The contribution of motor functions to academic achievement in primary school: State of the art and future directions

Introduction

An increasing body of studies highlights the significant contribution of motor functions to academic achievement in school-aged children. This article intends to point out the role played by motor proficiency in the scholastic attainment of typically and atypically developing pupils who are attending primary school. Specifically, the review is organised into five main sections. First, the interplay between the development of motor and cognitive processes in infancy and childhood is delineated, then the motor and cognitive phenotype associated with a neurodevelopmental condition known as Developmental Coordination Disorder (DCD) is defined. A further section is dedicated to the illustration of the contribution of motor processes to the academic attainment of typically developmental pupils and their peers with motor difficulties or with DCD. Next, an overview of the studies that have examined the tools used to screen motor functioning and the resources that enable the empowerment of motor and cognitive behaviours in atypically developing pupils is undertaken. The final goal of this review is to discuss from a practical educational perspective the future directions that should be followed in school to support children with motor problems.

This review cannot be exhaustive but, despite space limitations, it intends to highlight the relevance of motor functioning for academic success and the need for adequate tools to identify and support pupils with motor impairments (including those who receive a diagnosis of DCD).

The contribution of motor development in early infancy and childhood

Beginning in early infancy, the development of motor skills plays a crucial role in the acquisition of a child’s general world knowledge. If a child initially learns to perform gross motor patterns (which imply the control of large muscles underpinning activities such as grasping, balancing, walking, jumping), he/she gradually acquires fine motricity skills which are driven by competences in fine motor precision (e.g., control of finger movements), visual-motor coordination (e.g., manual dexterity) and visuo-motor integration (e.g., control of action patterns performed by the small muscles of the fingers or hands in combination with visual perception).

Embracing the Piagetian perspective, during the sensorimotor stage, the action schema is the first meaningful tool used by children through physical activity (defined as ‘any bodily movement produced by skeletal muscles that results in energy expenditure’; Meeks et al., 2013, p. 240) to build their expertise about the surrounding world. According to Piaget (1953), in typical developmental conditions, toddlers during the first two years of life discover the physical properties (e.g., softness, robustness) of objects with which they interact, performing motor patterns progressively more complex and integrated (e.g., taking an object, sucking and biting it and finally throwing the item away). Thus, through the interaction with the world in very early infancy, children actively build the foundations of their sensory-motor intelligence which, in turn, is crucial for successive cognitive development. In this regard, infants who are particularly fast and proficient in the development of posture skills at the age of 3–5 months exhibit a larger receptive vocabulary when they are 10 and 14 months old (Libertus & Violi, 2016). A very important motoric developmental milestone is represented by the acquisition of the skills which enable children to navigate into the environment. Crawling and the onset of the upright locomotor activities (walking) allow toddlers to reach and visuo-haptically explore far objects (e.g., Kermoian & Campos, 1988; Walle & Campos, 2014). The transition from crawling to walking lets children free the hands and actively start to use them as tools to reach and manipulate the objects of the world and to extend their knowledge about the properties of the surrounding stimuli. From this perspective, by interacting with his/her environment, a child knows his/her world. Thus, this developmental achievement not only lets children infer the distance between objects but also favours the development of the ability to create and update haptic and visuo-spatial representations of the world that are progressively more complex (e.g., assuming both an allocentric and egocentric perspective during the process that drives the creation of internal representations of the stimuli).

The onset of upright locomotion also lets infants develop the capacity to share referential gestural communication with the caregiver (such as pointing to an object and then reaching it, while the toddler waits for feedback from the parent) and acquire the ability to use both receptive and productive language (such as more vocalisations accompanied by more gestures towards the objects). From a social perspective, the development of the ability to walk also favours understanding, for example, of a mother’s facial expressions as well as the use of intonation of social signals in order to modulate the environmental exploration (for a review, see Campos et al., 2000). In line with this, Diamond (2000) claimed that motor skills and cognitive functions are intertwined since they share the same brain structures (e.g., cerebellum, prefrontal cortex), as well as follow similar developmental pathways. This implies that motor and cognitive developmental trajectories are accelerated between the ages of 5 and 10 and then are prolonged until adolescence when the individual learns to manage and integrate fine motor patterns and to perform complex mental operations, such as the mental flexibly to manipulate information (e.g., imagining the performance of a sequence of motor behaviours to reach a certain goal) or the imagination of hypothetical stimuli transformations (e.g., imagining to act on familiar objects and anticipate future consequences of the motor behaviour). Recent findings suggest that the relationship between the development of motor and cognitive skills is bidirectional. A longitudinal study conducted during the preschool period highlighted that attention deficits at the age of 3 predicted the occurrence of motor skills delays when the children were 5–6 years old, whereas the development of proficient language skills at the age of 3 facilitated explicit motor learning two years later (Peyre et al., 2019). It has also been documented that between the ages of 4 and 16, fine motor skills are significantly correlated to fluid intelligence (the capacity to solve problems in novel situations and to think logically), to visual processing (the capacity to give visual sensors meaning by the conversion of psychophysical stimuli into internal representations) and to passive working memory (a component of the temporary memory system involved in immediate information retrieval). In contrast, bilateral body coordination (demanding the involvement of all the body components and the organisations of the extremities of both sides of the body) is significantly associated with fluid intelligence, while object control, such as ball skills, fluid intelligence and working memory (the ability to temporarily maintain and manipulate information during different learning activities) are weakly correlated (for a review, see van der Fels et al., 2015).

