Postural Reactions in Infants with Down Syndrome : Relationship to Motor Milestone Development and Age Stephen M Haley PHYS

THER. 1986; 66:17-22.

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Postural Reactions in Infants with Down Syndrome

Relationship to Motor Milestone Development and Age
STEPHEN M. HALEY I examined the emergence of automatic postural reactions (righting, equilibrium, and protective reactions) in a group of infants with Down syndrome and in a developmentally matched group of nonhandicapped infants. I assessed the relationship of postural reactions to chronological age and to motor milestone development (as measured by the Bayley Scales of Infant Development). The relationship of postural reactions to chronological age was weaker in the infants with Down syndrome; a regression analysis revealed a slower rate of postural reaction development evident at an age of about five months and older in infants with Down syndrome. The association between postural reactions and motor milestone performance was remarkably similar for both infant groups in degree of association and pattern across the span of motor development tested. The results indicated that, even though the rate of development differed, the association between postural reactions and motor milestones was similar in normal and delayed development. These results support the current rationale that promotes intervention efforts focusing on the facilitation of postural reactions to enhance motor milestone development in infants with Down syndrome. Key Words: Child development, Down's syndrome, Equilibrium, Infant, Motor skills, Posture.

The investigation of movement behavior in infants with Down syndrome has concentrated mainly on the description and extent of gross motor milestone delays, such as sitting and walking.1-3 Surprisingly, the relationship of these gross motor delays to other motor dimensions has not been examined systematically in the infant and young child with Down syndrome. One clinically relevant motor dimension with which to compare the development of gross motor milestones is the system of automatic postural reactions. The emergence of automatic postural reactions is an important prerequisite for the attainment of motor skills in the course of early development. According to Bobath, the sequence of appearance of the postural reactions "underlies" and "explains" the ontogeny of motor behavior in infancy.4 Milani-Comparetti and Gidoni have identified the postural reactions (righting, equilibrium, and protective reactions) as the underlying responses that are related most functionally to motor milestones.5 Postural reactions provide automatic support and stability to the head, trunk, and extremities and facilitate normal weight shifts and mobility. They function to keep the head aligned vertically during movement, to provide balance and postural shift mechanisms when the center of gravity is disturbed, and to establish protective responses to prevent a fall (luring rapid movements.6,7

Dr. Haley was a student in the doctoral program, Department of Educational Psychology, College of Education, University of Washington, Seattle, WA, when this study was conducted. He is now Assistant Professor, Department of Physical Therapy, Sargent College of Allied Health Professions, University Rd, Boston, MA 02215 (USA). This study was conducted in partial fulfillment of the requirements for the PhD degree, College of Education, University of Washington. This project was made possible with funding from the Washington Association for Retarded Citizens. This paper was adopted from a presentation at the Combined Sections Meeting, American Physical Therapy Association, Houston, TX, February 1984. This article was submitted April 18, 1985; was with the author for revision three weeks; and was accepted July 11, 1985.

The well-documented gross motor delays in infants with Down syndrome have generated an interest in therapists and educators to develop training programs to stimulate mobility goals. A number of clinical reports8,9 and early motor intervention efforts10-12 have been published concerning the motor delays caused by Down syndrome. Even though intervention strategies often include facilitation of postural reactions, little attention has been given to the nature of postural reaction deficits and their possible association with the delay of motor milestone achievement in infants and children with Down syndrome. Cowie, in an extensive longitudinal study, found a delayed integration of primitive reflexes and a delayed emergence of righting and equilibrium reactions in a sample of 79 infants with Down syndrome.13 The strength of the relationship of these delays of postural reactions with motor milestone delays, however, was not examined. Molnar has examined longitudinally the relationship of postural reactions to motor delays in a group of young retarded children.1415 Her results indicated a strong temporal relationship between the emergence of postural reactions and the subsequent acquisition of gross motor milestones in motorically delayed young children. None of her subjects were reported to be children with Down syndrome. The purpose of this study was to examine the system of postural reactions as a component that may have a strong interrelationship with the development of gross motor achievements. I predicted that the development of postural reactions would be associated strongly with the development of motor behavior in infants with Down syndrome, even though the motor behavior may be delayed considerably when compared with nonhandicapped infants. Specifically, I expected to find the following relationships on examination of postural reactions, variables of motor milestone development, and chronological ages of infants with Down syndrome and nonhandicapped infants: 1) The relationship between age and postural reactions in infants with 17

