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Speech and Language Therapy For Children With Down Syndrome: Guidelines For Best Practice Based On Current Research
Speech and Language Therapy For Children With Down Syndrome: Guidelines For Best Practice Based On Current Research
70
Speech and language therapy for children with Down syndrome
a controversial issue and families Therefore vocabulary development The speech and language
receive different services depending is very important – the number of
on where they live and the knowledge words that a child knows when he profile associated with
and interest of local speech and or she enters school at five years will Down syndrome
language therapists in the specific have a very significant influence on
progress. Secondly, language sup- Specific speech and language
needs of children with Down
ports thinking and reasoning. The difficulties - Children with Down
syndrome. This article is an attempt
human brain has evolved a remark- syndrome usually have an uneven
to provide guidelines for speech
able ability to learn spoken language profile of social, cognitive and
and language therapists based on
with amazing ease and then to use language development – they do
the best evidence of the children’s
that spoken language for mental not have a profile of equal delay
specific speech and language needs
activities. Thinking, reasoning and in all areas, they have a profile of
currently available. It is a summary
remembering, for example, are usu- strengths and weaknesses. For
of the key facts about their speech
ally carried out in mind as ‘silent example, social development and
and language profile and needs,
speech’. It follows, therefore, that social understanding is typically a
followed by recommendations for
any child with significant delay in strength, while spoken language
service provision. References to
acquiring language will be delayed development is a weakness. There is
further reading are included to
in the ability to use these cognitive now consistent evidence that these
support the points made in this brief
processes. Although delayed, almost children have a profile of specific
overview.
all children with Down syndrome speech and language delay relative
Parents are encouraged to draw
will use spoken language as their to their non-verbal mental age.
these guidelines to the attention of
main means of communication. There are considerable individual
their therapy providers. They may
The use of signs in early years will differences in rates of progress but
be copied for individual use.
help them to progress but for most the overall specific profile is usually
children signs are used as a bridge evident for all children with Down
to talking, not to teach a sign lan- syndrome. [1,2]
guage.
© 2002 The Down Syndrome Educational Trust. All Rights Reserved. Copying for personal use only is permitted. ISSN: 1463-6212
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Down Syndrome News and Update 2(2), 70-76
71
Speech and language therapy for children with Down syndrome
An uneven profile within the lan- loop difficulties will affect both Principles for effective
guage domains - While the speech vocabulary learning and grammar
and language skills of children with learning. [see 26] interventions
Down syndrome are delayed relative Visual short-term memory is There is considerable agreement
to non-verbal mental abilities, dif- not impaired relative to non-verbal among international experts on the
ferent aspects of speech, language mental abilities and is described principles that should guide speech
and communication skills are not as a relative strength. In addition, and language therapy for children
equally delayed. research has indicated that visual with Down syndrome, based on
Communication skills are a coding of verbal information may research into their difficulties and
relative strength with good under- be used by children with Down into effective interventions. [see 1-5]
standing and use of non-verbal syndrome in short-term memory
communication skills and good use tasks. [6,7] Targets for all four domains
of gesture. [1,2] Hearing - Most children with All experts identify the need to
In language, the children show Down syndrome (at least 80-90%) have separate targets for the four
delayed development of vocabulary suffer from conductive hearing loss components of speech and language
in infancy, with comprehension and auditory discrimination difficul- skill - communication, vocabulary,
ahead of production, but by the ties which will compound the pho- grammar and speech work, for each
teenage years, vocabulary is a rela- nological loop difficulties. However, child.
tive strength with vocabulary ‘ages’ the phonological loop difficulties are Targets for comprehension
ahead of grammar ‘ages’. In gram- thought to exist independently of
any hearing impairment. [6]
and production
mar, there is evidence of specific
difficulties in both comprehension Speech-motor difficulties - speech In addition, for vocabulary and
and production. [1-3] sound and word production difficul- grammar separate targets will be
In speech, there is considerable ties also have physical causes. These needed for comprehension and for
difficulty at all levels from planning are linked to the motor skill difficul- production. [3]
to articulation and phonology. Most ties associated with Down syndrome Use of signing - There is agree-
teenagers still have significant intel- and the oral-motor difficulties ment on the use of sign systems
ligibility problems. [4,5] demonstrated from the first year of to promote spoken language with
Individual differences are seen life, which affect feeding and chew- benefits for both comprehension and
within the typical profile, with some ing patterns. For all children, first production.
