Speech sounds

[TODO] This topic offers guidance on how to ..

Most children with Down syndrome of primary school age have some delays and difficulties in developing clear speech. This can be very frustrating for them as it means that their speech is often not understood. Several small studies have demonstrated that speech work is effective at this age, and can be carried out by parents. Speech difficulties hold back the children’s ability to say sentences and to develop grammar, therefore speech work should be a priority in the primary school years, at home and at school - and can be built into reading and spelling activities. The advice in this section starts right at the early stages as many children with Down syndrome will have had no speech work before they start school and some may still have immature feeding, chewing, breathing and drinking skills.

Activities that encourage the young person or adult to practise their sound and word production are effective for improving speech into adult life. Speech is a motor skill and, like other motor skills, will only improve with practice. Teenagers with Down syndrome, because of their language delay, will have had much less practice at talking than their peers and this may explain at least part of their speech difficulty.

[TODO: references 47] and the Nuffield Centre Dyspraxia Programme [TODO: references 48] are examples of this type of work. These and other programmes may not always be suitable for every teenager though, and do require the guidance of a trained professional to advise when and how to introduce activities. If there is no speech and language therapist available however, parents and teachers can do much to help teenagers improve their speech using readily available materials and activities.

Development of sounds

For all young people, spoken words become more intelligible with increasing age and use of their language skills. Achieving intelligibility takes a number of years, even for young people who do not have specific speech and language disorders or delays.

Many of the speech difficulties noticed in young people with Down syndrome are part of the normal development of phonology (see box) [TODO: references 37], and will improve, provided the young people have sufficient practice through talking and using their skills. Studies report inconsistent production, that is, the teenagers may be able to say a sound on one day and not the next, and more practice and feedback over many months may be needed to establish consistent production. First attempts at words may not even be close approximations and so any attempt should be encouraged.

As teenagers progress in their language knowledge and skills, phonics materials which teach letter sound recognition for reading can be used. This will help to link their speech and language activities to their developing or established literacy skills. Some teenagers with very little speech who are still experiencing difficulties with single sound production may find it easier to get started with picture materials rather than letter cards. Vowel sounds in particular may need picture supports as well as letters to facilitate practice.

Research studies indicate that these errors are still common in the speech of teenagers with Down syndrome

While lack of confidence can contribute to slow progress, it is more likely that an unresponsive teenager cannot remember or cannot produce the sounds without a prompt, even though they may recognise it when it is said and can imitate it, rather than they are being deliberately resistant to producing the sound.

Never let your teenager feel that they have disappointed you or place them under pressure to produce sounds or words.

and tongue muscles. Being involved in physical activities and sports will improve general motor development and breathing. Text missing

evident in spontaneous speech. When reading, the teenager is not required to think and to plan his/her sentences in the same way as in spontaneous talking.

If we identify targets for speech work at each level - and make maximum use of reading activities to support spoken practice, we should be able to significantly improve speech clarity and sentence production for most teenagers. We have incorporated the principles of the therapy approaches shown to be effective with younger children with Down syndrome into the activities. These are summarised in the boxes.

The advice in this section starts right at the early stages as some teenagers with Down syndrome will have had no speech work in primary school and a small number may still have immature feeding, chewing, breathing and drinking skills. Research indicates that 16% of teenagers still have difficulty with chewing, 18% with swallowing and 25% with tongue thrusting. [TODO: references 51]

Development of sounds

For all young people, spoken words become more intelligible with increasing age and use of their language skills. Achieving intelligibility takes a number of years, even for young people who do not have specific speech and language disorders or delays.

Many of the speech difficulties noticed in young people with Down syndrome are part of the normal development of phonology (see box) [TODO: references 37], and will improve, provided the young people have sufficient practice through talking and using their skills. Studies report inconsistent production, that is, the teenagers may be able to say a sound on one day and not the next, and more practice and feedback over many months may be needed to establish consistent production. First attempts at words may not even be close approximations and so any attempt should be encouraged.

Research studies indicate that these errors are still common in the speech of teenagers with Down syndrome

While lack of confidence can contribute to slow progress, it is more likely that an unresponsive teenager cannot remember or cannot produce the sounds without a prompt, even though they may recognise it when it is said and can imitate it, rather than they are being deliberately resistant to producing the sound.

Never let your teenager feel that they have disappointed you or place them under pressure to produce sounds or words.

evident in spontaneous speech. When reading, the teenager is not required to think and to plan his/her sentences in the same way as in spontaneous talking.

If we identify targets for speech work at each level - and make maximum use of reading activities to support spoken practice, we should be able to significantly improve speech clarity and sentence production for most teenagers. We have incorporated the principles of the therapy approaches shown to be effective with younger children with Down syndrome into the activities. These are summarised in the boxes.

The advice in this section starts right at the early stages as some teenagers with Down syndrome will have had no speech work in primary school and a small number may still have immature feeding, chewing, breathing and drinking skills. Research indicates that 16% of teenagers still have difficulty with chewing, 18% with swallowing and 25% with tongue thrusting. [TODO: references 51]

Speech

From infancy activities that will lead to clear speech need to be a priority. Many aspects of the babies’ development will have an influence on later speech skills, including breathing, feeding and drinking skills and general motor control.

