Increasing Expressive Language in Children with Down Syndrome Erica Silvestri, B.S. & Abbie Olszewski, Ph.D., CCC-SLP
University of Nevada, Reno
External Evidence: Evidence suggested that both naturalistic therapy (Kaiser & Roberts, 2012; Warren et al., 2008) and the use of alternative and augmentative communication (Foreman & Crews, 1998; Millar, Light, & Schlosser, 2006) improved expressive language in children with Down syndrome. Internal Evidence to Client Preferences: The family would like to see Jack’s expressive language improve so he can communicate with his family and peers. They want Jack to have social relationships with other children with and without disabilities. His family prefers naturalist therapy because it will allow him to be exposed to language in natural occurring social interactions. E3BP Decision: Based on external evidence and internal evidence to the family and client, a naturalistic approach was decided to help improve Jack’s expressive language. To determine if this approach is successful, Jack’s grammar such as noun-verb agreement and the use of irregular nouns and plurals will be evaluated three months after implementation of this therapy approach.
• Down syndrome is the most common genetic disorder that causes both structural and functional abnormalities (Abbeduto, Conners, & Warren, 2007). Children with Down syndrome exhibit language impairments, which can impact their ability to communicate. • SLP’s work with children with Down syndrome to improve their communicative abilities using different therapy approaches. One approach is naturalistic therapy, which provides learning opportunities by setting up situations through an interactive processes (Vilaseca & Del Rio, 2004). Specific naturalistic therapy models include Milieu Teaching and Responsivity Education. • Another approach to improve communication is augmentative and alternative communication (AAC), which is a communication system that benefits individuals with disabilities who have significant speech and language impairments that affects their ability to communicate effectively (Millar, Light, & Schlosser, 2008). Specific types of AAC include PECs, Makaton, and COMPIC. • It is unclear if naturalistic therapy compared to AAC approaches would result in better communication skills for early elementary children with Down syndrome.
Using the PICO (Purpose, Intervention, Comparison, Outcome) format, the following question was asked (Gillam & Gillam, 2008):
Does implementing naturalistic language therapy (I) result in increased expressive language (O) compared to augmentative and alternative communication (C) in children with Down
syndrome (P)?
• Jack is a 6;7 year old boy with Down syndrome. He has a limited expressive vocabulary as well as deficits with syntax and morphology. These impaired areas of language affect his ability to effectively communicate with others in conversation as well as express his wants and needs. • Erica is a first year graduate student who sees Jack twice a week for 60 minutes therapy sessions. Currently, a structured language approach is being used to teach Jack noun-verb agreement, irregular nouns, and irregular plurals. Jack has not responded to this treatment well as his results are very inconsistent. In addition, there is not any carryover from therapy to conversation. • Because he has not demonstrated improvements with this approach, Erica is wondering if naturalistic therapy or AAC would improve Jack’s expressive language.