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TABLE 1 Age Grouping of Total Infant Sample Down Syndrome Groups by Age 1 2 3 4 TOTAL n 6 5 4 5 20 range 2-7 7-12 12-18 18-24 2-24 Age (mo) 4.39 10.23 15.34 19.68 11.88 s 1.03 1.26 2.31 1.31 6.12 n 10 10 10 10 40 range 2-4 4-6 6-8 8-10 2-10 Nonhandicapped Age (mo) 2.70 4.91 7.02 9.27 5.97 s 0.56 0.59 0.56 0.57 2.50

Down syndrome would be moderate; however, the relationship would be stronger in nonhandicapped infants; 2) the regression equation describing the relationship between age and postural reactions would have a smaller rate of change for the Down syndrome group than for the nonhandicapped group, thus, indicating a delayed development of postural reactions in infants with Down syndrome; 3) a strong, positive relationship would exist between postural reactions and motor milestone level as given by the Bayley Motor Score in infants with Down syndrome; this relationship would be similar in nonhandicapped infants; and 4) the regression equation describing the relationship between postural reactions and the Bayley Motor Score would have a similar rate of change and level for both infant groups, indicating that, at any motor performance level, postural reaction development would be similar across infant groups.

METHOD Subjects
Twenty infants with Down syndrome, ages 2 to 24 months, were recruited from four early intervention programs located in the greater King County, Washington, area. The majority of the infants with Down syndrome were enrolled in the Training Research and Intervention Program for infants and parents at the Child Development and Mental Retardation Center at the University of Washington. Forty nonhandicapped infants, ages 2 to 10 months, were recruited mainly from local community college parent-infant classes to serve as a normative comparison group. All were full-term infants (greater than 37 weeks gestational age). Male infants composed 35% of the infants with Down syndrome and 58% of the nonhandicapped infants. The age groupings of the infants are presented in Table 1. The demographic characteristics of parents in both infant groups were very similar; the nonhandicapped group had a slightly higher proportion of parents who had achieved a college education than the parents of the infants with Down syndrome. All parents signed a consent form approved by the Human Subjects Committee at the University of Washington before participation in the project. For proper assessment of the association of postural reactions and motor milestone development, both infant groups ideally should span the same developmental motor stages with equal distributions of infants sampled across all motor developmental levels. In nonhandicapped infants, postural reactions begin to appear around the age of 2 months and are nearly all present by age 10 months. To incorporate the same postural reaction and motor milestone developmental span in the Down syndrome group, I extended the age range to 24 18
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Fig. 1. Regression lines: Postural reactions with age.

months. The sample shows an equal spread of nonhandicapped infants across the age groupings of 2 months; the spread of infants with Down syndrome across the age span was closely approximated (Tab. 1). A sample selection of infants that did not spread equally across the developmental ages possibly could bias results at either extreme of the continuum.

Procedure
All nonhandicapped infants and infants with Down syndrome were seen for one test session by one of three examiners. At that time, each infant was assessed with the Bayley Motor Scale and a series of tests for postural reactions. The parents were allowed to be present during the test sessions. Frequent breaks were needed for the very young infants during the sessions. Most of the nonhandicapped infants were tested in a small clinic room at the Child Development and Mental Retardation Center at the University of Washington; a majority of the infants with Down syndrome were tested in their own early intervention classroom during their regularly
PHYSICAL THERAPY

RESEARCH

scheduled program time. A small number of the infants (less than 10%) had to be tested in the home because of scheduling or transportation problems. Previous reports have not provided evidence that a setting difference significantly alters infant test scores.16

