Intervention strategies

In this section of the module, we suggest a number of activities which should have an impact on speech, language and working memory development. Most of the activities are based on knowledge of how these systems develop for typically developing children, and the effectiveness of most of the activities for children with Down syndrome needs to be further evaluated.

Mainstream education and reading instruction

The most effective interventions that can be recommended, based on a growing body of consistent evidence from different research groups, is placement in mainstream nursery and school environments and including the children in reading instruction designed to support speech and language learning from an early age.

However, the authors strongly believe, on the basis of many years practical experience and their understanding of the current research evidence, that the activities described below will also enhance the children’s progress.

Reducing hearing difficulties

The first issue to address is hearing. If a child’s hearing is impaired, then they are not going to be able to establish clear phonological representations for spoken words. The majority of preschool children with Down syndrome (at least 80%) have hearing losses, usually due to ‘glue’ in the middle ear. More research into the causes of the ‘glue’ and effective treatments is urgently needed. Grommet surgery and aggressive repeated treatment to keep the ears free of ‘glue’ is recommended by some ENT consultants, but not all. The degree of loss caused by ‘glue’ is about 35-40dB and is considered to be a relatively minor loss by many consultants but not by the authors of this module. This level of loss will affect the ability to discriminate consonant sounds so that ‘man’ and ‘van’ sound the same to the child, similarly ‘hat’, ‘mat’ and ‘cat’. This will seriously impair the child’s ability to learn to talk. Parents need to press consultants to consider treatment with microsuction, grommets and other treatments, and to take this degree of hearing loss more seriously than they often do at present.

Treatment to keep the middle ear clear is not only important for hearing in infancy, there is evidence that the untreated ‘glue’ leads to long term damage in the middle ear. For example, a study of late adolescents and young adults [@marcell_relationships_1995] showed some 40% to have permanent dysfunction of the middle ear and no such dysfunction in a comparison group of peers with similar levels of learning disabilities but not Down syndrome. The young people with the middle ear problems showed greater difficulty in discriminating consonants, in recognising words and in speech and language skills.

Hearing aids are sometimes offered for young children, rather than treatments to remove the ‘glue’, but there is no published evidence to support their effectiveness and it is essential to demonstrate that they do, in fact, improve speech discrimination abilities and not just the detection of pure single frequency sounds.

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Figure 5. Examples of a speech sound discrimination game. The child is asked “which one is ‘b’?” or “where is ‘n’?”, using similar sounding pairs. (These cards were designed for preschoolers and the pictures on the cards are a prompt for the sound of the letter, e.g. “ch-ch-ch” for the chugging train, “sh” - the baby is sleeping, “n” for the noise of the sewing machine in action.)

Parents should insist that they are provided with full details of the hearing assessments carried out for their children, that is, copies of audiograms or tympanograms and that they are advised on ways of helping their children to improve their hearing. For example, reducing background noise will help and therefore the television and radio should not be on constantly. Family members and teachers should become conscious of the need to speak clearly, in a loud, clear voice and enunciating consonant sounds at the beginning and ends of words, when talking to a child with hearing loss. Whenever possible, the child should be able to see their face in order to make use of lip shapes and mouth shapes to help them discriminate sounds. Signing is an important aid to understanding new words and to keep children’s comprehension and communication abilities progressing but signing will not help the child’s auditory discrimination skills or the learning of the sound patterns of words. The ability to discriminate and produce speech sounds and words must be encouraged while using signs for infants and for children of all ages.

Activities to improve phonological loop function

Auditory discrimination of speech sounds

Infancy

Right from the first year of life, speech sound discrimination is important. Research indicates that typically developing babies are listening to speech sounds in the language used around them and that they tune their babble to the sound of that language by 12 months of age. There is, therefore, evidence that it is important to begin speech sound work in the first year of life with babies with Down syndrome. This has been recommended by the Swedish speech and language therapist Irene Johansson for many years and her published programme for parents is available in English. [@johansson_language_1994] This programme recommends that babies have the opportunity to listen to a range of speech sounds and sound combinations, changing them week by week. In addition, parents can be encouraged to play babble games to encourage their children to babble. First, it will help to listen and copy back the sounds the baby is making, then to introduce new sounds and see if the baby will listen to and/or copy the new sounds.

