Cognitive and social factors in the development of infants with Down syndrome
Derek Moore, John Oates, R Hobson and Julia Goodwin
Infants and young children with Down syndrome can be engaging and affectionate. It seems that in the early months of life their personal relations may be relatively 'spared' the effects of limitations in their capacities for information-processing. Yet how far is this the case as development proceeds? In this paper we discuss some ways in which social and cognitive development interact and mutually influence one another over the first year or so of life, and present preliminary findings from a longitudinal study of infants with and without Down syndrome. The evidence suggests that the development of 'triadic'(person-person-world) social interactions may be affected by limited information-processing capacities in infants with Down syndrome, through a complex socially-mediated developmental trajectory.
Moore DG, Oates JM, Hobson RP, Goodwin J. Cognitive and social factors in the development of infants with Down syndrome. Down Syndrome Research and Practice. 2002;8(2);43-52.
Delay in the development of cognitive capacities is a primary consequence of Down
syndrome. Despite such cognitive delay, however, young children with Down syndrome
can be empathic, affectionate and engaging (Wishart & Pitcairn,
2000). This might be taken to suggest that there are pre-specified, independent,
'domain specific' pathways for some aspects of social and cognitive development.
Yet if one adopts a perspective that overemphasises modularisation of function there
is a danger that one may underestimate the complex transactional processes that
occur between domains in social and cognitive development (see
Karmiloff-Smith, 1998). We need to consider not only the possibility of
relatively independent 'domain specific' developmental trajectories for some social
and cognitive capacities, but also to work out the extent to which cognitive and
social development capacities, even those that may appear initially to develop relatively
independently of each other, come to interact with and mutually influence one another,
and lead to unique developmental outcomes. To this end we have conducted a detailed
longitudinal study of a cohort of infants with and without Down syndrome and their
mothers, following their progress from an early age. We have assessed children with
Down syndrome at six monthly intervals from 6 through to 18 months, and contrasted
their development with a control group of typically developing infants seen at 4,
7 and 10 months.
Our aim was to study how social and cognitive capacities combine to create characteristic
forms of infant-parent interaction in families of children with Down syndrome, and
consider how these forms of interaction, in turn, regulate and influence other aspects
of their social and cognitive development. This approach may help to explain the
emergence of subtle differences as well as similarities in the social and cognitive
capacities of people with Down syndrome when compared to typically developing children
(Chapman & Hesketh, 2000). This paper gives an overview
of some findings emerging from this study and outlines some of the methodological
and conceptual issues that we have begun to address.
Difficulties in measuring cognitive capacities
For many years the dominant view was that 'cognition' could be construed largely
in terms of children's progressive construction of knowledge based on their own
active interaction with the world (Piaget, 1954). This view
was challenged by psychologists adopting a so-called Vygotskian perspective (e.g.
Bruner, 1975; Wertsch, 1985;
Rogoff, 1990). These theoreticians emphasised the role that social interaction
and context plays in the co-construction of a child's knowledge. Two issues relevant
to our research emerge from these theoretical views. Firstly, these perspectives
remind us that the functions and structure of the brain are not entirely predetermined,
they are also dependent on experience and active interaction with the world. Secondly,
this reminds us that experiences are not purely a consequence of the activities
of the individual. An individual's neuro-cognitive development is also determined
by the instruction and scaffolding of others. At the very least others help to regulate
the focus of the individual's attention and assign significance to information in
the external world through social referencing and other 'person-person-world' interaction
(see Hobson, 2002). Hence, particularly early in life, to
adequately characterise neuro-cognitive development we must consider the social
context in which the infant is immersed. Secondly, this approach has highlighted
limitations in tests of cognitive functioning and the importance, when testing children's
individual cognitive capacities, of considering the influence of the social context
in which a test occurs (Light, 1986). This does not mean that
a relatively 'pure' cognitive test cannot be devised, but it must be devised taking
into account the influence on performance of the social context.
Thus, to assess interactions and transactions between cognitive and social domains
we need to have measures of an individual's level of cognitive functioning that
have allowed for social influences. We also need to define clearly what 'cognitive'
functions are. Early cognitive ability has been characterised as the development
of abilities to form and utilise representations of the world and to develop conceptual
models or theory-like constructs. Some cognitive tests of babies, correspondingly,
look for abilities to represent hidden objects or to distinguish or match different
objects based on their conceptual meaning, for example in terms of category membership.
