Longitudinal Language Intervention in Down Syndrome ...

Longitudinal language Longitudinal language intervention in Down syndromeintervention in Down syndrome

JEAN A. RONDALJEAN A. RONDAL

University of LIEGEUniversity of LIEGE

BELGIUMBELGIUM

ObjectiveObjective

The main The main objectiveobjective of language intervention, of language intervention, naturally enough, is to naturally enough, is to improve substantiallyimprove substantially the the course and levels of attainment in course and levels of attainment in the languagethe language functioningfunctioning of the people with serious language of the people with serious language problems. problems.

In the developmental (and genetic syndromes) In the developmental (and genetic syndromes) such as such as Down syndrome – DS -Down syndrome – DS - –trisomy 21, it is –trisomy 21, it is to improveto improve developmentdevelopment and favor the attainment and favor the attainment of levels of functioning that would not have been of levels of functioning that would not have been possible otherwise.possible otherwise.

Knowledge requirementKnowledge requirement

In order to In order to intervene efficientlyintervene efficiently, again naturally , again naturally enough (but this point is not always satisfied in enough (but this point is not always satisfied in practice), it is essential practice), it is essential to dispose of as muchto dispose of as much knowledge as possibleknowledge as possible on the pathological entity, on the pathological entity, its caracteristics , and its course of development .its caracteristics , and its course of development .

Regarding Regarding language in DSlanguage in DS, the course of , the course of development and its typical characteristics are development and its typical characteristics are relatively well known thanks to the numerous relatively well known thanks to the numerous publications in the field, particularly over the last publications in the field, particularly over the last 25 years.25 years.

Language in DSLanguage in DS

The speech and language development of The speech and language development of persons with DS can be best defined – in persons with DS can be best defined – in generic terms – as presenting generic terms – as presenting markedmarked formal deficienciesformal deficiencies in conjunction with in conjunction with better preserved semantic and pragmaticbetter preserved semantic and pragmatic dispositions dispositions (Rondal & Edwards, 1997).(Rondal & Edwards, 1997).

There are also There are also important interindividualimportant interindividual differencesdifferences in development and functioning in development and functioning (cf. Rondal, 1995, 2003).(cf. Rondal, 1995, 2003).

Language in DS (following)Language in DS (following)

Artculatory and co-articulatory difficultiesArtculatory and co-articulatory difficulties are the rule, particularly with the more are the rule, particularly with the more delicate phonemes in the various languages.delicate phonemes in the various languages.

Concurrently, there is often a slow and Concurrently, there is often a slow and incomplete maturation of phonemicincomplete maturation of phonemic discriminationdiscrimination..

Morphosyntactic limitationsMorphosyntactic limitations reduce the reduce the length and formal complexity of the length and formal complexity of the utterances.utterances.


Inflexional morphologyInflexional morphology may be may be problematicproblematic and variable.and variable.

Production and comprehension of Production and comprehension of subordinate clausessubordinate clauses and and compoundcompound sentencessentences are are limitedlimited..

Discourse often lacks in cohesionDiscourse often lacks in cohesion..

In contrastIn contrast

No particular difficultyNo particular difficulty is observed usually is observed usually with the with the concrete meaningconcrete meaning aspects of aspects of current lexemescurrent lexemes as well as with as well as with the basicthe basic semantic structuressemantic structures involved in involved in combinatorial language.combinatorial language.

Additionally, there is Additionally, there is socially andsocially and contextually appropriate usecontextually appropriate use of the major of the major conventional speech actsconventional speech acts at mental age level at mental age level but with limited formal means.but with limited formal means.


The spatial, temporal, and social deixis andThe spatial, temporal, and social deixis and presuppositionspresuppositions are are effectiveeffective at mental age at mental age levels.levels.

DS persons have access to DS persons have access to coherentcoherent narrative, descriptive, and argumentativenarrative, descriptive, and argumentative discoursesdiscourses with increase in mental age but with increase in mental age but again with limited formal means.again with limited formal means.

