AN INVESTIGATION OF EFFECT OF COMMUNICATION SKILLS OF CHILDREN WITH DOWN SYNDROME ON NEEDS, ANXIETY AND SOCIAL SUPPORT LEVELS OF THEIR MOTHERS

: This study aims to investigate the effect of communication skills of children with Down Syndrome on their mother’s perceptions of needs, anxiety, and social support. The quantitative research method was used in the study, which was performed in the descriptive survey model. 71 mothers who have children between 4-16 years of age, diagnosed with Down Syndrome participated. The research data were collected using Communication Function Classification System (CFCS), Family Needs Survey (FNS), Questionnaire on Resources and Stress for Families with Chronically or Handicapped Members (QRS), and Social Support Scale (SSS). There was a positive significant relationship between CFCS and financial needs and QRS 2 and there was a negative significant relationship with social support. A negative significant relationship was found between QRS 3 and social support.


Introduction
Down Syndrome (DS) is one of the chromosomal disorders which are frequently seen in children today (Selikowitz, 2010).According to data from World Health Organization (WHO, 2017) an average of 3000-5000 babies are affected by chromosomal disorders every year, it is stated that approximately 1 out of every 1000 babies has Down Syndrome (DS) It is seen that children with DS generally experience some limitations and delays in all developmental areas (Buckley, 2012).They experience mental disability, difficulties in language and communication skills as well as health problems because of an extra chromosome in the twenty-first chromosome (Selikowitz, 2010;Abbeduto, Warren & Conners, 2007).

the chromosom
l disorders which are frequently seen in children today (Selikowitz, 2010).According to data from World Health Organization (WHO, 2017) an average of 3000-5000 babies are affected by chromosomal disorders every year, it is stated that approximately 1 out of every 1000 babies has Down Syndrome (DS) It is seen that children with DS generally experience some limitations and delays in all developmental areas (Buckley, 2012).They experience mental disability, difficulties in language and communication skills as well as health problems because of an extra chromosome in the twenty-first chromosome (Selikowitz, 2010;Abbeduto, Warren & Conners, 2007).

Cognitive development levels of children wit Cognitive development levels of children with DS differ from mild level to moderate level.Parallel to this situation, differences are seen also in mental functions and performances.These differences in mental processing negatively affect transferring information from short-term memory to long-term memory, cause-effect relationships, perception/attention skills, and finding different solutions to problem skills of the children.Besides all these limitations, they also experience difficulties in generalization skills to transfer information to different environments, people, and areas.It is seen that these difficulties experienced in cognitive skills negatively affect children's development in language and communication skills (Kumin, 2012).
DS differ from mild level to moderate level.Parallel to this situation, differences are seen also in mental functions and performances.These differences in mental processing negatively affect transferring information from short-term memory to long-term memory, cause-effect relationships, perception/attention skills, and finding different solutions to problem skills of the children.Besides all these limitations, they also experience difficulties in generalization skills to transfer information to different environments, people, and areas.It is seen that these difficulties experienced in cognitive skills negatively affect children's development in language and communication skills (Kumin, 2012).


Development of Language and Communication Skill

Development of Language and Communication Skills in Children with Down Syndrome
in Children with Down Syndrome

Language and communication skills, which are a part of our daily life, are in a complex structure and have critical importance for the developme Language and communication skills, which are a part of our daily life, are in a complex structure and have critical importance for the development of all children.The primary condition for every child to reach their true potential is to learn how to express themselves appropriately.For children with DS, like their peers, communication is a basic need and they are expected to use language skills functionally.While communication difficulties are very common in some of those children, they are rarer in some children.Development of language and communication skills are frequently accompanied by recurrent ear infections, hearing loss, weak muscle tone around the face and mouth, having a smaller mouth than the size of the tongue, excessive or low tactile sensation around the mouth, difficulties in memory and intellectual dimensions in children with DS.Children with DS, who desire to communicate from an early age, communicate through crying, smiling, and facial expressions.The reactions given by the families to these communication efforts contribute to these expressions, facial expressions, and sounds becoming a way of communication.Thus, it is highly important to educate the family, especially the mother, and include them in the process for language and communication skills to become a part of daily life.With the studies starting in early periods, families can help their children by giving them a great number of opportunities to use the words they can use in new situations and by providing experiences that will reinforce the concepts (Kumin, 2012).
t of all children.The primary condition for every child to reach their true potential is to learn how to express themselves appropriately.For children with DS, like their peers, communication is a basic need and they

uage skills func
ionally.While communication difficulties are very common in some of those children, they are rarer in some children.Development of language and communication skills are frequently accompanied by recurrent

r infections,
hearing loss, weak muscle tone around the face and mouth, having a smaller mouth than the size of the tongue, excessive or low tactile sensation around the mouth, difficulties in memory and intellectual dimensions in children with DS.Children with DS, who desire to communicate from an early age, communicate through crying, smiling, and facial expressions.The reactions given by the families to these communication efforts contribute to these expressions, facial expressions, and sounds becoming a way of communication.Thus, it is highly important to educate the family, especially the mother, and include them in the process for language and communication skills to become a part of daily life.With the studies starting in early periods, families can help their children by giving them a great number of opportunities to use the words they can use in new situations and by providing experiences that will reinforce the concepts (Kumin, 2012).