In infancy

It is important to encourage good feeding, sucking, chewing, drinking and breathing habits from the first months of life. The coordination and control of the movement of lips, tongue and breathing needed for chewing and swallowing develops similar actions that are needed for making clear speech sounds. Therefore it is important to steadily move your baby on to chewing lumpy foods, just increasing the texture a little at a time until they can chew ordinary pieces of food. At the same time, move your baby forward from drinking from a bottle to a cup in stages, using a cup with a teat, then a spout, then a recessed lid and finally an ordinary cup. Some babies may not go through all these stages and find it easier to use a straw. Watch that you baby keeps her/his tongue inside the mouth when drinking, and does not put her/his tongue down the outside of the cup. Encourage your baby to learn to drink from a straw. The special straws with built-in valves, sold in the pharmacy, for those with difficulties such as stroke patients, can help. Encourage bubble blowing and whistle blowing games to get your baby to make a round lip closure.

Some babies seem to be hypersensitive and to dislike touch around the mouth area or the feel of things in and around their mouths and these children need help to tolerate these sensations. A specialist speech and language therapist can provide advice but if this is not available, gently massage your babies face with fingers, a face cloth, or a soft brush for a few minutes several times a day. Encourage the baby to try different tastes and textures and sometimes eating with fingers is more acceptable to the child than the feel of a spoon in their mouth. Encourage mouth closure and nose breathing (use of dummy may help, but only when baby is not socialising and wanting to babble). Your baby’s gross motor development, including head and trunk control and muscle tone, will also influence your baby’s ability to control breathing and face, mouth and tongue muscles. Massaging you baby and encouraging her/him to enjoy kicking and splashing, during nappy changing and bath times, for example, will help to build up muscle tone and control.

A note on tube feeding

If your baby has been tube-fed during infancy, this may have affected the development of breathing, swallowing, chewing and muscle control. For this reason, tube-feeding should not continue for any longer than is absolutely essential. If your baby was tube-fed and you are concerned about her/his ability to chew or make sounds, seek expert help from a specialist in early oral-motor development through a paediatric or speech and language therapy service.

Many aspects of children’s development will have an influence on speech skills, including breathing, feeding and drinking skills and general motor control. It is important to encourage good feeding, sucking, chewing, drinking and breathing. The coordination and control of the movement of lips, tongue and breathing needed for chewing and swallowing develops similar actions that are needed for making clear speech sounds. Many 5 year olds will be chewing ordinary foods but some will not and if your child is delayed then feeding and drinking skills need to be addressed.

It is important to steadily move your child on to chewing lumpy foods, just increasing the texture a little at a time until they can chew ordinary pieces of food. At the same time, move your child forward to drinking from a normal cup in stages, using a cup with a spout, then a recessed lid and finally an ordinary cup. Watch that your child keeps her/his tongue inside the mouth when drinking, and does not put her/his tongue down the outside of the cup. Encourage your child to learn to drink from a straw. The special straws, with built-in valves, sold in the pharmacy for those with difficulties such as stroke patients, can help. Small drink cartons with straws can also be used to assist children to learn to use a straw, by squeezing the carton to send liquid up the straw. Encourage bubble blowing and whistle blowing games to get your child to make a round lip closure.

Often children with Down syndrome make progress with feeding and drinking skills once they are in school as they model their behaviour on the other children.

Some children with Down syndrome seem to be hypersensitive and to dislike touch around the mouth area or the feel of things in and around their mouths and these children need help to tolerate these sensations. A specialist speech and language therapist can provide advice but if this is not available, gently massage your child’s face with fingers, a face cloth, or a soft brush for a few minutes several times a day. Encourage the child to try different tastes and textures and sometimes eating with fingers is more acceptable to the child than the feel of a spoon in the mouth.

Encourage mouth closure and nose breathing. Games to encourage lip closure and breath control include blowing through a straw to move pieces of foil, tissue paper or small balls and blowing pipes and whistles.

Your child’s gross motor development, including head and trunk control and muscle tone, will also influence his/her ability to control breathing and face, mouth and tongue muscles. Your teenager’s gross motor development, including head and trunk control and muscle tone, will also influence his/her ability to control breathing and face, mouth and tongue muscles. Being involved in physical activities and sports will improve general motor development and breathing.

Most 11 year olds will be chewing ordinary foods and drinking normally from cups but some will have extra difficulties, and if your teenager is delayed then feeding and drinking skills need to be addressed.

Encourage smiling and babbling

Smiling, babble games, and engagement with others will all keep the face mobile and active and exercise oral-facial muscles. Auditory discrimination training for speech sounds can begin early, in babble games and then in specific sound practice activities.

Try to work on sounds, encouraging babies to copy sound and gesture from as early as possible, especially in babble games. Encourage babies to watch your lip movements - they can do this in face-to-face play and will copy the mouth shapes that they see. (Later you can do this sitting side by side in front of a mirror or when using sound cards). Singing games, working on words and sounds, can be fun and a good way to engage babies and toddlers.