Once the child has passed infancy it becomes possible to look at the development
of capacities to represent the world through language.
Cognitive abilities also implicate capacities to direct and control one's attention
and to regulate one's thinking and behaviour. These capacities for attending to
the world, storing and encoding experience and representations, creating and executing
planned actions (means-ends), and controlling and inhibiting responses, are often
referred to as information-processing capacities. It has been argued that information-processing
capacities may represent the most fundamental, purest and best estimate of mental
ability and that impairments in information processing may underlie delays in the
development of representational capacities (Zelazo & Stack, 1997).
This view is supported by evidence that estimates of information processing capacities
in infants appear to be better predictors of future IQ than standardised tests of
developmental progress (see Slater, 1995). In infancy, information
processing is most often assessed by studying infants' abilities to control and
direct their attention to visual stimuli. Approaches include the repeated presentation
of pairs of interesting stimuli on computer or television screens and the recording
of infants' spontaneous or novelty preferences. Alternatively, one can present infants
with a single stimulus and assess the rate at which infants become 'used to' the
stimulus (habituation) and the amount of recovery of attention they show when presented
with a new stimulus (dis-habituation).
Colombo (2001) has proposed that the development of four
separate neural substructures underpins the development of infants' attention, with
each structure responsible for a different aspect of attentional control. These
are: Alertness or anticipatory readiness for stimuli which is modulated by brainstem
activities; Spatial Orienting, the shifting of attention to and from particular
stimuli under the control of posterior brain systems; Attention To Object Features,
systems for analysing the visual properties of stimuli that will lead to their identification,
determined by pathways in the occipital and temporal cortex; and Endogenous Attention,
volitional capacities for directing, holding or inhibiting the direction of attention
mediated by the frontal lobes. This function being the last to develop in typically
developing infants. These sub-systems seem to represent important components of
information processing and it is proposed that these may be the basis on which cognitive
There is evidence that children with Down syndrome differ from typically developing
infants in the development and deployment of their attentional resources and have
known neurological impairments. For example, differences have been found both in
utero and in early infancy, in the rate of habituation of infants with Down syndrome
(Hepper & Shaidullah, 1992). Also infants with Down syndrome
show different patterns of visual preference in early infancy (Miranda
& Fantz, 1973; Miranda, 1976). Correspondingly,
when performing information processing tasks, people with Down syndrome show differences
in the amplitude of cerebral event-related potentials (Karrer, Wojtascek
& Davis, 1995). These differences in attentional performance and in
event-related potentials are likely to be a consequence of differences in the structure
and development of the frontal lobes and cortex (i.e. Logdberg &
Brun, 1993; Takashima, Becker, Armstrong & Chan, 1981).
Karrer, Karrer, Bloom, Chaney and Davis (1998) have proposed
that children with Down syndrome may have particular impairments in 'frontal' processing
that may affect a range of inhibitory processes (corresponding to Colombo's endogenous
attention). However, more detailed examinations of component attentional processes
are required. Focussing on different attentional systems in the terms outlined by
Colombo (2001), may allow us to describe the unique developmental
profile of infants with Down syndrome in a more fine-grained way. We may be able
to establish whether specific components are impaired or spared in infants with
Down syndrome or whether infants with Down syndrome have a more global information-processing
deficit. For example Zelazo and Stack (1997) suggest that
inhibitory problems may be consequence of slower overall processing and not a product
of a specific impairment in frontal processes.
In our studies we have presented infants with a series of static and moving stimuli
on computer screens. The primary intention was to look at capacities for visual
discrimination between meaningful stimuli, requiring what Colombo
(2001) refers to as 'attention to object features' but the tasks also yielded
measures relating to other aspects of attention. Zelazo and Stack
(1997) suggest that sequential stimuli may be the best visual stimuli to
use for assessing attentional capacities. Therefore, of particular interest, were
infants' responses during a task involving the repeated presentations of animations
of circles depicting 'billiard ball', causal and non-causal collisions (based on
Leslie & Keeble, 1987). The first test condition was a
non-causal event and involved one circle appearing from one side of the screen and
moving towards another circle located in the centre. The first circle stopped before
reaching the central ball. The second circle then moved off and disappeared off
the other side of the screen (a non-caused action). This event was repeated until
the infants habituated. A number of measures of attention were collected. These
were: the total duration of looking; the length of longest look; the number of looks;
the number of complete stimulus events seen; the total duration of looking away
and the latency of orienting to the first presentation of the event. Surprisingly
the last two measures are not normally reported in habituation studies but are the
most likely to provide useful information regarding inhibitory attentional processes
in infants with Down syndrome (Oates, Moore & Hobson, 1997;
Moore, Oates, Goodwin & Hobson, 2000).
