A longitudinal study of children with Down

syndrome who experienced early

intervention programming.
Studies on the mental and motor abilities of children with Down syndrome Down
syndrome, congenital disorder characterized by mild to severe mental retardation, slow physical
development, and characteristic physical features. Down syndrome affects about 1 in every 730 live
births and occurs in all populations equally. have been reported for many years. Initially, these
studies were cross-sectional in nature, and few, if any, longitudinal studies were done. These initial
reports document the development of children with Down syndrome as similar to that of typically
developing children, but occurring at a much slower rate. Several studies[1-6] have demonstrated a
general decline in intelligence quotients intelligence quotient
n. Abbr. IQ
An index of measured intelligence expressed as the ratio of tested mental age to chronological age,
multiplied by 100. (IQs) in children with Down syndrome from infancy to late childhood.

Motor skills in children with Down syndrome have also been studied in detail. The general rate
of motor skill development has been reported to be below that of children without Down syndrome,
although there is variability among children attributable to factors such as home rearing and health
status.[3,7,8] Attainment of early motor milestones are thought to be delayed because of problems
with ligamentous laxity Ligamentous laxity is a term given to describe "loose ligaments."

In a 'normal' body, ligaments (which are the tissues that connect bones to each other) are naturally
tight in such a way that the joints are restricted to 'normal' ranges of motion. in some joints,
decreased strength, and hypotonia hypotonia /hy·po·to·nia/ (-ton´e-ah) diminished tone of the
skeletal muscles.

hy·po·to·ni·a
n.
1. Reduced tension or pressure, as of the intraocular fluid in the eyeball.

2. .[9-11] Additionally, postural control problems have been identified in children with Down
syndrome. Shumway-Cook and Woollacott[12] found that postural responses to loss of balance were
slow in young children (1-6 years of age) with Down syndrome, and they concluded that these
responses were inefficient for maintaining stability. They also stated that the presence of the
monosynaptic monosynaptic /mono·syn·ap·tic/ (-si-nap´tik) pertaining to or passing through a single
synapse.

mon·o·syn·ap·tic
adj.
Having a single neural synapse. reflex during platform perturbations suggested that balance
problems in children with Down syndrome do not result from hypotonia, but rather from defects
within higher-level postural control mechanisms.

Motor proficiency pro·fi·cien·cy

n. pl. pro·fi·cien·cies
The state or quality of being proficient; competence.

Noun 1. proficiency - the quality of having great facility and competence studies in older children
with Down syndrome have revealed deficits in eye-hand coordination, laterality laterality
or hemispheric asymmetry

Characteristic of the human brain in which certain functions (such as language comprehension) are
localized on one side in preference to the other. , and visual motor control.[13-15] Connolly and
Michael[16] compared the scores on the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP)
of children with retardation retardation: see mental retardation. , both with and without Down
syndrome, who were between the ages of 7.6 and 11 years. They found that the group with Down
syndrome had significantly lower scores in running speed, balance, strength, and visual motor
control than did the group without Down syndrome. Henderson et al[17] reported that children with
Down syndrome who were between 7 and 14 years of age scored consistently low on agility and
balance tasks when compared with matched control matched study, matched control

a comparison between groups in which each subject animal is matched by a comparable animal in
terms of age and all other measurable parameters. Called also matched or paired control. children.
Le Blanc Le Blanc is a commune and a sous-préfecture in the Indre département of France.
Geography
Le Blanc is the main city of the Parc naturel régional de la Brenne, on the banks of the Creuse River.
et Al[18] also found that children with Down syndrome whose mean age was 12 years had
difficulty with static balance when they were compared with children matched for chronological age
chron·o·log·i·cal age
n. Abbr. CA
The number of years a person has lived, used especially in psychometrics as a standard against
which certain variables, such as behavior and intelligence, are measured. and IQ. More recently,
Shea[19] assessed a group of 11- to 14-year-old children with Down syndrome using the Peabody
Developmental Motor Scales and found that static balance was the area in the test of greatest
difficulty in gross motor skills The term gross motor skills refers to the abilities usually acquired
during infancy and early childhood as part of a child's motor development. By the time they reach
two years of age, almost all children are able to stand up, walk and run, walk up stairs, etc. .

The effects of early intervention ear·ly intervention

n. Abbr. EI
A process of assessment and therapy provided to children, especially those younger than age 6, to
facilitate normal cognitive and emotional development and to prevent developmental disability or
delay. programs (EIPs) on the developmental skills of children with Down syndrome have been of
interest to researchers for a number of years. Early intervention programs usually are focused on
stimulation of developmental skills in the child as well as on facilitating parent-child interactions.
The beneficial effects of early intervention have been demonstrated by Brinkworth,[20] Connolly et
al,[21] and Sharav and Shlomo.[22] These studies, however, did not have randomly assigned control
groups. An attempt at a controlled study was made by Piper and Pless,[23] who reported that early
intervention had no effect. Their study, however, was conducted for a relatively short time (ie, 6
months), and the investigators were unable to assess the degree to which the program was
implemented in the home by the parents. Additionally, the infants were seen for only 1 hour every
other week by the researchers. It is possible that infants in that study may have received as little as
12 hours of training during the study.[24] The choice of the Griffiths Scale for assessment of
outcome in these infants may also have limited the sensitivity of the evaluation and may not have
revealed important changes in the infants.[24] Few long-term follow-up studies have been under-
taken to validate the effort and expenditures of early intervention services. Only two such
longitudinal studies of the effectiveness of EIPs have been reported in the literature.[21,22]
Investigators in both studies concluded that EIPs, along with home rearing, have improved the
functioning of children with Down syndrome. Car[6] reported a longitudinal study longitudinal
study

a chronological study in epidemiology which attempts to establish a relationship between an

antecedent cause and a subsequent effect. See also cohort study. of individuals with Down
syndrome between the ages of 6 weeks and 21 years; however, these subjects were not involved in
an organized EIP (1) (Enterprise Information Portal) See corporate portal.

(2) (Extended Instruction Pointer) The program counter on x86 CPUs. .

