Research in Developmental Disabilities 32 (2011) 15141520

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Description of the motor development of 312 month old infants with

Down syndrome: The inuence of the postural body position
Eloisa Tudella a,*, Karina Pereira b,1, Renata Pedrolongo Basso a,2, Geert J.P. Savelsbergh c,3
a

Department of Physiotherapy, Federal University of Sao Carlos (UFSCar), Sao Carlos, Sao Paulo, Brazil
Department of Physiotherapy, Federal University of Triangulo Mineiro (UFTM), Uberaba, Minas Gerais, Brazil
c
Research Institute MOVE, Faculty of Human Movement Science, VU University, Amsterdam, The Netherlands
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 18 January 2011
Received in revised form 21 January 2011
Accepted 21 January 2011
Available online 1 March 2011

The purpose of the present study was to describe the rate of motor development in infants
with Down syndrome in the age range of 312 months and identify the difculties both in
performance and acquiring motor skills in prone, supine, sitting and standing positions.
Nineteen infants with Down syndrome and 25 healthy full term typical infants were
assessed using the Alberta Infant Motor Scale (AIMS) monthly from 3 to 12 months of age.
The infants with Down syndrome achieved signicant later the level of motor performance
of the typical infants. In the supine posture, the performance was signicantly lesser for
the Down syndrome infants in comparison to the typical infants from the 3rd to 6th month
and in the 8th month. In the prone, sitting and standing postures this difference is found
for all the months. In conclusion, the sequence of motor development of the Down
syndrome is the same as the typical infants. However infants with Down syndrome need
more time to acquire skills, mainly antigravitational ones, among them the standing
position.
2011 Elsevier Ltd. All rights reserved.

Keywords:
Down syndrome
Motor skills
Postures
AIMS

1. Introduction
Down syndrome (DS) is a genetic anomaly characterized by physical, mental and organismic alterations that lead to
motor delay and mental retardation, among other disorders (Anson, 1992; Dyer, Gunn, Rauh, & Berry, 1990). The main
factors that contribute to motor delay are hypotonia and ligamentous laxity, balance decits and postural control, which
restrict childrens movements and cause difculties for them to defy gravity and explore the environment (Haley, 1986,
1987; Lauteslager, Vermeer, & Helders, 1998; Shumway-Cook & Woollacott, 1985). Concerning the sequence of acquiring
motor skills such as rolling, sitting and crawling as observed in typical infants, occurs also in children with Down syndrome
but at a later age, i.e. the acquiring rhythm is slower (Palisano et al., 2001).
The most recent studies investigated specic skills of children with Down syndrome and focused on questions
related to skills like gait (Martin, 2004; Mauerberg-Castro & Angulo-Klinzler, 2000; Ulrich, Ulrich, & Collier, 1992;
Ulrich, Ulrich, & Angulo-Kinzler, 1998), kicking (McKay & Angulo-Barroso, 2006; Ulrich & Ulrich, 1995; Ulrich, Ulrich,

* Corresponding author at: Universidade Federal de Sao Carlos (UFSCar), Departamento de Fisioterapia. Via Washington Luiz, Km 235, Caixa-Postal: 676,
Monjolinho, CEP: 13565-905, Sao Carlos, SP, Brazil. Tel.: +55 33518407.
E-mail addresses: tudella@terra.com.br (E. Tudella), kpereira@sioterapia.uftm.edu.br (K. Pereira), renata.sio@gmail.com (R.P. Basso),
gsavelsbergh@vu.nl (Geert J.P. Savelsbergh).
1
Av. Leopoldino de Oliveira, 579, bloco 25, Apto. 104, CEP: 38081-000, Uberaba, MG, Brazil. Tel.: +55 34 33138445.
2
Rua Allan Kardec 540, Jardim Cruzeiro do Sul, CEP: 13572-080, Sao Carlos, SP, Brazil. Tel.: +55 16 97771062.
3
Faculty of Human Movement Sciences, VU University, Van der Boechorststraat 9, 1081BT Amsterdam, The Netherlands. Tel.: +31 20 5988461.
0891-4222/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2011.01.046

