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Disabil Rehabil, Early Online: 1–8

! 2015 Informa UK Ltd. DOI: 10.3109/09638288.2015.1070298

RESEARCH PAPER

Cognitive Orientation to (Daily) Occupational Performance intervention

leads to improvements in impairments, activity and participation in
children with Developmental Coordination Disorder
Ashleigh Thornton1, Melissa Licari1, Siobhan Reid1, Jodie Armstrong2, Rachael Fallows2, and Catherine Elliott3
1
School of Sport Science, Exercise and Health, The University of Western Australia, Perth, Australia, 2Child and Adolescent Health Services, Princess
Margaret Hospital for Children, Perth, Australia, and 3Faculty of Health Sciences, Curtin University, Perth, Australia
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Abstract Keywords
Introduction: Children diagnosed with Developmental Coordination Disorder (DCD) present Goal based, group, motor impairment,
with a variety of impairments in fine and gross motor function, which impact on their activity therapy
and participation in a variety of settings. This research aimed to determine if a 10-week group-
based Cognitive Orientation to Daily Occupational Performance (CO-OP) intervention improved History
outcome measures across the impairment, activity and participation levels of the International
Classification of Functioning, Disability and Health (ICF) framework. Methods: In this quasi- Received 5 November 2014
experimental, pre–post-test, 20 male children aged 8–10 years (x9y1m ± 9 m) with a confirmed Revised 23 June 2015
For personal use only.

diagnosis of DCD participated in either the 10 week group intervention based on the CO-OP Accepted 4 July 2015
framework (n ¼ 10) or in a control period of regular activity for 10 weeks (n ¼ 10). Outcome Published online 27 July 2015
measures relating to impairment (MABC-2, motor overflow assessment), activity (Handwriting
Speed Test) and participation [Canadian Occupational Performance Measure, (COPM) and Goal
Attainment Scale) were measured at weeks 0 and 10 in the intervention group. Results: Children
who participated in the CO-OP intervention displayed improvements in outcome measures for
impairment, activity and participation, particularly a reduction in severity of motor overflow.
Parent and child performance and satisfaction ratings on the COPM improved from baseline to
week 10 and all goals were achieved at or above the expected outcome. No significant changes
were reported for the control group in impairment and activity (participation was not measured
for this group). Conclusion: The strategies implemented by children in the CO-OP treatment
group, targeted towards individualised goal attainment, show that CO-OP, when run in a group
environment, can lead to improvements across all levels of the ICF.

ä Implications for Rehabilitation

 Development Coordination Disorder is a condition which has significant physical, academic
and social impacts on a child and can lead to activity limitations and participation restrictions.
 Cognitive Orientation to Daily Occupational Performance is an approach which uses
cognitive-based strategies to improve performance of specific tasks based on child chosen
goals.
 The intervention program had a positive effect on self-perceived levels of performance which
may lead to changes in quality of life.
 Parents felt the intervention enhanced socialisation, peer modelling and encouragement and
felt that this increased confidence and independence.

