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Efficacy of interventions to improve motor

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 DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY REVIEW

Efficacy of interventions to improve motor performance in children

with developmental coordination disorder: a combined systematic
review and meta-analysis
BOUWIEN C M SMITS-ENGELSMAN 1 , 2 | RAINER BLANK 3 | ANNE-CLAIRE VAN DER KAAY 2 | RIANNE
MOSTERD-VAN DER MEIJS 2 | ELLEN VLUGT-VAN DEN BRAND 2 | HELENE J POLATAJKO 4 | PETER H WILSON 5

1 Department of Kinesiology, KU Leuven, Leuven, Belgium. 2 Avansplus University for Professionals, Breda, the Netherlands. 3 University of Heidelberg and Child Centre,
Maulbronn, Germany. 4 Department of Occupational Science and Occupational Therapy, University of Toronto, Canada. 5 School of Psychology, Australian Catholic University,
Melbourne, Australia.
Correspondence to Dr Bouwien Smits-Engelsman at Department of Kinesiology, KU Leuven, Tervuursevest 101, 3001 Heverlee, Leuven, Belgium. E-mail: bouwiensmits@hotmail.com

PUBLICATION DATA AIM The aim of this study was to review systematically evidence about the efficacy of motor inter-
Accepted for publication 25th July 2012. ventions for children with developmental coordination disorder (DCD), and to quantify treatment
Published online. effects using meta-analysis.
METHOD Included were all studies published between 1995 and 2011 that described a systematic
ABBREVIATIONS review, (randomized) clinical trial, or crossover design about the effect of motor intervention in
CO-OP Cognitive orientation to daily occupa- children with DCD. Studies were compared on four components: design, methodological quality,
tional performance intervention components, and efficacy. Twenty-six studies met the inclusion criteria for the review.
DCD Developmental coordination disorder Interventions were coded under four types: (1) task-oriented intervention, (2) traditional physical
NTT Neuromotor task training therapy and occupational therapy, (3) process-oriented therapies, and (4) chemical supplements.
For the meta-analysis, effect sizes were available for 20 studies and their magnitude (weighted
Cohen’s d [dw]) was compared across training types.
RESULTS The overall effect size across all intervention studies was dw=0.56. A comparison
between classes of intervention showed strong effects for task-oriented intervention (dw=0.89) and
physical and occupational therapies (dw=0.83), whereas that for process-oriented intervention was
weak (dw=0.12). Of the chemical supplements, treatment with methylphenidate was researched in
three studies (dw=0.79) and supplementation of fatty acids plus vitamin E in one study (no effect).
The post hoc comparison between treatment types showed that the effect size of the task-oriented
approach was significantly higher than the process-oriented intervention (p=0.01) and comparison
(p=0.006). No significant difference in the magnitude of effect size between traditional physical
and occupational therapy approaches and any of the other interventions emerged.
INTERPRETATION In general, intervention is shown to produce benefit for the motor performance
of children with DCD, over and above no intervention. However, approaches from a task-oriented
perspective yield stronger effects. Process-oriented approaches are not recommended for improv-
ing motor performance in DCD, whereas the evidence for chemical supplements for children with
DCD is currently insufficient for a recommendation.

Children with developmental coordination disorder (DCD)
are identifiable by the difficulties they have in performing fine
and gross motor tasks, which affect their performance in the
classroom and in activities of daily living.1 According to the
DSM-IV,2 in DCD the level of motor coordination is below
that expected given the child’s chronological age and intelli-
gence, and may lead to problems in activities of daily living
and ⁄ or academic performance.3 The estimated prevalence of
children with DCD is between 6 and 13% of all school-aged
children,4 with some reports finding that males experience a
higher incidence than females.5 Forty per cent of the children
diagnosed as having delayed motor development before start-
ing school continue to have this problem 10 years later.6
These figures indicate that DCD is not a condition that exists
only in earlier childhood.
Several comorbid problems are common in children with
DCD including a substantial overlap with attention-deficit–
hyperactivity disorder (ADHD), dyslexia, and autistic spec-
trum disorders.7,8 Children with DCD show higher rates of
social difficulties, low self-esteem, and associated behavioural
problems during childhood and adolescence.9 In particular,
children with combined DCD and ADHD show poorer
outcomes when evaluated in early adulthood, in terms of
academic achievement and psychosocial adjustment.10 Indeed,

