Enhancing Oral and Written Language for Adolescents and Young Adults with Down Syndrome

ABSTRACT

Oral and written language development for adolescents and young adults with Down syndrome (Ds) are particularly challenging. Yet, research supports a syndrome-specific profile highlighting strengths and particular areas of difficulty for this group of individuals. For example, adolescents and young adults with Ds tend to understand more than they produce. In terms of oral language development, the domains of semantics and pragmatics are relative strengths whereas morphosyntax is particularly difficult. Much less is known about written language development because most adolescents and young adults with Ds are at the emergent literacy or word identification (i.e., ability to recognize and name single words) stages; however, relative strengths emerge in the area of word identification. The purpose of this article is to explore the research findings on oral and written language strengths and weaknesses and intervention strategies and techniques that facilitate development in these two interrelated domains. In addition, a case study example is provided to further enhance the clinical skills of speechlanguage pathologists who work with this population. KEYWORDS: Down syndrome, adolescents, young adults, oral language, written language

Learning Outcomes: As a result of this activity, the reader will be able to (1) describe the syndrome-specific language components for adolescents and young adults with Down syndrome, (2) discuss pertinent areas that are related to oral and written language development and list potential implications, and (3) describe three potential therapy activities to target specific areas of oral and written language development for this population

1 Department of Audiology, Speech-Language Pathology, and Deaf Studies, Towson University, Towson, Maryland. Address for correspondence: Christina Yeager Pelatti, Ph.D., CCC-SLP, Department of Audiology, SpeechLanguage Pathology, and Deaf Studies, Towson University, 8000 York Road, Towson, MD 21252 (e-mail: [email protected]).

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Spotlight on Adolescent and Adult Language and Literacy; Guest Editor, Karen A. Fallon, Ph.D., CCC-SLP. Semin Speech Lang 2015;36:50–59. Copyright # 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. DOI: http://dx.doi.org/10.1055/s-0034-1396446. ISSN 0734-0478.

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Christina Yeager Pelatti, Ph.D., CCC-SLP1

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ith a prevalence of 1 in 691 live births, Down syndrome (Ds) is the most common genetic syndrome that impacts cognitive/intellectual development.1 In addition to multiple organ system anomalies, individuals with Ds demonstrate differences in behavioral characteristics, including oral and written language development, the focus of the present article. Despite the well-established supposition among researchers and clinicians of phenotypic- or syndrome-specific characteristics, considerable variability of traits exists among individuals with Ds.2 This article summarizes the known syndrome-specific features, beginning with related domains that have implications to oral and written language (e.g., hearing, memory) and concluding with a detailed discussion of research related to development and intervention. A case study example of an adolescent with Ds is provided, with an emphasis on highlighting intervention programs and strategies to ameliorate skills in these two interrelated domains. LANGUAGE-RELATED DOMAINS Although 80% of individuals with Ds demonstrate moderate intellectual delays, a broad range of cognitive abilities from nearly normal to severely delayed skills has been documented.3,4 However, a syndrome-specific cognitive profile of relative strengths and areas of difficulties emerges, with the domains of auditory short-term memory, specifically phonological memory, and theory of mind being particular areas of difficulty.2,5,6 Despite empirical evidence that suggests cognitive (e.g., phonological short-term memory) and linguistic (e.g., expressive language) development are related, the specific profile of an individual with Ds is likely to change over time.7 For example, although the domain of visual memory may be a relative strength, during adolescence and young adulthood, visual patterning outpaces visual short-term memory.8 Individuals with Ds also tend to exhibit specific personalityrelated traits, including difficulty with taskoriented persistence, avoidance of particularly challenging tasks with inappropriate social engagement, and a relative strength in sociability.9,10

