VOLUME

65

MARCH

1980 #{149}
NUMBER

Pediatrics
Early Intervention
for Infants with Down
Syndrome:
A Controlled
Trial
Martha

C. Piper,

PhD, and I. B. Pless,

From the School of Physical

and Occupational
Epidemiology
and Health, McGill University,

ABSTRACT.
Down

control
an

group,

development
either

assessed

in

biweekly

ceived
mental

Scales

opmental

status

equal

in

initially

significant
early

in
and

intervention

not

in

in altering

those

the
program.
drome,
early

Down

the

groups,

period

the

which

mental

group

were
No

drome.
grams

shown

found.

in this

pattern

of

infants

was

tial

develop-

functioning

with

in

have
severity

Down

applied

syn-

influence
of such
proof Down
syndrome

remains
uncertain
in spite
of the fact that
infants
with Down
syndrome
are easily
identified
at
birth,
thereby
permitting
early
intervention
within
the first months
of life.
children

for

Reprint
tional
treal,

publication

requests
Therapy,
Quebec

(M.C.P.)

McGill
H3G

PEDIATRICS
American

June

to

accepted

School

of Physical

University,

3654

July

16,
and

Drummond

1979.

St,

Mon-

0031
of Pediatrics.

4005).

Copyright

1980

by

the

intervention
in children

programs
defined

with

such
these

diagnosed

forms

as Down
syndrome.
two populations

of

The
of chil-

overlooked.
the

tion
from

for children
comparisons

alized

children

positive

effect

of early

with Down
syndrome
ofthe
development
with

that

of children

interven-

inferred
of institutionwas

reared

in the

home.49
However,
the interpretation
of these
studies is extremely
difficult
since
selective
factors
may
have produced
comparison
groups
that are biased.#{176}
Although
more
tion
programs

recent
evaluations
for these
children

of early
report

intervenpositive

findings,
similar
difficulties
arise regarding
the comparison
groups
used
in several
of these
investigations.3
To date,
only
two
evaluations
of early
intervention
for children
with Down
syndrome
have
employed
matching

Moreover,

Occupa-

1Y5.

(ISSN
Academy

8, 1979;

to children

retardation,
between

Historically,

neither
factors
Received

of early
retardation

of

those
at risk
for mental
retardation
and
defined
as mentally
retarded,
although
essenwhen
discussing
the effect
of early
intervention,

is often

participating

associated
the

mental

dren,
those

study

mental

been
whether
has

mental
distinction

and Department

at risk for retardation

at some
later
date
established.3
However,
it is still unclear
early
intervention
remediates
retardation

as being

The

65:463-468,
1980;
Down
syninfants,
mental
development.

handicap

the

to

Therapy
Montreal

The
contribution
in deterring
mental

when

between

were

investigated

syndrome

Unfortunately,
on

re-

statistically

development
groups

the

Pediatrics
intervention,

mental

par-

to stim-

control

Infant
stimulation
and
training
programs
been developed
as means
to ameliorate
the
of

by

group

of variables.

control

regimen

efficacious

ment

two

a variety

differences

experimental

or

Griffiths
Mental
Developassess
changes
in the
devel-

to

the

on

with

designed

sessions

The

infants

experimental

experimental

while

used

an

a six-month

The

therapy

were

of 37
to

over

evaluator.

normal
development
no intervention.

ulate

the

mental
allocated

was

independent

ticipated

be

The

syndrome,

MD

adequate
subjects
study
that
the

control
on age,

groups;
but aside
sex,
and
mental

focused
might

attention
influence

effect

of intervention

from
age,

on other
potential
development.45
during

not evaluated
in spite
of evidence
that
sured
intelligence
declines
as the child
with
syndrome
grows
older.967
The
purpose
of this study
was
to evaluate
was

PEDIATRICS
Vol. 65 No. 3 March 1980
Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on March 22, 2015

infancy
meaDown
the

463

efficacy
of an early
intervention
with Down
syndrome.
In order

program
for infants
to rigorously
exam-

me this

a controlled

trial

and

groups.

using

question,

we conducted

comparable

experimental

Changes
in developmental
period
were assessed
with
velopmental
Scales.

