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Introduction

The main aim of this module is to provide practical advice and activities to improve the spoken language skills of children with Down syndrome during their primary school years. The focus is therefore on developing and extending their use of vocabulary, grammar and sentences and on improving their sound production skills to increase the intelligibility of their speech, at home and at school.

Children with Down syndrome vary widely in their rates of progress with speech and language skills and therefore the following summary should only be taken as a general guide. Some children will be further advanced and some much more delayed in their progress.

Most children with Down syndrome will enter school at 5 years with a spoken vocabulary of about 300 words and probably a larger comprehension vocabulary (words that they understand but do not yet use) of some 400 words. They will be communicating in 2 to 4 word 'telegraphic' (keyword) sentences. They will not be using all the correct word endings (e.g. for plurals and tenses) or all the joining (function) words in their sentences. At 8 to 9 years the average spoken vocabulary of children with Down syndrome is around 450-500 words but the range is from 150 to over 600 spoken words for different children, according to available research. The more delayed children include those with the more severe hearing or speech difficulties.

Most children with Down syndrome of primary school age will be difficult to understand until you get to know them, as their speech is not clear - they still have some difficulties with speech sound production (articulation and phonology) and with organizing and saying longer sentences (speech-motor planning). They are usually sociable and want to communicate, doing so using speech and gestures or signs. However, they may not be confident in starting conversations even though they join in when spoken to. They will also talk much less than most other children of their age and this means that they are getting less practice at talking. They need practice at talking to improve their speech clarity, the length of sentences that they can use and their ability to use appropriate language in all social and learning situations.

This profile of development indicates that vocabulary, grammar, speech and interactive communication skills all need to be assessed and to be targeted with appropriate intervention strategies during the primary school years. It is important that teachers and parents work together in assessing the children's skills and choosing targets. Ideally, a speech and language therapist, who is able to see the child, parents and teacher at least on a monthly basis, should guide them. However, as this level of speech and language therapy support is often not available, this module and the accompanying checklists are designed to enable parents and teachers to work effectively on their own, if necessary.

In school, most of the speech and language targets can be met within the regular curriculum. New vocabulary can be learned during reading, maths and during all topic work. Speech sound work can be linked to phonics and spelling activities. Daily conversations and interactions with other pupils and with staff provide opportunities to develop confidence in social communication, for example, through sharing news, answering questions and discussing topics.

The advice and programme of activities recommended in this module are based on four sets of information:

• research into the processes and influences on speech and language development in typically developing children
• research into the specific speech and language needs of children with Down syndrome
• research into effective interventions
• the extensive experience of the authors' and other colleagues from working with parents and teachers to provide interventions

A set of checklists, covering speech, vocabulary, grammar and interactive communication skills, is available to accompany this module. These checklists allow children's skills in each area to be evaluated, activities to be targeted at the right level, and provide a record of progress. The checklists cover development in each skill area from infancy, so no school-aged child with Down syndrome will be too delayed to be assessed on the checklists.

Some children with Down syndrome may be more advanced and already have many of the skills covered, especially if they are over 8 years old. However, we do advise that you complete all the checklists, just to be sure that the child does have all the vocabulary, grammar and speech sounds in place. If they do, then speech and language development for them should progress from the everyday literacy and curriculum work in school.

All typically developing children are learning new vocabulary and new grammar in school, mainly as a consequence of reading and writing, as required across the curriculum. (It has been estimated that new vocabulary is learned at the rate of some 3000 new words each year from 7 to 16 years and at a slower rate from 5 to 7 years).

Very few children with Down syndrome have totally clear, fluent and grammatically complete spoken language skills at 11 years of age, so we expect most children to need targeted speech and language intervention throughout their primary school years and in secondary school.

The skills and knowledge needed for talking

For all children, learning to talk is a complex process, involving a number of emerging skills, influenced by learning opportunities and accomplished over many years. To be competent at expressing themselves through language, children have to know the words and grammar needed to express their thoughts in spoken language (language knowledge), they have to be able to make the sounds and words clearly so that their speech can be understood (speech) and they have to know how to engage someone effectively in a conversation (interactive communication skills). 

The reader is referred to Speech and language development for individuals with Down syndrome - An overview for a full discussion of these issues and the key findings from research for both typically developing children and children with Down syndrome.

The principles of the programme

The programme is based on two main principles: The need to improve the quality and quantity of everyday communication with the child, and the need to target the specific skills that underpin effective communication as many of these skills are areas of particular difficulty for children with Down syndrome.

To maximise the child's speech and language progress both everyday communication experience and the child's underlying skills need to be considered at all times, for children with Down syndrome.

We then stress two additional principles: The need, at all ages, to develop interactive communication, speech and language skills in parallel, and the importance of keeping records of progress.

Improving everyday communication

It is essential that everyone involved with a child with Down syndrome at home or school or in the community considers and, if necessary, improves the way in which they are communicating with the child during ordinary activities.

Learning to talk is an everyday activity

Language is learned because children want to communicate and the single most important influence on the rate of progress in typically developing children is the quality and quantity of communication that the child experiences throughout their day at home or at school.

Therefore, one approach to language intervention is to encourage everyone who is with the child to be sensitive to the way in which they communicate with the child and to increase the amount of quality daily talk with the child.

Improving the quantity and quality of daily interaction

Intervention programmes that focus on interaction and language aim to improve the effectiveness of parents and teachers as language teachers, during all their ordinary everyday communication with the child. Of course, many parents and teachers are excellent natural communicators and they adapt to the child's needs without any further training. However, communication is a two way activity between partners and when one partner is having difficulty, and does not give natural, age appropriate responses during the communication exchange, then it is not certain that all adults or other children will adapt to this as effectively as they could without some explicit guidance and conscious effort.

For children with Down syndrome, these difficulties will have contributed to the extent of their language delays before coming to school. For example, if the child does not begin to point or hold up objects at the typical age, this may result in parents naming objects for the child less often, so delaying vocabulary learning. If the child does not begin to try saying words at the typical age, it may not be as easy to keep up the same level of talk to the child as it would be to the child who is talking and is demanding a response. If the child's words are unintelligible, the adult may need to ask the child to repeat the words, to be sure they understand what the child is trying to say, before they can respond. This disrupts the normal flow of conversation and the adult's ability to respond to the child's message by expanding or replying in a natural way.

All these examples indicate that when a child has even one area of delay or difficulty in her/his speech and language skills, this will almost certainly reduce the quality and quantity of natural talk to and with the child, in comparison with a typically developing child. Yet the child with difficulties needs more good quality language experience and learning opportunities than the typical child in order to make progress. In the mainstream primary school classroom, a child with Down syndrome will talk much less than most of the other children. This means less practice at talking, which will reduce opportunities to practice planning and producing words and sentences (using grammar) and reduce speech practice (using articulatory and phonological skills). In typical development all these skills improve with practice as children talk naturally everyday.

The first requirement for any parent or teacher using this programme is that you are familiar with the stages of speech and language development in typically developing children and with what is currently understood about the processes that influence their rate of progress. In particular you should be confident that you know what skills and style of communication will make you a good communicator. You can do this by reading the overview module in this series and other books from the recommended list at the end of this module. You can also do this by learning from your local speech and language therapy service or from going on a course.

The second requirement is that you should then take time to consider how you are currently communicating with your child with Down syndrome at home or in school (in and out of the classroom) and identify ways in which you could improve either your style or the quantity of communication experience that you are offering the child.

The third requirement is that, as you read in the next section about the additional ways that you can help your child, you remember that they are additional, they do not conflict with any of the principles which make you a good communicator. Some require you to try to absorb them and use them in all your everyday interactions to make all your communication with your child more effective (for example, speaking clearly, reducing background noise, maintaining eye contact, using signs). Others require some time to be spent each day on extra games and teaching activities. At home, try to absorb some of these activities into times that you already spend with your child. Others can be included in no more than a half hour session each day of planned language or reading activities with your child (or two 15 minute sessions). In school the teaching activities can be easily absorbed into the current curriculum in the classroom. Fifteen minutes of planned activities daily really will make a difference - and be more effective than an hour twice a week.

Targeting the specific profile of needs

Children with Down syndrome usually experience considerable delay and difficulties with learning to talk. Current research (described in Speech and language development for individuals with Down syndrome - An overview), identifies a common profile.

Most children and adults with Down syndrome understand more language than their expressive language skills suggest and therefore their understanding is often underestimated. Their social interactive skills and non-verbal communication skills are a strength but speech sound production (articulation and phonology) is a specific weakness. Vocabulary learning, while delayed, is also a strength but grammar learning is a weakness, so that the children tend to talk using keywords rather than complete sentences.

Children with Down syndrome show the same progression from one word to two word combinations, once they can say between 50-100 words, as other children, and they show the same progression to early grammar in their speech when they have a spoken vocabulary of 300-400 words. Unfortunately the usual delay in reaching a productive vocabulary of 300-400 words (at 5-6 years, instead of at 2-3 years) may compromise the ability to master fully sophisticated grammar and phonology in later speech.

Progress in comprehension and production of vocabulary is probably compromised by hearing difficulties. It is certainly compromised by the children's specific difficulty with speech sound production. Progress in sentence production and in later grammar learning is probably compromised by a weakness in the auditory or phonological short-term memory system.

