Research in Developmental Disabilities 32 (2011) 312321

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Effectiveness of virtual reality using Wii gaming technology in children

with Down syndrome
Yee-Pay Wuang a,b,*, Ching-Sui Chiang a, Chwen-Yng Su a, Chih-Chung Wang b
a
b

Department of Occupational Therapy, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan
Department of Physical Medicine and Rehabilitation, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 9 September 2010
Accepted 8 October 2010

This quasi-experimental study compared the effect of standard occupational therapy (SOT)
and virtual reality using Wii gaming technology (VRWii) on children with Down syndrome
(DS). Children (n = 105) were randomly assigned to intervention with either SOT or VRWii,
while another 50 served as controls. All children were assessed with measures of
sensorimotor functions. At post-intervention, the treatment groups signicantly outperformed the control group on all measures. Participants in the VRWii group had a greater
prepost change on motor prociency, visual-integrative abilities, and sensory integrative
functioning. Virtual reality using Wii gaming technology demonstrated benet in improving
sensorimotor functions among children with DS. It could be used as adjuvant therapy to
other proven successful rehabilitative interventions in treating children with DS.
2010 Elsevier Ltd. All rights reserved.

Keywords:
Virtual reality
Down syndrome

1. Introduction
Down syndrome (DS) is a chromosomal anomaly that leaves the individual affected with an additional chromosome (the
21th). The syndrome is associated with approximately 1/800 live births and is one of the leading causes of intellectual
disabilities (Roizen, 2002).
Children with DS are characterized by delays in motor milestone attainment, sensorimotor performance decit, and
perceptual dysfunctions, in addition to signicant limitations both in intellectual functioning and in adaptive behavior
(Burack, Hodapp, & Zigler, 1998; Hogan, Rogers, & Msall, 2000). One of the most established ndings is that children with DS
are slower at both initiating and executing goal-directed movements compared to typically developing peers (Savelsbergh,
van der Kamp, Ledebt, & Planinsek, 2000). They also exhibit greater movement time advantages as the accuracy demands of
the movement goal are increased (Hodges, Cunningham, Lyons, Kerr, & Elliott, 1995). Commonly reported sensorimotor
decits exhibited by children with DS also include perceptual-motor slowness (Elliott & Bunn, 2004), limb control problems
(Anson & Mawston, 2000) and decreased motor prociency (Wuang, Lin, & Su, 2009). Besides, children with DS demonstrate
very specic movement problems when they are required to organize a sequence of movement on the basis of verbal
information (Heath, Elliott, Weeks, & Chua, 2000). The specic verbal-motor difculties have implications for motor skill
instruction. These sensorimotor difculties may hinder their participation in school activities, academic performance,
independence in daily living, and social acceptance by peers (Hamilton, 2002; Pivik, McComas, & Laamme, 2002). Effective
therapy to enhance sensorimotor function is thus of paramount importance in facilitating integration into daily life, and
reducing the immediate burden and future expense on the society (Wuang & Niew, 2005).

* Corresponding author at: Department of Occupational Therapy, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung, 807, Taiwan. Tel.:
+886 7 3121101x2658; fax: +886 7 3215845.
E-mail address: yeepwu@cc.kmu.edu.tw (Y.-P. Wuang).
0891-4222/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2010.10.002

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313

The most effective traditional approaches for treating sensorimotor problems in children with DS include sensory
integrative (SI) therapy, the perceptual-motor (PM) approach, and neurodevelopmental treatment (NDT) (Wuang, Wang,
Huang, & Su, 2009). SI intervention is based on the premises that sensory input is necessary for optimal function for the
childs brain and that early intervention will promote underlying capabilities and minimize abnormal function as a result of
plasticity in the central nervous system that is greatest during early childhood (Ayres, 1989). SI therapy is justied in the
treatment of children with DS, since a common feature in this group of children is a failure to integrate sensory information
into adaptive responses that include making judgments about the environment, responding to the environmental
challenges with success and accomplishing the required role imposed by the occupation (Ayres, 2004). The PM approach
assumes a causal relationship between motor behavior and underlying perceptual processes. PM training provides the
child with an array of experiences with sensory and motor tasks via therapist-directed structured activities. General
improvement in perceptual and academic abilities is anticipated as a consequence of enhanced sensory and motor
experiences (Cratty, 1981). PM approach treatment of children with DS has a long history reecting the incidence of
perceptual motor decits (such as specic visualperceptual disturbances and learning difculties) (Batshaw & Shapiro,
2002; Hoover & Wade, 1985), and continues to be the treatment of choice for many clinicians (Wallen & Walker, 1995). The
NDT frame of reference focused on understanding childrens difculties related to muscle tone, stability, and, mobility and
implements targeted interventions to address these areas of difculty (Schoen & Anderson, 1999). NDT is appropriate for
use in children with DS because these children often present with accompanying neuromuscular dysfunction (i.e.,
hypotonia, unusual posture, poor limb control, atypical muscle activation; Adams, Chandler, & Schulmann, 2000; Bar-Haim
et al., 2006; Butler & Darrah, 2001).
However, traditional therapies for movement difculties in children with disabilities are repetitive and offer very little to
keep a young mind occupied (Adamovich, Fluet, & Merians, 2009). Besides, children with disabilities tend to show difculty
in repeated practice of functional activities because of the nature of their disabilities (i.e. movement limitation, attention
decit, or cognitive impairments) or a lack of intervention context variability (Taub, Ramey, DeLuca, & Echols, 2004; Wuang,
Wang, Huang, & Su, 2009). Interactive virtual reality (VR) can provide a much wider array of activities and scenarios for
movements. Virtual reality (VR) is dened as a means to a usercomputer interface that consists of real-time environmental
simulation, that is, the users could interact with the scenario or environment via multiple sensory channels (Burdea, 2003).
VR could create an exercise environment in which the practice intensity and positive sensory feedbacks (i.e. auditory, visual,
and proprioceptive) can be manipulated systematically in different natural-like environments to allow for individualized
motor training programs (Wilson, Foreman, & Stanton, 1997). Therefore, plenty of experimental evidence suggests that rapid
advancement of VR technologies has great potential for the development of novel strategies for sensorimotor training in
rehabilitation (Adamovich et al., 2009).
Neuroplasticity refers to the ability of brain structures to change. There is an abundance of research that supports the
concept of neuroplasticity in pediatric rehabilitation since neuronal organization and integration can take place through
participating types of purposeful activities used in therapeutic intervention (Ayres, 2004; Barthel, 2010; Kramer & Hinojosa,
2010; Mulligan, 2002; Parham & Mailloux, 2010), particularly through the mirror-neurons systems, including areas of
frontal, parietal, and temporal lobes in the human brain, which increase their ring rates when children observe movements
performed by other persons (Buccino, Solodkin, & Small, 2006; Rizzolatti & Fabbri-Destro, 2008). The gaming industry has
developed a variety of VR systems for home use, making this technology both affordable and accessible with potential
application in community settings (i.e., children school, classroom, therapy room). The novel VR gaming systems could
provide for massive and intensive sensorimotor stimulation to activate mirror-neuron systems needed to induce brain
reorganization by allowing the children to interact in 3 dimensional scenarios and observe the avatar movements captured
on the screen simultaneously (Buccino et al., 2006; Saposnik et al. 2010). Besides, the discrepancies between the real and
virtual feedback introduced in VR gaming system could activate targeted brain networks which is crucial for motor learning
(Adamovich et al., 2009).
In recent studies of patient with stroke, investigators started incorporating commercially available video games
(Nintendo Wii) into their treatment regimen and the results veried the treatment effect (Saposnik et al., 2010). However, to
date, no evidence is available on the effectiveness of an interactive virtual reality gaming system in children with intellectual
disabilities, so there is a legitimate need to evaluate effect of VR in this population. Thus, we hypothesized that virtual reality
using Wii gaming technology (VRWii) is potentially efcacious in enhancing sensorimotor functions compared to standard
sensorimotor training among children with DS.
2. Method
2.1. Participants
The study was conducted during 20092010 in the pediatric occupational therapy unit, Department of Rehabilitation
Medicine, of the university afliated medical center, after approval by its ethics committee. Inclusion criteria included (1)
aged between 7 and 12 years; and (2) a diagnosis of DS determined by the board-certied physicians at local designated
hospitals. Excluded were children who carried coexisting autism, cerebral palsy, blindness, and deafness in an attempt to
minimize confounding of data. Also excluded were children with previous history of neurological disorders such as
traumatic brain injury, muscular dystrophies, and epilepsy.

