3

Executive Function, the Brain’s Director

You hear it. You read it. Executive functioning, which is almost always broken in ADHD or autism and other developmental disorders and learning disabilities. Ever wonder what is executive functioning? What is executive functioning?

Image courtesy of Psychology Today. Executive Function in the brain.

Executive function (EF) (also known as cognitive control and supervisory attentional system) is an umbrella term for the management (regulation, control) of cognitive processes[1][2], including working memory, reasoning, task flexibility, and problem solving[1][3], as well as planning and execution.[1][4]

Executive function consists of several mental skills that help the brain organize and act on information. These skills enable people to plan, organize, remember things, prioritize, pay attention and get started on tasks. They also help people use information and experiences from the past to solve current problems.[5]

In short, executive function is comparable to a company’s CEO, a celebrity’s manager, a sport team’s coach, the film’s director, an orchestra’s conductor, or a computer’s CPU; all of them direct what a group or a person will do to make a group run smoothly.

Image courtesy of Balboa School. The brain’s executive function is comparable to a computer’s CPU.

There are 8 key executive functions in the brain according to Understood.[6] What are they?

Eight Key Executive Functions:

  1. Impulse Control – helps your child think before acting.
  2. Emotional Control – helps you child keep his feelings in check.
  3. Flexible Thinking – allows your child to adjust to the unexpected.
  4. Working Memory -helps your child keep key information in mind.
  5. Self-Monitoring – allows your child to evaluate how you’re doing.
  6. Planning and Prioritizing – help your child decide on a goal and a plan to meet it.
  7. Task Initiation – helps your child take action and get started.
  8. Organization – lets your child keep track of things physically and mentally.

Two of the major ADHD researchers involved in studying EF are Russell Barkley, PhD, and Tom Brown, PhD, have also their own version of key executive functions[7]:

Barkley breaks executive functions down into four areas[7][8]:

  1. Nonverbal working memory
  2. Internalization of Speech (verbal working memory)
  3. Self-regulation of affect/motivation/arousal
  4. Reconstitution (planning and generativity)

Brown breaks executive functions down into six different “clusters.”[7][9]

  1. Organizing, prioritizing and activating for tasks
  2. Focusing, sustaining and shifting attention to task
  3. Regulating alertness, sustaining effort and processing speed
  4. Managing frustration and modulating emotions
  5. Utilizing working memory and accessing recall
  6. Monitoring and self-regulating action

Hmm.. they’re like the soccer team. Each member must function and cooperate well to win a game.

(C) Cartoon Network. Key executive functions are like a soccer team.

With executive function in sync, learning is much easier for a growing child up to his adulthood.

How executive function develops?

A range of tests measuring different forms of executive function skills indicate that they begin to develop shortly after birth, with ages 3 to 5 providing an important window of opportunity for dramatic growth in these skills. Growth continues throughout adolescence and early adulthood; proficiency begins to decline later in life.[10]

Image courtesy of Harvard University/NIH Toolbox project. This graph shows executive function development and proficiency across the life span.

Where in the brain is executive function?

Historically, the executive functions have been seen as regulated by the prefrontal regions of the frontal lobes,[1] but a review found indications for the sensitivity but not for the specificity of executive function measures to frontal lobe functioning. This means that both frontal and non-frontal brain regions are necessary for intact executive functions.[1]

Neuroimaging and lesion studies have identified the functions which are most often associated with the particular regions of the prefrontal cortex.[1][11]

The prefrontal cortex has its parts where specific executive functions are:

  • The dorsolateral prefrontal cortex (DLPFC) is involved with “on-line” processing of information such as integrating different dimensions of cognition and behaviour.[12] As such, this area has been found to be associated with verbal and design fluency, ability to maintain and shift set (mental ability to switch between thinking about two different concepts, and to think about multiple concepts simultaneously), planning, response inhibition, working memory, organisational skills, reasoning, problem solving and abstract thinking.[11][13]
  • The anterior cingulate cortex (ACC) is involved in emotional drives, experience and integration.[12] Associated cognitive functions include inhibition of inappropriate responses, decision making and motivated behaviours. Lesions in this area can lead to low drive states such as apathy (absence of feelings), abulia (lack of will or initiative) or akinetic mutism (patients tending neither to move (akinesia) nor speak (mutism)) and may also result in low drive states for such basic needs as food or drink and possibly decreased interest in social or vocational activities and sex.[12][14]
  • The orbitofrontal cortex (OFC) plays a key role in impulse control, maintenance of set, monitoring ongoing behaviour and socially appropriate behaviours.[12] The orbitofrontal cortex also has roles in representing the value of rewards based on sensory stimuli and evaluating subjective emotional experiences.[15] Lesions can cause disinhibition, impulsivity, aggressive outbursts, sexual promiscuity and antisocial behaviour.[11]

Image courtesy of Wikipedia/Natalie M. Zahr, Ph.D., and Edith V. Sullivan, Ph.D. Preforntal cortex in the brain’s frontal lobe.