This profile of strengths and weaknesses identifies that any remedial programme needs to aim to:

1. Reduce the effects of hearing loss by:
   1. Regular hearing assessments and prompt, effective surgical and/or medical treatments
   2. Reducing background noise, speaking clearly and maintaining eye-contact while speaking
   3. Using compensating strategies in the child's communication environment which make maximum use of visual supports (signs, pictures, print)
2. Improve articulation and phonology by:
   1. Encouraging control over oral motor skills
   2. Building up sound discrimination and production skills
   3. Practising single speech sounds
   4. Keeping a record of the child's speech sound skills
   5. Practising whole word and sentence production
   6. Using signs and reading activities to support speech sound work
3. Accelerate vocabulary comprehension and production by:
   1. Teaching a target vocabulary
   2. Keeping a record of the child's comprehension and production of words
   3. Using an augmentative communication system, usually signs, to support comprehension and production of words
   4. Using reading activities to support the comprehension and production of vocabulary
4. Accelerate mastery of grammar and sentence building by:
   1. Encouraging the use of complete sentences
   2. Teaching the early grammatical markers (bound morphology)
   3. Teaching word order rules (syntax)
   4. Teaching function word grammar (closed class grammar)
   5. Keeping a record of the child's comprehension and production of grammatical markers and sentences
   6. Using reading activities to support the comprehension and production of grammar and sentences
5. Take account of the auditory short term memory weakness by:
   1. Practising words to improve the sound traces stored
   2. Playing memory games
   3. Supporting learning with visual materials, pictures and print, to reduce memory requirement
6. Capitalise on the children's good social interactive skills and develop them by:
   1. Being sensitive to all the child's attempts to communicate, by listening and responding to them
   2. Creating opportunities for the child to make choices and to express him/herself through language
   3. Encouraging the use of gesture to communicate as it is a strength and may be important throughout life for some individuals
   4. Remembering to listen and to wait to give the child a chance to organise their contribution to the conversation
   5. Using styles of conversation that encourage the child to expand on and develop their contribution
   6. Providing as many social opportunities as possible for the child to be able to communicate with and learn from other non-language delayed children and adults in ordinary classes, around school, clubs and social activities as possible

Working on speech, language and interactive communication skills in parallel

Whenever we communicate we are using all these skills, therefore at any age an effective speech and language therapy programme needs to consider the child's strengths and weaknesses in interactive communication, language knowledge and in speech. The programme should then work on each aspect as necessary, in parallel, rather than concentrate on language learning and neglect speech, for example.

Recording progress and planning

We believe that it is important to keep records of the child's progress as this:

• Encourages careful observation and an accurate knowledge of the stage the child has reached in each area of development
• Provides a record of progress and achievements
• Provides a guide to the next skill or step forward that is to be expected, allowing you to choose the next activity to focus on with confidence that your child should be ready for it
• Ensures that the child's skills are not underestimated
• Keeps parents and teachers on task and motivated

We do not wish to impose too much extra work for families and teachers but the evidence does suggest that speech and language skills need additional targeted help and that most children and adults with Down syndrome could be talking more and talking more clearly if we take relatively simple but planned steps to help them.

Learning to talk is the most important thing that children do. It is central to all other aspects of their development. It is critically important for social and emotional development and for the development of cognitive or mental abilities, so progress with learning to talk will benefit every other aspect of a child's life.

The DSE checklists

Down Syndrome Education International has developed a set of checklists to allow you to evaluate your child's current speech, language and communication skills and to record future progress in a simple and straightforward manner. The checklists cover interactive communication and play skills, speech sound skills, vocabulary and sentences and grammar.

For vocabulary, three lists are provided to take your child to an 800-word vocabulary in stages, the first 120, then the next 340 and the remaining 350. The words chosen are based on research on the order in which children learn words. The third list also includes the key vocabulary required for reading and for number in the first year or two in school and the words needed to develop more advanced grammar and sentence structures. Remember that it is important that your child masters a 300-400 word spoken vocabulary as soon as possible as research evidence indicates that this is necessary before grammar will develop and that it will promote development of speech production skills. However, the learning difficulties of children with Down syndrome vary widely, therefore what really matters is that your child is progressing, even in small steps, and that communicating together is fun and effective.

The Speech sounds checklists and record sheets cover all 44 single sounds (phonemes) used in English and the common blends and clusters. The Sentences and grammar checklist gives examples of the early two and three word combinations that children use and then provides a guide to developing grammar.

The Interactive communication and play skills checklist provides a guide to the range of communicative functions that children use, and to their ability to join in and initiate conversations. It also covers imaginative play activities as they demonstrate a child's growing understanding of the world and this can indicate the words and phrases that the child is ready to use.

The set of checklists are a guide to all aspects of speech and language development and communication skills for children with Down syndrome from birth to five years. Some of the skills that they cover will not be mastered by most children until they are into school, so the checklists will be a useful guide to be used over a number of years.

They are designed to allow children's progress to be carefully monitored and to ensure that activities are selected that are appropriate to advance children to the next step in development. The checklists are provided with the practical speech and language modules in this series and the speech and language overview module. They are intended to be used in conjunction with the information in those modules. However, the checklists are also available for purchase in sets for school, group, or speech and language therapy services.

Parent/teacher collaboration

For school age children, it will be helpful if parents and teachers can work together to complete the checklists. Children may use different language at home and at school, therefore observation records should be kept for a week or more by both parents and teachers (or support assistants) and then the records shared in order to complete the checklists and choose targets. Talking is a continuous activity during waking hours, and parents have as much opportunity to help their children to develop spoken language skills as teachers, so working together is the best way to help your child.

Using the checklists

Before you start choosing activities from those given in this module, we suggest that you observe your child over the next few days (at home if you are a parent, in school if you are a teacher or support assistant) and note down the gestures, signs and words that he/she is already using to communicate. If your child is joining words together, then note down the words that he/she is using during the day. Keep an observation diary close to hand and write the words down just as they are said - for example, 'juice, mum' or 'go school bus' or 'me car'. Make a note of the range of communication that your child engages in, for example, showing, asking, refusing or greeting. You will be able to use your observations to complete the checklists and decide on the correct targets for your child.

Remember we are all experts at language

The checklists and all the information in this and the overview module may seem daunting. When we analyse how we learn to talk and break it down into interactive skills, sounds, words and grammar, we make it seem complicated. We hope that the detail does help you to understand all the skills that your child is mastering step by step - but do remember that you are a competent talker and communicator and that you do use all the grammar described and the speech sounds, naturally. When some of the ideas seem difficult, just think about how you talk and you will see how you use tenses, prepositions and pronouns and auxiliary verbs, for example, without usually having to think about them.

Getting started

The activities are set out for each area of development starting with interactive communication skills, gesture and sign, then speech, vocabulary and grammar. In each area, activities are recommended in developmental order, so remember to identify your child's achievements in each area and choose activities to help her/him to progress in each area. It is important to recognise that the checklists cover at least five years of typical development and development to teenage years for many children with Down syndrome. You do not need to read the whole of the module and take in all the advice and ideas at once. Start by completing the checklists and then read in each section, the ideas and advice that will provide activities for the next steps, based on your child's current level of progress.

Interactive communication

Interactive communication skills are usually a strength for children and adults with Down syndrome. Most children and adults want to communicate and to participate in social situations. They use and understand the non-verbal communication skills that everyone uses including eye-contact, smiling, turn-taking, facial expressions and gesture, to communicate and to support spoken communication, right from infancy. They also use both verbal and non-verbal skills for the same range of communicative functions as everyone else (i.e. asking questions, answering questions, requesting, giving information, commenting, expressing feelings, greeting, drawing attention to self), even though they may not be able to express themselves as fluently in speech as their non-disabled peers.

Interactive communication skills include all the non-verbal skills identified, which are used throughout life, and they include the conversational skills that develop later as children become competent talkers, such as taking turns as listener and speaker, telling stories and initiating conversations with visitors.

It is important to encourage all forms of communication because non-verbal skills, including gestures, lead to spoken language and also because children with Down syndrome may rely on non-verbal skills for longer than other children. The development of communication skills is a gradual progression for all children, and your child can be helped along this developmental pathway - her/his communication skills are not unfolding in a predetermined way on a predetermined timescale, but are influenced by her/his interactions with others.

The Interactive communication and play skills checklist provides some guidance to the progression from gestures to words and also to the social interactive uses of language.

Non-verbal communication and signing

Research studies have shown that signing acts as an important bridge to speaking for children with Down syndrome, especially in their preschool years. They learn to understand and to use new words faster if they are accompanied by a sign and, in addition can often sign the word spontaneously before they can say it.

In the authors' experience, most children with Down syndrome will not need to learn more than 50 to 100 signs before they are moving on to using words as their main means of communication. As they can begin to say a word, they usually drop the sign for that word and use the spoken word. This should be encouraged, as the spoken word will only become clearer with practice. However, sign can still support the learning of new vocabulary, as we know this will speed up learning to understand and use the new words.

Some children will join signs together in primary school years, as they move to using sentences and this is fine, but they should be encouraged to practice saying the words and reading the words in these sentences. If children are still entirely dependent on signs when trying to put 2 and 3 words together, then their speech sound skills should be reviewed as they may be in need of extra help with speech sound production.

The use of sign at four years and older

By four years of age, the amount of signing a child needs will need to be judged on an individual basis. Some children will be moving to use speech confidently as their main mode of communication, others will still be dependent on signs and should be taught new signs. The critical issue will be the child's speech sound skills and spoken language; those with better sound production skills will be talking and those with more sound production difficulties and restricted vocabulary will need more signs. A speech and language therapist will be able to advise, but it is essential to take a careful look at the use of signing for each child. Speech is difficult for children with Down syndrome and their speech will only become clearer if they practice speaking. Few children with Down syndrome require a signing environment, where all spoken language is supported by signing, in the long term.

Used appropriately, with individual planning, signs continue to be an important aid at school age. Many individual case examples from parents and practitioners indicate that signing often helps the school age child with Down syndrome to find the word they want and to speak more clearly. Signs for sounds can help the production of initial and end sounds in words and signs for grammatical markers can help to teach grammar.

However, it is essential that speaking is encouraged as the main mode of communication by four years of age and that every child is working on speech sounds. In our view, it is not appropriate to send every classroom assistant on a signing course because a child with Down syndrome is coming to the school. Some children will be already reading and talking and these should be the main modes of communication and they should be used to continue to promote their speech and language development. Other children will still be very dependent on sign and someone confident with an early signing vocabulary should support communication with them.