Second year of life

During the second year of life, children with Down syndrome can begin to learn to copy the whole range of speech sounds including consonant and vowel sounds as a game, using Sound Cards [TODO: references 49] as illustrated in [Figure 5], or similar materials. Once a child is familiar with the each of the sounds in isolation, they can be asked to discriminate between similar sounds by choosing or pointing to the correct card for the sound.

Preschool

These kinds of games for single speech sound discrimination can continue throughout the preschool stage, encouraging the child to show that they can hear and discriminate sounds and that they can say each of the sounds. There is evidence from research with typically developing children [@stoel-gammon_sounds_1998] [TODO: 46,47] which indicates that their ability to make the sounds determines the rate at which they will try to say words.

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Figure 6. Examples of speech sound discrimination - rhyming words. The child is asked “Can you show me the chair?” or “Which one is the frog?” or “Which one is red?”

School - Primary and Secondary

Once children are in school the materials used for phonics can then be used to teach them to hear and to say all the speech sounds needed for spoken language and for reading and spelling. Many children with Down syndrome in primary and in secondary schools will still not be able to discriminate or to say all the speech sounds, therefore teachers with children in late primary or secondary schools may need to look for phonics materials or for materials from speech and language therapists to support the progress of the children.

Auditory discrimination of words

From infancy to adulthood

The fact that a child or a teenager can hear and say a speech sound in isolation does not mean that the child can always hear that sound in a word or discriminate between rhyming or similar sounding words. Word discrimination games can be played as soon as a child has comprehension for about 50 to 100 words. Young children can be asked to point to objects that have similar names, (such as chair, bear; dog, frog; red, bread) using real objects or pictures, as illustrated in [Figure 6]. Older children can play the same type of word discrimination game, using more advanced, age-appropriate vocabulary.

Auditory discrimination for sounds in words - phonological awareness

Primary and secondary school

The next step is to develop children’s abilities to detect sounds and sound patterns within words. These skills are referred to as phonological awareness abilities. Some typically developing children are able to identify words that rhyme or do not rhyme, or words that start or end with the same sound, when they start school but there is wide variation at this age. Phonological awareness skills generally develop in school over several years, while children are being taught to read.

In the first year, children do basic phonics work and learn to associate speech sounds with written letters or letter groups. This is important and most children with Down syndrome in mainstream schools enjoy the school phonics scheme and learn letter-sound correspondences. At the same time, all children are learning a ‘sight’ vocabulary, that is, a number of words that they recognise from the pattern of the whole word. This ‘sight’ vocabulary gives all children an important start in reading and provides the child with a database of written words which will help him or her to further understand letter/sound links.

The reason for learning phonics is that knowledge of the letter/sound correspondences enables a child to:-

1. Decode - that is to ‘sound out’ an unfamiliar printed to word in order to try and guess what the word is.
2. Spell - to think how to spell a word by thinking how the word is pronounced.

Children’s abilities in phonological awareness tasks increase steadily in their first few years in school and are greatly helped by reading, writing and spelling activities. As children learn to spell rhyming families such as ‘hat’, ‘mat’, ‘cat’, ‘sat’ the sound structure of the language becomes clearer to them. They can then identify rhyming words such as ‘ring’, ‘string’ and ‘thing’.

They become able to ‘segment’ words into their separate sounds e.g. cat into c-a-t, and to ‘blend’ sounds to make a word e.g. c-a-t- is cat. Segmenting and blending tasks are usually included in batteries of phonological awareness tests, which also include rhyming tasks, and tasks which require the child to identify the ‘odd one out’ for word sets such as ‘man’, ‘van’, ‘hat’. Even more difficult are phoneme deletion tasks such as “What is blend without the ‘b’ (=lend) or swing without the ‘s’ (=wing)?”

The reader will see that all these phonics and spelling activities associated with learning to read will help any child to discriminate speech sounds within words more effectively when listening and when talking, in addition to their benefits for reading and writing.

Summary

The advice is to include children with Down syndrome in all class reading and spelling activities and to develop their sound discrimination, phonic (sounds in print) and phonological awareness (sound in speech) skills, whatever their age. In addition, their articulation and speech production needs can be targeted alongside or within their reading work.

At home and in the car, games like “I spy something beginning with ‘t’’’ can be played, when the children have sufficient understanding of initial sounds in words.

