Every Child has different nature . Language therapy must be designed after consideration of child’s nature. There are some general observations that form the foundation for a speech and language treatment program.
Communication skills are important. It includes not only speech, but also facial expressions, smiles, gestures, pointing, high five signs, and alternative systems such as sign language and computer-based systems. Adults and children are more likely to interact when they can understand and be understood. At home, in school, and in the community, a functional understandable communication system facilitates relationships.
Though there are common speech and language problems, there is no prescribed pattern of speech and language common to all children with Down syndrome. There are, however, speech and language challenges for most children with Down syndrome. Many children with Down syndrome have more difficulty with expressive language than they do with understanding speech and language, that is, receptive language skills are usually more advanced than expressive language skills. Certain linguistic areas, such as vocabulary, are usually easier for children with Down syndrome than other areas, such as grammar. Sequencing of sounds and of words may be difficult for many children. Many children have difficulties with intelligibility of speech and articulation. Some children have fluency problems. Some children use short phrases, while others have long conversations. All of the speech and language problems that children with Down syndrome demonstrate are faced by other children as well. There are no speech and language problems unique to children with Down syndrome. This means that there is a great deal of knowledge and experience that can be applied to helping a child with Down syndrome with his/her specific areas of challenge.
The speech and language treatment program should be individually designed based on a careful evaluation of each child's communications patterns and needs. It is especially important to include the family as part of the treatment team. The child, family (including siblings and extended family), teacher, friends, and community members can all contribute to the child's communication success. The speech-language pathologist can guide, inform, and help facilitate and enhance the process of learning to communicate effectively. But language is part of daily living and must be practiced and reinforced as part of daily life.
During the school years, speech and language treatment must relate to the child's educational setting and the communication needs of the classroom and the curriculum. Speech and language treatment should also consider the child's needs in relation to community activities such as religious groups and scouting. Communication goes on outside of therapy sessions, as well as inside the sessions. Inclusion and community involvement promote interactive communication and provide models and communication partners.
On the path from infancy to adulthood, the child may need speech-language treatment at various points, and the family may need ongoing information, resources, and guidance to work with the child at home. At different developmental stages, the child may need periods of treatment and/or a home program.
ONE-WORD TO THREE-WORD PERIOD
Once the young child begins to use single words (in sign or speech), treatment will target horizontal as well as vertical growth in language. Treatment may address single word vocabulary (semantic skills) in many thematic and whole language activities, such as cooking, crafts, play, and trips (Kumin et al., 1996). So there may be a great deal of horizontal vocabulary growth. Treatment will also target increasing the length of phrases, the combinations of words that the child can use; this is known as increasing the mean length of utterance (Manolson, 1992). There are many meaningful relations that the child learns in two word phrases (e.g., agent-action, possession, negation), and then further expands into three word phrases.
We have found that the pacing board provides a visual and motoric cuing system that capitalizes on the strengths of children with Down syndrome, and helps children to expand the length of their utterances (Kumin et al., 1995). The pacing board is usually a rectangular piece of tag board with separate circles that represent the number of words in the desired utterance (e.g., "throw ball" would have two circles). The pacing system concept can also be implemented by putting a dot under each word in a book.
Pragmatics skills such as making requests and greetings, as well as conversational skills would be taught during this period.
Vocabulary, pragmatics, and other language activities would generally be approached through play activities. Play would also be used to increase auditory attending and on task attention skills (Schwartz and Miller, 1996). Language skills would be supported through the use of appropriate computer activities, such as First Words or First Verbs by Laureate or Living Books or Bailey's Book House by Edmark (Kumin et al., 1996).
The basis for developing speech during this period is sensory integration (translating auditory to verbal messages) and oral motor abilities. Most children with Down syndrome understand messages, and are able to produce language (through signs) well before they are able to use speech. So sensory integration and oral motor skills therapy are used to strengthen the readiness for speech during this period.
PRESCHOOL THROUGH KINDERGARTEN
The young child is usually far more advanced in receptive language skills than in expressive language skills, but both areas are targeted in therapy. During this stage, receptive language work may focus on auditory memory and on following directions, which are important skills for the early school years. It will also focus on concept development such as colors, shapes, directions (top and bottom), prepositions through practice, and play experiences. Expressive language therapy will include semantics, expanding the mean length of utterance, and will begin to include grammatical structures (word order) and word endings (such as plural or possessive). Pragmatics skills such as asking for help, appropriate use of greetings, requests for information or answering requests, as well as role playing different activities of daily living may be addressed. Again, play activities such as dressing and undressing a doll, crafts activities such as making a card, or cooking activities such as making cupcakes may be used. The same activity may target semantic, syntactic, and pragmatics skills, for example, how many cupcakes should we make, what color frosting should we use, and following the directions to make the cupcakes. Many children with Down syndrome learn to read effectively, and this can help in learning language concepts (Buckley, 1993).
