1. Introduction
The dominant narrative concerning developmental disabilities emphasizes early identification and intervention as efficient strategies. In contrast, a counter-narrative challenges the fundamental premise of developmental screening aimed at detecting and minimizing deviations. This article offers a rival narrative, examining these issues through the lenses of surveillance and medicalization. The objectives of this article are twofold: firstly, to articulate a theoretical construct synthesizing the juxtaposed evaluations inherent in the surveillance and medicalization of atypical motor development; secondly, to address specific empirically-based issues related to surveillance and medicalization.
Children exhibit marked individual differences in growth and abilities, such as height, weight, and cognitive, emotional, motor, and social skills (Papalia and Martorell 2023). This article focuses on young individuals who encounter challenges in executing daily movement tasks. This struggle is observed even in the absence of apparent disabilities, any discernible ‘underlying lesion’ (Armstrong 1995, 394), or substantiated evidence through conventional medical methods. These children may resemble their peers physically but find it exceptionally challenging to execute movement coordination for tasks such as eating, dressing, handwriting, and playing sports.
Ideally, individual differences and diversity in motor development should be accepted in preschool, school, and community environments. For example, some seven-year-old children can tie their shoelaces, others cannot; such differences should not be judged but rather understood, respected, and appreciated. However, in reality, some schools and neighborhoods foster a competitive and judgmental ‘toxic culture’ (Banks 2018). This culture may lead to teasing, labeling, and exclusion of these children from games and sports, discouraging their participation in such activities.
Individuals once colloquially termed ‘clumsy children’ used to receive care from non-medical professionals. This remains true to some extent, but in recent times a medicalized paradigm has increasingly been applied, involving diagnosis and treatment for Dyspraxia, or Developmental Coordination Disorder (DCD) (APA 2013). Accordingly, ‘symptoms’ have been identified for ‘syndromes’ related to atypical movements (Peters, Barnett and Henderson 2001) and associated psychosocial issues (Miyahara, Piek and Rigoli 2024). In response to these movement and psychosocial concerns, diagnostic assessment tools and treatment approaches have been implemented as integral components of public health surveillance efforts in such nations as Brazil, Korea, Norway, and the USA (Kim 2022). In what manner are these children subjected to surveillance and medicalization? Before discussing practical applications, it is helpful to outline the rationale and practice of surveillance and medicalization.
2. Background
2.1 Public health surveillance and the culture of surveillance
To understand children with atypical motor development, data have been collected from typically developing children, such as same-age peers or older siblings. Large-scale surveys are also performed as part of public health surveillance efforts.
Public health surveillance is the ongoing systematic collection, analysis, and interpretation of outcome-specific data essential to planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. Outcomes may include disease, injury, and disability, as well as risk factors, vector exposures, environmental hazards, or other exposures. The final link to the surveillance chain is the application of these data to prevent and control human disease and injury. (Thacker and Birkhead 2002, 26–27) (emphasis added by the present author)
Initially focused on preventing and controlling infectious diseases (Lombardo and Ross 2007), public health surveillance now also includes identifying developmental disabilities. When public health surveillance methods are used to detect, assess, and intervene in cases of atypical motor development, it is vital to ascertain the individuals who ‘need to know’, including those who may be involved in ‘prevention and control’ efforts. This is where cultures of surveillance assume a crucial role.
According to Lyon (2018), ‘the culture of surveillance is about how surveillance is imagined and experienced’. Moreover, ‘surveillance is also initiated and engaged by those who have become familiar with and even inured to surveillance’ (Lyon 2018, 2). The perceptions and experiences of public health surveillance programs designed for atypical motor development may differ among children, parents, professionals, and government officials. When initiated by governments and professionals, developmental surveillance can be viewed suspiciously by children, who may perceive it as ‘the unwanted eye’ (Lyon 2018, 22) or ‘public gaze surveillance’ (Malhotra and Rowe 2013, 75). Over time, developmental screening events may become a routine aspect of life for some but distressing for disabled children and their families (Tateishi 2023). While ‘Big Data’ in population-based screening is of interest to various actors, including healthcare providers, there are risks associated with surveillance, such as privacy violations and social sorting, which can impact opportunities in life, education, and professional pursuits (Lyon 2018).
Among the various cultural models of surveillance, the panoptic model (‘Panopticon’) conceived by Jeremy Bentham (Bentham 1778) has been particularly widely cited. The Panopticon was imagined as an all-seeing arrangement of efficient observation and control for prisons and other institutions to allow those in power (i.e., the few) to see ‘everything (i.e., the many) without ever being seen’ (Foucault 1979, 216). In the synoptic model of surveillance, by contrast, the many (via the mass media, for example) surveil and control the few (e.g., health and disability consumers) (Couch et al. 2015), thus disciplining people’s ‘soul’, or the consciousness and behavior in contemporary society. These two models will be separately applied to evaluate atypical motor development surveillance, highlighting different aspects.