Babble is important and sets the stage for later speech development. Babies practice speech sounds in their babble and they tune their babble to the particular sounds of the language that they are hearing by twelve months of age. The sounds that are contained in babies’ babble lead to the first words that they will attempt to say. Interventions with sound work, which should later improve speech clarity, can therefore begin from the first weeks of life. This is the rationale for a system developed by Professor Irene Johansson in Sweden. [TODO: references 3] Parents can follow the programme themselves, although they will be helped greatly by an experienced speech and language therapist. This programme encourages parents to repeat different rhythms of sounds and syllables from early babyhood, with games and activities to teach children to make sounds, understand and use simple language and gestures. Some parents may find the full programme too intensive, but they may be able to adapt it and use the activities that they feel fit comfortably into their daily routines with the baby.

Natural play with your child will also encourage babble and copying, if you do not want to follow a programme. Imitation seems to be an important milestone, in gesture and in speech. Imitate your baby’s sounds and babble, as well as encouraging particular new sounds, taking some of the initial sounds from the speech sounds checklist and introducing them to your baby.

Babies move from babbling a variety of separate vowel and consonant sounds to producing repeated sounds such as ‘baba’ or ‘dada’. This is setting the skills in place for trying easy words like “daddy” and “ball”. Repeat and expand babble and first attempts at words. This is rewarding for the baby as they are taking part in a ‘conversation’ that they have initiated. The baby is also hearing a more accurate version of the sound or word they are trying and you are giving it meaning. Once the child begins to imitate, you can encourage practice. This will often lead to their first meaningful words as you respond to babble as if it is a word and the baby realises the noise they are making does indeed mean something specific like “Daddy”.

Early sound games

Between the ages of 1 and 2 years young children with Down syndrome can be introduced to teaching activities that will help to develop their awareness of sounds and their ability to produce sounds through daily games. This type of work can be continued for as long as needed (and practice through talking and reading may take over), provided the activities are kept interesting and age appropriate for them. Activities that encourage the child, young person or adult to practice their sound and word production, with good models to copy and feedback, are effective for improving speech into adult life.

Pictures and signs help young children to remember sounds associated with those pictures and signs. Speech and language therapists in all countries have access to pictures, other materials and activities aimed at improving phonological awareness and speech production, although they may not know that these activities, designed primarily for children with speech and language disorders, are also appropriate for teaching children with Down syndrome. They may also not know how important it is for children with Down syndrome to begin learning through extra practice from their early years of life. Cued articulation [TODO: references 4] and the Nuffield Centre Dyspraxia Programme [TODO: references 5] are examples of this type of work. These and other programmes may not always be suitable for very young children though, and do require the guidance of a trained professional to advise when and how to introduce activities.

Sound cards

! DSE Sound Cards (fronts and backs)

Figure 2. DSE Sound Cards (fronts and backs)

Down Syndrome Education International has published consonant sound cards and vowel sound practice cards [TODO: updated]. The cards encourage imitated consonant and vowel sound production and facilitate practice with gesture and pictures, and they can be used from about 18 months of age. The rationale is best explained in the information accompanying the sound cards.

When a baby is born, although the major concerns are those of survival, feeling comfortable, being well fed and warm, there is also the need to be in contact with others, and to feel safe and happy. One of the ways we express such feelings is through sounds. In a tiny baby, the early sounds are simple, but it is not long before patterns of sounds with rising and falling intonation patterns emerge.

The first sounds are mainly those made with the mouth open - “a-ah” and “e-e”, etc. It is not long before other sounds, such as “d-d-d” and “m-m-m” are added. The baby is using the patterns of movement that are similar to sucking and are simpler versions of the ones we use in speech. As the muscles of the tongue get stronger, and the baby listens to all sounds his parents use when talking to her/him, so the range of sounds they produce gets larger. It is fun to play with these sounds not only when you are having a ‘conversation’ with someone, but also when you are on your own. Babies ‘play’ with sounds just as they play with their fingers and toes; it is a very good way to learn about making sounds.

Long before the first real words appear, babies realise that certain sounds joined together have a specific meaning. Babies practice the sounds that they hear around them over and over again. They will be able to make their tongues, lips, soft palates and vocal chords produce a wide variety of sounds, in fact, most of the sounds that occur in their own particular language. In the same way that a pianist has to practise in order to make his fingers move fast enough to play a piece of music at the correct speed, so every baby has to practise the wide variety of sounds that make up our speech. If the muscles of your mouth are not well coordinated (and that includes your tongue) then it is quite difficult to get fast movement as accurately as is needed for speech.

Babies love to play with sounds, but they will not develop the range of sounds needed for speech if they are finding the movements difficult, and will stick to sounds that are easy, such as all the vowel sounds. These make up the base upon which each word is built, but do not separate out one word from another. The tendency is also then, to stop listening to the soft sounds that change the meanings of words, so that ‘eat’, ‘feet’, ‘see’, ‘read’, etc all become “ee” with the meaning for each one distinguished by the context, just as we have to do for words such as ‘see’ and ‘sea’.

