Social cognition in children with Down’s syndrome ... · that may be unique to Down’s syndrome, and high-light areas in which critical data are missing. Along with outlining some

Social cognition in children with Down’s syndrome:challenges to research and theory buildingjir_1215 1..22

K. R. Cebula,1 D. G. Moore2 & J. G. Wishart1

1 Moray House School of Education, University of Edinburgh, Edinburgh, UK2 Institute for Research in Child Development, School of Psychology, University of East London, London, UK

AbstractCharacterising how socio-cognitive abilities develophas been crucial to understanding the wider devel-opment of typically developing children. It isequally central to understanding developmentalpathways in children with intellectual disabilitiessuch as Down’s syndrome. While the process ofacquisition of socio-cognitive abilities in typicaldevelopment and in autism has received consider-able attention, socio-cognitive development inDown’s syndrome has received far less scrutiny.Initial work in the 1970s and 1980s provided impor-tant insights into the emergence of socio-cognitiveabilities in the children’s early years, and recentlythere has been a marked revival of interest in thisarea, with research focusing both on a broaderrange of abilities and on a wider age range. Thisannotation reviews some of these more recent find-ings, identifies outstanding gaps in current under-standing, and stresses the importance of thedevelopment of theory in advancing research andknowledge in this field. Barriers to theory buildingare discussed and the potential utility of adopting atransactional approach to theory building illustratedwith reference to a model of early socio-cognitivedevelopment in Down’s syndrome. The need for a

more extensive model of social cognition is empha-sised, as is the need for larger-scale, finer-grained,longitudinal work which recognises the within-individual and within-group variability which char-acterises this population. The value of drawing onnew technologies and of adapting innovativeresearch paradigms from other areas of typical andatypical child psychology is also highlighted.

Keywords behavioural phenotype, developmentaltheory, Down’s syndrome, social cognition

Introduction

Definitions of intellectual disability (ID) changefrom decade to decade as research refines ourunderstanding of the challenges faced by those withsignificant levels of cognitive impairment. Alongsiderecognition of core cognitive difficulties, most defi-nitions of ID, past and present, refer to associateddifficulties in social adaptation. This wide-rangingterm covers both social coping and self-help skills,as well as more complex perceptual and interpreta-tive socio-cognitive processes.

In the field of IDs, there has been a perhapsunderstandable tendency for researchers to focusmore on studying children’s immediate social needsthan on exploring the socio-cognitive processes thatunderpin social behaviours and drive more complex

Correspondence: Dr Katie Cebula, Moray House School ofEducation, University of Edinburgh, Holyrood Road, EdinburghEH8 8AQ, UK (e-mail: [email protected]).

Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2009.01215.x1

© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd

forms of social learning. With the exception of thestudy of autism and Williams syndrome, there hasin fact been relatively little research into socio-cognitive development in children with IDs. Thismay be in part because of the clinical, life-skillsfocus of much research, but also perhaps becausesocial cognition is seen as the softer sister of ‘pure’cognition and not therefore the primary source ofthe everyday difficulties experienced by those withIDs.

In the case of Down’s syndrome, an additionalfactor contributing to this paucity of research maybe the stereotypical perception that children withDown’s syndrome are highly sociable and havegood ‘people’ skills (Down 1866; Rogers 1987;Wishart & Johnston 1990; Hines & Bennett 1996;Wishart & Manning 1996; Gilmore et al. 2003a;Fidler et al. 2008). This has led to a widely heldassumption that their social understanding isrelatively intact. This lack of research seemsunfortunate, as social processes have long beenacknowledged as a major driver of cognitive devel-opment in typically developing children (see e.g.Bruner 1963; Trevarthen 1977, 1979; Vygotsky1978; Flavell 1999; Flavell et al. 2002; Hobson2002; Carpendale & Lewis 2006; Zlatev et al. 2008)and there seems little reason to assume that thesesocial processes play any less of a role in the overalldevelopment of children with Down’s syndrome(for review, see Cebula & Wishart 2008). Indeed,one key theoretical challenge for this field is to rec-oncile the seemingly outgoing nature of childrenwith Down’s syndrome with their poor rate of cog-nitive development and the apparent decline in thisas they grow older (Dunst 1990; Hodapp & Zigler1990; Wishart & Duffy 1990; Carr 1995; Hodappet al. 1999).

Although social cognition in Down’s syndromehas been rather neglected in recent decades, agrowing number of researchers are now beginningto focus their attention on this core area of develop-ment. Building on the early work of Zigler and hiscolleagues (e.g. Zigler 1969; Zigler & Hodapp1986), recent studies have taken a developmentalapproach to teasing out where the socio-cognitivechallenges lie for children with Down’s syndrome.Rather than focusing on just differences or deficitsin developmental processes, researchers have alsolooked through the ‘lens’ of typical development at

the whole child and at the environment in whichthey grow and learn (Burack 2008). This has beencomplimented by the parallel trend of contrastingthe development and developmental pathways ofchildren with IDs of differing aetiologies in thecontext of behavioural phenotype theory, anapproach which involves the identification of dis-tinct profiles of development associated with spe-cific genetic syndromes (e.g. Dykens 1995; Dykenset al. 2000; Fidler 2005; Oliver & Woodcock 2008).

For the purposes of this annotation, social cogni-tion is broadly defined as the ability to make senseof other people (Kunda 1999) and includes theability to plan and execute appropriate ways ofresponding in everyday social contexts. Within thewide-ranging hierarchy of relevant abilities, there isa need to distinguish lower-level (though still essen-tial) perceptually driven processes from morecomplex cognitively driven abilities (see e.g. Tager-Flusberg & Sullivan 2000). In typical development,the core processes involved are first evidenced veryearly in life, primarily in episodes of emotionalengagement with others, and subsequently inincreasingly complex interpersonal interactions,with the latter supported by rapidly growing com-municative and language skills. The earlier aspectsof social understanding are sometimes referred to associal-perceptual abilities. Later, children develop amore interpretive understanding – a ‘theory’ thatother people have intentions, thoughts, beliefs andemotions, and that these influence their behaviourand how they interact with others (see e.g. Carpen-dale & Lewis 2006; Chiat & Roy 2008; Reddy2008). Because these later developing skills mayrequire some level of interpretation, they are oftentermed socio-cognitive abilities.

This annotation begins with a brief synopsis ofkey issues in the understanding of socio-cognitivedevelopment and then goes on to look at findingsfrom studies of social cognition in children withDown’s syndrome. Our aim is to provide an over-view of the current literature on the development ofsocial cognition in Down’s syndrome and to relatethis to current knowledge of typical development.We also begin to identify developmental pathwaysthat may be unique to Down’s syndrome, and high-light areas in which critical data are missing. Alongwith outlining some of the practical and conceptualobstacles which face researchers in this field, we

2Journal of Intellectual Disability Research

K. R. Cebula et al. • Social cognition and Down’s syndrome


consider the challenges the field faces in developingtheories of social cognition relating to this specificchild population and in applying them to developtailored interventions.

