Assessing the Cognitive Modifiability of Children and Youth with Down Syndrome

Yael Mintzker
Chapter 11
The Dynamic Assessment of Cognitive Modifiability
Feuerstein, Reuven; Feuerstein, Raphael S.; Falik, Louis H. & Rand, Ya'acov (2002). Jerusalem: ICELP Press
  Reprinted with the permission of Reuven Feuerstein

A nine year old boy with a pleasant face and very mild Down Syndrome characteristics gazes at me timidly, an uncertain smile on his face. He has lust done a drawing of a human figure (see figure 11.1) and in his gruff voice he says something I can barely understand due to the poor Intelligibility of his speech. Yet this same boy who produced a figure Characteristic of a much younger child, and showed problems in the area if fine motor control became a highly accomplished and creative artist as a young adult, acknowledged in his community and country. His paintings are vividly colorful and display an elaborate style and complex design. Even the simplistic person drawn as a child, when the Human Figure Drawing Test was administered according to the dynamic assessment procedures of the LPAD showed signs of changes in response to mediation.

This chapter describes the significant cognitive modifications which occur as a result of Mediated Learning Experience (MLE), even when the etiology of the mentally retarded performance consists of organic congenital, chromosomally determined factors. This is the case for Down Syndrome (or Trisomy 21), a defined genetic disorder of unknown etiology expressed in the presence of one extra 21 chromosome (see Lejeune et al, 1959). It occurs with a frequency of one out of approximately 600 to 800 live births (see Hook, 1981; Coleman, 1978).

Human Figure Drawing: Before and After Mediation
Before After

Figure 11.1: Human Figure Drawing: Before and After Mediation

Two groups of factors that may influence the actual level of the individual's cognitive performance need to be distinguished when attempting to understand the causes of differential cognitive development and functioning. The first group consists of environmental factors that impede mediating agents in performing their mediating function. The child is deprived of MLE because of factors such as social disruption or cultural discontinuity caused by immigration, war, or poverty that are reflected in the family system. In conditions of hardship, parents tend to restrict themselves to the immediate survival needs of the child, neglecting to attend to the transmission of the cultural heritage of their own family and community, or the spiritual aspects of life and the cognitive development of the child. This category can also include various manifestations of inadequate parenting due to personality problems.

In addition to this set of environmental exogenous factors interfering with the parental socializing role are endogenous factors relating to the child him or herself, and not to the structural characteristics of the environment. These endogenous factors impair the child's capacity to benefit from MLE when it is provided. Various sensory, emotional, organic and other constitutional conditions may reduce the power of the environment to affect the organism and induce modifiability. These exogenous and endogenous conditions are considered to be distal factors in the process of shaping the actual cognitive functioning of the child. They do not exert their influence directly, but rather through an intervening variable—the nature and quality of the mediated learning the child experiences. The proximal determinant of cognitive development is the educational, or mediational value of interactions between parents, educators and other caregivers and the child.


When a child is diagnosed as being born with Down Syndrome, organicity itself will more often than not be held to be the direct cause of the deficient cognitive and general development of the child. The impact of the various organic impairments and pathologies associated with this syndrome can be so powerful in limiting the child's capacity to learn and obstructing the channels to learning, that one would expect that the causal explanatory chain—the distal organic factors linked to the extent of mediated learning and its relationship to cognitive functioning—would also be broken. One of the organic factors which frequently restricts spontaneous learning is hypotonia—weakness of muscles and poor muscle tone. Hypotonia can impinge on the development of skills related to cognitive development. Gross and fine motor development are slowed down and without intensive early intervention (see Zausmer, 2000) several cognitive functions will be impaired. Delay in head control, rolling over, sitting, crawling and creeping may hamper motivation to move, explorative behavior, initiative and active interest in the surroundings, attention and span of attention. Many cognitive input functions may be delayed as well, including activities such as throwing, play, and manipulation of objects and consequently the learning of basic concepts of spatial organization. The delay in fine motor development and hand-eye coordination affect grapho-motor skills including drawing and writing. Consequently, the growth of independence and feelings of competence will be hindered.

