Playing with cubes: frequency of actions in children with Trisomy 21 and typical developmentAbstract
Introduction: Children with Trisomy 21 (T21) present motor challenges that influence object manipulation. Exploration of objects can promote advances in motor and sensory development.
Objective: To identify, describe, and compare the frequency of manipulative actions of children with T21 and typically developing children aged 8 to 10 years, using cubes of different sizes (large and small) and sensory stimuli (illuminated, high contrast, and textured).
Methods: This is a cross-sectional, observational, quantitative, and comparative study of manipulative actions in 10 children with T21 (9.2 ± 0.91 years) and 10 typical children (9.2 ± 0.91 years).
Results: Twenty-two manipulative actions were identified. Children with T21 most frequently manipulated the small, high-contrast cube, whereas typically developing children most frequently used the small, textured cube. Among children with T21, five actions were the most frequent: pushing the cube away (f = 127), shaking the cube (f = 307), shaking the cube back and forth (f = 211), rotating the cube (n = 322), and throwing the cube upward (f = 170). Typical children performed these actions more frequently (54.28%) and excelled in more complex manipulative behaviors.
Conclusion: Children with T21 performed 20 types of manipulative actions and showed a preference for actions close to the body and with the small, high-contrast cube. Typical children performed 21 types of manipulative actions and showed greater frequency and complexity in actions involving small, textured cubes.
Keywords:
Trisomy 21; Child; Toy; Motor skills; Sensory motor performance
Resumo
Introdução: Crianças com trissomia 21 (T21) apresentam desafios motores que influenciam a manipulação de objetos. A exploração desses materiais desempenha um papel fundamental na promoção do desenvolvimento motor e sensorial.
Objetivo: Identificar, descrever e comparar a frequência das ações manipulativas de crianças com T21 e crianças com desenvolvimento típico, de 8 a 10 anos, utilizando cubos de diferentes tamanhos (grande e pequeno) e estímulos sensoriais (luminoso, alto contraste e textura).
Métodos: Trata-se de um estudo transversal, observacional, quantitativo e comparativo das ações manipulativas, incluindo 10 crianças com T21 (9,2 ± 0,91 anos) e 10 crianças típicas (9,2 ± 0,91 anos).
Resultados: Foram identificadas 22 ações manipulativas, sendo que o cubo mais manipulado pelas crianças com T21 foi o pequeno de alto contraste, e entre as crianças típicas foi o pequeno com textura. Entre as ações realizadas pelas crianças com T21, cinco foram mais frequentes: afastar o cubo (f = 127), agitar o cubo (f = 307), agitar o cubo para frente e para trás (f = 211), girar o cubo (f = 322) e jogar o cubo para cima (f = 170). As crianças típicas apresentaram maior frequência de ações (54,28%) e se destacaram em comportamentos manipulativos complexos.
Conclusão: As crianças com T21 realizaram 20 tipos de ações manipulativas e mostraram preferência por ações próximas ao corpo e com o cubo pequeno de alto contraste. As crianças típicas realizaram 21 tipos de ações manipulativas e apresentaram maior frequência em ações complexas nos cubos táteis pequenos.
Palavras-chave:
Trissomia 21; Criança; Brinquedo; Destreza motora; Desempenho sensório-motor
Introduction
Motor development milestones depend on the integrity of the central nervous system, as well as the quality and quantity of stimuli provided and the relationships experienced by the child within their environment.1 The brain is primarily responsible for the learning process and for the stimuli that support action, cognition, reaction, and interaction.2 In this context, play activities contribute to learning by making cognitive processes more effective and by developing and improving motor and sensory skills,3 which contribute to observing, understanding, and interpreting the surrounding world, thereby promoting global development.4 Beyond motor and sensory gains, play also constitutes a powerful tool for socialization with other children, therapists, and family members, promoting inclusion, empathy, and nonverbal communication.5
In therapeutic and educational contexts, mediated play allows the observation of skills in a natural and spontaneous manner, revealing strengths and difficulties without compromising the child’s motivation.6 Play may occur in either free or structured forms, both of which offer distinct contributions to child development.7
Free play allows children to spontaneously explore their interests, emotions, and curiosities, stimulating autonomy, creativity, and self-regulation.8 Structured play, as proposed in the present study, is intentionally organized with specific objectives, and is particularly useful in therapeutic, educational, or research settings.9 Rather than opposing each other, free and structured play are complementary approaches and can be strategically combined to support children’s overall development, particularly in children with atypical development such as those with Trisomy 21 (T21).10
According to Piaget,11 children aged 8 to 12 years are in the concrete operational stage, characterized by a realistic understanding of the world. Although abstract reasoning is still developing, children at this stage show accelerated learning pace due to neurological development and neural plasticity, which contribute to the more precise acquisition of fine motor and sensory skills.12 At this stage, school integration increases exposure to structured learning environments, and toys and play become important tools for promoting motor development through opportunities for exploration of objects and the environment.13 It is important to distinguish motor development from motor learning, as the latter refers to relatively permanent gains in motor skills resulting from practice or experience.14 Therefore, this study analyzes and compares the manipulative actions of children with and without T21.
