Functional Performance Characteristics Associated

With Postponing Elementary School Entry Among

Children With Down Syndrome
Anne-Stine Dolva, Margareta Lilja, Helena Hemmingsson

KEY WORDS
Down syndrome
mainstream school
Pediatric Evaluation of Disability
Inventory (PEDI)
pediatrics
school entry

OBJECTIVES. This study investigated the relation between functional performance skills of children with
Down syndrome and the age of entry into mainstream elementary education.
METHOD. In a cross-sectional study of 70% of the 7-year-old children with Down syndrome in Norway
(N = 43), we measured functional performance using the Pediatric Evaluation of Disability Inventory (PEDI).
The study was a follow-up of a previous study of the same children at age 5 assessed using the same instrument. Data from both studies were used in the analysis.

RESULTS. Forty percent of the sample of children with Down syndrome in Norway had entered elementary
school after a 1-year postponement (i.e., at age 7). The functional performance skills of the children, as measured using the PEDI, were significantly lower at both age 5 and age 7 in self-care and social function compared with children with Down syndrome who entered elementary school at the usual time (i.e., at age 6). The
main characteristics associated with postponed elementary school entry were found in communication skills
and bladder and bowel management.
CONCLUSION. A certain level of development and independence seems to be required for a child with
Down syndrome to be viewed as ready to enter elementary school, and perceptions of readiness for school may
be culturally dependent. In addition to the well-described challenges in language and communication skills,
being viewed as ready for school includes having stopped using diapers, a topic not previously mentioned as
a factor in postponing elementary school entry for children with Down syndrome. Awareness of culturally influenced performance skills may give direction to parents and professionals in targeting areas in the preschool
years that might help promote these childrens readiness for school.
Dolva, A.-S., Lilja, M., & Hemmingsson, H. (2007). Functional performance characteristics associated with postponing elementary school entry among children with Down syndrome. American Journal of Occupational Therapy, 61, 414420.

Anne-Stine Dolva, reg OT, MSc, is Doctoral Candidate, Lillehammer University College, N-2626 Lillehammer, Norway, and Department of Occupational Therapy,
Karolinska Institutet, Stockholm, Sweden; annestine.dolva@hil.no.
Margareta Lilja, reg OT, PhD, is Assistant Professor,
Department of Occupational Therapy, Karolinska Institutet,
Stockholm.
Helena Hemmingsson, reg OT, PhD, is Assistant
Professor, Department of Occupational Therapy, Karolinska
Institutet, Stockholm.

lementary school entry is generally described as a key life cycle transition (Pianta
& Cox, 1999). Pianta and Kraft-Sayre (1999) suggested that the transition to
school sets the tone and direction of a childs school career and is a process that
begins years in advance. For children with disabilities, many parents have to fight
to achieve sufficient arrangements for their children at this critical transition point.
It is increasingly common for children with Down syndrome to be offered
places in mainstream education (Fox, Farrell, & Davis, 2004). In Norway, where
our study took place, the political vision is one school for all. Special education
is a right, and children with disabilities are often provided with assistance in school
that addresses their individual needs (Kunnskapsdepartementet, 2007). Norwegian
law requires all children, including those with disabilities, to enter elementary
school (first grade) in the calendar year in which they reach age 6. If there is any
doubt that a child is sufficiently mature to begin attending school (Education Act
2-1), an expert judgment is needed, and parents may apply for a 1-year postponement of elementary school entry. One group of children whose school entry
is often postponed is children with Down syndrome.

