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Thomas L. Layton, Ph.D. Talk and Total Communication Services Down syndrome: Education and Communication.

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Presentation on theme: "Thomas L. Layton, Ph.D. Talk and Total Communication Services Down syndrome: Education and Communication."— Presentation transcript:

1 Thomas L. Layton, Ph.D. Talk and Total Communication Services Down syndrome: Education and Communication

2 What we know about DS What we know about DS u Prevalence 1/700 live births in USA u Most children have delayed development u Wide range of abilities from mild to severe u For most, level ability can not be predicted at birth u Early intervention makes a difference Talk and Total Communication


4 Speech and Language Development Speech and Language Development u Spoken language delayed for most children with DS – first words months u Communication skills are poor u Vocabulary is delayed u Understanding ahead of expression u Grammar u Typically use only key words u Speech u Poor intelligibility, means difficult to understand u If child can not be understood, reluctant to speak Talk and Total Communication

5 Growth Problems u Separate Growth Chart u Early growth delays u Eventual Increase in Weight for Height Talk and Total Communication



8 u Musculoskeletal and Motor Disabilities u Atlantoaxial instability (15%) Increased mobility of the cervical spine at the level of the first and second vertebrae u Approximately 10% w/ AAI may have u Neck pain u Unusual posturing of the head and neck u Change in gait u Loss of upper body strength u Abnormal neurological reflexes u Change in bowel/bladder function Hypotonicity (arms, legs, face, oral motor) Talk and Total Communication

9 Vision Problems u uLazy Eye (strabismus) u Cataracts u Spotted Iris u Nystagmus u Myopia (Near Sightedness) Talk and Total Communication

10 Hearing Problems u 60 – 75% experience some hearing loss u Chronic Otitis Media u Anatomy of skull, foreface, ear canals, and Eustachian tube dysfunction u Higher incidence of Sensory-Neural loss Talk and Total Communication

11 Oral-Motor 30-40% demonstrate moderate-to-severe oral motor problems u Poor swallowing, poor tongue control, positioning, poor lip control. u Affects tongue-tip sounds...phonological process are atypical...front consonants are produced posterior u Affects tongue-tip sounds...phonological process are atypical...front consonants are produced posterior. Talk and Total Communication


13 Life Expectancies u In 1929 life expectancy was 9 years u In 1983 life expectancy was age 25 years u In 1997 life expectancy has risen to age 49 years u Current estimates indicates life expectancy is now 55 years u Due to improvements in medical care and advances in surgery. Talk and Total Communication


15 Life Expectancies u Alzheimer disease: A problem after age 20 years u Occurrence of senile plaques and neurofibrillary tangles in DS match brain lesions of Alzheimer disease Talk and Total Communication

16 Aging u Decline in cognition u No decline in language skills up to middle age u 50+ years may see decline in skills of speech, pragmatics, and receptive vocabulary (especially for those with dementia Talk and Total Communication

17 Down syndrome Perspective on Dual Diagnosis Talk and Total Communication

18 Prevalence of DS & ASD ~5% Impairments in: Reciprocal social and language function. No symbolic or imitative play Restricted interests: Repetitive or ritualistic behaviors. DSM-IV / ICD-9 criteria Autistic Disorder (onset <3 yr.) Pervasive Developmental Disorder-NOS Childhood Disintegrative Disorder (late-onset) Autistic Spectrum Disorder in Down Syndrome Talk and Total Communication

19 u Meeting DSM-IV criteria exhibit a spectrum of social-skill impairments u Concordant with low cognitive level social delay & adaptive impairment u Discordant with cognitive level social withdrawal – apathy social indifference – aloofness social avoidance - anxiety Autistic Spectrum Disorder in Down syndrome Talk and Total Communication

20 DS-ASD Early Onset Poor development, gradual onset of atypical behaviors (gaze, stereotypy) **Infantile spasms more frequent in this group Characteristic EEG pattern Severe neuro-motor impairments, feeding- swallowing problems Talk and Total Communication

21 DS-ASD Late Onset Typical early development followed by subacute behavioral deterioration and regression (speech, cognitive, social skills) Motor skills unchanged Seizures or EEG abnormality not typically observed Autoimmune? Leukemia ChemoTx ? None of the above ? Talk and Total Communication

22 Appears Like Autism..but Isnt Stereotypic movements - unusual sensory responding and inattention Obsessive compulsive disorder – perseveration & rituals Language, Play, and Social relatedness are relatively preserved Talk and Total Communication