If motor skills are so crucial for the cognitive, social, and communicative development of the child, one can argue that atypical developmental motor trajectories may be predictive of cognitive delays in early lifespan stages. Support for this argumentation will be provided in the next section; that is, the focus will be centered on the description of the Developmental Coordination Disorder (DCD) phenotype, whereas the implications of motor proficiency on academic achievement and the interventions aimed at enhancing motor and cognitive abilities will be discussed in the remaining part of this article.

The developmental coordination disorder

The American Psychiatric Association (APA, 2013) defines the DCD as a neurodevelopmental condition that is ‘characterized by deficits in the acquisition and execution of coordinated motor skills and is manifested by clumsiness and slowness or inaccuracy of performance of motor skills that cause interference with activities of daily living’ (p. 32). In order to be diagnosed (usually not before the age of 5), a significant delay in the development of coordinated gross and fine motor patterns that is capable to interfere with the everyday activities appropriate for the chronological age must be detected. Furthermore, the onset of the DCD cannot be justified by the occurrence of some motor-related neurological conditions (e.g., cerebral palsy), intellectual disability or visual impairment. According to Lee et al. (2019), the prevalence of high-risk DCD in primary school children (1.09%) as based on the application of the DSM 5 criteria (APA, 2013) is consistent with that estimated by a single objective assessment of motor coordination performed through standardised tools such as Henderson et al.’s (2007) Movement Assessment Battery for Children.

Since early infancy, children with DCD may show delayed achievement of motor milestones, such as crawling, sitting and walking, and they may be slowed in the development of complex motor patterns necessary to promote their autonomy in everyday life, such as buttoning clothes, using zippers and appropriately using utensils to eat meals in a coordinated fashion. Overall, DCD is quite stable and persists in adolescence and adulthood in approximately 30–70% of children (Scott-Roberts & Purcell, 2018), causing problems in daily activities (e.g., time management planning, folding paper sheets, riding a bike) and in coping with job demands (e.g., taking notes, learning complex motor routines). Thus, older children, adolescents and even adults may appear particularly clumsy, such as bumping into objects and slow or inaccurate in performing different tasks, such as playing ball games, carrying out self-care activities and driving. According to APA (2013), males are more subject to the occurrence of this condition; that is, the male/female ratio is estimated between 2:1 and 7:1. It must be noted, however, that although some authors recently documented a greater proportion of male pupils with DCD (e.g., Sujatha et al., 2020), the gender effect has not been consistently found in further epidemiological research (e.g., Amador-Ruiz et al., 2018; Lee et al., 2019).