ª The Authors. Developmental Medicine & Child Neurology ª 2012 Mac Keith Press DOI: 10.1111/dmcn.12008 1
the persistent nature of DCD in around one-half of individuals
first diagnosed in childhood emphasizes the importance of tar-
geted intervention.11–13
Therapeutic approaches are drawn from occupational ther-
apy,14–20 physiotherapy,21–30 medicine31–33 (e.g. methylpheni-
date), diet34 (e.g. fatty acids plus vitamin E supplementation,),
and education21,35,36 (teachers, parents, physical education).
Although different terms can be found in the literature to
describe interventions for DCD, approaches can be grouped
under three main types: process-oriented, task-oriented, and
conventional physical and occupational therapy. Chemical
treatments (e.g. fatty acids) represent a newer, fourth type.
Process-oriented approaches target the components or body
functions needed to perform activities. Sensory integration,
kinaesthetic training, perceptual training, or combinations are
examples of these bottom-up approaches. For DCD, the
hypothesis is that the improvement of body functions such as
sensory integration, kinaesthesia, muscle strength, core stabil-
ity, visual–motor perception, and so on leads to better skill
performance.37,38
By comparison, task-oriented approaches tend to focus on
motor performance, i.e. on learning particular motor skills,
with attention given to specific aspects of task performance
that are causing the child difficulty. Leading examples are neu-
romotor task training (NTT),26,35,39,40 the cognitive orienta-
tion to daily occupational performance (CO-OP)
approach,37,38,41 and imagery training.29 In reality, these task-
oriented approaches are all based on a combination of current
motor control or motor learning and ecological principles,
with the relative contribution of these frameworks varying
from one method to another.42
NTT can be considered a true hybrid: from motor learning
theory, it draws strongly on the notion that task structure and
scheduling are fundamental to the way skills are assembled
over repeated learning trials and sessions; from the ecological
approach, it considers how task and environmental constraints
can be manipulated to provide some leverage for the individual
child whose motor impairment does not enable direct and
seamless movement in a particular workspace.20,35–38
CO-OP can be considered the most pure example of a top-
down approach. It focuses particularly on the use of cognitive
strategies to facilitate skill acquisition, and uses a collaborative,
problem-solving approach adapted from cognitive-behavioural
therapy, particularly the work of Meichenbaum. The child is
encouraged to form a mental model of how to attack a move-
ment task; they are led to generate a movement goal, plan its
implementation, and reflect on how their performance was or
was not successful (goal, plan, do, check).37,38,42
From a traditional physical therapy or occupational ther-
apy training perspective, individuals with DCD are trained in
the most important fundamental gross motor and fine motor
skills (hopping, jumping, throwing, and catching; cutting,
drawing, writing), and in the basic motor abilities that are
thought to be prerequisite for skills (e.g. trunk stability for
certain fine-motor skills). These approaches combine under-
lying process-oriented approaches with direct skill training;
the underlying assumptions are that motor skills are
2 Developmental Medicine & Child Neurology 2012
What this paper adds
• Children with DCD benefit from some form of motor intervention.
• Task-oriented interventions and traditional motor-based skill training yield
significant effects.
• Task-oriented interventions improve motor performance more than process-
oriented interventions.
• Few intervention studies capture changes in the level of participation.
• Higher-quality studies are needed on optimal intensity and treatment duration.
developed in a sort of hierarchical fashion. Basic abilities
(such as postural control, in-hand manipulation, visual–per-
ceptual skills) need to be refined in conjunction with teaching
complex motor skills.
Although many different intervention strategies have been
used and studied, it remains unclear which best improve motor
performance or activities in children with DCD and alleviate
the associated problems. To determine the most effective
intervention strategy, we searched the literature on interven-
tions in children with DCD published between 1995 and
December 2011. The longer an intervention method has
existed, the larger the possibility that it has been investigated
for its treatment effects. This is certainly true for sensory inte-
gration and kinaesthetic training.5,26 Studies investigating sen-
sory integration and kinaesthetic training occurred mainly
between the early 1970s and 1996, with very few since 1996.
Several studies published after 1996 have investigated task-
oriented approaches like CO-OP and NTT, both of which
are relatively new. No meta-analysis has been conducted so far
that includes this work.
The main aim of this meta-analysis was to synthesize the
literature from 1995 to December 2011, a period during
which DCD gained greater recognition as a diagnosis in its
own right. In 1994 the London Consensus group43 pro-
duced a more detailed description of DCD compared with
the DSM-III-R (1987)44 and DSM-IV (1994).2 This was an
important milestone in the research into DCD. It meant
the beginning of a uniform approach to children with
motor impairment, not otherwise specified by a medical
diagnosis. From 2004 to 2006, several professionals from
different countries met to obtain a new agreement about
the diagnosis, research, and intervention characteristics and
comorbidities of DCD, resulting in the Leeds Consensus
statement in 2006.45 From these meetings, several issues
emerged: there was no consistency in the interpretation and
application of diagnostic tests, and no uniformity in the
application of the various evidence-based intervention meth-
ods. The Leeds Consensus set the following guidelines that
intervention approaches should meet: (1) activities should be
functional, based on goals that are relevant to daily living
and meaningful to the child; (2) they should enhance gener-
alization and application in the context of everyday life; and
(3) interventions must be evidence-based and grounded in
theories that are applicable to understanding children with
DCD.38,45