In addition to cognitive features, most individuals with Ds have ongoing, lifelong concerns with hearing. For example, approximately two-thirds of toddlers with Ds have conductive and/or sensorineural hearing losses, resulting from recurrent bouts of otitis media, structural differences (e.g., narrow ear canals), and a weak immune system (e.g., respiratory illness).11,12 Chapman and Hesketh found that at least 60% of adolescents and young adults with Ds had a hearing loss in one or both ears,3 a finding with direct implications to oral and written language development. Given the structural (e.g., narrow palate) and functional (e.g., low muscle tone) anomalies of the oral motor cavity, in particular, speech intelligibility is also an area of concern and potentially impacts expressive language development.13 Although articulation and phonology are important areas of development with potential implications for academic success, an in-depth discussion of speech production and intervention will not be provided here. Although individuals with Ds demonstrate phonological errors that are similar to their typically developing peers, the inconsistency and frequency with which they are produced distinguish the groups.14 Here, phonology is discussed in the context of phonological awareness. ORAL LANGUAGE DEVELOPMENT OF ADOLESCENTS AND YOUNG ADULTS WITH DS Because of these underlying, related difficulties, language development is nearly always negatively impacted for individuals with Ds and is arguably one of the most compromised domains of functioning; it has direct links to academic achievement, independence, and societal contributions.2 As with cognition, a syndromespecific profile emerges for this group, yet a splintered, uneven pattern of language knowledge and skills occurs as an individual with Ds ages.2 In addition to general consistencies of characteristics across individuals with Ds as a group, strengths and areas of difficulty shift within an individual throughout the life span, a notion that highlights individual variability. In the following section, the specific components of the language domains of semantics,

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pragmatics, and morphosyntax are provided, highlighting the syndrome-specific profile with an eye toward intervention. Although all domains of oral language tend to be affected, variations emerge when individuals with Ds are matched with peers. In general, comprehension serves as a relative strength, compared with production, and when matched for nonverbal age. Vocabulary acquisition tends to be superior compared with syntax and morphology, as measured by mean length of utterance (MLU) in conversation and narratives.8,11,15–19 Finally, pragmatics tends to be a relative area of strength, yet some researchers argue that it is more impacted than originally described in the literature.2 Semantics, particularly comprehension, is an area of relative strength for adolescents and young adults with Ds. Empirical evidence supports the notion that vocabulary comprehension surpasses nonverbal cognition in adolescents and young adults with Ds.15 Concrete as opposed to abstract words tend to be easier to learn; vocabulary describing emotional states is particularly challenging for individuals with Ds.2,5 Expressively, delays tend to become more pronounced during the adolescent years although not all research results converge on this finding. For example, Kay-Raining Bird and colleagues did not find significant differences in the number of different words used during narrative production when matched on reading ability with typically developing peers.20 Notably, much remains unknown about the processes by which individuals with Ds learn new words (i.e., fast mapping).8,11 This underexplored area of research has direct implications for intervention; it is possible that adolescents and young adults with Ds learn word meanings differently than their peers. Syntax and morphology are particularly challenging oral language domains for adolescents and young adults with Ds. These weaknesses reflect syndrome-specific features because individuals with other neurodevelopmental diagnoses (e.g., fragile X syndrome) do not exhibit similar marked difficulties.2 For example, individuals with Ds demonstrate increased difficulty with grammatical function words and morphemes,18,21 and they produce few grammatical and lexical verbs.22 More

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specifically, individuals with Ds have difficulty with the following inflectional forms: past tense, third-person singular, present progressive, plurality, and possessives.23 Context plays a critical role; individuals with Ds tend to produce higher MLU in narratives and story retells than during conversation.24 Previous research suggested that individuals with Ds reach a “syntactic plateau” during their early adolescent years during which they make little if any progress in syntactic acquisition.25 However, more recent studies suggest that adolescents and young adults with Ds continue to develop these skills well into adulthood.24,26,27 Although pragmatics tends to be a relative strength for adolescents and young adults with Ds, specific social difficulties have been noted. Individuals with Ds may rely on relative strengths in pragmatics to make up for particular difficulties in other expressive language domains, such as syntax and morphology.2 Individuals with Ds demonstrate relative strengths in turn taking and topic maintenance when compared with individuals with fragile X syndrome and Williams syndrome.11 Compared with those with fragile X syndrome, individuals with Ds did not perseverate or produce utterances unrelated to the topic.28,29 However, individuals with Ds tend to include ambiguous, vague comments and have difficulty with linguistic prompting.2,28 Notably, the presence of these pragmatic difficulties may cause misunderstanding between the speaker and listener and might lead to a communication breakdown. WRITTEN LANGUAGE DEVELOPMENT OF ADOLESCENTS AND YOUNG ADULTS WITH DS As with oral language development, individuals with Ds demonstrate a wide range of written language knowledge and skills. Indeed, adolescents and young adults with Ds demonstrate deficits in oral language and phonological memory, as previously described, which are central to written language acquisition for typically developing students.30 Although some never learn how to read, researchers argue that all individuals with Ds are capable of developing at least basic, functional written

