Tesis

Peran neurological soft signs dalam diagnosis developmental coordination disorder pada anak sekolah dasar = Neurological soft signs in the diagnosis of developmental coordination disorder in school-age children.

Latar belakang: Developmental coordination disorder (DCD) merupakan gangguan koordinasi motorik yang berpotensi mengganggu aktivitas sehari-hari, performa akademik, dan partisipasi dalam kegiatan olahraga. Dibutuhkan metode diagnosis DCD yang mudah dilakukan di praktik. Metode: Subjek diambil dari siswa lima sekolah dasar (SD) negeri dan swasta di Jakarta dan Tangerang yang dicurigai (suspek) DCD berdasarkan hasil Developmental Coordination Disorder Questionnaire (DCDQ) serta kontrol non-suspek DCD. Pada semua subjek dilakukan pemeriksaan fisis dan neurologis untuk menyingkirkan kelainan neurologis yang jelas maupun kondisi lain yang dapat memengaruhi kemampuan motorik. Dilakukan anamnesis mengenai riwayat perkembangan, prestasi akademik, kesulitan menulis, kesulitan dalam olahraga, screen time, dan aktivitas fisis subjek, serta pemeriksaan antropometri untuk menentukan status gizi subjek. Semua subjek menjalani pemeriksaan neurological soft signs NSS yang terdiri atas tujuh item pemeriksaan dikotom serta pemeriksaan baku Bruininks-Oseretsky Test 2 Short Form (BOT2 SF). Subjek dengan skor BOT-2 SF dalam rentang below average dan well below average didiagnosis sebagai DCD. Hasil: Dari 128 anak suspek DCD, 86 subjek dengan median usia 10,05 (rentang 6,3 sampai 12,5) tahun ikut serta dalam penelitian. Dua puluh subjek non-suspek DCD dipilih secara acak dari sekolah-sekolah yang sama. Sebanyak 55,7% subjek berasal dari sekolah negeri dan 67% subjek adalah lelaki. DCD ditemukan pada 28,3% subjek. Sebanyak 67% subjek memiliki ≥1 item NSS positif, 41,5% memiliki ≥2 item positif, 20,8% memiliki ≥3 item positif, dan hanya 6 (5,6%) memiliki ≥4 item positif. NSS berhubungan bermakna dengan DCD apabila ≥2 item positif (p=0,047). Sensitivitas NSS berkisar antara 16,7% (≥4 item positif) hingga 73% (≥1 item positif) dan spesifisitasnya berkisar antara 35,5% (≥1 item positif) hingga 99% (≥4 it em positif). Pada analisis kurva receiver-operator characteristics, nilai cut-off NSS optimal adalah ≥2 item positif, dengan sensitivitas 57% dan spesifisitas 64% [area under the curve 0,639 (IK95% 0,5120,767); p=0,026]. Pada 20% subjek DCD didapatkan komorbiditas kelainan neurodevelopmental lainnya, terdiri atas gangguan spektrum autisme, disleksia, dan sensory processing disorder. Simpulan: Pemeriksaan NSS pada DCD merupakan pemeriksaan yang spesifik namun kurang sensitif. Menggunakan nilai cut-off ≥4 item positif , pemeriksaan ini dapat digunakan untuk konfirmasi diagnosis DCD pada anak yang dicurigai DCD berdasarkan skrining atau anamnesis orangtua, dengan sensitivitas 16,7% dan spesifisitas 99%. Diperlukan penelitian lebih lanjut untuk karakterisasi NSS pada komorbiditas yang dapat menyertai DCD.
Kata kunci: developmental coordination disorder, neurological soft signs, Bruininks-Oseretsky Test, uji diagnostik, sensitivitas, spesifisitas


Background: Developmental coordination disorder (DCD) is a motor coordination disorder that may affect daily activity, academic performance, and participation in sports. There is a need for a simple diagnostic test that can be done in a pediatric practice. Method: Subjects are recruited from students of five public and private elementary schools in Jakarta and Tangerang, Indonesia, who are suspected of DCD through previous screening using the Developmental Coordination Disorder Questionnaire (DCDQ) and non-suspect controls. All subjects underwent physical and neurological examination for any clear neurological deficit or other conditions affecting motor ability. History was taken regarding the subjects’ development, academic performance, difficulty in writing, sports participation, screen time, and physical activity. Anthropometric measurement was done to determine nutritional status. A neurological soft signs (NSS) examination battery consisting of seven dichotomous items as well as the standard Bruininks-Oseretsky Test 2 Short Form (BOT-2 SF) was performed on all subjects. Subjects with BOT-2 SF scores classified as below average and well below average were diagnosed with DCD. Results: Out of 128 suspected children, 86 subjects with a median age of 10.05 (range 6.3 to 12.5) years were recruited. Twenty non-suspect controls were randomly chosen from the same schools. Males comprise 67% and public school students comprise 55.7% of subjects. DCD was diagnosed in 28.3% of subjects. One or more positive NSS item(s) was found in 67% of subjects, ≥2 positive NSS items in 41.5%, ≥3 positive NSS items in 20.8%, and ≥4 positive NSS items in only 5.6%of subjects. NSS were significantly associated with DCD when ≥2 items were positive (p=0.047). The sensitivity of NSS ranged between 16.7% (≥4 positive items) to 73% (≥1 positive item(s)), and the specificity ranged between 35.5% (≥1 positive item(s)) to 99% (≥4 positive items). On receiver-operator characteristics curve analysis, the optimal cut-off point for NSS was ≥2 positive items, with a sensitivity of 57% and specificity of 64% [area under the curve 0.639 (95%CI 0.512-0.767); p=0.026]. A neurodevelopmental comorbidity was found in 20% of DCD subjects, comprising of autism spectrum disorder, dyslexia, and sensory processing disorder. Conclusions: In the diagnosis of DCD, NSS is a specific, but less sensitive, test. Using a cut-off point of ≥4 positive items, this NSS battery can be used as a confirmatory test in children already suspected of DCD through screening or parental report, with a sensitivity of 16.7% and specificity of 99%. Further studies are needed to characterize NSS in comorbidities accompanying DCD.
Keywords: developmental coordination disorder, neurological soft signs, Bruininks-Oseretsky Test, diagnostic test, sensitivity, specificity