Research into the development of motor skills in children
and adults with Down syndrome is limited at the present time.[10,11,12]
The available research can be divided into two main types – descriptive studies
and experimental studies.
Types of research
The studies of infants and children are mainly descriptive.
Descriptive studies usually document the ages at which skills are attained. These
may be basic gross and fine motor skills, and sometimes recreational skills as well
as component skills such as balance, or hand-eye coordination. There have been a
small number of experimental studies of children but most of the experimental work
has examined the skills of teenagers and adults. Experimental studies usually require
participants to learn a new motor action or to carry out actions at speed and then
measure various aspects of their performance.
Limits of research
Unfortunately, the findings of many research studies in
the area of motor skills have to be interpreted with caution for several reasons.
Small numbers. Researchers have often
studied very small numbers of children or adults. For example, one widely quoted
study reports findings based on 2 children with Down syndrome in one age group and
4 in another. Given the considerable variability
of progress among children and adults with Down syndrome, it is impossible to judge
how representative the performance of such small numbers of children actually is,
and therefore whether the findings can be generalised to all other children and
adults with Down syndrome.
Date of studies. Some studies from the
1970s and 1980s will include children who grew up with low expectations, little
or no early intervention support, and limited social and educational opportunities.
Early studies may therefore be difficult to interpret.
Comparison groups. Another weakness of
many studies lies in the comparison groups that they use. Many studies of both adults
and children compare their motor skills with typically developing individuals of
the same chronological age, usually reporting significant differences in performance,
with those with Down syndrome having 'poorer' skills. However, when the comparison
group is matched on mental age, then there are often no significant differences
in the overall motor performance of the groups. Any differences that are found tend
to reflect strength and balance issues or speed and accuracy of performance, rather
than overall motor control. Examples of these findings are given in the relevant
sections later in this overview.
Motor development in children with Down syndrome
- Motor skills develop in largely the same sequence as in typical children
- They improve with practice – but may need more practice and take longer
- There is considerable individual variation in rates of progress.
- The majority of children with Down syndrome achieve all the basic skills
necessary for everyday living and personal independence.
- Their fine motor skills steadily improve with practice and many can
write, colour, draw and use a computer mouse and keyboard effectively.
- Achievements in recreational skills vary but often seem to reflect family
enthusiasms. Some children become very competent swimmers, skiers or gymnasts
- Most research suggests that their motor skills are similar to typically
developing children of similar general mental ability (therefore younger).
- However, balance seems to be a particular difficulty relative to progress
in general coordination and muscle strength.
Learning and practice effects. One problem
that arises when the motor skills of children or adults with Down syndrome are compared
with those of others is that it is difficult to control for their past experiences
and the opportunities that they have had to develop their motor skills. They will
usually have had less opportunity to practise than those they are being compared
with. Practice improves motor skills until an optimal level of skill is achieved
which does not improve further. In research studies, it is only possible to draw
conclusions about differences in motor abilities if the participants are able to
practise until they reach their peak performance, and there is evidence that individuals
with Down syndrome require significantly more practice than others to reach their
peak performance (see 'Practice improves
Practical relevance. A number of studies
are of theoretical rather than practical relevance. Currently many researchers are
interested in the detailed way in which movements are carried out by individuals
with Down syndrome and they measure differences in the angles of joint movements,
take measures of the actual activation patterns of muscles, or study the differences
in patterns of gait. Most of these studies indicate largely normal movement patterns.[13-16]
Some do indicate difference in muscle activation patterns[5,15,17]
or joint movements in experimental situations. However, since no one has conscious
control over the sequence of actions of muscles or joints when moving, these studies
have little direct practical relevance. It is also not clear from most of these
studies whether these differences are developmental (i.e. seen in the early stages
of learning a skill) and will disappear with practice.
The pattern of motor development for children and adults
with Down syndrome
One of the important issues in the study of motor development
in people with Down syndrome is whether there is delay in achieving milestones and/or
whether movements are abnormal or not properly suited for their purpose. Some of
the relevant research is considered in this section.