Key issues in social cognition

In typical infants, studies of social cognition havefocused mainly on joint attention, imitation andsocial referencing, and on the importance of car-egiver interaction and the development of attach-ments (see e.g. Rochat & Striano 1999; Bornstein &Tamis-LeMonda 2001; Eckerman & Peterman2001; Lock 2001; Meltzoff 2007). In pre-schoolchildren, the focus has been predominantly on theemergence of pro-social behaviours, theory of mindand moral understanding, and in older children, onthe nature of peer relations, the origins of antisocialbehaviours and the developing cognitive complexityassociated with these areas of functioning.

Work in the last 20 years has greatly clarified thenature of early socio-cognitive capacities and hascatalogued the sequence of their emergence in typi-cally developing infants. However, there is still noconsensus about how this understanding emerges(see e.g. Hobson 2002; Carpendale & Lewis 2004;Reddy 2008). There are ongoing debates about therelationships between and the relative importance ofeach aspect of functioning, about whether someaspects of social cognition are domain specific ornot (Saxe & Powell 2006; Stone & Gerrans 2006;Leekam et al. 2008), and about the nature of thetransactions between genes, brain, behaviour, cogni-tion and the environment (Karmiloff-Smith 2006,2007, 2009). Understanding social cognitionrequires integrated models of social developmentthat consider all levels of explanation, from molecu-lar genetics to the role of parenting. However, indi-vidual fields have become highly specialised andthere has been limited progress in developing anover-arching theory of socio-cognitive development,largely, we suspect, because of the rapidity withwhich new data are emerging in each of these dis-tinct fields of investigation.

One highly theoretical yet somewhat insular areaof research in social cognition in recent years hasbeen in the area of ‘theory of mind’. This focuseson children’s developing understanding of the

mental states of others, and on how they use thisinformation to predict and relate to the behaviourof adults and other children in social contexts(Wellman 1990). There is considerable debate aboutthe developmental sequelae of a ‘theory of mind’,with arguments about the relative importance ofperceptual processes and cognitive capacities suchas executive functioning and about the role of jointattention, empathy, emotion recognition and imita-tive capacities (see e.g. Carpendale & Lewis 2004;Bull et al. 2008). These debates have been invigo-rated by findings from the field of social-neuroscience. For example, recent work hasdiscovered mirror neurons, which respond to theintended actions of others at a sub-threshold leveland may give access to the minds of others throughsimulation of their emotions and intentions (Iaco-boni & Dapretto 2006, but see Gallagher 2007 for acritique). Understanding of the role that joint atten-tion and emotional patterning may play in thedevelopment of theory of mind, and in underpin-ning our abilities to ‘identify’ with others, is alsostill being developed (see e.g. Hobson & Hobson2007; Tomasello et al. 2007).

These ongoing debates over theory of mind havebeen closely linked with attempts to understand thenature of autism and have consequently focusedspecifically on those aspects of social functioningwith which children with autism have difficulties.While this approach has been fruitful, and hasyielded many important new theoretical perspec-tives on both autism and typical development, thefocus on autism may mean we have been underesti-mating the significance of aspects of behaviourthat may lead to differences in social cognition inchildren with other IDs. The detailed study ofsyndrome-specific developmental trajectories mayreveal small differences in early behaviour that arenot the primary source of social difficulties for chil-dren with autism, but which could nevertheless leadto unique developmental pathways. In the case ofDown’s syndrome, the children have often beeninvolved in social cognition studies only as controlparticipants, the implicit assumption being thatapart from being cognitively delayed they are other-wise socially typical. As we will highlight below, thisassumption may be false and there may be someareas of social cognition in which children withDown’s syndrome exhibit unique patterns of




behaviour. A better understanding of these differ-ences in Down’s syndrome and in other distinctivesyndromes is essential to building more completetheories of typical and atypical development(Karmiloff-Smith et al. 2004; Karmiloff-Smith2006, 2007, 2009).

Social cognition in children withDown’s syndrome

Much of the early research on the social abilities ofchildren with Down’s syndrome was undertaken inthe 1970s and 1980s. This tended to focus oninfants and toddlers, studying the precursors ofsocio-cognitive abilities which emerge in later child-hood and beyond. In many respects, development atthese early stages was found to be very similar totypical development in terms of the sequence inwhich early abilities unfolded (for overview, seeCicchetti & Beeghly 1990). However, there was alsoevidence of subtle differences in how children withDown’s syndrome attend to the social world aroundthem, differences which might well impact on thedevelopment of later, more complex, socio-cognitiveabilities such as emotion recognition, theory ofmind and empathy. Differences in these early inter-personal responses may also influence languagedevelopment, which in turn plays a central role inthe development of successful interpersonal func-tioning at later ages.

One example of differences in social attentionseen at the very earliest stages of development is inmutual gaze with caregivers (looking into eachother’s eyes). This is initially slow to emerge in chil-dren with Down’s syndrome, although by later inthe first year, as typically developing infants focuson the wider social and physical world around themand mutual gaze begins to decline, it continues tobe maintained at high levels (Berger & Cunningham1981; Carvajal & Iglesias 2000). This heightenedattention to people may be indicative of a higherlevel of inherent sociability (Ruskin et al. 1994), butit could also be an indication of a poorer ability toswitch attention efficiently between people, objectsand the environment.

Work by Legerstee & Weintraub (1997) indicatesthat although infants with Down’s syndrome dodevelop joint attention (directing their gaze in the

direction that others are looking or pointing), theiracquisition of this important ability is slower thanin typically developing children of a similar develop-mental age. Even when infants are able to initiatejoint attention episodes, they tend to spend moretime as passive participants, sharing attention toobjects with adults rather than coordinating atten-tion by actively pointing to objects themselves.These differences may become more apparent withage. Legerstee & Fisher (2008), for example, reportthat differences in joint attention between infantswith Down’s syndrome and typically developinginfants, while not apparent at a mental age of 9

months, were more evident by 18 months. Kasariet al. (1995), however, have reported similar fre-quencies of joint attention in young children withDown’s syndrome in comparison with typicallydeveloping children, and it may be that differencesarise only in specific contexts, such as those with ahigh cognitive load (see also R.P. Hobson et al.,unpublished data).