DS is diagnosed during the pregnancy of the mother or soon after the birth, in the early period.As children with DS experience limitations in receptive/expressive language in the early period, education services should be planned to start from the pre-linguistic period (Acarlar, 2006;Chapman, Hesketh & Kistler, 2002).The difficulties experienced in the receptive language skills of children with DS are related to the cognitive skills of the children.Thus, children who have difficulty in verbal communication usually try to express themselves with gestures and facial expressions in the early period (Fidler, 2005;John & Mervis, 2010).During the speaking period, they experience serious difficulties in talking about a topic, asking questions, understanding complex sentence structures, and continuing the conversation on the same topic (Acarlar, 2006;Ulkü-Kürkcüoğlu, 2009).It draw DS is diagnosed during the pregnancy of the mother or soon after the birth, in the early period.As children with DS experience limitations in receptive/expressive language in the early period, education services should be planned to start from the pre-linguistic period (Acarlar, 2006;Chapman, Hesketh & Kistler, 2002).The difficulties experienced in the receptive language skills of children with DS are related to the cognitive skills of the children.Thus, children who have difficulty in verbal communication usually try to express themselves with gestures and facial expressions in the early period (Fidler, 2005;John & Mervis, 2010).During the speaking period, they experience serious difficulties in talking about a topic, asking questions, understanding complex sentence structures, and continuing the conversation on the same topic (Acarlar, 2006;Ulkü-Kürkcüoğlu, 2009).It draws attention that the "babbling" period, which is seen in babies and called repetitive sequencing with murmuring continues in these children for a longer time and the transition to speech is prolonged (Vicari, Caselli & Tonucci, 2000).The language difficulties experienced by children with DS continue throughout their lives.Thus, the difficulty areas in the language skills of the children should be determined and they should benefit from appropriate intervention services as early as possible.It is important to plan early education services with the parents who know the children best.Children interact with whoever is the primary caregiver in the family from the moment they are born.This is generally the duty of the mother (Brassart & Schelstraete, 2000).Especially the mother's responsibilities increase when a child with disabilities is born into the family.With the birth of a child with disabilities, inter-family relationships break and some economic, social, and psychological problems occur.This situation causes emotions such as anxiety, hopelessness, stress, and burnout and cause some psychological problems in the family members (Natan, 2007).Mothers' burden increases in terms of taking care and meeting the needs of the child with DS.All these factors are a serious resource of stress and the mother needs more social support.While mothers struggle with the care of the child and economic difficulties, on one hand, they also deal with problems such as their children's getting behind in development from their peers, or who will take care of their children after them on the other hand.The mothers need to be provided with both emotional and physical support in terms of supporting the development of their children and dealing with their problems (Allen, Ciambrone & Welch, 2000;Sen & Yurtsever, 2007).

attention that th
"babbling" period, which is seen in babies and called repetitive sequencing with murmuring continues in these children for a longer time and the transition to speech is prolonged (Vicari, Caselli & Tonucci, 2000).The language difficulties experienced by children with DS contin

throughout their lives.Thus, the difficulty
reas in the language skills of the children should be determined and they should benefit from appropriate intervention services as early as possible.It is important to plan early education services with the parents who know the children best.Children interact with whoever is the primary caregiver in the family from the moment they are born.This is generally the duty of the mother (Brassart & Schelstraete, 2000).Especially the mother's responsibilities increase when a child with disabilities is born into the family.With the birth of a child with disabilities, inter-family relationships break and some economic, social, and psychological problems occur.This situation causes emotions such as anxiety, hopelessness, stress, and burnout and cause some psychological problems in the family members (Natan, 2007).Mothers' burden increases in terms of taking care and meeting the needs of the child with DS.All these factors are a serious resource of stre

and the mother nee
s more social support.While mothers struggle with the care of the child and economic difficulties, on one hand, they also deal with problems such as their children's getting behind in development from their peers, or who will take care of their children after them on the other hand.The mothers need to be provided with both emotional and physical support in terms of supporting the development of their children and dealing with their problems (Allen, Ciambrone & Welch, 2000;Sen & Yurtsever, 2007).

The quality of life of mothers who are psychologically anxious, nervous, and stressed reduces, as a result, they experience limitations The quality of life of mothers who are psychologically anxious, nervous, and stressed reduces, as a result, they experience limitations in reaching rehabilitation goals.It is important to determine the social and psychological needs of the mothers who have children with DS and to develop solution suggestions for these needs.This study aimed to investigate the effect of communication skills on the needs, anxiety, and social support levels of mothers.Answers to the following sub-problems were sought in the study: Do the needs, anxiety, and social support levels of the mothers of children with DS differ 1) according to the ages of the children? 2) according to the gender of the children?

reaching rehabilitation goals.It is important to determine the social and psychological ne
ds of the mothers who have children with DS and to develop solution suggestions for these needs.This study aimed to investigate the effect of communication skills on the needs, anxiety, and social support levels of mothers.Answers to the following sub-problems were sought in the study: Do the needs, anxiety, and social support levels of the mothers of children with DS differ 1) according to the ages of the children? 2) according to the gender of the children?

3) according to the communication levels of the children?4) Is there a relationship between the communication level of the children with DS and the needs, anxiety, and social support level perceived by the mothers?


Material and Methods


Research Design

The quantitative research method was used in the study (Cohen, Manion & Morrison, 2000), which was performed in the descriptive survey model.All data were collected in one-on-one interviews with mothers.


Participants

Partic 3) according to the communication levels of the children?4) Is there a relationship between the communication level of the children with DS and the needs, anxiety, and social support level perceived by the mothers?

Research Design
The quantitative research method was used in the study (Cohen, Manion & Morrison, 2000), which was performed in the descriptive survey model.All data were collected in one-on-one interviews with mothers.