Factor analysis of these measures in our cohort of typically developing infants
and infants with Down syndrome suggested that these measures might indeed be tapping
into separate attentional processes. The analysis yielded a three-factor solution.
These factors seem to map onto three of the components of attention identified by
Colombo. Duration of looking and the length of the longest look loaded together
and seemed to represent an alertness factor; the number of looks and number of complete
stimulus events seen loaded together and indicated spatial orienting; and the duration
of looking away between looks and the latency of orienting to the first presentation
of a stimulus seemed to be a measure of endogenous attention (Moore
et al., 2000).
We examined the performance of the infants with Down syndrome when 6 months old,
and compared their performance to our control group of typically developing infants
at 4 months of age, when considered comparable in general developmental level (see
Rauh, Schellhas, Goeggerle & Muller, 1996). Results revealed
that the infants with Down syndrome, showed significantly lower alertness (smaller
duration of looking) and endogenous attention (slower latency and longer looks away)
but were equivalent in spatial orienting (Moore et al., 2000).
Thus, these component measures of attention seem to capture specific differences
and not just delays in cognitive functioning between children with Down syndrome
and typically developing children. These differences may not be picked up by more
traditional cognitive tests, and while differences in alertness may be picked up
by traditional habituation measures, endogenous attention may only be possible to
index during habituation by examining patterns of latency and 'looking away'. One
particular advantage of this approach is that the measurement of attentional process
is not so dependent on establishing a social rapport with the infant. Thus it may
be a more profitable way to assess the 'pure' cognitive abilities of children with
Down syndrome independently of social competence (Zelazo & Stack,
While visual attention tasks may prove to be particularly useful for testing cognitive
functioning in infants, they are rarely used for this purpose. Instead developmental
tests such as Bayley Scales are often used to assess cognitive level (Bayley,
1969; 1993). The Bayley scales consist of a number of tasks devised to assess
the competence of babies at each month of development, and to provide an indication
of whether the babies have achieved a typical developmental level. Some tasks may
be administered only to younger or older infants. The scale includes Piagetian object-search
and means-ends tasks designed to assess the development of representational abilities,
as well as tasks assessing fine motor skills, visual perceptual processing, planning
abilities, memory, social abilities and language. By looking at performance across
the whole range of tasks administered, the Bayley scales deliver scores on four
developmental 'facets': cognitive, social, language and motor.
For this project, the central problem with using this scale for extracting a 'pure'
cognitive measure was that all the tasks of the Bayley scales, including those that
go to make up the cognitive facet score, involve a social interaction between tester
and infant, confounding social with cognitive competence. Some aspects of task performance
may be determined not only by an infant's cognitive abilities but also by the capacity
of child and tester to develop a rapport, and thereby to establish scaffolding.
There are also additional problems for researchers of infants with Down syndrome.
The tasks intended to be indicators of cognitive level also rely on motor manipulation
and language to demonstrate competence. In fact, many of the individual tasks contribute
to scores on the motor, language and cognitive facets. This is not a problem when
using the scales as a clinical tool to identify the presence of atypical development,
as the identification of a delay or difference in performance is the main objective,
not the identification of the source of the performance deficit. However, where
there are known specific language and motor delays, as is often the case for children
with Down syndrome, these language and motor delays may obscure other cognitive
competencies and lead to an underestimation of 'pure' cognitive abilities.
For this reason, we have made an attempt to extract out from the Bayley scales a
collection of those tasks where the social, motor and language components have a
reduced influence on the expression of cognitive competence. The aim has been to
create a shorter, relatively pure, cognitive scale (Goodwin, Oates & Moore,
2000). With this short-form, a score of cognitive achievement can be constructed
by considering the number of tasks passed at each age. This short-form can then
be used to assess the relationships, within-groups, between cognitive and social
abilities. While still in development, the measure has been useful as a means of
establishing the equivalence of our groups of infants with and without Down syndrome
in their cognitive functioning at each data sweep (Goodwin et al.,
2000). Using this technique we have been able to confirm that the cognitive
level of our infants with Down syndrome when 6, 12 and 18 months old is equivalent
to that of our control typically developing infants when 4, 7 and 10 months old.
