Supporting speech and language development

[TODO] This topic offers guidance on how to effectively support the development of communication, speech and language skills for children with Down syndrome…

Introduction

The main aim of this module is to provide practical advice and activities to improve the spoken language of children with Down syndrome. The focus is therefore on learning to understand and to use words and sentences and on developing the sound production skills necessary to produce intelligible speech.

Since babbling and early non-verbal communication using gesture and sign, are important and influence the rate of language learning in children with Down syndrome, sections on these are included but the emphasis in this module is on teaching vocabulary and developing sound discrimination and production. The aim is to help each child to develop a spoken vocabulary as quickly as possible and to acquire 400 words or more, used in sentences, by five to six years of age. There is evidence that this vocabulary size is necessary for the development of grammar and sentence structures and for control over speech sound production (phonology). DSii Language Overview p.10 Signs are used with words to accelerate early word comprehension and effective communication, particularly as a bridge to the first 50 to 100 words. When a child has 50 words in his/her signed or spoken vocabulary, reading activities are encouraged to develop the production of two and three words together, early grammar and sentences.

The advice and programme of activities recommended in this module are based on three sets of information

• research into the processes and influences on speech and language development in typically developing children
• research into the specific speech and language needs of children with Down syndrome
• research into effective interventions
• the experience of our and other colleagues from working with parents to provide interventions

A set of checklists, covering speech, vocabulary, grammar and interactive communication skills, is provided with this module to allow children’s skills in each area to be evaluated, the activities to be targeted at the right level and to record progress.

The skills and knowledge needed for talking

See also:

• Speech and language for individuals with Down syndrome - An overview

For all children, learning to talk is a complex process, involving a number of emerging skills, influenced by learning opportunities and accomplished over many years. To be competent at expressing themselves through language, children have to know the words and grammar needed to express their thoughts in spoken language (language knowledge), they have to be able to make the sounds and words clearly so that their speech can be understood (speech) and they have to know how to engage someone effectively in a conversation (interactive communication skills). The reader is referred to the Speech and Language overview module for a full discussion of these issues and the key findings from research for both typically developing children and children with Down syndrome.

Table 1. The skills and knowledge needed for talking

The principles of the programme

The programme is based on two main principles: The need to improve the quality and quantity of everyday communication with the child, and the need to target the specific skills that underpin effective communication as many of these skills are areas of particular difficulty for children with Down syndrome.

To maximise the child’s speech and language progress both everyday communication experience and the child’s underlying skills need to be considered at all times, for babies and children with Down syndrome.

We then stress two additional principles: The need, at all ages, to develop interactive communication, speech and language skills in parallel, and the importance of keeping records of progress.

Improving everyday communication

It is essential that everyone involved with a child with Down syndrome at home or school or in the community considers and, if necessary, improves the way in which they are communicating with the child during ordinary activities.

Learning to talk is an everyday activity.

Language is learned because children want to communicate and the single most important influence on the rate of progress in typically developing children is the quality and quantity of communication that the child experiences throughout their day at home or at school.

Therefore, one approach to language intervention is to encourage everyone who is with the child to be sensitive to the way in which they communicate with the child and to increase the amount of quality daily talk with the child.

Therapy based on quality interaction

The Hanen programme, [TODO: references 1] which teaches parents or carers about how language is learned by most children - the stages and the processes - and aims to improve the adult’s sensitivity to the child’s language learning needs, is one example of this approach. Intervention programmes that focus on interaction and language aim to improve the effectiveness of parents, teachers and carers as language teachers, during all their ordinary everyday communication with the child.

Of course, many parents, teachers and carers are excellent natural communicators and they adapt to the child’s needs without any further training. However, communication is a two way activity between partners and when one partner is having difficulty, and does not give natural, age appropriate responses during the communication exchange, then it is not certain that all adults or other children will adapt to this as effectively as they could without some explicit guidance and conscious effort.

For example, if the child does not begin to point or hold up objects at the typical age, this may result in parents naming objects for the child less often, so delaying vocabulary learning. If the child does not begin to try saying words at the typical age, it may not be as easy to keep up the same level of talk to the child as it would be to the child who is talking and is demanding a response. If the child’s words are unintelligible, the adult may need to ask the child to repeat the words, to be sure they understand what the child is trying to say, before they can respond. This disrupts the normal flow of conversation and the adult’s ability to respond to the child’s message by expanding or replying in a natural way.

All these examples indicate that when a child has even one area of delay or difficulty in her/his speech and language skills, this will almost certainly reduce the quality and quantity of natural talk to and with the child, in comparison with a typically developing child. Yet the child with difficulties needs more good quality language experience and learning opportunities than the typical child in order to make progress.

The first requirement for any parent, teacher or carer using this programme is that you are familiar with the stages of speech and language development in typically developing children and with what is currently understood about the processes that influence their rate of progress. In particular you should be confident that you know what skills and style of communication will make you a good communicator. You can do this by reading the overview module in this series and other books from the recommended list at the end of this module. You can also do this by learning from your local speech and language therapy service or from going on a course.