T21 is a genetic condition associated with mild to moderate delays in motor and cognitive development.15 Cognitive impairment results from reduced intrauterine brain development associated with intellectual disability, a hallmark of the non-mosaic form, with IQ ranging from 30 to 50.11 Among the most prevalent physical characteristics are flattened facial profile (in approximately 90% of cases), muscular hypotonia and joint hyperextensibility (both in about 80%), pelvic dysplasia (70%), fifth finger clinodactyly (60%), and single palmar crease (45%).
Furthermore, 100% of newborns present at least four of these alterations, and 89% present at least six of these findings.11 Physical therapists play a key role in preventing and managing these functional alterations by intervening in the child’s environment and promoting conditions that support global development, autonomy, and health.1
This study aims to identify, describe, and compare the frequency of manipulative actions in children with and without T21, aged 8 to 10 years, during play with cubes of different sizes (large and small) and sensory characteristics (illuminated, high-contrast, and textured). The use of cubes encourages spontaneous exploration and questioning of the object through play, promoting cognitive and visuomotor stimulation through hand, arm, and head movements, with potential differences in frequency and preference between groups.
Methods
This was a cross-sectional, descriptive, observational study approved by the Research Ethics Committee of the Universidade Federal do Triângulo Mineiro (UFTM), under protocol no. 5.932.874/2023.
Participants
The sample included 10 children with T21 (9.2 years ± 0.91 months) and 10 typically developing children (9.2 years ± 0.91 months), enrolled in public and private schools, as well as institutions serving this population, such as the Associação de Pais e Amigos dos Excepcionais (APAE) in the city of Uberaba, Minas Gerais, Brazil. Children who had previously participated in an extension project related to early intervention at UFTM (Projeto ABRACE Trissomia 21) were also included. Participation occurred after authorization from legal guardians through signing an Informed Consent Form (ICF).
Children with T21 (GI) were selected through convenience sampling, whereas typically developing children (GII) were matched by sex and age with the GI participants and recruited from local schools. GI included children with a confirmed diagnosis of T21 and without associated conditions that could interfere with manipulative performance, such as orthopedic deformities, neurological disorders, or a history of seizures. All participants were between 8 and 10 years of age.
GII consisted of typically developing children within the same age range and without genetic syndromes or neurological, orthopedic, sensory, or cognitive impairments. Children whose parents or guardians did not sign the ICF, did not authorize video recording of the assessments for later analysis, or did not complete all stages of the proposed tasks were excluded from the study.
Procedures
Assessments were conducted simultaneously by two previously trained examiners under the supervision of specialists in the field. One examiner was responsible for conducting the assessment, and the other provided operational support. The procedures took place in organized rooms provided by the institutions, with adequate lighting, comfortable room temperature, and minimal noise in order to facilitate the attention of the participating children.
Cube randomization was performed through the website Random.org, both regarding the order of presentation and the exposed face of each cube. This process was carried out prior to the assessment. The objects were organized according to the predefined sequence and placed beside the examiner, remaining covered with a black cloth until the moment of presentation. During the assessment, six cubes were used: three large cubes (15 × 15 cm, weighing 410 g) and three small cubes (7.5 × 7.5 cm, weighing 110 g) (Figure 1).
A - Cube with internal light stimulus, where two of the opposite faces were coated with transparent material and the others in the colors yellow, blue, green, and red. B - Cube with different high-contrast stimuli in black and white. C - Cube with tactile stimulus, presenting on each of the six faces a texture of different materials (soft; small and larger wavy aspect; rough and rugged). Prepared by Oliveira et al.13
The assessment individually, with one child at a time invited into the evaluation environment. The examiner positioned herself in front of the child to mediate the interaction during play with the cubes. Each child was instructed to remain seated with the legs abducted, allowing the cube to be placed on the mat in front of them.
The cubes were presented sequentially, one at a time. Each child interacted with each cube for 40 seconds, with a 10-second interval between presentations. The interaction began standardized verbal intruction by the examiner: “Let’s play with the cube?”. At the end of the sequence, all cubes were placed in front of the child, who was then asked which one had been their favorite.
