Excerpted from chapter 1 of Improving the Communication of People with Down Syndrome, edited by Jon F. Miller, Ph.D., Mark Leddy, Ph.D., CCC-SLP, & Lewis A. Leavitt, M.D.

Copyright © 1999 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

This book provides a description of the speech, language, and communication abilities of people with Down syndrome; a review of asessments and interventions that have proved effective in promoting the development of communication skills; and a summary of long-term family outcomes. It focuses on individuals' specific abilities, the relationships among their specific cognitive and language skills, and how these abilities contribute to the communication development process from childhood to adulthood. The goal of this book is to bring together research of the 1990s with advances in intervention strategies that have been successful in optimizing the development of communication skills in children, adolescents, and adults with Down syndrome.

An entire book on language and communication of children with Down syndrome is necessary for several important reasons:

1. Down syndrome is the most frequent identifiable cause of mental retardation currently known.
   
   
2. Language and communication are key areas that constrain social and personal development of children with Down syndrome.
   
   
3. Research conducted in the 1990s requires revision and restructuring of previous advice on the management of speech and language problems of children with Down syndrome.

Among the important advances in the field of developmental disabilities in the 1990s is the recognition that specific biologically based causes of mental retardation have distinct profiles of cognitive and functioning as well as development. To serve children with Down syndrome and their families properly, we must be knowledgeable about their similarities with and differences from the performance and development of children who are developing typically.

What can be expected from a child with Down syndrome with regard to the development of communication skills? The answer to this question is complex and requires an appreciation of the cognitive, environmental, and anatomical and physiological contributions to communication development. Adults communicate without effort almost everything or anything that can be imagined or perceived. Children must develop their communication skills over the course of many years, coordinating their abilities to perceive and produce the sounds of the language spoken around them; recognizing words; combining sounds to produce words; and combining words into sentences and sentences into logical descriptions of experiences, stories, or other communication needs. The marvel of this process is that it happens so effortlessly in typical children and presents so many challenges to children with Down syndrome. These challenges become evident when one reviews the research literature and when one engages in conversation with individuals with Down syndrome. The speech intelligibility of individuals with Down syndrome limits the effectiveness of their messages. Their messages are limited in complexity either because of their recognition that their speech is difficult to understand or because their expressive language is limited. Their language comprehension is difficult to judge without further exploration. The language comprehension of individuals with Down syndrome is almost always better than their language production skills. Their language comprehension skills can be predicted by their nonverbal cognitive skills, which supports the notion that cognitive skills are necessary for language to develop but are sufficient in most individuals with Down syndrome because their language production is not as advanced as their language comprehension.

This book germinated with a research project aimed at describing the early language abilities of children with Down syndrome. The literature prior to 1987 had emphasized the impairments in speech and language skills of children with Down syndrome and offered few causal constructs to account for the particular difficulties that these children were having in acquiring effective and oral communication skills relative to their other cognitive abilities. The original questions that the research project sought to answer concerned their rate of acquisition of several skills simultaneously rather than focusing on a single aspect of language and communication independently. The review of the previous research undertaken in the project appeared to show a trend toward asynchronous development when individual features of language performances were reviewed. The development of vocabulary skills in children with Down syndrome seemed to be more advanced than that of their syntax or the grammar of their language. At the same time, children with Down syndrome were better able to understand language spoken to them than to produce spoken messages of equal complexity. These differences were evaluated in detail through a series of research projects involving several hundred children between 1987 and 1995. Our goal in this book is to share the improved understanding of how the extra copy of chromosome 21 affects the cognitive, speech, language, and communication skills of children with Down syndrome.

There is still a great deal that is not understood about human communication and the processes that underlie its development. This book is organized to provide a readable account of research on the communication skills of people with Down syndrome, with the goal being to inform readers of the ways in which specific anatomical and physiological differences associated with the syndrome explain or fail to explain the communication abilities of and opportunities available to those individuals. The discussion begins with an overview of human communication to remind readers of the nature of the human communication process and its component parts. The chapters of this book review language and communication development and provide insight into expectations and challenges that parents and their children with Down syndrome face on their road to achieving communicative competence.

