Possible dyspraxia in a 4 year old. What do I need to know?

[gruffalocake2]

DS is 4 and seem to be lagging behind in his motor skills. It's been noticed by nursery which has given me confidence to go forward to ask for a referral and we now have a Pediatric appnt. coming up.

I am a bit worried about managing to convey DSs difficulties and differences from other children. I'm always unsure what is normal and what is not and there are so many small things which others might not notice but which I think are significant. I don't want to overload the Dr with lots of unnecessary info but at the same time if DS has got difficulties I really want them to be recognised so that he can get help as he starts school in September.

The nursery came to me with concerns about his gross motor skills but I also have concerns about his fine motor, can't use cutlery, can't hold a pen/crayon, can only scribble across a page, he has no control at all, unclear on which hand he prefers to use etc..

I'm also concerned about less tangible things. He finds it difficult to concentrate and this has been commented on by HCPs. He isn't naughty (wilfully disobeying) but finds it hard to take in and remember instructions. He can hear but doesn't really process. He is particularly bad in bigger groups. I also feel like he often doesn't understand other childrens games. He tries to join in by copying but he clearly hasn't grasped 'the rules' in the way others have.

He is very sensitive to sound, moisture (any wetness on his clothes or hands is very stressful to him), is a fussy eater (primarily texture I think).
He also wakes up at night quite often screaming about leg pains etc.

Do these things sound relevant and like dyspraxia or something else or just a sensitive child?

I am concerned that at an appointment I will give this picture of DS and then they will ask him to wash his hands or something and because he does it once ok for them they think it isn't a problem when generally it is....hope that makes sense.

V sorry this is so long!

My DS has dyspraxia and that sounds very similar to him. Have you had a look at the Dyspraxia Foundation website for their list of what to look out for in pre-schoolers?

I found it useful to group DS's difficulties into categories ie fine motor/gross motor/concentration/behaviour etc.

Can you ask someone from nursery to write down their concerns too?

As you may know, dyspraxia is a type of sensory processing disorder and many dyspraxics also have co-morbid sensory issues.

You might want to have a look at The Out of Sync Child which is a really good book about SPD

Thanks for your suggestions, that's really helpful.

I think writing things down in groups is a good idea to help me be clear with the Dr.

I'll check out that book.

Can I ask how your DS was diagnosed and if he has been given support since?

It's not a pretty story I'm afraid. He was originally referred for ASD and then discharged because he doesn't have ASD although the OT and the paed both agreed he has significant sensory issues. Last year I took him to a private OT who specialises in sensory processing who diagnosed him with dyspraxia.

He still doesn't have an NHS diagnosis - he's been referred back and is now being assessed for ADD. I'm not sure if it's because they don't recognise dyspraxia or if it falls between two stools where we are (mental health is one health authority, disability is a different one and dyspraxia as you know is a neurological condition with physical ramifications). He goes to weekly private OT which has really helped but is getting no support at the moment (beyond suggesting the ADD meds route) from CAMHS/NHS.

Having said that, the school have put a huge amount of interventions in place and made a lot of adjustments to support him despite the lack of 'official' diagnosis. He also receives weekly gross/fine OT at school. He can now do up a zip and finally do up his seatbelt in the car which is huge progress! And his sensory issues have really abated as he's got older (he's 7 now). I still can't take him into a public toilet with hand dryers but he will tolerate supermarkets and busy places better than he used to.

You might find visual instructions help - DS has numbered pictures up in his room to show him what order to put clothes on in for example and another one in the bathroom to help with teeth brushing.

There is an awful lot you can do yourself to help him - Growing an In Sync Child has lots of fun activities to do at home with minimal equipment

That sounds like a very difficult process. I think the lack of recognition is a bit of a worry.

I know the hand drier thing! I also have a rather dirty set of carpets because he can't stand the hoover and I need someone else around to look after him when I use it.

I think the cards idea sounds good, getting him ready for school in the morning will be a serious challenge. He is just learning to get dressed but finds it very hard and mostly ends up back to front, wrong feet, no pants on if he does manage it!

Thanks for sharing.

I think OddFodd has given good advice.

It sounds as if you have enough to push for a comprehensive assessment; it's helpful when visiting the Paed if you have your concerns already noted down. Try to categorise them the way you did above- gross motor, fine motor, sensory processing, concentration, difficulty with sequencing. Note any difficulty with spoken language- does he understand stuff at the level of his peers, or do you break things down for him?

Visual sequences are useful if he has problems with language processing or with working memory; use a list of jobs for dressing and use pictures to illustrate. Here has good resources.

For dressing you might have a list with:
Underwear
Socks,
Vest
T-shirt
Trackies
Hoody
Shoes
Hair
and let him practice this until he is competent and confident. The you do a different one for school uniform and so on.

It does sound like dyspraxia and sensory processing problems to me. My daughter screamed at the sound of the vacuum cleaner at that age. She could not stand clothes labels or a bath at a normal temperature either. I used to bath the other two together; and she got in after them, when it had cooled down. The sensory problems get better as they get older - or more likely, they learn to cope with them, without screaming!

Get what special equipment you can for him to help - special scissors (instead of two separate handles, it has a plastic band round the ends), elasticated laces, velcro where possible, extra thick pencils and felt tips (they are triangular) or rubber pencil grips.....