2.2 Exploring surveillance and medicalization in the context of developmental disabilities
Medicalization involves reclassifying non-medical issues as medical, granting authority to medical professionals, and influencing social norms (van Dijk et al. 2020). Centered around enforcing normalcy (Davis 1995) or pressuring to conform, medicalization assigns disability to individuals (Oliver 1996), promoting individual intervention like functional habilitation for developmental disabilities to achieve normalcy. The concept of medicalization, that was first introduced in North America in the 1970s (i.e., Zola 1972; Illich 1975), has found limited application to the study of developmental disabilities within Western academia with the notable exception of Attention Deficit/Hyperactivity Disorder (ADHD) (e.g., Prosser 2015), specifically in its pharmacological treatment. Within this context, Armstrong’s (1995) journal article published in the UK shed light on surveillance and medicalization of developing children, while Kimura (2006) in Japan and Tseng (2017) in Taiwan further explored these themes in the 21st century, focusing on developmental disabilities and employing interviews and ethnographic methodologies to substantiate these phenomena, as detailed later.
From these pioneering studies on developing children and developmental disabilities, a pertinent inquiry arises: Could there be latent advantages and disadvantages embedded within surveillance and medicalization? To unravel these intricacies, an extensive evaluation of atypical motor development surveillance is undertaken here, enriched by the perspectives of the panoptic and synoptic models. This analysis is grounded in the foundational principles of social justice and interwoven with evidence-based practice, involving the collection and analysis of data to determine prevalence and risk factors, predict causal relationships, control undesirable outcomes, evaluate cost effectiveness, as well as capture subjective views and experiences (Munn et al. 2018).
The present investigation aims to broaden the horizon of analysis to embrace the intricacies of medicalization, including its scope, ramifications, and legitimacy, in the context of atypical motor development. Based on the framework of critical disability studies that is self-critical and reflexive (Goodley 2016), valuable insights are offered by Shakespeare (2006) and Dokumacı (2019); they highlight how some proponents of the social model of disability have, on occasion, become entangled in what could be deemed as ‘strawman’ contentions against both the medical model and the concept of medicalization. This situation unveils an inherent imbalance in these discussions. With the goal of maintaining scholarly rigor, this article avoids such arguments while delving into an overarching historical and developmental analysis of the medicalization processes surrounding atypical motor development.
3. Methods
To evaluate the surveillance of atypical motor development, critical analysis (Muncie 2006) was conducted from the panoptic and synoptic perspectives. For the examination of medicalization, one of the two methods—the comparative method or the historical comparative method—was employed for appropriate analysis. The comparative method (Collier 1993) was used to evaluate the impact and the legitimacy of medicalization. The historical comparative method (Mahoney 2004) was applied to examine the extent of medicalization across the nations over time, testing the sequential model of medicalization of Conrad and Schneider (1980). The model is introduced in the results section to facilitate comprehension of the findings.
The analysis is based both on primary sources and on the present author’s personal experiences spanning 35 years of academic experience in Canada, Germany, Japan, New Zealand, the UK, and the USA. This diverse selection of nations, reflecting the author’s firsthand experiences, encompasses a linguistic spectrum beyond the standard English database, facilitating cross-cultural analysis of surveillance and medicalization. There are no ethical concerns as this study does not involve human subjects.
4. Results
4.1 Evaluating surveillance of atypical motor development
4.1.1 Panoptic perspective
Mass surveillance of motor development occurs in developmental health screening projects, such as those conducted in Japan (Kimura 2006) and Taiwan (Tseng 2017). A small number of medical, healthcare, and educational professionals, along with community workers, observe and assess a large number of children, profile and categorize them based on screening tools. The process of obtaining informed consent for these projects encompasses crucial issues, such as data storage and subsequent courses of action. However, even when an information sheet provides explanations, using plain language and infographics, to outline potential diagnoses and associated risks, comprehending the implications of labeling and categorizing children with DCD remains a challenge for many parents and caregivers, let alone the children themselves.
In the context of the panoptic model of surveillance, where few people (e.g., public health researchers) watch many individuals (e.g., mass screening participants) without their awareness, several pertinent questions come to the forefront. Firstly, it is important to consider whether both the child and the parent are fully aware of the potential consequences, such as the possibility of the child undergoing categorization, diagnosis, and the subsequent potential for discrediting stigmatization (Goffman 1963). Another critical aspect to address is the duration of validity for such categories or diagnoses. For instance, what happens with records of a DCD diagnosis as time progresses? Could these records resurface when children enter higher education or even as they enter the workforce? Understanding the longevity and potential impact of these categorizations is essential.
