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Running head: DEVELOPMENTAL COORDINATION DISORDER

Developmental Coordination Disorder: A Case Study about Natalie


Mariana Hall, Elizabeth Hares, Sam Mitchell, Sylvia Niemyjski, Tiffany Poon,
& Emily Severance
Touro University Nevada

DEVELOPMENTAL COORDINATION DISORDER

Occupational Performance
Natalie is a six-year-old girl living with her immediate family; her parents, a twelve year
old brother, a four year old sister and her maternal grandmother. She has been diagnosed with
developmental coordination disorder (DCD) comorbid with a learning disability. Natalie
participates in a regular education classroom and receives support from a special education
teacher who consults with her classroom teacher. She also receives thirty-minute sessions of
occupational therapy and physical therapy twice a week at school. Natalies academic functional
performance is impacted by problems with general and bilateral coordination as well as limited
fine motor skills. Additionally, Natalie has poor endurance that interferes with her ability to walk
for extended periods of time. Her strengths include that she is persistent and can tolerate
frustration well as long as she is participating in activities that she enjoys such as freeze tag,
concentration memory games, and cooking. Additionally her parents are very supportive and
want to see her succeed academically.
Activities of Daily Living
Natalie can get ready for school with minimum assistance in the morning. Her test scores
for the Pediatric Evaluation of Disability Inventory (PEDI) were average for all of the domains
except for getting dressed using fasteners. Natalie needs assistance before and after using the
restroom to button and unbutton her pants. Problems with bilateral coordination result in
difficulties in washing her hands. Self-feeding while at school is challenging as opening Ziploc
bags and food containers require good bilateral coordination. Independently tying her shoes
throughout the day is also problematic.
Instrumental Activities of Daily Living

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Bilateral hand coordination problems result in having difficulties buying lunch at school,
carrying, and manipulating the lunch tray. Low endurance and muscle strength have also
impacted Natalies ability to commute between classrooms as well. She is often left behind due
to needing frequent rest stops to lean against the wall. Additionally she tends to trip and bump
into desks and tables as a result of poor balance and lack of coordination. With regards to
emergency responses, Natalie is paired with a classmate to hold hands with during fire drills to
ensure that she participates and learns emergency procedures in order to promote her ability to
keep safe at school.
Play
Natalie takes on a passive role during recess and seems content to sit and watch other
children play games, especially kickball and baseball. Problems with balance, endurance, and
strength affect Natalies participation in physical education classes. Although Natalie is very
social and enjoys the company of other children, increased fatigue limits her ability to participate
in vigorous play activities that require gross motor skills. Long school days also impact Natalies
energy level once she goes home which interferes with homework completion.
Leisure
Activities that Natalie enjoys include helping her parents cook simple meals, baking,
playing card games, and concentration memory games. Even though Natalie usually steps back
during social gross motor activities at school, her occupational profile indicates that she enjoys
playing musical chairs and freeze tag. Due to fatigue it is likely that Natalie will prefer to engage
in passive and quiet leisure activities such as watching television with her grandmother and
siblings.
Social Participation

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As already mentioned, although Natalie is friendly and outgoing and enjoys the company
of her classmates, she seldom participates in play activities at recess. Natalie sometimes distracts
her peers throughout the day by talking and starting conversations, because of her inability to
complete academic activities that are challenging for her. She has occasional sleep-overs with her
closest friend from school. Natalie does not have problems interacting with her parents,
grandmother, or siblings at home. She maintains good eye contact when socializing with peers
and interacting with adults within the community.
Education
Natalie is currently in the first grade and was placed in a regular education classroom
with occasional support from the special education teacher. Natalie has difficulty with fine motor
tasks and tasks that require bilateral coordination, therefore, many academic activities throughout
the school day are challenging to her. Natalie cannot use scissors independently, and gets easily
frustrated during classroom art activities. Natalies handwriting skills are also poor. She struggles
when engaging in visual tasks, such as copying her homework assignments into her planner from
the whiteboard. Postural stability has also become an issue when sitting for long periods of time.
Natalie often demonstrates poor posture, or leans on her desk for support.
Rest/Sleep
Natalie is independent in her nightly routine for bed, but she needs assistance with
zippers and fasteners on her pants. Natalie sleeps well throughout the night, and has a strict
bedtime. She falls out of her bed occasionally, and sometimes trips when getting in and out of
bed. Her parents have recently installed a bed guard to address this problem.
Movement, Postural Reactions, and Reflexes
Movement