Development is the same but delayed
Motor development for children with Down syndrome is usually
significantly delayed. All the basic motor skills are achieved by infants and children
with Down syndrome in mostly the same order, but usually at significantly older
ages when compared with typically developing infants and children. This is illustrated
by the examples given in Table 1.
Table 1. Motor Milestones - A guide to ages
of attainment for children with Down syndrome
||Cunningham & Sloper
||Berry et al
||Average age (months)
||Average age (months)
||Average age (months)
||4 to 11
||2 to 12
||6 to 7
||2 to 10
|Sits steadily without support
||8 to 16
||7 to 16
||5 to 9
|Pulls to standing
||10 to 24
||8 to >28
||7 to 12
||16 to 36
||9 to 16
|Walks without support 3 steps or more
||16 to 42
||14 to 36
||9 to 17
||4 to 10
||3 to 7
|Passes object from hand to hand
||6 to 12
||4 to 8
|Puts 3 or more objects into cup/box
||12 to 34
||9 to 18
|Builds a tower of two 1 inch cubes
||14 to 32
||10 to 19
There is evidence that some motor skills, such as those
requiring fine finger to thumb opposition position (pincer grasp) and those requiring
fine control of balance, may be achieved later than is typical and therefore slightly
out of the usual sequence. One study of 220 young children with Down syndrome aged
3 months to 60 months assessed their progress
on specific gross and fine motor skills on the Bayley Scales of Infant Development.
This test provides norms for the ages and expected sequence of the achievement of
early motor skills in typically developing children. This study found that picking
up tiny objects, walking backwards, standing on one foot, jumping and walking downstairs
without support, were all achieved later than is typical, and late in relation to
other motor skills. The reader may note that standing and walking were not relatively
delayed, in fact both standing and walking 10 feet on tiptoes were achieved relatively
early in the sequence. It seems that it is skills requiring more complex balance
control that are achieved later. Balance is discussed more fully in the next section.
There is increased variability
There is greater variability in the basic motor progress
of children with Down syndrome when compared with typically developing children.
For example, the average age for walking in typically developing children is 13
months and the range is 9-17 months, while the average age for walking in children
with Down syndrome is 24 months and the range is 14-42 months. Some of this greater
variability may reflect the effects of health status for some children. Children
with major heart abnormalities may be slower to achieve some motor milestones until
they have corrective surgery, and the minority who cannot have corrective surgery
will continue to be delayed. Similarly, a small number of children with Down syndrome
have additional brain damage and will be more severely delayed in their motor progress.
We need to study the progress of large numbers of children and take account of their
health status, in order to develop sufficiently detailed data to enable parents
and practitioners to accurately predict the progress to be expected of individual
Guides to expected progress
The figures provided in Table 2 may be a useful general
guide to expected progress. They are based on a study of the gross motor progress
of 121 Canadian children with Down syndrome aged 1 month to 6 years.
The figures give the percentage of children who are expected to achieve a skill
at each chronological age point. The researchers in this study found that the children's
rate of progress slowed between the ages of 3 and 6 years when they were learning
to run, jump and climb stairs, confirming the findings of other studies that as
the balance, speed and coordination requirements of movements increase, the children
have relatively greater difficulty. However, these researchers also stress that
while having Down syndrome did affect the rate at which new skills were mastered,
it did not affect the upper limit of the skills achieved – most children can run,
climb steps and jump by 6 to 7 years. It takes children with Down syndrome longer
to reach a milestone and longer to refine and improve movements but, with enough
practice and encouragement, they will achieve it.
Table 2. The
percentage of children with Down syndrome expected to achieve skills at each age point.
permission from Elsevier [22 p.499]
Progress in teenage years
There is only one study reporting in detail on the motor
progress of older children with Down syndrome and this does not provide any normative
data for the achievement of particular scores but it does illustrate continued improvement
for most children on most skills from 10 to 16 years.[23,24]
In this study, information on the fine and gross motor skill development of 105
Australian children was studied over a number of years. The children were assessed
at regular intervals on the Bruininks Oseretsky Test of Motor Proficiency (BOTMP)
which has 8 subtests designed to assess:-
- Running speed and agility – the speed with which a child can run 13.7 metres,
pick up an object and return to the start.
- Balance – a number of balance items such as standing on one leg with eyes
open and closed.
