Determining appropriate supports for students with Developmental Co-ordination Disorder in third level education

Trish FergusonDisability ServiceUniversity of Dublin Trinity College

June 2010

Seirbhís do dhaoine faoí mhíchumas,Seomra 2054, Foígneamh na nEalaíon Coláiste na Tríonóide, Baile Átha Cliath 2, Éire

Disability Service,Room 2054, Arts Building,Trinity College,Dublin 2, Ireland

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Contents

Abstract

Section 1: Literature review

1.1 Introduction1.2 Symptoms of Developmental Coordination Disorder 1.3 Assessment 1.4 Prevalence1.5 Co-morbidity

Section 2: DCD at third level

2.1 Applications through Disability Access Route to Education (DARE) 2.2 Students with DCD at Trinity College Dublin 2.3 Statistics 2.4 CAO: personal statements 2.5 TCD: course choice 2.6 TCD: retention

Section 3: Determining appropriate supports for third level

3.1 Specific educational impacts 3.2 Motor difficulties 3.3 Non-motor difficulties 3.4 Reasonable accommodations 3.5 Suggested teaching supports

LecturesSeminarsWritten work

3.6 Assistive Technology (AT) 3.7 Academic Support 3.8 Unilink (OT-based one-to-one support)

Section 4: Summary

4.1 Discussion4.2 Further research

References and Bibliography

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Abstract

This presentation is a discussion of the difficulties encountered in adulthood

associated with DCD and specifically the difficulties experienced in the student

population at third level. Although the population is not homogenous DCD may

present as any number of the following difficulties: abnormalities in postural

control and/or fine motor skills; difficulties in learning motor tasks, such as

handwriting and sports; difficulties with educational tasks, such as reading

comprehension, attention and learning; poor time management.

This paper discusses aetiology, assessment and will examine trends in course

choices and retention rates within this group in recent years in Trinity College.

This study will then consider requirements within learning support and

reasonable accommodations for examinations. It will also consider appropriate

interventions for students in practical courses, considering the requirements and

possible interventions in laboratory work and placement situations. It also makes

recommendation on provision of supports at third level and suggests further

research and data collection will assist with future developments.

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Section 1: Literature review

1.1 Introduction

Developmental Coordination Disorder (DCD), also known as dyspraxia, is the

term now internationally recognised to describe ‘a specific learning difficulty in

gross and fine motor planning which is not caused by muscle/nerve damage’

(Poustie et al., 1997). Developmental Coordination Disorder is preferred over the

term ‘dyspraxia’. (Gibbs et al., 2007) The educational impact of DCD on children

is well documented but there are few studies on teenagers (Kirby 2004, Hellgren

et al., 1994a; Losse et al., 1991) or adults with DCD (Barnett and Kirby, 2009;

Kirby et al., 2008a; Kirby et al., 2008b; Colley, 2006; Cousins & Smyth, 2003;

Visser, 2003; Rasmussen and Gillberg, 2000; Cantell et al., 1994; Geuze and

Börger, 1993). This is because most often a diagnosis is made prior to school

age and in the first few years of primary school on account of obvious difficulties

with achieving age-related milestones that involve motor skills, like crawling,

eating, dressing and brushing teeth. Until recent years DCD has been the subject

of less research-based study than dyslexia. Due to this and the variability of the

disorder, which makes it more difficult to diagnose, it is expected that a

significant number of people with DCD now in adulthood have not been

diagnosed in childhood. Early case histories of children with DCD suggested that

a proportion do improve (Dare & Gordon 1970; Gubbay, 1975) but more recent

research indicates persistence and impact in adult life (Kirby et al., 2008;

Cousins & Smyth, 2003). Kirby et al. (2008) finds that ‘between 30 and 87% of

children with DCD will continue to exhibit poor co-ordination into adulthood’

(199). Recent studies on DCD in adulthood have focused on psycho-social

outcomes (Rasmussen and Gillberg, 2000) and specific motor skills, such as

handwriting and construction tested under timed conditions (Cousins & Smyth,

2003). A forum was launched in 2006 for adults with DCD

(http://www.dyspraxicadults.org.uk) and there has been a growing body of

research conducted on adults with DCD particularly in the last ten years,

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however, the experience of adults with DCD in third level education remains

under-researched. As a result of successful implementation of supports at

second level, more students are accessing third level education with a diagnosis

of DCD and seeking supports. This study aims to document the specific

educational impacts of DCD in third level education and to make

recommendations for intervention. These recommendations will then be critiqued

in terms of universal design and considered regarding the practicalities of

implementation with consideration given to resources available, funding

restrictions and fitness to practice issues.