Measures
The measures reported here include an assessment of postural reactions modified from the Movement Assessment of Infants (MAI)17 (copies are available from the author on request), an assessment of motor milestone development using the Bayley Scales of Infant Development,18 and chronological age. Postural reactions were defined as a combination of partial and full responses to 12 items: four righting reactions, five equilibrium reactions, and three protective reactions. Two of the equilibrium tests, supine and all-fours positions, are not part of the MAI, but were included here for comparison with other studies that have examined these responses.5,14,15 The dependent measure used was the total number of the partial and full postural reaction responses. The motor section of the Bayley Scales of Infant Development also was administered to each infant. These scales have been recommended specifically for the assessment of motor development in the Down syndrome population.19 The interrater reliability of the Bayley raw score has been reported to be high (r = .90).20 Because many of the scores of the infants with Down syndrome are greater than 3.00 standard deviations below the mean for their age, the standard scores could not be calculated. Therefore, the raw score of the Bayley Motor Scale was used in the analysis of estimates of overall motor milestone development. Interrater agreement for the postural reactions was calculated using a form of the intraclass correlation coefficient (ICC).21 For a sample of 10 infants examined throughout the study, reliability for the Bayley Motor Score was .98; reliability for the postural reactions was .94.

postural reactions present, a postural reaction subscore in three areas (righting, equilibrium, and protective reactions), and chronological age. To examine the degree of association among the variables, I calculated Pearson product-moment correlations within each infant group. The difference in the magnitude of the correlations between groups was tested for significance using Fisher's Z transformation.22 I also used an analysis of covariance (ANCOVA) to examine infant group differences in the proposed relationships of postural reactions, age, and motor milestones. Regression lines for each infant group were developed to compare age and motor milestone achievement with the number of postural reactions. These pairs of regression lines were tested for homogeneity of slope. The regression lines were tested using an ANCOVA if the slopes were similar or using a computer program to determine regions of significance if the lines were different and the slopes were heterogeneous.23

RESULTS
Nonhandicapped infants tended to have a somewhat stronger degree of relationship between age and postural reactions (r - .91) than infants with Down syndrome (r = .77), although the difference between the two groups did not meet a level of significance at the p = .05 level. The differences in the rate of change of postural reactions to age in both infant groups are illustrated in Figure 1. The regression solutions are given in Table 2. The two regression lines describing the relationship between age and postural reactions are considered different at approximately the age of 4.6 months (Tab. 3). The association between postural reactions and scores on the Bayley Motor Scale for both infant groups was high and positive. The magnitude of correlation for the Down syndrome group (r = .97) was significantly greater than that for the nonhandicapped group (r = .90), (Z = 2.05, p = .04). The ANCOVA regression lines for the summary postural reactions score and the raw score on the Bayley scale are given in Figure 2. In addition, the results of the ANCOVA using the subtotals for the three components of the postural reactions score (righting, equilibrium, and protective reactions) for both infant groups and the Bayley Motor Score as the covariate are in Table 3. No difference was seen in the adjusted means of

Data Analysis
Measures included in the analyses were the raw score from the Bayley Motor Scale, a summary score for the number of

TABLE 2 Adjusted Means and Regression Solutions for Group Comparisons of Postural Reactions with Bayley Score and Age Infant Group Mean Postural Reactions 22.90 23.52 22.90 23.53 9.70 9.85 7.70 8.27 5.40 5.40 Adjusted Mean Postural Reactions 18.70 25.62 22.65 23.65 9.62 9.88 7.61 8.31 5.31 5.44 Regression Equation Y = 14.4 + 0.71X Y = 10.9 + 2.12X Y = 7.91 + 0.52X Y = 9.14 + 0.51X Y = 5.07 +0.16X Y = 5.34 +0.16X Y = 2.59 +0.17X Y = 3.37 +0.17X Y = 0.32 +0.17X Y = 0.42 +0.17X

Comparison

r 11 .90 .96 .89 .88 .85 .95 .75 .96 .89

Postural reactions with age Postural reactions with Bayley Righting reactions with Bayley Equilibrium reactions with Bayley Protective reactions with Bayley
a b

DSa NHb DS NH DS NH DS NH DS NH

Down syndrome. Nonhandicapped.