Children may mix up these sorts of words while they are learning, and many others that sound similar, such as car and cart and card, and it is only by making mistakes and having them corrected (so they hear the correct pronunciation repeated back to them) that they learn the correct pronunciation and meaning.

The DSE Sound Cards work by giving parents the opportunity to introduce all the sounds in a way that is fun, while also helping their children to listen really well to each individual sound. The method is similar in principle to the methods used in remedial phonological training programmes for children and adults with Down syndrome.

Young children, beginning to use sound cards in play, are likely to look at the picture and may begin to watch the way in which the mouth and tongue moves, while listening to the sound. After a number of sessions of looking, listening and playing with parents with the sound cards, children typically begin to join and attempt to copy the sound. The sounds may not be clear at first, but they should be praised and encouraged as the more children practice the more accurate the sounds become.

[TODO: update] Each sound card provides a picture of an item that starts with the sound associated with it. The item in the picture itself does not necessarily begin with the sound - the focus is on the sound that is made by the activity illustrated in the picture, for example, the sound of water going down a plughole (g). Most of the sound pictures are within children’s daily experience, such as a ball (b), a drum (d), a lady singing (l), a balloon coming down (f), the wind blowing through curtains (h), a tap dripping (t) and so on. Some are not, such as a pea popping, although children quickly learn all of the cards as a part of the game.

First consonants

[TODO: tracker, update] Twenty of the 23 consonant sounds on the checklist are represented in the DSE sound cards. The pictures are chosen to represent the sound - that is the sound made by the object in the picture is the target sound.

Vowels

[TODO: update] Nineteen of the 21 vowel sounds on the checklist are represented on the DSE vowel sound cards. The pictures are chosen to represent the sound - that is the sound made by the object in the picture is the target sound.

Development of sounds

As an approximate guide, the ages by which children (90%) can produce the single speech sounds accurately are listed below, based on typically developing children who do not have Down syndrome or language delay. Among all children there is very wide variation, and the order of development of sounds cannot be predicted for individuals.

For all children, spoken words become more intelligible with increasing age and use of their language skills. Achieving intelligibility takes time, even for children who do not have specific speech and language disorders or delays. Studies suggest that at 2 years of age, 25% of children are intelligible, at 3 years, 70% and at 4 years, 90%. This does not mean that all the four year olds can pronounce all their words as clearly as adults but it does mean that 90% of them speak clearly enough to be understood by an unfamiliar adult.

A study by Libby Kumin and colleagues in the USA [TODO: references 6] provides some guidelines to the expected speech progress of children with Down syndrome.

The reader may note that many of the sounds are not delayed in this study and are being learned in a different order when compared to typically developing children. The children in this study were receiving intensive speech and language therapy and not all children mastered all of these sounds. There was great variation between children, with some children having clear early sounds at 2 years and others had not mastered the same sounds at 6 years.

Many of the early difficulties noticed in children with Down syndrome are part of a normal process, and will improve, provided the children have sufficient practice through talking and using their skills. The children may be able to say a sound on one day and not the next and more practice and feedback over many months may be needed to establish consistent production. Early attempts at words may not even be close approximations and so any attempt should be rewarded.

Please notice that some sounds are not accurately produced by many 5 years olds who do not have Down syndrome or language delay. Learning to say sounds may be slow, including the progression from being able to make the sound after it has been modelled and being able to produce it from memory without a prompt.

While lack of confidence can contribute to slow progress, it is more likely that an unresponsive child cannot remember the sounds without a prompt, even though they may recognise it when it is said and can imitate it, rather than he is she is being deliberately resistant to producing the sound. When children understand what the game is, most will say the sounds they know and can say, in a positive and enjoyable learning situation.

Never let your child feel that they have disappointed you or place them under pressure to produce sounds or words.

! Animal cards

Figure 3. Animal Cards

These can be used to play ‘What is it called’ and ‘What does it say?’ In a group, one child can select a card from the set and name the animal, and the next child can give the sound.

Remember that making sounds spontaneously during babble and play is a different and easier task than producing a sound on request or in imitation. Similarly, imitating sounds and producing sounds without prompts to imitate, are different skills. The more children use their sounds in play and in games with sound cards the more they are helped to progress through these stages. Having fun with sounds gives children the building blocks for when they start to talk. Practice through listening, watching, imitating and trying to say, will help to teach your child how to produce sounds and, later on, to say words.

Sound practice beyond sound cards

Letter sounds

As children progress in their language knowledge and skills and get older, it becomes appropriate to move into alphabetic systems of representation by teaching letter sound recognition. This will help to link their speech and language activities to their developing literacy skills. The majority of children with Down syndrome are likely to begin to learn letter sounds between 3.5 to 5 years. The groups of children participating in the Early Development Groups at Down Syndrome Education International in this age range have continued to enjoy using the familiar sound cards they know and have practised for several years, as well as to learn letter sounds and play letter sounds games. The two methods for facilitating speech sound practice have not confused the children.