children having more speech difficul- words can be predicted from the Use of reading - There is agree-
ties than others, relative to language speech sounds that they can make in ment on the importance of using
comprehension and some children babble – in other words early spoken reading activities to teach spoken
having larger differences between vocabulary is influenced by existing language for those of all ages. In
comprehension and production than articulation and phonological skills, particular, the benefits of using early
others, for example. Therefore, each not the reverse. [8] reading in preschool years as an
child with Down syndrome should explicit language teaching activity
receive an individualised therapy Possible secondary are recognised.
programme but the principles for Parents are the main
effective practice upon which this
causes
Slow vocabulary acquisition
therapists
should be based is the same for all
- The development of early gram- All experts identify that language is
children with Down syndrome.
mar has been shown to be linked learned all day, every day, as children
are involved in communication
Possible primary causes to total productive vocabulary for
with their families and friends
typically developing children as well
Research is beginning to provide and therefore the focus of effective
as for children with Down syndrome.
some useful information on the therapy must be to share skills with
Therefore, the very slow rate of
underlying causes of the speech parents because they will be their
productive vocabulary development
and language profile associated with child’s best therapist.
that is typical for children with
Down syndrome.
Down syndrome may mean that the
Working memory - Children
development of grammar is delayed Implications for a
with Down syndrome have specific
impairment in the phonological
beyond the optimal period for gram- comprehensive therapy
matical acquisition (1-6 years) – for a
loop component of working memory programme
full discussion of this issue see[24].
relative to their non-verbal abilities,
Speech-motor effects - Delayed
and this is now thought to be a major
output of first words and unintelligi-
Preschool services
cause of their speech and language Specialist training for work with
ble utterances may reduce or change
difficulties.[6] For all children, the children with Down syndrome will
the language input to the children.
phonological loop is thought to play be helpful and up-to-date knowledge
Difficulties with speech production
a critical role in learning a spoken of the research literature is essential.
probably compound the grammar
language as it holds the sound pat- The needs of children with Down
learning and grammar production
tern of the word to enable the child syndrome tend to be different from
difficulties.[2]
to both link this with meaning and the needs of other children with
to store it to support production learning difficulties. Their hearing,
of the spoken word. Phonological phonological loop impairment and
© 2002 The Down Syndrome Educational Trust. All Rights Reserved. Copying for personal use only is permitted. ISSN: 1463-6212
http://www.down-syndrome.net/library/periodicals/dsnu/02/02/
Down Syndrome News and Update 2(2), 70-76
72
Speech and language therapy for children with Down syndrome
speech-motor difficulties make them (or in intensive care if baby is children is motivating for parents of
different and therapists need to be sick) for several months from younger ones.
skilled in auditory discrimination, birth on at least a monthly basis • parents should be able to choose
oral-motor function and speech • in the second to fourth years the delivery models that suit
work as well as language work. various models can be effec- them as some parents will prefer
Knowledge and skills tive, including group sessions individual home visits to groups
to ensure families know about • any model used should offer
• to have up-to-date knowledge of
speech and language development continuous support throughout
the specific research literature
and at which individual targets this vital period for speech and
on speech and language develop-
can be set for them and their language development and no
ment, working memory and effec-
infant. family should receive less than
tive therapies for children with
Group activities can be started monthly contact with a therapist
Down syndrome
with babies from about 18 months
• to understand the significance and they usually enjoy learning in First year of life
of the specific impairment in the this way, with the opportunity to 1. Encourage a good communica-
phonological loop component of copy and learn from other children. tion environment at home and
working memory for the speech Group activities can also develop ensure that parents understand
and language profile associated attention and the ability to take the speech and language needs of
with Down syndrome turns. In the groups, activities their child, and how speech and
language develops.
2. Provide support for feeding and
activities for oral-motor develop-
ment.
3. Encourage all communication
skills, eye-contact, turn-taking,
pointing and joint-referencing by
the end of the first year.
4. Target auditory discrimination
for speech sounds to improve
auditory discrimination in the
phonological loop.
5. Target auditory discrimination for
speech sounds in order to support
the development of babble (typical
babies tune their babble to the
language they are hearing by 12
months – in other words they are
setting up the speech-motor skills
for talking).