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Natalie can walk unassisted, but becomes fatigued quickly. When transitioning between
classes she stops and rests frequently. During community outings, she does not utilize any
assistive technology devices, but chooses to sit whenever possible. Her muscles are fully
developed, but she demonstrates weak postural alignment and stability when sitting, standing,
and walking. When participating in games that require advanced gross motor abilities, Natalie
can execute tasks but performs them much slower than her peers. She also occasionally trips and
bumps into her surroundings. Activities that require bilateral coordination are extremely difficult
for Natalie. Similarly, she has trouble performing fine motor tasks. Natalie cannot open and close
zippers, buttons, or fasteners without assistance. Natalies handwriting is also a major concern, of
her parents and teachers.
Postural Reactions
Natalie has low coordination and postural stability which results in immature postural
reactions. Natalie demonstrates delayed protective and righting reactions. Deficits are also
present in her equilibrium and anticipatory reactions. Such deficits contribute to her difficulties
in performing her daily activities. Natalies deficits in all areas of postural reactions contribute to
her difficulties during the day, especially during times of transitioning between classes.
Reflexes
Natalies reflexes are not affected by her diagnosis.
Self-Regulation
Natalie demonstrates low levels of self-regulation when engaging in activities that she
does not like and/or views as difficult. Such activities include: handwriting, using scissors and
glue, and engaging in ball sports. When asked to participate in activities that she considers hard,
Natalie demonstrates a higher level of tolerance and self-regulation skills if verbal praise is

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provided. Her tolerance for a difficult activity is also increased when the activity is appropriately
graded to her ability. However, when participating in activities she views as enjoyable; Natalie
demonstrates a much higher level of persistence and controls her frustration. As previously
mentioned, Natalie enjoys helping her parents cook and bake, playing concentration memory
games, and freeze tag with her peers.
The Person Environment, Occupational Performance Model (PEOP)
The PEOPs approach is especially suitable for individuals with disabilities, because it
pays particular attention to the interaction between the person, occupation, and environment. The
activities Natalie enjoys the most are the activities that she has the greatest difficulties
performing within her school environment. This can be an advantage for school intervention,
because she is inherently motivated to work on those particular tasks. However, the mainstream
classroom is mainly designed for the typically developing child, thus creating an occupational
performance barrier for children with disabilities. However, as the PEOP states, the environment
can be more readily modified than the childs performance. Therefore, the use of adaptive
equipment and environmental modifications can quickly eliminate barriers to performance while
making the environment more supportive and conducive to independent functioning specifically
for Natalie. (Brown, 2014).
Most Appropriate Theories and/or Practice Models
Dynamic Systems Theory
The dynamic systems model takes a similar approach as the PEOP model as it
emphasizes the context and the interaction of many subsystems that make up the childs life.
Natalies different contexts and environments should be taken into consideration as a whole
when applying this model, as they influence her occupational performance. As the dynamic