Participants
Participants were the mothers of children with Down Syndrome who are between the ages of 4-16 years and speak Turkish.There were no other specific inclusion or exclusion criteria.The researchers contacted the administrators of the centers where the children who receive special education continue and explained the purpose of the study.Administrators of the institutions shared the official ethical permissions with the families and gave information.They shared the contact information of the mothers who volunteered to participate in the study with the researchers.The researchers conducted face-to-face interviews with the volunteer mothers.This questionnaire was used to collect all data for the study (including demographic data relating to the child, parent, and family as well as all outcome measures) Age and gender of children with Down Syndrome and the age and educational grade of parents were presented in detail in Table 1 and CFCS levels of children in Table 2.  Table 2 shows that CFCS levels included level I of 9 (12.7%), level II of 17 (23.9%),level III of 26 (36.6%), level IV of 13 (18.3%),and level V of 6 (8.5%) children with down syndrome.In the study, it has been determined most of the children (36.6%) belong to level III according to the CFCS level.

ants were the mothers
of children with Down Syndrome who are between the ages of 4-16 years and speak Turkish.There were no other specific inclusion or exclusion criteria.The researchers contacted the administrators of the centers where the children who receive special education continue and explained the purpose of the study.Administrators of the institutions shared the official ethical permissions with the families and gave information.They shared the contact information of the mothers who volunteered to participate i

the study with
the researchers.The researchers conducted face-to-face interviews with the volunteer mothers.This questionnaire was used to collect all data for the study (including demographic data relating to the child, parent, and family as well as all outcome measures) Age and gender of children with Down Syndrome

d the age and education
l grade of parents were presented in detail in Table 1 and CFCS levels of children in Table 2.  Table 2 shows that CFCS levels included level I of 9 (12.7%), level II of 17 (23.9%),level III of 26 (36.6%), level IV of 13 (18.3%),and level V of 6 (8.5%) children with down syndrome.In the study, it has been determined most of the children (36.6%) belong to level III according to the CFCS level.


Outcome Measures

Participation was measured using Communication Function Classification System, Family Need Survey, Questionnaire on Resources and Stress for Families with Chronically or Handicapped Members, and Social Support Scale.The tests used and their features are given below in detail.


Communication Function Classification System

Communication Function Classification System (CFCS) provides 5 levels from Level I to Level V to describe everyday communication performance (Hidecker, Paneth, Rosenbaum et al., 2011).CFCS is now being used to describe the communication performance of individuals with any disability (Communication Function Classification System, http://cfcs.us/).The Turkish CFCS had been previously translated and backtranslated from the original English version (http://cfcs.us/wpcontent/uploads/2014/02/Turkish).The pediatric physiotherapist who classified the children had training on CFCS online training.The first researcher who is both an audiology and speech pathologist and physiotherapist classified the children in CFCS.The children with DS who participated in the study are divided into (3) groups in terms of CFCS.The groups are defined as follows: first group, I, II mild level, second group; III moderate level, and third group; IV, V severe level.


Family Need Survey

Family Need Survey (FNS) was developed by Bailey and Simeonsson in 1988 to determine the needs of families.Its validity and reliability studies were conducted and it was adapted into Turkish in 1995 by Sucuoğlu (Bailey & Simeonsson, 1988;Neely-Barnes & Dia, 2008).The validity and reliability studies of FNS were investigated on different disability groups and the tool was shown to be reliable (Akcamete & Kargın, 1996;Mert, 1997).The scale is applied with three response options: (1) "No," (2) "Not Sure," and (3) "Yes."Information, explaining to others, and financial sections of the scale was used in this study (Sucuoğlu, 1995).


Questionnaire on Resources and Stress for Families with Chronically or Handicapped Members

The anxiety levels of the mothers have been evaluated by the Questionnaire on Resources and Stress for Families with Chronically or Handicapped Members (QRS) which consists of three sub-scales, developed by Jean Holroyd (1988) and was adapted to Turkish by (Akkök, 1989).QRS consists of three dimensions and eleven sub-dimensions.Problems regarding the person with a disability or a permanent disease dimension consist of dependency and self-management, cognitive inefficiency, physical restrictions subdimensions (QRS1); personal problems of the family members dimension consist of

Outcome Measures
Participation was measured using Communication Function Classification System, Family Need Survey, Questionnaire on Resources and Stress for Families with Chronically or Handicapped Members, and Social Support Scale.The tests used and their features are given below in detail.

Communication Function Classification System
Communication Function Classification System (CFCS) provides 5 levels from Level I to Level V to describe everyday communication performance (Hidecker, Paneth, Rosenbaum et al., 2011).CFCS is now being used to describe the communication performance of individuals with any disability (Communication Function Classification System, http://cfcs.us/).The Turkish CFCS had been previously translated and backtranslated from the original English version (http://cfcs.us/wpcontent/uploads/2014/02/Turkish).The pediatric physiotherapist who classified the children had training on CFCS online training.The first researcher who is both an audiology and speech pathologist and physiotherapist classified the children in CFCS.The children with DS who participated in the study are divided into (3) groups in terms of CFCS.The groups are defined as follows: first group, I, II mild level, second group; III moderate level, and third group; IV, V severe level.

Family Need Survey
Family Need Survey (FNS) was developed by Bailey and Simeonsson in 1988 to determine the needs of families.Its validity and reliability studies were conducted and it was adapted into Turkish in 1995 by Sucuoğlu (Bailey & Simeonsson, 1988;Neely-Barnes & Dia, 2008).The validity and reliability studies of FNS were investigated on different disability groups and the tool was shown to be reliable (Akcamete & Kargın, 1996;Mert, 1997).The scale is applied with three response options: (1) "No," (2) "Not Sure," and (3) "Yes."Information, explaining to others, and financial sections of the scale was used in this study (Sucuoğlu, 1995).

Questionnaire on Resources and Stress for Families with Chronically or Handicapped Members
The anxiety levels of the mothers have been evaluated by the Questionnaire on Resources and Stress for Families with Chronically or Handicapped Members (QRS) which consists of three sub-scales, developed by Jean Holroyd (1988) and was adapted to Turkish by (Akkök, 1989).QRS consists of three dimensions and eleven sub-dimensions.Problems regarding the person with a disability or a permanent disease dimension consist of dependency and self-management, cognitive inefficiency, physical restrictions subdimensions (QRS1); personal problems of the family members dimension consist of lifelong care, lack of personal rewards, consistent disease concern, preferring to be cared in an institution, difficulties for the family sub-dimensions (QRS2); inter-family problems dimension consists of restrictions on the family life, financial problems, inter-family inconsistency sub-dimensions (QRS3).The answers are given as true or false on this scale.

felong care, la
k of personal rewards, consistent disease concern, preferring to be cared in an institution, difficulties for the family sub-dimensions (QRS2); inter-family problems dimension consists of restrictions on the family life, financial problems, inter-family inconsistency sub-dimensions (QRS3).The answers are given as true or false on this scale.


