R E S E A R C H R E P O R T

Effect of Sensorimotor Groups on

Gross Motor Acquisition for Young
Children with Down Syndrome
Alyssa C. LaForme Fiss, PT, PhD, PCS, Susan K. Effgen, PT, PhD, Judith Page, PhD, CCC-SLP,
and Sharon Shasby, PhD, OTR/L
Divisions of Physical Therapy (A.C.L.F., S.K.E.), and Communication Disorders (J.P.), University of Kentucky,
Lexington, Kentucky; Division of Physical Therapy (A.C.L.F.), Georgia State University, Atlanta, Georgia; and
Department of Occupational Therapy (S.S.), Eastern Kentucky University, Richmond, Kentucky
Purpose: To examine whether participation in sensorimotor groups and individual intervention resulted in
greater improvements in motor skill acquisition than solely individual intervention for young children with
Down syndrome. Methods: Ten children with Down syndrome, 13 to 29 months of age, participated. Children
in both groups received individual intervention, and children in the intervention group participated in 10
weekly sensorimotor groups. All children were assessed at 3 points using the Gross Motor Function Measure
and Goal Attainment Scaling. Results: Children in the intervention group demonstrated significant improve-
ment compared with children in the control group at the p 0.10 level in lying and rolling, crawling and
kneeling, and total score domains of the Gross Motor Function Measure and in Goal Attainment Scaling.
Conclusions: Participation in sensorimotor groups and individual intervention resulted in greater improve-
ment in motor skill acquisition than solely individual intervention for young children with Down syndrome.
Additional research to support these exploratory findings is needed. (Pediatr Phys Ther 2009;21:158166) Key
words: child/preschool, comparative study, Down syndrome, goals, motor skills, peer group, physical therapy,
pilot projects, time factors, treatment outcome
INTRODUCTION
Determining the most effective and efficient model of
intervention to address motor skill development for chil-
dren with Down syndrome is needed. Infants with Down
syndrome who participated in group early intervention
sessions demonstrated earlier attainment of developmental
milestones when compared to children with Down syn-
drome who did not participate in group early intervention
models.
1
Further examination of the use of groups with
children with Down syndrome is not available. However,
use of group intervention with preschool and school-age
children with various diagnoses such as cerebral palsy, de-
velopmental coordination disorder, and obesity has shown
promising results on increasing gross motor skill acquisi-
tion with both positive and neutral comparisons to individ-
ual intervention.
26
Although not specific to young chil-
dren with Down syndrome, these studies suggest that
delays in gross motor skill development may be addressed
in group intervention models. Motor function,
5,6
vital ca-
pacity,
5
and self esteem
5
have been found to improve with
10 weekly group intervention sessions for children with
developmental coordination disorder. Improvement of
gross motor skills,
3
fine motor skills,
3
and Individualized
Education Plan
4
outcomes have been noted between group
and individual intervention sessions with young children
with developmental delay during the school year. These
studies suggest that group intervention may be an appro-
priate model for consideration for younger children with
developmental delay and may yield results similar to indi-
vidual intervention. Group intervention models also allow
for increased peer modeling, socialization, and efficiency of
therapy,
7,8
because the therapist is able to serve more than
0898-5669/109/2102-0158
Pediatric Physical Therapy
Copyright 2009 Section on Pediatrics of the American Physical
Therapy Association.
Address correspondence to: Alyssa LaForme Fiss, PT, PhD, PCS, Divi-
sion of Physical Therapy, Georgia State University, 1278 Urban Life
Building, Atlanta, GA 30303. E-mail: phtacl@langate.gsu.edu
This work was completed as Dr. LaForme Fisss Doctoral Dissertation
work at the University of Kentucky Rehabilitation Science Doctoral
Program.
DOI: 10.1097/PEP.0b013e3181a3dec7
158 LaForme Fiss et al Pediatric Physical Therapy
1 child in a session. Survey studies in pediatric physical
therapy indicate that therapists use group sessions with
children.
912
To date, research examining various models of inten-
sity of physical therapy intervention for children with dis-
abilities has provided inconclusive results. For children
with cerebral palsy, increasing intensity of intervention has
been shown to lead to improvements in motor skill devel-
opment,
13
Gross Motor Function Measure (GMFM)
scores,
1421
specific goal attainment,
1618
and Pediatric
Evaluation of Disability Inventory scores.