- Bilateral coordination – a number of items requiring different limbs to
be temporally coordinated e.g. synchronised tapping of the right finger and left
foot or right finger and right foot.
- Strength – tasks requiring strength, including sit-ups and push-ups.
- Upper-limb coordination – items exploring ball skill and manual dexterity
(e.g. finger/thumb opposition).
- Response speed – reaction times to a simple stimulus.
- Visual-motor control – items involving cutting, drawing and copying, without
- Upper-limb dexterity – items needing a sequence of manual movements e.g.
posting coins through a slot, and requiring tasks to be completed within a time
The BOTMP provides norms for the typical ages at which
specific levels of performance on the tasks will be achieved and age-related scores
can be computed for each of the 8 skill areas.
On all the skill areas the group showed some progress
between 10 and 16 years. There was considerable individual variability and the rate
of the children's progress was largely predicted by their mental age, rather than
chronological age. While there was a close link between mental and motor age, with
those with higher mental age scores tending to have higher motor age scores, on
most motor subtests the group had significantly higher mean ages for motor skills.
All the subtests scores are higher except for balance, which is lower, and response
speed, which is at the level expected for mental age. It is difficult to know how
to interpret these findings, as it is always difficult to draw firm conclusions
when comparing age-equivalent scores in different areas of development when the
tests used have been standardised on different groups of children at different times.
Looking at a subgroup of 16 boys and 13 girls for whom
consistent longitudinal data was available, the boys scored higher than girls on
running speed and agility, strength, and upper-limb coordination. While a number
of the teenagers were reported to be overweight (the Body Mass Index Scores were
analysed for the whole group), there was no measurable link between being overweight
and motor skill achievements on the BOTMP tests at this early stage of adolescence.
Clumsiness and refinement of movements
Some authors observe that many movements continue to seem
somewhat 'clumsy' in individuals with Down syndrome.
It takes them longer to improve their skills and they may not reach quite the same
levels of fine coordination that most of us take for granted, but the levels they
do achieve will usually be adequate for successful performance. Improvements in
basic fine motor skills such as tying a shoelace or writing often continue to improve
through early adult life. However, it is important to stress the wide variability
in progress again, as many children and adults with Down syndrome do not seem at
all 'clumsy' when walking, running, picking up a cup, writing, skiing, skateboarding
or doing gymnastics. The final level of co-ordination and skill achieved seems to
have much to do with encouragement and opportunities to take up sports and to practice.
We know many individuals who have achieved high levels of competence in basic, recreational
and employment skills, and therefore we should never assume that having Down syndrome
necessarily puts an upper limit on what a particular individual may achieve.
More difficulty with balance and strength
A number of studies[2,9,13]
indicate that balance is a particular difficulty and continues to be a weakness
in teenage years.[23,24]
This may explain why many young people with Down syndrome find riding a bicycle
rather difficult to master. Some children do become competent on two wheels but
many do not achieve this, although they may be very competent on a tricycle. In
a recent study of a representative group of teenagers conducted by the authors,
93% could ride a tricycle and 36% could ride a bicycle.
Strength also tends to be less even when the comparison
is with young people of similar age and general mental abilities.[25,26]
The explanation for this is not clear. Everyone increases their muscle strength
through active movement and it could be that individuals with Down syndrome engage
in less active movement, although there is no direct evidence of this. The babies,
toddlers and children that we see regularly in our preschool and school services
seem to us to be quite active. It could be that children with Down syndrome need
more exercise to reach the same levels of strength. This is another area where we
know from our practical experience that there are considerable individual differences,
with some teenagers with Down syndrome being as strong or stronger than their non-disabled
peer group in school. Teenagers who do gymnastics, karate or weightlifting, for
example, can be as strong as non-disabled peers, so again, having Down syndrome
per se does not impose upper limits on strength.
Experimental studies of movement skills
Studies which compare children or adults with Down syndrome
with typically developing individuals of the same age almost always report differences
or delays. These comparisons are of limited value as we need to know if these differences
simply reflect developmental immaturity – that is, are the individuals with Down
syndrome carrying out the task as a younger person of similar mental age would?