Although the two longitudinal studies on the effectiveness of EIPs have demonstrated beneficial
effects,[21,22] questions persist about positive outcomes of early intervention. Simeonsson et al,[25]
in a review of 27 studies on the benefits of early intervention, concluded that (1) children with
handicaps in EIPs seemed to make better progress than those children not in such programs, but
statistical significance was not attained because of the small sample sizes in the studies; (2) children
in the programs often made progress in areas not measured by the research instrument; and (3)
improvements were noted in areas not specific to the child (eg, family or sibling sibling /sib·ling/
(sib´ling) any of two or more offspring of the same parents; a brother or sister.

sib·ling
n. adjustment). White,[26] in a recent review, concluded that insufficient information was available
to be confident about the long-term impact of early intervention but felt that immediate positive
effects of intervention with disadvantaged children tend to provide support for long-term benefits.

In our last follow-up of children with Down syndrome who were involved in an EIP, we found that
they had significantly higher scores on measures of intellectual and adaptive functioning adaptive
functioning,
n the relative ability of a person to effectively interact with society on all levels and care for one's
self; affected by one's willingness to practice skills and pursue opportunities for improvement on all
levels. than did children of comparable ages with Down syndrome who did not participate in an
EIP.[21] Additionally, this group of children did not show the decline typically seen over time in
intellectual and adaptive functioning noted previously in children with Down syndrome.[4] As
expected, the children were found to be functioning below their chronological ages in gross and fine
motor skills The examples and perspective in this article or section may not represent a worldwide
view of the subject.
Please [ improve this article] or discuss the issue on the talk page.

“Dexterity” redirects here. For other uses, see Dexterity (disambiguation). , but, unexpectedly, their
fine motor skill levels exceeded their gross motor skill levels. In particular, the children were found
to perform poorly on measures of running speed, balance, strength, visual motor control, and overall
gross motor and fine motor skills in comparison with children without Down syndrome but of
comparable chronological chron·o·log·i·cal also chron·o·log·ic
adj.
1. Arranged in order of time of occurrence.
2. Relating to or in accordance with chronology. and mental ages.[16]

The purpose of this study was to examine the functioning of adolescents with Down syndrome who
experienced early intervention as infants and who continued their education in classrooms
appropriate to their needs. We compared the motor development of the children involved in an EIP
with the normative nor·ma·tive
adj.
Of, relating to, or prescribing a norm or standard: normative grammar.

nor data from a standardized standardized

pertaining to data that have been submitted to standardization procedures.

standardized morbidity rate

see morbidity rate.

standardized mortality rate

see mortality rate. motor assessment tool and with previous motor assessments using the same tool
on the same children. In addition to assessment of motor functioning, we used the same measures of
intellectual and adaptive functioning with these children as in our previous studies[21,27,28] in
order to evaluate developmental changes in these areas. We were also interested in comparing the
intellectual and adaptive functioning of these children with that of children with Down syndrome
who had not experienced early intervention. A control group was not used when this longitudinal
study was begun in 1973 because of the ethical concerns surrounding the withholding Withholding

Any tax that is taken directly out of an individual's wages or other income before he or she receives
the funds.

Notes:
In other words, these funds are "withheld" from your wages. of services from infants assigned to
control groups.[24] Shortly after the initiation of the study, state mandates that provided educational
services for all children with handicaps and permissive permissive adj. 1) referring to any act which
is allowed by court order, legal procedure, or agreement. 2) tolerant or allowing of others' behavior,
suggesting contrary to others' standards.

PERMISSIVE. programming for the preschool child precluded the use of children who might have
served as nonintervention non·in·ter·ven·tion
n.
Failure or refusal to intervene, especially in the affairs of another nation.

non control subjects,

The specific questions addressed in this study were 1. Did differences in gross motor and

fine motor skill levels occur over

time in our sample of adolescents

with Down syndrome who were

involved in an EIP? 2. Have the same areas of strengths

and weaknesses in gross motor

and fine motor skill levels as assessed

by the Bruininks-Oseretsky

Test of Motor Proficiency continued

over time in our sample of

adolescents with Down syndrome

who were involved in an EIP? 3. How do the current gross motor

and fine motor skill levels compare

with the intellectual levels of our

sample of adolescents who were

involved in an EIP? Have the motor

skill levels progressed at the same

rate as the intellectual levels since

the last systematic study of these

children? 4. Do differences in intellectual functioning

exist between our sample

of adolescents with Down syndrome

who participated in an EIP

and a comparison group that did

not participate in an EIP? 5. Do differences in social and adaptive

functioning exist between our

sample of adolescents with Down

syndrome who participated in an

EIP and a comparison group that

did not participate in an EIP? 6. Did our sample of adolescents with

Down syndrome who participated

in an EIP and subsequent appropriate

educational programming show

the typical deceleration deceleration /de·cel·er·a·tion/ (de-sel?er-a´shun) decrease in rate or speed.

early deceleration in intellectual

and adaptive functioning reported

in the literature with children

with Down syndrome?

Method

Subjects

Ten of the children with Down syndrome who participated in previous studies reported by Connolly
and colleagues[21,27,28] Constituted the early intervention (EI) group in this study. Forty children
with Down syndrome who were participating in an ongoing EIP were the subjects in the original
study.[27] By the time of the first follow-up study,[28] however, only 20 of the children could be
located. Sixteen of the children had moved from the area, 3 children failed to continue in their
educational programs, and 1 child did not consent to participate. Fourteen of the 20 children in the
second study also participated in the next follow-up study.[21] Only 10 of those children, however,
were available for follow-up evaluation in the current study. Three of the 14 children had moved
from the area, and 1 child's parents did not respond to requests for participation. All of these
children had completed the EIP at the University of Tennessee The University of Tennessee (UT),
sometimes called the University of Tennessee at Knoxville (UT Knoxville or UTK), is the flagship
institution of the statewide land-grant University of Tennessee public university system in the
American state of Tennessee. Child Development Center by 3 years of age, had remained in their
homes, and had been placed in educational settings appropriate to their level of functioning. For the
current study, the age range of the EI group subjects for the psychological testing psychological
testing

Use of tests to measure skill, knowledge, intelligence, capacities, or aptitudes and to make
predictions about performance. Best known is the IQ test; other tests include achievement tests—
designed to evaluate a student's grade or performance was 13.9 to 17.8 years (X [bar]=15.7,
SD=1.3). Their age range for gross and fine motor testing was 13.9 to 17.9 years (X [bar]=16.3,
SD=1.1). The EI group consisted of 7 female and 3 male subjects. Four of the children had attended
private special education schools, and 6 of the children had attended public special education
schools. A signed informed consent statement was obtained from each parent before testing.

