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Early Development Groups (EDGs) for pre-school children with Down syndrome run every Thursday at The Sarah Duffen Centre in Portsmouth. The sessions are currently attended by 36 families with children ranging in age from 13 months to 4 years and 4 months. There are eight groups, loosely divided by chronological age, with infants aged 12 months to 2½ years attending one week and those aged 2½ to 5, the next. We also welcome parents with babies aged less than 12 months to observe the group sessions and join the informal sessions in the playroom. Visiting professionals and those in training are also welcome by prior arrangement. Many of our families are relatively local to the centre although some travel much further for their fortnightly session.

This article provides an overview of the activities that take place during a typical session and describes the areas of development that they promote. Many of the activities can be incorporated into everyday family interactions or built into a 10-15 minute daily slot for focused work with the child. We aim to model activities to the parents to give them confidence in their own interaction and focused teaching at home. It should be noted at this point that the EDGs should be seen as a supplement to the statutory and voluntary services that should exist within the local community, e.g. Portage, speech and language therapy, child development centre and nursery or pre-school placements. We hope that this article might encourage people to establish their own groups in their local area.

The morning is divided into two parts; group sessions in the library or hall and informal play and discussion in the playroom. The groups offer structured, pre-school, educational activities to progress infants' speech, language, social, play and communication skills, reading, number and motor skills. Each group offers activities that are relevant for the children's age and stage of social, language and cognitive development. The direct work with the children lasts between 20-35 minutes depending on age and this is followed by 15 minutes or so of individual time with the parents to discuss progress and set targets, which can be followed up in activities at home. The children sit around a small table, with their parents sitting behind them. Parents are encouraged to assist their child as necessary, e.g. helping them to sign 'hand-over-hand', modelling the desired responses, prompting and supporting as appropriate. We also encourage the parents to take responsibility for their children's behaviour although we try to model appropriate strategies and responses.

During the informal play session, families have a chance to talk to each other and the staff over a cup of tea or coffee. It's a great opportunity to exchange ideas with other parents and gain individual advice regarding development and behaviour. Many parents have commented on the emotional support derived from the friendships formed with staff, (some of whom also have children with Down syndrome), and other parents who have shared similar experiences.

Each child has a confidential records folder where we keep information on their progress. Parents complete DownsEd speech sound and vocabulary checklists and at the end of each session, brief observations are recorded in each child's file. These records help us to set appropriate targets for families to work on at home and allow us to differentiate activities and resources according to each child's individual needs.

Each week the sessions are carefully planned to include activities to promote the different aspects of development such as social development, play skills, speech and language and an understanding of concepts such as number and colours. The variety of everyday objects, toys, pictures, musical instruments and vocabulary used within the sessions have been chosen to provide a positive multi-cultural experience and gender stereotypes are challenged in the toys, colours, pictures and sentences used in interactive play, vocabulary and sentence work.

The activities are varied each week and suggested follow-up work at home loosely leads into the activities planned for the next session. Whatever the variety or order of activities, the important things to remember are that the children need lots of positive reinforcement and praise; they need to experience errorless learning through modelling or prompting to achieve the correct response. The language used in the sessions is grammatically correct but natural, (not simplified), with some emphasis on the key words. The pace is relatively swift to maintain interest and the emphasis is always on teaching rather than testing. Signing is used to support the spoken word but signing is reduced for words that the children can both understand and produce themselves. The next section reviews the individual activities and the boxes include sample sessions for the different age groups.

Social development

Social development is considered to be a strength for children with Down syndrome, as they tend to be very good at 'reading' non-verbal cues in people's faces, body language and tones of voice. The children tend to have good social understanding and behaviour and this means that they are particularly well suited to learning in a group setting such as the EDGs. The following activities are used to develop social communication skills such as joint attention, listening, turn taking, sharing and eye contact. We work hard to develop the children's attention as it is a very important skill that underlies their ability to learn about the world.