METHODS

control

status
over
the Griffiths

upon
ence

by

a six-month
Mental
De-

into

age,

under
posttest

of

37

infants

24 months
experiment

received
treatment
for a six-month
received

no

two groups
was
to the program;

with

Down

syndrome,

of age, participated
in which
one
in an early
period
while
such

program
group
(n

Allocation

by
entering

tween
July and December
ment
group
while
those
and June
were
allocated
received
no treatment
months.
Those
enrolling

intervention
a control

treatment.

determined
infants

in a pretest,
group
(n
21)

the

to

Griffiths

in an

date
of referral
the program
be-

Scales.

sex,
pres-

disease,

It was

(HOME)

infants

type

judged

of

that

development.
The
by this Inventory,
predictor
of a normal

While

no

studies

of

have
been
of a retarded

identifies

environment

influence
measured
a good
measure
quality

the

heart

Inventory8

features

all

age,

of siblings,

variables
might
affect
the performance
in the trial.
Observation
for Measurement
of the

Environment

A total

chronologic

number

of congenital

the

any of these
of the infants
The
Home

AND MATERIALS

study:

weight,

care,
status
of the home
environment
as
by the Home
Observation
for Measurethe
Environment
Inventory,8
and
pre-

on

scores

the

birth

or absence

residential
assessed
ment
of

Design

16)

admission

maternal

those

most

likely

to

nature
of the home
as
has been
shown
to be
infants
intelligence.9

retarded

children

reported,
infants

with

this

we believed
that
home
environment

the

could
influence
the efforts
of an intervention
program.
The HOME
Inventory
uses 45 items
to assess
six
categories
of stimulation
available
to the infant:
emotional
and verbal
responsivity
of the mother;

were placed
in the treatreferred
between
March
to the control
group
and
throughout
the
summer
either
in January
or Feb-

avoidance

of restriction

and

punishment;

organiza-

ruary
received
treatment
but were not included
in
the trial
because
the summer
holiday
period
prevented
them
from having
six months
of continuous

tion
of the
physical
and
temporal
environment;
provision
of appropriate
play
materials;
maternal
involvement;
and opportunities
for variety
in daily

therapy.

activities.
Scoring
is based
partly
on observation
and
partly
on answers
to a semistructured
interview.
A composite
score,
as well as scores
for each
of the six categories,
is obtained.
A social
worker
who did not know
either
the design
of the study
or

In order

subjects,
year

we

to obtain

repeated

period,

from

an adequate

this

fall

the

number
of
over
a two-

procedure

of 1976

through

the

fall

of

1978.

the group
to which
the infant
was assigned
administered
the Inventory
in the home
with
the child
awake,
The
Griffiths
Mental
Development
Scales#{176}2
were
selected
as the
principal
outcome
measure
because
these
scales
were
initially
designed
to en-

Program

The
based
ration

intervention
program
consisted
of centerbiweekly
therapy
sessions
of one hours
dudesigned
to encourage
the childs
acquisition

of successive
developmental
levels.
Activities
to
stimulate
normal
development,
such
as rolling,
sitting, reaching,
or speaking,
were demonstrated
and
taught
to the parent.
In addition,
a set of written
instructions

home

was

between

special
worker,

cal therapist.

Upon
member
on

Scores

Scales

were
again

terms

on

for

child

parent

staff

acceptance,
who

a child

then

change

measure

of mental

(post

of

was

assigned

the

primary

was
minus

defined

and

464

age.

in

prescores)

only

development.