1.2 Symptoms of Developmental Coordination Disorder

Although the population is not homogenous DCD may present as any number of

the following difficulties: abnormalities in postural control (Wann et al., 1998;

Williams and Wollacott, 1997), as well as in fine motor skills (Smits-Engelsman et

al., 2001), difficulties in learning motor tasks, such as handwriting and sports

(Losse et al., 1991); educational tasks, such as reading comprehension (Kadesjo

and Gillberg, 1999); attention and learning (Dewey et al., 2002; Landgren,

Kjellman, & Gillberg, 1998; Kadesjo & Gillberg, 1998; Hellgren, Gillberg, &

Gillberg, 1994a; Gillberg & Rasmussen, 1982; Gillberg, Rasmussen, Carlstrom,

Svenson, & Waldenstrom, 1982;); time management (Kirby, 2004; Dewey et al.,

2002); behavioural problems (Dewey, Kaplan, Crawford & Wilson, 2002; Losse et

al., 1991); social skills and low self-esteem. (Poulsen, Ziviani & Cuskelly, 2007;

Cousins & Smyth, 2003; Cantell, Smyth, & Ahonen, 1994)

1.3 Assessment

DCD is assessed by the DSM-IV criteria for DCD developed by the APA or by

ICD-10, developed by the World Health Organization. According to the DSM-IV

the diagnostic criteria for DCD are as follows:

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A. Performance in daily activities that require motor coordination is

substantially below that expected given the person’s chronological age

and measured intelligence. This may be manifested by marked delays in

achieving motor milestones (e.g., walking, crawling, sitting), dropping

things, “clumsiness,” poor performance in sports, or poor handwriting.

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.

The following specialists make assessments for, and diagnose dyspraxia:

psychologists – educational, occupational or neurological; paediatricians who

specialise in developmental disorders, physiotherapists and occupational

therapists. Tests used for assessment should be age appropriate in all cases. In

the UK, the most commonly used test for motor-related difficulties in children is

the Movement Assessment Battery for Children-2 (Movement ABC-2)

(Henderson & Sugden, 2007). Movement ABC-2 is appropriate for assessing

children up to 12 years. The Bruininks-Oseretsky Test of Motor Proficiency-2

(2005) is a standardized, norm-referenced measure of fine and gross motor skills

that has norms up to the age of 21 years. There are two versions of this test: the

full version which takes 2 hours and a shorter form which takes 30 min to

administer (Bruininks, 1978). There is not as yet an adequate test for a range of

motor skills for adults older than 21 (Kirby at al., 2008b).

Acknowledging that adolescents have a different range of motor skill

requirements than children Kirby (2004) states: ‘In order to diagnose adolescents

we need to consider what are the unique features that highlight the co-ordination

difficulties. If we use the DSM-IV criteria as a guideline for this, in the adolescent,

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as with the child, it is ‘impairment significantly interfering with academic

achievement or activities of daily living’ (author’s emphasis) which is the most

important to consider. We then need to highlight in this age group what they are

likely to be.’ (17) The same is true of adults and this will be considered in relation

to needs assessment in university for this group.

The Morrisby Manual Dexterity Test is used for assessment of students entering

university to assess fine motor control indicators for difficulties associated with

DCD in adults is the (Morrisby, 1991). However, this tests only fine motor actions

in one setting and will not identify gross motor or balance difficulties rather than

fine motor difficulties (Kirby et al., 2008b). Kirby (2010) notes that ‘Current tests

are able to measure motor functioning (Criterion A of the DSM-IV), but are not

able to consider how and where the difficulties impact on the adult's life (Criterion

B of the DSM-IV).’ A new screening tool is currently under development in order

to provide appropriate interventions for adult life (Kirby, 2010). Currently

recommended by Kirby (2010) is The Adult Developmental Co-ordination

Disorders/Dyspraxia Checklist (ADC) which assesses ability within home,

academic and social environments including ‘handwriting, driving, attention,

organisation in time and space abilities and social skills’ (133). Kirby (2010)

concludes: ‘this is an area for further research that has clinical implications for

service providers such as universities, colleges, and occupational therapy

services’ (137). While the Adult Developmental Co-ordination

Disorders/Dyspraxia Checklist (ADC) is a useful tool for adult diagnosis through

studying a person’s childhood history it is not a tool for determining supports in

any given environment, including university. Developing an assessment for

students entering university is difficult because of the different tasks required for

each course, some requiring more use of motor skills than others and also on

account of the heterogeneity of difficulties associated with DCD. As Politajko

(1999) notes on a study of children, ‘one child with DCD is likely to be excellent

at one motor task but poor at another.’ The same is true of adults.

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As yet there is no specific standardized assessment for academic environments

and tasks, including handwriting and exam accommodations, laboratory work or

placements. While it is useful to have a history of a person’s motor skill abilities,

the development of an assessment tool for students entering university with DCD

must also take into consideration difficulties associated with other developmental

disorders on account of the high level of co-morbidity.

1.4 Prevalence

Studies in the United Kingdom suggest that between 5 and 18 per cent of

individuals are affected by DCD (Godfrey, 1994; Hall, 1994; Marks, 1994;

Portwood, 1996, cited in Dixon and Addy, 2004, 9). The American Psychiatric

Association (APA) (2000) cites the prevalence at 6% for children in the age range

of 5–11 years. Males are more likely to be affected than females; a study of

children with DCD in Sweden, found a boy: girl ratio of 5.3:1 (Kadesjö and

Gillberg 1998). It is difficult to assess prevalence in adulthood on account of

there being no commonly used standardized screening tool for adult assessment.

The Bruininks Oseretsky Test-2 (Bruininks & Bruininks, 2005), which is normed

up to 21 years is used in the United States (Kirby 2010) but is not commonly

used in the UK or Ireland. The assessment most commonly used for adults is the

Wechsler Adult Intelligence Scales (WAIS) which can reveal a pattern of

weaknesses and strengths typical of DCD but is an assessment tool used

primarily for specific learning difficulties and not specifically DCD. It is also

difficult to assess prevalence in adulthood because of the high level of co-

morbidity on account of which a diagnosis is often made on another

developmental disorder in adulthood rather than DCD.