References
Methodology
Abbeduto, L., Warren, S. F., & Conners, F. A. (2007). Language development in Down syndrome: From the prelinguistic period to the acquisition of literacy. Mental Retardation & Developmental Disabilities Research Reviews, 13(3), 247-261. doi:10.1002/mrdd.20158 Dollaghan, C. (2007). The handbook for evidence-based practice in communication disorders. Baltimore, MD: Paul H. Brookes Publishing Co. Foreman, P., & Crews, G. (1998). Using augmentative communication with infants and young children with Down syndrome. Down Syndrome Research And Practice, 5(1), 16-25. doi:10.3104/reports.71 Gillam, S. L. & Gillam, R. B. 2006. Teaching graduate students to make evidence-based intervention decisions: Application of seven-step process within an authentic learning context. Topics in Language Disorders, 28(3), 212-228. doi:10.1097/01.TLD.0000333597.45715.57 Kaiser, A. P., & Roberts, M. Y. (2013). Parent-implemented enhanced milieu teaching with preschool children who have intellectual disabilities. Journal of Speech, Language, and Hearing Research, 56(1), 295-309. doi:10.1044/1092-4388(2012/11-0231) Millar, D. C., Light, J. C., & Schlosser, R. W. (2006). The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A research review. Journal of Speech, Language, and Hearing Research, 49(2), 248-264. doi10.1044/1092-4388(2006/021) Vilaseca, R., & Del Rio, M. (2004). Language acquisition by children with Down syndrome: a naturalistic approach to assisting language acquisition. Child Language Teaching And Therapy, 20(20), 163-180. doi:10.1191/0265659004ct269oa Warren, S. F., Fey, M. E., Finestack, L. H., Brady, N. C., Brendin-Oha, S. L., & Fleming, L. K. (2008). A randomized trial of longitudinal effects of low-intensity responsivity education/prelinguistic milieu teaching. Journal of Speech, Language, and Hearing Research, 51(2), 451-470. doi:10. 1044/ 1092-4388(2008/033)
Search terms: down syndrome, down syndrome language, down syndrome therapy, aac, augmentative and alternative communication, augmentative and alternative communication down syndrome Databases: PubMed, Sage Premier, Gale, and Google Scholar Appraisal: Seven articles were appraised for internal validity using modified CATE and CASM forms (Dolloghan, 2007) and a binary system. Articles earned the following ratings:
CATE: 11 - 10 compelling, 9 - 7 suggestive, < 6 equivocal CASM: 6 - 5 compelling, 4 - 2 suggestive, < 1 equivocal
Four articles were selected based on their relevance to the purpose of this study. Inter-rater reliability for each of the seven articles was at least 87%.
Author, Design, Appraisal Service Delivery Model Par9cipants Diagnosis & Age
Dependent Variable Results
Warren et al. (2008)
Randomized Control Trial
CATE: Compelling
Naturalis9c Therapy: • Responsivity EducaCon • PrelinguisCc Milieu Teaching
N = 51 • Developmental delay & Down syndrome • Age: 24-‐33 months
Expressive Language measured by: • IntenConal communicaCon • Lexical Density • MCDI Spoken or Signed Words
Inten9onal Communica9on Acts: •Time x Treatment x Group, p = .51 • Time, p = .04 Growth rates were not related to children’s parCcipaCon in RE/PMT Lexical Density: • Time x Treatment, p = .80 • Time, p = .001 Time had an effect on lexical density with control over Bayley scores MCDI Spoken or signed words: • Time x Treatment, p = .72 • Time, p = .014 Time had an effect on MCDI spoken or signed with control over Bayley scores
Foreman & Crews (1998)
Experimental
CATE: SuggesCve
AAC: • Symbol using COMPIC • Sign using Makaton • MulCmodal (verbal + sign + symbol)
N = 29 • Down syndrome • Age: 2 -‐ 4 years
Expressive Language Expressive Language • Sign > symbol [F(1,18) = 8.362, p = .01] • MulCmodal > symbol • MulCmodal> Sign [F(1,18) = .607, p = .446)
Kaiser & Roberts (2013)
Experimental
CATE: SuggesCve
Naturalis9c Therapy: • Enhanced Milieu Teaching • Therapist vs. Therapist + Parent
N = 77 • Intellectual disability
Expressive language measured by: • MLU • NDW
MLU and NDW • EMT Therapy improved from pre to post 3 for MLU and NDW • No significant differences between parent and parent + therapist intervenCon for MLU and NDW MLU • Therapist: d = 0.62 • Parent + Therapist: d = 1.6 NDW • Therapist: d = 1.26 • Parent + Therapist: d = 1.00
Millar, Light & Schlosser (2006)
SystemaCc Review
CASM: Compelling
AAC
N = 23 • Developmental disability • Age: 2 – 60 years Best evidence review resulted in synthesis of 6 experimental studies
Expressive Language measured by: • Speech producCon
Speech Produc9on • Unaided manual signs and aided with no speech output AAC intervenCons increased speech producCon. • Speech producCon improved in children and adults ranging in age from 2 – 60 years.
Discussion
PICO Question
Case Scenario
Introduction Results