two

Scales
These

the comparability
groups,
we collected

EARLY

INTERVENTION

of the experimental
the following
data

FOR

INFANTS

and

the

areas,

and

more

motor

provide
features,

quotients
for
hearing

performance,

five
and

as well

development.
from
birth

commonly

DOWN

and

information
we believed,

evaluation

of a handicapped
a psychologist

WITH

eye,

sta-

as

Each
to 2 years

used

Bayley

of Infant
Development,22
all five skills
are
represented
at all ages thereby
providing
a
profile
of any child at any age.23 In addition,
the Bayley
Scales
render
information
in

sensitive

assess
control

of mental

in addition
to measurinfants.
Furthermore,

measure
of mental
consists
of 52 items
Unlike

Scales
equally
detailed
whereas

Measures
To

hand

overall

subscale

of

diagnosis

children
in normal

scale provides
developmental
areas,
locomotor,
personal-social,

speech,
an

differential

in handicapped
general
ability

this
skill

two

Development
into the study

Outcome

scores

at

follow

a detailed

tus
ing

one social
one physi-

became

the
Griffiths
Mental
gathered
at admission

the

to

consisted

care worker,
therapist,
and

at its conclusion.

of

this

the

The

educators,
one
one occupational

to one staff
therapist.

and

given

sessions.

able

of the

mental,

the

for five
would

specific
permit

developmental

infant.
Testing
hired
exclusively

Griffiths
areas.
a more
progress

was performed
by
for this investiga-

SYNDROME

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tion who was kept

unaware
of the group
status
of
the subjects
and of the basic
design
of the study.
The same
psychologist
administered
both
pre- and
post-measures
to all children.

the total
development
group
declined
an
six months
whereas
points.

However,

ences
of the

RESULTS
mine

the

linear

characterizes

were

performed

combination

to deter-

of variables

that

best

the

differences
between
the groups.
A
analysis
was
first
performed
to confirm
two groups,
experimental
and control,
were

stepwise

that

analyses

the

comparable.

The

means,
standard
deviations,
and
univanate
F-ratios
for all 19 variables
are presented
in Table
1. Only
one variable,
a HOME
Inventory
subscale,
discriminated
between
the two groups
(P
.04), the experimental
group
having
a significantly
higher
score
on this subscale.
=

The

means,

F-ratios

standard

for

the

six

deviations,

change

and

scores

univariate

(post

minus

pre-

score)
quotient

on the five subscales

and total developmental
of the
Griffiths
Mental
Development
Scales
are shown
in Table
2. As expected,
due to
advancing
chronologic
age, the mean
developmental quotients
in both
groups
for all subscales
dedined
over
the
six-month
period.
However,
the
experimental

group
eye,

decreased

group

in

only

two

performance).

scales,

the

than

the

remaining

quotients

experimental

Subject

than

subscales

the

groups

of the

TABLE 1 .

six

For

control

those

less

of the

and

four

sub-

of

For

less

example,

Experimental

and

six change

and

scores

were

were
then

differ-

found

for

employed

any

simul-

that

combination

the

of the

to
discriminate
groups.
was

six change

significantly

Following
performed

this,
with

mine

the

linear

ables

that

best

the groups.
ence
in the

scores

between

a stepwise
discriminant
the six change
scores

combination

of the

characterized

the

In order
to adjust
home
environments

two

analysis
to deter-

outcome

difference
for

failed

the

vanbetween

the initial
differbetween
the two

groups,
the HOME
Inventory
PLAY
subscale
was
entered
into this analysis
on the first step. Following
this adjustment,
none
of the change
scores
of the
developmental
quotients
provided
a significant
additional

to the

contribution

discriminant.

There
notion
trial,
Control

is no
that
was

statistical

early
efficacious

evidence

to

support

the

intervention,
as provided
in this
in remediating
retardation
in

Groups

(n

21)

SD

Control
Mean

(n

16)

P Value

SD

Family

Chronologic
Sex

significant

groups
scores.

in a discriminant
analysis
to differentiate
the experimental
and control
groups.
The
discriminant
function
had
a X6 of 6.057
associated
p value
of .417. It is concluded

Mean

Child

statistically

two
change

taneously
between
derived
with
an

Experimental

Characteristic

the

the
5.94

DISCUSSION

(hand
declined

group.