The Register

The group leader starts by drawing the children's attention to the register. This has the word 'register' and a list of the children's names in big letters. The group leader starts by asking each child to identify him/herself, saying something like, "Is Alice here?" Children are rewarded with individual greetings for saying "yes" or "me", pointing to themselves, holding up a hand, smiling or making eye contact depending on their age and individual needs. If someone is away, the group leader uses the opportunity to model negatives and pronouns, e.g. "Is Alice here? No, Alice is not here" or "she's not here". The "she" and "not" are emphasised and signed. Completing a formal register in this way not only develops age appropriate behaviour and prepares children for school, it also encourage turn taking, listening and learning from others.

Roll the Ball: A fabric ball is rolled 'to and fro' between the members of the group. The group leader might start by saying, "Look, it's a ball" and signing ball. She might encourage everyone to say or sign ball and then roll it to one of the other children saying "now Alice has the ball". Children should be encouraged to follow the ball and look at the person who has it. This develops shared attention to the ball and to the people they are receiving it from and rolling it to.

Maracas and Bells

This game introduces the instructions "stop" and "go". Children are encouraged to take either maracas or bells from the basket. The game starts when the group leader says "go" and shakes the bells or maraca. This models the desired behaviour to the children, who are praised for joining in. The leader should smile while the bells and shakers are in motion. The next command should be "stop", at which point the leader stops shaking the bells and sits quietly. This game encourages the children to make choices, listen, participate, follow instructions and develop shared attention. Children can be encouraged to sign 'more' if they would like to have another go. With the three to four year old children, we often ask "who would like to be the teacher now?" where the "who" is emphasised and signed. This child can be encouraged to start and stop the others. This develops understanding of 'who' and also of taking the lead.

Nursery rhymes

Children are offered the choice of two nursery rhyme cards, which display a simple picture to illustrate the rhyme. Parents may be asked to suggest two rhymes from the available selection, that the child knows and enjoys. This encourages pointing and making choices; it does not matter if the children do not understand the consequence of their actions at this point; they will come to understand this over time. The leader starts the singing, encouraging the children to join in. Often, they sing or sign the last word in each line or the key words in each line. Children can be encouraged to sign or say "again" if they would like to hear the song again.

Free drawing, puzzles and pretend play

In the 20 minutes at the end of the group session, children are encouraged to play independently while the parents discuss individual progress with the staff. Often the older children will be given felt tips and paper or puzzles to share. Additional sets of pretend play items could also be provided for the children to use during this time. Although, these activities will develop fine motor skills, it is also a good opportunity for the children to engage with play activities and with each other without an adult audience. It may help to develop intrinsic motivation, sharing and spontaneous communication and speech.

Pretend play skills

The group leader has a basket of pretend play items including a doll, brush, cup and plate with pretend food, flannel and bed cover. The leader will ask the child to "give dolly a drink" or "put the dolly to bed", modelling the actions first. After the child has demonstrated his or her understanding the leader encourages him or her to pass the equipment to the next child, by saying "David, it's your turn now", signing the possessive 'your' (turn). This activity develops children's comprehension of language at the two key-word level. The ability to link ideas in pretend play will support the ability to link ideas in speech. The game also develops shared attention, builds imaginary play skills and learning by watching others. Children can also be asked "Who would like to give dolly a drink?" etc. When children are able to indicate that they would like a turn, they are developing important social skills needed for inclusion in games with other children.

Speech and language

Our speech and language activities aim to develop speech motor skills, auditory discrimination, comprehension and production of single words (vocabulary) and early grammatical markers including amongst others 'ing' (present progressive tense), early prepositions such as 'in', 'on' and 'under' and pronouns such as 'he' and 'she'. The content of the activities, e.g. the targeted speech sounds, vocabulary and grammatical markers or function words, take into account the wealth of information regarding the developmental sequence in which these are typically acquired.^{[1, 2]} The children's checklists (completed by their parents) help us to differentiate the activities according to the children's stage of language development. It is important to recognise that language comprehension is always more advanced than expressive language and therefore it is important to include activities that support comprehension and production separately. Also, the difference between levels of comprehension and production for individual children can be large, some children may understand large numbers of words but produce only a few words or signs. It is therefore important to plan activities for comprehension that are at the correct level and not take limited expressive language as an indicator of a child's overall speech and language skills and knowledge.

For this reason, we target comprehension with activities at the single-word level for vocabulary development and use simple grammatically correct sentences with two, three and four information carrying words in our spoken language and in reading games. Similar activities are used to encourage expressive language at a level that is appropriate for individual children.