Although most children beginning this type of work at school age can skip the sound cards and commence their sound practice by learning letter sounds, some children with very little speech who are still experiencing difficulties with single sound production may find it easier to get started with sound cards. Vowel sounds in particular may need picture alternatives rather than letters to facilitate practice.

At infant school, phonics schemes used with the whole class will help children with Down syndrome to say letter sounds as well as link them to letters, and to be included in whole class activities.

As teenagers progress in their language knowledge and skills, phonics materials which teach letter sound recognition for reading can be used. This will help to link their speech and language activities to their developing or established literacy skills. Some teenagers with very little speech who are still experiencing difficulties with single sound production may find it easier to get started with picture materials rather than letter cards. Vowel sounds in particular may need picture supports as well as letters to facilitate practice.

! Sound Bubbles

Figure 4. Sound Bubbles

Place the cards face down, ask the child to select a bubble. The child then turns it over and makes the sound. In a group game, if the snake is found everyone makes the ‘sss…’ for snake noise. The bubbles illustrated can also be used to name the colours for another game.

Although most children beginning this type of work at school age can skip the sound cards and commence their sound practice by learning letter sounds, some children with very little speech who are still experiencing difficulties with single sound production may find it easier to get started with sound cards. Vowel sounds in particular may need picture alternatives to letters to facilitate practice.

[TODO: update] Computerised systems are also available as a complementary way of enabling children to practice sound production, for example, SpeechViewer III. [TODO: references 7] This laptop computer version provides visual feedback so that even young children (3 to 4 years), and certainly older children (7 years and above) can see how close they are getting to making a sound accurately. When they have made the right sounds (or series of sounds, or pairs of sound contrasts like ‘sh’ and ‘s’) they are visually rewarded for doing so. There are visual incentives that help to speed up the saying of single sounds in a series of repetitions, for example, with a frog jumping from lily pad to lily pad, every time a sound is said. SpeechViewer also has facilities for encouraging many other aspects of speech development, as well as phonology, including voice, pitch and control of breathing.

Improving sounds in words

Once children have begun to speak, they are practising sounds in words all the time. For example, even in the first 100 words that children typically use, almost every consonant and vowel sound is used. Initially children’s sounds in the words will be approximations, determined by their phonological and speech production skills. For children beginning to learn to speak, we would not expect consonant clusters (‘dr’ as in drink, ‘tr’ as in train, or ‘sp’ as in spoon) to be used, or even two consonants in a word, and many words will be recognisable to parents by the vowel sounds, context, use of sign. At this stage, the addition of one consonant somewhere in the word is good progress.

The 120 words on the first vocabulary checklist are used daily in most young children’s worlds and by practising these, children are developing their sound systems. Of these 120 words, about 20% begin with a ‘b’ sound, with 12% beginning with a ‘k’ and 10% with a ‘t’ sound. About 6% begin with ‘s’, ‘d’, ‘h’ and ‘w’, 4% with ‘p’, ‘m’, and ‘f’, 2% with ‘l’ and ‘sh’, and 1% with ‘y’ and ‘v’.

For the final or second consonants of the words, 17% end with ‘t’, 15% with ‘s’, 10% with ‘n’, 9% with ‘k’ and ‘g’, followed by ‘l’, ‘d’, ‘r’, ‘sh’ and ‘b’ in decreasing order.

For vowel sounds, the most commonly used in these words are ‘a’ as in ‘bag’, ‘oh’ as in ‘boat’, ‘i’ as in ‘big’, and ‘u’ as in ‘bus’, followed by ‘o’ as in ‘sock’, ‘ee’ as in ‘eat’, ‘ay’ as in ‘wave’, ‘oo’ as in ‘spoon’ and ‘eye’ as in ‘light’. Other vowels used are ‘ow’ as in ‘cow’, ‘e’ as in ‘bed’, ‘au’ as in ‘ball’, ‘a’ as in ‘want’, ‘ah’ as in ‘car’, ‘u’ as in ‘book’ and ‘look’.

Add to this, the complexity of the order in which the sounds occur and the changes in position of the speech muscles to sequence the sounds in the word and it is easy to understand why children omit consonants at the beginning or end, or both, especially in two and three syllable words. More positively, any amount of talking, even with very first words, will enable practice of the whole range of sounds needed for speech.

Repeating the words that children say so that they can hear them correctly spoken, and encouraging them to speak in games and through interactive play, with feedback, will develop their speech clarity. Be careful not to criticise though, as this may discourage your from child speaking. Repeating single words back on every occasion may distort the flow of conversation; so try to feed back the correct production of a word in a natural way. If words lose their communicative value, and the focus is totally on clarity of production in all situations, this could have a reverse effect and lead to the word being practised less. For example, when a child has asked for a ball you might say, “yes, let’s find the ball” (emphasising the word the child said, clearly and quite loudly) or “park, that’s right, we are going to the park” (again emphasising the word). For example, when a teenager has asked for a ‘coke’ by saying ‘coe’, you might say, ‘’yes, let’s get a coke’’ (emphasising the word the teenager said, clearly and quite loudly) or ’‘McDonald’s, that’s right, we are going to McDonald’s’’ (again emphasising the correct pronunciation of the word). If words lose their communicative value, and the focus is totally on clarity of production in all situations, this could deter some teenagers from talking.