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systems model suggests, Natalie should experiment with different movement patterns to
determine what works best for her at school (OBrien & Williams, 2010). The dynamic systems
model stresses that individuals learn best when self-correcting, because they rely on internal cues
to evaluate their own performance (OBrien & Williams, 2010).
Motor Learning Theory
The foundation of motor learning in occupational therapy is to learn and re-learn skills
through the use of meaningful activities. These activities must elicit the retention and transfer of
the desired skill to be used in a functional setting. When the treatment goal is to enhance the
transfer of skills such as handwriting or gross motor skills from therapy to school settings,
practicing these skills in different settings and encountering them frequently is most beneficial.
The most important aspect of motor learning relating to Natalie and her performance skills is the
use of practice schedules. Though there are many types of practice types within the motor
learning theory, the use of distributed practice would be most appropriate for Natalie. This
technique alternates long resting breaks with short periods of practice on a specific skill. This
gives Natalie time to rest and regain energy for her next task, thus Natalie will be able to practice
variable tasks, allowing her to increase her motor learning skills (OBrien & Williams, 2010).
Evidence on motor learning and different practice techniques have shown that random practice
yields greater retention and transfer of skills learned in treatment. Random practice involves
varying the demands of the task over different learning trials in therapy or in the natural
environment. An example includes practicing zipping and buttoning by using different types of
jackets or shirts and changing the time given to complete the task. The motor learning theory is
the basis of treatment for Natalie and focuses on a majority of the performance skills that are
proving difficult for Natalie. This theory will work on learning skills that can be applied across

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different environments and contexts. In pediatric practice in particular, a childs acquisition of


motor skills is important to his or her functioning in self-care activities, participating in school,
and engaging in play. Treatments based on motor learning have shown more promising results
compared to Sensory Integration for children DCD.
Assessments Appropriate for Client
Assessments are useful to determine the areas of functional performance that need the
most improvement. In Natalies case, the School Function Assessment (SFA) was used to
evaluate her school performance. This was the most appropriate assessment in Natalies case
because her parents two main concerns are her academic performance and difficulties with
handwriting. Once Natalies specific deficits in school are identified, the occupational therapist
can create an intervention plan that includes activities that address these problem areas and are
appropriate for school functioning. Specifically to address handwriting, another assessment that
would be appropriate is the Evaluation Tool of Childrens Handwriting (ETCH). To address
Natalies deficits outside of the classroom, The Pediatric Evaluation of Disability Inventory
(PEDI) assessment was completed. The PEDI focuses on areas of self-care, mobility and social
function in daily activities. This is an appropriate assessment because it is specifically designed
for children with disabilities and how their disabilities affect functional performance. The PEDI
is a valuable tool to assess Natalies level of functioning in the home specifically with dressing.
Using a variety of assessment tools will give the therapist an overall picture of Natalies problem
areas and aid in the intervention process.
Functional Problem Statements
Functional problem statements identify areas of functional performance that are difficult
for the client and also help to guide treatment goals and intervention methods. Natalies

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functional performance has been affected by symptoms pertaining to her dual diagnoses of
learning disability and DCD. The following functional problem statements have been based on
the information provided by Natalies occupational profile as well as the assessments that have
already been administered:
(1) The client is unable to legibly write full sentences with paper and pencil due to poor hand
muscle strength and bimanual coordination problems.
(2) The client is unable to engage in gross motor play activities such as playing kickball and
using the playground at school due to muscle weakness, decreased endurance, poor balance, and
decreased bilateral coordination.
(3) The client has difficulty transitioning between one area of the school to another in order to
participate in school activities due to poor muscle strength, balance, and endurance.
(4) The client has difficulty with completing dressing activities that require the use of fasteners,
thoroughly and within an appropriate time frame due to fine motor deficits and poor bimanual
coordination.
(5) The client has difficulty completing art projects involving cutting, pasting, coloring, drawing,
and writing due to fine motor manipulation deficits and bilateral incoordination.
Short term and long term goals to address these problem statements related to Natalies
functional performance at school will be developed as part of her treatment plan.
Family, Caregiver, and Child Goals
When determining occupational therapy goals for children, it is important to take into
consideration the goals and ambitions of the family. Natalies parents main concerns are as
follows:

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1. Natalies parents would like Natalie to complete her homework assignments legibly
with minimal assistance.
2. Natalies parents would like Natalie to fully participate in school games at recess with
peers with minimal cueing from her teachers.
3. Natalies parents would like Natalie to transition at the same pace as other classmates
when moving from classroom to other areas of the school.
4. Natalies parents would like Natalie to thoroughly fasten her jackets and jeans within a
reasonable time.
5. Natalies parents would like Natalie to fully participate in arts and crafts at school with
minimal assistance.
Family/caregiver goals will guide the therapist's intervention approaches to meet the
goals of the child and family. These goals will be taken into consideration when creating
meaningful activities for the child.
Occupational Therapy Goals, Objectives, and Activities
When writing goals the occupational therapist must ensure that the goals maintain and
promote function. Occupational therapy goals are highly individualized and are based on the
childs evident occupational performance problems as well as the concerns and priorities of the
family and child. Natalies goals have been determined by information from her case study,
family and her functional problem statements.
Occupational Therapy Goal: Natalie will demonstrate improved muscle strength, endurance,
and balance to participate in social play on playground equipment, gross motor activities, and
transitions between classrooms at the same pace as her peers within one school year.

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Objective: Natalie will engage in all classroom transitions at the same pace as her peers
in 4/5 trials with minimal assistance/redirection within 3 months.
Activities:
(1) Participate in the Ants Go Marching with peers: Natalie and her classmates will march
in a line around the classroom, through the hallways, or on the playground to the song
The Ants Go Marching. It is important to place Natalie in the middle of the procession
to decrease her chances of falling behind. It is also important to have classmates behind
her to encourage her to keep up and promote self-efficacy.
(2) Participate in Simon Says while standing: Actions such as clapping, balancing on one
foot, hopping on one foot, jumping jacks, and others are important to use during this
activity.
Objective: Natalie will actively participate with her peers on the jungle gym during
recess for 20 minutes independently within 6 months.
Activities:
(1) Hide and seek on the jungle gym: A friend or therapist will hide objects around the
jungle gym and have Natalie find the hidden objects. Natalie is only allowed to bring one
object down at a time to promote more mobility on the jungle gym.
(2) Follow the leader with a peer on the jungle gym: Natalie will participate with 2-3
peers, playing follow the leader on and around the jungle gym; encourage the peers to
climb up the stairs, go down the slide, and weave around the jungle gym below.
Occupational Therapy Goal: Natalie will have functional hand control and strength for greater
success with fine motor skills with increased independence in writing activities and self-help
skills within one school year.

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Objective: Natalie will don a jacket and tie shoes within 3 minutes independently 4/5 of
trials in 3 months.
Activities:
(1) Dress-up dolls: Natalie will practice dressing a medium-sized doll. She will don and
doff the dolls jackets, shirts, and pants. The dolls clothes will include buttoning,
fastening, and zipping.
(2) Practice lacing and tying shoes: Natalie will practice lacing and tying using the CanTie-My-Shoe Board. To grade the activity up, Natalie can practice on her own shoe.
Objective: Natalie will be able to complete a legible three sentence short story on a three
lined paper with minimal verbal cueing using a tripod grasp 4/5 trials within 6 months.
Activities:
(1) Writing spelling words on a vertical whiteboard: Natalie will practice writing her
spelling words on the whiteboard while standing; she may use fun colored or scented
markers. Natalie can sit or stand while doing this activity.
(2) Writing letters and shapes in shaving cream: Natalie will practice printing her letters
and shapes using a marker (with the lid on it) in shaving cream while seated at a table.
Occupational Therapy Goal: Natalie will demonstrate improved bilateral coordination and
motor planning to improve her gross motor and fine motor skills increasing her access to the
academic curriculum within one school year.
Objective: Natalie will participate in kickball with peers with minimal verbal cueing for
a duration of 10 minutes during recess within 3 months.
Activities:

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(1) Hot potato with a peer (using feet or hands): Natalie will catch, toss, or kick a ball
back and forth with a friend as fast as she can; the therapist can encourage the speed of
the game by playing faster music and stopping it abruptly.
(2) Take turns kicking a ball to a target with a peer: Natalie will kick a ball to certain
target areas; the therapist can grade this activity up and down by making the target farther
away or closer; also using different ball sizes to work on precision.
Objective: Natalie will cut out complex shapes and complete an art project 4/5 trials with
minimal verbal cuing within 6 months.
Activities:
(1) Cutting craft projects: Natalie will cut out a shape or picture of her choice, glue it to
another piece of paper and write one sentence about it. Encourage Natalie to use different
scissors and different sizes of shapes to cut out to promote generalizability.
(2) Putting coins into a piggy bank: Natalie will practice grasping 15 pennies with one
hand, transferring the penny to the other hand and placing it into the piggy bank. This
activity could be graded up by having Natalie complete this while being timed.
Treatment Plan
Environmental Setting
Natalie will attend treatment sessions during the school day with a school based
occupational therapist. Therapy sessions will take place in and out of Natalies classroom.
Typical settings that the OT will work with Natalie in the school include: the school playground,
the hallway, the lunch room, the gymnasium, and art class. The school playground has a big
jungle gym, monkey bars, slides, and an outdoor basketball court. The hallway will provide an

