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Thomas L. Layton, Ph.D. Talk and Total Communication Services

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

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


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

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



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

9 Talk and Total Communication
Vision Problems “Lazy Eye” (strabismus) Cataracts Spotted Iris Nystagmus Myopia (Near Sightedness) Talk and Total Communication

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

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


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


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

16 Talk and Total Communication
Aging Decline in cognition No decline in language skills up to middle age 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 Autistic Spectrum Disorder in Down Syndrome
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) Talk and Total Communication

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

20 Talk and Total Communication
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 Talk and Total Communication
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 Isn’t
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 IV Child dual Child dual Child DS Social Interaction Awareness for other’s feelings No No Yes Seeks comfort Imitates Social Play Some Yes Peer friendships No Some Communication Verbal or non-verbal Yes Yes Eye contact Imagination Echolalia NA Yes No Motor stereotyped Hand stereotyped Yes Yes No Preoccupation with objects Insistence on routines Yes Some

24 Addressing Challenging Behaviors in Children with Down syndrome

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

26 Talk and Total Communication
Setting events Changes in events that may influence behaviors Allergies, sleep disorder, illnesses Intervention: record setting and behavior; e.g., notebook at home to let school know child did not have a restful sleep Sharing with other caregivers setting event 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
Early intervention is key for children with DS Parental education Input should match child’s comprehension Sensory stimulation Monitor hearing Social skills development- i.e. peekaboo, turn-taking toys Consider total communication Daily routines to teach concepts Talk and Total Communication

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

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

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

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

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

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

35 Spontaneous speech activities
Action pictures Child describes actions – adult expands Frequent repeat same pictures Thematic activities Literacy kits Rehearsal and modeling Play situation to teach social interaction – little people Pretend going to park to play on swings Story starters iPad story starter aps Cloze procedure/choices 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 car eat ball cat on girl Abstract or less of a relationship play more please no, yes Talk and Total Communication

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

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

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

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

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

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

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

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

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

47 Talk and Total Communication
Signing: Summary A means for the child to communicate early A teaching tool for learning language skills and concepts 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 Vowels, semivowels, nasals, stops acquired first
Fricatives, affricates, and liquids are a problem even into adulthood.

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

52 Manner Position DS w/ OM DS w/out TD Artic Stops I 1.82 0.25 0.20 M 3.00 0.67 0.50 F 3.55 0.42 0.60 Fricatives 5.64 3.75 2.60 5.46 4.00 3.10 5.55 3.17 2.30 Nasals 0.64 0.17 0.00 1.09 1.55 Glides 1.00 0.08

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

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

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

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

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

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

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

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

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

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

63 Reading in Children 3 - 5 years
ELF Reading in Children years

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

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

66 Reading in preschool children
Buckley (1985) reported on Sarah who read at age 3 years. 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. Buckley also reported that Daniel used his reading to improve his expressive language skills. Talk and Total Communication

67 Talk and Total Communication
What is Known Home environment has a dramatic influence on literacy. Expectations by parents is important et al., 1991). Through reading, children w/ DS learn concepts that improve oral and written language (Buckley, 1995; Layton, 2000). 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
Read a familiar story several times. Pictures with accompanying words. Words without pictures...functional words. Simple stories with themes. Talk and Total Communication

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

Child chooses the book Remember to follow the child’s lead Expand child’s utterances Ask open ended questions or make inferences Talk about the print Encourage word identification Talk and Total Communication

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

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

75 Talk and Total Communication
Use holiday themes to compile lists, write letters, etc. Use pictures along with words. Use on computer to write to friend, relative, teacher. Compile a list of items wanted from grocery store. Let child select the items from list. 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 Talk and Total Communication
iPad apps 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! Talk and Total Communication

80 iPad apps Demonstration (Handout)

81 China

82 Talk and Total Communication
China USA Population 1,336,970 K 309,075 K SLPs 1K 140K Programs 3 postgraduate programs 1 undergraduate program 232 postgraduate programs 310 undergraduate programs Talk and Total Communication

83 Beijing NC Population 17,550K 9,491K SLPs 100 4,150

84 *Estimated number of individuals with Down
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

85 Talk and Total Communication

86 Talk and Total Communication

87 Talk and Total Communication

88 Talk and Total Communication
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 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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