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language skills with an appropriate, well-designed educational plan and long-term intervention.31,32 Because few individuals with Ds acquire advanced skills, there is considerably more research related to emergent literacy as well as basic decoding and word identification skills.2 Not surprisingly, adolescents and young adults with Ds are more successful when reading real words as opposed to nonwords.33 Researchers suggest that individuals with Ds in the emergent literacy stage tend to keep pace with nonverbal developmental expectations,31 and they demonstrate similar skill levels as matched typically developing peers on concepts related to print and letter identification.32,34 Over two decades ago, Cossu et al published a controversial article claiming that individuals with Ds could read in the absence of phonological awareness.35 Since then, data from an overwhelming number of studies have refuted this claim, citing methodological and analytical flaws with the original work.36,37 Lemons and Fuchs conducted a comprehensive review of reading and phonological awareness with children and adults with Ds.38 Despite differences in these skills when compared with their peers, these authors provided compelling evidence that, despite Cossu and colleagues’ original claim, reading does not develop independently of phonological awareness.38 Given the paucity of studies examining written language with this population, conclusions about a syndrome-specific reading profile are premature. Research has yet to determine if the difficulties with phonological awareness, for example, are specific to Ds compared with other literacy skills.2 In terms of writing and spelling, emerging evidence suggests that the written language abilities of individuals with Ds may not be as impaired as abilities in other domains. For example, Kay-Raining Bird and colleagues analyzed both handwritten and word-processed narratives of 21 individuals with Ds matched with typically developing students on word identification.20 The authors reported significant differences between the two groups on narrative length and handwriting, yet spelling and punctuation were not significantly different.20 More recently, Lim et al investigated the single-word spelling abilities of individuals with

Ds compared with typically developing students matched for receptive vocabulary and found that for participants with Ds, receptive vocabulary was a significant predictor of spelling ability.39 Post hoc analyses of spelling errors suggested that although individuals with Ds attempted to incorporate phonological awareness into spelling tasks, their success appeared to be limited by phonological short-term memory deficits. Briefly, research supports a syndromespecific profile for individuals with Ds, although considerable individual variability exists, with relative strengths in comprehension. The domains of semantics and pragmatics tend to be superior to syntax and morphology, which are particularly challenging. Most adolescents and young adults with Ds fall near the emergent-literacy and word identification stages of reading development; few are proficient at reading comprehension. In what follows, a case study is provided to highlight specific oral and written language considerations for intervention for one adolescent with Ds. Despite commonalities that are consistent with a syndrome-specific profile, it is imperative that clinical speech-language pathologists select appropriate treatment goals and include specific strategies and activities that best target the oral and written language needs of the individual with Ds. A CLINICAL CASE EXAMPLE History Robert is a 16-year-old who was diagnosed with Ds shortly after his birth. As an infant, he had a ventricular septal defect (VSD), or a “small hole in his heart.” The VSD closed by his first birthday, and surgery was not required. During his early years, Robert had many bouts of otitis media, and he had pressure-equalizing tubes placed bilaterally on three occasions (at 9, 17, and 28 months of age). In addition, he was diagnosed with a moderate sensorineural hearing loss in first grade and was fitted for bilateral hearing aids. His cognitive abilities were formally assessed when he was in second grade; he fell within the moderately impaired range as measured by standardized assessments.