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Children with DS were identied from relevant educational and clinical sources. Five elementary schools located in a
metropolitan city participated as educational sources in the current study. We contacted the teachers at each participating
school, explained the goals and procedures of the study, and asked them to nominate children eligible for the study. Clinical
sources included the departments of rehabilitation medicine and pediatrics at three hospitals in the metropolitan area. Using
diagnosis and date of birth, we identied the children by reviewing medical record information contained within the
databases compiled by these 3 hospitals.
We screened for the 210 children rst, and 179 children meeting the study criteria were selected through these sources.
An attempt was made to contact their parents or primary caregivers to explain the project and request consent. Of these, 19
refused and 160 agreed to participate in the study. Fifty of 160 children who had initially agreed to participate in the
intervention but could not attend due to practical reasons (e.g. time of the sessions) were assigned to the control group.
Although not chosen at random, parents of control children had initially wished to join the therapy group, so, presumably,
they formed a satisfactory control group.
2.2. Measures
2.2.1. The BruininksOseretsky Test of Motor Prociency-Second Edition (BOT-2) (Bruininks & Bruininks, 2005)
BOT-2 is a well-known measure of motor prociency designed to provide clinicians, educators and researchers with
useful information to assist them in evaluating the motor skills in students ranging from those who are normally developing
to those with moderate motor skill decits. The BOT-2 assesses prociency in four motor-area composites. Fine manual
control composite (FMC) is divided into ne motor precision (FMP) and ne motor integration (FMI) subtests that measure
the motor skills involved in writing and drawing tasks requiring precise control of nger and hand movements. Manual
coordination composite (MC) is classied into manual dexterity (MD) and upper-limb coordination (ULC) subtests that
evaluate reaching, grasping, and object manipulation, with the emphasis on speed, dexterity, and coordination of upper
extremities. Body coordination composite (BC) is grouped into bilateral coordination (BLC) and balance (BAL) subtests that
tap the balance and motor skills required for successful participation in sports and recreational games. Strength and agility
composite (SA) is split into running speed and agility (RSA) and strength (STR) subtests that assess large muscle strength,
running speed, and postural control during walking and running. The four composite scores are combined to yield a total
motor composite score. The average age-adjusted standard score for subtests and ve composites are 15 (S.D. = 5) and 50
(S.D. = 10), respectively.
For the composites, internal consistency reliability coefcients ranged from 0.78 to 0.97, testretest coefcients over an
interval of 742 days ranged from 0.52 to 0.95, and inter-rater reliability coefcients exceeded 0.92 (Bruininks & Bruininks,
2005). The BOT-2 total composite correlated fairly well with other measures of motor performance such as the Peabody
Developmental Motor Scales, Second Edition (Folio & Fewell, 2000) and the Test of Visual Motor Skills-Revised (Gardner,
1995) (0.62 and 0.73, respectively). In support of construct validity, the BOT-2 median scores increased across the age range,
with the peak performance occurring between ages 4 and 8.
2.2.2. The Developmental Test of Visual Motor Integration (VMI) (Beery, 1997)
VMI and its two supplemental standardized tests, Visual Perception and Motor Coordination, are designed to screen for
visual-motor integration decits that can lead to learning and behavior problems in children ages 318 years. The VMI
contains a developmental sequence of 27 geometric forms to be copied with paper and pencil. The Visual Perception test
requires the child to choose a geometric form identical to the stimulus form among others that look nearly but not exactly
the same. In the Motor Coordination test, the child has to trace the same 27 geometric forms with a pencil without going
outside the double-lined paths. Each design is scored on a passfail basis in the VMI and its supplemental tests. Higher scores
indicate better performance. Published standard scores of the VMI as well as supplemental tests have a mean of 100 and a
standard deviation of 15. The VMI and its supplemental Visual and Motor tests demonstrated overall good reliability (Beery,
1997). In terms of validity, the VMI correlated highly with chronological age (0.80  0.90), and with other tests that purport
to measure visual-motor integration (Demsky, Carone, Burns, & Sellers, 2000; Erford & Snyder, 2004).
2.2.3. The Test of Sensory Integration Function (TSIF) (Lin, 2004)
TSIF is designed to identify sensory integrative dysfunction in children aged from 3 through 12 years. It consists of 98
items divided into 6 subtests: postural movement control, bilateral integration sequencing, sensory discrimination, sensory
modulation, sensory searching, attention and activity, and emotional-behavioral reactivity. Each of the items is scored on a
5-point Likert scale from 1 = never to 5 = always based on the frequency of targeted behavior during the entire observation
period. Higher scores indicate poorer performance on sensory integration tasks. Subtest standard scores of the TSIF are based
on a distribution having a mean of 50 and standard deviation of 10. Internal consistency for the overall test demonstrated a
Cronbachs alpha of 0.89, while testretest reliabilities for the subtest scores ranged between 0.82 and 0.94. The TSIF subtest
scores signicantly varied as a function of age, sex, and residential location (urban versus rural) (Lin, 2004).
To sum up, the BOT-2 assesses qualitative aspects of motor behavior in relation to uency and exibility of movement
(Slaats-Willemse, de Sonneville, Swaab-Barneveld, & Buitelaar, 2005). The VMI was used to tap graphomotor function that
involves the use of ngers and hands to create written output (Levine, 2008). The Test of Sensory Integration Function (TSIF)
(Lin, 2004) was employed to assess for difculties in the sensory integrative process.