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area to practice transitioning with Natalie. The classroom and art class will provide the therapist
access to arts and crafts supplies.
SOAP Note
S: Subjective
Teacher reports client is tired and not participating in group activities today, however during tx
session, client seems to be engaged and happy to be in therapy.
O: Objective
The client participated in a 45-minute OT session in her school focusing on fine motor skills and
bilateral coordination. The client demonstrated good attention skills throughout the tx session.
Natalie was able to use an efficient scissor grasp when cutting out shapes on dotted lines 50% of
the time with minimal verbal cues. The client displayed a dynamic tripod grasp when holding a
No. 2 pencil with a pencil grip. She completed a two sentence short story on three lined paper
with low legibility. Verbal cueing 50% of the session was needed for the client to complete her
writing task.
A: Assessment
The clients attention level allowed her to focus on fine motor tasks but needed repetitive verbal
cueing to complete. Despite her bilateral incoordination, she was able to stabilize a scissor grasp
during the cutting activity, thus showing improvement in this area. Clients high potential of
improvement in her fine motor skills is apparent through the clients determination and
cooperation during the tx session. The client will benefit from continued school OT intervention
to increase her overall academic performance.
P: Plan

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Continue to treat client 45 minutes 3x/wk. for the remainder of the school year to allow client
full access to her academic potential. Plan to address poor fine motor skills with various art
activities involving cutting with scissors. Plan to further address handwriting skills by working
on clients dynamic tripod grasp.
Taking Whole Client into Consideration
When the occupational therapist is looking at the child, it is important to take a holistic
approach, not just focus on the child's disability. The occupational therapist must look at how
Natalies diagnosis affects her occupational performance and what social and financial support
the child has at home and in the school setting. Collaboration with the parents, caregivers and
teachers is recommended to integrate aspects of treatment into Natalies environment. Having the
parents practice play activities that work on fine motor, bilateral coordination, and gross motor
will allow Natalie to reach intervention goals and perform at her optimal level in and out of the
home and classroom setting.
Integrating the parents and caregivers into Natalies therapy will allow the therapist to
receive feedback from the parents on the current status of treatment, thus, aiding the therapist in
ways to either modify or adapt goals and means of therapy. Receiving feedback from Natalies
teachers and school aids will allow the therapist to modify treatment to meet the needs of Natalie
in the classroom and school. Receiving input from school officials will allow the occupational
therapist to modify the environment that works well for Natalie and promotes learning. Also,
interviewing the parents and caregivers often will allow the therapist to get a better picture of
Natalies contexts, environments, and areas in which she is having difficulty with, such as selfcare, feeding, play, and formal education.
Specific Recommendations

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For Natalie to perform optimally as a student, these recommendations are made for the
parents and Natalie to work on during and outside of school.
(1) We recommend that Natalie receive continuous positive reinforcement when she
performs gross motor activities and handwriting tasks with minimal cues.
(2) We recommend that Natalie receives rest breaks following gross motor activities, such
as after recess.
(3) We recommend that adaptive seating be provided for Natalie in the classroom, in
order to promote good postural alignment thus improving her fine motor skills
(4) We recommend that Natalie sits closer to the front of the classroom near the
whiteboard to help with copying.
(5) We recommend pairing all the children in the class during transitions to motivate
Natalie to keep up with her classmates.
(6) We recommend Natalie to use a pencil with a grip when doing writing activities.
Justification of Treatment
Natalies diagnosis of DCD is impacting many areas of occupation, especially one of the
most important areas of occupation for a child her age: play. When a child is having difficulty
with play within the school setting, it can affect the child's normal development and their ability
to create meaningful relationships with other students of the same age. This may also affect
Natalies confidence in school-based activities and her overall feelings of self-efficacy.
Addressing Natalies problem areas in fine motor and hand strength will allow her to complete
more classroom activities such as arts and crafts and improve her handwriting skills. Improving
these skills is very important for Natalies overall academic performance. If handwriting proves