Overall, there is evidence that 7–12 year old children with DCD report specific issues in the ability of smooth pursuit of an object (e.g., visually tracking a moving stimulus) which, in turn, implies the ability to predict the trajectory of the moving item and the skill to plan and act toward the object, adapting, when necessary, the trajectory of the motor patterns (Sumner et al., 2018). Perhaps because of their specific detriments in predictive control skills, pupils with DCD are described as impaired in motor planning (Pratt et al., 2014) and in the online adaptation/updating of movements (Ruddock et al., 2015). The atypical motricity associated with DCD seems to be strictly related to the occurrence of selective deficits in active visuo-spatial working memory and in central executive functions (defined as controlled and conscious cognitive skills implicated in the monitoring, regulation and control of behaviour; Diamond, 2000), such as response inhibition, planning, processing speed, set shifting and self-regulation (e.g., Leonard et al., 2015; Pratt et al., 2014; Sartori et al., 2020). Concerning the latter, the emerging evidence (Jokić et al., 2013) has well-established that pupils with DCD exhibit a smaller and less effective repertoire of self-regulatory mechanisms (e.g., goal setting, monitoring, adapting behaviours, self-evaluation, inhibition of irrelevant reactions or of socially inadequate motor responses) that are necessary to satisfy the task demands and to modulate one’s responses in order to reach certain aims (Pintrich, 2000). This would explain the difficulties met by children with DCD in performing even simple motor activities (i.e., including motor learning) and in transferring motor expertise to new situations as well as in modulating the emotional outputs (for a review, see Jokić & Whitebread, 2011). Despite this, the findings concerning the profile of executive functions in DCD are mixed, depending upon the nature of the tasks used in the studies (e.g., distanced in function of the degree of motor behaviours encompassed) and the type of executive function examined. In this regard, Leonard et al. (2015) pointed out that individuals (i.e., children and adults) with DCD are particularly impaired in motor planning tasks that require, for instance, reaching or throwing an object, whereas findings concerning deficits in the planning of complex motor sequences implicated in games aimed at reaching an end goal are less consistent (e.g., Pratt et al., 2014; van Swieten et al., 2010). Children with DCD are also less accurate (have a greater number of errors) or are slower than their typically developing peers in performing inhibition tests (Mandich et al., 2002; Michel et al., 2011; Pratt et al., 2014) and switching tasks which implicate cognitive flexibility resources (Michel et al., 2011, 2018). The strict relationship (or overlap) between motor and executive function deficits in children with DCD seems to be justified by the fact that some of the underpinning etiological neural factors, such as alterations in the circuits involving the prefrontal cortex and cerebellum, are shared (Diamond, 2000).

From an applied perspective, it has been suggested that the constellation of central executive issues (e.g., planning) with motor impairments implies lower manual dexterity and scarce visuo-motor coordination skills in everyday life (e.g., using scissors to cut a piece of paper, folding a sheet, conducting self-care tasks such as putting on clothing), such that it even reduces the opportunities for children with DCD to interact with their peers by the involvement in physical team games requiring, for instance, balance and ball skills (Poulsen et al., 2007). Therefore, the reduced opportunities of physical activity associated with a scarce self-regulation imply both fewer occasions to enhance motor learning and the increased risk of emotional difficulties, such as low self-esteem, and social isolation in school-age children with DCD, especially in boys (Green et al., 2011). It has also been documented that even preschool-aged children at risk for DCD report emotional regulation problems, including internalising behavioural difficulties (withdrawn, depressive, anxious, etc.) and externalising behavioural difficulties (aggression, attention, etc.; Rodriguez et al., 2019) which, in turn, can disrupt their interaction with others. There is also evidence about the pervasive persistence of the impairment in different quality of life domains, such as inadequate self-care, scarce engagement in social and skill-based leisure activities and lower life satisfaction, of individuals with DCD, especially when further comorbid conditions like Attention Deficit Hyperactivity Disorder occur (for a review, see Zwicker et al., 2013).

With the set of cognitive difficulties in mind, such as reduced processing speed and deficits of working memory and central executive function, along with motor difficulties that characterise the DCD phenotype, it is not surprising that, according to the APA (2013), this neurodevelopmental condition negatively impacts the academic life of approximately 5–6% of 5–11 year old pupils. According to a recent body of epidemiological literature, the prevalence rate of DCD can be biased by the ages of sampling; that is, a significant increase in DCD occurrence has been reported (Delgado-Lobete et al., 2019) from the ages of 6–7 (4.9%) to 8–9 (11.7%). It has also been argued that when the severity of this neurodevelopmental condition is mild or moderate, a variable and even greater proportion of school-aged children can satisfy the criteria for a diagnosis of DCD. Lee et al. (2019) evaluated that mild DCD occurs in approximately 9.85% of Korean pupils, a prevalence rate consistent with that reported in a Spanish sample (9.9%; Amador-Ruiz et al., 2018) and in a Greek one (10.8%; Kourtessis et al., 2008). In contrast, the prevalence rate seemed to be lower in the Indian school-aged population (3.8%; Sujatha et al., 2020) and significantly higher in the English population (13.7%; Schoemaker et al., 2013). Differences in DCD prevalence across distinct cultural contexts have been attributed to methodological causes (such as type of screening tools used for the assessment, age of the participants in the studies, criteria used to identify children at risk for DCD or with motor impairments) and cultural causes (for a review, see Lee et al., 2019).