Thereafter, various (inter-)national professionals inside and
outside Europe, some of whom participated in the seminars in
Leeds, decided to write a directive for diagnosis, prognosis,
and intervention for children with DCD. This resulted in the
European Academy for Childhood Disability recommenda-
tions for diagnosis and treatment of DCD, issued in January
2012.46 In support of these recommendations for intervention,
a systematic review on treatment efficacy was initiated. It was
the aim of this review to rate both the scientific quality of the
studies and compare the magnitude of differences across treat-
ment types, highlighting the most effective.
METHOD
Criteria for inclusion and exclusion
In advance of the actual literature search, selection criteria
were set for the abstracts. Abstracts of meta-analysis, system-
atic reviews, randomized controlled trials (RCTs), clinical tri-
als, and narrative reviews were included. The papers had to be
written in English, German, or Dutch and published between
1995 and 2011.
The populations included in the studies were children of
any age, diagnosed with DCD or with possible DCD. DCD
was defined either according to the criteria of the DSM-IV2
or as motor impairment not otherwise specified by a medical
diagnosis, but examined with standardized motor tests con-
firming motor impairment. Studies reporting on children with
poor motor performance, which was defined as 1SD below the
mean, were also included. Studies investigating a sample of
children with a syndrome (like ADHD or dyslexia), were
included in the descriptive part of the study but excluded from
the meta-analysis.
The included studies had to have motor outcome measures
with standardized and internationally accepted assessments,
for example, the Movement Assessment Battery for Children,
the Concise Assessment Method for Children’s Handwriting,
or the Test of Gross Motor Development-2.
Literature search
The literature search spanned the period January 1995 to
December 2011. The following databases were consulted:
Medline, the Cochrane Library, PubMed, CINAHL, PsychI-
nfo, PsychLit, OTDBase, OTseeker, PEDRO, ERIC,
Embase, and HealthSTAR. The search terms were agreed
upon at a meeting of the international working group for the
EACD recommendations for DCD in 2008.
The following search terms were used (connected with
‘OR’): motor skills disorder, developmental coordination
disorder, clumsiness, clumsy, clumsy child syndrome, clumsy
child, in-coordination, dys-coordination, minimal brain
dysfunction, minor neurological dysfunction ⁄ disorder, motor
delay, perceptual-motor impairment, motor coordination dif-
ficulties ⁄ problems, motor learning difficulties ⁄ problems, mild
motor problems, non-verbal learning disability ⁄ disorder ⁄
dysfunction, sensorimotor difficulties, sensory integrative
dysfunction, physical awkwardness, physically awkward, psy-
chomotor disorders, motor control and perception, apraxias,
developmental dyspraxia, perceptual motor dysfunction, mini-
mal cerebral dysfunction.
These search terms above where combined (with ‘AND’)
with the general terms (connected with OR) ‘physical therapy’,
‘physiotherapy’, ‘occupational therapy’, ‘intervention’, ‘treat-
ment’, and the more specific treatment approaches (connected
with OR) sensory integration, Neuro-Developmental Treat-
ment (NDT): Neuromotor Task Training (NTT), Cognitive
Orientation to daily Occupational Performance (CO-OP),
Perceptual Motor Training (PMT), motor imagery training
(MIT), sensory integration training (SIT), task-specific train-
ing, cognitive training, timing control, kinaesthetic training.
The following exclusions (‘NOT’) were used to obtain
more pure DCD studies: cerebral palsy, stroke, traumatic
brain injury, leukodystrophia or muscular disorders. Addition-
ally, references of all selected articles were checked for further
papers suitable for inclusion.
Each abstract resulting from the search was individually
screened for inclusion by at least two of four independent
experts (BS-E, A-CvdK, RM-vdM, EV-vdB). When consensus
existed, the full-text articles were evaluated.
Each full-text article was again rated by two independent
experts who needed to reach a consensus to include the paper
in the study. If consensus was not reached, a third expert was
consulted.
Next, for each of the included studies, the experts had to
agree on the level of evidence rated according to levels of evi-
dence (Oxford Centre for Evidence-Based Medicine,47 or in
case of an RCT, the PEDro scale;48 Tables I and II). If con-
sensus was not reached by the two experts, a third was con-
sulted. Authors did not rank their own studies. Moreover, all
conclusions and recommendations were reviewed by the inter-
national DCD guideline group in several meetings.46
Data analysis
All abstracted study characteristics are shown in Table SI
(online supporting information). These include population
description, number of participants, age and relevant baseline
testing results, type of intervention, description of the inter-
vention, frequency, intensity and duration, outcome measures,
description of results of the populations, short description of
the conclusion and limitations, main conclusions.
Included articles were assessed by members of project group
for methodological quality using the instruments mentioned,
and results were added to Table SI results. To classify their
efficacy, the results were characterized by either a ‘+’ for sig-
nificant improvement in the experimental group(s) or ‘0’ for
no significant change.
Estimates of effect size were calculated for each comparison
of pre- and post-test results of a given treatment. The pre-
ferred estimate was Cohen’s d.49 To calculate estimates of
effect size, means and standard deviations for pre- and post-
test results were used whenever they were reported.
The inclusion of multiple dependent measures (and associ-
ated statistics) was allowed for each study. Mean effect sizes
are not unduly affected by non-independence in most
instances,50 and many authors choose not to weight studies
according to the number of effect sizes. Pseudo-independence
of effect size was assumed here. Outcome measures were
therefore analysed at the level of each finding; there were 54
effect sizes, distributed among four treatment types, plus one
for comparison groups, pre- and post test.
Review 3
 Table I: Levels of evidence (modified according to Oxford Centre for Evidence-Based Medicine), March 200947

