Consistency of Responding. One of the most frustrating characteristics of these children is the lack of consistency of responding in assessment tasks. This variability is associated with two things in our experience. The first is rapid shifts in attention and the second is motivation.
Clearly, these constructs are interrelated and it would be impossible to determine which is causal for any specific behavior. We have found that motivation is central to maintaining consistent response patterns. If we can provide a task that is sufficiently motivating, attention is maintained and responses are more consistent. Our work suggests that successful assessments can be conducted by careful preparation and understanding the interests of each child, what activities they like, what holds their attention at home and school, and then selecting assessment materials that can be imbedded into these activities.
Memory. The work of Michael Marcell (Marcell and Weeks, 1988) documents verbal short-term memory deficits. This has significant implications for assessment of language comprehension and production, particularly when using standardized procedures that require processing specific stimuli and remembering it long enough to provide to appropriate response. Clearly, memory deficits may also be contributing to behaviors that may be labeled as inattention or that result in inconsistent response patterns. In our experience, providing visual support enhances performance when verbal abilities are tested. This may involve pictures, graphic material, or printed words.
Motor Limitations. It has been widely reported that children with Down syndrome have motor deficits. Hypotonia is frequently cited as a cause, but there are little data to support this claim. Motor deficits are quite variable, with some children performing at age level and others show significant motor limitations delaying the onset of ambulation and other motor milestones. Testing protocols must take into consideration the motor demands on the child relative to the child's motor abilities. Make sure that the assessment tasks require motor responses within the child's capabilities.
Vision. France (1992) provides a detailed account of the visual deficits of children with Down syndrome. He followed a group of 90 children and reported that 49% had visual acuity deficits, with myopia being the most common. He also documented oculomotor imbalance in over 40% of the children, convergent strabismus accounting for the majority of these cases. In the majority of these cases only glasses were required to achieve normal vision. The message here is to make sure the children can see the stimuli during testing.
Hearing. Hearing remains an issue for children with Down syndrome because of frequent episodes of otitis media. Monitoring hearing should be done every 6 months for the first 10 years of life. In our work we have found that 33% of our children always had a hearing loss, 33% had a loss sometimes, and only 33% never had a loss. This was after screening out all of those children with significant hearing loss due to other causes. When oral language is tested, it is important to know the child's hearing status on the day of testing.
Summary. Designing a testing protocol requires attention to the skills and abilities the child is expected to bring to the task. These include attention and motivation differences, memory deficits, hearing and visual deficits, and motor limitations. Each of these can compromise the outcome of the assessment if accommodations are not made. It is also clear that in order to optimize the consistency of responding, alternative testing formats will have to be implemented. These testing formats will need to be less rigid, be context-based, and be child-centered rather than examiner-centered. A skilled clinician will have to follow the child's lead to implement functional, criterion reference, play-based assessments. Observational methods will also provide important information.
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