THE EFFECTS OF FINE MOTOR VERSUS GROSS MOTOR TREATMENT ON

FINE MOTOR SKILL DEVELOPMENT IN A PEDIATRIC POPULATION

A THESIS

SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF MASTER OF ARTS

IN THE GRADUATE SCHOOL OF THE

TEXAS WOMAN'S UNIVERSITY

SCHOOL OF OCCUPATIONAL THERAPY

BY

LINNEA MERRITT, B.S.

DENTON, TEXAS

MAY, 1990
 TEXAS WOMAN'S UNIVERSITY

DENTON, TEXAS

December 14, 1989

To the Provost of the Graduate School:

I am submitting herewith a thesis written by Linnea Merritt

entitled "The Effects of Fine Motor versus Gross Motor

Treatment on Fine Motor Skill Development in a Pediatric

Population". I have examined the final copy of this thesis

for form and content and recommend that it be accepted in

partial fulfillment of the requirements for the degree of

Master of Arts, with a major in Occupational Therapy.

Chairman

We have read this thesis

and recommend its acceptance:

, ' ,

-f-~~/ .

Accepted

Provost of the Graduate School

 ACKNOWLEDGMENTS

I would like to express appreciation to the following

people:

Dr. Grace Gilkeson, Dean of the School of Occupational

Therapy, for encouraging me to pursue the masters program.

The Parents and Staff of Trinity Easter Seal Society

for Children for making this study possible. A special

thanks to Dianne Holt, Occupational Therapist at Trinity

Easter Seal Society for Children, for her assistance with

the research.

My committee composed of Dr. Nancy Griffin, Mrs.

Rosalyn Fisher and Mrs. Rebecca Palmer, all members of the

facility of the Occupational Therapy Department at Texas

Woman's University.

My family for their encouragement and support.

My friends who were always there for me.

A special thanks to Jean Penney for the endless hours

spent entering the data on her computer.

iii
 The Effects of Fine Motor Versus Gross Motor
Treatment on Fine Motor Skill Development
in a Pediatric Population

Linnea Merritt

May, 1990

ABSTRACT

A single subject ABA design was used to determine the

effects of therapy using gross and fine motor tasks on the

development of fine motor skills. The subjects were five

children diagnosed with Down Syndrome. Pre and posttesting

was done using the Peabody Developmental Motor Scale.

Weekly data were collected by measuring the number of beads

each child could string and pegs each child could place in

holes, then graphing these results. The results of this

study showed that 4 of the 5 subjects showed significant

gains on their post Peabody DMS testing. Weekly testing

using beads and pegs showed the scores to fluctuate,

although the weekly testing did show the subjects to do

equally as well in testing when gross motor treatment was

being administered as when fine motor treatment was

administered. These findings have implications for further

research.

iv
 TABLE OF CONTENTS

ACKNOWLEDGMENTS iii

ABSTRACT iv
Chapter

I. Introduction . 1

Statement of Problem. . . . . . . . . .
. . . . . . . . . . . .
2
Statement of Purpose
.. . . . . . . . . .
2
Hypothesis . . . .
. . . . . . . . . . . .
2
Definition of Terms
. . . . . .
2
Limitations of the Population .
.. . . .. . . ..
3
Assumptions . . . . . . 4

II. Review of the Literature • 5

III. Methodology. • 8

Test Design . . . . • 8
Procedure .... • 9
Potential Problems. 11

IV. Results 13

v. Summary and Conclusions . . 31

REFERENCES 34

APPENDICES

A. Letter of Approval 35

B. Parental Release 37

C. Profile of each child. 39

D. ABA - BAB Schedules. 45

E. Lists of Activities. 48

V
 vi
F. Test Design for Weekly Progress Test .... 51

G. Peabody Test .........•.....• 53

 vii

LIST OF TABLES

1 - Pre/Post Scores - Age Equivalent . . . . . 13

LIST OF FIGURES

1 - Weekly Average Beads - Fine Motor Group 15

2 - Weekly Average Pegs - Fine Motor Group 17

3 - Weekly Average Beads - Gross Motor Group 19

4 - Weekly Average Pegs - Gross Motor Group 21

5 - Fine Motor Treatment - Beads . . . . . . 23

6 - Fine Motor Treatment - Pegs . . . . . . . . 25

7 - Gross Motor Treatment - Beads . . . . . . . 27

8 - Gross Motor Treatment - Pegs . . . . . . . . 29

 CHAPTER I

Introduction

In light of changes taking place in pediatric

occupational therapy, it is felt that occupational

therapists' need to sharpen their skills in assessment and

documentation of services. In October, 1984 Ottenbacher

noted that "Documentation of the effectiveness of

therapeutic intervention is currently a high priority in

occupational therapy" (p. 647). He advocated use of the

single-system research design to document clinical change.

Occupational therapists must be accountable for their

treatments to the client, the client's family, doctors and

insurance companies.

Therapeutic intervention provided through fine and gross

motor tasks has been widely used in pediatric settings. At

Trinity Easter Seal Society for Children 8.8% of the

caseload admitted for evaluation from June 1984 through

December 1988 had a diagnosis of Down Syndrome. Most of

these clients have been referred to occupational therapy to

improve their fine motor skills.

1
 2

statement of Problem

This study was done to measure the effectiveness of

gross motor vs. fine motor therapy in treating a child with

a fine motor skill delay.

Statement of Purpose

This study explored a way to document improvement.

Results may also be useful in designing the most efficient

treatment plan.

Hypothesis

It was hypothesized that there would be no significant

difference in effects of fine motor vs. gross motor

treatment as determined by the Peabody Developmental Motor

Scale.