This supported our initial estimates of likely cognitive levels based on
Rauh et al. (1996).
In summary, we have established, using a short form of the Bayley scales, that it
may be possible to measure some aspects of cognitive functioning relatively independently
of social, motor and language capacities. This also established more clearly the
cognitive equivalence of our cohorts of typically developing infants and infants
with Down syndrome at each data collection point. We have also been able, using
habituation tasks, to measure important differences in attentional capacities between
the cohorts that may underpin delays in cognitive development. It may, for example,
prove that these attentional differences underpin the different profiles of errors
and instability in cognitive performance of infants with Down syndrome noted, for
example, by Morss (1983) and Wishart and Duffy
Cognitive influences on social development
How do these unique profiles of cognitive delay and difference influence social
development in children with Down syndrome? In particular, to what extent and by
what mechanisms do attentional differences influence the development of social understanding?
One argument might be that just because infants with Down syndrome have problems
with attending to the world in general it is not inevitable that they will be impaired
in attending to people. Indeed, it is plausible to argue that some early processes
used for interpreting people's faces and extracting social meanings, such as their
emotions, may use specialised, dedicated, modular like, low-level neurological architecture.
At least in early development, these may operate independently of the neurological
systems responsible for general attention detailed by Colombo (see
Moore, Hobson & Anderson, 1995). It is also possible that these systems
may be relatively spared in people with intellectual deficits and, because of this,
people with attentional problems and intellectual deficits may be able, in early
infancy, to develop relatively typical social relationships.
Recent evidence partly supports this view, as it seems that young children with
Down syndrome perform similarly to typically developing children matched for mental
age on emotion recognition tasks (Kasari, Freeman & Hughes,
2001), and Heimann, Ullstadius and Swerlander (1998)
report spared imitative abilities. However, there is also evidence that older children
with Down syndrome perform poorly on emotion recognition tasks relative both to
mental age equivalent typically developing children and to people with general learning
difficulties (Wishart & Pitcairn, 2000). The source
of these performance deficits remains to be established. Perhaps they do reflect
a basic impairment in emotion recognition. However it may be that primary emotional
capacities are intact, and it is the expression of these that is constrained by
the reduced information-processing capacities of the infants with Down syndrome.
This difference may not controlled for by matching on measures such as the Bayley
scales. If infants with Down syndrome are slower or more inconsistent in orienting
and responding then this may well impair their ability to perform emotion recognition
tasks (Moore, 2001) and affect their responses to people
in social interactions. Even if basic sensitivities to emotional patterning are
preserved, the differential responses of infants with Down syndrome may create a
different quality of social interaction that will lead to different developmental
outcomes (Richard, 1986).
In order to develop a fuller picture of the development of infants with Down syndrome
we need to explore these transactional processes across time. Specifically we need
to assess: infants' constituent attentional capacities in non-social situations;
infants' attention and behaviour within social interactions; the effect of their
behaviour on caregivers; and the processes by which different forms of mother-infant
interaction, in turn, influence the social and cognitive development of the child.
As outlined above, there is already evidence that infants with Down syndrome demonstrate
attentional problems in non-social situations. There is also some evidence that
infants show different attentional profiles in social interactions.
For example, in a longitudinal study of five infants with Down syndrome and a control
group of typically developing infants from 1 to 6 months, Berger
and Cunningham (1981) reported that during a face-to-face interaction with
their mother typically developing infants showed the greatest levels of eye-contact
between 2 and 4 months of age. After four months of age this level of eye contact
then falls off. In contrast, infants with Down syndrome showed a delayed but steady
increase in percentage eye-contact over the course of the first six months reaching
the levels of 4-month-old typically developing infants by around six months of age.
Infants with Down syndrome did not then show a fall off in looking and seem to maintain
higher levels of looking to their mothers. Also, their looking was characterised
by shorter lengths of individual eye-contact episodes.