In summary, all children with Down syndrome benefit from the use of up to 100 signs, always used with the spoken words, to establish a spoken vocabulary, but speech sound work must continue alongside the use of signs. The amount of signing that it is appropriate to use once a child understands and uses 100 or more words/signs needs to be judged on an individual basis. Signs used to support new words, sentences, sounds and grammar can help every child. In the authors' view, most children with Down syndrome should be encouraged to speak as their main mode of communication from four years of age, with reading as the main support system for learning new words and practising words and sentences. Too much use of unplanned signing when it is no longer necessary may hold back clear speech. However, a significant minority of four year olds (perhaps 25%) and older children will still need to use signs as their main mode of communication and should be taught new signs, alongside speech and reading work.

We suggest that parents may be the best judge of the sign/spoken word balance as they will know how best their child learns to understand new words and how best he/she communicates in everyday situations.

Conversational skills

Initiating and responding

As children become talkers and use their spoken language more confidently, we need to consider the way they are joining in and also starting conversations. If you ask a question, does your child respond? Does your child comment on things that he/she sees when you are out? Does he/she ask questions? Does he/she join in family conversation at the meal table? In school, does your child ask questions, contribute in class or start conversations with friends?

If not - is it possible to think of ways to include your child in school and family conversation and encourage him/her to ask questions? Initially, you may need to draw him/her into conversations by asking questions and then giving your child time to answer, followed by comments like ''that's interesting'' - and ''what else happened?'' or ''can you tell me more?'' You may need to take turns around the table, as this will provide your child with model sentences to copy and support him/her in taking a turn in the conversation.

Be a good listener

Being interested in children's activities and being a good listener will really help in encouraging children to talk and to share their experiences. However, it is not easy for children with Down syndrome to become fluent and confident in social situations and they do need thoughtful and sensitive encouragement in order to join in and initiate conversations.

Increasing the quality and quantity of language experience

Increasing the quantity of language use and experience as well as the range of useful phrases that your child can use is important. If you observe your child at home, in a social situation or in the classroom, how much does he or she talk compared to other children of the same age in these situations. It may not be easy to increase this, but it is important to try. At school, make sure your child takes full part in 'news times', taking his or her turn with whatever support is necessary, such as a holiday picture or object to help the children to understand or the use of a conversation diary for support (see the Conversation diaries section for more details).

Include the child in answering questions during lessons and in conversations during group work around the table. Remember that the other children will act as models for the language needed to talk in the classroom, so turn taking with other children will be valuable. It is important that the other children fully understand the difficulties of the child with Down syndrome in the class, and in the school, and that they are encouraged to be sensitive, to listen and to include the child in their activities. Explain to the other children how they can help by taking turns, modelling sentences, being sensitive and taking time to listen. Even five year olds are well able to understand and to help if they are asked to. It is important that both adults and children do not become too helpful and talk for the child or jump in to prompt him/her too quickly. Remember, it will take your child with Down syndrome longer to organize what he/she wants to say.

The social use of language

Children with Down syndrome may need help to learn the language for opening a conversation such as ''Hello, Mrs Andrews'', ''Hello Susie, where have you been/did you have a good time?'' ''This is a delicious cake Gran'', ''May I have a drink/watch TV please?'', ''Thank-you for a lovely party, I've had a great time'', ''Thank-you for having me to play/for sleep over'', ''Where's the toilet''. Meeting strangers for the first time phrases such as ''Hello, I'm Julie. What's your name?'', ''Hello, Have you come to see Mr Green? Can I show you the way?'', ''Hello, I'm Julie and this is my sister Sally''. The most effective way to learn these social sentences may be to write them down on cards, which can be used to support practice and used in the real situations while the child is learning.

Behaviour and communication

School communication in lessons and elsewhere can be a problem and lead to behaviours, often disruptive behaviours, as the child's only means of communicating. Some of the behaviours that seem inappropriate in young children at school are often used because the child cannot say what they want or what the problem is. In the playground, other children crowding a child or being over anxious to 'mother' the child can lead to the child with Down syndrome pushing or seeming to hit out at children. In the classroom, a child may slide under the desk or become 'stubborn' because they cannot say ''This work is too difficult, can I have some help please?'', or ''I am hot/thirsty/have a headache''.

You may need to model, expect and prompt socially appropriate language at a level your child can master, for example ''leave me alone, please'' instead of ''go away'' or pushing. Sometimes, other children lead the child with Down syndrome into trouble by encouraging them into naughty behaviours but the child cannot say ''Terry pushed me'' or ''Sally took that pencil, not me''.

In the classroom phrases such as ''I need help please, Mrs Jones'', ''Can I go to the toilet, please?'', ''What are we going to do after play?'', ''Where is my book?'', ''I cannot do this, it is too hard'', ''I do not understand this'', ''May I work on the computer please?'', ''Can I read a book now?'', ''I have finished my work'', ''Is it dinnertime/playtime yet?'', ''When do we go home?'', ''Where are my shoes?'', ''Please help me with my shoes/coat'', ''I'm too hot'', ''I'm cold, may I get my coat/jumper/sweater please?'', ''I fell ill/poorly/sick'', ''I have an earache/tummy ache/headache'', ''My head/leg/arm/hurts'', ''I'm tired/thirsty'', ''I'm thirsty, may I have a drink please?

Some of these sentences may seem much too difficult for your child at the moment but write them on cards and help them to use them. At first your child may be able to choose the right card because they can recognise one keyword on it or you could put cartoon drawings to help - but this might deter your child from learning to say the words, so only use pictures to get started. Remember to model the sentence so that your child can copy you, both at home and at school.

Social scripts or stories^[1] can help children to understand what is expected of them in social situations and at school. For example, ''In assembly, a Year 2 pupil is expected to sit and listen quietly. First we sing and then the Headteacher will talk to us. After that we go back to our class''. ''When the bell rings, a Year 1 pupil lines up by the red door. If you can do this on your own, Mr Brown will be very pleased''. Sometimes we forget that, although we tell children off for behaving inappropriately, no one has actually made sure that they know what behaviour is actually expected of them. This issue is discussed in more detail in the social development module, with further examples of social scripts.

Speech

Most children with Down syndrome of primary school age have some delays and difficulties in developing clear speech. This can be very frustrating for them as it means that their speech is often not understood. Several small studies have demonstrated that speech work is effective at this age, and can be carried out by parents. Speech difficulties hold back the children's ability to say sentences and to develop grammar, therefore speech work should be a priority in the primary school years, at home and at school - and can be built into reading and spelling activities. The advice in this section starts right at the early stages as many children with Down syndrome will have had no speech work before they start school and some may still have immature feeding, chewing, breathing and drinking skills.

Skills that affect speech

Many aspects of children's development will have an influence on speech skills, including breathing, feeding and drinking skills and general motor control. It is important to encourage good feeding, sucking, chewing, drinking and breathing. The coordination and control of the movement of lips, tongue and breathing needed for chewing and swallowing develops similar actions that are needed for making clear speech sounds. Many 5 year olds will be chewing ordinary foods but some will not and if your child is delayed then feeding and drinking skills need to be addressed.

It is important to steadily move your child on to chewing lumpy foods, just increasing the texture a little at a time until he/she can chew ordinary pieces of food. At the same time, move your child forward to drinking from a normal cup in stages, using a cup with a spout, then a recessed lid and finally an ordinary cup. Watch that your child keeps her/his tongue inside the mouth when drinking, and does not put her/his tongue down the outside of the cup. Encourage your child to learn to drink from a straw. The special straws, with built-in valves, sold in the pharmacy for those with difficulties such as stroke patients, can help. Small drink cartons with straws can also be used to assist children to learn to use a straw, by squeezing the carton to send liquid up the straw. Encourage bubble blowing and whistle blowing games to get your child to make a round lip closure.

Often children with Down syndrome make progress with feeding and drinking skills once they are in school as they model their behaviour on the other children.

Some children with Down syndrome seem to be hypersensitive and to dislike touch around the mouth area or the feel of things in and around their mouths and these children need help to tolerate these sensations. A specialist speech and language therapist can provide advice but if this is not available, gently massage your child's face with fingers, a face cloth, or a soft brush for a few minutes several times a day. Encourage the child to try different tastes and textures and sometimes eating with fingers is more acceptable to the child than the feel of a spoon in the mouth.

Encourage mouth closure and nose breathing. Games to encourage lip closure and breath control include blowing through a straw to move pieces of foil, tissue paper or small balls and blowing pipes and whistles.

Your child's gross motor development, including head and trunk control and muscle tone, will also influence his/her ability to control breathing and face, mouth and tongue muscles.

Speech sounds

Sound games

Children with Down syndrome can be introduced to teaching activities that will help to develop their awareness of sounds and their ability to produce sounds through daily games. This type of work can be continued for as long as needed provided the activities are kept interesting and age appropriate for them. Activities that encourage the child, young person or adult to practice their sound and word production, with good models to copy and feedback, are effective for improving speech into adult life. Practice through talking and reading may take over from specific speech sound activities.

Pictures and signs will help children to remember sounds associated with those pictures and signs. Speech and language therapists in all countries have access to pictures, other materials and activities aimed at improving phonological awareness and speech production, although they may not know that these activities, designed primarily for children with speech and language disorders, are also appropriate for teaching children with Down syndrome. They may also not know how important it is for children with Down syndrome to begin learning through extra practice from their first years in school. Cued articulation^[2] and the Nuffield Centre Dyspraxia Programme^[3] are examples of this type of work. These and other programmes may not always be suitable for every child though, and do require the guidance of a trained professional to advise when and how to introduce activities.

Development of sounds

As an approximate guide, the ages by which children (90%) can produce the single speech sounds accurately are listed below, based on typically developing children who do not have Down syndrome or language delay. Among all children there is very wide variation, and the order of development of sounds cannot be predicted for individuals.

For all children, spoken words become more intelligible with increasing age and use of their language skills. Achieving intelligibility takes time, even for children who do not have specific speech and language disorders or delays. Studies suggest that at 2 years of age, 25% of children are intelligible, at 3 years, 70% and at 4 years, 90%. This does not mean that all the four year olds can pronounce all their words as clearly as adults but it does mean that 90% of them speak clearly enough to be understood by an unfamiliar adult.