6. Encourage the use of gesture and
sign primarily to aid comprehen-
sion.
The Swedish therapist Irene
Johansson has evaluated and
promoted this type of programme
for infants with Down syndrome
for a number of years and others
• to understand the importance can be modelled by the therapist have stressed the need for speech
of reading work to support the to increase parent’s confidence at as well as language work to begin
development of vocabulary, gram- carrying them on at home. Parents early. [4,5,9]
mar and speech clarity, using frequently report that children are Second year
strengths in visual memory often more willing to show what they
can do in groups than when asked to 1. Encourage a good communica-
• to understand the importance
do the same things at home! Groups tion environment at home and
of auditory discrimination for
may reduce the individual pressure ensure parents understand the
speech sounds, phonics activities,
on children, though sometimes speech and language needs of
phonological awareness train-
children do not enjoy groups and their child, and how speech and
ing and speech work in order to
can become resistant to group language develops.
improve working memory func-
tion as well as speech. activities. Groups are a cost effective 2. Continue with targeted work in
way to offer services and also provide support of hearing and produc-
Models of delivery ing speech sounds – single
general parent support. Parents
• in the first year of life families often have effective tips to share with sounds and reduplicated babble
should receive a service at home each other and the progress of older (for speech and for auditory
© 2002 The Down Syndrome Educational Trust. All Rights Reserved. Copying for personal use only is permitted. ISSN: 1463-6212
http://www.down-syndrome.net/library/periodicals/dsnu/02/02/
Down Syndrome News and Update 2(2), 70-76
73
Speech and language therapy for children with Down syndrome
© 2002 The Down Syndrome Educational Trust. All Rights Reserved. Copying for personal use only is permitted. ISSN: 1463-6212
http://www.down-syndrome.net/library/periodicals/dsnu/02/02/
Down Syndrome News and Update 2(2), 70-76
74
Speech and language therapy for children with Down syndrome
and language profile associated rate speech and language targets vocabularies (800 words or even less)
with Down syndrome into literacy activities and limited productive grammar.
• to understand the importance 5. to review oral-motor function, Reading activities will still be an
of reading work to support the feeding, chewing and drinking important way to help all teenagers.
development of vocabulary, gram- patterns and advise accordingly Most will still have phonological and
mar and speech clarity, using 6. all targets should be shared with intelligibility difficulties that should
strengths in visual memory parents, teachers and assistants be targeted, and the social use of
• to understand the importance 7. encourage a good communica- language, particularly the ability to
of auditory discrimination for tion environment at home and initiate and maintain conversations,
speech sounds, phonics activities, at school, and ensure parents, may need addressing.
phonological awareness train- teachers and learning support Goals for speech and
ing and speech work in order to assistants understand the speech language therapists working
improve working memory func- and language needs of their child,
tion as well as speech. and how speech and language
with 11-16 year olds with
Therapy plans develops. Down syndrome
1. to have clear targets for 4 areas of 8. address communication skills if Knowledge and skills
work, speech, vocabulary, gram- necessary (3-5% have autistic • to have up-to-date knowledge of
mar and communication skills spectrum difficulties). the specific research literature
and to keep detailed records of Models of delivery on speech and language develop-
progress • children with Down syndrome ment, working memory and effec-
2. for vocabulary and grammar, to should be seen at least monthly tive therapies for children and
have separate targets for compre- in school, targets reviewed and teenagers with Down syndrome
hension and for production, as activities set for parents, teachers • to understand the significance
comprehension in both domains and assistants to include in their of the specific impairment in the
is typically significantly ahead of daily routines phonological loop component of
production • these activities should be mod- working memory for the speech
3. for speech work, separate targets elled with the child by the speech and language profile associated
may be needed for articulation, and language therapist, so that with Down syndrome
phonology and intelligibility parents and assistants can confi- • to understand the importance
(pacing, voice etc) dently enable the child to practice of reading work to support the
4. to assist teachers in using reading daily. Therapy sessions will not development of vocabulary, gram-
to teach language and to incorpo- change speech and language mar and speech clarity, using
development unless they lead strengths in visual memory
to an increase in daily teaching • to understand the importance
activities and appropriate styles of auditory discrimination for
of communication at home and at speech sounds, phonics activities,
school. phonological awareness train-
• some children with Down syn- ing and speech work in order to
drome of primary school age may improve working memory func-
need weekly individual or group tion as well as speech.