This is the only way to identify any differences which would have a practical implication
for therapy or teaching approaches. We have focused, therefore, on reporting studies
that include mental age matched comparison groups and discuss some representative
examples of these studies.
Laboratory studies of basic skills
Some experimental studies have looked in detail at the
way in which basic skills such as reaching and grasping or walking are carried out
by children and adults with Down syndrome, others have studied the ways in which
they perform experimental movement tasks.
Reaching and grasping. In a study of reaching and grasping
– the movements used throughout the day to handle objects, the skills of 12 children
aged 8 to 10 years with Down syndrome were compared with two groups of typically
developing children, one of the same age and one younger and mental age matched.
The researchers report that the performance of the children with Down syndrome was
essentially the same as that of the younger children. They performed the tasks at
the same speed and showed the same ability to adjust their grasps for the size of
the object to be picked up as the younger children. They mostly showed the same
use of a pincer grip, although 2 children with Down syndrome had unusual grasps,
with a tendency to use the palm and all their fingers, rather than finger and thumb.
There was more variability in the movement patterns, and a little less accuracy,
which the researchers suggest indicates that more practice would be needed to establish
more effective motor patterns. Overall, the study indicated that reaching and grasping
were delayed rather than different. Similar findings, indicating the ability to
adjust to the size of the object, are reported in another study of grasping in 4
to 11 year olds with Down syndrome.
Walking. In a study of the walking patterns of children
and adults with Down syndrome, 5 children aged 4 to 9 years and 3 adults of 30 to
38 years were compared with a typical adult of 22 years on several tasks, walking
and running in bare feet on a hard floor, walking on the elastic surface of a trampoline
and walking on a narrow beam. The researchers report [13
p.79,80] that the walking patterns of the children with Down syndrome on a
hard floor were very similar to those of the adults with Down syndrome and the typical
adult. The movements of their joints are described as showing 'very smooth trajectories'
and to 'resemble adult patterns of walking'. The children and adults with Down syndrome
also showed patterns of co-ordination similar to that of the typical adult when
running. There was some evidence of differences in the precise details of the range
of joint and limb movements but the overall picture was of effective, smooth and
largely normal movement. As this study does not include any mental age matched children
or adults for comparison, any reported differences may only indicate immaturity
at this point. On the trampoline and the balance surfaces, the children and adults
with Down syndrome had more difficulty. Both tasks require more skill in balance
and they were less able to manage these tasks competently than the typical adult.
The changes that they showed in their knee movements and step lengths were attempts
to compensate for balance difficulties. Here again, with no mental age comparison
and small numbers, the significance of these patterns cannot be interpreted. They
could indicate ongoing difficulties with balance, and/or delayed progress.
Laboratory studies of specific movements
Slower reaction times
When teenagers and adults with Down syndrome are asked
to perform motor tasks in experimental situations, such as tapping a particular
button when a particular light comes on, their reaction times have been reported
as slower than those of typical individuals of the same age and the same when compared
with mental age matched controls.[see 14,15]
However, in some studies there is a difference in reaction times for people with
Down syndrome when instructions are visual rather than verbal. They show faster
reaction times when instructions are visual and show significantly slower reaction
times when the instructions are verbal. In everyday life, reaction times influence
the speed of starting a movement from the time an instruction is given, for example,
at the start of a race.