Characteristics

control

no

between
individual

All
Discriminant

quotient
in the experimental
average
of 7.33 points
over
the control
group
declined

age

(M

(mo)

1, F = 2)
age (yr)

Maternal
Birth
weight
(gm)
No. of siblings
Congenital
heart
disease

(no

Residential

care

6.26

8.43

5.79

1.52

0.51

1.62

0.50

30.43

7.11
607.50
0.97
0.48
0.36

29.81
2,990.00
0.81
1.38
1.06

2,949.10

(natural

1, yes

1, foster

0.95
1.33
1.14

2)

2)

6.00
568.25
0.93
0.50
0.25

NS
NS
NS
NS
NS
NS
NS

9.33

HOME*
Emotional

and

Avoidance

of restriction

Organization

verbal
of

responsivity

8.67

2.42

7.62

2.92

NS

6.86

0.79

6.69

0.70

NS

4.57

1.12

4.50

1.26

NS

materials

5.43

2.48

3.62

2.73

.04

the child

3.00
2.67

1.90
1.20

1.94

1.84

NS

2.38

1.02

NS

79.05

9.67
10.27

78.88
81.25

16.60
21.68

NS
NS

84.62

11.95

83.56

19.36

NS

76.24

14.42

76.76

18.51

NS

72.17

14.88

74.75

17.57

NS

84.57

1 1.54

83.44

15.48

NS

and

the

of the

mother

punishment

physical

and

temporal

environ-

ment

Provision

of appropriate

Maternal

involvement

Opportunities
Griffiths

for

play

with
variety

Prescore/total

activities

quotient

79.38

Prescore/locomotor
Prescore/personal-social
Prescore/hand

quotient
quotient
and

eye

Prescore/performance
Prescore/hearing
*Home

in daily

Scales

Observation

quotient
quotient

and
for

speech

quotient

Measurement

of the

Environment

Inventory.

ARTICLES
Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on March 22, 2015

465

TABLE 2.

Outcome

Variables

(Post

minus

Prescores)

Experimental

for

and

Control

Groups

Experimental
Total

developmental

-7.33
developmental

-8.81
13.31

-2.38
9.56

NS

developmental

-8.19

-7.56

NS

quotient

Mean

14.36

SD

Hand

and

eye

developmental

-2.71

developmental

15.00
and

speech

developmental

-11.00

assessed
Scales
ence

even

by

the
after

between

the

-7.56

15.64

SD

syndrome.

The

performance

group
was
not
in any of the areas
Griffiths
adjustment
two

of

superior
to
of development

the

Mental
Development
for the initial
differ-

groups

on the

NS

15.84

quotient

Mean

Down

-9.56

-5.71

SD
Hearing

NS

16.36

quotient

Mean

with

-3.12

12.24

SD

the
experimental
control
group

10.15

quotient

Mean

Performance

NS

8.86

quotient

Mean
SD
Personal-social

-5.94

7.79

SD

infants

(N=16)

quotient

Mean
Locomotor

P Value

Control

(N=21)

home

environ-

length

NS

12.85

of

treatment

may

be

than
in others;
intervention
infancy
only when
applied

different

in

may
be
for a period

months.
In addition,
the positive
tion
may
only
be detectable

our

trial

efficacious
greater

than

in

six

effect
with

of infant
intervenmaturation,
al-

ment
variable.
The
negative
findings
of this trial
are in sharp
contrast
to others
reported
in the
literature,5
each of which
suggests
some
beneficial
effects
from
early
intervention.
Several
possible
explanations
for
this discrepancy
should
be considered.
Because
we

though
this
explanation
is not supported
by the
experience
with
culturally
disadvantaged
children.
Bronfenbrenner3
found
the positive
effects
of intervention
diminished
following
discontinuation
of

did
not
assess
development
month
period
for both
groups,

over
the
a seasonal

quotients
syndrome

be

to

present.