It is probable that many adults with Down syndrome will benefit from targeted speech sound discrimination, word discrimination and speech production activities, in order to improve their listening abilities and their intelligibility when talking.

Activities to improve attention and to increase processing capacity

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Figure 7. Examples of choosing for group activities

Activities to improve children’s attention can begin very early and should continue throughout the school years. For example, playing face-to-face babble games encourages extended periods of attention for babies, as do all early games. In the second and third years of life, attending to teaching games which require sitting still and following instruction are important, first one-to-one with an adult and then as part of a group. In a group, the child has to learn to attend to the ‘teacher’ and to wait until it is their turn. One research study demonstrated better attention skills in children who had attended preschool language groups which provided this type of experience. [@le_prevost_effectiveness_2001] Reading books with an adult is another activity which many children enjoy and which can be used to extend the periods when they will sit still and concentrate on a task.

Many children with Down syndrome do not have attention difficulties, but some do and they may become apparent quite early. If a child is unable to develop meaningful play and tends to get into wandering, climbing or generally aimless behaviour, it is very important to play with that child and to teach them how to play.

Increasing attention in situations which require the child to process information and to learn to share attention can begin early with simple choice tasks. The number of items offered for the child to make a choice can start at two and then increase to three or four. The child can be asked to choose one item at first and then to choose two. [Figure 7] shows two examples of choosing activities which can be used in groups with children from 18 months of age. For the music session, a child can be asked to choose maracas or bells (both placed in front of child), then the whole group picks up the same one from their own pair for the next game. Similarly, each child could choose a nursery rhyme from picture cards made to depict the rhymes that the children know.

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Figure 8. Hiding game

At home, meaningful choices can be encouraged from the second year of life, especially at mealtimes. A child can be asked “Would you like juice or milk?” or “Would you like a biscuit or a cake?”, with both items in front of the child, who can then indicate their choice by pointing, signing or naming the item.

Activities to improve remembering lists or numbers of items

Preschool

Games to help children to remember two or more items can begin in preschool years and follow on from the simple choice activities described above.

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Figure 9. “What’s gone?” game

Hiding games can be introduced in the second year of life by hiding items under a cloth - first one item, then two and asking the child what is hidden ( [Figure 8]) or by removing one object and leaving the others, again asking the child what has gone ( [Figure 9]).

Primary and secondary school

Simple memory games can be extended for older children using objects or picture materials. At present many teenagers only have short-term spans for 3 or 4 items when using pictures and maybe only 2 or 3 items if asked to remember spoken words. However, school age children will be helped by explicit rehearsal training.

Rehearsal training

Activities designed to teach children to remember items in the order they were given is known as rehearsal training. This has been the activity used in published memory training studies. The steps are illustrated in full in [Figure 10] and [Figure 11]. Start with only one item, then progress to two. Add another item once the child is confident with a list of two items.

1. Turn one over and name (“ball”). Child repeats “ball” (with prompt while learning).

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2. Point and remember: “what was it?” Child says “ball” (prompt with answer while learning).

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3. Turn two cards over and name both in order (“ball”, “boat”).

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4. Point to each of first two cards in order and say “what was it?” Child says “ball”, “boat” (prompt with correct answers while learning).

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5. Show and name three items: “ball”, “boat”, “drum”.

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6. Point to each of the three cards in order and say: “what was it?”. Child says “ball”, “boat”, “drum” (prompt with correct answers while learning).

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Figure 10. Rehearsal shown with picture cards

1. Turn one over and name

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2. Point and remember: what was it?

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3. Turn two over and name

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4. Point and remember: what was it?

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5. Show and name three items

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6. Point and remember: what was it?

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Figure 11. Rehearsal with ‘lift the flap’ chart. The flap-chart and cards illustrated above were produced for the University of Portsmouth memory training research studies discussed earlier in the module. [@broadley_working_1995; @laws_effects_1996][TODO: 39,40] A limited number of these materials are still available for purchase.[TODO: 50]

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Figure 12. Rehearsal with language cards

Begin each new session with a sequence of a length that the child was able to remember easily at the previous session rather than starting with a more difficult sequence, and only use a list one item longer than the list the child can consistently succeed on. Remember that, in typical development, it may take two years to add an item to a short-term memory span.

Variations of the task

Once the child has understood the basic procedure and is making some progress, you can include the following variations of the rehearsal task.