Longitudinal language Longitudinal language interventionintervention

The available knowledge regarding The available knowledge regarding language development and functioning in language development and functioning in DS persons suggests that the best way to DS persons suggests that the best way to conceive of intervention is according to conceive of intervention is according to aa developmental life-span perspectivedevelopmental life-span perspective..

In this respect, it is possible to distinguish 4 In this respect, it is possible to distinguish 4 major phasesmajor phases..

Four phases for language Four phases for language intervention in DSintervention in DS

(1) (1) EarlyEarly intervention intervention (2) Intervention at (2) Intervention at school agesschool ages (3) Continued intervention at (3) Continued intervention at the adult agethe adult age (4) (4) Maintenance interventionMaintenance intervention during during thethe

aging yearsaging years..

Phases of language intervention Phases of language intervention (following)(following)

Each phase has its specific contentsEach phase has its specific contents and and objectivesobjectives, which I will briefly outline. , which I will briefly outline. Given time limitation, I will extent myself Given time limitation, I will extent myself only on only on prelinguistic trainingprelinguistic training, on the one , on the one hand, and hand, and maintenance trainingmaintenance training in older in older ages, on the other, because they are less ages, on the other, because they are less well known and still insufficiently well known and still insufficiently practiced.practiced.

Early language interventionEarly language intervention

In Belgium, early intervention is legally defined as In Belgium, early intervention is legally defined as the supportive activities to the handicapped child the supportive activities to the handicapped child and her/his family as well as the technical aid that and her/his family as well as the technical aid that can be supplied can be supplied from the first months of life untilfrom the first months of life until six yearssix years..

Nowadays it is hardly necessary to justify the Nowadays it is hardly necessary to justify the prospect of early intervention in DS. As a quick prospect of early intervention in DS. As a quick reminder, the reminder, the main reasonsmain reasons are: are:

(a) in the industrialized countries, (a) in the industrialized countries, DS is currently DS is currently diagnoseddiagnosed before or at birthbefore or at birth, which allows for , which allows for abilitation to operate right from the beginning.abilitation to operate right from the beginning.

Reasons for early intervention in Reasons for early intervention in DSDS

(b)not only is it possible to intervene early, it is (b)not only is it possible to intervene early, it is also also highly recommendablehighly recommendable to do so if one wants to do so if one wants to achieve the best possible results regarding to achieve the best possible results regarding numerous aspects of development in the DS child. numerous aspects of development in the DS child. Additionally, Additionally, the development of the majorthe development of the major cognitive and language systems and subsystems iscognitive and language systems and subsystems is cumulative.cumulative. This means that any gain in the first This means that any gain in the first phases of development will have positive phases of development will have positive repercussions on further attainment and on the repercussions on further attainment and on the level reached eventually.level reached eventually.

Reasons for early intervention in Reasons for early intervention in DSDS

(c) if, as numerous scientists now think, there (c) if, as numerous scientists now think, there exists exists critical or sentitive periodscritical or sentitive periods for the for the acquisition of basic skills (among them, acquisition of basic skills (among them, prominently, prominently, languagelanguage ), ),whereby a maturationalwhereby a maturational calendar interacts with lifecalendar interacts with life experiences and experiences and sensory inputssensory inputs, it becomes even more , it becomes even more important to important to planplan early interventionearly intervention in such a way as to render in such a way as to render the DS child able to develop better and more the DS child able to develop better and more rapidly.rapidly.

Delay hypothesis confirmedDelay hypothesis confirmed

The research works of the last 25 years confirm The research works of the last 25 years confirm that in DS, development regarding that in DS, development regarding motricitymotricity, , cognitioncognition,,emotions and affective aspectsemotions and affective aspects, , socialization, and languagesocialization, and language, follows , follows the same the same sequence of steps and stagessequence of steps and stages as nonretarded as nonretarded developmentdevelopment. Therefore the answer to the question . Therefore the answer to the question ,raised years ago, as to whether development in ,raised years ago, as to whether development in DS is delayed (and incomplete) or genuinely DS is delayed (and incomplete) or genuinely different from normal development, is different from normal development, is DELAYDELAY. .