Moving beyond awareness, strategies to mitigate the adverse consequences of surveillance (including assessment results and diagnoses) need exploration within educational institutions, healthcare systems, workplaces, and the broader community. This entails seamless longitudinal collaboration between children, families, researchers, clinicians, and local government officers involved in the screening process. Furthermore, it is important to outline the course of action available for a child or parent who chooses to decline the diagnosis and associated interventions. Does the child’s labeled status, such as having DCD, persist even if the diagnosis is refused by the child or the parent? Addressing this question is crucial in offering options and considering the lasting implications of the diagnosis.
In the early stages of developmental screening projects, not all stakeholders, including researchers and administrators, might foresee the long-term impacts of the categorization and diagnosis on individual children. As a result, it is imperative that once a risk of or a definite DCD diagnosis is made on the basis of screening data, the child and the guardian hold the right and options to decide whether to accept the classification and diagnosis, or refuse them, declining intervention. This emphasizes the need for autonomy in decision-making and consideration of the potential lifelong effects that this classification and intervention, or their absence, can wield.
To illustrate specific issues related to panoptic surveillance, two governmental documents have been selected for accessibility and level of detail. The first document is a manual for population-based screening of developmental disabilities, available only in Japanese on the Japanese Ministry of Health, Labor, and Welfare website since 2007 (Koeda et al. 2006). The second document is a review of evidence and a research proposal titled ‘Neurodevelopmental Screening and Surveillance,’ commissioned by the New Zealand Ministry of Health and made available online in English in 2019.
4.1.1.1 The Japanese manual for developmental screening
According to the manual (Koeda et al. 2006), local city governments in Japan have been encouraged to screen five-year-old children before they are to enter primary school at six years of age. This approach aims to facilitate early identification of developmental disorders, provide support and preparation for school entry, and assist in consultation with caregivers. Among the included screening items, five items regarding gesture imitation and motor coordination are incorporated, presumably to identify Dyspraxia and DCD.
The final section of the manual consists of nine case studies. Out of the nine cases introduced, eight were characterized as successful, whereas one exhibited less favorable outcomes in the transition from public health surveillance to medicalization to educational and community support. Although this was not a case of DCD/Dyspraxia, the case is most revealing, providing a concrete context and conditions for explaining how the public health surveillance staff attempted medicalization and reflected on alternative strategies when they encountered challenges. Because the manual is available only in Japanese, the present author provides a summary of the case here:
This case involves a five and a half-year-old boy who displayed concerning behavior during developmental screening. He exhibited restlessness, frequently shifting attention to whatever caught his eye, an inability to answer questions or follow instructions unless he was interested, and difficulty playing a word game or reading alphabets. In the home environment, he exhibited noisy and tantrum behavior when faced with unmet needs, but these instances were of less concern to the parents. His behavior at kindergarten was more of a concern to the teachers, where he displayed restlessness, a short attention span during play sessions, and occasional aggression towards other children.
The developmental screening doctor suspected ADHD and recommended a visit to a habilitation center. Although the family initially had reservations, they eventually attended the habilitation center, where the diagnosis of ADHD was confirmed. On the day of this visit, the child was asked to complete an intelligence test. However, he struggled to follow instructions during the test, wandered around the room, avoided making eye contact when called, and touched various objects in the testing room. This made it impossible to conduct the test. Subsequently, the family did not return to the habilitation center, leaving the screening staff without a clear path forward.
From this case, three pieces of advice are offered by the manual authors: (1) Consider referring the child to the habilitation center when the family is prepared and willing to engage in the process or provide them with contact information if they are not yet ready to proceed. (2) In the screening stage, it is advisable to refrain from making a diagnosis and instead prioritize obtaining information about the family’s background and perspectives while building trust with them. (3) Identify the primary decision-maker within the family and ensure their active participation in discussions.
By analyzing this case description and reflection, one can discern the unwavering commitment of the public health surveillance staff to the process of medicalization with diagnosis, standardized assessment, and intervention. Notably, the reflection does not address procedures for handling uncooperative standard test takers. This omission sheds light on the limitations in screening and diagnosis procedures, prompting questions about the effectiveness or appropriateness of standardized tests in diagnosing developmental disabilities and the provision of appropriate support. In contrast to ADHD, DCD/Dyspraxia receives a lower level of recognition, making it potentially more challenging for parents, not to mention the child who is experiencing it, to comprehend and embrace the diagnostic, formal assessment, and interventional procedures.