An attempt was made to compare the intellectual and adaptive skills of the EI group with those of
children with Down syndrome who had been evaluated at the same center but who had not
experienced early intervention. Our 1984 study[21] used, as a comparison group, children with
Down syndrome of comparable ages from a normative study.[3] The normative data, however, did
not include mean IQs or social quotients (SQs) for children over 10 years of age. For the current
study, the comparison data were drawn from the records of children who had been evaluated at the
center during the previous 12-year period and who fell within the same age range at the time of
testing as the EI group subjects. From a pool of 20 children, 10 children were selected on the basis
of three criteria: (1) availability of scores on the Stanford-Binet Intelligence Scale Stanford-Binet
Intelligence Scale

test used to measure IQ; designed to be used primarily with children. [Am. Education: EB, IX: 521]

See : Intelligence , Form L-M,[29] and the Vineland Social Maturity Scale[30]; (2) closeness in age
to the EI group subjects at the time of testing; and (3) gender. Age at time of testing was used as the
primary matching variable because previous studies have consistently shown a deceleration in the
rate of development in intellectual and adaptive skills with increased chronological age in children
with Down syndrome.[3,4]

The age range (at time of testing) of the children in the comparison group was 12.1 to 18.6 years (X
[bar]=14.8, SD=1.8). A t test indicated no significant differences in age at testing between the EI
group and the comparison group. The gender distribution of the comparison group was 6 females
and 4 males. A chi-square test chi-square test: see statistics. revealed no significant differences in
gender distribution between the EI and comparison groups.

Although the comparison group was from the same geographic region as the EI group and both
groups appeared to be representative of a broad socioeconomic so·ci·o·ec·o·nom·ic
adj.
Of or involving both social and economic factors.

socioeconomic
Adjective

of or involving economic and social factors

Adj. 1. range, lack of precise records on such variables as parental income and educational level
precluded control of socioeconomic level, which could be a confounding variable A confounding
variable (also confounding factor, lurking variable, a confound, or confounder) is an extraneous
variable in a statistical or research model that should have been experimentally controlled, but was
not. . Another problem concerned the possible cohort effect The term cohort effect is used in social
science to describe variations in the characteristics of an area of study (such as the incidence of a
characteristic or the age at onset) over time among individuals who are defined by some shared
temporal experience or common life because the children in the comparison group were, on the
average, 8 years older than the children in the EI group although their chronological age at the time
of testing was comparable) and may not have had, for example, the same educational opportunities.
The implications of these limitations in comparative data are discussed later.

Tests

The BOTMP (long form) was individually administered to each of the children who had been
involved in the EIP by a physical therapist experienced in the administration of the test.31 Validity
of the BOTMP scores has been established through consideration of (1) the relationship of test
content to significant aspects of motor development as cited in research studies, (2) the relevant
statistical properties of the test, and (3) the functioning of the test with contrasting groups of
handicapped and nonhandicapped children.[31] Reliability for test scores has been established
through studies on interrater reliability (r=.90-.98) and test-retest reliability test-retest
reliability Psychology A measure of the ability of a psychologic testing instrument to yield the same
result for a single Pt at 2 different test periods, which are closely spaced so that any variation
detected reflects reliability of the instrument (r=.86-.89).[31] The BOTMP consists of subtests in
running speed, balance, bilateral coordination of the arms and legs, strength, upper-limb
coordination, response time, visual motor control, and speed and dexterity of the upper extremities
upper extremity
n.
The shoulder, arm, forearm, wrist, or hand. Also called superior limb, thoracic limb. . The BOTMP,
a standardized test A standardized test is a test administered and scored in a standard manner. The
tests are designed in such a way that the "questions, conditions for administering, scoring
procedures, and interpretations are consistent" [1] , yields two ages for each of the individual
subtests: a gross motor skills composite age and a fine motor skills composite age. if a child scores
below the basal basal /ba·sal/ (ba´s'l) pertaining to or situated near a base; in physiology, pertaining
to the lowest possible level.

ba·sal
adj.
1. age of the test (ie, 4 years 2 months), he or she is assigned a score of below 4 years 2 months.
The test is standardized for children between the ages of 4 years 2 months and 16 years. Although
most of the children in this study were chronologically chron·o·log·i·cal also chron·o·log·ic
adj.
1. Arranged in order of time of occurrence.

2. Relating to or in accordance with chronology. beyond 16 years of age, the test was felt to be
appropriate because their mental and motor ages were below 16 years. Motor ages on the eight
subtests of the BOTMP as well as a gross motor and a fine motor composite age were determined
for each child. Data on the BOTMP were not available on the comparison group because of the lack
of availability of the BOTMP prior to 1978. The test scores of the children involved in the EIP were
compared against the normative data presented on the BOTMP and against their own previous
scores.

Both the Stanford-Binet Intelligence Scale, Form L-M, and the Vineland Social Maturity Scale were
individually administered to the children by a trained psychological examiner. The Stanford-Binet
Scale served as a measure of general intellectual functioning, and the Vineland Scale served as a
measure of general adaptive functioning including socialization socialization /so·cial·iza·tion/ (so?
shal-i-za´shun) the process by which society integrates the individual and the individual learns to
behave in socially acceptable ways.
so·cial·i·za·tion
n. , communication, and self-help skills. Both scales have been demonstrated to be psychometrically
sound instruments with acceptable reliability and validity.[29,30] For the Vineland Scale, each
child's mother or father provided the information from which the SQ was derived. Although more
recent editions of each of these scales are now available, the editions used in our past follow-up
studies were used to allow for more valid comparisons from study to study.