Definition of Terms

Fine Motor Skills: small muscle movements, for eye-hand

skills, i.e., shoe tying. (Scardina, 1988)

 3

Gross Motor Skills: large muscle movement body skills, i.e.,

jumping. (Scardina, 1988)

Fine Motor Treatment: activity program which involves small

muscle use.

Gross Motor Treatment: activity program which involves large

muscle use.

Age Equivalents: scores that indicate the age group in which

an obtained score is average. (Folio and Fewell, 1983)

Scaled Scores: a form of standard score that is calculated

across the entire score range of a test, independent of age

or other factors. (Folio and Fewell, 1983)

Limitations

The following limitations were set:

1 - Subjects were referred to the Dallas or Trinity Easter

Seal Society for Children.

2 - Subjects were from one geographic location/area.

3 - Subjects were of varying ethnic background.

4 - Subjects were from 3 to 5 years in age.

5 - Subjects had an IQ within the retarded range.

6 - Subjects had no severe visual problems.

 4

7 - Subjects were selected from those who have shown

progress in the past according to the Peabody

Developmental Motor Scale.

8 - Subjects had a diagnosis of Down Syndrome.

Assumptions

The following assumptions were made:

1 - Therapists who collected data were familiar with

the Peabody Developmental Motor Scale and other

testing instruments as identified.

2 - Therapists had access to files at Dallas and

Trinity Easter Seal Society for Children.

3 - Subjects were able to cooperate for testing and

were available for the necessary 10 week period.

 CHAPTER II
Review of Literature

The literature search did not yield many recent articles

related to the topic of Fine Motor or Gross Motor treatment
for the Down Syndrome population. Articles were available
in two broad categories 1) Down Syndrome 2) fine motor and
gross motor skills.
By definition, Down Syndrome means the person has one
extra chromosome, 47 instead of the normal 46 chromosomes.
Over 6,000 babies are born with Down Syndrome in the United
States every year. It is one of the most common birth
defects, which occurs in all races, in all countries and
happens to girls and boys evenly (Stray-Gundersen, 1986).
Babies with Down Syndrome have low muscle tone. This
affects their movement, strength and development.
A study by Esenther (1984) found that intervention at an
early age, using fine and gross motor skill activities, can
improve the skills of a child with Down Syndrome.
This research study was set up to address fine and gross
motor skills and their impact on fine motor skill
development. A book by Pueschel, Canning, Murphy and
Zausmer (1978) addressed the theory of more advanced motor

5
 6

skills (sitting, creeping, standing and walking) needing to

be present before complex fine motor skills can develop.

These authors feel this theory is not necessarily true for

the child with Down Syndrome. A Down syndrome child may be

delayed in gross motor development because of significant

muscle weakness, heart disease or other physical defects.

This same child may be ready maturationally for more

advanced fine motor activities.

Addressing this motor development concept further, were

several articles on fine and gross motor skills. Among them

was a study done by Loria (1980) assessing proximal and

distal function in motor development. She found that distal

development does not necessarily follow proximal motor

development. She felt they should be treated as separate

systems as it was possible that there were two different

motor-control systems involved with proximal and distal

control.

A recent article in the October 1989 issue of American

Journal of Occupational Therapy had the same theme. The

people doing this study, Case-Smith, Fisher, Bauer, came to

similar conclusions as in the previously mentioned study of

proximal and distal control.

So in therapy, and in this study, the author has

attempted to address both fine and gross motor skills. The

theory that gross and fine motor skills involve separate

 7

control systems may be supported in the present comparison

of treatment methods. If fine motor skills are influenced

by a fine motor control system then the fine motor treatment

conditions might be expected to produce more improvement

than the gross motor treatment.

 CHAPTER III

Methodology

Written permission was given by the director of Trinity

Easter Seal Society for Children to do this study (see

Appendix A). Written consent was also obtained from each

child's parent for his/her child to be in the study (see

Appendix B).

Subjects for this study were clients of Trinity Easter

Seal Society for Children Occupational Therapy Department.

Each child was between 3 and 5 years of age and had a

diagnosis of Down syndrome. Five subjects, three males and

two females, were in the study which utilized a single

subject design. See profiles of the subjects in Appendix c.

Test Design

The subjects were treated in 30 minute sessions twice a

week for a period of nine weeks. Subjects' performances

were measured against their prior performances. The Peabody

Developmental Motor Scales-fine motor scale was administered

by the author prior to and immediately following the nine

weeks of designated therapy to test the stated hypothesis.

8
 9

The study involved a therapy program based on fine motor

{A) and gross motor {B) skills on two specified fine motor

skills procedures. Weekly testing determined the effects of

the program. Each segment of the program lasted three

weeks, resulting in an ABA or BAB format. Each subject

received both types of therapy programs, but in varying

amounts. Three subjects, assigned to the ABA format,

received six weeks of fine motor and three weeks of gross

motor activities; the two subjects assigned to the BAB

format received six weeks of gross motor and three weeks of

fine motor therapy.

The subjects were placed in ABA and BAB groups at random

to eliminate any bias in procedure. Treatment was

administered by two therapists. The assisting therapist

treated 1 ABA and 1 BAB subject, while the author treated 2

ABA and 1 BAB subjects.

Procedure

All procedures were carried out in the OT department at

Trinity Easter Seal Society for Children {TESSC). Equipment

and activities used were all modalities of the OT

department. In order to promote randomness, within each

major type of activities (i.e., fine or gross motor)

specific tasks were rotated so those tasks performed just

 10

prior to testing would not always be the same.