Hypotonia is also involved in the quality of speech, because it affects numerous speech muscles of the tongue, soft palate, and breathing muscles. In addition, a buccal cavity too small for an oversized, hypotonic and flabby tongue contributes to impaired lingual mobility and upper-respiratory problems, making speech unintelligible (see Rondal, 1995). The resultant speech problems (articulation and flow/fluency) restrict the interactions between the child and other persons in the child's environment—peers and adults—and reduce the potential for important mediated learning experience interactions, and extended means of socialization.

Slow reaction time or slowness in general has been often noted by people teaching children with Down Syndrome. It has been suggested that this is related to hypotonia. It is manifested in slow data gathering and slow input processing, and in slowly moving from one activity to another. This slowness is evidenced in almost all of the LPAD instruments, as for example in the Diffuse Attention Test (Lahi Test), but the picture is not uniform for this test or for the nature of slowness in general—there are children for example who speak too quickly and this adds to the unintelligibility of their speech.

Another powerful organic factor influencing speech and language and resulting in deficient cognitive development is hearing loss, which affects the majority of children with Down Syndrome to different degrees of severity (see Roizen, 1997). Hearing loss can be caused by sensory-neural, conductive or a combination of both sensory-neural and conductive problems. It can be fluctuating or permanent. Deficient auditory discrimination is manifested in faulty articulation and deficient language development (on language development in Down Syndrome, see for example Miller, 1992).

In addition, many disorders of vision affect individuals with Down Syndrome. Up to 50% of children with Down Syndrome have been reported to be near- sighted and another 20% are far- sighted (Pueschel 2000). Strabismus may also limit learning through the visual modality. Sensory defects, visual and auditory, as well as olfactory and tactile, may all restrict or distort the processing of incoming stimuli, and further limit the child's learning about the world.

Mental retardation in Down Syndrome has been studied in relation to brain structure, morphology and cortical development. Brain changes of several types have been found, but they are highly variable in both number and severity. In one study, no relation was found between the number of brain anomalies and performance on the Peabody Picture Vocabulary Test among subjects with Down Syndrome (see Pearlson et al, 1998; see also Florez - Colloque Lyon 1990, p. 37). The high variability found in this study is similar to the high variability and the uneven distribution in the population of facial stigmata and other organic disorders (as for example congenital heart disease) and also cognitive functioning.

Facial stigmata of children with Down Syndrome, especially when mere are features that generate socially rejecting responses such as a protruding tongue (the face itself is not necessarily dysmorphic and may be quite attractive) are often associated with prejudices and stereotypes concerning mental retardation. Children with various types of physical deformities or stigmata are perceived as mentally subnormal to a higher degree than normal appearing children (see Strauss and Mintzker et al, 1988; Berscheid, 1980).


As frequently observed in our clinical work, it is not only the child's initial problem that renders mediational attempts ineffective. In many cases, internal barriers to mediation are reinforced by prevalent interpretations of the child's prospects for normal development and cognitive modifiability. Thus a child whose disorder, Down Syndrome, was diagnosed at birth will have been exposed to a double risk of becoming cognitively deficient, first as an outcome of an organic disorder, and then because less mediated learning experience may be provided by parents and other socializing agents (see Early Intervention: Blessing or Curse, Feuerstein, 1997 Existing attitudes towards the prospects of modifiability of children with Down Syndrome will lower the educational expectations of parents and teachers and discourage them from persevering in their mediating endeavors. The combination of these two categories of endogenous and exogenous factors can produce a severe lack of MLE when the child needs it most (see Mintzker, 1991).


Most individuals with Down Syndrome are assessed (psychometrically) to function in the mild to moderate range of mental retardation (IQ 40 to 69) with a few in the severe (IQ 25 to 39) category and some reported to be in the borderline normal range (Rynders, 1978). Contemporary studies tend to disprove previous data indicating that Down Syndrome is usually associated with severe mental retardation. Rynders (1997) reports that according to several studies, many children were functioning at the "educable" level and actually should have been accepted in inclusionary educational placements. Cunningham (1996) gives an account of a cohort survey (from 1973 to 1980) with findings of IQs ranging from under 20 to 100, with a mean around 50. Other researchers' findings are similar (see Pueschel, 2000).

