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Gross Motor Development and Down Syndrome
The Goal and Opportunity of Physical Therapy
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Gross Motor Development and Down Syndrome

Written by Patricia C. Winders, PT
Senior Physical Therapist, Down Syndrome Specialist
Sie Center for Down Syndrome
The Children's Hospital, Aurora, CO

What are some of the challenges that babies with Down syndrome face in their gross motor development?

Children with Down syndrome want to do what all children want to do: they want to sit, crawl, walk, explore their environment, and interact with the people around them. To do that, they need to develop their gross motor skills. Because of certain physical characteristics, which include hypotonia (low muscle tone), ligamentous laxity (looseness of the ligaments that causes increased flexibility in the joints), and decreased strength, children with Down syndrome don’t develop motor skills in the same way that the typically-developing child does. They find ways to compensate for the differences in their physical make-up, and some of the compensations can lead to long-term complications, such as pain in the feet or the development of an inefficient walking pattern.

The goal of physical therapy for these children is not to accelerate the rate of their development, as is often presumed, but to facilitate the development of optimal movement patterns. This means that over the long term, you want to help the child develop good posture, proper foot alignment, an efficient walking pattern, and a good physical foundation for exercise throughout life.

What do you do in a typical physical therapy session?

First, I observe what skills the child has already mastered on his or her own. Then I determine what the child is ready to learn next. It’s critical that we teach children what they’re ready to learn within the next month rather than work on something that’s too advanced for them.

Once I know what skill the child is ready to learn, I develop a way to teach him that skill. I break the skill down into its component parts, and then I practice the skill with a variety of strategies to test with which method the child is most successful. The strategies are based on the child’s learning style and physical make-up.

Lastly and most importantly, I teach the parents how to practice the skill with their child. The parents can practice the skill when the child is feeling rested and strong, and the skills can be incorporated into the daily routine. Through practice and repetition, the child will develop strength and efficiency, leading to mastery of the skill.

You write that children are typically either “motor-driven” or “observers” by nature. How does temperament impact physical therapy?

Temperament is a person’s characteristic manner of thinking, behaving and reacting. I look at a child’s pattern of thinking, behaving and reacting when learning gross motor skills. It is my observation that children with Down syndrome fall into two basic categories of temperament: motor-driven and observer. Children who are motor-driven tend to be risk-takers. They like to move fast and tolerate new movements and positions. They do not want to stay in one place and dislike being stationary. Children who are observers are more cautious, careful, and want to be in control. They prefer stationary positions and are easily frightened when learning new movements.

When children who are motor-driven are learning how to walk, for example, they will take risks to take independent steps and will be undeterred by frequent falls. Observers will be more cautious and will only risk independent steps when they are sure of their balance.

Understanding your child’s temperament and what motivates him will help you be more effective in helping him learn gross motor skills. You will know in advance which activities he is likely to enjoy and which activities he is likely to resist. Knowing this, you can begin with activities he enjoys and only move on to more difficult ones when he is well rested and motivated to learn.

What are some general tips that parents should keep in mind when working with their child on gross motor skills?

The development of gross motor skills is the first learning task that the child with Down syndrome and his parents will face together. This is an opportunity for parents to begin to understand how their child learns. Use these tips as a starting point to begin to explore your child’s learning style.
  • Determine what motivates your child. Your child is more likely to move when there is something motivating him. For example, he may crawl to get to a favorite toy. When practicing motor skills, your child’s success and enjoyment will depend on how you play, what types of toys you use, and where you place them.
  • Think how your child thinks. Figure out what gross motor skills your child likes to do and then build on those skills. For example, if your child likes to be on his belly, teach him pivoting, crawling and climbing; if he likes to sit, teach him to move into sitting by himself. Children often are motivated to learn skills in a different order and it is OK to follow your child’s lead and work on what he is ready and willing to learn.
  • Set your child up to succeed. Practice skills that your child is ready to learn so that he can accomplish them. Practice when he’s at his physical best so that he has the energy, concentration and patience to work on new or emerging skills. Know how to position him and use the best motivators. Lastly, know when to quit. A few well-timed moments when your child understands a new skill and succeeds at it are much more valuable than an hour of struggling that leaves both of you frustrated and upset.
  • Read your child’s cues. Pay attention to how your child is responding to practicing the skills. If it is too hard, make it easier by changing the set-up or giving more support. Practice as long as your child is doing his best. The quality of time you spend practicing gross motor skills is much more important than the quantity.
  • Treat it as a game. You really want to think of teaching and practicing a skill as a game. First, introduce the “game” so your child feels and tolerates the movement. Second, help your child become familiar with the game and understand what you want him to do. Third, practice the game together and gradually lessen your support. Fourth, progress toward independence. The ultimate goal is for your child to master the game and be able to do it on his own.
Children with Down syndrome have a unique learning style, and we need to understand and respect it. A psychologist named Jennifer Wishart has written extensively on this subject. She says we “could run the risk of changing slow but willing learners into reluctant, avoidant learners.” I really customize the work I do with each child. I make sure the physical therapy sessions provide a pleasant learning environment for children so that they are willing learners, and I encourage parents to do the same at home. If your child feels imposed upon, he or she is just going to find ways to resist and avoid learning.