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315

2.3. Study interventions

2.3.1. Virtual reality using Wii gaming technology (VRWii)
Nintendo introduced a novel style of VR (Wii, 2006) by using a wireless controller that interacts with the player through a
motion detection system and its avatar representation in the video. The acceleration sensors embedded in the controllers
could be responsive to the changes in speed, direction, and acceleration/deceleration that enable participants to interact
with the games while performing different movements. The movements performed by the children could be captured and
reproduced on the screen via the infrared light sensor mounted on TV top. The feedback provided by the TV screen as well as
the opportunity to observe their own movement in real time, generates positive reinforcement, thus facilitating training and
task improvement (Saposnik et al., 2010).
Several distinctive features favored the selection Wii over other VR systems, including novel and widely available 3D
technology using gaming simulations, affordability, and clinical applicability using simple graphics with real-time feedback
with the intellectual limitations in DS. Provision of multimodal sensory feedback with the avatar could allow adjustments
while children perform and self-observe the execution of diverse tasks. The software used in this study was the publicly
available sports (ie, Wii Sports), accounting for 60 min each in the VRWii group.
2.3.2. Standard occupational therapy (SOT)
SOT comprises various activity combinations incorporating the principle of SI, NDT, and PM approaches. SI program
(Parham et al., 2007) included activities such as linear and circular swinging, tactile-perception, bilateral integration and
sequencing, and equilibrium reactions for the purpose of presenting the child with opportunities for various sensory
experiences. Linear and circular swinging activities were carried out with platform swing, T-swing, and tire-swing in
different positions. Tactile-perception activities involved feeling various shapes and exploring different textures. Bilateral
integration and sequencing were facilitated through dance activities and gymnastics, while equilibrium reactions were
elicited by therapeutic ball or tilting board in different positions. The therapist selected and modied activities according to
the childs needs and interest while taking opportunities to help the child successfully meet a challenge. At the same time,
the therapist allowed the child to actively exert some control over activity choice by encouraging the child to initiate and
develop ideas and plans for activities.
NDT treatment was directed to facilitate normal postural control as well as to promote optimal movement patterns to
achieve the best energy-efcient performance through the use of positioning, handling, weight shifting, and weight bearing
techniques (Howle, 2002). NDT program involved activities such as developmental movement patterns, walking,
strengthening of anti-gravity muscles, and ne motor skills. Developmental movement patterns training consisted of
obstacle crawl and use of different body positions (kneeling, half-kneeling, and standing) to throw the ball. Walking activities
included walking forward, backward and sideways, walking on line, animal walking (like monkey and crab), stepping, and
galloping. Strengthening of anti-gravity muscles were performed with scooter board games, sit-up exercises, and dowel
moving in different ways. Fine motor activities entailed copying designs, cutting with scissors, and various chalkboard
activities. PM program consisted of ne and gross motor training. Examples of ne motor activities were cutting and pasting,
mazes, dot-to-dot puzzles, tracing designs, and educational card games, whereas gross motor activities included jumping
jacks, skipping, hopping, and tumbling. An equal amount of time was spent with gross motor and ne motor activities, in
which gross motor activities always preceded ne-motor activities. However, unlike SI and NDT, no effort was made to
control the degree or variety of sensory inputs in performing perceptual-motor training activities. Nor were the inhibitory or
facilitatory handling techniques directly incorporated into the PM program.
Treatment delity was veried by an audit of 20 videotaped therapy sessions from two therapists who participated in the
intervention stage of the study at about rst week and 12 weeks of intervention, 10 for each time period, and 10 for each
group. Two pediatric occupational therapists not involved in the present study separately rated the level of therapists
adherence to specic treatment approach in accordance with the recommended activities listed in the training manual,
using a 4-point scale: 1 (non/irregular, 024%), 2 (rather irregular, 2549%), 3 (rather regular, 5074%), and 4 (regular, 75
100%). The median scores for the adherence of SOT and VRWii approaches were 4 across raters and time periods.
2.4. Procedures
2.4.1. Randomization
Using a computer generated random table, 110 children were randomly assigned to two equal-sized intervention groups.
However, ve children dropped out and only 105 children completed all treatment sessions and assessments (with 53, 52 for
the SOT and VRWii group, respectively).
2.4.2. Sessions
Each intervention group received a 1-h session 2 days per week for 24 weeks. Treatment was conducted on an individual
basis, and each child was randomly assigned to two therapists who administered either SOT or VRWii techniques according
to the childs assigned group. All treating therapists had more than ten years of clinical experience in pediatric occupational
therapy. To ensure consistency in the treatment techniques delivered to the children within each group, the therapists were
required to thoroughly review the training manual prior to the start of the intervention, in which a comprehensive listing of