Slower movement times
Learning specific movements in experimental situations
When learning new movements and being expected
to be as fast and accurate as possible, in comparison with others of a similar
mental or general functional age, individuals with Down syndrome are usually:
- Slower to react and initiate a movement
- Slower to complete a movement
- More accurate - make fewer errors
- Their reaction times improve with practice
- They perform better when instructions are visual rather than verbal
Some studies have reported slower times (compared with
mental age matched groups) for the movement component of tasks as well as the reaction
movement time is the time taken from the initiation of the movement to reaching
the end point of the movement – for example, the time taken from initiating the
movement to completing the tap in the reaction time task. Individuals with Down
syndrome show slower movement times on experimental tasks when instructions are
verbal, but when instructions were visual, their performance was the same as mental
age matched peers.[see 14] One research group
suggests that this indicates a specific verbal-motor impairment in individuals with
Down syndrome and that this may reflect different brain organisation for movement
control, but this hypothesis needs more
Delayed but visual learners
Overall, this group of leading movement researchers identify
that research studies consistently show that the development of motor skills of
individuals with Down syndrome is essentially delayed rather than different. It
is linked to progress in general mental age and progresses in a typical but slower
way, except for the specific difficulty in processing verbal instructions. They
conclude therefore that "a developmental model of information processing and skill
acquisition should be used to guide the instructional protocols used by clinicians,
teachers and parents attempting to optimise skilled performance".[14
p. 67] The advice to use a 'developmental model' means that parents and teachers
should expect movements to be achieved and improved in the same way as they are
in typically developing children and adults, although more slowly. Teaching activities
should, therefore, be those appropriate for the stage of movement skill that a child
or adult has achieved. The practical implications of the verbal instruction findings
are that, within a developmental framework, instructions for motor activities of
all kinds, from writing to dancing, should be by modelling or demonstrating actions
whenever possible. There are, in fact, studies showing that the motor areas of the
brain which control movement are activated by passively watching a movement, which
may partially explain the advantage of learning by watching, rather than by verbal
Data from experimental studies requiring fine motor tasks
to be carried out [6,15]
and from real life studies of activities such as running,
report significant improvement in the performance of tasks with practice – improvements
in both speed and accuracy of movements. For example, a group of adolescents with
Down syndrome enrolled in a physical training programme showed considerable improvements
as a result of training. The mean time to run the 50 metre dash dropped from 15.39
to 10.69 seconds. However, some of these studies concluded that individuals with
Down syndrome require about twice as much practice to reach the same level as typically
developing individuals of the same mental age.
They seem to need more practice to establish motor programmes.
The positive effects of practice are well illustrated
in a series of studies[29-31]
in which the researchers compared the performance of 10 adolescents with Down syndrome,
average age 16 years, with that of 3 other groups of students; one group of the
same age with learning disabilities but not Down syndrome, one group of typically
developing high school students of the same age and one group of younger typically
developing children of the same developmental age. The young people were asked to
perform a pursuit–tracking task (see Figure 2) which requires them to move the pointer
to the target light. The pointer is moved by turning the steering wheel and once
the pointer has been on that target light for 200 milliseconds, the light goes off
and another comes on. The pointer then has to be moved to that light. In one trial
of 100 moves, the lights come on in a pattern that requires 50 moves to the right
and 50 moves to the left. The probability of moving in a particular direction varies
according to current position, as illustrated in Figure 2. If the pointer is on
the far left light, there will be 100% probability that the next required move will
be to the right and if the pointer is on the middle light, the probability of moving
right or left is the same – 50%. The probabilities for each light are illustrated
in the figure. In the studies, the researchers were interested in the speed (measuring
both reaction time and movement time) and accuracy with which the young people could
carry out the task, and whether they used the probability information to improve
Figure 2. Pursuit tracking
Speed and accuracy
In the first study
the young people carried out 8 trials comprising 800 actual moves of the pointer.
The young people with Down syndrome scored at the same level on reaction times as
their peers with learning disabilities and both these groups were slower than the
typically developing high school and elementary school students. On movement times
the pattern was the same. However, on accuracy, the young people with Down syndrome
were significantly better than all the other groups – therefore they were even more
accurate than non-disabled peers of the same chronological age. They were slower
than their non-disabled peer group but they made fewer errors. The mean error rate
for the group with Down syndrome was 8%, and for the learning disabled and high
school groups 13%. However, the young people with Down syndrome did not show any
evidence of making use of probability data, that is, they did not react faster when
it was possible to predict the likely direction of movement, although the other
groups were able to do this.
Reaction times improve with practice
These researchers went on to extend this work
and in another study using the same groups and design, they increased the amount
of practice to 24 trials and, therefore, 2400 moves. For reaction times, again,
the typically developing high school students were faster, but the other 3 groups
were not different from one another – that is, the young people with Down syndrome
were as fast as the younger typically developing children and their peers with learning
disabilities. This time, having been given much more practice at the task, the young
people with Down syndrome did show evidence of using probability information when
reaction times were analysed to take account of this, i.e. the more predictable
the direction to move in for the next light the faster their reaction time. However,
their reaction times continued to be longer for longer movements, and this is not
easy to interpret.