4.1.1.2 Literature review and research proposal for developmental screening in New Zealand
In their rationale for the planned study, Saraf and Marks (2019) emphasize that only limited data are available regarding the prevalence of neurodevelopmental disorders. Although the study is intended to elucidate prevalence rates, it does not include a description of the sampling method. The study includes assessments of the following disorders: ADHD, Autism Spectrum Disorder (ASD), learning disabilities, intellectual disabilitites, conduct disorders, impairments in vision and hearing, and cerebral palsy (CP). However, neither DCD nor Dyspraxia is mentioned throughout the document. Paradoxically, no specific screening tool for cerebral palsy is included, although two standardized developmental motor ability tests, often used to support the formal diagnosis of DCD, are proposed for initial screening and post-intervention secondary screening of ‘motor disorders including Cerebral Palsy’ (Saraf and Marks 2019, 15).
Motor intervention based on positive screening (i.e., children identified with neurodevelopmental disorders) has reportedly demonstrated ‘significant improvements’ (Saraf and Marks 2019, 31) based on evidence from six intervention studies. One of the inclusion criteria for the ‘mainly randomised controlled trials’ is a report of the randomization method used in each intervention study. Surprisingly, no information concerning the randomization method is provided in any of the six studies, and only one appears to be a randomized controlled trial. The other studies included a qualitative review study and a qualitative interview study. Given the inappropriate motor tests for screening and assessment, and the inaccurate review of the intervention effects, the value of the screening and intervention study proposed by Saraf and Marks (2019) is highly questionable.
The experiences of children and parents during participation in the screening event, as well as the adverse effects of segregated intervention for children with positive screening results, should be considered when planning population- or school-based screening projects. Hence, the review and proposal by Saraf and Marks (2019) require serious reconsiderations and modifications from the perspective of evidence-based practice, as well as social justice for efficient allocation of public resources to support this frequently overlooked disadvantaged population.
4.1.2 Synoptic perspective
The synoptic model of surveillance illuminates a scenario where a small group, comprising a minority, such as individuals who are considered to display atypical motor development, faces the gaze of many individuals (Mathiesen 1997). The agent of the gaze ranges from close family members, peers, colleagues, teachers, and supervisors to the remote influence of the mass media and social media. This combined direct and indirect scrutiny intricately weaves a fabric of social control and social change within the synoptic surveillance model. Simultaneously, it prompts critical questions about the privacy and autonomy of those subjected to such gaze.
Direct observation of proximate individuals involves physical surveillance, encompassing the direct visual scrutiny of subjects to acquire information about their identity and activities (Siljander and Fredrickson 1977). Surveillants in close proximity to a subject can discern atypical motor behavior, such as clumsiness or motor incoordination, while the observed subject participates in diverse activities, including daily living tasks, educational and occupational pursuits, as well as sports and leisure activities. Consequently, identity becomes intricately woven into the individual’s motor activities.
Given that such public naturalistic observation and subsequent evaluation are inherent in daily routines, there exists limited control over privacy. Nevertheless, scrutinized movements and the ensuing evaluation can function as a foundation for support and reasonable accommodation, contingent upon the individual’s preference, at best. At worst, these observations may lead to undesired consequences, such as name-calling, teasing, bullying, social exclusion, team or class placement, and unwanted intervention. As with the surveillance cameras, observation itself can be value-neutral; its impact is shaped by how the surrounding individuals interpret and apply the evaluations.
In the synoptic model, the mass media and social media (‘the many’) may see and influence individuals who are perceived as displaying atypical motor development (‘the few’) in various scenarios, including the hero and anti-hero archetypes. Capitalizing on the archetypes, diverse media outlets, ranging from news sources to academic journals, may cast therapists as heroines and heroes who save victimized children, often highlighting breakthroughs in the process (Couch et al. 2015). In the context of atypical motor development, medicalized terms like DCD and Dyspraxia serve as the villain, amplifying victimization.
In an alternative scenario, individuals with DCD or Dyspraxia, their families, and professionals take on heroic roles, actively confronting the challenges posed by non-accommodating environments or systems, hindering the activity and participation of individuals with DCD or Dyspraxia. The stakeholders may be involved in developmental screening projects (e.g., Wakschlag et al. 2022) and the formulation of guidelines (e.g., Barnett et al. 2015). Social media platforms become crucial arenas, allowing the stakeholders to disseminate information, mobilize support, and amplify their advocacy message. Simultaneously, mass media serves as a storyteller, portraying the struggles and triumphs of these heroes in their quest for reasonable accommodation for activity and participation. Together, the collective efforts of stakeholders and the influence of social and mass media converge in a multifaceted campaign against the obstacles of non-accommodating environments and systems, highlighting the interconnectedness of advocacy and media portrayal in fostering societal change.
