Evidence Based Strategies for Children with Down Syndrome

Evidence Based Strategies for Children with Down Syndrome
Kathleen M. Feeley, PhD, BCBA Associate Professor Director Center for Community Inclusion C.W. Post Campus of Long Island University Phone:

Become Familiar with the Down Syndrome Behavioral Phenotype and Corresponding Interventions
Debra Fiddler – University of Colorado Emily Jones - CUNY– Queens College

Behavioral Phenotype Dykens (1995) defined behavioral phenotype as “…the heightened probability or likelihood that people with a given syndrome will exhibit certain behavioral and developmental sequela relative to those without the syndrome” (p. 523). This does not mean that all children with Down syndrome will demonstrate all of the characteristic behaviors; rather, there will be in an increased likelihood.

Down Syndrome Behavioral Phenotype
Pattern of Syndrome specific strengths and weaknesses that characterize the disorder Strengths Weaknesses Social Behaviors Some areas of Motor Development Visual-imitation Early Communication Skills Receptive Language Areas of Cognitive Development

Down syndrome Cognition: Motor
Weaknesses: auditory short term memory, spatial memory and visuo-constructive tasks, visual exploration in play Relative strengths: visuo-spatial processing especially visual motor integration and visual imitation Motor Weaknesses: early delays, hypotonia, hyperflexibility, delayed integration of reflexes, motor planning (praxis), precise limb and finger movements, gross motor tasks such as sit ups Relative strengths: running speed and agility, visual motor control Down syndrome as example

Language, speech, and communication:
Weaknesses: expressive language, comprehension of syntax, grammar, morphological and syntactical development, vocal imitation, early requesting, atypical vocalizations in first year of life Relative strengths: receptive vocabulary, overall amount of vocalization in infants, joint attention, use of gestures Social-emotional Weaknesses: overuse of social skills Relative strengths: overall area of strength, friendships, empathy Fidler, D. J. (2005). The emerging Down syndrome behavioral phenotype in early childhood: Implications for practice. Infants & Young Children, 18,

Wishart (1998) Findings from studies examining operant learning and object concept development: The growing use of avoidance strategies when faced with cognitive challenges The less-than-efficient use of existing problem solving skills The failure to consolidate newly-acquired skills into the repertoire An increasing reluctance to take the initiative in learning.

Fidler, Most, and Philofsky (2008) contrasted the field of Down syndrome intervention with that of autism intervention: They described how autism researchers have methodically identified core deficits of the disorder, the extent to which these deficits predict outcomes, and, as a result, this research has guided early intervention with respect to target skills, the timing of intervention, and the degree to which interventions need to be specialized for children with this developmental disability. Fidler et al. stated emphatically that this type of science is readily adapted for and very much needed in the field of Down syndrome research.

The NYS Department of Health Report of the Recommendations: Down Syndrome
The NYS DOH report specifically states: “It is recommended that cognitive skills be taught using principles of learning theory” (p. 121). An overview of basic principles of learning theory can be found on page 122. - “It is recommended that individualized one-on-one intervention with the child and parent be done by someone who is experienced using the principles of learning theory with infants” (p. 123).

The NYS DOH Report of the Recommendations: Down Syndrome
Specifically states: “It is recommended principles of learning theory be applied to interventions… “… for communication development” (p. 126) “…for motor development” (p. 132) “…for development of social skills” (p. 138) “…teaching adaptive/self-help skills” (p. 140)

Specifically states on pages 144 and 145: “It is recommended that intervention approaches for young children with Down syndrome include aspects of behavioral techniques. Important concepts include: Individualizing the strategies to the child (there is no single approach that is appropriate for all children) Use of reinforcing stimuli that are appropriate to the individual child Use of consistent reinforcing stimuli (i.e., continuous mass-trial learning to facilitate learning a new skill”

Specifically states on pages 145: “It is important to remember, children with Down syndrome may require multiple trials to learn most tasks.” “It is recommended that complex skills and tasks be introduced sequentially by breaking them down into component parts that are easier to learn (i.e., teaching new tasks step – by step)”. “It is recommended that parents be educated in the use of reinforcement strategies to facilitate development of cognitive, social, linguistic, educational, and self-help skills.” p. 145

“Typical” Preschool Placements
Special Education Preschool Entirely separate school Self contained classes only (all children in the class have disabilities) Preschool with a variety of class placements Integrated class (some of the children have disabilities and some are typical) Self contained class (all children in the class have disabilities)

“Typical” Program Self contained class with related services delivered in a multidisciplinary manner Occupational therapy Speech therapy Physical therapy The majority of instruction is delivered to children within a group (the size corresponding to the class size) Related services are provided in a pull out fashion (the child is removed from the classroom for 1:1 therapy) and/or within a “push in” model (the therapist works with the child in the classroom in the presence of the other students).

