The Clumsy Child

Years ago, I took care of a little girl whose mother worried tremendously about her clumsiness. When she was 4 or 5, my patient was still tripping and falling more than other children her age, her mother thought. She had trouble with the clapping games in her preschool. The mother was visibly distressed when she talked about this. She told me that she herself had been “that kid,” the clumsy one, the last one chosen for every team.

For a long time, a variety of terms were used in medicine and education to describe children who struggled with coordination but had no underlying condition, terms like the ominous-sounding minimal brain dysfunction, the milder movement-skill problems, and yes, clumsy child syndrome. In 1994, these were consolidated under a single diagnosis, developmental coordination disorder, though this covers a wide range of children who may struggle with anything from handwriting to riding a bicycle.

There is always a risk when you apply a diagnosis, always a chance that it will be seen as “pathologizing” or stigmatizing children. Are kids better off thinking of themselves as just kind of awkward? Should parents shrug and say, “no one in our family is a good dancer”?

“I think there is a perception out there that children who are clumsy are just children who aren’t good at sports,” said Dr. John Cairney, a professor of family medicine at McMaster University in Hamilton, Ontario, which maintains a website about the disorder with useful advice for parents. It’s more important, he said, to think about “how it affects children and adults in everyday activities — tying shoelaces, using knives and forks.”

The need for a diagnosis depends on whether the child is actually struggling. Pediatricians and pediatric neurologists do sometimes encounter parents who worry because a child isn’t gifted at sports, or at a particular sport. Not being gifted, or even good, at sports is not a diagnosis, and it’s probably more important for that child’s well-being to help parents take a new look and find the child’s real strengths and inclinations.

“Some of these kids come in referred to me, and they really look pretty normal; a lot is parental anxiety,” said Dr. Stephen Nelson, a pediatric neurologist and an associate professor of pediatrics at Tulane University, who wrote the Medscape article on developmental coordination disorder. “It’s O.K. if he doesn’t throw the ball well; he can have other skills,” Dr. Nelson said. “We don’t all have to excel at everything.”

On the other hand, a child whose fine-motor skills are far behind what is age appropriate may struggle to put on clothing, or feel bad about activities that children do for fun, like playing with Legos. And there are children whose problems go beyond just being average (or a little worse) at basic athletic skills, and those children can find themselves dreading gym class, and in some cases even being bullied.

“You have parents and teachers attempting to push them into activities, believing the problem is motivational, not neurologic or motoric,” Dr. Cairney told me. “They get bullied, called stupid or klutzy.” With a diagnosis, he said, the children’s quality of life might improve, especially if they are given good advice about how to manage the problem.

Taking the clumsy child for evaluation is all about whether the child could use some help. That may involve modifying the child’s environment: Lots of children are referred for evaluation because of dysgraphia, or terrible handwriting. Learning how to use a keyboard can make a huge difference for their school functioning.

Occupational therapy is a mainstay for these children. They have to practice the specific skills they want to improve, whether that means handwriting, tying shoelaces or using a knife and fork.

An evaluation may help tease out problems that aren’t actually coordination issues. Some children look clumsy because they’re distracted, not paying attention to the motor — or athletic — task at hand. Others may have visual impairments. Doctors worry more if a child is delayed in several realms at once; if speech, fine-motor and gross-motor are all lagging. Most concerning of all is when a child who wasn’t originally clumsy starts to lose coordination skills, or begins to walk differently. Such a child should definitely be evaluated, because something new and medically serious could be going on.

So what about my patient? Well, she illustrates another point: Developmental coordination disorder is found more often among children with other issues, like attention problems, learning issues and autism. Parents with a child who is not doing well in school and also seems uncoordinated should take the lack of coordination as a reinforcing reason to have developmental and academic testing done.

That was true with my patient; her mother was very focused on her daughter’s clumsiness, but her preschool teachers were worried that something was getting in her way in the classroom. She ended up needing some special help with reading and schoolwork as she entered school. I would probably take her mother’s concern about clumsiness more seriously sooner these days, looking at it as a clue to that larger issue.

Clumsier children may become more self-conscious about displaying their motor skills and less likely to participate in games and activities, and this may mean they get less practice. And practice does help everyone, from the naturally gifted to the rest of us.

“In general, most of this gets better with time,” Dr. Nelson said. However, he added, it’s not something that children completely outgrow; clumsy children, on the whole, tend to become clumsy adults.

With more screen time and less freedom to play outside unsupervised, there’s also a concern that many children may have a lower chance of developing and practicing many motor skills (other than swiping and clicking). “We need to do more to support children’s global motor development,” Dr. Cairney said, “not to ensure they become athletes, but to ensure they can participate in a range of activities.”

(Source: well.blogs.nytimes.com)