When children talk and are given feedback through interaction, they will continue to develop their phonological system and improve their speech. This is likely to be accelerated when they have been introduced to literacy teaching and if they are in a good language learning environments at home and school.

But, for the majority of children with Down syndrome ordinary communication experience alone is not sufficient to lead to the development of clear, intelligible speech in later years, and they can be helped to progress more quickly by focused practice on single sounds, series of single sounds, series of varied sounds, sounds in words, pairs of words with contrasting sounds and additional practice for joining words together in longer combinations.

Practice sessions that are focused on improving phonology and speech production have an advantage to practice during everyday communication, in that the child and parent both know that the game is about how you say the word and it focuses their attention on phonology. When a word can be said in a practice session, then it can be generalised to everyday language, with activities designed for this purpose.

Choosing sounds and words to practice

In order to speak clearly, children have to be able to say single sounds, then to join sounds together in a variety of ways to produce clear words of one or more syllables and finally string words together to produce sentences. At each step, the speech-motor planning and control required increases. Most children with Down syndrome will be helped by activities for each stage - at the sound level, the word level and the multi-syllable, multi-word or sentence level.

For young children in the early stages of speaking, who are not able to produce the full range of sounds, and children who are finding it very difficult to speak who are a little older, words that contain sounds that they can say can be targeted for practice, as these are more likely to be achieved. You can use the vocabulary checklists with this module to choose words to try with them. For children who are not able to produce the full range of sounds, words that contain sounds that they can say can be targeted for practice, as these are more likely to be achieved. You can use the vocabulary checklists with this module to choose words to try with them.

Speech and language therapists are able to listen to children’s speech or look at records of words they can say, and make suggestions for therapy, to move them forward gradually and with success, without asking them to say words that are just too difficult at that stage in their speech development. Of course children need to practice difficult words and phrases too, and need to be gently encouraged to do so all of the time, but targeting a set of words closer to their current skill level will help them to be successful and to gain in confidence.

Without a speech and language therapist to help guide and structure the practice, we advise parents to use the speech sounds and vocabulary checklists to guide the selection of sounds and words for practice and to record progress. The sound list will help you to choose sounds for sound games and the word lists indicate words that your child can attempt but not yet say clearly.

Games with individual sounds

Practising with individual letter sounds in games, and speeding up a child’s ability to accurately produce sounds is good practice for all children. Some children will still need vowel sound practice, so use vowel picture cards or combine letters in your language that usually make that sound, ideally with a character or visual reminder as well, or you can choose words that contain the vowel sounds (eyes, ear, mouth, nose, and animal sounds, baa, moo, etc). Practise letter sounds you are working on (not too many at once) and also practice words (with pictures) beginning with the same letter sounds as a complementary activity. Do not wait for all consonant and vowel sounds to be achieved before practising words, but choose words that contain some of the sounds your child can say.

Practice words that are important to the child and will help her/him gain some control over daily events. Words that your child wants to use to request and comment will be learned the fastest. Next, choose topics of interest to expand vocabulary such as the farm, animals, or - for older children - a project in progress in the classroom. Next, choose topics of interest to expand vocabulary such as the farm, animals or - for older children - a project in progress in the classroom. Scrap books can be made with pictures and words to support practice.

[TODO: update] Various ‘ladder’ games (like those illustrated in [Figure 5]) made with pictures and letters can be used to encourage children to practice single sounds repetitively, and the same technique can be used for whole word practice or contrasting word practice. Large clear ladders with characters that physically jump up the ladder rungs can be used for young children, as well as letters that jump across markers on a table or grid into a bag or to be eaten by a glove puppet. Where children are familiar with formal work, printed ladders of various types can be used, for letters or words, as illustrated below for the word ‘dog’. The stickers on this example were awarded, as the child was able to complete each stage for the first time.

! Example of a game to make for sound practice ! Example of a game to make for sound practice
! Example of a game to make for sound practice ! Example of a game to make for sound practice

Figure 5. Examples of games to make for sound practice.

**The top two examples illustrate contrasting pairs: The child has to work along each line saying the words. The lower two examples illustrate ladders to climb: The child ‘climbs’ the ladder, pointing to each rung of the ladder and saying the word. These are fun games which can be made with any words to encourage speech practice.

Choose words with one letter sound targeted in one position

For example, choose a list of pictures and words that all begin with ‘b’. Work through groups of words beginning with different letter sounds that you are targeting for practice. Picture resources or books that have vocabulary items listed alphabetically are useful for this, as you will already have child-interest words all beginning with the same sound presented together. Please note that clusters such as ‘sl’ or ‘tr’ need to be practised separately and are not suitable for practising the single sounds ‘s’ or ‘t’.

