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MacPherson- Down Syndrome1

Jen MacPherson

DPT 598 Special Topics in Physical Therapy Research

Annotated Bibliography

Down Syndrome Mobility, Cognition, Sensory Integration and Socialization


Down Syndrome Mobility, Cognition, Sensory Integration and Socialization

1. Cristina-Elena P, Ghiorghita G. The effectiveness of physical therapy in developing the basic motor skill in children who have Down syndrome. Scientific Journal of Education, Sports and Health. 2014; 15(1):22-27.

This study hypothesized that the participation and functional abilities of children with Down syndrome can be improved through early implementation of physical therapy interventions. Variables tested included muscle strength, balance, coordination and controlled abilities contributing to the development of basic motor skills. Physical therapy interventions included proprioceptive neuromuscular facilitation, physical exercise, therapeutic massage and dynamic kinetic techniques. These interventions were implemented in five children with Down syndrome between the ages of four and six years of age. The Gross Motor Function Measure (see Appendix A & B), which looks at five dimensions, lying and rolling, sitting, crawling and kneeling, standing, walking and running, and jumping, was used to measure the effects of the interventions. The results of the initial evaluation were compared to post-treatment measures. Improvements in all five categories and the overall total score were seen in all five children. The findings support the study’s hypothesis as the GMFM has previously demonstrated high inter- & intrarater reliability and high responsiveness2.

While results from this study are promising in relation to improving motor skills of children with Down syndrome, limitations exist. Details of the physical therapy intervention were not stated in the article nor were the raw scores from each child’s initial and post-intervention evaluation using the Gross Motor Function Measure. The article did not include exclusion criteria for the subjects or state specifically how the children were chosen to participate. Although the authors stated that the children reached their goals, much more detail is needed to prove the significance of this study.

This study has shown that implementing rehabilitation programs in treating children with Down syndrome as early as possible offers a multitude of benefits. Early intervention can improve children’s mobility and, subsequently, their independence. This independence will facilitate more social and cognitive interactions as well. Programs similar to this study can easily be implemented in a multitude of settings by Physical Therapists, improving a child’s assimilation into a school environment among typical and disabled peers.


2. Bruni M, Cameron D, Dua S, Noy S. Reported sensory processing of children with Down syndrome. Physical & Occupational Therapy in Pediatrics. 2010; 30(4): 280-290.

Parents of 75 children with Down syndrome were surveyed to determine the impact of sensory processing behaviors in children 3-10 years of age. Parents also reported coping strategies. Two surveys were completed by the parents; the Short Sensory Profile (SSP) (see Appendix C), a standardized outcome measure evaluating sensory issues affecting functional and daily performance, and a parent questionnaire (PQ) (see Appendix D) reporting on;

Additional indications of sensory information relevant to the occupational performance of the child’s daily living skill

Sensory-related behaviors Strategies employed by the parents to deal with the problem Comorbid medical concerns Communication styles

The survey showed that children with Down syndrome fell below two standard deviations compared to children of typical development for the their total score on the SSP meaning there is a definite difference to be seen between the two groups and 25% had “Probable Differences”. There were also “Definite Differences” in the low energy/ weak, responsive/seeks sensation and auditory filtering categories.

Variables Definite Differences (% of subjects)

Probable Differences

Low Energy/Weak 69% 7%Under-Responsive/Seeks Sensation

48% 25%

Auditory Filtering 43% 31%Visual/Auditory Sensitivity 21% 31%Movement Sensitivity 13% 21%Total Score 49% 25%

68% of parents also reported that their child “always, frequently or occasionally” experience tactile sensitivity to grooming and dressing routines. The PQ reported that 60% of the Down syndrome children use verbal communication while the rest use a combination of verbal and augmentative. Nearly half of the parents reported spending time on their child’s sensory needs daily and 53% reported that the impact of the sensory problems on the child’s life is moderate to significant.


Overall, this study provides insightful results into the lives of children with Down syndrome suffering from sensory integration difficulties. The SSP provides normative values and demonstrates good reliability, .70-.90, and high validity, >95%1. The parent questionnaire however was produced by a researcher in this study and implemented for the first time. The reliability and validity have not been tested and the results should be viewed with caution. As these were self-administered surveys, bias on the parents’ part may have been introduced in the answers and in the self-scoring. Also, there is a chance that the parents who participated in the study did so because they already believe their child had sensory problems. This may have inflated the results. Finally, the surveys did not address the relationship between cognition and sensory responsiveness.