1.5 Co-morbidity

With all developmental disorders there is a high level of co-morbidity but this is

particularly so with DCD. Having DCD with only motor difficulties is the exception

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rather than the rule (Peters & Henderson, 2008). DCD co-occurs commonly with

dyslexia and ADHD (Barnett and Kirby 2009, Visser, 2003, Dewey et al., 2002;

Dewey et al., 2000; Gillberg, 1998; Gillberg and Kadesjö, 2000; Gillberg and

Kadesjö, 1998; Kadesjö and Gillberg, 2001; Martini et al., 1999; Kaplan et al.,

1997). Also, Kirby, Salmon and Edwards (2007, 336) note that ‘there is clear

evidence of association or co-morbidity of ADHD with a number of other

psychiatric conditions, including oppositional defiant disorder, conduct disorder,

and depression and anxiety disorders (Loeber, 1982; Barkley et al., 1990; Taylor

et al., 1991), and these should be routinely considered at the time of

assessment.’ However, in their study they note that it is not known whether

clinicians routinely check other developmental disorders during assessment

despite the fact that statistics suggest that prevalence of co-morbidity with ADHD

may be up to 50% (Kadejs & Gillberg 1999) and there is also a high co-morbidity

with specific learning difficulties.

Section 2: DCD at third level

2.1 Applications through Disability Access Route to Education (DARE)

In recent years Dyspraxia has become assessed and recognised as a distinct

disability having previously been grouped under Specific Learning Difficulty in

college application processes. The application process remains the same but

evidence is now required to state a diagnosis of Developmental Co-ordination

Disorder (DCD) / Dyspraxia. Candidates applying for College through the

Disability Access Route to Education (DARE) must submit a full psycho-

educational assessment from the Psychologist and the Evidence of Disability

Form which should be completed by an Occupational Therapist/Physiotherapist.

The applicant is eligible for consideration once the appropriate professionals

have provided a diagnosis of Developmental Co-ordination Disorder (DCD) /

Dyspraxia. While there is no age limit on diagnostic evidence submitted

applicants are advised to submit a recent report. Applicants who have an existing

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report completed by the accepted Medical Consultant/Specialist may submit this

report. The report must have been completed within the appropriate timeframe

and must contain the same detail as the Evidence of Disability Form. The report

should state difficulties from childhood or evidence from a specialist that there is

historical information which evidences Developmental Co-ordination Disorder

(DCD) / Dyspraxia, and that the applicant is presenting with difficulties that has

impacted on home and school. For adult assessments the standardized

Developmental Co-ordination Disorder (DCD) / Dyspraxia Checklist should be

referenced, which is in line with the DSM IV/ICD10 (Kirby 2010). Applications

through DARE must also include the student’s personal statement which should

outline the impact of disability on their academic and educational experience to

date. An academic reference is also required which provides background

information on the student’s educational experience and can confirm challenges,

stating the educational impact of disability and describing the need for any

teaching and learning adjustments. This form also helps to determine appropriate

supports at third level.

Table 1: DARE applications: students with DCD

2008 2009 20100

20

40

60

80

100

120

32

74

110

2.2 Students with DCD at Trinity College Dublin

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There are currently 20 students with DCD registered with Trinity College’s

Disability Service, 15 active, 3 withdrawn and 2 graduands. 14 are male and 6

are female. This is a ratio of 7:3, compared with 5.3:1 in Kadesjö and Gillberg

(1998). The slightly higher number of females may be accounted for by the

gender breakdown of the College population as a whole, as there are a

significantly higher number of female undergraduates than males in the College

population as a whole.

2.3 Statistics

Table 2: College Standing

Year 1 Year 2 Year 3 Year 4 graduand withdrawn0

2

4

6

8

10

12

10

5

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Table 3: Ages of students registered with DCD

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19-21 22-24 25-26 26-30 31-35 35+0

2

4

6

8

10

12

14

16

18 17

21

17 of the 20 students registered are aged between 19 and 20. This accounts for

85% of this group, which are primarily first and second years so this means that

students are coming directly to College from secondary school. It may be that

they have been well supported in school which accounts for their successful

transition in their first application. As will be shown below, a high proportion of

students with DCD entered on merit rather than via the supplementary

admissions process. It should be noted however, that the 3 students who have

withdrawn from College are all within this 19-21 age bracket, two having

withdrawn without completing first year and one other in second year.

Table 4: Breakdown by Entry Route

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Merit Supplementary Mature0

2

4

6

8

10

12

14 13

6

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The chart above shows that 13 students (65% of this group) entered on merit, 6

students (30%) via the supplementary system and 1 student (5%) entered as a

mature student. These statistics are not particularly helpful as an indication of a

student’s experience of college due to the nature of the disability which can be

exacerbated by a change of environment and requirements and as the majority

of students are still in first year it is not yet possible to comment on

progression/retention rates for this group. As noted above, immediate

progression from school and also a high rate of entry on merit suggests success

at school level, whether on account of the nature of the environment, which is

more directive than university, or whether this is due to the success of supports

put in place at second level. Taking this into consideration emphasizes the

importance of the needs assessment stage at third level to ascertain how much

support a student has had in school when recommending or granting supports

and accommodations. It will also be useful to look at personal statements given

in CAO forms for background regarding experiences in education, which can be

very diverse.

