Using concept maps in cognitive treatment for children with developmental coordination disorder

doi:10.4236/health.2010.27104

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Vol.2, No.7, 685-691 (2010)

doi:10.4236/health.2010.27104

Health

Using concept maps in cognitive treatment for children

with developmental coordination disorder

Tsameret Ricon

Occupational Therapy Department. Faculty of Health & Welfare Sciences, University of Haifa, Mount Carmel, Israel;

tricon@univ.haifa.ac.il

Received 13 January 2010; revised 20 January 2010; accepted 21 January 2010.

ABSTRACT

Children with Developmental Coordination Dis-

order (DCD) often seem to possess a narrow

repertoire of cognitive strategies. In particular,

they have difficulties in learning and internaliz-

ing the rules and strategies that other people

intuitively use to approach common everyday

problems. As a result, they often appear to have

organizational, planning, memory and learning

difficulties. The article proposes using a Con-

cept Map (CM) as a visual strategy to facilitate

interaction between a child with DCD, his/her

family and therapist, as reflected in Client Cen-

tred and cognitive approaches. The CM is used

as a method of assisting the child to identify,

develop and utilize cognitive strategies in order

to manage daily tasks effectively, as a tool in

organizing his own therapy and in order to en-

courage participation. A demonstration of the

concept mapping usefulness is brought by a

case report. Further uses of concept mapping

as a useful strategy within the framework of

intervention remain to be studied.

Keywords: Concept Map; Cognitive Approach;

Developmental Coordination Disorder;

Organization Problems; C ase Report

1. INTRODUCTION

Children with Developmental Coordination Disorder

(DCD) experience problems with planning, ordering and

then carrying out coordinated movements and tasks ap-

propriate for their age. The use of cognitively-based in-

terventions designed to help children with DCD to de-

velop problem-solving strategies shows greater transfer

to other areas of skill development than do traditional

physical and occupational therapies [1]. This article aims

to demonstrate the use of the concept map (CM) as a

cognitive strategy for treating children with DCD.

A concept map consists of a central word or concept

surrounded by a few main ideas that relate to that word.

It is a graphical two-dimensional display of concepts,

connected by directed arcs encoding brief relationships

(linking phrases) between pairs of concepts forming

propositions.

Concept maps serves as tools for organizing and rep-

resenting knowledge. They offer a method to represent

information visually and therefore harness the power of

our vision to understand complex information “at-a-

glance”. We can assist the sequencing by which tasks are

learned through attainment of progressively more ex-

plicit knowledge that can be anchored into developing

conceptual frameworks.

Concept maps are, representation of concepts and

their interrelationship, and are intended to represent the

knowledge structures that humans store in their mind [2].

Concept maps are important when adopting a construc-

tive view of learning. This view locates cognition and

understanding within the individual [3], and is based on

the theory that each of us develops mental schema that

serve to inform future thinking or action [4]. It is thought

that these schemas enable us to function with confidence

in a complex environment, and it is these schemas that

CM aims to represent diagrammatically.

In 1976, Novak [5] defined concept maps as a visual,

organized representation of knowledge enhancing me-

aningful learning. Concept maps give structure to “the

to-be-learned domain”, including the before, during, and

the after phases of action, thus playing an important role

as an integrative organizer.

The use of cognitive-based approaches to enhance

occupational performance (in the case of children with

DCD, this is defined as their ability to successfully un-

dertake their daily school, play, leisure and self care ac-

tivities) has been a developing focus in contemporary

occupational therapy literature [6]. In the early 1990s,

Polatajko and colleagues [7] set out to develop a new

T. Ricon / HEALTH 2 (2010) 685-691

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approach to the treatment of children with DCD. Given

the fact that children with DCD have difficulties in

learning and generalizing motor skills, it seemed that the

motor skills needed to be learned in more efficient way.

