Is task‐oriented training effective for children with developmental coordination disorder? A Cochrane Review summary with commentary

The aim of this commentary is to discuss from a rehabilitation perspective the published Cochrane Review ‘Task-oriented interventions for children with developmental co-ordination disorder’ by Miyahara et al.,,1 under the direct supervision of the Cochrane Developmental, Psychosocial and Learning Problems Group. This Cochrane Corner is produced in agreement with Developmental Medicine & Child Neurology and Cochrane Rehabilitation. Developmental coordination disorder (DCD) is a developmental disorder defined by the American Psychiatric Association as a marked impairment in motor skills, not attributable to a known neurological or physical medical condition, which significantly interferes with a child’s activities of daily living or academic achievement, or both.2 The prevalence of DCD in school-age children is reported to be between 2% and 12%,2-4 and the sex ratio of males to females is 1.9:1.3 The motor difficulties experienced by children with DCD have a significant impact on their lives, including their self-esteem and social participation, and persist into adulthood. Children with DCD also have higher rates of anxiety and depression compared to typically developing children.5 Interventions for children with DCD include movement-based therapies and education, drugs, dietary supplements, and psychological interventions. The movement-based interventions can be categorized in terms of whether they are task- or process-oriented. This review1 evaluated the evidence for task-oriented interventions. Task-oriented interventions focus on the use of specific tasks to improve skills, and include task-specific training,6 the cognitive-motor approach,7 cognitive orientation to daily occupational performance,8 neuromotor task training,9 and ecological interventions.10 Given the impact on children’s lives, it is important to evaluate the evidence for interventions to address the skill deficits in children with DCD. The aims of this Cochrane Review1 were to assess the effectiveness of task-oriented interventions on movement performance, psychosocial functions, activity, and participation for children with DCD, and to examine differential intervention effects according to age, sex, severity of DCD, and type and intensity of intervention. The population addressed in this review was children and adolescents aged between 4 and 18 years of age with a diagnosis of DCD, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM), DSM-IV,11 DSM-V,2 or children referred to as clumsy, physically awkward, or with dyspraxia who otherwise meet the criteria. The interventions studied were task-oriented, focusing on the practice of everyday tasks as the principal form of intervention (e.g. tying shoelaces, ball catching, and handwriting). The intervention was compared to either an inactive control intervention (e.g. usual care or waiting-list control) or an active control intervention (e.g. a process-oriented approach, pharmacology, counselling, or dietary advice). The primary outcomes studied were changes in gross and fine motor function. Secondary outcomes were changes in motor coordination, measures of impairment (e.g. sensation, strength), measures of psychosocial factors (e.g. self-esteem), and measures of participation (academic level, sporting participation, recreation). The review authors searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, 13 other databases, and five trials registers to identify studies that had been published up to March 2017. They also searched reference lists and relevant websites and contacted members on the International Conference on DCD mailing list. The review included 15 studies (eight RCTs, seven quasi-RCTs) involving 649 children aged between 5 and 12 years. Participants were from Australia, Canada, China, Sweden, Taiwan, and the UK. Six studies (two RCTs, 17 participants; and four quasi-RCTs, 59 participants) that used the Movement Assessment Battery for Children (MABC)7 were combined in a meta-analysis. The meta-analysis showed that task-oriented interventions have a moderately positive effect on movement problems/motor performance (very low-quality evidence) compared to no intervention. A second analysis was performed to test the robustness of the results using the two strongest studies (RCTs) with 17 participants. This indicated that task-oriented interventions do not improve movement problems/motor performance (low-quality evidence). No significant effects of intervention were observed for the secondary outcomes. However, there was a high level of heterogeneity in methodology or insufficient reporting of these outcomes, or both. No adverse effects were reported in 11 studies; two reported no adverse effects and the authors of nine studies confirmed through correspondence that no injuries had occurred. The authors concluded that task-oriented interventions may be useful for children with DCD in improving performance on movement tests. However, the duration of the intervention was short (<6mo), most trials were small and of poor quality, and the quality of the evidence was low or very low. Therefore there is uncertainty about the effect estimates based on the findings of the studies included in the review. The primary objective of the review was to assess the effectiveness of task-oriented interventions on movement performance, psychosocial functions, activity, and participation for children with DCD. The limited number of included trials with small sample sizes and concerns about risk of bias resulting in low and very low-quality evidence are insufficient to address this objective definitively. Whether or not task-oriented interventions improve motor skills (assessed with the MABC) compared with an inactive control remains uncertain. It is therefore uncertain whether task-oriented interventions improve motor skills more than an inactive control, as assessed by the MABC. A quantitative synthesis of the results for the secondary outcomes (psychosocial functions) was not possible due to methodological heterogeneity or insufficient reporting. The studies were conducted in diverse settings (including hospitals, university-based clinics or laboratories, community centres, at home or school or both), with most interventions conducted in research settings. The age of participants in the included studies was between 5 and 12 years. The findings therefore have limited generalizability to adolescents and adults with DCD and to non-research settings. Important aspects of the included studies were: (1) the control interventions were diverse, with five studies having active controls and therefore excluded from the meta-analysis; (2) there was a variety of outcome measures used; (3) few studies included outcome measures of psychosocial functions, activity, and participation; (4) there was insufficient information on intervention intensity and type of intervention. Several implications for clinical practice and for further research arise from this review. Many of the task-oriented interventions address motor difficulties. More attention needs to be given to the outcome measures selected and to ensure that they are sufficiently sensitive to detect a change in performance on the task that is being trained. Second, including measures of psychosocial function, activity, and participation would enable evaluation of the effects of any interventions provided on other aspects of DCD, such as self-esteem, activity, and social participation. Third, it is highly desirable that clinicians and researchers record the elements of each intervention and the intensity of practice in order to overcome the limitations highlighted in this review regarding the insufficient reporting of these elements. Better reporting of interventions, in accordance with the TIDieR checklist,12 is not only important for replication and building upon research findings, improving the completeness of reporting, and understanding the observed efficacy of interventions, but ultimately will ensure that the interventions can be appropriately implemented in the clinical setting. The author thanks Cochrane Rehabilitation and the Cochrane Developmental, Psychosocial and Learning Problems Group for reviewing the contents of the Cochrane Corner. The author has stated that she had no interests that could be perceived as posing a conflict or bias.

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