The tests selected for evaluation included insertion of

plastic pegs into a rubber peg board, and stringing of

wooden beads onto a heavy string with an extended tip. The

tests were given once a week during the second treatment

session. The first treatment session included three

activities each lasting 10 minutes. The second treatment

session included two activities each lasting 10 minutes and

the testing for which 10 minutes was allotted. See ABA-BAB

Schedules in Appendix D). Each test was administered three

times in one-minute segments, so approximately 10 minutes of

each second treatment session was spent in testing. The

format incorporated five 10-rninute treatment segments and

one 10-minute testing period, continued through a nine-week

period. During second session, testing and recording of

results was easily completed within the allotted 10-minute

time span.

An activity list was developed, designating specific

gross and fine motor tasks to be addressed each therapy

session (see Appendix E). This provided variety of activity

for the subjects, uniformity of task administration between

the therapists, and ease of record-keeping.

There were nine rotations of activities, one per week,

for each child. Each identified the activity area to be

stressed for each session; ex. Gross Motor (B)- area 1

 11

climbing. Then it listed sub-areas which could be addressed

under climbing (such as rope ladder, slide, etc.) so that

the therapist only had to check off the activities which

were performed during that session. No time was taken from

the treatment program itself to describe activities. Quick

notes could be used to aid in recall of significant

behaviors and problems. Check lists were color-coded to aid

in record-keeping (see Appendix E).

Potential Problems

The author was aware of several problem areas in the

test design which could affect validity of the data. These

included:

1. respondent's familiarity with a test after

repetition.

2. effects of practice and repetition on

performance.

3. disruptive effects of test administration by an

unfamiliar person. (The author who is not

directly working with the other therapist's

children.)

4. possible bias by therapists in administration of

tasks and testing.

To minimize testing effects, tasks selected for testing

 12
were not perfomed at any other times throughout the stud~t'.
The average of the three one- minute tests rather than a
single longer- timed test was used as basis for performance
evaluation. The two therapists followed the same structured
activity rotati on and timed- test procedures in accordance
wi th client rotati on assi gnment (ABk or BAB).
 CHAPTER IV

Results

Table 1 gives the individual pretest and posttest scores

on the Peabody Developmental Motor Scale.

Table 1

Pre and Post Scores and Age Equivalents on Peabody OMS

ABA Group (fine)

Subject Pre- Age Post- Age

test Equi test Equi

Child 1 486 24 502 27

Child 2 483 23 500 26

Child 3 478 22 479 22

BAB Group (gross)

Child 4 506 29 516 33

Child 5 526 36 541 40

Child 3 in the ABA group made no change in age

equivalent. Both children in the BAB group increased age

equivalent scores by 4 months. The remaining children

gained 3 months in age equivalent scores over the 10 week

period.

13
 14

Child 1 made a 16 point scaled score gain, child 2 made

a 17 point gain and child 3 made a 1 point gain. These

children were in the ABA group.

Child 4 made a 10 point scaled score gain and child 5

made a 15 point gain. Children four and five were in the

BAB group.

The scaled scores points were reported in addition to

the age equivalent scores on Table 1, because the scaled

scores measured the degree of change. A change of 10 scaled

score points would be the same no matter where it occurred

on the scale (Folio and Fewell, 1983).

 15
Figure 1

Weekly Average Number of Beads by Fine Motor Group

0 ______..______....___--'-__. . . . .___-'-___..____,..__,
WK1 WK2 WK3 WK4 WK5 WK6 WK7 WK8 WK9
-11- CHILD 1 -+- CHILD 2 _._ CHILD 3

Figure 1

Figure 1 shows the average number of beads strung on a

string over the 9 week period for the children in the fine

motor design. This table addresses the group in which the

fine motor skills were emphasized. Their schedule was A-

fine motor activities for 3 weeks, B-gross motor activities

for 3 weeks, A-fine motor activities for the final 3 weeks.

There were 3 children in this group. Child 1 was the only

 16

child to be seen and tested for the full 9 weeks and this

figure represents this. Children 2 and 3 were both absent

for a week during the study so their scores were collected

for only 8 weeks. When the children returned after being

absent, the treatment continued where it had left off to

complete the 3 week treatment session. The study had to

stop after 9 weeks because the children were no longer

available. Therefore, the last week of treatment was not

completed and was graphed as zero on the figures.

All three children's scores fluctuated throughout the

nine weeks. Each of them showed a drop in score in week 4,

after the first change in treatment program. Child 2's

scores showed an overall gradual decline in performance,

while Child 1 and Child 3 ended the study with higher

average scores than their first week scores.

 17

Figure 2

Weekly Average Number of Pegs by Fine Motor Group

11

10
9

5
4

1
0 ...._.__ ____.__ ___....._ _
---1,._ ___....._ _---1,._ _......J.._ _---1,._ _..J.-J

WKl WK2 WK3 WK4 WK5 WK6 WK7 WK8 WK9

- CHILD 1 ..,._ CHILD 2 -.- CHILD 3

Figure 2

Figure 2 shows the average number of pegs inserted into

a peg board over the 9 week period for the 3 children in

this fine motor design.