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too difficult for the child, she may avoid handwriting and have feelings of poor school
achievement and low self-esteem.
Extensive research has been conducted on effective treatment methods for children with
Developmental Coordination Disorder. In a study published in Developmental Medicine & Child
Neurology Journal, researchers tested the effectiveness of Neuromotor Task Training in
children with DCD. Neuromotor task training is a method of treatment that is based upon a
cognitive neuroscience approach to motor control processing. This approach emphasizes the
motor and cognitive processes that can be distinguished when performing functional motor tasks
such as the processing of task-related information, action planning, and initiation of movement.
Research into Neuromotor task training provides evidence of effective treatments that are based
on a foundation of motor control processing in children with Developmental Coordination
Disorder. Having Natalie practice coordinated activities such as throwing and bouncing a ball,
action planning, and initiation of movement would incorporate evidence on motor control.
(Niemeijer, Smits-Engelsman, & Schoemaker, 2007).
In an article published by the Developmental Medicine and Child Neurology, Dr. Sugden
reviewed the current research on intervention approaches used for children with Developmental
Coordination Disorder and found that occupational therapists commonly use two major types of
intervention approaches: 1) Process or deficit approaches 2) Functional Skills approaches. The
overall goal of the deficit approach is to remedy an underlying process deficit with intervention
targeting a specific structure, such as proprioception or a neural structure. Using this approach
will help remediate the deficit and improve everyday tasks that the structure is involved in. The
functional skills approach, unlike the deficit approach, is not trying to remediate a deficit. This
approach aims to work on functional skills that the child needs to perform such as dressing or

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feeding. This functional skills approach can be applied to Natalie by working on self-care skills
such as dressing, and the deficit approach can be applied by working on fine motor skills that are
responsible for many tasks that Natalie is having trouble with such as handwriting. (Sugden,
2007)
Poor handwriting skill in children with Developmental Coordination Disorder is a very
common deficit. School activities can become frustrating for children who are experiencing
problems with fine motor strength and coordination. Theyre Bright but Cant Write, an article
written by Cheryl Missiuna, Lisa Rivard, and Nancy Pollock, examine the hardships children
with DCD experience in the classroom setting and ways classrooms and activities can be
modified to meet the needs of these children in the present. The authors created the program
M.A.T.C.H. that provides teachers a way to modify the classroom. M.A.T.C.H. stands for
modifying the environment, Alter your expectations, Teach strategies, Change the environment,
and Help by understanding. Natalies occupational therapist may incorporate aspects of this
program into her treatment plan as a beneficial way to address her current deficits in the
classroom. Consulting with her teacher and suggesting ways to modify the environment and
teach strategies to help compensate for current fine motor deficits may increase Natalies current
classroom performance while Natalie is receiving treatment and growing as a child. Modifying
the environment allows Natalie to put effort into the activity but still experience success. This is
important for motivation and feelings of self-efficacy in future class activities. Teaching
strategies for children with DCD may include using a teaching approach that best fits Natalies
learning methods. Teaching strategies for Natalie may help her learn the same material and keep
up with her peers in the academic curriculum. (Missiuna, Rivard, & Pollock, 2004)

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When creating a treatment plan and coordinating activities to meet goals, it is important
to do your research and incorporate successful techniques that are proven effective for the
specific disorder. When researching evidence, it is always important to remember that you want
to give client-centered treatment. Treatment techniques and activities should always meet the
needs of the client and caregivers.

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Missiuna, C., Rivard, L. & Pollack, N.(2011). Children with developmental coordination
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