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Running Head: A CASE STUDY ON DOWN SYNDROME

Liz: A case study on a child with Down syndrome


Evelyn Babaroudi, Jared Hansen, Melody Klatt, Leslie Ramos, Jennifer Tom, and Michelle
Wilson
Touro University Nevada

A CASE STUDY ON DOWN SYNDROME

Description of Occupational Performance


Evaluating the clients performance across various settings is vital to identifying barriers
between their functional capabilities and demands of their daily life. Liz, is a 6-year-old female
with Down syndrome (DS) undergoing challenges with gross and fine motor skills, activities of
daily living, play skills, and attention to task. While Liz exhibits challenges in multiple domains,
an appropriate intervention can be implemented to increase optimal function in these areas.
Education
At the age of three, Liz attended an early childhood program at a local public school
where she received speech therapy in a group setting, as well as physical therapy (PT) and
occupational therapy (OT) services. During this time, the PT and OT noted that Liz had low
muscle tone, which contributed to weakness in gross and fine motor skills. She currently attends
a public school in the Clark County School District and is in a special education program with
part time inclusion.
Activities of Daily Living
Liz displays difficulty with her morning routine. Dressing and grooming are two areas of
self-help that requires support. Her mother helps with fastening the buttons on her pants and
zipping up zippers on her clothing. Although she is able to don and doff her shoes and socks, her
weakness in fine motor skills inhibits her ability to tie her shoelaces. Liz is also able to brush her
teeth; however, she requires assistance with preparation for the task. She lacks the proper grasp
patterns and muscle strength to squeeze the toothpaste and apply it to the toothbrush.
When it comes to self-feeding, she is unable to manipulate utensils
independently. During mealtime, Liz attempts to use an appropriate utensil, however, due to her
difficulty with utensil manipulation, she switches to finger feeding. Due to Lizs delay of fine

A CASE STUDY ON DOWN SYNDROME

motor development, she does not utilize an age appropriate grasp during self-feeding. Lizs
mother reports that she is frequently spilling food, due to lack of control of the spoon when
bringing it toward her mouth.
Instrumental Activities of Daily Living (IADLs)
Liz enjoys partaking in household choresin particular, helping her mother set the
dinner table. Her mother uses plastic cups, plates, and utensils, so that Liz can transfer the
supplies to the table. In addition to this, she utilizes a visual schedule so that she can reference
the table-setting. Liz also enjoys accompanying her mother when walking their new, eightmonth-old yorkie, Sweety, around the neighborhood. She requests to hold the leash, but her
mother redirects her to walk beside her. Her mother expresses that Liz is not strong enough to
control the dog and fears that Sweety will run off or pull the leash. In the past, Liz has attempted
to manage the leash, but due to her size, lack of motor coordination, and being easily distracted,
she has tripped and fallen on the sidewalk. She hopes to one day walk Sweety around the
neighborhood independently, but until then, she continues to simply accompany her mother on
the walk. Preparing the dinner table and taking Sweety on a walk independently are two things
that Liz hopes to accomplish in the future.
Leisure
Active engagement in leisure activities can support ones overall health and wellbeing. A few of Lizs leisure interests are singing and listening to music. She spends most of her
Sunday mornings watching Disney sing-alongs with her younger sister. They enjoy singing,
laughing, and dancing together around the living room.
Social Participation

A CASE STUDY ON DOWN SYNDROME

Socialization is important for facilitating interaction with peers. Liz tends to interact
more frequently with the adults at school such as, the teachers and classroom aides, rather than
her peers. Although Liz is motivated to socialize with her classmates, they tend to ignore her or
walk away once she initiates contact. Lizs mother is concerned that she is teased by the other
children in her general-education class. While recess is Lizs favorite time of day, her lack of
friends inhibit her ability to form proper friendships and thus, engage in socialization and play.
Play
Liz has the cognitive capacity to engage in imaginary play. She and her younger sister
have a favorite spot in the house for play--the wardrobe. They spend hours in their mothers
wardrobe playing dress-up from a box of scarves, purses, shoes, and hats. She will dress up and
imitate her mother. During family time, she enjoys playing Candy Land, a board game with
simple rules. She is able to participate in the game, but requires HOH assistance to move her
piece to the corresponding picture or color. She displays good turn-taking skills and is able to
wait patiently for her turn. However, at times she demonstrates difficulty with self-regulation,
particularly when losing. Before starting the game, her mother will prime her of the rules and
remind her that the purpose of the game is to have fun. At school, Liz demonstrates an interest
in playing on the playground apparatus, however, lacks the gross motor skills required to utilize
the equipment, such as swinging, jumping, and climbing. She tends to play by herself away from
the other children who are playing on the playground equipment.
Sleep
Liz displays regular sleeping patterns. She shares a bedroom with her younger sister, which is
near her mothers bedroom. She sleeps in her own bed and her mother reports that she is able to
sleep well throughout the night without any issues.