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activities used for both SOT and VRWii program was described in detail. Home programs were not provided to the parents or
caretakers to minimize possible confounding due to practice effects and variations of treatment techniques between
therapists and parents. Video games may induce photosensitive seizures (1/40,000, Fisher, Harding, Erba, Barkley, & Wilkins,
2005) and repetitive motion injuries (Bonis, 2007). The primary investigator (YPW) monitored the participants for
symptoms suggesting seizures or body pain, and stopped the session as soon as the participant felt unwell.
Another two pediatric occupational therapists, who were blind to child group status, administered the BOT-2, VMI, and
TSIF to the children at pre-and post-therapy according to standardized procedures provided by the appropriate test manuals.
The examiners undertook an intensive one-day training session led by the principal investigator. During training, particular
attention was drawn to the tests explicit nature, administration and scoring. To meet the competency requirement in test
administration, each examiner completed a case under the supervision of the principal investigator to ensure correctness
and appropriateness in administering and scoring prior to formal testing. After training, a video recording of the assessment
of one child was made. Each of the two therapists viewed the recording and scored it individually. High inter-rater reliability
with the three instruments was reached, with 0.97, 0.95, and 0.97 for the BOT-2 VMI, and TSIF, respectively. To decrease
possible experimenter bias, the examiner did not reacquaint herself with the childs scores from the rst assessment when
conducting the retest. Children in the intervention groups were tested at occupational therapy unit, whereas children in the
no-treatment control group were tested in a quiet classroom at the childrens respective schools or facilities. The testing was
conducted on an individual basis in one session lasting approximately 11.5 h, with a suitable number of breaks to minimize
the effects of fatigue.
2.5. Data analysis
SPSS 15.0 was used to analyze the data. To facilitate analyses, raw scores were rst converted to standard scores using the
publisher-provided norms. Next, to determine pre-intervention differences in test performance across three groups,
multivariate analysis of variance (MANOVA) was applied with pre-intervention test scores as dependent measures, and
group as a between-subjects factor. A second MANOVA was conducted to investigate post-intervention differences in test
performance among groups. If the multivariate test indicated a signicant group effect, follow-up univariate F-tests were
performed with Scheffe post hoc comparisons. In order to quantify the magnitude of the post-intervention difference
between intervention and control groups, effect sizes (ES) were calculated as d = [treatment mean  control mean]/SD. SD
was calculated as the square root of the pooled estimate of population variance SD2 N 1  SD21 N2  SD21 =
N1 N2  2. As a guide to interpreting these values, Cohen (1977) labeled an effect size small if ES  0.2 < 0.5,
moderate if ES  0.5 < 0.8, or large if ES  0.8. ES were again computed by dividing the mean change in a test score by the
standard deviation of the test score at baseline to quantify the magnitude of change between pre- and post-intervention test
scores for each group.
3. Results
3.1. Group comparability
The three groups did not differ signicantly in age (F = 0.11, p = 0.90) or gender (x2 = 2.84, df = 1, p = 0.09). Prior to
performing the MANOVA, Boxs M test of equality of covariance matrices was carried out to test the assumptions of
homogeneity of variance. The Boxs M test yielded a non-signicant result (Boxs M = 375.91, p = 0.85); thus the assumption
of homogeneity of variancecovariance matrices was supported. The overall MANOVA for the pre-intervention test scores
was non-signicant (Wilks lambda = 0.76, F[34,271] = 1.18, p = 0.24, partial h2 = 0.13) and similarly, none of the univariates
between group comparisons for the BOT-2, VMI, or TSIF were signicant (see Table 1). In other words, there was no
signicant pre-intervention difference in test scores between the control group and either of the intervention groups.
3.2. Post-intervention differences between intervention and control groups
In regard to the group differences in post-intervention test performance, the results of MANOVA revealed a signicant
overall group effect (Wilks lambda = 0.03, F[34,272] = 42.31, p = 0.000, partial h2 = 0.84). Follow-up univariate F-tests were
performed accordingly. In light of the number of univariate analyses conducted, the a level was set at 0.003 (0.05/17) for all
follow-up analyses to maintain a family-wise error rate of <0.05. As shown in Table 2, three groups performed signicantly
differently across test measures. The Scheffe multiple comparisons test showed that the VRWii group signicantly
outperformed the SOT group on three BOT-2 subtests (ne motor integration, upper-limb coordination, and running speed
and agility) and all of the TSIF subtests with the exception of the sensory discrimination subtest (see Table 3). On the ne
motor precision, manual dexterity, bilateral coordination and strength subtests of the BOT-2 and TSIF sensory discrimination
subtest, no signicant difference emerged between intervention groups. As for VMI, signicant difference was observed
between SOT and VRWii groups in this measure; both groups also scored signicantly higher than the control group.
Inspection of Table 3 also showed statistical signicant differences between intervention and no-treatment control groups
on all test measures (see Table 3). Effect sizes were provided to describe the magnitude of these between-group comparisons
(SOT between controls, VRWii between control) (see Table 4). Relative to control group, moderate to large effect sizes were seen

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317

Table 1
Summary of the univariate ANOVAs on the pre-intervention standard scores for each group.
Test

BOT-2
Fine motor precision
Fine motor integration
Manual dexterity
Upper-limb coordination
Bilateral coordination
Balance
Running speed and agility
Strength
VMI
Motor coordination
Visual perception
TSIF
Postural movement control
Bilateral integration sequencing
Sensory discrimination
Sensory modulation
Sensory searching
Attention and activity
Emotional-behavioral reactivity

Group mean (SE) test scores

F*

Partial h2

Controls

SOT

VRWii

6.64(0.60)
8.20(0.81)
5.94(0.94)
7.82(1.32)
10.10(1.42)
10.66(1.14)
7.14(0.93)
10.54(1.15)

6.87(0.96)
8.28(1.05)
6.08(1.02)
8.11(1.12)
9.43(2.07)
11.40(1.74)
7.47(1.09)
10.94(1.59)

6.63(0.69)
8.23(0.98)
5.94(1.00)
7.96(1.14)
9.06(1.46)
11.08(1.37)
7.38(1.07)
10.69(1.25)

1.57
0.10
0.33
0.78
0.79
2.37
1.42
1.19

0.02
0.00
0.00
0.01
0.01
0.04
0.02
0.02

53.54(2.44)
51.92(4.14)

55.74(4.97)
54.58(4.27)

55.31(5.61)
54.52(4.25)

0.10
0.24

0.00
0.00

52.54(2.55)
50.92(1.14)
65.59(6.08)
56.46(0.49)
60.94(4.08)
58.98(0.97)
59.74(1.77)

53.02(2.06)
51.93(1.06)
65.56(1.16)
56.35(0.40)
63.88(1.23)
58.90(0.90)
59.73(1.59)

52.96(2.07)
52.00(0.80)
65.59(1.49)
57.03(1.60)
64.05(1.21)
58.94(0.84)
59.75(1.71)

1.06
0.11
0.01
0.02
0.24
0.11
0.00

0.01
0.00
0.00
0.03
0.00
0.00
0.00

Note: ANOVA, analysis of variance; SE, standard error; SOT, standard occupational therapy; VRWii, Wii gaming technology; partial h2, partial eta squared;
BOT-2 BruininksOseretsky Test of Motor Prociency-Second Edition; VMI, Developmental Test of Visual Motor Integration; TSIF, Test of Sensory
Integration Function.
*
The univariate F-tests were non-signicant.

across BOT-2, VMI and TSIF measures for the VRWii group. With regard to children in the SOT group, moderate to large effect
sizes were achieved for all TSIF subtests and all BOT-2 subtests except for strength subtest. Taken together, SOT and VRWii
groups substantially outperformed the control group on most sensorimotor measures at post intervention.
3.3. Pre- and post-intervention differences within groups
Estimates of effect size for each group are summarized in Table 5. Cohen d values for most prepost comparisons across
two intervention groups noticeably exceeded 0.8, thereby reecting robust effect sizes. In particular, VRWii therapy
produced the largest effect sizes in all of the VMI, BOT-2, and TSIF subtest with the exception of manual dexterity, sensory
Table 2
Summary of the univariate ANOVAs on the post-intervention standard scores.
Test