While infants with Down syndrome seem to differ in the time they spend looking to
the mother, both typically developing infants and infants with Down syndrome show
a similar reduction in eye contact when their mother ceases interacting with them
during a 'still-face' period. This suggests that the infants in each group have
similar emotional reactions to the unresponsive behaviour of the mother.
Berger and Cunningham (1986) also reported that infants with Down syndrome
showed reduced smiling during face-to-face interactions. Similar findings were reported
by Legerstee and Bowman (1989) and by Crown,
Feldstein, Jasnow, Beebe and Jaffe (1992).
Similarly despite delays in the achievement of levels of eye-contact, and shorter
individual eye-contact episodes in face-to-face interactions, Gunn,
Berry and Andrews (1982) reported that 6- to 9-month-old infants with Down
syndrome spent more total time during play looking at their mother than at objects.
This looking was nearly twice that of typically developing infants of the same chronological
age. Landry and Chapieski (1990) studied 6-month-old infants
with Down syndrome and found that infants with Down syndrome looked more to the
mother and less at a toy even compared to pre-term infants matched for mental age.
This also occurred even when the mothers were not actively involved in play. Thus,
early in development, infants with Down syndrome may be exhibiting less eye contact
but actually looking for longer amounts of time at their mothers than chronological
age- and mental age-comparable control infants.
How does the behaviour of the infants with Down syndrome influence maternal behaviour?
Is there any evidence that the behaviour of mothers of infants with Down syndrome
is different from that of mothers of typically developing infants?
Hyche, Bakeman and Adamson (1992) reported that mothers who had brought
up children with Down syndrome were more sensitive to the communicative cues captured
on videotape of children with Down syndrome than mothers of typically developing
infants. However, mothers of infants with Down syndrome, despite being more sensitive
to the cues of infants with Down syndrome, still found infants with Down syndrome
of around 7 months of age more difficult to 'read' than typically developing infants
of the same age. How would this influence their behaviour? Buckhalt,
Rutherford and Goldberg (1978) reported that their sample of babies with
Down syndrome, ranging in age from 9 to 18 months, smiled and vocalised less and
that, correspondingly, the mothers of infants with Down syndrome spoke to their
infants at a significantly faster rate than mothers of typically developing infants.
This suggests that the form of mother-infant interaction for Down syndrome dyads
may come to differ in some important respects to that of typical dyads.
Thus there is evidence that infants with Down syndrome differ in their attentional
capacities and propensities and this is evident in their behaviour in both social
and non-social situations. There is also some evidence that maternal behaviour may
differ as a consequence of these differences in attentional capacities. However,
there have been no studies that have concurrently measured social and non-social
attentional factors and established their role in influencing maternal interactional
style. This is necessary if one is attempting to develop a transactional model of
the development of infants with Down syndrome.
In our study, we examined mother-infant interactions during early infancy (at 4
months for typically developing children and 6 months for children with Down syndrome).
We used the still-face paradigm of Tronick, Als, Adamson, Wise and
Brazelton (1978) to assess the quality of early mother-infant interactions.
In the first phase of the procedure mother and infants engaged in face-to-face interaction
for three minutes. In the second phase the mother was asked, when a signal was given,
to display a passive face and not to respond to the infant for up to 90 seconds,
but less if the infant became distressed. In the final phase the mother and infant
re-engaged in their normal interaction for 3 minutes.
We found that our sample of infants with Down syndrome responded similarly to typically
developing infants. The groups showed the same percentage amount of looking and
smiling to the mother during the first and final phases, and a similar decrement
in looking and smiling when a still face was displayed. They did differ however
in the amount of fussing, with infants with Down syndrome showing less fussing during
the still face event than typically developing infants (Oates, Moore,
Goodwin, Hobson & Reynolds, 2002). These findings do not concur with
those of Berger and Cunningham (1981) and this may be due
to different methods, but an additional important finding emerged from this task
that may also help explain these contrary findings.
While, in general, the infants with Down syndrome did not appear to behave differently
to typically developing infants, the mothers did. We found that the mothers of infants
with Down syndrome in our sample differed from typically developing mothers in their
behaviour during the interaction phases when rated on the mother-infant interaction
scales devised by Murray, Fiori-Cowley, Hooper and Cooper (1996).