Level of evidence Grade Oxford level Oxford definition (intervention studies)

1 (high) Evidence from a meta-analysis of randomized Ia Evidence from a meta-analysis or systematic

controlled trials
Evidence from at least one randomized
controlled trial (intervention study) or
well-controlled trial with well-described sample
selection (diagnostic study); confirmatory data
analysis. QUADAS rating >10.
2 (moderate) Evidence from at least one controlled study
without randomization or QUADAS rating >7.
Evidence from at least one other type of
quasi-experimental study.
3 (low) Evidence from observational studies. QUADAS
rating >4.
4 (very low) Evidence from expert committee reports or
experts.
review of randomized controlled trials (with
homogeneity).
Ib Evidence from at least one randomized controlled trial.
IIa Evidence from systematic review of cohort
studies (with homogeneity); or evidence from
at least one controlled study without randomization.
IIb Individual cohort study (including low-quality
randomized studies, e.g. <80% follow-up).
Evidence from at least one other type of
quasi-experimental study.
III Evidence from case–control studies; or evidence
from observational studies
IV ⁄ V Evidence from expert committee reports or
experts.

QUADAS, Quality Assessment Tool for Diagnostic Accuracy Studies.

Table II: Definitions of the PEDro scale48

1. Eligibility criteria were specified (not rated). No Yes

2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated another in No Yes
which treatments were received).
3. Allocation was concealed. No Yes
4. The groups were similar at baseline regarding the most important prognostic indicators. Yes
5. There was blinding of all subjects. No Yes
6. There was blinding of all therapists who administered the therapy. No Yes
7. There was blinding of all assessors who measured at least one key outcome. No Yes
8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups. No Yes
9. All subjects for whom outcome measures were available received the treatment or control condition as allocated No Yes
or, whether this was not the case, data for at least one key outcome was analysed by ‘intention to treat’.
10. The results of between-group statistical comparisons are reported for at least one key outcome. No Yes
11. The study provides both point measures and measures of variability for at least one key outcome. No Yes

The PEDro scale is a 10-point scale with dichotomous (1 ⁄ 0, referring to yes ⁄ no) responses that account for key quality aspects of an experimental
study. A score of 7 or higher indicates a good, reliable study, and a score of 5 or 6 as acceptable. No, no points; yes, one point for questions 2–11.
Total score ‡7, good; 5–6, moderate; <5, weak.