19,22
However,
other studies have reported a lack of significant differences
between intensive and more conventional therapy mod-
els.
23,24
Compounding the conflicting conclusions, results
of many of these previous studies have been questioned
due to methodological concerns.
21
For example, Bower et
al reported improvement in GMFM scores and in specific
goal attainment in 3 studies with increased intensity of
intervention provided over 2,
18
3,
16
or 5 weeks.
17
However,
questions regarding the accuracy of these results exist be-
cause of the lack of information on specific interventions
provided during the studies.
21
In contrast to their previous
findings, Bower et al
23
examined intensive physical therapy
over a 6-month period and noted no significant differences
on GMFM scores for either group. The authors concluded
that increasing intensity of intervention did not have an
effect gross motor function or performance. However, they
reported low compliance with the intensive intervention,
which may have contributed to the nonsignificant results.
It is important to note that a contributing factor to the
decreased compliance may have been the length of the
intervention phase in this study, which was 6 months when
compared with 2 to 5 weeks in their previous work. Results
of later research appear to support increasing the intensity
of intervention when provided on an individualized and
intermittent basis.
20,21
Other methodological concerns related to these pre-
vious studies include use of small sample sizes and case
report designs, which limit generalization of positive re-
sults,
14,20
and questionable duration of therapy provided
during the intensive interventionperiods.
13,24
Researchexam-
ining increased intensity of intervention for children with
Down syndrome is limited to early intensive treadmill train-
ing to increase the acquisition of ambulation.
25,26
There is a
need for additional research to examine specific models of
intensive intervention for young children with disabilities.
The GMFM-88
27
and Goal Attainment Scaling
(GAS)
28
are commonly used measurement tools in pedi-
atric physical therapy. The GMFM-88 is a clinical tool
developed to measure change over time in gross motor
function in children with cerebral palsy
27
and Down syn-
drome.
29,30
Test-retest and interrater reliabilities have
been found to be excellent (all intraclass correlation
coefficients [ICC] 0.90) for children with Down syn-
drome
29
and cerebral palsy.
31
GAS is a criterion referenced outcome measure that uses
individualizedbehavior objectives toassess progress.
28
Touse
GAS, behavioral objectives are createdfor the childat baseline
and ordinal coded levels of the expected outcome are deter-
mined. Typically, the expected outcome is given a value of 0,
less favorable sequential outcomes are given values of 1 and
2, and more favorable sequential outcomes are given values
of 1 and 2. The 2 value typically represents the childs
baseline level. After intervention, the childs progress is mea-
suredusing this scale. GAS has beenreportedto be family and
patient centered because it allows increased collaboration in
goal setting,
28,32,33
and has been found to be a responsive mea-
sure for individual goal assessment.
34
When comparing GAS
scores, simple change scores are not adequate and the GAS T
score should be calculated. For ease of analysis, Cardillo
35
created a summary score conversion key for GAS average
scale scores and T scores. Once determined, the T scores can
be used for statistical analysis between subjects.
Group intervention as a means to increase intensity of
intervention provides a beginning model to examine effec-
tive intervention for children with Down syndrome. Group
intervention models may assist physical therapists in de-
termining effective models to increase independent move-
ment, increase the rate of gross motor skill acquisition, and
subsequently increase the ability of children with Down
syndrome to participate fully in their environment. The
purpose of this exploratory study is to investigate if young
children with Down syndrome, aged 1 to 3 years, who
participate in 10 weekly sensorimotor group sessions in
addition to individual intervention display greater im-
provements in gross motor skill development and goal at-
tainment than young children with Down syndrome who
participate solely in individual intervention.
METHODS
Subjects
A power analysis was used to determine the sample
size needed for this study based on an alpha of 0.05, a
power of 80%, and an effect size of 0.59 determined from
previous work on children with cerebral palsy using the
GMFM.
36
Current work examining the effect size for the
GMFM for children with Down syndrome is not available.
Results indicated a sample size of 74 children would be
required, which was not realistic for an initial single site
study. Therefore, this study was considered exploratory to
determine the feasibility of conducting a larger controlled
trial. A sample size of 10 subjects was chosen as an appro-
priate sample for this study, because it allowed for a real-
istic and effective group size for the intervention group
sessions.