Blowing bubbles

The group leader blows a bubble and catches it on the bubble wand. The bubble is presented to the first child who is asked to blow the bubble. The action is modelled first to show the child what to do. This encourages the children to make an 'O' shape with their mouth, so developing oral motor control. Children normally go through a developmental sequence of popping the bubbles with their hands, then looking as though they are trying to eat the bubbles (although they are probably just trying to imitate the correct mouth shape!) and finally blowing the bubble. Children often find this a motivating interlude, which regains wandering attention and can be used to give a break between tasks which make higher cognitive demands. Again, the words or signs for 'more' and 'again' can be practised in order to request another turn.

Speech sounds

We use the DownsEd sound cards in the groups. A selection of cards can be worked through fairly swiftly, with the leader modelling the sounds and the children joining in where possible, either signing or producing the sounds. The children also enjoy choosing individual foam letters from a plastic wallet and jumping them back into the bag while making the appropriate sound, e.g. "b, b, b, b". These activities promote auditory discrimination, speech sound production and develop the phonological loop, that is, the part of short-term memory concerned with processing verbal information. The second activity also develops knowledge of the sounds that correspond to the different letters of the alphabet (grapheme/phoneme correspondence).

Vocabulary

Research conducted by the charity over the past 23 years has suggested that 'teaching reading to teach talking' can be the single most effective strategy to improve speech and language in children with Down syndrome. Research has shown that children are likely to learn from simple reading activities when they have a receptive vocabulary (an understanding) of at least 50 words and they are able to picture match. One of the major aims of the EDGs for younger children is to model and engage children in activities that will help them to build a receptive vocabulary of 50 words. At this stage they will benefit from reading activities to develop their speech and language skills. The EDGs for older children focus on the reading as a way to develop children's receptive and expressive vocabulary, their understanding of grammatically correct sentences and their ability to join words together in their expressive language. The use of reading activities will be returned to below.

The following activities are used to develop vocabulary. The targeted vocabulary is linked to the children's developmental checklists, which indicate the general order in which words are acquired. The target vocabulary for younger children is drawn from the first developmental checklist (first 120 words) and in the older groups, we might begin to use some vocabulary from the second checklist (second 340 words). We include nouns and verbs so that the children are able to progress to the next developmental level, understanding and producing two words together, in two word utterances such as "Daddy sleep" or "dolly eat".

The words are said to the children and vocabulary development is supported by signing. The signs are used as a bridge to the spoken word and help to 'show what you mean' as children with Down syndrome do not learn words easily purely from spoken input. Evidence suggests that children in sign-supported intervention programmes have bigger spoken vocabularies at five years old.^{[3, 4, 5]} We do not emphasise the use of signing to the same extent, however, if we know that the child can say the word for him or herself. In the following descriptions, note that the activities can be manipulated to encourage understanding and/or production, depending on the individual child's speech and language needs.

Matching, selecting and naming games

We use matching, selecting and naming games to teach new vocabulary at the single-word level. For example, children are shown four of the DownsEd language cards, 'picture-side up'. They have to match a corresponding set of pictures to them. Once this skill is mastered, they can be encouraged to select a particular picture to give to the group leader to 'put away' or 'post' in a post-box. This targets single-word comprehension. When the child 'posts' the picture, the group leader might say "the ball's gone" or "the biscuit's gone". This paves the way to two-word understanding and could be used as an extension activity that parents and children can play at home with objects and pictures.

Children who can match and select certain noun or verb pictures are demonstrating their understanding and the next stage is to encourage production of the words. The following activity can target single-word production but can be adapted to target comprehension. We use a selection of the large ColorCards Nouns or ColorCards Verbs for group work, although our DownsEd Language Cards are useful for home-use as they cover 54 words from the first vocabulary checklist. The cards are handed out upside down and the children are asked to turn their card over when it is their turn. The group leader asks each child to turn over his or her card and asks, "what is it?" emphasising and signing "what". Some children may be able to sign or say the word but often this activity is used to model correct responses to the children and builds both their understanding of the words (receptive vocabulary) and naming skills (expressive vocabulary). With the verb cards, the children can be encouraged to act out the verb or to clap the rhythm of the two syllables, e.g. 'drink-ing', 'kick-ing', 'wav-ing', 'danc-ing'. It is important to include a range of nouns or verbs that are suited to the receptive and expressive needs of the children in the group, e.g. using simpler nouns and verbs in the naming part of the game (production) and modelling more complex ones to develop their receptive vocabulary.