Introduction activities of daily living [1]. They also experience activity

Developmental Coordination Disorder (DCD) is a movement
disorder characterised by impaired motor function. Children
diagnosed with this disorder have a marked impairment in motor
coordination that interferes with academic achievement and
Address for correspondence: Dr. Ashleigh Thornton, School of Sport
Science, Exercise and Health, University of Western Australia, M408 35
Stirling Highway, Crawley, Western Australia 6009, Australia. Tel: +61
864882661. E-mail: ashleigh.thornton@uwa.edu.au
limitations including mobility, domestic life and self-care and
consequentially experience participation restrictions [1]. These
difficulties are not just present during childhood, many individ-
uals diagnosed with DCD continue to show symptoms throughout
adolescence and into adulthood [2].
Current evidence supports the use of task specific and
cognitive interventions to improve impairments in functional
performance of children with DCD [3,4], with a focus on the
cognitive elements involved in task performance proven to be
effective in this population [5]. The Cognitive Orientation to daily
 2 A. Thornton et al.
Occupational Performance (CO-OP) is one such approach
developed for children with DCD, which uses cognitive-based
strategies to improve performance of specific tasks based on child
chosen goals. From a motor learning and control perspective, the
theoretical framework for CO-OP is based upon the proposition
that motor learning is a process of solving movement problems,
originally proposed by Bernstein [6]. Further developed by
Thelen [7], and now known as the dynamic systems theory, it
suggests that musculoskeletal, neurological and cognitive systems
all interact with the performance of a task. To facilitate motor
learning, factors relating to each system must adapt to the task
required. CO-OP intervention requires the child to generate
several alternative ways of ‘‘solving’’ the movement problems to
overcome these barriers to motor learning and, through guided
discovery, determine the most effective solutions to their move-
ment problems [8].
Several studies have found CO-OP to be a successful approach
to learn, maintain and transfer strategies related to the perform-
ance of fine motor skills such as handwriting and cutting, as well
as gross motor skill such as running and basketball shooting, in
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children with DCD aged 7–12 years [9–12]. To date this
intervention has been shown to be effective in improving motor
performance in individuals and also in a group environment.
Given that children with DCD present with fine and gross motor
impairments, activity limitations and participation restrictions,
focusing on improving performance through interventions such as
CO-OP, is a vital progression in understanding this disorder.
Using the World Health Organisation’s International
Classification of Functioning, Disability and Health (ICF) [13]
framework allows for a holistic approach to evaluating treatment
For personal use only.
outcomes, across the levels of impairment, activity and partici-
pation in children with DCD. The framework offers a conceptual
support for intervention and suggests that impairment, activity
and participation are all interconnected and, through various
contextual factors, can influence a person’s daily life [14].
Research has demonstrated that DCD is a heterogeneous
disorder [15], thus the impairments and activity limitations, as
classified by the ICF, that children with DCD experience are
varied. Impairment such as poor motor coordination may manifest
itself as poor balance, dropping or bumping into things or
persistent delay in the acquisition of basic motor skills such as
catching, running and jumping [15]. Challenges in terms of
activity, such as dressing, cutting, colouring and handwriting [14]
are also reported in this population.
Impairments in fine motor proficiency have been shown to
affect the education and academic achievement of children with
DCD [16]. Specifically, laborious handwriting techniques and
difficulties in copying from the board [17] hamper children with
DCD’s ability to participate in a structured classroom setting.
These participation restrictions are not limited to the classroom,
children with DCD are found to be restricted in their ability to
participate in most typical childhood activities [18]. Additionally,
evidence shows that as a result of low gross motor proficiency,
children with DCD display much lower levels of physical activity,
and extremely low levels of participation in team sports [19].
There are a number of factors thought to contribute to poor
skill execution in children with DCD, including issues with
muscle tone, postural control and spatial awareness [20]. Another
characteristic of the disorder is the presence of neurological soft
signs, such as the presence of extraneous movements during the
performance of voluntary movement [21,22]. These movements
may decrease the biomechanical efficiency and increase the
energy cost of their actions [21], leading to a decrement in
movement quality. A number of different terms have been used to
describe the presence of these mirror movements, including motor
overflow and associated movements [23]. Motor overflow will be
Disabil Rehabil, Early Online: 1–8
the term used throughout this paper and the type of motor
overflow that will be the central focus of this work is contralateral