Since motor difficulties are strictly related to the development of different cognitive processes, including selective executive functions, it seems relevant to illustrate the consequences of motor deficits at school. Therefore, the role of motor functioning on learning performance of typically motoric developing pupils attending primary school and the scholastic consequences of the occurrence of DCD and of milder motor problems will be clarified in the next section.

Motor proficiency and academic achievement in pupils with and without DCD

A growing literature suggests that academic achievement can be selectively associated with motor proficiency in pupils attending primary school. For instance, Macdonald et al. (2020) documented that during the first year of primary school, fine motor integration skills predict the performance of mathematic skills, for example, numerical operations and math reasoning, and reading skills, for example, decoding words and pseudowords. A further investigation conducted with 5 year-old kindergartners suggested that fine motor coordination skills indirectly predicts mathematic proficiency (e.g., number awareness, geometrical knowledge, measurement skills) via visuo-motor integration at the end of the first grade in primary school (Kim et al., 2018). Moreover, positive and bidirectional associations occur between mathematic gains and visuo-motor-integration skills; that is, changes in visuo-motor efficiency over time predict later changes in mathematic performance and vice versa (Kim et al., 2018). Consistent with this, there is evidence that fine visuo-motor coordination efficiency in 5–6 year-old kindergartners directly and indirectly via executive functions (updating, inhibition, set shifting) predict academic learning (addition/subtraction operations, text comprehension and reading speed skills) in second grade (Oberer et al., 2018). The significant mediational and indirect role of executive functions (updating, inhibition, set shifting) in the relation between motor coordination (jumping) and academic achievement (assessed in terms of a composite score of the efficiency in mathematics, reading and spelling) has also been found in 10–12 year-old children (Schmidt et al., 2017).

Different hypothetical mechanisms have been proposed to account for the links between motor skills, mathematics and early literacy attainments but at present the nature of this association is unclear. It has been argued that in numerate societies, preschool-aged individuals spontaneously use their fingers to count and to represent numerosities (finger arithmetic; Butterworth, 1999); that is, children learn to control and coordinate the movements and positions of their fingers and hands to express quantities by linking the finger movement to the quantity concepts, to do simple non-symbolic algebraic operations and even to express a judgement about the magnitude of small sets of items by watching their hands perform the judgement (e.g., Gashaj et al., 2019). Following this, the fine motor ability necessary to perform the finger-counting method is considered the tool driving the child to develop the advanced mathematics skills underpinning abstract number calculation, an ability that is learned in formal schooling. This would explain why 5 to 7 year-old children who are more proficient in performing the finger motor schemas to represent quantities are also later more accurate in solving simple arithmetic problems (Penner-Wilger et al., 2007). Additionally, according to Cameron et al. (2016), the use of fine motor skills gives children the opportunity to practise mapping visual representations to mathematics or literacy concepts, such as drawing letters with different tools (e.g., pencils, crayons) to recall their shapes, sorting stimuli by the application of mathematical concepts, such as numbers (creating groups of four), size (small vs. big), shape (e.g., circles, squares), or cutting out shapes. Becker et al. (2014) speculated that fine motor skills are strongly associated with emergent literacy and early mathematics, such as understanding quantities, because the motor patterns driving the copying and writing of numbers and letters since early childhood are used, first, to geometrically represent and memorise the visuo-spatial features of those stimuli (for example, shape, presence of inclined segments), then the child associates letter or number sounds to the corresponding shapes and, finally, he/she learns to apply the decoding rules, such as grapheme/phoneme matching, for reading and writing.

There is also evidence that gross motor skills, such as the organisation of movements, are massively engaged in socially oriented sports and games (Skinner & Piek, 2001) and, therefore, as reported earlier, an inadequate development of the former skills precludes correct social and self-efficacy development throughout the school years.

A further line of research conducted with children affected by DCD showed that fourth graders with an inappropriate gross motor and motor coordination skills development (e.g., balancing, jumping, hopping on one leg) exhibited lower language and mathematics performance than typically developing peers (Lopes et al., 2013). In order to perform a numerical operation, one must engage sustained attention to focus on the task for a certain period of time, temporarily hold information while inhibiting irrelevant stimuli and shift the attentional resources between related but distinct aspects of the problem in order to perform the operation (e.g., Clements et al., 2016). Prunty and Barnett (2020) reported that children with DCD are slower in producing legible handwriting compared with typically developing peers; that is, the former group tends to include more within-word pauses (indicating that the transcription skills are less automatic and fluent, perhaps because of the visuo-motor coordination difficulties) and exhibit more letter production errors (letter reversal, such as ‘d’ instead of ‘b’), than do controls.