Child 1 and Child 3's scores showed much fluctuation,

and both showed increase in number of pegs inserted by the

end of the study. Child 2's scores showed an overall

 18

decline, ending the study with fewer pegs placed than in the

initial week. Child 1 and Child 2's scores showed a drop

after the first change in treatment program and an increase

after the second change of treatment type in week 7. Child

J's scores were the opposite, an increase in week 4 and a

drop in week 7.
 19

Figure 3

Weekly Average Number of Beads by Gross Motor Group

0
WKl WK2 WK3 WK4 WK5 WK6 WK7 WK8 WK9
-e- CHILD 4 -e,- CHILD 5

Figure 3
Figure 3 shows the average number of beads strung on a

string over the 9 week period for the children in the gross

motor design. The gross motor design is the one in which

the gross motor skills were emphasized. The schedule was B-

gross motor activities for 3 weeks, A-fine motor activities

for 3 weeks, B-gross motor activities for the final 3 weeks.

 20

There were 2 children in this group. Both children were

absent for a week at some point during the study. Their

scores were collected for only 8 weeks.

Child 4's scores fluctuated throughout the study, while

Child 5's scores showed a steady increase over the 8 week

period. Both children's scores increased at the first 3

week change of the program and dropped after the second

change of treatment type. Child 4 and Child 5 ended the

study with higher average number of beads strung.

 21

Figure 4
Weekly Average Number of Pegs by Gross Motor Group

15

10

0 ------'----..L-----.IL-----L---1---L----L---lt-l
WKl WK2 WK3 WK4 WK5 WK6 WK7 WK8 WK9
-e- CHILD 4 CHILD 5

Figure 4
Figure 4 shows the average number of pegs inserted into
a peg board over the 9 week period for the 2 children in the

gross motor design.

Child 4 and Child 5's scores fluctuated and both
children's scores ended slightly higher than their beginning
scores. Child 4 and Child 5's scores increased at the first
 22

3 week change of the treatment program. Child 4's scores

dropped after the second change of treatment type, while
Child 5's scores increased after the second change of
treatment type.
Further comparisons could be made of each child with
the others in his or her group, and with all of the other
children in the study. However, this would not be
beneficial, as this study is examining how the scores of
each child improve or decline over the 8 to 9 week period.
 23

Figure 5
Fine Motor Treatment Average Number of Beads

WK1 WK2 WK3 WK4 WK5 WK6 WK.7 WKS \\TK9

Child 1 Child 2 lrJJ Child 3 0 Child 4 Child 5

Figure 5
Figure 5 is a bar graph of all 5 children. The figure
shows each child's average weekly test scores for number of
beads strung during the fine motor treatment sessions. Week
9 shows only one bar, this is Child 1, who was the only
child present all nine weeks. The two groups (ABA and BAB)
are interposed on each other, showing the scores from the
 24

fine motor treatment sessions. The first 3 weeks represents

a bar graph of each of the 3 children in the ABA design.

Weeks 4, 5, and 6 represent the 2 children in the BAB design

and the final 3 weeks once again represent the 3 children

in the ABA design.

Child 1, Child 3 and Child 5's scores increased or

maintained during the fine motor portion of the study.

Child 2 and Child 4's scores fluctuated and showed a drop in

performance over the 9 week period.

 25

Figure 6
Fine Motor Treatment Average Number of Pegs

15

10

0
WK1 WK2 WK3 WK4 WK5 WK6 WK7 WKS WK9
OOc-1 ~c-2 ~c-3 IKJc-4

Figure 6
Figure 6 is a bar graph of all 5 children. The figure
shows each child's average weekly test scores for number of
pegs placed in holes during the fine motor treatment
sessions. The two figures (ABA and BAB) are interposed on
each other, showing only the scores from the fine motor
treatment sessions. The first 3 weeks represent the 3
 26

children in the ABA design. Weeks 4, 5, and 6 represent the

2 children in the BAB design and the final 3 weeks once
again represent the 3 children in the ABA design.
Child l's scores showed an overall increase in peg
placements, with a temporary drop in week 7. Child 2 and
Child 5's scores showed a general decrease by their 8th week
of testing. Child 3 and Child 4's scores fluctuated, but
were maintained overall.
 27

Figure 7
Gross Motor Treatment Average Number of Beads

WKl WK2 WK3 WK4 WK5 WK6 WK7 WK8 WK9

OOc-1 ~c-2 ~c-3 IKJc-4

Figure 7
Figure 7 is a bar graph with all 5 children
represented. The figure shows each child's average weekly
test scores for number of beads strung during the gross
motor treatment sessions. The two groups (ABA and BAB) are
interposed on each other, showing only the scores from the
gross motor treatment sessions. The first 3 weeks represent
 28

the 2 children in the BAB design. Weeks 4, 5, and 6

represent the 3 children in the ABA design and the final J

weeks once again represent the 2 children in the BAB design.
Child 5's scores increased throughout the 8 weeks.
Child 4's scores initially increased then decreased during
the final two weeks of gross motor tasks. Child 1 and
Child 2's scores decreased during the 3 weeks (4-6) of gross
motor activities and Child J's scores, fluctuated, but
maintained during the 3 weeks of gross motor activities.
No scores were obtained for week nine, as that was the
BAB gross motor children, neither of whom attended the full
nine weeks.
 29

Figure 8
Gross Motor Treatment Average Number of Pegs

15

10

WK1 WK2 WK3 WK4 WK5 WK6 WK7 WK8 WK9

OOc-1 ~c-2 ~c-3 IKJc-4

Figure 8
Figure 8 is a bar graph with all 5 children
represented. The figure shows each child's average weekly
test scores for number of pegs placed in holes during the
gross motor treatment sessions. The 2 groups (ABA and BAB)
are interposed on each other, showing only the scores from
the gross motor treatment sessions; The first 3 weeks
 30

represent the 2 children (child 4 and child 5) in the BAB

design. Weeks 4, 5, and 6 represent the 3 children in the
ABA design and the final 3 weeks once again represent the 2

children in the BAB design.