A study by Libby Kumin and colleagues in the USA^[4] provides some guidelines to the expected speech progress of children with Down syndrome.

The reader may note that many of the sounds are not delayed in this study and are being learned in a different order when compared to typically developing children. The children in this study were receiving intensive speech and language therapy and not all children mastered all of these sounds. There was great variation between children, with some children having clear early sounds at 2 years and others had not mastered the same sounds at 6 years.

Many of the early difficulties noticed in children with Down syndrome are part of a normal process, and will improve, provided the children have sufficient practice through talking and using their skills. The children may be able to say a sound on one day and not the next and more practice and feedback over many months may be needed to establish consistent production. Early attempts at words may not even be close approximations and so any attempt should be rewarded.

Please notice that some sounds are not accurately produced by many 5 years olds who do not have Down syndrome or language delay. Learning to say sounds may be slow, including the progression from being able to make the sound after it has been modelled and being able to produce it from memory without a prompt.

While lack of confidence can contribute to slow progress, it is more likely that an unresponsive child cannot remember the sounds without a prompt, even though he/she may recognise it when it is said and can imitate it, rather than he is she is being deliberately resistant to producing the sound. When children understand what the game is, most will say the sounds they know and can say, in a positive and enjoyable learning situation.

Never let your child feel that they have disappointed you or place them under pressure to produce sounds or words.

Sound cards

Please note: since publishing the first edition of this book, other sound cards have become widely available. As a result, we no longer publish the DSE Sound Cards, and instead we recommend the Jolly Phonics sound cards - as these are now in widespread use in many early years and foundation stage / primary settings. [Note added March 2009]

Down Syndrome Education International has published consonant sound cards and vowel sound practice cards, developed by Patricia Le Prevost, an experienced speech and language therapist who is recognised as an expert in working with children with Down syndrome. The cards encourage imitated consonant and vowel sound production and facilitate practice with gesture and pictures.

The sound cards work by giving parents the opportunity to introduce all the sounds in a way that is fun, while also helping their children to listen really well to each individual sound. The method is similar in principle to the methods used in remedial phonological training programmes for children and adults with Down syndrome, reviewed in the research overview.

Each sound card provides a picture of an item that makes the sound associated with it. The item in the picture itself does not necessarily begin with the sound - the focus is on the sound that is made by the activity illustrated in the picture, for example, the sound of water going down a plug hole (g). Most of the sound pictures are within children's daily experience, such as a ball (b), a drum (d), a lady singing (l), a balloon coming down (f), the wind blowing through curtains (h), a tap dripping (t) and so on. Some are not, such as a pea popping, although children quickly learn all of the cards as a part of the game.

First consonants

Twenty of the 23 consonant sounds on the checklist are represented in the DSE sound cards. The pictures are chosen to represent the sound - that is the sound made by the object in the picture is the target sound.

Vowels

Nineteen of the 21 vowel sounds on the checklist are represented on the DSE vowel sound cards. The pictures are chosen to represent the sound - that is the sound made by the object in the picture is the target sound.

Sound practice beyond sound cards

Letter sounds

As children progress in their language knowledge and skills and get older, it becomes appropriate to move into alphabetic systems of representation by teaching letter sound recognition. This will help to link their speech and language activities to their developing literacy skills. Although most children beginning this type of work at school age can skip the sound cards and commence their sound practice by learning letter sounds, some children with very little speech who are still experiencing difficulties with single sound production may find it easier to get started with sound cards. Vowel sounds in particular may need picture alternatives rather than letters to facilitate practice.

At infant school, phonics schemes used with the whole class will help children with Down syndrome to say letter sounds as well as link them to letters, and to be included in whole class activities.

Computerised systems are also available as a complementary way of enabling children to practice sound production, for example, SpeechViewer III.^[5] This laptop computer version provides visual feedback so that even young children (3 to 4 years), and certainly older children (7 years and above) can see how close they are getting to making a sound accurately. When they have made the right sounds (or series of sounds, or pairs of sound contrasts like 'sh' and 's') they are visually rewarded for doing so. There are visual incentives that help to speed up the saying of single sounds in a series of repetitions, for example, with a frog jumping from lily pad to lily pad, every time a sound is said. The Speechviewer also has facilities for encouraging many other aspects of speech development, as well as phonology, including voice, pitch and control of breathing. Children unable to make a particular sound may need a speech and language therapist to show them how to make those sounds.

Improving sounds in words

Once children have begun to speak, they are practising sounds in words all the time. For example, even in the first 100 words that children typically use, almost every consonant and vowel sound is used. Initially children's sounds in the words will be approximations, determined by their phonological and speech production skills.

Repeating the words that children say so that they can hear them correctly spoken, and encouraging them to speak in games and through interactive play, with feedback, will develop their speech clarity. Be careful not to criticise though, as this may discourage your child from speaking. Repeating single words back on every occasion may distort the flow of conversation; so try to feed back the correct production of a word in a natural way. If words lose their communicative value, and the focus is totally on clarity of production in all situations, this could have a reverse effect and lead to the word being practised less. For example, when a child has asked for a ball you might say, ''yes, let's find the ball'' (emphasising the word the child said, clearly and quite loudly) or ''park, that's right, we are going to the park'' (again emphasising the word).

When children talk and are given feedback through interaction, they will continue to develop their phonological system and improve their speech. This is likely to be accelerated when they have been introduced to literacy teaching and if they are in a good language learning environment at home and school.

But, for the majority of children with Down syndrome ordinary communication experience alone is not sufficient to lead to the development of clear, intelligible speech in later years, and they can be helped to progress more quickly by focused practice on single sounds, series of single sounds, series of varied sounds, sounds in words, pairs of words with contrasting sounds and additional practice for joining words together in longer combinations.

Practice sessions that are focused on improving phonology and speech production have an advantage over practice during everyday communication, in that the child and parent both know that the game is about how you say the word and it focuses their attention on phonology. When a word can be said in a practice session, then it can be generalised to everyday language, with activities designed for this purpose.

Choosing sounds and words to practice

In order to speak clearly, children have to be able to say single sounds, then to join sounds together in a variety of ways to produce clear words of one or more syllables and finally string words together to produce sentences. At each step, the speech-motor planning and control required increases. Most children with Down syndrome will be helped by activities for each stage - at the sound level, the word level and the multi-syllable, multi-word or sentence level.

For children who are not able to produce the full range of sounds, words that contain sounds that they can say can be targeted for practice, as these are more likely to be achieved. You can use the vocabulary checklists with this module to choose words to try with them.

Speech and language therapists are able to listen to children's speech or look at records of words they can say, and make suggestions for therapy, to move them forward gradually and with success, without asking them to say words that are just too difficult at that stage in their speech development. Of course children need to practice difficult words and phrases too, and need to be gently encouraged to do so all of the time, but targeting a set of words closer to their current skill level will help them to be successful and to gain in confidence.

Without a speech and language therapist to help guide and structure the practice, we advise parents and teachers to use the speech sounds and vocabulary checklists to guide the selection of sounds and words for practice and to record progress. The sound list will help you to choose sounds for sound games and the word lists indicate words that your child can attempt but not yet say clearly.

Games with individual sounds

Practising with individual letter sounds in games, and speeding up a child's ability to accurately produce sounds is good practice for all children. Some children will still need vowel sound practice, so use vowel picture cards or combine letters in your language that usually make that sound, ideally with a character or visual reminder as well, or you can choose words that contain the vowel sounds (eyes, ear, mouth, nose, and animal sounds, baa, moo, etc). Practise letter sounds you are working on (not too many at once) and also practice words (with pictures) beginning with the same letter sounds as a complementary activity. Do not wait for all consonant and vowel sounds to be achieved before practising words, but choose words that contain some of the sounds your child can say.

Practice words that are important to the child and will help her/him gain some control over daily events. Words that your child wants to use to request and comment will be learned the fastest. Next, choose topics of interest to expand vocabulary such as the farm, animals or - for older children - a project in progress in the classroom. Scrap books can be made with pictures and words to support practice.

The THRASS reading and writing system^[6] teaches groups of letters that make the same vowel sound and is good for teaching older children of around 6 years and older.

Various 'ladder' games (like those illustrated in Figure 3) made with pictures and letters can be used to encourage children to practice single sounds repetitively, and the same technique can be used for whole word practice or contrasting word practice. Large clear ladders with characters that physically jump up the ladder rungs can be used for young children, as well as letters that jump across markers on a table or grid into a bag or to be eaten by a glove puppet. Where children are familiar with formal work, printed ladders of various types can be used, for letters or words, as illustrated below for the word 'dog'. The stickers on this example were awarded as the child was able to complete each stage for the first time.

Choose words with one letter sound targeted in one position

For example, choose a list of pictures and words that all begin with 'b'. Work through groups of words beginning with different letter sounds that you are targeting for practice. Picture resources or books that have vocabulary items listed alphabetically are useful for this, as you will already have child-interest words all beginning with the same sound presented together. Please note that clusters such as 'sl' or 'tr' need to be practised separately and are not suitable for practising the single sounds 's' or 't'.

At this stage you will know which sounds in words, at least in the initial position, are difficult or easy for your child to say, as well as how easily he/she can say sounds in isolation. You might chose to put a difficult word in with a list of easy words for your child to practice, to encourage them, and as you get more practised and your child more confident, you can choose words that really target your child's particular difficulties. If you listen to your child carefully, you will notice what some of their difficulties are, but you will need to break up words and design activities that are at the easiest level you can think of, and that you can build up later on, so that practice items are not so difficult that they are discouraging for the child.

Joining sounds for words and syllables

Joining one consonant to one vowel, as in 'key' or 'see', is easier than saying words with more sounds in them (cat, brick, slip) or a multi-syllable word, where many changes in position of the tongue, lip and soft palate are needed to make the word. (The soft palate closes so that air does not go down your nose, as in 's' and 'sh' words, and opens so that it does come down your nose a little, when you say 'm' and 'n'). Words with one consonant, like 'Emma' are easier than 'packet' with two consonant positions or 'snail' or 'school' with consonant clusters at the beginning.