An epidemiological investigation carried out by Margari et al. (2013) with atypically developing Italian pupils pointed out that DCD significantly occurred in both a subgroup of children with specific learning disabilities (dyslexia, dysgraphia and dyscalculia) and in a subsample of pupils with some Learning Conditions Non-Otherwise Specified (defined as a neurodevelopmental condition referring to a learning disorder including reading, written expression and number processing impairments, as well as non-verbal learning deficits). Similarly, significant motor coordination impairment has been reported elsewhere in 10–26% of children with dyslexia in Italy (Gagliano et al., 2007; Stella et al., 2009) and it has been hypothesised that the comorbidity between DCD and dyslexia could be justified by an abnormal development of the cerebellum which is responsible for the execution of overlearned cognitive tasks such as reading(Fawcett & Nicolson, 2004). Thus, it has been argued that perhaps the atypical development of the cerebellum could cause the inadequate motor control driving the phonological articulation following the conversion of the graphemes in the corresponding phonemes.

Concerning the comorbidity between DCD and Learning Conditions Non-Otherwise Specified, Poletti (2019) highlighted the (at least) partial overlap between DCD and the Non-Verbal Syndrome (also called visuo-spatial or non-verbal learning disability). This is a specific learning disorder characterised by proficient verbal abilities (e.g., vocabulary) contrasted with evident deficits in the visuo-spatial domain (Rourke, 1995). Children exhibiting visuo-spatial deficits perform poorly in tasks that demand visuo-motor coordination, visuo-constructive skills, the temporary maintenance of visual (e.g., shape) and spatial relations among stimuli or the active mental manipulation of two-dimensional and three-dimensional configurations, as well as in perceptual and planning tasks that require the copying of a geometric model or the matching of similarly oriented lines in space. Thus, pupils with Non-Verbal Syndrome tend to perform very poorly in academic subjects such as natural sciences, geometry and geography. Considering the concurrent involvement of motor and visuo-spatial skills in many formal and informal educational attainments, children with visuo-spatial learning disability also appear less proficient (e.g., clumsy) in activities demanding gross and fine motor control, such as team sports (for a detailed review of this condition, see Cornoldi et al., 2016). According to Margolis et al. (2020), one of the criteria used to diagnose the Non-Verbal Syndrome is the detection of specific deficits in at least two different domains, including fine motor skills, social functioning, visual executive functions and math achievement. Cornoldi et al. (2016) considered the occurrence of fine motor impairments together with social problems or poor academic achievements in disciplines demanding visuo-spatial skills as necessary conditions for the diagnosis of non-verbal learning disability. Thus, one can wonder whether DCD and the Non-Verbal Syndrome are part of the same condition. According to Poletti (2019), it is urgent to disentangle the partial overlap between visuo-spatial learning disability and DCD to clarify whether it is possible to isolate specific primary clinical symptoms that characterise the former learning disorder or whether the Non-Verbal Syndrome can be embedded within the recognised DCD profile. At present, definitive conclusions are lacking and to the best of my knowledge, no investigations have been performed comparing the cognitive phenotypes of children with DCD with that of pupils with non-verbal learning disability.

From a clinical viewpoint, this evidence suggests that the partial overlap between DCD and further developmental conditions can complicate the identification of the cognitive phenotype that characterises the DCD condition, and this can represent an obstacle to its early diagnosis. Therefore, future research is necessary to shed light on this issue.