motor overflow, which refers to movements on one side of the
body while the opposite performs a voluntary movement [24].
Considering children with DCD display more pronounced motor
overflow than children of the same age [25], it is possible that
motor overflow could consequently be one of the contributing
factors toward delayed motor development and reduced fine and
gross motor proficiency in children with DCD.
While traditionally, intervention methods have focused on the
impairment level of the ICF in children with DCD [18], there has
been no research investigating whether interventions such as CO-
OP, can successfully integrate dynamic neurological, musculo-
skeletal and cognitive systems to facilitate improvements in
impairments such as motor overflow, and fine and gross motor
coordination. In addition, if CO-OP intervention results in
improvements in these impairments, this may benefit outcomes
at the activity and participation levels of the ICF. Therefore, this
research aims to establish if a 10-week group-based intervention
program, using the CO-OP framework, aids in the improvement of
outcomes associated with impairment, activity and participation
levels in children with DCD. It was hypothesised that improve-
ment would be seen across outcomes associated with fine and
gross motor impairment, motor overflow, performance of
activities and participation following the intervention period.
Methods
Participants
Power calculations were completed a priori. With an expected
effect of 0.8 [19] it was determined that a sample of 10 children
per group would achieve a power of 0.97, and detect a meaningful
difference between intervention and control group. A total of 20
male right handed children aged 8–10 years (x9y1m ± 9 m) were
recruited for participation in this quasi-experimental, pre–post-
test study. Each participant was block randomised into either the
CO-OP group or the control group, with children in both groups
individually matched for age (within six months). As reported by
parents all children met the diagnostic criteria from the
Diagnostic and Statistical Manual IV (DSM-IV) [1], that being:
(A) performance in daily activities that require motor coordination
is substantially below that expected, given the person’s chrono-
logical age and measured intelligence, (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.
Criterion A was established using the Movement Assessment
Battery for Children-2 (MABC-2), and Criteria B, C and D
established through parental report. Males were selected to
control for potential gender differences that might exist in the
presentation of impairment. Written informed consent from
parents and assent from children were obtained prior to data
collection. The Code of Ethics of the World Medical Association
(Declaration of Helsinki) was followed and human research ethics
approval was obtained from the University of Western Australia
Ethics Committee; RA/4/1/4351.
Procedures
The intervention program was conducted over 10 weeks, with
children allocated into groups of 3–4, based on common
occupational performance problems, identified by the children
and their parents through the use of the Perceived Efficacy and
 DOI: 10.3109/09638288.2015.1070298
Table 1. Goals developed through use of the PEGS by children in the CO-OP group.
Group 1
Child 1 Using a knife
Tying shoelaces
Writing speed
Child 2 Handwriting speed
Handwriting legibility
Kicking a football
Child 3 Cutting with a knife
Catching a ball
Handwriting legibility
Child 4 Handwriting legibility
Handwriting speed
Kicking a football
Table 2. Outcome measures used at week 0 and 10 across the ICF domains of impairment, activity and participation.
ICF domain Assessment
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Impairment 3D UL motion analysis
Flex-sensor glove
Movement Assessment Battery for Children–2
Activity Handwriting Speed Test
Participation GAS
COPM
Goal Setting system (PEGS) [20] (Table 1). Each group session
For personal use only.
was conducted once a week for approximately 1 h in duration,
along with 15 min/day of home activities, and run by two
Occupational Therapists trained and experienced in the use of
the CO-OP intervention. Both therapists were blinded to the
specific outcome measures of the study but were aware of the
children’s goals. All children involved in the intervention
program were required to have a minimum of two fine motor
related goals for inclusion in this study. All children identified
fine motor goals of handwriting speed and legibility, other fine
motor goals included using scissors and cutlery appropriately.
Sessions were focused on the global problem solving strategy,
described as the Goal-Plan-Do-Check method [26], to create
strategies to improve the child’s functional performance and goal
achievement. The group program was developed to address at
least 2–3 goals for each child and was themed as a Police
Detective Club. The therapists used a Police Detective puppet to
introduce the ‘‘Goal-Plan-Do-Check’’ strategy to help solve
(performance) problems. Goal is the task that the child wishes to
perform (e.g. handwriting). Plan refers to how the child will
tackle the goal (involving specific strategies). Do refers to the
performance of the task, requiring the child to practice. Check is
the child’s evaluation of the strategies employed and whether
they were successful [26]. During each session, children were
encouraged to develop and modify individual plans to achieve