Thus the evaluation of the cognitive capacities of people with Down Syndrome requires revision and there is a general trend to consider that these capacities have been unjustly underestimated. Many individuals can learn to read and write and acquire important daily life skills. However, nearly normal performance (in general or in certain fields) is often still considered to be exceptional and to characterize a minority at the extreme upper end of the curve of intelligence functioning (see for example Rondal, 1995, who presents an in-depth study of a young woman with Down Syndrome whose language is "unusually close to normal for a DS person, in spite of severe central cognitive limitations.")


Dynamic assessment of groups of children and young adults with Down Syndrome reveals a richness of findings indicating the existence of cognitive modifiability. In order to evaluate the ability to learn and improve abstract thinking we used, among other tests Raven's Colored Progressive Matrices. The Colored Progressive Matrices (Sets A, Ab, B) and the Standard Progressive Matrices (Sets A, B, C, D, E) were administered according to the LPAD procedures (see LPAD Revised Examiner's Manual, 1995 and Chapter 4 in this book), as well as the LPAD Set Variations instruments. The correct solution to Raven's Matrices (and the LPAD Set Variations) involves many higher order cognitive capacities: the capacity for observation and clear thinking, discrimination between identical and different figures, Gestalt completion, breakdown of the perceived whole into its constituent parts, and mental operations such as the forming of comparisons, reasoning by analogy, and others. According to Raven (1979), a "high-grade" mentally retarded person will not be able to solve the analogy tasks in part B, even with practice.

However, a very different picture emerges from examining children and youngsters with Down Syndrome using the MLE oriented dynamic assessment procedure, with variations in mediational intervention from mild to intensive. Our subjects with Down Syndrome, in spite of psychometric evaluations which would predict otherwise, are indeed able to engage in a process of learning and improving their cognitive capacities. To illustrate, findings on the results for Raven's Test for 20 individuals—children and young adults ranging in age from 8 to 25—will be presented. All were very poor students performing below the range of expected academic achievement for their age or grade. About half were diagnosed by psychometric tests (mainly Wechsler and Stanford-Binet) as having "borderline intelligence" or were within the "upper boundary of mild disability." Other assessments included "borderline intelligence with attentional deficit, hyperactivity, neuro-organic brain damage, poor judgment, deficient understanding of social situations" etc. One young man was assessed by the psychological service of the state social security agency as being "not mentally retarded". However, at age two he was assessed on the Gesell scales as having an IQ of 64; two years later he was "borderline", and then—still later—was categorized as "mildly mentally and generally retarded"—until he was found to be not retarded at all. Nonetheless, the previous diagnoses played a crucial role in the life of this young man with Down Syndrome, as he was placed from the beginning of his schooling in special education schools.

For the purposes of this chapter and to best illustrate the use of the LPAD with this population, I will not only focus on the more capable children, but also on the children who were defined mostly as exhibiting mild, or mild-moderate mental retardation. However, dynamic assessment showed how modifiable the children from both groups were when provided with mediated learning experience, and the levels of higher function and abstract thinking they were able to demonstrate and achieve. In particular, the scores obtained on the Raven Matrices administered according to the LPAD procedures showed the higher functioning subjects (who were below normative levels on conventional non-dynamic procedures) to be well within the normative range for their ages or grades in Israel (see Raven 1963 and Giantz, 1989). Some of these subjects were also administered the Standard Progressive Matrices—all or only a part. Their results corresponded to the 50th percentile respectively for their ages. These results are considerably above the attainment one would expect from individuals assessed to function significantly below average IQ, and run counter to Raven's and Jensen's contentions that such operations, as presented in the matrices, are inaccessible to the retarded performer (see Chapters 1 and 2). The LPAD test scores achieved by the lower functioning subjects were below the normative ranges but here too their performance on the tests was manifestly modified, as discussed below.