Delay (following)Delay (following)

This has important implications for intervention. This has important implications for intervention. The fact that The fact that development indevelopment in DS appears to be a DS appears to be a « copy » of normal« copy » of normal development but distributed development but distributed differently in timedifferently in time and eventually incompleteand eventually incomplete (the (the ultimate levels of development reached varying ultimate levels of development reached varying substantially from one person to the next - due to substantially from one person to the next - due to an interaction between constitutional and an interaction between constitutional and experiencial factors), experiencial factors), supplies us withsupplies us with (1) (1) a precise a precise working planworking plan; (2) ; (2) aa sensitive scheme for assessing sensitive scheme for assessing the efficiency ofthe efficiency of interventionintervention..

Working planWorking plan

Normal development gives usNormal development gives us « automatically » the steps to follow and to« automatically » the steps to follow and to favor through our intervention procedures favor through our intervention procedures inin order to speed up as much as possible theorder to speed up as much as possible the passing of the DS child from stage A to B, passing of the DS child from stage A to B, C,C, etc.,etc., in the sequences of stages in the sequences of stages constituting development in a given respect constituting development in a given respect (e.g.,here a given aspect of language (e.g.,here a given aspect of language acquisition).acquisition).

General assessment deviceGeneral assessment device

In the same way, the In the same way, the relative speedrelative speed with with which we are able to move a DS child from which we are able to move a DS child from level A to B,C, etc., in a sequences of stages level A to B,C, etc., in a sequences of stages regarding a given aspect of development, as regarding a given aspect of development, as well as the well as the stability of thestability of the acquisitionsacquisitions once once they have been introduced, are they have been introduced, are among the among the most importantmost important indications in assessing the indications in assessing the value, interest,value, interest, and efficiency of an and efficiency of an intervention programintervention program..

Early language interventionEarly language intervention

The The following targetsfollowing targets should be assigned to should be assigned to any intervention program regarding the any intervention program regarding the prelinguisticprelinguistic stage in the DS child: stage in the DS child:

Sensitizing the baby to the spectral andSensitizing the baby to the spectral and prosodic characteristics of maternal voiceprosodic characteristics of maternal voice and languageand language through systematic and through systematic and variegated exposure.variegated exposure.

Prelinguistic training (following)Prelinguistic training (following)

Sensitizing the baby to the rhythmical, syllabicSensitizing the baby to the rhythmical, syllabic, , vocalic , and consonantic regularities of maternalvocalic , and consonantic regularities of maternal languagelanguage in order to favor in order to favor phonetic discriminationphonetic discrimination of basic language material.of basic language material.

In the following months, In the following months, pay a lot of attentionpay a lot of attention, , « « capture », carefully respond to, and reinforcecapture », carefully respond to, and reinforce thethe baby’s attempts at vocalizing and babblingbaby’s attempts at vocalizing and babbling ((vocalicvocalic, , consonanticconsonantic, , syllabicsyllabic, , reduplicatedreduplicated, , thenthen variegated babblingvariegated babbling), ), closing up on a gradualclosing up on a gradual saturation of the baby’s vocal productions with thesaturation of the baby’s vocal productions with the specific sounds (phonemes) of the input languagespecific sounds (phonemes) of the input language..

Prelinguistic training (following)Prelinguistic training (following)

Still later, watch carefully for the Still later, watch carefully for the first protowordsfirst protowords or or attempts at signifyingattempts at signifying in the DS child and in the DS child and reinforce them systematically.reinforce them systematically.

Foster nonverbal communication and gesturalFoster nonverbal communication and gestural imitationimitation at the same time as advanced babblingat the same time as advanced babbling and protowordingand protowording..

Promote symbolic playing and creativityPromote symbolic playing and creativity in the in the child, as this type of play procedes from the same child, as this type of play procedes from the same semiotic dimension as early language (lexical).semiotic dimension as early language (lexical).

Lexical, semantic, and Lexical, semantic, and morphosyntactical trainingmorphosyntactical training

Lexical development is slow and sometimesLexical development is slow and sometimes difficultdifficult in the DS child. in the DS child. Various aspectsVarious aspects need to be worked onneed to be worked on to foster this to foster this development. development.