their identified goals and then perform the do and check tasks as
a group to decide which strategies were successful and which
were not. While children worked on common goals throughout
the sessions, the level of difficulty was graded to meet the needs
of the individual child. Children allocated to the control group
received no intervention, and were encouraged to participate in
activities as they normally would for the duration of the 10-week
period. Due to time and funding restrictions, it was not possible
for children within the control group to be offered the CO-OP
intervention at the conclusion of the 10 weeks and instead, they
were offered access to a remedial movement program run by the
coordinating institution.
CO-OP to improve children with DCD 3
Group 2 Group 3
Writing neater Handwriting speed
Writing faster Handwriting legibility
Doing up buttons Cutting with scissors
Tying shoelaces Cutting with scissors
Doing up buttons Doing up shoelaces
Handwriting legibility Writing legibility
Handwriting legibility Handwriting speed
Doing up buttons Handwriting legibility
Cutting food Hitting a tennis ball
Area of measurement
Motor overflow
Motor overflow
Movement proficiency
Handwriting speed and legibility
Goal attainment
Occupational performance
All 20 participants completed impairment and activity out-
come measures, with the CO-OP group also completing additional
measures of participation, prior to and at the conclusion of the 10-
week intervention. All outcome measures were completed with an
independent therapist blinded to intervention status. Each out-
come measure and its domain within the ICF framework is
outlined in Table 2. Parents of children allocated to the CO-OP
group also completed a satisfaction survey at the completion of
the 10-week intervention period.
Impairment
Contralateral motor overflow was quantified in the inactive non-
dominant hand while the dominant hand executed three upper
limb movement assessment tasks; finger sequencing, clip
pinching and the pegboard task, before and after the intervention
period. All tasks were selected due to their use in previous
research into motor overflow [21,22,27]. Movements pertaining to
motor overflow, quantified as range of motion about the inactive
limb, were collected via three-dimensional motion analysis
using a twelve camera Vicon MX system (Oxford Metrics,
Oxford, UK) capturing at 250 Hz. Thirty-eight, 15 mm diameter,
retro-reflective markers were affixed to the body, in accordance to
the UWA Upper Limb Assessment Protocol [28].
Contralateral motor overflow was also measured using gloves
equipped with flex sensors, to detect movement of the non-
dominant inactive hand, during the finger sequencing task. This
movement was measured as mean amplitude of displacement of
each finger of the inactive hand. To standardise the timing of
finger sequencing between participants, a metronome was set at
50 bpm, with participants instructed to tap their thumb to each
finger in time with the metronome and complete five sequences of
the task at this speed. Data were collected at 100 Hz during the
finger sequencing task, using LabView Signal Express for DAQ
software (LabView, National Instruments, Austin, TX) and
processed using customised MATLAB script (MATLAB, The
MathWorks Inc., Natick, MA).
 4 A. Thornton et al.
The MABC-2 [29] was administered by a trained movement
specialist blinded to the individual’s group allocation and used to
determine movement proficiency prior to and at the conclusion of
the CO-OP intervention. Test–retest reliability for this assessment
is reported to be 0.80 [29].
Activity and participation
The PEGS [20], a tool used to set and prioritise goals, was
administered by an occupational therapist independent to the
study, as a process that would provide participants with the
opportunity to reflect on their strengths and abilities for daily
tasks in the school, home and community settings and to establish
goals for the intervention period. The top four tasks each child
chose as a result of the PEGS were used as prompts for both the
child and parent to identify occupational performance problems
on the Canadian Occupational Performance Measure (COPM)
[30]. As all children identified handwriting as a primary goal, the
Handwriting Speed Test (HST) was used as an outcome measure
of activity with the outcome of handwriting speed and legibility
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measured [31]. The writing sample was then scored by two
independent examiners blinded to group’s allocations for speed;
by recording letters per minute and letter and word legibility; with
scoring criteria from the Evaluation Tool of Children’s
Handwriting – Manuscript version (ETCH-M) [32], a method
used successfully in previous research [33].
The occupational performance issues as rated most important
by the child and parent on the COPM were used as the basis for
the development of goals for the Goal Attainment Scale (GAS)
[34]. Both were administered by an independent occupational
For personal use only.
therapist. The most common occupational performance area that
was identified as a problem, by the child and parent was
productivity – school (handwriting speed and legibility, drawing
and other fine motor manipulation skills such as cutting) and self-
care (using cutlery, managing buttons and shoelaces). The control
group did not complete the COPM or GAS, but in an initial