Social Support Scale

Social Support Scale (SSS) was used to evaluate the social support levels perceived by the mothers.It was developed by Cutrona and Russell (1987) to measure the social support types that were defined by Sacle, and Weiss (1974).It was adapted into Turkish by Duru and Balkıs (2007).The internal consistency coefficient of the scale is 90, and the test-retest correlation coefficient is 75.Each item on the scale is given points between 1-4 (4 "strongly agree", 1 "strongly disagree") (Işıklı, 1998).


Data Analysis

Statistical analyses were conducted using SPSS 25.0.Arithmetic mean, frequency, and percentage were calculated.Kruskal-Wallis, Mann-Whitney U t

Social Support Scale
Social Support Scale (SSS) was used to evaluate the social support levels perceived by the mothers.It was developed by Cutrona and Russell (1987) to measure the social support types that were defined by Sacle, and Weiss (1974).It was adapted into Turkish by Duru and Balkıs (2007).The internal consistency coefficient of the scale is 90, and the test-retest correlation coefficient is 75.Each item on the scale is given points between 1-4 (4 "strongly agree", 1 "strongly disagree") (Işıklı, 1998).

Data Analysis
Statistical analyses were conducted using SPSS 25.0.Arithmetic mean, frequency, and percentage were calculated.Kruskal-Wallis, Mann-Whitney U test, and Spearman correlation analysis were performed (Leech, Barrett & Morgan, 2007).A probability level of p<0.05 was considered statistically significant.
st, and Spearman correlation analysis were performed (Leech, Barrett & Morgan, 2007).A probability level of p<0.05 was considered statistically significant.


Results and Discussion

This section has included the demographic data regarding the participants with the finding of the analysis conducted according to the research questions.Table 3 shows the analysis results of the scores of the mothers who have children at or under the age of 5, between 6-11 years of age, and above 12 years of age in the family needs (Financial, Explaining to others, Information, General support, and Community service), anxiety (QRS 1, QRS2, QRS 3) and social support scales in terms of age groups.When examining Table 3, family needs survey results indicated that three age groups with Down Syndrome differed significantly in mothers' financial needs χ 2 (2, n=71) = 17.312, p= .000Post hoc Mann-Whitney U tests were used to compare three age groups with Down Syndrome in mothers' financial needs.The mean rank of mothers whose children were under 5 years of age (31.16, n=22) was significantly higher than mothers whose children were between the ages of 6-11 (22.29, n=29), z=-2.175,p=.030, r=.30, a small to medium effect size according to Cohen (1988).The mean rank of mothers whose children were under the age of 5 (29.16, n=22) was significantly higher than mothers who have children above the age of 12 (13.08,n=20), z=-4.282,p=.000, r=.65 a medium to large effect size according to Cohen (1988).The mean rank of mothers whose children were between the ages of 6-11 (28,41 n=29) was significantly higher than mothers whose children were 6-11 (20.05, n=20), z=-2.070,p=.038, r=.30 a small to medium effect size according to Cohen (1988).Mothers' anxiety results indicated that the mean rank of mothers whose children were under the age of 5 (21.34, n=22) was