Slower but more accurate
For movement times, the young people with Down syndrome
were slower than all the other groups but again, they were more accurate – they
made fewer errors than all the other groups.
When given sufficient training, the young people with
Down syndrome significantly reduced their reaction times – they were about 36% faster
in reacting and initiating movements, but they did not improve their movement times.
They seemed to focus on accuracy and were unwilling to increase speed. This is entirely
sensible as, in all studies looking at speed and accuracy on this sort of task,
there is a link or 'trade-off' as a point is reached where it is not possible to
improve one without a negative effect on the other; after this level of performance
has been reached, an increase in speed leads to a decrease in accuracy (this is
called Fitt's Law).
Within the group of 24 young people with Down syndrome
who took part in one of the studies using
this task, the performance of individuals tended to be linked to general mental
age, that is, those with higher mental ages did better on the tasks than those with
lower mental ages.
The importance of practice
These general findings of improvement with practice, slower movement
speeds and a focus on accuracy rather than speed have been confirmed in other
studies.[see 15] Many studies indicate
that teenagers and adults show considerable improvement with practice. This
indicates that they have not yet reached their optimal levels of performance,
possibly because they have not had enough opportunity to practise both gross and
fine motor skills during childhood. In some studies, their performance after
practice is as good as typically developing individuals of the same age.[5,43]
Why this profile of development?
At the present time, we do not have enough knowledge about the reasons for
these features of motor development in individuals with Down syndrome but we do
have several facts which may provide some clues and guidance for more effective
Closely linked to mental age
Both the descriptive studies of children's progress and some experimental
studies of motor skills in adults identify that the motor performance of
individuals with Down syndrome is closely linked to their general cognitive
progress. In other words, for gross motor, fine motor and experimental tasks,
they usually perform like other children or adults with the same cognitive or
mental age. This suggests that the main effect is delay rather than difference
in motor progress.
The close relationship between early mental and motor development is
illustrated in the graphs in Figure 3. These graphs are
based on 707 assessments of 220 children on the Bayley Scales of Infant
A team of researchers pooled the data collected on children in Australia, Canada
and Germany and some of the children had been assessed several times at
different ages as they were involved in on-going longitudinal studies. This
provided some 707 separate assessments covering the chronological age range from
3 months to 54 months. The reader can see that the group is progressing at a
very similar rate in mental and motor development. The correspondence is
exceptionally close at this age range and studies of older children show that the relationship holds into the
Figure 3. Mental and
motor progress in children with Down syndrome (Adapted from [32,
p.339] with permission)
One American study charted the progress
of 15 children with Down syndrome who were 7 to 10 years of age, and who had had
the advantage of well-organised early intervention and education. The findings in
Table 3 show the close relationship between their mental and motor progress. For
the reader interested in the data, the correlations between the fine motor and gross
motor skills and mental age are both .64 and statistically highly significant.
A study of 99 Australian 10 to 16 year olds with Down syndrome also showed the close
link between motor skills and mental age, with the children's mental age rather
than their chronological age, predicting performance and progress.[23,24]
Relationship between mental and motor progress in children with Down
syndrome. Based on data published in [33,
Table 2, p.1317]
||3y 3m - 6y 6m
|Gross motor age
||3y 5m - 6y 0m
|Fine motor age
||4y 2m - 6y 2m
|Note: The fine motor
scores are based on 12 children, as three children with mental ages
between 3 years 3 months to 3 years 9 months were not tested on the fine
The reason for the close association of overall mental
and motor development is not clear, but it may reflect that the control of motor
skills is largely a central nervous system activity and that brain functions play
a central role in motor development in the same way as they do in other aspects
of development. It could be that both mental and motor development are delayed by
similar differences in brain processes. One of these differences could be speed
of information processing in the brain. Another could be the ability to establish
learned programmes in the brain. A number of studies have highlighted the inconsistent
performance of children with Down syndrome on both cognitive and language tasks.