Testing motor functioning and treating school-aged pupils with motor difficulties

As reported earlier, a growing body of longitudinal data documents that motor proficiency in kindergartners is associated with cognitive development and academic achievement. Overall, this suggests at least three implications. First, the early assessment of motor skills is crucial to detect atypically developing children at risk for unsuccessful academic experience. Secondly, systematic screenings which include the motor skills assessment should be encouraged even in kindergarten in order to identify possible children with DCD or milder motor impairment patterns. Concerning this, in their systematic review, Asunta et al. (2019) stressed the need to provide specific observational screening tools (e.g., questionnaires, scales) for teachers because it is in the scholastic environment that motor difficulties are often highlighted in everyday activities (e.g., self-care, the use of scissors, tasks related to artwork) and learning achievement. Embracing a multi-stage approach, a preliminary motor efficiency screening based on the use of questionnaires should be recommended even for kindergartners. However, according to Asunta et al. (2019), at present only a limited pool of observational instruments for parents (5 well-validated questionnaires) and teachers (6 instruments) have been developed and culturally adapted for identifying 3–15.6 year-old children with DCD. Asunta et al. (2019) also highlighted that the feasibility of the psychometric properties of the available screening tools for the identification of suspected children with DCD has not been properly examined. Although ‘there is no gold standard tool to assess children with DCD’ (p. 2) in population-based screening, the authors recommended to first clarify to parents and teachers that the goal of the screening is the identification of children with DCD (in order to implement specific psychoeducational interventions for these pupils) and then to select a set of observational tools validated for that purpose and that are robust from a psychometric perspective that allows the collection of information about the motor efficiency of the child exhibited in different ecological environments (motor behaviours can change in different contexts). The authors also recommended that the raters be properly trained about DCD and the role played by motor functioning in childhood prior to proposing the observational tools, because this practice reduces possible errors in the assessment. Among others, the Developmental Coordination Disorder Questionnaire (Cairney et al., 2008) represents a useful tool for the identification of pupils with motor impairment. This questionnaire is the tool most adapted to different languages and it presents more psychometric testing (although the inter-rater reliability and face validity need to be tested) than other valid questionnaires, such as the MOQ-T tool for 5–11year-old pupils (for a review, see Asunta et al., 2017).

Another implication of what has been discussed so far is that the implementation of combined interventions to empower cognitive functions (e.g., executive functions, visuo-spatial working memory) and motor functions of children at risk for motor deficits or with a diagnosis of DCD is crucial in order to boost different aspects of their life, including their academic learning. At present, different types of interventions have been developed for children with DCD, some of them aimed at empowering only motor skills (e.g., balance, manual dexterity), while others intend to also be effective in terms of academic learning (e.g., writing, mathematics). However, the provided findings do not so far allow consistent conclusions to be drawn about which treatment is the most effective in improving motor functioning and related performance in children with DCD. Smits-Engelsman et al. (2013) highlighted the scarce efficacy of the process-oriented approaches (e.g., sensory integration therapy, kinaesthetic training), according to which the motor skills problems of children with DCD are due to specific deficits in a given body part or sensory process; it is therefore assumed that by performing certain activities, the motoric problems are controlled. In contrast, Smits-Engelsman et al. (2013) recommended the use of task-oriented interventions (treatments focused on the training of specific motor skills by specific difficult tasks, paying great attention to those aspects of the task causing motor difficulties in the child) with children with DCD. There is also evidence that 7–10 year-old pupils with DCD can benefit from a short-term gaze training (e.g., 4 weeks) based on the use of videos and physical exercises, such as catching a ball, developed to enhance motor coordination (Słowiński et al., 2019). Cheng et al. (2019), however, documented the lack of effectiveness of a 12-week neuromuscular training designed to empower the balance of 6–9 year-old pupils affected by DCD via a series of motoric exercises based on the use of a roller board. Within the task-oriented approach, imagery trainings (alone or in combination with observational interventions) also seem to be promising. For instance, Marshall et al. (2020) showed the effectiveness of an intervention based on the observation of videos showing the performance of some motor tasks accompanied by concurrent motor imagination (mental rehearsal) of that action for the empowerment of eye-hand coordination in 7–11 year-old children with DCD. However, future studies are needed, since the research using the imagery approach is still limited.

Smits-Engelsman et al. (2013) also reported the effectiveness of the CO-OP approach for the treatment of children with DCD. This is a child-centred intervention based on the use of cognitive-behavioural modification (e.g., verbal self-instruction strategy) and problem-solving strategies which enable children to reflect on their performance and to understand the reasons for their unsuccessful output, stimulating them to apply new or modified action plans to correct their performance. Moreover, from an academic achievement perspective, handwriting task-oriented treatments developed to improve fine motor control and handwriting speed of children with DCD have been successful (e.g., Baldi et al., 2015).