Meichenbaum [8,9] proposed that children could learn

to regulate their behaviour by instructing themselves to

identify a goal, develop a plan, enact the plan, and

evaluate its success. In the Cognitive Orientation to daily

Occupational Performance approach [10]; cognitive st-

rategies are used to influence skill acquisition by chil-

dren with occupational performance deficits. Generali-

zation and transfer of skills is supported through the use

of an executive or problem-solving strategy that trains

the child to monitor his or her performance and self-

evaluate the outcome. Domain-specific strategies form

the bridge between the child’s ability and skill level and

help the child to develop appropriate motor plans.

1.1. CM as a DCD Intervention Tool

The behaviour of children with DCD often seems disor-

ganized, presumably deriving from altered use of cogni-

tion, caused by otherwise biology (Figur e 1) [11].

However we currently lack tools to directly assist

children develop strategies that will enable them to be-

come better organized at the cognitive level. In addition,

to generalize and then transfer a learned strategy, the

child must have knowledge of how, when and where to

use that strategy [12]. Pressley and colleagues [12] rec-

ommend guided discovery learning as the optimal me-

thod for achieving transfer. CM, being a visual means of

organizing cognition, can act precisely as such a learning

method, and so assist children organize both their cogni-

tion and their behaviour, generalizing and transferring

the learned strategies to other areas of their lives.

Intervention approaches have been mainly criticized

for achieving only limited improvements for children

with DCD in terms of generalized motor performance.

An evaluation of the various techniques was performed

by Mandich et al. [13], who found no difference, in

terms of effectiveness, between Sensory Integrative (SI)

therapy, physical education classes and perceptual motor

treatment. A Meta analysis performed by Hen, Mayseles

and Josman [14] analysed the mean effect size of the

effectiveness of intervention approaches that had been

reported in studies between 1987 and 2007, and found

no significant differences in the effectiveness of the

various approaches to treating children with DCD.

If we relate to DCD using Morton’s model [11]—we

see a biological defect that causes a cognitive cones-

quence that manifests as a behavioural impairment (see

Figure 1). Similarly, DCD interventions should aim at

the biological, consequence, or impairment levels (Fig-

ure 2).

Defect

Impaired Diagnostic Criteria

Consequence

Biology

Cognition

Figure 1. Morton’s (2006) basic causal model.

DCD

Impairment

Consequence

Defect

Diagnostic Criteria

Comorbidities

Subtype

Earlier

Terminology

Clinical

Top

down

Bott

om up

Medical

intervention

Figure 2. Concept Map of the Issues DCD Therapists must consider in making clinical Decisions.

T. Ricon / HEALTH 2 (2010) 685-691

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Neuromaturational, hierarchical theories consequently

led to focus therapy on remediation underlying deficits

with the expectation of subsequent improvement in mo-

tor performance. Other approaches define the objectives

of intervention as facilitating skill acquisition, and ther-

apy focuses on functional splinter skills. However, they

have not been found to be effective in improving the

functional ability of children with DCD [1]. These ap-

proaches need to be integrated into interventions aimed

at higher levels.

Top down approaches focus on the role that the con-

text of motor behaviour plays in organizing the motor

system for performance. Contemporary theories propose

that behaviour is self-organized and emerges from vari-

ous subsystems, and emphasize a problem solving ap-

proach to motor skill acquisition. Top down approaches

included task specific interventions, and cognitive treat-

ments [1].

Cognitive theory literature has shown the use of strat-

egies to facilitate performance. According to the Morton

[11] model (Figure 1), the cognitive level is above the

behavioural level of carrying out a task Cognitive strate-

gies are in the conscious cognitive level and are control-

lable.

Feuerstein, Hoffman & Miller [15] believed that chil-

dren’s cognition could be modified. Their cognitive de-

ficiencies are observed either when the child approaches

the task, thinks about the task or responds to it.