Child 4 and Child 5's scores, which are represented in
week 1, reflect an increase in number of pegs placed for the
first 3 week period and a decrease for the final 2 weeks.
Child 1 and Child 2's scores reflect a decrease during weeks
4-6, their 3 weeks of gross motor treatment. Child 3's
scores fluctuate but show an increase during weeks 4-6.
In conclusion, on the 4 figures, there were data
collected on only child 1 for all nine weeks.
It was noted that the BAB group appeared to maintain
higher scores during both the fine and gross motor treatment
sessions. Other generalizations and comparisons of the
children would not be beneficial to this study, as the
treatment design is not to compare the children to each
other, but to measure their individual progress over the 9
week period.
 CHAPTER V

Summary and Conclusions

Several factors became evident over the course of the 9

weeks. The first was that at some point, behavior in

general became a factor. Some of the children threw their

toys and got out of their chairs. One child just said "NO"

to the activities, but later did them anyway. Behavior,

however, was usually a short term problem.

The format used seemed effective. For the 9 week

study, having the activities all planned out and easy to

record on weekly sheets was very helpful. It did not take

away from treatment, as therapy at TESSC is scheduled every

30 minutes. On the negative side, the schedule of

activities was confining, as the therapists had to do gross

and fine motor skills separately. For example jumping and

climbing activities could not be done on the same day as

dressing skills, and there was no time allowed for snacks.

For study purposes it was good, as it kept research "clean"

and therapists on track. Involved note taking was

eliminated with use of activity checklist and weekly

testing.

The pre and posttesting using the Peabody OMS, showed a

31
 32

greater than two month gain in development on fine motor

skills in 4 of the 5 children. This confirms the author's
belief that therapy is beneficial. The Peabody OMS did not
address which treatment type (gross or fine) made the most
impact on fine motor skill development, if indeed one type
did. That was the purpose of the weekly testing. The
Peabody OMS was used to make sure everything was measured,
but the results are not statistically significant with
respect to the hypothesis.
This was a test of limited subjects and limited time
span. Generalization can not take place at this point.
According to an article by Hacker in the February 1980 issue
of AJOT "the key to generalizability then, becomes
replication." (p.105). The single subject design can be
duplicated with other clients in other areas of the country.
If the data still holds true in different settings with
different therapists, then generalizations can be made. The
author would like to see this study pursued with larger
numbers and possibly with a control group. The study could
be replicated with normal 3 to 5 year olds. It would be
interesting to determine if discontinuing treatment of Down
Syndrome children would result in regression of fine motor
skills. This issue of not treating a child is one that few
therapists would be comfortable attempting.
It is felt that conclusions can not be generalized to
 33

the Down Syndrome population, but that replication of the

study would be beneficial since it was documented that 4 of
the 5 subjects showed noticeable improvement.
For further reading of the developmental progression of
normal motor development a good resource is a book called
The Developmental Therapist, by Banus, Kent, Norton,
Sukiennicke, and Becker. This book was a helpful guideline
in setting up this research study.
 References
Banus, B., Kent, c., Norton, Y., Sukiennicki, D., &
Becker, M. (1979). The Developmental Therapist.
(ed. 2). New Jersey: Slack Inc.
Case-Smith, J., Fisher, A., & Bauer, D. (1989).
An Analysis of the Relationship Between Proximal and
Distal Motor Control. American Journal of Occupational
Therapy, 43, 657-662.
Esenther, s. (1984). Developmental Coaching of the
Down Syndrome Infant. American Journal of Occupational
Therapy, 38, 440-445.
Folio, M.R., & Fewell, R.R. (1983). Peabody
Developmental Motor Scales. Hingham, MA: Teaching
Resources Corp.
Hacker, B. (1980). Simple Subject Research Strategies
in Occupational Therapy, Part 1. American Journal
of Occupational Therapy. 2L_ 103-108.
Loria, c. (1980). Relationship of Proximal and Distal
Function in Motor Development. Physical Therapy. 60,
167-172.

Ottenbacher, K., & York, J. (1984). Strategies for

Evaluating Clinical Change: Implications for
Practice and Research. American Journal of
Occupational Therapy, 38, 647-659.
Pueschel, s., Canning, c., Murphy, A., & Zausmer, E. (1978).
Down Syndrome Growing and Learning. Kansas City. New
York: Andrews and McMeel, Inc.
Scardina, V. (1988). Sensory Integration: Its
Relationship To Human Development. Proceedings from
workshop sponsored .Q.Y Easter Seal Society for
Children. Dallas, Tx.
Stray-Gundersen, K. (1986). Babies with Down Syndrome-A
New Parents Guide. Woodbine House, Inc.

34
 APPENDIX A
Letter of Approval

35
 36
Euta-Seel5ocicf
,_Cluldna

February 22, 1989

J·
-~Gs~~~_._..-_,.___'fn.
.......~~--~·---------' a staff member at Easter Seal
Society for Children-Trinity, has permission to conduct a research
study as part of her thesis requirements. The study will involve
clients at Trinity Easter Seal. Permission from the parents for the
use of their children will be obtained by ~~<3< 1?2~
A copy of the thesis, all forms and permissions will be given to the
Easter Seal Society for Children at the completion of the thesis.