When children have opportunities to develop executive function and self-regulation skills, individuals and society experience lifelong benefits. These skills are crucial for learning and development. They also enable positive behavior and allow us to make healthy choices for ourselves and our families.[10]

When children have opportunities to develop executive function and self-regulation skills, individuals and society experience lifelong benefits.

We usually have this executive function taken for granted. But for people in neurodiversity, their executive function is broken or impaired, inhibiting their normal functioning.

What happens if executive function is impaired?

If executive functioning is working well and the task is fairly simple, the brain may go through these steps in a matter of seconds. If your child has weak executive skills, though, performing even a simple task can be challenging. Remembering a specific word may be as big a struggle as planning tomorrow’s schedule.[5]

When executive functioning is impaired, all of its functions cannot be done or sustained. Hence, this is called executive function disorder (EFD) or executive dysfunction.

If your child has executive functioning issues, any task requiring these skills could be a challenge. That could include doing a load of laundry or completing a school project. Having issues with executive functioning makes it difficult to:

  • Keep track of time
  • Make plans
  • Make sure work is finished on time
  • Multitask
  • Apply previously learned information to solve problems
  • Analyze ideas
  • Look for help or more information when it is needed[5]

To explain this further, let’s include the 8 key executive functions and how they become impaired when executive function is broken:

  1. Impulse Control – Kids with weak impulse control might blurt out inappropriate things. They’re more also likely to engage in risky behavior.[6]
  2. Emotional Control – Kids with weak emotional control often overreact. They can have trouble dealing with criticism and regrouping when something goes wrong.[6]
  3. Flexible Thinking – Kids with “rigid” thinking don’t roll with the punches. They might get frustrated if asked about something from a different angle.[6]
  4. Working Memory – Kids with weak working memory have trouble remembering directions – even if they’ve taken notes or you’ve repeated them several times.[6]
  5. Self-Monitoring -Kids with weak self-monitoring may be surprised by a bad grade or negative feedback.[6]
  6. Planning and Prioritizing – Kids with weak planning and prioritizing skills may not know which parts of a project are most important.[6]
  7. Task Initiation – Kids who have weak task initiation skills may freeze up because they have no idea where to begin.[6]
  8. Organization -Kids with weak organization skills can lose their train of thought – as well as their cell phone or homework.[6]

EFD is relatively common in neurodiversity and less so in neurotypical people and can affect people of any degree of intelligence and capability.[16] Unfortunately, EFD is often mistaken as ADHD or LD (learning disabilities) by doctors (ADHD can have no EFD, just their hyperactive and inattentive problems). But despite giving learning therapies, children with EFD do not respond to them, thus mistaking them as lazy, unmotivated, stubborn or uncooperative. Usually, nothing could be further from the truth. They are working as hard as they can to keep pace with the demands in their lives.[16]

Very bad. Not only they will suffer in school and cause educational underachievement –  suspension, dropping out of school, repeating a grade, but also they will have a high risk of becoming unemployed and socially isolated, increasing risk for mental disorders.

What causes EFD?

In most cases of executive dysfunction, deficits are attributed to either frontal lobe damage or dysfunction, or to disruption in fronto-subcortical connectivity. Neuroimaging with PET and fMRI has confirmed the relationship between executive function and functional frontal pathology.[2][17] Certain genes have been identified with a clear correlation to executive dysfunction and related psychopathologies.[17] Not surprisingly, plaques and tangles in the frontal cortex can cause disruption in functions as well as damage to the connections between prefrontal cortex and the hippocampus.[17][18] Another important point is in the finding that structural MRI images link the severity of white matter lesions to deficits in cognition.[17][19]

The heritability of executive functions is among the highest of any psychological trait.[17][20] The dopamine receptor D4 gene (DRD4) with 7′-repeating polymorphism (7R) has been repeatedly shown to correlate strongly with impulsive response style on psychological tests of executive dysfunction.[17][21]

Image courtesy of http://www.des-livres-pour-changer-de-vie.fr./all-gifted.com. Einstein’s desk shortly after his death. Disorganized work areas don’t necessarily mean sloppy. This is one manifestation of executive function disorder (EFD).

Image courtesy of The Telegraph. This is a messy table. Can be an EFD or just simply lazy.

What needs to be done for EFD?

Early assessment needs to be done to avoid problems in school, work, and social relationships that could affect a person with EFD.

According to a local expert on EFD, Sarah Ward, M.S.,CCCSLP, of Lincoln, Massachusetts, one of the biggest complaints about children with EFD is, “They did it yesterday, why can’t they do it today?” For such children, however, the organizing pattern is not established in one pass; pathways must be developed through repeated practice. An important method of helping these kids is by teaching processing skills. Ward believes that this can be done most effectively through[16]:

  1. Segmentation: Teaching (not telling) students how to break down a task into smaller, manageable parts.
  2. Verbal approach: Using declarative language, instead of imperative language
  3. Mental picturing: Teaching students to think through a situation in order to envision how a goal can be accomplished
  4. Using visuals as a reinforcement.

