Speech and Language Intervention for Children with Down Syndrome

1. Speech and Language Interventionfor Children with Down Syndrome Presentation by: Marinet Janse van Vuren Consultant Speech and Language Therapist

2. Early Intervention Research demonstrates the effects and benefits of early speech-language intervention for children with Down Syndrome (Spiker & Hopmann, 1997). Address each child�s individual areas of need through treatment. Individual! 120 features that are the hallmark of Down Syndrome: 6-7 per child. More differences than similarities: physical appearance, temperament, range of abilities. All: some degree of intellectual disability. Ignore generalisations � each child is a unique individual.

3. Early Intervention �We don�t provide speech and language therapy for children with Down Syndrome until they are two�, or �we don�t provide speech and language therapy until your child begins to talk.� - against federal law (USA). Speech and language therapy work needs to begin early. Many areas that can be worked on in therapy with young children with Down Syndrome before they begin to talk. Parent training programmes (e.g. the Hanen approach) effective but not sufficient on its own (Buckley, 2009). Needs to be accompanied by specific techniques to target oral motor skills, speech sound production and specific language skills.

4. Early InterventionOur Role Early Intervention is NOT to accelerate pace of development (Capone, 2004). Support development by teaching specific strategies that can be learned as neuromaturation proceeds. Monitor developmental function . Prevent maladaptive patterns and secondary handicaps from emerging. Educate parents. Provide home training programme. Facilitate onward referral if necessary. * this argues favourably for additional specialised training to become more cognizant of many dimensions of Down Syndrome (Capone, 2004).

5. Target specific areas Strengths and weaknesses (Pulsifer, 1996). Delays (esp. in early language-based & performance-based cognitive milestones ) are evident toward the end of the 1st year of life. Greater deficits in verbal-linguistic skills relative to visual-spatial skills. Asynchrony of language development: language production skills lag behind language comprehension skills. Factors impacting on verbal-linguistic skills: hearing loss, deficits in auditory memory (Chapman, 1997)

6. Language Precursors There are 3 precursors to language development: steps children need to acquire before they are able to speak. Precursors develop from birth . Critical period for acquiring these prerequisite skills that can be up to 6-7 years of age (Buckley, 2000). Not to say that children�s language skills seize to develop at 7 years of age. Research indicates that a person�s language skills can continue to develop and grow even in adulthood. Difference: skills naturally acquired versus taught through direct instruction. The language precursors are roughly divided into 3 skill areas: (i) cognition, (ii) social and communication development, and (iii) sound production.

7. Speech and Language Ideas(0-18 months) � Eye contact & being face-to-face (including Hanen-principles) Attention span & joint attention (incl. object permanence) Sounds & rhythm Early imitation (vocal & motor skills) Turn taking Sensory skills: Sensory play & bilateral hand tasks: shaving foam, sand & water play, finger painting. Heuristic basket & Exploratory play Baby massage Body Awareness Programmes, e.g. TAC PAC (www.tacpac.co.uk)

8. Speech and Language Ideas(0-18 months) Oral-facial massage Babbling facilitation Oral-sensory stimulation & Oral Play Social interaction Rhymes, songs and Music (Kids Express CDs available from www.sensationalkids.ie) Anticipation games and songs Reading books to your child (black and white �Baby Sees� series for young babies: www.picthallandgunzi.com or Usbourne touchy-feelie books from Tesco & Easons: That�s not my ...) Vocabulary development: Knock-knock box (functional objects � turn taking) Dressing up � functional body awareness. Farm animals (pictures, large and small animals, sound tape) Using our senses (eyes/ears/nose/mouth) Feeding Issues Eating, Drinking & Swallowing Equipment

9. Normsfor children with DS Babbles �dada� �mama� ? 7-18m (5-14m) Responds to familiar words ? 10-18m (5-14m) First words ? 13-36m (9-17m) Shows needs by gesture ? 12-30m (11-19m) Two-word phrases ? 18-60m (15-32m) Drinks from cup ? 12-23m (9-17m) Feeds self biscuit ? 5-14m (4-10m) J.D. MacDonald (2007)

10. EDS & Feeding Equipment Cup and straw drinking effective ways to develop oral-motor skills, help develop correct swallowing patterns and reduce tongue protrusion. When? 6 months greater control of head, motorically and cognitively prepared to be more active participants in the feeding process. Cup drinking can be introduced from as early as 7 months (a month after introduction of spoon feeds.). Oral-motor skills are still developing: mostly forward-backward tongue movements , difficult to cope with free flowing liquids. Thicken liquids slightly (to a syrup- or yop-thick consistency): flows slower & gives time to cope with the liquid, form a cohesive mass for improved control better.