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When development is delayed, as it typically is for children with Down syndrome, parents have many questions
about reasonable expectations for their child, and they want
information that can help them set realistic individual goals.
Because children with Down syndrome increasingly are
included in mainstream education, a research question of
interest is which performance skills might be associated
with viewing a child as ready for school. This study investigated the relation between functional performance skills of
children with Down syndrome and the age of elementary
school entry in mainstream education, which is a critical
transition for the child and family as well as for the school.
Down syndrome is the most common genetic cause of
developmental disability, caused in 96% of cases by a third
chromosome 21 (hence the scientific name for the syndrome, trisomy 21). The remaining 4% of people with
Down syndrome have either a form called translocation,
in which the extra chromosome 21 is acquired in a different way, or a form called mosaic, in which not all cells are
affected. Down syndrome is characterized by developmental delays in all areas of functioning, although the degree of
delay varies greatly among individuals (Spano et al., 1999).
Some children with Down syndrome have associated
impairments that may affect their development. The most
common impairments are hypotonia, heart defects, and
hearing and visual impairments (Annern, Johansson, Kristiansson, & Lw, 1997). Functional performance skills are
influenced by the childs total development and by the same
environmental supports and barriers as for all children. The
available research describes typical areas of strength and
weaknesses in the functioning of children with Down syndrome. In general, these children display a relative strength
in tasks that involve visual over auditory processing and a
relative weakness in communication skills, specifically in
expressive language and grammar (Berglund, Eriksson, &
Johansson, 2001; Dykens, Hodapp, & Evans, 1994).
Jobling (1998) described aspects of motor function, including difficulties with precise movements of limbs and fingers,
and a recent study (Fidler, Hepburn, Mankin, & Rogers,
2005) suggested that children with Down syndrome show
a specific profile of praxis deficits in early development.
A Norwegian study provided baseline information
about functional performance in 5-year-old children with
Down syndrome before entry to elementary school (Dolva,
Coster, & Lilja, 2004). These children showed a wide
range of functional performance as reflected in scores on
the Pediatric Evaluation of Disability Inventory (PEDI;
Haley, Coster, Ludlow, Haltiwanger, & Andrellos, 1992)
and additional data. Independent of the PEDI, parents
identified their main concerns as language skills, interaction with peers, not being toilet trained, and the manage-

ment of toileting skills in relation to starting school (Dolva

et al., 2004).
The finding related to toilet training and the use of diapers interested us most, because toileting skills had not previously been identified as a common difficulty in 5-year-old
children with Down syndrome. In a national survey of children with Down syndrome in the United Kingdom, Rogers
(1998) found that most children were toilet trained at ages
3 to 4. The Scandinavian literature, however, suggests that
children with Down syndrome are toilet trained at ages 4 to
5 (Annern, et al., 1997; Lofterd, 1989). A study from the
field of urology in Brazil (Bruschini, Faria, Garcez, &
Srougi, 2003) found that lack of bladder control was clearly
correlated with the grade of mental disability and not with
the etiology of the disability. Their study included 100 children with mental disabilities of a variety of etiologies; 15
had Down syndrome.
Evidence increasingly shows that successful transitions
to school are based substantially on the childs social skills
(Ladd, Birch, & Buhs, 1999; McClelland, Morrison, &
Holmes, 2000); independent mastery and social interactive
skills are critical to school adjustment in typically developing
children (e.g., Pellegrini, 1992). These skills appear to be
important for children with developmental disabilities as
well. The most frequently cited difficulties in children with
Down syndrome around the age of elementary school entry
are related to speech and communication. The empirical evidence, however, is insufficient to judge which functional performance skills are critical in relation to, or associated with,
postponed entry in mainstream elementary school education.
The aim of our study was to investigate the relation
between functional performance skills of children with
Down syndrome and age at elementary school entry. Planning for the transition to elementary school requires knowledge and understanding unique to occupational therapy.
The focus of most pediatric occupational therapy research
has been on children with physical disabilities. Less is
known about children with developmental disabilities such
as Down syndrome. Knowledge is limited about the functional performance skills of children with Down syndrome
at specific ages and in connection with entry to elementary
school. A greater understanding of the functional performance skills that present challenges to this population
would help practitioners and teachers target individual
needs and environmental barriers to promote such childrens readiness for school.

Method
This study is a follow-up of a Norwegian cross-sectional
study of 5-year-old children with Down syndrome (Dolva

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et al., 2004). The follow-up was conducted 2 years later,