Now, there is an application of these strategies in the following quotation from aane.org[16]:

Ward gives an example that uses these four techniques. A child was asked to set the table for dinner. She got stuck and overwhelmed in her attempts to do the task.

  1. The child was helped to break down the task to a manageable level, in this case putting out four plates.
  2. Once this was accomplished, the use of declarative language helped determine the next step. Rather than saying, “Okay, now put out the forks and knives” (imperative), the statement Ward made was, “Great, the plates are out. Now we’ll need something to eat the food with” (declarative).
  3. In this one brief statement, the child was given specific positive feedback for what she had done (“Great, the plates are out” as opposed to the generic “Good job”), and was asked to assess the situation and figure out what came next.
  4. Ward often uses photos or drawings to reinforce the concept being taught. In this case she used a photo of a correctly set table. It “conjured up the whole” and showed what it would look like if the table were set properly. Ward often uses stock images such as those found in Google Images (Ward even Googled Hamlet to show whatever images there were to help a student write an essay about the character!)

These concepts work equally well in school situations. As teachers we often say something like, “Take out your ruler and calculator and get ready for math.” Ward suggests that a better way to help students develop skills that will generalize to future situations is to say, “We’re going to do graphing now. How would your desk look? What is involved in graphing?” This teaches the student to become more self-directed by encouraging the development of self-talk, which Ward calls “notes to self.” The development of this kind of self monitoring is essential to effective, independent thinking and functioning.

Another crucial concept children need to learn, Ward says, is the “sweep and passage of time.” She explains that we teach kids to read the clock, but this has little to do with monitoring the passage of time. Ward uses a wall clock with a glass cover and actually draws on its surface with erasable markers to block off the amount of time that will be allowed for a task. In Ward’s estimation this concrete visual “pie shape” method of demonstrating the passage of time gives a sense of control and improves motivation, because “They can see they are succeeding.”

There are tests to diagnose EFD in people. Here they are:

Clock Drawing Test (CDT) – The Clock drawing test (CDT) is a brief cognitive task that can be used by physicians who suspect neurological dysfunction based on history and physical examination.[17]

The procedure of the CDT begins with the instruction to the participant to draw a clock reading a specific time (generally 11:10). After the task is complete, the test administrator draws a clock with the hands set at the same specific time. Then the patient is asked to copy the image.[17][22] Errors in clock drawing are classified according to the following categories: omissions, perseverations, rotations, misplacements, distortions, substitutions and additions.[17][23] Memory, concentration, initiation, energy, mental clarity and indecision are all measures that are scored during this activity.[17][24] Those with deficits in executive functioning will often make errors on the first clock but not the second.[17][23]

Stroop task – The Stroop task requires the participant to engage in and allows assessment of processes such as attention management, speed and accuracy of reading words and colours and of inhibition of competing stimuli.[17][25] The stimulus is a colour word that is printed in a different colour than what the written word reads. For example, the word “red” is written in a blue font. One must verbally classify the colour that the word is displayed/printed in, while ignoring the information provided by the written word. In the aforementioned example, this would require the participant to say “blue” when presented with the stimulus. Although the majority of people will show some slowing when given incompatible text versus font colour, this is more severe in individuals with deficits in inhibition. The Stroop task takes advantage of the fact that most humans are so proficient at reading colour words that it is extremely difficult to ignore this information, and instead acknowledge, recognize and say the colour the word is printed in.[17][26]

Wisconsin card sorting test (WCST) – The WCST utilizes a deck of 128 cards that contains four stimulus cards.[17][25] The figures on the cards differ with respect to color, quantity, and shape. The participants are then given a pile of additional cards and are asked to match each one to one of the previous cards. Typically, children between ages 9 and 11 are able to show the cognitive flexibility that is needed for this test.[17][27][28]

Trail-making test – This test is composed of two main parts (Part A & Part B).[17] The participant’s objective for this test is to connect the circles in order, alternating between number and letter (e.g. 1-A-2-B) from start to finish.[17][29] The participant is required not to lift their pencil from the page. The task is also timed as a means of assessing speed of processing.[17][30] Set-switching tasks in Part B have low motor and perceptual selection demands, and therefore provide a clearer index of executive function.[17][31] Throughout this task, some of the executive function skills that are being measured include impulsivity, visual attention and motor speed.[17][30]

What about the adult with EFD?

Just like the child/student with EFD, an adult who has it certainly has problems in working memory, task completion, and emotional regulation. An adult with EFD will struggle to sustain a regular job, run a household, and control her emotions as well as maintaining relationships.