From the latter half of the first year onwards,typically developing infants gradually develop theability to use nonverbal gestures such as pointingand requesting. These support the child’s acquisi-tion of language and open up a world of possibili-ties for learning about objects and people in thesurrounding environment. In general, it has beenfound that young children with Down’s syndromeuse pointing and requesting gestures competently tocommunicate with others. However, there are againsome subtle differences, particularly in the use ofrequesting gestures, with the children making fewersuch spontaneous gestures than their mental-agematched peers (Mundy et al. 1988; Franco &Wishart 1995; Fidler et al. 2005). Again, contextproves to be important, with this diminished use ofrequesting behaviours less pronounced in socialthan in toy-play situations (Fidler et al. 2005). Workby Adamson et al. (2009) comparing children withDown’s syndrome, autism and typically developingchildren of similar language ability found that thechildren with Down’s syndrome were more likely tobe unengaged during contexts designed to encour-age requesting or commenting than during contextsdesigned to encourage simple interaction, a differ-ence not seen in typically developing children (notsurprisingly perhaps, the children with autismshowed significantly less engagement across all




contexts). The authors interpret this as indicativenot only of differences in willingness to becomeengaged in specific kinds of interpersonal interac-tions, but also as evidence of how different dis-orders impact differently within different socialcontexts. They also drew attention to specific differ-ences in ‘symbol-laden’ (i.e. language-based) jointattention, which they suggest may be particularlyproblematic for children with Down’s syndrome.

The imitation of others is widely recognised as abehaviour which is crucial to learning in the earlyyears. The ability to imitate is evident very soonafter birth in typically developing infants (Meltzoff& Moore 1977, 1989) and underpins both thedevelopment of relationships with others andsocially-based learning. Down himself (1866) drewattention to the ability of children with Down’s syn-drome to imitate others, and indeed a number ofstudies suggest that this may be a relative strength,something which fits with evidence of the childrenbeing, at times, more socially orientated than theirtypically developing peers (Neeman 1971; Pueschelet al. 1987; Hodapp et al. 1992; Rast & Meltzoff1995). However, while there is some evidence forintact neonatal imitation in newborns with Down’ssyndrome (Heimann et al. 1998), there is also evi-dence from a large-scale longitudinal study ofmarked differences in the growth of vocal imitationover the first 3 years of life, with a clear slowingdown in the acquisition of key stages with increas-ing age (Dunst 1990). Work by Wright et al. (2006)likewise suggests that there may be important dif-ferences in how imitation is used by toddlers withDown’s syndrome, with imitative strategies appliedto solve cognitive tasks in situations where moreindependent, cognitively-driven strategies, as usedby typical children of comparable cognitive level,would be more appropriate and more successful.The authors suggest that this imitative ‘bias’ mayresult from a predisposition to attend to social,rather than non-social, aspects of the world.

Another important socio-cognitive tool for inter-acting and learning from others is social referenc-ing, the ability to use emotional cues from others ininterpreting shared contexts. Social referencingstudies with young children focus on the extent towhich they use their parent’s affective reaction to asituation to guide their own response. Findingsindicate that children with Down’s syndrome may

make fewer and shorter social referencing looksthan typically developing children, with their ownresponses often incongruent with the parent’s affec-tive reaction (Knieps et al. 1994; Kasari et al. 1995).This suggests that even in the early years, childrenwith Down’s syndrome may have difficulties inemotion recognition and/or in making use of thisinformation to guide their own behaviour.

These early developing capacities for joint atten-tion, non-verbal requesting, imitation and socialreferencing underpin children’s ongoing relation-ships with people and their interactions with objectsin their environment. In typical development, theseearly capacities lead on to the development ofincreasingly complex socio-cognitive abilities, suchas understanding emotions and theory of mind.

Studies with school-aged children with Down’ssyndrome suggest that the difficulties with emotionrecognition found in social referencing studiesmight continue into later years. Tasks using photo-matching or puppet paradigms to explore emotionrecognition have shown that in comparison withtypically developing children of a similar level ofcognitive ability, some children with Down’s syn-drome may experience difficulties in recognisingsome of the core facial expressions of emotion. Dif-ficulties have been found in particular with the rec-ognition of fear, surprise and anger (Wishart &Pitcairn 2000; Kasari et al. 2001; Williams et al.2005; Wishart et al. 2007a), with similar findingsrecently reported in a study with adults (Hippolyteet al. 2008). To date, the difficulties found havebeen relatively subtle and the evidence for asyndrome-specific profile of emotion recognitiondifficulties is not yet strong, as comparisons withchildren with other aetiologies such as non-specificID or fragile X syndrome have found few significantbetween-group differences (Turk & Cornish 1998;Wishart et al. 2007a). Nevertheless, across anumber of these studies, in comparison with closelymatched groups of typically developing children,evidence has been found for some differences inthis important aspect of social understanding.

Research into other areas of social cognition,such as theory of mind, similarly suggest that chil-dren with Down’s syndrome may experience diffi-culties in this domain, but with these difficultiesbeing less obvious and more subtle than thosefound in children with autism (Yirmiya et al. 1996;




Zelazo et al. 1996; Abbeduto et al. 2001; Binnie &Williams 2002). Studies of empathic responses alsoreveal some differences, with children with Down’ssyndrome not only showing equivalent, or higher,levels of pro-social empathetic behaviours than typi-cally developing children of similar cognitive andlinguistic ability in situations where an adult isaffecting distress, but also showing lower levels ofaffective responses themselves (Kasari et al. 2003).A relative dampening of affective responses, in par-ticular a tendency not to show distress, has forsome time been suggested as a core feature ofinfants with Down’s syndrome (Emde et al. 1978).

Overall then, studies to date suggest that while itmay appear that socio-cognitive development inDown’s syndrome unfolds in a similar fashion tothat seen in typical development, albeit at a slowerrate, there are also some important qualitative dif-ferences. Despite the common assumption that chil-dren with Down’s syndrome have a predispositionfor being sociable, there is evidence from a widevariety of studies of subtle differences across arange of socio-cognitive abilities, from early infancyonwards. These differences occur in combinationwith difficulties in developing efficient task-orientated strategies in problem-solving tasks(Wishart 1993, 1996; Pitcairn & Wishart 1994;Kasari & Freeman 2001; Jahromi et al. 2008), diffi-culties with goal-directed persistent behaviour(mastery motivation) on challenging tasks forinfants and toddlers (Glenn et al. 2001, but see alsoGilmore et al. 2003b contrasting results at slightlyolder ages), and lower levels of mastery motivationas measured by parental ratings from infancythrough to the early school years (Ruskin et al.1994; Glenn et al. 2001; Gilmore et al. 2003b).Taken together, these differences may account, atleast partially, for differences seen in interactionswith peers and adults in both social and educationalcontexts (e.g. Wishart et al. 2007b). They must alsoundoubtedly add to problems in developing inter-personal relationships throughout life, and may ulti-mately impact on quality of life and mental healthin adulthood.