This study has shown that a large percentage of children with Down syndrome suffer from sensory integration deficits. As physical therapists, our treatment is based on our ability to be hands-on with our patient’s bodies. We must be aware of the sensory problems many children face and realize that this hands-on approach may not be tolerated by someone with Down syndrome. Interventions should revolve around understanding our patients and in what ways they tolerate distractibility, noise, tactile sensations and transitions. It is also crucial to educate the parents on how to intervene at home and understand their child’s needs.


3. de Graaf G, van Hove G, Haveman M. More academics in regular schools? The effect of regular versus special school placement on academic skills in Dutch primary school students with Down syndrome. J of Intellectual Disability Research. 2013; 57(1): 21-38.

Researchers surveyed the parents of over one hundred Dutch children with Down syndrome who attended either specialized or regular schools. Differences in academic skills between the two educational settings in the Netherlands were assessed. The questionnaire used in the study covered topics such as:

regular vs. specialized schooling parental education level extent parents worked on academics at home with their child position of child in the family & number of siblings age & gender language skills self-help IQ

Total academic performance was broken down into categories of reading, writing and math and evaluated along with the listed variables. Lastly, the researchers estimated the total time of teaching in each setting. The results showed that academics were indeed predicted based on age, non-academic skills, parental education and time spent at home working on academics. Regression values showed that age and IQ, p<0.0001, had the largest indirect impact on total academic performance. Although it cannot be stated as fact, it is may be likely that the students in regular schools, who receive twice the amount of time spent on academics, can attribute this fact to their improved scoring.

Regression analysis was used to support the findings of this article. Findings are listed below;

Regression Analysis

Ages 5-13 years Averaged Total Academic ScoreChildren in Regular Education 21+/-18.6Specially Placed Children 14+/-10.8

Prediction of academic skills, using child and parent characteristics.

Category R2 Value (in percentages)Reading 61.3Writing 71.6Math 69.9Total Academics 72.0


These scores mean that the responses given on the questionnaire, and the scores, reasonably predict a correlation between academic abilities and the basis of child and parental characteristics. The total academic percentage improved to 78% and 76% when factoring in school history (regularly placed vs. specially placed) and total teaching time. The study lacked or can improve upon its results by surveying educators who may provide less subjective data. Also, a longitudinal study following these children from ages 4-12 would be more ideal to accurately identify how these factors can affect children with Down syndrome’s primary education.

The study shows promising results related to the inclusion of children with Down syndrome into regular schools. The academic skills learned now will increase these children’s participation in society including in daily activities, further education, employment and extracurriculars through adulthood. Inclusion with typically developing children will also help foster a sense of belonging among their peers and encourage more social interactions. While physical therapists do not provide direct academic services to children in schools, it is important for us to improve upon the child’s physical abilities and sensory integration so that they can assimilate into any setting, giving them the a better chance at a successful, independent future.


4. Laws G, Hall A. Early hearing loss and language abilities in children with Down syndrome. International Journal of Language & Communication Disorders. 2014;

49(3): 333-342.

This retrospective study aimed to investigate the impact of early hearing loss on language outcomes for children with Down syndrome. Past audiology records were accessed by researchers to look at;

Type and severity of hearing loss Previous hearing tests Previous treatments, including the use of assistive devices and language

assessments.

The Leiter International Performance Scale-Revised is a nonverbal response test administered to estimate the children’s IQ scores and mental age. Several language assessments were administered such as;

The British Picture Vocabulary Scale II (BPVS-II): measuring receptive vocabulary

Reynell Develpmental Language Scales (RDLS): clinical assessment for children 18 months to 7 years, measures expressive language and comprehension

Mean length of utterance in words (MLUw) Goldman-Fristoe Test of Articulation, Second Edition (GF2): speech accuracy

(See Appendix E)

The results of these assessments showed the group of children with hearing impairments scored below those with normal hearing. It also found that the children with Down syndrome and normal hearing were behind, in all categories compared to typically developing children of their chronological age. Below are the raw unadjusted scores:

Variables Normal Hearing Hearing ImpairedLeiter MA 43.12 43.75RDLS Comprehension 38.24 26.63RDLS Expression 15.88 10.31BPVS II 34.40 25.25GF2 58.28 34.85

This study thoroughly provides significant statistical proof that there are differences in language abilities among different levels of hearing loss compared to children with normal hearing. An ANOVA (univariate analysis of variance) test and p-


values (p<.05) were obtained from the data. Of significance are the p-values relating to languages tests measuring;

Comprehension: p=0.002 Expressiveness: p=0.036 Responsiveness: p=0.038 Accuracy: p=0.011

Although these are statistically significant values, p<.05, the researchers did not account for other factors affecting language abilities such as cognition and current hearing levels.