A convenience sample of children with Down syn-
drome between 1 to 3 years of age was recruited. Inclusion
criteria included gross motor skill abilities between the
stages of independent sitting and independent walking.
Independent sitting was defined as the ability to sit on a
mat, maintaining arms free for 3 seconds. Independent
walking was defined as the ability to walk forward without
support for 10 steps. These criteria were based on the skill
criteria found in the GMFM, item numbers 24 and 69,
Pediatric Physical Therapy Group Treatment for Young Children with Down Syndrome 159
respectively.
27
Exclusion criteria included present partici-
pation in a gross motor-based play group, inability to at-
tend regular group sessions if enrolled in the intervention
group, active leukemia treatment, established atlantoaxial
instability, and serious behavior issues that would interfere
with group participation.
Three girls and 7 boys with Down syndrome (mean age
18.4 5.6 months, range 1329 months) were included in
the study, with 5 children assigned to the intervention and 5
children to the control group. Randomization could not be
used for group placement because participation in the inter-
ventiongroup was based onthe parents ability to enable their
children to attend group sessions. Table 1 displays subject
characteristics and frequencies of physical therapy and occu-
pational therapy.
Assessment Tools
Motor performance of each child was evaluated using
the GMFM
27
and GAS.
28
These assessments were com-
pleted in the childs home by a physical therapist with 30
years of pediatric experience, who was unfamiliar with the
children and who was blinded to the group placement.
Interrater reliability completed on the GMFM before data
collection was found to be 95% (ICC 0.988). Reliability
was also examined on 20% of the subsequent assessment
sessions and ranged from 93% to 98% (ICC 0.975
0.991). GMFM administration was completed in accor-
dance with the GMFM Users Manual, using the same
equipment for all children.
27
Determination of the GAS
objectives was completed by a second blinded assessing
therapist with 30 years of experience in pediatrics based on
the childs assessment results, family priorities, and expe-
rience. These goals were then reviewed by the therapists
currently serving the children to ensure that they were
appropriate and were an accurate reflection of the childs
current level of motor skills. Each objective had 5 possible
levels of skill achievement as recommended for GAS. The
majority of these objectives centered on stability or mobil-
ity skills such as crawling, standing, and walking, which
represented typical intervention activities for this age
group and population. A GAS score of 2 was assigned to
the childs current status on each objective. A GAS score of
0 was assigned to the most probable outcome for each goal
and a score of 2 was assigned to the most favorable out-
come after 10 weeks. Scores of 1 and 1 were assigned to
levels of the outcome between levels 2 and 2. Sample
GAS objectives are shown in Table 2.
Assessments for the study included assessment 1, ini-
tial assessment; assessment 2, 10 to 12 weeks postinterven-
tion or post control phase; and assessment 3, 4 to 5 weeks
postsecond assessment.
Intervention Methods
Children in both groups continued their regular
schedule of physical therapy and occupational therapy
based on their current plan of care. Intensity of each of
their current therapy services was documented, but inter-
vention activities outside of the sensorimotor groups was
not measured and it was not possible to control these ac-
tivities. Children were seen by different therapists with
various levels of experience, skill, and differing treatment
philosophy. Children in the intervention group partici-
pated in a short-term sensorimotor group intervention,
once per week for 10 consecutive weeks. The 10-week du-
ration was chosen because it was used in previous work on
group intervention
5,6
and because it represented a rela-
tively short duration of intervention to assist with increas-
ing compliance of families with session attendance. For the
purposes of this study, sensorimotor groups were defined
TABLE 1
Subject Characteristics at Initial Assessment
Control
(n 5)
Treatment
(n 5) p*
Age (mo) 20 3.5 16.8 6.8 0.427
Male 4 (80%) 3 (60%) 0.490
Physical therapy (x/mo) 3.2 1.2 3.6 0.8 0.666
Occupational therapy (x/mo) 1.9 1.2 2.4 1.5 0.616
* Level of significance was determined by independent t test for
continuous variables and chi square for categorical variables comparing
children in the control and intervention groups.
Values are mean SD or number (percentage).