Once the children are able to match, select and sign or say some pictures, we move onto matching single printed words. We use two sets of the DownsEd Language Cards 'word-side up' or make our own cards with printed words on them. The children have to match corresponding printed words. Again, once they are able to word-match, activities can involve word selection and word naming (single-word reading). During teaching, we are careful to say the word clearly at the same time as the child looks at the printed word. The child then takes the printed word card and matches it to the same selection of four word cards.

The next stage is to match words to pictures. The words chosen may be from a particular category, eg animals or food, although the category name itself would not be introduced until the child has a much larger vocabulary. It is important that when you are encouraging the child to read/say a printed word, you show them the printed word and then the picture or object otherwise he or she will simply be telling you what the picture is and not telling you what the word says. This rule also applies to reading activities at the sentence level.

Games involving real objects provide a change. Children have the opportunity to handle a variety of toys and objects and engage with both the object and the activity. With the younger children, we use a feely bag containing first animal toys such as pig, duck and cat or first objects such as ball, keys and socks to promote comprehension and/or production of first vocabulary. The children are asked to take one out and then name/sign what it is. If children are not at the expressive level, the word is modelled and signed for them. At the end, the toys are returned to the bag or basket while the leader says things like, "Thank you Alice, the duck is in the bag" emphasising the noun 'duck' and modelling the preposition 'in'.

At the moment, the children in our groups particularly enjoy an activity using toy vehicles. They are asked to choose a toy from the basket, which they are allowed to play with on the tabletop for a minute or so. The group leader then shows pictures of the toys and asks "Who has got the bus/train/helicopter?" matching the real toys to the pictures. Selecting can be incorporated by putting two toys in front of a child and asking them to put one of them in the basket. The group leader models the names to the children; as each vehicle is named, the child is asked to put the toy "in the basket". Some children can name the vehicles for themselves. The final part of the game is to match the individual printed words with the same words (in the same size and font) on an A4 sheet of card. The children are asked to "find the same", where the leader signs 'same', saying "Well done they're the same" for a correct match. Children will need to be encouraged to 'have a look round' when they are matching words or pictures to ensure that they scan all four choices. These activities will help the child to build the skills necessary for reading and help the children to develop a sight vocabulary.

During activities, we use attribute words like colour and size and for more advanced children with particularly large receptive vocabularies, we may introduce attribute words such as prickly, smooth, heavy, light, soft or hard. Children are encouraged to feel objects and the words are modelled to them. We would not expect children to necessarily demonstrate their understanding, this would simply be an exercise to expose them to more complex vocabulary and prepare them for the type of activities they will experience at school.

Grammar

Children with Down syndrome tend to develop their understanding of grammar and function words like 'in' 'the' and 'is' from reading simple sentences and this is explained further below. However, there are a number of speech and language activities targeting specific function words like the pronouns 'he' and 'she' and the prepositions 'in', 'on' and 'under' which do not involve reading printed words.

Prepositions

The feely bag game described above can also be adapted for the older children to teach prepositions. The 'tidy up phase' now becomes the main focus of the teaching work. The children would be asked to put the items 'in', 'on' or 'under' the bag with the leader modelling sentences such as, "the duck is under the bag". This activity targets comprehension and would be appropriate for the children aged around 2½ years and older. The group leaders have also played games involving the ColorCards – Prepositions and small world play equipment where children can be encouraged to put the boy 'in the cupboard', 'on the table' or 'under the chair' and with large vehicles, for example placing the man or lady 'in', 'on' or 'under' the tractor.

Pronouns

With children aged four and above, we might show one of the ColorCard Verbs pictures and say "Look, he's drinking". This enables us to work on the children's understanding of 'he' and 'she'. At the comprehension level, children could be asked to select "he's drinking" from a choice of two pictures, one of a man drinking and one of a lady cutting. At the production level, some children might be able to join two or more signs or words together to tell the leader what is happening in a certain picture. The same cards can also be used to practise negatives, e.g. from a choice of two pictures the child has to select "the boy is not drinking" where 'not' is emphasised and signed. This would only be appropriate for children with quite advanced receptive language skills.