The second requirement is that you should then take time to consider how you are currently communicating with your baby or child with Down syndrome and identify ways in which you could improve either your style or the quantity of communication experience that you are offering the child.

The third requirement is that, as you read in the next section about the additional ways that you can help your child, you remember that they are additional, they do not conflict with any of the principles which make you a good communicator. Some require you to try to absorb them and use them in all your everyday interactions to make all your communication with your child more effective (for example, speaking clearly, reducing background noise, maintaining eye contact, using signs). Others require some time to be spent each day on extra games and teaching activities. Try to absorb some of these activities into times when you already play with your child (during changing, bathing, bedtime and mealtimes, for example). Others can be included in no more than an a half hour session each day of planned playing or reading activities with your child (or two 15 minute sessions). In school the teaching games can be easily absorbed into the current programme of the nursery, preschool or classroom. Fifteen minutes of planned activities daily really will make a difference - and be more effective than an hour twice a week.

Targeting the specific profile of needs

Children with Down syndrome usually experience considerable delay and difficulties with learning to talk. Current research, described in the accompanying speech and language overview module, identifies a common profile.

Most children and adults with Down syndrome understand more language than their expressive language skills suggest and therefore their understanding is often underestimated. Their social interactive skills and non-verbal communication skills are a strength but speech sound production (articulation and phonology) is a specific weakness. Vocabulary learning, while delayed, is also a strength but grammar learning is a weakness, so that the children tend to talk using keywords rather than complete sentences.

Children with Down syndrome show the same progression from one word to two word combinations, once they can say between 50-100 words, as other children, and they show the same progression to early grammar in their speech when they have a spoken vocabulary of 300-400 words. Unfortunately the usual delay in reaching a productive vocabulary of 300-400 words (at 5 to 6 years, instead of at 2 to 3 years) may compromise the ability to master fully sophisticated grammar and phonology in later speech.

Some of the reasons for the speech and language difficulties

• Learning difficulties - need more examples to learn
• Anatomical differences - affect speech skills
• Learning language from listening is affected by:
• hearing loss
• auditory discrimination
• verbal short-term memory
• Speech motor difficulties:
• delay vocabulary and grammar development
• affect the way a child is talked to and included in conversations
• Joint attention difficulties and slow development of speech will both reduce language learning opportunities

All these difficulties can be targeted with appropriate and effective intervention strategies

Progress in comprehension and production of vocabulary is probably compromised by hearing difficulties. It is certainly compromised by the children’s specific difficulty with speech sound production. Progress in sentence production and in later grammar learning is probably compromised by a weakness in the auditory or phonological short-term memory system.

This profile of strengths and weaknesses identifies that any remedial programme needs to aim to:

1. Reduce the effects of hearing loss by:

• Regular hearing assessments and prompt, effective surgical and/or medical treatments
• Reducing background noise, speaking clearly and maintaining eye-contact while speaking
• Using compensating strategies in the child’s communication environment which make maximum use of visual supports (signs, pictures, print)

2. Improve articulation and phonology by:
3. Encouraging control over oral motor skills from infancy
4. Building up sound discrimination and production skills at babble stage
5. Practising single speech sounds from 12-18 months
6. Keeping a record of the child’s speech sound skills
7. Practising whole word and sentence production
8. Using signs and reading activities to support speech sound work
9. Accelerate vocabulary comprehension and production by:
10. Teaching a target vocabulary
11. Keeping a record of the child’s comprehension and production of words
12. Using an augmentative communication system, usually signs, to support comprehension and production of words
13. Using reading activities to support the comprehension and production of vocabulary
14. Accelerate mastery of grammar and sentence building by:
15. Teaching the use of two, three and four word combinations
16. Teaching the early grammatical markers (bound morphology)
17. Teaching word order rules (syntax)
18. Teaching function word grammar (closed class grammar)
19. Keeping a record of the child’s comprehension and production of grammatical markers and sentences
20. Using reading activities to support the comprehension and production of grammar and sentences
21. Take account of the auditory short term memory weakness by:
22. Practising words to improve the sound traces stored
23. Playing memory games
24. Supporting learning with visual materials, pictures and print, to reduce memory requirement
25. Capitalise on the children’s good social interactive skills and develop them by:
26. Being sensitive to all the child’s attempts to communicate, by listening and responding to them
27. creating opportunities for the child to make choices and to express themself through language
28. Encouraging the use of gesture to communicate as it is a strength and may be important throughout life for some individuals
29. Remembering to listen and to wait to give the child a chance to organise their contribution to the conversation
30. Using styles of conversation that encourage the child to expand on and develop their contribution
31. Providing as many social opportunities for the child to be able to communicate with and learn from other non-language delayed children and adults in ordinary classes, clubs and social activities as possible

Working on speech, language and communication skills in parallel

Whenever we communicate we are using all these skills, right from infancy, therefore at any age an effective speech and language therapy programme needs to consider the child’s strengths and weaknesses in communication, language knowledge and in speech. The programme should then work on each aspect as necessary, in parallel, rather than concentrate on language learning and neglect speech, for example.