E. Tudella et al. / Research in Developmental Disabilities 32 (2011) 15141520

1515

Angulo-Kinzler, & Chapman, 1997), reaching (Cadoret & Beuter, 1994; Campos, Rocha, & Savelsbergh, 2010; Charlton,
Ihsen, & Oxley, 1996), postural control (Polastri & Barela, 2002, 2005), and general movements (Mazzone, Mugno, &
Mazzone, 2004).
Recent studies rapport an inuence of postural body position, that is prone, supine or sitting position on the quality and
quantity of reaching in TD infants (Carvalho, Tudella, Caljouw, & Savelsbergh, 2008; Carvalho, Tudella, & Savelsbergh, 2007;
Savelsbergh & Van der Kamp, 1994), which brings up the question whether similar observation can be made in more atypical
development of motor behavior.
However, there are no studies on the motor developmental process in infants with Down syndrome studying the
inuence of postural position on skill, while it would be useful for clinical practice to study at which age and postures
(supine, prone, sitting and standing positions) infants with Down syndrome have more difculty in acquiring gross motor
skills. Having these kind of results, clinics could identify beforehand, which infants with Down syndrome develop slower
than expected in terms of pathology and still intervene actively not only in posture, but also in skills that are recognizably
more difcult to achieve.
Taking this into account, the aim of the current study is to describe the rate of motor development in infants with Down
syndrome in the age range of 312 months and identify the difculties both in performance and acquiring motor skills in
prone, supine, sitting and standing positions.
In order to fulll the aims of the study, the following three hypothesis are tested. First, infants with Down syndrome will
acquire motor skills in the same sequence as typical children, however at a slower pace. Secondly, infants with Down
syndrome will have more difculty in acquiring skills in antigravitational postures. Finally, infants with Down syndrome will
take longer to master an acquired skill.

2. Methods
2.1. Participants
This longitudinal study consisted of non-probability and convenience sampling. Over a two-year period, 25 parents of
Down syndrome (trisomy 21) infants were invited to take part in this study. However, only 16 full term infants (GA:
38.1  2.6 weeks) and three preterm infants (GA: 35  0 weeks) remained in the study. All of them were healthy and had an
average birth weight of 2.832 g (0.682), an average birth length of 45.92 cm (4.60), and an Apgar score of 7 or 8 in the rst
minute and 7 or 9 in the fth minute. As in the study conducted by McKay and Angulo-Barroso (2006), the premature infants were
maintained in this sampling due to the fact that they were healthy, and in terms of age no signicant differences between them
and the others were found. The infants were assessed at least 3 times within the age range of 312 months. Thus, the number of
infants assessed each month varied, ranging from 8 to 16 (see Table 1). All the infants in this group underwent physiotherapy
based on both the Bobath concept and the Sensory Integration method; six of them also underwent occupational therapy and
three of them speech therapy.
Sixty typical infants were invited to take part in the study, however only 25 healthy full term typical infants concluded it
(GA: 38.6  1.0 week), having an average birth weight of 3.266 g (0.431), an average birth length of 48.68 cm (2.49) and Apgar
score of 8 or 9 in the rst minute and 9 or 10 in the fth minute. All the infants in this group were assessed monthly from 3 to 12
months of age.
In order to form the group of infants with Down syndrome, those that experienced alterations in the central and
peripheral nervous system, auditory, visual or orthopedic alterations were excluded. The same criteria of exclusion to form
the group of typical infants were established.
The infants started being studied at 3 months, rather than earlier on account of the fact that the parents of the children
with Down syndrome usually look for intervention from this age onwards. In fact, the rst two months of life are considered
to be a period when the family of infants with Down syndrome is adjusting to deal with a special child and nding ways to
include him/her into society.

Table 1
Number of participants in the Down syndrome group at each assessment age.
Number of participants

Each assessment age

8
11
12
15
15
16
15
13
12
12

3 months (89.13 days  2.95)

4 months (122.45 days  3.50)
5 months (151.17 days  3.46)
6 months (182.00 days  2.74)
7 months (211.31 days  3.82)
8 months (243.60 days  2.23)
9 months (271.44 days  3.18)
10 months (301.50 days  2.28)
11 months (332.50 days  3.72)
12 months (360.93 days  3.54)