Reading

Children who understand 50 or more words, who are able to match pictures can begin reading work at the sentence level, e.g. "The cat is sleeping". The child is encouraged to point at each word as the parent and child read the sentence together. When carrying out a sentence reading activity, you should present the sentence on its own, (without a picture) to encourage the child to focus on the words and build a sight vocabulary. A picture to illustrate the sentence can be introduced afterwards, and the child can be encouraged to put the two together. Comprehension could be tested by giving the child two pictures to choose from. The activity can be differentiated for a child with more advanced language development by using sentences with more information carrying words such as "the cat is sleeping in the basket" or presenting a larger variety of pictures to choose from. A child at an earlier stage of language development could be encouraged to match single words to the correct sentence from a choice of two, e.g. cat, sleeping. It is important to remember that children who are unable to read independently or who have very limited speech production will still be benefiting from this type of activity. They will be increasing their receptive vocabulary and will be benefiting from the opportunity to learn from others in the group.

Variety can be introduced by asking the children to match phrases with real objects, e.g. the big cup, the small brick, the red ball. This game works at the two-word comprehension level and is therefore suitable for children who can understand at least 50 words. The same basic activity can be differentiated for children with more advanced language development, by adding more information carrying words and more advanced vocabulary, e.g. the stripy ball. To work on prepositions, you could encourage children to read the sentence with their parents and then, as mentioned above, create the scene with small-world play equipment, e.g. "the mouse is under/on the chair".

Personal books: We have made our own small reading books to give children to read at home. The first one was about animals using single animal words, pictures and short phrases. We will build up the complexity of the sentences as we work on different concepts: "Here's the white dog", "The white dog is sleeping" etc. The older children are asked whether anyone would like to read their book to the group.

Number skills

Number line: Children point to the numbers along the number line from 1 to 10, saying the words where possible. The counting is supported by the group leader and parents and the pace is swift so as not to put pressure on the child if they are unable to say the numbers. Some of the older children, with more advanced speech and language and cognitive skills, use a number line 1 to 20.

Matching, selecting and naming the numerals: Children are given a set of numbers from 1 to 10 which have been cut up individually to match with the number line. Once they have mastered matching, children can be asked to 'give' the group leader various different numbers or name a number which is pointed to on the number line. This is a fairly advanced skill and is only practised with the older children.

Counting objects: The group leader asks each child "Would you like to count cars or eggs?" The 'cars' are six small plastic cars and the 'eggs' are six sparkly egg-shaped shakers which the children love. The child is encouraged to count the objects from one basket into another, counting together with the leader at first. The concept of cardinality is reinforced by saying "Well done, there are six eggs in the basket", with the emphasis on the six.

Numicon matching: DSNU has run various articles, (April 2002, February 2003, and May 2003) about Numicon, an approach to teaching number that encourages the use of visual and tactile representation of the numbers to aid calculation. We introduce the Numicon shapes in our groups for children aged between 2½ and 3½ years old. We lay the one, two, three and four shapes out in the correct order and then encourage the children to lay out a second set of shapes underneath or on top of the first set. Tactics such as modelling, prompting and handing the child the correct shapes can be used to help the child and promote errorless learning.

Concepts

Colours: A simple game to introduce colour involves matching coloured circles with coloured balloons on a picture. Reading activities can also work on matching the colour words and introducing colour into the personal reading books. The colour words can easily be emphasised and reinforced in many other games such as the 'bells and maracas' game mentioned above. Recently, we have tried a game to teach clothing words using items of clothing made from card and felt that are used to dress a cardboard cut out of a boy or girl. We have also linked a reading activity to this to practise the colour words, e.g. 'the red jumper', 'the blue trousers'.

Shapes: The words for simple shapes, e.g. circle, square and triangle, can be introduced by encouraging the child to match, select and name plastic shapes. Some of the children learn more shape words such as hexagon, star and oblong.

Size: The words big and small can be introduced when playing simple reading and speech and language games at the single and two-word level, e.g. matching the phrase 'big cup' to the correct one from a choice of two toy cups, small and big.