A random-effects approach to data analysis was used, based
on the method of Lipsey and Wilson.51 Here it is assumed
that variation between effect sizes is due not only to random
sampling error but also to other factors within studies (e.g.
methodological differences). The random-effects model is
preferable when heterogeneity of effect sizes is present,
indexed by Q statistics. Although less powerful than a fixed-
effects approach, it does allow greater generalization. Effect
sizes were weighted by the inverse of their variance. For each
treatment type, a mean weighted Cohen’s d (dw) value was cal-
culated using the SPSS (SPSS Inc, Chicago IL, USA).
Homogeneity of effect sizes was investigated using the Q
statistic.52,53 Heterogeneity indicated that the variability in the
effect sizes might be due to outliers or a moderator variable. A
group of effect sizes was deemed homogeneous when the value
of Q obtained was not significant at p<0.01. Outliers were also
considered, if necessary.
The magnitudes of the mean effect size estimates (d) were
then interpreted according to the convention of Cohen:
d=0.30 (small effect size), d=0.50 (moderate effect size), and
d=0.80 (large effect size).
RESULTS
The total number of studies matching the search terms was
3708. Each abstract was then reviewed by the members of the
project group (BS-E, A-CvdK, RM-vdM, EV-vdB) and
assessed to determine inclusion or exclusion in the review.
Eighty-five full-text studies were evaluated independently by
two individual experts. Of these, 72 papers were deemed as
candidates for this review. From these 72 studies, 44 were
excluded after reading the full paper because the outcomes of
the study did not include motor skills, were descriptive, did
not describe any intervention method, or were a single-case
study. The final complement of eligible studies in the

4 Developmental Medicine & Child Neurology 2012

systematic review was 26 (Fig. 1). For the meta-analysis
proper, there were 20 eligible studies.
Level and quality of evidence
Twenty-six studies met the inclusion criteria. The dates of
publication ranged from 1995 to 2011. Of those 26 articles,
one was a systematic review, one was a meta-analysis, and the
remainder were primary studies. The primary studies were
scored with the PEDro scale to evaluate all RCTs and clinical
trials. The overall quality was variable, with a mean of 6.0
(range 4–10).
The methodological quality of these studies was scored to
determine the strength of the evidence according to the guide-
lines of the Oxford Centre for Evidence-based Medicine -
Levels of Evidence.47
A total of 912 children with DCD or motor impairment
classified with a test score of at least 1SD below the mean,
with no other medical diagnoses, participated in the studies
included in this review. The average sample size was 44 partic-
ipants. Seventeen studies had fewer than 44 partici-
pants,2,5,14,16,17,20,22,24,26–28,30,31,33,35,36,65one had over a 100.34
The duration of the intervention ranged from 2 weeks to
6 months, and the amount of instruction ranged from 4 to
26 hours.
In the 26 studies, the following terms for the intervention
were most often found: (1) under task-oriented intervention,
CO-OP, NTT, and motor imagery were mentioned; (2)
under process-oriented intervention, sensory integrative train-
ing and kinaesthetic training were mentioned; (3) under tradi-
tional therapy (physical therapy and occupational therapy),
perceptual motor training and contemporary treatment
approach, contemporary physical therapy based on fundamen-
tal motor training and occupational therapy, psychomotor
training, and therapist-guided parent or teacher intervention
were mentioned.
The Movement Assessment Battery for Children was the
measure most frequently used for diagnostic purposes (12
studies), followed by the Concise Assessment Method for
Children’s Handwriting (4), the Test of Gross Motor Devel-
opment (second edition) (2), the Kinesthetic Sensitivity Test
(2), and the Test Of Motor Impairment (2). Diagnostic tests
that featured for a specific intervention were the following:
The Tennessee Self-Concept Scale (1), the Child Anxiety
Scale, the Perceived Motor Competence scale (1), the Devel-
opmental Test of Visual-Motor Integration (1), the Southern
California Sensory Integration Test (1), the Finger Identifica-
tion test (1) and the Evaluation Tool of Children’s Handwrit-
ing (1), the Bruininks–Oseretsky Test of Motor Proficiency
(1), the Canadian Occupational Performance Measure (2), the
Performance Quality Rating Scale (1), the Vineland Adaptive
Behavior Scale (VABS) (1), the Self-Perception Profile for
Children (1), the Harter’s Scale of Perceived Compe-

Initial number of articles for this review with matching titles, in

databases (N = 3708)

Exclusion for this review based upon population or study other than intervention:
Abstract information (n = 3576)
Full text version (n = 85)

Number of related articles based on references (n = 5)

Absolute number of included articles for review (n = 72)

Final number of included articles with complete data

available for systematic review (n = 26)
Final number of studies for the meta-analysis (n = 20)

Figure 1: Flowchart of the literature search.