There are still many gaps in our knowledge ofsocial cognition in Down’s syndrome and explana-tions for socio-cognitive difficulties at the neurologi-cal, cognitive and environmental level all need to beconsidered. Unravelling these different contributory

factors presents a considerable challenge. At theneurological level, there is evidence of both struc-tural and processing differences in Down’s syn-drome which may be tied to the socio-cognitivedifficulties evidenced at different stages in the chil-dren’s development. For example, some areas of thetemporal limbic system – an area crucial for theprocessing of emotions – have been found to bedisproportionately reduced in volume and complex-ity in Down’s syndrome, although this seems torelate more to the hippocampus than to theamygdala (Aylward et al. 1999; Pinter et al. 2001;Jernigan et al. 1993). The frontal cortex is also dis-proportionately reduced in volume (Jernigan et al.1993) and during visual recognition tasks there isevidence of differences between typically developinginfants and those with Down’s syndrome in frontaland parietal site brain activity (Karrer et al. 1998).Knowledge of any underlying neuropathology andof differences in neurological processing in childrenwith Down’s syndrome is still remarkably limited,but differences such as these may well be implicatedin the difficulties seen in socio-cognitivedevelopment.

Neurological differences have also been linked tocognitive development more broadly in Down’s syn-drome. For example, there is some evidence thatchildren and adults with Down’s syndrome experi-ence difficulties with some ‘executive functions’ –goal-directed behaviours which are linked to thedevelopment of frontal areas of the brain (Zelazo &Stack 1997; Karrer et al. 1998). For example, diffi-culties with set shifting, verbal short-term memoryand dual-task processing have all been reported(Zelazo et al. 1996; Jarrold & Baddeley 1997; Jarroldet al. 2000; Brock & Jarrold 2005; Rowe et al. 2006;Kittler et al. 2008). If these difficulties are presentat younger ages, they may contribute to problemswith aspects of early socio-cognitive developmentsuch as joint attention. Additional difficulties withexpressive language and syntactic developmentwhich emerge in the preschool years (Fowler 1990;Miller 1999; Chapman 2003; Roberts et al. 2007),as well as long-term memory difficulties (Penning-ton et al. 2003), may further contribute to problemswith the development of subsequent, more complexsocio-cognitive abilities.

It must also be recognised that this profile ofsocial and cognitive strengths and weaknesses will




shape the children’s social environment and changethe landscape of their social interactions with chil-dren and adults, at home and at school. From thefirst year onwards, differences in caregiver interac-tions and parenting style can be observed, withcaregivers adjusting their style of interaction in anumber of ways to adapt to their children (Slonims& McConachie 2006). For example, while there aresimilarities between mothers of toddlers withDown’s syndrome and mothers of typically develop-ing toddlers in play situations (e.g. both becomeattuned to the child’s level of play and contribute tothe child’s play development), there are also cleardifferences, with maternal interaction leading toincreases in exploratory play in toddlers withDown’s syndrome but to increases in sophisticatedsymbolic play in typically developing toddlers(Venuti et al. 2009). Mothers may develop means ofadapting to meet their child’s specific developmen-tal needs. Studies have also reported, for example,that mothers of young children with Down’s syn-drome provide more supportive behaviours thanmothers of other children and may take moreopportunities to stimulate their child during play, astyle of interaction characterised as ‘directive butwarm’ (Buckhalt et al. 1978; Sorce & Emde 1982;Cielinski et al. 1995; Roach et al. 1998; Moore et al.2008). These patterns of interaction may be a posi-tive response to limitations in the infant’s attentionregulation and information-processing capacity,although as Moore et al. (2002, 2008) point out,the longer-term developmental implications of theseinteractive styles may not necessarily be positive ifthey interfere with the infant’s own development ofa sense of agency. As noted by Moore et al., furtherlongitudinal studies are required to explore thelong-term impact of maternal interaction style. Anysuch work should consider other variables, includ-ing parent demographic factors, stress levels, cogni-tive coping strategies and perceptions of theirchild’s behavioural characteristics, as these all havethe potential to influence mother–child interaction(see e.g. Atkinson et al. 1995; Kasari & Sigman1997). It is of note here that although mothers ofchildren with Down’s syndrome have in the pastbeen considered to have relatively low levels ofstress, compared with mothers of children withother developmental disabilities, in fact this‘Down’s syndrome advantage’ may be less substan-

tial than often assumed, and partly explained bymaternal age and child adaptive behaviour levels(Corrice & Glidden 2009). The potential influenceof culture on maternal interactive style must also beconsidered. For example, the often reported higherlevel of directiveness has not been found in Italianmothers of toddlers with Down’s syndrome (Venutiet al. 2009), something which the authors suggestmay relate to cross-cultural differences in maternallevels of sensitivity and sociability towards theirchildren. Maternal interactive style is also likely tobe highly variable. For example, Venuti et al. (2008)report marked individual differences in sensitivitylevels in mothers of children with Down’s syn-drome, something which contributed to differentialeffects on their children’s symbolic play.

Differences in mothers’ interaction styles con-tinue as the child develops. Kasari et al. (2001), forexample, note evidence from Tingley et al. (1994)that mothers of 3- to 8-year-old children withDown’s syndrome use fewer emotional and cogni-tive state terms in meal-time conversations withtheir children than mothers of typically developingchildren do. Again, although this adjustment may beto better meet the ability level of their child, it hasbeen suggested that it could also contribute to latersocio-cognitive difficulties, in areas such as emotionrecognition (Kasari et al. 2001). There is growingevidence from studies of young, typically developingchildren that maternal talk about mental states pro-vides a ‘stepping stone to others’ minds’ (Taumoe-peau & Ruffman 2008), predicting children’s ownuse of mental state language, theory of mind abilityand emotional understanding (Meins et al. 2002;Taumoepeau & Ruffman 2006, 2008; Ensor &Hughes 2008). There is no reason to assume thatthis would not also be the case in Down’s syn-drome, but as yet this developmental pathway hasnot been explored.

To date, with few exceptions (e.g. Knott et al.1995, 2007; de Falco et al. 2008), studies in thisfield have focused primarily on early mother–childinteractions and rather less is known about howinteractions with fathers, siblings and peers shapedeveloping socio-cognitive abilities at either youngeror older ages. This is an area ripe for investigation.In relation to father–child interactions, it is not cur-rently clear whether fathers adopt the same ‘direc-tive but warm’ style shown by mothers, although




very recent research on emotional availability sug-gests there are no differences in terms of sensitivity,structuring of interactions, or intrusiveness, nor arethere significant differences in child responsivenessin the early years (de Falco et al. 2009). Positivepaternal influences on the play of preschool chil-dren with Down’s syndrome have also beenreported (de Falco et al. 2008), with childrenshowing more symbolic play in sessions with theirfathers than in solitary sessions, particularly whenfathers displayed a high degree of emotional avail-ability. However, there appears to have been noresearch on father–child interactions at older agesand none directly comparing the extent to whichfathers of children with Down’s syndrome maydiffer from fathers of typically developing childrenin their interactive style.