23 Case Studies (Two dual dx; One DS only) DSM IVChild dualChild dual Child DS Social Interaction Awareness for others feelings No No Yes Seeks comfort No No Yes Imitates No No Yes Social Play No Some Yes Peer friendships No No Some Communication Verbal or non-verbal No Yes Yes Eye contact No Some Yes Imagination No No Some Echolalia NA Yes No Motor stereotyped Hand stereotyped Yes Yes No Preoccupation with objects No Yes No Insistence on routines Yes Yes Some

24 Addressing Challenging Behaviors in Children with Down syndrome

25 Intervention Strategies u Setting events u Replacement skills u Consequence strategies Talk and Total Communication

26 Setting events u Changes in events that may influence behaviors u Allergies, sleep disorder, illnesses u Intervention: record setting and behavior; e.g., notebook at home to let school know child did not have a restful sleep u Sharing with other caregivers setting event u Adjust demands on child, like at school, and increase highly preferred activities. Talk and Total Communication

27 Communication in Infants and Toddlers

28 Early Language Development u Early intervention is key for children with DS u Parental education u Input should match childs comprehension u Sensory stimulation u Monitor hearing u Social skills development- i.e. peekaboo, turn-taking toys u Consider total communication u Daily routines to teach concepts Talk and Total Communication

29 Useful tools/techniques u Visual cues u Because of possible hearing loss, supplement verbal communication with visual cues, i.e. gestures u Pacing boards u Multi-word stages – 1 dot per word u Increase MLU – 1 dot per morpheme or syntactic element u Carrier phrases: to promote multi-word phrases u Expansion of single word utterances to multi-word utterances u Mirrors to promote self-awareness Talk and Total Communication

30 Vocabulary/Semantics u Expand vocabulary u Use whole language activities – i.e. daily activities u Increase length of utterances/phrases u Use play-based activities - Talk and Total Communication

31 Selecting First Words u Functional words, child interest, child directed u Follow normal development, child skill level u Items should be reinforcing u Food: cookies, juice, chips u Toys: bouncing ball, action, sounds u Motor: tickle, bouncing on trampoline, wiggle u Sensory: music, hot/cold, down u Social: bye, finished, please Talk and Total Communication

32 Intervention u Scaffolding and Generalization u Milieu language teaching – naturalistic u Modeling u Prompting u Speech and Language recasts- childs utterance is expanded into a grammatically form Talk and Total Communication

33 Recasting speech and language u Speech u Adult utterances that add only sound information to the childs oral output u For example, child says, This is a -at. u Adult says, Yes cat. u No new grammar information is added. u Grammar u Adult utterances that add grammar or semantic information to the childs oral output u For example, child says, She seep. u Adult says, Yes, she sleeps. (adding speech and correct verb ending. u New grammar information is added Talk and Total Communication

34 Use of verbal routines u Verbal routines are useful when child acquires common utterance in discourse situations u For instance, child says, I want ___, I see ___, or even No more ___, and Where ___? Talk and Total Communication

35 Spontaneous speech activities u Action pictures u Child describes actions – adult expands u Frequent repeat same pictures u Thematic activities u Literacy kits u Rehearsal and modeling u Play situation to teach social interaction – little people u Pretend going to park to play on swings u Story starters u iPad story starter aps u Cloze procedure/choices u Model choice during requesting – child makes choice between two toys, food, pictures Talk and Total Communication

36 The Role of Signing in Early Communication

37 Signing is Like a Picture Iconic Shapes are visually like the concept u car u eat u ball u cat u on u girl Abstract or less of a relationship u play u more u please u no, yes Talk and Total Communication

38 Intervention u AAC sign language u Some children do not acquire first word until 6 years old u Sign can be used as supplement, as verbal communication skills are still minimal u a Sign can be a primary means of communication when necessary u Sign can be an additional support to decrease frustration because receptive skills better than expressive Talk and Total Communication

39 Children with Down syndrome u Overall slower developing motor areas u Typically hypotonia, flaccid motor skills u Data suggest myelination along motor strip is delayed in development u This could account for the delays in expressive words. Talk and Total Communication

40 Children w/ DS: Comprehension u Comprehension in auditory cortex develops earlier than production in motor cortex u Comprehension may occur in both left and right hemispheres u Child has early understanding of language, similar to typical child u Child may have a need to communicate, similar to typical child, but no means u Signing is a means for early communication Talk and Total Communication

41 Hypotonia u Complicates expressive language, nearly all children with Down syndrome have hypotonia u Demonstrated in poor strengthening of large and fine motor skills u Walking, writing, drawing are affected u Tongue, lip, jaw movements also affected u Speech is subsequently impaired Talk and Total Communication

