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Introduction

In the first year of life, infants begin to gain control over movements – they begin to be able to hold their heads steady, to reach out and grasp objects, to roll, sit and crawl and to hold cups or bottles for feeding. They then go on to walk, run, climb stairs, use a spoon, knife and fork, and dress themselves. Later they draw, write, use the computer, play football and dance. We tend to take our movement abilities for granted as, for most of us, they have developed effortlessly and most are carried out as we go through our day without conscious attention to them at all. However, there is a large research literature devoted to trying to understand how the brain controls our everyday movements so skilfully, and the processes are still not fully understood. In the first section of this overview we will discuss the current views of the motor research experts, as it is relevant to our understanding of progress for children with Down syndrome.

Many babies and young children with Down syndrome are late to reach the early motor milestones such as grasping, rolling, sitting, standing and walking. There is wide variability in progress, with some reaching these milestones as early as typically developing infants and some being particularly slow in achieving them. Most parents are advised that physiotherapy will help, but do we actually know the reasons for this slower progress in order to provide guidelines for effective therapy? Do we know if physiotherapy actually makes any difference to progress and, if so, how? Is the motor progress of children with Down syndrome just delayed (i.e. slower but otherwise the same as in other children) or is it actually different – due to physical differences in their muscles, ligaments or central nervous systems?

Whatever the answers to these questions, we know from our own practical experience and research that the majority of children with Down syndrome achieve all the basic motor skills necessary for everyday living and personal independence. They may be later to achieve them and their movements may seem a little clumsy or less refined as they carry out tasks but they still have adequate skill for daily competence. Many continue to improve and refine their abilities in daily tasks such as handwriting, making a cup of tea, and tying shoelaces, well into adult life. They may have more difficulty in becoming skilled in games and recreational activities but many individuals do reach high levels of achievement when given the opportunity.

Research into the motor development and motor skills of children and adults with Down syndrome is limited and, as we have studied the available information, we have come to believe that some unhelpful myths keep being repeated, without supporting evidence. One of these myths is hypotonia, or 'poor muscle tone'. Almost every article we have read has used hypotonia as an explanation, when in fact it probably plays little part in determining children's motor progress. We will return to this issue later.

In this overview, we consider four questions.

1. What do we know about motor development in typically developing children and the factors that may influence rates of progress or levels of skills achieved for different motor activities?
2. What do we know about the pattern of motor development usually seen in infants, children and teenagers with Down syndrome?
3. What do we know about the effects of therapeutic interventions?
4. Can we draw on these three sources of evidence to identify some principles for effective intervention and activity programmes for individuals with Down syndrome across the age range?

Before we can discuss motor skills, we need to recognise that the term covers a wide range of activities and actions, and we have divided them into somewhat arbitrary groups in order to more conveniently discuss therapies and interventions later.

What are motor skills?

The ability to move is essential to human development, and children develop a remarkable range of motor skills from the first year of life through to adult life. Some are essential to basic human development and others are specialised and optional. For practical purposes, motor skills can be considered under two main headings:

• basic skills necessary for everyday life activities, and
• recreational, employment or specialist skills which are optional and based on interests and aptitudes.

Basic skills include sitting, walking, running, climbing stairs, picking up objects, using cups, knives and forks, pouring drinks, dressing and managing fastenings, holding and using pencils, pens, scissors and using keyboards.

Recreational skills include skipping, throwing, catching, hitting and kicking balls, riding a tricycle or a bicycle, swimming, skiing and all sporting activities, playing a musical instrument and playing computer games. Employment skills may be specific to a particular job and involve learning to operate machinery. They may also be an extension of basic daily living skills, such as those used in catering or gardening work.

Basic skills are usually further divided into gross motor skills and fine motor skills.

• Gross motor skills are those concerned with whole body movement including sitting, walking, running and climbing stairs.
• Fine motor skills tend to be those requiring fine manipulation of fingers and hands including picking up objects, using cups, knives and forks, pouring drinks, dressing and managing fastenings, holding and using pencils, pens, scissors and keyboards.

These divisions are somewhat arbitrary and do not imply the use of separate parts of the motor system, as elements of gross motor control such as maintenance of balance and body posture play a part in carrying out all fine motor activities. However, they provide a useful practical way of dividing the whole range of possible motor skills and they link with the sources of therapy and teaching available to children and parents. Physiotherapists tend to be expert in the development of basic gross motor skills and occupational therapists tend to be experts in basic fine motor skills, although their skills will often overlap. Recreational skills tend to be taught by teachers, physical education experts, sports coaches and specialists such as music teachers. Employment skills may be taught by supervisors or job coaches.

We have not included speech-motor skills in this discussion, as the ability to talk, while a motor skill, is ill-understood, and is influenced by the ability to hear and store the sound patterns of words (phonology). Speech is therefore specialised and different, in at least some ways, from other motor skills. Some information on speech-motor development can be found in the speech and language books in this series.

Movement influences social and cognitive progress

While progress in basic gross and fine motor skills is important because the ability to carry out the movements has direct and practical benefit on a child's daily living and independence, motor progress is also important because these abilities influence social and cognitive development as well. The following list gives just a few examples of these links:

• being able to reach and grasp allows a child to begin to explore the characteristics of objects in his or her physical world;
• being able to sit increases the ability to use arms and hands for playing;
• being able to walk allows a child to carry toys and objects and to explore the world more effectively than crawling on hands and knees;
• being able to move independently also increases opportunities for social interaction and language learning. For example, once a child can move, they can go to see what happens when a visitor comes to the door or the telephone rings. They can follow their carers around so that they are talked to and included in everyday activities;
• being able to run, jump, climb and catch a ball increases a child's ability to join in games in the playground;
• being able to dance, swim or play football increases opportunities for leisure activities and friends, from childhood to adult life.