Consequently, Polatajko et al. [7] proposed a problem

solving approach, which uses cognitive skills through

verbal self guidance to improve the child’s motor per-

formance. In this top-down approach, the goal is the

activity defined by the clients and objectives are: skill

acquisition, transfer of skills across environments and

tasks, and development of appropriate cognitive strate-

gies [7]. Figure 3 illustrates where concept mapping fits

within interventions aimed at the consequence (cognitive)

level and within the broader DCD context.

This original pilot study suggests a step-by-step, new

problem solving approach—using concept mapping. The

visual presentation of organized linked ideas about any

activity that is about to be done plays a role in facilitate-

ing cognitive strategizing. This approach can be used

with any age and with problems of any complexity by

everyone: the child/parent/therapist/teacher/case manager

and so forth. An example usage of CM to aid a child in

achieving a desired skill is shown in Figures 4 and 5.

Research into visual processing in children with DCD

leads us to another controversial domain. Children with

DCD experience difficulties iof all kinds n performance

DCD Impairment

Consequence-

Cognitive

level

Biological

Defect

Comorbidities Subtypes

Concept

mapping

Clinical Decisions

Evidence based

practice---Cognitive

Approaches

Strategies

Visual

Ve rbal

Other

No visual

problems Existing Visual

problems?

Figure 3. Clinical decisions deriving from the consequence level lead us to the use of cognitive approa-

ches and concept mapping.

T. Ricon / HEALTH 2 (2010) 685-691

688

View Activity/

Subject

Evaluate and Resolve

Reflect and

Represent

Execute and

Confirm

Figure 4. Phases of the constructed adoption of the visual

strategy.

of motor skills, deficits in perceptual processes have

often been assumed to underline these difficulties. Sch-

oemaker and her colleagues [16] showed that children

with DCD were not a homogenous group on the matter.

They were as able as typical children to detect and match

figures in a complex, confused background, and their

most pronounced problems had motor nature. At this

point the issue of co morbidity arises. Some studies that

did show visual-perceptual problems failed to control for

comorbidy and could not exclude the possibility of in-

fluence from other factors [17]. Another brief concept

summary is presented in Figure 3.

Considering the overall picture with respect to DCD,

and in light of the effectiveness of cognitive approaches,

we suggest using the Concept Map as a cognitive visual

tool in DCD intervention.

In the process of Concept Mapping, in parallel to the

processes outline thus far, knowledge is anchored in

conceptual frameworks that enable clients to develop

more effective solutions to problems in occupational

performance. Concept mapping can be used as a plan-

ning tool prior to the activity, as an organizational strat-

egy during the activity, and as a reflective activity that

answers the needs of both the therapist and the child.

Using Concept Maps requires explication (making

explicit what is normally implicit). The child becomes

more aware of the required regulation of his/her learning

processes in relation to task performance and the abili-

ties to be acquired. Both explication and awareness con-

tributes to the development of auto-monitoring tech-

niques/strategies [4]. The constructed adoption of the

visual strategy is demonstrated in Figur e 4.

In the first node, the child is asked to “View the activ-

ity” in a preliminary stage that includes a graphic pres-

entation of information. The activity could be any activ-

ity or even any subject, such as planning study for an

exam or planning how to climb a ladder. In both cases,

the aim is to arrive at implement able actions, bringing

together all knowledge and previous experience. The

second node is “Evaluate and resolve”, and relates to the

actual planning part. This is the process of building up a

concept map in order to serve thinking/action and to

enable functioning in a complex environment. The child

is asked to elaborate on the problem verbally. S/he must

write down or tell the therapist all the required steps of

the activity or sub topics of the main subject, which re-

quire attention. Furthermore, the child must internalize

and understand the relation between the sub-topics and

the dynamic structure of the map. The therapist can serve

as a mediator during this phase, to the extent required by

children at different levels.

