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