To record the manipulative actions performed during play, two digital cameras were used. A Samsung® camera (DVD SC-DX103), positioned on a tripod (PowerPack – Trip 21), was placed frontally, while a mobile phone was positioned laterally, allowing comprehensive recording of the assessment.
Camera height, distance, and angle were standardized based on a pilot study in order to adapt the parameters to the anthropometric profile of the evaluated children. The assessment environment was arranged with two square rubber mats (1 m × 1 m × 3 cm) and a cushion (32 × 21 × 3 cm thick) to ensure comfort and postural stability during the procedure. As shown in Figure 2, a digital stopwatch was used to precisely control the manipulation time for each cube.
After data collection, the recorded videos were analyzed by two examiners using the BSPlayer Pro software. Playback speed was adjusted to 70% of the original speed, allowing more detailed observation of the movements performed by the children in response to the cube exploration commands. Each child was analyzed individually. At the end of this stage, the obtained results were compared to verify the level of agreement between the evaluators. Reliability was calculated using Cohen’s kappa coefficient (k) through the SPSS Statistics software (version 20.0).
The present study followed the methodology proposed by Pereira et al.5 to identify children’s manipulative actions during play with the cubes. In the study, 21 manipulative actions were identified in children with T21 aged 3 to 5 years.
Data were analyzed using the SPSS Statistics software, with a significance level of 5% (p < 0.05). Data normality was assessed using the Shapiro–Wilk test. Variables with normal distribution were compared using Student’s t-test for independent samples, whereas non-normally distributed variables were analyzed using the Mann–Whitney test. Results are presented in tables and expressed as mean, standard deviation, minimum values, and maximum values.
Results
Table 1 presents the manipulative actions identified in children with T21 aged 8 to 10 years. A total of 22 distinct manipulative actions were observed.
Manipulative actions and their definitions performed by children with Trisomy 21 aged 8 to 10 years (n = 10)
Among these 22 distinct manipulative actions, six were identified as new for this age group: shaking the cube back and forth; squeezing the cube; kicking the cube; throwing the cube diagonally; throwing the cube forward; and transferring the cube from one hand to the other. The manipulative actions performed by GI and GII, highlighting relevant differences in the frequency of execution between groups, are presented in the Supplement. Although many actions were observed in both groups, some showed significant variations in frequency depending on the type of cube and the group analyzed.
For cubes with visual and tactile stimuli, GII demonstrated a higher frequency of certain action, such as rotating the illuminated cubes (p = 0.017) and the large textured cube (p = 0.002), as well as sliding the hand and fingers over the large textured cube (p = 0.045). In contrast, GI stood out in actions such as bringing the cube closer to the body (large high-contrast cube: p = 0.021; small illuminated cube: p = 0.030), bringing the eyes closer to the cube (large high-contrast cube: p = 0.053; large illuminated cube: p = 0.025), and shaking the cube back and forth (small illuminated cube: p = 0.036).
These behavioral differences appear to be sensitive to the type of cube used in the task, particularly those with more salient stimuli, such as the large illuminated, large textured, large high-contrast, and small illuminated cubes.
Overall, GII presented a greater number of actions with statistically significant differences compared to GI, observed across all cubes, although these differences varied according to the specific action performed, such as rotating the object (large high-contrast cube: p = 0.000; small high-contrast cube: p = 0.007; large illuminated cube: p = 0.170; small illuminated cube: p = 0.002; large textured cube: p = 0.002; small textured cube: p = 0.018) and sliding hands and fingers (large high-contrast cube: p = 0.012; small illuminated cube: p = 0.039; large textured cube: p = 0.045).
Figure 3 shows the frequency of manipulative actions by group. GII generally showed higher frequencies of actions compared to GI, especially with the large illuminated, small illuminated, small textured, and large textured cubes. Individual variability in responses was also observed: within GI, some children interacted more frequently with the high-contrast cube, whereas others demonstrated less interest or performed fewer actions with cubes such as the small illuminated or small tactile cubes. These findings quantify the children’s level of motor engagement, allowing comparisons between the use of large and small cubes and highlighting individual preferences or difficulties.
Children’s preferences for the cubes were also identified. In GI, the small illuminated cube was the favorite, chosen by three children, followed by the large illuminated cube and the large textured cube, each selected by two children. The small high-contrast and small textured cubes received two and one preferences, respectively, whereas the large high-contrast cube was not identified as a favorite by any child in this group. In GII, the large illuminated cube was the most frequently chosen, with five preferences, followed by the large textured cube, preferred by two children. The small illuminated, small high-contrast, and small textured cubes were each mentioned as favorites by one child. Similarly to GI, the large high-contrast cube was not selected as a favorite by any child.
