Sensory processing disorder covers a wide variety of sensory impairments, one of which is dyspraxia. Children with dyspraxia are typically uncoordinated and clumsy due to deficits in processing sensory information. Physical therapists provide services to these children to improve muscle tone, balance, coordination and praxis (motor planning).

In breaking down the term dyspraxia, praxis means "based on will" and the prefix "dys" refers to dysfunction. Children with dyspraxia have difficulty performing motor tasks with perceived effort or at will. Children with dyspraxia often perform complex motor tasks during self-directed play quite well; however, may be unable to perform these same tasks with intent or perceived effort. They have difficulty planning and executing non-habitual motor tasks. Although these children often develop adequate motor performance with practice, they lack the intuitive know-how in performing a new or novel motor challenge.

Children with dyspraxia often master a high level of motor skills without necessarily mastering the lower level, prerequisite skills. Alex, for example, is an 8-year-old boy who practices playing baseball with his dad on a daily basis. He can bat a ball far into the outfield, yet this same boy has difficulty in gym class. He cannot catch a ball, cannot ride a bike, has poor balance and is very slow at learning new motor tasks. Additionally, he is always the last one to get his shoes and clothing changed for gym class and he usually looks disheveled when he finally arrives. He is often accused of being inattentive and lazy.

Children with dyspraxia, such as Alex, have difficulty with sequencing, timing and force of movement. These children are typically intelligent and able to identify and predict their own shortcomings. Because these children are bright and because their motor planning deficits are usually subtle, they often adapt and go unidentified until the demands of school or home become so great that they no longer have sufficient coping strategies.

Praxis in Our Own Lives

Consider the first time you got behind the wheel of a car. Driving was not the highly practiced task that it has now become for most of us. You had to think about most every movement, including putting the key in the ignition, putting the foot on the brake, and putting the hand on the lever to shift into drive. When learning to drive, you were engaged in a task that involved motor planning or praxis.

Even though the task of driving was not yet automatic, you had the instinctive know-how in approaching this new motor task of driving a car. For most of us highly experienced drivers, getting into a car and driving to a frequently traveled location is no longer a task that involves motor planning or praxis, but is a highly practiced task that we perform well due to the constant repetition. Conscious thought is not usually required and, at times, it's as if you're on auto pilot.

The Sensory Systems Involved

Sensory-based dyspraxia usually results from poor processing of vestibular and proprioceptive sensory systems. In more severe disorders of dyspraxia, the tactile system is also affected. Typically, children with sensory-based dyspraxia are under-responsive to vestibular and proprioceptive sensory information, and as a result they need added intensive sensory input that is specifically designed and graded to meet this particular need.

Deficits in processing vestibular and proprioceptive information usually result in low muscle tone. These children have difficulty stabilizing their bodies to meet the demands of the environment for a given motor task. It is characterized by inappropriate muscle tension and inadequate control of movement resulting in poor postural control.

Postural control is needed to provide a stable, yet mobile, base for refined movement of the head, eyes and extremities which develops as a result of integration of vestibular, proprioceptive and visual information.

When postural control is poor, children often slump when standing or sitting, or they may display the opposite extreme and hyper-extend their spines for stabilization. In either instance, there is poor activation of core trunk musculature.

Prone linear movement provides intensive vestibular and proprioceptive sensory input which facilitates muscle tone, ocular control and central nervous system arousal while providing an opportunity to work on ball skills.

They may also exhibit difficulty maintaining or adjusting their body position so tasks can be performed efficiently. They may appear awkward as they run or move because their movements lack smoothness, rhythm and refined control.

These children have poor awareness of where their body is in space and are often unaware of where their arms and legs are if not specifically looking at them. Poor balance and equilibrium reactions, avoidance of trunk rotation and inability to control and isolate eye movements are also symptoms that are frequently observed when postural control is poor.

When muscle tone is low and the central nervous system is sluggish, it is difficult to maintain appropriate attention and focus for extended periods of time. Children with dyspraxia often seem lethargic and fatigued, especially during seated work.

Their activity level, however, can fluctuate between being relatively inactive (preferring to lie on the floor to play) to being highly active and engaging in sensory-seeking movement experiences to increase their muscle tone and overall central nervous system state of arousal and attention. Maintaining a quiet-alert state of attention needed for learning is a challenge for children with dyspraxia.

Behavior Issues

Unlike children with ideational dyspraxia, who are unable to comprehend or form an idea about what is to be done, children with sensory-based disorders of praxis understand what they are trying to do, however become frustrated and discouraged when they are unable to perform the task to their expectation. They realize that their performance is not as good as that of their peers. As a result, they often develop behavior difficulties to mask their motor planning deficits.

Some cope by becoming the class clown, as they would rather be viewed as silly or uncooperative than to face their greatest fear of being perceived as dumb, stupid or klutzy. Some cope by becoming shy or withdrawn. This coping strategy provides them with additional time to observe other children performing tasks before attempting the task themselves.

Some children develop an over-reliance on language as a compensatory tool to avoid participation in effortful tasks. Self-esteem may be poor due to dissatisfaction with personal performance and repeated feelings of failure. Low frustration tolerance is common, and these children can be perceived as manipulative or controlling as they avoid participation and failure.

Intervention Approaches

Two main methods of treatment are generally used with this patient population. The process-oriented approach focuses on the abnormal or immature processes underlying the sensory and motor systems, as frequently occurs in sensory integration therapy.

When treating a child with sensory-based dyspraxia, the initial focus is on providing intensive vestibular and proprioceptive stimulation that is graded and adapted to meet the child's particular need. This provides the central nervous system with the added sensory input needed for improved muscle tone, coordination and alertness.

Effective treatment gives consideration to activities that provide stimuli in a variety of positions and planes of three dimensional space, that vary in speed from static holding to fast movement, that are linear and angular, and that are transient and sustained.

Activities that provide linear vestibular and proprioceptive input while the child maintains a visual focus are highly effective in improving neck and trunk extension and ocular control while working on anticipatory and projection action sequences.

Activities such as lying prone on a scooter while pushing and pulling a bungee cord provide intensive proprioceptive and vestibular input while developing bilateral coordination, rhythm, timing and visual convergence.

For children with sensory-based dyspraxia, participation in activities that are rich in vestibular and proprioceptive sensory input provide the foundation of improved muscle tone and central nervous system alerting needed for successful participation in of a task-oriented approach, aims to improve and refine specific skills through practice such as skipping, dribbling a ball or riding a bike.

The key to successful intervention for children with dyspraxia is to find the balance between spontaneity and perceived effort. When too much effort is perceived on the part of the child, performance often becomes worse despite their best efforts.

When effectively using combined approaches for treatment of the child with dyspraxia, the first improvement usually demonstrated by most children is improved self-esteem and the belief in their own abilities to master new challenges. 

Debra Denniger is director of pediatric therapy at Sovereign Rehabilitation in Naperville, IL. For further information on sensory-based motor dyspraxia or sensory integration therapy, e-mail her at debbie.denniger@sovereignrehab.com