more practical goals to address the current needs of the child. Natalie is
currently having difficulties with fine motor activities specifically during school tasks such as
handwriting. Due to the parents concerns with Natalies handwriting skills and lack of
strength, fine motor activities to enhance handwriting skills may address these concerns. Having
Natalie work on fine motor activities that will strengthen her intrinsic hand muscles and fine
motor manipulation paired with functional handwriting activities that are meaningful to the child
may improve her overall hand strength and endurance thus improving handwriting skills.
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Increasing hand strength and fine motor manipulation may also address Natalies deficits in self-
care and dressing specifically with buttons, zippers, and shoe laces. In school, Natalie does not
feel comfortable playing with other children during recess time due to her deficits in bilateral
coordination, gross motor, and strength. These areas are affecting Natalies ability to play with
other kids, and because of this, Natalie does not feel confident playing sports and being active on
the playground. Working on play activities that do not require a lot of energy, but that work on
bilateral coordination, gross motor, and overall endurance at home with her siblings may address
these problems. Such activities may include throwing and catching a larger bouncy ball back and
forth with her siblings or parents. Adding time intervals such as Natalie will throw and kick the
ball for 10 minutes a day for 1/wk and increase this time each week by 10 minutes will increase
Natalies endurance and will allow her to engage in play longer with other children her age during
recess. With progressing endurance and strength this will aid with Natalies transitioning
between classes with time. At the moment, having a buddy system where the teacher assign a
different student each week to hold hands and walk with Natalie in between classes will help
with class transitioning and allow Natalie to not feel left out or fall behind the class when
moving environments.
Occupational Therapy Goals, Objectives and Activities
When writing goals the occupational therapist must ensure that the goals maintain and
promote function and prevent dysfunction at all times. Occupational therapy goals are highly
individualized and are based on the childs evident occupational performance problems as well
as the concerns and priorities of the family and child. Natalies goals have been determined by
information from her case study, family and her functional problem statements.
Occupational Therapy Goal: Natalie will demonstrate improved muscle strength, endurance
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and balance to participate in social play on playground equipment, participation in gross motor
activities and transitions between classrooms within the same pace as her peers.
Objective: Natalie will engage in 2 classroom transitions per day at the same pace with
her peers in 75% of trials with minimal assistance/redirection within two weeks.
Activities:
- Participate in the Ants Go Marching with peers: Natalie and her classmates will march
in a line around the classroom, through the hallways, on the playground to the song The
Ants Go Marching. It is important to have Natalie line up in the middle of the
procession to emphasize the need to keep up with the group in front and to not let the
group behind her fall back. It is also important to have classmates behind her to
encourage her to keep up to promote confidence in her speed.
- Participate in Simon Says while standing: actions such as clapping, balancing on one
foot, hopping on one foot, jumping jacks, and others are important to use here.
Objective: Natalie will actively participate with her peers on the jungle gym during
recess for 5 minutes with minimal assistance within three weeks.
Activities:
- Hide and seek on the jungle gym: have friend or therapist hide objects around the jungle
gym and have Natalie find the hidden objects, only have Natalie bring the object down
one by one to promote more mobility on the jungle gym
- Follow the leader with a peer on the jungle gym: include Natalie in a group of peers to
play follow the leader on and around the jungle; encourage the peers to climb up the
stairs, go down the slide, and weave around the jungle gym below.
Occupational Therapy Goal: To improve functional hand control and strength for greater
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success with fine motor skills with increase independence in writing activities and self help
skills.
Objective: Natalie will be able to complete a legible three sentence short story on a three
lined paper with minimal assistance using a tripod grasp 75% of trials within six weeks.
Activities:
- Writing spelling words on a vertical white board: Natalie will practice writing her
spelling words on the classroom white board while standing, she may use fun colored or
scented markers.
- Writing letters and shapes in shaving cream: Natalie will practice printing her letters
and shapes using a marker (with the lid on it) in shaving cream while seated at a table.
Objective: Natalie will don jacket and tie shoes within 5 minutes with minimal
assistance 75% of trials in one month.
Activities:
- Dress-up dolls: Natalie will practice dressing a medium-sized doll. She will don and
doff the dolls jackets, shirts and pants. The doll clothes will include buttoning, fastening,
and zipping.
- Practice lacing and tying shoes: Natalie will practice lacing and tying using the Can-
Tie-My-Shoe Board.
Occupational Therapy Goal: Natalie will demonstrate improved bilateral coordination and
ability to sequence steps to improve participation in gross motor activities, fine motor skills and
academic skills.
Objective: Natalie will be able to cut out complex shapes such as a square and diamond
75% of trials with minimal assistance within one month.
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Activities:
- Cutting activity worksheets: Natalie will cut across dotted lined activity worksheets to
practice her snipping.
- Putting coins into a piggy bank: Natalie will practice grasping pennies with one hand,
transferring the penny to the other hand and placing it into the piggy bank
Objective: Natalie will participate in kickball with peers with minimal assistance for a
duration of at least 10 minutes during recess within three weeks.