Procedures

Data collection took place at the Boling Center for Developmental Disabilities developmental
disabilities (DD),
n.pl the pathologic conditions that have their origin in the embryology and growth and development
of an individual. DDs usually appear clinically before 18 years of age. at The University of
Tennessee, Memphis, or at the Department of Psychology at Memphis State University. One child
was seen at Vanderbilt University Vanderbilt University, at Nashville, Tenn.; coeducational;
chartered 1872 as Central Univ. of Methodist Episcopal Church, founded and renamed 1873, opened
1875 through a gift from Cornelius Vanderbilt. Until 1914 it operated under the auspices of the
Methodist Church. , but by the same examiners who evaluated the other children in the study. The
order of testing of the children was random and not according to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3. their individual developmental or chronological ages. To obtain the data, a total of 4 hours on
two separate occasions was spent with each child and parent. The administration of the cognitive,
adaptive, and academic tests at times different (with one exception) from that of the administration
of the motor tests should not have influenced the results of the study.

Data Analysis

Descriptive and inferential statistics inferential statistics

see inferential statistics. were used to describe and analyze fine motor and gross motor skills of the
EI group subjects as well as their intellectual and adaptive functioning. Means, ranges, and paired t-
test values were used for analysis of the first two research questions. The Pearson Product-Moment
Correlation Coefficient Noun 1. Pearson product-moment correlation coefficient - the most
commonly used method of computing a correlation coefficient between variables that are linearly
related
product-moment correlation coefficient was used to determine the relationships between changes in
mental ages and motor ages for research question 3. Means, ranges, and independent t-test values
were also used to analyze the data pertaining per·tain
intr.v. per·tained, per·tain·ing, per·tains
1. To have reference; relate: evidence that pertains to the accident.

2. to research questions 4 and 5. Descriptive statistics descriptive statistics

see statistics. of means, ranges, and percentages were used to analyze information related to
research question 6. When inferential in·fer·en·tial
adj.
1. Of, relating to, or involving inference.

2. Derived or capable of being derived by inference.

in statistical analysis was performed, a .05 level of significance was used. Caution should be used
in interpreting statistical significance from multiple t tests, because at least 1 of every 20 tests
undertaken will achieve statistical significance by chance alone. Use of a smaller alpha-risk or level
of significance, however, allows one to be more certain about accepting or rejecting a hypothesis.

Results

Motor Skills

On the average, the children in the EI group had a mean gross motor composite age of 6.05 years
(SD=1.38) compared with a fine motor composite age of 5.64 years (SD=1.01), as determined by
the motor assessment tools. The range of individual scores was from 3.5 to 7.7 years in gross motor
skills and from 3.0 to 7.5 years in fine motor skills. Table 1 compares the scores obtained for the EI
group in the previous follow-up study[21] and in this study.
Table 1. Composite Scores for Fine Motor Skills and Gross Motor Skills of Early
Intervention Group (N=10)
Second Follow-up Present
Category Study[21] Study
Gross motor composite age (y)
X [bar] 4.85 6.05(a)
SD 0.72 1.38
Range 3.5-5.9 3.5-7.7
Fine motor composite age (y)
X [bar] 4.50 5.64(b)
SD 0.82 1.01
Range 3.0-5.7 3.0-7.5
(a) significant at t=2.69, df=18, and P=.0249.
(b) significant at t=4.02, df=18, and P=.0003.

Changes for the EI group on specific subtests of the BOTMP are shown in Table 2. Significant
differences were noted in running speed, balance, strength, visual motor coordination Gross motor
coordination addresses the gross motor skills: walking, running, climbing, jumping, crawling,
lifting one's head, sitting up, etc.

Fine motor coordination , and upper-limb speed and dexterity. A further comparison of the subtest
scores of the children revealed that strength, upper-limb coordination, bilateral coordination, and
upper-limb speed and dexterity continued to be areas of strength and that balance, visual motor
coordination, running speed, and response time continued to be areas of weakness (Tab. 3). Five of
the children had fine motor skill scores that exceeded their gross motor skill scores; the other five
children had gross motor skill scores that exceeded their fine motor skill scores. Interestingly, those
children who had attended a private school that emphasized participation of the children in Special
Olympics Special Olympics
International sports program for people with intellectual disability. It provides year-round training
and athletic competition in a variety of Olympic-type summer and winter sports for participants.
programs had gross motor skill scores that surpassed their fine motor skill scores.
Table 2. Bruininks-Oseretsky Test of Motor Proficiency Mean Component Scores
for Fine Motor Skills and Gross Motor Skills of Early Intervention Group (N=10)
Second Follow-up Present
Component Study[21] Study
Running speed >4.17 5.42(b)
Balance 4.00 4.92(b)
Bilateral coordination 5.17 5.92
Strength 5.92 7.42(a)
Upper-limb coordination 5.92 6.67
Response speed >4.17 4.92
Visual motor coordination 4.42 5.92(c)
Upper-limb speed and dexterity 5.42 6.42(b)
(a) Significant at P=.05.
(b) Significant at P=.01.
(c) Significant at P=.005.
Table 3. Motor Skills of Early Intervention Group(a) (N=10)
Second Follow-up Study(21) Present Study
Upper-limb coordination Strength
Strength Upper-limb coordination
Bilateral coordination Upper-limb speed and dexterity
Upper-limb speed and dexterity Bilateral coordination
Balance Visual motor coordination
Visual motor coordination Running speed
Running speed Balance
Response time Response time
(a) Ranked highest to lowest.

Table 4 illustrates the changes in the rate of development that occurred since the last assessment of
the EI group subjects in the areas of gross motor, fine motor, and cognitive functioning cognitive
function Neurology Any mental process that involves symbolic operations–eg, perception, memory,
creation of imagery, and thinking; CFs encompasses awareness and capacity for judgment . As
noted, the ratio of gross motor skill development to mental age improved in 8 of the 10 children.
The ratio of fine motor skill development to mental age improved in 7 of the 10 children.
Additionally, using the Pearson correlation coefficient Correlation Coefficient

A measure that determines the degree to which two variable's movements are associated.