BOT-2
Fine motor precision
Fine motor integration
Manual dexterity
Upper-limb coordination
Bilateral coordination
Balance
Running speed and agility
Strength
VMI
Motor Coordination
Visual perception
TSIF
Postural movement control
Bilateral integration sequencing
Sensory discrimination
Sensory modulation
Sensory searching
Attention and activity
Emotional-behavioral reactivity

F*

Group mean (SE) test scores

Partial h2

Controls

SOT

VRWii

6.56(0.58)
8.22(0.82)
5.86(0.95)
7.64(1.37)
10.54(1.30)
10.88(0.90)
7.22(1.00)
11.26(1.21)

8.92(1.25)
9.92(1.37)
6.68(1.37)
9.32(2.44)
11.42(1.86)
12.66(1.56)
9.36(1.33)
14.36(1.87)

9.31(1.23)
10.65(0.95)
6.44(1.02)
10.62(2.64)
11.83(1.67)
13.27(1.74)
10.12(1.10)
15.37(1.80)

97.59
68.42
7.10
22.80
8.28
37.25
86.12
20.55

0.56
0.47
0.09
0.23
0.10
0.33
0.53
0.21

55.22(5.86)
54.40(4.77)

64.89(6.09)
66.19(4.60)

68.69(7.48)
71.38(6.65)

57.62
130.94

0.43
0.63

53.65(2.60)
51.77(1.39)
59.82(2.34)
56.64(0.52)
64.02(1.23)
59.00(1.02)
59.61(1.77)

49.38(2.47)
48.97(1.69)
56.97(1.69)
53.40(0.56)
61.02(2.85)
54.74(1.77)
51.81(2.98)

47.11(2.45)
47.11(2.55)
56.87(2.20)
52.80(0.78)
58.01(3.92)
50.37(3.20)
48.26(2.23)

89.15
77.67
32.72
544.89
54.04
196.21
299.54

0.54
0.51
0.30
0.88
0.42
0.72
0.80

Note: ANOVA, analysis of variance; SE, standard error; SOT, standard occupational therapy; VRWii, Wii gaming technology; partial h2, partial eta squared;
BOT-2 BruininksOseretsky Test of Motor Prociency-Second Edition; VMI, Developmental Test of Visual Motor Integration; TSIF, Test of Sensory
Integration Function.
*
The univariate F-tests were signicant at the 0.0001 level.

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Table 3
Post hoc Scheffe multiple comparisons at post-intervention.
Test

Multiple comparisons
SOT-VRWii

BOTMP
Fine motor precision
Fine motor integration
Manual dexterity
Upper-limb coordination
Bilateral coordination
Balance
Running speed and agility
Strength
VMI
Motor Coordination
Visual perception
TSIF
Postural movement
Bilateral integration sequencing
Sensory discrimination
Sensory modulation
Sensory searching
Attention and activity
Emotional-behavioral reactivity

SOT-C

VRWii-C

0.38
0.73*
0.24
1.29*
0.41
0.61
0.76*
1.01

2.36*
1.70*
0.82*
1.68*
0.88*
1.78*
2.14*
1.10*

2.75*
2.43*
0.58*
2.98*
1.29*
2.39*
2.90*
2.11*

3.80*
5.20*

9.67*
11.79*

13.47*
16.98*

2.27*
1.86*
0.10
0.61*
3.01*
4.37*
3.55*

4.26*
2.80*
2.85*
3.24*
3.00*
4.27*
7.80*

6.54*
4.66*
2.95*
3.85
6.00*
8.63*
11.35*

Note: SI, sensory integration; PM, perceptual-motor; NDT, neurodevelopmental therapy; C, controls; BOT-2, BruininksOseretsky Test of Motor ProciencySecond Edition; VMI, Developmental Test of Visual Motor Integration; TSIF, Test of Sensory Integration Function.
*
p < .003.

discrimination and sensory modulation subtests compared with SOT group. SOT group yielded the largest effect sizes in
manual dexterity subtest of the BOT-2 together with two TSIF subtests (sensory discrimination and sensory modulation).
4. Discussion
Although the scientic evidence supporting the benets of virtual reality (VR) are plentiful (Brutsch et al., 2010; Bryanton
et al., 2006; Chen et al., 2007; Koenig et al., 2008; You et al., 2005), studies regarding the effect of virtual reality using Wii
gaming technology (VRWii) in children with special needs is still limited. The results of this study indicated that VRWii
improved motor prociency, visual-integrative abilities, and sensory integrative functions for children with DS.

Table 4
Summary of Effect Sizes for Post-Intervention Differences between Intervention and Control Groups.
Test
BOT-2
Fine motor precision
Fine motor integration
Manual dexterity
Upper-limb coordination
Bilateral coordination
Balance
Running speed and agility
Strength
VMI
Motor coordination
Visual Perception
TSIF
Postural movement
Bilateral integration sequencing
Sensory discrimination
Sensory modulation
Sensory searching
Attention and activity
Emotional-behavioral reactivity

SOT-control Cohen d

VRWii-control Cohen d

2.38a
1.48a
0.68b
0.84a
0.54b
1.37a
1.80a
0.69

2.84a
2.70a
0.59b
1.39a
0.85a
1.70a
2.74a
1.35a

1.60a
2.49a

1.96a
2.89a

1.66a
1.78a
1.39a
5.89a
1.32a
2.90a
3.13a

2.12a
2.16a
1.04a
4.05a
1.63a
2.77a
4.30a

Note: To quantify the magnitude of the difference between intervention and control groups at post intervention, effect sizes were calculated
as d = [treatment mean  control mean]/SD. SD was calculated as the square root of the pooled estimate of population variance
SD2 N 1  SD21 N 2  SD21 =N 1 N 2  2.
a
A Cohen d value  0.8 indicates a large effect size.
b
A Cohen d value  0.5 < 0.8 indicates a medium effect size.
c
A Cohen d value  0.2 < 0.5 indicates a small effect size.