A CASE STUDY ON DOWN SYNDROME

Description of: Movement, Postural Reactions, and/or Reflexes


Liz displays functional ambulation and is able to walk independently. She climbs on and
off furniture; this behavior is speculated to be due to her seeking vestibular input to compensate
for the under-responsiveness of her vestibular system. Liz is able to use momentum to increase
speed but lacks coordination and postural control, as she frequently falls when running further
than 25 yards. In addition, because of visual and auditory distractions, she regularly falls when
she is outdoors, which can affect her ability to play during recess and participate in any outdoor
activities. Liz also displays hypermobility in her joints increasing her risk of joint dislocation
and lack of motor control. She also exhibits overall hypotonia, contributing to her lack of
strength and displays weaknesses in her fine and gross motor skills. In addition, Liz displays
lumbar lordosis (an excessive anterior concavity of the lumbar spine), has a wide base of
support, and poor foot clearance during the swing phase of walking. She has difficulties with her
fine motor skills affecting her participation in school work and ADLs. Finally, Liz also has
difficulties with her gross motor skills, indicated by the fact that her mother reports that Lizs
three-year-old sister is surpassing her in this area.
Sensory Integration and/or Self-Regulation
A study done by Fidler, Hepburn, Mankin, and Rogers (2005), found, by parent-report,
that children with DS have strengths in socialization and weaknesses in communication and
motor skills. In the case of Liz, signs show that her vestibular system is under-responsive in that
she is clumsy, has poor motor planning, and falls more frequently than others her age. Children
who are under-responsive lack motivation to master developmental milestones. Her mother
stated that six-year-old Liz is falling behind her three-year-old sister in gross and fine motor
skills. With this under-responsiveness, she is seeking vestibular input through fidgeting, taking

A CASE STUDY ON DOWN SYNDROME

risks by climbing on furniture, and she becomes distracted easily. This sensory-seeking will
impact her participation in basic ADLs, school, and social groups. Her mother stated that she
wants her to participate in community groups, but is reluctant to do so because she fears that she
will be teased by peers. The OT group will provide support and encourage Lizs mother to allow
her to partake in these social opportunities.
Additionally, she is demonstrating tactile perception problems due to her difficulty with
higher level fine motor skills. If not addressed, utilizing writing and feeding utensils will be
further affected. If she is using vision to compensate for poor tactile discrimination, her eyehand coordination - which is important for play and fine motor skills - will also be
affected. Lastly, it appears that her auditory system is hyper-responsive. She is easily distracted
and noises divert her attention from the current task she may be trying to complete.
Person-Environment-Occupation-Performance Model
The Person-Environment-Occupation-Performance (PEOP) model is a client-centered
approach that focuses on interventions that affect the individuals current occupational
performance. Based on the PEOP model, occupational performance is influenced by the
interdependent relationships between the person, environment, and occupation (Cole & Tufano,
2008). The components of the PEOP model play a large role in Lizs ability to develop mastery
within her environment. In order for Liz to find success in her environment, she must learn
adaptation techniques to overcome day-to-day challenges and develop the ability to use resources
that are available (Cole & Tufano, 2008).
Liz was born as a premature baby, and since then has experienced several health conditions
that have influenced her daily occupations. Her current home environment involves her single
mother and three-year-old sister in an upstairs apartment. Her school environment is spent in a