The findings of this study should be taken into consideration when working with children with Down syndrome in any setting. It is important to understand that hearing loss is a common problem associated with the genetic disease. Cognitive delays have been observed in children with Down syndrome compared to peers of their age. This study proves that a decreased hearing ability can increase this discrepancy in cognitive abilities and greatly affect their language development. Therapists should be cognizant of any assistive devices being used or available to assist the child. They should work as part of a multidisciplinary team, along with Speech Therapists, to implement interventions beneficial to the whole child.


5. Lloyd M, Burghardt A, Ulrich DA, Angulo-Barroso R. Physical activity and walking onset in infants with down syndrome. Adapted Physical Activity Quarterly. 2010; 27: 1-16.

Researchers hypothesized that increased amounts of leg motion in children with Down syndrome is a better predictor of independent walking onset than total trunk activity. In addition, the authors attempted to establish whether other growth and developmental factors influence the onset of walking. Parents of 30 children implemented at home infant treadmill protocols. The infants of this study ranged from 10-15 months of age. Subjects were placed in one of two groups;

High-individualized intensity group Low-generalized intensity group.

The study found a positive relationship between high leg activity and the onset of walking at 12 and 14 months.

Significant statistical evidence supports these findings through the use of p-values and regression analysis. Leg activity, measured using activity monitors and accelerometers on the ankles and iliac crests, during the initial assessment proved to be a significant predictor of the age of onset of walking. High leg activity also showed the most variance, R2=0.349. Results from the study found no significant differences in age, height, weight or Bayley Scales of Infant Development scores. The authors determined no other factors contributed to the age of onset, including training protocol. Although the treadmill protocols showed results approaching significance (HI: p=.08 and .06 at 14 months, LG: p=.05), they did not impact the age of independent walking in these children. Limitations of this study include use of a small sample size. In addition, the authors did not specifically address factors of ligamentous laxity and hypotonia which commonly affect a child’s ability to independently walk.

Correlation between age of walking and high leg activity

Age of walking (months) P-value10 0.0412 0.0114 0.01

Differences between high-individualized and low-generalized intensity groups

Variable P-valueAge 0.30Height 0.67Weight 0.95Bayley Scales of Infant Development 0.77


The results of this study show a significant correlation between early leg movement and the age at which children with Down syndrome begin independently walking. It can be inferred that early leg activity may promote neural connections providing sensory information and feedback as well as increased strength, endurance and coordination. To prevent long-term consequences on the nervous system and mobility, it is crucial to intervene early. Programs including partial weight baring exercises using a harness and kicking exercises should be implemented as early as possible, along with developmentally appropriate skills, to give children with Down syndrome the best chances possible to gain mobility and independence throughout their lifespan.


6. Logan SW, Huang HH, Stahlin K, Galloway JC. Modified ride-on car for mobility and socialization: single-case study of an infant with Down syndrome. Pediatric Physical Therapy. 2014; 26: 418-426.

This single case study followed a 13 month old child with Down syndrome to assess the feasibility and family perceptions of using a modified ride-on car (ROC) to increase mobility and socialization. Modifications were made to the ROC to accommodate the child’s needs in relation to the switch, seating and steering components. A roll cage, seat belt and trunk support belt were also added for safety. Researchers followed the family for a total of 28 weeks divided into 3 periods;

Baseline: 12 weeks, 6 visits to make modifications and observe 20 minutes of natural and car play

Intervention: 12 weeks, education and training, 20-30 minutes of daily ROC play Retention:4 weeks, ROC was removed from the home, brought to the house

once a week for 10minutes of play

The family was trained in the use of the ROC and instructed to keep an activity log. The child was encouraged to participate in 20-30 minutes of daily ROC activity including exploration, goal-oriented driving and play-based activities with family and friends. Measures included;

Mobility: independent and assisted Total time of ROC play Visual attention to the switch Number of times the child reached for toys or interacted with their environment Facial expressions: positive and negative

Also, the Pediatric Evaluation of Disability Inventory (PEDI) (See Appendix F) was given at baseline, preintervention and postintervention. This measured the child’s performance of basic skills and the level of assistance or adaptations required for self-care, mobility and social function.