1516

E. Tudella et al. / Research in Developmental Disabilities 32 (2011) 15141520

2.2. Materials
A protocol for parents and infants was used to collect data about personal details, pregnancy, delivery, and the infants
development. The Alberta Infant Motor Scale (AIMS) (Piper & Darrah, 1994) was chosen to meet the objectives of this study as
it evaluates the gross motor development in different postures (supine, prone, sitting and standing position) and identies
motor skills in each one of them. Furthermore, it shows how many skills are gained considering the quality of carrying them
out because to credit points for a determined skill, transferring weight, posture and antigravitational movements are
considered (Bartlett & Fanning, 2003). It should be mentioned that AIMS is a valid and reliable scale to evaluate the risk of late
motor development and is administered by trained examiners (Snyder, Eason, Ridgway, & McCaughey, 2008).
2.3. Description of the scale
AIMS (Piper & Darrah, 1994) is a validated scale for assessing motor behavior in infants from birth to 18 months or to the
age of walking alone. It consists of 58 items, subdivided into four positional scales: prone (21 items), supine (9 items), sitting
(12 items) and standing (16 items). The items represent the major motor skills emerging in the rst 18 months of life and are
shown in the scale in accordance with a progressive sequence of motor development, that is, starting from the most primitive
skills (e.g. supine- and prone-lying) followed by increasingly complex skills (e.g. standing from modied squat). Each
positional scale is specically described in terms of the weight-bearing surface of the body, the posture necessary to achieve
the skill and the antigravity or voluntary movement performed by the infant in the position.
The motor skills performed by an infant during the evaluation period are classied as observed and the ones not
performed are classied as not observed. The least and most mature skills observed in a given position outline the
infants motor window, which represents his/her possible motor repertoire in this position. Each skill before the window
and each observed skill are credited 1 point, and the sum of these points represents the infants positional score. To
determine an infants raw score (i.e. total AIMS score), the scores for each of the four subscales are calculated and added
together. The infants raw score is plotted on a graph of percentile ranks consisting of six percentiles (5th, 10th, 25th,
50th, 75th and 90th), which indicate the infants motor performance relative to the AIMS normative sample (Lopes, Lima,
& Tudella, 2009).
In the current study, some terminologies are used to describe the infants motor development. The term motor
performance is used to refer to the motor repertoire developed monthly by the infant, taking into account the raw scores.
The term positional performance is used to refer to the motor repertoire developed monthly by the infant, taking into
account the subscales scores. Finally, the term motor acquisition is used to refer to the number of new motor skills
acquired from one month to another in either the subscale score or the raw score. For example, if an infant raw scored 9 at 3
months and 12 at 4 months, his/her total motor acquisition at 4 months was equivalent to a gain of 3 scores, that is, this
infant acquired three new skills from the third to the fourth month of age.
2.4. Procedures
This study was approved by the Research Ethics Committee of the University Federal of Sao Carlos (UFSCar), Sao Paulo/
Brazil. The infants with Down syndrome were selected from different institutions in three different cities. Informed legal
consent was previously obtained from the infants parents.
All infants were evaluated on their date of birth, always by the same researcher, with a leeway of plus or minus ve
days. The infants remained in either inactive or active alert states (Prechtl & Beintema, 1964). If the infant was
distressed, the assessment was interrupted and resumed on another day within the leeway. The infants were evaluated
in a laboratory under controlled environmental conditions, using an EVA mattress and a wooden stool (90 cm length,
43 cm height, and 35 cm width), which could evaluate the standing position and lateral motion. The postures were either
spontaneously adopted by the infant or elicited by the examiner using auditory and visual stimulation, according to the
AIMS manual.
A study among the examiners was carried out prior to the AIMS manual as one of them was trained by the author of the
scale and the concordance rate was calculated.
The inter-rater agreement between two observers was 86.65%, and the intra-rater agreement was 85.67%.
2.5. Statistical analysis
The mean and standard deviation of the infants gestational age and Apgar scores were calculated in order to characterize
the sample of the study. The amount of infants classied into each of the six AIMS percentiles is presented in terms of
percentages. Raw and positional scores are presented in terms of the median.
Since the scores are ordinal variables, the non-parametric methodology was used to compare the groups. Accordingly, the
MannWhitney test was used to compare the motor performance, positional performance and motor acquisition between
the groups at each age. With regards the intragroup analysis, raw scores between ages were compared by using the Friedman
test for the control group, and the KruskalWallis test for the Down syndrome group. These two tests were followed by
Dunns multiple comparisons. The level of signicance was 5% in all analyses.