42 Oral Motor Problems u 40% or more of children with Down syndrome have moderate-to-severe oral motor problems u Oral motor problems impede speech production and speech intelligibility u Sign can be used to augment poor speech intelligibility during social communication exchanges Talk and Total Communication

43 We introduce signs: u At the same time we introduce words - usually around months u Use of signs comes before speech production u Sign while communicating to child u e.g. Dog - dog I see dog See dog! Talk and Total Communication

44 We introduce signs: u Introduce Iconic signs first u Stimulation (comprehension) first u Later on, we shape the sign by taking childs hand while stimulating u Remember to use SPEECH u Stimulate, shape hands, wait for child to produce it u Reinforce all attempts Talk and Total Communication

45 Does signs prevent talking later on? u All data show sign does not delay speech u Our own empirical data show signs drop off when a child is ready to talk. u Wisconsin research suggests children who are early signers have better speech and language skills later on. u Even if child has severe oral motor problems, signing can help in speech intelligibility Talk and Total Communication

46 Bobbys data u Oral training first two stages u Sign training stages 3 through 6 u Follow-up one year later Talk and Total Communication

47 Signing: Summary u A means for the child to communicate early u A teaching tool for learning language skills and concepts u An imaginative, interesting, and fun experience Talk and Total Communication

48 Communication in preschool and early elementary children

49 Speech Intelligibility Techniques

50 Development of Speech u Vowels, semivowels, nasals, stops acquired first u Fricatives, affricates, and liquids are a problem even into adulthood.

51 Study with oral-motor problems u Three groups matched by age and gender u DS w/oral-motor problems u DS w/out oral-motor problems u Typically developing group with developmental articulation errors

52 MannerPositionDS w/ OMDS w/outTD Artic StopsI M F FricativesI M F NasalsI M F GlidesI M F

53 Types of errors: substitutions, distortions, omissions u DS w/ OM – more omissions u DS w/out and TD Artic produced similar errors (substitutions & distortions)

54 Improving Intelligibility u Keep in mind: pitch, rate, oral-motor abilities, working memory u Apraxia u Articulation test to obtain profile of errors u Use of typical intervention u Focus on syllable structure u Phonological Awareness: books u Phonological Processes Talk and Total Communication

55 Suggestions for Stimulating Language u Follow the child lead. Talk about what s/he is doing using single words or short phrases. u Speak slightly slower and a little louder u Sit face-to-face while playing and talking u Hold objects and toys near your mouth u Talk about what you are doing while doing it u Think out-loud. Let child hear your thoughts u Be aware of over talking. Leave some silence u Look for opportunities to emphasize new vocabulary and stimulate language throughout the day Talk and Total Communication

56 Suggestions for Stimulating Language u Use open-ended questions (e.g., what do you want to play?) or choice questions (e.g., Do you want blocks or cars?). u Have fun with language! u Introduce new words, short poems, finger play, and songs u Make book reading and stories a daily routine u Respond to vocalizations in a meaningful way Talk and Total Communication

57 Treatment Strategies: u Frequency: u Intensive direct therapy u Daily activities in the clinic and at home u Shorter, more frequent is better u Goals: u Divide long term goals into shorter steps u Make goals concrete u Child needs to see progress Talk and Total Communication

58 u Positive Image u Help child develop positive image as a communicator u Work on activities to increase intelligibility u Augmentative Communication u Sign language u Communication boards u Pacing u Use a pacing board u Teach slower and more rhythmic rate Talk and Total Communication

59 u Sound selection u Teach early developing and frequently occurring consonants first u Teach oral-motor awareness u Associate tactile and visual symbols with sounds u Use a set of phoneme-grapheme associated pictures u Use tactile stimulation to teach continuant, syllables, plosives Talk and Total Communication

60 u Selecting key words u Practice sounds in frequently occurring words u Select relevant vocabulary u Progress from individual consonants (p) to nonsense syllables (po) to mono-syllabic words (pop). u Multisyllabic words u Teach separately, using pacing and tactile cues u Difficulty is co-articulation and rapid movements. Talk and Total Communication

61 u Picture Communication Systems (PECS) u Make picture boards of objects in the home u Locate throughout the home u Place visually enticing toys in clear containers u Do the same with videos, foods u Request approximations to desired object u Book Reading u Read books with animal sounds u Read books that produce different voices, Goldilocks u Let child finish sentence, Ill blow your house… u Use Social Routines: u Encourage phrases, I want… u Incorporate sound production into activity Talk and Total Communication