Parents reported an increase in freedom of mobility and increase in socialization between the subject and her family and friends. The self-reported daily activity log showed a compliance rate of only 41.7%, however it was not always filled out and therefore, as stated by the authors, the rate may be higher. The child’s mobility independence increased to 100% upon daily use of the ROC and was maintained during the retention period. The subject’s positive facial expressions increased throughout the entire case study as well, which may be due to her familiarity and comfort with the ROC, the environment and the researchers. Using the PEDI, a tool with established concurrent (gross motor= 0.84, fine motor= 0.91) and construct validity


and internal consistency, interrater=0.98, research showed improved scores from pre- to postintervention for functionality, self-care, mobility and social skills. This study can be improved upon by increasing the sample size, observing the child for more than 10 minutes per day, as this is very subjective to the child’s mood at that particular time, and by increasing the compliance level of the parents. Overall, the study showed positive outcomes by increasing the child’s independent mobility, socialization and fun.

The use of a ride on car is a cost effective option to allow children with disabilities to explore their environment and socialize without stigma. Its small size makes it easily transportable and therefore can be taken outside of the home to public places allowing the child to explore new settings. The new found independence will improve a child’s quality of life by increasing the number of socializations, forging friendships and being active. A ride on car is not a replacement for independent walking, but a transitional tool for the child to gain all of the benefits of such before mastering the skill. Therapists may consider this as a possible intervention for the clients with mobility issues. It may also encourage therapists to think outside of the box and be creative in finding therapeutic interventions that are fun for kids, efficient for parents and eliminate social stigma.


7. Morris AF, Vaughan SE, Vaccaro P. Measurements of neuromuscular tone and strength in Down’s syndrome children. Journal of Mental Deficiency Research. 1982; 26: 41-46.

The purpose of this study was to evaluate muscle tone and strength in a population of children with Down syndrome. The subjects were compared to children of typical development and similar chronological ages. Muscle tone was measured by evaluating involuntary reflex responses of the patellar tendon using the Lafayette knee reflex apparatus. The neuromuscular response was measured in centimeters. Upper and lower extremity muscles were palpated and rated on a five-point scale, 5 being hypertonicity, 3=normal and 1=hypotonicity. Hand/grip strength was also measured using a handheld dynamometer. The results found that the children with Down syndrome scored lower compared to their typically developing peers in all measured variables.

The results of the study showed a positive correlation between muscle strength and muscle tone. Muscle strength and tone were observed to increase with age in both groups.

Mean differences of variables tested on subjects with and without Down syndrome

Measure Mean DifferencesPatellar Tendon Tap 2.22cmMuscle Tone With DS: 2.74 Without DS: 3.14

Male: 3.02 Female: 2.86Grip Strength 12.3kg

The study was limited in that researchers assumed that strength and muscle tone increases with age, however they were not studying the same subjects over time nor did they have baseline measurements for the older subjects to compare their findings to.

Early implementation of muscle strengthening and activity for children with Down syndrome may improve the child’s mobility. The findings of this study support previous research suggesting a slower physical developmental process. Therapy done to improve upon this impairment will not only progress the child’s current physical status but may have long-term positive effects. The earlier the child gains the strength to walk, the more likely they are to learn to be active. An active lifestyle is important to prevent any further health issues such as obesity or depression.


8. Ragonesi C, Chen X, Agrawal S, Galloway JC. Power mobility and socialization in preschool: a case study of a child with cerebral palsy. Pediatric Physical Therapy. 2010; 22: 322-329.

Researchers of this single case study observed a three year old boy with spastic quadriplegic Cerebral Palsy (CP) and the effects of a ROC on his mobility and socialization. The study’s goal was to determine if it was feasible for the subject to utilize a power mobility device in a preschool classroom through video observation. The goals were to increase the child’s independent mobility within the classroom and the time he spent interacting with teachers and peers. The study consisted of two phases;

Baseline: 10 days without ROC use Mobility Phase: 13 days with ROC

The most active 30 minutes of the child’s day were coded for minutes of movement (in or out of car), minutes of interaction with peers either while stationary or in motion and minutes of no motion and no interaction.