It has long been argued that sibling relationshipsare critically important to the acquisition of socialabilities in childhood (Dunn 1988a, b), and manysiblings play a major role in the social life of thechild with Down’s syndrome. While there has beensome detailed family research on the effects on sib-lings of having a brother or sister with Down’s syn-drome (e.g. Cuskelly & Gunn 1993, 2003, 2006;van Riper 2000), there have been few investigationsof the actual nature of sibling interactions at differ-ent ages and at different developmental stages.Ambramovitch et al. (1987) studied sibling interac-tions and reported that, irrespective of birth orderor gender, the child with Down’s syndrome tendedto adopt the role of the ‘younger’ sibling, imitatingthe actions of their typically developing brother orsister and following their lead rather than initiatingactivities themselves. Similarly, Stoneman et al.(1987) and Knott et al. (2007) have reported strongrole asymmetries in observed interactions, with sib-lings often taking on a ‘teacher’ role. AlthoughKnott reported some increase in frequency of initia-tion of pro-social interactions by the children withDown’s syndrome over a 1-year period, this provedto be largely the result of the typically developingsiblings ‘stage-managing’ the interactions. Thissibling interactive style shows some parallels withthe warm directive style reported as characteristic ofmothers of infants with Down’s syndrome, andagain, although well-motivated and possibly produc-tive in the short-term, the longer-term effects of thisstrategy on the development of the children’s socio-

cognitive understanding and on their future expec-tations of social partners are unclear.

While it seems likely that some of the differencesin socio-cognitive development described in thispaper would also impact on, and be influenced by,peers, most research on peer interactions in chil-dren with IDs has focused on heterogeneousgroups. As such, little is known specifically aboutpeer interactions in children with Down’s syn-drome. Studies do suggest some similarities withdevelopmentally-matched children in terms of thecharacteristics of the children’s involvement withpeers, such as number of regular playmates and fre-quency of contact with peers (Guralnick 2002;Guralnick et al. 2009a,b), although it is notable thatsome mothers of 4- to 7-year-olds with Down’s syn-drome in the Guralnick et al. studies could notidentify a single regular, out-of-school playmate fortheir child. In addition, while many children withDown’s syndrome in their early school years maymeet the criteria for having a reciprocal friendship,unlike typically developing children, these relation-ships may not be with children of a similardevelopmental level, leading to concerns over theirlong-term stability (Freeman & Kasari 2002).Moreover, as Guralnick and his colleagues note,it is often parents and teachers, rather than thechildren themselves, who initiate, structure andsupport these peer interactions and friendships.

Despite a widespread perception that sociability isa relative strength in children with Down’s syn-drome, the teachers in Guralnick et al.’s (2009b)study in fact rated the children as being less pro-social and more asocial than either their age- orstage-matched typically developing peers and asneeding the greatest amount of assistance in gettingplay started, remaining involved, understandingsocial rules and knowing how to play with others.They were also rated as more distractible andhyperactive and as having higher levels of behav-ioural problems than their typically developingmatches, all characteristics likely to be disruptive topeer interactions within the classroom.

Given the emphasis on improving educationalattainment in recent decades, it is perhaps remark-able how little research there has been examiningthe nature and outcomes of peer interactions withinthe classroom for the child with Down’s syndrome.One recent exception is a study which looked at




collaborative problem-solving in three performance-matched child groups: typically developing children,children with non-specific ID and children withDown’s syndrome (Wishart et al. 2007b). On thebasis of individual pre-test performance on a shapesorting task, collaborative pairs were formed inwhich one partner was slightly more able at sortingthan the other, although this was not made explicitto the children. Following the collaborative session(working jointly on a furniture sorting task), indi-vidual post-test shape sorting scores indicated sig-nificant improvement in lower ability partners inthe typically developing pairs and in higher abilitypartners in the pairings made up of two childrenwith non-specific ID. Neither partner improved sig-nificantly in pairings in which one partner hadDown’s syndrome and the other non-specific ID,however, suggesting that the sociability attributed tochildren with Down’s syndrome did not necessarilysupport either their or their partner’s learning inthis particular socio-cognitive context. Interactionswere in fact characterised by low levels of bothsocial and task-related communication, with the‘partners’ sometimes simply working in parallel onthe set task. Collaborative interaction was alsonoticeably more limited and was less frequently ini-tiated by the partner with Down’s syndrome.

Findings such as these have led some researchersto express concern that inclusive education policiesmay be based on an underestimation of the educa-tional and socio-cognitive difficulties which manychildren with Down’s syndrome experience atschool as the developmental gap between them andtheir chronological age peers widens (Wishart2005). Other researchers have emphasised the needfor intervention strategies at all ages to better recog-nise the aetiology-specific nature of some of the dif-ficulties which may arise (e.g. Dykens et al. 2000;Dykens & Hodapp 2001; Fidler & Nadel 2007).

The extent to which difficulties in socio-cognitivedevelopment impact on peer interactions at laterages is clearly not yet well-researched but there isgood evidence that by adolescence, many childrenwith Down’s syndrome experience loneliness, evenin school and community settings intended to beinclusive (see e.g. D’Haem 2008). Only a minorityof children experience true sustained friendships,some have imaginary friends well into adolescence,and a good number often prefer their own company

to that of others (Buckley & Sacks 1987; Byrneet al. 1988; Sloper et al. 1990; Carr 1995; Dykens &Kasari 1997; Cuckle & Wilson 2002). As youngpeople with IDs are twice as likely as other youngpeople to develop mental health problems (MentalHealth Foundation 2002), this pattern of increasingsocial isolation is of considerable concern.

The significant speech and language difficultieswhich accompany the cognitive impairments associ-ated with Down’s syndrome (for overviews, seeFowler 1990; Chapman 2003; Martin et al. 2009;Timmins et al. 2009) can only exacerbate the chil-dren’s interpersonal difficulties. In a large survey ofparents of children with Down’s syndrome, over95% reported that individuals immediately outsidethe family experienced difficulties in understandingtheir child’s speech (Kumin 1994, see also Buckley& Sacks 1987). These intelligibility problems arerarely targeted in traditional speech and languagetherapy although encouraging results have recentlybeen reported from interventions using high-tech,computer-based approaches to correct speech pat-terns in children and adolescents with Down’s syn-drome (Wood et al. 2009).