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TABLE 3 Analysis of Covariance Summary: Group Comparisons of Postural Reactions with Bayley Score and Age Comparison Postural reaction with age Source within + residual age group age x group within + residual Bayley Motor Score group Bayley x group within + residual Bayley Motor Score group Bayley x group within + residual Bayley Motor Score group Bayley x group within + residual Bayley Motor Score group Bayley x group SS 499.87 704.76 435.43 370.91 311.02 1686.60 13.26 .09 56.72 163.93 .94 .01 101.07 194.93 6.56 .01 37.02 199.15 .21 .01 df 56 1 1 1 56 1
1

Postural reaction with Bayley

Righting reaction with Bayley

1 56 1
1

Equilibrium reactions with Bayley

1 56
1

Protective reactions with Bayley

1 1 56 1 1 1

MS 8.92 704.76 435.43 370.91 5.55 1686.60 13.26 .09 1.01 163.93 .94 .01 1.80 194.93 6.56 .01 .66 199.15 .21 .01

F 78.95 48.78 41.55 303.67 2.38 .10 161.83 .93 .01 108.00 3.63 .01 301.19 .32 .01

P .001a .001 .001 .001 NS NS .001 NS NS .001 NS NS .001 NS NS

Region of significance for covariate was age >4.6 months.

Score all had homogeneity of slope. For each type of postural reaction (righting, equilibrium, and protective), the nonhandicapped infants tended to have a higher level of reactions at corresponding Bayley raw score levels, although none of the differences between adjusted mean values reached significance. The equilibrium responses tended to differ the most between infant groups across the range of Bayley scores (Tab. 3). DISCUSSION As predicted, the magnitude of the association between postural reactions and chronological age was considerably less in the infants with Down syndrome than in the nonhandicapped group. Furthermore, the regression lines describing the association between postural reactions and age had a slower rate of change (smaller slope) in the infants with Down syndrome, which indicates a slower development of these reactions than a similar developmental group of nonhandicapped infants. This finding is consistent with previous reports that have indicated delays in motor development in infants with Down syndrome increase after the first six months.13 It further suggests that delays in development become much more obvious when the expected development of many of the postural reactions between four to six months does not occur in infants with Down syndrome. Harris24 reports that certain precocious behaviors may exist in some infants with Down syndrome during the early months, such as early rolling from prone to supine positions, in part because of the lack of development ofrightingreactions. In my study, the regression lines indicating the relationship between postural reactions and age can be considered significantly different at age 4.6 months and older. The relationship between postural reactions and the Bayley Motor Score actually is higher in infants with Down syndrome than in nonhandicapped infants. This may indicate a lack of
PHYSICAL THERAPY
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Fig. 2. Regression lines: Postural reactions with Bayley Motor Score.

postural reactions (Tab. 3) or the slope of the regression lines between the two infant groups (Fig. 2). In general, nonhandicapped infants tended to have a higher level of postural reactions for each corresponding Bayley Motor Score across the entire range of scores, although the difference was not significant. The regression lines between infant groups for each subsection of the postural reactions and Bayley Motor 20