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2.4 CAO: personal statements

The following are excerpts from personal statements collated from CAO

applications from 2009:

“The main effect my disability has had is its effect on my writing and note-

taking. I find that when I am under pressure to write or take notes that my

brain moves faster then my hand with the result that I sometimes skip

words or letters leave words unfinished or merge the first part of one word

with the last part of the next. It also affects my handwriting so that even

though I can usually read it other people have great difficulty reading my

writing.”

“Due to my dyspraxia I have difficulty in processing information quickly

leading to periods needed to fully understand and absorb information. My

hand writing is slower and less clear than others leading to difficulty in

exam situations for both myself and the correcting examiner.  My

organisation is also affected by my disability leading to great and

significant difficulties in recilation organisation if notes and work in

prepeartion for exams etc. My dyslexia though mild means spelling and

grammer are difficult for myself thus affecting exam results.”

“In primary school I was diagnosed with Dyspraxia; during those years I

had classes in the CPI unit in Sandymount. From third year in secondary

school I attended classes in the resource department. My main problem in

class is that I cannot listen and take notes at the same time. I made the

decision just to listen in class and when I go home study the textbooks.

The resource teachers have tried to help me with note taking and

organising my thoughts.”

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These testimonies all indicate difficulties typically associated with dyslexia,

including time management, difficulty with organizing thoughts, slower

processing speed and difficulties with spelling and grammar. This highlights that

a holistic approach be taken when assessing a student with DCD as other

difficulties around producing written work may be present that are not motor-

related.

Other personal statements testify to the significance of when the diagnosis is

made and interventions put in place.

“With assistive technology I have not have encountered too many

problems. However before this was provided or allowed I had

considerable difficulties completing work on time which hindered my

potential.”

“Unfortunately I was not diagnosed with Dyspraxia until the beginning of

my final year in school. Due to this my dyspraxia had a massive negative

effect on my school work until now. All this I feel has left me behind in my

class work especially in subjects like history and english where wriiten

work compiles the bulk of the subject matter. Dyspraxia has directly

affected my motor skills especially my fine motor skills my organisation

and time management skills.”

These personal statements suggest that intervention at school level can make a

positive difference and difficulties with organization and time management skills

may be addressed through study skills and/or an occupational therapy model of

intervention at second and third level.

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2.5 TCD: course choices

The current student population registered with the Disability as having DCD

(whether or not this is co-morbid with any other disability) is as follows:

Course College Standing

BESS (3 students) 1

Law and French 1

Business and Computing 1

Business and Polish 1

Management Science and Information Systems Studies 1

Foundation Course for Higher Education - Young Adults 1

Religions and Theology 1

Theoretical Physics 1

TSM English and Philosophy 2

TSM Religions and Theology/ Philosophy 2

History 2

Law 2

Philosophy and Political Science 2

Nursing graduand

TSM English and History of Art and Architecture graduand

Political Science and Geography withdrawn

English withdrawn

TSM Film Studies and English Literature withdrawn

The number of students currently registered for College who are registered with

the Disability Service (DS) as having DCD (20) represents 2% of students

registered with DS.

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Within this group of TCD students, practical courses, such as Science and Health

Science, are not represented, with the exception of one Nursing student.

Faculty breakdown (TCD 2009-10)Arts, Humanities and Social Sciences, 18

Health Science, 1

Engineering, Mathematics and Science, 1

A study conducted by Kirby et al. (2008a) comparing course choices between

students with DCD and students with dyslexia found that no students with DCD

had chosen physical science, health courses or humanities courses in

comparison with those with a diagnosis of dyslexia (Kirby et al., 2008b). Kirby

(2004) notes that ‘DCD may affect the type of career choices the individual

makes, as he perceives himself less able than he may actually be’ (15). Further

research could be conducted into reasons for course choices. Kirby et al. (2008)

study found that a high proportion of students with DCD study Arts, media and

design; Business, Education and Social Sciences, which all come under the Arts,

Humanities and Social Sciences category in the table above. The findings are

consistent with the representation of this group in courses in Trinity College.

2.6 TCD: retention

It is difficult to assess retention rates for this student from such a small group,

particularly as a high number of students registered with DS with DCD are in their

first year of College. This is indicative of a recent increase in students with DCD

accessing third level education, as attested in recent studies. 5 students have

progressed to second year and there are two graduands but a high proportion of

this group (15%) have withdrawn from College. This small group does not allow

for an in-depth study of retention rates but notably there is a high rate of

withdrawal even in Junior Freshman year:

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1 student withdrew from College in Junior Freshman year.

1 student withdrew from College in Senior Freshman year.

1 student withdrew from College having failed to complete requirements

for passing Junior Freshman year.

3 students in this group (20%) availed of Academic Support Tuition while no

students engaged with Unilink. Both services made contact with students during

the academic year to instigate appointments/ check on progress. There was a

high incidence of missed appointments and also one student had missed exams.

This coupled with a high rate of withdrawal from College indicates that supports

for this group need to be re-evaluated.