A better understanding of the causes and devel-opmental profiles of the socio-cognitive difficultiesdescribed above is essential if appropriately targetedand effective interventions are to be developed. Aswith research into many key areas of functioning inthose with IDs (Hatton et al. 1999), social cognitionin Down’s syndrome has to date been surprisinglyneglected, even within ID research itself. The rangeof ways in which neurological, cognitive and envi-ronmental factors all contribute to the developmentof the abilities necessary for successful interpersonalinteractions is still by no means clear in typicaldevelopment, but it is even less so in Down’s syn-drome. The extent to which the adoption of a moretheoretical approach would move this field forwardis therefore an important consideration.

Developing theoretical frameworks

It is clear that although recent years have seen agradual increase in knowledge of some importantaspects of social cognition in children with Down’ssyndrome, the overall picture remains very incom-plete, particularly with respect to developmentbeyond infancy and the preschool years. It is also




clear that this is a field in which theory has played aless prominent role than it has in other areas oftypical and atypical development. Would a moretheoretical focus be beneficial, and if so, in whatways? One area to explore is whether a more theo-retical focus would lead to an improved conceptu-alisation of the socio-cognitive profile associatedwith Down’s syndrome. The second is whether itwould lead to more appropriately targeted andmore successful ways of supporting development inchildren with Down’s syndrome in interventionsand in educational settings.

In relation to the first point, it is worth notingthat in both typical and atypical development someareas of research have moved forward very rapidlyfollowing advances in theory building. A particularlyclear example of this was the impact that theories of‘theory of mind’ had on autism research (see e.g.Baron-Cohen et al. 2000). While these theories hadlimitations, they led to clear, specific and testablepredictions, and were undoubtedly partially respon-sible for the growth of interest in social cognition inchildren with autism. Other factors also contributedto this growth, however, including the design ofresearch tasks that could be easily and widely used(e.g. the unexpected transfer task, Wimmer &Perner 1983). It also benefited from the concurrentdevelopment of innovative technologies (e.g. func-tional Magnetic Resonance Imaging and eye-tracking) and from the availability of substantialfunding specifically for research into autism.

A more theoretical focus might, then, lead tomore detailed knowledge and a deeper understand-ing of the socio-cognitive profile associated withDown’s syndrome. This alone may not be sufficientto stimulate and drive research in this area,however. Some agreement on core paradigms andprotocols is clearly needed, as is a much greaterinvestment in research into IDs in general, and intoDown’s syndrome in particular (Morris 2008; Ras-mussen et al. 2008).

Whether a more theoretical focus would ulti-mately lead to more successful interventions isperhaps even less certain. At present, findings fromsocio-cognitive research in Down’s syndrome arenot sufficiently detailed to be translated into effec-tive interventions. For example, although there issome evidence, as discussed above, that childrenwith Down’s syndrome may experience difficulties

in emotion recognition, knowing how best to inter-vene to support development in this area is far fromobvious. It is not yet clear, for instance, why somechildren experience greater difficulties in recognis-ing emotions than others, precisely what role isplayed by levels of language, memory and cognitiveability in emotion recognition, or how early interac-tions with peers and caregivers may support orhinder development of this aspect of socio-cognitivefunctioning.

Interventions for children with Down’s syndromehave moved away from being solely child-centredand focusing on purely cognitive abilities, and nowrecognise both the importance of social cognitionand the central role that the child’s early interac-tions with others play in development (e.g. Iarocciet al. 2006). However, the most appropriate ways tosupport socio-cognitive development in childrenwith Down’s syndrome at different stages in theirdevelopment have still to be identified. Interven-tions which focus on developing socio-cognitive andsocial adaptive skills have important potential con-sequences for social inclusion and quality of life,and must take into account the child’s family, peerand community context (Guralnick 2006; Iarocciet al. 2008). Without more detailed knowledge ofhow social cognition develops throughout the child-hood years in Down’s syndrome, this will be diffi-cult to fully achieve. Numerous parent-directed andchild-led interventions are currently available forchildren on the autism spectrum, but it is not clearwhich, if any, of these approaches could be adaptedfor use with children with Down’s syndrome. Whilethe findings discussed earlier of mothers’ ‘directivebut warm’ interactive style suggest that a parent-directed intervention, such as Applied BehaviorAnalysis (see e.g. Lovaas 1987), might be a suitablestrategy, there is no research evidence available tosupport this. A more child-led approach, whichencourages the child to take the lead in ongoingsocial interactions (e.g. Intensive Interaction; Nind& Hewett 1994), might also be appropriate, giventhe evidence that children with Down’s syndromemay be more passive partners in interactions.Without evaluation studies, and further moredetailed knowledge of socio-cognitive development,it will remain difficult to identify the interventionroutes which are most appropriate for children withDown’s syndrome and their families.




These challenges in mapping theory to interven-tion are by no means unique to research intoDown’s syndrome. Even in relation to autism, someof the most influential theories, like theory of mind,have not yet been successfully translated into inter-ventions that have led to significant and generalis-able gains in socio-cognitive abilities. As a result,many practitioners continue to base their interven-tion methods on prior clinical experience and pro-fessional opinion, rather than on theoretically drivenscientific findings (Jones & Jordan 2008).

Despite some difficulties in translating theoryinto practice, it seems unlikely that the developmentof a more theoretical approach to socio-cognitivedevelopment in Down’s syndrome, as in autism,would not be of benefit to the field. We need,though, to consider why attempts to do so have sofar been limited. One obvious barrier to theorybuilding is the fact that, to date, the majority ofresearch involving children with Down’s syndromehas focused on providing increasingly detailedbehavioural descriptions, rather than on testingcompeting theoretical accounts. This is in sharpcontrast to the fields of autism and typical develop-ment, where there is now a large body of socio-cognitive research which tests findings againstdiffering theories. For example, there has been con-siderable study of the development of an under-standing of intended actions, of the development ofmeta-representations and theory of mind, and ofthe relationship between cognitive processingcapacities and social abilities (see e.g. Hughes &Leekam 2004; Tomasello et al. 2005; Begeer et al.2008). All of these areas have been under-researched in children with Down’s syndrome. Thisdifference may be due to a number of inherent bar-riers to developmental research into Down’s syn-drome which need to be acknowledged and whichmay explain both the major gaps in our knowledgeof the sequence and nature of socio-cognitive devel-opment in Down’s syndrome, and also the lack ofany significant advances in theory-building in thisarea. A strategic attempt to fill these knowledgegaps is urgently required, along with a drivetowards developing studies that are aimed at testingcompeting theoretical accounts rather than simplyproviding behavioural descriptions.

A further barrier to theory-building in Down’ssyndrome has been the relative lack of links made

between behavioural research and the fields ofgenetics and neurosciences. For these links to bemade, we need to develop far better psychologicalaccounts of individual differences in ability profilesacross children with Down’s syndrome and ofcross-group overlap in strengths and deficits inDown’s syndrome and in other IDs with differingaetiologies (such as fragile X syndrome and Will-iams syndrome, see e.g. Kogan et al. 2009; see alsoPennington 2009). Children with Down’s syndromeshow considerable variation in levels of socio-cognitive competence, but despite this, behaviouralstudies often treat groups of children with Down’ssyndrome as homogeneous; likewise, genetic andneurobiological studies often use incomplete modelsof the Down’s syndrome social behavioural pheno-type when trying to relate genes to behaviour(Chapman & Hesketh 2000).