Discussion
The identification of 22 manipulative actions expands findings previously described in the literature. Six of these actions had not been reported by Silva and Lima,16 and one of them, squeezing the cube, was exclusive to the group of typically developing children, which may reflect more refined motor development at 8 to 10 years of age. However, the absence of the action of squeezing the cube in GI should not be interpreted as an indication of lack of stimulation. On the contrary, the occurrence of five additional new manipulative actions — shaking the cube back and forth, kicking the cube, throwing the cube diagonally, throwing the cube forward, and transferring the cube from one hand to the other — observed in both groups, demonstrates overlap in motor repertoire between children with T21 and typically developing children. This result is consistent with the proposal of Messer and Grave,17 who emphasize object manipulation as a core component of child motor development.
Differences in exploration frequency between groups appear to be related to characteristics associated with T21, such as muscular hypotonia and brachydactyly.18 From the perspective of affordance, where object properties (size, weight, color, and texture) guide motor responses,19 these differences become more understandable. In this sense, actions such as shaking the cube back and forth (p = 0.036), bringing the cube closer to the body (p = 0.030), bringing the cube closer to the eyes (p = 0.003), and holding the cube with only one hand (p = 0.051) presented higher mean frequencies in the GII group, particularly with the small illuminated cubes.
Analysis of Figure 3 indicates the highest overall frequency of actions occurred with the small high-contrast cube (405 actions). When grouped by size, manipulation involving small cubes (Figure 3) accounted for 966 actions, representing 151 additional actions when compared to the total number of manipulative actions involving large cubes by GI. Therefore, the concept of affordan-ce is reinforced by these findings, particularly regarding object size and type of stimulus.
Group differences were most pronounced with illuminated and high-contrast cubes (Supplement), support ing evidence that visual stimuli increase exploration and engagement13 and reinforce findings in children with low vision, for whom high-contrast cubes with opposing colors and varied patterns facilitate visual perception.13 The combination of size, texture, illumination, and contrast appears to enhance motor responses, particularly in children with T21, highlighting the importance of adapted materials.20
The highest frequencies of actions were observed with the small high-contrast cubes, followed by the textured cubes. The small high-contrast cube was most frequently manipulated by children with T21 (405 actions), whereas the small textured cube showed the highest frequency of actions in GII (413 actions) (Figure 3). These findings corroborate the studies by Pereira et al.5 and Silva et al.,16 who identified a preference for the small high-contrast cube among children with T21. Such preference may be associated with the presence of faces containing contrasting colors and varied patterns.21
When comparing groups, cube size also demonstrated a significant impact: small cubes elicited 283 more actions than large cubes (Figure 3). After organizing and categorizing the actions according to stimulus type, cube size, and the group with the highest mean frequency of actions, statistically significant differences were observed as follows: large textured cube (GII: p = 0.002); small illuminated cube (GI: p = 0.003; GII: p = 0.002); small high-contrast cube (GII: p = 0.007); large high-contrast cube (GII: p = 0.012); large illuminated cube (GII: p = 0.017); small textured cube (GII: p = 0.018); large illuminated cube (GI: p = 0.025); small illuminated cube (GI: p = 0.030); small illuminated cube (GI: p = 0.036); small illuminated cube (GII: p = 0.039); and large textured cube (GII: p = 0.045). Thus, among the twelve manipulative actions showing differences between groups, only five were performed with large cubes. This finding is in agreement with Marques et al.,22 who reported lower motor engagement when interacting with bulky objects, and with Pereira et al.,5 who also highlighted the difficulty experienced by children with T21 in supporting large objects, which may explain this difference.
Previous studies, such as those by Pereira et al.5 and Oliveira et al.,13 have reported between 12 and 19 manipulative actions in children with T21 aged 3 to 10 years. This period, especially between 6 and 9 years of age, has been identified as a peak in motor development, characterized by greater diversity of responses.23 These findings reinforce the importance of early stimulation in expanding motor repertoire.