Infants

received
months

group

winter

allocated

intervention
whereas

the

same
bias

sixmay

experimental

throughout
control
subjects

the

fail
were

for developmental
change
occurring
during
the spring
and
summer.
Accordingly,
the experimental
infants
may have
had a slight
disadvantage
associated
with the timing
of their
assessments.
For
example,
some
minor
illnesses
such as colds and flu,
are more
prevalent
in winter
than
summer,
which
in turn
mxy interfere
with developmental
progress.

taking
play,

winter

young
shopping,

It is also

in Montreal
children
or social

possible

that

tion would
have
produced
for the study
by Aronson
there
is no other
published
greater

than

six

investigations
than

466

months.

have

infants,

the

EARLY

dealt
association

is not

conducive

for

whether

for

out-of-doors,
visits.
a longer

But,

of interven-

because

previous
rather
outcome

FOR

INFANTS

and

decline

of developmental

factor.

Carr24

found

in developmental
6 and 10 months

that

quotients
of age.

child

with Down
may also be

the

greatest

took
Because

de-

place
bethe mean

age of the infants

in our trial was nine months,
it is
possible
that
intervention
was initiated
at a time
when
the natural
decrease
in intelligence
was ocat a rapid
rate. Accordingly,
arguments
be made
for the necessity
to either
intervene
aggressively
or for the futility
of treatment
this period.
curring

of
on

preschoolers
between

INTERVENTION

dine
tween

documented

over time,
the age of the
at the time
of intervention

Similarly,
more
age,
may
be

earlier

period

different
results.
Except
and Fallstrom,#{176} however,
evaluation
for a period
with

the

a critical
and
as-

sessed

Moreover,

treatment.
With

studies

more

intensive
necessary

reporting

intensive

treatment

intervention,
although
positive
results
than

can
more
during

regardless
none
of the
were based

that

of the

pro-

gram
examined
in this study.
Nonetheless,
the interaction
of amount
of treatment
with
the age of
the child
may
necessitate
a different
approach
for
infants
children.
The

WITH

than

that

actual

DOWN

site

usually
of the

employed
therapy

with
may

SYNDROME

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on March 22, 2015

preschool
also

be

an

important

factor.

home

versus

this

The

study,

parents

and

received

gram

to be

carried

sessions.

the

therapist

the

not

because

for

with

Bronfenbrenner3
programs
for

vantaged
children,
strongly
home
visits
by a therapist
in the

may

treatment.

facilitate
than

participation

of the

parent-child

may

be

did

not

with

the

ance
dren

as it pertains
is a complex

prescribed

niques

not
per

tiveness

attempt

the
than

se

but

an

it

results

early

the

with

the

compliance

1. Heber

of compli-

handicapped
gains
from

pattern

syndrome

of mental
infants

par-

program.

intervention

tional

study

be

are

only

Mental
be that
would

stressed

one

Development

studies

where

positive

the

mea-

from
Pro-

the
objectives
encompass
other

of
areas

diation
of a childs
retardation.
the child into the family
structure,

the

and
the
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the National
Health
Research
and
Development
gram,
Health
and Welfare,
Canada.

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developmental
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feelings,
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ACKNOWLEDGMENT

more

issue

intervention

measure

guilt

efficacy

parent

assessing

outcome

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the

is doubtful.

intervention

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that

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parents
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treatment.
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with

rather

Griffiths

in detecting
tant to note

suggest

minor

in those

ticipating

syndrome.
exist
for

intervention

some

efficacious

development

programs

assess

The

nonetheless,

this

Although
it may
ment
instrument

tion

particular

5.

should,
of

sure-the

the

bein

not

clearly

of early
with

was

retardation
in Down
possible
explanations

findings

conclude,

problem
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the technique
itself.
Our
con-

early

whole.
Assuming
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ficient
importance
ings,

the
other

fre-

frequent
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than

to

regimens.

primarily

of

al-

objectively.

minimizing

productivity

important

to therapy
for
one; immediate

program,
rather
was

programs

to be proven

the

the

interaction

ment
are seldom
seen
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for whatever
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fail to

cern

by

components

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Families.
parents

report.

of

Early Intervention for Infants with Down Syndrome: A Controlled Trial

Martha C. Piper and I. B. Pless
Pediatrics 1980;65;463
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1980 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on March 22, 2015

Early Intervention for Infants with Down Syndrome: A Controlled Trial

Martha C. Piper and I. B. Pless
Pediatrics 1980;65;463

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/65/3/463

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1980 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on March 22, 2015