when the same group of participating children was 7 years
old. In line with the ideology of family-centered service
(Rosenbaum, King, Law, King, & Evans, 1998), which
acknowledges that parents know their child best, we chose
parents to be the informants in this study. We used the
PEDI in data collection and defined age 7 as having passed
the seventh birthday but not yet reached the eighth. We
used data from both studies in our analyses. The Regional
Ethical Committee (Eastern Region) and the Norwegian
Social Science Data Service (Personvernombudet) approved
the study.
Sample
Fifty to 80 children with Down syndrome were born each
year in Norway between 1992 and 2002 (Medical Birth
Registry of Norway, 2005), an incidence of 1 in 700 births.
We identified 62 five-year-old children with Down syndrome in the whole country with help from local Down
syndrome associations and county child rehabilitation services. By letter, we asked parents to participate in the study,
which would involve completing a structured interview
with the researcher. Seventy percent of the identified population with Down syndrome age 5 years (6072 months) in
Norway were included in our previous study of functional
performance (Dolva et al., 2004). We maintained parent
confidentiality by sending the information letter through
the associations and agencies; thus, no information about
the 19 parents who did not reply was available for analysis.
Two years later, we invited parents of the same 43 children to participate in a follow-up study. We received 43
informed consents, for a response rate of 100% in relation
to the previous study. As in the previous study, all the children lived in the community with their families. Ninetythree percent of the sample had trisomy 21, 5% had the
mosaic type, and 2% had the translocation type of Down
syndrome. The main health impairments reported were
congenital heart conditions (in 56% of the children), visual
impairments (in 49%), and hearing impairments (in 30%).
Instrument
We used the PEDI to gather information on functional performance in both the previous study (Dolva et al., 2004) and
this follow-up. The PEDI is a well-known and much-used
instrument in child rehabilitation, and we used the Norwegian translation (Jahnsen, Berg, Dolva, & Hyem, 2000).
The PEDI, which was standardized and published in
1992, measures a childs capability and skill in performing
selected functional activities within the domains of selfcare, mobility, and social function on three scales. Research
has provided support for this tools internal consistency,

interrater and testretest reliability, and discriminative

validity (Feldman, Haley, & Coryell, 1990; Haley et al.,
1992; Nichols & Case-Smith, 1996). For further details
about items and scoring, see Dolva et al. (2004).
Berg, Frey Froisli, and Hussain (2003) conducted a
pilot study investigating the applicability of the instruments reference values to 52 Norwegian children without
disabilities ages 1.0 to 5.9 years. The results showed good
agreement in Functional Skills Scales and Caregiver Assistance Scales in the social function domain and in Caregiver
Assistance Scales in the mobility domain. The Norwegian
sample, however, scored significantly lower than the U.S.
reference values in Functional Skills Scales in the self-care
and mobility domains and in Caregiver Assistance Scales in
the self-care domain. A larger study is in process investigating a validation of the PEDI on Norwegian children without disabilities. In the meantime, normative scores are used
with caution because of the potential cultural differences
Berg et al. (2003) observed in the self-care and mobility
domains. We include preliminary results from the Norwegian validation study in the Discussion section to account
for possible cultural differences.
Procedure
The researcher, who was trained in administration of the
PEDI, conducted all interviews in the follow-up study,
mainly by phone. Respondents were 40 mothers, 2 fathers,
and 1 couple together.
Data Analyses
We used the PEDI software program to calculate normative
and scaled scores. Using SPSS Version 12.0, we calculated
descriptive statistics from PEDI scores. We calculated both
means and medians of normative and scaled scores to
account for the variability in the sample. We divided the
children, who were all 7 years old, into two groups: those
who had entered elementary school at age 6 and those who
had entered at age 7. For between-group analyses, we used
nonparametric statistics (MannWhitney test) with a significance level of p < .05. We conducted analyses on two
levels. The first level was domain (i.e., self-care, mobility,
social function), which involved mean normative and
scaled scores from the PEDI Functional Skills Scales and
Caregiver Assistance Scales. When significant findings on a
domain level were found, we conducted analyses on the
next level to find which items or tasks within a domain
accounted for significant differences between the groups. To
see whether domain score or items at age 5 were critical in
relation to elementary school entry, we analyzed the previous data on the children at age 5 and compared it with data
on children who entered school at ages 6 or 7.