A CASE STUDY ON DOWN SYNDROME

general education kindergarten class for three hours and the remaining four school hours are
spent in a self-contained special education classroom. As mentioned above, she has many
occupations, but her most important occupations are her roles as a daughter, sister, and
student. These areas highly affect her overall performance in the activities she needs and wants
to do in her daily routine.
The performance area is the major focus of the PEOP model. Liz is able to walk
independently and run short distances; however, she is unable to run greater distances or increase
her speed. This is because of her hypotonia as well as her poor strength and hypermobility in the
majority of her joints. She displays poor attention when she is outside, as she frequently falls
due to the distractions from environmental activity, noises, or people. Liz has problems with her
fine and gross motor skills which greatly affects her work as a kindergarten student as well as her
daily occupations.
An OT can use the PEOP model to help her master her environment and increase her
occupational performance in the areas mentioned above. Through use of compensatory
strategies in her environment, she may develop greater control over her occupational
performance. For instance, clearing the outside environment and creating open space may
prevent her from falling. The use of adaptive equipment such as a pencil grip can greatly
improve her fine motor skills in school. Her gross motor skills can be mastered by adding
motivation to have her work on strength and mobility including, pet therapy where she can walk
a dog longer distances. Overall, there are many aspects of the physical and social environment
that can be manipulated to increase her overall occupational performance. In addition to the
PEOP model, there are several frames of references that can help guide the development of
interventions.

A CASE STUDY ON DOWN SYNDROME

Frames of References
Frames of references are concepts of knowledge that help influence a therapists
perceptions, decisions, and practice methods. Based on her occupational performance, the
psychosocial coping model, motor learning, and neurodevelopmental theory frames of references
will be utilized to help guide Lizs interventions.
Psychosocial: Coping Model
Lizs mother is hesitant to allow her daughter to participate with other children in
community activities, therefore, the psychosocial coping model frame of reference may help ease
her tension by providing continued support in Lizs social atmosphere. Her occupational
performance can be improved through the use of the coping model in order to develop social
skills and build relationships with her peers (Case & Smith, 2010). Now that she is beginning to
fall behind her three-year-old sister in fine and gross motor skills, she may need to learn new
strategies to cope with stress in order to stay motivated. The coping model allows her to cope
with daily stress put on by the demands of her physical and social environment. She can use
internal and external coping resources whenever she may begin to lose the drive to participate in
an activity. Internal coping methods would be used to help regulate her frustration by using
strategies such as counting to ten when feeling angry, listening to calming music, or taking deep
breaths.
A helpful external coping method for her would be the ability to voice concern to peers or
teachers when she needs assistance. This would utilize the resources in her environment to attain
success as a student in school. In addition, her teacher can also help create a supportive
environment in the classroom to feel more confident with her condition. The teacher can educate
peers about her diagnosis of DS so that her classmates can learn appropriate behaviors when she

A CASE STUDY ON DOWN SYNDROME

is present in class. This may ease the concerns of her mother and decrease fear of her daughters
classmates teasing her for being different.
Motor Learning
The motor learning frame of reference is an occupation-based approach to learning motor
solutions through an individuals interaction with the task and environment (Case & Smith,
2010). This approach would be used to improve Lizs fine and gross motor abilities. She has
difficulty manipulating her fingers to successfully button and zip her clothes. By incorporating
activities that focus on increasing her fine motor skills, she will learn how to button and zip her
clothes independently. For instance, she will first learn how to button by stringing beads onto a
pipe cleaner. This focuses on a tip pinch grasp which is needed to button clothes. This fine
motor activity may be difficult at first, but by using a repetitive task method called blocked
practice, she will master the action. Eventually, she will learn how button clothes with random
practice by varying different sized buttons on a felt box to increase skill and ability.
Gross motor tasks will be addressed through play activities in her outside
environment. For instance, she has a difficult time walking distances longer than 25
feet. Walking is involved in many aspects of her day, as it is her method of transportation
around school and home. It is also the foundation for skipping and running, which would help
her to take part in school play with her peers. In order to further work on this skill, she can learn
a new activity, like red-light-green-light, which requires her to follow rules that have walking,
running and stopping at different distances. This is a novel task, so learning each section of the
game would involve the process of motor learning. Eventually, she will learn how to integrate
all of these steps to play a full game of red-light-green-light.
Neurodevelopmental Theory