Section 3: Determining appropriate supports for third level

3.1 Specific educational impacts

While some studies suggest that children grow out of the difficulties associated

with DCD, others, such as Kirby (2010), have noted that the difficulties may just

be hidden through persons choosing to avoid environments in which DCD is

manifest, such as sports and social activities, such as dancing. As a study by

Losse et al. (1991) has revealed a change of environment, such as a new school,

can place new demands on the student with DCD which provide new difficulties:

‘Our examination of the school reports of our subjects showed that in some

cases the academic and social demands of being in a large school had not only

increased their difficulties but had also revealed new ones.’ (66) Denckla (1984)

notes: ‘persons given the advantage of training or overpractice on essential

motor skills may enter adult life without obvious difficulty unless challenged by

new skills to learn’ (cited in Losse et al., 1991, 64). Given these observations it is

to be emphasized that third level education provides a completely new set of

demands on students, both physical and organizational.

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3.2 Motor difficulties

Colley lists the following motor difficulties that may be encountered by students

with DCD: problems using computer keyboards; frequent spills in the laboratory;

lack of organization in experiments, difficulty measuring accurately, slow and

illegible handwriting, messy presentation (2006: 91). Compensatory strategies for

motor difficulties including poor handwriting are available on an online forum

which provides useful advice for adults with a number of threads focused on

university study (www.dyspraxicadults.org.uk/forums). In many cases the advice

given on the forum by adults with DCD is that motor skills improve through

practice, reflecting the task-orientated approach, one of the approaches

advocated by Gibbs et al. (2007) This approach has been recommended for a

number of motor skills for those wishing to pursue Performing arts, sports and

music. For some to the pursuit of a particular course in which specific career-

related motor skills need to be developed, this may be the only approach, but this

is not however, always a practical or time-efficient approach for all DCD-related

motor skill difficulties.

Handwriting is frequently an area of difficulty for students with DCD; Kirby et al.

(2008, 208) states that ‘50% of those with DCD stated handwriting specifically as

a continuing difficulty.’ A handwriting test may be used to determine the level of

supports required although as Summers and Catarro (2003) caution ‘It is difficult

to define the parameters by which the degree of disadvantage can be judged as

a number of processes may affect written output in an examination.’ (148) Their

study concludes that ‘the written output of 66 second-year university students

demonstrated that a short duration handwriting speed test was unable to predict

written output (number of words) in a 2-hour written examination. (156) There are

few standardised tests for handwriting speed. ‘SpLD Working Group 2005/DfES

guidelines’ suggest testing writing using a ‘speed of writing prose task’ and a

‘free writing task’:

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The student’s free writing should be analysed to

provide information about ability to write

grammatically, the complexity of sentence structure,

the coherence of writing, use of vocabulary, writing

speed and legibility of handwriting. It is also important

to report handwriting speed in a copying task so that

difficulties relating to the process of composition and

to motor skills can be teased apart (25).

The DASH has UK norms for 9-16 year olds and an extension for 17-25 year olds

is due to be published in late Spring 2010 (Barnett & Kirby, 2009). This may be

used in a third level environment to assess for the need for supports for

handwriting difficulties. It must be noted that the application of the guidelines of

the SpLD Working Group 2005/DfES guidelines cited above will not give an

indication of a student’s ability to take accurate and legible lecture notes and this

should be considered if a handwriting test is introduced as part of assessment for

third level.

Although Summers and Catarro (2003, 156) found that legibility, writing style and

fatigue did not appear to influence written output, they found that poor pencil

grasp could contribute to a slower writing speed in a three-minute writing task.

Students with DCD frequently have a poor writing grip and for lecture note taking,

if a student is taking their own notes, this factor should be considered. Ergonomic

measures, such as changing furniture, such as level of desk, or using a sloping

desk may improve posture and consequently handwriting also, but this may not

be possible in a lecture environment. A better pencil grip can sometimes be

attained through use of a hand-held ‘stetro grip’ which can be fit onto a roller ball

pen. (Sawyer et al., 1993) Experimenting with different types of pen may also be

useful, for example fibre tip, rather than biro. Pascoe et al (1993) recommend

equipment to assist with pencil grip, including small grips, holders or splints,

larger diameter products and weighted or magnetic products.

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Working on improving handwriting may not be practical for third level students

with DCD, particularly if there is a lot of note-taking involved in lectures and this

needs to be established early in the academic year. Many will have used

computers for exams at second level and may require same at college. However,

students with DCD may also have difficulty with keyboard skills and find it difficult

to type for extended periods. This may be alleviated by use of a specific

ergonomically designed keyboard and use of same in exams. Also an Anir

mouse, like a joystick, may be easier to use than a regular mouse (Colley, 2005).

Computer skills can also be assessed upon entry to college. Students with DCD

may best be supported by a scribe and a note taker during the academic year for

lectures, although there is a greater cost involved in providing these services.

Colley notes that laboratory work may pose a difficulty for students with poorer

motor skills and co-ordination. The task-based approach of improving through

practice would not be appropriate here if there were risks involved. In this case a

laboratory assistant may be assigned to a student but again this may not be

financially viable long term.

Students with DCD who undertake to study Nursing should make their Clinical

Placement Supervisor aware of any motor difficulties they experience to consider

modifications to specialist equipment and/or treatment techniques. Again, it

should be determined, ideally prior to entry, whether it is practical to pursue this

course depending on motor skills and course requirements and whether the

student can be supported sufficiently in the workplace if that would be necessary

for specific Nursing tasks.