During this stage, sounds and specific sound production would be targeted; articulation therapy could begin. But the therapy would also include oral motor exercises and activities on an ongoing basis to strengthen the muscles and improve the coordination of muscles. Intelligibility is the goal of the speech component of therapy.
ELEMENTARY SCHOOL YEARS
During the years in elementary school, there is a great deal of growth in language and in speech. Speech-language pathology may involve collaboration with the teacher and may be based in the classroom. Often, the curriculum becomes the material used for therapy, both proactively, to prepare the child for the subject and reactively, to help if problems occur. This makes sense, because school is the child's workplace, and success in school greatly affects self esteem.
Receptive language work becomes more detailed and advanced (Miller, 1988), including following directions with multiple parts, similar to the instructions given in school. Receptive language might include comprehension exercises, reading and experiential activities, and specific comprehension of vocabulary, morphology (word parts such as plurals), and syntax (grammatical rules).
Expressive language therapy would also focus on more advanced topics in vocabulary, similarities and differences, morphology, and syntax. Expressive language work might also include work on increasing the length of speech utterances. The pacing board, rehearsal, scaffolds, and scripts have been found helpful in facilitating longer speech utterances.
Pragmatics becomes very important during this stage; using communication skills in real life in school, at home, and in the community is the goal. Therapy might address social interactive skills with teachers and peers, conversational skills (discourse), how to make requests, how to ask for help when the child doesn't understand material in school, how to clarify statements that people do not understand, and so forth. As the child matures, the communicative activities of daily living will change. Treatment and/or home practice must keep pace with the child's communication needs at every stage.
Speech skills with emphasis on articulation and intelligibility would be targeted in therapy during this period (Swift and Rosin, 1990). An individual analysis of oral motor strengths and challenges is important to determine what specific skills need to be addressed, for example, does the child have low muscle tone or muscle weakness in the oral facial area? difficulty with motor coordination? difficulty with motor planning? Are other speech areas such as voice and fluency affecting intelligibility? Each of these areas can be worked on if they are affecting communication ability for an individual child.
There are many different approaches to speech and language treatment that can be used, and some may be used simultaneously as part of a comprehensive individually designed program.
Therapy may be programmed based on linguistic skills, that is, there may be individual goals for semantics, morphology and syntax, pragmatics, and phonology. Therapy may also focus on different channels. So the goals for therapy may target auditory skills or speech and oral motor skills, or encoding a language message or producing a language message. One channel, such as reading, may be used to assist another channel such as expressive language or written language. Therapy may also be approached through the needs of the curriculum. In this approach, vocabulary would be taught based on the vocabulary that the child needs for success in science or social studies. The therapy may be proactive, teaching in advance the language skills that the child will need for the official curriculum, formal and informal classroom interactions, following directions in class and learning the rules and routines, and skills for interacting with peers. Curriculum-based therapy may also be reactive, targeting areas of difficulty as they occur and providing assistance with study skills and strategies to meet classroom expectations or to overcome difficulties when they occur. The speech-language pathologist can also suggest adaptive and compensatory strategies such as seating in front of the room, using a peer tutor, and visual cue sheets.
Whole language is a current approach in which reading, understanding, writing, and expressive language are taught as a whole. This often is based on children's literature and thematic activities accompanying the books; for example, a book about weather might also involve weather reporting, building a weather station, or drawing pictures or taking photographs of different weather conditions. Whole language does not teach in discrete linguistic units, such as focusing on plurals or verb tenses. Rather, it teaches in larger themes using meaningful multisensory experiences to teach concepts.
Communication in context is a pragmatics approach often used in classroom-based collaborative programs. It considers the entire communication situation including the participants (child, teacher, other children, school stall), the various settings in which the child communicates, and the differences between settings. This approach is very real-world oriented. Therapy might work on scripts and may provide assistance through scaffolds (e.g., fill-in sentences) to help the child learn to communicate more effectively with specific people or in specific settings based on a variety of objectives.
Speech and language treatment is complex and can include different approaches, a variety of goals, and many different activities. The goal is to find treatment approaches and methods which will enable each child to reach his communication potential.