Bridging this gap will not be an easy task. Involv-ing sufficiently large numbers of participants withDown’s syndrome across the necessary age rangesto allow studies to have the statistical power toidentify and track key developmental changes – par-ticularly when these may be very subtle and detect-able only in some cross-group comparisons – hasalways been a major problem for Down’s syndromeresearchers. For real advances to be made, large-scale, multi-site, collaborative studies, using sharedagreed protocols are sorely needed. Finding fundingfor such national or international studies is notlikely to be easy, however.

A final barrier to theory development has beenthe lack of a good framework for the representationof theoretical models across all of the many disci-plines involved in Down’s syndrome research, onewhich would enable causal theoretical accounts ofsocial cognition in Down’s syndrome to be con-structed. At present there are few accounts ofDown’s syndrome that attempt to make linksbetween molecular genetics, neuroscience, cognitiveprocesses and social behavioural outcomes, orwhich attempt to develop integrated overarchingtheories. Complete causal theories of socio-cognitive development require a full understandingof the long-term sequence of behavioural develop-ment and must explain not only group characteris-tics, but also how individual differences within thepopulation emerge through transactions between alllevels of explanation. Morton (2004) has gone some




way to developing a universal means of notatingcausal, developmental relationships that incorporateall levels of explanation in theories. While thisapproach needs additional refinement if extended toDown’s syndrome, it has been usefully applied inthe field of autism, fragile X and Williams syndromeand could similarly be applied to explanations ofDown’s syndrome, perhaps helping in clarifyingcompeting theoretical positions in the future.

It is clear from the preceding discussion that thedevelopment of children with Down’s syndrome islikely to be influenced by a great many factors otherthan the inherent constraints that Down’s syndromeitself places on cognitive development. For socio-cognitive development in particular, the opportuni-ties and support provided by the child’s family andwider social and educational networks are likely tobe critical in driving development. It is also clear,though, that despite the potential benefits oftheory building in this field, the developmentof an over-arching theory of social cognition inDown’s syndrome is still some considerableway off.

In typical development, transactional theories ofdevelopment are now dominant. Such theoriesattempt to describe the nature, extent and directionof influence of different areas of psychological func-tioning on each other and the bidirectional natureof the relationship between children and their envi-ronment. It might, therefore, be profitable toexplore the extent to which a transactionalapproach might be helpful in understanding andextending knowledge of the pattern of socio-cognitive strengths and weaknesses found inDown’s syndrome.

Although there is, as yet, no established transac-tional theoretical model of development in Down’ssyndrome, one preliminary model, which may behelpful to consider, is an adaptation of an infancymodel proposed by Moore et al. (2002) (see Fig. 1).Moore et al. adapted the approach of Morton andcolleagues (Morton & Frith 1995; Morton 2004)and explicitly distinguished between levels of expla-nation, specifically those of neuro-biology, cogni-tion, social behaviour and the social environment.This adaptation builds on Morton’s linear causalapproach to explaining developmental change, byallowing for multidirectional transactions amonglevels of explanation, and particularly acknowledges

the influence of the child’s social environment, overtime.

Starting from the left-hand side of Fig. 1, themodel attempts to capture the transactional natureof development in Down’s syndrome between birthand mid-childhood. It provides an outline of theimpact that the over-expression of genes, caused byTrisomy 21, appears to have on brain function andstructure. The means by which these impairmentsthen lead to specific differences in aspects of cogni-tive functioning is not specified in detail, as theserelationships have yet to be clearly established. Atthe cognitive level, Moore et al. (2002) proposedthat subtle differences in early attention regulationin infants with Down’s syndrome may make themslower to respond and orient in social interactions.This then may elicit a warmer maternal style duringinteractions that serves to maintain levels of atten-tion. This adapted maternal social style, along withthe infants’ possible difficulties in switching atten-tion efficiently, may lead the infants to becomemore focused on people, particularly the mother,and may serve an important and useful function indeveloping early emotional attachments (Berry et al.1980). However, Moore et al. proposed that it mayalso make infants more likely to become ‘locked in’in interactions and depend more on others for regu-lating their attention, an outer-directedness firsthighlighted by Zigler (1969) as characteristic ofthose with IDs. This will contribute to a tendencyto focus on other people rather than objects, andperhaps lead to the adoption of a strategy of ‘overimitation’, with infants with Down’s syndrome imi-tating the actions of others in situations where moreindependent problem-solving would be more appro-priate (e.g. Wright et al. 2006). In response to thisgreater focus on people than objects, and perhapsalso in response to ‘over-imitation’ by the child, it ispossible that the mothers not only show greaterwarmth in interactions, but also begin to adopt amore directive role, leading their infants in socialexchanges.

This style of interaction will also impact on jointattention and ‘triadic’ engagement where attentionis to be shared between other people and objects –an important component of shared understandingand language. Subsequently, when ‘topic’ bids aremade by infants with Down’s syndrome, they maynot be picked up because mothers are continuing to




work hard to direct and maintain attention using aforceful but warm affective style. This in turn wouldexplain the findings of reduced frequency ofrequesting behaviours. Moore et al. suggested thatthis differential style of engaging in triadic interac-tion could have consequences for the developmentof language and other cognitive processes thatrequire a sense of agency – not least the develop-ment of means-ends and problem-solving functions.

Extending this model here, we additionallysuggest the reduced use of mental state andemotion terms by mothers may also, along withother factors, impact on the subsequent develop-ment of sensitivities to emotional stimuli in childrenwith Down’s syndrome – that is, if mothers are notdrawing attention to these events through language

then this may reduce the salience of this informa-tion. In turn, this may lead to a differential sensitiv-ity to emotional stimuli and difficulties in emotionrecognition. However, the subtle difficultiesreported to date in emotion recognition are likely tobe the result of a number of factors and, as high-lighted earlier, the potential role of maternal inter-active style should be further explored. Thedifficulties in emotion recognition, when combinedwith a reduced sense of agency, may lead to subtle,as yet uninvestigated differences in aspects of theoryof mind.

This preliminary model fits with the relativelylimited data available on early social cognition inDown’s syndrome. It is inevitably somewhat simpleand incomplete, with many potential causal links

Figure 1 A developmental causal model of social cognition in young children with Down’s syndrome adapted from Moore et al. (2002).




uncharted and more extensive testing of those linkswhich have been proposed clearly required. Furtherdevelopment – for example, incorporating the rolesplayed by other children and adults in the child’swider family, social and educational environment –is needed. An extension of the model into adoles-cence would also be an obvious next step,stimulating research which will hopefully provide adeeper understanding of the origins of the typicallypoor social and cognitive outcomes at later ages inchildren with Down’s syndrome, and ideally pin-pointing effective intervention strategies whichcould be implemented at key transitional stages insocio-cognitive development.