Memory: A full range of activities to develop memory are described in the DSii module Memory development for individuals with Down syndrome. We play 'hiding' games in the groups. An object will be shown to the children, named, and then hidden under a cloth and the children are asked to say or sign what it was. Another game, which might be more motivating, uses objects which make a sound which you can hide. For example, the group leader would show the children a toy duck, then hide it behind her back, and say "Quack, quack! Oh, what says quack, quack?" A more complex game involves hiding two objects under a cloth and removing one while the children shut their eyes. Then the group leader can show the children the object which is left and ask them 'what' has gone. The 'what' should be emphasised and signed. Another game, for older children uses a simple 'flip book'. Up to four vocabulary picture cards can be inserted into the plastic pockets and then hidden behind the flaps. The children are shown the pictures one at a time and have to try to remember them. The group leader might show the children the picture of a cup and hide it under the flap and the children have to sign/say cup. Then she might show the children a picture of an apple and hide it. Then she would point to the flap with the cup behind it without saying anything (extra information from talking might affect their memory) and wait for the children to say/sign cup. Then she would point to the flap with apple behind it and see whether they can remember the second item.

Motor skills

Children are developing their tactile and fine motor skills when they are handling objects, turning over cards, lifting flaps, placing items 'in', 'on' or 'under' and completing inset puzzles. Free scribbling/drawing with the felt tips helps to refine the child's grip, moving from the palmar grasp (using whole hand) towards the tripod grip (using 2 fingers and thumb).

Food for thought ...

Hopefully, this article has provided some insight into the work that goes on in the Early Development Groups and may inspire parents and professionals to work on similar projects in their own regions. Finally, the activities do not necessarily need to be carried out in a group as described in this article, they can also be played at home with other adults and/or brothers and sisters modelling the activities for the child with Down syndrome.

If you are interested in starting a group in your own area, please contact us, as we would like to offer you support and advice on a variety of issues associated with running groups besides the activities themselves.

References

1. Buckley, S. (2000). Down Syndrome issues and information: Speech and language development for individuals with Down syndrome – An overview. Portsmouth, UK, Down Syndrome Education International. [Open Access Full Text ]
2. Buckley, S. (1999). Improving the speech and language skills of children and teenagers with Down syndrome, Down Syndrome News and Update, 1(3), 111-128. [Open Access Full Text ]
3. Miller, J. (1992). Development of speech and language in children with Down syndrome. In I. Lott and E. Coy (Eds.), Down Syndrome: Advances in Medical Care. New York: Wiley-Liss.
4. Miller, J.F., Leddy, M. and Leavitt, L.A. (1999). A view toward the future: Improving the communication of people with Down syndrome. In Miller, J.F., Leddy, M. and Leavitt, L.A. (Eds.), Improving the Communication of People With Down Syndrome. (pp. 241-262). Baltimore, MD: Paul H. Brookes Publishing Co.
5. Kumin, L., Councill, C. and Goodman, M. (1998). Expressive vocabulary development in children with Down syndrome. Down Syndrome Quarterly, 3(1), 1-7.

Further reading

• Buckley, S. and Bird, G. (2001). Down Syndrome issues and information: Speech and language development for individuals with Down syndrome - (0-5 years). Portsmouth, UK: Down Syndrome Education International. [Open Access Full Text ]
• Buckley, S. and Le Provost, P. (2002). Speech and language therapy for children with Down syndrome: Guidelines for best practice based on current research, Down Syndrome News and Update, 2(2), 70-76. [Open Access Full Text ]
• Buckley, S. and Bird, G. (2001). Down Syndrome issues and information: Memory development for individuals with Down syndrome. Portsmouth, UK: Down Syndrome Education International. [Open Access Full Text ]
• Bird, G. and Buckley, S. (2001). Down Syndrome issues and information: Reading and writing development for infants with Down syndrome (0-5 years). Portsmouth, UK: Down Syndrome Education International. [Open Access Full Text ]
• Bird, G. (2001). Down Syndrome issues and information: Number skills development for infants with Down syndrome (0-5 years). Portsmouth, UK: Down Syndrome Education International. [Open Access Full Text ]