Is EPIC suitable for children with DCD/Dyspraxia?

This blog post was written by Sinead Rhodes, Claire Tai, Peter Wu and Penny Shutt

We have been busy working on a pilot study to see if EPIC activities would be suitable for children with Dyspraxia/Developmental Co-ordination Disorder (DCD). A pilot study is a small-scale study with a small number of children taking part – in this case – to see if a programme would be suitable for children with DCD. DCD is a common condition that affects movement and coordination.

Why would activities focused on thinking difficulties be relevant for children with DCD when the condition is characterised by fine and or gross motor skill difficulties, such as tying shoelaces and cycling a bicycle?

Research with children with DCD is not as extensive as for other neurodevelopmental conditions such as ADHD and autism, but the evidence available suggests that these children also have difficulties in what is known as ‘executive functions.’ These are processes such as using thinking skills to remember information, how you plan and organise tasks in your mind, being able to control responses, and using your attention flexibly.

A growing number of studies suggest that these thinking processes are an area of difficulty for children with DCD. Children with the same condition can differ in the set of executive function difficulties they present, and the EPIC approach focuses on helping a child to understand the specific aspects they need support with. For one child it may be memory and planning, and for another it could be being able to think flexibly and control their responses. What is important is that the child and their support network (especially their parents and teachers) understand the child’s particular set of difficulties. This is known as ‘Psychoeducation’ (i.e. the ‘P’ in EPIC!)  

Once everyone understands the child’s particular thinking difficulties, we can then look at appropriate strategies to support them. Sometimes what we call ‘internal’ strategies can be useful. Examples of internal strategies include rehearsal, mental imagery, and chunking (also known as grouping) information to help remember information.

‘External’ strategies can also be useful — such as making a mind map to plan out writing a story or using a mini-whiteboard or planner to identify steps in a task and their best order. Another strategy is to simply practice these strategies through playing games like ‘Simon Says’ as a way to practice holding back responses.                     

In this pilot study, we carried out an 8-week 16-session EPIC programme with primary school aged children with DCD, a parent and a teacher. Children completed thinking and educational tasks before and after participating in the intervention, and parents and teachers completed questionnaires about their child’s symptoms and behaviour. The study identified that the EPIC programme was feasible and acceptable for these children, parents and teachers. While the small numbers preclude statistical analysis, we can see that children made gains in the thinking skills that were the focus of the intervention delivery such as planning and memory.

Most importantly, the children and teachers were interviewed before and after they took part in the EPIC programme. Children showed improved understanding of DCD following intervention involvement. Prior to taking part, they referred to the movement aspects of DCD but in the interview afterwards they showed awareness of DCD being associated with thinking skill differences. They also showed an awareness of a greater range of strategies that could be used to support their thinking skills.

Teachers similarly showed a broader understanding of DCD in the range of thinking skills they associated with the condition after participation in the programme. They also showed an awareness that these thinking differences may not just impact learning, but also, for example, social relationships.  They, similarly to the children, showed an awareness of a greater range of strategies that could be used to support their thinking skills. Teachers expressed that participation helped not only the child taking part in the research study but also other pupils benefitted because they were able to use some of the strategies they learned with other pupils. They witnessed the pupils putting these into practise as a result of the ongoing dialogue with the teacher around when a strategy might come in useful and which one.

This study shows that EPIC activities can potentially be useful for children with DCD. This condition has been considerably overlooked in relation to other conditions like ADHD and Autism, despite being more common.

It is critical that every child is understood and supported in relation to all the difficulties they have that influence their learning, social relationships and wellbeing. The learning we have from this pilot study is that the support and understanding from the resources and use of EPIC activities has been a step towards identifying this. Use of the EPIC programme has helped to address unmet needs that have wide-reaching implications for an under-recognised population. That is epic! 

Our free downloadable booklets can be found here: https://www.ed.ac.uk/clinical-brain-sciences/research/epic-edinburgh-psychoeducation-intervention/epic-resources

This study was funded by the RS MacDonald Seedcorn fund.  

