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Disability and Rehabilitation

Volume 38, 2016 - Issue 10

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Research Paper

Cognitive Orientation to (Daily) Occupational

Performance intervention leads to improvements
in impairments, activity and participation in
children with Developmental Coordination
Disorder
Ashleigh Thornton , Melissa Licari, Siobhan Reid, Jodie Armstrong, Rachael Fallows & Catherine Elliott
Pages 979-986 | Received 05 Nov 2014, Accepted 04 Jul 2015, Published online: 27 Jul 2015

Download citation http://dx.doi.org/10.3109/09638288.2015.1070298 Crossmark

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Abstract

Introduction: Children diagnosed with Developmental Coordination Disorder (DCD) present with a
variety of impairments in fine and gross motor function, which impact on their activity 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 outcome
measures across the impairment, activity and participation levels of the International Classification of
Functioning, Disability and Health (ICF) framework. Methods: In this quasi-experimental, prepost-test,
20 male children aged 810 years (

9y1m 9 m) with a confirmed diagnosis of DCD participated in either the 10 week group intervention
based on the CO-OP framework (n = 10) or in a control period of regular activity for 10 weeks (n = 10).
Outcome 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

In this article

 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.
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.

Keywords:Goal based,group,motor impairment,therapy

Introduction

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 activities of daily living [ 1]. They also
experience activity limitations including mobility, domestic life and self-care and consequentially
experience participation restrictions [ 1]. These difficulties are not just present during childhood,
many individuals 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 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 movement problems [ 8].
strategies related to the performance of fine motor skills such as handwriting and cutting, as well as
gross motor skill such as running and basketball shooting, in children with DCD aged 712 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 Organisations International Classification of Functioning, Disability and Health
(ICF) [ 13] framework allows for a holistic approach to evaluating treatment outcomes, across the
levels of impairment, activity and participation 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 persons 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 DCDs 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 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
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, musculoskeletal 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 improvement 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 (

9y1m 9 m) were recruited for participation in this quasi-experimental, prepost-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 persons chronological 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.
The intervention program was conducted over 10 weeks, with children allocated into groups of 34,
based on common occupational performance problems, identified by the children and their parents
through the use of the Perceived Efficacy and Goal Setting system (PEGS) [ 20] (Table 1). Each group
session 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 childrens 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 childs functional performance and
goal achievement. The group program was developed to address at least 23 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 childs
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.

Table 1. Goals developed through use of the PEGS by children in the CO-OP
group.
CSV Display Table

All 20 participants completed impairment and activity outcome 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 outcome 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.

Table 2. Outcome measures used at week 0 and 10 across the ICF domains
of impairment, activity and participation.
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).

The MABC-2 [ 29] was administered by a trained movement specialist blinded to the individuals
group allocation and used to determine movement proficiency prior to and at the conclusion of the
CO-OP intervention. Testretest 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 measured [ 31]. The writing
sample was then scored by two independent examiners blinded to groups allocations for speed; by
recording letters per minute and letter and word legibility; with scoring criteria from the Evaluation
Tool of Childrens Handwriting Manuscript version (ETCH-M) [ 32], a method used successfully in
previous research [ 33].
were used as the basis for the development of goals for the Goal Attainment Scale (GAS) [ 34]. Both
were administered by an independent occupational 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. MannWhitney U tests were employed to compare differences between the groups prior to and
following the completion of the intervention. KruskallWallis 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 MannWhitney U
and KruskallWallis comparisons, resulting in an alpha level of p = 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 finger sequencing task, significant differences were
seen between groups for range of motion about the shoulder during abduction/adduction (Z = 3.78,
p = 0.001), at the elbow in flexion/extension (Z = 3.55, p = 0.001) and pronation/supination (Z = 3.38, p
= 0.001) and wrist abduction/adduction (Z = 3.59, p = 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 = 2.86, p = 0.004) and internal/external rotation (Z = 3.02, p = 0.003)
and at the elbow for flexion/extension (Z = 3.02, p = 0.003) and pronation/supination (Z = 3.10, p =
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
intervention group for wrist abduction/adduction (Z 2.80, p 0.005), with thorax lateral flexion (Z
2.60, p = 0.009) and shoulder abduction (Z = 2.70, p = 0.007) range of motion approaching
significance. At the elbow, flexion/extension (Z = 2.67, p = 0.008) and pronation/supination (Z = 2.67,
p = 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 = 2.80, p = 0.005) and in
shoulder adduction/abduction (Z = 2.80, p = 0.005). There were also significant decreases in range of
motion in elbow flexion/extension (Z = 2.80, p = 0.005). For the pegboard task, significant decreases in
range of motion were found across two planes of motion at the thorax; flexion extension (Z = 2.80, p
= 0.005) and lateral flexion (Z = 2.80, p = 0.005) with rotation approaching significance (Z = 2.70, p =
0.007 effect size 0.83). No significant changes were found at the shoulder, elbow or wrist on this task.

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.
CSV Display Table

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.

Table 4. Mean (SD) amplitude of the inactive fingers at 0 and 10 weeks in

the control and CO-OP groups.
CSV Display Table

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) = 2.13, p = 0.73) or manual dexterity scores (F(1) = 0.22, p =
0.65). No significant differences were found between MABC-2 percentile rank over time (F(1) = 1.96, p =
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) = 14.16, p = 0.018), as was word legibility (F(19) = 4.45, p = 0.030). Letter
legibility did not differ between groups over time (F(19) = 0.01, p = 0.94).

Figure 1. HST component averages at week 0 and 10 for the control group and intervention (CO-OP)
group. *Significant difference within group p < 0.05.
PowerPoint slide Original jpg (558.00KB) Display full size

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) = 5.78, p < 0.01) and
satisfaction (t(9) = 3.81, p < 0.01) following the intervention. Children also rated performance (t(9) =
3.64, p < 0.01) and satisfaction (t(9) = 6.08, p < 0.01) significantly higher post-intervention, with 100%
of individuals reporting 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 (

64.30, 9.66) at week 10 significantly higher than baseline scores (40.80, 13.71) at week 0 (t(9) =
5.27, p = 0.001).

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 Value < 0.05.
PowerPoint slide Original jpg (476.00KB) Display full size

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
demonstrated 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 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.
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 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 interventions 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
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 capability 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 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 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 childrens 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 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 information to the profile of children with DCD.
Children receiving CO-OP as an intervention in this study developed strategies that enabled them to
display some improvement 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.

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