sessions of speech and language Therapy plans
therapy with a therapist who has
1. to have clear targets for 4 areas of
the specialist knowledge and the
work, speech, vocabulary, gram-
skills to address their profile of
mar and communication skills
difficulties, particularly for speech
and to keep detailed records of
and intelligibility work.
progress
Secondary school years 2. for vocabulary and grammar, to
Speech and language therapy have separate targets for compre-
should continue for all teenagers hension and for production, as
with the same list of key objectives comprehension in both domains
and targets as for the primary age is typically significantly ahead of
group, but adapted to focus on age production
appropriate language needs and 3. for speech work, separate targets
activities. may be needed for articulation,
Some teenagers with Down syn- phonology and intelligibility
drome will be making good progress (pacing, voice etc)
and talking in reasonable sentences, 4. to assist teachers in using reading
others will still have fairly limited to teach language and to incorpo-
spoken language. The range of indi- rate speech and language targets
vidual differences is very wide. Many into literacy activities
secondary school pupils with Down
syndrome will have small productive
© 2002 The Down Syndrome Educational Trust. All Rights Reserved. Copying for personal use only is permitted. ISSN: 1463-6212
http://www.down-syndrome.net/library/periodicals/dsnu/02/02/
Down Syndrome News and Update 2(2), 70-76
75
Speech and language therapy for children with Down syndrome
5. to review oral-motor function, retardation and Developmental nal of Clinical speech and Language
feeding, chewing and drinking Disabilities Research Reviews, 3, 307- Studies, 1,14-35.
patterns and advise accordingly 312. 14. Dodd, B., McCormack, P. & Woody-
2. Miller, J.F., Leddy, M. & Leavitt, L.A. att, G. (1994) Evaluation of an inter-
6. all targets should be shared with
(Eds.) (1999) Improving the Commu- vention program: relation between
parents, teachers and assistants nication of People with Down Syn- children’s phonology and parent’s
7. encourage a good communica- drome. Baltimore: Paul H Brookes communicative behaviour. American
tion environment at home and at Publishing. Journal on Mental Retardation. 98
school, and ensure parents, teach- 3. Chapman, R.S. (2001) Language, (5) 632-645.
ers and learning support assist- cognition and short-term memory 15. Laws, G., MacDonald, J., Buckley,
ants understand the speech and in individuals with Down syndrome. S.J. & Broadley, I. (1995). Long-term
language needs of their teenager, Down Syndrome Research and Prac- maintenance of memory skills taught
tice, 7 (1), 1-8. to children with Down syndrome.
and how speech and language
4. Stoel-Gammon, C. (2001) Down Down Syndrome Research and Prac-
develops tice, 3, 103-109.
syndrome phonology: Developmental
8. address communication skills if progress and intervention strate- 16. Laws, G., Byrne, A. & Buckley, S.J.
necessary (3-5% have autistic gies. Down Syndrome Research and (2000). Language and Memory
spectrum difficulties). Practice, 7 (3), 93-100. Development in children with Down
5. Stoel-Gammon, C (in press) Speech syndrome at mainstream and special
Models of delivery schools: A comparison. Educational
acquisition and approaches to inter-
• teenagers with Down syndrome vention. In J.A. Rondal & S.J.Buckley Psychology, 20(4), 447-457.
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daily routines
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so that parents and assistants Buckley, S.J. (1995). Working influence of reading instruction on
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© 2002 The Down Syndrome Educational Trust. All Rights Reserved. Copying for personal use only is permitted. ISSN: 1463-6212
http://www.down-syndrome.net/library/periodicals/dsnu/02/02/
Down Syndrome News and Update 2(2), 70-76
76
Speech and language therapy for children with Down syndrome
Acknowledgements
The authors would like to thank Leela Baksi and Margaret Wright, Speech and Language Therapists, for feedback on an earlier draft of these
guidelines. However, the opinions expressed, and any errors or omissions, are the responsibility of the authors.
See our Services brochure for details of these and other Workshops, or visit our website at: http://www.downsed.org
© 2002 The Down Syndrome Educational Trust. All Rights Reserved. Copying for personal use only is permitted. ISSN: 1463-6212
http://www.down-syndrome.net/library/periodicals/dsnu/02/02/