With 90% reliability between primary and secondary raters, researchers found that ROC use was feasible in the classroom increasing mobilization and without being a barrier to socialization. Although his interactions were more comparable to his peers with the ROC, he was still observed spending less time doing so compared to other children.

With Roc Without Roc 80-100% of time in car Drove less than 10% of time Mostly stationary Less time in parallel play More time interacting with peers

and teachers

Spent about 1/3 less time socializing than peers

More time in solitary and parallel play

Interactions were less variable

These findings show promise, but the study was limited by the short amount of time the child had access to the ROC. To gain better insight into the use of the ROC’s effects on a child’s development, researchers should allow the child to have access to the car in multiple settings including the home. Interactions may vary based on the different environments and social expectations (rules in classroom vs. fun on playground). It could be hypothesized that more time in the car would produce more significant changes. Validation is needed through group study to truly assess the usefulness of the ROC.

While barriers exist when using assistive technology, this study is the first step to showing the feasibility of using small ROC in common settings such as a school or


home. The study showed the integration of technology into classrooms. With more education and training this can become standard practice in all schools. It is a way to help children adapt to their environments, gain independence, increase socialization and participate in more educational activities. This will increase the child’s likelihood to succeed in school and help prepare them for further education or employment as they get older. This study can be expanded to multiple other public settings, increasing a child with disabilities chance to explore and experience more of the world. In the long run, assistive technology can only improve a child’s quality of life and enhance their life experiences and relationships with family and friends.

9. Ringenbach SDR, Bonertz C, Maraj BKV. Relatedness of auditory instructions is important for motor performance in persons with Down syndrome. J on Developmental Disabilities. 2014; 20(1): 83-90.


This study examined the motor performance of people with Down syndrome when instructed to begin a task using verbal, visual and auditory cues, in a direct and indirect manner. Seven young adults with Down syndrome were tested and compared to two control groups. One group consisted of persons of similar chronological ages and one group consisted of children with typical development and similar mental ages. The upper limb serial movements of all subjects were tested by moving a mouse/cursor on a computer screen to different targets under four different conditions. Each trial started using different cues and the test time was measured. Indirect auditory signals resulted in an increased total test time and errors committed during the trials. The other three cues were found to have similar results to each other. The average total trial time and error percentages can be found below.


Results also showed that the Down syndrome group performed more slowly overall compared to their chronologically aged peers. More total errors were committed compared to both the chronological and mental age groups. The study suffered from a small sample size. Despite this, the results can be transferred to practical use in clinical, educational and home settings. This study can be expanded upon by seeking out any correlation between instructional methods and the learning ability in children with Down syndrome.

This study shows that teens and adults with Down syndrome are more likely to successfully complete tasks when given direct auditory, visual or verbal cues. This information can be used when intervening with someone of this population. Direct instructions will produce the most accurate movements. Knowing this or the most effective means of communication for your clients will help build rapport, create a comfortable learning environment and encourage the client to participate in treatment. It can be inferred from this study that therapists will have more positive outcomes in relation to their interventions when providing such cues.


10. Wuang YP, Su CY. Correlations of sensory processing and visual organization ability with participation in school-aged children with Down syndrome. Research in Developmental Disabilities. 2011; 32: 2398-2407.

Developmental continuums on measures of body function, including sensory processing and visual organization abilities, in children with Down syndrome were investigated in this study. The authors looked to examine any associations between body function variables, as classified by the World Health Organization’s International classification of Functioning, Disability and Health (ICF), and participation in activities in children aged 6-12 years. The researchers surveyed parents and teachers of children with Down syndrome using a multitude of tests. These tests included;

A demographic questionnaire The Hooper Visual Organization Test (HVOT) (See Appendix G) Sensory Profile (SP) (See Appendix H) The Wechsler Intelligence Scale for Children-Third Edition (WISC-III) (See

Appendix I) The Vineland Adaptive Behavior Scale-Chinese version (VABS-C) (See

Appendix J) School Function Assessment-Chinese Version. (SFA-C) (See Appendix K)

The study found increased visual organization ability and IQ scores correlated with older ages. Participation and socialization was limited by sensory seeking, processing and multisensory processing. Difficulties related to low muscle tone were sustained across the age groups despite studies showing that hypotonicity normalizes with increasing age. Overall, deficiencies were observed in comparison to typically developing children in all facets surveyed.