Visual production credit: photographer sturti via Getty Images

Co-production of the EPIC programme with children, parents, education and clinical professionals

The EPIC programme aims to improve thinking, learning and behaviour in neurodivergent children. EPIC focuses on understanding and supporting thinking difficulties, through psychoeducation and use of strategies. This understanding and support can help improve everyday life for neurodivergent children at home and school. The principles of EPIC such as a transdiagnostic individualised approach were developed from a considerable body of research evidence. Alongside that research evidence though, the voices of young people, their parents/carers and the health and education professionals who support them, have been critical to EPIC. Their voices have played a central role in how these principles work in practice and in designing and shaping the resources used in EPIC. This infographic summarises the process by which the EPIC programme was shaped and refined.

Children and young people are at the centre of EPIC. If we want to truly understand a condition it is vital to include the perspectives of these young people themselves. Members of our team were involved in a research priority exercise a few years back (a very systematic exercise called the James Lind Alliance priority setting partnership). The outcome of this exercise which was produced by young people with learning difficulties, their parent(s), and professionals who support them was a list of the Top Ten questions they wanted answered by research. The number 1 prioritised question was ‘what knowledge, skills and training do educational professionals need to identify the early signs of learning difficulties and provide optimal support for children and young people affected to help them achieve the best possible outcomes?’ This highlights the need for research to support teachers in understanding how best these young people can be supported at school. We followed this up with interviews with neurodivergent children to find out what children themselves understood about being neurodivergent and the strategies they found useful at school. At every stage we have involved children and young people informally and formally to identify the kinds of supports they would find useful. One of the key findings that came out of this was that neurodivergent young people feel they can engage best when tasks and activities are personalised to their interests. Some of the examples included using lego to do number work or using crafts to learn about thinking skills such as planning and breaking tasks down into steps. Children have also given us huge insights into strategies they find helpful. Many of these are quite practical – such as being able to use fidget toys, and taking movement or sensory breaks.

Teachers and other education professionals have also influenced the shaping of the EPIC programme across interviews and workshops. In a formalised set of interviews, teachers gave us their insights into strategies they find useful in the classroom. Very importantly, they identified that using a child’s strengths to overcome their difficulties can be a particularly good approach such as using a child’s creativity to complete a language task. In a series of workshops, teachers worked with us to design booklets that would focus on understanding and supporting children with ADHD and DCD. More recently, we have had teacher involvement in designing our new booklet focused more generically on neurodivergent children (so it will be suitable for children on waiting lists and those who don’t end up getting a diagnosis). This involvement has been essential to make sure that resources we develop are useful and appropriate to the context the child is in. Teachers have consistently commented on how neruodivergent children with the same diagnosis can differ greatly from one another in their individual strengths and difficulties. They have also emphasised that a strategy that is successful with a child one day may not work the next with the same child and similarly may not work for all children even if they have the same diagnosis. As a result we have developed the booklets in the style of ‘pick and choose’ the areas of strengths and difficulties a teacher or parent/carer wants to focus. The booklets also have a range of strategies to draw on and there is an emphasis on being flexible – from using a ‘chunking’ technique to support memory with one child to using an external item like a mini whiteboard to achieve the same goal with another child.

Parents and carers have also been critical to the development of the EPIC programme and the resources we use. Across 3 research studies we have conducted interviews with parents to identify the issues they need support with and the strategies that best work. At the moment we are developing a ‘self-delivery with support’ version of the EPIC programme that parents and teachers can do with their child / the child in their class with support from the team. Ultimately the idea is that this will be an empowering approach with parents leading the way on identifying their child’s strengths and difficulties and ways to use EPIC activities and resources to support the needs of their individual child.