What the model does hopefully at least illustrateis how the field might begin to characterise a trans-actional developmental model of social cognition inDown’s syndrome. Further development of this, orof other transactional models using a similar formof notation, would be of potential benefit in that itwould allow for empirical testing and more detailedcomparative evaluations of different theoretical posi-tions. Ultimately, more detailed transactionalmodels may allow for the development of moretheoretically driven, and possibly more effective,interventions.

Conclusions

Contrary to public perceptions, for many childrenwith Down’s syndrome, engaging with others andunderstanding their emotions and intentions maynot be as easy a developmental step as it is for theirtypically developing peers. It would appear from theevidence available to date that this area of under-standing may be more impaired than would be pre-dicted on the basis of the children’s overall levels ofcognitive ability.

As with development in other cognitive domains,the development of interpersonal understanding isaffected by both biological and environmentalfactors. The biological mechanisms underpinningthe difficulties seen in social understanding inDown’s syndrome are unlikely to be open to inter-vention in the near future, leaving environmentallybased intervention programmes as the more realisticaim. As highlighted in this overview, however, thelack of sufficiently detailed research findings

hampers progress at present. Although there havebeen encouraging advances in delineating thebehavioural phenotype of Down’s syndrome, therestill remains a wide gap between research findingsand the development of evidence-based interven-tions and effective educational approaches for chil-dren with Down’s syndrome (Fidler & Nadel 2007;Davis 2008). Truly translational research that leadsto effective interventions is likely to require theco-ordination of many different levels of explana-tions of behavioural outcomes in Down’s syndrome.This remains the major challenge to progress in thisfield, and to research in learning and IDs in general(Oliver & Woodcock 2008; Cicchetti & Toth 2009;Diamond & Amso 2009; Pennington 2009).

Undoubtedly, developing a comprehensiveexplanatory model of social cognition in Down’ssyndrome which could underpin and drive futureresearch – and ultimately intervention design – pre-sents a considerable challenge, as is illustrated bythe incompleteness of the preliminary model pro-posed above. As can be seen in the fields of autismand Williams syndrome, much progress has beenmade through theoretically driven comparativestudies of socio-cognitive development which haveincluded comparisons with typically developingchildren. This has led to the development of newmethodologies and increased rigour, resulting notonly in greater explanatory power but also in thecross-fertilisation of theoretical ideas. It seems likelythat research into social cognition in children withDown’s syndrome would similarly benefit if castwithin a more theoretical framework.

Some of the most interesting recent findings inthe field of intellectual difficulties have come fromexploring cross-phenotype developmental trajecto-ries, with particular research interest in autism,fragile X and Williams syndrome, developmentaldisabilities which present intriguing profiles ofsocial strengths and weaknesses. These reveal moresubtle patterns of performance than are oftendetectable by simply making comparisons with typi-cally developing children (see Karmiloff Smith2007). However, even with prenatal screening pro-grammes, Down’s syndrome continues to representa very large subgroup of children with IDs and ifwe are to continue to develop more detailed theo-retical accounts of Down’s syndrome, it is impera-tive that researchers include these children in these




multi-phenotype studies. We hope that this reviewemphasises that this syndrome presents an equallychallenging and potentially unique profile deservingof similar levels of scrutiny. Longitudinal studieswould be particularly welcome, as examining howearly socio-cognitive abilities relate to interpersonalskills in later childhood and how they support orhinder higher-level socially based learning is crucialto the design and implementation of futureinterventions.

Several of the studies included in this reviewreported wide variation on many developmentalmeasures in children with Down’s syndrome, oftenalong with an absence of the clear associationsbetween ability levels in different domains found intypically developing children (e.g. Wishart &Pitcairn 2000; Kasari et al. 2001; Williams et al.2005; McCann et al. 2009). This seems an area par-ticularly ripe for future cross-phenotype investiga-tion. Such findings suggest that development acrossdomains in Down’s syndrome may not be as wellintegrated as in typical development, which in turnsuggests that fundamentally different interventionapproaches and pedagogical strategies may berequired. On a more positive note, the wide indi-vidual variation in level and ages of acquisition ofsocio-cognitive abilities in children with Down’ssyndrome indicate that Down’s syndrome in and ofitself does not necessarily constrain development inthis area in any pre-determined way. This leavesroom for optimism that a much more detailedaccount of socio-cognitive development in Down’ssyndrome could lead to more effective interven-tions, producing lasting and meaningful benefits.

In sum, we suggest that for significant progress tobe made in this field, theorists need to becomemore engaged in explaining the distinctive socio-cognitive profile of children with Down’s syndromeand how this is expressed in their behaviour at dif-ferent ages. Correspondingly, researchers in thefield of Down’s syndrome need to engage morewith theoretical advances being made in the studyof typical socio-cognitive development. In thispaper, we have highlighted some of the difficultiesin social cognition seen in Down’s syndrome, butalso some of the similarities to typical development,at least in the earliest stages of childhood. We hopethat this may encourage renewed interest in study-ing children with Down’s syndrome for their own

sake, and not simply as a control group for cogni-tive impairment in studies of typically and atypicallydeveloping children. This, in turn, may lead to newtheoretical models capable of accounting for bothwithin- and across-phenotype developmental differ-ences in social cognition.

Harnessing new technologies and innovativeparadigms, such as eye-tracking, functional mag-netic resonance imaging, event related potentials,electroencephalography and magneto-encephalography techniques, may also furtherenhance understanding of socio-cognitive develop-ment in Down’s syndrome. Although increasinglyused in the study of autism and other developmen-tal disabilities, their use to date with children andadults with Down’s syndrome has been remarkablylimited (for important exceptions see e.g. Karreret al. 1998; Cheung & Virji-Babul 2008; Virji-Babulet al. 2008). This is unfortunate, as the potentialfindings from such studies, in combination with awell-differentiated account of the role of the socialenvironment in promoting socio-cognitive develop-ment, could well lead both to powerful theories andto more successful intervention strategies.

Acknowledgements

The authors would like to thank the many childrenand young people with Down’s syndrome, as wellas their families and schools, who have worked withthem over the years and who stimulated their inter-est in this particular field. Thanks are also due tothe various funders who have supported theauthors’ work on development in Down’s syndromeover this period.

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Accepted 27 August 2009




Documents

Social cognition in children with Down’s syndrome ... · that may be unique to Down’s syndrome, and high-light areas in which critical data are missing. Along with outlining some