While their intentions are commendable, these well-meaning efforts might paradoxically contribute to further stigmatization and worsen the psychosocial challenges associated with medical labels of DCD and Dyspraxia. This phenomenon aligns with established research (Link and Phelan 2001; McDonald and Raymaker 2013) that highlights how attempts to reduce stigmatization by fostering an inclusive environment can sometimes backfire, unintentionally intensifying the very issue they aim to alleviate. This emphasizes the need for cautious, well-informed communication strategies that aim to educate and support without inadvertently perpetuating the very stigma they seek to mitigate within the synoptic model of surveillance.
4.2 Evaluation of medicalization
4.2.1 Extent of medicalization
Medicalization typically proceeds not in a single step but in stages. The stages of medicalization in the context of atypical motor development were appraised by the five-stage sequential model proposed by Conrad and Schneider (1980). As summarized in the two left columns of Table 1, the model consists of Stage 1: Common-sense definition of behavior as deviant; Stage 2: Prospection; Stage 3: Claim-making; Stage 4: Legitimacy; Stage 5: Institutionalization. As described in the right-most column of Table 1, Stage 1 of medicalization in atypical motor development is characterized by common-sense definitions, such as ‘clumsy’ and ‘uncoordinated’ without using medical terms. However, as shown in Table 2, the remaining stages sometimes proceed in different sequential orders.
Table 1
Description of the five-stage sequential model of medicalization and corresponding milestones in the context of atypical motor development.
| STAGE | DESCRIPTIONS BY CONRAD & SCHNEIDER (1980) | MILESTONES OF ATYPICAL MOTOR DEVELOPMENT |
|---|---|---|
| 1. Common-sense definition of behavior as deviant | Before a medical definition emerges, a particular behavior is defined as deviant. Compared to the medical definition, the common-sense definition appears vague. | Motor behaviors that are deviant from the expected level of the child’s age group may be perceived and described as clumsy, awkward, and uncoordinated. |
| 2. Prospection: medical discovery | A medical conception of deviant behavior first appears in a professional medical journal, book, or conference presentation. The conception consists of diagnosis, etiology, and treatment. At this stage of prospecting, a limited number of professionals are involved in the new medical ‘discovery’. The conception may not be accepted until champions and moral entrepreneurs catch public attention. | Apraxia, Clumsy Child Syndrome, Dyspraxia, and physical awkwardness have been reported in medical journals and books. Some of the authors became medical or academic champions. |
| 3. Claim-making | Champions, moral entrepreneurs, and organized interest groups make claims for the new medical designation. Medical professionals may treat the behavior or work for an institution designated for the issue. However, they are not usually involved in claim-making activities directly. | Special issue of academic journals dedicated to DCD, consensus on terms, Dyspraxia groups, DCD and Dyspraxia conferences. Parental support groups serve as moral entrepreneurs for public awareness and lobbying, supported by some medical or academic champions. |
| 4. Legitimacy: securing medical ‘turf’ | An instrumental challenge is laid to the existing deviance designation for the recognition of the medical viewpoint. There may be conflicts between the old and the new regimes. To secure assimilation into the domain of medical authority, governmental approval and support are required. | There is minor disagreement between academic researchers and the parental support groups concerning the labels. Governmental support is minimal, regardless of the labels. |
| 5. Institutionalization | The medical designation of deviant behavior is stably institutionalized and publicly accepted. | Diagnostic manuals, national health institutes, school-based programs |
Table 2
Medicalization developmental stage numbers and the first authors of milestone events and developmental motor ability tests.
| NATION | 1920S | 1940S | 1950S | 1960S | 1970S | 1980S | 1990S | 2010S |
|---|---|---|---|---|---|---|---|---|
| USA | Stage 2. Orton (1925) | Bruininks (1978) | Stage 5. APA (1987) DSM-III-R | Stage 5. APA (1994) DSM-IV | Stage 5. APA (2013) DSM-5 | |||
| Canada | Stott (1972) | Stage 3. Polatajko (1995) Consensus | Stage 5. Missiuna (2012) | |||||
| UK | Stage 2. Gubbay (1965) | Stage 2. Gubbay (1975) | Stage 3. Dyspraxia Trust founded in 1987 | Stage 2. Henderson (1992) Stage 3. Henderson (1994) | Henderson (2007) | |||
| Germany (Russia) | Gurewitsch (1925) | Stage 2. Kiphard (1966) | Kiphard (1974) | Stage 2. Doll-Tepper (1989) | Stage 4. Blank (2011) Stage 4. Blank (2019) | |||
| New Zealand | Stage 3. Dyspraxia Support Group of New Zealand founded in 1992 | |||||||
| Japan | Karino 1953 | Stage 2. Yamaguchi (1973) | Stage 2. Nanakida (1994) | |||||
| Occupied Taiwan | Naka (1941) | |||||||
[i] Note. Italics indicates publication of a developmental motor ability test. Bold indicates medicalization events with the stage number defined by Conrad and Schneider (1980).