Communication involves generating an idea or a thought that needs to be transmitted, initiating and receiving a message with a medium for transferring the message between the sender and the receiver, and understanding the meaning of the message:

Idea  >  Message initiation  >  Medium  >  Message reception  >  Understanding

Human beings are usually capable of both message initiation and message reception. The exceptions to this might involve people with perceptual impairments, hearing or vision impairments, or motor problems limiting their speech production or the use of their hands and arms. Communication is usually thought of as involving speaking and listening, and the medium is usually thought of as the air transferring the acoustic energy to the message recipient's eardrum for conversion to neurological energy routed to the brain for interpretation. The communication process can be hindered in many ways, such as by the speaker's failure to produce an intelligible message or by the listener's experiencing limited hearing acuity, language-processing impairments, or limited knowledge of the spoken language. Messages are then transferred by means other than speech, including writing, gestures, and symbols. These modes use alternative media to transmit the message, including print, visual images, and graphics. To receive these message types, the message recipient must have the faculty of vision and specific knowledge of the system (e.g., printed alphabet and written language, American Sign Language [ASL], Signing Exact English [SEE], specific graphic symbol systems). These detailed components result in a more complete communication model that specifies how a message is initiated, transferred, and received:

Idea  >  Message initiation  >  Medium  >  Message reception  >  Understanding

Speech  >  Sound  >  Hearing
Writing  >  Print  >  Reading
Gestures  >  Visual image  >  Vision
Symbols  >  Graphic  >  Vision

Speech is usually accompanied by gestures, facial expressions, and body posture that elaborate the spoken message and aid the recipient's message. Detailed study of speech communication reveals the rich complexity and paradoxes of human communication, including the ability to convey one message via speech and another by facial expression and body posture. Some experts (D. Yoder, personal communication, October 1985) have claimed that only about 30% of the content of face-to-face verbal messages is conveyed by verbal language; the remaining 70% is communicated by gestures, facial expressions, and body postures.

As the communication of people with Down syndrome is evaluated in this book, the conception of human communication must be expanded beyond speech to include reading and writing and the use of gestures and sign systems as well as graphic symbols. People use variations of each of these systems every day in their communication with adults and children. Each of these different modes of communication can complement the others when limitations in the sender, the receiver, or the medium reduce effective message delivery.

In this book, Murray-Branch and Gamradt, in Chapter 9, review the use of symbol systems for communication, specifically discussing the use of augmentative and alternative communication (AAC) systems that have proved beneficial to children with Down syndrome. Clearly, knowledge of how the world works is fundamental to the child's acquisition of a language with which to map that knowledge. Children who are typically developing acquire their language over a number of years, from childhood through adolescence seemingly without instruction. Instruction is delivered by parents and others who engage children in the communication process in a variety of subtle ways. A number of specific features of this communication interaction process are particularly important for fostering children's language and communication skills development. Parents who talk more to their children promote their children's rapid vocabulary learning. Parents who respond to their children's communication attempts promote more verbal initiations by their children. Parents who take their children on more outings enhance their children's development of more advanced language skills. All of these factors are products of environment and therefore can be modified. Language intervention programs focus on these features to promote children's more rapid language learning. In Chapter 6, Roach, Stevenson, Barratt, and Leavitt review these aspects of parents' communication with young children who have Down syndrome. They document how parents of children with Down syndrome cope effectively by modifying their interaction styles to meet the language and communication needs of their children. The specific challenges facing speakers with Down syndrome can be elucidated by examining the human communication process. The listening or comprehension side of the process has been documented as a strength of people with Down syndrome in spite of the fact that such individuals have more frequent middle-ear infections that continue through childhood and, for some, into adolescence and adulthood. Although there is an increase in mild to moderate hearing loss among these individuals, the impact of hearing loss on individuals with Down syndrome appears to be on their phonological speech processing and speech production rather than on their word- and sentence-level linguistic knowledge. These effects may have an impact on their reading-skills acquisition as well as on their intelligibility throughout their lives.