interview, parents of children in the control group did identify
handwriting speed and legibility, along with participation in age-
appropriate physical activity as common performance problems.
Data analysis
As the data did not meet assumptions for normality and
homogeneity, non-parametric statistics were used. Mann–
Whitney U tests were employed to compare differences between
the groups prior to and following the completion of the
intervention. Kruskall–Wallis tests were also used to compare
within group differences pre- and post-intervention or control
period. Due to the number of comparisons made within the range
of motion data, a Bonferroni correction was applied to the Mann–
Whitney U and Kruskall–Wallis comparisons, resulting in an
alpha level of p ¼ 0.005 denoting statistical significance.
MABC-2 and HST scores complied with the assumptions of
normality and homogeneity, as such, were compared using
parametric statistics, using a repeated measures ANOVA. For
the CO-OP group, COPM scores were analysed using paired
samples t-tests and baseline and achieved GAS scores were
converted to aggregate T-scores [33], then analysed using paired
samples t-tests.
Results
Impairment
At baseline, there were no significant differences between the
control and intervention groups in motor overflow. At the
conclusion of the intervention period differences were observed
between the two groups (Table 2). During performance of the
Disabil Rehabil, Early Online: 1–8
finger sequencing task, significant differences were seen
between groups for range of motion about the shoulder during
abduction/adduction (Z ¼ 3.78, p ¼ 0.001), at the elbow in
flexion/extension (Z ¼ 3.55, p ¼ 0.001) and pronation/
supination (Z ¼ 3.38, p ¼ 0.001) and wrist abduction/adduction
(Z ¼ 3.59, p ¼ 0.001), with the intervention group displaying
lower range of motion than the control group in all instances.
For the clip pinching task, range of motion was significantly
lower in the intervention group at week 10 than the control
group at the shoulder in flexion/extension (Z ¼ 2.86, p ¼ 0.004)
and internal/external rotation (Z ¼ 3.02, p ¼ 0.003) and at
the elbow for flexion/extension (Z ¼ 3.02, p ¼ 0.003) and
pronation/supination (Z ¼ 3.10, p ¼ 0.002). No differences
were noted between groups at week 10 for the pegboard task.
Within group comparisons of motor overflow in the inactive
non-dominant limb (Table 3), demonstrated no significant
differences in range of motion at any joint across all tasks over
the control period. During the finger sequencing task, range of
motion decreased at week 10 in the intervention group for wrist
abduction/adduction (Z ¼ 2.80, p ¼ 0.005), with thorax lateral
flexion (Z ¼ 2.60, p ¼ 0.009) and shoulder abduction
(Z ¼ 2.70, p ¼ 0.007) range of motion approaching significance.
At the elbow, flexion/extension (Z ¼ 2.67, p ¼ 0.008) and
pronation/supination (Z ¼ 2.67, p ¼ 0.008) also approached
significance. For the clip pinching task, significant decreases in
range of motion occurred within the intervention group at the
thorax for rotation (Z ¼ 2.80, p ¼ 0.005) and in shoulder
adduction/abduction (Z ¼ 2.80, p ¼ 0.005). There were also
significant decreases in range of motion in elbow flexion/
extension (Z ¼ 2.80, p ¼ 0.005). For the pegboard task, signifi-
cant decreases in range of motion were found across two planes of
motion at the thorax; flexion extension (Z ¼ 2.80, p ¼ 0.005)
and lateral flexion (Z ¼ 2.80, p ¼ 0.005) with rotation approach-
ing significance (Z ¼ 2.70, p ¼ 0.007 effect size 0.83). No
significant changes were found at the shoulder, elbow or wrist
on this task.
The flex-sensor glove was used to assess movement of fingers
on the inactive hand during the finger sequencing task. Finger
movement of the inactive hand, displayed as mean amplitude, is
shown in Table 4. Movements of the fingers on the inactive hand
increased significantly in both groups from week 0 to week 10,
with no significant differences between groups pre- and post-
intervention.
Movement proficiency was assessed using the MABC-2 over
the course of the intervention. No significant differences were
found between the control and CO-OP groups at baseline or after
intervention for the MABC-2 raw score (F(1) ¼ 2.13, p ¼ 0.73) or
manual dexterity scores (F(1) ¼ 0.22, p ¼ 0.65). No significant
differences were found between MABC-2 percentile rank over
time (F(1) ¼ 1.96, p ¼ 0.178).
Figure 1 shows the mean scores for components of the activity
measure, the HST. The HST raw score (letters per minute) was
significantly higher in the intervention group when compared to
the control group at week 10 (F(19) ¼ 14.16, p ¼ 0.018), as was
word legibility (F(19) ¼ 4.45, p ¼ 0.030). Letter legibility did not
differ between groups over time (F(19) ¼ 0.01, p ¼ 0.94).
Activity and participation
Figure 2 illustrates parent and child performance and satisfaction
ratings for the CO-OP group, based on the COPM. Parents
reported significant improvements in performance (t(9) ¼ 5.78,
p50.01) and satisfaction (t(9) ¼ 3.81, p50.01) following the
intervention. Children also rated performance (t(9) ¼ 3.64,
p50.01) and satisfaction (t(9) ¼ 6.08, p50.01) significantly
higher post-intervention, with 100% of individuals reporting
 DOI: 10.3109/09638288.2015.1070298 CO-OP to improve children with DCD 5
Table 3. Mean (SD) degrees of range of motion about the non-dominant, inactive limb in the control and intervention groups at week 0 and week 10 –
within groups comparison.