The main deficient cognitive functions or difficulties demonstrated in varying degrees by most of the subjects in both groups can be summed up in the following way: (1) taking into account two or more variables or sources of information simultaneously; (2) solving analogies—from learning to understanding the concept of analogical reasoning itself (in some instances developing an initial understanding of the concept of symmetry); (3) constructing efficient strategies to solve problems requiring analogical relationships; (4) comparative and summative behavior, and the capacity to integrate stimuli, instead of dealing with them in an episodic and fragmented way; that is, perceiving discrete parts of the designs without connecting them to each other to form whole entities. AH these difficulties are related to the lack of or impairment of abstract thinking.

Another set of difficulties derived from impaired perceptual processes and interfered with efficiency at the input phase. We found dysfunctions such as reduced or blurred perception, impaired Gestalt completion, limited attentional capability, and deficient orientation in space. Inadequate visual transport contributed to deficient output phase functions in many tasks. Impulsiveness was demonstrated both in the input and the output phases.

Visual and auditory memory were examined by two LPAD instruments—Associative Recall (using the original, non-adapted version of Rey, 1966) and 16 Word Memory (see descriptions in Chapter 4), since individuals with Down Syndrome are known to have memory dysfunctions, especially short-term memory (see Rondal op. cit., chs. 2, 5 and 6). In the Associative Recall task, memory function is assessed through the use of cues, using schematic figures that symbolize 20 objects that are first named aloud by the subject. The subject is then asked to recognize the reduced schemas, then these same objects from a more reduced visual cue (a "trace" level), and further to recall the original object in both conditions of reduction but with a different order of presentation. At the end of the test the examinee is asked to recall the original objects freely, in the absence of any visual cues. Mediation in this test is rather limited and consists of repeated and focused exposure to the stimuli—the drawings of objects and of reduced figures. Thus memory can be assisted by the capacity of symbolization. The results of this instrument with the Down Syndrome population demonstrate that most examinees, including those from the lower functioning group, benefited from the limited mediation and that symbolization processes were understood and used in the recall process. However, the examinees scored less well on the "free recall" than when the recall was based on the availability of visual symbols—somewhat contradicting earlier findings by Rey. Rey presented an average profile of 30 mentally retarded subjects, all of whom were in special schools. His data profile shows that the more schematic the figure, the more absent or faulty was the recall and recognition. There was almost no learning, and free recall scores were higher than the rest, suggesting that schemas or symbols that are not understood interfered with memory (see Rey, op. cit. chapt. 11), whereas our subjects demonstrated that they could benefit and understand schemas.

The capacity to recognize categories and to make use of them was revealed in the other mnemonic test, the 16 Word Memory Test. In the 16 words presented to the examinee there are hidden categories. Identifying them enhances memory. The examinee is presented the list of the words, is requested to listen to them as they are read aloud by the examiner, and to repeat them each time, engaging in four or more unmediated trials before mediation is directed to observed functions and cognitive processes. Most of the Down Syndrome subjects needed about five repetitions to recall all the words (ten repetitions is the maximum allowed), and many of them did not need mediation to discover that there were categories of words. They appeared to group them spontaneously first by association and then in a conscious, volitional way evidencing recognition of categories. This illustrates yet another facet of learning shown by the Down Syndrome subjects, which was very visible in this test (and which plays an important role in all LPAD assessments), namely, an awareness of the reflective processes which take place while working on the tests. Mediation is directed towards conscious, introspective insight into the use of concepts, and an understanding of operations and learning, which is within the potential behavioral and cognitive repertoire of the individual with Down Syndrome.

Visual-motor, hand-eye coordination difficulties and perceptual problems are frequently found in individuals with Down Syndrome. The Complex Figure Drawing Test (Rey, 1959) examines the capacity to integrate stimuli on the levels of perception, spatial organization, and planning, in a visual-graphic modality. A small study on another group of 14 children with Down Syndrome on this test shows that despite their perceptual and fine motor difficulties and impaired capacity for integration reflected in the spontaneous first copy, many subjects benefited from the mediation in the learning phase of this test. Mediating by modeling how to copy the figure and what sequence of working steps to follow, and mediating spatial concepts and organization transformed the performance of the subjects. They became able to modify their drawings (see figures 11.2 and 11.3).

