Clumsy child: what are we missing?

Dear Editor,

Balance problems are not infrequent in the geriatric population. Nevertheless, awareness of paediatric vestibular and balance conditions remains scarce. Nearly 6–13% of school children have been reported to suffer from balance problems,¹ which have been found to interfere with academic and scholastic performance, as well as cause psychosocial problems. The rise in interest in paediatric vestibular medicine in most parts of the world has increased awareness of balance problems among the younger ones. The prevalence of vestibular dysfunction in children and adolescents is 30.4%,² based on a recent meta-analysis.

It is noteworthy that children with balance problems tend to manifest earlier with atypical symptoms, such as being clumsy.³ Although clumsiness is common among toddlers, appearing clumsy beyond 3 years of age should raise a red flag of a possible underlying vestibular impairment. A clumsy child is typically referred for neurodevelopmental assessment to exclude various sensory processing and integration disorders such as autism spectrum disorder (ASD) and attention-deficit hyperactive disorder (ADHD). However, concomitant presentation such as hearing loss should raise suspicion of a possible vestibular impairment.

 A child is typically termed as “clumsy” in a child with normal intelligence who frequently falls with no apparent cause, bumps into cupboards and doors, finds it difficult to climb or descend stairs and may struggle to perform age-appropriate self-care activities.

Left untreated, research has shown that children with clumsiness secondary to vestibular dysfunction tend to struggle with reading and learning,⁴ which typically requires an intact gaze stabilising function, and this, in the long term, may result in poor scholastic performance, psychosocial issues and poor overall quality of life.⁴

Sadly, due to a lack of awareness, physicians and general practitioners may disregard a “clumsy child” due to the belief that the child will eventually catch up. Parents and physicians generally are not aware that clumsiness could be due to an underlying vestibular impairment that remains unnoticed and tends to manifest at a later age or following an acute decompensation event such as stress, psychological issues, trauma or infection.² Besides that, the robust neuroplasticity among children with compensation from the vision and proprioception is another factor that may lead to the delay in the diagnosis of vestibular dysfunction.²

Currently, assessment of a clumsy child focusses on conditions like ADHD¹ and ASD,¹ and neuromuscular or neurological conditions, as many physicians are unaware that vestibular dysfunction could be the culprit. The significant contribution of the vestibular system to our balance system cannot be denied. Yet, peripheral vestibular assessment is not incorporated as a main assessment criterion when assessing a child with clumsiness assessment. We would like to highlight that vestibular and balance assessment is performed as a routine practice so that vestibular dysfunction in children can be identified earlier and referred for further assessments. A thorough vestibular investigation and quantification can be carried out, as well as early commencement of vestibular rehabilitation therapy, which will ensure the child is able to carry out and perform age-appropriate activities and learning.

Early vestibular rehabilitation therapy improves gaze stability, perception of verticality, balance and motor development and alleviates symptoms of motion sickness and dizziness.⁵ In addition, early rehabilitation in an otherwise “normal” child with vestibular dysfunction will enable them to catch up with their age- and gender-matched peers. Moreover, timely treatment of balance function in children has satisfying and rewarding outcomes, improving cognitive and psychological wellbeing.