Control CO-OP
Segment Movement Week 0 Week 10 Z p CO-OP Week 0 CO-OP Week 10 Z p
Finger sequence
Thorax Flex/Ext 5.63 (4.86) 6.17 (2.70) 1.274 0.203 6.11 (5.30) 4.25 (4.63) 0.255 0.799
Lat Flex 3.46 (1.67) 4.15 (1.76) 0.764 0.445 3.82 (1.53) 1.42 (3.25) 2.599 0.009
Rot 5.64 (6.29) 6.40 (6.50) 0.459 0.646 3.50 (.87) 0.81 (2.40) 2.803 0.005*
Shoulder Flex/Ext 30.58 (27.95) 28.95 (17.14) 0.357 0.721 25.88 (20.02) 16.78 (5.42) 1.478 0.139
Abd/Add 27.47 (8.68) 54.27 (13.10) 0.051 0.959 22.32 (6.60) 15.30# (10.92) 2.701 0.007
Int/Ext Rot 30.02 (25.02) 28.05 (16.09) 0.153 0.878 29.31 (21.03) 24.82 (5.08) 1.886 0.059
Elbow Flex/Ext 10.91 (2.42) 15.57 (10.98) 1.183 0.237 11.02 (9.96) 8.31# (8.41) 2.666 0.008
Pro/Sup 14.14 (9.74) 16.81 (7.63) 0.000 1.00 14.33 (6.89) 8.57# (3.46) 2.666 0.008
Wrist Flex/Ext 20.90 (10.48) 18.81 (10.14) 0.420 0.674 25.13 (16.14) 14.86 (7.67) 1.274 0.203
Abd/Add 11.78 (11.37) 13.03 (6.47) 0.140 0.889 15.19 (11.20) 6.22# (10.91) 2.803 0.005*
Clip pinch
Thorax Flex/Ext 8.39 (4.73) 9.11 (4.35) 0.357 0.721 9.86 (5.23) 2.97 (8.07) 2.701 0.007
Lat Flex 6.01 (2.49) 5.88 (1.63) 0.459 0.646 5.63 (1.53) 2.08 (1.63) 2.395 0.017
Rot 9.43 (5.97) 9.94 (6.44) 0.153 0.878 10.31 (6.51) 1.75 (8.06) 2.395 0.017
Shoulder Flex/Ext 11.50 (6.32) 12.56 (8.38) .059 0.953 11.11 (5.82) 6.25# (3.42) 2.547 0.011
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Abd/Add 11.50 (5.99) 13.63 (8.96) 0.178 0.859 13.44 (7.98) 8.67 (5.90) 1.955 0.051
Int/Ext Rot 19.82 (18.66) 19.15 (14.31) 0.533 0.594 22.25 (18.89) 4.10# (14.12) 2.310 0.021
Elbow Flex/Ext 22.22 (31.04) 16.95 (14.11) 0.415 0.678 23.77 (32.26) 6.86# (3.80) 2.310 0.021
Pro/Sup 33.68 (39.44) 26.51 (9.01) 0.770 0.441 36.41 (43.01) 21.57# (19.34) 2.599 0.011
Wrist Flex/Ext 19.55 (14.55) 15.54 (12.57) 1.070 0.285 17.91 (13.72) 3.55 (13.33) 1.886 0.059
Abd/Add 13.16 (10.50) 10.50 (10.92) 0.968 0.333 12.17 (9.84) 1.28 (10.47) 1.784 0.074
Pegboard
Thorax Flex/Ext 7.57 (2.17) 11.53 (9.57) 0.051 0.959 6.88 (4.93) 4.07 (10.07) 2.803 0.005*
Lat Flex 9.18 (2.70) 6.19 (5.36) 1.274 0.203 6.38 (2.82) 4.19 (5.41) 2.803 0.005*
Rot 10.86 (1.91) 9.25 (6.12) 0.153 0.878 8.13 (2.94) 4.62 (3.13) 2.701 0.007
Shoulder Flex/Ext 7.17 (3.86) 7.49 (8.33) 1.836 0.066 14.22 (13.45) 7.64 (8.16) 2.380 0.017
Abd/Add 10.70 (5.17) 19.37 (16.80) 1.362 0.173 13.67 (8.21) 25.98 (16.32) 1.120 0.263
For personal use only.