Approval of this reseach study is given by:

sir,a~u:re and Ti~Ie

,;/6-4.r;f'. . .
SJ.gnat~ andTi
fi;-4-~ Da1:.a
 APPENDIX B
Parental Release

37
Easter Seal Society 38
For Children

PAREN.TAL RELEASE

I hereby grant permission to the EASTER SEAL SOCIETY FOR CHILDREN-

TRINITY to release any and all information on my child_ _ _ _ __
to the below named staff member for a research project.

No medical service or compensation is provided to subjects by the

university as a result of injury from participation in research.

Staff's Name::
---------------------------
Program Director: _________________________

PARENTAL RELEASE DATE PERIOD:

FROM:
--------------- (beginning)
TO:
--------------- (end)
Parent/Guardian:
--------------------------
Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
 APPENDIX C
Profile of Each Child

39
 40

Profile of Child 1

Child 1 was a 3 year 11 month old boy (at start of

testing) with a diagnosis of Down Syndrome. Each week he

received two 30 minute sessions in speech, occupational

therapy and physical therapy. He was also enrolled in an

Early Childhood Program through his school district,

receiving physical therapy and speech therapy at school. He

had perfect attendance throughout the study. He

demonstrated some uncooperative and silly behavior during

the initial week of testing and at each 3 week change of

type of treatment. He was cooperative for testing the rest

of the time. He was cooperative for pre and posttesting and

attempted all tasks. Hand preference appeared to be right

hand.

During the third week of the study, shoe lifts were

added to his tennis shoes by his physical therapist. This

was done so that his weight would be shifted onto on his

heels. This had no effect on the study at this point, as he

was doing fine motor tasks. The shoe lifts were worn during

weeks 4-6 (his gross motor program). During the 9th week,

child 1 told the therapist "NO" when tasks were presented.

This was unusual, as he rarely voiced an opinion. He did

eventually do some tasks from the specified categories. His

overall cooperation was good. He was in the study for the

full 9 weeks.
 41

Profile of Child I
Child 2 was a 3 year 1 month old boy (at start of

testing) with has a diagnosis of Down Syndrome. Each week

he received two 30 minute sessions in speech and

occupational therapy. He was also enrolled in a pre school

program through his school district. His attendance in the

study was good. He was out one week for family vacation,

which was approximately half way into the study. Child 2

demonstrated 3 separate occasions of silly behavior during

the weekly testing. For the most part he was cooperative.

During the last session of weekly testing (pegs and beads),

he threw one peg in the wastebasket, put himself in the

"time out" corner (in order to get out of his chair), then

tried to sit in the examiner's lap to finish his work. Pre

and posttesting went smoothly. Hand preference was not

fully established. He was cooperative for all tasks - gross

and fine, but did demonstrate a shorter attention span for

some of the gross motor tasks. His 9th week was dropped

because of the week he was out for vacation. Child 2 wore

glasses throughout the study.

 42

Profile of Child d

Child 3 was a 3 year 8 month old boy (at start of

testing) with a diagnosis of Down Syndrome. Each week he

received two 30 minute sessions in speech and occupational

therapy and received physical therapy once a week for a 30

minute session. He was not enrolled in any other therapy or

school program. His attendance in the study was good. He

was out one week during the study. Child 3 was somewhat

uncooperative in therapy when the tasks were lengthy.

During weekly testing of pegs and beads, he was fairly

cooperative on the first two trials but by the third trial

he would begin to act out in small ways with both the beads

and pegs testing. His behavior was fairly steady throughout

the 9 week study. Child 3 seemed to enjoy gross motor

activities more than the fine motor activities. Hand

preference appeared to be left hand. His 9th week

activities and testing were dropped because he was out a

week. Child 3 wore glasses throughout the study.

 43

Profile of Child~

Child 4 was a 4 year 5 month old girl {at the start of

testing) with a diagnosis of Down Syndrome. Each week she

received two 30 minute sessions in speech and occupational

therapy. She was also enrolled in an Early Childhood

Program through her school district. Her attendance in the

study was good. She was out for a week to have her tonsils

removed. When she returned she tired quickly the first

session back and had lost weight from not eating. She

demonstrated some silly behavior during the first week of

testing {pegs and beads) but was cooperative after that,

being proud of how many beads she could put on the string.

She was cooperative for pre and posttesting and attempted

all tasks. Hand preference was not fully established. At

the start of the gross motor portion of her treatment

program, child 4 did not like the rocking boat and would not

try the teeter totter. She also could not jump off a raised

surface or jump in place. By the 7th week, child 4 was

riding in the rocking boat, on the teeter totter and had

learned to jump. She did not have a 9th week of activities

and test scores because of being out earlier in the study

for surgery.
 44

Profile of Child~

Child 5 was a 4 year 2 month old girl (at start of

testing) with a diagnosis of Down Syndrome. Each week she

received two 30 minute sessions in speech and occupational

therapy. She was also enrolled in a Montessori School

Program. Her attendance in the study was inconsistent.

Despite her decreased attendance, her cooperation was good.

She enjoyed the fine motor activities more than the gross

motor tasks. During gross motor sessions, if the activities

were too challenging, she would melt into the floor and

refuse to try. This was different from her behavior during

fine motor sessions when she was very motivated to try new

activities. She was cooperative for pre and posttesting and

attempted all tasks. Hand preference appeared to be Right

hand. She did not have a 9th week of activities and

testing.
 APPENDIX D
ABA - BAB Schedules

45
 46

Schedule

Week one - Writer will pretest subjects (30 minute sessions)

Week two thru ten - Data collection

Week eleven - Writer will post test subjects (30 min.)