Make a list of words your child can say clearly and see what similarities there are - in vowel and consonant type and position. Can he/she imitate two or three syllable words? Children's progress will be affected by how difficult it is for them to make each single sound. The easier this is for them, the more likely they can move from one sound to the next to join the sounds swiftly enough to make a word.

For focusing on the production of the rest of the word, after the initial sound, choose words where your child can say the initial sound, and that have a different ending, as illustrated in the example below for 'bun' and 'bus'.

Although choosing sounds and words to practice seems and is quite difficult, we usually expect children to learn how to say them just from listening to the words around them, without any structured help. Some selection of words that they are already trying to say, and defined practice activities, will make the task easier. Do not be too worried about 'doing it wrong'. Make sure the tasks are fun and designed to help your child to achieve the next step - if they can't, do more practice at an earlier step. Ideally, you will have a speech and language therapist who can help you. When practising two or three syllable words, encourage your child to tap out the number of syllables, in order to focus their attention on them.

For practising words, one way of deciding what is close to being achieved is to identify what words the child can imitate but is unable to say clearly without a model to copy. The vocabulary checklists provide a column for you to record these words. Successful imitation indicates that the child can physically say the words and the sounds in the words, but has not yet said them enough to remember how to say them spontaneously. With some extra practice, they will learn to do so.

Important words, words that children need, words that are likely to be practised every day

Another approach for choosing words to practice to improve children's production is to choose words that the child needs or wants to say, and practice these. For example, most children at school, will need to say number words, and will be practising every time they count. They will need to say the names of members of their family, or pets names, their teacher's name and title (Mrs Xxxx), where they live, how old they are etc., to request their favourite activities, or asking simple questions that can get them more information or aid their communication (help please?, my turn), and the more they practice the better they will get. With this approach parents will need to be very accepting of every effort, as some words will be very difficult for some children, even though they are motivated so say them. You may need to break words down into smaller parts and practice these, and of course break sentences down into words to practice in turn (just as you do when reading word by word).

Targeted practice can help at any stage or age

Children who talk fairly well (or are considered to, compared with other children with Down syndrome) will still benefit from these types of activities to improve their speech clarity, and some examples of more advanced words are included for this reason, for example 'ch' words and 'str' words.

Joining words together

Joining words together is more difficult than saying single words on their own, and it is typical for children's clarity to fall back a little when they try to do this. But with practice they get better, although they should be able to say the single word clearly before they are expected to say it clearly in a sentence. You can build up two, three, four and five word sentences, practised with visual prompts, like words and pictures, with a model to copy, which help children to focus on their pronunciation.

Features of successful therapy programmes for improving phonology

Of the few evaluated and published therapy programmes, one that dramatically improved the phonology of young children with Down syndrome, aged between 4 and 6 years at the start of the programme, provided weekly or fortnightly therapy from a speech therapist, with 20 minute practice session by parents daily when possible, over input periods of 4 to 6 weeks followed by breaks of 4 to 10 weeks. This study, by Clothra Ni Cholmain^[7] monitored changes that occurred during the training programme.

The programmes were individual according to each child's skills, but each shared the following key features:

1. Listening

The child listens to lists of words read to them by the parent for 6 to 10 minutes every day, with the help of a portable amplifier. Amplification was used to ensure that the child attended and that, by excluding distractions and compensating for possible hearing losses, the words and all the sound in them were heard clearly by the child.

2. Production

The child is asked to produce some of these words (chosen from those they could imitate) with the child saying the words into the portable amplifier. Guidance was provided for parents to include these same words in everyday games and activities, such as picture lotto and a shopping game. Parents were encouraged to request that the child repeat or clarify the target words, by expressing uncertainty about what the child had said.

3. Sound practice

Sound cards or books were provided for the children, which contained picture symbols both for phonemes being targeted and those already in the child's system. They were used to encourage the children to think about speech sound as sounds, and provided opportunities for listening and production practice in play.

All of the 6 children who participated in the programme showed change in their phonological systems within the first two weeks and appeared to begin to reorganise their phonological and sound production system.

Remember that the activities for encouraging all aspects of speech and language development will also help speech clarity, and that the more children speak and listen the more they will improve in their speech production. Children with severe hearing loss are greatly disadvantaged in learning to speak clearly and treatment with hearing aids is vital.

Consider how you can practice and improve clarity of speech through play, using the activities described as useful for developing vocabulary comprehension and speech, through everyday conversation and through reading activities.

For activities and games that break speaking tasks down, for graded practice with pictures, words and letters, please refer to the box (right).

Teaching vocabulary

All children learn new vocabulary throughout their school years as their knowledge increases. Vocabulary size is very important as it reflects the rate at which a child is learning new information about his/her world and it enables (or restricts) the child's ability to communicate. For children with Down syndrome (and many other language delayed children in regular classrooms) teaching vocabulary should be an explicit targeted activity. Vocabulary development is central to language development, and speech and language delays will have an adverse effect on progress in reading and writing, and on all other aspects of school learning and social communication opportunities.

A core vocabulary

The vocabulary covered on the three vocabulary checklists is a core vocabulary of over 800 words. It contains a range of nouns, verbs and adjectives that are used in everyday communication and, perhaps more importantly, it contains the other parts of speech necessary to develop sentences and grammar. We therefore strongly recommend that you complete the vocabulary checklists in order to identify the gaps in your child's vocabulary, even if they have good speech and language skills. Most primary age children will not have spoken vocabularies of over 800 words and the checklists will help you to identify the words that your child is not yet using in order to teach them.

Do not limit your vocabulary teaching to words from the checklists. Add any words for activities and events that your child is interested in, for project and subject work in class and for reading schemes, for example. In the primary school years it is important to teach children to link ideas and concepts together and to learn the vocabulary that links to places and events. This means that you might choose the vocabulary to work on a project on the farm or the hospital, or that you choose to work on the words in categories such as shapes, colours, animals, food or later, fruit, vegetables, birds, fish.

Choosing vocabulary to teach

These guidelines for choosing vocabulary are based on the principles used in vocabulary teaching studies reviewed in the overview module. They have been successfully used with children with Down syndrome, late talkers and children who have had hearing difficulties due to middle ear problems (otitis media) similar to those commonly experienced by children with Down syndrome.

While vocabulary is being learned during everyday learning opportunities at home and at school, children with Down syndrome need more structured help to support their learning. In the early years of primary school, using modelling (you name the object, picture, event or action) and imitation (you encourage your child to repeat the word with you) may still be necessary to help some children.

Choose two sets of words, one set for comprehension activities from the words that your child does not yet understand and one set for production activities from words that your child understands but does not yet say.

First complete the appropriate vocabulary checklists to identify the words that your child understands and the words that he/she uses in speech or in sign and complete the speech sounds checklist. (Start with Vocabulary Checklist 1 even for an older child, just to be sure that he/she does understand and use all these early words, and then Vocabulary Checklist 2). Choose to work with words that you feel your child will be interested in and that you can use naturally in play or daily activities - or by making a topic book.

Choosing comprehension targets

From the checklist, choose 5 words that your child does not yet understand and that you think that he/she will be interested in learning. As your child learns to understand the words on the list, mark their success on the checklists and choose new words to work with.

Choosing production targets

From the appropriate checklist, choose 5 words that your child understands but does not yet say. Choose words that start with sounds that your child can make or attempt to make. As your child learns to say the words on the list, mark their success on the checklists and choose new words to work with.

You may find that it is helpful to put the words up in the kitchen or on a notice board to remind everyone in the family or the class to help you to teach the words.

These lists of target words will help you to make a planned effort to extend your child's vocabulary, but you will also be teaching them other new words during your daily talk with them at home and at school, so remember to update the checklist by reviewing it from time to time. If you keep a notebook handy you can note down words that your child is saying and understanding as you observe them.

Choosing vocabulary beyond the core vocabulary

The vocabulary covered by the checklists is only a core vocabulary provided for guidance. Even before they have all these words, many children will be learning other words related to their experiences and interests, therefore choose any additional words to teach that are relevant to children's daily lives.

In school, new vocabulary will be needed for literacy and numeracy work and most of this can be anticipated in advance from curriculum guidance, and the school reading and number schemes. A 'word box' can be made to hold flashcards with the new vocabulary to be learned for reading or number or topic work that is planned. More than one word box may be useful, one for reading, one for maths and one for science or French for example.

For many lessons, it is possible to identify target vocabulary and make words in advance of the lesson, but for some subjects this may not be possible and the new words that come up in the lesson need to be noted and added to the child's word box. Picture materials may need to be devised to help children to learn the meanings of new words.

Games for vocabulary learning

All sorts of games can be played to support vocabulary learning, including finding, matching and sorting real objects, doing the same with picture cards and learning from picture books and picture dictionaries. These activities provide the opportunity to give children many more opportunities of hearing a word and associating it with the correct meaning than will occur naturally during the course of the day.

The natural opportunities for drawing the child's attention to the language being used in every day interactions are equally important. Speak clearly to children at all times, describing what they are doing or interested in and involving them in the conversation.

When teaching vocabulary, remember to teach some verbs, adjectives, pronouns and grammatical words as well as nouns so that the child can develop sentences and grammar. Remember that comprehension comes before production, especially for children with Down syndrome.

It is very important to continue to expand the number of words that children understand, even though they cannot say them, if we do not want to hold back cognitive development, that is, world knowledge, thinking and reasoning and remembering.

The child's understanding can be checked by asking them to choose the right picture or object from a choice of items for verbs and adjectives, place things correctly for prepositions and demonstrate the action for verbs. It is important to proceed at the child's pace and to be sure that he/she is really understanding and responding at each step. Plenty of fun repetition from playing games, singing rhymes and reading stories will help the learning process.