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The Neurodevelopmental Theory (NDT) frame of reference can be used to help guide
interventions based on facilitating movements. When identifying Lizs ability to demonstrate
ADLs, she displays atypical movements that limit her ability to complete a task. NDT is used to
facilitate postural control and movement synergies and to inhibit or constrain motor patterns
that, if practiced, would lead to secondary deformities and dysfunction (Case & Smith, 2010, p.
43). An OT would be able to use NDT strategies to help Liz achieve basic ADLs such as selffeeding with movements that are energy-efficient and age-appropriate. For example, she will
learn how to self-feed herself using age appropriate utensils. Through the use of an adaptive
utensil, she will first learn how to functionally hold the spoon and bring it to her mouth. She will
work on her fine motor skills required for self-feeding through meaningful movement. Activities
such as scooping and stabbing different textured foods will work on task repetition as well as
progressively challenging her fine motor skills based on her performance. This movement can
be facilitated by an OT to help keep Liz stay motivated throughout the activity.
Appropriate Assessments
She was previously assessed using the Gross Motor Function Measure (GMFM) and the
Pediatric Evaluation of Disability Inventory (PEDI). She scored a summary score of 85% on the
GMFM, but was well below the standard mean score on the PEDI. Scores on the PEDI range
from 0-100 and scored a 31.4 on self-care, less than 10 for mobility, and 24.4 for social
function. The clients mother stated that the IEP team is currently focusing on academics and
language development at school, but are not focusing on motor development. These are skills
that can be addressed at an outpatient OT clinic.
The Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) will additionally
be utilized to further assess her current developmental level. This is a norm-referenced test

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designed to measure adaptive behavior of individuals from ages 0 to 90. The five domains
include communication, daily living skills, socialization, motor skills, and maladaptive behavior
(optional). These domains contain subdomains as well. Scores will help aid in intervention
planning as well as monitoring the clients progress (Sparrow, 2011).
There are three various forms to choose from when administering the Vineland-II. First,
there are two interview forms which include a caregiver rating form as well as a survey interview
form. These interview forms assess communication, daily living skills, socialization, and motor
skills as well as the optional maladaptive behavior domain. There is also an additional expanded
form used to assess the broad domain areas, which will then assist in intervention
planning. Lastly, the clients teacher would fill out information related to educational level
(Sparrow, 2011).
The OT team will utilize results from all of these domains to create an intervention
plan. Although the intervention plan is primarily focusing on increasing motor development,
they can do so through a variety of daily living activities as well as through play and leisure.
5 Functional Problem Statements
The OT team composed five functional problem statements for Liz in regards to
performance in essential, functional activities. These were written to address the main areas of
concern as identified by her mother, and also as identified by the OT team after becoming
familiar with her case. The five functional problem statements are as follows:

Delayed fine motor skill development limit the clients ability to engage in self-feeding.

Delayed gross motor skill development limit the clients ability to actively participate in
functional play.

Deficits in social skills limit the clients ability to initiate continued peer interaction.

A CASE STUDY ON DOWN SYNDROME

Limited attention to task limit the clients ability to participate in safe, functional IADLs.

Delayed fine motor skill development limit the clients ability to participate in independent

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dressing.
5 Family/Caregiver/Child Goals
The areas addressed in the intervention plan are driven by the client/familys selfperceived needs. A collaborative approach is used to ensure that the clients goals are being
met. Lizs mother has set five goals based on difficulties identified in the report and observation
of her occupational performance across various domains. Her mother would like to see Liz (1)
develop coordination and strength so that she can utilize the playground apparatus, (2) improve
independence in ADLs with emphasis on buttoning and zipping her clothing, (3) manipulate
eating utensils during meal time (4) engage in social interaction with peers during recess, and (5)
improve her attention to tasks to assist her with participation in IADLs, particularly involving the
care of the family dog.
3 COAST Goals, 2 Objectives and 2 Activities for Each
COAST Goal 1: Within six months Liz will independently eat one meal using an appropriate
utensil.
Objective 1: She will eat one meal with an adaptive utensil independently within two
months.
Activity 1: She will scoop and stab three different kinds of food with the adaptive
utensil for one feeding session within one month.
Activity 2: Within one month she will independently transfer rice from a bucket
to a bowl utilizing a small shovel 3 out of 5 trials.