[()TD$FIG]

E. Tudella et al. / Research in Developmental Disabilities 32 (2011) 15141520

1517

Fig. 1. Average raw score for Down syndrome infants and typical infants at the ages of 312 months.

3. Results
3.1. Motor performance and acquisition
In Fig. 1, it can be observed that the infants with Down syndrome developed increasing motor performance over the
months. However, they are lower than the typical infants ( 5.099 < Z < 4.009; p = 0.001).
Considering the motor performance, the infants with Down syndrome showed signicant changes in the interval of 4
months (KW = 224.047; p < 0.001), i.e. from the third to the seventh month. Nevertheless, the typical infants presented
signicant changes every three months (Fr = 224.120; p < 0.001) until the twelfth month.
Tests showed that in most months the infants with Down syndrome were lower in the 5th percentile, except for the 4th,
7th and 8th months where they were in the 10th percentile. The typical infants were between the 25th and 50th percentiles
from 3 to 8 months, and between the 50th and 75th percentiles from 9 to 12 months (Table 2).
With regards motor acquisition, it was signicantly less for Down syndrome infants than for typical infants at 6 months
(Z = 2.431; p = 0.014) and 9 months of age (Z = 2.478; p = 0.013).
3.2. Positional performance and motor acquisition
Fig. 2 shows that the rate of positional performance was less for Down syndrome infants than typical infants in all
positions.
In the supine posture, the group of Down syndrome infants presented a positional performance, which was signicantly
less in relation to the typical infants from the 3rd to 6th month ( 3.210 < Z < 2.284; p  0.032) and in the 8th month
(Z = 2.573; p = 0.024).
The group of Down syndrome infants presented a positional performance that was signicantly less than the typical
infants in all the months of prone posture ( 4.490 < Z < 2.780; p  0.006), sitting ( 5.282 < Z < 3.100; p  0.002) and
standing ( 5.100 < Z < 3.888; p  0.003).
Concerning motor acquisitions, in the supine posture there was no signicant difference between the groups. In the prone
posture, there was a signicantly smaller difference for the group of Down syndrome infants in the 8th (Z = 2.522;
p = 0.012) and 9th months (Z = 2.914; p = 0.004). In the sitting position, the difference was between the 5th month
Table 2
Percentiles in which most of the Down syndrome infants and typical infants are from 3 to 12 months.
Months

3
4
5
6
7
8
9
10
11
12

Down syndrome

Typical

Percentile

% Infants

Percentile

% Infants

<5th
10th
<5th
<5th
10th
10th
<5th
<5th
<5th
<5th

88
40
62
80
33
44
67
92
92
85

25th
50th
25th
25th
25th
25th
75th
75th
50th
50th

52
40
36
40
44
32
24
36
52
40

[()TD$FIG]1518

E. Tudella et al. / Research in Developmental Disabilities 32 (2011) 15141520

Fig. 2. Average positional score for Down syndrome infants and typical infants at the ages of 312 months.