Resources:

Gross Motor Skills in Children with Down Syndrome: A Guide for Parents and Professionals (1997) by Patricia C. Winders. Published by Woodbine House.

www.woodbinehouse.com

“The Goal and Opportunity of Physical Therapy for Children with Down Syndrome.” (2001) Down Syndrome Quarterly 6(2), 1-4.


Down Syndrome: The First 18 Months (2003) by Will Schermerhorn.

www.blueberryshoes.com

 
Download Down Syndrome Quarterly PDF

Occupational Therapy and the Child with Down Syndrome
Written by Maryanne Bruni, BSc OT(C)

If you are a parent reading this website, you likely have a child with Down syndrome, as I do. My intent with this article is to provide you with some information about how an occupational therapist (OT) may be able to help you and your child. Occupational therapists who work with children have education and training in child development, neurology, medical conditions, psychosocial development, and therapeutic techniques. Occupational therapists focus on the child's ability to master skills for independence. This can include:
  • self care skills (feeding, dressing, grooming etc.)
  • fine and gross motor skills
  • skills related to school performance (eg: printing, cutting etc.)
  • play and leisure skills
When your child is an infant, your immediate concerns relate to his health and growth, development of the basic motor milestones, social interaction with you and others, interest in things going on around him, and early speech sounds and responses. At this stage an OT may become involved to:
  • assist with oral-motor feeding problems (this can also be addressed by Speech Pathologists). Due to hypotonia and weakness of the muscles of the cheeks, tongue and lips, feeding is difficult for some infants with Down syndrome. OTs suggest positioning and feeding techniques, and can be involved in doing feeding studies, if necessary.
  • help facilitate motor milestones, particularly for fine motor skills. Occupational therapists and Physical therapists work closely together to help the young child develop gross motor milestones (eg: sitting, crawling, standing, walking).OTs work with the child at this stage to promote arm and hand movements that lay the foundation for later developing fine motor skills. The low muscle tone and loose ligaments at the joints associated with Down syndrome are real challenges to early motor development and occupational therapy can help your child meet those challenges.
When your child is a toddler and preschooler, she will likely have some independent mobility and will be busy exploring her environment. To assist her development you will want to provide her with many opportunities for learning, you will want to encourage the beginning steps in learning to feed and dress herself, you will want her to learn how to play appropriately with toys and interact with other children, you will be encouraging speech and language skills, and you will continue to provide opportunities for refinement of gross motor skills. At this stage an OT may become involved to:
  • facilitate the development of fine motor skills. This is an important stage in the development of fine motor skills for children with Down syndrome. Now they will be developing the movements in their hands that will allow them to do many things as they get older, but many children need some therapy input to ensure that these movements do develop. Children do this through play; they open and close things, pick up and release toys of varying sizes and shapes, stack and build, manipulate knobs and buttons, experiment with crayons etc. Your child may face more challenges learning fine motor skills because of low muscle tone, decreased strength and joint ligament laxity.
  • help you promote the beginning steps of self help skills. An OT can help parents break down the skills so expectations are appropriate, and can suggest positioning or adaptations that might help the child be more independent. For example, a child may have more success feeding herself with a particular type of spoon and dish.
Then your child enters the school system and the focus of your energies changes somewhat again! You help your child adjust to new routines, you attend school meetings to plan your child's educational program, you focus on speech and communication, you help your child practise fine motor skills for school (such as learning to print), you expect your child to develop more independence in self help activities, and you search out extracurricular activities that will expose your child to a variety of social, physical and learning experiences. At this stage an OT may become involved to:
  • facilitate fine motor skill development in the classroom. Many OTs work in the school system and provide programs to help children with Down syndrome learn printing, handwriting, keyboarding, cutting etc. They will also look at physical positioning for optimal performance (eg: desk size etc.) and assist with program adaptations based on the child's physical abilities.
  • facilitate self help skills at home and at school. As with all children, our kids with Down syndrome vary in personality, temperament, and motivation to be independent. Some children with Down syndrome have a desire to do things themselves, such as dress and feed themselves. These children may learn these skills by watching others and participating from a young age. Other children may be happy to let others do things for them, and may resist attempts to help them learn these skills. In these cases an OT may be able to help a parent work out these challenges, while helping the child develop better motor skills to be successful in self help skills.
  • address any sensory needs your child may have. Sometimes a parent has a concern about things their child does that may relate to the child's sensory development. For example, a child may excessively put toys in her mouth, she may have poor awareness of her body in space, she may squeeze everything too hard or drop things a lot, or she may not tolerate very well some routines like washing and brushing hair. An OT can offer suggestions to help the child and parents deal with these issues.
As parents we must be concerned with the well-being of our child in all respects. We have so many things to think about and keep track of: medical and dental needs, motor and communication needs, educational needs, advocacy, social and behavioral needs : the list seems to go on and on! We need the help of trained professionals to guide us and to work with our children to help them achieve their potential in life. An occupational therapist is one member of the team that we can rely on to provide professional assistance throughout the growth and development of our children. In Canada, occupational therapy services for children with Down syndrome can be accessed through hospitals, home care programs, infant development programs, specialty nursery schools, public schools, and through private therapy services.

(Editor's note: In the US, OT services can be obtained through Early Childhood Intervention programs, public and private schools, and from private therapists.)

Further information about fine motor development can be found in my book "Fine Motor Skills in Children with Down Syndrome", published by Woodbine House (800-843-7323) in 1998.