Activities:
- Hot potato with a peer (using feet or hands): Natalie will catch and toss and kick a ball
back and forth with a friend as fast as she cans; can encourage the speed of the game by
playing music and stopping it abruptly.
- Take turns kicking ball to a target with a peer: Natalie will kick balls to certain target
areas; therapist can grade this activity up and down by making the target further or away
or closer; also use different size balls to work on precision even further
The occupational therapist will be able to use these goals to develop an intervention plan
specific to Natalies school performance.
Treatment Plan
Environmental Setting
Natalie will attend treatment sessions during the school day with a school based
occupational therapist that has his/her own office. Therapy sessions will take place in Natalies
classroom and the OT office. In addition to the occupational therapists desk, the OT office has a
table and seating for handwriting/fine motor activities, and has enough space to play same floor
games with one or two children. Sessions will also utilize the school playground and hallways
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within the school building. The school playground has a big climbing structure/jungle gym,
monkey bars, slides, and an outdoor basketball court.
SOAP
S:Subjective
Client was energetic and eager to participate in the tx session. The client was able to
communicate efficiently and effectively.
O: Objective
The client participated in a 60-minute OT session in an outpatient clinic which focused on
improving fine motor skills, endurance , bilateral coordination and balance. Client demonstrated
very good attention skills throughout the tx session. Client demonstrated difficulty when
working on endurance and bilateral coordination in gross motor activities. Client was able to
independently walk 7 feet before having to hold on to a wall for support. When working on
fine motor activities, Natalie was able to use an efficient scissor grasp when cutting out shapes
on dotted lines and stayed on the dot 50% of the time. The client displayed a mature handwriting
grasp when holding a No. 2 pencil. Natalie was able to complete a legible two sentence short
story on a three lined paper with minimal assistance using a tripod grasp . However, the client
was extremely fatigued after the sentences. Verbal encouragement was needed for the client to
finish her writing task.
A: Assessment
The clients poor coordination and apparent low tone impacts bother her gross and fine motor
tasks. This was demonstrated during her walking activity and in the handwriting
activity. Despite her low tone issues, the client knows which graps to use when interacting with
different writing tools. Potential to improve is apparent in the clients determination and
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cooperation during the tx session. The client will benefit from continued skilled OT intervention
in order to increase fine motor skills, endurance , bilateral coordination and balance.
P: Plan
Continue to treat client 60 minutes 2x/wk for 6 months in order to improve fine motor skills,
endurance , bilateral coordination and balance. Plan to improve endurance and bilateral
coordination by utilizing the game of kickball and hot potato. Plan to further address fine
motor skills, specifically handwriting skills by writing on a whiteboard and using different
writing utensils.
Taking Whole Client into Consideration
When the OT practitioner is looking at the child, it is important to look at the child as a
whole, and not just the child's problem area. The OT must look at how her affects her
occupational performance and what social and financial support the child has at home and in the
school setting. Collaboration with the parents, caregivers and social therapist or aide is
recommended to integrate aspects of treatment into Natalies environments. Having the parents
practice play activities that work on fine motor, bilateral coordination and gross motor will allow
natalie to reach intervention goals and perform at her optimal level in and out of the home and
classroom setting. Having the parents and caregivers incorporated into Natalies therapy will
allow the therapist to receive feedback that the OT can utilize to either modify or adapt goals and
means of therapy. Getting feedback from Natalies teachers and aides will allow the therapist to
modify treatment to meet the needs of Natalie in the classroom and school settings. Interviewing
the parents and caregivers often will allow the therapist to get a better picture of Natalies
context and environments and areas in which she is having difficulty with, such as self-care at
home and play at school.
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Specific Recommendations and Post Discharge Environment
When working with a client who has DCD as well a learning disability, there are important
considerations to take into account. Both at school and at home the Natalie ought to receive
plentiful encouragement to play games that will her get her physically involved; such as kickball
and freeze tag.
Because Natalie has a difficult time with self care, her parents can look into buying her clothes
that better fit her abilities. This can include pants with elastic bands instead of buttons and
velcro shoes instead of shoe laces.
Natalie should also be encouraged to contribute to daily activities in the house that will help in
the areas of fine motor control and bilateral coordination, this could be as simple as standing
while making cookies for dessert with her parents.
Justification of Treatment
Natalies Developmental Coordination disorder is interrupting many areas of occupation
for natalie, especially the most important area of occupation for a child her age, play. When a
child is having difficulty with play within the school setting, this can affect the child's normal
development and their ability to create meaningful relationships with other students her age. This
may also affect Natalies confidence in school based activities and affect her overall feelings of
self-efficacy. Addressing Natalies problem areas in fine motor and hand strength will allow her
to complete more classroom activities such as crafts, art, and improve her handwriting skills.
Improving these skills are very important for Natalies overall academic performance, if
handwriting proves too difficult for the child, she may avoid handwriting and have feelings of
poor school achievement and low self-esteem.

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