The correlation coefficient is calculated as: , no significant correlations were found between changes
in motor skill levels and changes in cognitive functioning of the children using the mean gross
motor composite, fine motor composite, and mental age data (r=.04-.43).
Table 4. Ratios of Gross Motor Age and Fine Motor Age to Mental Age for the
Early Intervention Group (N=10)
Child Gross Motor Age/Mental Age Fine Motor Age/Mental Age
1
1984 1.46 1.17
1989 1.38 1.44
2
1984 0.89 0.81
1989 0.54 0.65
3(a)
1984 0.96 0.89
 1989 1.17 1.00
4
1984 1.08 0.92
1989 1.56 1.78
5(a)
1984 0.89 0.89
1989 1.08 0.85
6(a)
1984 1.00 1.00
1989 1.27 1.03
7(a)
1984 1.04 1.17
1989 1.15 0.85
8
1984 1.11 0.94
1989 1.18 1.06
9(a)
1984 0.84 1.02
1989 1.03 1.24
10
1984 0.72 0.76
1989 0.89 1.00
(a) Involved in organized physical education program.

Intellectual and Adaptive Skills

Table 5 shows the comparison between the EI group and the comparison group in terms of
chronological age, IQ, and SQ. Although the two groups were comparable in age at the time of
testing for this study, the differences in scores should be used only for rough comparative purposes
because of the previously noted uncontrolled variables. As in each of our previous studies,[21,27,28]
the EI group showed significantly higher IQs and SQs than did the comparison group. The mean IQ
for the EI group was about 10 points higher than that for the comparison group, a difference that is
statistically significant (t=2.18, df=18, P<.05). Further, the mean SQ for the EI group was 24.5
points higher than that for the comparison group, which represents a highly significant difference
(t=3.55, df=18, P<.01).
Table 5. Chronological Age, Intelligence Quotient (IQ), and Social Quotient (SQ)
of Early Intervention (EI) Group and Comparison Group
EI Group Comparison Group
(n=10) (n=10)
Chronological age (y)
X [bar] 15.7 14.8
SD 1.3 1.8
Range 13.9-17.8 12.1-18.6
IQ(a)
X [bar] 40.1(b) 30.5
SD 9.6 10.1
Range 25-53 17-45
SQ(c)
X [bar] 60.2(d) 35.7
SD 18.6 11.4
Range 34-96 21-61
(a) assessed by Stanford-Binet Intelligence Scale (Form L-M).
(B) Significant at t=2.18, df=18, P<.05.
(c) Assessed by Vineland Social Maturity Scale.
(d) Significant at t=3.55, df=18, P<.01.
Table 6 compares the EI and comparison groups with regard to percentage of children at each level
of mental retardation mental retardation, below average level of intellectual functioning, usually
defined by an IQ of below 70 to 75, combined with limitations in the skills necessary for daily
living. as defined by IQ range. The majority (70%) of the EI group subjects were at the mild and
moderate levels, whereas the majority (60%) of the comparison group subjects were at the severe
and profound levels. Moreover, none of the EI group subjects were at the profound level, whereas
20% of the comparison group subjects were at this level.
Table 6. Percentage of Children at Each Mental Retardation Level in Early
Intervention (EI) and Comparison Groups
Mental Retardation
Level(a) EI Group (n=10) Comparison Group (n=10
Mild (IQ=52-67) 10 0
Moderate (IQ=36-51) 60 40
Severe (IQ=20-35) 30 40
Profound (IQ<20) 0 20
(a) According to American Association on Mental Retardation classification.

Table 7 compares IQ and SQ means and ranges for the 10 children in the EI group at the time of the
first two follow-up studies[21,28] and in this study. Although the mean SQ has remained relatively
stable for the three studies (1980-1989), the mean IQ showed a statistically significant decrease
(t=7.82, df=9, P<.001) from 53.5 to 40.1 during the 6.8 years between the time of data collection of
the second follow-up study[21] and this study. [Tabular tab·u·lar
adj.
1. Having a plane surface; flat.

2. Organized as a table or list.

3. Calculated by means of a table.

tabular

resembling a table. Data 7 Omitted]

Discussion

Motor Skills

The outcome of the motor assessment revealed that the children in the EI group, on the average, had
gross motor skill levels that exceeded their fine motor skill levels. Additionally, the children's
overall gross motor age (6.05 years) more closely approximated their average mental age (6.1 years)
than did their fine motor age (5.64 years).

Previous studies have demonstrated that children with Down syndrome generally have deficits in
eye-hand coordination, balance, laterality, visual motor activities, and reaction time.[12-19] Our
previous data on the EI group using the BOTMP in 1984 revealed that eye-hand coordination,
bilateral coordination, and upper-limb speed and dexterity were found to be among the most
advanced motor skills for the children.[21] These skills were also found to be high in this study.
Areas of deficit continued to be running speed, balance, and reaction times.

As previously stated, running speed and balance continued to be problematic for these children.[16]
Our results are consistent with previous reports of balance problems in other studies of children with
Down syndrome.[18,19] The neuropathology neuropathology /neu·ro·pa·thol·o·gy/ (-pah-thol´ah-je)
pathology of diseases of the nervous system.

neu·ro·pa·thol·o·gy
n.
The study of diseases of the nervous system. associated with children with Down syndrome
included delayed cerebellar cerebellar /cer·e·bel·lar/ (ser?e-bel´ar) pertaining to the cerebellum.
Cerebellar
Involving the part of the brain (cerebellum), which controls walking, balance, and coordination.
maturation maturation /mat·u·ra·tion/ (mach-u-ra´shun)
1. the process of becoming mature.

2. attainment of emotional and intellectual maturity.

3. and a relatively small cerebellum cerebellum (sĕr'əbĕl`əm), portion of the brain that coordinates
movements of voluntary (skeletal) muscles. It contains about half of the brain's neurons, but these
particular nerve cells are so small that the cerebellum accounts for and brain stem brain stem, lower
part of the brain, adjoining and structurally continuous with the spinal cord. The upper segment of
the human brain stem, the pons, contains nerve fibers that connect the two halves of the cerebellum.
.[32] We hypothesize hy·poth·e·size
v. hy·poth·e·sized, hy·poth·e·siz·ing, hy·poth·e·siz·es

v.tr.
To assert as a hypothesis.

v.intr.
To form a hypothesis. that the problems noted in balance, running speed (as related to motor
planning), and coordination (as measured by reaction times) in the children with Down syndrome
may be related to neuropathological causes.

Although we did not perform specific sensory evaluations on the EI group subjects during this
study, we suspected problems in the somatosensory somatosensory /so·ma·to·sen·sory/ (so?mah-to-
sen´so-re) pertaining to sensations received in the skin and deep tissues.

so·mat·o·sen·so·ry
adj. and vestibular ves·tib·u·lar
adj.
Of, relating to, or serving as a vestibule, especially of the ear.