It seems to take them longer (i.e. they need more practice) to effectively consolidate
The reader should note that the close link between the
development of mental and motor skills indicated in these studies does not mean
that this close correspondence will apply to every individual child at any particular
stage. For example, a particular three year old with Down syndrome may be making
rapid progress with language but still not be walking, another three year old may
show the opposite profile, walking but not yet talking. The overall mental and motor
age scores used in these studies are each based on a large number of tasks to give
an overall picture of mental and motor development and there will be variability
in the way individual children achieve their overall scores. However, the link between
overall mental age and progress in overall motor skills is a powerful trend in all
studies that have looked at both, and is clearly of significance in understanding
More dependent on visual feedback
Researchers have reported that children and adults with
Down syndrome rely more on visual feedback while carrying out a task than typically
developing individuals.[see 9,35]
They may need to rely to a greater extent on visual feedback because they take much
longer to establish learned motor programmes for the task. This can make their performance
seem as if they are tackling each repetition of the task as if they have not performed
it before. It also means that their pattern of movement may be jerky and inconsistent
from one time to the next even though they can actually perform the task correctly.
This finding could explain longer movement times because, as a learned programme
is established, the sequence of movements required for a movement can be performed
As already identified, there is some evidence that balance
may be a particular difficulty for individuals with Down syndrome. In one experimental
study, the balancing abilities of infants with Down syndrome were compared with
typically developing infants and the two groups were carefully matched for their
ability to stand unsupported. The infants
were put into a small room in which the floor was stable but the walls could be
moved to give the impression of the room tilting. All the infants reacted as if
the floor was also tilting by leaning, swaying, staggering or falling, that is,
they reacted as if to stop themselves from falling even though the floor they were
standing on did not move. The visual information suggested they were being tilted
even though the vestibular and proprioceptive feedback would not have suggested
The children with Down syndrome were more affected and
made larger postural adjustments than the typically developing children. Both groups
of children improved as they increased their experience of walking and after some
12 months of walking the typically developing children were finally able to stay
stable in the tilting room and not react to the false visual cues. The children
with Down syndrome needed longer to become stable and did not show complete stability
after a year or more of walking experience, even though they were improving. The
authors suggest that these findings indicate that children with Down syndrome are
more dependent on visual cues to judge body position than typically developing children
at the same stage of walking, because they need extra visual information to compensate
for less effective vestibular and proprioceptive feedback at this stage.
Another similar study of 26 older children with Down syndrome
(mean age 10.6 years) showed that they were still more affected by this kind of
experience and showed more body sway than other children of the same age. 
There is other evidence to suggest that balance continues
to be an area of specific difficulty into the teenage years. In an Australian study
of the motor skills of 81 twelve year olds,[23,24]
balance was the weakest area and still at a 4 year level when their other motor
skills range from 5 to 9 year levels. Their mean mental age was 4 years 9 months
and therefore most of the motor skills for the group were higher than might be expected,
with response speed at the same level as mental age and only balance lower than
mental age. There was considerable variability in motor skills between individuals
and, as in other studies, mental and motor skills were related. Individuals with
lower mental ages tended to have lower motor skill scores, and vice versa.
Many authors assume that the profile of motor development
in Down syndrome is largely the result of physical differences, but the evidence
for this point of view is limited. Almost every discussion of motor development
in children with Down syndrome starts with descriptions of hypotonia and lax ligaments,
and suggests that they are to blame for the motor delays.
The significance of hypotonia
At birth, babies with Down syndrome are observed
to be more 'floppy' than other babies.
This has been described as hypotonia but there
is no agreed definition of hypotonia.
There seems to be evidence for:
- lower muscle 'tone', defined as either less resistance to passive movement
or feel softer if pressed – both unsatisfactory as there are no precise
measures and no comparisons with mental age matched infants without disabilities.
- 'lax ligaments', implied by the fact that limbs can be more widely rotated
– there is more movement in the joints allowing children to take up unusual
postures such as widely splayed hips when moving on floor or sitting.
Both muscle 'tone' and 'lax ligaments' improve
with age and with movement.
There is no convincing evidence that these factors
affect movement ability, i.e. the brain may be compensating for them when child
However, it has been suggested that they may affect
the development of movements if child takes up odd postures or tries to move
limbs differently in the early stages of learning a movement – studies are needed
on this issue.