Complex Figure Drawing Test Performance by a 12 year-old girl
Figure 11.2: Complex Figure Drawing Test Performance by a 12 year-old girl (Sally)

Figures 11.2 and 11.3 are examples of the Complex Figure Drawing Test by a 12- year old girl (Figure 11.2) and a 16- year old girl (Figure 11.3). Sally (in Figure 11.2) first refused to perform the test as requested and instead started tracing (i.e. putting the blank page on top of the model and tracing the figure). Then she copied, as requested. However, she drew the figure vertically, as young children often do, thereby finding a more concrete way of perceiving the complex figure that has no realistic meaning. The poor first memory drawing shows that this non-mediated activity (tracing, copying) did not bring about any learning. However, the MLE learning phase resulted in quite accurate copy and drawing from memory.

Complex Figure Drawing Test Performance by a 16 year-old girl
Figure 11.3: Complex Figure Drawing Test Performance by a 16 year-old girl

This learning is reflected, in particular, in the drawing from memory (as shown in Figure 11.4). This task demands representational thinking and planning—cognitive processes that one does not usually expect to be developed in individuals with Down Syndrome. Figure 11.4 shows the results for these 14 Down Syndrome children and youngsters on this test. The X-axis represents the normative mean score for this test, as established by Rey (1959), who scored by giving 2 points for a correctly drawn and positioned unit (line/figure), 1 point for a poorly drawn, but recognizable line and ½ point if this line was badly positioned, and 0 for an unrecognizable line, or no line (max. 36 points). This scoring method was used here. The Y-axis shows the differences (in percent) for each of the subjects from Rey's normative mean score, for the first copy, first drawing from memory, and then after mediation, for the second copy and second drawing from memory. In most cases, the subjects also scored lower in their first drawing from memory. However, following the learning phase, all subjects improved their scores (even when they remained below the norm). In all cases except one, the improvement was uniformly more marked in the drawing from memory than in the copy. This suggests that when prevented from following a model—given that the subject participates in a learning process and thus is equipped with new skills—he or she can learn to mobilize emerging new capacities (such as organization of space) and rely on the formation of an inner representation. For this reason, reproduction from memory proved at times to be more accurate than piecemeal copying.

Complex Figure Drawing Test
Figure 11.4: Complex Figure Drawing Test.
Differences (in percent) of subjects' scores from zero, the normative mean score (from Rey, 1959 without mediation) according to age.
Dot 1 = score for first copy; Dot 2 = score for first drawing from memory;
Dot 3 = second copy; Dot 4 = second drawing from memory.

In an additional analysis which is not presented here we found that the changes that occurred first were in the conceptual organization of the figure, and only secondarily in the graphic accuracy of the figures and the relative proportions of the different parts of the whole. The work on the Complex Figure Drawing Test illustrates a finding that is seen in other tasks and other modalities as well, namely that given the right conditions of learning and MLE, individuals with Down Syndrome can attain higher levels of functioning than that usually expected or believed to be typical of most of them.


The goal of the qualitative analysis of the learning processes occurring during dynamic assessment is to discover what cognitive dysfunctions were manifested, to what extent they were modified, and what brought about these modifications. The list of dysfunctions discussed above is not inclusive although it is illustrative. Many cognitive deficiencies presented by our examinees, representing substantial dysfunctions, were modified during the process of the administration of the LPAD instruments. Cognitive modification was observed in each of the instruments administered. In about two thirds of the cases, the LPAD was repeated twice or more after a period of time, and improvement (to varying extents) in subject performance was observed (taking age into account). This improvement over time is indicative that the changes experienced in the assessment have become part of the individual's cognitive structure. Sometimes meaningful improvement was not so much in the resulting performance but rather in the drop in amount of mediation (e.g., duration, intensity, type) required in the various tasks, especially the analogies.

By analyzing the ways subjects work and respond to various approaches and methods of mediating a number of conclusions can be drawn regarding the effectiveness of the different interventions, and a tentative path of steps of mediated learning can be delineated. The first two steps were teaching or mediation of concepts when there were hardly any concepts at all, or mediation of the active use of concepts when they were passively known (that is, possessed by the examinee but not spontaneously or efficiently manifested). Passive knowledge was often observed in the subject's ability to rapidly acquire a concept that had not been used spontaneously—as for example a spontaneous correction on a Raven or LPAD Set Variations problem.