(Z = 3.249; p  0.001), 6th month (Z = 3.753; p < 0.001) and the 10th and 12th months ( 4.161 < Z < 2.234; p  0.05). In
the standing position, there was a signicant difference between the 9th and 12th months ( 4.832 < Z < 2.096; p  0.05).
4. Discussion
This study set out to characterize the motor performance and identify the motor difculties in different ages and postures
of Down syndrome infants. The motor performance of Down syndrome infants, which was signicantly less than typical
infants, from the 3rd to the 12th months, conrmed that the motor development pace of these infants is slow. Moreover, the
acquisition of motor skills in Down syndrome infants can be identied using the AIMS scale. Although it was slow, it
happened gradually and in the same sequence as the typical infants, conrming the rst hypothesis of the current study and
is in agreement with the current literature (Block, 1991; Dyer et al., 1990; Jobling & Mon-Williams, 2000; McKay & AnguloBarroso, 2006; Silva & Kleinhans, 2006; Ulrich & Ulrick, 1993).
The infants with Down syndrome were in the 10th percentile at 4 months and from 9 months lower than the 5th
percentile. This data supports the study conducted by Darrah, Piper, and Watt (1998), who afrm that if they are either equal
or below the 10th percentile at 4 months and in the 5th percentile at 8 months and thus indicates that the child is at risk.
Regarding motor performance, it can be observed that up to the 7th month, the Down syndrome infants were behind by 1
month in terms of motor development in relation to the typical infants. Subsequently, this difference was higher by one
month that indicates that these infants require more time to acquire more complex motor skills. When evaluating a child
with Down syndrome, this new information helps to identify those who have a decient performance up to the 7th month.
On the other hand, it is expected that after the 7th month, this late development is more than one month in relation to the
typical infants. It should be mentioned that infants with Down syndrome were in intervention, which could have contributed
to the late motor development not having been more than it was.
The hypothesis that antigravitational positions are more difcult to be adopted in infants with Down syndrome can be
conrmed. This is due to the fact that they require more static and dynamic control. This information was conrmed by the
gap of scores in the positional performance from the 7th month in the prone, sitting and standing positions (Fig. 2), as well as
the lower score in the 5th percentile from 9 months of age in the infants with Down syndrome.
In the initial months (36 months), it could be observed that the positional performance was higher in the supine position
for both groups, however for the infants with Down syndrome it was lower than the typical infants.
Concerning the motor skill acquisition, there was no difference between the groups, contributing to curves which were
close to the performance in the supine posture (Fig. 2). The late development in this posture happened when acquiring skills
which require an alignment of their head to their torso (maintaining their head at midline) and joining hands,
antigravitational control such as rolling from the supine to prone position and touching their feet with their hands. The
infants with Down syndrome acquired all of these skills in this posture at 9 months while the typical infants at 8 months of
age.
In the prone position, it could be observed that there was a difference in the positional performance between the infants
with Down syndrome and the typical infants in all the months. In the 7th month, the infants with Down syndrome had not
yet rolled from the prone to supine position without rotating. It should be mentioned that this skills is acquired by the typical
infants in the 6th month.
In the 12th month, the infants with Down syndrome did not complete the positional performance staying on all fours and
balancing, while the typical infants completed the positional performance at the 11th month, acquiring reciprocal crawling.
Between the 8th and 9th months, the infants with Down syndrome were only able to pivot, while the typical infants acquired
many motor skills such as: staying on all fours, lying on their side leaning on their arm and lifting their head and torso from
the surface, reciprocal dragging, from sitting to all fours and reciprocal dragging (Dyer et al., 1990).