The next phase is “Execute and confirm”, meaning

Therapy Session Plan

Time frame,

Setting facilities

Activities are chosen by the therapist

And the child, within

Time frame:

Activity 1-Climbing a ladder

Goal: 1. The child will improve

his climbing skills in

order to facilitate

Participation in

School environment

Ladder Height, # rungs,

Climbing techniques,

Previous experience etc.-

Verbal elaboration.

Satisfaction,

analysis of

Strategies

Climbing

a Ladder

Climbing, time evaluation,

Success evaluation, etc.

Verbal feedback

Observing, verbal

guidance,

describing action,

giving feedback,

identifying

strategies

Figure 5. An example of concept map used in therapy.

T. Ricon / HEALTH 2 (2010) 685-691

689

that the child executes as planned, and the therapist sup-

ports the child’s actions with verbal guidance and rein-

forcement. During the last phase, “Reflect and repre-

sent”, both the child and the therapist function as a “cog-

nitive mirror”. The child must reflect on his/her actions,

organization and structure. With the assistance of the

therapist, the child tries to manage cognitive resources

more effectively and to establish/refine new/existing

strategies.

An example of practical management of a CM is

shown in Figure 5. The concept map must be a context

related (“what are we going to do today”) map. It has to

have familiar content. We must ensure that the child

recognizes the relationships between concepts (show

him/her an example of a relationship, and let him point

out a new one). And it is created by the child and thera-

pist together, that is, it is “client cantered”. After decide-

ing with the child upon the activities to engage, the child

elaborates on the activity verbally, make plans, draw

them and so forth. Then execute and reflect on his per-

formance.

The therapist has indirect control over the client’s mo-

tivation in choosing to learn by attempting to incorporate

new meanings into their prior knowledge, rather than

simply memorizing the concept or plan. CM can func-

tion as an easy-to-use tool that enables the therapist to

assess how the child is learning, where and how cogni-

tive errors are occurring, and to undertake an overall

evaluation of the learning strategies being taught.

2. CASE STUDY

2.1. “Yoav”-An 8 Year Old Boy with DCD

“Yoav” (the original name is kept confidential) an 8 year

old boy was diagnosed by a physician as having DCD.

He was referred to occupational therapy in order to re-

late to his organizational problems manifested in school

and at home environments. Yoav has normal intelligence

(IQ ≤ 85), no deficits in hearing and vision, and is

right-handed. He and his parents had signed a parental

consent and agreement to participate in therapy sessions

using “concept map strategy”, after they where ex-

plained about it. They also agreed to the presentation of

this case report, anonymously.

Yoav did not get previous or other present cognitive-

based treatment for his motor problems. Yoav was not

diagnosed with any neurological disorder, physical or

other sensory deficits.

3. METHOD

The tests that were administered during clinical intake

included the Movement Assessment Battery for Children

Test (M-ABC); [18] Movement Assessment Battery for

Children (Manual). Sidcup, Kent, UK: The Psychologi-

cal Corporation. Yoav scored less than the 15th percent-

tile, suggesting a DCD diagnosis.

3.1. Pre- and Post-Measures Used to

Evaluate Treatment

In order to evaluate Changes in the tasks performance,

identified by Yoav’s perspective of himself, we used the

Canadian Occupational Performance Measure (COPM)

[19]. Canadian occupational performance measure. To-

ronto, Ont.: CAOT Publications A. The COPM is a

semistructured interview designed to help clients iden-

tify problems in occupational performance. Yoav was

asked to identify two major tasks out of five to be

worked on during therapy. Using a 10-point scale, Yoav

rated the tasks on perceived performance and satisfac-

tion. The COPM was repeated after treatment to evaluate

perceived change in performance and satisfaction.

Baseline data for the two tasks that Yoav defined were

obtained prior to treatment. Performance baseline for

each task was obtained for three repetitions of each of

the two tasks. Yoav had chosen: 1. organizing his school

bag 2. Making plans for a complex activity (such as

studying for an exam, planning a trip). His performance

seemed unorganized, unplanned and unsatisfying for

him in terms of “end product” and self image.