At this stage you will know which sounds in words, at least in the initial position, are difficult or easy for your child to say, as well as how easily they can say sounds in isolation. You might chose to put a difficult word in with a list of easy words for your child to practice, to encourage them, and as you get more practised and your child more confident, you can choose words that really target your child’s particular difficulties. If you listen to your child carefully, you will notice what some of their difficulties are, but you will need to break up words and design activities that are at the easiest level you can think of, and that you can build up later on, so that practice items are not so difficult that they are discouraging for the child.

Joining sounds for words and syllables

Joining one consonant to one vowel, as in ‘key’ or ‘see’, is easier than saying words with more sounds in them (cat, brick, slip) or a multi-syllable word, where many changes in position of the tongue, lip and soft palate are needed to make the word. (The soft palate closes so that air does not go down your nose, as in ‘s’ and ‘sh’ words, and opens so that it does come down your nose a little, when you say ‘m’ and ‘n’). Words with one consonant, like ‘Emma’ are easier than ‘packet’ with two consonant positions, or ‘snail’ or ‘school’ with consonant clusters at the beginning.

Make a list of words your child can say clearly and see what similarities there are - in vowel and consonant type and position. Can they imitate two or three syllable words? Children’s progress will be affected by how difficult it is for them to make each single sound. The easier this is for them, the more likely they can move from one sound to the next to join the sounds swiftly enough to make a word.

For focusing on the production of the rest of the word, after the initial sound, choose words where your child can say the initial sound, and that have a different ending, as illustrated in the example below for ‘bun’ and ‘bus’.

Although choosing sounds and words to practice seems and is quite difficult, we usually expect children to learn how to say them just from listening to the words around them, without any structured help. Some selection of words that they are already trying to say, and defined practice activities, will make the task easier. Do not be too worried about ‘doing it wrong’. Make sure the tasks are fun and designed to help your child to achieve the next step - if they can’t, do more practice at an earlier step. Ideally, you will have a speech and language therapist who can help you. When practising two or three syllable words, encourage your child to tap out the number of syllables, in order to focus their attention on them.

For practising words, one way of deciding what is close to being achieved is to identify what words the child can imitate but is unable to say clearly without a model to copy. The vocabulary checklists provide a column for you to record these words. Successful imitation indicates that the child can physically say the words and the sounds in the words, but has not yet said them enough to remember how to say them spontaneously. With some extra practice, they will learn to do so.

Important words, words that children need, words that are likely to be practised every day

Another approach for choosing words to practice to improve children’s production is to choose words that the child needs or wants to say, and practice these. For example, most children at school, will need to say number words, and will be practising every time they count. They will need to say the names of members of their family, or pets names, their teacher’s name and title (Mrs Xxxx), where they live, how old they are, etc., to request their favourite activities, or asking simple questions that can get them more information or aid their communication (help please?, my turn), and the more they practice the better they will get. With this approach parents will need to be very accepting of every effort, as some words will be very difficult for some children, even though they are motivated so say them. You may need to break words down into smaller parts and practice these, and of course break sentences down into words to practice in turn (just as you do when reading word by word).

Another approach for choosing words to practise to improve teenagers’ production is to choose words that they need or want to say, and practise these. One parent, who is also a speech and language therapist, describes how her 15-year-old son was successfully persuaded to improve his production of ‘ch’ when he had difficulty ordering chilli and chocolate chip cookies in a restaurant because his version sounded like ‘’silly’’ and ‘’socolate sip’’. [TODO: references 56]

Teenagers will be keen to talk about favourite pop stars, pop music, TV programmes and ‘soap’ stars. They will be keen to order their favourite foods in the school canteen or in restaurants. They may be interested in purchasing magazines, sweets, snacks or other items in shops. They need to be able to say their name, address, birthday and age clearly. They need to be able to pronounce teachers’ and learning support assistants’ names, as well as the names of friends and leaders at clubs they attend. They may be keen to talk about sports and famous players.

Sound work can be combined with vocabulary and grammar work, by making books on topics of special interest to your teenager. With this approach parents will need to be very accepting of every effort, as some words will be very difficult for some teenagers, even though they are motivated so say them. You may need to break words down into smaller parts and practise these, and of course break sentences down into words to practise in turn (just as you do when reading word by word).

Targeted practice can help at any stage or age

Children who talk fairly well (or are considered to, compared with other children with Down syndrome) will still benefit from these types of activities to improve their speech clarity, and some examples of more advanced words are included for this reason, for example ‘ch’ words and ‘str’ words.

Joining words together

Joining words together is more difficult than saying single words on their own, and it is typical for children’s clarity to fall back a little when they try to do this. But with practice they get better, although they should be able to say the single word clearly before they are expected to say it clearly in a sentence. You can build up two, three, four and five word sentences, practised with visual prompts, like words and pictures, with a model to copy, which help children to focus on their pronunciation.