Almost simultaneously, and sometimes as an initial objective of mediation, the next step in the process of modifiability is the acquisition of a systematic approach to the tasks, strategies, orderly explorative behavior, work discipline and restraint of impulsiveness. In other words, what is important is the mediation of self- regulation and control of behavior. This facet of learning lays the foundation for further learning, and higher reflective processes such as representational thinking and analogical reasoning.

Repetitions also are very important. Learning a new approach or pattern of functioning needs consolidation in order to become an integral part of the individual's cognitive abilities and functioning. The LPAD sessions cannot provide stable internalization but only indicate propensity for modifiability and accordingly lead to the setting up of educational goals. However, whenever we repeat certain tests, there is an improvement in learning itself. This does not only apply to LPAD situations. In a study concerned with object concept testing of children with Down Syndrome it was found that: (1) a single testing session often inadequately measured competence, and (2) concepts which had been inadequately consolidated at the time of the initial acquisition were lost, and therefore a test given later often yielded poor results. However, performance improved very rapidly in additional sessions when children seemingly re-acquired former learning (Wishart, 1990).


The case of Natalie captures some of the general principles presented in this chapter. In spite of the presence of constitutional and medical factors that could have impaired her learning processes (and which are usually considered as a handicap limiting normal development), Natalie's intellectual faculties have evolved and increased. Natalie's medical problems consisted of ocular disorders involving congenital cataracts, refractive problems, myopia (that reduced sustained visual focusing and efficiency), hearing loss, hypothyroidism and diabetes. Her work and behavior during the assessment revealed the learning and establishment of good thinking patterns and work discipline. This was reflected in her approach to problems, her analysis of task components, the way in which she adopted methods and strategies, controlled her impulsiveness, and systematically gathered information. She also learned to justify her answers, and to present logical evidence. Natalie showed, in her response to the LPAD instruments, a readiness to receive mediation and assistance, and an aspiration to work independently.

On several occasions we have witnessed a process of transfer of principles in the process of learning: one such instance was by an 11 year old girl during the LPAD evaluation who generalized what she had learned to other tasks done at home, such as sorting and ordering arithmetic exercises according to the structure of the equation (this had not been in the specific content of any LPAD task, but could well be implicitly learned, as for example while working on matrices, the Complex Figure Drawing, and the like). We frequently encounter children who were assessed on the LPAD bringing back to us copies of Complex Figure Drawings done many weeks or months after the assessment, and being quite aware and proud of their accomplishments—"Look at what I learned and still remember!"


In addition to cognitive factors, the assessment of an individual's learning propensity, both through the LPAD and in general, is sometimes hampered by certain situational by-products of conflicting pressures operating on the child with Down Syndrome. Children may at times not cooperate with the LPAD examiner (or teacher or parent). As soon as a learning session begins, a child who would in other circumstances be friendly and participate in a diversity of games and other activities, may refuse to follow instructions, listen, look, or do anything that relates to learning. The child seems to reject any attempt at mediation. (This rejection is very different from the phenomenon of unresponsiveness in children from the autistic spectrum). Such attitudes towards learning are not only socially problematic. They are detrimental to any learning process and must be dealt with in order to enable the child to learn. A variety of reasons may cause this behavior, including a feeling of frustration at not achieving what other children seem to do effortlessly, habitual fear of repeated failure; very low expectations; no practice in engaging in unknown and unfamiliar tasks which seem to be too hard in the child's opinion, or having little or no prior experience with meeting challenges. Sometimes the child's wish to prove his or her autonomy will be expressed in a negative manner for lack of positive means to prove it by mastering new skills. As with all applications of dynamic assessment, and for all populations, these questions become the focus of mediational interventions.

One cannot overestimate the importance of the special structure and characteristics of the LPAD procedure. Optimal conditions are essential to motivate the child to open up to mediation and help to overcome a lack of self-confidence when faced with unfamiliar contents. The child must be allowed to work slowly, and have strategies explained gradually. The examiner's reward will be to share the child's joy and happiness when a task is completed successfully. As success increases so too will the desire and need to continue to learn, to master skills and thus acquire feelings of competence so crucial to this group.