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Robert received speech and language services through early intervention from birth until he was 3 years old. He then transitioned to his local school district, where he was enrolled in an inclusive classroom with typically developing peers. At that time, he received speechlanguage intervention in the classroom and in pullout therapy sessions. In addition, he intermittently received private speech and language therapy to supplement his academic goals as mandated by his Individualized Education Plan (IEP).

Baseline Currently, Robert is in ninth grade at the local public high school. He is included in several classes with his typically developing peers (e.g., music, other electives) and also attends a functional academic classroom where he participates in individual and small-group educational activities led by his special education teacher. As dictated by his IEP, he receives 45 minutes per week of group speech and language therapy and literacy instruction. In addition, he has biweekly individual therapy. Robert’s family is very supportive and committed to helping him achieve his highest potential. A recent comprehensive oral and written language evaluation was conducted at his school. Although standardized test results revealed considerable difficulties in all oral language domains, Robert demonstrated relative strengths in semantics, pragmatics, and word identification. Specifically, he named a variety of pictures of increasing complexity, responded appropriately to and initiated a variety of social questions, maintained eye contact, took turns, and identified all letter–sound correspondence and at least 75 sight words in print. Standardized test results highlighted particular difficulties in the areas of morphosyntax, phonology, and decoding, and analysis of a speech and language and narrative sample revealed that he typically communicated with four- and five-word utterances in which he conveyed meaning through the inclusion of key content words. He frequently omitted morphemes, and he tended to use simple subject–verb–object sentence structure. Robert was difficult to understand, especially during conversation that

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was unfamiliar to the listener. In terms of written language, although Robert demonstrated mastery of grapheme–phoneme correspondence, he had particular difficulty with decoding single words and answering a variety of wh- questions, including simple, direct ones about reading passages. His oral story retelling contained very few elements from the story, despite multiple prompts from the examiner. What follows are hypothetical recommendations intended to target Robert’s oral and written language development based on the previously described research.

Language-Related Areas Remember that Robert has a moderate sensorineural hearing loss. However, he refuses to wear his hearing aids or use the frequency modulation (FM) system at school. Based on research evidence, Robert’s clinician could consider recommending a thorough hearing evaluation to determine his current hearing level. Assuming that he continues to demonstrate a hearing loss, it is important that he wears his hearing aids at all times and uses the FM system at school.40 This mandates that an in-depth conversation occur with Robert, his audiologist, and his family about the importance of these aids. Robert’s teacher and speech-language pathologist might also lead a class discussion about hearing, hearing aids, and FM systems aimed at impressing on Robert that he does not need to feel stigmatized as well as to facilitate the use of these devices. Furthermore, classroom modifications, including preferential seating, the reduction of background noise, and the use of a sound field, may also be made.41 In fact, other students in his class may benefit from these adaptations. Because individuals with Ds demonstrate relative strengths in the area of visual skills and to reduce the cognitive load, auditorily presented classroom material could be supplemented with visual support. This may include, for example, writing down verbal instructions or including developmentally appropriate pictures when possible.42 Thus, visual supports could be provided during instruction as a strategy to facilitate functional communication. In Robert’s case, a bulleted

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list of classroom expectations and routines provided at his desk may be beneficial. In addition, during intervention, graphic organizers and other visual aids could be provided to supplement auditorily presented information. Because answering wh- questions may be an appropriate goal, a chart including pictures and words for wh- questions may serve as a visual reminder and may be particularly helpful for Robert.