“Typical” Program Classroom activities reflect a typical preschool classroom Circle time Story time Learning centers Curriculum varies across preschool programs

Preschool Since the 1970s, researchers have demonstrated the facilitative effects of educating preschoolers with disabilities alongside their typical peers. The trend in Nassau County (as well as in NYC) is to place children with Down syndrome in classes with typical peers only if they are functioning within or close to the normal range of intelligence. This is in direct conflict with IDEA and best practices, yet, it has become the norm in this region.

A Different Approach to Educating Children with Down Syndrome
Interventions are implemented that target core deficits in young children with Down syndrome Children with Down syndrome attend typical preschool setting and receive intensive behavioral interventions (interventions adhering to learning theory) in the form of Discrete trial instruction Activity based instruction Naturalistic teaching strategies

Another Model for Providing Early Intervention Services
Transdisciplinary approach to intervention Therapists share their strategies and tips with other team members so that the child receives the intervention several times per day/week rather than just when that specific therapist is with the child. “The trandisciplinary team is characterized by the commitment of its members to teach, learn, and work together to implement coordinated services” King, et al., 2009,p. 211) Article can be found at:

The “Placement” Community Preschool with supports
½ day special preschool with ½ day community placement ½ day community preschool with related services at home Full day community preschool with related services at the community preschool

Transition to Elementary School
Segregated preschool settings lead to segregated elementary school placements. Alternatively, a typical preschool placement, leaves parents in the position to advocate for a typical kindergarten placement.

A 5 year old – Preschool or Elementary
A 5 year old – Preschool or Elementary??? In NY state a parent may enroll their child in kindergarten at age 5 or 6 A child with a developmental disability beginning kindergarten at age 6 is often at an advantage because: it enables the child with a developmental disability to acquire one more year of development child can perform in an educational setting where the goals are closer to their instructional needs.

Potential Options Attend community preschool The child may be enrolled in a community preschool rather than a kindergarten class. Services may be provided in that setting, at home, or within the school district. The family is expected to pay the community preschool tuition. Attend district preschool Kindergarten year, the child may be enrolled in the district preschool rather than a kindergarten class. Services are then provided in that setting.

Attend half-day kindergarten and half-day community preschool
In some instances, children with developmental disabilities have spent part of their day in a kindergarten class, where they receive related services and the other part of their day in a community preschool with support (again with tuition paid by the family) or within the district’s preschool class. Destiny did this in district – ½ day preschool in the district and ½ day kindergarten general ed.

½ day kindergarten and ½ day community preschool
In some instances, the 1/2 day kindergarten class was a self contained class, allowing for many opportunities for intensive instruction and related services. Unfortunately, in these instances, there was a change in “philosophy” when it came time to transition to a general education kindergarten the following year (enabling the child to start kindergarten at age 6), resulting further advocating for an inclusive kindergarten placement. When choosing this option, be prepared for a potential change of viewpoints. This was Matt Hoffmans and Owen’s program – but both districts said no to going to general ed. placement

Important Aspects of Preschool Programming
Positioning Preventing challenging behavior Make communication a priority Systematic instruction that prepares the child for kindergarten Working with district personnel for a smooth transition

Positioning

Challenging Behavior

An understanding of how behaviors are learned
Certain events occasion certain behaviors How those behaviors are consequated will impact their future likelihood If a challenging behavior is followed by a pleasurable event (something good is delivered or something non preferred is taken away), the behavior is likely to continue to occur

Preventing Challenging behaviors from Entering the Repertoire of Young Children
Provide caregivers with information regarding identifying and intervening upon potentially challenging behaviors Challenging behaviors do serve a function Their responses affect behaviors Intervention should be implemented in a timely manner Effective speech/language strategies should be utilized