Very briefly: Very briefly: Working on Working on lexical symbolismlexical symbolism, i.e., the , i.e., the

understanding that words (sequences of understanding that words (sequences of sounds) hold for categories of referents.sounds) hold for categories of referents.

Lexical development (following)Lexical development (following)

Implementing with the DS child Implementing with the DS child the lexical the lexical strategiesstrategies used by nonretarded children used by nonretarded children (see next slide).(see next slide).

Working on Working on short-termshort-term and and longer-termlonger-term memorymemory development. development.

Working on Working on articulatory and co-articulatoryarticulatory and co-articulatory developmentdevelopment..

Lexical strategiesLexical strategies

1. 1. Whole objectWhole object (a new name refers to a whole referent and (a new name refers to a whole referent and not to one of itsnot to one of its

properties, qualities, parts, its substance, etc.).properties, qualities, parts, its substance, etc.).

2.2.Mutual exclusivityMutual exclusivity (to each object corresponds a different (to each object corresponds a different name).name).

33..TaxonomyTaxonomy (lexical categories are constituted of similar (lexical categories are constituted of similar

objects and not, forobjects and not, for example, of objects that can be associated thematicallyexample, of objects that can be associated thematically

Lexical strategies (following)Lexical strategies (following)

4. 4. FormForm5.5. FunctionFunction 6.6.ContrastContrast (Every formal difference (Every formal difference

codes for a difference in meaning and/or codes for a difference in meaning and/or ininformal class status, e.g., noun—verb, formal class status, e.g., noun—verb, object—attribute, etc.).object—attribute, etc.).

7.7.ConventionalityConventionality (words have (words have conventional meaning that are stable conventional meaning that are stable over time).over time).

8.8.ReferenceReference

Lexical strategies (following)Lexical strategies (following)

9.9. ExtensionalityExtensionality (words come to (words come to refer beyond their initial referents; refer beyond their initial referents; formal and functional similarities and formal and functional similarities and associations control the extensions). associations control the extensions).

10.10. New name — category New name — category without a namewithout a name (new words usually (new words usually refer to categories for which one refer to categories for which one does not have a name yet).does not have a name yet).

Semantic and morphosyntactic Semantic and morphosyntactic trainingtraining

Grammar is based on relational semanticsGrammar is based on relational semantics (i.e., the (i.e., the compound meaning structures holding between (not compound meaning structures holding between (not within) words). See next slide for a short list of the within) words). See next slide for a short list of the major earlier semantic structures in child language).major earlier semantic structures in child language).

It is essential to start combinatorial languageIt is essential to start combinatorial language training with this language leveltraining with this language level before turning to before turning to the formal structures per se (grammatical categories, the formal structures per se (grammatical categories, phrase and sentence structures; which are beyond phrase and sentence structures; which are beyond the scope of the present communication; cf. the scope of the present communication; cf. Rondal Rondal & Edwards, 1997& Edwards, 1997, for a presentation)., for a presentation).

First major semantic relationsFirst major semantic relations

ExistenceExistence (presence, absence, recurrence, (presence, absence, recurrence, disparition of an entity).disparition of an entity).

PossessionPossession Qualitative attributionQualitative attribution Quantitative attributionQuantitative attribution Conjunction, accompanimentConjunction, accompaniment Intransitive relationship (e;g., Intransitive relationship (e;g., The boy is smilingThe boy is smiling)) Transitive relationship (e;g., Transitive relationship (e;g., The milkman bringsThe milkman brings

the milkthe milk).). Affirmation, negation, acceptation, rejection,Affirmation, negation, acceptation, rejection, refusalrefusal

Intervention at schoolagesIntervention at schoolages

Given the relative slowness of language Given the relative slowness of language acquisition in DS, acquisition in DS, most DS children will need most DS children will need furtherfurther language training during maternal, language training during maternal, primary, andprimary, and secondary school timessecondary school times..