Oral and Written Language Intervention Considerations Given the lifelong learning challenges faced by individuals with Ds, quite frequently the goal of oral and written language intervention is not for the adolescent or young adult with Ds to demonstrate age-appropriate skills. Instead, a shift of therapy approaches typically occurs where the emphasis of therapy is on functionality.11 Ultimately, oral and written language difficulties should not impede independence, employment, or social functioning. In addition, intervention should be adapted to meet the individual’s specific needs, capitalizing on relative strengths and facilitating development of basic skills. Because research on written language, in particular, is limited, a syndrome-specific profile has not fully emerged, further strengthening the need for individualized instruction. To have the greatest impact, intervention should be long-term and consistent.37 Educators and clinicians cannot expect that an adolescent or adult with Ds will carry skills over to different situations and environments. Professionals should also be mindful of the individual’s cognitive capabilities as well as incorporating visual supports to compensate for hearing difficulties.37 Oral and written language intervention targets should not be considered independently but should be overlapping so that mastery of a specific goal in one will have a positive impact on the development of another.43 Both oral and written language may be targeted simultaneously via a comprehensive intervention program. With Robert, perhaps the 75 sight words that he accurately identifies can be incorporated into both oral and written language interven-

tion with additional targets, such as morphosyntax. For example, Robert may be asked to write a sentence using a complex sentence structure with one of his sight words. To achieve this, researchers and clinicians agree that meaningful goals should be targeted across a variety of settings (e.g., educational in classroom and pullout, private, home).11 As with typically developing children, it is imperative that the families of adolescents and young adults with Ds are fully aware of treatment goals, progress, and strategies to incorporate in daily communication interactions that occur outside of structured therapy sessions. Because communication is central to our lives and individuals tend to learn the most through repeated, ongoing practice and feedback,44 the previously discussed findings support the notion that adolescents and young adults with Ds do not reach a “language plateau” and that individuals continue to make progress well into their teenage years.26

Oral Language Intervention Because Robert demonstrates relative strengths in receptive language across the domains of semantics and pragmatics, intervention should capitalize on these. To continue to facilitate the understanding and use of functional vocabulary, adolescents and young adults benefit from multiple exposures across a variety of contexts, accessing background knowledge, incorporating prior experiences, and using prediction about an unknown word’s meaning, when appropriate.5,45 Individuals with Ds are more successful with frequently occurring concrete words than they are with more abstract ones,2,5 thus intervention may include concrete words that Robert successfully understands and uses across a variety of contexts that also include less familiar or unknown abstract words, such as relational and directional words. Also, because Robert struggles with understanding and using emotion words, such as “excited” and “angry”, these may also be targeted during intervention. Robert may benefit from the inclusion of story maps,46 semantic webs,47 and graphic organizers48 as he continues to develop semantic links. To promote generalization of skills across other environments and contexts, the clinician

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may incorporate techniques, such as prompting, modeling, using recasts, and targeting the word across a variety of contexts.11 The oral language domains of syntax and morphology are particularly challenging for Robert; the development of skills in these two areas would considerably improve his language functionality. During spontaneous conversation, Robert tends to use nouns and simple subject–verb–object sentence structure during spontaneous conversation. Thus, intervention goals may include a general increase in the use of verbs, prepositions, and articles as well as syntactically complex sentence structures. For example, Robert can practice these skills by combining two simple sentences to form one longer, more complex one. For morphology, Robert may benefit from structured therapy activities that target past tense (-ed) and third-person singular (-s). Goals for him might include the identification of root words and how the word’s meaning changes by adding prefixes and suffixes. Further, given Robert’s particular difficulties in these areas, he may also benefit from opportunities to paraphrase and summarize and to practice repair strategies when others do not fully understand his underlying intent. Although Robert demonstrated a relative strength in pragmatics, he may continue to benefit from strategies that facilitate ongoing mastery of social language. For example, although Robert understands and uses general pleasantries during conversation (e.g., “I’m fine; how are you?”), he had difficulty elaborating and clarifying (e.g., “You went to a baseball game this weekend; which team did you cheer for?”). One specific way to target these deficits during therapy could be to include barrier games, as described by Paul and Norbury.47 During these games, the clinician produces unclear or incomplete responses, and Robert must ask for clarification. When the roles are reversed, the clinician models appropriate use of these strategies. Also, Robert may benefit from role-playing and video modeling. Individuals with Ds tend to have difficulty identifying the plot and pertinent characteristics and cohesive devices when they tell stories.49 Thus, these may also be appropriate treatment goals that integrate all domains of oral language.