Int/Ext Rot 13.44 (6.28) 17.38 (5.29) 0.77 0.441 18.71 (12.16) 11.07 (9.12) 2.380 0.017
Elbow Flex/Ext 13.69 (9.00) 15.63 (9.54) 1.836 0.066 20.34 (18.39) 10.13 (6.50) 2.100 0.036
Pro/Sup 17.57 (8.24) 10.51 (13.39) 1.007 0.314 19.56 (7.19) 9.11 (7.09) 2.521 0.012
Wrist Flex/Ext 14.77 (7.26) 7.26 (3.21) 0.357 0.721 15.93 (3.21) 7.48 (4.03) .561 0.575
Abd/Add 7.59 (3.71) 4.71 (9.15) 1.682 0.093 12.63 (10.92) 2.87 (10.85) 2.803 0.005*

Flex/Ext, flexion/extension angle, Lat Flex, lateral flexion angle, Rot, rotation angle, Abd/Add, abduction/adduction angle, Int/Ext Rot, internal/
external rotation angle, Pro/Sup, pronation/supination angle.
*p50.005.
#p50.05.

Table 4. Mean (SD) amplitude of the inactive fingers at 0 and 10 weeks in the control and CO-OP groups.

Control CO-OP
Week 0 Week 10 Z p Week 0 Week 10 Z p
Finger 1 3.41 (1.29) 3.95 (0.54) 1.59 0.112 3.59 (0.21) 3.87 (0.21) 2.52 0.012
Finger 2 3.65 (0.51) 3.88 (0.51) 2.32 0.020 3.57 (0.27) 3.84 (0.27) 2.52 0.012
Finger 3 3.77 (0.61) 4.01 (0.63) 2.32 0.020 3.68 (0.32) 3.95 (0.32) 2.52 0.012
Finger 4 3.73 (0.67) 3.97 (0.66) 2.32 0.020 3.66 (0.37) 3.94 (0.32) 2.52 0.012