Finally, recent findings have highlighted the promising effectiveness of game-based interventions for children with DCD, which are performed using electronic devices such as Wii Fit or PlayStation. The use of electronic tools has the specific advantage to train motor functions in a playful fashion and in a familiar environment (home), thereby boosting the child’s motivation to attend the training. There is evidence (Hammond et al., 2014) of the effectiveness of a 4-week intervention in which 7–10 year-old pupils exhibiting movement difficulties (including children with a diagnosis of DCD) participated in a supervised Wii Fit game (children could choose among nine games) enhancing balance and coordination for 10 minutes three times a week. This training was particularly successful in empowering not only balance and coordination, but also related motor functions, such as motor precision and visuo-motor integration, suggesting a clear transfer effect to untrained motor skills. Moreover, the motivation of the children to attend the training through the Wii games was reinforced; that is, their parents reported less emotional and behavioural problems after the intervention, indicating a significant improvement of the self-regulatory processes of the trained children. Despite these encouraging outcomes, the positive effects were not maintained less than three months after the end of the treatment. Further, Ashkenazi et al. (2013) consistently documented the effectiveness of a virtual reality game-based training provided via electronic devices. This intervention was successful in enhancing motor performance, self-efficacy, motivation and emotional self-regulation of a group of children with DCD. However, according to Ferguson et al. (2013), task-oriented interventions are more effective in terms of functional abilities, improvement in balance and manual dexterity than game-based trainings for children exhibiting DCD.

Future directions

DCD is a neurodevelopmental condition not yet well defined and treated. It is plausible to hypothesise that the underestimation of this neurodevelopmental condition can be attributed to the fact that the definition (type and level of severity) of the core symptoms and of the criteria that allow differentiation between DCD and milder motor dysfunctions or from further neurodevelopmental disorders (e.g., Non-Verbal Syndrome) is still lacking. Following Poletti (2019), one ambitious goal for the future is to provide a better definition of the diagnostic criteria to detect DCD, identifying, if possible, the specific clinical features that allow this disorder to be distinguished from other neurodevelopmental conditions, such as the non-verbal learning disability (Cornoldi et al., 2016; Rourke, 1995). Future research could provide evidence by conducting longitudinal studies with children affected by DCD who do or do not present comorbidity with the Non-Verbal Syndrome. Better specification and definition of the criteria that support the diagnosis of DCD will also allow to distinguish the cognitive and motor repertoire that characterises the DCD condition from the cognitive and motor phenotype associated with milder motor deficits.

From an applied viewpoint, since the diagnosis of the DCD is underestimated, screening activities in kindergartners and school-aged children should be encouraged, especially among very-preterm individuals who are particularly at risk for motor impairments (Ouellet-Scott et al., 2020). As suggested elsewhere (Asunta et al., 2019), in order to promote the early identification of children with motor difficulties or DCD, it is first of all necessary to develop experimentally robust screening tools, such as observational scales and questionnaires, designed for teachers and parents. Future research is needed to validate instruments for the assessment of motor skills which show high sensitivity (the ability to detect the occurrence of DCD), high specificity (can correctly identify children without DCD) and that present further crucial psychometric properties (e.g., inter-rater reliability, face validity). If adequate instruments to detect DCD features will be available in different cultural contexts, then they can be consistently used in educational settings.

Finally, greater attention needs to be paid to the research on the implementation of robust and long-term effective protocols designed to empower motor proficiency and academic achievement, for example in writing and math of school-aged children with DCD or mild motor difficulties. The use of new technologies (e.g., the Wii device), perhaps in combination with a cognitive-behavioural approach, could be promising for children with DCD, especially for those showing further comorbid conditions (e.g., ADHD). In addition, the long-term effects of treatments boosting self-regulation, self-efficacy and social functioning are also needed. At present, no systematic studies have been conducted to examine the effectiveness of treatments for improving participation outcomes (a crucial indicator of wellbeing) of children with DCD (O’Dea et al., 2020). Therefore, future research is needed to provide evidence about these issues.

Embracing an educational approach, school and educational psychologists should be actively involved in the development and validation of psychometrically adequate screening tools to be used for the assessment of motor competences in kindergarteners and school-aged children. This will favour both the early identification of children experiencing motor impairments and the prevention of consequences from possible emotional difficulties (e.g., internalising and externalising symptoms) on their quality of life. Furthermore, school psychologists should help teachers to adapt the educational materials and activities to meet the special needs of pupils with motor impairments or DCD (e.g., providing extra time to perform the tasks, setting short-term goals, breaking a complex activity down into a sequence of steps and suggesting the use of specific materials, such as papers having widely spaced lines or pencil grips to help children who have difficulties in pencil grasp and pen pressure). Additionally, school psychologists should support teachers in classroom management of the emotional problems associated with DCD, for example, internalising symptoms, as well as the social problems, for example, relationships with peers. School psychologists could also contribute in coaching teachers to favour the creation of a more enabling environment that promotes the learning of motor skills, for example, suggesting the use of observational scales to point out if the posture of the child at the desk is correct, if his/her distance from the blackboard is appropriate and if he/she can independently perform motor activities requiring the use of scissors.