Stage 2 of medicalization in atypical motor development notably features the ostensibly emergent medical ‘discovery’ denoted as apraxia or Dyspraxia, representing an apparent appropriation of an adult neurological nomenclature to delineate a pediatric phenomenon. Orton (1925) first used the term apraxia in his article published in a neurology journal in the USA. Four decades later in the UK, an Australian neurologist published a medical article (Gubbay et al. 1965), followed by a book (Gubbay 1975) on the clumsy child and apraxia. In West Germany, Kiphard (1966) authored a German-language book on clumsy children, and Doll-Tepper (1989) contributed an English academic article in an international peer-reviewed journal on the assessment, diagnosis, and treatment of atypical motor development. In Japan-occupied Taiwan, a school-based study of gesturing ability was published in a Japanese medical journal (Naka, Ho and Ikeuchi 1941) without any medical labels for atypical motor development. A Japanese child psychiatrist, Yamaguchi (1973), reported ‘three cases of clumsy children’ who were diagnosed with ‘disorder of praxis’ based on a French gesture imitation test (Bergès and Lézine 1963).
At Stage 3 of medicalization in atypical motor development, claim-making of medicalized motor development occurred in the UK with the launch of Dyspraxia Trust in 1987, and the Dyspraxia Support Group of New Zealand was formed in 1992. A special journal issue on DCD was edited by Henderson (1994). A consensus on the term DCD was reached among professionals in 1994 (Polatajko, Fox and Missiuna 1995).
Stage 4 involves the birth of the diagnostic name, Developmental Coordination Disorder (DCD) (APA 1987). Interestingly, it was not until five years after the ‘birth’ before the first appearance of DCD in academic journal articles (Stage 2) occurred. In an international English-language journal, Henderson, Rose, and Henderson (1992) first used DCD to label the characteristics of their research participants in the UK. A Japanese translation of the DSM term, DCD, appeared in the Japanese translation of DSM-III-R published in 1988. Similar to the international situation, it took several years before DCD was first discussed in an article by Nanakida and Nanakida (1995) published in a Japanese child health journal. At this point, the term DCD was neither known nor accepted right away even among scholars, not to mention clinicians, parents, and children.
At Stage 4 of medicalization in atypical motor development, the legitimacy of Dyspraxia and DCD does not necessarily follow Stage 3. Instead, in Stage 5, the institutionalization of DCD takes place earlier than in Stage 4 with its first appearance in DSM-III-R (APA 1987). The medical ‘turf was secured (Stage 4) later by the publication of guidelines for DCD (Blank et al. 2012; Blank et al. 2019).
At Stage 5 of medicalization in atypical motor development, institutionalization and public acceptance of DCD and Dyspraxia are also actualized by medical/healthcare professionals (e.g., occupational therapists) working with children with DCD in the school system in Canada (Missiuna et al. 2012).
To summarize, the five stages of medicalization in atypical motor development unfold in both Western nations and Japan, although not necessarily following the sequential stages postulated by Conrad and Schneider (1980). It is noteworthy that, in comparison to Western nations, a medicalized approach to atypical motor development was adopted later in Japan. The subsequent sections will delve into the evaluation of the impact and legitimacy of the medicalization process.
4.2.2 Impact of medicalization
The left side of Table 3 shows a direct quote from the framework developed by Kaczmarek (2019) detailing the assessment domains of medicalization impact (risks vs. opportunities) on health, economic, psychological, and social effects. The right side of Table 3 shows the present author’s analysis of the risks and opportunities for medicalized atypical motor development, DCD, or Dyspraxia on the four effects domains.
Table 3
Medicalization impact assessment (Kaczmarek 2019).