This training should be conceived of and carried This training should be conceived of and carried on on in close collaboration with the schools and thein close collaboration with the schools and the teachersteachers..

This is a very complex problemThis is a very complex problem far from being far from being satisfactorily dealt with in our countries at the satisfactorily dealt with in our countries at the present time despite some progresses in recent present time despite some progresses in recent years.years.

Intervention at schoolages Intervention at schoolages (following)(following)

We need to operate We need to operate teams ofteams of specialistsspecialists working working with the schoolteacherswith the schoolteachers (hopefully (hopefully better informed and formed than is the case better informed and formed than is the case most often nowadays) in order most often nowadays) in order toto implement ongoing individualized languageimplement ongoing individualized language training programstraining programs for the DS child either in for the DS child either in special schoolsspecial schools or in or in integrated schoolintegrated school settingssettings..

Continued intervention at the Continued intervention at the adult ageadult age

Research data indicate that Research data indicate that it is still possibleit is still possible to improve significantly several aspects of to improve significantly several aspects of the languagethe language of DS persons of DS persons during theduring the first first part of adult lifepart of adult life..

Learning still appears possible (with an Learning still appears possible (with an important interindividual variationimportant interindividual variation, , however) particularly in the however) particularly in the lexicallexical, , semanticsemantic, , pragmaticpragmatic, and , and discursive aspectsdiscursive aspects of language functioning.of language functioning.

Maintenance intervention during Maintenance intervention during the aging yearsthe aging years

There seems to be an There seems to be an earlier onsetearlier onset of of neuropsychological decline in DSneuropsychological decline in DS for most for most individuals, individuals, unrelated to incipient Alzheimerunrelated to incipient Alzheimer disease disease – AZ -– AZ - (Brown, 1985; Thompson, 1999; Van (Brown, 1985; Thompson, 1999; Van Buggenhout et al., 2001).Buggenhout et al., 2001).

Predisposition towards earlier aging in DS may be Predisposition towards earlier aging in DS may be associated with the associated with the overexpression of genesoverexpression of genes located located on chromosome 21on chromosome 21, , distinct from the gene codingdistinct from the gene coding for amyloid preproteinfor amyloid preprotein (supplying one key factor(supplying one key factor to to AZ disease),AZ disease), as well as genes on chomosomesas well as genes on chomosomes other other than chromosome 21than chromosome 21 (Royston, mannn, Pickering- (Royston, mannn, Pickering-Brown, & Owen, 1994). Brown, & Owen, 1994).

Maintenance intervention Maintenance intervention (following)(following)

Regarding language (Regarding language (receptivereceptive as well as as well as productiveproductive), it would seem, according to the cross-), it would seem, according to the cross-sectional data collected by Rondal & Comblain sectional data collected by Rondal & Comblain (1996, 2002), Das, Divis, Alexander, Parrila, & (1996, 2002), Das, Divis, Alexander, Parrila, & Naglieri (1995), and the longitudinal data gathered Naglieri (1995), and the longitudinal data gathered by Devenny, Hill, Patxot, Silverman, & by Devenny, Hill, Patxot, Silverman, & Wisniewsky (1992), Burt, Loveland, Chen, Wisniewsky (1992), Burt, Loveland, Chen, Chuang, Lewis, & Cherry (1995), and George, Chuang, Lewis, & Cherry (1995), and George, Thewis, Van der Linden, Salmon, & Rondal, Thewis, Van der Linden, Salmon, & Rondal, 2001), 2001), that no clear decline takes place at least that no clear decline takes place at least until 50until 50 years of ageyears of age. .


What may happen in the same respect to the What may happen in the same respect to the DS persons DS persons beyond 50 yearsbeyond 50 years or so is or so is notnot clearclear at this time for the lack of systematic at this time for the lack of systematic data. data. It could be that there is a gradualIt could be that there is a gradual decline taking place over the yearsdecline taking place over the years and and before what is usually reported of before what is usually reported of nonretarded people (Rondal & Edwards, nonretarded people (Rondal & Edwards, 1997). 1997).