Using Principal Component Analysis we found that these 14 scales reduce to three
meaningful factors. We found that the mothers of infants with Down syndrome significantly
differed from the mothers of typically developing infants on two of these factors.
Mothers of children with Down syndrome scored significantly higher than the mothers
of typically developing infants on the factor comprised of ratings of 'effort to
engage', 'warmth', 'happiness', 'absorption in their infant', etc. - the factor
we have labelled 'warmth'. However, alongside this positive interaction quality
the mothers also differed on the factor we have labelled 'forcefulness' derived
from ratings of 'intrusiveness', 'sensitivity', and 'responsivity', with mothers
of Down syndrome being rated as less sensitive, less responsive and more intrusive
(Oates, Moore, Goodwin, Hobson, & Reynolds, 1998;
Oates, et al., 2002).
We have come to call this combined style of interaction 'forceful warmth', and have
found that the degree to which the mothers of infants with Down syndrome demonstrated
'forceful warmth' was strongly associated with the infants' endogenous attention
measured on the non-social visual attention task described earlier. We hypothesise
that the reason the infants with Down syndrome in our cohort showed similar levels
to the typically developing infants in attention and smiling during the face-to-face
interaction (in contrast to the findings of Berger & Cunningham,
1981, 1986) is that the mothers were working to increase their infants'
responsivity to them by showing greater warmth. While this style may be positive
in terms of engaging the infants, the mothers may also demonstrate a corresponding
reduction in their sensitivity to their infants within the interaction. Their concentration
on giving warm and positive feedback may make them more 'forceful' and less likely
to pick up on the social bids of their infants.
While it is important to seek further support for this finding by examining interactions
in more naturalistic settings and with larger samples, it seems that constraints
in the attentional capacities of infants with Down syndrome may create a form of
early social interaction in which the mother plays a central role in maintaining
and redirecting infant attention (Landry & Chapieski, 1989).
What might be the implications of this early form of interaction for the later development
of infants with Down syndrome?
Social influences on cognitive development
One possibility is that the form of interaction where the infant is dependent on
the mother for engaging its attention within a dyadic social interaction may tend
to 'lock in' the infant and make them less likely to spontaneously attend to objects
beyond this dyad. This is supported by the findings of Landry and
Chapieski (1990), who reported that 6-month-old children with Down syndrome
tended to look more to their mother than an object during play. If this continues
then there is a possibility that infants with Down syndrome will not engage in typical
'triadic', joint attention interactions involving mother, infant and objects with
implications for later cognitive development. Triadic interactions emerge in typical
infants around the end of the first year, and may be critical for the development
of language, flexible thought and meta-cognitive awareness (Hobson,
2002). Even at six months atypical interactions may already have repercussions
for language development (see Berger & Cunningham, 1983).
But what evidence is there that these 'forceful' interaction styles continue beyond
early infancy, and does this affect the quality of triadic interactions between
mothers and infants with Down syndrome? Furthermore, is there any evidence that
this then impacts of the development of language and flexible thinking?
Cielinski, Vaughn, Seifer and Contreras (1995) studied
children with Down syndrome of 17 to 44 months during play episodes. They measured
infant engagement with toys during individual and social play and examined the quality
of mother-infant interaction during the social play episodes. They found no significant
group differences in comparison to typically developing children of similar developmental
levels in the proportion of time infants with Down syndrome engaged with toys during
individual play. However, they found significant differences in the proportion of
time the infants spent engaging with toys in social play, with the children with
Down syndrome spending less time engaged with toys than the typically developing
children. Furthermore the children with Down syndrome spent a greater proportion
of time engaging with the mother in face-to-face interaction without toys.
Cielinski et al (1995) also reported that the quality of
the mother-infant interactions during the social play episodes differed, with mothers
of boys and girls with Down syndrome rated as more 'intrusive' and mothers of girls
with Down syndrome rated as more 'directive' than mothers of typically developing
girls. It was also found that maternal directiveness was positively correlated with
the proportion of time the children engaged with toys for the group of children
with Down syndrome but not for typically developing children. The infants with Down
syndrome of more directive mothers spending more time playing with the toys. Thus,
the mothers of 17-month-old infants with Down syndrome are demonstrating qualitatively
different maternal behaviour in responses to their infants, compared to mothers
of typically developing infants, with the mothers of infants with Down syndrome
playing a more pivotal role in directing their infants' attention.