The involvement of school psychologists must also be encouraged for the implementation of the most appropriate psychoeducational interventions directed to pupils with motor deficits or with DCD. The clinical signs (severity, types of symptoms, impact on daily life, etc.) shown by pupils with motor difficulties or who have received a diagnosis of DCD can be very heterogeneous, and they can, not rarely, occur with other conditions, such as ADHD. Therefore, the implementation of evidence-based interventions, such as using task-oriented approaches, and individualised interventions that address pupil impairments should be preferred by school psychologists, who must also evaluate the effectiveness of the treatments. From this perspective, the school psychologist can actively strengthen the link between teachers and parents, coaching them (e.g., providing better information, support) on how to scaffold the child with motor difficulties in order to favour the development of his/her potential motor, cognitive, emotional and social learning (e.g., Novak et al., 2012).

Conclusions

This review examined the literature concerning the impact of motor functions on academic achievement of typically and atypically (pupils with motor impairments or with DCD) developing school-aged children. Moreover, this article intended to shed light on the efficacy of psychoeducational interventions for enriching motor and cognitive functions in pupils showing motor difficulties or who have received a diagnosis of DCD. A further aim was related to the need of pointing out the urgency of experimentally robust tools for the early detection of atypical motor developing conditions (DCD and situations characterised by milder motor difficulties).

The existing body of studies highlights the interplay between the development of motor and cognitive functions since early infancy, suggesting that the acquisition of locomotion allows infants to explore their environments and to develop a gradually more complex knowledge about the properties of the surrounding objects with which they interact. The onset of motor proficiency involving both the upper and the lower extremities (once children can walk, they can use the hands to manipulate and interact with the objects) enriches children’s experiences and, therefore, their knowledge about the world and about their own competences. In short, action is strictly related to the development of cognitive processes which impact the acquisition of motor skills during childhood.

From a methodological viewpoint it should be noted that in the current literature, an explicit distinction among terms such as ‘motor problems’, ‘motor difficulties’, ‘motor impairments’ and ‘motor clumsiness’, on the one hand, and DCD symptoms, on the other hand, is lacking, and these terms are often used interchangeably. This generates confusion and does not help to define the criteria that would allow the differentiation of DCD from milder motor dysfunctions. Recent studies have pointed out the validity of several inventories for the early screening of motor functions in kindergarteners and pupils who attend primary school. Despite this, the literature elucidates the heterogeneity of the protocols used in different cultural contexts to identify children with and without motor impairments or with DCD (use of the APA’s criteria vs. use of single objective assessment of motor functioning). Direct consequences of this are the lack of cross-cultural comparisons of the dysfunctional motor profiles and the wide range of prevalence rates of motor disturbances reported in the epidemiological research. Assuming a clinical practice viewpoint, this stresses the need to provide more specific and detailed criteria for the differential diagnosis of milder motor deficits, DCD and possible concurrent conditions (e.g., Non-Verbal Syndrome), as well as the need to define the best tools to diagnose motor impairments and DCD.

As was illustrated earlier, the contribution of motor functions to academic achievement is very relevant; nonetheless, current literature points out that the involvement of motor processes in primary school performance has not been extensively investigated either in typically developing pupils or in children with neurodevelopmental conditions like DCD.

This review has also discussed the literature concerning the treatment of school-aged children with motor difficulties or with DCD. It has been argued that the combination of traditional (e.g., pencil-and-paper) psychoeducational interventions with electronic devices could be promising because the computer-based treatments are very useful in motivating the users and in promoting the enhancement of self-regulation. However, further research is needed to shed light on the long-term effects of these psychoeducational instruments and on their impact on the quality of life of children with DCD or motor difficulties. Longitudinal studies conducted with individuals at risk for motor delay (e.g., preterm children) from early infancy to adulthood could be helpful in clarifying the developmental motor trends across lifespan. To the best of my knowledge, this literature is still lacking at present; therefore, future research investigating these aspects is also necessary.