Hypotonia and lax ligaments
Many newborn children with Down syndrome have very flaccid
muscles and are described as 'floppy'. There are many specific disorders which are
associated with the birth of 'floppy' infants; in some cases this disappears as
the child develops and in some cases they remain in this 'floppy' state. There are
a few follow up studies of infants with Down syndrome and it seems that this infant
floppiness does improve over time. There is a fairly widespread belief that the
children remain with a degree of hypotonia and this state is often invoked as being
responsible for much of the 'poor' motor function seen in people with Down syndrome.
However, this is a rather controversial issue since there
is no proper agreement as to the definition of hypotonia and there is no consensus
as to how to measure it. In addition, some recent studies have demonstrated that
the hypotonia seen when children and adults with Down syndrome are not moving (i.e.
their tendency to have more 'floppy' muscles at rest) is not evident when they are
moving and does not actually impair coordinated movement.[see
It is generally accepted that ligaments and tendons in
individuals with Down syndrome are more 'stretchy' than is usual. This would explain
why they are often able to move their joints into extreme positions. However, research
indicates that this does not prevent coordinated control of the joints to perform
Both muscle 'tone' and 'lax ligaments' improve with age and with movement, and there
is no convincing evidence that these factors affect the development of movements,
i.e. the brain is likely to be compensating for them as the child moves.
Clearly, a great deal of research needs to be done to
clarify the different contributions of the stretchiness of ligaments and tendons,
the strength of the muscles, the 'tone' of the muscles and the contribution of the
nervous input to the greater picture of motor function in individuals with Down
Some authors rightly draw attention to a number of medical
conditions that are more common in individuals with Down syndrome and which may
affect a child's or adult's ability to be active, if not effectively treated.[10,11,36]
These include heart conditions, underactive thyroid function, vision and hearing
issues, atlanto-axial instability and obesity. It will be important to take account
of health factors for individual children and adults when considering active sports
but most will not prevent progress in basic gross or fine motor skills. The relevance
of each of these illness conditions for activity will be the same as it is in the
rest of the population.
Health and physical issues which may affect movement
Health and physical issues may account for some of the individual
differences in progress among children and adults with Down syndrome.
Any specific medical conditions will have the same effects as they
would in typically developing individuals.
However, babies or children with Down syndrome may have more difficulty
in compensating for these effects.
Individuals with Down syndrome may be at a greater risk for:
- Sensory impairments:
Visual impairments – may reduce feedback on position, and depth
and distance perception.
Hearing impairments – will make following instructions more difficult.
- Uncorrected heart abnormalities – may significantly reduce energy
- Atlanto axial instability – minority issue which has been
exaggerated, but parents, teachers and sports instructors should be
aware of the risk in order to spot symptoms rather than to restrict
- Obesity – may reduce enjoyment of movement; healthy diets and
exercise should be encouraged for the same reasons as for everyone else.
Individuals with Down syndrome tend to be small in stature, with short
arms and legs, and small fingers when compared with the typical population –
this will have the same effects on movement and on recreational choices as
it does for small people in the general population.
Parents and carers are likely to know about their children's
medical and healthcare needs and will inform teachers and therapists. Some authors
also draw attention to the tendency for individuals with Down syndrome to have small
stature and small hands relative to typically developing individuals. However many,
if not most, have similar stature to those at the small end of the general population
and the restrictions this imposes on achievements in sports will be the same for
both groups. More information on health issues for children with Down syndrome can
be found in each age-specific overview in the DSii series – see
The movement skills of children with Down syndrome are
largely delayed rather than different and progress at the same pace as their general
mental development. They may take longer and need more practice to improve their
performance and they may continue to have more difficulty with tasks requiring balance.
Most children achieve competence in all everyday gross and fine motor skills even
though they develop more slowly. Despite the presence of lax ligaments and possible
hypotonia, there is little evidence that they impair controlled movements as the
central nervous system controls all movement and usually compensates for such variables.
Teenagers and adults with Down syndrome may be slower
to perform movements in some situations, possibly reflecting slower information
processing in the central nervous system and/or a focus on accuracy and safe, effective
movements rather than on speed.