Results and Discussion
This section has included the demographic data regarding the participants with the finding of the analysis conducted according to the research questions.Table 3 shows the analysis results of the scores of the mothers who have children at or under the age of 5, between 6-11 years of age, and above 12 years of age in the family needs (Financial, Explaining to others, Information, General support, and Community service), anxiety (QRS 1, QRS2, QRS 3) and social support scales in terms of age groups.When examining Table 3, family needs survey results indicated that three age groups with Down Syndrome differed significantly in mothers' financial needs χ 2 (2, n=71) = 17.312, p= .000Post hoc Mann-Whitney U tests were used to compare three age groups with Down Syndrome in mothers' financial needs.The mean rank of mothers whose children were under 5 years of age (31.16, n=22) was significantly higher than mothers whose children were between the ages of 6-11 (22.29, n=29), z=-2.175,p=.030, r=.30, a small to medium effect size according to Cohen (1988).The mean rank of mothers whose children were under the age of 5 (29.16, n=22) was significantly higher than mothers who have children above the age of 12 (13.08,n=20), z=-4.282,p=.000, r=.65 a medium to large effect size according to Cohen (1988).The mean rank of mothers whose children were between the ages of 6-11 (28,41 n=29) was significantly higher than mothers whose children were 6-11 (20.05, n=20), z=-2.070,p=.038, r=.30 a small to medium effect size according to Cohen (1988).Mothers' anxiety results indicated that the mean rank of mothers whose children were under the age of 5 (21.34, n=22) was significantly lower than mothers whose children were between the ages of 6-11 in QRS1 (29.53, n=29), z=-1.976,p=.048, r=.28 a small to medium effect size according to Cohen (1988).There was no difference between the scores of the mothers with children under the age of 5 and mothers who have children above 12 years of age z=-.950, p=.342.Social support results indicated that three age groups with Down Syndrome differed significantly in mothers' social support χ 2 (2, n=71) =6.834, p=.033.Post hoc Mann-Whitney U tests were used to compare the three age groups with Down Syndrome in mothers' social support levels.The mean rank of mothers whose children were under the age of 5 (20.02, n=22) was significantly lower than mothers whose children were between the ages of 6-11 (30.53, n=29), z=-2.175,p=.012, r=.30 a small to medium effect size according to Cohen (1988).There was no difference between the scores of the mothers whose children were under the age of 5 and mothers whose children were above 12 years of age (z=-1.816,p=.069) and there was no difference between the scores of the mothers whose children were between the ages of 6-11 and mothers whose children were above 12 years of age (z=-.713, p=.476)Table 4 shows the analysis results of the scores received from needs, anxiety, and social support scales in accordance with gender.
ignificantly lower than mothers whose children were between the ages of 6-11 in QRS1 (29.53, n=29), z=-1.976,p=.048, r=.28 a small to medium effect size according to Cohen (1988).There was no difference between the scores of the mothers with children under the age of 5 and mothers who have children above 12 years of age z=-.950, p=.342.Social support results indicated that three age groups with Down Syndrome differed significantly in mothers' social support χ 2 (2, n=71) =6.834, p=.033.Post hoc Mann-Whitney U tests were used to compare the three age groups with Down Syndrome in mothers' social support levels.The mean rank of mothers whose children were under the age of 5 (20.02, n=22) was significantly lower than mothers whose children were between the ages of 6-11 (30.53, n=29), z=-2.175,p=.012, r=.30 a small to medium effect size according to Cohen (1988).There was no difference between the scores of the mothers whose children were under the age of 5 and mothers whose children were above 12 years of age (z=-1.816,p=.069) and there was no difference between the scores of the mothers whose children were between the ages of 6-11 and mothers whose children were above 12 years of age (z=-.713, p=.476)Table 4 shows the analy Because the dependent variables were ordinal and the variances were unequal, Mann-Whitney U tests were performed to compare the gender.38 male children with Down Syndrome have a significantly higher mean rank (40.72) than the 33 females (30.56) on financial need, U=447.5, p=.036, r=.25 which, according to Cohen (1988), is small effect size.Likewise, there was a significant difference in the mean rank of males (40.87) and females (30.39) on explaining to others, U=442, p=.032, r=.25, which is considered a small effect size.There was a significant difference in the mean rank of males (42.54) and females (28.47) on QRS3, U=378.5, p=.004, r=.34, which is considered a small to medium effect size.There was a significant difference in the mean rank of males (29.49) and females (43.50) on social support, U=379.5, p=.004, r=.39, which is considered a small to medium effect size.However, male and female children with Down Syndrome did not differ in information needs, QRS1, QRS 2. Table 5 shows the analysis results of the scores the mothers obtained from the needs, anxiety, and social support scales according to CFCS levels of children.
and the variances were unequal, Mann-Whitney U tests were performed to compare the gender.38 male children with Down Syndrome have a significantly higher mean rank (40.72) than the 33 females (30.56) on financial need, U=447.5, p=.036, r=.25 which, according to Cohen (1988), is small effect size.Likewise, there was a significant difference in the mean rank of males (40.87) and females (30.39) on explaining to others, U=442, p=.0 2, r=.25, which is considered a small effect size.There was a significant difference in the mean rank of males (42.54) and females (28.47) on QRS3, U=378.5, p=.004, r=.34, which is considered a small to medium effect size.There was a significant difference in the mean rank of males (29.49) and females (43.50) on social support, U=379.5, p=.004, r=.39, which is considered a small to medium effect size.However, male and female children with Down Syndrome did not differ in information needs, QRS1, QRS 2. Table 5 shows the analysis results of the scores the mothers obtained from the needs, anxiety, and social support scales according to CFCS levels of children.

A Kruskal-Wallis analysis of variance indicated that CFCS levels with Down Syndrome differed significantly in mothers' information needs χ 2 (2, n=71) = 7.189, p= .027.Post hoc Mann-Whitney U tests were used to compare three levels of Down Syndrome in mothers' information need levels.The mean rank of mothers whose children were level I-II was significantly lower than mothers whose children were level IV-V (z=-1.989,p=.047, r=.30), a small to medium effect size according to Cohen (1988).CFCS levels with Down Syndrome differed significantly in mothers' financial needs χ 2 (2, n=71) = 10.116,p=.006.Post hoc Mann-Whitney U tests compared the three age groups with Down Syndrome on mothers' financial needs.The mean rank of mothers whose children were Level I-II was significantly lower than mothers whose children were Level III (z=-2.558,p=.011, r=.35 a small to medium effect size according to Cohen (1988).The mean rank of mothers whose children were Level I-II was significantly lower than mothers whose children were Level IV-V (z=-2.852,p=.004, r=.43), a small to medium effect size according to Cohen (1988).There was no difference between Level III and Level IV-V (z=-.658,p=.510).For the anxiety scores, there was no difference between QRS 1 and QRS 2. QRS 3 indicated that three age groups with Down Syndrome differed significantly χ2 (2, n=71) =6.174, p=.046.Post hoc Mann-Whitney U tests were used to compare CFCS levels with Down Syndrome on mothers' QRS 3. The mean rank of mothers whose children were level I-II was significantly lower than mothers whose children were level IV-V (z=-2.193,p=.028, r=.33) a small to medium effect size according to Cohen (1988).There was no difference between levels I-II and A Kruskal-Wallis analysis of variance indicated that CFCS levels with Down Syndrome differed significantly in mothers' information needs χ 2 (2, n=71) = 7.189, p= .027.Post hoc Mann-Whitney U tests were used to compare three levels of Down Syndrome in mothers' information need levels.The mean rank of mothers whose children were level I-II was significantly lower than mothers whose children were level IV-V (z=-1.989,p=.047, r=.30), a small to medium effect size according to Cohen (1988).CFCS levels with Down Syndrome differed significantly in mothers' financial needs χ 2 (2, n=71) = 10.116,p=.006.Post hoc Mann-Whitney U tests compared the three age groups with Down Syndrome on mothers' financial needs.The mean rank of mothers whose children were Level I-II was significantly lower than mothers whose children were Level III (z=-2.558,p=.011, r=.35 a small to medium effect size according to Cohen (1988).The mean rank of mothers whose children were Level I-II was significantly lower than mothers whose children were Level IV-V (z=-2.852,p=.004, r=.43), a small to medium effect size according to Cohen (1988).There was no difference between Level III and Level IV-V (z=-.658,p=.510).For the anxiety scores, there was no difference between QRS 1 and QRS 2. QRS 3 indicated that three age groups with Down Syndrome differed significantly χ2 (2, n=71) =6.174, p=.046.Post hoc Mann-Whitney U tests were used to compare CFCS levels with Down Syndrome on mothers' QRS 3. The mean rank of mothers whose children were level I-II was significantly lower than mothers whose children were level IV-V (z=-2.193,p=.028, r=.33) a small to medium effect size according to Cohen (1988).There was no difference between levels I-II and level III (z=-1.857,p=.063).There was no difference between level III and level IV-V (z=-.987,p=.325).
level III (z=-1.857,p=.063).There was no difference between level III and level IV-V (z=-.987,p=.325).

