Vol.2, No.7, 685-691 (2010)
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/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;
Received 13 January 2010; revised 20 January 2010; accepted 21 January 2010.
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
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
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).
Impaired Diagnostic Criteria
Figure 1. Morton’s (2006) basic causal model.
Diagnostic Criteria
om up
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-
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
Comorbidities Subtypes
Clinical Decisions
Evidence based
Ve rbal
No visual
problems Existing Visual
Figure 3. Clinical decisions deriving from the consequence level lead us to the use of cognitive approa-
ches and concept mapping.
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View Activity/
Evaluate and Resolve
Reflect and
Execute and
Figure 4. Phases of the constructed adoption of the visual
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.
analysis of
a Ladder
Climbing, time evaluation,
Success evaluation, etc.
Verbal feedback
Observing, verbal
describing action,
giving feedback,
Figure 5. An example of concept map used in therapy.
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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
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-
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.
2.1. “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.
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
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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.
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
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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