Matching, selecting and naming

Teaching games that use matching, selecting and naming activities, with real objects, toys or pictures, are a very effective way to teach new words and concepts. These activities can be used for many years to teach new words and concepts such as colours, shapes and numbers. These games are included because some primary age children will still need this kind of support for their learning while others will be able to learn new vocabulary from ordinary classroom activities, topic work and reading.

Matching - This simply involves having two identical objects, words or pictures and showing your child how to find the one that is the same though we would not use that instruction at first. We would say 'can you put the square with the square' or 'the red circle with the red circle' and help the child so that they get it right while they are listening to and learning the words.

Selecting - the next step is to ask you child to select the picture or object that you name, for example, 'can you give me the square', 'can you show me the red circle'. When he/she can do this you know that they now associate the word that they are hearing with the right object - they understand the word.

Naming - the last step is to ask the child 'what is this' or 'what's this called' as you point to an object or picture. The child can respond with a sign or a word, though you should always say the word as you point to it.

Your child will progress from matching, to selecting and then naming, maybe taking several weeks at each stage when starting to learn words. He/she will be able to show you, by selecting, that she/he understands many more words than he/she can name.

We recommend that you use real objects, toys and pictures to teach vocabulary. We discuss the use of symbols systems later but most children with Down syndrome do not need to be introduced to picture symbol systems - they will learn in the ordinary way from everyday experiences, play with toys, and from pictures and picture books. However, if you have a child who is particularly delayed and having difficulty in learning words, then the use of symbols may help.

Like signs, symbols need to be used with thought and with planning, based on individual needs, and not used indiscriminately and certainly not just because your child has Down syndrome. This applies to their use in school as well as at home. Many symbols have no advantage over actual pictures of the object, action or event, which occur in the everyday environment and in books. Most symbols have to be specially learned, their meaning is not obvious, and at this point you are teaching another 'system' to be learned (rather like teaching Chinese symbols) and you need to be clear why this is helpful and why you are not moving straight to printed words if you need a visual language.

The importance of books

Reading books together is one of the most valuable activities that you can engage in with any child to assist their language learning. Books provide pictures to help you to teach new words and ideas but they also give practice at sentences. As you read even short stories, you are using grammatically correct sentences with expression and intonation. Favourite stories are read over and over, allowing your child to learn from the repetition (as they do from favourite games and singing rhymes).

Many people who study children's language learning emphasise that the main way in which children learn language is when it is embedded in familiar contexts, with all the familiar emotions and associations that go with them. We cannot over emphasise this point - it also applies to the language you use at bath times, mealtimes, when greeting and so on. The language is learned because it is experienced over and over in situations where the child can see what you mean. Stories in books provide another opportunity for learning in a situation of emotional warmth, closeness and sharing enjoyment of the story together. New information and the activities of characters outside daily experience can be shared from books.

Please find time to read with your child daily, at home and at school. If you can, join a children's library. Children's librarians are experts on the current books available for children of different ages and stages. Here we are stressing the benefits of being read to and listening to language in the context of reading together. Later, we will discuss the benefits of teaching your child to read. Your child will probably have preferences, but it is an idea at first to choose books that are not too long and have clear simple pictures.

You can teach vocabulary from books but do not do this instead of reading the story together or your child may miss out on the pleasure of the story, and the flow of the language as the story is read. Perhaps go back to talk about the pictures after reading the page first. At this point, try asking your child to point to certain objects or to people doing activities. In addition, you could try asking him to point to people, events or activities in the pictures. It is also important to give your child an opportunity to initiate speech as well as doing things as directed by you. So as well as asking her/him to name pictures and tell you what people are doing, give her/him space to comment without your direct questioning. Expand your child's comments. Books are also a way of seeing that they are generalising the language they are learning in other situations and adapting them to new situations.

Imitation with expansion

One of the best ways to help your child make the transition from the one and two-word combinations to sentences is to use imitation with expansion. To do this you imitate and expand what he/she has said, stressing the keywords.

For example, your child may say ''school?'' while getting on his/her coat and you may respond with ''Are we going to school? Yes''. Or your child may point and say ''train'' and you say ''Yes, There's a train''. One more example might be, your child says ''more'' and you expand to ''do you want more juice'' or ''do you want more toast''.

Using visual and motor cues

Libby Kumin^[8] suggests the use of a pacing board to provide a visual and tactile reminder of the number of words your child is trying to use. For example, she suggests that a pacing board may consist of two coloured dots on a piece of cardboard, or two teddy bear blocks put next to each other, or anything else that your child likes. As you use two words point to each spot on the board as you do so. She suggests that helping your child to put their hands on the spots as they say the word will prompt them to recall the number of words that they need and to help them increase their combinations to two, three and four word sentences.

Encouraging your child to continue to sign as he/she speaks may also act as a prompt as they begin to join words. It seems that if they sign each word they may well be able to recall the signs in sequence, and this will act as a prompt for the words that they need. However, remember that at this stage we do not want signs to be used without an explicit reason for them, so you might use signs to model a two word utterance but not use the same signs in other contexts where the child can understand and use the words without help. It will also be apparent that the use of printed words can also help the child to produce multi-word sentences.

Reading

The teaching of reading and the use of print to support practice should begin in the preschool years for children with Down syndrome, therefore children should enter primary school with a 'sight vocabulary' (printed words that she/he can read). If children have not yet started to read, we would expect them to be able to match and select pictures, for example when playing a picture lotto game, and to name some of the pictures. They can then be introduced to learning printed words by playing matching, selecting and naming games as described in Reading and writing development for children with Down syndrome (5-11 years).

Researchers worldwide all agree that children with Down syndrome are visual learners. Their visual discrimination and visual memory skills are strengths, while their auditory discrimination and auditory memory skill are a weakness. We have been teaching children with Down syndrome to read from the age of two years for the past twenty years. Progress will vary but many children make surprisingly fast progress and the words that they see in print soon emerge in their spontaneous spoken language. Furthermore, children who start early - at two to three years of age - make the greatest gains in both spoken language and reading skills. They are often reading at an age appropriate level at 8 or 9 years and have very good comprehension and use of spoken language. We would speculate that we may be taking advantage of a period when the brain is most receptive to language learning and that we really are using print as a way into spoken language for these children. Please look at the programme described in the reading module and make maximum use of reading to help your child.

Symbols

Picture symbol systems are often advocated for use with children with learning delays and children with Down syndrome. These are often associated with sign systems such as Makaton signs, but we do not recommend that they are used unless your child is having particular difficulty with learning to talk or to read. We always use ordinary printed words to teach children to read, from as early as two years of age. If properly taught, almost all children will learn the words as easily as symbols. In school situations, placing the word cards around the environment - with picture clues if necessary - will be far more likely to teach children to read than putting symbols everywhere. Like spoken words, the more often a printed word is seen in a context where you can see what it means the faster a child will learn and remember it.

If symbols are used in an unplanned way, learning symbols and then print is like learning two languages, like learning Chinese and then learning English. A further problem with the use of sign and symbol systems is that they cannot teach English grammar, unless adapted to do so. Written English is essentially the same as spoken English.

Symbols can be used to support reading and writing of print if used in a planned way. For example, symbols can help to prompt the grammatical words or new words in sentences. Symbols can also be used to interest a child in reading and writing, when the child has already experienced failure and is not keen to try reading activities. Then a symbol-supported system, particularly used on the computer, may motivate the child because it looks like something new rather than something already disliked.

Two and three words together

Some children with Down syndrome will be talking in short sentences when they start at primary school but many will be using two and three keywords together. Examples of the range of two and three word phrases that children use is set out in the Sentences and grammar checklists and record sheets. Most children will have comprehension at the three keyword level and will probably be ready to move to using three word combinations to communicate.

For both two and three word phrases one way of encouraging children to move on and to string three words together is to engage in imaginative play. Playing games with your child gives you many opportunities for encouraging choices that require comprehension or production of three words or more, such as 'put the cat in the box', 'put the red car on the big box'.

Once your child has comprehension at the three word level, you can encourage expression by playing with your child and getting your child to instruct you to carry out the activities, so reversing the roles of teacher and pupil. Libby Kumin^[8] draws attention to 'carrier phrases' such as 'I want', 'I like', 'I see' , 'I can', and identifies that these can be readily taught requiring the child only to add a novel third word.

Prepositions such as 'in', 'on' and 'under', are learned at this three word stage and it is easy to devise games asking children to put something in or on a box or a table or a chair.

Making simple books on a theme such as 'I like' or 'I can' and developing reading activities will help your child to expand the sentences that they understand and use.

Teaching grammar

All the evidence indicates that few children with Down syndrome will learn grammar easily from simply listening to everyday conversations, even though this is how other children learn grammar. The main reason for this may be the slow development of the verbal short-term memory span. Learning grammar involves the processing of sentences rather than single words and this will be very difficult for most children with Down syndrome. There are many ways in which various aspects of grammar can be taught using games but we would argue that reading is the most powerful way to teach sentences and grammar once children have reached a two-word stage in comprehension.

Your child is learning grammar all the time you are talking to them in natural sentences. One simple rule will be effective once your child begins to put two and three words together and that is:-

Listen to your child's key words and expand them into the shortest complete sentence. For example ''Jenny gone'' to ''Jenny has gone'', ''Cat sleeping'' to ''The cat is sleeping''. ''Play ball'' to ''Can I play with the ball, please?''

''Mummy go car'' to ''Mummy has gone out in the car'', ''Daddy go work'' to ''Daddy is going to work''. You will already be using these expansions naturally (without thinking) as you talk to your child during the day at home or at school. This simple approach will also ensure that you teach using examples that are relevant to you child and will be able to be used by them often when they want to communicate in real situations.

You can use the same strategy when thinking about making simple books. Words that you wish to teach from the vocabulary lists, such as prepositions and joining words will also give you ideas for sentences to practice in games or with reading activities. For example ''Put the book on the table'', ''The shoe is here not over there'', ''There is a dog and a cat'', ''If you get your coat, we can go out'', ''We need our coats because it is raining''.