According to the CFCS levels of the children with Down Syndrome, the scores of the mothers' from the social support scale did not differ significantly χ2 (2, n=71) =5.990, p= .050.

Table 6 shows the correlation results between the CFCS levels of the children with Down Syndrome and the scores of the mothers they received from needs, anxiety, and social support scales.There was a positive significant relationship between CFCS and financial needs and QRS 2 (personal problems of the family members dimension), and a negative significant relationship between CFCS and social support.There was a significant relationship between all sub-dimensions of the family needs survey tool.There was a negative relationship between the family needs survey in financial needs and QRS1 (problems regarding the person with a disability or a permanent disease dimension), a positive relationship with QRS3 (inter-family problems dimension), there was a positive relationship between explaining to others and QRS3, a negative relationship between financial and explaining to others and social support.a negative significant relationship was found between QRS3 (inter-family problems dimension) of the anxiety and stress level tool and social support.
-- -- -- -- -- -- .302* .050 7. QRS 3 -- -- -- -- -- -- -- -321** 8. Social support -- -- -- -- -- -- -- -- *p <.
This study aims to investigate the effect of communication skills of children with Down Syndrome on the needs, anxiety, and social support levels of their mothers.Besides, this study examines whether the anxiety levels of the mothers differ in accordance with the age, gender, and communication function levels of the children.In this section, findings obtained regarding the purpose of the study and the literature are discussed.

DS, an inherited disease that is the most common among mental disabilities, negatively affects language and communication skills.Language and communication difficulties can be limiting for children with DS to socialize/interact with their peers and fulfill the roles expected from themselves (Bradley, 2002).Social problems resulting from their language and mental development can cause behaviors such as deficiencies in expected behaviors, and externalizing/internalizing.Externalizing problems (like aggressive behavior) can be more dominant than internalizing problems (like anxiety, or withdrawal).Studies on the functional use of social skills indicate that variables of language, socioeconomic status, age, and gender are predictive.Although socioeconomic level (SEL) is an important determinant in terms of social functionality, the second deter According to the CFCS levels of the children with Down Syndrome, the scores of the mothers' from the social support scale did not differ significantly χ2 (2, n=71) =5.990, p= .050.
Table 6 shows the correlation results between the CFCS levels of the children with Down Syndrome and the scores of the mothers they received from needs, anxiety, and social support scales.There was a positive significant relationship between CFCS and financial needs and QRS 2 (personal problems of the family members dimension), and a negative significant relationship between CFCS and social support.There was a significant relationship between all sub-dimensions of the family needs survey tool.There was a negative relationship between the family needs survey in financial needs and QRS1 (problems regarding the person with a disability or a permanent disease dimension), a positive relationship with QRS3 (inter-family problems dimension), there was a positive relationship between explaining to others and QRS3, a negative relationship between financial and explaining to others and social support.a negative significant relationship was found between QRS3 (inter-family problems dimension) of the anxiety and stress level tool and social support.
This study aims to investigate the effect of communication skills of children with Down Syndrome on the needs, anxiety, and social support levels of their mothers.Besides, this study examines whether the anxiety levels of the mothers differ in accordance with the age, gender, and communication function levels of the children.In this section, findings obtained regarding the purpose of the study and the literature are discussed.
DS, an inherited disease that is the most common among mental disabilities, negatively affects language and communication skills.Language and communication difficulties can be limiting for children with DS to socialize/interact with their peers and fulfill the roles expected from themselves (Bradley, 2002).Social problems resulting from their language and mental development can cause behaviors such as deficiencies in expected behaviors, and externalizing/internalizing.Externalizing problems (like aggressive behavior) can be more dominant than internalizing problems (like anxiety, or withdrawal).Studies on the functional use of social skills indicate that variables of language, socioeconomic status, age, and gender are predictive.Although socioeconomic level (SEL) is an important determinant in terms of social functionality, the second determinant that follows it is age (Bradley, 2002;Patterson, DeBaryshe & Ramsey, 1989).While some studies state that SEL does not have negative effects on the functional use of social skills by children with DS (McCarthy, 2008), it is stated that age is more prominent in the functional use of social skills (Bradley, 2002;Rosner, Hodapp & Fidler, 2004;Eisenhower, Baker & Blacher, 2005).It is emphasized that while social skills and communication activities increase with age in children with typical development, children with DS at young ages experience more difficulties in the functional use of social skills.There also are study findings that state that externalizing problems increase in children with DS as age progresses and gender is not effective in social skills (Dykens & Kasari, 1997;Eisenhower, Baker & Blacher, 2005).The results of our study show that there is a relationship between the age of the children with DS and the needs, anxiety, and social support levels of the mothers.It is seen that as the age of the children increases, the anxiety levels of the mothers decrease.It is thought that the decrease in the mothers' anxiety can be related to the decrease in the uncertainties about their children and an increase in their knowledge level over time.In these circumstances, it draws attention that mothers stated that they overcome difficulties more easily and spend more time with their children over time thanks to the fact that the children with DS benefit from education services starting from a young age.
inant that follows it is age (Bradley, 2002;Patterson, DeBaryshe & Ramsey, 1989).While some studies state that SEL does not have negative effects on the functional use of social skills by children with DS (McCarthy, 2008), it is stated that age is more prominent in the functional use of social skills (Bradley, 2002;Rosner, Hodapp & Fidler, 2004;Eisenhower, Baker & Blacher, 2005).It is emphasized that while social skills and communication activities increase with age in children with typical development, children with DS at young ages experience more difficulties in the functional use of social skills.There also are study findings that state that externalizing problems increase in children with DS as age progresses and gender is not effective in social skills (Dykens & Kasari, 1997;Eisenhower, Baker & Blacher, 2005).The results of our study show that there is a relationship between the age of the children with DS and the needs, anxiety, and social support levels of the mothers.It is seen that as the age of the children increases, the anxiety levels of the mothers decrease.It is thought that the decrease in the mothers' anxiety can be related to the decrease in the uncertainties about their children and an increase in their knowledge level over time.In these circumstances, it draws attention that mothers stated that they overcome difficulties more easily and spend more time with their children over time thanks to the fact that the children with DS benefit from education services starting from a young age.