Recording progress and planning

We believe that it is important to keep records of the child’s progress as this:

• Encourages careful observation and an accurate knowledge of the stage the child has reached in each area of development
• Provides a record of progress and achievements
• Provides a guide to the next skill or step forward that is to be expected, allowing you to choose the next activity to focus on with confidence that your child should be ready to move towards it
• Ensures that the child’s skills are not underestimated
• Keeps parents and teachers on task and motivated

We do not wish to impose too much extra work for families, teachers and carers but the evidence does suggest that speech and language skills need additional targeted help and that most children and adults with Down syndrome could be talking more and talking more clearly if we take relatively simple but planned steps to help them.

Learning to talk is the most important thing that children do. It is central to all other aspects of their development. It is critically important for social and emotional development and for the development of cognitive or mental abilities, so progress with learning to talk will benefit every other aspect of a child’s life.

The DSE checklists

Down Syndrome Education International has developed a set of checklists to allow you to evaluate your child’s current speech, language and communication skills and to record future progress in a simple and straightforward manner. The checklists cover interactive communication and play skills, speech sound skills, vocabulary and sentences and grammar.

For vocabulary, three lists are provided to take your child to an 800-word vocabulary in stages, the first 120, then the next 340 and the remaining 350. The words chosen are based on research on the order in which children learn words. The third list also includes the key vocabulary required for reading and for number in the first year or two in school and the words needed to develop more advanced grammar and sentence structures. Remember that it is important that your child masters a 300-400 word spoken vocabulary as soon as possible as research evidence indicates that this is necessary before grammar will develop and that it will promote development of speech production skills. However, the learning difficulties of children with Down syndrome vary widely, therefore what really matters is that your child is progressing, even in small steps, and that communicating together is fun and effective.

The Speech sounds checklists and record sheets cover all 44 single sounds (phonemes) used in English and the common blends and clusters. The Sentences and grammar checklist gives examples of the early two and three word combinations that children use and then provides a guide to developing grammar.

The Interactive communication and play skills checklist provides a guide to the range of communicative functions that children use, and to their ability to join in and initiate conversations. It also covers imaginative play activities as they demonstrate a child’s growing understanding of the world and this can indicate the words and phrases that the child is ready to use.

The set of checklists are a guide to all aspects of speech and language development and communication skills for children with Down syndrome from birth to five years. Some of the skills that they cover will not be mastered by most children until they are into school, so the checklists will be a useful guide to be used over a number of years.

They are designed to allow children’s progress to be carefully monitored and to ensure that activities are selected that are appropriate to advance children to the next step in development. The checklists are provided with the practical speech and language modules in this series and the speech and language overview module. They are intended to be used in conjunction with the information in those modules. However, the checklists are also available for purchase in sets for school, group, or speech and language therapy services.

Parent/teacher collaboration

For school age children, it will be helpful if parents and teachers can work together to complete the checklists. Children may use different language at home and at school, therefore observation records should be kept for a week or more by both parents and teachers (or support assistants) and then the records shared in order to complete the checklists and choose targets. Talking is a continuous activity during waking hours, and parents have as much opportunity to help their children to develop spoken language skills as teachers, so working together is the best way to help your child.

Using the checklists

Before you start choosing activities from those given in this module, we suggest that you observe your child over the next few days and note down the gestures, signs and words that they are already using to communicate. If your child is already joining words together, then note down the words that they are using during the day. Keep an observation diary close to hand and write the words down just as they are said - for example ‘juice, mum’ or ‘go school bus’ or ‘me car’. Make a note of the range of communication that your child engages in, for example, showing, asking, refusing or greeting. You will be able to use your observations to complete the checklists and decide on the correct targets for your child.

Remember we are all experts at language

The checklists and all the information in this and the overview module may seem daunting. When we analyse how we learn to talk and break it down into interactive skills, sounds, words and grammar, we make it seem complicated. We hope that the detail does help you to understand all the skills that your child is mastering step by step - but do remember that you are a competent talker and communicator and that you do use all the grammar described and the speech sounds, naturally. When some of the ideas seem difficult, just think about how you talk and you will see how you use tenses, prepositions and pronouns and auxiliary verbs, for example, without usually having to think about them.

Getting started

The activities are set out for each area of development starting with interactive communication skills, gesture and sign, then speech, vocabulary and grammar. In each area, activities are recommended in developmental order, so remember to identify your child’s achievements in each area and choose activities to help her/him to progress in each area. It is important to recognise that the checklists cover at least five years of development. You do not need to read the whole of the module and take in all the advice and ideas at once. Start by completing the checklists and reading the sections that will provide activities for the next steps, based on your child’s current level of progress.

Table 2. Typical production milestones for children with Down syndrome