Correlations between all measures and age and IQ (r, 95%CI)

Measure Age (r-values) IQ (WISC-III)HVOT 0.59 0.69SP

Sensory Processing Modulation Behavior and Emotional

Response

0.110.160.08

0.160.170.18

VABS-C Communication domain Daily living skills domain Socialization skills domain Motor skills domain Adaptive behavior domain

0.390.470.230.210.44

0.460.420.480.490.46

Madalynn, 07/23/15,

If you have any of these, can add as appendices


SFA-C Total participation Total physical tasks Total cognitive-behavioral

tasks

0.220.340.25

0.310.320.33

r≥.5: large effect sizer≥.3<.5: medium effect sizer≥.1<.3: small effect size

Correlations between measures of sensory processing, visual organization ability and occupational performance.

Measures HVOT SP (Total Scores)VABS-C

Communication Daily living skills Socialization skills Motor skills Adaptive behavior

composite

0.380.400.340.470.45

0.400.280.450.250.33

SFA-C Participation Physical tasks Cognitive-behavioral

tasks

0.400.420.38

0.350.200.35

r≥.3<.5: medium effect sizer≥.1<.3: small effect size

In theory, the use of five different tests and surveys allow researchers to gain as much detail about each subject as possible. However, the parents and teachers completing these surveys may become overwhelmed by the large number of questions. Therefore, a potential limitation of this study was the number of surveys/tests used and the time required for their completion. Bias may have been introduced in this study as all results were obtained by persons close to the subject, objective data was not obtained. A longitudinal study could be conducted to better understand a true continuum of development in children with Down syndrome.

Sensory processing difficulties may lead to a lack of inner drive to explore different environments in children with Down syndrome. Hyposensitivity to different sensations can make these children more prone to injury as they seek out stronger sensations. Difficulties with sensory processing may impair the child’s desire to socialize and reduce meaningful participation as well as self-esteem and quality of life.


Therapists must take into account that these behavior and psychosocial problems may persist into adulthood. It is important to identify and intervene early in the life of a child with Down syndrome to increase the child’s functional capabilities. This can be done through structured environments and age-appropriate activities. Parents should also be involved in their child’s treatment and care to help develop more efficient sensory processing.


Summary

The information provided in this annotated bibliography provides an overview of the physical, cognitive and sensory delays of children with Down syndrome and how they affect socialization and participation. Each study found significant deficits in these categories for children and young adults of this population. General takeaways from this research include:

the importance of early intervention relating to mobility the use of different communication styles understanding the effects of sensory processing difficulties

Physical therapists can use the results of these studies to form a basic intervention plan when treating persons with Down syndrome. Early intervention will help children gain mobility leading to increased socializations, independence, cognitive abilities, physical fitness and overall well-being. Implementing a structured, enriched environment for children with Down syndrome will minimize societal boundaries that can interfere with their quality of life.


References

1. Ermer, J, Dunn W. The sensory profile: A discriminant analysis of children with and without disabilities. The American Journal of Occupational Therapy. 1998; 52(4): 283–289.

2. Ko J, Kim MY. Reliability and responsiveness of the gross motor function measure-88 in children with Cerebral Palsy. Journal of the American Physical Therapy Association. 2013; 93 (3): 393-400.

Appendices


Appendix A

Gross Motor Function Measures

Between 4th and 6th Birthday

Level ClassificationI Children get into and out of, and sit in, a chair without the need for hand support.

Children move from the floor and from chair sitting to standing without the need for objects for support. Children walk indoors and outdoors, and climb stairs. Emerging ability to run and jump.

II Children sit in a chair with both hands free to manipulate objects. Children move from the floor to standing and from chair sitting to standing but often require a stable surface to push or pull up on with their arms. Children walk without the need for any assistive mobility device indoors and for short distances on level surfaces outdoors. Children climb stairs holding onto a railing but are unable to run or jump.

III Children sit on a regular chair but may require pelvic or trunk support to maximize hand function. Children move in and out of chair sitting using a stable surface to push on or pull up with their arms. Children walk with an assistive mobility device on level surfaces and climb stairs with assistance from an adult. Children frequently are transported when travelling for long distances or outdoors on uneven terrain

IV Children sit on a chair but need adaptive seating for trunk control and to maximize hand function. Children move in and out of chair sitting with assistance from an adult or a stable surface to push or pull up on with their arms. Children may at best walk short distances with a walker and adult supervision but have difficulty turning and maintaining balance on uneven surfaces. Children are transported in the community. Children may achieve self-mobility using a power wheelchair.