In our study, there is a significant difference between the variable of the gender of the children with DS and the needs, anxiety, and social support levels of the mothers.

Our study shows that the mothers of female children have higher anxiety levels than the mothers of male children.The literature has similar results to the findings of our study (Besikçi, 2000).For example, it is stated that In our study, there is a significant difference between the variable of the gender of the children with DS and the needs, anxiety, and social support levels of the mothers.
Our study shows that the mothers of female children have higher anxiety levels than the mothers of male children.The literature has similar results to the findings of our study (Besikçi, 2000).For example, it is stated that the mothers of female children with disabilities experience more anxiety than the mothers of male children.It is thought that this situation mainly results from the cultural structure.Based on the view that female children are culturally more vulnerable and in need of support than male children in the region where the study was conducted, it is thought that the findings support the results about approaching female children more protective and having anxiety about the future.In literature, in the studies that investigated the developmental skills of the children with DS compared to their peers or themselves regarding the gender factor, it is stated that the verbal, perceptual-performance, social skills, memory, and motor skills scores of the male children are lower than the female children (Allhusen et al., 2003;van Gameren-Oosterom, Fekkes, Buitendijk et al, 2011).In some studies that do not support the findings regarding the gender factor in our study, it is stated that there is not a significant difference in the anxiety levels of the families according to the gender of the children with DS and the families experience general anxiety and stress resulting from the disability of the children independently of the gender (Cengelci, 2009;Coskun & Akkas, 2009).It is thought that the main reason for this situation may be due to the cultural differences of the region as well as the severity of the disability of the child.It is thought that the anxiety levels of the parents increase as the severity of the child's disability increases.The depression level of the family can differ according to the gender of the child.Especially the families of male children with disability who need caring stated that they accepted the care of the male child more easily (Ergin, Şen, Eryılmaz, Pekuslu & Kayacı, 2007).In terms of gender factors, our study shows that the information needs of the mothers do not differ, however, mothers of male children with DS have higher scores in financial support needs and explaining to others; their scores are significantly different from the scores of the mothers of the female children.The finding of our study is similar to the finding that states that the quality of life and social support levels of the family do not differ according to gender in the literature (Sarıkaya, 2011).
he mothers of female children with disabilities experience more anxiety than the mothers of male children.It is thought that this situation mainly results from the cultural structure.Based on the view that female children are culturally more vulnerable and in need of support than male children in the region where the study was conducted, it is thought that the findings support the results about approaching female children more protective and having anxiety about the future.In literature, in the studies that investigated the developmental skills of the children with DS compared to their peers or themselves regarding the gender factor, it is stated that the verbal, perceptual-performance, social skills, memory, and motor skills scores of the male children are lower than the female children (Allhusen et al., 2003;van Gameren-Oosterom, Fekkes, Buitendijk et al, 2011).In some studies that do not support the findings regarding the gender factor in our study, it is stated that there is not a significant difference in the anxiety levels of the families according to the gender of the children with DS and the families experience general anxiety and stress resulting from the disability of the children independently of the gender (Cengelci, 2009;Coskun & Akkas, 2009).It is thought that the main reason for this situation may be due to the cultural differences of the region as well as the severity of the disability of the child.It is thought that the anxiety levels of the parents increase as the severity of the child's disability increases.The depression level of the family can differ according to the gender of the child.Especially the families of male children with disability who need caring stated that they accepted the care of the male child more easily (Ergin, Şen, Eryılmaz, Pekuslu & Kayacı, 2007).In terms of gender factors, our study shows that the information needs of the mothers do not differ, however, mothers of male children with DS have higher scores in financial support needs and explaining to others; their scores are significantly different from the scores of the mothers of the female children.The finding of our study is similar to the finding that states that the quality of life and social support levels of the family do not differ according to gender in the literature (Sarıkaya, 2011).

The social development of children with DS should be evaluated in many ways.The families stated that they care about the participation of children with DS in community life, however, the children prefer inactive, individual activities such as watching TV outside of school life (MacDonald, Leichtman, Esposito, et al., 2016;Wuang, Su, 2012).Participation in community life and social skills may differ in accordance with the factors related to the child (such as behaviors, and cognitive skills) and factors related to the family (such as difficulty in manag The social development of children with DS should be evaluated in many ways.The families stated that they care about the participation of children with DS in community life, however, the children prefer inactive, individual activities such as watching TV outside of school life (MacDonald, Leichtman, Esposito, et al., 2016;Wuang, Su, 2012).Participation in community life and social skills may differ in accordance with the factors related to the child (such as behaviors, and cognitive skills) and factors related to the family (such as difficulty in managing daily family responsibilities, and lack of time) (Lyons, Brennan, Carroll, 2016).Although parents have great responsibilities with the birth of children with DS, the biggest responsibility falls on the mothers.Thus, social support levels perceived by the mothers are an important variable in the decrease or increase of anxiety levels.While the support provided to the mothers will make their adaptation to the environment and their child easier, it is also an important factor for them to deal with the difficulties (Kırbas, 2013).The fact that there is a decrease in the social support needs as the children grow older shows that the maternal age of the mothers is important for their adaptation period to their children with DS (Akandere, Acar & Bastug, 2009).Because children with DS who have language problems experience more social problems, families tend to support the language skills of their children in the early childhood period.It is observed that progress is seen in the children with DS whose language skills are supported and their problem behaviors decrease (Brassart & Schelstraete, 2015;Delaney & Kaiser, 2001;Petersen, Bates, 2013).The studies that show the language skills of children largely develop due to the family-child interaction draw attention to the applied interventions in the early childhood period (Sen & Yurtsever, 2007).