62 Activities for auditory memory skills u Use picture snapshots from story to aid in retelling u Sound to letter identification u Learning letter sounds u Literacy, reading, spelling u Decoding sounding out u Matching pictures to pictures – words to pictures Talk and Total Communication

63 ELF Reading in Children years

64 History of working with children with Down syndrome u Self contained programs u Expectations - sheltered workshops u Little expectations of reading, calculations Talk and Total Communication

65 History continued u Mid 70s early intervention u Mid 80s reading in young children u Mid 90s realized value of early intervention with infants u Current: need for phonics and literacy Talk and Total Communication

66 Reading in preschool children u Buckley (1985) reported on Sarah who read at age 3 years. u Buckley (1995) reports on Digby who read at 25 months of age, long before he spoke his first word. Emma and Daniel read at 28 months, Zoe at 3 years 5 months, and Jamie at 3 years. u Buckley also reported that Daniel used his reading to improve his expressive language skills. Talk and Total Communication

67 What is Known u Home environment has a dramatic influence on literacy. u Expectations by parents is important et al., 1991). u Through reading, children w/ DS learn concepts that improve oral and written language (Buckley, 1995; Layton, 2000). u Children w/ DS can learn to read early (Buckley, 1995; Layton, 2000; Lorenz et al., 1985). Talk and Total Communication

68 Introduce reading...whole word approach initially u Read a familiar story several times. u Pictures with accompanying words. u Words without pictures...functional words. u Simple stories with themes. Talk and Total Communication

69 Introduce Phonics u Phonics assists in reading unfamiliar words u Begin Phonics when child has understanding of words u Phonics and speech intelligibility u pronouncing words with missing sounds u pacing u Phonics and writing u Begin by writing and sounding out letters u Combine letters and sounds Talk and Total Communication

70 SHARED STORYBOOK READING CREATE - READ Child chooses the book Remember to follow the childs lead Expand childs utterances Ask open ended questions or make inferences Talk about the print Encourage word identification Talk and Total Communication

71 Read and re-read the same book Expand on new words and concepts Always pause and let the child talk Do have fun Talk and Total Communication

72 Reading in Older Children

73 u Read for comprehension...answer questions u discuss reading material u Record dialogues u Answering questions u Writing sentences, simple paragraphs Talk and Total Communication

74 u Words to popular music for teaching reading and comprehension. u Subscribe to age appropriate magazines. u Obtain library card, let child select reading material u Read from daily newspaper, such as sports page, teen section, movies section u Introduce writing with reading. u Do not let motor difficulty impair writing, select alternative devices.. Talk and Total Communication

75 u Use holiday themes to compile lists, write letters, etc. Use pictures along with words. u Use on computer to write to friend, relative, teacher. u Compile a list of items wanted from grocery store. Let child select the items from list. u Write in a personal diary. Child can write anything or draw. Make this a short (10 minute) daily activity. Diaries are confidential. Talk and Total Communication



78 iPad apps

79 iPad applications are starting a revolution in the field of speech and language therapy! Portable and easily accessible. Immediate access to internet. Used for inpatient or rehab clients. Motivating for children Used for AAC, assess skills, keep data, or as therapy tools, incentives, games and MORE! iPad apps Talk and Total Communication

80 iPad apps Demonstration (Handout)

81 China

82 ChinaUSA Population1,336,970 K 309,075 K SLPs1K140K Programs 3 postgraduate programs 1 undergraduate program 232 postgraduate programs 310 undergraduate programs Talk and Total Communication

83 BeijingNC Population17,550K9,491K SLPs1004,150

84 In China, because of the one child per family policy, women usually choose to have their child between 25 and 27 years of age. Pregnant women of advanced maternal age are rare. Therefore, the birth prevalence of Down syndrome in China is very low, less than 1/1000 live births. *Estimated number of individuals with Down Syndrome is 1,623,559 Talk and Total Communication




88 u Meetings with other families at a special school had been arranged two days of our trip. When I informed them that I had a prenatal diagnoses of DS and a heart defect with Caroline, you could see the shock on everyone of their faces. China does not offer anything as far as services, public school, etc. like we experience here. They do not take their kids out in public. Only one of the families that we talked to actually had a diagnosis at birth, the rest found out months and up to 2 years later, after realizing themselves there were developmental delays. Once diagnosed, most did not tell their extended family that they had a child with DS. Unfortunately, the evolution of China is decades behind our way of thinking that every child deserves every opportunity. Talk and Total Communication

89 Thanks for for Listening! Listening!

90 What lies behind us and what lies before us are tiny matters compared to what lies within us. Oliver Wendell Holmes

91 Web Pages

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