Clinicians have also play a key role in the development of the EPIC programme. Many of our researcher led sessions in our studies were run by CAMHS psychiatrists with involvement of other health professionals. They also provided regular feedback on the development of resources and for example providing feedback on the need to design booklets that are generic so they can be given to children on waiting lists and be useful for those who end up not getting a diagnosis. Ultimately, if we want to truly understand neurodivergent children and effect change for them then all of those who support and care for them need to be involved in translating research evidence into effective practices.

Thinking skills and learning maths in children with ADHD

Successful maths learning is linked to a range of skills involving processing of numbers. When a child finds learning maths tricky these number skills are often focused on as the source of the difficulty. Learning maths also relies on having good thinking skills such as efficient memory. Much less focus though has been given to the importance of these thinking skills. Understanding this relationship is particularly important for helping children with ADHD learn maths as many of these children show difficulties with these thinking skills.

We recently published a systematic review, which is a ‘study of studies’ on this topic. Our review looked at published papers of studies that had researched the relationship between thinking skills and maths learning in children with ADHD. This review revealed that there are very few studies that have looked at this important relationship – only 4 studies matched the criteria we had set. These studies differed from one another in a number of ways such as the tasks they used to assess thinking skills. However we were able to systematically review them and come to some conclusions about what research is telling us on this topic.

First, as expected, thinking skills were positively related to children’s maths performance. This means that better thinking scores were related to higher maths test scores in children with ADHD. Memory emerged as playing an important role in maths learning. There are different types of memory such as short-term memory where we hold information in a short term store and more strategic aspects of memory which involve not just holding the numbers in our mind but also when we have to update the information we are holding in memory. Updating is far more than just holding the numbers in memory but involved when you have to for example add or delete numbers and really actively update the information you are holding in your mind. Our review showed that this latter type of memory known as ‘working memory’ was particularly important for maths attainment in children with ADHD. Our own research studies has shown that many children with ADHD have difficulties in their working memory and it is therefore important that there is understanding that this may be contributing to any problems that the child is having with maths. Our EPIC intervention focuses on improving understanding and supporting this type of memory and ideas from our booklets may be useful in supporting children’s educational learning.

In our review we found differences between what is known as ‘verbal’ and ‘non-verbal’ types of memory and their relationship with maths. ‘Verbal memory’ involves memory processes such as those involved in rehearsal of number facts (e.g. repeating 5+5=10, 6+6 =12). What is referred to as ‘visuospatial memory’ in a nutshell involves seeing and representing information ‘spatially’. What is meant by that? The best way to understand this is with an example. So when working out what 6+7 adds up to – one way is to visually see 6+6=12 while at the same time working out 12+1=13 in your mind.

Our review seemed to suggest that verbal memory (such as being able to repeat numbers in your mind) was linked to numerical calculation skills (i.e. being able to add numbers). Quite differently, what is known as ‘visuospatial memory’ (described in the example above) was linked to children’s conceptual understanding which means being able to understand the rules of maths while calculating numbers. What does this all mean for children who have memory difficulties? This means that the type of memory difficulties children with ADHD (or other condition) have will impact the type of maths they have difficulties with. If they have typical verbal working memory they may not have difficulties with learning to add numbers. If they have reduced ‘visuospatial memory capacity’ though (see example above of visually holding numbers in mind) they may not be able to use conceptual rules that help us do maths as easily as their peers.

The key question is how can we help children with ADHD (or others with these thinking difficulties) with their learning? Reducing memory load is a really useful technique to support children with this type of difficulty, such as using a mini-whiteboard so they can see a visual breakdown of sums or using items like lego pieces to represent numbers. The child being active in their learning, such as using the lego pieces themselves to work out sums, can make a transformational impact on them wanting to participate as well as their understanding.

Much more research is needed on this important topic. We know that maths attainment can be an important predictor of many life outcomes such as career attainment. It is really important we understand the thinking difficulties that underlie being able to confidently engage in maths learning and develop strategies to support these children. This is not only important for them being able to access learning like their peers but also that they understand the everyday strategies they need to have a happy school experience.

Visual photo credit: Photographer valentinrussanov via Getty images.