g daily fam
ly responsibilities, and lack of time) (Lyons, Brennan, Carroll, 2016).Although parents have great responsibilities with the birth of children with DS, the biggest responsibility falls on the mothers.Thus, social support levels perceived by the mothers are an important variable in the decrease or increase of anxiety levels.While the support provided to the mothers will make their adaptation to the environment and their child easier, it is also an important factor for them to deal with the difficulties (Kırbas, 2013).The fact that there is a decrease in the social support needs as the children grow older shows that the maternal age of the mothers is important for their adaptation period to their children with DS (Akandere, Acar & Bastug, 2009).Because children with DS who have language problems experience more social problems, families tend to support the

udies that
With CFCS applied in the study, a positive significant relationship was found with the financial need dimension, personal problems of the family members dimension (QRS2), inter-family problems dimension (QRS3), and a negative significant relationship was found with the social support.It is determined that mothers have anxiety about the care services for their child, especially after themselves.This result shows that they need more social support.Besides care difficulties, economic difficulties, problems in reaching the rehabilitation centers; problems such as the fact that their children fall behind their peers and who will take care of the child after themselves can cause anxiety and stress for the mothers.The lack of correlation between problems regarding the person with a disability or a permanent disease dimension (QRS1) and CFCS can be explained by the low education level of most mothers, their being housewives, and their acceptance of their children's condition.In the studies, it is stated that mothers who have children with disabilities experience anxiety about topics such as health and feeding in the first times after birth (Neely- Barnes & Dia, 2008).When the mothers are seen as the primary responsible for the care of the children, they have more duties and responsibilities.Mothers experience more stress when the care services of children with disabilities are completely left to the mothers compared to healthy children in this process in which the fathers participate less (Karner, 2004).Whether the social support levels of the family are sufficient or not forms a great part of the problems experienced.Mothers stated that they feel lonely and have a limited social life.They stated that the heavy care services of the children at young ages and the attitudes of society put a physical burden on them and they need social support services more to overcome these difficulties (Olsson, 2004).Similarly, it is emphasized that mothers need more intense social support for the issues such as adaptation to children with disability and condition, and dealing with the problems (Jones & Passey, 2004).Besides the social support services provided in different ways, emotional support provided by the relatives and family has an important place for the mothers.As for the perceived social support, when the support provided is sufficient and efficient, the mothers perceive themselves as a part of society.Thus, it is seen that the anxiety levels of the mothers decrease and their quality of life increases (Pelchat, Lefebvre & Levert, 2007).Strategies and support applied in the early period positively affect the language skills of the children.During this period, the stress levels of the parents decrease thanks to the education services provided for the families (Delaney & Kaiser, 2001;DeVeney, Hagaman & Bjornsen, 2017;Fey et al., 2006).

Conclusion
The results of this study revealed that the needs of the mothers who spend more time with their children should be met and support should be provided to the mothers.It is thought that the stress and anxiety levels of the mothers will decrease thanks to this support.Meeting the information needs and providing social support will help the mothers to increase the adaptation levels of mothers to their children and to deal with the problems.It is thought that if the support is qualified, accessible, and sustainable, mothers will be able to follow the development of their children more closely and their family life will be affected positively.Determining the mothers' anxiety levels and stress perceptions regarding the communication skills of their children with DS will guide in planning the social support that will be provided for them and their children.

and their
Sciences Institute of the University of Çukurova as the top-scoring student in September Individual differences, techniques for acquainting with students, teaching methods and techniques, communication skills, measurement and evaluation in education, qualitative research, multiple intelligence practices, and scientific research methods and graduated in 2008 after submitting her dissertation analyzing the relationship between the levels of acceptance of new primary education programs among form teachers and their professional satisfaction.Kayhan enrolled in the doctoral program of Special Education Department of the Education Sciences Institute of the University of Ankara in 2008.Kayhan was employed by the Education Faculty of the University of Aksaray as a research assistant in 2009 and worked for the Pre-School Education department until 2014 and served as a unit coordinator for the inclusive education of higher education students with different needs.She worked as a lecturer in the Special Education Department of the Education Faculty of the University of Eastern Mediterranean from 2014 through 2016 and received a doctoral degree with her study entitled "Effect on effective teaching skills of form teachers in inclusive settings of the lecturing observer model among unified teaching approaches" which she completed in consultation with Prof. Gönül Akçamete, Ph.D. in 2016.Kayhan's dissertation aimed at improving teachers' effective teaching and planning skills, and teaching implementation and evaluation skills in order to support their social and academic involvement while enhancing the quality of education provided by individuals with special needs and with different linguistic skills and cultures and spreading integration practices in our country and she is currently working as a lecturer for the Special Education Department of the Education Faculty of Ege University.
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05, **p<.01CFCS: Communication Function Classification System QRS1: Problems regarding the person with a disability or a permanent disease dimension QRS 2: Personal problems of the family members dimension QRS 3: Inter-family problems dimension * Spearman correlation analysis.

Table 1 :
Characteristics of the children with Down Syndrome and their parents (n=71)

Table 2 :
CFCF Levels of Children with Down Syndrome

Table 3 :
Kruskal-Wallis analysis results of mothers' need, anxiety, and social support scores by age groups of children with Down Syndrome

Table 4 :
Comparison of male and female children with Down Syndrome, needs, anxiety, and social support test scores of mother

Table 5 :
Kruskal Wallis analysis results of mothers' needs, anxiety, and social support levels according to CFCS levels of children with Down Syndrome

Table 6 :
Correlation between CFCS levels of the children with Down Syndrome and needs, anxiety, social support perception of the mothers