V Physical impairments restrict voluntary control of movement and the ability to maintain antigravity head and trunk postures. All areas of motor function are limited. Functional limitations in sitting and standing are not fully compensated for through the use of adaptive equipment and assistive technology. At Level V, children have no means of independent mobility and are transported. Some children achieve self-mobility using a power wheelchair with extensive adaptations.

Appendix B

Gross Motor Function Measures Score Sheet

outcome measures\gmfmscoresheet.pdf

Appendix C

outcome measures\SSP.pdf


Appendix D

Parent Questionnaire

Appendix E


Goldman-Fristoe Test of Articulation, Second Edition Example Score Sheet

Appendix F


Pediatric Evaluation of Disibility Inventory

Appendix G

Hooper Visual Organization Test

Purpose: Assesses the visual organization or visual-constructional abilities.

Pshychometrics:

Internal consistency: 0.85-0.89 Interrater reliability: 0.99 Test-retest coefficients: 0.69-0.86 Moderate concurrent and discriminative validity

Appendix HSensory ProfilePurpose: Parent report measuring behaviors associated with abnormal responses to sensory stimuli for children 5-10 years of age.

Psychometrics:


Internal consistency: 0.47-0.90 SEM: 1.13-2.81 Moderate correlations between SP and SFA

Appendix I

Weschsler Intelligence Scale for Children- Third Edition

Purpose: Full scale IQ test representing overall ability in both verbal and performance subtest measures, children 6-16 years and 11 months.

Information: oral, "trivia"-style. general information questions. Scoring is pass/fail.

Similarities: explaining how two different things (e.g., horse and cow) or concepts (e.g., hope and fear) could be alike. Scoring is 2-1-0, according to the quality of the responses.

Arithmetic*: oral, verbally framed math applications problems without paper or, for most problems, any visual aids at all. Scoring is pass/fail.

Vocabulary: giving oral definitions of words. Scoring is 2-1-0, according to the quality of the responses.

Comprehension: oral questions of social and practical understanding. Scoring is 2-1-0, based on quality.

Digit Span: repeating dictated series of digits (e.g., 4 1 7 9) forwards and other series backwards. Series begin with two digits and keep increasing in length, with two trials at each length.

Verbal IQ is based on Information, Similarities, Arithmetic, Vocabulary, and Comprehension.

Verbal Comprehension Factor is based on Information, Similarities, Vocabulary, and Comprehension.

Freedom from Distractibility Factor (a misnomer -- attention, concentration, and working memory describe it better) includes Arithmetic and Digit Span.

Picture Completion*: identifying missing parts of pictures. Coding A**: marking rows of shapes with different lines according to a code as

quickly as possible for 2 minutes (under age 8) Coding B**: transcribing a digit-symbol code as quickly as possible for two

minutes (eight and older). Picture Arrangement**: sequencing cartoon pictures to make sensible stories. Block Design**: copying small geometric designs with four or nine larger

plastic cubes. Object Assembly**: puzzles of cut-apart silhouette objects with no outline

pieces.


Symbol Search**: deciding if target symbols appear in a row of symbols and marking YES or NO accordingly.

Mazes*: no pencil lifting, points off for entering blind alleys. Performance (nonverbal) IQ is based on Picture Completion, Coding, Picture

Arrangement, Block Design, and Object Assembly. Perceptual Organization (nonverbal) Factor is based on Picture Completion,

Picture Arrangement, Block Design, and Object Assembly. Processing Speed Factor, or visual-motor, clerical speed and accuracy,

includes Coding & Symbol Search. Full Scale IQ is based on the ten tests included in the Verbal and Performance

(nonverbal) IQ scales.

* time limit ** time limit and bonuses for speed

Appendix J

Vineland Adaptive Behavior Scale-Chinese Version

Purpose: birth-18 years 11 months, assessment of participation, adaptive behaviors and age-related performance of daily activities required for personal and social sufficiency.

Psychometrics:

Split-half reliability: 0.91-0.99 Test-retest reliability: 0.74-0.93 “sound” discriminative and current validity


Appendix K

School Function Assessment-Chinese Version

Purpose: Rates children’s functional performances on school-related activities compared to their peers

Psychometrics:

Internal consistency: 0.94-0.96 Test-retest reliability: 0.87-0.99 Good validity

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