In the present study, children with T21 performed 20 manipulative actions, whereas typically developing children performed 21, demonstrating similarities in motor repertoire between groups. However, actions such as squeezing the cube and hitting with the cube were not observed in GI, whereas kicking the cube did not occur in GII and was recorded in only one child with T21 (GI). This specific difference corroborates the findings of Ambrosano et al.,15 who stated that children with T21 may present motor and cognitive delays, considering that the developmental milestone for actions involving “applying force to” or “receiving force from” objects (such as throwing, catching, kicking, and receiving objects) occurs during early and middle childhood, approximately between 3 and 7 years of age.24 In the study by Silva et al.,16 children with T21 aged 6 to 7 years performed actions such as rotating the cube in the air, supporting it on the feet, lifting and dropping it, sitting on the cube, resting the face on it, and rotating it with the feet, which, although not observed in the present study, are part of the expected motor development for this age group.
A recent study conducted by the same research group investigating manipulative actions with cubes in children with T2112 complements the findings of this study. That investigation identified significant differences in the frequency of nine actions among children with T21 aged 6 to 7 years, with four actions more frequent in the T21 group and five in the typically developing group. In that previous study, children with T21 presented higher frequencies of simpler actions, such as bimanual reaching, bringing the cube closer to the eyes, bringing the cube closer to the body, and throwing the cube forward.12
In this study, the actions of shaking the cube back and forth (p = 0.036), bringing the cube closer to the body (p = 0.030), bringing the cube closer to the eyes (p = 0.003), bringing the eyes closer to the cube (p = 0.025), and holding the cube with only one hand (p = 0.051) were observed (Supplement). Despite two shared findings, children with T21 aged 8 to 10 years demonstrated greater motor planning and manual dexterity in more complex actions. Naturally, as previously mentioned, this may be explained by increased age and life experience, which allowed children with T21 aged 8 to 10 years to improve their motor repertoire, positively influencing neuropsychomotor development.13
The playful approach adopted in this study demonstrated not only therapeutic potential but also evaluative value. Observing manipulative actions within a play context allowed the identification of motor skills, postural control, attention, and individual strategies without formal impositions. This reinforces play as a functional screening tool, especially for children with atypical development.
Although the task was structured for individual manipulation of cubes, spontaneous moments of choice, verbalization, and emotional expression occurred. During the assessments, strengthening of affective bonds and stimulation of autonomy were observed. As highlighted by Oliveira and Milani,20 these interactions are fundamental for the development of communication, self-esteem, and language, particularly in children with T21.
The intraindividual variability observed within the T21 group reinforces the need for personalized approaches. Such variability may be related to access to early stimulation, schooling, family support, and cognitive profile. Recognizing individual strengths and limitations is essential for planning effective interventions.25 The adult’s role as a mediator, as described by Brito and Kishimoto,26 proved fundamental for initiating actions, although autonomous exploration was what ultimately provided meaningful learning. While the evaluators’ initial mediation was necessary to engage the children, subsequent actions emerged spontaneous and internally motivated.
Among the limitations of this study, the small sample size should be emphasized, which limits the generalization of the results. Furthermore, the controlled environment and the presence of only two evaluators may have influenced the children’s behavior, compromising the naturalness of some responses.
Children who demonstrated greted curiosity and engagement showed a wider variety of actions, accompanied by expressions of enthusiasm, laughter, and verbalizations, confirming the relationship between motivation, affect, and motor performance.13 The main contribution of this study lies in highlighting structured play as both a stimulation and functional assessment tool.
These findings have significant practical implications, as they may support individualized therapeutic interventions, guide the creation and design of adapted and inclusive toys that promote greater motor and sensory engagement, and contribute to educational strategies aimed at the integral development of children with and without T21.
Conclusion
In this study, 22 manipulative actions were identified in children with and without T21 aged 8 to 10 years, six of which were specific to this age group. Children with T21 (GI) showed greater engagement in sensory exploration actions performed close to the body, whereas typically developing children (GII) demonstrated greater frequency and complexity of actions, particularly “rotating the object” and “sliding hands/fingers.”
The comparative analysis demonstrates that, despite greater manual dexterity in GII, children with T21 share a substantial motor repertoire, revealing important similarities between groups. At the same time, the observed differences reinforce the strengths and developmental profile of each group, highlighting the importance of individualized motor interventions. The results underscore the importance of structured and varied play materials, reinforcing playfulness as a central strategy for stimulating and evaluating the integral development of children with different functional profiles, while also supporting adapted educational and therapeutic practices for each group.
Supplement
Supplement
Data availability statement
Data are available from the corresponding author upon reasonable request.
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Edited by
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Associate editor:
Ana Paula Cunha Loureiro
Note: Cameras 1 (A) and 2 (B), assessor (C) and child (D). Prepared by Oliveira et al.
Note: GI = children with Trisomy 21 (n = 10); GII = typically developing children (n = 10).