11. EDS & Feeding Equipment Here are a few ways to naturally thicken liquids: Watered down apple sauce / puree. Watered down spoon feeds � make sure there are NO lumps and it has a smooth runny consistency. Mix a bit of liga into cooled boiling water. Add extra milk to baby rice to turn it into a runny consistency. Add baby custard to milk. Thickener (e.g. Nutilis or Thick & Easy, but only after consulting your GP)

12. EDS What Cups are good for Cup Drinking? Flexi cups or Kapi cups Nosey cups or glasses Doidy cups � Slanted (like the doidy cup) or have a nose cut-out. Encourage optimal drinking position - preventing children from tilting their heads back to drain the cup. The flexi cups: flexible plastic & squeezed into a spout, thus helping control the flow of the liquid. Attachments like handles can be ordered for the flexi or kapi cups. The doidy cups have handles to encourage independent drinking when your child is ready and able. From: O�Neill Healthcare Limited, or www.thinkingtoys.ie or www.sensationalkids.ie

13. EDS & Feeding Equipment NO! to sippy cups Children with low tone should not use spouted beakers. Poor jaw stability: learn to compensate by biting onto spouts or glasses during drinking. Doesn�t help develop a good swallowing pattern. Bite on the spout to stabilise the cup or put their tongue underneath the spout thus reverting back to an immature suckling pattern that can cause further tongue protrusion & can develop an incorrect swallowing pattern. Cause poor dental hygiene and dental cavities: Journal of Dentistry for Children, nearly two-thirds of toddlers with tooth decay problems used sippy cups.

14. EDS & Feeding Equipment Mr Juice Bear from www.thinkingtoys.ie Soft plastic, gently squeeze the bear�s belly to teach children straw drinking skills. Straw drinking: target lip strengthening, lip rounding and tongue retraction. Encourages a more mature drinking pattern. Special spill-proof lid. A word of caution: use only lips during straw drinking (no more than � inch into the mouth). Watch out for bite marks on the straw and tongue is not under straw. An alternative: Kids Smoothie cartons (e.g. Innocent Smoothies). Change the straw to slightly larger diameter.

15. ReducingTongue Protrusion NEVER: push tongue back inside the mouth!! From 4 months ... Oral-facial stimulation programme (practical) Intra-oral stimulation programme (practical) From 7-8 months ... The importance of Lateral Feeding for tongue lateralisation: melt-in-the-mouth (boudoir biscuits, liga, skips, meringue, buttons) & bite and stay firm (liquorice, dried fruit) From 2 years... Oral-Motor Programme (Mr Tongue and exercises of jaw, lips, tongue and soft palate). Remember your norms!

16. Best Practice Guidelines Best Practice Guidelines (Buckley & Le Prevost, 2002): Experts identify need to have separate targets for 4 components of SLT: (i) Communication (ii) Vocabulary (iii) Grammar (iv) Speech Work. Agreement on the use of sign systems to promote spoken language (benefits in receptive and expressive). Agreement on importance of using reading activities to teach spoken language for all ages. Benefits of using reading in preschool yrs as language teaching activity. Language is learned all day, every day ? parents.

17. Best Practice Guidelines Models of Service Delivery: 1st year of life: at home or ICU (from birth) � monthly basis. 2nd to 4th years: various models incl. group sessions. Group therapy from 18m � copy and learn from others. No family should receive less than monthly contact with SLT.

18. Best Practice Guidelines 1st Year Encourage good communication environment at home. Support feeding and OM development. Encourage all communication skills, eye-contact, turn-taking, pointing, joint referencing. Target auditory discrimination for speech sounds. Encourage use of gestures & sign.

19. Visual Supports When I see ... I understand When I hear, I forget In one ear, and out the next. But it makes more sense to me When there�s something I can see Whether I�m young, or if I�m old It helps to see what I am told A written word, a picture card Can simplify what might be hard. A visual aid describes it best And gives the voice and ears a rest From making friend to handling fear Showing me how makes it more clear There�s not much left to explain When a picture shows my brain Who or where or what you mean On a clear computer screen To recall what you heard A picture paints a thousand words. �(anonymous)

20. References Capone, G.T. (2004). Down Syndrome � Genetic Insights and Thoughts on Early Intervention. Infants and Young Children, Vol. 17, no. 1, pp. 45-58. Selikowitz, M. The Facts. Oxford University Press. Spiker, D. & Hopmann, M. (1997). The effectiveness of early intervention for children with Down Syndrome. (pp.271-305). Baltimore, MD: Paul H. Brookes. Chapman, R. (1997). Language development in children and adolescence with Down Syndrome. Mental Retardation and Developmental Disabilities Research Reviews, 3, 307-312. Reilly, C. (2009). www.downsyndromecentre.ie.

21. References The importance of Imitating your Child�s Sounds. J.D.MacDonald (2007). Down Syndrome News, Volume 30, No. 2, Spring 2007. National Down Syndrome Centre, Atlanta, Georgia. Kumin, L. Speech Intelligibility and Childhood Verbal Apraxia in Children with Ds. DS Research and Practice, 10(1), 10-22 (2006). Buckley, S & Le Prevost, P. (2002). Speech and Language Therapy for children with DS. Down Syndrome News and Update, 2(2), 70-76.