This , in my view,justifies the introduction in our This , in my view,justifies the introduction in our intervention programmes of a intervention programmes of a particularparticular section section devoted to maintaining the languagedevoted to maintaining the language acquisitions acquisitions in aging DS personsin aging DS persons. In so doing (. In so doing (little to nothing little to nothing exists at the present timeexists at the present time in this respect), one in this respect), one would have would have the bestthe best hope of slowing down the hope of slowing down the earlier aging process regarding language in these earlier aging process regarding language in these personspersons ( of course other aspects of ( of course other aspects of neurobehavioral functioning could also benefit neurobehavioral functioning could also benefit from corresponding endeavors).from corresponding endeavors).


What should we What should we targettarget in such language in such language programme?programme?

The following aspects should be given The following aspects should be given priority:priority:

(1) Keep the aging DS person (1) Keep the aging DS person attending toattending to and discriminating auditory inputand discriminating auditory input (in order (in order to to contrast changes in the auditory systemcontrast changes in the auditory system of these persons).of these persons).


(2) (2) Encourage lexical productionEncourage lexical production (to contrast(to contrast anan increased difficulty in retrieving lessincreased difficulty in retrieving less frequent frequent verbal material from semanticverbal material from semantic memory).memory).

(3) (3) Stimulate receptive and productiveStimulate receptive and productive language language processes processes (to contrast the slowing down of these (to contrast the slowing down of these processes in elderly people)processes in elderly people)..

(4) (4) Retrain discourse production andRetrain discourse production and comprehensioncomprehension (narrative, descriptive, (narrative, descriptive, argumentative structures) argumentative structures) which tend to bewhich tend to be reduced and exhibit lesser cohesionreduced and exhibit lesser cohesion..

ConclusionConclusion

It is essential to start It is essential to start conceiving of languageconceiving of language (and (and possibly overall) possibly overall) intervention in DSintervention in DS along along a life-a life-span dimensionspan dimension in order to reach in order to reach maximalmaximal efficiencyefficiency..

In this respect, one has to keep in mind that In this respect, one has to keep in mind that inin spite spite of a decrement in the of a decrement in the incidenceincidence of DS of DS in industrial in industrial societies in recent years (due to the conjunction of societies in recent years (due to the conjunction of earlier diagnosis and the practice of so-called earlier diagnosis and the practice of so-called therapeutic abortion), the therapeutic abortion), the frequencyfrequency of persons with of persons with DSDS, including the adult and elderly people, , including the adult and elderly people, is is actually increasing and will continue toactually increasing and will continue to do so for do so for several decadesseveral decades..

Conclusion (following)Conclusion (following)

Recent estimates of the Recent estimates of the present-day averagepresent-day average life expectancy in DS are around 60 yearslife expectancy in DS are around 60 years ( e.g., Baird & Sadovnick, 1995; Strauss & ( e.g., Baird & Sadovnick, 1995; Strauss & Eyman, 1996; Jancar & Jancar, 1996).Eyman, 1996; Jancar & Jancar, 1996).

Estimates call for Estimates call for an increase in thean increase in the frequency of adult persons with DS in thefrequency of adult persons with DS in the next decades of over 200%next decades of over 200% (Steffelaar & (Steffelaar & Evenhuis, 1989).Evenhuis, 1989).

Conclusion (ending)Conclusion (ending)

It is therefore entirely appropriate, to try to speedIt is therefore entirely appropriate, to try to speed up the setting of more efficient interventionup the setting of more efficient intervention programmes with DS peopleprogrammes with DS people, in order , in order to improveto improve as much as possible their developmentalas much as possible their developmental outcomesoutcomes, , for the higher the individual levels offor the higher the individual levels of development reacheddevelopment reached, , the better the likelihood ofthe better the likelihood of carrying over a more rewarding lifecarrying over a more rewarding life, , the mostthe most useful people will be for society’s sakeuseful people will be for society’s sake, and in the , and in the longer run longer run the lesser the overall social resourcesthe lesser the overall social resources that will need to be devoted theretothat will need to be devoted thereto. .

Longitudinal Language Intervention in Down Syndrome ...

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