Y.-P. Wuang et al. / Research in Developmental Disabilities 32 (2011) 312321

319

Table 5
Summary of intervention gains and effect sizes for each group.
Test

BOT-2
Fine motor precision
Fine motor integration
Manual dexterity
Upper-limb coordination
Bilateral coordination
Balance
Running speed and agility
Strength
VMI
Motor coordination
Visual perception
TSIF
Postural movement
Bilateral integration sequencing
Sensory discrimination
Sensory modulation
Sensory searching
Attention and activity
Emotional-behavioral reactivity

SOT

VRWii

Control

Change

Cohen d

Change

Cohen d

Change

Cohen d

2.05
1.64
0.60
1.21
1.99
1.26
1.89
3.42

2.14a
1.56a
0.59b
1.08a
0.96a
0.72b
1.73a
2.15a

2.68
2.42
0.50
2.66
2.77
2.19
2.74
4.68

3.88a
2.47a
0.50b
2.33a
1.90a
1.60a
2.56a
3.74a

0.08
0.02
0.08
0.18
0.44
0.22
0.08
0.72

0.13
0.02
0.09
0.14
0.31c
0.19
0.09
0.63c

9.15
11.61

1.84a
2.74a

13.38
16.86

2.39a
3.97a

1.68
2.48

0.69b
0.18

3.64
2.96
8.59
2.95
2.86
4.16
7.92

1.77a
2.79a
7.41a
7.38a
2.33a
4.62a
4.98a

5.85
4.89
8.72
4.23
6.04
8.57
11.49

2.83a
6.11a
5.85a
2.64a
4.99a
10.20a
6.72a

1.11
0.85
0.95
0.18
0.75
0.02
0.13

0.44c
0.75b
0.49c
0.37c
0.48c
0.02
0.07

Note: SI, sensory integration; NDT, neurodevelopmental therapy; PM, perceptual-motor; change, mean difference scores (post-minus pre-intervention test
standard scores); BOT-2, BruininksOseretsky Test of Motor Prociency-Second Edition; VMI, Developmental Test of Visual Motor Integration; TSIF, Test of
Sensory Integration Function.
a
A Cohen d value  0.8 indicates a large effect size.
b
A Cohen d value  0.5 < 0.8 indicates a medium effect size.
c
A Cohen d value  0.2 < 0.5 indicates a small effect size.

Of the two intervention groups, children who received VRWii therapy demonstrated the largest increase in postintervention scores on the BOT-2 gross motor subtests. Signicant improvement in gross motor function may be accounted
for by the accumulated effects from a series of training steps that are structured, progressive, goal-directed, and interrelated.
For instance, once the child initially learned to maintain equilibrium on VRWii Sports items, more challenging dynamic tasks
such as jumping, striking and catching balls were introduced. VRWii could allow the child to interact with a computersimulated environment and receive near real-time augmented feedback on performance. After mastering the VRWii tasks,
the child was better able to use body feedback to understand the movement outcomes (feedback), anticipate upcoming
events (feedforward), and plan alternative strategies (Brooks, 1986). Simultaneously, the child was encouraged to rely more
on internal feedback and self-evaluation of performance than external feedback from others and environment. By adjusting
the difcult level of Wii Sport items, more mature patterns of motor control emerged from better use of feedback and
feedforward mechanisms.
The VRWii group achieved the greatest progress primarily in the BOT-2 ne motor subtests as well. A probable
explanation is that success with skilled ne motor tasks relies upon sophisticated motor control and higher-level motor
planning. The nature of VRWii therapy promotes an optimal sensory intake by allowing the child to actively explore and
organize diverse sensory inputs. An overall improved organization of sensory input may subsequently enhance motor
planning and sequencing ability, thereby leading to the improvement in ne motor skills (Humphries, Wright, Snider, &
McDougall, 1992). In addition, the improvement in hand function also depended on the childs ability to modify the patterns
of grasping Wii handle according to the different somatosensory input from diverse VRWii Sport items. An essential
component of all extremities movements experienced in VRWii Sports is proactive visual and somatosensory control
(Augurelle, Smith, & Lejeune, 2003; Jeannerod, 1986, 1990), which is responsible for the correct execution of limb movement
and the coordination between limbs and vision (Johansson, 1996; Whitney & Wrisley, 2004). Therefore, tasks involved with
visual motor integration of VMI and BOT-2 were also improved by VRWii.
Unexpectedly, the VRWii group alone demonstrated larger increase in all TSIF subtest scores post intervention than SOT
that included sensory integration therapy. This result offers direct evidence that children with DS are able to benet from
VRWii therapy to optimize the integrated processing of sensory cues and motor responses. VRWii itself could provide
constant opportunities for children to integrate visual, vestibular, and proprioceptive inputs. In particular, signicant gains
in emotion and behavior subtest of the TSIF after VRWii intervention implies that the playfulness inherent in the VRWii items
was able to tap into the childrens inner drive to engage with VRWii therapy. By actively participating in the goal-directed
and enjoyable activities, the therapeutic effects could be maximized (Larin, 2000; Parham & Mailloux, 2010), and the
psychosocial needs of children were fullled as well (Tye & Tye, 1992). The principle of Wii by using self-initiation,
meaningful, and challenging activities in increasing neural plasticity coincided with the principles of sensory integration
theory proposed by Ayres (Ayres, 1972; Jacobs & Schenider, 2001).

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Y.-P. Wuang et al. / Research in Developmental Disabilities 32 (2011) 312321

