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Article 2. Using Multiple Modalities to Address Communication Needs

To enhance the communication skills of individuals with Down syndrome (DS), all interviewed seemed to agree that:

• a multi-modality/total communication approach is beneficial;

• continued attention to the development of intelligible/functional speech should be an ongoing part of this intervention;

• early and ongoing communication intervention is important.

Strategies briefly described do not represent a comprehensive review. They are, however, being used by master clinicians and illustrate a variety of approaches.

Speech

Speech intelligibility problems in persons with DS persist into adulthood. Yet, sometimes speech training is lost in the shuffle when sign language, communication boards, computers and augmentative devices are being introduced. In England, a survey of the families of 90 adolescent children with Down syndrome revealed that although only 3 had no speech by age eleven, most used short, simple sentences and had limited vocabularies. Between 55% and 90% of these teen-agers had trouble making themselves understood by strangers; however, most (80%) were understood at home and school.¹⁷

A three-stage remediation sequence to improve speech intelligibility was proposed by Swift and Rosin.⁹ Theoretically consistent with the hypothesis of sequential processing deficits in persons with DS, it also accounts for auditory acuity and oral motor problems. Goals and strategies of the stages are:

I. Prelinguistic

Goal: To maximize opportunities for cognitive/linguistic and motor stimulation and minimize future difficulties.

Strategies/tools: Hearing aids, signing, oral motor work, and parent training.

II. Early linguistic

Goal: To encourage the production of single words and early word combinations.

Intervention strategies/tools: Structured sound play, drill, scripts and carrier phrases, augmentative communication systems (sign, photographs, pictures, graphic representations), oral motor work and computers. Medical interventions such as tongue surgery and palatal lifts also are discussed.

Note: Parsons, Iacono, and Rozner¹⁸ demonstrated no differences in intelligibility between a group of 9 children who had tongue reduction surgeries and 9 who did not. They concluded that reduced tongue mass does not improve the underlying difficulty of producing sequenced movements that interferes with intelligibility.

III. Late linguistic

Goal: To encourage use of basic syntax and beyond.

Intervention strategies/tools: Drill, scripts, repair strategies and graphic symbols.

Marriner¹⁹ describes an approach to speech intervention based on Pamela Marshalla's, motoric model of phonologic development and studies of babbling development.²⁰ This model provides a frame of reference and allows clinicians to analyze phonology on the basis of motoric skill components. Initially, the clinician determines a person's ability to produce and sequence phonemes. Many children with DS have very limited speech motor abilities and are unable to sequence phonemes or produce final consonant sounds. Strategies include establishing mutual imitation, with the child in control so as to build confidence in making sounds. The proposed hierarchy that follows includes prolonging vowels and adding some prosody, repeating vowels and gradually moving to consonant vowel (CV) and CVCV combinations, and then gradually increasing the phonologic and motoric complexity.

Manual Signs and Gestures

Several master clinicians commented on the creative use of natural gestures demonstrated by many individuals with DS. Gestures and pantomime should not be overlooked. ²¹

Approaches to teaching sign language often mirror other language learning methods. A major concern, however, is most "teachers" (parents, speech-language pathologists, educators) are not fluent users of sign. In the United Kingdom and Australia, the Makaton vocabulary, developed by Mrs. Margaret Walker, a speech therapist, is taught. Based on natural gestures and used to emphasize key words/concepts in a sentence when talking to children, "experience suggests this approach particularly helps the children with Down Syndrome"¹⁷ (p.27). Initially parents are taught signs for a few words of significance (no more than 20). They are then asked to use them as naturally as possible as an accompaniment to their normal speech. They are told not to "make a thing about it." The child is given time to begin to understand what signs mean and is not expected to use signs early on.

Iacono¹⁰ addresses a concern that few children with DS use a variety of semantic combinations, i.e., the transition from single words to two-word phrases is limited. In a case study of two young children, one child had DS, she demonstrated that specific teaching using speech and signs in one condition and speech, signs and an electronic communication aid in another condition resulted in an increase in the number of spontaneous productions of targeted 2-word combinations. Differences were noted in the effectiveness of the two conditions and tendencies to use signs versus a communication aid.

Communication Boards, Books, Devices

Individuals with DS use communication books successfully in the community, school and in residential settings. However, teaching methods, symbol configuration, use of speech output/written output, and many other related questions await more careful study. We need to know with whom, for what tasks, and under what circumstances over a person's lifetime, graphic symbols and AC aids would be beneficial. Rotholtz¹⁶ described successful use of communication books and Hunt, Alwell, and Goetz²² reported on the use of conversation books.

Marriner¹⁹ suggests setting up communication books as follows:

1. Use a small notebook (8 1/2 x 5 1/2).

2. To facilitate page turning, use round door cushions or foam available in many hardware stores.

3. To protect the pages use small, clear tab holders.

4. To create and arrange the symbols, consider using Board maker software or MJ stickers.²³

Reading

Some children with DS learn to read before they speak. Others have "reading ages" better than their "mental ages" would predict. Thus, it is important to consider literacy skills as part of communication training programs with this population and to capitalize on these strengths. Teaching reading to people with DS may require a different process because most children learning to read have already mastered their spoken language system. On the other hand, persons with DS and limited language skills may have good visual memories and acquire sight word vocabularies that can be quite large (one 5 year old learned to read 600 words). For them, reading may even facilitate mastery of new vocabulary, grammar and sentence structures. Even limited sight-reading capabilities can be useful for functional reasons and can foster independence in the community.

The Portsmouth Down Syndrome Project, which began in 1980, uses the following structured approach to literacy.¹⁷

• Teaching matching: Start with picture matching using 2 pictures of everyday objects. Add new pictures one at a time. Lotto games can be useful, but limit them to four pictures. Help the child learn to associate names with picture.

• Teaching selecting: Ask child to select between 2 pictures. Build up slowly, until he can choose any picture from among 8 pictures.

• Teaching naming: Even if the word is not spoken clearly, encourage imitation. Accept all utterances/answers supportively.

• Teaching reading: Use the same process and same vocabulary: matching, selecting and naming. This time use written words.

They suggest making the child a book, using family photos and writing names below each picture. After a child has a small sight vocabulary, they build words into 2-word phrases such as "Daddy gone, car gone, ball gone, Mummy sleep baby sleep, kick ball." Comprehension games include giving children little written requests to carry out and giving them pictures to match with words.

A more "whole language" approach is also useful. Read, read, read and write, write, write. Begin to draw a child's attention to pictures, letters, and words. In addressing writing skill development, clinicians suggest using activities that involve making words with plastic letters or letter stamps and using computers.

Although a total communication approach is recommended when facilitating the communication of persons with DS, it should be carefully planned and be balanced.²⁴

This article appears in ACN Volume 5, # 2.

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