With regard to the requirements of specific courses issues of fitness to practice

may be relevant. If a student discloses DCD a risk assessment may be

conducted with the student to establish ‘a careful and systematic account of what

can cause harm and how this can be prevented’ (TCD, Fitness to Practice

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guidelines). This may result in the implementation of supports, such as an

assistant for laboratory or placement with due consideration given to whether this

is deemed appropriate and could be sustained in the workplace and with

consideration given to the cost involved in providing this support.

3.3 Non-motor difficulties

Third level education entails increased academic and time management

demands as students have much more independence than formerly when in

school. There are a number of demands that may provide a challenge to

students with DCD related to non-motor difficulties. Colley cites potential

difficulties with written expression, work organisation, personal organisation,

memory and attention span and visual skills, oral skills and numeracy skills.

(Colley, 2006: 92-93) Kirby (2004) describes these difficulties as ‘executive

dysfunctioning’ and in a study conducted Kirby et al. (2008) 52.4% of a group

with DCD reported this as a weakness, which was significantly more than the

group with dyslexia (17.4%). The following are the key features of ‘executive

dysfunctioning’:

Poor cognitive flexibility – difficulty leaping from one idea to another

Lack of adjustment of behaviour using environmental feedback – being

able to learn from experiences around you

Difficulty extracting social rules from experiences – seeing the implied rule

rather than the explicit one) the individual may have been in a similar

situation before but does not seem to learn from it and ends up making the

same mistakes)

Difficulty in selecting essential from non-essential information – the

individual sees all the information at the same level of importance and

finds it hard to ‘sieve’ it according to priority or see what may be risky

22

Impaired working memory – this may make it harder to hold on to several

pieces of information at one time and juggle information – the individual

also can’t juggle several different tasks at once

Difficulty in organisation and completing tasks may prevent the individual

even trying to begin the task. (76-77)

In a presentation at Trinity College Dublin (March 2010) Kirby outlined how the

study skills interventions at third level for students with Dyslexia may not be

appropriate for difficulties related to the production of written work, because

students with DCD may have further difficulties with ‘executive function tasks’

including time management and organization skills, which can be significantly

poorer in students with DCD. Kirby et al. (2008b) carried out a study on three

groups of students; those with a self-reported diagnosis of DCD, those with DCD

and dyslexia and a third group with dyslexia. This study found the DCD group

(54.2%) reported executive functioning as a weakness significantly more than the

dyslexia group; problems cited related to organization and memory (208).

However, there was no difference in the type of support being given between the

three groups. (209) Students with DCD may receive the same supports as those

with dyslexia in many cases as often students with DCD received a diagnosis of

dyslexia because of lack of standardised assessment tool for DCD. Kirby et al.

(2008b) noted that students with DCD often are assessed using tools for dyslexia

and the dyslexia-related issues that they experience in addition to any others are

sufficient to give a diagnosis of dyslexia, although this results in them perhaps

being under-supported or given inappropriate supports.

While students with DCD often experience dyslexia-related difficulties a holistic

approach that appreciates all the possible motor and organization difficulties

associated with DCD should be taken into consideration during assessment. This

is particularly relevant in relation to executive dysfunction, the difficulties

associated with this being experienced at a higher level by those with just a

diagnosis of DCD and dyslexia, and at a much higher level than those with a

23

diagnosis of dyslexia (Kirby et al., 2008b). Kirby has noted that the supports often

given to enhance organization skills for this group can be ineffective if they do not

easily become automatic skills through habitual use. A support worker may feel

that they are supporting a student by giving suggestions around time

management and organization but they are of no use if the student forgets to use

them. She also noted that time concept was an increased difficulty experienced

by students with DCD: ‘The inner clock does not always seem to tick in the same

way for the young person with DCD. He may not seem to be aware of time

passing. […] The more routine activities are, the less effort they become; this

helps to improve time management – see what elements of the day are repeated

and create a routine that frees the adolescent to concentrate on the variables in

his day’ (Kirby, 2004, 98).

Kirby suggested incorporating technology commonly used by young adults as a

means of assisting students with organization skills (Kirby, Trinity College, March

2010). Tools such as an iPhone can be utilised for students to access a calendar

on a daily basis as it is more likely that this would become habitual and would be

something a student would remember to carry with them, rather than a diary.

Kirby (2004, 81) notes that a tendency to lose or break things is common with

this group and this must be remembered when suggesting or providing supports.

The use of a Watch Minder which can be prompted to go off with reminders may

be useful (Colley, 2005). The Unilink service in Trinity College Dublin is currently

developing a self-management tool in the form of a fold-up booklet that could be

utilised for a check-list of daily tasks, which can be wiped clean and re-used. This

may be useful as an alternative to technological equipment for this group of

students. Kirby noted that a laptop is an expensive piece of equipment to lose or

break. It may be advisable to have a note taker attending lectures for students

with DCD who find it difficult to take notes or to re-read their handwriting. A

Dictaphone may also be useful for recording lectures if suitable for the course,

depending on the nature of the material being delivered and also the number of

hours of lectures. Poor sense of direction is often associated with DCD and

24

orientation around a new college environment prior to beginning a course may be

beneficial to this group.