Features of successful therapy programmes for improving phonology

Of the few evaluated and published therapy programmes, one that dramatically improved the phonology of young children with Down syndrome, aged between 4 and 6 years at the start of the programme, provided weekly or fortnightly therapy from a speech therapist, with a 20 minute practice session by parents daily when possible, over input periods of 4 to 6 weeks followed by breaks of 4 to 10 weeks. This study, by Clothra Ni Cholmain, [TODO: references 8] monitored changes that occurred through the training programme.

The programmes were individual according to each child’s skills, but each shared the following key features:

1. Listening

The child listens to lists of words read to them by the parent for 6 to 10 minutes every day, with the help of a portable amplifier.

2. Production

The child is asked to produce some of these words (chosen from those they could imitate) with the child saying the words into the portable amplifier. Guidance was provided for parents to include these same words in everyday games and activities, such as picture lotto and a shopping game. Parents were encouraged to request that the child repeat or clarify the target words, by expressing uncertainty about what the child had said.

3. Sound practice

Sound cards or books were provided for the children, which contained picture symbols both for phonemes being targeted and those already in the child’s system. They were used to encourage the children to think about speech sound as sounds, and provided opportunities for listening and production practice in play.

All of the 6 children who participated in the programme showed change in their phonological systems within the first two weeks and appeared to begin to reorganise their phonological and sound production system.

Remember that the activities for encouraging all aspects of speech and language development will also help speech clarity, and that the more children speak and listen the more they will improve in their speech production. Children with severe hearing loss are greatly disadvantaged for learning to speak clearly and treatment with hearing aids is vital. Consider how you can practice and improve clarity of speech through play, using the activities described as useful for developing vocabulary comprehension and speech, through everyday conversation and through reading activities.

For activities and games that break speaking tasks down, for graded practice with pictures, words and letters, please refer to the box (right).

Dysfluencies

In teenage years, dysfluencies such as stuttering can become a cause for concern. They are common in teenagers with Down syndrome but usually improve or disappear over several years. [TODO: references 42] Researchers are not clear about the reasons for this [TODO: references 12] but the usual advice is to try to ignore these difficulties and not react to them. Some authors feel they are due to the anxiety which may result from the teenagers becoming more aware of their difficulties in saying what they want to say and being understood. The advice, therefore, is to be patient and to listen, maintaining eye-contact, interest and an encouraging smile. There is no evidence that doing speech work to improve intelligibility increases the likelihood of dysfluencies - provided, of course, that the speech work is not done in a manner that causes anxiety or stress. In fact, speech work done in the early years to increase clarity of production may help to prevent the development of stuttering.

Singing

Recently, the first author observed a significant improvement in the conversational speech intelligibility of a 32 year old woman with Down syndrome after she had taken singing lessons with a professional teacher for two years. Singing teachers know how to encourage clarity of production when singing and breath control. Many teenagers with Down syndrome enjoy singing, especially pop songs, so that the benefits of singing, especially when supervised by a singing teacher, should be explored. [TODO: references 55]

Speech and speech intelligibility

Most teenagers with Down syndrome of secondary school age have some delays and difficulties in developing clear speech. This can be very frustrating for them as it means that their speech is often not understood. Speech difficulties hold back the teenager’s ability to say sentences and to develop grammar, therefore speech work should be a priority in the secondary school years, at home and at school - and can be built into reading and spelling activities.

Research indicates that, for teenagers with Down syndrome, speech intelligibility difficulties result from difficulties at every stage of speech production. [TODO: references 30], [TODO: references 31] Teenagers have difficulties with the articulation of single sounds, with phonology - the production of the range of speech sounds, blends and clusters in the language, with producing clear words and with producing clear sentences. The production of sentences requires retrieval of words and grammar, and speech-motor planning.

Experts agree that there is evidence of difficulties at all these levels and therefore we recommend activities for each level from sounds to sentences.

Researchers have also suggested that poor production of words may be the result of poor storage of the phonological or sound pattern of the word, [TODO: references 13], [TODO: references 40] so that the teenager does not have an accurate specification of the word in memory from which to organise correct production. This is a very plausible hypothesis given evidence for significant phonological loop impairment in children and teenagers with Down syndrome which would cause exactly this problem.

Further, there is evidence that the planning and processing needed to produce a clear string of words as a sentence overloads the working memory and cognitive processing capacity of many young people with Down syndrome. They can do part of the task well, e.g. produce two or three words clearly, but not a sentence of six or seven words - and they can usually read with much greater clarity, fluency and even intonation than is evident in spontaneous speech. When reading, the teenager is not required to think and to plan his/her sentences in the same way as in spontaneous talking.

If we identify targets for speech work at each level - and make maximum use of reading activities to support spoken practice, we should be able to significantly improve speech clarity and sentence production for most teenagers. We have incorporated the principles of the therapy approaches shown to be effective with younger children with Down syndrome into the activities. These are summarised in the boxes.

The advice in this section starts right at the early stages as some teenagers with Down syndrome will have had no speech work in primary school and a small number may still have immature feeding, chewing, breathing and drinking skills. Research indicates that 16% of teenagers still have difficulty with chewing, 18% with swallowing and 25% with tongue thrusting. [TODO: references 51]