Review 5
tence ⁄ Harter and Pike’s Pictorial Scale of Perceived Compe-
tence (1), the Motor Teaching Principles Taxonomy (1), the
Visual Analogue Scales (1), the Rhythm Integrated Test (1),
and the Sensory Integrated Praxis Test (1).
The outcome measures are all standardized, general assess-
ments for gross- and ⁄ or fine-motor function. All studies
included in our systematic review are presented in Table SI.
Twenty-two of the 24 primary studies were effective
in improving motor performance. Of these, most were
longer than 10 weeks, and the frequency of intervention
was mostly once a week, with home exercises in three
studies.24,28,55 In ten studies treatment was given in a group
setting.15,18,20,21,23–25,28,30,54
Based on the data in Table SI, there is strong evidence that
children with DCD benefit from task-oriented approaches
(see also Pless and Carlsson55). In addition, there was sufficient
evidence that motor-training-based interventions, as used in
traditional physical or occupational therapies, were generally
effective for children with DCD.14,17,19,22–26,28–30,36 Third,
evidence for the efficacy of process-oriented approaches (e.g.
sensory integrative training and kinaesthetic training) was con-
flicting.
Meta-analysis of intervention studies
Characteristics of the treatment and comparison samples are
shown in Table SI. The total number of effect sizes for all
studies combined was 54. Q statistics revealed homogeneity
for each treatment category (p>0.01). The mean effect size
across all treatment types was dw=0.56, indicating that treat-
ment generally had a moderate effect. When the different
treatment types were compared, the effect sizes were signifi-
cantly different (F4,49=5.04, p=0.002); the task-oriented
approach had the highest mean value (dw=0.89; 95% CI
0.64–1.14), followed by the traditional motor-training-based
therapy (d=0.83; 95% CI 0.46–1.20), process-oriented inter-
vention (dw=0.12; 95% CI )0.10–0.35), and comparison
(dw=0.23; 95% CI 0.04–0.43). Chemical treatments contrib-
uted only four effect sizes, but yielded a moderate to large
value (dw=0.79; 95% CI 0.15–1.42). The post-hoc Bonfer-
roni comparison between treatment types showed that the
effect size of the task-oriented approach was significantly
higher than the process-oriented approach (p=0.01) and
comparison (p=0.006). No significant difference in the
magnitude of effect size between traditional physical and
occupational therapy approaches and any of the other
interventions emerged. The effect size of the methylpheni-
date was 0.81 and not significantly different from any of the
other treatments.
DISCUSSION
The results of meta-analysis of recent research support the
view that task-oriented (dw=0.89) and traditional motor-train-
ing-based therapies (dw.83) show strong treatment effects in
children with DCD, whereas that for process-oriented therapy
is weak (dw=0.12). The implications of these numbers and of
the other findings of the reviewed studies for theory and prac-
tice are discussed.
6 Developmental Medicine & Child Neurology 2012
Task-oriented approach
For the task-oriented approaches, individual and group pro-
grammes were both effective ways of teaching motor skills in
DCD. Task-oriented approaches work on teaching essential
activities of daily living and, thereby, stimulate participation at
home, school, in leisure, and sports.22,26,30,36–38,55 Whether
the training effects are attributable mainly to flow-on effects
for participation is an issue for continued research. On current
understanding, it is recommended that NTT be used for chil-
dren with DCD, with training yielding positive (task-specific)
change on measures of gross- and fine-motor skill.21,22,26,27
The efficacy of CO-OP was also evident but work here
requires more robust metrics. Children with DCD are shown
to generate more effective strategies than those receiving other
approaches consisting most commonly of sensory-integration
and non-problem-related general fine- and gross-motor activi-
ties.14,16 Importantly, children with better verbal ability tend
to make better gains in approaches where language plays an
important mediating role; their ability to interpret cues and
prompts and to implement responses to them may be a predic-
tive factor here.14 In short, we recommend that task-oriented
intervention methods like NTT and CO-OP should be pre-
scribed with some confidence to children with DCD who are
in need of intervention to improve their motor performance.
Motor imagery training
Caution is needed when considering the efficacy of motor
imagery training because, first, there is only one study available
(Wilson et al.29). In addition, of the total referred sample, 36%
had a test score within the low normal range on the Movement
Assessment Battery for Children. Therefore, conclusions
about motor imagery training for severe DCD should be inter-
preted with care. However, the average change of scores on the
Movement Assessment Battery for Children showed that per-
ceptual motor training and motor imagery training improved
motor performance to a similar degree.29 More high-quality
research is needed to clarify the conditions under which motor
imagery training is best implemented for children with DCD.
Traditional physical therapy and occupational therapy
There is sufficient evidence that traditional physical or occupa-
tional therapies (either individual or group) are also effective in
teaching motor skills to children with DCD.14,17,19,22–26,28–30,36
Individual therapy was studied in two good-quality RCTs. In
the RCT by Wilson et al.,29 it was evident that perceptual
motor training results in improved motor performance