E. Tudella et al. / Research in Developmental Disabilities 32 (2011) 15141520

1519

Owing to the fact that the skills in the prone position require more antigravitational control and extending the whole
body, they generally beneted from the motor development, including controlling the torso, mainly in the sitting position
(Dudek-Shrider & Zelazny, 2007; Fleuren, Smit, Stijnen, & Hartman, 2007; Majnemer & Barr, 2006; Monson, Deitz, & Kartin,
2003). Taking this into account, it is worth emphasizing activities in the prone position at early ages for children with Down
syndrome to help develop suitable toning.
In the sitting position, differences in the positional performance were also observed every month. The 6th month for
infants with Down syndrome can be highlighted as they were still sitting with extreme abduction and external hip rotation,
as well as the torso caved forwards, leaning on their hands. From the 6th to the 9th months, they started sitting with an
extended torso still with support of their hands, and only at 11 months did they sit without any support. The typical infants
sat without any support in the 6th month, completing the positional performance in the 9th month when they were able to
sit without any support, handling objects and doing various movements with their legs.
In the standing position, as in the prone and sitting positions, differences were observed in both groups in the positional
performance in all the months. The 6th month can be highlighted for the infants with Down syndrome as they stood with
help and without aligning their shoulder to their hip, while the typical infants stood with help aligning their shoulder to their
hip. From the 6th to the 12th months, the infants with Down syndrome acquired only one skill, i.e. they were able to stand
with help aligning their shoulder to their hip. On the other hand, the typical infants acquired 8 skills and could stand without
support. It should be mentioned that concerning the evaluated postures, the infants with Down syndrome showed the latest
motor development in the standing position. From the 5th to the 10th months, they maintained themselves without postural
alignment. This skill was achieved between the 11th and 12th months. However, the typical infants maintained themselves
without postural alignment only from the 3rd to the 5th months and from the 6th to the 8th months, they were able to stand
with support aligning their head, torso and hip.
These ndings conrm the second and third hypotheses of this study, that is, infants with Down syndrome have more
difculty in adopting antigravitational postures and require more time to improve an acquired skill.
According to Lopes et al. (2009), in the rst semester the period of 56 months is when most changes are observed in
terms of typical infant development, both quantitative and qualitative. This can be considered as a milestone in motor
development for these infants. In the 6th month, the typical infants acquired the static and dynamic postural control, which
conrms what Hadders-Algra (2005) concluded. Nevertheless, in this study, control was achieved by the infants with Down
syndrome in the 10th month.
Therapists should be advised that the sequence of motor development is the same as the typical infants, however infants
with Down syndrome need more time to acquire skills, mainly antigravitational ones, among them the standing position.
All the infants with Down syndrome in this study were in intervention, which could have minimized the difference in the
late motor development compared to the typical infants. Consequently, this study reinforces the idea that intervention
should be started up to the 3rd month so that the infant can have adequate stimulus in different postures. If stimulation is
started earlier, it can be a way of minimizing long periods necessary to improve a skill in the motor development required by
the infants with Down syndrome, and thus facilitate motor acquisitions, mainly antigravitational postures.
References
Anson, J. G. (1992). Neuromotor control and Down syndrome. In J. J. Summers (Ed.), Approaches to the study of motor control and learning (pp. 387412). Elsevier
Science Publishers.
Bartlett, D. J., & Fanning, E. K. (2003). Use of the Alberta infant motor scale to characterize the motor development of infants born preterm at eight months
corrected age. Physical & Occupational Therapy in Pediatrics, 23, 3145.
Block, M. E. (1991). Motor development in children with Down syndrome: A review of the literature. Adapted Physical Activity Quarterly, 8, 179209.
Cadoret, G., & Beuter, A. (1994). Early development of reaching in Down syndrome infants. Early Human Development, 36, 157173.
Campos, A. C., Rocha, N. A. C. F. , & Savelsbergh, G. J. P. (2010). Development of reaching and grasping skills in infants with Down syndrome. Research in
Developmental Disabilities, 31, 7080.
Carvalho, R. P., Tudella, E., & Savelsbergh, G. J. P. (2007). Spatio-temporal parameters in infants reaching movements are inuenced by body orientation. Infant
Behavior & Development, 30, 2635.
Carvalho, R. P., Tudella, E., Caljouw, S. R., & Savelsbergh, G. J. P. (2008). Spatio-temporal parameters in infants reaching movements are inuenced by body
orientation. Infant Behavior & Development, 31, 2333.
Charlton, J. L., Ihsen, E., & Oxley, J. (1996). Kinematic characteristics of reaching in children with Down syndrome (Vol. 15, pp. 727743). Elsevier Science B.V. Human
Movement Science.
Darrah, J., Piper, M., & Watt, M. (1998). Assessment of gross motor skills of at-risk infants: Predictive validity of the Alberta Infant Motor Scale. Developmental
Medicine & Child Neurology, 40, 485491.
Dudek-Shrider, L., & Zelazny, S. (2007). The effects of prone positioning on the quality and acquisition of development milestones in four-month-old infants.
Pediatric Physical Therapy, 19, 4855.
Dyer, S., Gunn, P., Rauh, H., & Berry, P. (1990). Motor development in Down syndrome children an analysis of the motor scale of the Bayley scales of infant
development. In Vermeer, A. (Ed.). Motor development, adapted physical activity and mental retardation (Vol. 30, pp. 720).Karger: Medicine and Sport Science
Basel
Fleuren, K. M. W., Smit, L. S., Stijnen, T. H., & Hartman, A. (2007). New reference values for the Alberta infant motor scale need to be established. Acta Paediatrica, 96,
424427.
Hadders-Algra, M. (2005). Development of postural control during the rst 18 months of life. Neural Plasticity, 12, 99107.
Haley, S. M. (1986). Postural reactions in infants with Down syndrome: Relationship to motor milestone development and age. Physical Therapy, 1, 66.
Haley, S. M. (1987). Sequence of development of postural reactions by infants with Down syndrome. Development Medicine & Child Neurology, 29, 674679.
Jobling, A., & Mon-Williams, M. (2000). Motor development in Down syndrome: A longitudinal perspective perceptual-motor behavior in Down syndrome. New
Zealand: Human Kinetics. 226-247.
Lauteslager, P. E. M., Vermeer, A., & Helders, P. J. M. (1998). Disturbances in the motor behavior of children with Downs syndrome: The need for a theoretical
framework. Physiotherapy, 84, 513.