The adult with EFD experiences the following struggles in an excerpt from the Yellow Brick Program:

For those emerging adults who are not competent in these life skills, their self-image and self-esteem suffer tremendously. They feel debilitating shame and self-recrimination. They try to hide their incompetence, not asking for help, soon they are overwhelmed with dirty laundry, broken appliances, messy refrigerators, and unpaid bills. For example, one young man is fully capable of showering, dressing himself, and making it to appointments, but he has never experienced independent living. He has not learned how to do laundry, budget his money, or set up utilities in a new apartment.

He feels great shame and self-contempt, as if he’s “supposed to know how” to do these things, even though he has not had a chance to learn. Instead of reaching out to those around him who can show him the way, he denies his needs out of humiliation and self-condemnation. Instead of asking for assistance, he laughs at the thought, stating he doesn’t need the help. At these moments, he feels utterly alone in the world, unable to request the help he needs because he thinks he should already know how to do everything. Even when those around him offer support, he brushes it off, later resenting that no one is there to support him. The idea of successfully living an independent life seems hopeless.

To a parent, teacher, or boss, what looks like laziness or irresponsibility may actually be executive functioning deficits, which are neurological mechanisms tied to specific brain functions key to development at this age. The parent sees the son who isn’t showering and is distressed, concludes that he is lazy or doesn’t care about his appearance, when it is really a deficit in the executive function of “initiation.” A teacher observes a student who forgets to turn in homework all the time and concludes that student is irresponsible when, really, it is a deficit in “planning.” A boss sees an employee who gets stuck on simple tasks as “dumb” when, in reality, it is a deficit in “problem-solving.”[32]

Very embarrassing, isn’t it?

That’s why identification of a executive function disorder is important in order to manage its problems so the person affected will have less problems in his everyday life. Managing EFD in adults is similar to therapies done on children, but on an adult level.

If you are a person with EFD or suspected EFD, follow the given intervention above of segmentation of tasks to avoid confusion. Also, try to choose a job with less “procedural” tasks, i.e., musician versus nurse (where a nurse has a lot of “procedural” tasks that needs very intact executive function; musicians do not need to have that as they are only require to repeatedly play a musical instrument plus memorize a particular piece).

Remember, next time you encounter a”lazy” child or “disorganized person,” maybe you can suspect that he has impaired executive function, which most of us would normally take it for granted.

To conclude this, let’s take an excerpt from all-gifted.com:

Before that goes away, we as parents must work hard so that our children at least keep up with the work required of them.  We must chip in to help, teach time management and organization skills, and look out for tools to phase them into self-reliance.[33]

That’s right. The earlier the identification and assessment, the better.

So if you have a child who is so gifted in other areas that his executive function falls behind and into judgmental eyes, would you crucify him for what he lacks, or would you patiently work and put things in place for him until he finds his next champion or develop his own planning methodologies and coping strategies?[33]

References:

  1. https://en.wikipedia.org/wiki/Executive_functions
  2. Elliott R (2003). Executive functions and their disorders. British Medical Bulletin. (65); 49–59
  3. Monsell S (2003). “Task switching”. TRENDS in Cognitive Sciences 7 (3): 134–140.doi:10.1016/S1364-6613(03)00028-7. PMID 12639695.
  4. Chan, R. C. K., Shum, D., Toulopoulou, T. & Chen, E. Y. H., R; Shum, D; Toulopoulou, T; Chen, E (2008). “Assessment of executive functions: Review of instruments and identification of critical issues”. Archives of Clinical Neuropsychology. 2 23 (2): 201–216.doi:10.1016/j.acn.2007.08.010. PMID 18096360.
  5. https://www.understood.org/en/learning-attention-issues/child-learning-disabilities/executive-functioning-issues/understanding-executive-functioning-issues
  6. https://www.understood.org/en/learning-attention-issues/child-learning-disabilities/executive-functioning-issues/key-executive-functioning-skills-explained
  7. http://www.help4adhd.org/faq.cfm?fid=40tid=9varLang=en
  8. Barkley, Russell A., Murphy, Kevin R., Fischer, Mariellen (2008). ADHD in Adults: What the Science Says (pp 171 – 175). New York, Guilford Press.
  9. Brown, Thomas E. (2005). Attention Deficit Disorder: The Unfocused Mind in Children and Adults (pp 20 – 58). New Haven, CT, Yale University Press Health and Wellness.
  10. http://developingchild.harvard.edu/key_concepts/executive_function/
  11. Alvarez, J. A. & Emory, E., Julie A.; Emory, Eugene (2006). “Executive function and the frontal lobes: A meta-analytic review”. Neuropsychology Review 16 (1): 17–42. doi:10.1007/s11065-006-9002-x.PMID 16794878.
  12. Lezak, M. D., Howieson, D. B. & Loring, D. W. (2004). Neuropsychological Assessment (4th ed.). New York: Oxford University Press. ISBN 0-19-511121-4.
  13. Clark, L., Bechara, A., Damasio, H., Aitken, M. R. F., Sahakian, B. J. & Robbins, T. W., L.; Bechara, A.; Damasio, H.; Aitken, M. R. F.; Sahakian, B. J.; Robbins, T. W. (2008). “Differential effects of insular and ventromedial prefrontal cortex lesions on risky decision making”. Brain 131 (5): 1311–1322.doi:10.1093/brain/awn066. PMC 2367692.PMID 18390562.
  14. Allman, J. M., Hakeem, A., Erwin, J.M., Nimchinsky E. & Hof, P., John M.; Hakeem, Atiya; Erwin, Joseph M.; Nimchinsky, Esther; Hof, Patrick (2001). “The anterior cingulate cortex: the evolution of an interface between emotion and cognition”. Annals of the New York Academy of Sciences 935 (1): 107–117.Bibcode:2001NYASA.935..107A. doi:10.1111/j.1749-6632.2001.tb03476.x. PMID 11411161.
  15. Rolls, E. T. & Grabenhorst, F., Edmund T.; Grabenhorst, Fabian (2008). “The orbitofrontal cortex and beyond: From affect to decision-making”.Progress in Neurobiology 86 (3): 216–244.doi:10.1016/j.pneurobio.2008.09.001. PMID 18824074.
  16. http://www.aane.org/asperger_resources/articles/education/executive_function_disorder.html
  17. https://en.wikipedia.org/wiki/Executive_dysfunction
  18. Clark C, Gallo J, Glosser G, Grossman M (2002). Memory encoding and retrieval in frontotemporal dementia and Alzheimer’s disease. Neuropsychology. 16(2); 190–96
  19. Buckner, R. (2004). Memory and executive function in aging and AD: multiple factors that cause decline and reserve factors that compensate” Neuron 44;195–208
  20. Friedman, et al (2008). Individual differences in executive functions are almost entirely genetic in origin. Journal of experimental psychology, 137(2), 201–10.
  21. Langley K, Marshall L, Bree M van den, Thomas H, Owen M, O’Donovan M, Thapar A (2004). Association of the dopamine D4 receptor gene 7-repeat allele with neuropsychological test performance of children with ADHD” American Journal of Psychiatry161(1),133–38.
  22. Jeste DV, Legendre SA, Rice VA, et al (2004). “The clock drawing test as a measure of executive dysfunction in elderly depressed patients.” Journal of Geriatric Psychiatry and Neurology. 17(190)
  23. Shulman, K (2000). Clock drawing: Is it the ideal cognitive screening test? International Journal of Geriatric Psychiatry. 15(6); 548–61
  24. Damasio H, Rudrauf D, Tranel D, Vianna E (2008). Does the clock drawing test have focal neuroanatomical correlates? Neuropsychology. 22(5); 553–62
  25. Biederam J, Faraone S, Monutaeux M, et al (2000). Neuropsychological functioning in nonreferred siblings of children with attention deficit/hyperactivity disorder” Journal of Abnormal Psychology 109(2); 252–65
  26. MacLeod C (1991). Half a century of research on the Stroop effect: An integrative review”Psychological Bulletin 109(20); 163–203
  27. Kirkham, N. Z.; Cruess, L.; Diamond, A. (2003). “Helping children apply their knowledge to their behavior on a dimension-switching task”. Developmental Science 6: 449–476. doi:10.1111/1467-7687.00300.
  28. Chelune, G. J.; Baer, R. A. (1986). “Developmental norms for the Wisconsin Card Sorting Test”. Journal of Clinical and Experimental Neuropsychology 8: 219–228. doi:10.1080/01688638608401314.
  29. Gaudino E, Geisler M, Squires N (1995). Construct validity in the trail making test: What makes part B harder? Journal of Clinical and Experimental Neuropsychology. 17(4); 529–35
  30. Conn H (1977). Trail-making and number-connection tests in the assessment of mental state in portal systemic encephalopathy. Digestive Diseases. 22(6); 541–50
  31. Arbuthnott K, Frank J (2000). Trail making test, Part B as a measure of executive control: validation using a set-switching paradigm. Journal of Clinical and Experimental Neuropsychology. 22(4); 518–28
  32. http://www.yellowbrickprogram.com/Papers_By_Yellowbrick/ExecutiveFunctionEmergingAdult_P1.html
  33. http://www.all-gifted.com/executive-dysfunction.html

Further Reading:

  1. http://www.additudemag.com/adhd/article/8392.html
  2. https://www.psychologytoday.com/blog/aristotles-child/201107/executive-functioning-and-the-troubled-brain
  3. http://www.rainbowrehab.com/executive-functioning/
4

Clumsy Awkwardness (Dyspraxia)

image
(C) Pokemon/Nintendo. All rights reserved.