You can make use of an observation diary to help you observe and encourage your child's grammatical development and ability to use longer sentences. Keep a note pad handy and note down the phrases and sentences that your child is using, both in imitation and spontaneously. This will help you to be aware of exactly how he/she is putting words together and it will help you to follow the guidance on expansion above.

Conversation diaries

The first author developed the use of conversation diaries^[9] during a research project set up to evaluate the effectiveness of language intervention for teenagers with Down syndrome some years ago and they were popular with the teenagers, their parents and teachers. They can be used to support children of any age to develop their use of sentences and grammar.

A conversation diary is a personal book, which your child can take between home and school. In the book, write a sentence about something that your child has done or is going to do, that he or she would like to tell his/her friends/teacher about - using the words that he or she would use to tell someone about this event. For example, ''Last night, I watched TV'', ''I am going on holiday tomorrow to Spain'', ''We made a cake at Grandma's'', ''I helped Mrs Smith to tidy the table today'', ''Mum and I will go to the park tomorrow/on Saturday/after school'', ''Mrs Andrews helped me on the computer today. We made a book about electricity'', ''I played the drum in music today'', ''Ben and I played football in the playground''.

The conversation diary will help your child to say complete sentences and to be able to share their experiences with family and friends. If he/she can read, they will be able to write (perhaps with help) their own sentences and read them. If he/she is not yet able to read and write, then you should read the sentence and help your child to imitate it (at home and at school).

The conversation diary will serve two useful purposes. It will support your child's development of spoken language, sentences and grammar, and it will enable him/her to tell everyone what they do at home and at school. When a child has limited communication skills, they are not able to tell Mum and Dad what they did at school today and they are not able to tell their teacher or friends about the important experiences that they have out of school. The conversation diary can bridge that gap and enable everyone to talk with them about their daily lives. It is important that the child is actively engaged in choosing what he/she wants to tell using the conversation diary. It is one of the times when you will use expansion to decide on what to write. Ask the child what he/she/wants to tell and make the shortest correct sentence from their keywords. For example, if the child says ''Played drum'' you write ''I played the drum today''.

Syntax and grammar

While we know that most children with Down syndrome have difficulty mastering all the grammar and using it in their speech, there have been almost no intervention studies to provide guidance on the best ways to help them. We know that both speech production difficulties and auditory short-term memory difficulties play a part, so speech work will help and so will reading activities. We encourage the use of an observation diary in which you simply note down how your child does try to express themselves in order to see how to help them to progress, using expansions as described above, in speaking to them and in writing activities.

Grammar will be being taught also in all the reading and project activities that you are engaged in across the curriculum.

Grammar can be discussed under two headings - syntax and grammar.

Syntax refers to understanding the way word order changes meaning, for example, ''Pat hits Mary'' does not mean the same as ''Mary hit Pat''. Similarly ''Daddy has gone to work'' changes from a statement to a question if we change the word order to ''Has Daddy gone to work?''

Grammar refers to the 'bound morphemes', the word endings that change meaning (for example, 'ed', 'ing' or 's') and the 'function' or joining words such as 'a', 'the', 'is', 'are', 'if'. The function words seem to be the most difficult for children with Down syndrome, though this is also true for other children with speech and language impairments.

Syntax

Children begin to understand and use word order rules in their 3 and 4 keyword sentences and they then move on to question forms and more complex sentences.

Question forms

Your child will display understanding of question such as ''What's that?'', ''Who is coming'' from quite early, and they will 'ask' questions at the one and two word stage by pointing - but use of question forms in spoken language will come later. Remember to use them as you talk to your child - and to use 'can' and 'will'- ''Can you come here please?'', ''Could you go and look for your shoes, please?'', ''Will you take this to dad please?'', ''Will you drink up your drink please?''

It is possible to model questions and answers to encourage your child, for example, ''Why are we putting our coats on? - Because it is raining'' or ''When are we going out? - When Granny comes''. In your observation diary, keep a note of the way in which your child 'asks' questions and her/his use of question words. You will also be marking them on the vocabulary lists.

Negatives

As all parents soon find out, from quite early on children understand and use 'no' when they do not want something or they do not want to do something! Children can be helped to understand negatives in a wider range of uses with simple games such as placing objects in a bag, with one odd one out - for example 4 cars and an animal - and saying ''Is it a car?'' as you take each one out - then ''Yes, it is a car'' or ''No, it is not a car, it is a dog''.

Picture materials can also be used to teach negatives, for example ''He has his glasses on'', He has no glasses on'', or ''He hasn't got his glasses on''. Games to encourage your child to use negatives can be played - ''Have you got a hair band on?'' - and the answer modelled ''No, Jenny hasn't got a hair band on?'' This game can be played in front of a mirror, with a hat! In you observation diary, keep a note of the way in which your child indicates negatives and his/her use of 'negative' words. You will also be marking them on the vocabulary lists.

Grammar

When your child has some 250 to 300 words in her/his vocabulary, he/she will begin to use some of the grammatical markers (for example for plurals or tenses) and more of the function words in their sentences, until they talk in grammatically complete sentences. When you begin to work with Vocabulary Checklist 3, you will use these markers on the words used in sentences.

Plurals

The use of/s/on the end of a word to indicate a plural is a grammatical rule that is learned early in typical development and simple games can be played to show one or more than one item and use the plural/s/form. Children with Down syndrome may understand the plural/s/but not be able to put the/s/on the words they say because of speech sound production difficulties. There are a number of plural words that are irregular such as feet, and teeth. These just have to be learned and some of the most common ones are in the vocabulary checklists. In your observation diary, keep a note of the way in which your child indicates 'more than one' and the words that he/she is using. You may be marking some of them on the vocabulary lists. When he/she uses the/s/on words, record this on the Sentences and Grammar checklist.

The use of plurals in sentences also requires the use of the correct auxiliary with the verb, for example, 'the boy is running', 'the boys are running'.

Possession

The use of/s/on the end of a word to indicate possession is also learned early. Here again, children with Down syndrome may clearly demonstrate comprehension of the possessive form but not be able to actually sound the/s/on a word when speaking. They may use possessive pronouns such as 'mine' before using/s/on words. In your observation diary, keep a note of the way in which your child indicates 'possession' and the words that he/she is using. You will also be marking some of them on the vocabulary lists. When he/she uses the/s/on words, record this on the Sentences and Grammar checklist.

Function words

Prepositions

Some of the first grammatical words children master are prepositions, such as 'on', 'in', 'under'. Games to teach the meanings of these are not difficult to plan. More difficult pronouns, such as beside, above, below, may not be understood by children of primary school age. These can be used in sentences and acted out by children in games. In your observation diary, keep a note of the way in which your child indicates 'place' and the prepositions that he/she is using. You will also be marking them on the vocabulary lists.

Pronouns

Pronouns are a little tricky to demonstrate, especially 'I', 'you', and 'me'. Games played in front of a mirror can help, pointing to yourself while modelling 'I' and helping your child to do the same. Children usually refer to themselves using their own name or 'me' before using 'I'. The use of 'carrier' phrases, such as 'I like...'. or 'I see ..' , and their use in home-made books with photos of your child can help.

In your observation diary, keep a note of the way in which your child indicates 'person' and the pronouns that he/she is using. You will also be marking them on the vocabulary lists.

Articles

The use of the articles 'the' and 'a', and others such as 'some', takes a while to develop. These words, and the auxiliary verbs such as 'is' and 'are', may be difficult because they add little to the meaning of the sentence. They are also not stressed in normal talk and therefore may be difficult to hear and to process in the flow of words. In our experience, children with Down syndrome do not easily learn to use them in their language and reading them in sentences will help them.

In your observation diary, keep a note of the way in which your child is talking and note down any use of articles. You will also be marking them on the vocabulary lists. When you have heard the use of 'a' and 'the' consistently, tick and date the checklist.

Tenses

There are many tenses in the language, but we have simplified them to present, future and past tenses. To use many tenses properly, an auxiliary or 'helping' verb is used, for example, 'He is going', 'They will be going', 'He has been', 'They are running'. It takes most children with Down syndrome a number of years to master the use of auxiliaries and some individuals never learn to use them. However, most children do learn to use present, present progressive and simple past and future tenses to convey these meanings appropriately.

Children use the present tense of verbs first for example 'push', 'jump', 'sleep', 'run', and this is the way most of the verbs appear in the vocabulary checklists

Present progressive tense

The next tense children learn is the present progressive 'ing' form, for example, pushing, jumping, sleeping, running. To use this form correctly in sentences they need to use auxiliary verbs -for example, 'I am pushing', 'he is jumping', 'they are sleeping', 'we are running'. You will note that the auxiliaries change with the pronouns (I am, he is, she is, Mummy is) and with singular or plural agents (He is, they are). However children will use the 'ing' form of the verb on its own before they begin to use the auxiliaries. When you hear your child using 'ing' on verbs, tick and date the checklist.

Past tenses

The past tense of verbs comes in two forms, regular and irregular. The regular form is the 'ed' form, for example, jumped and pushed. The irregular forms are all different and have to be learned individually, for example, slept and ran.

Children learn a number of irregular past tense forms before they use the 'ed' form. Early ones may include 'broke', 'came', 'cut', 'drank', 'fell', 'gave', 'had', 'made', 'ran', 'sat', 'saw', 'took', 'were', 'went'. A further list of irregular past tense verbs is included in the Sentences and Grammar checklist.

Use of the 'ed' ending

In typically developing children, there is a stage when they seem to realise that 'ed' on the end of a word creates a past tense and they 'over use' it - saying 'buyed', or 'goed', for example. In our experience, children with Down syndrome rarely do this but we would be interested to know if you hear your child doing this.

In your observation diary, keep a note of the way in which your child indicates past events and her/his use of the 'ed' ending. In order to use the past tense and to help your child understand, a wall chart for the week or the month can be a great help. Mark significant events on the chart, then you can look at it with you child and say, ''Yesterday, we went to the park'', or ''Last week, we rowed a boat on the pond at the park''.