This study was the rst to systematically assess the effects of VRWii therapy approach on sensorimotor performance in
school-aged children with DS. These ndings also provided empirical credence to the perceptions of parents, therapists and
teachers that therapeutic intervention using either VRWii or SOT is effective in improving sensorimotor function to varying
degrees in children with disabilities as compared with no treatment (Cohn, 2001; Wuang & Niew, 2005). Further, VRWii
technology could be used as adjuvant therapy to other proven successful interventions (ie. PM, NDT, or SI approaches).
The strengths of this study include the well-dened interventions, inclusion of a no-treatment control group for a valid
interpretation of treatment effects, and use of psychometrically sound test instruments. There were some limitations with
respect to the differences in the intensity and frequency of home practice with techniques taught in the therapy sessions, and
lack of long-term follow-up to distinguish long-term impact of the interventions on the childrens sensorimotor function
development. In the rst place, owing to the large sample size and long treatment duration used in our study, it was difcult
to control for the amount of practice time at home. Future studies could take into consideration the covariate of practice
effect by having parents record the type and frequency of physical activities carried out at home in a log on a daily basis.
Secondly, the results of the present study reect the VRWii training effects during a 24-week training intervention.
Continued improvement or maintenance of sensorimotor functions would strengthen support for VRWii. Therefore,
replication of this study with a long-term follow-up (e.g. one or two years after intervention) is warranted. Follow-up studies
are also needed to verify the functional outcomes of VRWii (i.e. the correlation between improved motor prociency, sensory
integration functions and P. E. performances in schools).
Despite these limitations, VRWii is a feasible and potentially effective intervention to enhance sensorimotor functions in
children with DS. Repetitive intensive training and the observation, practice, and representation on the screen of taskspecic activities can facilitate brain plasticity of children that engage the mirror neuron system or long-term effects. In
conclusion, therapeutic intervention (i.e. VRWii or SOT) conducted at a regular basis was benecial in improving
sensorimotor functions in school-aged children with DS. More effort should be made to help these children generalize the
training effects to the functional tasks that demand similar motor skills.
References
Adamovich, S. V., Fluet, G. G., & Merians, A. S. (2009). Sensorimotor training in virtual reality: A review. Neurorehabilitation, 25, 2944.
Adams, M., Chandler, L., & Schulmann, K. (2000). Gait changes in children with cerebral palsy following a neuro-developmental treatment course. Pediatric Physical
Therapy, 12, 114120.
Anson, J. G., & Mawston, G. A. (2000). Patterns of muscle activation in simple reaction time tasks. In D. J. Weeks, R. Chua, & D. Elliott (Eds.), Perceptual motor
behavior in Down syndrome (pp. 324). Champaign, IL: Human Kinetics.
Augurelle, A. S., Smith, A. M., & Lejeune, T. (2003). Importance of cutaneous feedback in maintaining a secure grip during manipulation of hand-held objects.
Journal of Neurophysiology, 89, 665671.
Ayres, A. J. (1972). Sensory integration and learning disorder. Los Angeles: Western Psychological Services.
Ayres, A. J. (1989). Sensory integration and praxis tests manual. Los Angeles: Western Psychological Services.
Ayres, A. J. (2004). Sensory integration and the child (2nd ed.). Los Angeles: Western Psychological Services.
Bar-Haim, S., Harries, N., Belokopytov, M., Frank, A., Copeliovitch, L., Kaplanski, J., et al. (2006). Comparison of efcacy of Adeli suit and neurodevelopmental
treatments in children with cerebral palsy. Developmental Medicine and Child Neurology, 48, 325330.
Barthel, K. (2010). A frame of reference for neuro-developmental treatment. In P. Kramer & J. Hinojosa (Eds.), Frames of reference foe pediatric occupational therapy
(3rd ed., pp. 187233). Philadelphia: Williams & Wilkins.
Batshaw, M. L., & Shapiro, B. (2002). Mental retardation. In M. L. Batshaw (Ed.), Children with disabilities (5th ed., pp. 287305). Baltimore, ML: Paul H. Brookes.
Beery, K. E. (1997). Developmental test of visual-motor integration: Administration, scoring, and teaching manual (4th ed.). Los Angeles: Western Psychological
Services.
Bonis, J. (2007). Acute Wiiitis. New England Journal of Medicine, 356, 24312432.
Brooks, V. B. (1986). The neural basis of motor control. New York: Oxford University Press.
Bruininks, R. H., & Bruininks, B. D. (2005). BruininksOseretsky test of motor prociency (2nd ed.). Minneapolis, MN: Pearson Assessment.
Brutsch, K., Schuler, T., Koenig, A., Zimmerli, L., Merillat, S., Lunenburg, L., et al. (2010). Inuence of virtual reality soccer game on walking performance in robotic
assisted gait training for children. Journal of NeuroEngineering and Rehabilitaiotn, 7, 1523.
Bryanton, C., Bosse, J., Brien, M., McLean, J., McCormick, A., & Sveistrup, H. (2006). Feasibility, motivation, and selective motor control: Virtual reality compared to
conventional home exercise in children with cerebral palsy. Cyberpsychology and Behavior, 9, 123128.
Buccino, G., Solodkin, A., & Small, S. L. (2006). Functions of the mirror neuron system: Implication for neurorehabilitation. Cognitive and Behavioral Neurology, 29,
5563.
Burack, J. A., Hodapp, R. M., & Zigler, E. (1998). Handbook of mental retardation. New York: Cambridge University Press.
Burdea, G. C. (2003). Virtual rehabilitation-benets and challenges. Methods of Information in Medicine, 42, 519523.
Butler, C., & Darrah, J. (2001). Effects of neurodevelopmental treatment (NDT) for cerebral palsy: An AACPDM evidence report. Developmental Medicine and Child
Neurology, 43, 778790.
Chen, Y. P., Kang, L. J., Chuang, T. Y., Doong, J. L., Lee, S. J., Tsai, M. W., et al. (2007). Use of virtual reality to improve upper-extremity control in children with
cerebral palsy: A single-subject design. Physical Therapy, 87, 14411457.
Cohen, J. (1977). Statistical power for the behavioral sciences. New York: Academic Press.
Cohn, E. S. (2001). Parent perspectives of occupational therapy using a sensory integration approach. American Journal of Occupational Therapy, 55, 285294.
Cratty, B. J. (1981). Sensory-motor and perceptual-motor theories and practices: An overview and evaluation. In H. L. Pick & R. D. Walk (Eds.), Intersensory
perception and sensory integration (pp. 345373). New York: Plenum Press.
Demsky, Y., Carone, D. A., Jr., Burns, W. J., & Sellers, A. (2000). Assessment of visual-motor coordination in 6- to 11-yr.-olds. Perceptual and Motor Skills, 91, 311
321.
Elliott, D., & Bunn, L. (2004). Motor disorders in children with intellectual disabilities. In D. Dewey & D. E. Tupper (Eds.), Developmental motor disorders: A
neuropsychological perspective (pp. 142). New York: Guilford Publications.
Erford, B. T., & Snyder, H. (2004). Reliability and validity of score on the Slosson visual perceptual skill screener. Perceptual and Motor Skills, 99, 621627.
Fisher, R. S., Harding, G., Erba, G., Barkley, G. L., & Wilkins, A. (2005). Photic- and pattern-induced seizures: A review for the Epilepsy Foundation of American
Working Group. Epilepsia, 46, 14261441.
Folio, M. R., & Fewell, R. R. (2000). Peabody developmental motor scales (2nd ed.). Austin, TX: PRO-ED.
Gardner, M. F. (1995). Test of visual-motor skills-revised. Hydesville, CA: Psychological and Educational Publications.
Hamilton, S. S. (2002). Evaluation of clumsiness in children. American Family Physician, 66, 14351440.