(d=0.76). Here, 13 of the 17 children in the perceptual motor
training group exceeded the upper limit of the 95% CI for
comparisons. Moreover, Peens et al.23 showed that a combina-
tion of motor- and psychological-based intervention improved
motor proficiency and self-concept in DCD. The findings
from our meta-analysis showed that children with DCD bene-
fit the most from task-oriented approaches; we recommend
that perceptual motor training adopts a task-specific approach.
For example, this integrated approach is effective in improving
the motor performance of children with combined
DCD ⁄ ADHD. Fifty per cent of these children obtained nor-
mal scores on the Movement Assessment Battery for Children
immediately after training, while 35% reached normal limits
after 4 weeks.28
Process-oriented training
Although the sensory integration method is the most com-
monly investigated approach, evidence is mixed. It is qualified
by Hillier54 as being an effective treatment method in children
with DCD. However, in the meta-analysis of Pless and Carls-
son,55 sensory integration was not as effective as functional
skill-specific interventions, and in the older analysis of Vargas
and Camilli19 results for sensory integration did not show a gen-
erally positive effect for studies published between 1983 and
1993. This conflicting report warrants deeper consideration.
The meta-analysis by Vargas and Camilli19 evaluated 16 stud-
ies published between 1972 and 1994. Overall, the average effect
size of sensory integration was d=0.29. Larger effect sizes were
found in psycho-educational (d=0.39) and motor categories
(d=0.40). Sensory integration methods were effective overall,
but were not shown to differ from alternative ones. In studies
comparing sensory integration with no treatment, a significant
effect for sensory integration was replicated in earlier studies
(1972–1982), but not in more recent studies (1983–1993). What
must also be kept in mind is that sensory integration methods
are relatively long in duration by normal standards.19
In the systematic review by Hillier,54 six studies reported
positive effects for sensory integration,57–61 which was taken as
support for this approach. Included among these were two
very old studies by Wilson et al.61 and Humphries et al.57–59
Kaplan et al.60 investigated two papers in which all groups
receiving intervention improved, but no one method was more
effective than another. Leemrijse et al.,52 in a crossover study,
showed a positive effect for sensory integration, although the
sample was small (n=6). Finally, the meta-analysis of Pless and
Carlsson55 showed that specific skill interventions in children
with DCD had stronger treatment effects than sensory inte-
gration. The highest effect was noted for skill-specific inter-
ventions (1.46), the lowest for sensory integration (d=0.21).
Watemberg et al. concluded in his RCT that sensory inte-
gration is an effective treatment for DCD ⁄ ADHD; however, it
was given in combination with other interventions and used in
a task-specific manner.28 In addition, the RCT of Sudsawad
et al.18 showed that although kinaesthetic training did improve
kinaesthetic acuity, it did not assist handwriting or motor per-
formance in children aged between 6 and 7 years.18 Taken
together and in light of our review, there is no recent evidence
of well-designed studies in support of sensory integration or
kinaesthetic training.
Parent- and teacher-guided intervention
The complement of studies showed that parents and teachers
were able to provide effective intervention for children with
DCD provided this was tuned to their specific movement
problems, and monitored by a professional. Involvement of
parents and teachers is likely to ensure that the learned
skills will continue to be used after the formal interven-
tion.21,37,56 We need more studies to clarify how best to facili-
tate the involvement of parents and teachers, for example the
use of user-friendly online resources that model good training
practices.62–64
Methylphenidate
Methylphenidate had a positive effect on both behavioural
ADHD symptoms and fine-motor performance (i.e. hand-
writing) in children with combined DCD and ADHD.
Additional motor therapy was indicated for around one-half of
the combined group. We do not know whether methylpheni-
date can be used to improve motor performance in DCD
without comorbidities. Moreover, there are some important
issues with longer-term side effects.31–33 Finally, although
fatty acids with vitamin E can improve academic skills like
reading and spelling as well as behaviour, there is no evidence
for a positive effect on motor performance.34
Handwriting
Schoolchildren having handwriting problems are often pre-
sented for treatment; this is between 25 and 50% of all the
referred children in the Netherlands.65 Prewriting exercises
(and fine motor training, if required) has been shown to
improve handwriting.27 Three different studies using a task-
oriented approach based on NTT all showed significant
improvement in handwriting.21,26,27 More specifically, task-
oriented self-instruction involving knowledge of results had a
positive effect on the quality of handwriting in children; impor-
tantly, this occurred both in regular and special schools.21
Limitations and implications for future research
After evaluating 3708 abstracts and 77 full-text papers, we
were able to locate 24 primary studies addressing the research
questions posed in this paper. Of these studies, 12 were cate-
gorized as ‘physical therapy and occupational therapy’, 10
were categorized as ‘task-oriented’, and three as methylpheni-