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Results
Twenty girls and 23 boys were included in the study. The
girls mean age was 88.9 months (range 8495), and the
boys mean age was 88.0 months (range 8494). Sixty percent of the children in this sample had entered elementary
school at age 6, as is customary in Norway. The remaining
40% had applied for an additional year in kindergarten.
The scores of the children who entered elementary
school at age 7 tended to be lower than those of children
who started school at age 6, although a wide range was
found in both groups. Because of this wide range, we provide both mean and median values in Table 1, which presents the childrens normative and scaled scores on the
Functional Skills Scales, and in Table 2, which presents normative and scaled scores on the Caregiver Assistance Scales.
A significant difference between the two groups was
found in Functional Skills Scales scaled scores in the domains
of self-care (p = .010) and social function (p = .019). Moreover, a significant difference between the groups was found
in Caregiver Assistance Scales scaled scores in the domains
of self-care (p = .002) and social function (p = .016).
In analyzing data from the previous study (Dolva et al.,
2004), we found that all 43 children improved their scaled
scores on the PEDI Functional Skills Scales in the domains
of self-care, mobility, and social function from age 5 to age
7. The scores of the two groups at age 5 confirmed the same
significant difference in retrospective analyses as found at
age 7. Analyses of variance confirmed that there were no
significant interaction effects between the domains.
Further analyses investigated which items within the
domains yielded significant differences between the groups.
The domains were the PEDI Functional Skills Scale
domains of self-care and social function and the Caregiver
Assistance Scale domain of social function. In addition,
consistency across studies made it possible to compare data
from the previous study in relation to age of subsequent

school entry. Table 3 presents all items associated with postponement of elementary school entry and indicates which
items already differentiated between groups at age 5.
We found no correlation between lack of bladder control
and the normative PEDI Functional Skills Scales scores in the
social function domain. We further compared the groups
improvements in Functional Skills Scales mean scaled scores
between ages 5 and 7. Scaled scores provide an estimate of the
current level of performance (regardless of age) on a scale
from 0 to 100. The children who had postponed school entry
for 1 year had about the same mean scaled score improvement in self-care and mobility as those who had started
school on time. In the social function domain, the mean
score improved slightly more in the group who entered elementary school at age 6. The mean increased from 58.8 to
67.3, compared with 54.8 to 61.4 for those with postponed
school entry. However, and because of the wide range in both
groups, the differences were not significant.

Discussion
Results indicate that a certain level of development and
independence are required for children with Down syndrome in Norway to be viewed as ready to start school. By
analyzing PEDI data gathered at ages 5 and 7, we found
that postponement of school entry was related to skills in
self-care and social function. Retrospective analyses showed
that skills related to toileting, functional comprehension
and expressive communication, problem solving, and initiation of simple household chores were significantly lower at
age 5 among children whose school entry was postponed
than among children who started on time (i.e., at age 6).
In the previous study of these children at age 5, Dolva
et al. (2004) found that parents worried that a child who
used diapers on entry to elementary school would risk
social stigmatization. The use of diapers has not previously
been mentioned in the literature as a challenge in relation

Table 1. Normative and Scaled Scores on the Pediatric Evaluation of Disability Inventory Functional Skills Scales for Children
With Down Syndrome (N = 43) Who Entered Elementary School at 6 and 7 Years Old
Normative Scores
Scale
Self-care
Started school at age 6 (n = 26)
Started school at age 7 (n = 17)
Mobility
Started school at age 6 (n = 26)
Started school at age 7 (n = 17)
Social function
Started school at age 6 (n = 26)
Started school at age 7 (n = 17)

Mean (Median)

Scaled Scores

SD

Range

8.5
8.0
8.4

13.845.9
18.245.9
13.845.9

29.2 (26.9)
31.2 (30.1)
26.1 (24.6)

Mean (Median)
69.5
71.5
66.3
85.9
86.5
85.2
65.4
67.9
61.4

(68.3)
(71.3)
(65.3)
(82.5)
(83.9)
(82.5)
(62.3)
(65.7)
(59.9)

SD

Range

7.2
7.4
5.9
8.1
6.9
9.8
9.2
8.8
8.8

56.885.1
57.485.1
56.875.9
71.6100.0
77.3100.0
71.6100.0
48.585.2
53.285.2
48.582.2

The Pediatric Evaluation of Disability Inventory (Haley, Coster, Ludlow, Haltiwanger, & Andrellos, 1992) does not provide normative score equivalents for scores of
less than 10; therefore, children with scores in that range were excluded from analyses.