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Objective 2: Within four months, she will independently take five bites of one meal
using an appropriate utensil.
Activity 1: She will stab five different types of textured food independently with
an appropriate fork within two months.
Activity 2: Within one month she will manipulate one bite of macaroni and
cheese in her mouth and swallow it without letting any food fall out.
COAST Goal 2: Within six months she will independently dress herself in age appropriate
clothing with buttons and zippers.
Objective 1: Within four months Liz will independently button her pants utilizing a tip
pinch grasp.
Activity 1: She will independently button and unbutton a button felt 10 times
within two months.
Activity 2: Within one month she will string 10 different sized beads onto a pipe
cleaner to make a bracelet utilizing a tip pinch grasp.
Objective 2: Within two months she will independently complete zippers on her clothing
utilizing a lateral pinch grasp.
Activity 1: Within one month she will complete one game of Bed Bugs with her
younger sister using oversized tongs to collect plastic bugs using a lateral pinch
grasp.
Activity 2: Within one month she will complete zippers on her clothing with
HOH Assistance utilizing a lateral pinch grasp.
COAST Goal 3: Liz will take a therapy dog on a walk for 10 minutes around her neighborhood
with adult supervision within six months.

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Objective 1: She will walk a puppy pull-toy for five minutes around the apartment
courtyard with adult supervision, within two months.
Activity 1: She will complete one game of red-light-green-light in the outpatient
therapy gym with verbal cueing while pulling the puppy pull-toy within two
weeks.
Activity 2: She will complete an obstacle course with physical cueing in her
apartment courtyard while walking a puppy pull-toy within one month.
Objective 2: Liz will take a therapy dog on a walk for five minutes around her
neighborhood with HOH Assistance within four months.
Activity 1: She will navigate a safe route on a walk around her neighborhood
while accompanied by therapist and therapy dog, with verbal cueing 3 out of 5
times within one month.
Activity 2: Within three months she will complete an obstacle course with
physical cueing 4 out of 5 trials in her apartment courtyard while walking a
therapy dog.
Treatment Plan
The treatment plan will focus on the COAST goals that were created based on the
concerns that were identified. The OT team will be collaborating with Liz and her mother to
ensure that treatment goals are being met, and will modify the treatment plan as necessary to
accommodate her needs and progress.
Environmental Setting
Treatment will take place in an outpatient clinic and the occupational therapist will also
travel to Lizs home environment to conduct certain treatment sessions. She will receive OT

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treatment sessions two to three times a week; sessions focusing on fine motor skills will take
place within the outpatient clinic while sessions focusing on gross motor and socialization goals
will take place in the home environment.
SOAP Note
S: Liz stated Im tired x 2 during the session, and mother reported Liz was up past her
bedtime the night before.
O: Liz was seen for 60 minute 1:1 skilled occupational therapy treatment session in the
outpatient setting to increase independence and safety with gross motor, fine motor and self-care
skills. Liz transitioned to session with min verbal cues and began with a gross motor climb/slide
activity for vestibular and proprioceptive input in prep for work. Liz was noted to smile and
laugh throughout. Transitioned to a fine motor activity to increase independence with buttons.
Liz demonstrated the ability to utilize a pincer grasp for 3/7 buttons with mod assist, requiring
max assist for the remaining 4. Liz then transitioned to a gross motor coordination, attention and
safety awareness activity to increase safety with walking the family dog. Liz demonstrated the
ability to maneuver a pull toy through an obstacle course 3/5 trials with mod verbal cues to
attend to the pull toys location and the objects in front of her. In 2/5 trials Liz required physical
redirection x 2 and max verbal cues. Liz then transitioned to a fine motor feeding activity to
increase independence with spoon feeding, demonstrating a palmar supinate grasp while utilizing
a spoon with a built-up handle. She demonstrated the ability to transfer cereal from a bowl to her
mouth with mod I secondary to extra effort, without spilling, 2/5 trials. Liz transitioned from
session with min verbal cues.
A: Liz continues to demonstrate progress and potential for improvement in the areas of gross
motor coordination, fine motor and self-care skills that affect her independence in activities of