There are other past tense constructions such as 'we have been, he has jumped, he might have jumped before'. We suggest that you leave these to develop through reading and writing activities. If at the stage your child is learning to read, you help her/him to keep a simple 'conversation' diary, you will find that you begin to use these constructions.

Children with Down syndrome will understand the language more quickly if the examples used refer to their own activities and actions, rather than to characters in a book - hence the value of keeping a diary.

In your observation diary, keep a note of the way in which your child talks about past events and think of ways to expand her/his own combinations to fully grammatical sentences for practice.

Future tenses

The future tense comes next, but again needs the use of auxiliaries and the verb 'go', for example, ''We are going to Grandma's house'', ''Daddy is going to work on Monday'', ''You are going to school tomorrow'', ''He will be going to school tomorrow''.

The wall planner for the week or the month will help you to use future tenses and to encourage your child to do so. Mark the future events in the next week and talk to your child about them. As your child gets older, you can extend the planner to cover the year - and teach days of the week, seasons, months, weather - time words, ''tomorrow'', ''today'' - and time concepts - ''next week'', ''last month''- all with reference to events on the wall planner that your child takes part in.

In your observation diary, keep a note of the way in which your child talks about future events and think of ways to expand her/his own sentences to fully grammatical ones for practice.

More advanced structures

There is a lack of research into the emergence of more complex structures in children's language and even less research on effective ways to teach children to use them. However, the evidence does suggest that both modelling by expanding your child's utterance to the correct sentence and getting your child to imitate by copying you or by reading, are both important strategies. Most children with Down syndrome will be using 3 and 4 keyword sentences by 5 years of age, some will be further ahead than this and some more delayed. Therefore, most children will not use complex sentences until they are in primary school or even later. Young adults with Down syndrome often continue to improve their spoken language through their twenties.

The examples included here are those that will be needed in primary school, such as comparatives for understanding quantity, and those that occur in assessments of children's grammar. More research is needed on the development of grammar in the spoken language of children with Down syndrome and we suggest that you continue to use your observation diary to note down the sentences your child is using as a basis for deciding how to extend them.

Comparatives

Once children have some understanding of words such as big and small, they move on to understanding that size can be relative.

• Big, bigger, biggest
• Small, smaller, smallest
• Daddy is taller than Mummy
• Jenny is taller than Bob but Mummy is taller than Jenny

In this example - Daddy is the tallest and Bob is the smallest. Many children with Down syndrome will be in junior school or older before they really understand comparatives. We have used the example of height because it is easy to choose real life examples from family or school friends to teach it.

More complex sentences

There are many more complex sentence constructions such as embedded clauses, passives and the use of 'but not' for example. You may not feel that your child needs to be able to use these but they are included to provide further development for children who are making good progress and are reading and writing at junior school level or above (8 years and older). Many complex sentence forms will be used in children's reading books at this level and children's ability to understand what they read will be undermined if their grammatical knowledge is very limited.

Embedded clauses

'The dog chasing the cat is black' and 'The boy who is hungry is getting his dinner' are examples of sentences containing embedded clauses.

A child who can understand, 'The dog is chasing the cat' and 'The dog is black' as two separate sentences, may not understand the compound sentence. Picture material can be used to help children to understand these expressions. For children with Down syndrome, reading them in order to support learning to understand them will help, as their limited verbal short term memory skills may make these sentences very difficult to listen to and process.

Passive sentences

'Sally is being teased by her brother', 'The cat is being chased by the dog' are examples of passive sentences.

'The cat is being chased by the dog' is the passive form of 'the dog is chasing the cat'. Many typically developing children do not master passives until they are in school and reading from books. If you wish to teach this construction to older children, again use their everyday experiences to make teaching materials. They can act out - for example, 'Jenny is brushing Annie's hair' to 'Annie's hair is being brushed by Jenny' - and then write the two examples down under a picture of the action. -Billy is cleaning the car' or 'the car is being cleaned by Billy'.

X but not Y sentences

'It is windy but not raining'. 'Billy has fallen over but he is not crying'. This type of sentence can be taught with actions and simple picture materials.

These are just some examples of complex sentences that we all use. However, we would remind you that if you listen to what your child wants to talk about and then expand their utterances into correct sentences, you will teach them all the useful grammar that they need and that they will be able to use in real situations. Always try to teach using examples that are relevant to you child and will be able to be used by them often when they want to communicate for real.

Overview

This module has been written to encourage you, as a parent or teacher, to make a carefully planned effort to accelerate your child's speech, language and communication skills. We hope that you have found the checklists, the advice and activities useful and relatively easy to use. We realise that we have provided a large amount of information and have asked you to spend some weeks learning about communication and assessing your child in order to make use of the programme.

We have included this amount of information and detailed guidance because we think that it is impossible to exaggerate the importance of speech and language development for every aspect of your child's social and mental development. Please let us know how helpful or difficult you have found this module and please contact us if you need further help.

Remember that you are helping your child to progress all day everyday, at home and at school, as you talk naturally to them - the extra activities will help but are an addition to all the language learning that is occurring naturally. Remember to speak clearly and to encourage eye-contact with your child in these everyday conversations. They need to be looking and listening. They will also be helped by visual cues in sign or picture. Remember also that background noise will make listening much more difficult for them if they have any hearing loss. Small rooms help, turn off the TV and radio at home and sit children near the front of the class in school.

Your primary age child will also benefit from as much social experience at clubs and activities with non-disabled children as possible, to offer a range of experience and communication opportunities.

Speech and language therapy

It is clear from the evidence reviewed in Speech and language development for individuals with Down syndrome - An overview that children with Down syndrome will benefit from speech and language therapy during their primary school years. In many countries, this will not be a possibility, and parents and teachers will need to use these materials without expert help. Parents in this situation might find working together in a small group helpful.

The way in which services are offered obviously depends on the availability of speech and language therapists. It is important that therapists have some specialist training and knowledge of the specific needs of children with Down syndrome, and access to the research literature and appropriate resources. Experience of working with children with moderate to severe learning difficulties is not an adequate basis for working with children with Down syndrome.

A typical level of service to children included in mainstream schools in the UK will be a visit to school by a speech and language therapist two to four times each term, to assess the child's progress and set targets for activities. The aim of this expert therapy should be to assist the parents and teachers or classroom assistants to become experts themselves, by setting appropriate targets with them for speech, language and communication work, and then modelling effective activities and interactions for them, to enable them to help their child all day, every day, during ordinary daily routines and through planned play and teaching.

We have found that classroom assistants and parents appreciate being shown how to do the activities by watching the speech and language therapists work with their child, rather than just having the activities explained. It is also helpful if the speech and language therapist can help to set appropriate targets for reading, writing and spelling work based on the child's language comprehension level and expressive speech needs. It is especially helpful if the therapist is able to build the child's speech work and language work into the daily curriculum of the classroom.

In some areas, group sessions are offered to children with Down syndrome who meet up with children from other schools for speech and language therapy. These groups may also have other goals such as helping to develop age appropriate behaviour and to provide the social opportunity to mix with other children with Down syndrome, to interact with others at a similar developmental level and develop play skills, and to explore over time their understanding of having Down syndrome.

At the present time, there is no ideal model of service that is universally agreed upon and, of course, each child with Down syndrome should receive a service based on specific individual needs, not on the diagnosis. As inclusion develops it is likely that speech and language therapy services will move to being school based, making the level of service available to each child much more frequent and appropriate. This will lead to the speech and language therapist being a full member of the school team and to make a much more significant contribution to the curriculum and the speech, language and communication environment in school.

Acknowledgements

The authors would like to thank all of the children, families and colleagues that they have had the privilege to work with and learn from over a period of 20 years. In particular, they would like to record their thanks to Patricia Le Prevost, Specialist Speech and Language Therapist, who provided most of the games illustrated and from whom they have learned a great deal that they hope is accurately reflected in this publication.

The authors would also like to thank Patricia Le Prevost, Ben Sacks and Leela Baksi for their helpful comments on various drafts of this module and the checklists. However, the responsibility for the final content, and any errors, is solely that of the authors.

Terminology

The term 'learning difficulty' is used throughout this module as it is the term currently in common use in the United Kingdom. The terms 'mental retardation', 'intellectual impairment', and 'developmental disability' are equivalent terms, used in other parts of the world.

In this module, the authors have adopted a straightforward and direct style in which the reader is addressed in the first person. They have done this because the module is mainly concerned with practical activities and instructions, and the authors have found that this direct, active style has been appreciated by readers in previous publications.

Resources

Many of the resources referenced in this publication are available via Down Syndrome Education International's specialist mail-order service. For further information and a catalogue, please call +44 (0)23 9285 5330, or see http://www.dseinternational.org/.

References

1. Gray, C. (1994). The new social story book. Arlington, USA: Future Horizons.
2. Passy, J. (1993). Cued articulation and cued vowels. Ponteland, UK: STASS.
3. Nuffield Centre Dyspraxia Programme. London, England: The Nuffield Hearing and Speech Centre.
4. Kumin, L., Councill, C., and Goodman, M. (1994). A longitudinal study of the emergence of phonemes in children with Down syndrome. Journal of Communication Disorders, 27(4), 293-303.
5. SpeechViewer for Windows [Computer Software]. (1998). Armonk, NY, USA: IBM Corporation.
6. THRASS. Teaching Handwriting, Reading and Spelling Skills. Chester, UK: THRASS. Website: http://www.thrass.co.uk/
7. Cholmain, C. N. (1994). Working on phonology with young children with Down syndrome a pilot study. Journal of Clinical Speech and Language Studies, 1, 14-35.
8. Kumin, L. (1994). Communication Skills in Children with Down Syndrome: A guide for parents. Bethesda, MD, USA: Woodbine House.
9. Buckley, S. Improving the expressive language skills of teenagers with Down syndrome. Down Syndrome Research and Practice, 3(3) 110-115. [Open Access Full Text ]