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Table 2. Normative and Scaled Scores on the Pediatric Evaluation of Disability Inventory Caregiver Assistance Scales for Children
With Down Syndrome (N = 43) Who Entered Elementary School at 6 and 7 Years Old
Normative Scores
Scale
Self-care
Started school at age 6 (n = 26)
Started school at age 7 (n = 17)
Mobility
Started school at age 6 (n = 26)
Started school at age 7 (n = 17)
Social function (N = 42a)
Started school at age 6 (n = 26)
Started school at age 7 (n = 16a)

Mean (Median)
32.9
34.9
30.1
47.4
49.5
44.0
42.9
45.3
39.1

(31.8)
(35.5)
(29.9)
(57.8)
(57.8)
(36.5)
(41.4)
(46.1)
(39.2)

Scaled Scores

SD

Range

7.5
7.2
7.0
12.2
11.7
12.7
12.0
12.7
10.0

16.051.7
18.351.7
16.047.6
24.757.8
24.757.8
24.757.8
13.174.1
26.874.1
13.152.5

Mean (Median)

SD

65.6
67.6
62.5
91.5
93.3
88.7
68.4
71.6
63.6

8.1
7.6
8.3
10.1
9.6
10.4
12.8
12.6
11.9

(64.5)
(68.8)
(62.2)
(100.0)
(100.0)
(82.5)
(67.6)
(72.5)
(65.4)

Range
45.983.2
48.683.2
45.983.2
72.7100.0
72.7100.0
72.7100.
35.9100.0
53.1100.0
35.978.6

a
The Pediatric Evaluation of Disability Inventory (Haley, Coster, Ludlow, Haltiwanger, & Andrellos, 1992) does not provide normative score equivalents for scores of
less than 10; therefore, one child with a score in that range was excluded from analyses.

to elementary school entry for children with Down syndrome. Available clinical literature in Scandinavia indicates
that children with Down syndrome stay dry day and night
by ages 4 to 5 years, about 1 year after typically developing
children (Annern et al., 1997; Lofterd, 1989); according
to Dolva et al., more than three-quarters of Norwegian 5year-olds with Down syndrome still used diapers daily. The
results of this follow-up study indicate that 51% of the 7year-old children with Down syndrome consistently stay
dry day and night (PEDI Item 68, Self-Care Scale).
Preliminary results of the Norwegian PEDI validation
study with typically developing children indicate a 10month delay in bladder and bowel management skills
(Berg, Aamodt, Stanghelle, Krumlinde-Sundholm, & Hussain, 2007) compared with U.S. reference values from a sur-

vey by Schum et al. (2002). The Norwegian reference values are in accord with results from a Swedish study by Jansson, Hanson, Sillen, and Hellstrom (2005). Although typically developing Norwegian children seem to be toilet
trained later than U.S. children, more than 90% of both
groups consistently stay dry day and night at ages 4.5 to 5.0
(Berg et al., 2007). In contrast to the custom in the United
States, most parents in Norway do not try to toilet train
their child as early as possible, instead waiting until the
child shows signs of being ready. This cultural difference
might explain why Norwegian children are toilet trained
later but nevertheless in time for elementary school entry.
Consistent with findings for both typically developing
children (e.g., Schum et al., 2002) and those with Down
syndrome (e.g., Dolva et al., 2004; Rogers, 1998), girls in

Table 3. Items From the Pediatric Evaluation of Disability Inventory Functional Skills and Caregiver Assistance Scales With a Significant
Association With Postponing Elementary School Entry Among 7-Year-Old Children Who Entered Elementary School at Age 6 (n = 26)
and Age 7 (n = 17) and Items Showing a Significant Association in Retrospective Analyses at Age 5
Item

p (Age 7)

PEDI Functional Skills Scale: Self-Care

18. Thoroughly brushes teeth
19. Prepares toothbrush with toothpaste
27. Wipes nose using tissue without request
28. Blows and wipes nose without request
38. Washes and dries face thoroughly
66. Consistently indicates need to urinate with time to get to toilet (daytime)
67. Takes self into bathroom to urinate (daytime)
71. Consistently indicates need to use toilet with time to get to toilet (daytime)
PEDI Functional Skills Scale: Social Function
10. Understands two sentences that are about the same subject but have a different form
13. Seeks information by asking questions
20. Connects two or more thoughts to tell a simple story
24. In ordinary situations, child can describe the problem and his or her feelings with some detail (usually does not act out)
25. Faced with an ordinary problem, child can join adult in working out a solution
53. Occasionally initiates simple routines to care for own belongings; may require physical help or reminders to complete
PEDI Caregiver Assistance Scale: Self-Care
B. Grooming
G. Bladder management
H. Bowel management
PEDI Caregiver Assistance Scale: Social Function
C. Joint problem solving
E. Safety

.020
.016
.019
.026
.023
.025
.010
.025
.025
.028
.015
.025
.047
.010
.048
.038
.034
.027
.020

Significant
by Age 5

*
*
*
*
*
*
*

*
*
*

*Difference significant between groups at both age 7 and age 5. Significance level was set at .05.