3.2. Treatment

Over 10 individualized sessions, Yoav learned the con-

cept mapping strategy and then applied it in performing

better organization of trip planning and his school bag.

Using the Concept mapping strategy, Yoav had learned

to disassemble the task to its components and reorganize

the task sequence and process through problem solving.

3.3. Treatment Protocol

The protocol of learning and implementing the concept

map strategy in a chosen activity-planning a trip will be

presented here : the overall sessions were built according

to the phases of acquiring the visual strategy-“View the

activity”, “Evaluate and resolve”, “Execute and confirm”,

“Reflect and represent”.

Two first sessions were dedicated to learning the idea

of concept-mapping strategy. On this stage we exercise

different kinds of concept maps (family tree, human

senses etc.) and made sure that Yoav could add new

concepts or nodes and understood their relations, for

example-we drew the basic family tree and ask him to

add an extra horizontal node (in the same horizontal

level of hierarchylike a brother or sister) and a vertical

node (which is a different level in hierarchy like great

T. Ricon / HEALTH 2 (2010) 685-691

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grandmother above grandmother).

Session 3-5: gathering information for the trip plan to

the desert. Organizing information becomes more im-

portant as the amount of information increases. Yoav and

the therapist wrote down every trip planning component

(equipment, maps, dates, tracks, food requirements, en-

tertainment activities…) and made a graphic representa-

tion of them using computer flow charts (Figure 6).

Each time, adjustments were made. A new node or

new connectors were added to the map. Parts that needed

more information such as “tracks” were marked down

and led to a new information quest. The quest usually

yielded new nodes and new connectors, and usually new

problems to solve (delays in driving hours, shortage of

food and water supplies...).

Session 6 and 7: Defining responsibility domains ac-

cording to the map: After finalizing map demands and

domains, Yoav had to elaborate on it to his family mem-

bers and give each member a responsibility domain. This

presentation process strengthened his awareness and

shown his broadening knowledge. Members of the fam-

ily raised adequate questions.

This stage demonstrated the learning process-gather-

ing knowledge-remembering, recognizing and identify-

ing. Comprehension-interpreting, translating from one

medium to another, describing in one’s own words, or-

ganization and problem solving-selection of facts and

ideas, use of facts, analysis of rules and principles and

Synthesis i.e. creating an original product (the concept

map), forming a new ensemble using ideas that come

from the analysis process.

Sessions 8-10: executing the plan and evaluating its

success. On this phase, Yoav was requested to make

value decisions about his plan; develop an opinion and

judge decisions, and resolved ambiguity regarding the

trip plan.

3.4. Post Test

After the completion of treatment, The COPM was re-

administered to Yoav. All activities were videotaped for

future analysis.

4. RESULTS

Treatment effects were tested by comparing pre-test and

post-test scores. The COPM performance and satisfac-

tion ratings of Yoav were averaged across Yoav two

goals, yielding an average performance rating and an

average satisfaction rating. For both performance and

satisfaction, improvements from pre-test to post-test

were achieved (Table 1).

Figure 6. One of Yoav’s concept maps in prepa

ration and planning of the trip (translated from Hebrew).

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Ta ble 1 . COPM satisfaction and performance mean scores pre

and post intervention.

Score Pre-test M Post test M

COPM performance 4 8

COPM satisfaction 3 9

5. CONCLUSIONS

The purpose of this article was to demonstrate the use of

the concept map as a visual cognitive strategy in the

treatment of children with DCD, and it’s utility on as

shown on a case report.

Similarly to other cognitive approaches, the use of

concept mapping focuses directly on child-performance

issues, and engages the child as an active problem solver

and a significant partner in the therapy process. The re-

sults although limited to the case study and were done in

a limited pre-post analysis, are encouraging with regard

to the effectiveness of the concept mapping, and indicate

that further uses of concept mapping as a useful visual

strategy within the framework of intervention for chil-

dren with DCD remain to be studied.

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