RESEARCH variability of expression of postural reactions at each motor milestone level in infants with Down syndrome. The very high correlation supports the notion that postural reactions and milestone achievements have an exceedingly high correspondence throughout early motor development. The regression lines describing the relationship between postural reactions and the Bayley Motor Scale further support the notion that nearly similar levels of postural reactions are present at corresponding motor milestone levels. The number of equilibrium reactions, however, tends to be slightly less across the motor milestone spectrum for infants with Down syndrome. Even though the difference in equilibrium reactions between groups is not significant, an important pattern emerges. This pattern suggests that infants with Down syndrome develop only those equilibrium reactions necessary for the acquisition of a motor milestone phase with very little intrasubject variability. At corresponding motor phases, nonhandicapped infants develop a wide variety of equilibrium reactions at higher levels and with more intrasubject variability than infants with Down syndrome. This project, however, did not record many of the abnormal and exaggerated postures that many infants with Down syndrome use to maintain or assume certain milestone skills. For example, Lydic and Steele8 describe a typical pattern of coming to sit from the prone position in infants with Down syndrome as using exaggerated hip abduction and poor active trunk rotation. This prone-to-sitting pattern appears to be an effective compensation for the diminished postural reactions seen in infants with Down syndrome. These abnormal patterns may block or delay further the development of postural reactions and the development of a normal pattern of motor milestone progress.8 In general, the data provide strong evidence that postural reactions are delayed in infants with Down syndrome. The delays reinforce the argument that postural reactions are not related strongly to age but develop in close correspondence to motor milestones. The data also support the hypothesis that the levels of postural reaction development nearly are similar at corresponding phases of motor milestone development for both infant groups. The data in this paper have both theoretical and practical implications. The results are consistent with the premise that postural reactions are strongly associated with motor milestone development. The confirmation of this relationship in infants with Down syndrome provides further support for the generalization of this premise across both normal and delayed motor development. Clinically, an important implication can be mentioned. Although the evidence of an association between postural reactions and motor milestones does not imply strictly that remediation of one behavior will augment the other, the findings are consistent with that notion. Furthermore, the delays in postural reactions are consistent with the delays observed in motor milestones in infants with Down syndrome. This suggests that educational and therapeutic intervention programs designed to promote the stimulation of postural reactions may have considerable impact in altering the severe motor delays in this population. The cross-sectional nature and the small available sample size of the infants with Down syndrome impose caution on the interpretations and implications of this study. Verification of the results presented here should be attempted with longitudinal data. Longitudinal data could help establish temporal Volume 66 / Number 1, January 1986
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relationships between postural reactions and developmental milestones. An increased sample size of both infant groups would improve the power of detecting group differences in correlations of postural reactions with motor milestones and in mean postural reactions. Further studies examining the descriptive data of the sequential nature of postural reactions and their profiles with motor milestones are needed. In this study, the postural reactions are defined as those behaviors that can be elicited in a formal testing session. Although this procedure is designed to provide a standardized format for infant behavioral observation, not all reactions may be assessed accurately in such a procedure. For example, equilibrium reactions in the supine and prone positions are observed rarely in the test situation, yet they may still be present (albeit difficult to elicit). The results of this study should be interpreted with the knowledge that postural reactions are recorded only for the behaviors noted in the formal testing situation with examiner handling. Although numerous clinical reports are available that discuss possible underlying mechanisms related to motor milestone development, few reports have attempted to validate empirically these associations. This study has attempted to validate the notion that postural reactions are related closely to motor milestone development in a normal and a delayed motor development sample of infants. Future research endeavors examining the underlying movement components of milestone behaviors will promote more accurate conceptualizations of motor development in nonhandicapped infants and infants with Down syndrome. CONCLUSIONS The development of postural reactions was examined in a group of infants with Down syndrome and in a group of nonhandicapped infants. A series of hypotheses was tested to determine if the fundamental associations between postural reactions and motor milestones in infants with Down syndrome were similar to nonhandicapped infants. The overall results suggest that the interrelationship between postural reactions and motor milestones is similar in both nonhandicapped infants and those with Down syndrome. Postural reactions are related more closely to age in nonhandicapped infants than in infants with Down syndrome. The delays in postural reaction development are seen in conjunction with the delays in motor milestone achievement in infants with Down syndrome. These results are consistent with current rationales shaping the educational and therapeutic intervention techniques for infants with Down syndrome. These intervention techniques attempt to promote motor milestone progress in infants with Down syndrome by following a model of normal motor development. This model suggests that postural reactions are underlying components for the expression of motor milestones. Acknowledgments. I express my appreciation to Carol Gray and Susan Harris for their support and guidance in this project. Special thanks to Wendy Tada, Kathy Washington, and Sharon Diamond for their data collection efforts. The project was supported by the Washington State Association for Retarded Citizens. 21

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Postural Reactions in Infants with Down Syndrome : Relationship to Motor Milestone Development and Age Stephen M Haley PHYS THER. 1986; 66:17-22.

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