| OVER-MEDICALIZATION-RISKS | WELL-FOUNDED MEDICALIZATION-OPPORTUNITIES | RISKS FOR DCD/DYSPRAXIA | OPPORTUNITIES FOR DCD/DYSPRAXIA | |
|---|---|---|---|---|
| Health effects | Harm to health caused by undue treatment | Possibility of using tools of evidence-based medicine | No treatment harm has been reported. Non-inclusive individual intervention or protracted treatment may lead to stigmatization and psychosocial problems. | There are possibilities of using assessment and intervention tools of evidence-based medicine. However, at present, there is no high-quality evidence for treatment efficacy evaluated with standardized developmental motor assessment tools. |
| Economic effects | Suboptimal expenditure and waste of public or private money | Improvement in the financial situation of individuals whose condition has officially been recognized as a disease | Ineffective screening, assessment, diagnosis, and treatment for DCD/Dyspraxia with high costs can lead to the waste of both public and private resources. | A cost-effective DCD/Dyspraxia identification and treatment can significantly benefit the individuals with DCD, their families, and governmental budgets. |
| Psychological effects | Stigmatizing certain conditions, individuals, or their behavior as sick; restriction of personal freedom; pressure to adjust one’s own needs and behavior to fit the prevailing standards | De-tabooization of disease, explanatory value | The diagnosis and individual treatment of DCD/Dyspraxia can pose risks for both self and public stigma, which may lead to internalized shame, lowered self-esteem, teasing, bullying, social isolation, the feelings of helplessness and oppression, and disadvantage for entering higher schools and the workforce. | The diagnosis of DCD/Dyspraxia may make the condition more socially acceptable and provide an explanation for it. |
| Social effects | Ignoring the social, political, and interpersonal background of certain phenomena and inadequate reactions stemming therefrom | Raising health awareness of the public, recognizing medical grounds for particular behaviors and starting treatment instead of punishing the patient | The environmental factors in the family, school, and community that facilitate atypical motor development can be overlooked by medicalizing the condition. | The diagnosis can raise public awareness, recognize medical grounds, and initiate treatment for improving desired motor skills. |
Opportunities to derive benefits from evidence-based medicine and healthcare exist alongside potential harms, including physical, psychological, and social sequelae that may arise during treatment and care. To date, there is no high-quality evidence for treatment efficacy evaluated by standardized developmental motor assessment tools (Miyahara et al. 2017a; Miyahara et al. 2020; Miyahara et al. 2017b). However, positive treatment experiences, such as opportunities for physical practice in a non-threatening environment, have been anecdotally reported by stakeholders (see Miyahara et al. 2023 for a comprehensive review). In terms of potential harm, the possibility of physical injury is inherent to any physical activity, but the risk can be minimized by careful planning and practice. To date, no harm has been reported from task-oriented intervention in peer-reviewed international journals (Miyahara et al. 2017a). Individuals with DCD or Dyspraxia can be adversely affected psychologically by the therapist’s inadvertent insensitivity or demotivated by unsuccessful treatment, deepening their sense of helplessness. Individuals with DCD or Dyspraxia may also be stigmatized and discriminated against by people who know about the individual’s treatment. For example, if a child with DCD or Dyspraxia attends an individual treatment instead of a team sport activity, the sports team may consider the child as being less capable or different, potentially leading to the child’s feelings of isolation and exclusion. To enjoy the anecdotally reported treatment benefits on health and wellbeing, potential harms should be carefully prevented and managed. High-quality evidence needs to be generated to evaluate any benefits of surveillance and medicalization.
The economic ramifications of medicalization necessitate examination across multiple levels. Access to reasonably priced or publicly funded effective medical treatments can yield significant benefits for individuals with DCD, their families, and governmental budgets alike. Conversely, the adoption of ineffective treatments with high costs may result in the inefficient allocation of both public and private resources. In light of the limited empirical evidence supporting intervention effect on standardized assessments (Miyahara et al. 2017a) and the anecdotal merits of certain treatments (Miyahara et al. 2023), the potential risks of medicalization for DCD/Dyspraxia encompass expenses related to costly mass screening, standardized assessments, medical diagnostic procedures, and medical treatment.
The psychosocial effects of medicalizing atypical motor development can be influenced by society’s stigmatization of individuals with DCD or Dyspraxia, as well as its control over their personal freedoms and behavioral standards. For instance, when someone is diagnosed with DCD or Dyspraxia, they may feel ashamed of the pathological extent of their motor difficulties and judged for them. They may also feel anxious about the consequences of the diagnosis, including differential treatment in school and other educational and vocational systems. While the medical diagnosis may legitimize and account for their movement difficulties, the diagnostic label may be misused for bullying and social exclusion.
The social effects of medicalizing atypical motor development can be both positive and negative. Although a lack of opportunity for learning and using motor skills is deemed an exclusion criterion for the diagnosis (APA 2013; APA 1994), it is important to note that movement difficulties can arise from an impoverished environment, such as the absence of safe learning space, equipment, peers, and instructions. Consequently, medicalizing atypical motor development may inadvertently serve to ignore the role of such environmental inadequacy by attributing the movement difficulties to individual internal mechanisms. On the positive side, medical recognition and legitimization of the condition may be more effective than casual labels to increase public understanding, address the issue, and receive necessary support and reasonable accommodation.
4.2.3 Legitimacy of medicalization
To distinguish legitimate medicalization from over-medicalization for a particular condition X, Kaczmarek (2019) formulates four questions that inquire: 1) whether X is appropriately acknowledged as a problem; 2) whether such recognition is rooted in reasonable societal expectations; 3) if medicine offers the best means to comprehend X and its origins; and 4) whether medicalization guarantees the most efficient and secure solutions for X. The present author endeavors to address these questions by substituting DCD/Dyspraxia for X in Table 4.