TABLE 2
Sample Goal Attainment Scaling Objectives (Subject 5)
Creeping on all
fours
2 Child will attain 4 point position
on hands and knees
1 Child will rock while on hands and
knees on the floor
0 Child will reach forward with one arm,
hand above shoulder level
1 Child will move at least 2 extremities
forward while on hands and knees on
the floor without collapsing
2 Child will move forward 1 foot while on
hands and knees on the floor
Standing
2 From floor, child pulls to standing at a
large bench
1 In standing, child maintains arms free
from support for 3 seconds
0 In standing, child maintains arms free
from support for 20 seconds
1 In standing, child lifts foot, arms free
from support for 10 seconds
2 Child attains standing from a
small bench
Walking with
support
2 Child will stand at a supporting surface
and using the surface side or forward
step at least 5 steps
1 Child will stand with both hands held and
take 10 steps
0 Child will stand with one hand
held and take 10 steps
1 Child will stand independently and lift
one leg/ foot (may fall)
2 Child will stand independently and move
one leg and then the other (may fall)
160 LaForme Fiss et al Pediatric Physical Therapy
as group intervention sessions with an emphasis on task
specific, functional motor skill practice, sensorimotor ex-
periences, and socialization.
37
Group sessions lasted ap-
proximately 1 hour and were lead by a physical therapist
and occupational therapist with experience working with
children with Down syndrome. A private practice office
setting was used, and the environment was structured as a
natural environment with use of general, natural play ma-
terials instead of therapy equipment. Parent participation
was encouraged during the sessions to provide increased
parent instruction and socialization.
Group activities consisted of task-specific practice of
skills identified as requiring intervention. Activities were
designed to increase strength and sensory processing to
encourage skill development. Sensorimotor-themed activ-
ities were planned by the therapists. Sample themes in-
cluded a day at the beach, on the road, camping, Hallow-
een, and fall on the farm. The group sessions began with a
group story book to introduce a theme. After the introduc-
tion, activities focused on standing and crawling activities
with structured theme play. Group activities continued
with free play within a structured environment to encour-
age movement and stability activities incorporating sen-
sory activities. Sessions ended with sensory or fine motor
play in standing such as standing and playing in pudding,
painting or coloring with markers, followed by a rereading
of the introductory book. Task-specific gross motor activ-
ities included crawling, creeping, and climbing on various
surfaces; pulling to stand to play with toys; cruising or
supported standing activities; use of push toys or support
to walk; or bench sitting activities. Activity-based interven-
tion was designed to provide multiple opportunities for
practice of functional movement and sensory stimulation.
Environmental modifications included placing toys on ta-
bles and boxes to encourage standing and pull to standing
for play; use of tunnels and boxes to encourage crawling
and creeping through objects to get to toys; spacing of toys
to encourage supported walking; and other similar modi-
fications to increase the opportunities for children to prac-
tice their emphasized motor skills.
Therapists alternated among the children to focus on
individual goals, and parents often supervised and assisted
the children while the therapists were attending to another
child. The physical therapist and occupational therapist
communicated throughout the group sessions to ensure
that each child had the opportunity to focus specifically on
his or her individual goals for multiple trials. Activities
conducted during group sessions were documented for
each child in weekly activity logs. All of the children at-
tended at least 9 of the 10 group intervention sessions with
an overall attendance of 98% for the group sessions.
Analysis
Data were analyzed using the Statistical Package for the
Social Sciences 14.0 for Windows statistical analysis software.
Because of the small sample size and no prior evidence to
support the assumptionof normality of the distributionof the
outcome measures, nonparametric Mann-Whitney U tests
were usedtoanalyze the data. At test for independent samples
was used to analyze the parametric demographic data. It has
beensuggestedthat the significance level for a studyshouldbe
determined according to the purpose of the study and not
only by general convention.
3842
In research that employs
small sample sizes or that is exploratory in nature, it may be
acceptable to increase the alpha level to p 0.10.
4244
This
increase may lead to the identification of differences that may
be of value clinicallybut maynot be identifiedat a significance
level of p 0.05, which is the conventional significance lev-
el.
43
McEwen
38
discussed the issue of increasing the alpha
level to p 0.10 in pediatric research based on criteria estab-
lished by Labovitz.
39
Relevant criteria for increasing the alpha
level insome pediatric therapy researchinclude minimal con-
sequences resulting froman error, lack of current evidence to
suggest the credibility of the results, and the need to discover
all potential interrelations for the purpose of developing hy-
potheses to direct future research.