With regard to speech production, speech intelligibility impairments of people with Down syndrome result in listeners' failing to comprehend these individuals' messages. Many children who are striving to overcome limited speech intelligibility reduce their messages to a minimum, selecting one- or two-syllable words and using single-thought-unit utterances in their efforts to be understood. These adaptations are made by all communicators whose listeners evidence difficulty in processing their messages. Speakers with Down syndrome and their conversational partners have been observed to adapt rapidly to the speakers' abilities. Whereas speakers with limited speech intelligibility shorten their messages by selecting their most intelligible words, partners reduce their demands by asking direct questions that elicit short answers rather than risk having to process a lengthy explanation or description. These adaptations leave many individuals with Down syndrome with the appearance of having limited language production skills. The importance of alternative methods of message production for these individuals is obvious. The use of gestures, graphic symbols, or writing is helpful as an alternative to speech, particularly early in the child's development. The work of Buckley (1985, 1995a, 1995b, 1997) in England has demonstrated that children as young as ages 2 and 3 years can learn to sight-read a large number of words. These abilities suggest that children have visual information-processing strengths that can be used to support and improve their auditory processing systems. The language strengths in comprehension of oral language and reading of people with Down syndrome suggest that more attention should be directed at the phonological level to improve both reading abilities and speaking abilities. This strength may exist at all ages, regardless of language and speech development in people with Down syndrome.

Conclusions

This book provides an interdisciplinary focus on language and communication skills with contributions from professionals in speech-language pathology, social work, assistive technology, pediatrics, and developmental psychology. In addition to separate chapters by Miller (Chapter 2) and Chapman (Chapter 3) reviewing the language and communication progress of children and adolescents with Down syndrome, several chapters discuss the speech production challenges that these children face. If one were to name the biggest challenge to effective communication for people with Down syndrome, it would have to be speech intelligibility. Improved speech intelligibility improves social interactions, offers exposure to language, and induces more language practice. Leddy, in Chapter 4, reviews the physical ability of people with Down syndrome to produce speech and discusses, with Miller, speech intelligibility and fluency in Chapter 5. In Chapter 7, Miller, Leddy, and Leavitt describe speech, language, and communication assessment procedures. In addition, Rosin and Swift, in Chapter 8, present case studies describing specific methods by which to improve speech intelligibility and communication for those individuals who experience difficulty in producing speech; and Leddy and Gill, in Chapter 10, document improvements in communication in adulthood resulting from speech and language therapy.

The future holds promise for funding solutions to the most troubling challenges that people with Down syndrome face. Viewing the future in context provides people with Down syndrome and their families hope that solutions to their challenges will be found. The long-term family perspective is provided by Seltzer and Kraus's (Chapter 11) description of life-span issues that families of people with Down syndrome face. Their findings provide some optimism, and their chapter provides an uplifting view, for families with young children with Down syndrome. Finally, Miller, Leddy, and Leavitt (Chapter 12) offer suggestions for the future, including recommendations for integrating new approaches to assessment and intervention into school systems, health care services, and communities.

References

Buckley, S. (1985). Attaining basic educational skills. In D. Lane & B. Stratford (Eds.), Current approaches to Down syndrome (pp. 211-234). Eastbourne, England: Holt Saunders.

Buckley, S. (1995a). Improving the expressive language skills teenagers with Down syndrome. Down's Syndrome Research and Practice, 3, 110-115.

Buckley, S. (1995b). Teaching children with Down syndrome to read and write. In L. Nadel & D. Rosenthal (Eds.), Down syndrome: Living and learning in the community (pp. 158-169). New York: Wiley-Liss.

Buckley, S. (1997, April). Links between literacy, language, and memory development in children with Down syndrome. Paper presented at the 2nd International Conference on Language and Cognitive Development in Down Syndrome, Portsmouth, England.