5 subjects (4 needed- one is for backup)

ABA - 3 subjects
BAB - 2 subjects
Weekly schedule will be:
Day one - 3 activities (10 min. each)
Day two - 2 activities (10 min. each, 10 min. testing)

J.. Week schedule will be:

( Fine/Gross)

Week one items

day 1 1 - 2 - 3
day 2 4 - 5 - test

Week two
day 1 2 - 3 - 4
day 2 5 - 1 - test

Week three
day 1 3 - 4 - 5
day 2 1 - 2 - test

Weeks - .§ Change - A/B

Weeks 7 - .2. Change

Activities identified:
Gross Motor Fine Motor

1 - climbing 1 puzzles & shape toys

-
2 - throwing/catching 2 -
Play doh/Therapy putty
3 - scooter boards 3 -
color/write/paint
4 -
manipulation of small objects
4 - jumping (coins, game pieces)
5 - balance 5 - bilateral tasks
(pop beads, barrel toy)

(Within each activity group specific items will be

determined by ability levels - these will be from a pre
determined list of applicable items.)
Schedule 47
ABA
Week 1
Day 1 climbing Day 1 puzzles/shape toys
throw/catch Play Doh/Therapy Putty
scooter color/paint
Day 2 jumping Day 2 small objects
balance bilateral activities
test test
Week 2

Day 1 throw/catch Day l Play Doh/Therapy Putty

scooter color/paint
jumping small objects
Day 2 balance Day 2 bilateral activities
climbing puzzles/shapes
test test
Week 3
Day 1 scooter Day l color/paint
jumping small objects
balance bilateral activities
Day 2 climbing Day 2 puzzles/shape toys
throw/catch Play Doh/Therapy Putty
test test
Week 4
Day 1 puzzles/shape toys Day 1 climbing
Play ooh/Therapy Putty throw/catch
color/paint scooter
Day 2 small objects Day 2 jumping
bilateral activities balance
test test
Week 5
Day 1 Play Ooh/Therapy Putty Day 1 throw/catch
color/paint scooter
small objects jumping
Day 2 bilateral activities Day 2 balance
puzzles/shapes climbing
test test
Week 6
Day l color/paint Day 1 scooter
small objects jumping
bilateral activities balance
Day 2 puzzles/shape toys Day 2 climbing
Play ooh/Therapy Putty throw/catch
test test
Weeks 7. 8. 9 same as 1, 2, 3
 APPENDIX E
List of Activities

48
 49

NAME ROTATION ABA BAB

WEEK 1 2 3 4 5 6 7 8 9

FINE MOTOR ACTIVITIES

I. PUZZLES/SHAPE TOYS IV. SMALL OBJECT MANIPULATION

indiv. piece with knob coins
indiv. piece without knob game pieces
wooden fit-together puzzles rings on fingers
indiv. shape toys tape
other buttons
beads
sand box
keys
II. PLAY DOH/THERAPY PUTTY zippers
roll & shape lacing
cookie cutter snaps
rolling pin pouring
roll & cut with scissors other
cut with knife & fork
other

V. BILATERAL ACTIVITIES
pop beads
screw/unscrew
III. COLOR/WRITE/PAINT ACTIVITIES barrel
free color nuts & bolts
color within lines jars
copy basic shapes other
pre-printing opening/closing other containers
chalkboard rhythm activities
finger paints drum/using hands
paint with brush drum/using sticks
other xylophone
piano
hand clap
finger plays
other
 50

NAME ROTATION ABA BAB

WEEK 1 2 3 4 5 6 7 8 9

GROSS MOTOR ACTIVITIES

I. CLIMBING ACTIVITIES IV. JUMPING ACTIVITIES

bolsters jump in place
cube chairs jump off raised surface
rope ladder jump over line or rope
outdoor slide jump on tramp
fire engine jump on different surfaces
other shoes on
shoes off
other

II, THROW/CATCH ACTIVITIES

one-hand at target
bean bags
tennis balls v. BALANCE ACTIVITIES
nerf balls stand on one foot/holding on
velcro pingpong balls stand on one foot/free stand
two-hand slide sideways
throw/catch with therapist walk sideways
throw or push large ball walk backward
carry balls/drop into bucket walk on line
bounce balls walk on beam
bounce & catch shoes on
other shoes off
steps/one foot leading
steps/alternative feet
sit on tilt board
III. SCOOTER BOARD ACTIVITIES 1/2 kneel on tilt board
sit on board/hold rope/be pulled full kneel on tilt board
prone/propel with arms stand on tilt board
prone/hold to rope/be pulled rocking boat
prone/carry or move objects teeter totter
go backward tire swing
propel in circle chair swing
pull up on ramp slide
go down ramp merry go round
other
 APPENDIX F
Test Design for Weekly Progress Test

51
 52

Test Design for Weekly Progress Test

Each test is administered for 1 minute. Score for each is

number of completed tasks within allotted time. Tasks are

divided into 4 steps for more accurate recording.

1. PEGS

1/4 task - grasp peg in either hand

1/2 " - position peg in hand correctly

3/4 " - touch board or target area with peg

1 " - push peg into hole

2. BEADS

After string is picked up begin timing.