Maybe you know someone who always trips and bumps into many objects (maybe more that once a day). He or she can’t live a day without spilling food, tripping on the floor, bumping into walls or posts or even other people, or misplacing or dropping things. Or maybe you have watched anime, J-dorama, and K-drama series, even Hollywood films and American TV series, with a lot of clumsy protagonists.

Very funny, right?

image
(C) Pony Canyon/A-1 Pictures/Bridge/Dentsu/Satelight/TV Tokyo. All rights reserved.

Not really. It DOES hurt to the clumsy person. Literally and figuratively hurt. Although clumsy people  are funny, they usually struggle to finish tasks completely, keep balance, and use a skill without much difficulty everyday despite their conscious efforts. This condition is called developmental coordination disorder (DCD) or dyspraxia (also known as motor skills disorder or specific developmental disorder of motor function).

What is dyspraxia?

Dyspraxia is the term used when someone has an inability to carry out and co-ordinate skilled, purposeful movements and gestures with normal accuracy. Someone with dyspraxia has difficulty planning and organising their thought processes (planning what to do and how to do it).[1] Although most people do expreience accidents and mistakes, a person with dyspraxia (dyspraxic) does experience accidents and mistakes more frequently than the neurotypical person. It doesn’t necessarily mean that the dyspraxic is dumb or airheaded as it is portrayed in media.

Dyspraxia is a common disorder affecting fine and/or gross motor coordination in children and adults. It may also affect speech. DCD is a lifelong condition, formally recognised by international organisations including the World Health Organisation.[2] Because it is lifelong, most daily activities become difficult to the dyspraxic person.

But mistakes happen to everyone including me. Maybe dyspraxics should just learn to practice.

Er, yes, but dyspraxics DO experience more dificulty than the rest of us. Here’s why.

Dyspraxia is a chronic neurological disorder beginning in childhood that can affect planning of movements and co-ordination as a result of brain messages not being accurately transmitted to the body.[3] It is like broken electrical wires that cannot deliver electric current properly to the appliance that may cause malfunction.

What causes dyspraxia?

Nothing is known about the exact cause of dyspraxia, but some factors have been hypothesized as causes of dyspraxia. These include immaturity of the nerves at the time of conception. Dyspraxia may be caused by a problem with the nerve cells that send signals from the brain to muscles. Children who were born prematurely, had low birth weights or were exposed to alcohol in the womb may be more likely to have dyspraxia.[4]

Certain neurones in the brain, called motor neurones, do not seem to develop and mature as quickly in someone with dyspraxia. As a result, they are not as effective in transmitting information from the brain telling the muscles to move.[1] Because of this, dyspraxics have weak motor coordination that makes it hard for them to do movements correctly or smoothly.

What are the symptoms of dyspraxia?
image

(C) Kyoto Animation. All rights reserved.
Oops! You really don’t know whether this girl is stupid or is dyspraxic.

Symptoms vary per person and also its severity. But here is the list of general symptoms of dyspraxia:

Gross Motor Symptoms – the general whole body movement like running and dancing is difficult to execute by the dyspraxic[3]:

-Poor timing[5]
-Poor balance[5][6] (sometimes even falling over in mid-step). Tripping over one’s own feet is also common.
-Difficulty combining movements into a controlled sequence.
-Difficulty remembering the next movement in a sequence.
-Problems with spatial awareness,[6][7] or proprioception.
-Some people with developmental coordination disorder have trouble picking up and holding onto simple objects such as pencils, owing to poor muscle tone and/or proprioception.
-This disorder can cause an individual to be clumsy to the point of knocking things over and bumping into people accidentally.
-Some people with developmental coordination disorder have difficulty in determining left from right.
-Cross-laterality, ambidexterity, and a shift in the preferred hand are also common in people with developmental coordination disorder.
-Problems with chewing foods.

Fine Motor Symptoms – movements of only body parts (arm, hand) that do small work like sewing, using knife and fork, combing hair, and applying cosmetics – these are also difficult to the dyspraxic.[3] Handwriting also is not coordinated. Problems associated with this area may include[3]:

-Learning basic movement patterns.[8]
-Developing a desired writing speed.[9]
-Establishing the correct pencil grip[9]
-The acquisition of graphemes – e.g. the letters of the Latin alphabet, as well as numbers.

image

Image courtesy of wikipedia.org

Example of fine motor skill deficit in dyspraxia shown in this girl completing a globe puzzle.