Vestibular
Pertaining to the vestibule; regarding the vestibular nerve of the ear which is linked to the ability to
hear sounds. systems because of the deficits identified. Previous research supports our suppositions
about improper integration of sensory information in children with Down syndrome. Anwar and
Hermelin[33] reported that children with Down syndrome had more difficulty than control groups in
making directional In one direction. Contrast with omnidirectional. judgments after participation in
asymmetrical a·sym·met·ri·cal or a·sym·met·ric
adj. Abbr. a
Lacking symmetry between two or more like parts; not symmetrical. pointing. These authors
suggested that the children with Down syndrome experienced a disruption of their spatial frame of
reference because of the kinesthetic kin·es·the·sia
n.
The sense that detects bodily position, weight, or movement of the muscles, tendons, and joints.

[Greek k aftereffects aftereffects after npl → Nachwirkungen pl of the asymmetrical pointing and
that the use of proprioceptive Proprioceptive
Pertaining to proprioception, or the awareness of posture, movement, and changes in equilibrium
and the knowledge of position, weight, and resistance of objects as they relate to the body.
reafferent feedback might be beneficial in children with Down syndrome.

Henderson et al[15] found that tasks requiring the use of both proprioceptive and visual reference
systems (ie, drawing and copying) were deficient de·fi·cient
adj.
1. Lacking an essential quality or element.

2. Inadequate in amount or degree; insufficient.

deficient

a state of being in deficit. in children with Down syndrome. They speculated that children with
Down syndrome have difficulty with integration of information across modalities Modalities
The factors and circumstances that cause a patient's symptoms to improve or worsen, including
weather, time of day, effects of food, and similar factors. . In support of the results reported by
Henderson et al, we found that the EI group subjects had deficits in visual motor coordination and
response time tasks on the BOTMP that could have resulted because they experienced difficulty in
integrating visual and proprioceptive information.

Butterworth and Cicchetti[34] reported that young children with Down syndrome needed longer
periods of visual cuing than did children without Down syndrome when they were placed in a
situation in which the walls moved and the floor on which they were sitting remained stable. They
suggested that infants with Down syndrome may require a higher level of vestibular input in order to
respond to information from the environment. In view of these reported somatosensory deficits
noted in children with Down syndrome, the need for increased somatosensory input may become
clinically important.

As a group, the children involved in the EIP continued to make gains in their gross and fine motor
skills between the time of second follow-up study and this study. When comparisons were made of
the ratios between their mental ages and their gross and fine motor skill ages, 8 of the 10 children
had motor ages that increased at a faster rate than their mental ages. When individual comparisons
were made, only 2 of the 10 children did not show this increase in gross motor skills. Both of these
children were overweight, although 2 of the other 8 children were also overweight. Additionally, 1
child who did not show an increase in the ratio of gross motor skills to mental age had received a
cardiac pacemaker cardiac pacemaker A device that delivers a small electric shock to the heart to
effect cardiac contraction at a pre-determined rate at 6 months of age. This particular child has had
several "demand" type pacemakers Pacemakers Definition

A pacemaker is a surgically-implanted electronic device that regulates a slow or erratic heartbeat.

Purpose

Pacemakers are implanted to regulate irregular contractions of the heart (arrhythmia). implanted
im·plant
v. im·plant·ed, im·plant·ing, im·plants

v.tr.
1. To set in firmly, as into the ground: implant fence posts.

2. since the time of the original pacemaker pacemaker

Source of rhythmic electrical impulses that trigger heart contractions. In the heart's electrical system,
impulses generated at a natural pacemaker are conducted to the atria and ventricles. and has been
restricted in her physical activities since her early teens.

On the average, the children who demonstrated the greatest increases in their gross motor skill levels
were children who were involved in organized physical education programs that culminated in their
participation in Special Olympics events. Participation of adolescents with mental retardation in
structured physical training programs has been shown to be beneficial in several studies. Wright and
Cowden[35] reported that adolescents with mental retardation who participated in a Special
Olympics swimming program had a significant improvement in self-concept and cardiovascular
endurance after only a 10-week period. Skrobak-Kaczynkie and Vavik[36] reported that male
subjects with Down syndrome (ages 11-31 years) responded well to circuit-training programs that
were aimed at increasing aerobic aerobic /aer·o·bic/ (ar-o´bik)
1. having molecular oxygen present.

2. growing, living, or occurring in the presence of molecular oxygen.

3. requiring oxygen for respiration.

4. capacity and muscular strength. Additionally, they stated that those subjects who participated in
the circuit-training programs had significant weight loss and subcutaneous fat Subcutaneous fat is
found just beneath the skin as opposed to visceral fat which is found in the peritoneal cavity.
Subcutaneous fat can be measured using body fat calipers giving a rough estimate of total body
adiposity. loss as well as having a marked increase in muscle strength.

Observations during the administration of the subtests of the BOTMP in this study revealed that the
children, as a group, were slow in their fine motor movements during the administration of the tests.
Overall, the children were attuned at·tune
tr.v. at·tuned, at·tun·ing, at·tunes
1. To bring into a harmonious or responsive relationship: an industry that is not attuned to market
demands.
2. to accuracy and had increased error correction during the testing. For example, when a bead bead

Small object, usually pierced for stringing. It may be made of virtually any material—wood, shell,
bone, seed, nut, metal, stone, glass, or plastic—and is worn or affixed to another object for
decorative or, in some cultures, magical purposes. was dropped during the stringing of beads, most
of the children opted to pick up the dropped bead (even from the floor) and string it next rather than
taking another bead from the container. During pencil tracing inside a pathway, the children self-
corrected and returned to the point at which they had exited the pathway in error with the pencil
rather than continuing to the end of the pathway This increased attention to accuracy cost" the
children valuable seconds during the testing and thus lowered their scores on the subtest.

Intelectual and Adaptive Skills

In view of uncontrolled variables between the two groups, the differences in intellectual and
adaptive scores should be interpreted with great caution within the context of this descriptive study.
Table 5 reveals the mean IQ for the EI group to be about 10 points higher than that for the
comparison group and the mean SQ to be almost 25 points higher. Furthermore, as shown in Table
6, 70% of the El group subjects were at the mild or moderate level of retardation, with none at the
profound level. In contrast, 80% of the comparison group subjects were at the moderate or severe
level, and 20% were at the profound level.