38,39
These criteria were met
for this exploratory study, indicating a significance level of
p 0.10 was appropriate.
A t test for independent samples was completed to
determine whether significant differences were noted be-
tween age or therapy schedule at the initial assessment for
the control and intervention groups. Age was calculated in
months for each child, and therapy schedules were calcu-
lated as number of sessions per month for each discipline.
Gender was compared using the Chi square statistic.
GMFM scores were compared using the Mann-Whit-
ney U test to determine if between group differences ex-
isted on each of the domains of the GMFM at pretest, from
pretest to posttest, from pretest to follow-up, and from
posttest to follow-up. Average percent improvement was
also calculated for the control and intervention groups on
the various domains of the GMFM, and the difference in
these improvements was calculated between the 2 groups.
GAS T scores were determined for the control and inter-
vention groups using the Summary Score Conversion Key of
Cardillo.
35
Once the T score was determined, Mann-Whitney
Utests were completed to determine whether between group
differences existedonGASscores at pretest, frompretest topost-
test, frompretest to follow-up, and fromposttest to follow-up.
Effect size using Cohens d was used to determine the
magnitude of the experimental treatment effect or the
strength of the relationship between 2 variables.
45
While sig-
nificance testing could determine whether a treatment had a
statistically significant effect, effect size provided a measure of
the size of the observed treatment effect. An effect size of 0.20
was considered a small effect; 0.5 was considered a medium
effect; and above 0.80 was considered a large effect.
45
RESULTS
Age, Gender, and Therapy Frequency
No significant differences were found for age, gender,
or the frequency of physical therapy and occupational ther-
apy between the control and intervention groups at the
beginning of the study.
Pediatric Physical Therapy Group Treatment for Young Children with Down Syndrome 161
Gross Motor Function Measure
No significant differences were found between the 2
groups at pretest on the GMFM (see Table 3). Using the
significance level of p 0.10, significant differences were
found between the control and intervention groups from
pretest to posttest for the crawling and kneeling domain
(p 0.028) and the total GMFM score (p 0.076). Signif-
icant improvement in change in GMFM from pretest to
follow-up was noted for the lying and rolling domain (p
0.094) and the total GMFM score (p 0.075). No signifi-
cant differences were noted from posttest to the follow-up
assessment. The intervention group demonstrated between
a 1.4% and a 14.8% greater average improvement in the
various domains of the GMFM when compared with the
control group (see Table 4).
Effect size of GMFM scores and change in GMFM
scores were also calculated for the comparison of scores
between the control and intervention groups. Large ef-
fect sizes were found from pretest to posttest for lying
and rolling (d 0.889), sitting (d 0.933), crawling
and kneeling (d 1.311), and total GMFM scores (d
1.116).
Goal Attainment Scaling
Since the score of 2 was assigned to each childs
objective for the current level of function at the initial as-
sessment for all subjects, no significant difference was
found between the 2 groups at pretest for GAS scores. Us-
ing a significance level of p 0.10, a significant difference
in GAS scores in favor of the intervention group was found
from pretest to posttest (p 0.081). No significant differ-
ences were noted frompretest to follow-up or fromposttest
to follow-up. Large effect sizes were found for GAS from
pretest to posttest (d 1.075) (Table 5).
DISCUSSION
Ten young children with Down syndrome partici-
pated in this exploratory research study to determine if
participating in short-term sensorimotor group sessions
and individual intervention led to greater improvements in
gross motor skills than young children with Down syn-
drome who participated in individual intervention, but did
not participate in the group intervention.
Gross Motor Function Measure
At the start of the study, there were no significant
differences in GMFM scores between the intervention and
control groups. After participation in the group interven-
tion, the intervention group demonstrated greater im-
provements in some GMFM scores than the control group.