3.4 Reasonable accommodations

A reasonable accommodation is an adjustment to alleviate a disadvantage that a student experiences in the academic environment on account of their disability. This may include any of the following:

adjustment to course delivery adjustment to assessment procedures provision of additional services (e.g. notetaker in lectures, extra time in

exams)

These reasonable accommodations are determined during a detailed needs assessment that is carried out when a student registers with the Disability Service in Trinity College. For students with DCD this should consider the individual, the tasks required in the course selected and the environment in which the student will be learning. A Learning Educational Needs Summary (LENS) is written during the needs assessment which outlines the student’s accommodations provided by the Disability Service and those that are required from the student’s department(s). These may include the following:

Provide details of assignment deadlines well in advance.

Staff who correct assignments or examinations should refer to

Notes on Correcting Scripts written by Students with Specific

Learning Difficulties for further information. This information is

available on the Disability Service website.

Where possible, prioritise reading lists.

Provide copies of lecture notes, PowerPoint and overhead

slides.

These adjustments are designed to make the curriculum more accessible

to students and will not confer any added advantage.

25

3.5 Suggested teaching supports

Lectures

Give clear handouts and Powerpoint presentations following Clear Print

guidelines

Allow lectures to be recorded

Use on-line teaching forums such as WebCT, Blackboard or Moodle.

Put lectures up on i-Tunes U.

Provided prioritized and annotated reading lists

Seminars and Tutorials

Be clear as to what will be covered at the beginning of the term. Provide

written outline in week one of topics to be covered each week.

Be clear as to expectations regarding work to be done for seminars and

tutorials.

Encourage all students to prepare written notes to bring with them to class

to help prompt memory and organize thoughts for discussion.

Written work

Students may require extra time on account of organization difficulties, but

bear in mind that extensions can cause an endless backlog of work.

Give sensitive feedback if there is a lot of difficulty evident with written

expression.

Existing essays and reports can be offered as examples to students.

3.6 Assistive technology (AT)

In Trinity College at the beginning of the academic year an Assistive Technology

needs assessment is carried out following which the following supports may be

suggested/provided:

26

Word processors with good spell and grammar checks.

Large monitors

Larger, ergonomic mice and keyboards

Cushions

Pencil grips

Screen clamps to move monitor

Wrist pad

Voice-activated software

Text-to-speech software

As noted above, some students with DCD find using a keyboard difficult and if

handwriting is also difficult it is important for students to develop keyboard skills.

Trinity College’s Disability Service runs Touch-Typing Read and Spell (TTRS)

course which is a multi-sensory computer-aided course to build touch typing

skills while also aiding spelling and writing difficulties. As noted above, there are

also larger monitors, ergonomic mice and keyboards with large keys that aid

students with difficulties with the fine motor skills necessary for using a computer.

An AT assessment will consider the whole study environment for a student and

suggest ergonomic supports and equipment to reduce physical fatigue or

repetitive strain. These include, chairs with back supports or cushions, wrist

supports, screen clamps that can adjust the position of the monitor. These are

also available if needed for exams, as are the adaptive equipment for computers

(larger screen/keyboard or ergonomic mouse).

3.7 Academic Support

A number of studies have shown that students with DCD have difficulties with

reading and writing skills; a study conducted by Dewey et al. (2002) found that

the DCD group scored significantly lower than the comparison group on all 4

measures of reading skills (Letter Word Identification, Passage Comprehension,

Reading Vocabulary, Word Attack) and all 7 measures of writing skills (Dictation,

Writing Samples, Proofreading, Writing Fluency, Punctuation and Capitalization,

27

Spelling and Word Usage). Their study was conducted on children but it is likely

that difficulties in these areas are likely to continue to adulthood and that

students should be given the opportunity of working on these skills with a tutor on

an ongoing basis. As noted above the provision of support in this area needs to

be carefully tailored to meet the needs of individual and assessed during regular

meetings with the student. In Academic Support currently, the practice to date

has been to carry out a needs assessment which identifies areas that the student

foresees as being difficulties. This includes analysis of the student’s learning

style by carrying out an on-line learning style survey such as VARK or the DVC

Learning Style Survey. Areas of prospective difficulty are discussed and

prioritized and a subsequent appointment is made to begin to work on these. The

onus is on the student to make appointments subsequently. In future during the

needs assessment the Academic Support Tutor will focus on the course

requirements as per student handbook and identify when coursework and exams

are due. Subsequently, the Academic Support Tutor will make contact with the

student to arrange half-hour appointments and take a more task-based approach

to providing support, focusing on specific areas, such as using the Library, note

taking, referencing, database research, essay structure. Regular follow up

contact will be made.

3.8 Unilink (OT-based one-to-one support)

Unilink is an OT-run one-to-one support service for students with disabilities.

Unilink 1 supports students with mental health difficulties, while Unilink 2 caters

for students with physical, sensory, chronic health or specific learning disabilities.

Students with a primary diagnosis of Dyspraxia/DCD can be referred to the

Unilink 2 service for support in meeting the varying demands placed upon them

in their student role. An initial appointment will establish the tasks required of the

students in College using a profile form to assess self-care, productivity and

leisure tasks and goals. The student will identify and prioritize areas of difficulty

on which they wish to work and follow up meetings will identify and prioritize

28

weekly tasks. Where tasks are specifically related to research skills, use of

Library or producing written work a referral to AST may be made. As noted

above, there is a high rate of no show/cancellation. It is not considered practical

to require students to meet weekly but in order to minimise no shows and

cancellations Unilink staff will email next appointment when it has been agreed

and also text reminders in advance to students of appointment times at the

beginning of the day of the appointment.

