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

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

2. 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 24-48 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. Growth Problems • Separate Growth Chart • Early growth delays • Eventual Increase in Weight for Height Talk and Total Communication

8. Musculoskeletal and Motor Disabilities • Atlantoaxial instability (15%) • Increasedmobility 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. Vision Problems • “Lazy Eye” (strabismus) • Cataracts • Spotted Iris • Nystagmus • Myopia (Near Sightedness) Talk and Total Communication

10. 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. 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. 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. 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. 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. 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 Disorderin Down Syndrome Talk and Total Communication

19. 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 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 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)

24. Addressing Challenging Behaviors in Children with Down syndrome

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

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

38. 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. 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. 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. We introduce signs: • At the same time we introduce words -usually around 6 - 8 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. 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. Bobby’s data • Oral training first two stages • Sign training stages 3 through 6 • Follow-up one year later Talk and Total Communication

47. 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.