Evidence Based Strategies
Over the past several decades, our knowledge has grown exponentially in relation to assessment, prevention, and amelioration of challenging behaviors in individuals with developmental disabilities. Functional Assessment Process Positive Behavior Support Plan

Functional Assessment Process (O’Neill et al., 1997 )
Interview What is the behavior of concern? What environmental/medical factors may contribute to the behavior? When/where/with whom/within what activities does it happen most/least? Direct Observation View student in his/her natural environment and recording what is observed Environmental Manipulations (Functional Analysis) Systematic manipulation of controlling variables to demonstrate the function of the behavior

Preventing Challenging Behavior
Consider the function that challenging behavior serves Be proactive Have a plan in place if challenging behavior does occur Consider a four component treatment Setting event strategies Antecedent strategies Skill building Consequence

Positive Behavior Support Plan
Strategies to Address Setting Events Antecedent Strategies Skill Building Strategies Consequence Strategies

I did it!!

Communication Gestural Verbal Graphic

AAC High Tech. Low Tech.

When Child has Skill Cue to Respond Discriminative stimulus (Sd) Skill
Behavior Response Consequence Reinforcement Reward Cue to Respond Child sees toy Skill Says “Want toy” Consequence Child given toy

An Instructional Opportunity
Cue to Respond Child sees toy PROMPT Parent says “Say ‘want toy’” Skill Says “Want toy” Consequence Child given toy

Instructional Prompts
Can be directed toward the child (response prompts) Verbal Say “Hi” Gestural Point to direct child’s attention to a communication partner (peer) Physical Physically help child form sign for “cookie”

Instructional Prompts (continued)
Can be a manipulation of something in the environment (stimulus prompts) Print A card with “help me” is placed where child can see it and read when she/he needs assistance. Pictures Picture of food items placed on refrigerator door is a cue to the child that they should ask for the item

Contexts for Instruction
4/20/2017 Contexts for Instruction Naturalistic Teaching Instruction Embedded within an Activity Discrete Trial Teaching Number of Teaching Opportunities Extent of Teacher Directedness Generalized Responding Natural Contingencies 44

Naturalistic Teaching
4/20/2017 Naturalistic Teaching During ongoing interactions, situations arise that occasion the target skill Use the event as a teaching opportunity Preferred/motivating materials are placed in the environment Learner-directed Naturally-occurring reinforcers are delivered, however, additional reinforcers can be added May achieve more generalization than direct teaching (but fewer opportunities) 45

Naturalistic Teaching
4/20/2017 Naturalistic Teaching Incidental teaching is used to get elaborated language by waiting for another person to initiate conversation about a topic and then responding in ways that ask for more language from that person” (Hart & Risley, 1982) Milieu teaching: “a naturalistic, conversation-based teaching procedure in which the child’s interest in the environment is used as a basis for eliciting elaborated child communicative responses” Kaiser (1993) Pivotal Response Training: a comprehensive, naturalistic, and child-directed treatment for children with autism that is based on the principles of ABA (Koegel & Koegel, 2006). Incidental teaching, the mand-model procedure, and the time-delay technique have been combined with other strategies to elicit language in the natural environment (Hart & Rogers-Warren, 1978; Alpert & Kaiser, 1992). focus on five core (i.e., pivotal) areas including: motivation, responsivity to multiple cues, self-management, self-initiations, and empathy. Several demonstrations of the effectiveness of this approach (e.g.., Koegel, Carter, & Koegel, 2003; Koegel & Frea, 1993). 46

Promoting Initiations:
4/20/2017 Promoting Initiations: Control access to materials Play games/toys that are of special interest Set up repetitive play situations Withhold materials needed to pursue activities Display photographs of preferred activities Begin favorite activity, then stop Look at materials, then look expectantly at child 47

Instruction Embedded within an Activity
4/20/2017 Instruction Embedded within an Activity Use a structured activity (e.g., board game, blocks, farm house, “Simon Says”) Specific goals are systematically addressed within the target activity Teacher directs the activity so multiple opportunities may be provided (across the activity) Activity-related materials in addition to verbal reinforcement are delivered for engagement in the target skill Activity-Based Intervention (Bricker, 1998) Joint-Action Routines (Snyder-McLean, Solomonson, McLean, & Sack, 1984) Embedded instruction (Johnson & McDonnell, 2004; Wolery, Anthony, Caldwell, Snyder, & Morgante, 2002) 49