Numbers

Make up some cards with numbers on. Use the number cards to encourage remembering longer sequences of numbers. You can use single digits and, for children who know them, some higher numbers.

You can use this method to teach counting by putting numbers in sequence e.g. (1-5) (5-10) (11-15) (16-20) or to teach adding in ‘2’s’ or ‘5’s’ as illustrated in [Figure 13]. You can also use it to teach your child to remember a telephone number.

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Figure 13. Rehearsal for learning to count in 5’s

Words and sentences

For children who can read, the rehearsal game can be used to encourage accurate remembering of short phrases or sentences. Children with Down syndrome, when asked to repeat a sentence, will often repeat only the key words. This task can be used to help repetition of all the words in the phrase or sentence. This may be an effective way to improve your child’s ability to use grammatically correct sentences when they talk. Write each word of a selected phrase or sentence on a separate card and use in the same way as the picture sequences, i.e. by showing one word at a time and gradually increasing the number of words.

Begin very simply, e.g. “the big cat”, and gradually increase the length of the phrase, e.g. “the big cat is sleeping”. Words should be chosen as appropriate for each individual child’s speech and language level and reading vocabulary.

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Figure 14. Rehearsal for spellings

You can also use rehearsal to support spelling activities. Try putting the letters of words that the child is learning to spell on to cards (see [Figure 14]).

In fact, the rehearsal strategy can be used to support any learning activity where remembering a sequence is important: a list of written instructions, the timetable for the day, learning days of the week, months of the year etc.

Other pictures

Using materials that children are particularly interested in will increase their success in learning. If your child has some special interest, say transport or a particular TV programme, find pictures to cut out and use for the rehearsing. Alternatively, you could use photographs of family members and friends. Any activity which requires the child to remember a sequence of words or names can be taught using this rehearsal strategy.

Training auditory rehearsal

All the examples of rehearsal training illustrated so far have used visual prompts to help the child remember the items. It is also important to play games which require listening only, once a child understands the visual rehearsal game, in order to improve auditory and verbal short-term memory. Listening games, when the child has no picture prompts, will be more difficult. However, [Figure 15] illustrates a way of helping a child progress from using visual prompts to hearing and remembering the spoken word: the adult says the name of each item, but the child is able to respond using the pictures. Listening games can be played with lists of words or numbers.

1. Show and name (three) pictures with the child.

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2. Turn the pictures over.

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3. Offer the child a selection of cards, face up.

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4. The child chooses and lines the pictures up in the right position and order.

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5. Turn over the top line and show the child if they are correct.

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Figure 15. Part 1: Moving from rehearsal with picture prompts to auditory rehearsal (Game designed by Leela Baksi of Symbol UK)

1. Place cards face down. Point to each and name it with the child. Do not turn the cards over. The child has to remember the spoken word without a picture prompt.

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2. Offer a selection of cards, face up.

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3. The child places the cards in position. The blank cards help the child remember how many are needed.

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4. The top cards are turned over to see if the child is correct.

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Figure 15. Part 2: Auditory presentation of items to be remembered (Game designed by Leela Baksi of Symbol UK)

Grouping or organisation skills

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Figure 16. Grouping by category, for young children

Grouping items to be remembered by the categories to which they belong is another strategy for increasing the number of items which can be remembered. The aim of this activity is to teach the children to organise and store information in memory by categorising items into groups.

Once the child knows the names of most of the items, you can include some work on grouping in memory sessions.

Sorting task

Begin by selecting pictures or objects from just two categories. Place one item from each category on the table, and then hand the child one item at a time from the remaining items, and ask him or her to find the category that it belongs to. Reinforce the teaching of the appropriate category names as the child places the cards (for example say: “Yes, that’s fruit”). Once the child can manage to sort two categories in this way, increase the number of categories that are to be sorted.

Oddity task

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Figure 17. Grouping by category

This task will draw attention to the groups and reinforce the category names. The child will also learn which item does not belong to a group.

Select all the items from one category and place on the table along with just one item that will be the ‘odd one out’. Look at and name each picture, and say “Which one does not belong?” or “Which one does not belong to the group?”

If there is difficulty in understanding the meaning of “not”, then say (for example): “Show me an animal. Now show me another one, now show me the one that’s not an animal”. If there is still difficulty point to the odd one out and say “Is this an animal?”