These results indicate that children in the intervention
group made progress on multiple areas of gross motor skill
more rapidly than children in the control group. Impor-
tantly, the area of improvement in crawling and kneeling
TABLE 3
Mann-Whitney U Test and Effect Size of GMFM Comparing the
Control and Intervention Groups
GMFM Domain and Test Session Z
Significance
(2-tailed)
Effect Size
Cohens
Lying and rolling pretest 0.529 0.597 0.889
Lying and rolling pretest to 1.156 0.248
posttest
Lying and rolling pretest to 1.676 0.094*
follow-up
Lying and rolling posttest to 0.638 0.523
follow-up
Sitting pretest 1.261 0.207
Sitting pretest to posttest 1.567 0.117 0.933
Sitting pretest to follow-up 1.576 0.115
Sitting posttest to follow-up 0.105 0.916
Crawling and kneeling pretest 0.419 0.675
Crawling and kneeling 2.200 0.028 1.311
pretest to posttest
Crawling and kneeling 1.567 0.117
pretest to follow-up
Crawling and kneeling posttest 0.105 0.917
to follow-up
Standing pretest 0.000 1.000
Standing pretest to posttest 0.631 0.528 0.262
Standing pretest to follow-up 0.318 0.750
Standing posttest to follow-up 0.000 1.000
Walking pretest 0.775 0.439
Walking pretest to posttest 0.557 0.577 0.318
Walking pretest to follow-up 0.106 0.915
Walking posttest to follow-up 0.323 0.746
Total pretest 0.731 0.465
Total pretest to posttest 1.776 0.076* 1.116
Total pretest to follow-up 1.781 0.075*
Total posttest to follow-up 0.105 0.917
* p 0.10.
p 0.05.
GMFM indicates Gross Motor Function Measure.
TABLE 4
Average Percentage Improvement GMFM Control Group Versus
Intervention Group Pretest to Posttest
GMFM Dimension
Control
Control
Pre to Post
Intervention
Pre to Post
Difference
InterventionControl
Lying and rolling 16.6% 3.6% 13%
Sitting 4.6% 17% 12.4%
Crawling and
kneeling
11.8% 26.6% 14.8%
Standing 8.8% 12.6% 3.8%
Walking, running and
jumping
3% 4.4% 1.4%
Total 2.24% 11.56% 9.32%
GMFM indicates Gross Motor Function Measure.
TABLE 5
Mann-Whitney U Test and Effect Size Correlation of GAS Comparing
the Control and Intervention Groups
GAS Test Session Z
Significance
(2-tailed)
Effect Size
(Cohens d)
GAS pretest 0.000 1.000
GAS pretest to posttest 1.747 0.081 1.075
GAS pretest to follow-up 0.949 0.343
GAS posttest to follow-up 0.107 0.915
p 0.10.
GAS indicates Goal Attainment Scaling.
162 LaForme Fiss et al Pediatric Physical Therapy
was heavily emphasized during the sensorimotor groups
because they had been identified and selected as goal areas
for all of the children in the intervention group. Although
not demonstrating significant differences in all areas, chil-
dren in the intervention group displayed greater percent-
ages of average improvement in scores on all domains of
the GMFM when compared with the control group. This
may have important clinical significance and should be
examined more closely in future studies.
Children in the intervention group continued to dis-
play greater improvement in GMFM scores from pretest to
the follow-up assessment suggesting that the progress in
gross motor skill acquisition made by the children contin-
ued to outpace the improvements in the control group after
the intervention phase ended. Therefore, children in the
control group did not achieve the equivalent level of gross
motor skill progress as the children in the intervention
group.
Effect size calculations were performed on the GMFM
scores for each of the domains comparing the groups scores.
A large magnitude of treatment effect, or a large effect size,
was noted for 4 domains on the GMFM: lying and rolling,
sitting, crawling and kneeling, and total GMFMscores. These
large effect sizes were a positive result of this study and sug-
gest that the group intervention used in this study should
continue to be examined as an intervention model for young
children with Down syndrome.
Scores on the GMFM were heavily affected by the
childrens compliance with completing items on the
GMFM. For many of the children in both groups, scores on
the lying and rolling subsection of the GMFM decreased as
the study progressed. This was most often due to the child
performing more advanced skills in place of a simple skill.
For example, instead of rolling prone to supine, the child
would transition quickly to sit or quadruped to obtain a
presented toy. Based on standardized procedures, rolling
would then receive a score of zero even though the child
was performing more advanced skills. Multiple trials of
each skill were provided as detailed in the instruction man-
ual; however, compliance on this test was affected by the
childrens young age and their inability to follow specific
instructions. The assessing therapist was often unable to
score skills children refused to complete, therefore, the
scores for the lying and rolling domain appear to have
regressed when they did not, and only the score changed.