Y.-P. Wuang et al. / Research in Developmental Disabilities 32 (2011) 312321

321

Heath, M., Elliott, D., Weeks, D. J., & Chua, R. (2000). A functional system approach to movement pathology in persons with Down syndrome. In D. J. Weeks, E. Chua,
& D. Elliott (Eds.), Perceptual-motor behavior in Down syndrome (pp. 305320). Champaign, IL: Human Kinetics.
Hogan, D. P., Rogers, M. L., & Msall, M. E. (2000). Functional limitations and key indicators of well-being in children with disabilities. Archives of Pediatrics and
Adolescent Medicine, 154, 10421048.
Hodges, N. J., Cunningham, S. J., Lyons, J., Kerr, T. L., & Elliott, D. (1995). Visual feedback processing and goal-directed movement in adults with Down syndrome.
Adapted Physical Activity Quarterly, 12, 176186.
Hoover, J. H., & Wade, M. G. (1985). Motor learning theory and mentally retarded individuals: A historical review. Adapted Physical Activity Quarterly, 2, 228252.
Howle, J. M. (2002). Neurodevelopmental treatment approach: Theoretical foundations and principles of clinical practice. Laguna Beach, CA: Neuro-Developmental
Treatment Association.
Humphries, T. W., Wright, M., Snider, L., & McDougall, B. (1992). A comparison of the effectiveness of sensory integration therapy and perceptual motor training in
treating children with learning disabilities. Journal of Developmental Behavior in Pediatrics, 13, 3140.
Jacobs, S. E., & Schenider, M. L. (2001). Neuroplasticity and the environment. In S. S. Roley, E. I. Blanche, & R. C. Schaaf (Eds.), Understanding the nature of sensory
integration with diverse populations (pp. 2942). San Antonio, TX: Therapy Skill Builders.
Jeannerod, M. (1986). The formation of nger grip during prehension: A cortically mediated visuomotor pattern. Behavior and Brain Research, 19, 99116.
Jeannerod, M. (1990). The neural and behavioral organization of goal-directed movements. Oxford: Clarendon Press.
Johansson, R. S. (1996). Sensory control of dexterous manipulation in humans. In A. M. Wing, P. Haggard, & J. Flanagan (Eds.), Hand and the brain: The
neurophysiology and psychology of hand movements (pp. 381414). New York: Academics Press.
Koenig, A., Wellner, M., Koneke, S., Meyer-Heim, A., Lunenburger, L., & Riener, R. (2008). Virtual gait training for children with cerebral palsy using the Lokomat
gait orthosis. Studies in Health Technology and Informatics, 132, 204209.
Kramer, P., & Hinojosa, J. (2010). Developmental perspective: Fundamentals of developmental theory. In P. Kramer & J. Hinojosa (Eds.), Frames of reference foe
pediatric occupational therapy (3rd ed., pp. 2330). Philadelphia: Williams & Wilkins.
Larin, H. M. (2000). Motor learning: Theory and strategies for the practitioner. In S. K. Campbell, R. J. Palisano, & D. W. Vander Linden (Eds.), Physical therapy for
children (pp. 170197). Philadelphia, PA: W.B. Saunders.
Levine, M. When ngers do the working: Fine motor and graphomotor facility or futility. Retrieved from: http://www.allkindsofminds.org/ArticleDisplay.aspx?
articleID=7
Lin, J. K. (2004). Test of sensory integration function: Users manual. Taipei: Psychological Corporation.
Mulliganc, S. (2002). Advances in sensory integration research. In A. C. Bundy, S. J. Lane, & E. A. Murray (Eds.), Sensory integration: Theory and practice (2nd ed., pp.
339340). Philadelphia: Davis.
Parham, L. D., Cohn, E. S., Spitzer, S., Koomar, J. A., Miller, L. J., Burke, J. P., et al. (2007). Fidelity in sensory integration intervention research. American Journal of
Occupational Therapy, 61, 216217.
Parham, L. D., & Mailloux, Z. (2010). Sensory integration. In J. Case-Smith & J. C. OBrien (Eds.), Occupational therapy for children (6th ed., pp. 325372). Maryland
Heights, MO: Mosby.
Pivik, J., McComas, J., & Laamme, M. (2002). Barriers and facilitators to inclusive education. Exceptional Children, 69, 97107.
Rizzolatti, G., & Fabbri-Destro, M. (2008). The mirror system and its role in social cognition. Current Opinions in Neurobiology, 18, 179184.
Roizen, N. (2002). Down syndrome. In M. L. Batshaw (Ed.), Children with disabilities (5th ed.). Baltimore, ML: Paul H. Brookes.
Saposnik, G., Teasell, R., Mamdani, M., Hall, J., McIlory, W., Cheung, D., et al. (2010). Effectiveness of virtual reality using Wii gaming technology in stroke
rehabilitation: A pilot randomized clinical trail and proof of principle. Stroke, 41, 14771484.
Savelsbergh, G., van der Kamp, J., Ledebt, A., & Planinsek, T. (2000). Information coupling in children with Down syndrome. In D. J. Weeks, R. Chua, & D. Elliott
(Eds.), Perceptual-motor behavior in Down syndrome (pp. 251275). Champaign, IL: Human Kinetics.
Schoen, S., & Anderson, J. (1999). Neurodevelopmental treatment frame of reference. In P. Kramer & J. Hinojosa (Eds.), Frames of references for pediatric occupational
therapy (2nd ed., pp. 4986). Baltimore: Williams & Wilkins.
Slaats-Willemse, D., de Sonneville, L., Swaab-Barneveld, H., & Buitelaar, J. (2005). Motor exibility problems as a marker for genetic susceptibility to attentiondecit/hyperactivity disorder. Biological Psychiatry, 58, 233288.
Taub, E., Ramey, S., DeLuca, S., & Echols, K. (2004). Efcacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor
impairment. Pediatrics, 113, 305312.
Tye, B. B., & Tye, K. A. (1992). Global education: A study of school change. Albany, NY: State University of New York Press.
Wallen, M., & Walker, R. (1995). Occupational therapy practice with children with perceptual motor dysfunction: Findings of a literature review and survey.
Australia Occupational Therapy Journal, 42, 1525.
Whitney, S. L., & Wrisley, D. M. (2004). The inuence of footwear on timed balance scores of the modied clinical test of sensory interaction and balance. Archives
of Physical Rehabilitation and Medicine, 85, 439443.
Wilson, P., Foreman, N., & Stanton, D. (1997). Virtual reality, disability and rehabilitation. Disabilities and Rehabilitation, 19, 213220.
Wuang, Y. P., Lin, Y. H., & Su, C. Y. (2009). Pasch analysis of the BruininksOseretsy test of motor prociency-second edition in intellectual disabilities. Research in
Developmental Disabilities, 30, 11321144.
Wuang, Y. P., Wang, C. C., Huang, M. H., & Su, C. Y. (2009). Efcacy of sensory integration, neuron-developmental treatment, and perceptual motor therapy on
sensorimotor performance in children with mild mental retardation. American Journal of Occupational Therapy, 63, 439450.
Wuang, Y. P., & Niew, W. I. (2005). The effect of adapted physical education program on the outcome of school-aged children with cerebral palsy. Bulletin of Special
Education and Rehabilitation, 14, 217240.
You, S. H., Jang, S. H., Kim, Y. H., Kwon, Y. H., Barrow, I., & Hallett, M. (2005). Cortical reorganization induced by virtual reality therapy in children with hemiparetic
cerebral palsy. Developmental Medicine and Child Neurology, 47, 628635.