Memory task

In this task, unlike the rehearsal memory tasks, you can place less emphasis on remembering the items in correct sequence. The aim is to encourage the child to remember the items in the groups or categories they have been taught.

For example, put some of the animal pictures on the table and point to each one in turn naming the picture and encourage the child to name the picture also. Turn the cards over and say: “Now tell me which pictures you have seen”.

If they cannot remember them all, say “What other animal did you see?”

Try this with other categories.

If the child becomes proficient enough to remember four or five items, you can try using items from two categories at the same time.

Other activities

It is important that the children do not see rehearsal simply as a way of remembering items during the formal training sessions. They should be encouraged to use this strategy as a way of remembering useful lists of items, for example during a game, running an errand or reporting a message. We want the skill to be generalised from the training situation to everyday life. To achieve this, it is important to practice these skills in other situations. Some ideas are listed here.

Delivering messages

Use everyday opportunities for asking the child to deliver messages to others. Ask them to fetch things required from another room, or ask them to pass on messages to other family members, or children in the class if you are working at school. Start with simple messages and make them more complicated as proficiency and confidence increases.

Giving instructions

Opportunities to encourage memory use arise at home and in the classroom whenever a child is being asked to fetch something, point to something, put something away, pick something up etc. Be aware of these opportunities and make use of them to gradually increase the number of items the child is being asked to remember.

Recall of activities

At school, ask the child to recall the events of the previous day or what happened at home the previous evening. At home, ask the child to recall the events of the school day. Try to encourage remembering in sequence by using such prompts as: “And then what happened?”

Recall of stories or nursery rhymes

After reading a story, ask the child to remember the main events of the story in sequence. Some stories, like ‘The Very Hungry Caterpillar’, are especially good for practising the recall of lists of items or events, as they include cumulative lists in the story.

Teach nursery rhymes and songs. Ask questions about the story in the rhyme - being asked to recall the answers may encourage the child to ‘sing’ the lines to himself or herself.

Use of songs

Many children’s songs include sequenced or ordered items. These are very good for teaching sequencing:

Ten Green Bottles; Ten Little Indians; One Potato, Two Potato; One, Two, Buckle my Shoe; Old MacDonald had a Farm; This Old Man; I know an Old Lady who Swallowed a Fly; etc.

Games

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Figure 18. Example of a ‘pairs’ memory game

Most of the activities described can be turned into games, with children taking turns to remember lists of items. ‘Pairs’ memory games can be bought or made (see [Figure 18]). Each child turns over one card, then turns it face down again, and if anyone in the group can remember where the other identical card is, they take the pair. The player with the most pairs at the end of the game is the winner.

Play a game remembering items. The traditional game of remembering an ever-increasing shopping list (I went to the shop and bought a……..) is usually played in a small group but could be played with just one adult and one child. If the child finds it too difficult to add and item to the list, then this aspect can be dropped and only the adult need add an item.

This game can be adapted to all sorts of lists - animals on a farm, animals at the zoo, clothes in the cupboard, toys in the toy-box etc.

Kim’s game

Place a number of small objects on the table. Name each of the objects with the child. Cover them (or get the child to close their eyes) and remove one object. The child must then remember which one is missing. If there is no immediate answer, encourage the child to name the remaining objects - this may prompt the solution. Naming the objects rather than just looking at them encourages the use of a verbal rehearsal strategy for remembering.

Computer games

There is a range of computer programs available for use at home or at school which includes memory games and phonics activities. The memory program used in [the training study described earlier] was ‘Mastering Memory’,[51] a program designed to teach rehearsal strategies. A number of programs are available which include memory games in a range of other learning activities, such as ‘Jemima’.[52]

Supporting working memory in the classroom

So far, the focus of all the practical advice in this module has been on how to improve children’s memory skills. However, even if these activities do help, children with Down syndrome are likely to have significant difficulty in the classroom where the demand to process spoken language is usually high. Children will be given verbal instructions about the day’s activities and classroom routines. Much of the instruction during lessons will be given verbally. When children with Down syndrome are in an age-appropriate mainstream classroom, the difference between their verbal short-term memory abilities and those of their classmates will be significant.

It is, therefore, important to use as many ways as possible to support the children’s learning by using approaches which do not put an excessive demand on their verbal short-term memory skills.