Children in the control group demonstrated a significant
decrease in scores in this domain due largely to compliance
issues. The decrease is scores was not noted to be signifi-
cant for children in the intervention group. This difference
may have been attributed to continued practice of the lying
and rolling skills during the group sessions, or may be
explained by the small sample size used in this study. Sim-
ilar concerns about compliance of the child affecting scor-
ing in the lying and rolling dimension has been expressed
by Kolobe et al.
46
These researchers found that younger
children with disabilities (920 months) often displayed
inconsistencies in skill performance from initial assess-
ment to subsequent assessments when they demonstrated
improved motor development in general. Children often
failed to perform easier motor skills once more advanced
skills were mastered. Failure to perform the more basic
level skills may have affected the overall scores for both the
control and intervention groups on the GMFM. These non-
compliance issues on the GMFMmust be addressed. Meth-
ods to increase compliance with young children or meth-
ods of evaluating the reliability of parental report need to
be considered. Kolobe et al
46
recommended a modification
to the GMFM scoring, which would give credit for items
previously achieved on assessments if more advanced skills
were achieved on subsequent assessments. This change in
scoring should be considered in future studies since non-
compliance issues could have an important effect on future
study results.
Goal Attainment Scaling
The starting scores on the GAS, as required, were the
same for all children. Children in the intervention group
did improve their GAS scores more than children in the
control group after the group intervention. This suggests
that the intensity of intervention provided in sensorimotor
groups was effective at improving targeted gross motor
skills. This was an important finding because GAS uses
individualized goals to determine goal achievement and
does not assume that all children would follow the same
predetermined series of developmental steps as assumed
with standardized assessments. Because of individualized
objective selection, GAS is often considered to be a more
valid measure of performance than traditional standard-
ized assessments.
47
Four weeks after the end of the group intervention
session, all children were reassessed to determine contin-
ued changes in performance. No significant differences for
GAS were found between the 2 groups from pretest to
follow-up or posttest to the follow-up assessment. This
suggests that without the additional group intervention
that the gains in achieving goals were similar in both
groups while they received individual intervention.
Effect size was calculated for GAS and a large treat-
ment effect was found frompretest to posttest (d 1.075).
The large effect size noted from pretest to posttest lends
support to the potential benefit of increased intensity of
therapeutic intervention for children as presented in this
study.
The results of this research have implications for pe-
diatric physical therapy intervention; however, because
this is an exploratory study with young children with
Down syndrome, the results must be interpreted cau-
tiously. The results suggest that increasing intensity of in-
tervention by participation in a short-term weekly group
intervention session led to improved gross motor skill ac-
quisition compared with individual intervention alone.
This suggests that young children with Down syndrome
may benefit from this intervention model with services
provided in sensorimotor groups as well as individual
intervention.
Pediatric Physical Therapy Group Treatment for Young Children with Down Syndrome 163
Limitations
There were several limitations in this exploratory
study. Although it seems positive, results obtained from
this study with a small sample size are merely exploratory
pending a larger study. Because of the relatively low power
in this study, results cannot be generalized to a larger pop-
ulation. Increased risk of type II error, or the failure to
reject a false null hypothesis, also resulted from the small
sample size. Type II error means a hypothesis indicating no
difference between the control and intervention groups
would be accepted when a difference does exist. To reduce
this risk, the significance level chosen for this study (p
0.10) was larger than typically used. Post hoc Bonferroni
correction was not completed to allow for examination of
all potential significant differences to determine the value
of additional research in this area. These methods were
chosen based on the exploratory nature of this study.
The chosen assessment tools and outcome measures
may not have been sensitive to minor changes in develop-
mental skills. The GMFM and GAS have been found sensi-
tive to change over developmental intervals greater than 3
to 6 months.
30,48,49
Because of this studys relatively short
intervention phase (10 weeks), the assessment tools may
not have been sensitive enough to detect all changes within
the subjects.