Kirby identified that executive functioning is one significant difficulty. Kirby also

cautions that when implementing supports it is important to consider what can be

easily made habitual for students with DCD. It is proposed that in future Unilink

will suggest various strategies for time management, including (where

appropriate) using an iPhone calendar, myzone calendar, wall planner or Unilink

2 handbook. The approach taken will give the student more involvement in their

self-management and regular follow-up appointments will assess how well this

has been taken up by the student and change strategy if necessary. Unilink will

also address ergonomic issues with students with DCD if there are issues with

posture, handwriting or use of technological equipment that could be causing

pain or fatigue.

Gibbs et al. (2007) emphasize the psychological and social issues associated

with DCD in childhood and recommend psychological supports particularly for

transitional times such as the move from primary to secondary education. In

adulthood it is more likely that students accessing third level education have

developed social skills and a study conducted by Kirby et al. (2008) found that

45.8% of the group with DCD reported social skills as a perceived strength. It

must, however, be remembered that many social aspects of third level involve

physical activity; many societies are sports related and dancing and drinking

alcohol are often key social elements for this age-group. Many of these activities

provide or exacerbate difficulties for students with DCD and this should be

considered during assessment upon entry to college. A meeting with an OT-

29

based support service may be appropriate to find ways of helping students with

DCD integrate socially into college life. If a College does not have this kind of

service Learning Support should adopt the same approach and ensure that they

maintain regular contact with students with DCD and re-evaluate the supports

provided or suggested, as necessary. Difficulties in this area could be a

significant contributory factor to a student’s decision to withdraw from college.

Unilink staff take this aspect of College life into consideration during the first

meeting with a student and will consider with the student with DCD various social

options in College, including gym, sports, societies and social activities that do

not tax motor skills or may involve a task that can be mastered.

Summary of recommended interventions (AT, Learning Support and OT service)

Motor skill difficulties Interventions

Handwriting Pencil grips

Experiment with different pens

Computer and use of keyboard Build computer and touch typing skills

Provide ergonomic supports, such as

cushions, wrist supports, back supports,

screen clamps, ergonomic keyboard

and/or mouse

Writing skills Interventions

30

Structure and writing skills Prioritize areas of difficulty in the

production of written work

Provide carefully tailored academic support

building on the student’s learning style and

strengths as indicated by on-line test, such

as VARK or DVC Learning Style Survey

Organization and Social Skills Interventions

Organization

Social Skills

Analyse options for organising timetabling

using a calendar or diary, incorporating

technology where appropriate and where it

can best be made habitual.

Discuss social options available to student

within and without College that may avoid

the student’s motor difficulties and build on

their strengths.

Section 4: Summary

4.1 Discussion

Developmental Co-ordination Disorder (DCD) has only recently been

distinguished in the CAO application process as a distinct group from Specific

Learning Difficulty. This emerging population at third level has a set of needs

which frequently overlap with other developmental disorders but should also be

considered as distinct from the difficulties traditionally associated with Specific

Learning Difficulty (eg. Dyslexia). This study recommends that a holistic

31

approach be taken at needs assessment and by those providing supports to

consider motor and non-motor difficulties and, as stressed by Kirby, difficulties

with executive functioning (organizational tasks). It should be remembered that

supports that are traditionally recommended by learning support tutors for

students with Specific Learning Difficulties may not be appropriate on account of

the fact that they may not be learned by students with Developmental Co-

ordination Disorder. It is recommended that appropriate AT supports be used as

interventions but that this be supplemented with regular, timetabled one-to-one

tuition to assess the suitability of supports and consider not only their

appropriateness but whether or not use can be made habitual.

Currently there is a strong trend of students with DCD at Trinity College pursuing

Arts and Humanities courses but as this is an increasing population thought

should be given to supporting students with DCD who wish to pursue more

practical courses that may involve tasks that require a high level of manual

dexterity, such as using Nursing equipment or laboratory work. Supporting these

students may be against the student’s interest on account of fitness to practice

requirements for the career that the course leads to and the costs involved in

supporting the student, for example, the provision of a laboratory assistant.

4.1. Further Research

As noted in this study, it is difficult within the present group in TCD to study

progress and retention on account of the low number of students with DCD

currently registered with the College Disability Service. Students with DCD may

have entered College with a report confirming Specific Learning Difficulty as it is

only in 2008 that the DCD group was distinguished as a distinct group by the

DARE process of application. Further research could be conducted in the future

or with a wider population to study progress and retention of students with DCD

at third level.

32

Regarding course choices, TCD shows a similar trend to the findings of a study

by Kirby et al. (2008a). There is a strong trend toward Arts and Humanities

subjects, but given that it is now recognized as a distinct group and that this

emerging population is growing rapidly, it is more likely that in future students

with DCD will be applying and accepted for a wider spectrum of courses and this

may include courses with a manual element that requires physical dexterity that

could challenge students with DCD who have motor difficulties. Further research

could be undertaken to consider how to support students in courses with

laboratory or placement work as the provision of a personal assistant would be

difficult to implement on account of funding constraints. This is also an area of

study to consider under issues of fitness to practice.

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