Ruskin, Kasari, Mundy and Sigman (1994) studied the attention
of 22-month-old children with Down syndrome during presentations of social (a person
singing) and non-social (a toy) stimuli. They reported that children with Down syndrome
looked for significantly longer at the person and were more likely to engage in
singing than mental age-equivalent typically developing infants. While there were
no differences in attention to the toy, the infants with Down syndrome were more
likely to push it away. Importantly, while this might suggest that the children
with Down syndrome have relatively typical social responses with a stranger and
a toy, it is important to note that the children with Down syndrome engaged in significantly
less off-task looks to their mothers during this interaction, again suggesting a
different quality to their joint attention with mothers. Kasari,
Freeman, Mundy and Sigman (1995) also reported that compared to typically
developing controls, children with Down syndrome tend to show fewer social referencing
looks to their mother in an ambiguous situation, although their responses to initiated
joint attention did not differ.
These results show that there is a complex relationship between an infant's attentional
capacities and maternal behaviour, and that by the middle of the second year this
may have evolved into a form of interaction in which mothers of children with Down
syndrome act as important mediators of the infant's attention. Mothers may be compensating
for constraints in capacities for endogenous attentional control by becoming more
directive but also correspondingly less sensitive to the infants' bids. The findings
of Ruskin et al. (1994) suggest that a possible cost of this
compensatory strategy may be in the infants' subsequent inability to regulate their
own behaviour in associated joint attention episodes and to spontaneously perform
Thus, we may have an example of an earlier social factor, the nature of early mother-infant
interaction, acting on the later development of spontaneous joint attention. What
impact does this then have on cognitive development? While Mundy,
Sigman, Kasari and Yirmiya (1988) reported relative strengths in social-interaction
in 18-48 month old children with Down syndrome compared to mental age equivalent
typically developing children, they also found a relative deficit in the tendency
for children with Down syndrome to make requests for objects or for assistance with
objects. Individual differences in requesting in their sample were also significantly
associated with measures of expressive language. Indeed there seems to be an overall
tendency for infants with Down syndrome to make fewer spontaneous social-communicative
signals (Fischer, 1987). Further support for an association
between early social-communicative capacities and language development in this population
comes from a longitudinal study by Mundy, Kasari, Sigman and Ruskin
(1995) which looked at children with Down syndrome when 22 and then 35 months.
They found significant group differences in comparison to mental age equivalent
typically developing controls in requesting and in responding to joint attention
initiations from others. Also they found that individual differences in requesting
and in initiating joint attention at 22 months predicted expressive language in
the children with Down syndrome when 35 months old. Requesting also predicted expressive
language capacities in the typically developing children but tendency to initiate
joint attention did not. Mundy et al. (1995) proposed that
deficits in requesting behaviour might explain expressive language deficits in children
with Down syndrome and proposed that these requesting deficits may represent a primary
deficit and are not a consequence of differences in affective processes or caregiver
responsivity and directiveness.
However specific requesting deficits have not been found in other studies (more
on this later) and, in contrast, Harris, Kasari and Sigman (1996)
have reported strong associations between joint attention capacities and the development
of receptive language in children with Down syndrome. While a relative strength
compared to expressive language, the development of receptive language in children
with Down syndrome was also found to be related to capacities for non-verbal communication.
Harris et al. (1996) reported that children with Down syndrome,
once engaged in joint attention will spend longer attending to caregiver selected
foci of attention and that caregivers of infants with Down syndrome are more in
control of the topic of attention. Critically, the best predictor of receptive language
was not infant's attention to mothers' topics. Rather, receptive language was related
to mothers' sensitivity to their infants' attention: mothers who more frequently
redirected their attention away from the topic selected by the infant had infants
who were less able in terms of receptive language.
Thus, children's attentional deficits may have a determining influence on the nature
of mother-infant interaction which in turn may influence the development of expressive
and receptive language. In our study, we were interested in exploring these issues
taking a longitudinal perspective. We wished to establish, whether, as reported
by Franco and Wishart (1995), there were differences between
mental age equivalent groups of typically developing and Down syndrome infants (at
10 and 18 months), in triadic communicative acts critical for language development
such as joint attention, social referencing and requesting. We also wanted to establish
whether the quality of early mother-infant interaction evidenced at 6-months-of-age
in infants with Down syndrome predict these differences. While the studies above
provide evidence for a relationship between the quality of mother infant interaction
and triadic communicative acts, they do help to determine the transactional nature
and origins of this association.