Our findings are consistent with the hypothesis that early intervention has a beneficial effect on
intellectual and adaptive skills that extends well into the adolescent years; however, the limitations
of the design allow for alternative explanations. We cannot conclude that the higher scores of the El
group were unequivocally due to early intervention. Because the EIP was open to any family and
participation was voluntary, we were unable to randomly assign children to either a treatment group
or a control group. in the absence of a randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment.
groups design or a matched groups design, certain uncontrolled variables could well have
contributed to differences between the two groups.

Foremost among these variables is that of the cohort effect. Because the children in the comparison
group were, on the average, 8 years older than the children in the EI group, there is the strong
likelihood that they did not have comparable educational opportunities and experiences as their
younger counterparts. Another confounding variable that could conceivably con·ceive
v. con·ceived, con·ceiv·ing, con·ceives

v.tr.
1. To become pregnant with (offspring).

2. have contributed to the differences in scores is the possible differences in socioeconomic levels
between the two groups. Another significant variable that must be considered is the substantial
attrition Attrition

The reduction in staff and employees in a company through normal means, such as retirement and
resignation. This is natural in any business and industry.

Notes: that occurred in the EI group from the time of the original study. It is likely that this group
represents a select group in terms of health as well as intellectual and adaptive functioning.
Moreover, their parents probably constitute a select group in terms of motivation and interest, as
reflected both in their pursuit of appropriate educational programs and in their participation in a
series of follow-up studies.

In interpreting differences between groups from one follow-up study to another, it should be kept in
mind that the same comparison group could not be used for the three studies. Examiner bias may
have been present because only the El group was evaluated for gross motor and fine motor skills
across the 16-year longitudinal study and the physical therapist was therefore not blinded to the
status of the children. The scores obtained were either compared with normative data from
standardized tests or from the children's own previous scores on the evaluative tool. Less chance of
examiner bias was present in the IQ and SQ testing, as the psychological examinations were
performed by psychologists who had not been involved in the EIP or in previous psychological
testing with the El group subjects. All of these design problems necessitate ne·ces·si·tate
tr.v. ne·ces·si·tat·ed, ne·ces·si·tat·ing, ne·ces·si·tates
1. To make necessary or unavoidable.

2. To require or compel. cautious interpretations of our findings and consideration of alternative

explanations for the differences between the groups.

In this study, we also did a longitudinal lon·gi·tu·di·nal

adj.
Running in the direction of the long axis of the body or any of its parts. comparison of IQs and SQs
for the 10 EI group subjects, who participated in all three of the follow-up studies. Although this
group showed similar mean IQs from the first follow-up study[28] (IQ=55.3) to the second follow-
up study[21] (IQ=53.5), the group's mean IQ dropped to 40.1 during the 6.8 years from the second
follow-up study to this study. Nevertheless, the mean IQ in this study was significantly higher than
the mean IQ of 30.5 in the comparison group. These results suggest that the rate of deceleration in
intellectual development shown in most children with Down syndrome was not as pronounced in the
EI group subjects.[4] An encouraging finding was that the mean SQ, which serves as a measure of
adaptive functioning, demonstrated no corresponding decrease and remained fairly stable for the
first (SQ = 59.8), second (SQ = 63.3), and third (SQ = 60.2) follow-up studies. This finding
indicates that the El group subjects' adaptive skills were maintained at a relatively high level (mild
retardation) and were less affected by increasing age than were their intellectual abilities.

Clinical Implications

The developmental therapist working with children with Down syndrome needs to be aware of gross
motor and fine motor skill deficits that are seen in children with Down syndrome during the
adolescent years. Balance and visual motor tasks continue to be problem areas[12,18,19,34] for
children with Down syndrome, and we believe EIPs should emphasize therapeutic interventions in
these areas as a means of decreasing functional deficits.[33,37-39] Functionally, balance may be a
problem for the older child with Down syndrome who must be able to perform in situations in which
his or her center of gravity is routinely perturbed per·turb
tr.v. per·turbed, per·turb·ing, per·turbs
1. To disturb greatly; make uneasy or anxious.

2. To throw into great confusion.

3. (eg, crowded school hallways, shopping malls, city streets, playgrounds, and other recreational
areas). We concur CONCUR - ["CONCUR, A Language for Continuous Concurrent Processes",
R.M. Salter et al, Comp Langs 5(3):163-189 (1981)]. with others who suggest that techniques that
involve proprioceptive, vestibular, and visual input may be beneficial to children with Down
syndrome.[33,37-39]

Based on the findings of the 10 EI group subjects, participation in an organized physical education
program even during the adolescent years may be important in order for the children to continue to
make optimal progress in their gross motor skill development. Physical therapists should play a
consultant role to physical educators in offering suggestions for activities that improve gross motor
and fine motor functioning as well as physical fitness.

In the area of fine motor development, perhaps less emphasis should be placed on accuracy with
adolescents with Down syndrome and more emphasis placed on speed if speed is needed in the
motor tasks that are asked of them. This would be of particular functional importance if the
adolescent is being prepared for a vocation that requires speed but not necessarily precision.

Conclusions

The overall results indicated that our sample of adolescents with Down syndrome continued to show
deficits in similar areas of gross motor and fine motor skills that were identified during their late
childhood. As a group, however, their gross motor and fine motor skills improved over time. The EI
group subjects' intellectual and adaptive functional levels were found to be higher than expected at
13 to 17 years of age in comparison with other children of comparable age with Down syndrome.
Although there are threats to the validity of these findings and we cannot clearly attribute the
subjects' levels of functioning to the EIP, we continue to believe that early intervention with the
child and the family is a critical first step in the long-range educational program of children with
Down syndrome. We also believe that the EIP served as a motivator for parents in securing
appropriate programs and services for their children.

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• Ability to lift and control the orientation of the head

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• Walking begins
• Speech begins
•

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A firth.

[Alteration of firth.]
Frith woods or wooded country collectively. See also forest. U, Frith CD. Specific motor
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1. Often Offensive Affected with mental retardation.