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daily living. This is demonstrated by her ability to transfer cereal to her mouth without assist 2/5
trials versus 0/5 trials as seen in previous sessions, her ability to utilize an appropriate pincer
grasp for 3/7 buttons versus 1/7 buttons, and her ability to maneuver an obstacle course 3/5 trials
with mod verbal cues versus max verbal cues for 5/5 trials. Liz would continue to benefit from
OT services to improve deficits in gross motor coordination, fine motor, safety awareness,
attention, and self-care skills.
P: Continue to address above deficits as per POC goals. Recommended activities include eating
utensil manipulation activities, pincer/lateral pinch fine motor activities for dressing, and
obstacle courses in a busy environment to improve safety awareness, gross motor coordination
and attention to task
Post-Discharge Plan
The post-discharge environments for Liz will include the apartment she lives in with her
family, and also the general education kindergarten classes that she attends at school. She will
practice ADLs, play, and complete homework at home, and will participate in play and
educational activities at school with her peers. She will continue to develop skills in these
natural environments.
There are several specific recommendations that the OT team will have for Liz and her
family, which will help her to continue developing skills and also experience a better quality of
life. It will be recommended for Liz to participate independently in ADLs as much as possible
(such as dressing and feeding) to enhance her motor skills and help her to develop self-care
skills, and it will also be recommended to incorporate plenty of peer interaction. Peer interaction
will help to facilitate language development and encourage play habits that will enhance both
gross and fine motor skills (i.e. playing on the playground, playing board games, etc.).

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A specific recommendation will also be made to her mother concerning Lizs ability to
participate in community programs, though the team acknowledges her reluctance on this
subject. Her mother will receive encouragement and information about the benefits of Liz
participating in community programs, such as the fact that it will allow further development of
social interaction skills, and will also allow her to develop in other areas such as her motor skills,
depending on what the program may entail. The team will provide Lizs mother with strategies
to cope with the possibility of other children being insensitive to Liz, and may also help her to
identify a specific program in her community that may be ideal for Liz to participate in.
Justification of Treatment based on Research
According to Wuang et al. (2011), the most effective traditional OT approaches used for
children with DS include sensory integration (SI), neurodevelopmental treatment (NDT), and
perceptual-motor approach (PM). While each approach alone has its own focus and strengths, a
combination approach, using multiple approaches or a variety of these frameworks, can be
developed and utilized to reach the goals of the child. According to Anderson, Hinojosa, and
Strauch (1987), A therapist may even use more than one frame of reference during a treatment
session either simultaneously or sequentially (p. 424). When using any of these approaches it is
both important to incorporate, as much as possible, the natural environment and context of the
child, while focusing on feeding, fine motor skills, and gross motor skills, and including play
into the intervention.
Feeding difficulties were found to be a common issue for individuals with Down
syndrome, being found in about 16% of individuals (Palisano, 2001). Dolva, Coster, and Lilja
(2004), linked self-care tasks, such as feeding, and fine motor skills when they said that poor
fine motor skills may be disabling in this population, for example, by affecting performance of

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complex self-care tasks that involve fine motor skills (p.627). Some common interventions for
those with feeding difficulties include facilitating oral-motor skills, improving foot placement,
and facilitating hand function (Edwards, 1990). Many feeding difficulties can be addressed by
focusing on fine and gross motor milestones (Edwards, 1990). As a therapist remembers to
incorporate play, fine and gross motor milestones and feeding goals can be met.
By incorporating the use of play in developing gross motor skills, Liz will have the added
benefit of increasing her social interaction, and her perceptual motor skills. Palisano et al. (2001)
observed that in children with DS there was a delay in motor development that increased with
age. They further noted that many children with DS may successfully achieve motor goals
through play and structured developmental activities while others may not achieve motor
development goals without therapy intervention (p. 499). One example of how to include play
in her intervention program is to incorporate the use of a pull toy. Fidler et al. (2005) observed
that Children with Down syndrome also had difficulty with full-body tasks. On the pull toy
task, 72.7% (8 of 11) of children with Down syndrome could not coordinate walking multiple
steps and watching the toy in a smooth fashion. Most children were able to move the toy
through locomotion, but did not simultaneously move forward while watching the toy, or did not
sustain this movement beyond a few steps (p. 134). By incorporating the use of a pull toy,
gross motor skills can be achieved within the context of play while focusing on reaching Lizs
goals.

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References
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Sparrow, S. S. (2011). Vineland Adaptive Behavior Scales. In Encyclopedia of Clinical
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Wuang, Y.-P., Chiang, C.-S., Su, C.-Y., & Wang, C.-C. (2011). Effectiveness of virtual reality
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