1/4 task - pick up bead with either hand

1/2 II
- locate hole in bead with string tip

3/4 " - push string through hole

1 II
- slide bead onto string so it will fall to

end
APPENDIX G
Peabody Test

53
Peabody Developmental Motor Scales 54

Response/Scoring Booklet
Yr. Mo. Day
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Date of Testing
Educational Program _ _ _ _ _ _ _ _ _ __ Date of Birth
Examiner _ _ _ _ _ _ _ _ _ _ _ _ _ __ Chronological Age
Examination Center _ _ _ _ _ _ _ _ _ _ __ Age in Months

SUMMARY

Gross Motor Fine Motor

Basal Age Level

Ceiling Age Level

Scaled Score

Age Equivalent

Mean Motor Age Equivalent

GROSS-MOTOR SCALE

z-score Developmental
Raw Score Percentile
T score Motor Quotient
Skill A - Reflexes

Skill B - Balance

Skill C - Nonlocomotor

Skill D - Locomotor

Skill E - Receipt and Propulsion

Total Score

FINE-MOTOR SCALE

z-score Developmental
Raw Score Percentile
T score Motor Quotient
Skill A - Grasping

Skill B - Hand Use

Skill C - Eye-Hand Coordination

Skill D - Manual Dexterity

Total Score

Copyright 1983 Teaching Resour ces Cor por~t1 on

Reproduction of this form without prio r s.ri tten perm1 ss 1on 1s a violation of cop y r ight law. . . Teaching
I 2 3 4 !> 6 7 B 9 10 qo 89 88 87 86 85 84 83 .._ Resources
 55
Fine-Motor Scale
Skill Categories
A B C D
0-1 Month
1. Grasping Reflex
2. Positioning Hands
3. Fixating on Rattle
4. Tracking Rattle
5. Tracking Rattle
6. Releasing Involuntarily
Cumulative Maximum 4 + 2 + 6 12
2-3 Months
7. Tracking Rattle
8. Manipulating Rattle
9. Grasping Rattle
10. Holding Rattle
11. Reaching for Rattle
12. Perceiving Rattle
13. Tracking Ball
14. Regarding Hands
Cumulative Maximum 12 + 2 + 14 28
4-5 Months
15. Activating Arms
16. Holding Rattle
17. Grasping Voluntarily
18. Approaching Midline
19. Pulling String
20. Securing Paper
21. Grasping Precariously
22. Bringing Hands Together
Cumulative Maximum 22 + 6 + 16 44
6-7 Months
23. Lifting Cup
24. Banging Cup
25. Grasping:
Radial-Palmar
26. Rotating Wrist
27. Grasping:
Ulnar,Palmar
28. Retaining Cubes
29. Transferring Cubes
30. Grasping: Raking
Cumulative Maximum 28 + 14 + 18 60
Fine-Motor Scale continued 56

Skill Categories
A B C D
8-9 Months
31. Removing Peg
32. Grasping:
Thumb-Finger
33. Combining Cubes
34. Retaining Cubes
35. Grasping:
Raking Radial
36. Grasping:
Inferior Pincer
37. Manipulating Paper
38. Clapping Hands
Cumulative Maximum 34 + 24 + 18 76
10-11 Months
39. Removing Ring
40. Poking Finger
41. Shaking Bottle
42. Grasping:
Superior Pincer
43. Releasing Cube
44. Releasing Cubes
45. Stirring Spoon
46. Hitting Spoon
Cumulative Maximum 36 + 30 + 24 + 2 92
12-14 Months
47. Removing Pegs
48. Opening Box
49. Removing Pellets
50. Turning Pages
51. Grasping: Overhand
52. Building Tower
53. Grasping Cubes
54. Inserting Shape
Cumulative Maximum 40 + 36 + 28 + 4 = 108
Fine-Motor Scale continued 57
Skill Categories
A B C D
15-17 Months
55. Unwrapping Cube
56. Filling Cup
57. Building Tower
58. Imitating Scribble
59. Grasping: Pronation
60. Placing Pegs
61. Removing Socks
62. Inserting Shapes
Cumulative Maximum 42 + 40 + 38 + 4 = 124
18-23 Months
63. Placing Pellets
64. Separating Beads
65. Turning Pages
66. Inserting Shapes
67. Building Tower
68. Imitating Stroke
69. Stringing Beads
70. Snipping Scissors
Cumulative Maximum 42 + 42 + 46 + 10 - 140

24-29 Months
71. Placing Rings
72. Turning Knob
73. Removing Cap
75. Separating Beads
75. Imitating Stroke
76. Building Train
Cumulative Maximum 42 + 46 + 52 + 12 - 152

30-35 Months
77. Building Tower
78. Building Bridge
79. Copying Circle
80. Washing Hands
81. Unbuttoning Buttons
82. Cutting Paper
Cumulative Maximum 42 + 48 + 60 + 14 - 164

36-4 1 Months
83. Showing Hand Prefere nee
84. Removing Cap
85. Stringing Beads
86. Winding Toy
87. Cutting Line
88. Copying Cross
Cumulative Maximum 42 + 52 + 64 + 18 - 176
Fine-Motor Scale continued SR

Skill Categories
A B C D
42-4 7 Months
89. Tracing Line
90. Holding Marker
91. Copying Cross
92. Copying Square
93. Cutting Circle
94. Lacing Shoe
Cumulative Maximum 44 + 52 + 72 + 20 188

48-59 Months
95. Dropping Pellets
96. Buttoning Button
97. Building Gate
98. Folding Paper
99. Cutting Square
100. Placing Clips
Cumulative Maximum 44 + 52 + 80 + 24 200

60-7 1 Months
101. Connecting Dots
102. Building Pyramid
103. Touching Fingers
104. Winding Spool
105. Coloring Within Lines
106. Placing Pennies
Cumulative Maximum 44 + 52 + 84 + 32 212

72-83 Months
107. Copying Word
108. Drawing Person
109. Copying Diamond
110. Touching Fingers
111. Building Steps
112. Placing Pennies
Cumulative Maximum 44 + 52 + 92 + 36 224