2. Occurring or developing later than desired or expected; delayed. children, with and without
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per·cept
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1. The object of perception.

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Harvard College, originally for men, was founded in 1636 with a grant from the General Court of
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A lengthy, formal treatise, especially one written by a candidate for the doctoral degree at a
university; a thesis.

dissertation
Noun

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a. 1. Of, pertaining to, or involving, kinaesthesia.

Adj. 1. kinaesthetic - of or relating to kinesthesis

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Commentary

The last two decades have witnessed extraordinary changes in the lives of individuals with Down
syndrome, beginning with the deinstitutionalization de·in·sti·tu·tion·al·i·za·tion
n.
The release of institutionalized people, especially mental health patients, from an institution for
placement and care in the community. movement and continuing with the current effort toward
inclusion in the mainstream of society. Connolly and colleagues have conducted an interdisciplinary
study of the motor, mental, and social attainments of a group of children with Down syndrome who
had participated in an early intervention program in the 1970s. The current report is the fourth in
their series.[1-3] They are to be commended for their perseverance Perseverance
See also Determination.

Ainsworth

redid dictionary manuscript burnt in fire. [Br. Hist.: Brewer Handbook, 752]

Call of the Wild, The

dogs trail steadfastly through Alaska’s tundra. [Am. Lit. in this difficult, but very worthwhile, task.
In designing the study, the authors also identified a group of children with Down syndrome who had
not experienced early intervention for comparison of mental and social abilities with the study
group. They acknowledge several factors that limit comparison of the two groups. Another issue that
may be relevant is that samples drawn from clinic populations, such as the comparison group in this
study, frequently include children who are having problems of some sort, which is the reason for
their referral for testing. Although the latter may not have been true in this study, I agree with the
authors' opinion that this should be considered a descriptive study rather than an experimental study
of early intervention.

An area of concern is the small size of the study group. Although the small sample size is
understandable, given the problems of keeping in contact with families over a long period, it limits
the application of the findings because of the marked variability in all areas of growth and
development that has been noted in Down syndrome.[4] This variability is thought to be related to a
variety of factors, including gene dosage Gene dosage is the number of copies of a gene present in a
cell or nucleus. An increase in gene dosage can cause higher levels of gene product if the gene is not
subject to regulation from elsewhere in the body. , gender, muscle tone, severity of congenital heart
defects Congenital heart defects
Congenital means conditions which are present at birth. Congenital heart disease includes a variety
of defects that babies are born with.

Mentioned in: Heart Failure, Heart Surgery for Congenital Defects , and parental follow-through
with developmental activities, as well as to their interrelationships.[5-7] Accounting for these
sources of variability, which have been found to relate to developmental outcome, requires studies
with relatively large samples.

The Bruininks-Oseretsky Test of Motor Proficiency, which was used to test gross and fine motor
skills, is one of a very few standardized tests available for testing children with mental retardation in
late childhood and early adolescence.[8] It was not possible, because of the chronological ages of
the study sample, to use standard scores or percentiles to describe their performance; therefore, age
equivalents, with their well-known limitations, were the available option. The test manual lists
battery composite age-equivalent scores and separate gross and fine motor composite age-equivalent
scores. (I was somewhat confused about the meaning of the ranges of gross and fine motor
composite scores in Table 1 because the test manual does not list specific age equivalents below 4.2
years.) The test authors suggest caution in interpreting the gross and fine motor composite scores,
because they are computed from a very limited number of subtest scores and are therefore not
considered stable. This restricts the applicability of the comparisons of gross and fine motor scores
as well as the comparisons of motor and mental ages in

Table 4. The broad range of numbers of subtest items (ie, from one for running speed and response
speed to nine for upper-limb control) makes it difficult to attempt comparisons such as those found
in Tables 2 and 3. Recognizing all of these limitations, it is still interesting to see that areas of
competence and difficulty are not dissimilar to those that have been found in other studies.[9,10]
This is a very heartening heart·en
tr.v. heart·ened, heart·en·ing, heart·ens
To give strength, courage, or hope to; encourage. See Synonyms at encourage.

Adj. 1. finding and adds to our very small store of information about later motor skills in
individuals with Down syndrome. Of interest also are the observations about the children's approach
to motor tasks and their participation in physical education programs.

Further studies of both younger and older children are needed to attempt to understand the
components of motor deficits in Down syndrome as well as motor learning styles. Motor control
studies by physical therapists and occupational therapists occupational therapist A person trained to
help people manage daily activities of living–dressing, cooking, etc, and other activities that
promote recovery and regaining vocational skills Salary $51K + 4% bonus. See ADL. have
identified some of these components and have pointed out that noting delays and deficits in motor
skill development is the important first step, but that we must go on to look at factors such as
strength and stability and then to evaluate treatment efficacy.[11-13] Such an approach is given
some support by the earlier study by Harris[14] of the efficacy of early neurodevelopmental
treatment in infants with Down syndrome, which found no differences in standardized test scores
between treatment and control groups, but some differences in attainment of motor behaviors that
were part of the treatment objectives by the treatment group. Additional factors such as pulmonary
function, overweight, and body proportions and their relationship to posture and movement remain
to be explored. Physical therapists and occupational therapists are in a unique position to approach
these tasks.

Although the authors have taken advantage of their longitudinal data to make comparisons of results
at follow-up, it would also have been interesting to look at the progress of individual children over
time. One could examine, for example, whether good performance in motor skills in early life
carried over into adolescence, even though we recognize the limitations of prediction of later
development for individual children.15 Of interest also would be some information from the parents
of the children, who are clearly an interested and motivated group, about their view of the children
and their experiences in parenting a child with a disability. Perhaps information of this type, which
would be valuable information for practitioners, is forthcoming.

Alice M Shea, ScD, PT Associate for Research and Education Department of Physical Therapy and
Occupational Therapy Services Children's Hospital A children's hospital is a hospital which offers
its services exclusively to children. The number of children's hospitals proliferated in the 20th
century, as pediatric medical and surgical specialties separated from internal medicine and adult
surgical specialties. 300 Longwood Ave Boston, MA 02115

References

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RM, Cronk Verb 1. cronk - utter a hoarse sound, like a raven
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