They are often unstable in the shoulders and hips, and if there is instability there, they will struggle with fine motor skills in the fingers. Build up his body strength - play lots of ball games, let him sit on a football in front of the television for 10 - 20 minutes a day, do obstacle races to improve sequencing. Intensive practice improves many of the skills. My daughter has severe dyspraxia, but with intensive practice she can be average at ball games, etc.

As for getting dressed - look up back chaining or forward chaining.

Lots of great advice on this thread already. I really second 'The Out of Sync Child'. We also have the hand driers thing!

On fear of sounds: try ear defenders? We've had a bit of success with this. Now, if we could always remember to have them handy...

When talking to the paed: emphasise that OT now, while he is only 4, will be of much more help than a year or two down the line, so if he can be made a priority for referral, that's really important. There's a 40 week waiting list for an appointment in our area, for example. Paeds aren't experts in dyspraxia, so they may not realise the importance of early intervention.

Have you considered your ds' speech and language / communication? For ds1 (now 8), we didn't really think about this, as he can speak. For ds2 (4), nursery picked up on this and he's been found to have moderate/severe issues with communication, which we'd have missed, tbh, and he's been referred for SALT. I guess you get used to the way your dc talk, and don't realise it's not quite right.

I find with my two, that you sort of need to give them instructions a bit like you'd speak to a dog . So, rather than 'can you get your shoes on now, it's time to go to school', or such, I'd say 'Shoes!'. Essentially, single-word instructions are good, not rude!

Thank you so much for all this advice. I can't believe there is a 40 week wait list for an OT!! That's crazy.

I think the scissors and pencils sound great.

I do break instructions down. I tend to remind him with sentences like 'what did I just ask you to do? I asked you to pick up the.....' and wait for him to fill in the gap because it helps him remember that he did hear the instruction he just couldn't process it. I repeat a lot of what other people say to him as well, more simply and clearly because often he looks a bit blank.

Sometimes (50% of the time?) he speaks quite repetitively. So he will say ' I want, I want to, I want to, I want to wear my, my pirate top' not because he can't physically say the words....he just seems to take a while to get things out. We have had SALT in the past the first SALT felt there were issues in his communication, the second thought he just had poor concentration and signed him off.

I think this kind of thing is difficult as it takes time and attention to spot the difficulties and so perhaps for busy SALTs (and other HCPs) with serious/obvious cases on their books they aren't that interested in cases like this.

The repetitive speech might be dyspraxia of speech i.e. he may have difficulty with sequencing words in a sentence, or co-ordintating oral muscles.

At 4 this would probably be more evident than at younger age, and I would go back and ask for a SaLT review (if this is open to you).

I would also start a diary with the daily things that you notice and the accommodations that you make to simplify life for him. When you have about a month of this, take it to your GP and ask for a team assessment.

With DCD/Dyspraxia, at 4 they may adopt a wait-and-see approach as many skills don't mature for another 2-3 years (e.g. laterality).
But input now will be valuable for him.

One thing I regularly notice with children who have problems is that they have weak core strength. It might be useful to work on that with him.

Can I jump in? My 4 year old is seeing the OT next month (it wasn't 40 weeks for us, thankfully, more like 12). Dyspraxia hasn't been mentioned for a bit (the OT who saw her at school was convinced she was hypermobile but I'd bet the mortgage she isn't, she's the least bendy person in the world) but the more I read the more I think that's what we're dealing with.

DD's core strength is weak but she's been doing swimming / ballet off a year and it hasn't improved. She also scribbles rather than draws and has difficulty with 3 part instructions (and often 1 part instructions!) and dressing herself. BUT she's very very good at reading (top of her class despite bring August born) and spoke early with a wide vocab. Can you be dyspraxic with those skills? Does speaking / reading need to be affected as well.

LTJ
You would think that hypermobility and being "unbendy" wouldn't go together.

I find that this does often happen in fact: it is common to see hypermobility at the fingers/elbows/core and the child has trunk stiffness and shortened hamstrings.

Why?
As they struggle to find a stable base for fine motor function, they shorten muscles as a compensatory strategy. So the assessment would take both of these into account.

I also find that children with hypermobility can be excellent at ballet/martial arts type activities: they are praised for their stretching. But it's not typical stretching: it is the hypermobility and low muscle tone which allows them to go to the end range of movement.

In that case, you need to specifically target core strength, and work at it. It can take several months of daily work for core strength to come up to average levels; and these children/adults need to be stronger than average at their core, in order to give a stable base for function.
It does improve BTW and has a positive knock on effect on their other activities.

One of the key criteria for a diagnosis of DCD/Dyspraxia is that the child has a higher verbal vs Performance IQ on testing....so yes, it is often the case that they will be good talkers and readers, and they play to this strength.
HTH

Thank you. So what should she and I be doing every day? She swims, as mentioned, and is nearly there riding her bike without stabilisers. We also have a trampoline (any good?) and could get a wobble board??

I'm in a bit of a rush so have a look at this OT blog
Core strength is the connection between pelvis and rib-cage first and then
moving to shoulders, neck, hips.

I'll be back

Bless you