Developmental Verbal Dyspraxia or Childhood Apraxia of Speech:

This symptom involves dificulty in language expression not as a result of muscle weakness, paralysis, or deafness, but of the brain having difficulty coordonating the muscle movements to say sounds, syllables, and words.[10]

Key problems include[3]:

-Difficulties controlling the speech organs.
-Difficulties making speech sounds
-Difficulty sequencing sounds
-Within a word
-Forming words into sentences
-Difficulty controlling breathing, suppressing salivation and phonation when talking or singing with lyrics.
-Slow language development

These are general symptoms. Here are the signs of dyspraxia per age range[4]:

Waring Signs in a Toddler:

Is a messy eater, preferring to eat with fingers rather than a fork or spoon
Is unable to ride a tricycle or play ball
Is delayed at becoming toilet trained
Avoids playing with construction toys and puzzles
Doesn’t talk as well as kids the same age and might not say single words until age 3

Warning Signs in Preschool or Early Elementary School:

Often bumps into people and things
Has trouble learning to jump and skip
Is slow to develop left- or right-hand dominance
Often drops objects or has difficulty holding them
Has trouble grasping pencils and writing or drawing
Has difficulty working buttons, snaps and zippers
Speaks slowly or doesn’t enunciate words
Has trouble speaking at the right speed, volume and pitch
Struggles to play and interact with other kids

Warning Signs in Grade School or Middle School:

Tries to avoid sports or gym class
Takes a long time to write, due to difficulty gripping pencil and forming letters
Has trouble moving objects from one place to another, such as pieces on a game board
Struggles with games and activities that require hand-eye coordination
Has trouble following instructions and remembering them
Finds it difficult to stand for a long time as a result of weak muscle tone

Warning Signs in High School:

Has trouble with sports that involve jumping and cycling
Tends to fall and trip; bumps into things and people
May talk continuously and repeat things
May forget and lose things
Has trouble picking up on nonverbal signals (gestures, body language, figures of speech) from others

How is dysraxia diagnosed?

A diagnosis of dyspraxia can be made by a clinical psychologist, an educational psychologist, a pediatrician, or an occupational therapist. Any parent who suspects their child may have dyspraxia should see their GP (general practitioner, primary care physician), or a special needs coordinator first.[11]

Assessment for dyspraxia includes developmemtal history, intellectual abilities, and gross and fine motor skill testing.[11] There, the assessor will test specific skills including hand grip, balance, and touch sensitivity. This will be compared to the developmental milestones of the typical child. Comparing children to normal rates of development may help to establish areas of significant difficulty.[3]

However, dysraxia is very hard to diagnosed becauuse it does not present symptoms obviously like ADHD (being hyperactive) or autism (being aloof). It is also difficult because the dysraxia/DCD is not recognized yet in most parts of the world except in English-speaking countries and some parts of Europe (in Scandinavia, dyspraxia is called deficits in attention, motor control and perception (DAMP)[12]). Especially when the health care peovider is not completely aware of the disorder, the diagnosis may not be made clearly and dyspraxia may be missed.

How is dyspraxia treated?

There is no cure for dyspraxia, but there are a lot of mamagement techniques needed to cope with dyspraxia. The earlier the detection, the better the outcome of dyspraxia management. Therapies include occupational therapy, speech and language therapy, and physical therapy. Other strategies include educational modification like one-on-one coaching[13] so it will be easier fof the dyspraxic to acquire skills and knowledge.

For adults, structure and routine at work stations can help a dyspraxic employee get the work done. Office technology like ergonomic office furniture and electronic gadgets and word processors can also help. Breaking own their work into manageable chunks and to use different coloured folders for different tasks to help with organisation. Allowing regular breaks can improve productivity.[14]

If the diagnosis is made during late childhood to adulthood, the dyspraxic has already acquired anxiety, depression, or emotional disturbances due to repetitive failure at school or work, social isolation, and discrimination made be colleagues, schoolmates, and teachers. Usually, dyspraxics have low sense of self-esteem, thus, psychological counselling is also recommended. Medications like antidepressants can also help.

What happens if dyspraxia is not diagnosed?

If dyspraxia has not given intervention, life will be hard for the dyspraxic. He or she will continually struggle at school especially with skills like art, music, physical education or gym, and crafting. Because dyspraxics cannot read nonverbal communication, they are often struggling in making and keeping friends and romantic relationships, which in turn may leave the dyspraxic isolated and depressed. By the time the dyspraxic reaches adulthood, he or she has the high risk of unemployment, underachievement, and divorce or having unstable relationships.

Awareness of dyspraxia

Interest in studying dyspraxia started in the 1960s[15], although the term dyspraxia is not yet coined. In 1972, A. Jean Ayres called dyspraxia disorder of sensory integration.[3][16][17] Dr Sasson Gubbay called it the ‘clumsy child syndrome’ in 1975.[3][18][19][20] Dyspraxia is only coined
by the American Psychiatric Association (APA) in 1987[21], though Samuel Orton first coined developmental dyspraxia in 1937.[22]

Since dyspraxia is only a recent diagnosis, still most people are not yet aware of the condition, which may conclude that there are people with undiagnosed dyspraxia and may be struggling in their everyday lives. More awareness is needed to recognize dyspraxia especially in most parts of the world.

How common is dyspraxia?

According to Dyspraxia Foundation USA, 1 out of 10 people have dyspraxia[23]. It is 4 times more common in males than in females, and it is hereditary.[3]

Can a dyspraxic be successful?