In our sample we found that when the infants with Down syndrome were 18 months of
age, relative to typically developing infants tested at 10 months of age, there
were no specific deficits in requesting behaviour. Indeed we found some evidence
for relatively spared requesting in our sample (Moore et al, 2000).
In addition we did not find group differences in responses to joint attention when
initiated by the tester. These findings contrast with those of Mundy
et al. (1995) but mirror those of Sigman and Ruskin (1999)
who, with a larger sample, reported no deficits in the initiation of requesting
behaviours compared to children with other developmental delays of equivalent mental
age. However, they found that the frequency of requesting and frequency of responding
to joint attention was significantly less than that of mental age equivalent typically
developing children. They also reported that measures of initiation and responses
to joint attention were associated with measures of verbal abilities.
The reasons for the different levels of responses to joint attention in the two
studies requires further exploration and may be explained in terms of matching procedures.
However, although the levels of responding may have been higher for our sample,
it is perhaps of more relevance that we found that within-group variation in responses
to adult prompts to joint attention at 18-months were strongly associated with the
quality of mother-infant interaction (maternal 'forceful warmth') when 6-months-old.
More specifically, those mothers who displayed 'forceful warmth' had infants who
were less responsive to the tester's prompts for joint attention (pointing and looking
at objects). This suggests that their attention is more mediated through their mother
and not easily modulated by others. Interestingly this correlation also held for
typically developing infants from 4 to 10 months. However, while maternal 'forceful
warmth' was predicted by the infant's attention during the non-social visual attention
task for the infants with Down syndrome, this was not so for typically developing
infants. While similar developmental processes may be unfolding, individual differences
in 'forceful warmth' of the mothers of typically developing infants may be due to
factors other than their infants' attentional capacities.
Our findings, and those of other researchers in the field, support a transactional
account of the development of infants with Down syndrome. We have proposed developmental
process that lead to children with Down syndrome developing different patterns of
triadic relations as manifest in social-communicative acts. While further work is
needed to establish which social-communicative acts are most affected by the factors
we have studied (i.e. requesting and/or joint attention) we can now provide a general
developmental account that may underlie these deficits. A transactional model is
presented in Figure 1.
Figure 1. A transactional account of the development
of infants with Down syndrome
We propose that neurologically-based differences in early attention regulation in
children with Down syndrome may make them slower to respond and orient in social
interactions. This then elicits a warmer but more forceful maternal style during
interactions that serves to maintain typical levels of attention in infants with
Down syndrome. This different social style may make infants with Down syndrome more
focussed on the mother and may serve an important and useful function in developing
early emotional attachments (Berry, Gunn & Andrews, 1980).
However, this may also make infants more 'locked in' and dependent on their mothers
for regulating their attention. Subsequently, aspects of 'triadic' engagement and
joint attention are more likely to be driven by the mother. Thus, when less frequent
but critically important 'topic' bids are made by infants with Down syndrome, they
may not be picked up because mothers are continuing to work hard to direct and maintain
attention using this 'forceful' and 'warm' affective style. Ultimately, the characteristic
quality of these triadic interactions may add to delays in language development
and in the development of flexible symbolic thought (Hobson, 2002).
The results of our studies support an account of the development of children with
Down syndrome that goes beyond simple deterministic or environmental explanations.
We also offer an account that explains the development of infants with Down syndrome
within the same parameters as those used to explain typical development. Of course,
to confirm our hypotheses further longitudinal studies are needed, starting in early
infancy and utilising additional measures and larger samples. If these studies confirm
our findings, then it may be possible to provide useful suggestions for early interventions
with infants with Down syndrome and their mothers, interventions that would hold
promise for facilitating both social and cognitive development.
This paper is based on a keynote presentation made to the 3rd International Conference
on Language and Cognition in Down Syndrome, Portsmouth UK, September 2000. We would
like to thank the mothers and infants who participated in our studies and acknowledge
the ESRC for financial support (Research Grant: R000236722).
Derek Moore • Department of Psychology, University of East London, Romford Road,
London, E15 4LZ • E-mail: firstname.lastname@example.org
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