Table 4
Legitimacy of medicalization.
| QUESTION | ANSWERS FOR DCD/DYSPRAXIA |
|---|---|
| 1. Has X been rightly recognized as a problem? | ✓ Yes, DCD/Dyspraxia has been recognized as a problem of movement skills required for daily life, as well as the risk of psychosocial issues. |
| 2. Does recognizing X as a problem not result from unfounded, exaggerated social expectations? | – DCD/Dyspraxia can be recognized as a problem when social high expectations are unfounded and exaggerated. |
| 3. Does medicine provide the most adequate methods of understanding X and its causes? | – By definition, DCD should not have any medical causes, and thus, medicine does not provide the most adequate method for understanding DCD and its causes. |
| 4. Does medicalizing X ensure the most effective and safest methods of solving it? | ? Medicalizing atypical motor development in terms of DCD/Dyspraxia can facilitate an effective and safe method of addressing it if the local media, educational, and social systems sufficiently accommodate the medicalized condition. Whether or not it is the most effective and safest option is open to question. |
[i] Note. ✓: affirmative answer; –: negative answer; ? : open to question.
Firstly, DCD/Dyspraxia has been appropriately acknowledged as a problem due to its profound impact on daily activities, where movement difficulties not only disrupt these activities but also extend to affect psychosocial well-being. The recognition of the psychosocial aspects is a rationale for the inclusion of DCD in the diagnostic manual for mental disorders (Spitzer et al. 1994). Even with an ideally reasonable accommodation for the movement difficulties in society, the subjective experience of difficulties would remain to a certain degree.
Secondly, the recognition of DCD/Dyspraxia as a problem can be closely tied to societal expectations, which may sometimes be unfounded and exaggerated. In many cases, individuals with DCD or Dyspraxia are subjected to societal standards and expectations that do not take into account the challenges posed by their condition. Such unrealistic expectations can exacerbate feelings of frustration and inadequacy among those affected. However, when medical professionals acknowledge the condition characterized by movement difficulties and diagnose DCD/Dyspraxia, it can lead to a shift in these societal expectations. As awareness grows and the medical community validates these challenges, there is potential for a more realistic and compassionate understanding of the condition to emerge. This recognition can pave the way for adjustments in societal attitudes and expectations, ultimately fostering a more supportive environment for individuals with DCD or Dyspraxia to thrive in.
Thirdly, it is important to note that DCD is defined as having no medical causes (APA 1987; APA 1994; APA 2013). Consequently, relying solely on the medical perspective may not offer the most comprehensive understanding of DCD and its underlying mechanism. Instead of being solely linked to medical factors, DCD is likely influenced by a complex interplay of physical, psychological, and social elements. In addition to the traditional neuromotor and psychomotor approaches, alternative research methods such as ethnographic observation, case studies, and qualitative interviews, approached through the lens of disability studies, would provide valuable insights. These approaches offer a deeper understanding of the contextual interactions, subjective experiences, and potential reasons for psychosocial issues (Miyahara, Piek and Rigoli 2024). Expanding our investigative methods beyond the medical realm allows for a more holistic understanding of DCD.
As indicated in Table 4, a definitive affirmative response can be assigned to the initial question concerning the recognition of DCD/Dyspraxia as a problem. However, the subsequent three inquiries pertaining to social expectations, medical understanding, causes, and solutions yield either negative or ambivalent answers. Therefore, drawing a conclusive determination on whether atypical motor development is appropriately medicalized or excessively medicalized presents a challenge.
5. Conclusion
Surveillance and medicalization of atypical motor development have evolved and prevailed across various decades in recent history and in multiple countries around the world. This trend raises questions concerning identity and privacy protection, stigmatization, and the allocation of competitive medical resources. However, these approaches could be beneficial if they are based on evidence of high quality, which has not yet been forthcoming. Similarly, they should help improve individual persons’ desired skills, discourage stigmatization, teasing, and bullying, and protect concerned individuals until ideal inclusive schools, workplaces, and communities are actualized. As an alternative to surveillance and medicalization, social intervention should be considered to promote diversity and to prevent or reduce the stigma of atypical motor development. The present study demonstrates the usefulness of dismantling and evaluating specific components of surveillance and medicalization rather than accepting them unquestioningly or dismissing them without careful consideration. Future critical disability research is encouraged to extend such evaluations to theory-building, praxis, and activism in support of social justice for oppressed individuals with DCD, Dyspraxia, and other developmental disabilities.
Acknowledgements
The author would like to thank Mark McGuire, Douglas Booth, and Jonothan Logan for their comments on the earlier version of this paper.
Competing interests
The author has no competing interests to declare.
Author contributions
The author has accepted responsibility for the entire content of this manuscript.