Yes with early detection and mamagement. Dyspraxics can also have strengths like in literature, music, acting, math, and science, and computer studies too. Below are some people with diagnosed or suspected dyspraxia[24]:

Sir Isaac Newton
Pablo Picasso
George Orwell
Ernest Hemingway
Emily Bronte
G. K. Chesterton
Jack Kerouac
Richard Branson
David Bailey
Daniel Radcliffe
Albert Einstein
Robin Williams
Samuel Taylor Coleridge
Bill Gates
Marilyn Monroe
Stephen Fry
Florence Welch of Florence + The Machines

If that’s so, can I also count Jennifer Lawrence? She is clumsy particularly at the Oscars.

image
Image courtesy of dailymail.co.uk

Well, I guess so…

Who knows? Maybe your clumsy best friend might actually write the sweetest romance novel ever or be an award-winning actor or become a Nobel laureate in medicine.

How about Mr. Bean?

image
Image courtesy of buzzfeed.com

Er?…

Reference:
1. http://www.patient.co.uk/health/Dyspraxia.htm
2. http://www.dyspraxiafoundation.org.uk/about-dyspraxia/
3. http://en.m.wikipedia.org/wiki/Developmental_coordination_disorder
4. https://www.understood.org/en/learning-attention-issues/child-learning-disabilities/dyspraxia/understanding-dyspraxia#item2
5. Missiuna C, Gaines R, Soucie H, McLean J (October 2006). “Parental questions about developmental coordination disorder: A synopsis of current evidence”. Paediatr Child Health 11 (8): 507–12. PMC 2528644. PMID 19030319.
6. Geuze RH (2005). “Postural control in children with developmental coordination disorder”. Neural Plast. 12 (2–3): 183–96; discussion 263–72. doi:10.1155/NP.2005.183. PMC 2565450. PMID 16097486
7. Wilson PH, McKenzie BE (September 1998). “Information processing deficits associated with developmental coordination disorder: a meta-analysis of research findings”. J Child Psychol Psychiatry 39 (6): 829–40. doi:10.1017/s0021963098002765. PMID 9758192.
8. Lacquaniti F (August 1989). “Central representations of human limb movement as revealed by studies of drawing and handwriting”. Trends Neurosci. 12 (8): 287–91. doi:10.1016/0166-2236(89)90008-8. PMID 2475946.
9. Polatajko HJ, Cantin N (December 2005). “Developmental coodination disorder (dyspraxia): an overview of the state of the art”. Semin Pediatr Neurol 12 (4): 250–8. doi:10.1016/j.spen.2005.12.007. PMID 16780296.
10. http://en.m.wikipedia.org/wiki/Developmental_verbal_dyspraxia
11. http://www.medicalnewstoday.com/articles/151951.php
12. Hellgren L, Gillberg C, Gillberg IC, Enerskog I (October 1993). “Children with deficits in attention, motor control and perception (DAMP) almost grown up: general health at 16 years.” Dev Med Child Neurol 35 (10):881-92. doi:10.1111/j.1469-8749.1993. PMID 8405717
13. http://www.webmd.boots.com/children/guide/dyspraxia?page=2
14. http://www.dyspraxiafoundation.org.uk/dyspraxia-adults/workplace-employers/
15. http://www.dyspraxia.ie/aboutus_history
16. Ayres AJ (1972). “Types of sensory integrative dysfunction among disabled learners”. Am J Occup Ther 26 (1): 13–8. PMID 5008164.
17. Willoughby C, Polatajko HJ (September 1995). “Motor problems in children with developmental coordination disorder: review of the literature”. Am J Occup Ther 49 (8): 787–94. doi:10.5014/ajot.49.8.787. PMID 8526224.
18. Gibbs J, Appleton J, Appleton R (June 2007). “Dyspraxia or developmental coordination disorder? Unravelling the enigma”. Arch. Dis. Child. 92 (6): 534–9. doi:10.1136/adc.2005.088054. PMC 2066137. PMID 17515623.
19. Gillberg C, Kadesjö B (2003). “Why bother about clumsiness? The implications of having developmental coordination disorder (DCD)”. Neural Plast. 10 (1–2): 59–68. doi:10.1155/NP.2003.59. PMC 2565425. PMID 14640308.
20. Gubbay SS (October 1978). “The management of developmental apraxia”. Dev Med Child Neurol 20 (5): 643–6. PMID 729912.
21. Addy L, Dixon G (2013). “Making Inclusion Work for Children with Dyspraxia: Practical Strategies for Teachers.” Routledge. ISBN 1134378033.
22. Davis AS (2010). “Handbook of Pediatric Neuropsychology.” Springer Publishing Company. ISBN 0826157378.
23. http://www.dyspraxiausa.org/
24. http://www.aucklanddyspraxia.org.nz/drupal/Article%20-%20Famous%20Dyspraxics

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