Instruction Embedded within an Activity
Instruction occurs within activities available in the natural environment Instructional opportunities include: those that are learner directed and/or those that are interventionist directed. Teaching opportunities can be: Numerous and closely spaced Few and distributed across the activity

Instruction Embedded within an Activity (continued)
Can use consequences that are: available within the ongoing activity Child asks for doll and is given doll Child comments on car and is given car those added to the activity to enhance responding Child is asked to say “doll” and is given a high five Child is asked “What color is the car?” and is verbally praised “Great job!” Allows for several skills to be addressed within the same activity

Give it a try…

“Simon” electronic game
4/20/2017 “Simon” electronic game Program Target Set up Expressive Communication Indicates his turn using full sentence Hold onto game and look expectantly at Jason Short term memory Remembers up to three color sequence Game is set up. Identifying colors Identifies the red, blue, and green Point to a panel and say “Jason, what color is this?” Identifying numbers Identifies the number corresponding to his score (1, 2, 3) Have number cards on table out of order, say “Jason, you scored a 3, where is the 3?” 55

Discrete Trial Training
4/20/2017 Discrete Trial Training Usually presented in a 1:1 format with the teacher having tight control over the teaching situation. Many trials in rapid succession and lots of repetition. Effective even for those with severe learning problems, has a clearly discriminable beginning and end, is clear and simple, and utilizes specific prompts, consequences (e.g.., primary and/or secondary reinforcers), and criteria Increases attention to task Helps in teaching subcomponents of a behavior 57

Components of every instructional opportunity
4/20/2017 Components of every instructional opportunity Pre-attending Discriminative Stimulus (SD) Prompt Response Consequence Inter-trial Interval 58

Prompting 4/20/2017 Stimuli that increases the likelihood for a correct response. Should be delivered simultaneously, or immediately following the SD, before the student has an opportunity to respond, especially before responding incorrectly. Facilitates the acquisition of a new behavior by reducing the number of errors that the student makes. 59

4/20/2017 Consequence A stimulus presented after the student’s response to change the frequency of that response (i.e., increase or decrease the frequency of that response) Be sure to provide an adequate period of time for the response to occur before delivering the consequence. 60

Consequences 4/20/2017 Verbal prompts can be very intrusive and difficulty to fade In developing prompting procedures: Choose a type of prompt: Physical, gestural, verbal Choose a prompt level: Full, partial, (independent) Correct Response Immediately reinforce the response Can be specific to the response when appropriate (e.g., “Great! That’s the letter ‘A’”) When using primary reinforcers (e.g., food), pair with secondary reinforcement (e.g., praise) Incorrect Response Utilize a correction procedure (specific to each goal) May consist of ignoring/turning away then re-presenting the SD with an immediate prompt 61

Skill Area : Speech/Language
4/20/2017 Skill Area : Speech/Language GOAL DISCRETE TRIALS ABI NATURALISTIC TEACHING Will articulate the “g” sound Run multiple opportunities to learn the “g” sound Will initiate interaction with peers Playing in dress up corner Will request help Throughout the day, will be taught to request “help” 64

Skill Area: Gross Motor
4/20/2017 Skill Area: Gross Motor GOAL DISCRETE TRIALS ABI NATURALISTIC TEACHING Will stop soccer ball Run multiple opportunities to learn this skill Will stand on “tip toes” During “Simon says” Will go from sit to stand pushing up on knee Throughout the day, as child transitions from sit to stand 65

List of Preschool Vocabulary
Name: Sam Program: Preschool Vocabulary Skills Intro Date Mastery Date Maintenance Lunch box Back pack Paint brush

Identifying Communicative Targets
Have caregivers identify targets that would be appropriate for the child. Once they are identified, use verbal imitation procedures to teach the child to articulate the word correctly Once the child is correctly articulating the word, begin to introduce instruction within the context of the stimuli.

List of Social Questions
Name: Jason Program: Answering social questions Skills Intro Date Mastery Date Maintenance 3/ / /17 What’s your name? 3/12 3/17 + Where do you live? 3/20 3/30 What’s your mom’s name? 4/1 4/15 What’s your phone #?