The inability to randomize group placement was a
limitation to this study. Families who were willing and able
to attend groups were assigned to the intervention group,
while families who were unable to attend group sessions
were assigned to the control group. This may have lead to
bias in the group placements. Parents of children in the
intervention group may have thought their children
needed more intervention and were, therefore, more will-
ing to attend the group sessions. However, several of the
families in the control group wanted to participate in the
intervention group but were unable to participate because
of schedule conflicts or location of the group sessions. In
addition, parents who participated in group session re-
ceived additional instruction, modeling, and practice in
activities to promote movement with their children. This
additional practice may have led to increased carryover of
activities outside of the group sessions by the intervention
group. The effect of parent participation on group out-
comes is not known and was not measured specifically in
this study. Future studies should randomize group place-
ment to reduce the risk of parent motivational bias and
should examine the role of parent participation and train-
ing effects.
The lack of control over therapy activities completed
during individual intervention sessions and the equiva-
lence of individual therapy might have been an issue. How-
ever, all children were working toward similar gross motor
goals of crawling, standing, and walking. Future studies
may determine that standardizing individual intervention
sessions or collecting data on the activities completed in
the individual sessions may assist in establishing equality
of services.
Further Research
Further research is needed to investigate the use of
sensorimotor group intervention to increase intensity of
intervention for children with Down syndrome. Larger
randomized controlled trials should be conducted to at-
tempt to confirm or expand the results found in this ex-
ploratory study.
Within larger studies, intervention group size
should continue to be limited to 2 to 3 children per adult
to ensure that each child receives adequate direct atten-
tion. Parent participation should be encouraged to assist
with maintaining the adult to child ratio without in-
creasing the cost. Cost saving measures may also include
using physical therapist assistants, certified occupa-
tional therapy assistants, developmental intervention-
ists, or student therapists to assist the lead therapists.
Additionally, integration of children without disabilities
into the group sessions may provide for increased peer
modeling and socialization in a more natural, inclusive
environment.
Adding a second intervention group in which partic-
ipants receive 2 weekly individual intervention sessions of
physical therapy would allow for a true comparison be-
tween increased intervention using combined group and
individual intervention and only individual intervention. If
children who receive weekly group intervention and
weekly individual intervention perform as well as chil-
dren who receive twice weekly individual intervention,
an argument could be made supporting the cost effec-
tiveness of group intervention as a means to increase
intervention intensity. Based on previous research,
maintaining relatively short, targeted durations of inten-
sity may be important to decrease family fatigue and
burden with intensity and to increase family compliance
with intensive models.
18,20,21
Motor skill development may affect functional devel-
opment in other domains of development in children with
disabilities. Correlations between motor development and
physical activity have been linked to cognitive,
25,50,51
so-
cial,
25,52,53
and language
51,54
development. Studies that ex-
amine the long-term effect of early intensive intervention
on these multiple domains of development would add to
the information on the effect of intensive early interven-
tion. If increasing the intensity of intervention using
weekly sensorimotor play groups for children with Down
syndrome does improve the rate of gross motor skill acqui-
sition, examining the effect of these improvements on
other domains of development would be important. Earlier
attainment of skills may also limit the need for prolonged
intervention providing a financial benefit to early intensive
intervention. Family time may also be reserved because of
the decreased amount of time spent participating in ther-
apy sessions. Although more research is needed, implica-
tions of increasing the rate of gross motor skill acquisition
on ecological development and financial interests must be
explored.
164 LaForme Fiss et al Pediatric Physical Therapy
CONCLUSIONS
The purpose of this exploratory study was to investi-
gate if young children with Down syndrome who partici-
pated in 10 weekly sensorimotor group sessions in addi-
tion to individual intervention sessions displayed greater
improvements in gross motor skill development than
young children with Down syndrome who participated in
only individual intervention. Results suggest that children
who participated in the sensorimotor group sessions made
greater gross motor skill progress on the lying and rolling,
crawling and kneeling, and total score portions of the
GMFM and the individualized objectives of GAS than chil-
dren who participated in individual intervention alone.
The results of this study suggest that larger controlled trials
need to be completed to validate these results and to ex-
plore other areas of development that may be affected by an
accelerated rate of gross motor skill acquisition.
ACKNOWLEDGMENTS
The authors thank Catherine LaForme, PT, MA, and
Kristy Stamper, OTR/L for their assistance with the data
collection and intervention for this research. Alyssa
LaForme Fiss thanks Jennifer Grisham-Brown, PhD and
Donna Horn, PhD, CCC-SLP for their mentorship and as-
sistance with the study completion. Finally, deep gratitude
is given to the children and families who participated
enthusiastically.
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