1520

E. Tudella et al. / Research in Developmental Disabilities 32 (2011) 15141520

Lopes, V. B., Lima, C. D., & Tudella, E. (2009). Motor skill acquisition rate in Brazilian infants. Infant & Child Development, 18, 122132.
Majnemer, A., & Barr, R. C. (2006). Association between sleep position and early motor development. Journal of Pediatric, 149, 623629.
Martin, K. (2004). Effects of supramalleolar orthoses on postural stability in children with Down syndrome. Development Medicine & Child Neurology, 46, 406411.
Mauerberg-Castro, E., & Angulo-Klinzler, R. M. (2000). Locomotor patterns of individuals with Down syndrome: Effects of environmental and task constraints.
Perceptual-motor behavior in Down syndrome. New Zealand: Human Kinetics. pp. 7298.
Mazzone, L., Mugno, D., & Mazzone, D. (2004). The general movements in children with Down syndrome. Early Human Development, 79, 119130.
McKay, S. M., & Angulo-Barroso, R. M. (2006). Longitudinal assessment of leg motor activity and sleep patterns in infants with and without Down syndrome. Infant
Behavior & Development, 29, 153168.
Monson, R. M., Deitz, J., & Kartin, D. (2003). The relationship between awake positioning and motor performance among infants who slept supine. Pediatric Physical
Therapy, 15, 196203.
Palisano, R. J., Walter, S. D., Russell, D. J., Rosenbaum, P. L., Gemus, M., Galuppi, M. E., et al. (2001). Gross motor function in children with Down syndrome: Creation
of motor growth curves. Archives of Physical Medicine and Rehabilitation, 82, 494500.
Piper, M. C., & Darrah, J. (1994). Motor assessment of the developing infant. (pp. 210). Philadelphia, Pennsylvania: W.B. Saunders Company.
Polastri, P. F., & Barela, J. A. (2002). Percepcao-acao no desenvolvimento motor de criancas portadoras de sndrome de Down. Revista Sobama, 7, 18.
Polastri, P. F., & Barela, J. A. (2005). Perceptionaction coupling in infants with Down syndrome: Effects of experience and practice. Adapted Physical Activity
Quarterly, Human Kinetics Publishers, 22, 3956.
Prechtl, H. F. R., & Beintema, D. J. (1964). The neurological examination of the full-term newborn infant. Clinics in Development Medicine, 12, 173.
Savelsbergh, G. J. P., & Van der Kamp, J. (1994). Effects of body orientation to gravity on infant reaching. Journal of Experimental Child Psychology, 58, 510528.
Silva, M. F. M., & Kleinhans, A. C. S. (2006). Processos cognitivos e plasticidade cerebral na sndrome de Down. Revista Brasileira de Educacao Especial, 12, 123138.
Shumway-Cook, A., & Woollacott, M. H. (1985). Dynamic of postural control in the child with Down syndrome. Physical Therapy, 65, 13151322.
Snyder, P., Eason, J. M., Ridgway, A., & McCaughey, T. (2008). Concurrent validity and reliability of the Alberta infant scale in infants at dual risk for motor delays.
Physical & Occupational in Pediatrics, 28, 267282.
Ulrich, D. A., Ulrich, B. D., Angulo-Kinzler, R. M., & Chapman, A. (1997). Sensitivity of Infants with and without Down syndrome to intrinsic dynamics. Research
Quarterly for Exercise and Sport. American Alliance for Health, Physical Education, Recreation and Dance, 68, 1019.
Ulrich, D. A., Ulrich, B. D., & Angulo-Kinzler, R. M. (1998). The impact of context manipulations on movements patterns during a transition period. Human
Movement Science, 17, 327346.
Ulrich, B. D., Ulrich, D. A., & Collier, D. H. (1992). Alternating stepping patterns: Hidden abilities of 11-month-old infants with Down syndrome. Development
Medicine & Child Neurology, 34, 233239.
Ulrich, B. D., & Ulrick, D. A. (1993). Dynamic systems approach to understanding motor delay in infants with Down syndrome. In G. J. P. Savelsbergh (Ed.), The
development of coordination in infancy (pp. 445459). Indiana University.
Ulrich, B. D., & Ulrich, D. A. (1995). Spontaneous leg movements of infants with Down syndrome and nondisabled infants. Society for Research in Child Development,
66, 18441855.