Nonverbal SDs Responses
Person sneezes “Bless you” Person makes a sad face “What’s wrong?” Person expresses hurt “Are you okay?” Person expresses concern & says “Uh-oh!” “What happened?” Person falls down Person drops something “Whoops!” Person talks really loudly “Be quiet” or “Shhh” with finger over lips Person whispers to child “What?” Person knocks on door “Who is it?” or “come in” Person opens a stinky bag “Peeuu!” with fingers over nose Person sticks tongue out “Stop it” Person sniffles “Want a tissue?” Person looks for something on bag/shelf “What are you looking for?” Person blocks the child’s path “Move” or Excuse me” Person does something goofy “That’s silly or “You’re so silly!” Person waves to child “Hi _____” Person gestures come here (e.g., with hand or index finger) “Coming” Person makes or plays weird noise on a tape player “What’s that noise?”

Teaching Spontaneous Language
Set up the situation so that the non-verbal stimuli can be repeatedly presented Deliver the nonverbal stimuli Knock on the door Sneeze Drop something Immediately prompt the response Say “say ‘who is it?’” Say “say ‘Bless you’” Say “say “uh,oh’” Deliver reinforcement Over teaching opportunities, begin to insert a “wait period” (time delay) before delivering the prompt

Teaching sight words Take photographs of the child’s favorite things/people On separate cards write the word Ball ball

During initial phases of intervention, place the photo in front of the child.
Hand the child the word card and say this is “ball” put with “ball” In early stages, saying the word “ball” functions as a prompt – you can also prompt the correct response by touching the photo (then deliver reinforcement) Place two photos (the target and a distractor) and deliver the word card for the target saying “What’s this?” or “Where does this go?”

You can teach two different words in isolation and then begin to present them together, giving the child one written word at a time to match. As you teach more words, expand the array.

I U Hi Visual Cues Visual Cues
Remind child to say something, what to say Cue cards = contain a message in picture or written form Replace verbal prompts, so child functions more independently I U Hi

Using Textual Prompts Once you have established some sight words, you can start to use them as textual prompts. Provide an opportunity for the child to emit the target utterance Point to the message When the child reads the message deliver reinforcement Start to fade the textual prompt

Transitioning to Kindergarten

General Education Class Placement Intensive Instruction Delivered in Self Contained Class
Primary placement a general education classroom Supported by a teaching assistant Goes to self contained classroom for part of the day for intensive instruction Overseen by special education teacher

General Education Class with Resource Room
General education placement Resource room services where intensive instruction is delivered. Amount dependent on child’s needs Two 1 hour sessions Two 45 minute sessions One 1 hour session Related services on a consult delivered while in the resource room 1:1 teaching assistant or shared assistant Owen’s program now.

Collaborative Class Placement
Collaborative class placement (where more than one child has a disability) Classroom staff may consist of: 1 general education teacher 1 special education teacher Present either a full or ½ day 1 teaching assistant 1 classroom aide In some, but not all cases a 1:1 teaching assistant East Rockaway serves Sarah Keady this way – no 1:1 – but an assistant, an aide in all day and a special ed. Teacher there ½ day – but only ½ the number of kids that would typically be in a integrated class (or collaborative teaching class). Works really well – with no 1:1. Matt has this placement with a 1:1 – as does a little girl in Glen Cover (angelina – kindergarten)

Collaborative Class Placement
The special education teacher in the classroom oversees programming Advantages Allows for constant collaboration between general and special educators. Disadvantages Some districts have integrated classes in some but not all of their elementary schools. Thus, once the student has that placement, they can be transferred to an elementary school other than their home school.

Work on a Model of Strengths
Identify the student’s strengths to determine instructional and non-instructional sessions from which they benefit Morning prep -Recess Morning meeting -Lunch Snack -Computer Art -Music Physical Education -Math Science -Social Studies Health

A Model of Strengths Enables the student to remain a part of the general class community for longer periods than a traditional “mainstreaming” model. It provides the student with a disability access to general education curriculum within several areas. It enables team members to focus on a limited number of content areas in which to implement curriculum accommodations

Evidence Based Strategies for Children with Down Syndrome

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