date. Of the 24 primary studies, seven used a research design
that produced definite evidence (level Ib). However, most of
the studies (17) used a research design (seven at level IIa and
10 at level IIb) that did not control for all other factors that
could have produced the observed results, and are considered
to have given moderate levels of evidence. This should be
taken into account when interpreting the results. However,
the advantage of a systematic review is that the consistency of
the results adds to the grading of evidence. Moreover, analysis
of the combined data set in the meta-analysis adds information
not available in the isolated studies.
The scheduling of treatment was variable, from once a
week14,16,22,24–27,29,31 to every (school-)day.15,17,31,32,34 As well,
the amount of instruction ranged from 4 to 26 hours. The
meta-analysis had too few effect sizes (n=54) to dissect the
effects of frequency and duration. Moreover, few studies had a
sufficient sample size to enable designs that would allow com-
parison between different forms of intervention.15–17,23,28,29
Most studies compared one intervention with no interven-
tion.14,18,21,22,24–27,30–32,34,43
It was also alarming that many studies did not describe the
intervention in sufficient detail to help researchers and clini-
Review 7
cians alike to understand fully what it was about the treatment
that made it successful. In other words, it was not always obvi-
ous that treatments using the same term were identical in nat-
ure (see Table SI). Most papers provided only a global
description of the intervention, for example ball skills and bal-
ance activities.14–16,18,22–24,26–28,30,43
Additionally, there is a need to profile those children who
do respond to treatment, as opposed to those who do not,
including factors like age and comorbidity. Finally, only three
studies17,25,27 investigated follow-up effects of 3 months or
longer. Hence, no statements can be made about the longer-
term effect of the treatment approaches. Next to more rigid
scientific designs, this is a prime issue for future research.
Importantly, the costs of intervention for DCD are enormous.
For instance, in Germany, the public insurance system is pay-
ing about 400 million euros a year for occupational therapy
for children with sensorimotor problems (mainly children with
DCD, of whom the largest part are referred for fine motor
and handwriting problems). A next step would be to conduct
cost-effectiveness analysis, once these evidence-based recom-
mendations are implemented.
Recommendations for practice
Our literature review largely substantiates the Leeds Consen-
sus for intervention.45 These guidelines stipulate the follow-
ing: treatment activities should be task-oriented, functional,
and relevant to daily living; be child-centred in the process of
therapy; involve significant others including parents and teach-
ers; and be evidence-based and grounded in theories that are
applicable to understanding children with DCD.
Although training effects are commonly shown at a task-
specific level, it is not always apparent how they transfer
across related and disparate areas of function. This refers to
the classic issue of horizontal versus vertical transfer. Because
the purpose of treatment is to achieve participation in mean-
ingful life areas as independently as possible and with high
quality of life, measures that capture the level of participation
should also be used to evaluate treatment effects. Involvement
of parents, teachers, and physical education is needed to max-
imize transfer into daily life and to ensure longer-term pro-
gress.21,36 More studies are needed to research the most
effective way that parents and teachers can be engaged in
instruction.38
CONCLUSION
We conclude that, in general, task-oriented (e.g. NTT and
CO-OP) and motor-training-based intervention (physical
therapy, occupational therapy) both show strong treatment
effects (dw=0.89 and dw=0.83 respectively), whereas that for
process-oriented therapy is weak (dw=0.12). Moreover, thera-
pies should ideally have some task-oriented elements to them
to promote transfer. Of the more top-down approaches, NTT
could be the therapy of choice for younger children and those
with lower verbal or learning capabilities. Children with well-
developed verbal skills may well be the ones who benefit most
from CO-OP. For handwriting problems, a task-oriented
approach based on NTT is the best option. It is too early to
state with confidence that motor imagery training is effective
for treating DCD.29 Process-oriented approaches (e.g. sensory
integration and kinaesthetic training) show only a weak effect,
the same level as no-treatment comparison, and are not rec-
ommended for improving motor performance in DCD. More-
over, they do not follow current thinking on motor control or
motor learning.
Finally, chemical supplements (like fatty acids and vitamin
E) did not improve motor performance. However, daily doses
of methylphenidate may be useful in children with comorbid
ADHD and DCD, particularly for fine-motor issues like
handwriting.
SUPPORTING INFORMATION
The following additional material may be found online.
Table SI: Levels of evidence (modified according to Oxford Centre for
Evidence-Based Medicine), March 2009.46
Please note: This journal provides supporting online information sup-
plied by the authors. Such materials are peer reviewed and may be re-orga-
nized for online delivery, but may not be copy-edited or typeset.
Technical support issues or other queries (other than missing files) should
be addressed to the authors.

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