Visual supports for learning

Information that is illustrated visually, with words, sentences, pictures and symbols through lists, timetables and writing frames can support children’s learning in all aspects of lessons. This includes support for understanding the verbal presentation of information they receive from the teacher, the activities undertaken to promote learning, recording, responding and assessment linked with the aims of the lesson.

Particular styles of lists or writing frames that children understand and can follow can be used repeatedly in a variety of lessons with minor changes to help them access new information, record, rehearse and learn e.g. a story board format.

Lists of tasks can be used in maths lessons as well, to practice remembering of a sequence of activities, for example, for addition or subtraction.

Visual presentation is particularly helpful for:

• Developing independent work habits through a list or plan of subtasks the child can follow.
• Increasing the length of time a child can attend and participate in tasks through short activities, clearly illustrated and described.
• Prompting or cueing the child to listen to the teacher’s verbal presentation by providing context.
• Improving behaviour, as expectations can be clearly explained using picture prompts or written instructions.
• Learning and practising new concepts and vocabulary using written words and pictures.
• Understanding and fulfilling the lesson aim by reading the sentences written by an assistant or teacher about the important information of the lesson (in grammatically correct sentences). These sentences will link new vocabulary with familiar vocabulary in sentences, explain meanings, and clearly convey the information the child is expected to understand and learn.

The child will be helped to learn this information by reading back the sentences, reconstructing the sentence(s) through handwritten work, word cards, words on stickers and on the computer and discussing the sentence(s). Most importantly, visual information in the form of pictures, words and sentences, can be used to rehearse information from the previous lesson before continuing with a linked lesson, or to revise a whole topic.

Some techniques used by teachers and assistants for creating dynamic visual records to support children’s memory and help them to learn and remember information (and the language for that information) are listed below.

Visual records to support verbal presentation of information

• Pictures and words will help to focus children’s attention and help them to listen, by providing a context or background for the teacher’s lesson presentation.
• The teacher may use a board and displays as well as verbal presentation.
• Children should have a suitable text book with pictures as well as text to look at (especially in secondary school).
• Some children may need additional pictures and sentences to hold and look at while the teacher is speaking.
• Many children listen to the teacher’s verbal presentation and then immediately rehearse this with an assistant, who can discuss the content, with visual aids, and then list the important points, making clear the tasks required by creating a visual record.
• The assistant can write the aim of the lesson in the child’s record book.

Visual records to support learning activities

Tasks and activities can be described in structured and clear steps in a list or frame, with line drawings where possible to reinforce meaning.

The child can be supported to complete each activity as necessary, and given explicit encouragement to read and rehearse the list, find out what to do ‘next’ and follow the list to completion. The child can tick off or cross through each stage as it is completed.

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For example, as part of a lesson about food at primary school, a child may be asked to:

1. Cut out the pictures.
2. Sort out the pictures into ‘meat’ and ‘fruit’.
3. Stick the pictures into your book.
4. Write the food names underneath the picture.
5. Ask for help to make a sentence: “Cherries are fruit”

Visual records to assist children to record the key points of the lesson

In discussion with the child, the assistant can create an appropriate sentence or several sentences that link with the aims of the lesson. The sentence(s) can include new vocabulary and ideas e.g. “Meat is a type of protein. Protein builds our muscles and helps to make us strong”.

The child can copy write a sentence, either by hand, by using word cards, word stickers, or the computer.

The child can read the sentence(s) back, with help if necessary.

The child can reconstruct the sentence from cards, and verbally.

Visual records to assist children to respond and show their understanding

The aims may be discussed by the assistant and child, using the written record of the lesson.

Can the child answer questions by talking, signing or pointing to pictures or words appropriately, using pictures, sentences, words, lists, storyboards, writing frames, to support assessment?

Can the child generalise the information learned, to apply it in other appropriate tasks? How much help is needed for the child to do this?

Can the child listen to the group discussion and summary by the teacher with the support of a visual record?

Can the child participate in the group or class discussion and answer questions directed at him or her by the teacher?

Summary

These examples of the ways in which visual support can be offered in the classroom have focused on how to assist children to process, remember and record information in all lessons. They provide support for the children’s verbal short-term memory difficulties and their speech and language difficulties.

More information on the ways in which the working memory difficulties of children with Down syndrome can be supported in the classroom during numeracy and literacy lessons are included in the specific practical modules on these topics.