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the present study acquired toileting skills earlier than boys.

Bruschini et al. (2003) found that lack of bladder control
was correlated with degree of mental disability. Using the
U.S. normative reference values of the PEDI Functional
Skills Scale, we found no correlation between the scores for
our sample and lack of bladder control.
Parents view independence in toileting skills as important, and more research is needed to understand the delay
in some children with Down syndrome. Occupational therapists can initiate discussion to address parents worries about
this issue. A starting point might be to assess performance
skills using culturally relevant assessment tools. Awareness
of cultural influences on parents expectations of their childrens toileting skill acquisition may help occupational therapists detect intervention potentials to meet a need shared
by many parents and to help set realistic goals for the child.
Some parents might contact training programs earlier if
they knew that this issue could be culturally dependent.
Because functional performance in toileting skills seems to
be associated with postponing elementary school entry,
occupational therapists need to address the issue.
Speech, language, and communication difficulties are
critical in the development of children with Down syndrome. This topic is given much attention in planning for
elementary school entry and in individual educational programs (Berglund et al., 2001; Fidler, Lawson, & Hodapp,
2003; Fowler, Gelman, & Gleitman, 1994). The results of
this study suggest that comprehension and expressive language functioning, problem solving, and initiative in simple
activities at home have a significant impact on age of elementary school entry. Problem solving and initiative in
activities may be viewed as challenges with close connections
to communication and cognition abilities. Performance on
the PEDI Caregiver Assistance Scale showed a significant
association between postponed school entry and the childs
need for assistance with safety as well. Parents expressed great
worry about their childrens need for help; they feared that
their child might impulsively run away from school and be
unable to safely navigate traffic along the school route.
The pros and cons of postponing elementary school
entry for children with Down syndrome, although relevant,
are beyond the aim of this small study. The results indicate
that postponement was not reflected in self-care and mobility outcomes but was associated with an improvement in
social skills outcomes for the children who started school at
the usual age. Being in a class with children of the same age
may provide more stimulation than staying in kindergarten
with younger children. It is important to investigate from
each childs perspective the possible consequences of postponed entry and whether the year of postponement benefits the development of the child. It may be possible for

occupational therapists and parents to focus on target areas

that will improve a childs potential to enter school on time.
Professionals need to learn from parents, because parents understand their childrens needs in the context of the
family better than any outsider, and parents see the weaknesses and shortcomings in services from a different perspective than professionals. Parents need professionals to
share their knowledge and expertise with them and to help
promote the development of their children by providing the
range of services that the children need. Professionals must
be knowledgeable about and aware of culturally influenced
differences to detect environmental barriers that might present opportunities for development through intervention.
In addition, occupational therapists should continue to
advocate for the importance of meeting the needs of parents
and children with disabilities. Finally, intervention should
be based on assessment findings supported by expert
knowledge and clinical judgment, including knowledge and
awareness of culturally influenced expectations.

Limitations and Directions

for Future Research
This study is a cross-sectional follow-up study of a small
sample of children with Down syndrome in Norway. Norwegian regulations regarding elementary school entry may
differ from those in other countries. Thus, findings should
be interpreted as providing guidelines about typical strengths
and weaknesses in functional performance associated with
elementary school entry for children with Down syndrome
and as a reminder about influences on expectations about
development toward independence in children. The findings
are limited to the areas covered by the PEDI.
This study suggests a need to further examine the toilet
training needs of children with Down syndrome, and more
investigation is needed from different countries and cultures.
Toilet training is a self-care skill, and self-care skills play an
important role in performance and quality of life. As Swart,
Kanny, Massagli, and Engel (1997) found, self-care intervention might not receive in practice the prominence called
for in occupational therapys core philosophy.

Acknowledgments
The authors are grateful to all the parents who again willingly shared their knowledge and experiences on behalf of
their children, to senior lecturer Jo Kleiven of Lillehammer
University College for statistical supervision, and to the
professional board of the Norwegian Network for Down
Syndrome for their support. The study was partially funded
by Sykehuset Innlandet.

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