clinically significant changes of two points or greater in both
areas. All children in the CO-OP group showed improvement in
GAS scores from week 0 to week 10, with mean achieved scores
(x64.30, ± 9.66) at week 10 significantly higher than baseline
scores (x40.80, ± 13.71) at week 0 (t(9) ¼ 5.27, p ¼ 0.001).
Discussion
This research aimed to determine if CO-OP intervention approach
facilitated improvements across levels of the ICF framework in
children with DCD. Consistent with our hypothesis, children who
undertook the 10 week intervention program experienced
improvements in impairment, activity and participation.
In terms of impairment, levels of motor overflow (measured by
range of motion of the inactive limb) decreased in children who
participated in the CO-OP intervention, with no change demon-
strated by the control group. These results suggest that CO-OP
intervention has aided the suppression of motor overflow in the
more proximal segments of the body. This is a promising finding,
given that previous research into the suppression of motor
overflow in children with DCD found no improvement over an 8-
week training period [35]. This previous intervention program
focused on the specific task of running, with an emphasis on
correcting inefficient movement patterns to decrease impairment.
This is different to the CO-OP approach, where the focus is
on utilising a global problem solving method to improve
task performance, rather than concentrating directly on the
impairments that limit task performance. Evidence suggests
intervention protocols that make use of global problem solving
training strategies are an effective way of remediating
 6 A. Thornton et al.
Disabil Rehabil Downloaded from informahealthcare.com by 180.216.58.124 on 07/27/15
Figure 1. HST component averages at week 0 and 10 for the control
group and intervention (CO-OP) group. *Significant difference within
group p50.05.
For personal use only.
Figure 2. Performance and satisfaction ratings of parents and children
in the CO-OP group, based on the COPM at week 0 and week 10.
*p Value50.05.
impairments at an executive level, as they allow a greater
understanding of the task requirement. By directing cognitive
attention to the task and asking the individual to identify the key
features of their performance, rather than trying to correct
technique, transfer of the strategies developed to other tasks [7] is
more likely to take place.
Despite improvements in motor overflow presentation in
proximal segments, there were no improvements made in motor
overflow presentation in the fingers of the inactive limb, with
movements of the inactive digits increasing marginally. The lack
of improvement in motor overflow in the fingers suggest an issue
with distal inhibition as opposed to proximal, particularly when it
is considered that reduced range of motion of the inactive limb
was found predominantly at the shoulder and elbow, with some
Disabil Rehabil, Early Online: 1–8
improvement at the wrist. Herzog and Durwen surmised that the
more distal muscles are involved in task performance, the greater
the levels of motor overflow produced [36]. It is possible that
while the strategies children in the CO-OP group developed were
successful in suppressing proximal motor overflow, they were not
able to overcome the greater neurological demand placed on
activities that recruited distal muscles, in the time period of the
current intervention. This has potential implications for interven-
tions targeting motor overflow in the future which, based on the
results of this research, should potentially look to longer periods
of intervention in order to address this problem, or generate
strategies around targeting distal segments specifically.
The nature of the cognitive strategies employed by the children
alludes to the underlying issues of DCD and provides insight into
why there were improvements in skills that had been addressed in
the past with little success. Traditional bottom-up approaches,
which target the underlying motor components of performance,
have been documented to be the most effective means of
facilitating functional improvement [4]. Yet if this were the
case, it is likely that the children with DCD would have adopted
more strategies based around their body position or feeling the
movement. In fact, strategies that enhanced children’s awareness
of the task requirements were used most extensively, which is
consistent with other studies into the effectiveness of CO-OP as
an intervention [37,38]. This suggests that the children’s
difficulties with their chosen skills originated from a lack of
understanding of what steps constituted the task and how to
proceed with these steps. The dominance of the task specification
and modification strategies supports the notion that DCD may in
fact be a motor-based learning problem [19].
MABC-2 scores did not differ between intervention and
control groups over time. However, when it is taken into account
that the MABC-2 incorporates aspects of movement that were not
in the scope of the intervention, such as balance and aiming and
catching, this may provide some reasoning behind the lack of
improvement. When assessing the individual components of the
MABC-2, there were no differences in manual dexterity scores
between groups over time. This was in contrast to expectations, as
fine motor tasks were the focus during the intervention period.
However, all children chose fine motor goals which involved
improving handwriting speed and legibility. As the tasks
comprising the manual dexterity component of the MABC-2 do
not include a measure of handwriting, it is difficult to draw
comparisons between the two. The MABC-2 tasks have greater
time and performance constraints than other tests of handwriting
proficiency [39] which more accurately emulate how the task is
performed on a daily basis. Handwriting speed and legibility were
both found to improve significantly over the intervention period in
the treatment group, further demonstrating that in this instance,
manual dexterity scores in the MABC-2 are not indicative of
handwriting proficiency.
In terms of activity and participation, children in the CO-OP
intervention group displayed significant changes in performance
and satisfaction ratings on the COPM for the goals worked on
during the intervention period post-treatment, with all individuals
reporting changes of two or greater in both areas, the critical unit
for suggesting a clinically significant change [34]. These changes
were also seen in parent scores of perceived performance and
their satisfaction with the outcomes. This provides valuable
information in terms of child and parent perception of their
improvement over the intervention period. While the outcome
measures employed by this study have provided an objective
measure of this improvement, higher levels of perceived capabil-
ity displayed in the participants of this study have been shown to
provide feelings of empowerment which lead to increased goal
commitment and confidence to set new goals [40]. Higher
 DOI: 10.3109/09638288.2015.1070298
perceived levels of capability may also mediate outcomes in a
wider range of activities for this population [41].
The higher ratings of performance and satisfaction, as well as
significant improvement in GAS scores for the goals targeted in
the present study, also indicate that the service model used was
successful. Cooperative group formats, where the group works
together to achieve a goal, provide optimal conditions for self-
esteem enhancement and promote higher achievement [42,43].
When children are grouped according to common goals, utilising
the CO-OP approach in a group setting is successful in terms of
goal achievement and also positive ratings of performance and
satisfaction. This study helps to build on and support current
literature indicating that CO-OP intervention can also be
conducted effectively in a group setting [44].
The parent satisfaction survey conducted at the completion of
the CO-OP group intervention indicated 100% satisfaction with
the intervention being provided in a small group format as
opposed to individually. Parents cited the advantages of the small
group being socialisation, peer modelling and encouragement
from peers at the same level. Parents reported that the CO-OP
Disabil Rehabil Downloaded from informahealthcare.com by 180.216.58.124 on 07/27/15
approach was different to traditional intervention received as
it provided a framework to break down tasks and allowed
children to make mistakes and learn from these. As a result,
parents felt that this increased their children’s confidence and
independence. This finding has important implications for
therapists, with the ability to successfully perform group
interventions both time and cost efficient, and at no detriment
to the outcomes for the child.
While the results of this study are limited to boys with DCD
and focused on fine motor tasks, the compliance with the
For personal use only.
theoretical framework provided by CO-OP has provided positive
outcomes to the participants involved, and adds to its significance.
The lack of follow up in the present study indicates that further
research is required to determine if changes in motor overflow
presentation, handwriting and self-rating of performance remain
over time. Furthermore, separate measures around the effect of
CO-OP on quality of life and environmental factors that influence
impairment, activity and participation would add valuable infor-
mation to the profile of children with DCD.
Conclusion
Children receiving CO-OP as an intervention in this study
developed strategies that enabled them to display some improve-
ment in performance across the impairment, participation and
activity levels of the ICF. Results show some decrease in the
presence of motor overflow, a possible contributor to low motor
proficiency in this population, when compared to a control group
with the same disorder. This study has also shown the CO-OP
approach to improve handwriting speed and legibility, as well as
improved ratings of perceived performance and satisfaction from
both parents and children. However, we do not understand the
transfer of these benefits to other core impairments experienced
by children with DCD as yet. The use of the ICF framework in
this study has provided a holistic, comprehensive measure of
health, with outcomes that are important and relevant to both the
child and family.
Acknowledgements
The authors wish to acknowledge the children and their families
who participated in this research, as well as Dr. Esther Chia for
her assistance in data collection.
Declaration of interest
The authors report no conflicts of interest.
CO-OP to improve children with DCD 7
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