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Written Language Intervention Because Robert is able to identify 75 sight words, instruction may focus on both regular and irregular words (e.g., saw, said, of) to continue to build his sight word repertoire. Advocates of this approach directly teach students how to recognize orthographic patterns of individual words.50 Because Robert has considerable difficulty when he encounters an unfamiliar word, he will likely benefit from learning strategies to help him decode via a phonics-based approach while also continuing to improve his sight word vocabulary.51 Specifically, intervention may teach him to identify words in “rime families,” such as –ight and -og.52 Teaching Robert to identify base words (i.e., free morphemes) as well as commonly used prefixes and suffixes (i.e., bound morphemes) will not only target his written language skills but also his morphological difficulties. Robert will benefit from the inclusion of strategies that facilitate oral and written language, including reading comprehension, although specifics remain unknown at this time for this population. Although more research is needed to develop effective phonological awareness intervention for this population, preliminary results suggest that adolescents and young adults with Ds improve these specific skills that are targeted via the treatment. Specific targets for Robert may include the following skills: initial and final sound identification53,54 and phoneme segmentation.52 To target phoneme segmentation, a foundational skill linked to literacy success, a clinician could use Elkonin boxes (squares that represent corresponding phonemes) to visually represent the number of phonemes in a word. Lemons and Fuchs recommended limiting the number of phonemes to three or four because of deficits with auditory memory.38 Robert’s therapists and teachers may incorporate the technique of chunking,54 in which a multisyllabic word is divided into smaller segments, such as tele- and -phone. Targeting phonological awareness in intervention should also improve related domains, such as fluency, comprehension, and spelling, although more research is needed prior to definitive claims.

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CONCLUSION The overall goal of this article was to review the extant research related to the oral and written language development of individuals with Ds, highlighting the syndrome-specific profile as related to relative strengths and challenges. Although nearly all adolescents and young adults with Ds demonstrate oral and written language difficulties, research supports the notion that they can continue to make progress toward meaningful, functional goals well into adulthood. In this article, a case study example of Robert, an adolescent with Ds, is included. To address the article’s goal, examples of potential intervention targets for him are provided. Clearly, it is not expected that all of these possibilities would be targeted during therapy. In the end, the clinician is responsible, after thorough discussion with the family and his educational team, for intentionally selecting and implementing those particular goals that are the most meaningful and functional for the individual with Ds. Individuals with Ds can continue to make progress toward their oral and written language goals well into adolescence and beyond. Such success may continue to have a positive impact on academic achievement, overall independence, and quality of life. REFERENCES 1. Parker S, Mai CT, Canfield MA, et al. Updated national birth prevalence estimates for selected birth defects in the United States, 2004–2006. Birth Defects Res Clin Mol Teratol 2010;88(12): 1008–1016 2. Abbeduto L, Warren SF, Conners FA. Language development in Down syndrome: from the prelinguistic period to the acquisition of literacy. Ment Retard Dev Disabil Res Rev 2007;13(3):247–261 3. Chapman RS, Hesketh LJ. Behavioral phenotype of individuals with Down syndrome. Ment Retard Dev Disabil Res Rev 2000;6(2):84–95 4. Roizen NJ. Down syndrome. In: Batshaw ML, ed. Children with Disabilities. Baltimore, MD: Brookes; 2002:361–376 5. Miolo G, Chapman RS, Sindberg HA. Sentence comprehension in adolescents with Down syndrome and typically developing children: role of sentence voice, visual context, and auditory-verbal short-term memory. J Speech Lang Hear Res 2005; 48(1):172–188

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ENHANCING LANGUAGE FOR ADOLESCENTS WITH DOWN SYNDROME/PELATTI

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Enhancing oral and written language for adolescents and young adults with Down syndrome.

Oral and written language development for adolescents and young adults with Down syndrome (Ds) are particularly challenging. Yet, research supports a ...
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